multiple personality disorder
[dissociative identity disorder]
....students often ask me whether multiple personality disorder (MPD) really exists. I usually reply that the symptoms attributed to it are as genuine as hysterical paralysis and seizures....
--Dr. Paul McHugh
Multiple personality disorder (MPD) is a psychiatric disorder characterized by having at least one "alter" personality that controls behavior. The "alters" are said to occur spontaneously and involuntarily, and function more or less independently of each other. The unity of consciousness, by which we identify our selves, is said to be absent in MPD. Another symptom of MPD is significant amnesia which can't be explained by ordinary forgetfulness. In 1994, the American Psychiatric Association's DSM-IV replaced the designation of MPD with DID: dissociative identity disorder. The label may have changed, but the list of symptoms remained essentially the same.
Memory and other aspects of consciousness are said to be divided up among "alters" in the MPD. The number of "alters" identified by various therapists ranges from several to tens to hundreds. There are even some reports of several thousand identities dwelling in one person. There does not seem to be any consensus among therapists as to what an "alter" is. Yet, there is general agreement that the cause of MPD is repressed memories of childhood sexual abuse. The evidence for this claim has been challenged, however, and there are very few reported cases of MPD afflicting children.
Psychologist Nicholas P. Spanos argues that repressed memories of childhood abuse and multiple personality disorder are "rule-governed social constructions established, legitimated, and maintained through social interaction." In short, Spanos argues that most cases of MPD have been created by therapists with the cooperation of their patients and the rest of society. The experts have created both the disease and the cure. This does not mean that MPD does not exist, but that its origin and development are often, if not most often, explicable without the model of separate but permeable ego-states or "alters" arising out of the ashes of a destroyed "original self."
A rather common view of MPD is given by philosopher Daniel Dennett.
...the evidence is now voluminous that there are not a handful or a hundred but thousands ofcases of MPD diagnosed today, and it almost invariably owes its existence to prolonged earlychildhood abuse, usually sexual, and of sickening severity. Nicholas Humphrey and Iinvestigated MPD several years ago ["Speaking for Our Selves: An Assessment of MultiplePersonality Disorder," Raritan, 9, pp. 68-98] and found it to be a complex phenomenon thatextends far beyond individual brains and the sufferers.
These children have often been kept in such extraordinary terrifying and confusing circumstances that I am more amazed that they survive psychologically at all than I am thatthey manage to preserve themselves by a desperate redrawing of their boundaries. What they do, when confronted with overwhelming conflict and pain, is this: They "leave." They create aboundary so that the horror doesn't happen to them; it either happens to no one, or to someother self, better able to sustain its organization under such an onslaught--at least that's whatthey say they did, as best they recall.
Dennett exhibits minimal skepticism about the truth of the MPD accounts, and focuses on how they can be explained metaphysically and biologically. For all his brilliant exploration of the concept of the self, the one perspective he doesn't seem to give much weight to is the one Spanos takes: that the self and the multiple selves of the MPD patient are social constructs, not needing a metaphysical or biological explanation so much as a social-psychological one. That is not to say that our biology is not a significant determining factor in the development of our ideas about selves, including our own self. It is to say, however, that before we go off worrying about how to metaphysically explain one or a hundred selves in one body, or one self in a hundred bodies, we might want to consider that a phenomenological analysis of behavior which takes that behavior at face value, or which attributes it to nothing but brain structure and biochemistry, may be missing the most significant element in the creation of the self: the sociocognitive context in which our ideas of self, disease, personality, memory, etc., emerge. Being a social construct does not make the self any less real, by the way. And Spanos should not be taken to deny either that the self exists or that MPD exists.
