dissociative identity disorder, with early trauma causing increased fantasy-proneness, which may in turn render individuals more vulnerable to socio-cognitive influences surrounding the development of dissociative identity disorder. another suggestion made by hart indicates that there are triggers in the brain that can be the catalyst for different self-states, and that victims of trauma are more susceptible to these triggers than non-victims of trauma; these triggers are said to be related to dissociative identity disorder. paris states that the trauma model of dissociative identity disorder increased the appeal of the diagnosis among health care providers, patients and the public as it validated the idea that child abuse had lifelong, serious effects. paris asserts that there is very little experimental evidence supporting the trauma-dissociation hypothesis, and no research showing that dissociation consistently links to long-term memory disruption. non-trauma-related model the prevailing trauma-related model of dissociation and dissociative disorders is contested. it has been hypothesized that symptoms of dissociative identity disorder may be created by therapists using techniques to "recover" memories (such as the use of hypnosis to "access" alter identities, facilitate age regression or retrieve memories) on suggestible individuals. referred to as the non-trauma-related model, or the sociocognitive model or fantasy model, it proposes that dissociative identity disorder is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes, with unwitting therapists providing cues through improper therapeutic techniques. this model posits that behavior is enhanced by media portrayals of dissociative identity disorder. proponents of the non-trauma-related model note that the dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of dissociative identity disorder who, through the process of eliciting, conversing with and identifying alters, shape or possibly create the diagnosis. while proponents note that dissociative identity disorder is accompanied by genuine suffering and the distressing symptoms, and can be diagnosed reliably using the dsm criteria, they are skeptical of the trauma-related etiology suggested by proponents of the trauma-related model. proponents of non-trauma-related dissociative identity disorder are concerned about the possibility of hypnotizability, suggestibility, frequent fantasization and mental absorption predisposing individuals to dissociation. they note that a small subset of doctors are responsible for diagnosing the majority of individuals with dissociative identity disorder. psychologist nicholas spanos and others have suggested that in addition to therapy caused cases, dissociative identity disorder may be the result of role-playing, though others disagree, pointing to a lack of incentive to manufacture or maintain separate identities and point to the claimed histories of abuse. other arguments that therapy can cause dissociative identity disorder include the lack of children diagnosed with did, the sudden spike in rates of diagnosis after 1980 (although dissociative identity disorder was not a diagnosis until dsm-iv, published in 1994), the absence of evidence of increased rates of child abuse, the appearance of the disorder almost exclusively in individuals undergoing psychotherapy, particularly involving hypnosis, the presences of bizarre alternate identities (such as those claiming to be animals or mythological creatures) and an increase in the number of alternate identities over time (as well as an initial increase in their number as psychotherapy begins in did-oriented therapy). these various cultural and therapeutic causes occur within a context of pre-existing psychopathology, notably borderline personality disorder, which is commonly comorbid with dissociative identity disorder. in addition, presentations can vary across cultures, such as indian patients who only switch alters after a period of sleep – which is commonly how dissociative identity disorder is presented by the media within that country. proponents of non-trauma-related dissociative identity disorder state that the disorder is strongly linked to (possibly suggestive) psychotherapy, often involving recovered memories (memories that the person previously had amnesia for) or false memories, and that such therapy could cause additional identities. such memories could be used to make an allegation of child sexual abuse. there is little agreement between those who see therapy as a cause and trauma as a cause. supporters of therapy as a cause of dissociative identity disorder suggest that a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position though it has also been claimed that higher rates of diagnosis in specific countries like the united states may be due to greater awareness of did. lower rates in other countries may be due to artificially low recognition of the diagnosis. however, false memory syndrome per se is not regarded by mental health experts as a valid diagnosis, and has been described as "a non-psychological term originated by a private foundation whose stated purpose is to support accused parents," and critics argue that the concept has no empirical support, and further describe the false memory syndrome foundation as an advocacy group that has distorted and misrepresented memory research. children the rarity of dissociative identity disorder diagnosis in children is cited as a reason to doubt the validity of the disorder, and proponents of both etiologies believe that the discovery of dissociative identity disorder in a child who had never undergone treatment would critically undermine the non-trauma related model. conversely, if children are found to develop dissociative identity disorder only after undergoing treatment it would challenge the trauma-related model. as of 2011, approximately 250 cases of dissociative identity disorder in children have been identified, though the data does not offer unequivocal support for either theory. while children have been diagnosed with dissociative identity disorder before therapy, several were presented to clinicians by parents who were themselves diagnosed with dissociative identity disorder; others were influenced by the appearance of dissociative identity disorder in popular culture or due to a diagnosis of psychosis due to hearing voices – a symptom also found in dissociative identity disorder. no studies have looked for children with dissociative identity disorder in the general population, and the single study that attempted to look for children with dissociative identity disorder not already in therapy did so by examining siblings of those already in therapy for dissociative identity disorder. an analysis of diagnosis of children reported in scientific publications, 44 case studies of single patients were found to be evenly distributed (i.e., each case study was reported by a different author) but in articles regarding groups of