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Chapter 2

The Background to Multiplicity

Child abuse

In most cases of Dissociative Identity Disorder, child abuse is at the core of the dissociative response. Ninety-seven percent of individuals with Dissociative Identity Disorder have a history of child abuse (Putnam et al., 1986), usually incest (68%) (Putnam, 1985). Current studies indicate that one in four girls will be sexually abused before the age of 18 (Briere & Runtz, 1988) and some studies indicate that the rate is closer to one female child in three (Russell, 1986; Finkelhor, 1986). In Russell's study of childhood abuse (1986) 16% of the women interviewed were sexually abused by members of their own families, and the abuse was reported to continue for years.

The mental health profession has been less than supportive in uncovering the incidence of child sexual abuse in our society. When Freud presented a famous paper on the etiology of hysteria that related child sexual abuse to the origin of neurosis, he was not prepared for the disbelief and professional scepticism he would encounter in response to the implication that incest and child abuse was not an uncommon event (Masson, 1984). Freud ultimately retracted his statement, replacing it with the theory of the Oedipal complex. The Oedipal theory explained away disclosures of child abuse as the fantasy longings of female children for their fathers, and denied that the abuse had ever occurred (Masson, 1984). This theory became the foundation of Freud's conceptualization of neurosis, and has been subsequently used for generations of psychiatrists to deny and disbelieve the stories of child sexual abuse reported to them by their clients (Rivera, 1988). The widespread abuses of women and children, in those cases where the proof was indisputable, were viewed as the isolated, individual acts of deviant men (Finkelhor, 1986; Russell, 1986).

The mental health profession reinforced this view. Psychology textbooks cited estimates of incest as occurring in one case per million (Freedman, Kaplan & Sadock, 1975). Later approaches to child abuse also took a "family" oriented perspective to incest; specifically, blaming the mother for her inadequate parenting. Levine (1989) quotes from an article in the Ottawa Citizen in 1978 that states "A local psychiatrist ... believes incest should be seen for what it is - quite literally a family affair. There are always at least three people involved, the mother, the father and the daughter ... usually it is done without violence" (p. 254). This commonly held attitude among mental health professionals reflects the attitude that incest itself is not an act of violence, and either the mother is to blame for not complying with the sexual demands of her husband, or the daughter is to blame for being seductive (Levine, 1989). The violent actions of male perpetrators are often shunted to the sidelines. Outright disbelief of disclosures of child abuse is also common (Goodwin, 1985a).

Interventions by the mental health profession can reflect these victim-blaming attitudes. Even well-meaning interventions into abusive situations can be traumatic to the child because social agencies are established to protect, not empower children. For example Levine (1989) cites a case where in 1980 a girl who was sexually abused by her father was put into a foster home by child welfare workers to study her "sexually provocative" behaviour. Even in cases where the abuser is identified as a threat to the child, the removal of the father often results in a severe drop in the standard of living for the now single-parent family (Ward, 1984).

This can be seen as a form of economic punishment for refusing to accept the rule of the man of the household. Individual intervention has limited effectiveness, because the problem lies in systemic, economically reinforced power relationships.

The focus of psychology is basically the management of mental illness. However, research into the etiology clearly points to the fact that Dissociative Identity Disorder is entirely preventable. Unfortunately, putting research into such a politically applied context is beyond the realm of many researchers. While broadly accepted theories of Dissociative Identity Disorder (Kluft, 1985b; Braun & Sachs, 1985) incorporate an understanding that the abused child is not protected from the abuser, few researchers put this into a social perspective. There is little profit in preventing the abuse of a patriarchal society (Brownmiller, 1975). Psychology remains a culturally bound profession that follows the tenets of the broader culture, and one of the purposes it serves in patriarchy is to privatize and individualize experiences of abuse(Levine, 1989). Defining and creating only individual solutions to the pain and problems of survivors of abuse ignores a political understanding of the larger issues of the oppression of children, especially female children, and the forms of and responses to oppression.

The broader understanding of child abuse emerged out of the Women's Movement of the 1970s and 1980s, not the individualized setting of private therapy (Rivera, 1988). Feminists conceptualized child abuse as a linked aspect of systemic violence against women and children and a tool of patriarchal oppression (Morgan, 1977; Brownmiller, 1975). Once the feminist political activism brought issues of child abuse and violence against women into the public consciousness, the issue was taken up by mental health professionals (Rivera, 1988).