But if thinkers of Dennett's stature accept MPD as something which needs explaining in terms of psychological dynamics limited to the psyche of the abused rather than in terms of social constructs, the task of convincing therapists who treat MPD to accept Spanos' way of thinking is Herculean. How could it be possible that most MPD patients have been created in the therapist's laboratory, so to speak? How could it be possible that so many people, particularly female people [85% of MPD patients are female], could have so many false memories of childhood sexual abuse? How could so many people behave as if their bodies have been invaded by numerous entities or personalities, if they hadn't really been so invaded? How could so many people actually experience past lives under hypnosis, a standard procedure of some therapists who treat MPD? How could the defense mechanism explanation for MPD, in terms of repression of childhood sexual trauma and dissociation, not be correct? How could so many people be so wrong about so much? Spanos' answer makes it sound almost too easy for such a massive amount of self-deception and delusion to develop: it's happened before and we all know about it. Remember demonic possession?
Most educated people today do not try to explain epilepsy, brain damage, genetic disorders, neurochemical imbalances, feverish hallucinations, or troublesome behavior by appealing to the idea of demonic possession. Yet, at one time, all of Europe and America would have accepted such an explanation. Furthermore, we had our experts--the priests and theologians--to tell us how to identify the possessed and how to exorcise the demons. An elaborate theological framework bolstered this worldview, and an elaborate set of social rituals and behaviors validated it on a continuous basis. In fact, every culture, no matter how primitive and pre-scientific, had a belief in some form of demonic possession. It had its shamans and witch doctors who performed rituals to rid the possessed of their demons. In their own sociocognitive contexts, such beliefs and behaviors were seen as obviously correct, and were constantly reinforced by traditional and customary social behaviors and expectations.
Most educated people today believe that the behaviors of witches and other possessed persons--as well as the behaviors of their tormentors, exorcists, and executioners--were enactments of social roles. With the exception of religious fundamentalists (who still live in the world of demons, witches, and supernatural magic), educated people do not believe that in those days there really were witches, or that demons really did invade bodies, or that priests really did exorcise those demons by their ritualistic magic. Yet, for those who lived in the time of witches and demons, these beings were as real as anything else they experienced. In Spanos' view, what is true of the world of demons and exorcists is true of the psychological world filled with phenomena such as repression of childhood sexual trauma and its manifestation in such disorders as MPD.
Spanos makes a very strong case for the claim that "patients learn to construe themselves as possessing multiple selves, learn to present themselves in terms of this construal, and learn to reorganize and elaborate on their personal biography so as to make it congruent with their understanding of what it means to be a multiple." Psychotherapists, according to Spanos, "play a particularly important part in the generation and maintenance of MPD." According to Spanos, most therapists never see a single case of MPD and some therapists report seeing hundreds of cases each year. It should be distressing to those trying to defend the integrity of psychotherapy that a patient's diagnosis depends upon the preconceptions of the therapist. However, an MPD patient typically has no memory of sexual abuse upon entering therapy. Only after the therapist encourages the patient do memories of sexual abuses emerge. Furthermore, the typical MPD patient does not begin manifesting "alters" until after treatment begins (Piper 1998). MPD therapists counter these charges by claiming that their methods are tried and true, which they know from experience, and those therapists who never treat MPD don't know what to look for.*
Multiple selves exist, and have existed in other cultures, without being related to the notion of a mental disorder, as is the case today in North America. According to Spanos, "Multiple identities can develop in a wide variety of cultural contexts and serve numerous different social functions." Neither childhood sexual abuse nor mental disorder is a necessary condition for multiple personality to manifest itself. Multiple personalities are best understood as "rule-governed social constructions." They "are established, legitimated, maintained, and altered through social interaction." In a number of different historical and social contexts, people have learned to think of themselves as "possessing more than one identity or self, and can learn to behave as if they are first one identity and then a different identity." However, "people are unlikely to think of themselves in this way or to behave in this way unless their culture has provided models from whom the rules and characteristics of multiple identity enactments can be learned. Along with providing rules and models, the culture, through its socializing agents, must also provide legitimation for multiple self enactments." Again, Spanos is not saying that MPD does not exist, but that the standard model of (a) abuse, (b) withdrawal of original self, and then (c) emergence of alters, is not needed to explain MPD. Nor is the psychological baggage that goes with that model: repression, recovered memory of childhood sexual abuse, integration of alters in therapy. Nor are the standard diagnostic techniques: hypnosis, including past life regression, and Rorschach tests.
