Does Dissociative Personality Disorder (Multiple Identity Disorder) Really Exist?

The symptoms of dissociative identity disorder (DID) now are set forth at DSM-IV-TR §300.14. It requires “The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self) and “At least two of these identities or personality states recurrently take control of the person’s behavior.”

DID formerly was known as “multiple personality disorder.”  Under that name it became a subject of fascination throughout history (North, Ryall, Ricci & Wetzel, 1993); and, more recently, a pop culture phenomenon with books such as The Three Faces of Eve (later made into a movie), Sybil, and the television show United States of Tara. The Internet has made it possible for people to assume alternative identities with ease, especially in chat-rooms, on dating web-sites and in role-playing games such as Second Life (Dreyfus, 2008). In fact, a new clinical disorder called “internet addiction” has been proposed for inclusion in the forthcoming DSM-V (Block, 2008; Young, 1998), even as DID has become a target for removal (Gharaibeh, 2009).

Because it implicates concepts such as “self” and “personal identity,” DID is intrinsically interesting in its own right (Braude, 1995). The experience of it undoubtedly is disturbing from a phenomenological standpoint; see, e.g., the essays and other creative works collected at Cohen, Giller & Lynn (Eds.), 1991. There are a half dozen treatment modalities, none of which are particularly effective, ranging from psychopharmacology to psychoanalysis, with stops in between for cognitive behavioral therapy and group therapy; for a review, see Braun (Ed.), 1986, and Putnam (1989). Although there are plenty of theories, DID’s epidemiology and etiology remain uncertain (Ross, 1996). Even as they defend it as a viable psychiatric diagnosis and distinct clinical pathology, the most current authorities recognize it is the source of confusion, gaps in knowledge and conjecture (Dell & O’Neil, 2009; Ross, 2006).

It seems quite likely there is such a thing as DID. Unlike many others (e.g. Lynn & Deming, 2010), I am not a DID skeptic. Most likely DID is caused by severe childhood trauma, such as sexual abuse. The victim creates an alternative personality and assigns the traumatic event (or series of traumatic incidents) to it, rather than to his or her “core personality” or “self.” In that way, the trauma becomes contained by or encapsulated in the alternative personality. Conversely, it becomes depersonalized or derealized vis-à-vis the victim’s core personality, enabling him or her to cope with greater facility in daily life.

That notwithstanding, there are several reasons why DID has had such a mixed reception. Some of them are practical; some, more theoretical. Here are a few of them:

1. How is developing a stand-alone, independently viable alternative identity different from simply expressing a personality trait or characteristic, or being in an affective state or mood?  DID theory confuses “who” with “what.” “Who” refers to an entire person. “What” refers to an ascriptive predicate attributable to that person, such as, “that person is a student,” or “that person is a musician” or “that person has red hair.” This does not necessarily entail, nor should it, an inference that each of those ascriptive predicates leads to the development of a discrete personality, centered on that trait or characteristic. DID may involve simply a reallocation or redistribution of one’s ascriptive predicates, i.e., “today I feel like playing music” or “today I feel like writing poetry,” rather than the creation of an entirely new personality (“poet” or “musician”).

2. How is it possible for somebody to acquire more than one alternative personality?  It is not difficult to see how one might develop a single one, as a way to compartmentalize early trauma, such as childhood sexual abuse. It is harder to develop a rationale, though, for the subsequent proliferation of additional personalities. Does each require separate new trauma, so there is a one-to-one correspondence with each new personality?  If so, why wasn’t the existing alternative personality sufficient to accommodate the new trauma within its scope?  Perhaps new personalities develop as the victim ruminates on certain salient features or aspects of the original trauma. How do these new internal narratives proliferate, and how do they catalyze the creation of additional alter egos?  Why certain features, and not others?

3. If there is “more than one” alternative personality, then how do they relate to each other?  What are the parameters within which each operates, and what determines these boundary conditions?  Do they share characterological traits?  If so, then why is there more than one of them?  Does it make sense to think of one as being “dominant,” in the sense of organizing reality for the others?  Can it even be said to begin with, that one is an “original” or “core” personality, especially if it is expressed with less temporal frequency than some other one?  What causes a segue or transition from one personality to another?  There must be some sort of a trigger, or prime – almost like a startle response. But how strong must the trigger be; must it cross some kind of an imaginary threshold in order to activate the alternative personality, or is just a little bit of exposure or recollection sufficient?  Can one be “half in one personality,” and “half in the other” – that is, blend traits or characteristics of two (or more), depending on situational or environmental factors?

4. What if the victim is mistaken about some aspect of the trauma, or (in an extreme case) it never happened, to begin with?  It is not difficult to see how one’s recollection of factual details might be incorrect, particularly with memories arising in young childhood (the most likely age for DID trauma to occur). Then, later interpretation is based not so much on the original trauma, as it is on previous recollections of the trauma at subsequent points in time. At each such later point in time, the victim has reflected on the original trauma, and on previous recollections of it, and experienced intervening life events. These may attenuate his or her recollection of the original trauma. It may subsequently become confabulated, based on reinforcing experiences – possibly, to the point where the original recollection is obliterated entirely. Therapy itself may have caused the victim to adopt a meta-analysis, which has overtaken events as they originally occurred. If so, then the phenomenological experience of DID is not based so much on trauma, as it is on the transience and variability of memory and recollection. Other alternative selves are not traceable to earlier trauma, but rather, on subsequent recollections and elaborations of it. Theorists such as Derek Parfit (1975) have devised complex theories about how one’s singular personal identity remains consistent over time. This process would become impossibly complex – factorially – if one were juggling multiple personal identities simultaneously. How much importance one assigns to different aspects of one’s reality depends entirely on how attention one devotes to them. Given this arbitrary, even chaotic environment, where nothing really is as it seems, one can become convinced of just about anything.