Multiple personality disorder, as indisputably related to child abuse, represents a new opportunity for psychologists to explore the relationships between mental illness and social oppression. To understand Dissociative Identity Disorder as the result of trauma (Ross, 1994) is not enough. Dissociative Identity Disorder must be viewed in the larger social context of the oppression of women and children. Dissociative Identity Disorder is not merely the result of traumatic abuse, it is also the result of the social indifference to this abuse that allows violence against children to continue without intervention, that denies the disclosure of women and children who have experienced abuse and that fails to provide adequate support and care to survivors of abuse.

Part of understanding multiple identities as an adaptation, is understanding the nature of the abuse to which it is adapting. Child sexual abuse is not only an assault on the body of the child. It is an expression of control over the child, teaching the child their status as the sexual private property of men (Brownmiller, 1975). Physical and sexual is an attempt to colonize the mind and body of the child, an expression of the domination and power that adult men hold over women and children in the patriarchal nuclear family unit (Levine, 1989). Training ground for a lifetime of hierarchical oppression, the perpetrator punishes any sign of resistance and anger (Finkelhor, 1986). Child abuse involves a violation of the body which usurps the body from the control and intentions of the child. This leads to ongoing difficulties in "embodiment", or the relationships of the self to the body, in virtually all survivors of childhood abuse (Young, 1992). The body/mind split has little heuristic value when dealing with physical and sexual abuse. The body/mind connection is readily apparent in both the personal response to abuse and the political context in which abuse occurs.

The abuser also assaults the child's self-esteem y blaming the child for their own abuse, in order to displace their own guilt, ensure the child's silence and further dominate the child (Levine, 1989). This also is a divide and conquer strategy, where the child will expend energy blaming and fighting him or herself, rather than resisting the abuser. By examining child abuse as part of a political strategy of oppression that employs such colonizing tactics as "divide and conquer" and "blame the victim" (Hooks, 1981; Davis, 1981; Lorde, 1984), parallels between the response of dissociation and sociopolitical consequences of colonization become more clear. The inner turmoil and conflict of the person with multiple personality is similar to the infighting and internalized oppression of oppressed political groups. The amnesia that prevents even the survivor of child abuse from being aware of their own history is parallel to the silencing of women's voices and realities in a patriarchal system (Levine, 1989).

Dissociation

Modern psychology is predicated on the idea of the divided self. An awareness of the fundamental divisions of our seemingly unified sense of self is evident in many investigations into personality structure. Whether the divisions are seen as ego/id and superego conflicts (Freud, 1893), Hilgard's "hidden observer" (Hilgard, 1977), the archetypal figures of Jung (Jung, 1937), ego state theory (Watkins & Watkins, 1979), Beahrs' argument that multiple consciousness is inevitable in humans (Beahrs, 1983), or Wolff's (1987) work on infant's states of consciousness; the multiplicity of the human mind has been noted throughout psychology. There are a number of proposed model for understanding these divisions; the models that relate to the study of Dissociative Identity Disorder include a theory of dissociation. Janet (1889) is credited with conceptualizing the idea of dissociation as a mechanism, in which systems of thought can be split off from each other and congeal into a secondary personality that is unconscious, but can be accessed via hypnosis. In searching for definition to the pattern of this structure, studies in Dissociative Identity Disorder and other dissociative states have been ongoing. The clinical history of Dissociative Identity Disorder extends back into the seventeenth century (Price, 1988).

General theories of dissociation

Psychoanalytic theory

Joseph Breuer and Sigmund Freud contributed to the conceptualization of dissociation in their interpretation of the case of "Anna O.", reported in their "Studies in Hysteria" (Breuer & Freud, 1895). Anna O. was treated for a number of somatic illnesses and dissociative absences. Breuer regarded these absences as a form of autohypnosis, and characterized hysteria as an illness with three states of consciousness - normal waking state, the sleeping state and hypnoid states. He argued that some form of "double consciousness" was present in every case of hysteria to some degree. Freud (1893) interpreted the absences more functionally, as a defensive mechanism. Repression was described as a "horizontal" split between the conscious and unconscious minds. Dissociation was conceptualized as a vertical split between separate aspects of consciousness. Although Freud went on to place greater emphasis on the mechanism of repression, neo-Freudians have begun to reexamine Freud's original work and ideas on dissociation. Marmer (1991) adds that the purpose of the splitting is to preserve the good self and the good object. Marmer hypothesized that in Dissociative Identity Disorder, the self is split more than the object, whereas in borderline personality, the object is more split, with larger swings between idealization and devaluation. Marmer (1991) argues that the creation of identities is a response to a need for transitional objects, which fulfill the need for soothers and good objects.

