Cooper B Holmes. 21st Century Psychology: A Reference Handbook. Editor: Stephen F Davis & William Buskist. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.
In this chapter, the focus is on a group of disorders that generates more controversy than any other diagnostic category, especially two of them: dissociative identity disorder, more commonly known as multiple personality disorder, and dissociative amnesia. Throughout this chapter I use the designations mental health field and mental health professionals rather than psychology and psychologists to reflect the wide diversity of professions involved in the controversy over these diagnoses, for example, psychiatry, social work, counseling, and, of course, psychology. The controversy is principally over the dramatic increase in the frequency of dissociative diagnoses since the 1970s, although some professionals also seriously question the legitimacy of these diagnoses. For example, some research indicates only about one fourth of psychiatrists believe multiple personalities are strongly supported by data. Thigpen and Cleckly (1984)—authors of The Three Faces of Eve (1957)—reported that of many thousands of cases referred to them they found only one genuine multiple personality. Even if one accepts the diagnoses, does the reported increase reflect a genuine rise in the rate of the disorders or is it a result of misdiagnosis? We examine both sides of this controversy subsequently in a separate section.
The concept of dissociative disorders rests in the word itself. To dissociate is the opposite of associate; therefore, to dissociate is to separate. In this case, the separation refers to a separation within the person’s psychological makeup. A person with this disorder has separated some part of his or her psychological experience(s) from other aspects of psychological functioning. The amount of separated material may vary from relatively restricted to all encompassing. In recent years the information media, especially television news, have presented numerous cases of reported dissociative disorders, specifically amnesia, fugue, and multiple personality. The media attention generates the impression these disorders are more common than is true.
The designation dissociative disorder was introduced in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (abbreviated DSM, followed by the edition, such as DSM-III; see Chapter 79) in 1980 and continues unchanged in the current manual. In the first DSM (1952), the disorder was categorized as a psychoneurotic disorder (i.e., a disorder involving many characteristics, but centering on very high levels of unwarranted anxiety) and was termed dissociative reaction. By the time of the second edition (DSM-II) in 1968, the disorder was in the neuroses section and was listed under two subtypes: hysterical neurosis, dissociative type(which included amnesia, fugue, and multiple personality) and depersonalization neurosis. Prior to the first DSM, there was no consistent nomenclature, but the disorder was recognized and was usually labeled with some variation of hysterical neurosis or reaction.
Dissociative Disorders and Subtypes
The current edition of the diagnostic manual, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000), describes the dissociative disorders category as involving a disruption of what are usually integrated psychological functions such as memory, perception, identity, or consciousness. The manual designates five subtypes of dissociative disorders: dissociative amnesia, dissociative fugue, dissociative identity disorder (DID), depersonalization disorder, and dissociative disorder not otherwise specified(NOS). The last category, Dissociative Disorder NOS, is for the occasional individual who has symptoms of a dissociative disorder, but the symptoms do not correspond to any of the first four categories. Because it does not describe any specific set of symptoms, I will not describe this category further.
Amnesia refers to an inability to recall important material. Some amnesia is due to brain involvement, such as injury or the effects of drugs (e.g., alcohol-related blackouts), and is not included in this category. Dissociative amnesia means the inability to recall important personal material is due to psychological factors and cannot be explained by normal forgetfulness. The lost material, usually of some traumatic or very stressful situation, is not forgotten; rather, it is being actively kept out of consciousness or awareness in an attempt to protect the person from being psychologically overwhelmed. Different theories characterize this activity differently. For example, psychoanalysis would say the material is being forcefully kept in the unconscious by repression; a behaviorist would say the material is out of awareness—but both agree memory of the event(s) or thoughts is not readily available to the person’s immediate recall.
The DSM does not offer separate diagnoses for different types of dissociative amnesia, but it does describe five types. Localized amnesia refers to not being able to recall something that occurred in a limited time span, usually from a few minutes to a few days at most. Selective amnesia means an inability to recall some details of an event whereas other details are available. Generalized amnesia refers to a global failure of memory for the person’s whole life, whereas continuous amnesia means an inability to recall any material from the time of the traumatic event to the present. Finally, systematized amnesia is the inability to recall a certain category of information, such as military or educational events. Regardless of the type of amnesia, including the generalized type, not all memories are lost. For example, the person can still do basic academic skills, drive, shop, or play cards. The current DSM presents no data on the prevalence of this disorder, but most professionals in the field consider it extremely rare.
