Reflections On The Diagnosis of DID/MPD
See also: But It’s In The DSM
Multiple personality disorder was included in the Diagnostic and Statistical Manual-III in 1980. This fact has encouraged some people to claim that MPD was generally accepted in the medical community. A 1988 study, however, raises serious questions about the acceptance of MPD in the professional community.
Professional Skepticism about Multiple Personality, Paul F. Dell, Journal of Nervous and Mental Disease, Vol. 176(9), 1988, p.528-531.
The author randomly selected 40 psychiatrists, 40 Ph.D.-level psychologists, and 40 masters-level therapists who were members of the International Society for the Study of Multiple Personality and Dissociation (now known as the International Society for the Study of Dissociation). Sixty-two of this group (52 percent) completed a questionnaire asking if they had experienced skepticism about the MPD diagnosis. The questionnaire asked how frequently respondents encountered skepticism, who had shown skepticism, and whether it adversely affected the patients’ treatment. Respondents were also asked to report the worst incident of skepticism they had encountered. Answers were assigned to 1 of 5 categories ranging from ordinary doubt to aggression.
Ninety-eight percent of the respondents said they had encountered skepticism; 82 percent considered the skepticism to be moderate to extreme. Dell observed that "Psychiatrists not only tended to receive the most extreme forms of skepticism, but were the most frequent (and most severe) purveyors of that skepticism."
Narratives of the worst incidents included practitioners who were banned from their hospital units, who repeatedly had to undergo staff reviews, or whose patients were refused admission to the hospital. Respondents described nursing staff who refused to follow treatment plans and medical directors who ordered staff not to treat patients as having MPD. Dell commented that "the incidents were not rare exceptions but instead almost the rule."
Dell acknowledged that the 52 percent response rate weakened the report. However, he commented that "even if we assume that non- responders to the survey had encountered no skepticism, the data would still indicate that more than 40 percent of clinicians who treat patients with MPD have encountered strong disbelief, interference with treatment, and extreme harassment."
From where we sit, the results of this paper indicate that MPD was not generally accepted in 1988. Rather, it seems obvious from the ISSMP&D’s own members that skepticism ran deep in 1988.
Consider what two major editors of the American Psychiatric Association’s Diagnostic and Statistical Manual-IV say about MPD (also known as Dissociative Identity Disorder or DID):
"A good rule of thumb is that any condition that has become a favorite with Hollywood, Oprah, and checkout-counter newspapers and magazines stands a great chance of being wildly overdiagnosed" (p. 288).
"Many therapists feel that the popularity of Dissociative Identity Disorder represents a kind of social contagion. It is not so much that there are suddenly lots of people with lots of personalities as there are lots of people and lots of therapists who are very suggestible and willing to climb onto the bandwagon of this new fad diagnosis" (p. 286).
"[W]e are worried that the current overdiagnosis of multiple personality is an illusory fad that leads to misdiagnosis and mistreatment and does a disservice to the vast majority of patients who fall under its sway" (p. 287).
"If you are wondering whether you qualify for this diagnosis it is a very good bet that you almost surely do not" (p. 289).
"For any of you who suspect that you have Dissociative Identity Disorder, or are now in treatment for it, our suggestion is to focus your energies on the here-and-now problems in your everyday life. We would recommend avoiding any treatment that seeks to discover new personalities or to uncover past traumas" (p. 290).
Quotes from: Frances, A. and First, M.B. (1998). Your Mental Health: A Layman’s Guide to the Psychiatrist’s Bible. New York: Scribner, 1998.
The controversies surrounding the diagnosis of Multiple Personality Disorder (MPD) or Dissociative Identity Disorder (DID) as it is now called, focus on two areas: The cause of the disorder (Is it iatrogenic, i.e. caused by the therapeutic experience?) and The treatment for the disorder. Does one pay attention, for instance, to the alters and ask for their names, or does one simply ignore them and lead the discussion to what is going on with the patient today and what he or she might be able to do about the here and now.
The point is that at one time or another in life, all of us assume different roles that we play. We take one role on the soccer field, for example, and a vastly different role when we interview for a job. If a vulnerable person happens to seek help from an authority such as a therapist who asks what name the person gives herself on the soccer field and then the therapist starts calling her by that name, it is almost inevitable that she will cooperate and play the role that she feels is hers on the soccer field.
If the therapist encourages a certain role for a while, that role may, for some people, be real take over. What began as a role can then eventually come to define what they see as their true "self."
