23 Mar 2015
Multiple Personality Disorder, or Dissociative Identity Disorder, as it is now identified by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM - IV -TR) continues to be a disputed diagnosis after decades of diagnoses, treatment, and research. Psychiatrists, medical doctors, psychologists, counselors and social workers, as well as attorneys and judges, continue to seek the validity of this mental disorder. While the primary concern of those in the medical community is a correct diagnosis in order to direct treatment, the legal community relies on a proper diagnosis to determine both guilt and sentencing for those who use the diagnosis to plead a "not guilty by reasons of insanity" defense. Despite the lengthy battle between the opposing sides debating the actual existence of the disorder, the disorder will be included in the May 2013 edition of the DSM - V. Neither the medical nor the legal community doubts the need for therapy or counseling of some form for these patients. However, the proper treatment is, or should be, directly related to an accurate diagnosis. Determining the validity of Multiple Personality Disorder continues to be, after all these years, a serious concern. The question remains, "Is there sufficient scientific research to prove the validity of Multiple Personality Disorder?"
I was 23 years old when the movie When the Rabbit Howls aired on television. The "true story" film adaptation of Truddi Chase's story of extreme child abuse and subsequent diagnosis and treatment of Multiple Personality Disorder was a horrific tale of severe family dysfunction leading to vicious sexual abuse beginning at the age of two. Despite the massive volume of books I have read, the many movies watched, and the television shows viewed, none of them continue to haunt me as this movie has. Apparently, I was not alone in my fascination of Truddi Chase. Oprah Winfrey invited her to be the first guest on her radio program, as well as an early guest on her television program. Chase later returned in 1990 for a second interview on the Oprah Winfrey Show. Her appearance on the Oprah Winfrey Show was later listed as one of TV Guides "Top 25 Oprah Moments". Chase claimed to have 92 distinct personalities.
Despite my awe and fascination of the life of Truddi Chase, I am left wondering; is this possible? Does this disorder actually exist? To be able to blame all of our faults, sins, or shortcomings on another, someone other than our "self" could be the ultimate fantasy for some. If one is caught in a compromising position of sexual infidelity, drug use, driving under the influence or any other serious crime, one could simply wake up and claim someone else did this, another "self". To walk benignly through life accepting responsibility for only the noble deeds we perform, the good we display, would that not be the best of all possible lives? Perhaps. Or perhaps it is a life of tormented existence, lost time, forgotten experiences, disrupted, fragmented pieces of a life half lived.
While some claim Multiple Personality Disorder was diagnosed as early as the 1800's, the first famous or possibly infamous case in the United States was the case of Christine Costner in 1951. The classic 1957 film, The Three Faces of Eve was the story of
Dr. Corbett Thigpen, a young neuropsychiatrist who treated Christine Costner (called Eve White to protect her identity) in 1951. The existence of more than one "personality" became manifested gradually during treatment, in 1952. After about 100 therapy sessions over 2-3 years, Ms. Costner seemed well. Ms. Costner subsequently wrote three autobiographical books. She revealed her identity in 1977 (as Chris Costner Sizemore, her married name). She has claimed that she actually had about 20 personalities, that they were not resolved until years after her treatment with Dr. Thigpen, and that they were not the result of childhood trauma, as she had reported during treatment. (Atkinson, 2009)
Even after this rather dubious case, the disorder did not fully manifest itself until after the renowned story of Sybil in the 1970's. Sybil was a television miniseries, based on a 1973 book by science journalist Flora Rheta Schreiber. Sybil Dorsett was a pseudonym for the patient, Shirley Ardell Mason. Dr. Schieber was asked to write a book by the patient's psychiatrist, Dr. Cornelia Wilbur while Dr.Herbert Spiegel was asked by Dr. Wilbur to consult on the case as a hypnotist. The hypnotist reported he
did not think that Ms. Mason had MPD, he believed Dr. Wilbur had suggested this to her patient, and that Ms. Mason's allusions to separate personalities amounted to "game playing" in a hysterical patient prone to dissociation. He said that Ms. Mason told him that she had read "The Three Faces of Eve" during her therapy and was impressed by it. According to Dr. Spiegel, Ms. Schreiber visited him and said, "But if we don't call it a multiple personality, we don't have a book! The publisher wants it to be that; otherwise it won't sell." After treatment (more than 2,000 sessions), Ms. Mason always maintained the truth of her claims of experiencing multiple personalities (16 in all) and childhood physical and sexual abuse by her mother. (Atkinson, 2009)
After the popular movie of Sybil, the diagnosis of Multiple Personality Disorder ballooned "from perhaps no more than 100 beforehand to 40,000 or more 20 years later, mainly in North America." (Atkinson, 2009) Was it merely cases of misdiagnoses? Or was this a new phenomenon, a new disorder?
