Exploring the Risk of Dissociative Identity Disorder in Autistic Individuals
- Anne
- Mar 22
- 14 min read
Abstract
Despite increasing demands from the mental health community, research on Dissociative Identity Disorder (DID), formerly known as multiple personality disorder, remains scarce especially in regard to risk factors and comorbidities. This post evaluates the psychological and neurobiological profiles of individuals with Autism Spectrum Disorder (ASD), shedding light on their heightened vulnerabilities to trauma, increased intensity of trauma encoding, higher risk of PTSD, diminished sense of self, and heightened dissociation. These factors collectively increase their risk of developing DID compared to the general population. There is also discussion on how current therapeutic approaches can be adapted to address these overlapping complexities effectively.
I. Introduction
Much of the current focus for Autism Spectrum Disorder (ASD) research is on its genetic causes and comorbidities with conditions like obsessive compulsive disorder, anxiety, and depression. However, the potential link between ASD and trauma-related dissociative disorders, such as Dissociative Identity Disorder (DID), has been under-researched. Addressing this gap is essential for the vulnerabilities of autistic people and ensuring they receive equitable mental health care in regard to trauma treatment.
ASD is a neurological and developmental disorder that affects processing, communication, and behavior (National Institute of Mental Health [NIMH], 2024). It is believed to result from a combination of genetic factors and environmental influences (epigenetic) (National Institute of Environmental Health Sciences, n.d.). The symptoms vary widely in range and severity, including poor eye contact, difficulty with social engagement, repetitive actions, compulsive behaviors, obsessive interests, impulsivity, depression, anxiety, developmental delays, attention difficulties, emotional dysregulation, introspection difficulties, and sensory sensitivities. In 2020, an estimated 2.8% of 8-year-olds in the United States were autistic, though this figure may be underestimated due to the underdiagnosis of females (who often display traits differently) and limited (but gradually improving) access to diagnostic resources (NIMH, 2024).
DID is a dissociative disorder characterized by the presence of two or more distinct identity states, along with disruptions in memory, consciousness, perception, motor control, identity, emotions, behavior, and sense of self (Cleveland Clinic, n.d.-a). Common precursors include intense childhood trauma, such as abuse (often sexual) (Lynn, Lilienfeld, Merckelbach, Giesbrecht, McNally, Loftus, Bruck, Garry, & Malaktaris, 2014), disorganized attachment styles, and a lack of familial support during traumatic experiences (Gillig, 2009). In individuals with DID, alternate identities known as “alters,” are an uncontrolled, protective adaptation to cope with the trauma the individual has experienced. These alters serve specific roles that help the individual navigate and survive overwhelming experiences (Mitra & Jain, 2023). Each alter has a unique way of perceiving the world, forming relationships, and interpreting their environment. Due to dissociative amnesia/barriers, especially before awareness of the disorder, alters often do not share memories of the times they were in control of the body which leads to memory gaps for significant life events and personal information. It is important to understand that alters are not inherently harmful or “bad”; rather, they reflect the brain's remarkable resilience, while the trauma itself remains the true harm. It is estimated that 1-3% of the general population has DID, with a prevalence of 6% among psychiatric outpatients (Reinders, Marquand, Schlumpf, et al., 2019). Diagnosis often takes 5 to 12.5 years (Brand, Loewenstein, & Spiegel, 2014), delayed by limited understanding of the disorder and its neurological basis, its covert and protective nature, and pervasive stigma. The lengthy diagnosis delay is especially concerning for individuals with ASD, as overlapping symptoms may complicate targeted treatment. The focus of this paper is to demonstrate that autistic people are at an increased risk of developing DID due to unique neurobiological, psychological, and environmental factors. This includes a heightened vulnerability to trauma, distinct sensory processing differences, and the increased triggered use of dissociative coping mechanisms.
