Jacqueline Costello, York College of Pennsylvania Abstract
Dissociative identity disorder (DID) is not a new phenomena, yet it has remained controversial for years.Formerly multiple personality disorder, DID has many in the field of psychology undecided if it should even be included in the DSM-IV without reservation.
This paper will discuss the opinions of board certified American psychiatrists concerning DID and the various reasons why many remain skeptical about this disorder.The DSM-IV criteria, alleged claims of abuse, cultural specificity, and the clinical defining features of dissociative identity disorder will be discussed.The treatment of traumatic memories and the effectiveness of this treatment will also be discussed in this paper.
Dissociative Identity Disorder: Controversies and Treatments
Dissociative Identity Disorder, formerly Multiple Personality Disorder remains a highly controversial disorder.The diagnostic criteria for this disorder as cited in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), states that an individual displaying at least two personality states in which these personality states take control of the persons behavior can be diagnosed with dissociative identity disorder (DID).
The individual diagnosed with this disorder tends to be depressed, passive, and often displays feelings of guilt. The last element of the criteria, which is the presence of amnesia, is often what leads the physician to suspect a dissociative disorder.According to the DSM-IV criteria (1994), the individual is often unable to recall important personal information and has frequent gaps in their memory.Research has discovered that the amnesia is often asymmetrical; the more passive identities will have more constricted memories while the more hostile identities will have more complete memories (DSM-IV ,1994).
According to the DSM-IV (1994), this diagnosis is more commonly found in females and is concentrated more heavily in North America, especially the United States.Not only are more women diagnosed with DID, but they also tend to have more alternate personalities.
The disorder tends to become dormant as individuals enter middle age, but the symptoms can resurface during periods of stress.With this disorder it is necessary to rule out any effects from substance abuse or a general medical condition. Since the DSM-IV (1994) has included it as an actual disorder, the logical next step would be to determine why so much controversy surrounds this disorder.
There are a few reasons why many are skeptical about the validity of this disorder.Accompanied with this disorder are often high rates of sexual and physical abuse.After Pope, Oliva, Hudson, Bodkin, and Gruber (1999) surveyed a group of 301 board certified American psychiatrists their results indicated that only 1/3 of those surveyed felt that DID should be included in the DSM-IV (1994) without hesitation, while the remaining felt that it should only be a proposed diagnosis. There are many that are skeptical about the claims of abuse in DID.Although the task is quite difficult, various researchers have sought to obtain objective documentation of the alleged abuse individuals with DID claim they have been subjected to.
Alleged Abuse in DID
Otnow-Lewis, Yeager, Swica, Pincus, and Lewis,M. (1997) conducted research which sought to verify dissociative symptoms and alleged abuse of a group of individuals diagnosed with DID.Their study included 11 men and one woman who had been previously convicted on murder charges.The study included an objective verification of childhood abuse and dissociative symptoms.Family and childhood friends were interviewed and the various records were reviewed (police, social service, psychiatric, etc.) in an attempt to verify that the symptoms were present before the murders and that childhood abuse did actually occur (Otnow-Lewis et al., 1997)
After Otnow-Lewis and colleagues (1997) completed the various interviews and review of the records, the researchers were able to objectively verify dissociative symptoms in all 12 of the participants, as well as extreme childhood abuse in 11 of the 12 participants.A common belief about dissociative identity disorder is that people "fake" the symptoms or false memories are produced during the course of therapy
.However, with these 12 participants, this was not the case.None of the murderers that took part in this study were even aware of their psychiatric condition and remembered very little, if anything of their childhood. The participants either had total or partial amnesia for the abuse that had occurred during their childhood.These individuals either claimed that the abuse never occurred or minimized the abuse.There was not one individual in this study that produced a memory concerning abuse that the researchers were not able to objectively verify (Otnow-Lewis et al., 1997).Another controversy concerning DID is the high prevalence of the disorder in North America.
