A. Freeland, M.D., R. Manchanda, M.B., B.S., S. Chiu, M.D., Ph.D., V. Sharma, M.B., B.S., and H. Merskey, D.M.
Canadian Journal of Psychiatry, Vol. 38,(4), May 1993, 245-247.
Posted with permission of the Canadian Journal of Psychiatry.
Four cases are presented in which an unjustified diagnosis of multiple personality disorder was made. These cases are used to illustrate the concern that some cases of multiple personality disorder may be the result of misdiagnosis by both patients and clinicians.
Traditionally, multiple personality disorder (MPD)  has been considered rare; only 72 cases were reported between 1816 and 1944 . It has been diagnosed with increasing frequency in North America [3,4]. The change began after Thigpen and Cleckley  wrote The Three Faces of Eve and a film was made from the book. The number of cases increased significantly again after the description of Sybil by Schreiber . This has sparked criticism [8,9] and concern that media interest and subsequent publicity about MPD may result in its artificial production .
A 42 year old single female presented to the emergency ward complaining of restlessness, depression and inability to concentrate. She was disheveled and agitated, with blunted incongruous affect, thought disorder and auditory hallucinations. She claimed to be unable to remember details of her childhood and that both her parents were alcoholics. She had done well in school until age 16, when she began abusing drugs and alcohol. She worked steadily for several years, until she was limited by her substance abuse and frequent hospitalizations and was then supported by a disability pension. She had several short-lived unstable relationships with men and reported having been raped four times. At age 17 she accidentally cut herself, noticed no pain and began cutting herself repeatedly. She was hospitalized in her early 20s and was treated with phenothiazines for about four years; she was subsequently hospitalized because of suicide attempts and "behaving strangely." She met the DSM-III-R criteria for schizophrenia. A differential diagnosis of a personality disorder with schizophreniform episodes was also considered. A second psychiatric opinion supported this assessment.
The patient was convinced that she had MPD; this was first suggested to her by a friend because of her intermittently childish manner, mood swings and poor recall of childhood events. She read several books on MPD and demanded hypnosis and intensive psychotherapy. After several consultations, she was diagnosed as having MPD by one therapist (with a special interest MPD), and "probable dissociative disorder" by a second therapist. The diagnosis of MPD appeared to be based on the patient’s psychopathology and history and not on the observation of a second, distinct personality. Her psychotic symptoms improved with neuroleptics. The patient, however, refused to even consider the diagnosis of schizophrenia, stating she preferred a diagnosis of MPD since it was "treatable."
This 32 year old single female was wheelchair-bound. She reported having suffered a fall in her teens, which led to a discectomy at L3/4, followed by arachnoiditis, a paraparesis and chronic pain. Subsequently, abscesses complicated injections of medication in the left hamstring region with loss of muscle tissue, requiring a myocutaneous hamstring flap and contributing to a contracture.
She had been placed in 47 different foster homes between the ages of 12 and 19 and had been sexually abused throughout her childhood and adolescence by male acquaintances and male foster parents. She admitted to abusing alcohol and street drugs and deliberately harming herself. Nevertheless, she succeeded in earning an income as a wheelchair model and completed several years of university.
A psychiatrist who had hypnotized her decided that she had four additional personalities: Diana, four years old, sought security and attention and had temper tantrums; Gail, age 12, had a personality similar to the patient’s as a teenager; John, age 26, appeared as an auditory hallucination disturbing her sleep, which reactivated her memories of sexual abuse; the Deathman, age 27, intervened when John, Gail and Diana argued. The patient would become suicidal after receiving orders to die from the Deathman or from John. However, Gail and Diana would then provide sufficient support to allow her to get help either from the police or from psychiatric services.
At this admission to hospital, she presented to the emergency with chronic pain, feelings of sadness, hopelessness and suicidal ideation and stated that her symptoms were the result of MPD. When seen, she commented: "I was also treated by a psychiatrist who discovered under hypnosis that I had four different personalities." The doctor’s reply to this was, "I don’t altogether buy the idea of MPD," to which she replied "nor do I." The patient’s subsequent treatment focused on management of her suicidal ideation and chronic pain and not on multiple personalities.
Accordingly, she was transferred to the care of a specialist in physical medicine. It was thought that much, if not all, of her limitation of movement and contractures were not the result of organic disease. Physiotherapy improved the flexion of her knee and hip on the left, and she began to use a walker. She then became depressed and suicidal and was returned to the psychiatric hospital. Morphine sulphate was gradually reduced from 60 mg bid to 30 mg bid. Once again she became free of suicidal thoughts, was able to sit again in her wheelchair and was discharged.
This 29 year old female who was separated from her husband presented to the emergency with diaphoresis, confusion and slurred speech. Laboratory work revealed hypoglycemia and she was admitted to hospital for assessment and treatment. Over the next two days, she had two further episodes of unexplained hypoglycemia. She appeared depressed, and self-administration of insulin was suspected.
She described being amnesic for several hours before the onset of her episodes and complained of depression, inability to concentrate, social isolation and hopelessness. She remembered little about her childhood, but recalled that both parents had been chronically ill and that she had had to take care of them. She reported that her mother had multiple sclerosis and agoraphobia and that her father had a bipolar affective disorder. She completed high school and married when she was 19 years old.
The next day, the patient revealed to the psychiatrist that "Mindy," a voice in her head, wanted to hurt her and told her that she was bad. The psychiatrist made no comments on Mindy and asked no further questions about her. The following day the patient admitted that she had been injecting insulin, but insisted that Mindy made her do this. Later that day, she described hearing voices that belonged to Miranda, Kim, Catherine and Sam. She elaborated on their personalities and reported knowledge of them through letters she found signed by them and hearing their voices in her head. She was then transferred to a psychiatric ward.