patients, four researchers were responsible for the majority of the reports. the initial theoretical description of dissociative identity disorder was that dissociative symptoms were a means of coping with extreme stress (particularly childhood sexual and physical abuse), but this belief has been challenged by the data of multiple research studies. proponents of the trauma-related model claim the high correlation of child sexual and physical abuse reported by adults with dissociative identity disorder corroborates the link between trauma and dissociative identity disorder. however, the link between dissociative identity disorder and maltreatment has been questioned for several reasons. the studies reporting the links often rely on self-report rather than independent corroborations, and these results may be worsened by selection and referral bias. most studies of trauma and dissociation are cross-sectional rather than longitudinal, which means researchers can not attribute causation, and studies avoiding recall bias have failed to corroborate such a causal link. in addition, studies rarely control for the many disorders comorbid with dissociative identity disorder, or family maladjustment (which is itself highly correlated with dissociative identity disorder). the popular association of dissociative identity disorder with childhood abuse is relatively recent, occurring only after the publication of sybil in 1973. most previous examples of "multiples" such as chris costner sizemore, whose life was depicted in the book and film the three faces of eve, disclosed no history of child abuse. pathophysiology despite research on did including structural and functional magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, event-related potential, and electroencephalography, no convergent neuroimaging findings have been identified regarding did, making it difficult to hypothesize a biological basis for did. in addition, many of the studies that do exist were performed from an explicitly trauma-based position, and did not consider the possibility of therapy as a cause of did. there is no research to date regarding the neuroimaging and introduction of false memories in did patients, though there is evidence of changes in visual parameters and support for amnesia between alters. did patients also appear to show deficiencies in tests of conscious control of attention and memorization (which also showed signs of compartmentalization for implicit memory between alters but no such compartmentalization for verbal memory) and increased and persistent vigilance and startle responses to sound. did patients may also demonstrate altered neuroanatomy. experimental tests of memory suggest that patients with did may have improved memory for certain tasks, which has been used to criticize the hypothesis that did is a means of forgetting or suppressing memory. patients also show experimental evidence of being more fantasy-prone, which in turn is related to a tendency to over-report false memories of painful events. diagnosis general the fifth, revised edition of the american psychiatric association's diagnostic and statistical manual of mental disorders (dsm-5) diagnoses did according to the diagnostic criteria found under code 300.14 (dissociative disorders). did is often initially misdiagnosed because clinicians receive little training about dissociative disorders or did, and often use standard diagnostic interviews that do not include questions about trauma, dissociation or post-traumatic symptoms.(p 118) this contributes to difficulties diagnosing the disorder and clinician bias. did is rarely diagnosed in children, despite the average age of appearance of the first alter being three years old. the criteria require that an individual be recurrently controlled by two or more discrete identities or personality states, accompanied by memory lapses for important information that is not caused by alcohol, drugs or medications and other medical conditions such as complex partial seizures. in children the symptoms must not be better explained by "imaginary playmates or other fantasy play". diagnosis is normally performed by a clinically trained mental health professional such as a psychiatrist or psychologist through clinical evaluation, interviews with family and friends, and consideration of other ancillary material. specially designed interviews (such as the scid-d) and personality assessment tools may be used in the evaluation as well. since most of the symptoms depend on self-report and are not concrete and observable, there is a degree of subjectivity in making the diagnosis. people are often disinclined to seek treatment, especially since their symptoms may not be taken seriously; thus dissociative disorders have been referred to as "diseases of hiddenness". the diagnosis has been criticized by supporters of therapy as a cause or the sociocognitive hypothesis as they believe it is a culture-bound and often health care induced condition. the social cues involved in diagnosis may be instrumental in shaping patient behavior or attribution, such that symptoms within one context may be linked to did, while in another time or place the diagnosis could have been something other than did. other researchers disagree and argue that the existence of the condition and its inclusion in the dsm is supported by multiple lines of reliable evidence, with diagnostic criteria allowing it to be clearly discriminated from conditions it is often mistaken for (schizophrenia, borderline personality disorder, and seizure disorder). that a large proportion of cases are diagnosed by specific health care providers, and that symptoms have been created in nonclinical research subjects given appropriate cueing has been suggested as evidence that a small number of clinicians who specialize in did are responsible for the creation of alters through therapy. the condition may be under-diagnosed due to skepticism and lack of awareness from mental health professionals, made difficult due to the lack of specific and reliable criteria for diagnosing did as well as a lack of prevalence rates due to the failure to examine systematically selected and representative populations. differential diagnoses people with did are diagnosed with five to seven comorbid disorders on average – much higher than other mental illnesses. due to overlapping symptoms, the differential diagnosis includes schizophrenia, normal and rapid-cycling bipolar disorder, epilepsy, borderline personality disorder, and autism spectrum disorder. delusions or auditory hallucinations can be mistaken for speech by other personalities. persistence and consistency of identities and behavior, amnesia, measures of dissociation or hypnotizability and reports from family members or other associates indicating a history of such changes can help distinguish did from other conditions. a diagnosis of did takes precedence over any other dissociative disorders. distinguishing did from malingering is a concern