The word fugue, which is usually associated with musical compositions, comes from Latin and refers to “flight.” It follows that dissociative fugue involves flight as well. A person with this diagnosis combines psychological amnesia, almost always of the generalized type, with physically leaving, usually after a trauma or severe stress. He or she may leave home or work and move within the same city or may move to a distant location with little or no recall of the details of her or his previous life. There is, of course, uncertainty about identity, but only occasionally does the individual assume a completely new identity. In other areas of psychological and social functioning, the person does not appear to be seriously impaired. The fugue may last from hours to years. The DSM reports a prevalence rate of 0.2 percent
As was true of dissociative amnesia, the basis for the fugue must be psychological, not medical. For example, there is a type of seizure that involves dissociative-like symptoms and may be accompanied by physically leaving. This seizure disorder is known by several names: temporal lobe seizures, psychomotor seizures, and its more formal title, complex-partial seizures.
Dissociative Identity Disorder
Most people, including professionals, refer to this category as “multiple personality disorder.” In this section it will be addressed by its abbreviation, DID. With this category, the individual deals with a traumatic or stressful event by developing at least one more personality; there are two or more distinctly different personalities, very much as if two or more people inhabit the same body. This is the ultimate dissociation. The number of personalities may range from as few as two to a hundred or more. One psychiatrist reported a patient with 127 personalities. The DSM notes half the reported cases have 10 or fewer personalities. Usually, the various personalities are not aware of one another, and over time each personality temporarily takes control of the person’s behavior. The amount of time any one personality is in control varies widely. Psychological amnesia is, not surprisingly, an aspect of this diagnosis. This category is diagnosed more frequently in adult women than in men but is diagnosed about equally in boys and girls. Women tend to have more personalities than men, and there are differences in rate of diagnosis by country. The diagnosis is much more frequent in the United States and Canada; in fact, it is rarely diagnosed elsewhere. The DSM reports no prevalence rate for this category, but notes a “sharp rise” in reported cases in recent years.
As was previously noted, the DID category is steeped in controversy. This will be addressed in a later section. To clarify a very common misconception, although many people refer to schizophrenia as a “split personality” or “dual personality,” it should now be apparent that those terms actually refer to dissociative disorders.
To depersonalize literally means “to remove the person.” The experience of depersonalization is both common and normal. It refers to the experience of briefly feeling detached from oneself or the environment. It is variously described as being in a dreamlike state; as feeling as if one is outside his or her body and is an observer; as feeling detached from one’s surroundings, as if everything is “unreal.” Depersonalization is the feeling a person has as she recalls a traumatic scene such as an automobile accident and knows she was there but feels as if it was someone else. It is the feeling a person has walking down the street and suddenly feeling he is strangely detached from everything around him. During these episodes the person is aware of the peculiar feelings and is not out of touch with reality. Impaired reality contact is a characteristic of psychotic disorders such as schizophrenia.
To be diagnosed with Depersonalization Disorder, the person must have what the DSM notes as “persistent or recurrent” depersonalization episodes that adversely affect his or her life. The person may incur severe distress or be otherwise impaired in social or psychological functioning, such as having an intense fear of returning to where the depersonalization episode occurred, or fearing he or she has some serious medical or other psychological disorder. This diagnosis includes the requirements that reality contact must be unimpaired during the depersonalization episodes and the episodes must not be due to any other condition, medical (e.g., brain disorder) or otherwise psychological (e.g., psychosis). The DSM notes the prevalence rate for this disorder is unknown.
Causes and Treatment
Any discussion of causes and treatment for the dissociative disorders must begin with an important caveat. Depending on which side of the controversy one accepts, there are either large numbers of cases from which the mental health field can derive causes and effective treatments, or there have been so few documented cases that little can be said with any certainty about any aspect of these disorders. Skeptics of the category believe it is grossly overdiagnosed and the clients warrant another (more accurate) diagnosis; therefore, whatever is concluded about causes and treatment is based on a misdiagnosis and is, by extension, misinformation. I discuss the full extent of this controversy in the next section.