She had yet another episode of hypoglycemia. On confrontation, she admitted that she administered the insulin deliberately. She described Mindy and the other personalities as "creations." Her comment was, "I can’t resist the impulse to change to a different role. I created a role and really got into it. I took a part of myself and embellished it." She was very familiar with medical illnesses because she read textbooks and the DSM-III and had gotten herself admitted to several hospitals in the past. She had also been admitted with symptoms resembling multiple sclerosis, Guillain-Barre syndrome, abdominal pain (for which she underwent a laparoscopy), psychoses, fugue states and depression. She frequently signed herself out when suspicion about her symptoms arose. These hospitalizations resulted in a separation from her husband.
She first began thinking about MPD four years earlier when a psychiatric nurse informed her that the attending doctor had considered this diagnosis. She familiarized herself with the symptoms and developed Mindy and the other personalities. She was later admitted, diagnosed and treated as having MPD on several occasions, using her personalities as aliases for some admissions to hospital. However, there were never any lapses in her memory and at no time had an alternate personality ever emerged. Over the previous ten months, she had been receiving weekly supportive psychotherapy. This had gone well and she had not feigned MPD until two months earlier, when the therapist suggested she had some signs of MPD. The patient then felt compelled to assume the roles of the different personalities and was quite upset that a useful coping mechanism was found out.
A 30 year old divorced woman had been diagnosed with several disorders. A psychiatrist who saw her for a year told her she had four different personalities equalling the same number of mood states observed in his office. She was relieved to learn that she suffered from this disorder, which fit with what she had read in the book Sybil. Treatment consisted of psychotherapy and occasional psychotropic drugs. She stopped seeing the psychiatrist because her condition did not improve.
She sadly recounted various vegetative depressive symptoms, including weight gain, and mentioned similar past episodes interspersed with brief periods of increased irritability, poor impulse control resulting in numerous fights, and an increase in libido. She changed jobs frequently and her interpersonal relationships were unstable. At times, she would indulge in such uncharacteristic behavior as exotic dancing.
She reported that her husband (to whom she was married for one month) had physically and sexually abused her. She also reported that she had been sexually abused by her grandfather (fondling genitalia) when she was eight. After completing school, she left home to fulfill her ambition of singing with a rock band and began abusing street drugs and alcohol.
Both the patient and her mother reported that everyone in the immediate family had been treated for depression. Two uncles had committed suicide, and one aunt had been treated with lithium. Her history revealed numerous visits to her family physician and emergency rooms for frequent migraine headaches.
BipolarII illness was diagnosed on the basis of her present state, the course of the illness and family history. After treatment with lithium for one month, she reported, "this is the best I have felt over the last ten years." Her colleagues and family commented on how well she was doing. She no longer believes she has multiple personality disorder, but has mentioned that she knew the existence of a personality named "Shelley" who liked to "swear, deceive and lie."
Putnam et al.  found that MPD could have varied features including amnesia, affective disturbance, suicidal thoughts, insomnia, substance abuse, auditory hallucinations, thought disorder and significant childhood abuse. Out patients fit many of the above features. Three had attempted suicide, all showed affective disturbance, two abused street drugs or alcohol, and one probably abused prescribed narcotics.
These cases show in different ways that MPD can be diagnosed inappropriately. Sometimes it can be abandoned easily (cases 2 and 4), but sometimes the patient may hold it intractably (case 1), perpetuating a misdiagnosis. Treatment may be extensive but inappropriate (cases 3 and 4). The chance of patients hearing of MPD prior to presentation is now so great that it cannot be assumed that anyone with the "condition" will have developed it without prior preparation or suggestion, whether from the media or from health care professionals. If all modern cases are uncertain, it is important to determine the way in which the classic cases emerged. These cases were reviewed, and several appeared to be cases of bipolar affective illness and many more were induced overtly under hypnosis with the therapist directly naming separate personalities . All of the patients suffered from misdiagnosis, iatrogenesis or encouragement by enthusiastic hypnotists.
Fahy  reviewed the recent literature and concluded that there is little evidence to support MPD as a distinct diagnosis. He notes the wide variation with cultural conditions of the number of cases diagnosed (one in Britain in the previous 15 years and thousands in North America), the lack of significant physiological evidence, the weakness of some suggested explanations (such as self-hypnosis), the practice of giving priority to the diagnosis of MPD in patients who have a number of other symptoms which would justify alternative psychiatric diagnoses, the potential for molding by therapists, the failure to elicit a clear pattern of psychiatric diagnosis among the first-degree relative of the patients and the poor scientific quality of the literature on MPD.
Aldridge-Morris  regards multiple personality as a cultural phenomenon and a social role. Kenny  likewise sees it as a play on social roles. Many psychiatrists with extensive experience have never seen a valid case. Ljungberg mentions no case in 381 patients with overt physical symptoms. Takahashi  found that no cases of MPD had been diagnosed in Japan.
Chodoff  noted the rarity of cases in his own practice and observed that in two cases which had been video taped, he was struck by the bolstering of defences--with a stultifying effect on the psychotherapeutic progress--exerted by concentration on the characteristics of the individual personalities rather than the patient’s underlying conflicts. In fact, we agreed that our four patients were misdiagnosed with MPD and were better treated once they were diagnosed correctly.
We think it is very unlikely that a sustained diagnosis of an alternate personality ever occurs without social or medical encouragement. Where occasional cases of dissociation do arise in which another identity is assumed, these do not appear to last long if they lack subsequent fostering. Adityanjee et al.  described cases of naive young people who had hysterical dissociation and adopted new roles which quickly remitted.
In developed countries there is always the risk that the patients will have encountered the diagnosis in the popular media. This, in addition to the influence of doctors interested in the field, makes the validity of any modern diagnosis of MPD debatable.
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