It should be noted that books and films have had a strong influence on the belief in the nature of MPD, e.g., Sybil, The Three Faces of Eve, The Five of Me, or The Minds of Billy Milligan. These mass media presentations influence not only the general public's beliefs about MPD, but they affect MPD patients as well. For example, Flora Rheta Schreiber's Sybil is the story of a woman with sixteen personalities allegedly created in response to having been abused as a child. Before the publication of Sybil in 1973 and the 1976 television movie starring Sally Fields as Sybil, there had been only about 75 reported cases of MPD. Since Sybil there have some 40,000 diagnoses of MPD, mostly in North America.
Sybil has been identified as Shirley Ardell Mason, who died of breast cancer in 1998 at the age of 75. Her therapist has been identified as Cornelia Wilbur, who died in 1992, leaving Mason $25,000 and all future royalties from Sybil. Schreiber died in 1988. It is now known that Mason had no MPD symptoms before therapy with Wilbur, who used hypnosis and other suggestive techniques to tease out the so-called "personalities." Newsweek (January 25, 1999) reports that, according to historian Peter M. Swales (who first identified Mason as Sybil), "there is strong evidence that [the worst abuse in the book] could not have happened."
Dr. Herbert Spiegel, who also treated "Sybil", believes Wilbur suggested the personalities as part of her therapy and that the patient adopted them with the help of hypnosis and sodium pentothal. He describes his patient as highly hypnotizable and extremely suggestible. Mason was so helpful that she read the literature on MPD, including The Three Faces of Eve. The Sybil episode seems clearly to be symptomatic of an iatrogenic disorder. Yet, the Sybil case is the paradigm for the standard model of MPD. A defender of this model, Dr. Philip M. Coons, claims that "the relationship of multiple personality to child abuse was not generally recognized until the publication of Sybil."
The MPD community suffered another serious attack on its credibility when Dr. Bennett Braun, the founder of the International Society for the Study of Disassociation, had his license suspended over allegations he used drugs and hypnosis to convince a patient she killed scores of people in Satanic rituals. The patient claims that Braun convinced her that she had 300 personalities, among them a child molester, a high priestess of a satanic cult, and a cannibal. The patient told the Chicago Tribune: "I began to add a few things up and realized there was no way I could come from a little town in Iowa, be eating 2,000 people a year, and nobody said anything about it." The patient won $10.6 million in a lawsuit against Braun, Rush-Presbyterian-St. Luke's Hospital, and another therapist.
defenders of MPD
The defenders of the MPD/DID standard model of genesis, diagnosis, and treatment argue that the disease is underdiagnosed because its complexity makes it very difficult to identify. Dr. Philip M. Coons, who is in the Department of Psychiatry at the Indiana University School of Medicine, claims that "there is a professional reluctance to diagnose multiple personality disorder." He thinks this "stems from a number of factors including the generally subtle presentation of the symptoms, the fearful reluctance of the patient to divulge important clinical information, professional ignorance concerning dissociative disorders, and the reluctance of the clinician to believe that incest actually occurs and is not the product of fantasy." Dr. Coons also claims that demonic possession was "a forerunner of multiple personality."
Another defender of the standard model of MPD, Dr. Ralph Allison, has posted his diagnosis of Kenneth Bianchi, the so-called Hillside Strangler, in which the therapist admits he has changed his mind several times. Bianchi, now a convicted serial killer serving a life sentence, was diagnosed as having MPD by defense psychiatrist Jack G. Watkins. Dr. Watkins used hypnosis on Bianchi and "Steve" emerged to an explicit suggestion from the therapist. "Steve" was allegedly Bianchi's alter who did the murders. Prosecution psychiatrist Martin T. Orne, an expert on hypnosis, argued successfully before the court that the hypnosis and the MPD symptoms were a sham.