As most of the general public realizes, and mental health professionals know, there are a multitude of explanations for all mental disorders, including dissociative disorders. Quite simply, how one explains this category depends on which theory is accepted; however, it is beyond the scope of this chapter to discuss various theoretical viewpoints. Suffice it to say that the most popular theoretical explanation is some form of psychodynamic approach (e.g., Freudian psychoanalysis). Regardless of which specific theory is employed, the common thread would be that the individual has suffered a traumatic event, almost always in childhood. The event is so psychologically overwhelming that to protect itself, the mind pushes recognition of the event into the unconscious, thus preventing any overt awareness of it. By doing so, the person does not have to consciously deal with the event and can continue to operate more effectively in other aspects of psychological and social functioning. The person’s symptoms are the clue to the diagnostician that something is deeply buried in the unconscious. It follows that treatment involves uncovering what is deeply buried in the unconscious and resolving it, sometimes with drugs and with hypnosis. The exact form of treatment would depend on which theory one accepts. Why one person develops one form of dissociative disorder—for example, dissociative fugue—and another person develops multiple personalities is not known. Regardless of which disorder is manifested, it is clear the person is attempting to escape the inner turmoil by mentally separating from it. For discussions of treatment, the books The Three Faces of Eve and Sybil should be read. There are, of course, other possible explanations, such as the operant conditioning view that avoiding the memory of the traumatic event is reinforced because it reduces tension or stress, hence reduction in stress or tension is a negative reinforcer. Some theorists have suggested the possibility of self-hypnosis, whereas others have begun to investigate possible neurological factors. Other explanations have been offered but a detailed discussion is beyond the scope of this chapter.
Independent of specific theories, some common factors are known about the people who develop dissociative disorders. There is wide agreement among those who endorse this category that the client was exposed to severe stress or trauma. In the case of DID, the trauma is commonly severe sexual and physical abuse. There is also wide agreement that individuals with dissociative disorders, regardless of which subtype, are unusually anxious. Finally, in terms of personality traits, individuals receiving these diagnoses are highly suggestible and hypnotizable. Given the debate over the number of dissociative disorders, success rates for treatment are unknown.
To fully appreciate the controversy over the dissociative disorders requires an understanding of the history of this diagnosis. The controversy has centered on multiple personalities, which will be the main focus of this discussion, but controversy over amnesia and repressed memories must also be noted. The first recorded instance of multiple personality disorder was several hundred years ago, but the first widely known case in more recent times was that of Morton Prince’s patient, Sally Beauchamp (several different names are offered in the literature), in the early 1900s. The estimates of the number of cases prior to the early 1970s vary widely. Some writers have suggested that in the history of the world there have been no more than 200 documented cases of this disorder. Other writers believe an estimate of 200 cases is a gross exaggeration and place the number at 100 or so. Still others believe the true number of cases is as few as 50; some believe it to be as few as 10. What no professional would disagree with is that the reported occurrence of true multiple personalities was extremely rare prior to the 1970s. The vast majority of mental health professionals today have not, in their entire careers, encountered a single instance of any of the dissociative disorders. Most of these professionals acknowledge the reality of the diagnoses but temper it with the rarity of its occurrence. Sybil was published in 1973; at about the same time, several journal articles were published on multiple personalities. Since the early 1970s the number of reported cases of multiple personalities has reached into the tens of thousands. Some mental health professionals report having personally treated hundreds of cases. Comparing the soaring numbers since the 1970s to the exceeding rarity of cases before that time, it is easy to appreciate the skepticism of critics. What follows are the two sides of the controversy.
Supporting the Increase in Diagnoses
There are two primary arguments in favor of the increase in diagnoses. The first, to be discussed in more detail presently, is that there has been an actual increase in the number of new cases. The second, also to be discussed further, is that there has not been an increase in the actual occurrence rate; rather, today the field is doing a much better job of diagnosing the conditions. I use the term therapist, rather than diagnostician, in this discussion because nearly all cases emerge during therapy (i.e., the therapist is the diagnostician).
Actual Increase in Number of Cases
The belief that there are actually more cases of dissociative disorders today assumes some causal agent has increased—thus, the increase in occurrence. The exact nature of the suspect causal agent depends on which theory one endorses, but a likely suspect is the increasing stress of today’s life. Since World War II the possibility of world annihilation from atomic weapons is ever present. Media images of horrific violence began to enter the home via television during the time of the Vietnam War and have only worsened. Social changes have resulted in various groups being exposed to stresses that would not have been known in earlier times. For example, the number of women helping to raise a family and working outside the home has increased dramatically, in part because of the women’s rights movement of the 1960s but also because of financial necessity. There are many other examples, but these suffice to make the point. Stress may not be the only factor, of course. There may be some biological component or environmental influence. The common thread is that something is causing a rise in the rate of dissociative disorders.
