from the DSM-IV-TR (American Psychological Association (2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision).Washington, D. C .)
DID is defined in the DSM-IV-TR as the presence of two or more personality states or distinct identities that repeatedly take control of one's behavior. The patient has an inability to recall personal information. The extent of this lack of recall is too great to be explained by normal forgetfulness. The disorder cannot be due to the direct physical effects of a general medical condition or substance.
DID entails a failure to integrate certain aspects of memory, consciousness and identity. Patients experience frequent gaps in their memory for their personal history, past and present. Patients with DID report having severe physical and sexual abuse, especially during childhood. There is controversy around these reports, because childhood memories may be exposed to distortion and some patients with DID are highly hypnotizable and vulnerable to suggestive influences. But, the reports of patients with DID are often validated by objective evidence. People that are responsible for acts of sexual and physical abuse may be prone to distorting or denying their behavior.
Physical evidence may include variations in physiological functions in different identity states, including differences in vision, levels of pain tolerance, symptoms of asthma, the response of blood glucose to insulin and sensitivity to allergens. Other physical findings may include scars from physical abuse or self-inflicted injuries, headaches or migraines, asthma and irritable bowel syndrome.
DID is found in a variety of cultures around the world. It is diagnosed three to nine times more often in adult females than males. Females average 15 or more identities, males eight identities. The sharp rise in the reported cases of DID in the U.S. may be due the greater awareness of DID's diagnosis, which has caused an increased identification of those that were previously undiagnosed. Others believe it has been overdiagnosed in those that are highly suggestible.
The average time period from DID's first presentation of symptoms to its diagnosis is six to seven years. DID may become less manifest as patients reach past their late 40's, but it can reemerge during stress, trauma or substance abuse. It is suggested in several studies that DID is more likely to occur with first-degree biological relatives of people that already have DID, than in the regular population.
The History of DID/MPD
From the "Diagnosis and Treatment of Multiple Personality Disorder," Frank W. Putnam (1989) On pages 29 - 31, he discusses the ascent of MPD between 1880-1920 "...there was a great flourishing of interest in multiple personality...a relatively large number of cases were reported... It was also a time of great international medical conferences...many of which devoted extensive time to sessions on dissociation." He also discusses Janet's case studies.
On pages 31 - 34, he discusses "The Decline of Interest in Multiple Personality Disorder: 1920 - 1970." "...it appears as if a number of factors were responsible for creating a widespread climate of disbelief and skepticism. The decline of interest in dissociation as a clinical and laboratory phenomenon,... paralleled the increasing suspicion of MPD and undoubtedly contributed to the outright rejection of the disorder in some circles..." He also discusses how public criticism may have cut the amount of cases reported. "Some critics...continued to hammer on the theme that multiple personality was an artifact of hypnosis." Rosenbaum (1980) "notes that the diagnosis of schizophrenia...caught on in the ...late 1920's and early 1930's....Beginning about 1927...there is a sharp increase in the number of reported cases of schizophrenia, matched by an equally dramatic decline in the number of multiple personality reports....Bleuler included multiple personality in his category of schizophrenia...The finding that MPD patients are often misdiagnosed as suffering from schizophrenia has been replicated several times (several 1980's studies). "
Pages 34 -36 discuss the re-emergence of MPD as a separate disorder. The re-emergence of Multiple Personality as a Separate Disorder: 1970 - Present
"During the 1970's, a foundation was laid upon which the current resurgence of interest in and knowledge of MPD rests. The dedication and hard work of a small number of clinicians, initially in an isolated and independent fashion but later with increasing cooperation and mutual support, re-established MPD as a legitimate clinical disorder."
from Brown, D., Frischholz, E., Scheflin, A. (1999). Iatrogenic dissociative identity - an evaluation of the scientific evidence. The journal of psychiatry and law. 27, 549-637. Historically by 1910, a believable view of DID began to decline, partly due to the increase in psychoanalysis and then behaviorism, and partly due to skeptical views toward hypnosis and the connection between hypnosis and hysteria. During the period of decline, Taylor and Martin reviewed 76 cases in the literature from the 1800's to the mid 1940's. They found that even though some multiple personalities may have been caused by suggestion, they concluded that multiple personality is a genuine phenomenon. This is because of the wide spread of these cases, because most of them had no information about other cases and because they had been judged as authentic sufferers of multiplicity by different observers. Sutcliffe and Jones believed the number of cases reported in the late 1800's was increased by misdiagnosis. They added that many of the cases of DID could not be simply dismissed as simply being incorrectly diagnosed. They also stated that though shaping has played a part in the development of multiple personality cases, it doesn't explain the nonexistence of these cases. Some cases manifested multiple behavior prior to therapy. They concluded that one should reject the idea that shaping in hypnosis may explain DID, but multiple behaviors can be shaped in those that already have DID.