Jungian theory

Noll (1989) reviewed Jung's notes regarding dissociation and argues that Jung is one of the earliest pioneers in the study of dissociation. Jung's complex theory included a benign concept of dissociation. Jung stated that dissociation occurs along a continuum from normal mental states to abnormal states. Dissociation itself was natural and essential to the operation of the psyche. While contemporaries such as Freud and Breuer focused on the pathological aspects of dissociation, Jung posited a central and benign role, fundamental to the processes of the psyche (Jung, 1947). He argues that the main adaptive benefit of dissociation was that it allowed the expansion of the personality through greater differentiation of function.

Jung (1937) states:

"As we have seen, the inherent tendency of the psyche to split means on the one hand dissociation into multiple structural units, but on the other hand the possibility of change and differentiation. It allows certain parts of the psychic structure to be singled out so that, by concentration of the will, they can be trained and brought to their maximum development. In this way certain capacities, especially those that promise to be socially useful, can be fostered to the neglect of others. This produces an unbalanced state similar to that caused by a dominant complex - a change of personality" (p. 121).

Jung, therefore, saw all of us as essentially multiple, our changes of personality as socially functional, and dissociation as a part of everyday life. Jung hypothesized that two main factors in the development of complexes (or identities) were the environment and the inherent predisposition in the individual. The complexes split off into "psychic fragments" as a result of traumatic influences.

Even moral conflicts can result in tiny psychic fragments that are present in all neurotic and normal individuals (Jung, 1937). Severe trauma leads to deep splinters in the psyche, and alternate personalities develop. This theory is very similar to Kluft's four factor theory of Dissociative Identity Disorder (Kluft, 1985b), except for Kluft's final condition of a hostile or unprotective environment that fails to protect the child from abuse.

Jung followed the philosophical tradition of polypsychism which was common among mesmerists in the 19th century (Noll, 1989). This theory argued that human personality exists in multiplicity. There are many centres of consciousness with varying degrees of control, and they are organized hierarchically. Jung also noted that each fragment has its own character, sets of memories, exists with relative independence from each other and exhibits evidence of amnesiac barriers between personalities. Jung also noted that the healing of neuroses occurred through the "assimilation" of unconscious contents into the ego-complex through an inner dialogue, which brings the fragments under the control of the ego-complex and also expands the functioning capacity of the centre of consciousness (Jung, 1934).

Noll (1989) initially argued that the structure of the identities commonly found in individuals with Dissociative Identity Disorder reflects the archetypal characteristics of Jungian analyses. With the centralizing personality weakened, the unconscious archetypes step forward and act more directly. Noll believed that archetypes of the child, the shadow, various aspects of self and anima and animus figures manifested in the identities of Dissociative Identity Disorder, as the structure of the psyche was laid bare to witness. However, in a later paper, Noll (1993) corrected his statement that the identities reflected the collective unconscious, and stated that their formation was primarily in response to sociocultural influences.

Behavioral state theory

Wolff (1987) conducted research in infant states and hypothesized that children exist in behavioral states that are self-organizing and self-sustaining. He drew examples from nonlinear dynamic systems theory to explain the structure of early developmental states. Children had predictable state fluctuations anchored around sleeping and eating needs. As development progresses, the "architecture" of state sequences becomes more complex and more responsive to the environment. He argued that regulating the behavioral state is an important task of early development, which includes increased concentration and attention span, the ability to screen out distractions and respond to social cues. Putnam (1985) proposed that dissociation represented a disruption in the development task of learning to generalize across different states of consciousness. Putnam argued that abused children were unable to complete these normal developmental tasks in the face of ongoing trauma.

Mechanisms of dissociation

Hypnosis theory

Hilgard (1977) and Bliss (1986) contributed to the understanding of dissociation through their work on hypnosis. They viewed multiple identities as a form of self-hypnosis, also called autohypnosis. Autohypnosis was proposed as the mechanism of how dissociation operates. Hypnosis is an extension of normal processes of dissociation, which allow people to focus attention. The attention mechanism is a network of reticular tissue in the brain (Bliss, 1986). There is natural variation in the population of the degree to which individuals can be hypnotized (Hilgard, 1965; Ross, 1991). Research into the hypnotizability of individuals with Dissociative Identity Disorder found that high levels of hypnotizability were always found in Dissociative Identity Disorder patients (Bliss, 1986). Children are also much more hypnotizable than adults and report more dissociative experiences (London & Cooper, 1969; Ross, 1991; Ross et al., 1989).