II. Intersection of Autism and Trauma
Heightened Risk of Abuse for ASD Individuals
Autistic people face an increased risk of abuse compared to the general population, which can perpetuate a cycle of victimization. Autistic adolescents are disproportionately affected by bullying, with a victimization prevalence rate of 46.3% (Sterzing, Shattuck, Narendorf, Wagner, & Cooper, 2012). This alarming statistic highlights the social challenges autistic people face, such as difficulty forming relationships and getting personal support, and an increased likelihood of being targeted due to naivety. Additionally, sensory overstimulation (commonly experienced by autistic people) can lead to behaviors such as tantrums, aggression, and repetitive actions. Unfortunately, abusive caregivers or others may exploit or escalate these responses, furthering patterns of maltreatment (Stith, Liu, Davies, Boykin, Alder, Harris, Som, McPherson, & Dees, 2009). Repeated exposure to trauma, particularly without access to effective support, can solidify dissociation as the brain’s primary coping strategy, increasing the risk of more complex dissociative disorders like DID.
Heightened Risk of Trauma-caused Disorders for ASD Individuals
Autistic people are at a significantly higher risk of developing PTSD (45%) compared to neurotypical populations (4.5%) (Rumball, Brook, Happé, & Karl, 2020). Those with ASD experience and process traumatic events differently due to their unique neurobiological and psychological profiles. Autistic people experience deficits in theory of mind (ToM), meaning they struggle to identify and understand the thoughts, feelings, and intentions of others (Peterson, Earl, Fox, Ma, Haidar, Pepper, Berliner, Wallace, & Bernier, 2019). They also experience higher rates of alexithymia, which causes difficulties in identifying, describing, and expressing one’s own emotional state (Peterson et al., 2019). This combination directly contributes to the increased risk of traumatic experiences, as well as leaving these experiences unprocessed, priming the manifestation of dissociative responses.
Chronic Stress and Dissociation
Autistic people process stress differently, which contributes to their dissociation. Dissociation occurs as a result of a disruption in the typical integration of consciousness, memory, identity, emotion, perception, and behavior, often in response to overwhelming stress or trauma (Entiva Behavioral Health, n.d.). Sensory processing differences in individuals with ASD range from overwhelming intensity to muted sensations, which can lead to sensory overload, prompting the triggering of dissociation as a coping mechanism to escape from the overwhelming stimuli (Entiva Behavioral Health, n.d.). Additionally, autistic individuals tend to have more reactive and less flexible nervous systems, making it harder for them to adapt to stressors and changes in routine (Peterson et al., 2019). This inflexibility leads to heightened anxiety. Autistic people also often exhibit increased cortisol levels in response to stress compared to the typical population, and experience a prolonged recovery period after a stressor to baseline levels (indicating heightened sensitivity to stress) (Corbett, Mendoza, Wegelin, Carmean, & Levine, 2008; Spratt, Nicholas, Brady, Carpenter, Hatcher, Meekins, et al., 2012). They also experience elevated cortisol levels during play, which suggests that social interactions are perceived as stress-inducing (Corbett et al., 2008). Autistic individuals also often experience perseverative thinking, or an over-focus on distressing thoughts (Lecavalier, 2006). Trauma-related thoughts can become fixated, reinforcing a cycle of re-experiencing the trauma, contributing to a heightened state of distress and leading to dissociation as a coping mechanism to disconnect from the distress.
Spectrum of Dissociation
Dissociation exists on a spectrum, ranging from mild detachment like daydreaming to more severe forms like Dissociative Identity Disorder (DID). As you move further along the spectrum toward DID, the integration of consciousness, memory, and identity becomes less cohesive. In less severe dissociative states, there may be a temporary disconnect from the present moment or certain emotions, but the person's sense of self and memory remain intact. However, in DID, this lack of integration can lead to the formation of multiple, distinct identities, each with a unique set of memories and behaviors. The more fragmented these parts of the self are, the harder it is to maintain a cohesive sense of identity, and the more pronounced the dissociative experience becomes. In the context of autism, the individual might retreat mentally and emotionally to cope with stress, and the lack of integration can escalate with trauma/stress.
