Their claim is evinced by the fact that only 5%–10% of people receiving treatment worsen in their symptoms.Psychiatrists August Piper and Harold Merskey have challenged the trauma hypothesis, arguing that correlation does not imply causation – the fact that people with DID report childhood trauma does not mean trauma causes DID – and point to the rareness of the diagnosis before 1980 as well as a failure to find DID as an outcome in longitudinal studies of traumatized children. They assert that DID cannot be accurately diagnosed because of vague and unclear diagnostic criteria in the DSM and undefined concepts such as "personality state" and "identities", and question the evidence for childhood abuse beyond self-reports, the lack of definition of what would indicate a threshold of abuse sufficient to induce DID and the extremely small number of cases of children diagnosed with DID despite an average age of appearance of the first alter of three years. Psychiatrist Colin Ross disagrees with Piper and Merskeys conclusion that DID cannot be accurately diagnosed, pointing to internal consistency between different structured dissociative disorder interviews (including the Dissociative Experiences Scale, Dissociative Disorders Interview Schedule and Structured Clinical Interview for Dissociative Disorders) that are in the internal validity range of widely accepted mental illnesses such as schizophrenia and major depressive disorder. In his opinion, Piper and Merskey are setting the standard of proof higher than they are for other diagnoses.
If this individual experiences minimal or no negative consequences (punishment), then the likelihood that the behavior will reoccur is increased. As the behavior continues to occur, stronger antecedents or cues become contingently linked with it, in what ultimately becomes a powerful behavioral chain. According to cognitive-behavioral theory (CBT), both antecedents and consequences may either be in the environment or cognitions. For example, Kohn and Antonuccio (2002) describe a clients antecedent cognitions, which include thoughts such as "I’m smarter than others and can get away with it"; "they deserve it"; "I want to prove to myself that I can do it"; and "my family deserves to have better things". These thoughts were strong cues to stealing behaviors. All of these thoughts were precipitated by additional antecedents which were thoughts about family, financial, and work stressors or feelings of depression. "Maintaining" cognitions provided additional reinforcement for stealing behaviors and included feelings of vindication and pride, for example: "score one for the little guy against the big corporations". Although those thoughts were often afterward accompanied by feelings of remorse, this came too late in the operant sequence to serve as a viable punisher. Eventually, individuals with kleptomania come to rely upon stealing as a way of coping with stressful situations and distressing feelings, which serve to further maintain the behavior and decrease the number of available alternative coping strategies.