Multiple Personality Disorder (MPD), long considered a rarity, a curiosity, and even a chimera, is being diagnosed, treated, and researched with increasing frequency. Rosenbaum has offered thoughtful reflection on why the condition was eclipsed and underrecognized for several decades.1 Since 1978, however, reports of large series have doubled the amount of known cases, 2y and MPD has received its own classification in DSM-III. M Pioneering neurophysiological and psychophysiological research has begun to bear fruit"'3 and treatment results have been presented.14 Courses on MPD have been offered and a society for its study has been launched. An updated bibliography with 350 entries became available.15
Despite its long inclusion among the recognized forms of mental illness, MPD remains a controversial condition, rarely deemed worthy of serious scientific interest.16 This is not difficult to understand. Normative concepts of psychological monism, identity, and responsibility are challenged by MPD.17 Its manifestations can be sufficiently dramatic and flamboyant as to inspire disbelief and strain credulity. The spectre of iatrogenesis hangs over MPD, and diminishes clinicians' comfort in making the diagnosis. Also, there is an unfortunate tendency to discount these patients' reports of abuse experiences as inevitably being the fruits of fantasy and/or confabulation.
The profession has been indifferent and/or skeptical toward MPD. Training programs rarely give substantial attention to the dissociative disorders or to hypnosis, and MPD, as Bliss has observed, is a hypnotic pathology.4 Most psychiatrists become familiar with it via its depiction in the lay media or through consultation after encountering a case (R. P. Kluft, unpublished data, 1980-I983).
MULTIPLE PERSONALITY DISORDER
Long grouped with the hysterias, MPD was reclassified as a dissociative disorder in DSM -II!. M) Many were surprised by the omission of amnesia as a diagnostic criterion. Braun and Braun unite classic and contemporary descriptions: ". . . one human being demonstrating two or more personalities with identifiable, distinctive, and consistently ongoing characteristics, each of which has a relatively separate memory of its life history . . . There must also be a demonstration of the transfer of executive control of the body from one personality to another (switching). However, the total individual is never out of touch with reality. The host personality (the one who has executive control of? the body the greatest percentage of the time during a given time) often experiences periods of amnesias, time loss, or blackouts. Other personalities may or may not experience this. "18 Females outnumber males 4:1 in the author's series.
Most cases in the older literature had relatively few personalities. Forty-eight of the 76 reviewed by Taylor and Martin had two, 12 had three.19 Only one had more than eight. However, among recent cases, "Sybil" had 16 personalities, "Eve," 22, and Billy Milligan, 24. Kluft reported a "modal range" of 8 to 13 personalities20; in one series of seventy, 55.7% had between two and ten, and 44.2% eleven or more.8 Very complex cases are known.21 When there are several personalities, there may be some which, were they the only other personality, would not have sufficient definition to qualify the patient for the diagnosis of MPD.20
Clinically, the personalities' overt differences and disparate self-concepts can prove puzzling and striking. They may experience themselves as of different genders, ages (older and/or younger), and sexual orientations. They may have separate wardrobes, possessions, pursuits, and interpersonal styles. Their values, beliefs, and manifest problems may diverge. Some may have symptoms which others do not experience.13 Their behavior reflects their inner senses of difference; they may have received completely different diagnoses before the MPD was discovered.
Psychophysiological variations are documented.13 Different handwritings and different handedness are seen. Voices, vocabularies, speech patterns, accents, and even languages may vary. The facial expressions of the several personalities, both when "neutral" and affectively engaged, may show dramatic and consistent differences, as may their movement characteristics. When personalities have acquired separate wardrobes, followed different interests, and chosen different avenues of creative expression, their distinctness can be marked. Dozens of colleagues have shared experiences of failing to recognize their patients (R. P Kluft, unpublished data, 1980-1983).
The different personalities usually have come into existence to serve defensive purposes. Many acquire a high degree of secondary autonomy and narcissistic investment in separateness. Convictions about autonomy may be held with a degree of intensity the author has termed "pseudo-delusional. " While not psychotic, personalities may behave with the conviction that the actions they take against other personalities will not affect "themselves" or "their body." They may try to kill one another, refusing to concede that the death of the body dooms all, or mutilate the body and say that the personality to whom they feel "that" body belongs is now ugly, while they are untouched.