State dependent learning theory

State dependent learning is incorporated into a number of models (Braun, 1989; Putnam, 1989; Kluft 1991) as another mechanism of dissociation. The basic concept of state dependent learning is that people experience a variety of states that change according to emotions, behaviours and perceptions of the world. Something learned in one state is best retrieved under a similar state. The closer the state to the original experience, the better the retrieval. This process is thought to include a variety of factors, including learning processes, neurological conditioning processes and methods of encoding information. Ongoing trauma forces dissociative states to reoccur. Personalities are formed and learn through their repeated interactions with the environment. When the states become too disparate, inter-state retrieval becomes nearly impossible, and an amnesiac barrier is said to exist.

Not all trauma results in state-dependent learning effects, however. Braun (1989) notes that although Post Traumatic Stress Disorder is a dissociative disorder, it does not manifest state-dependent learning disruptions evident in Dissociative Identity Disorder.

Kluft (1988a) based his definition of alternate identities on the model of state dependent learning, and states that:

"a disaggregate self state (i.e., personality) is the mental address of a relatively stable and enduring particular pattern of selective mobilization of mental contents and functions, which may be behaviourally enacted with noteworthy role-taking and role-playing dimensions and sensitive to intrapsychic, interpersonal, and environmental stimuli ... It functions both as a recipient, processor, and storage center for perceptions, experiences, and the processing of such in connection with past events and thoughts, and/or present and anticipated ones as well. It has a sense of its own identity and ideation, and a capacity for initiating thought processes and actions." (p. 51)

Theories of the etiology of Dissociative Identity Disorder

Ego state theory

Ego state theory extends the argument that the mind is polypsychic with many existing processes and systems throughout life (Kelley & Kodman, 1987). The human personality develops through two different processes, integration and differentiation. Putting common concepts together, through the process of integration, results in more complex concepts, for example the realization that dogs and cats are both animals. By differentiation, the child separates concepts, for example, there are large dogs and small dogs. Dissociation occurs when this separating process becomes excessive and maladaptive (Watkins, 1993). Watkins & Watkins (1990) also argued that pain is eliminated in the primary personality by displacing it into underlying identities, often at their expense. They hypothesize that this process can be a source of internal conflict and further dissociation.

Federn (1952) argued that whether a physical or mental process was identified as part of the self or something other than the self, was determined by whether ego or object energy activated it. A personality is all of one's perceptions and emotions clustered into ego states, to create "an organized system of behaviour and experience whose elements are bound together by some common principle" (Watkins, 1993, p. 233). One state is invested with ego energy, and becomes the "executive self" (Watkins, 1993; Beahrs, 1983). Other ego states are invested with object energy and are experienced as "other". Price (1988) argues that one ego state is perceived as the "real" self because it is currently cathected and can therefore act as the executive self, however, this self can change over time. Ego states can be large and include all work related thoughts and feelings, or they can be related to a single memory. Everyone has covert ego states, which can be accessed through hypnosis. In individuals with Dissociative Identity Disorder, however, these covert states become overt. Price (1988) views the problem with multiple identities as being the permeability between ego states. The ego states are permeable to the flow of cathexis (allowing different ego states to assume executive control), but impermeable to information (causing amnesia). This creates a discontinuity in the perception of a unified self.

Kluft's Four Factor theory

Kluft (1985b) proposed a four factor theory of the etiology of Dissociative Identity Disorder. In order for Dissociative Identity Disorder to develop, the individual would have to:

a) possess the capacity to dissociate

b) experience overwhelming trauma that draws on the dissociative capacity as a defense mechanism (such as profound sexual or physical abuse by a parent)

c) develop an alternate personality around such naturally occurring phenomena as the hidden observer, ego states or an imaginary companion. This prevents the personality from achieving a cohesive sense of self.

d) experience the failure of significant others to protect the child from further trauma and reestablish normal development.

The double-bind theory

Braun (1986) suggests that the primary mechanism driving multiple personality is the contradiction between two primary injunctions from a parent, in addition to the rule that this contradiction may not be discussed. For example, if a father who brutalizes his child tells the child that he is abusing her because he loves her, it combines the need for attention and loving from the parent with pain and fear. The child is forced to internalize these contradictions and become one child who is dependent, passive and eager for attention, and another who is angry and resistant. Repeated abuse forces the child to protect him or herself from an irrational environment.