Allison claims, but offers no evidence, that the controversy over MPD is one between therapists, who defend the standard model, and teachers, who deny MPD exists.* The battle took place in committee when preparing the DSM-IV, he claims. The teachers won and MPD was removed and DID replaced it. The DSM-IV is the current version (1994) of the American Psychiatric Association's Diagnostic & Statistical Manual of Mental Disorders. It lists 410 mental disorders, up from145 in DSM-II (1968). The first edition in 1952 listed 60 disorders. Some claim that this proliferation of disorders indicates an attempt of therapists to expand their market; others see the rise in disorders as evidence of better diagnostic tools. According to Allison, MPD was called "Hysterical Dissociative Disorder" in DSM-II and did not have its own code number. MPD was listed and coded in DSM-III, but removed in DSM-IV and replaced with DID.
It is possible, of course, that some cases of MPD emerge spontaneously without input from the MPD community, while other cases--perhaps most cases--of MPD have been created by therapists with the cooperation of their patients who have been influenced by authors and film makers. In either case, the suffering of the person with MPD is equally pitiable and deserving of our understanding, not derision.
Finally, there are some MPs who do not consider their condition to be a disorder, and whose main suffering comes from the thought of what others will think or do if they find out. They consider just about everything presented above from the psychiatrists, psychologists, philosophers, and other professionals to be myths. Like the fantasizing women in Wilson and Barber's study (1983) of "fantasy-prone persons," there are many MPs who don't reveal their "secret" for fear of ridicule and ostracism.
See alsoexorcism, false memory, fantasy-prone personality, hypnosis, hystero-epilepsy, New Age psychotherapies, repressed memory, and repressed memory therapy.
books and articles
Coons, P.M. (1986). "Child abuse and multiple personality: review of the literature and suggestions for treatment." International Journal of Child Abuse and Neglect, 10, 455-462.
Dennet, Daniel. Consciousness Explained (Little, Brown, and Co., 1991), ch. 13, "The Reality of Selves."
Diehl, William. Primal Fear (Del Rey, 1996). (Note: this is a novel, recommended by Grant Middleton of the band 'The Demon Haunted World'!)
Keenan, Matt. The Devil & Dr. Braun (Bennett G. Braun, M.D., author of The Treatment of Multiple Personality Disorder, was the founder and former Medical Director of the Dissociative Disorders Unit [now closed] at Rush-Presbyterian-St. Luke's Medical Center in Skokie, Illinois. He founded of the International Society for the Study of Multiple Personality Disorder, now known as The International Society for the Study of Dissociation.)
Lewis, Dorothy Otnow, M.D., Catherine A. Yeager, M.A., Yael Swica, B.A., Jonathan H. Pincus, M.D., and Melvin Lewis, M.B.B.S., F.R.C.Psych., D.C.H. "Objective Documentation of Child Abuse and Dissociation in 12 Murderers With Dissociative Identity Disorder," THE AMERICAN JOURNAL OF PSYCHIATRY Volume 154, Number 12 December 1997 by (summary)
Lilienfeld, Scott O., et al. "Dissociative Identity Disorder and the Sociocognitive Model: Recalling the Lessons of the Past," Psychological Bulletin, 125(5) 507-523.
McHugh, Paul R., M.D. and Henry Phipps. Multiple Personality Disorder (Dissociative Identity Disorder)
Morris, Ray Aldridge. Multiple Personality an Exercise in Deception (Psychology Press, 1990).
Muller, René J., Ph.D., A Patient with Dissociative Identity Disorder 'Switches' in the Emergency Room
Pendergrast, Mark. Victims of Memory : Sex Abuse Accusations and Shattered Lives 2nd ed.(Upper Access Book Publishers, 1996).
Piper, August. Hoax and Reality : The Bizarre World of Multiple Personality Disorder (Jason Aronson, Inc.: 1997).
Piper, August. "Multiple Personality Disorder: Witchcraft Survives in the Twentieth Century,"Skeptical Inquirer, May/June 1998.
Ross, Colin A. Dissociative Identity Disorder : Diagnosis, Clinical Features, and Treatment of Multiple Personality (John Wiley & Sons, 1996).
Spanos, Nicholas P. Multiple Identities and False Memories: A Sociocognitive Perspective (Washington, D.C.: American Psychological Association, 1996).