There are many reasons I believe the diagnosis of Multiple Personality Disorder to be faulty, overzealous, or patently untrue. I will attempt to provide both sides of this argument for or against the validity of this diagnosis as I found many professionals weighing in.
A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).Â
B. At least two of these identities or personality states recurrently take control of the person's behavior.Â
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.Â
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures).Â Note:Â In children, the symptomsÂ are not attributable to imaginary playmates or other fantasy play (American Psychiatric Association, 2000)
Therefore, my first argument would be that Multiple Personality Disorder's appearance in the DSM was late in being included and has changed with each issuance of the manual. Multiple Personality Disorder did not appear in the DSM until 1980, the Third Edition. The criteria and terminology changed in the 1994 DSM IV edition, and according to Helen Farrell in Current Psychology, the "American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013." (Farrell, 2011) I have been unable to find the proposed changes, but am anxious to see if they were approved and what those changes are. The questions remain. Why was this disorder not observed in a number of patients prior to the 1980's? Why does the criterion continue to be so difficult to define?
Many of the patients diagnosed with MPD have been found to have been highly suggestible and easily hypnotizable, with a tendency to fantasize, and unreliable in their counseling sessions. Roland Atkinson reports
Subjects who are highly hypnotizable ("virtuosos") may self-induce trance states or respond to a therapist's instruction to enter such a state with rudimentary, or even unwitting, cues. Thus, "personalities" may also have been cued, even if they seemed to have emerged spontaneously. In such circumstances, patient and therapist alike may inadvertently and honestly believe in an MPD diagnosis, and in "memories" of childhood trauma, which are not valid. This may have occurred in the filmed cases; that is, both may have been at least partly iatrogenic in origin. (Atkinson, 2009)
Iatrogenic means "Induced in a patient by a physician's activity, manner, or therapy." (Dictionary, 2000). In fact, it is not until the person is in therapy do they become aware of the multiple personalities. (Leuder & Sharrock, 1999) (Murray, 1994) The patient becomes aware of these alter egos through regression therapy or hypnosis. Most of the patients "discover" they were sexually abused as children, causing such trauma, the child forms another personality to deal with the pain and mental stress. (Piper Jr., 1998) The argument for the lateness in the diagnosis of MPD in patients is the client's use of repression, denial, and rationalization. According to John Murray in The Journal of Genetic Psychology, the alter egos may present themselves only during "a window of diagnosibility" and be unable to detect at later times, remaining latent in the patient. (Murray, 1994)The MPD symptoms may be present in one session only to disappear in another, much like bipolar depression symptoms.
The issue of childhood sexual abuse also becomes an issue of concern in the MPD diagnosis due to the difficulty in proving abuse. Sexual abuse is very hard to confirm in a child, it becomes even more difficult in an adult victim of child sexual abuse. This is NOT to say the abuse never happened, merely that it is difficult to substantiate. As the clients are highly suggestible, implantation of false memories becomes easily arguable. A few of the memories are so bizarre as to be unbelievable, consider the following
one patient claimed to have witnessed a baby being barbecued alive at a family picnic in a city park; another patient alleged repeated sexual assaults by a lion, a baboon, and other zoo animals in her parents' back yard - in broad daylight. (It should be mentioned that both therapists in these cases are prominent MPD adherents, and neither appeared to have any difficulty believing these allegations)." (Piper Jr., 1998)
Independent corroboration would be very helpful in cases such as these and certainly helpful in the prosecution of current cases today, but, alas, this has never been, and will doubtfully ever be, the case.