The classic host personality, which often seeks treatment, is depressed, anxious, somewhat neurasthenic, compulsively good, masochistic, and conscience-stricken, constricted hedonically, and suffers both psychophysiological symptoms and time loss/distortion. While no personality types are invariably present, several are seen frequently: child-like personalities (fearful, recalling traumata, or love-seeking), protectors, helpers/advisors. Inner Self Helpers (glossary), guardians of memories and secrets (and of family boundaries), memory traces (glossary), inner persecutors (often based on identification with the aggressor), anesthetic personalities (glossary), expressors of forbidden impulses (pleasurable and otherwise, such as defiant, aggressive, or antisocial), avengers (which express anger over abuses done and may wish to redress the wrongs), defenders or apologists for the abusers, those based on lost love objects or identifications, specialized encapsulators of traumatic experiences and affects, very specialized ones (glossary), and those (often youthful) which preserve the idealized potential for happiness, growth, and the healthy expression of feelings distorted (by traumata) in others.
Several phenomena should be noted. Personalities may or may not be aware of one another. Some may have alliances, inner relationships, or ongoing civil wars. Some are protected and/or suppressed by others; ie, a child guarded by a protector, or an avenger or expressor of some feeling perceived as dangerous controlled by those who fear the consequences of such action or expression. Inner persecutors, a common type, often are responsible for resistance, self-harm, and suicide attempts. They may "punish" others for cooperating in therapy. They may be based on actual abusers or culturally-accepted representations of evil intent. In three recent cases, persecutors were an introjection of an abusive mother, a Nazi concentration camp guard, and the devil. The latter resembled a possession state,
PRESENTATION AND DIAGNOSIS
Florid and straightforward presentations are the tip of the iceberg; most are pleomorphic and perplexing. For example, a personality may qualify for its own diagnosis, or, if unrecognized switching and its consequences or battles for control predominate, a borderline or psychotic diagnosis may be reached. Quasi-physical symptoms may mask MPD.22
There has been such concern over false over-diagnosis that the risk of false negative diagnosis has been grossly underestimated .4-8-20.23-25 putnam, et al, reported 100 cases, which had averaged 6.8 years between initial mental health contacts and being diagnosed.9
Clinicians have low indices of suspicion, high indices of skepticism, and usually have never seen MPD apart from its representation in the media. In a research series of 73, approximately 5% presented self-diagnosed, but were generally disbelieved by their psychiatrists, 15% openly dissociated either during assessment (rarely) or during therapy (usually after months or years), 40% showed subtle hints which could have alerted a clinician to MPD, and 40% had shown no overt signs at all.20 The last group was discovered serendipitously or during the field-testing of new diagnostic protocols.8,20 More than half of them had come from a cohort of neurotic patients refractory after ten or more years of verbal therapy! Fifty-nine percent of the research series admitted they had withheld data which might have suggested the diagnosis.
Coons has authored an excellent recent review of diagnosis.25 Greaves cites eight suggestive signs (abbreviated): 1) Time distortion or time lapses, 2) Being told of disremembered behavior, 3) Observers' reports of notable changes, 4) Other personalities elicitable by hypnosis, 5) Use of "we" in a collective versus editorial sense, 6) Discovery of productions (such as writing or art) or objects among one's possession which neither can be recognized nor accounted for, 7) Severe headaches, 8) The hearing of voices, originating within, but separate, entreating toward good or bad deeds.7
Allison (R. B. Allison, unpublished manuscript, Psychotherapy of the Multiple Personality, 1978) and Braun have emphasized the importance of hypnosis in making the diagnosis.5·6 Braun6 and Kluft8·23 have discussed the overstated risks of false positives.
Diagnosis proceeds with the recognition that the patient may defensively withhold or misrepresent data, that the presenting personality may be unaware of the information the clinician needs to elicit to make the diagnosis (and therefore could not produce it despite his own strong motivation and the skills of the interviewer), and that confabulation or knowledge misstated as if it were memory (first described by Braun),26 may confound matters.24 When time is limited or a Clinical emergency exists, one may choose to press forward aggressively with hypnotic efforts, but generally, it is best to be unhurried and non-intrusive initially.5,8,;23
Direct and indirect data suggesting dissociation are accumulated. Hie patient is asked about problems with memory, and if he experienced any of the overwhelming experiences common in MPD histories. He is asked if, as a child, he was called a liar or blamed for things he disremembered doing, did he hear inner voices, did imaginary companions persist, and if he had any autohypnòtic experiences. Almost all patients had some difficulties in school. Often it seemed to them that the rest of the class had been taught something, but they had not. A youngster would be called on and be totally unfamiliar with the material; a straight A student might suddenly be incapable of performing.
Since most patients deny direct inquiry about amnesia early in treatment, or undo positive responses, indirect inquiries are made.20 Patients are asked if they had ever found something in their possession for which they could not account, ie, items or clothing they did not recall buying, unfamiliar handwriting on paper in their domicile, etc. They are asked if they ever experienced perplexing incidents in relationships, such as people behaving toward them in ways that suggested their relationship had been influenced by factors they could not explain. They are asked if people they did not know appeared to know them, or greeted them with a name other than their own. Questions about problems in school and at work, as described above, are asked. If any answers are suggestive, they are further explored as clinical circumstances permit. Patients are asked to write whatever thoughts pass through their minds for one half-hour each day and bring the written thoughts to the session. Many times personalities announce themselves through this diary method.