Wilson, Sheryl C., and Theodore X. Barber. 1983. The fantasy-prone personality: Implications for understanding imagery, hypnosis, and parapsychological phenomena. In Imagery, Current Theory, Research and Application, ed. by Anees A. Sheikh, New York: Wiley, pp. 340-390.
The British False Memory Society - see Twelve Myths about False Memories
MP websites that don't consider MP a disorder
Pavilion: Voices of Plurality in Action
Ex Uno Plures
Hershel Walker's got a book coming out - his publicist says he has MPD
State of Illinois Department of Professional Regulation complaint against Dr. Braun
Braun's license to practice in Illinois has been suspended
Texas Jury Awards Largest Amount Ever to Patient in Recovered-Memories Case
Ex-patient tells of bid to save son after cult diagnosis by therapists
Psychologist accused of planting false abuse memories in patient Minneapolis Star Tribune by Glenn Howatt
MPD - the religious tolerance page
National Public Radio exposes recovered memory therapy
08/14/98, AKRON BEACON JOURNAL
ILLINOIS TO DISCIPLINE PSYCHIATRIST ACCUSED OF BRAINWASHING PATIENT
Illinois has moved to discipline a prominent psychiatrist accused of convincing a patient that she was a child molester, a cannibal who ate human flesh meatloaf and the high priestess of a satanic cult.
Depressed after the birth of her second son, Patricia Burgus sought therapy from Dr. Bennett Braun. Burgus says the doctor, through repressed-memory therapy, led her to believe among other things that she possessed 300 personalities and sexually abused her children.
Interviewer: Hollywood has been banking on fascinating taboos in their shows and movies and this is why psychiatric illness have been such a major theme. But what do you really know about them? That's next on The Scope.
Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier and healthier life. You're listening to The Scope.
Interviewer: We're talking today with Dr. Jason Hunziker, psychiatrist at the University of Utah about Hollywood and psychiatric illnesses, in movies and TV shows. One that pops into my head is the film Sybil, which was actually a real case taken from a book that was actually based on a real life patient.
Dr. Hunziker: Yes, dissociative identity disorder or at that time known as multiple personality disorder.
Interviewer: Like Sybil had.
Dr. Hunziker: Exactly. It is one of the more common psychiatric illnesses used in movies because so much is not known about that illness. But it also plays on all of our kind of fantasies and fascinations, and our interest about what the brain can do and how fragile it really can be.
Interviewer: So what exactly is Hollywood's definition of dissociative identity disorder?
Dr. Hunziker: The way films look at it is a way that I think it was described early on, which is somebody who has suffered from a very bad trauma, usually some type of sexual trauma, when they were young, that may or may not have been repeated over and over again, that somehow fractures their brain.
Interviewer: What does fracture your brain mean?
Dr. Hunziker: What that means is that the brain is so powerful that it does what it can to protect the human body against some outside source that's so overwhelming that it feels like you might die literally from that exposure. So the brain then separates itself and allows you to protect it by sending your consciousness level off somewhere else while your body just kind of remains there in person dealing with that trauma.
Interviewer: So it's kind of like you have multiple views.
Dr. Hunziker: Exactly, and that's where this came from. While you're gone somebody else is interacting with the people around, and so the thought was that people would form these different personalities to deal with different stressors in their life. And so Hollywood, of course, jumped all over that. What a great story, you have all these different people living inside you and when you go to the grocery store you can be Jill, and when you go to the carwash you're Bobbie, and when you're at home with your Mom you're a three-year-old girl who's scared. So Hollywood loves that stuff. But that's not the reality of what this illness really is.
Interviewer: Reality then; what have you seen in your studies and patients' cases?
Dr. Hunziker: There is so much controversy, even in the mental health industry about dissociative identity disorder. There are those that swear by almost the Hollywood version of what this looks like. And then there are others who say people clearly use dissociation to help protect themselves, and that's kind of where I fall in line. I think that people use that mechanism to get out of a stressful situation, and they then have a different personality style that interacts with you during those moments that they are real self is not present.