Estabrooks worked with the experimental creation of personality states in the 1920's. He was trying to create hypnotically programmed couriers for certain intelligence agencies. The extent of his success of creating artificial DID for the military is unclear, since publication was not encouraged. The CIA however, formally conducted such experiments with Estabrooks consultation for some in the 1950's. He claims to have created unconscious couriers that were amnesic for specific information. None of his work describes a single case in any detail, nor do any of his writings show that he succeeded in creating DID.
Harriman extended Estabrooks work by inducing a profound hypnotic trance in good hypnotic subjects and then he suggested a role to produce automatic writing in a subject. The subject's arm and hand had been dissociated from the body by hypnotic suggestion. He claims the subjects were like different persons when they did the writing. Problems with Harriman's work include his repeated work with a small number of subjects, that he did not control for extraneous variables and that the secondary personality states he created were, for the most part, temporary states produced partially by the subject, which were used to explain dissociated experiences. He experimentally failed to meet the criteria of the DSM-IV-TR, where an alter personality must take executive control. His personalities produced ineffectual, poorly acted and complaint personalities limited to the demonstrations he made.
from Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Publications. Putnam writes about Multiple Personality Disorder (MPD), now called DID, and the way therapists can determine its diagnosis. He defines it as a chronic dissociative condition, not transient like psychogenic amnesia and fugues. A thorough history can help determine if a patient has had dissociative experiences. But other diagnostic interventions may be necessary. It may be difficult to get a clear chronology of life events. The host personality, which usually presents for treatment, may have the least access to early biographical information. MPD patients may describe their lack of memory as the result of having a poor memory. MPD patients may have developed compensatory behaviors to help them answer or avoid questions when they have memory gaps. Useful inquiries may include asking question about time loss or fugue-like experiences, depersonalization and derealization experiences (though these symptoms may be present in other disorders),questions about common life experiences, like being called a liar, large gaps in the continuousness of childhood memories, the occurrence of intrusive mental images, having dreamlike memories and having life skills that have unknown source, and questions about Schneiderian Primary Symptoms for schizophrenia, like hearing voices or feeling as if their body is controlled by an external force.
Manifestations of MPD may be displayed during interview interactions with patients. Two ways of detecting personality switching with patients are to notice the physical signs, which include facial and vocal changes. The second is to be alert for intrainterview amnesia, due to an alter personality's emergence, admitting to and then denying symptoms. Other signs include a patient's making references to themselves in the third person or the first person plural and an exaggerated startle reflex.
A diagnosis of MPD is more likely to be made after an extended period of observation. Diagnostic procedures include a mental status examination for appearance, speech, motor and thought processes, hallucinations, intellectual functioning, judgment and insight. Extended interviews for three hours may help, as it is difficult for MPD patients to keep from switching that long during the stress of an interview. The MMPI questions relating to blank spells and lack of knowledge of past actions show fairly high retest validity. The Rorschach test has a lot of diversified movement responses and labile and conflicting color responses. Physical examinations can help rule out other neurological disorders causing amnesia and may help detect self-mutilation scars. A diagnosis of MPD can only be made once a clinician has met a distinct alter state and not a transient ego-state phenomena.
Physiological studies showing differences between DID patients and non-DID patients
J Am Optom Assoc. 1996 Jun;67(6):327-34. Visual function in multiple personality disorder. Birnbaum MH, Thomann K. State College of Optometry, State University of New York, NY 10010, USA. BACKGROUND: Multiple personality disorder (MPD) is characterized by the existence of two or more personality states that recurrently exchange control over the behavior of the individual. Numerous reports indicate physiological differences, including significant differences in ocular and visual function, across alter personality states in MPD....The possibility of MPDs should be considered in patients who demonstrate unusual variability in ocular and visual findings, particularly with a positive psychiatric history. The existence of visual and other physiologic differences across alter personalities in MPD offers a unique potential for the study of mind-body relationships.
