I have recently heard a discussion about a man who is serving a life sentence for murder. Reportedly this man lately applied for a sex change, and allegedly a judge did approve his application. They focused on the prisoner’s assertion that he always had been a woman in man’s body. Now, he wants his gender change in order that his physical body could match up with his persona of a female. A question was raised that the prisoner is scheming to get out of prison. After the sex change, the prisoner may say I did not commit this murder. I always had been a woman but the murder was committed by a different person a man. Such turn of events would be interesting since sometimes defense lawyers tried to use the psychological phenomenon of multiple personalities for legal defense of their clients.
In 1989 my colleague, Dr. Seymour Tozman, and I published an article in the Journal of Nervous and Mental Disease: “MPD Further Skepticism – Without Hostility, We Think” in which we questioned the existence of Multiple Personality Disorder (MPD). We stated: “As practitioners with thousands of patients seen over 40 people-years, we report that we have never seen a legitimate case of multiple personality disorder (MPD). We note the high level of skepticism…”
As a director of St. Mark’s Pl. Institute for Mental Health, with nearly 40 thousand patients treated in the clinic over a period of 34 years, I have never seen a genuine case of MPD. I have often noted that clinicians who believe in MPD have MPD clients/patients. It appears as if the patients accommodate the beliefs of his psychotherapist or psychiatrist.
Research also raised real doubts about MPD. In Scientific American, Aug 25, 2011, Scott O. Lilienfeld and Hal Arkowitz wrote a commentary entitled “Putting the Pieces Together “ … persuasive evidence for discrete coexisting personalities in individuals is lacking. They reported, “distinctions among alters (different personalities) are mostly anecdotal, unconfirmed, and difficult to interpret.”
Films, such as The Three Faces of Eve (1957) and Me, Myself, and Irene (2000), persuasively showed individuals as possessing more than one personality. The woman is known as Sybil – in the 1973 best-selling book and two TV movies – disseminated the notion of MPD. (Later evidence appeared suggesting that Sybil’s primary therapist inspired her to display multiple personalities). In some reported cases, the number of different personalities may reach into the hundreds or even thousands.
The DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revised) accepted multiple personality disorder as a real diagnosis and identified the core features of the disorder as the “presence of two or more distinct identities or personality states.”
The International Society for the Study of Trauma and Dissociation stated that the occurrence of MPD is between 1 and 3% in the general population, and from 1% to 5% in an inpatient population in Europe and North America.http://en.wikipedia.org/wiki /Dissociative_identity_disorder – cite_note-Guidelines-5 MPD is diagnosed more frequently in North America than in the rest of the world and is diagnosed three to nine times more often in women than in men. The incidence of MPD (now renamed as Dissociative Identity Disorder – DID) increased greatly in the latter half of the 20th century and continues in 21. MPD is also debated within the legal system where it has been used as the insanity defense.
Dissociative disorders, including MPD, have been attributed to disturbances in memory caused by physical traumas, e.g. head injury, stroke, and/or other forms of stress. Another hypothesis (as mentioned above) is that of iatrogenic origin, i.e. the product of a therapist’s influence, and patient’s susceptibility for suggestions, especially in those who were hypnotized. Despite the extensive depiction of this disorder, research doubts the idea that anyone truly possesses more than one personality.
So, why does such a questionable disorder gets much attention?
DMS-IV-TR states that posttraumatic stress disorder (PTSD), especially sexual abuse in childhood, might be a causative factor in the development of MPD. If PTSD does cause MPD, why is not PTSD emphasized, inasmuch as this is a more significant, frequent, and often unrecognized pathological condition in treating MPD? Also, when associated with alcoholism, PTSD, rather than MPD, maybe the prevailing pathology.
During the 30 years of St. Mark’s Place existence, numerous alleged MPD cases were referred. However, at St. Mark’s Place, we did not find in these patients more than one personality and seldom have these cases manifested some degree of dissociation. Even, the authors of The Three Faces of Eve state that they have seen only one bona fide, case of MPD in the hundreds (misdiagnosed) of cases sent to them after the publication of their book. Since, as mention above, clinicians who believe in MPD have the MPD patients, this phenomenon should be considered as a “self-hypnotic” disorder, and so designated. In legitimate instances, a dissociative disorder with self- hypnotic personality characteristics would be more useful. Fragmented personality was suggested rather than multiple personalities Such terminology would be a more accurate description.