III. Neurobiological Considerations
Emotional Processing, Stress, and Memory
In ASD, an overgrown amygdala heightens emotional responses and strengthens the connection between emotions and memories, making individuals more prone to anxiety and PTSD (UC Davis Health, 2022). When exposed to chronic trauma, this hyperactive emotional processing system may become overwhelmed, increasing the likelihood of dissociation as a coping mechanism. In DID, by contrast, the amygdala is smaller compared to the typical population (<31.6%) due to trauma-induced atrophy, impairing emotional regulation and contributing to the development of dissociative symptoms (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006). The hippocampus further illustrates a shared vulnerability. In ASD, increased hippocampal volume (Schumann, Hamstra, Goodlin-Jones, Lotspeich, Kwon, Buonocore, et al., 2004) disrupts social memory and synaptic plasticity (Hitti & Siegelbaum, 2014; Piskorowski, Nasrallah, Diamantopoulou, Mukai, Hassan, Siegelbaum, et al., 2016), potentially impairing the ability to contextualize stressful or traumatic events. This dysfunction may parallel the memory fragmentation seen in DID, where the hippocampus is markedly smaller compared to the typical population (<19.2%) as a result of prolonged exposure to stress hormones (Vermetten et al., 2006). Both disorders exhibit memory-related dysfunction, with ASD laying the groundwork for maladaptive responses to trauma.
Emotional Regulation, Motivation, Cognitive Functioning
In ASD, the Anterior Cingulate Cortex (ACC) (a region vital for emotional regulation and social behavior) often shows disruption. Research on Shank3 mutations, a gene strongly associated with ASD, reveals that dysfunction in glutamatergic synapses within the ACC leads to social interaction deficits in animal models (Guo, Chen, Chen, et al., 2019). This suggests that ACC dysfunction plays a role in the social and emotional impairments seen in ASD, particularly in the difficulty individuals with ASD face when processing emotions and regulating social behavior. In DID, the ACC is similarly crucial for emotional regulation and motivation. There is dysfunction in this region that contributes to emotional dysregulation when individuals are overwhelmed by emotions (Raccah, Block, & Fox, 2021). The Dorsolateral Prefrontal Cortex (DLPFC), which is involved in cognitive control and emotional regulation, shows underactivation in ASD (Lukito, Norman, Carlisi, Radua, Hart, Simonoff, & Rubia, 2020), impairing attention, working memory, and emotional regulation. In DID, the DLPFC manages cognitive and emotional functioning. Hyperactivation of the DLPFC during working memory tasks has been linked to dissociative states (Elzinga, Ardon, Heijnis, De Ruiter, Van Dyck, & Veltman, 2007).
Although these activity levels are different, the imbalance of homeostatic activity disallows emotional balance and cognitive control under stress. The activity level may start low in ASD individuals, but swing to the higher end if they develop DID.
In individuals with ASD, the frontal cortex shows cortical thickening, while variability in the temporal lobe complicates emotional processing and cognitive flexibility (Ecker, Ginestet, Feng, et al., 2013). In DID, structural imaging reveals decreased volume in the superior frontal regions (Reinders et al., 2019), which are essential for higher cognitive functions and emotional regulation. This disruption leads to emotional under- or over-regulation, triggering dissociative episodes. Additionally, structural imaging in DID shows reduced grey and white matter in the frontal, temporal, and occipital lobes, which are regions associated with memory and emotional regulation (Reinders et al., 2019). Compensatory increases in grey and white matter in areas like the superior frontal gyrus and cerebellum suggest that there may be potential adaptations to trauma.