Clin Electroencephalogr. 1990 Oct;21(4):200-9. Brain mapping in a case of multiple personality. Hughes JR, Kuhlman DT, Fichtner CG, Gruenfeld MJ. Department of Neurology, University of Illinois, Chicago 60612. Brain maps were recorded on a patient with a multiple personality disorder (10 alternate personalities). Maps were recorded with eyes open and eyes closed during 2 different sessions, 2 months apart. Maps from each alternate personality were compared to those of the basic personality "S", some maps were similar and some were different, especially with eyes open. Findings that were replicated in the second session showed differences from 4 personalities, especially in theta and beta 2 frequencies on the left temporal and right posterior regions....Maps from S acting like some of her personalities or from a professional actress portraying the different personalities did not reveal significant differences. Some of these findings are consistent with those in the literature.
J Nerv Ment Dis. 1988 Sep;176(9):519-27. Multiple personality disorder. A clinical investigation of 50 cases. Coons PM, Bowman ES, Milstein V. Carter Memorial Hospital, Indianapolis, Indiana 46202. To study the clinical phenomenology of multiple personality, 50 consecutive patients with DSM-III multiple personality disorder were assessed using clinical history, psychiatric interview, neurological examination, electroencephalogram, MMPI, intelligence testing, and a variety of psychiatric rating scales. Results revealed that patients with multiple personality are usually women who present with depression, suicide attempts, repeated amnesic episodes, and a history of childhood trauma, particularly sexual abuse. Also common were headaches, hysterical conversion, and sexual dysfunction. Intellectual level varied from borderline to superior. The MMPI reflected underlying character pathology in addition to depression and dissociation. Significant neurological or electroencephalographical abnormalities were infrequent. These data suggest that the etiology of multiple personality is strongly related to childhood trauma rather than to an underlying electrophysiological dysfunction. PMID: 3418321
Arch Gen Psychiatry. 1982 Jul;39(7):823-5. EEG studies of two multiple personalities and a control. Coons PM, Milstein V, Marley C. There are few reports of EEG findings in patients with multiple personalities. In our study, EEGs were visually scanned and frequency analyzed in two patients with multiple personalities and one control....These data suggest that EEG differences among personalities in a person with multiple personalities involve intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of persons with multiple personalities and those of normal persons.
Responses to those that state that DID is iatrogenic or a social construct
Iatrogenic DID-An Evaluation of the Scientific Evidence: D. Brown, E. Frischholz & A. Scheflin" from The fall-winter 1999 issue of "The Journal of Psychiatry & Law - "Conclusions...At present the scientific evidence is insufficient and inadequate to support plaintiffs' complaints that suggestive influences allegedly operative in psychotherapy can create a major psychiatric disorder like MPD per se...there is virtually no support for the unique contribution of hypnosis to the alleged iatrogenic creation of MPD in appropriately controlled research.....alter shaping is not to be confused with alter creation." p. 624
D. Gleaves July, 1996 "The sociocognitive model of dissociative identity disorder: a reexamination of the evidence" Psychological Bulletin Volume 120, issue=1, pages=42-59 "No reason exists to doubt the connection between DID and childhood trauma."
C. Ross, G. Norton, G. Fraser (1989) "Evidence against the iatrogenesis of multiple personality disorder "Dissociation" volume=2, issue=2, pages 61-65, https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1424/1/Diss_2_2_2_OCR.pdf "Exposure to hypnosis does not appear to influence the phenomenology of MPD(DID)....There is no evidence derived from the study of clinical MPD that the disorder is artifactual. In fact there is not one case of MPD created artifactually by a specialist in dissociation reported in the literature. Given the absence of positive evidence for the artifactual nature of clinical MPD, the data in the present study provide compelling evidence that MPD is a genuine disorder with a consistent set of core features."