So when patients that I've seen, and that's generally what I've seen, is that when they get under stress they fall back onto disassociation to protect themselves, and they literally are not the same person. I talk to them, and they don't respond as quickly. They respond differently. But they are not Bobbie or Johnny, or Cindy; they don't have a name to it. It's just a part of their personality that remains to get the job done while the other part is protected and away from the stress.
Interviewer: This sounds to me, and correct me if I'm wrong, but kind of like a PTSD.
Dr. Hunziker: Exactly like PTSD. I think we see that a lot more now and I think dissociation is becoming more prominent because of our soldiers who are coming home and they struggle with flashbacks and paranoia, and depression and anger. All of these things, and when they get into a experience that's similar to what they experienced in the Middle East, they shut down and disappear, and they try to alleviate the stress by letting their brain wander somewhere else.
Interviewer: But it's not exactly like having multiple personalities, and that's what the illness was called back then.
Dr. Hunziker: That's correct. And again, it's hard, because there are two different camps on this, and there will be arguments that there are distinct personalities, and those distinct personalities need to all be reintegrated into one person, so the person can be whole again. But that's just not been my experience clinically when I have somebody who has that diagnosis or come to me with that diagnosis. That's not what I have seen.
Interviewer: When someone comes to you and they tell you, I have multiple personalities, as you mentioned before that some of your patients come and they tell you that they have multiple personalities, are they aware then that they have multiple personalities?
Dr. Hunziker: Again, that's where the controversy is, too. If they really are not present with the other personalities, it's hard to know why they know that they have multiple people and who they are and what their names are and what they are doing.
Dr. Hunziker: But they will, and I do have patients who tell me they have multiple personalities, and they'll have four or five or ten, and they have names for all of them. And some patients have been through the reintegration process and so they feel like it's mainly under control and all their personalities are meshed together. Others say they're still struggling with that. But the importance is when they tell me that, what I understand is they are extremely distressed, and whatever that stress is is causing their brain to not function in a way that's healthy for them. And so we focus more on that, and not so much on each individual personality.
Interviewer: Because you really don't know how many personalities they might have.
Dr. Hunziker: That's correct, and it's easier to say, we want to keep you, the real you, here with us dealing with everyday life, and we don't want you to keep using that crutch or that defense mechanism of dissociation to leave and then not deal with the issue that we really need to deal with.
Interviewer: How do you develop something like this? It's so fascinating, and like you said, controversial in so many areas of film and life?
Dr. Hunziker: It's hard to know how this really develops and we do see patterns in people who have dissociation as a major feature of their illness. And that pattern generally is the trauma. Some type of extreme trauma where you think your life is being threatened will then promote this type of defense.
Interviewer: It's almost like you're protecting yourself.
Dr. Hunziker: Yes, from experiencing what's going on, because it's too overwhelming. Because when you're young, we use these types of defense mechanisms all the time. I mean, we all use dissociation...
Interviewer: We play house or doctor.
Dr. Hunziker: Exactly, and we disappear into, and you'll hear your mom say, well you used to disappear into this different world. Well you did, and that works for us when we're kids. But when we're adults disappearing doesn't work as well. But when you get a trauma, particularly at that age, you get stuck and then that defense mechanism can become the prominent defense mechanism that you use later in life when it doesn't work anymore to disappear and go to your...
Interviewer: Happy place.
Dr. Hunziker: Your happy place, exactly. And instead you are not present with the people around you and then when you interact with them it's different, it's odd.
Interviewer: Any final thoughts on this?
Dr. Hunziker: Again, I'm glad that Hollywood brings awareness to mental illness, but I think we have to remember that Hollywood tends to over generalize and/or overly extreme put mental illness in the forefront that some of the symptoms that they describe are not accurate. But if you do have family members that struggle from zoning out or not being present all the time, or forgetful and don't remember doing certain things, that's probably time to get them into the doctor and be evaluated to make sure that dissociation is not something that they are experiencing.
Dr. Miller: We're your daily dose of science, conversation, medicine. This is The Scope; University of Utah Health Sciences Radio.