Awareness of Self and Others
In ASD, the medial prefrontal cortex (mPFC) shows decreased activity and connectivity (Mohapatra & Wagner, 2023), which may impair the integration of emotional experiences, similar to the dysfunction observed in DID. This hypoactivity is linked to executive functioning deficits, particularly in prefrontal regions (Philip, Dauvermann, Whalley, Baynham, Lawrie, & Stanfield, 2012), contributing to difficulties in decision-making and social interactions. In DID, the mPFC also exhibits functional aberrations, but with increased activation in some cases (Modesti, Rapisarda, Capriotti, & Del Casale, 2022). As a region critical for regulating emotions and social behavior, dysregulation of the mPFC can lead to emotional disturbances in dissociative states. When the mPFC is disrupted, it impairs emotional responses to stress, triggering dissociative episodes. Additionally, reduced activation in the medial prefrontal cortex (including the ventromedial prefrontal cortex and left frontal pole) during traumatic states in DID patients points to dysfunction in self-awareness and emotional regulation, both crucial to maintain a coherent sense of self (Vissia, Lawrence, Chalavi, Giesen, Draijer, Nijenhuis, Aleman, Veltman, & Reinders, 2022).
Although ASD and DID show different patterns of mPFC activity, the emotional and cognitive dysregulation seen in ASD could act as a risk factor for developing DID due to the difficulty in processing and integrating emotions, increasing the likelihood of dissociative states. Decreased activity is also observed in other key brain areas for those with DID, including the cingulate, insular, inferior parietal, and superior temporal cortices (Lotfinia, Soorgi, Mertens, & Daniels, 2020). These disruptions align with the symptoms of dissociative states, interfering with emotional integration and the sense of self (core features of DID). In ASD, the anterior insula (AI), which is often overlooked in studies, shows atypical size and connectivity (Nomi, Molnar-Szakacs, & Uddin, 2019), with disruptions potentially contributing to dissociative-like experiences by impairing interoception (the perception of internal bodily states) and emotional regulation.
IV. Proposed Therapeutic Interventions
Early detection is the first step for effective treatment. ASD, PTSD, and DID each have unique symptomatology that often overlap. It is important to recognize these on psychological and neuroscientific levels (Saxena, Tote, & Sapkale, 2023; Cleveland Clinic, n.d.-b; Centers for Disease Control and Prevention, n.d.). There have been some recent advancements in DID research, leading to the identification of biomarkers that offer diagnostic accuracy at approximately 74% (Reinders et al., 2019). This could be used in treatment. However, more research is needed in these areas, as the current literature on dissociation in autism specifically remains severely limited (only a handful of papers exist).
There is no published paper that specifically addresses the combination of DID and autism, despite increasing demand for such research in online communities. This gap in research emphasizes the importance of this post, as I hope this will bring awareness to this issue.
The second step is individualized trauma-informed therapeutic interventions, tailored to the individual’s unique neurobiological profile. Integrating sensory regulation strategies, trauma-focused cognitive behavioral therapy, and mindfulness-based approaches can help autistic people to process trauma more effectively.
The third step is systemic changes, to overcome practical barriers like limited healthcare access and stigma. DID remains highly stigmatized, with diagnosis often taking between 5 to 12.5 years as mentioned before, and is frequently ridiculed in the media, often portrayed as "multiple personalities" with "evil alters" that are "psychopathic killers” (Spine Online, n.d.). Additionally, there is a severe lack of resources for ASD, with a focus on genetic factors or behavioral outcomes but little attention paid to the additional risks individuals with ASD face regarding trauma and related disorders. Psychiatric comorbidities are especially common among individuals with ASD, particularly as they age, further highlighting the need for targeted interventions (Simonoff et al., 2008; Kohane et al., 2012). This can make the healing process more difficult for those with ASD.
V. Conclusion
This review highlights the unique intersection between ASD and DID, emphasizing how neurobiological and cognitive factors, along with chronic stress and trauma, heighten the risk of developing DID in individuals with ASD. These factors contribute to a "perfect storm" in a sense, because individuals with ASD are more likely to be repeatedly abused, process trauma with greater intensity, be at higher risk of developing PTSD, and have a diminished ability to form a sense of self. Current therapies focus on the behavioral aspects of ASD, but there is a gap in research specifically exploring the internal psychological experiences of those with DID, particularly the risk of developing a trauma-induced dissociative disorder. Moving forward, further exploration of how ASD and trauma interplay could lead to more effective treatments and a more comprehensive understanding of dissociation in ASD. There is a huge potential for future research in this area, and it will be a pivotal aspect of the field's evolution.
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