Braun's BASK theory

Braun (1984) developed a theory of the structure and etiology of Dissociative Identity Disorder that focused on the forms of dissociation found in Dissociative Identity Disorder. He theorized that:

"in persons with the biopsychophysiologic capacity to dissociate, the predominant defense mechanism may be pathologic dissociation. If the victim suffered childhood incest in the context of an abusive family, the dissociative disorder that develops as its sequel may be seen as complete disruption of behaviour, affect, sensation and knowledge (BASK): that is, multiple personality disorder" (Braun, 1989, p. 307).

Braun argued that behaviour, affect, sensation and knowledge are processes which function congruently over time. Dissociation can occur in any of these elements, for example a disruption in sensation results in hypnotic anaesthesia. A disruption on all BASK elements corresponds to Dissociative Identity Disorder. Braun believes that awareness and dissociation occur on a continuum, and that dissociation and Dissociative Identity Disorder represent the most pathological extremes.

3-P factor theory

Braun & Sach's (1985) 3-P factor theory of etiology is again very similar to Kluft's 4 factor theory. The factors are:

Predisposition: The genetic capacity to dissociate, and the repeated, long-term experience of severe childhood trauma.

Precipitation: Overwhelmed by the trauma, dissociation is triggered as a defensive mechanism. Through state dependent learning and other mechanisms, dissociative episodes become linked into alter personalities or fragments.

Perpetuation: Ongoing abuse, and other situational factors that involve the patient's repeated use of dissociation, affect the shaping of the fragments and ensure the continuation of the personalities.

Attachment theory

Barach (1991) argues that Dissociative Identity Disorder can also be viewed as an attachment disorder. He uses Bowlby's theory of attachment (1988) to relate to dissociation. This is a variation on the concept of Dissociative Identity Disorder as a developmental disorder, in this case the child abuse interrupts the developmental task of forming secure attachments. Barach argues that detachment (the failure to form attachments) is basically the same thing as dissociation. Barach states when one caretaker is detached or emotionally distant from the child, the child may use dissociation as a defense against the trauma of abuse perpetrated by the other parent. He argues that alternating between assault and abandonment is the core problem. Several studies have confirmed that inconsistent treatment is especially likely to create traumatic dissociation in children (Allison & Schwartz, 1980; Braun & Sachs, 1985; Coons & Milstein, 1986; Kluft, 1982; Wilbur, 1984a). For example, a child might alternately be beaten, ignored or rewarded for the same behaviour on different occasions. Contradictory messages, and alternating patterns of affection and abuse are intermingled. Parental discipline and affection are often unpredictable. There is no one way to respond that will ensure the child's safety or parental approval (Sachs, Frischholz, & Wood, 1988).

Abused children form dysfunctional attachments with their abuser, who hold life and death power over them, and often are in a situation where no one, including the mother, extended family, teachers and so on, believe the child's disclosure of abuse and/or are willing or able to take action to prevent further abuse. Putnam et al. (1986) found that over 60% of patients with Dissociative Identity Disorder reported extreme neglect in childhood. This basic emotional deprivation prevents the child from learning to form trusting relationships, creating anxious attachments later in life.

This is again similar to Kluft's fourth factor of an unsupportive environment and that fails to protect the abused child.

Limitations of the research into Dissociative Identity Disorder

There are few large, direct studies of individuals with Dissociative Identity Disorder in the literature. Many of the larger studies are actually reports compiled entirely (Ross, Norton & Wozney, 1989; Putnam et al., 1986) or mostly (Rivera, 1991) from therapists' clinical observations. Such indirect data has obvious problems of reliability. Much of data has already been subject to the interpretation of the therapists, who in turn are basing their conclusions on the self-reports of their clients. One of the limitations is that the relative infrequency of Dissociative Identity Disorder makes it difficult to compile large samples.

Although Rivera (1991) found no differences between the reports from individuals with Dissociative Identity Disorder and therapists' reports of clients with Dissociative Identity Disorder in her study, more direct research through multicentre collaborative sampling needs to be done. Many reports are based on small studies from clinical experience (Adityanjee, Raju & Khandelwal, 1989; Kluft, 1991; Young, 1987; Fike, 1990a; Braun, 1989; Dawson, 1990; Dell & Eisenhower, 1990; Angel, 1989; Kluft, 1986b). There are some indications that the clinical population may not be representative to the general population (Ross 1991), which limits the generalizeability of such methods of study.