Readers can see where this is going. If a few other roles including negative or evil ones are also adopted, the patient may redefine his or her self as having multiple persona over which they have little or no control.
Problems the patient may have encountered in the here and now come to be seen as a consequence of multiple personalities. In addition, such a patient may now also be more interesting to the therapist. A therapist’s alert and rewarding response to the multiple personalities could encourage the dredging up more stories and more personalities.
It can be difficult to work through one’s problems so as to function in the hear and now. It can be difficult to assume responsibility and gain control, especially when having multiple personalities is more dramatic and also reinforced by an authority figure.
Following is an excerpt from a paper entitled Reflections on Multiple Personality by Orne and Bates that explains the therapeutic issues.
Risks and Benefits of the Therapeutic Process
"It is also vital to understand that the therapeutic process of "uncovering" remote events is anything but the risk-free venture that some practitioners consider it to be. Just as Janet’s work demonstrates that distant memories can be altered in a positive way to help patients, it is likewise the case that remote memories can be reconstructed in a negative manner and can have a very destructive influence on patients’ lives and on the lives of those who care for them. False "recollections" of childhood abuse can cause patients to become even more confused, disorganized, depressed, and self-destructive. As a result of these "memories," patients’ feelings of victimization and helplessness may be heightened, their perception of personal responsibility reduced, and their sense of social isolation intensified. If matters are allowed to get even further out of hand, entire families can be literally destroyed. Hence, there is reason to be concerned about treatment regimens that rely on "recreating" a traumatic past for each patient, vivifying negative "memories" without recognizing their dubious authenticity or potentially deleterious effects."
"In the end, a traditional approach toward psychotherapy, in which the meaning of patients’ recollections is our primary concern, continues to be an appropriate form of intervention. Although it is easy to become captivated by the intricate and dramatic descriptions provided by MPD patients concerning their early childhood, we must guard against relying on this process as an end unto itself. The task of therapy is to assist individuals in living more healthy lives now and in the future. In this regard, psychotherapy with MPD patients would cease to be an esoteric enterprise in which separate and uncooperative alters must be cajoled into fusing; instead, therapy would proceed as it does with any patient, along the traditional lines of gently enabling patients to understand and take responsibility for their own wishes, desires, hopes, fears, and behaviors."
From Orne, M. T. & Bates, B. I. (1992) Reflections on multiple personality. In Kales, A., Pierce, C. M., & Greenblatt, M. (Eds.) The mosaic of contemporary psychiatry in perspective. New York: Springer-Verlag, p. 258.
A paper by psychiatrist-researcher Martin Orne, M.D., Ph.D., and Nancy Bauer-Manley, Ph.D. provides an insightful perspective of issues involved with the diagnosis and treatment of MPD. Although the article is written primarily for professionals, all should find it interesting, particularly the sections starting with "The Use and Misuse of Myths, Metaphors, and Memories." Orne, M.T. and Bauer-Manley, N.K. (1991). Disorders of self: Myths, metaphors, and the demand characteristics of treatment. In J. Strauss and G.R. Goethals (Eds.) The Self: Interdisciplinary Approaches. New York: Springer-Verlag, (1991). 93-106.
In a two-part review article, psychiatrists August Piper, M.D. and Harold Merskey, M.D. analyze the problems with the arguments in support of MPD and DID. One of the most persistent problems is the fact that DID cannot be reliably diagnosed.
See Piper, A. and Merskey, H. (2004, September). The Persistence of Folly: Critical Examination of Dissociative Identity Disorder. Part I. Canadian Journal of Psychiatry, 49:592-600.
and Part II, The Defense and Decline of Multiple Personality of Dissociative Identity Disorder (2004, October). Canadian Journal of Psychiatry 49:678-683.
Freeland and colleagues in 1993, published Four Cases of Supposed Multiple Personality Disorder: Evidence of Unjustified Diagnosis. Canadian Journal of Psychiatry 38: 245-247. This paper demonstrates the problem with reliable diagnosis.
Sybil was the first major book to tie "MPD" to child abuse. Published in 1973, it was followed by a compelling 1976 movie. Sybil played a substantial role in the cultural and psychiatric tsunami, later known as the "false" or "recovered" memory debate.
According to author Debbie Nathan "In the entire history of Western civilization, there had been less than 200 cases over a period of centuries. But after the book and film, suddenly there were hundreds and thousands. And by the late 1980s there were 40,000 cases diagnosed in the United States alone." See Sybil Exposed
The story of Sybil has now been thoroughly debunked by investigative journalist Debbie Nathan in Sybil Exposed: The Extraordinary Story Behind the Famous Multiple Personality Case. We now know that the author of the book Sybil, Flora Rheta Schreiber, the psychiatrist who treated Sybil, Cornelia Wilber and the patient conspired to create a compelling, but untrue story. There is no evidence, for example, that Sybil was ever abused in the way depicted in the book.