Cultural Aspects
According to the DSM-IV (1994), DID is culturally specific.The United States has relatively high rates of this disorder.Many authors feel that Dissociative Identity Disorder is rare outside of North America although Sar, Yargic and Tutkun (1996) found that this view may not hold as much truth as once thought.Through the use of the Turkish versions of the Dissociative Disorders Interview Scale and the Dissociative Experiences Scale, Sar and colleagues concluded that DID may not be a culturally bound disorder.
The patients in their study were similar to many North American patients with respect to the fact that there were high rates of physical and sexual abuse.Although the rates of abuse and trauma were similar to North American patients, the rates of substance abuse were much lower among the Turkish patients.Sar and colleagues attribute this to the fact that substance abuse in general, is much lower in Turkish culture (Sar, et al., 1996). Aside from the fact that many believe DID to be culturally specific and even more are skeptical about the allegations of childhood abuse, there seems to be an even bigger problem, which surrounds the controversy of the disorder.In order for dissociative identity disorder to be taken seriously, there needs to be a set of defining clinical features which will differentiate individuals diagnosed with DID with individuals not diagnosed with DID (Scroppo, Weinberger, Drob, & Eagle, 1998).
Clinical Features
Scroppo and colleagues (1998) used structured interview assessments and gathered data using the Rorschach test and the Tellegen Absorption Scale in an attempt to differentiate individuals diagnosed with DID from psychiatric patients who have never been diagnosed with a dissociative disorder (Scroppo et al., 1998)
The findings of this research conducted by Scroppo and colleagues (1998) strongly indicate that diagnosed individuals with DID indeed display defining clinical features, which aid in differentiating them from individuals who have not been diagnosed with a dissociative disorder.Some defining features are a higher rate of substance abuse, frequent occurrence of changes in consciousness, and episodes of sleep walking. Scroppo and colleagues (1998) found that childhood trauma (sexual and physical abuse) was experienced much more often among the DID diagnosed group than the control group.
Through their research, Scroppo and colleagues (1998) also found that individuals diagnosed with DID differed in their use of imaginative and projective operations.On the Rorschach test, these individuals tended to bestow movement or dimensionality to the inkblots.Overall, the research of Scroppo and colleagues (1998) strongly suggests the notion that individuals diagnosed with DID possess defining sets of clinical features which can differentiate them from individuals that have not been diagnosed with DID.
The fact that these researchers have found defining clinical features may assist resolving some, but not all, of the controversy surrounding the disorder. Various research has presented the reader with the controversies surrounding the actual diagnosis of dissociative identity disorder, now the treatment of these alleged traumatic memories that emerge in therapy must be addressed (Kluft, 1996).
Treatment
Kluft (1996) conducted research concerning the treatment of traumatic memories.Treating these memories is one of the most important parts of the therapy, as well as the most painful.These memories should be dealt with very delicately otherwise the effects can be quite damaging to the patient.Once the memories emerge, the patient may feel very overwhelmed.Patients will often require hospitalization during the time that the memories are being worked through.Kluft, along with numerous other researchers, feels that the therapist should not attempt to deal with the trauma immediately.Rather, the first step is establishing safety.
This is the phase when the patient begins to trust the therapist.After trust is established, the remembrance of traumatic events can occur and then when that is worked through, a reconnection of the personality states can occur (Kluft, 1996).As with all disorders, individuals with DID will progress at different stages.
Kluft (1996) states that individuals with DID who are seeking treatment will generally fall into one of three progress categories.Kluft places these individuals in either low, middle, or high trajectory groups.Individuals in the low trajectory group are not yet ready to work on traumatic memories; they are not progressing very quickly.Those in the middle trajectory group are apt to deal with trauma work occasionally when it is necessary.
Individuals that fall into the high trajectory group are able to deal with trauma work and they are recovering much more quickly than the other two groups.Even those individuals in the high trajectory group should not engage in uninterrupted trauma work (1996).Many researchers theorize whether or not treatment of dissociative identity disorder is effective and if so, if the effects are long lasting.