The lack of longitudinal studies creates further problems of validity, as virtually all the data relies on the self-reporting of patients about events that happened far in their personal past.

The literature also lacks integration with cross cultural data. While some cross cultural studies have documented cases of Dissociative Identity Disorder (Adityanjee, Raju & Khandelwal, 1989; Coons, Milstein & Bowman, 1990; Ensink & van Oterloo, 1989; Malarewicz, 1990; Martinez-Taboas, 1989), the research is limited to urban centres and/or industrialized countries.

The literature is still small, with only a dozen or so researchers contributing the bulk of the material. Surely, fresh insight would result from the integration of individuals with multiple identities into the academic exploration of the phenomena. A less socially dissociated response to child abuse would include both caregivers and survivors in dialogue. Margo Rivera (1988) notes a conference she attended where the strongest feminist voices came from women with multiple identities who presented papers on self-help groups, social analysis of multiple personality in maintaining societal norms and cross-cultural and cross-racial issues and problems in therapy. Rivera comments that "it is significant and not surprising that the strongest feminist voices at the conference were those of women with multiple personalities" (p. 39). I can only imagine what it would be like if all the professionals engaged in research would devote the same time and effort into providing a forum for individuals with multiple identities to talk about their experiences and share their theories.

Stress

Dissociative Identity Disorder is often described as a stress-related phenomena, specifically an adaptation to the stress of an abusive childhood environment (Spiegal, 1984; Briere & Runtz, 1988; Fagan & McMahan, 1984; Kluft, Braun & Sachs, 1984; Wilbur, 1984a; Bliss; 1980; Greaves, 1980; Schultz, Braun & Kluft, 1985; Putnam, 1985; Kluft, 1985b; Ross, Norton & Wozney, 1989). But what exactly is meant by stress? Often, this term is misinterpreted to refer to an external event, for example, to describe the abused child as being "under stress" or in a "stressful" environment, or to say that Dissociative Identity Disorder is "a response to stress". However, stress was originally conceptualized as an internal state, or specifically as "the state manifested by a pecific syndrome which consists of all the non-specifically induced changes within a biologic system" (Selye, 1978, p. 64).

Understanding stress in this way, instead of as external events, is a useful heuristic for exploring Dissociative Identity Disorder. Hans Selye, a well-known endocrinologist, redefined disease and biology with a radical (at the time) theory about the way human beings adjusted to the world. Selye (1950, 1967) developed a model called the General Adaptation Syndrome (GAS) which explains physiological patterns and mechanisms of adaptation to changes. Before Selye's work, Western medicine defined diseases as the work of a pathogen, such as a virus or a bacteria that would attack the body (Hinkle, 1987). Selye redefined these concepts with a more dynamic, systems model of interactions between the body and the environment.

Selye's dynamic model of stress

Homeostasis is a steady state, waiting for change, that exists before a new stressor is introduced. Adapting to a new environment or new information, involves the process of heterostasis, incorporating these changes into our bodies or lives. After adaptation has occurred, a new state of homeostasis is reached. The process of adaptation has incorporated some degree of change, a new immunity to a pathogen, or a new self-concept. And then another stressor comes along and the process begins all over again.

Selye (1974) believed humans were meant for change, for learning and growing. He believed that regulating the processes of stress would result in "dynamic equilibrium". Managing stress is like riding a bicycle, if we stop we fall over, if we go too fast we

break down. We need to keep moving, lack of change can be one of life's most frustrating and stressful situations. However, the changes need to be at a controlled pace that we can adapt to without disturbing the dynamic equilibrium.

Defining stages of stress

Selye defined stress as "the state manifested by a specific syndrome which consists of all the non-specifically-induced changes within a biologic system" (Selye, 1978, p. 64). The process of living involves some level of stress and ongoing changes, for better or for worse. Positive changes can be stressful without causing distress. Selye named this process "eustress", which involved having to make changes for positive stressors in our lives. However, too many positive changes can still be distressing; they still provoke the stress response - increased heart rate, sweating and increased blood pressure.

Stress is the mechanism of heterostasis. The physiological state of stress can be broken down into three basic phases, also called the General Adaptation Syndrome - the alarm stage, the resistance stage and the stage of exhaustion.