The preponderance of sexually abused patients succumbing to MPD leads to another factor of the disorder. Ninety percent of the patients are women. (Atkinson, 2009), but it has been reported to have been as high as 92 percent in a 1996 study. (Murray, 1994) Ruling out gynecological concerns, I can think of no other illness with such a high rate of gender inequality. However, one must take into consideration that girls are subjected to higher rates of childhood sexual abuse than boys are.
Another concern deals with how psychiatrists and other professionals diagnosis MPD. The doctors assert that they had been alerted to the possibility of MPD when a client reported such benign symptoms as headaches, insomnia, listlessness or forgetfulness. Even more ridiculous was the absolute randomness and inanity of the following diagnostic clues reported by August Piper Jr.
glancing around the therapist's office; frequently blinking one's eyes; changing posture, or the voice's pitch or volume; rolling the eyes upward; laughing or showing anger suddenly; covering the mouth; allowing the hair to fall over one's face; developing a headache; scratching an itch; touching the face, or the chair in which one sits; changing hairstyles between sessions; or wearing a particular color of clothing or item of jewelry In one case known to the author, a leading MPD proponent claimed that the diagnosis was supported by behavior no more remarkable than the fact that the patient changed clothes several times daily and liked to wear sunglasses. (Piper Jr., 1998)
With such diagnostic "alerts" to the doctor, one cannot be surprised at the large number of MPD cases some doctors had the opportunity to "treat". MPD diagnosis and treatment became a cottage industry for some self-promoting doctors and therapists. In his article Film, fame, and the fashioning of an illness, Atkinson believed the films portraying "Sybil" and Eve" perpetuated this mass diagnosis. "Many cases shared features in common with false memory phenomena, such as the influence of coercive suggestion by therapists in producing the desired but invalid memory reports of highly susceptible patients." (Atkinson, 2009)
There are many diagnostic tools used by therapists to confirm the MPD diagnosis. A few include: Structured Clinical Interview for Dissociative Disorders, Dissociative Disorder Interview Schedule, Dissociative Experiences Scale, Childhood Trauma Questionnaire (Farrell, 2011) (Murray, 1994), as well as the Thematic Apperception Test (T.A.T) and the Minnesota Multiphasic Personality Inventory (MMPI) (Murray, 1994). Most notable in all of these tests and diagnostic tools is that they are all self-reporting. While many would argue you cannot "beat" the test, I find that argument to be untrue in some cases, particularly if an eager or leading therapist coaches the patient. However, Murray contends in a blind test "for 63 adult psychiatric patients, using the MMPI MPD profile, and correctly identified 68% of the 25 MPD patients. The MMPI seemed a valuable aid in diagnosing MPD." (Murray, 1994)
The fact that no clear, specific method of treatment for MPD has been established also deals a blow to MPD's validity. Even staunch supporters, such as David Hartman MSW of the Wellness Institute and psychologist Dr. John B. Murray agree that there are no particular methods of treatment and that it was all still very experimental. Some of the methods currently being used are psychotherapy, pharmacotherapy, behavior modification, group therapy sessions (with some difficulty, I will not mention the humor I found in this, as I was unsure if the "group" therapy would include multiple personalities and one physical person), psychodynamic therapy, the use of sodium amobarbital (a drug with sedative/hypnotic properties) and of course hypnotherapy. (Murray, 1994) (Piper Jr., 1998) (Hartman, An overview of the psychotherapy of dissociative identity disorder, 2010) (Hartman, Treatments for dissociative disorders, 2010)While hypnotherapy often led to the initial diagnosis, it is also part of the treatment. However, Murray warns while "Hypnosis is usually a constructive intervention, it can be misused." (Murray, 1994) And while hypnosis "provides access to "secret" personalities, it may enhance rather than repair the dissociation process." (Murray, 1994) In his support of hypnosis, he continues, "hypnosis is useful in therapy when it helps MPD patients understand and use the past and present for better self-understanding and direction." (Murray, 1994)
There are several diagnoses which MPD patients could also be diagnosed. A few include, schizophrenia, affective disorder, posttraumatic stress disorder, dissociative disorders other than MPD, depression, bipolar disorder, even drug abuse. Prior to the diagnosing of MPD, I would hope all other possible disorders be completely ruled out, rather than MPD being ruled in. Again, despite being a advocate of the validity of MPD, Dr. John B. Murray writes, "MPD features can overlap with other psychiatric diagnoses, and clinicians have been wary of inducing MPD in patients and of treating MPD patients." (Murray, 1994) He, too, recognizes the danger of MPD inducement!