An earlier investigator into the Sybil story, psychologist Robert Reiber, wrote:
"From all that I have discovered, I concluded that the three women -- Wilbur, Schreiber, and Sybil -- are responsible for shaping the modern myth of multiple personality disorder. A psychological oddity, so bizarre and rare that it did not merit much publicity in most textbooks before 1973, multiple personality disorder had acquired a sudden respectability and acceptance."(p. 109)
Reiber, Robert - Bifurcation of the Self: History and Theory of Dissociation and its Disorders.
See FMSF Newsletter, May/June 2006, Vol. 15, No. 3
Dr. Allen Frances offers his regrets for not doing enough to combat the ritual abuse craze:
"As Chair of the DSM IV Task Force, I had a bully pulpit to point out the utter craziness of the fad. Instead, I justified my passivity on the grounds that it was not really my fight and that getting involved might compromise my neutrality as DSM IV Chair. These were lousy excuses, considering that innocent people were going to jail and kids were being traumatized by fake therapists who professed to be experts in childhood trauma."
Sex and Satanic Abuse Fad Revisited
FMSF Newsletter, September 1999, Vol. 8, No. 6.
Review of Creating Hysteria: Women and Multiple Personality Disorder, a book by Joan Acocella.
FMSF Newsletter, April/May 1999 Vol. 8 No. 3.
MPD in the Courts.
FMSF Newsletter, April/May 1999, Vol. 8, No. 3.
Overview of First Person Plural: My Life as A Multiple, a book by Cameron West, Ph.D.
Borch-Jacobsen, M. (1997) Sybil - The making of a disease: An interview with Dr. Herbert Spiegel.
The New York Review, April 24, p. 60-64.
Dell, P.F. (1988). Professional skepticism about multiple personality. Journal of Nervous and Mental Disease. 176 (9), 528-531.
Dinwiddie, S.H., North C.S. & Yutzy, S.H.
Multiple Personality Disorder: Scientific and Medicolegal issues.
(1993) Bulletin of the American Academy of Psychiatry & Law, 21 (1) p 69-79.
Frankel, F.H. (1993). Adult reconstruction of childhood events in the multiple personality literature.
American Journal of Psychiatry, 150, pp. 954-958.
Freeland, A., Manchanda, R., Chiu, S., Sharma, V. & Merskey, H. (1993)
Four cases of supposed multiple personality disorder: Evidence of unjustified diagnoses.
Canadian Journal of Psychiatry, 38, p 245-247.
Lalonde, J.K., Hudson, J.I., Gigante, R.A., Pope, H.G., Jr. (2001, June).
Canadian and American psychiatrists’ attitudes toward dissociative disorders diagnoses.
Canadian Journal of Psychiatry. 46(5):407-12.
Miller, M. & Kantrowitz, B. (1999)
Unmasking Sybil: A re-examination of the most famous psychiatric patient in history.
Newsweek, January 25, pp. 66-68.
Nathan, D. (2011). Sybil Exposed: The Extraordinary Story Behind the Famous Multiple Personality Case. New York: Simon & Shuster.
Pendergrast, M. (1996) Multiple Personalities and Satanic Cults. Excerpts from Victims of Memory, Upper Access.
Piper. Jr., A., Hoax and Reality: The Bizarre World of Multiple Personality Disorder. Northvale, New Jersey: Jason Aronson.
Piper, Jr., A. (1998, May) Multiple Personality Disorder: Witchcraft survives in the Twentieth Century. Skeptical Inquirer, p. 44-50.
Piper, Jr., A. Comments on First Person Plural: My Life as a Multiple.
FMSF Newsletter, April/May 1999, Vol. 8, No. 3
Pope, H.G., Barry, S., Bodkin, A.,Hudson, J.I. (2006).
Tracking scientific interest in the dissociative disorders: A study of scientific publication output 1984-2003.
Psychotherapy and Psychosomatics, 75, 19-2.
Rieber, R. (2010) Bifurcation of the Self: The History and Theory of Dissociation and Its Disorders. Springer-Verlag.
Spanos, N.P. (1996) Multiple Identities & False Memories: A Sociocognitive Perspective. Washington, DC: American Psychological Association.
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