Stage 1 The Alarm Stage

The alarm reaction has hallmark physiological responses, the enlargement of the adrenal cortex, the atrophy of the thymicolymphatic organs, gastrointestinal changes and a variety of chemical changes in the body fluids and tissues. Long-term signs also include loss of weight, changes in the regulation of body temperature and loss of eosinophil cells from the blood. In issues more directly affected by stress, a local adaptation syndrome (LAS) also develops, for example, inflammation where the poison from a bite has entered the body. This is closely coordinated with the GAS. Chemical signals from the directly stressed tissue are sent to the coordinating centres of the nervous system, especially the pituitary and adrenal glands. These glands produce hormones to mobilize the body's defence against the stress, as well as providing specific responses for the directly stressed area. The hormones fall into two categories, anti-inflammatory hormones which prevent the defensive reaction of inflammation (such as ACTH, and cortisone) and proinflammatory hormones which stimulate inflammation (such as STH and aldosterone). Both hormone types help the body cope with the stressor, either by reducing sensitivity to it and making it easier to coexist with it, or by cutting it off from further entry to the body by barricading it within the inflammatory tissue.

These processes all interact with each other, and can be affected by a variety of factors, such as diet, genetic composition and tissue memories of previous exposure to stress. And although the stressor can be non-specific, the stress response can be highly specific.

The overall level of resistance is lowered during the alarm stage. For example, many of the hormones released during the alarm stage have deleterious effects on the immune system (Selye, 1978).

Stage 2 The Resistance stage

The resistance stage ensues if continued exposure to the stressor is compatible with adaptation (i.e. survivable). The body's resistance, which was lowered during the alarm stage, resumes at a higher level than normal. Adaptation to the stressor characterizes this process. There are different types of adaptation; developmental adaptation (where modifications are required in the current structure and function of a cell or system in response to a stressor), and re-developmental adaptation (where tissue which has been organized for one type of action, is forced to readjust itself completely to an entirely different kind of activity).

Stage 3 The Exhaustion stage

The exhaustion stage follows long-continued exposure to a stressor that the body has become adapted to. The signs of the alarm reaction may reappear if the stressor is still present, and the individual may die. The capacity for adaptation, which Selye believed was finite, has been exhausted at this point.

The Process of Adaptation

Selye (1978) defines adaptation as the "balanced blend of defense and submission" (p.169). Adaptation is the blending of life and death, resistance and submission, composition and decomposition, as every manifestation of growth necessitates destruction. Every time a muscle is flexed, stressed and developed; destruction and "wear and tear" occurs at the same time.

Adaptive does not always mean healthy. Selye's model challenges the definition of health, as much as it challenges the concept of disease. Adaptation occurs only relative to the environment, what is adaptive in one environment is not adaptive in another. Rapidly changing environments, that require ongoing, rapid internal changes, result in a high state of stress. Even though successful adaptations are produced in response to each stressor, the cumulative effects of stress can be detrimental and will eventually diminish the adaptive energy.

Selye hypothesized that adaptive energy, the capacity to respond to the environment, was finite. Adaptability is not simply a matter of calories, but a different kind of energy, similar to the concept of vitality or vital energy.

The non-specificity of the stress response

The state of stress is generalized throughout the body's systems. A LAS does not occur in isolation, but in conjunction with a general mobilization of the body's defenses. Often, the process and degree of the GAS depend on the type of stressor. It can be more effective to localize the response as much as possible. When there are a limited number of effector mechanisms or a limited success with which they can respond to the stressor that the state of stress becomes more systemic and the response is non-specific.

Diseases of adaptation

Some stressors can directly cause disease. For example, if you put the hand of a corpse into acid it would cause burning regardless of the fact that the corpse showed no adaptive responses to the stressor. However, more complex, long-term syndromes and cumulative environmental responses are the result of diseases of adaptation.

A disease of adaptation occurs when the adaptive responses of the GAS produce damaging effects (Selye, 1978). The external agent is not the (direct) cause of the disease, just the stressor, and possibly one of many factors. For example, consuming fat in one's diet is a stressor. In order to transport the fat through the bloodstream, the liver produces cholesterol. Large amounts of dietary fat leads to a large stress response (more cholesterol) which can be trapped in the lining of the arteries. This begins to limit the blood supply to the organs. According to Selye, it is the adaptation to the stressor (the production of cholesterol) that creates the manifestation of disease.

Using this analysis, a multifactorial approach can be used to understand disease syndromes, not related to a direct cause and effect relationship. For example, seemingly unrelated factors such as a sedentary lifestyle, certain chemicals inhaled in tobacco smoke and a variety of other stressors can also affect the response of cholesterol levels. These different factors can have complicated relationships, for example chemicals in tobacco damage the lining of the arteries and increase the likelihood that cholesterol will be trapped in them.