Kluft, R.P. (2003) Current Issues in Dissociative Identity Disorder in journal Bridging Eastern and Western Psychiatry 1(1) |p. 71-87 http://www.psyter.org/allegati/180/Kluft.pdf "In inpatient psychiatric populations, mixed inpatient uncommon, occurs in many different countries at and outpatient groups, and chemical dependency approximately the same rate in the psychiatric inpatient treatment settings, previously undiagnosed DID is found population, and usually goes undiagnosed. Even among in between 4% and 18.6% of the patients. Taken diagnosed DID patients, Putnam and his coworkers together, these studies suggest that DID is not found that the average patient had been in the mental health care delivery system for 6.8 years before being accurately diagnosed....It has long been clear that many of the symptoms of DID can be created by simple suggestion or experimental manipulation, and that with minimal suggestion, subjects can be induced to enact several DID behaviors. This data has been summarized by many authors. However, the enactment of behaviors associated with a mental disorder is not proof that one has the mental disorder -- anymore than a stage hypnotist's subject's clucking like a chicken is a justification for cooking him or her for dinner. Cultural influence and expectations may exert a significant impact upon the phenomenology of DID, but this does not make the condition invalid....There is considerable controversy over whether the condition can be created de novo from iatrogenic pressures. My review of the literature, and my experience with many situations in which this is alleged to have occurred, suggest that if this does occur, it is infrequent and happens only after prolonged and intense interventions. Therefore, if the manifestations of DID are noted after relatively brief clinical contact, or in the context of efforts that do not involve prolonged and intense indoctrination, iatrogenesis is not a likely etiology....A review of the DID literature demonstrates numerous instances of documented abuse. Two studies of younger dissociative patients found documentation of abuse for 95% of their young subjects. The documentation of recovered memories of childhood abuse in DID populations has been documented. However, I have also documented that DID patients may represent confabulated recollections of abuse as if they had occurred and that both accurate recovered memories patient, either spontaneously or in response to of abuse and confabulated memories of abuse may occur in the same DID patient. The literature, then suggests that DID patients usually have a background of overwhelming childhood circumstances, usually involving child abuse, but that pseudomemories can be encountered in this patient population....DID is emerging as a not uncommon consequence of overwhelming childhood events. It has been identified as occurring in many nations and is often very responsive to treatment.:
Braun, B. Iatrophilia And Iatrophobia in The Diagnosis And Treatment of MPD M.d. - Dissociation, Vol. II, No. 2: June 1989 "The most convincing evidence that alters are not being iatrogenically induced comes with time," Putnam writes, "Although new personalities may be created in therapy, the great majority will have a life history that predates therapy. This history, with sufficient documentation, will emerge as the therapist and patient reopen the past and make it clear. In the long run, the question of iatrogenesis becomes less urgent" (1989, p. 132). In this statement, an experienced MPD clinician and investigator erodes the myth that hypnosis can induce an alter personality that meets the criteria of DSM-III-R (1987) including an enduring pattern of perceiving, relating to and thinking about self and the environment....Hypnotizability, as a manifestation of the ability to dissociate, is not an indication that hypnosis can induce true alter personalities....other means is highly unlikely, given the DSM-III-R criteria for defining an alter. Fear of iatrogenesis may deter some therapists from making the diagnosis of MPD or undertaking therapy."
from Brown, D., Scheflin, A. W., Hammond, D. C. (1998). Memory, trauma treatment and the law. New York: W. W. Norton & Company. "Proponents of the iatrogenesis hypothesis argue that patients simulate DID to get attention, yet Gleaves cites several empirical studies that show no significant relationship between histrionic personality and other attention-seeking traits and DID. In a study done by Ross, Norton and Wozney (1989), only 27% of those with DID had hypnosis before getting the DID diagnosis. The iatrogenesis argument also doesn't account for the fact that many patients with DID had a long history of dissociative symptoms before the DID diagnosis was made. Putnam in 1986 showed no significant differences in the clinical features of those with DID, whether hypnosis was used or not in treatment. Gleaves also states that researchers have found a strong association between forms of childhood trauma and DID." "The treatment strategy recommended by proponents of the iatrogenesis of DID that therapists discourage alter behavior and recollections of abuse may be harmful. Not dealing with the condition of DID may cause interminable treatment. Simply because some of the features of DID can be role played, this does not meaningfully explain the etiology of any mental disorder. Gleaves believes the iatrogenesis model is flawed and lacks support. The role-playing theory cannot account for the primary features of DID."
MPD/DID connection to severe abuse
Paley, K. Dream wars: a case study of a woman with multiple personality disorder Dissociation : Vol. 5, No. 2, p. 111-116 https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1646/1/Diss_5_2_9_OCR.pdf Multiple personality is seen as the adult manifestation of child abuse (Fraser, 1990; Baldwin, 1990; Ross, 1988; Kluft, 1986; Bliss, 1985; Greaves, 1980) . Putnam, Guroff, Silberman, Barban, and Post's (1986) survey of 100 patients revealed significant childhood trauma in 97% of the cases; incest was the most commonly reported trauma (68%).