5. Does DID have neurological correlates?  From a materialist perspective, it is clear that even victims of DID have only one brain. Although there a variety of theories about whether, why and how this occurs, that brain gives rise to, or is the substrate of, phenomena such as “self,” personality, memory, personal identity and “mind.” However described, do people with DID instantiate two (or more instances) of them?  Does each entail a separate neural wiring scheme, or activate different brain regions (as shown by fMRI)?  If so, how are they different?  In principle, one and the same neurological state might give rise to any number of different phenomenological experiences, and a person could have as many different memories as there are neural connections or potentials comprising them. But it’s a long way from this to a completely different personality state. Someone who has undergone commissurotomy certainly is entitled to have two separate selves. But what about people (most of us) with only one brain?

6. Several DID theorists conjecture it originates in cult and ritual abuse (Noblitt & Perskin, 2000). Like all conspiracy theories, this has too many moving parts to be plausible. Compare:  Freud originally thought that all cases of hysteria were caused by paternal sexual molestation during childhood. He was forced to retract this hypothesis when his colleagues discovered cases of hysteria where no childhood seduction was implicated (Makari, 2008). Cult and ritual abuse theorists make this same type of over-generalization.

Based on concerns like these, I often have heard it said, or implied, that persons with DID are “acting” or “faking it.” This hypothesis seems unlikely to me, because it’s too complicated. It hypothesizes the existence of at least four different psychological states, each of which must be maintained simultaneously. Here they are: (1) the subject must have some concept of what might be referred to as a “normal” or non-pathological state – the shared reality in which all of us exist. (2) The subject then must have some concept of what a “pathological” state is, particularly in contrast to (1). The subject must be able to discriminate his or her altered or (ostensibly) pathological state, and discern the myriad ways in which it’s different, or has a different feature set. (3) The subject then must have a subjective impression of “what it’s like” to be in (2); a personal “take” or understanding of what it involves, the cognitions it implies, and the behaviors it requires. Finally, (4) the subject must plan a series of steps in order to implement (3), that is, not only a subjective impression of (3), but also the practical, operationalized steps necessary to achieve it.

This is where some variant of “acting” comes in. It would be difficult to attend to all four of these separate cognitions, simultaneously. If one is “switching” between (say) a dozen different personalities, then 12 times 4 = 48 separate mental states are implicated. Earlier in this note I hypothesized it isn’t necessary (and probably impossible) for the subject to adopt a complete feature set for each different personality, rather, only a more limited set of ascriptive predicates that might be attributed accurately to that state. If so, then the number of separate cognitions required could be virtually limitless; at the least, it might approach 12! (factorial) or even 1212th power. If DID theory is true, then it would be more parsimonious simply to infer that the subject is transparently assuming, with ease and facility, the alternative identity. This would reduce considerably the dimensionality of the vexing issues DID presents. A subject who is “acting” doesn’t really implicate a genuine alternative identity; the subject lacks some form of “sincerity” condition, and only is being “as if.” This may be a form of psychopathology, but it’s different than DID.

References

Block, J. (2008). Issues for DSM-V: Internet addiction. The American Journal of Psychiatry, 165, 306 – 307. doi: 10.1176/appi.ajp.2007.07101556

Braude, S. (1995). First person plural: Multiple personality and the philosophy of mind. Lanham, MD: Rowman & Littlefield Publishers.

Braun, D. (1986) (Ed.). Treatment of multiple personality disorder. Washington, DC: American Psychiatric Press.

Cohen, B., Giller, E. & Lynn, W. (1991). Multiple personality disorder from the inside out. Baltimore, MD: Sidran Press.

Dell, P. & O’Neil, J. (Eds.). Dissociation and the dissociative disorders: DSM-V and beyond. New York, NY: Routledge.

Dreyfus, H. (2008). On the internet (thinking in action). New York, NY: Routledge.

Gharaibeh, N. (2009). Dissociative identity disorder: Time to remove it from DSM-V?  Current Psychiatry, 8(9), 30 – 36.

Lynn, S. & Deming, A. (2010). Review: The “Sybil Tapes”: Exposing the myth of dissociative identity disorder. Theory & Psychology, 20(2), 289 – 292.

Makari, G. (2008). Revolution in mind: The creation of psychoanalysis. New York, NY: HarperCollins.

Noblitt, J. & Perskin, P. (2000). Cult and ritual abuse: Its history, anthropology, and recent discovery in contemporary America. Santa Barbara, CA: Praeger.

North, C., Ryall, J, Ricci, D. & Wetzel, R. (1993). Multiple personalities, multiple disorders – Psychiatric classification and media influence. New York, NY: Oxford University Press.

Parfit, D. (1971). Personal identity. Philosophical Review, 80(1), 3 – 27. Reprinted in J. Perry (1975) (Ed.). Personal identity, pp. 198 – 223. Berkeley, CA: University of California Press.

Putnam, F. (1989). Diagnosis & treatment of multiple personality disorder. New York, NY: Guilford Press.

Ross, C. (1996). Dissociative identity disorder: Diagnosis, clinical features, and treatment of multiple personality. New York, NY: Wiley.

Ross, C. (2006). Dissociative identity disorder. Current Psychosis and Therapeutics Reports, 4(3), 112 – 116. doi: 10.1008/BF02629306

Schreiber, F. (1973). Sybil. New York, NY: Penguin

Thigpen, C. & Cleckley, H. (1957). The three faces of Eve. Kingsport, TN: Kingsport Press.

United States of Tara (2009 – 2011). Showtime Network.

Young, K. (1998). Internet addiction: The emergence of a new clinical disorder. CyberPsychology & Behavior, 1(3), 237 – 244. doi:10.1089/cpb.1998.1.237