The generalized response of the individual includes intellectual and emotional aspects. The body responds to intellectual demands, and the intellect responds to physical demands. Therefore, in studying the GAS, the entire body-mind system must be examined. The artificial separation between the physical and mental is not a useful heuristic in this context. The GAS includes changes in gross motor behaviour, patterns of activity that change exposure to stressors and other behaviours, ideations and affects that mediate the impact of a physical stressor.

In some way, many diseases can be understood to be diseases of adaptation. However, the meaning of disease is changed. The linear concept of pathogen and illness, stimulus and response, need to be redefined to accommodate more complex realities. If diseases occur as a result of adaptation, we need to rethink the relationship of illness and health. For example, we get sick as a result of immunization, yet being immunized is a healthful process. Chicken pox is a dangerous disease in adulthood, and contracting the illness is considered a normative, healthy aspect of childhood to prevent future damage (Selye, 1978). We think of disease as something bad that we should try and eliminate, rather than examining the complex interrelationships of our environments and our responses to these environments. Disease is rarely a passive experience of something that happens to us, it is a dynamic and interactive relationship we have with our environment. Often, the immediate signs of disease, are really the results of adaptations to the environment. Intervention in the environment will naturally reduce the signs of disease, as the adaptive responses are no longer elicited. Complex, adaptive responses, such as Dissociative Identity Disorder, need to be analyzed by examining GAS effects.

One example that clarifies the implications of the GAS, is weightlifting. In weightlifting, it has always been assumed that by lifting weights, and forcing the muscles in the body into a state of stress, that they would adapt to this stressor by increasing in strength. However, weightlifters, who regularly seek to maximize this state of stress, also know that at some point in intensive training, long plateaus of weeks or years can result in no change to the muscles, despite continuing stressors (Garhammer, 1986).

This is the result of the body reaching a level of homeostasis that incorporates the regular activity. It has entered the resistance stage, where the system is accommodating the current level of stress without making further responses to the stressor. The plateau experience is the conservation of adaptive energy, your body is reluctant to begin a new cycle of heterostasis. Overtraining can also lead to the exhaustion stage, where new adaptive responses simply cannot be activated by that specific stressor. Exposing the system to stress at this stage damages the muscles and joints instead of strengthening them.

Weightlifters also discovered that lifting more poundage does not always lead to the fastest improvements. For example, lifting 20 pounds ten times a session, three times a week equals a total amount of 600 pounds. Lifting 20 pounds in a sequence of 8, 10 and 12 times over the course of the week will result in faster improvement, even though the total remains 600 pounds (Garhammer, 1986). Not training can improve performance as well. Regular breaks during training are needed to keep improving, even though the muscles are being subjected to less stress (Garhammer, 1986). Selye (1978) explains that the body adjusts to the pattern of the stressor, as well as each individual period of exposure. Constant variations in the type of stressor will stimulate new cycles of the heterostasis to adapt to the new changes. Many weightlifters advise beginning with a simple exercise routine and then adding variations to the workout. If too many variations are introduced all at once, the initial rapid improvement will quickly lead to long plateaus.

Psychological stress

Psychological stress is often defined in a relatively mechanistic way, in analogy to the body's GAS. This is partly because psychological stressors and biological ones usually produce overlapping stress responses. The generalization of the stress response is critical in expanding the model for psychological and sociological applications. Hinkle (1987) states that psychological stress has an obvious effect on the central nervous system, and produces changes in moods, thoughts and behaviours. Hinkle (1987) also states that:

"information acquired from the social and interpersonal environment and mediated by the central nervous system through its control of internal regulatory processes, is able to produce alterations of internal functions down to the biochemical level" (p. 562).

Social stressors

Social stress occurs for a person when "he [sic] is faced with a situation that implies for him two or more different kinds of behaviour, based on two or more different set of guidelines and values, which are in conflict and not readily reconcilable" (Hinkle, 1987, p.562).

Applying Stress Models to Dissociative Identity Disorder

Selye's model of stress can be applied to Dissociative Identity Disorder, in examining the etiology, stages and structures through a dynamic model. The model implies that it is possible to trace a life history of the course of Dissociative Identity Disorder, and examine the impact of different stressors affecting the individual. Examining Dissociative Identity Disorder as not only a defensive response for survival, but a reactive and proactive adaptation, implies that the individual is not merely fleeing from pain but heading towards something else; that they are not merely coping with abuse, but resisting it.

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