Van Benschoten, S. (1990) Multiple Personality Disorder and Satanic Ritual Abuse: the Issue Of Credibility - Dissociation, Vol. III, No. 1 http://www.empty-memories.nl/dis_90/vanbenschoten_sra.pdf Finkelhor- et al. (1988) found the ritualistic cases in their national study of substantiated day care sexual abuse to be the ones "whose allegations seemed to most strain public and professional credulity. . (and) in which the children appeared to have suffered the most serious and lasting kind of damage " (p. 32). This impression is supported by the work of Kelley (in press)....A large number of adult MPD patients in psychotherapy are reporting memories of explicitly satanic ritual abuse beginning in childhood. The authors of two limited surveys, conducted with a select group of MPD therapists, suggest the percentage of reported satanic ritual abuse in the MPD population to be 20% (Braun & Gray, 1986) and 28% (Braun & Gray, 1987). A survey by Kaye and Klein (1987) reveals that 20 of the 42 MPD patients in treatment with seven Ohio therapists describe a historv of satanic ritual abuse. Ilopponen (1987) states that 38 of the more than 70 MPD patients she has treated report memories of "satanic-type ritualized abuse " (p. 11). Two inpatient facilities specializing in the treatment of MPD report that approximately 50% of their patients disclose memories of satanic ritual abuse (Braun, 1989a; Ganaway, 1989)....In their national investigation of 270 cases of substantiated sexual abuse of 1,639 children in day care, Finkelhor, Williams, and Burns (1988) found 13% of the cases involved allegations of ritual abuse. According to Jonker and Jonker-Bakker, "The National Society for the Prevention of Cruelty to Children in Britain reported in its 1989 Annual Report that seven out of 66 Child Protection Teams in England and Wales were currently working with children victimized by ritualistic abuse."
The reliability of memories of SRA elucidated by clients in treatment for MPD has been a major point of contention in the popular media and amongst clinicians. Some healthcare professionals continue to express ambivalence over the reliability of narratives of SRA provided by patients, although most acknowledge that such a narrative is likely to be indicative of serious victimisation and trauma. Schmuttermaier, J. and A. Veno "Counselors' beliefs about ritual abuse: An Australian Study", Journal of Child Sexual Abuse, 8, 3, 1999, 45 - 63.
Leavitt, F. (1994) Clinical Correlates of Alleged Satanic Abuse and Less Controversial Sexual Molestation. Child Abuse and Neglect: The International Journal 18(4) p. 387-92 Women alleging SRA described higher levels of dissociation, in a range often shown by patients with MPD. http://eric.ed.gov/ERICWebPortal/recordDetail?accno=EJ483422
PSYCHOLOGY - Identity Crisis - What is it like to live with 17 alternate selves? A survivor of multiple personality disorder discusses the disease and the painful integration process that made her whole. By Anne Underwood | Newsweek Web Exclusive Oct 22, 2007 Multiple personality disorder is a perplexing phenomenon to outside observers, believed to be brought on by persistent childhood abuse. What is it like living with MPD? And how does a sufferer function, with so many alternate personalities--or "alters"--some of them adults and some children? NEWSWEEK's Anne Underwood spoke with Karen Overhill--a former sufferer and the subject of a new book, "Switching Time," by Dr. Richard Baer. Excerpts: http://www.newsweek.com/id/57861
Mysteries of the mind unfold at program 10-06-2006 "Eve," whose real name is Chris Costner Sizemore, and her son, Bobby, spoke to Stetson University students recently at a special program that included a lecture, slide show of Chris' artwork, a frank question-and-answer session, and a reception. Chris talked openly of her struggles with Multiple Personality Disorder, which in her case had manifested itself in more than 20 personas over several decades. She has been healed for 30 years....Chris was the subject of the 1957 book by Drs. Corbett H. Thigpen and Hervey M. Cleckley, "The Three Faces of Eve" (Kingsport Press), and of the subsequent movie of the same name. Chris said her many personalities arose in response to "hurtful events" during childhood. Today, "I don't need them," she said of the personalities. "As a whole person, I can face my realities and deal with them." http://www.stetson.edu/marcom/articles/view.php?type=stories&id=198
Dissociation and Trauma Archives - Full text searchable articles and case studies published in the 1800s and early 1900s. http://boundless.uoregon.edu/digcol/diss/index.html
Multiple personality and dissociation, 1791-1992: a complete bibliography - Author Goettmann, B. A. Greaves, B. G. Coons M. P. "Multiple personality and dissociation, 1791-1992(2nd edition)" is a bibliography. It contains the 1st edition as well as updates through November 30, 1993. Article errors have been corrected when possible. The bibliography is divided up into the following areas: Multiple personalities, Dissociation and Amnesia, Depersonalization and Derealization, Fugue States, and Medico-legal Aspects. Sidran Press. 2nd Edition. - University of Oregon Libraries - http://boundless.uoregon.edu/cdm4/item_viewer.php?CISOROOT=/diss&CISOPTR=38
Gould, C. & Neswald, D. (1992). Basic treatment and program neutralization strategies for adult MPD survivors of satanic ritual abuse. Treating Abuse Today, 2(3), 5--10.