Many special hallucinations and passive influence experiences once considered pathognomonic for schizophrenia27 are common in MPD.20 These patients often hear voices arguing in their heads or commenting on their actions. They frequently experience their body under some form of influence, thoughts withdrawn from their minds, influence upon their mind by thoughts ascribed to others, and the sudden imposition of "made" feelings, impulses, and volitional acts. Especially among patients who have been suicidal, the majority have had several such experiences. Hence one's mental status exam may be expanded to include these items (ie, Schneiderian primary symptoms, exclusive of thought diffusion, delusional perception, and audible thoughts).27,28
It is clear that MPD may not become manifest despite years of clinical observation.9 Therefore, if exploration of the above indicators and a period of clinical observation does not resolve the matter, hypnosis is used in the diagnostic process.4-6,8
Although many articles on MPD have been published recently. and more are in press, the richest vein of clinical wisdom regarding MPD has been an oral tradition. Indeed, the purpose of this issue of Psychiatric Annals is to make aspects of that oral tradition, passed on in workshops and supervision, more generally available. A certain number of terms have acquired general use in these settings. Many definitions are taken or derived from Braun 's highly-regarded list of terms, which was circulated privately.26
1. Personality: an entity with a firm, persistent, and well-founded sense of self and a characteristic and consistent pattern of behavior and feelings in response to given stimuli. It must have a range of functions, a range of emotional responses, and a significant life history (of its own existence).20,26
2. Fragment: an entity, as above, but with a more limited range of function, emotion, or history. For example, a specialist in protection, one limited to the expression of anger, or one which assumes control for a limited period of time or a special circumstance.26
3. Special Purpose Fragment: a fragment with a very limited function, ie, a particular type of baking.26
4. Original Personality: "the identity which developed just after birth and split off the first new personality in order to help the body survive a severe stress."26
5. Birth Personality: synonym for 4.
6. Host Personality: "the one who has executive control of the body the greatest percentage of time during a given t'ime.",s
7. Primary Personality: an ambigöus term which has been used as a synonym for 4 and 6. Difference determined by context.
8. Presenting Personality: whichever personality "presents" itself for therapy.
9. Alternate: denotes a personality other than the original, host, or presenting. Determined by context.
10. Alter: a generic term for any personality or fragment"·2" useful because, in clinical situations, it often is unclear, for protracted periods, which personalities are original, host, presenting, etc., or whether an entity is sufficiently distinct and elaborate for a more precise label.
11. Inner Self Helper (ISH): described first by Allison.2" these are serene, rational, and objective commentators and advisors.
12. Memory Trace Personality: rather neutral and non-interventive with more or less access to the thread of historical continuity over the patient's life. Ascribed to Wilbur.30
13. Anesthetic Personality: has the (autohypnotic) capacity to be impervious to pain, and is developed to endure abuse. Independently described by several sources.9,20,26
14. Ego State: as defined by Wafkins and Watkins, this is "an organized system of behavior and experience whose elements are bound together by some common principle but are separated from one another by boundaries which are more or less permeable." Whereas all personalities can be defined as ego states (hence the synonymous use of the terms), all ego states are not personalities. The Watkins' conceptual scheme understands the human personality to be divided into organized subsystems called ego states.31
15. Hidden Observers: a term used by Hilgard 32 to denote covert cognitive systems which 1) continue to register ongoing experiences and sensations even when they are hypnotically suggested out of awareness; and 2) can be accessed and interviewed. The theoretical importance of these findings for the understanding of MPD cannot be overstated.
16. Co-consciousness: Prince33 used this term to describe the awareness of one personality of the feelings, actions, and thoughts of another.
17. Co-presence: Kluft 's20,23 term for the influence of one personality on another to the extent that the personality ostensibly in control has its behavior or affective state altered. It facilitates description of the passive influence experiences quite common in the condition, and links the modern literature to the "lucid possession" form of MPD described by Ellenberger. 16 A crisis of copresence20·23 denotes alters' struggling to control the body.
18. Splitting: "creating a new personality."26
19. Switching: "changing personalities between already existing ones."26
20. Shifting: synonym of 19.
21. Fusion: the unification of personalities, spontaneously, in the course of therapy, or via hypnotic suggestion. Criteria have been published.8
22. Integration: used by some as a synonym for 21 . However, others understand it to denote a more pervasive and thorough psychic restructuring, and see fusion as more of a "compacting" process, which is preliminary to it (B. Braun, personal communication, 1983).