The second argument in favor of the increased diagnoses is that the mental health field is doing a better job of detecting the cases that have always been there but were missed. This argument assumes the dissociative disorders were never as rare as critics purport. A very likely source of inaccurate diagnoses was schizophrenia, a form of psychosis. The symptoms of dissociative disorders may at least superficially appear psychotic. Descriptions by patients of feelings of unreality may be interpreted as being out of touch with reality. Distortions in perception may seem hallucinatory. Reporting additional personalities may seem to the diagnostician to be delusional thinking. Because of these psychotic-like symptoms the patients were erroneously diagnosed with schizophrenia. A person with fugue symptoms may have been erroneously diagnosed as having had a psychotic manic episode. Proponents of this view argue that clinicians are now much better trained in differential diagnosis and are more sensitive to the symptoms of dissociative disorders. Simply stated, this view argues that clinicians are finding more cases because they are doing a better job of diagnosing, an argument used virtually every time a critic questions a rise in the frequency of a diagnosis.
Skeptics of the Increase in Diagnoses
Professionals in this group obviously do not accept that the increase in diagnoses is legitimate. They see the increase since 1970 as simply another diagnostic fad. There is no doubt the mental health field goes through such fads. Any mental health professional can cite different periods of time when a particular legitimate diagnosis, for no obvious reason, captures the fancy of diagnosticians and therapists, resulting in an inordinate number of cases being diagnosed or, to be more precise, misdiagnosed. As the fad dies out, a new one takes its place. Critics view the dissociative disorders, especially DID, as being such a fad, albeit an unusually long lasting one.
Skeptics present four central arguments critical of the supporters: a lack of increase in any known causal factor to account for the increase in diagnoses, misdiagnosis based in disregard for diagnostic criteria, loosening the criteria for diagnosis, and iatrogenic factors. The term iatrogenic refers to a problem caused by treatment, medically or psychologically. For example, a number of physical movement disorders such as tardive dyskinesia can result from the medications used to treat psychotic disorders.
No Increase in Causal Factors
In an earlier section it was noted that supporters of the increase in diagnoses believe some causal factor has increased, resulting in more cases of dissociative disorders. Critics point out there is no evidence of any such increase, including the dubious argument that stress is greater now than before. Although agreeing that today’s world presents many stressors, critics point out that each generation has had its share of stressors. Although the source of the stress may change over time, each epoch has had its own stressors—for example, the various plagues, worldwide economic depressions, life expectancy in the 30s, and so on. To critics, the argument that today’s world is uniquely stressful is simply not true.
This cause for the increase in diagnoses rests on frank misdiagnosis, ignoring the established DSM criteria or uniquely interpreting them to fit a client. Skeptics consider the therapist who makes this diagnosis as seriously misinformed if not outright incompetent. He or she is desperately seeking a dramatic, interesting case or needs to feel he or she is on the latest “cutting edge” of diagnostic acumen. Any student of psychology is aware of the many facets of personality and how those facets are manifested differently in different situations. It would be a most unusual person who acts exactly the same in the company of strangers as in the company of close family. Is it any surprise that the role one fills in an occupation is different from the one he or she fills as a spouse—for example, being forceful and assertive at work but passive and compliant at home? To a therapist looking for a multiple personality, these differences would be used to support the diagnosis—even though they clearly do not meet the criteria for DID. A person reporting in therapy a normal depersonalization experience can be diagnosed as depersonalization disorder. A temporary but normal inability to recall something leads to a diagnosis of amnesia. The person wanting to sneak away for some forbidden activity knowingly reports, “I don’t know how I got there,” and is diagnosed as a fugue. To no one’s great surprise, many a criminal activity has been blamed on a dissociative state that the therapist accepts and reports as legitimate. One case in the news involved a person claiming over 20 personalities as a method of trying to avoid criminal charges. A case of fugue reported in the news turned out to be a person escaping financial problems, another fugue led to the possibility of writing a book about it. To critics, in cases such as these, the therapist is seeing what he or she wants to see, not what is actually there. Ross (1997) presented a discussion of dissociative phenomena experienced by a random sample of over 1,000 adults.
Loosening Diagnostic Criteria
In the previous section, I discussed frank misdiagnosis. In this section, a closely related phenomenon is presented: loosening the diagnostic criteria. How a problem is defined will directly affect the rate of occurrence. For example, if one defines alcohol abuse and dependency very strictly, the problem affects around 9 million persons in the United States. If less strict criteria are used, the number goes to about 15 million—a difference of 6 million people! A study was recently released reporting a dramatic increase in autism in the United States. Some professionals and nonprofessionals believe this accurately reflects the situation. Other professionals and nonprofessionals believe there is no true epidemic; rather, the criteria for the disorder have been expanded to include individuals who would not have been previously included. In fact, the category is now often referred to as the autism spectrum disorders. Many other examples could be provided, but these suffice to make the point.