Though life may often be stranger than fiction, I found the ridiculousness of the many reports derived from MPD cases to further cause my doubts of its validity. I will list several I found particularly absurd. "C. A. Ross writes of alters that "force [the patient] to jump in front of a truck. [The alters] then go back inside just before impact, leaving the [patient] to experience the pain" (Piper Jr., 1998), or the French woman who spoke no German would "suddenly" speak in another language. Carter writes, "as her French self, she could remember everything she had said or done during her previous French "episodes". As a German woman, she knew nothing of her French personality." (Carter, 2008) Some multiple even have different immune systems and bodies, "Felida X, for example, had three different personalities, each with their own illnesses. One of them even had her own pregnancy, unknown, at first, to the others." (Carter, 2008) The fact that some alter egos can create their own alter egos is also incongruous. "Sheila claimed she consciously chose a masculine identity". (Layton, 1995)
Another absurdity are the form alter egos may take according to their therapist, "There are alters of people of the opposite sex, of the treating therapist, of infants, television characters, and demons. Alters of Satan and God, of dogs, cats, lobsters, and stuffed animals - even of people thousands of years old or from another dimension - have been reported by MPD proponents". (Piper Jr., 1998)
And lastly in the area of ridiculousness, throughout the reading about MPD, I found time after time, journal article after journal article, from proponents to nay-sayers, asserting that the "alter personalities" "identities,", "alter egos, "ego states," "personality states" or merely "alters," could number two, sixteen, ninety-two, two thousand, or even ten thousand! How does a therapist keep up with these characters? After all, many are deceitful, some are aging, some stay nine years old, some will split yet again, some will be hidden, and others will be repressed. Keeping track of the multiples would create a full-time job for a therapist with a single patient!
Lastly, MPD simply does not meet the legal test. Some in the legal community have said the diagnosis "may be the most controversial diagnosis introduced into the criminal justice system." (Hafemeister, 2009) In fact, most recently, "courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury." (Farrell, 2011) The State of West Virginia has also spoken to the validity of this controversial diagnosis, "Similarly, in State v Lockhart (2000), Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence." (Farrell, 2011)
Does it matter? Does a diagnosis of Multiple Personality Disorder versus another matter? I maintain that it does. Billy Milligan, a serial rapist from Ohio in the 1970s, was excused from any criminal responsibility with his diagnosis of MPD. In Current Psychiatry, Helen M. Ferrell writes, "The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful." (Farrell, 2011)
"Public outrage was extraordinary." Indeed! I am sure it was. As I suggested previously, being able to blame all of our faults, sins, or shortcomings on another, someone other than our "self", could be the ultimate fantasy for some. Commit multiple rapes? Milligan would simply wake up and claim someone else did this, his other "self".
Another case making this argument matter, is the woman in Chicago who consulted a psychiatrist for depression.
He concluded that she suffered from MPD, that she had abused her own children, and that she had gleefully participated in Satan-worshiping cult orgies where pregnant women were eviscerated and their babies eaten. Her failure to recall these events was attributed to alters that blocked her awareness. No one had produced any evidence for the truth of any of this, no one had seen her do anything unusual, no one had come forward to say they had participated in satanic activities with her. But no matter. The doctor notified the state that the woman was a child molester. Then, after convincing her that she had killed several adults because she had been told to do so by Satanists, he threatened to notify the police about these "criminal activities." The woman's husband believed the doctor's claims. He divorced her. And, of course, because she was a "child molester," she lost custody of her children. (Piper Jr., 1998)
The validity of a MPD diagnosis also matters so we, as counselors, therapists and others in the mental health field can provide appropriate treatment to these patients. For, despite the label we may wish to give an illness, the illness MUST be treated.
Multiple Personality Disorder was a fad, a psychological trend, a craze, perhaps. Therapists, the public, even Oprah Winfrey, became enthralled by these captivating stories of abuse, human survival and the mind's incredible fortitude. However, the diagnosis has led to more harm for the patients, abuse from malingerers, and prevented those with true mental illnesses from receiving the treatment they need and deserve.
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