1. Rosenbaum M: The role of the term schizophrenia in the decline of diagnoses of multiple personality. Arch Gen Psychiatry- 1980: 37:1383-1385.
2. Braun BO: Hypnosis for multiple personality, in Wain JH (ed): Clinical Hypnosis and Medicine. Miami. Year Book Medical Publishers. 1980.
3. Allison RB. Schwarz T: Minds in Many Pieces. New Yost. Rawson Wade Pubs Inc. 1980.
4. Bliss EL: Multiple personalities. Arch Gsa Psychiarn 1980; 37:1388-1400,
5. Brain BC: Hypnosis for the diagnosis of multiple personality. A paper presented at a Course: Multiple Personality: Finding and Fusing (R. Allison, Director), at the Annual Meeting of the American Psychiatric Association. Chicago. May 1979.
6. Braun RU: Hypnosis creates multiple personality: Myth or reality. In,) C/In Er Hsy,n 1984. in press.
7. Greases C: Multiple personality: 165 years after Mary Reynolds. ./ Meet' Men, Di, 1980; 168:577.596.
8. Kiuft RP: Varieties of hypnotic interventions in the treatment of multiple personality. Am IC/in ll,vpn 1982: 24(4)130-240.
9. Putnam FW. Post kM. Curoff II, et al: 100 cases of multiple personality disorder. Presented at the Annual Meeting of the American Psychiatric Association. New Research Abstract #77. New York. May 983.
10. American Psychiatric Association: Diagnostic and Statist lea! Manual Ill, Washmgton. DC, American Psychiatric Association. 1980.
11. Putnam FW: Traces of Eve's faces. Psychology Today 982; 16(101:88.
12. Cohen lit Multtple personality shown to be a distinct clinical entity. Psychiatric News 1982: 0(7): I.
13. Braun BG: Psychophysiologic phenomena in multiple personality and hypnosis. Am) CNn Flvpn 1983; 26(2). in press.
14. KIufi RP: Treatment results in multiple personality. Psyc'hiatr C/in North Am 984: 7(1), in press.
15. floor M. Coons P: A comprehensive bibliography of literature pertaining to muhiple personality. Psycho! Rep 1983: 53:295-3)1).
16. Ellenberger H: The Discovery c(the Unconscious. New York. Basic Books, [970.
17. Beahrs JO: Unity and Mulxiplkint New York. Brunner/Mazel. 1982.
18. Braun BC. Braun RE: Clinical aspects of multiple personality. Paper presented at the Annual Meeting of the Americas Society of Clinical Hypnosis. San Francisco, November 1979.
19. Taylor WS, Martin ME: Multiple personality. Journal of Abnormal on) Soda! Psvrlsologv 1944; 39:281-300.
20. Klull RP: Epidemiology of multiple personality. Paper presented at a Course. Multiple Personality: Finding and Fusing (R. Allison. Director), at the Annual Meeting of the American Psychiatric Association. Chicago, May 1979.
21. Klufr RP: The very complex multiple personality. Pbper presented at the Annual Meetiag of the Anserican Society of Clinical Hypnosis. Dallas, November 1983.
22. Kltafi RI': Multiple personality in general medical populations. Pennsylvania Medicine, to he published.
23. Kluft RP: I-lypnotherapeutic crisis intervention in multiple personality. An, I C/in Hypn 1983: 26(2). in press.
24. Kluft RP: Diagnosis of multiple personality. Paper presented at a Course. Mrdtiple Personality. Diagnosis and Treatment (R.P. KIuft and 8.0. Bnsun. Directors), at the Annual Meeting of the American Psychiatric Association. New York. May 983.
25. Coons PM: Multiple personality: Diagnostic considerations. I C/in Psychiatry 1980: 170:330-336.
26. Braun BC: Muitiplictty: Form. Function, and Phenomena. Copyrighted Mantiscript. Chicago, 1983.
27. Schneider K: Clinical Psychopathology. New York. Grune and Stratton. 1959.
28. MeIlor CS: First rank symptoms of schizophrenia. Br J Psychiatry 970: 117:15-23.
29. Allison R: A new treatment approach for multiple personality. Am) C/in Ilypn 1Q74; 17111:15-32.
30. Schreiber F: Sybil. Chicago. Regnery. 1973.
31. Watkins Xi. Watkins ITH: Ego states and hidden observers. Journal of Altered States of Consciousness. 1979-1980: 5:3-IS.
32. Hilgard E: Multiple Controls in Human Thought and Action. New York. John Wstey and Sons. 1977.
33. Prince M: The Diasoc'iario,s of a Personality. London. Longmans Green and Company, 905.