In this case, the therapist may have a client with some symptoms suggestive of a dissociative disorder, but a careful application of the diagnostic criteria should preclude the diagnosis. In essence, the therapist makes the diagnosis because it is “close enough.” To the skeptics, even a casual reading of many cases of reported DID reveals a very loose application of diagnostic criteria. For example, a client who for a few minutes regresses and acts childishly and then becomes quiet and withdrawn for a few minutes is diagnosed DID with three personalities (the primary one, the child, and the quiet one). If this hypothetical client then tells the therapist that once he felt like an elderly person, the client is very likely to get a fourth personality, and so on. Such fleeting, transient states hardly qualify as distinctly different personalities. The same reasoning can be applied to the other dissociative disorders. It is interesting to note that some research found that three psychiatrists accounted for about 50 percent of DID diagnoses.
The iatrogenic effects of treatment for DID have been shown in a number of cases. The famous case of Sybil must be qualified by her own report that her therapist influenced her to have different personalities. Itarogenic effects as a cause of the rise in diagnoses rests in the well-recognized fact that most people receiving a dissociative diagnosis are suggestible and easily hypnotizable (hypnosis and drugs are common treatments for DID). They could very easily be led by the therapist into believing they have multiple personalities. News accounts of individuals suing therapists and treatment centers often include the client’s report that the therapist misled him or her into believing the diagnosis. News accounts of these cases report events that stretch to the breaking point the bounds of credulity. The clients may believe they were part of some evil ritual worship that occurred while in another personality, including killing infants, for example, even though, for obvious reasons, no police report is available to substantiate such claims.
When a client is highly suggestible, it is not difficult for a therapist to create the problem. A new personality may emerge as the therapist states, “I am puzzled. Are there parts of your personality you have not yet revealed to me?” or, even more obvious, “There has to be another aspect of your personality to explain what we are seeing.” A client who temporarily regresses in therapy can have it suggested that this indicates another personality, and, under the influence of the therapist, he or she develops more and more aspects of the newly created personality. To a suggestible client, normal variations in personality can, by the therapist’s influence, be viewed as different personalities. To a very suggestible client, the subtle suggestions of the therapist may have the force of an order. Certainly, in some cases the therapist may be purposefully, knowingly, creating dissociative symptoms. In other cases, the therapist may be following what she or he considers good practice. In either instance, regardless of the therapist’s intention, a misdiagnosis occurs. Under hypnosis, the same results can be effected, perhaps even more readily because of the client’s altered state of consciousness.
No discussion of iatrogenic effects would be complete without addressing the intense debate since the 1990s over the legitimacy of reportedly “repressed memories” that are “recovered” later in life. These “recovered memories,” some decades old, invariably emerge during therapy and reflect what are reported to be instances of severe childhood abuse or other severe traumas. Supporters of the repressed memory debate believe repressed memories are genuine. Critics, most notably Elizabeth Loftus, question if it is even possible for someone to suffer such a severe trauma and have absolutely no recall of it. Loftus’s work has shown how completely fabricated stories can be implanted and accepted by people as genuine memories, thus raising the possibility that “repressed memories” are iatrogenic in nature.
Critics of the increase in dissociative diagnoses point out that misdiagnosis leads to a related, very serious issue: errors in treatment. If, in fact, the dissociative diagnosis is inaccurate, it follows the client is being treated for a problem she or he does not have. More to the point, if the client has a problem, it is not being addressed by the therapist. This raises ethical questions as well as the possibility of civil legal action against the therapist and, if applicable, his or her agency.
The dissociative disorders category has always had some degree of controversy surrounding it, but the debate intensified beginning in the 1970s, and three decades later it shows no signs of resolution. As the listings in the References and Further Readings section indicate, the topic continues to generate pro and con discussions. Given the nature of disagreements about theories in psychology, with each position being certain of its view, it is unlikely there will ever be agreement about this category; after all, theories are interpretations, not facts. At least hypothetically, it would appear well-designed research could help answer questions about the dissociative disorders. Unfortunately, this is not as simple as it might at first appear. The key to successful research on the legitimacy and occurrence rate is establishing diagnostic criteria that are very specific, with as little judgment as possible on the part of the researchers. Unfortunately, given the schism between supporters and critics, the criteria that one group established would be rejected by the other, and the debate would continue in spite of the research.