Ellason and Ross (1997) examined the effectiveness of the treatment for dissociative identity disorder in a two-year follow up study.In their research they use the concept of integration. Integration occurs when behaviorally separate identities are no longer present and the individual has had three stable months of memory that are current.Of the original 135 patients, a total of 54 agreed to participate in this study and complete the various interviews and complete questionnaires (Dissociative Experiences Scale and the Dissociative Disorders Interview Scale).
The results of Ellason and Ross' research (1997) indicate that 12 out of the 54 participants achieved integration in the two-year follow up.The reports of childhood abuse documented by the individuals in 1993 did not differ from their reports in 1995.The integrated patients in this study showed a more substantial improvement with symptoms of depression, as evidenced by their scores on the Dissociative Disorders Interview Schedule.
Overall, the findings of their research indicate that both patients who achieved and didn't achieve integration showed improvement on the two-year follow up.However, the patients who achieved integration were doing extremely well in the two-year follow up.These findings suggest that over a sufficient time period, treatment can be quite beneficial for patients diagnosed with dissociative identity disorder (Ellason and Ross,1997).Now that the diagnosis, controversies, and treatments concerning DID have been addressed, the review of a well-known case study will further clarify the distinctiveness of the disorder.
In the DSM-IV casebook (Spitzer, et al.,1994), a case study of Mary Kendall, a 35 year-old caseworker is discussed.Mary does not have much of a social life, but rather devotes herself to helping others.Mary has a quite extensive medical history, including chronic pain in her right hand and forearm, which is actually what led her to meet with a psychiatrist. She displays many of the characteristics common in individuals diagnosed with DID such as the ability to be easily hypnotized and frequent gaps in her memory (especially memory for events that occurred in her childhood).
The case study of Mary Kendall (Spitzer, et al., 1994) describes her frequent gaps in memory, which she realized when she noticed that her gas tank would often be almost full when she returned home from work, but almost empty in the morning.After Mary began to keep track of the odometer reading she realized that 50-100 miles were often put on the car overnight, even though she could not remember driving anywhere.During a hypnosis session with the therapist, one of the hostile personalities (Marian) emerged.Marian described rides that she often took at night in an attempt to work out her problems.
The alter personality, Marian, displayed strong contempt for Mary.Marian felt that Mary was very pathetic and that it was a waste of time to always be concerned about others.In the course of therapy about six personalities emerged, who were often in conflict with one another Spitzer, et al., 1994).
Various childhood memories emerged through the course of therapy including abuse (physical and sexual) committed by her father and guilt surrounding these events since she did not protect her other siblings from encountering the same fate (Spitzer, et al., 1994).
Psychotherapy, especially in the case of DID, is not a rapid process.Mary Kendall participated in therapy for four years before a gradual integration of the personality states was evident.Although some of the personality states were able to integrate, others were not and remained in conflict with one another (DSM-IV casebook, 1994).
Conclusion
In conclusion, although DID remains a highly controversial disorder, the clinical criteria for this disorder are still included in the DSM-IV (1994).There remain critics who feel that DID is a "fake" disorder suggested to highly hypnotizable patients.Many of these critics also feel that the memories that emerge are often false and the supposed abuse never actually occurred.However, recent research has objectively verified the accusations of abuse of patients diagnosed with DID (Otnow-Lewis et al., 1997).
Sar and colleagues (1996) have conducted research in an attempt to dispel the myth that DID is a culturally bound disorder.Scroppo and colleagues (1998) have discovered defining clinical features that differentiate DID diagnosed individuals from those not diagnosed with a dissociative disorder.All of this research is attempting to objectively examine the defining features of this disorder and answer many of the critics' arguments with objective data.
However, future research is necessary to further examine DID and gain a deeper understanding of the disorder and the individuals it affects. In psychology, as in all fields, it is impossible to draw conclusions from a few studies.The present research needs to be replicated numerous times in order for researchers to begin to draw conclusions concerning this controversial disorder.
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