In 1990, one of our treatment cases, a young law student, was asked in a rough projective test to draw a person. He was totally unable to do so but could copy very accurately. Then he dramatically revealed he was “multiple” like “Sybil” (moreover, he vaguely alluded to be a “monster”). He was tested psychologically and found to have a right hemispheric neurological deficit with a retarded Performance IQ and a near-genius verbal IQ. He suffered from a learning disability from a “soft” neurological condition localized at his right parietal-occipital lesion. His great verbal storage capability permitted excellent verbal proficiency despite exceedingly poor visuospatial capabilities. This deficit had translated into enigmatic and addictive behavior (parenthetically, Ted Bundy, a law student, the executed serial killer, had this very, same IQ disparity: “I am convinced he was not multiple, but he came so close wrote his psychiatrist in Vanity Fair, May 1989.)
The MPD should be regarded as a rare dissociative disorder. Naturally, MPD seems related to hypnotizability. The acceptance by DSM-IV-TR of this rare iatrogenic disorder as legitimate diagnosable and treatable, does no justice to scientific psychology, generating media and literature distortion. It often provides flawed and pretentious legal defense maneuvers for criminals. For example, ABC May 1, 2002, the case of Thomas Huskey. “Police heard the confession on tape: A man said he raped and strangled a woman. After that, ‘I threw her down and left her lying there’ said the loud and angry voice on tape. Prosecutors and defense lawyers agreed that the voice belongs to Thomas Huskey… But Huskey’s lawyers said that the man confessing was someone else: another personality who” lives” inside Huskey’s body but is completely beyond his control. Was Huskey inventing another persona, completely changing his tone and vocabulary as part of a ploy for acquittal or a more lenient sentence, or does he suffer from multiple personality disorder?” was the question asked. As I indicated above the diagnosis of dissociative identity disorder is rare, and psychiatry should not reinforce something mythical or unusual which could be used for other than treatment goals.
DSM-V includes multiple personalities into dissociative identity disorder and defines it as the presence of two or more distinct personality states or as an experience of possession. Each personality is a fully integrated and complex unit with memories, behavior patterns, and social friendships. The transition from one personality to another is sudden. The manifestation of these personality states varies as a function of psychological motivation, level of stress, culture, internal conflicts and dynamics, and emotional resilience. This is accompanied by a retrospective gap in the memory of important personal information that far exceeds ordinary forgetfulness. The changes in identity are not due to substance use or to a general medical condition. Frequent themes that are shared in these dissociative states are a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. All types of dissociative disorders tend to disappear after a few weeks or months, particularly if their onset is associated with a traumatic life event.
More chronic disorders may develop if the onset is associated with unsolvable problems or interpersonal difficulties. These disorders have previously been classified as various types of “conversion hysteria”. They are presumed to be psychogenic in origin, being associated closely in time with traumatic events, unsolvable and unbearable problems, or disturbed relationships. The symptoms often represent the patient’s concept of how a physical illness would be manifest. Medical examination and investigation do not reveal the presence of any known physical or neurological disorder. In addition, there is evidence that the loss of function is an expression of emotional conflicts or needs. The symptoms may develop in close relationship to psychological stress, and often appear suddenly.
Psychotherapy will help affected persons with DID to integrate their states, which is a process that happens over time. Unlike movies and media depictions, integration isn’t a big dramatic event. Instead, slowly, the differences among states diminish, and the person is better able to handle strong feelings and memories without switching self-states and retreating from reality. Freud used hypnosis to retrieve correct memories (like memories of abuse). Now, substantial research has found that experiences recalled under hypnosis can feel very true, although the person never experienced these events. Hypnosis should never be used to facilitate recall memory of traumas.
An Example DID Case
A female patient with a long history of mental health problems is seeking help for her self-destructive behaviors – suicide attempts, self-mutilation, self-cutting who also struggle with a disabling depression. She never mentions any example of dissociation. (Most people with DID don’t realize they have it, or if they do, they keep it hidden because they don’t want to be seen as “crazy.”) During the examination, the woman presents with gaps of in her memory and appears spaced out. Often the examiner had to call her name to bring her back to the present. The patient may admit that her friends and family member mentioned her out-of-character behavior – drinking a lot of alcohol, stealing, walking at night, sexual promiscuity. A patient realizes that this must be true because of hangovers but couldn’t remember having a single drink. The patient usually would admit only in a therapeutic session that they tend not to think about these unexplained, frightening experiences.
If a patient presents with DID it is important to investigate about traumas and symptoms of PTSD. There might be suppressed traumatic experiences, struggles with a poor body image, low self-esteem, and a number of chronic health problems, including fibromyalgia and migraines.
Regardless of the controversy, dissociative identity disorder is a real disorder but something mysterious, something that a person cannot recover from and the persons is not crazy but rather traumatized. Hope for recovery is in finding appropriate psychotherapy.