Dissociation and the Dissociative Disorders

(and a Couple of Papers on Somatization)

Kihlstrom, J.F. & Hoyt, I.P. (1990). Repression, dissociation, and hypnosis. In J.L. Singer (Ed.), Repression and dissociation: Implications for personality theory, psychopathology, and health (pp 181-208). Chicago: University of Chicago Press.

Kihlstrom, J.F. (1992). Dissociative and conversion disorders. In D.J. Stein & J. Young (Eds.), Cognitive science and clinical disorders (pp. 247-270). San Diego: Academic.

Kihlstrom, J.F., Tataryn, D.J., & Hoyt, I.P. (1993). Dissociative disorders. In P.J. Sutker & H.E. Adams (Eds.), Comprehensive handbook of psychopathology, 2nd Ed (pp. 203-234). New York: Plenum.

Angiulo, M.J.  (1993).  Screening instruments for dissociative disorders: Their evaluation in a college population.  Unpublished doctoral dissertation, University of Arizona.

Kihlstrom, J.F., & Canter Kihlstrom, L. (1999). Self, sickness, somatization, and systems of care. In R.J. Contrada & R.D. Ashmore (Eds.), Self, social identity, and physical health: Interdisciplinary explorations (pp. 23-42). New York: Oxford University Press. 

Kihlstrom, J.F. (2001). Dissociative disorders. In P.B. Sutker & H.E. Adams  (Eds.), Comprehensive handbook of psychopathology, 3rd ed. (pp. 259-276). New York: Kluwer Academic/Plenum.

Kihlstrom, J.F.  (2005).  Dissociative disorders.  Annual Review of Clinical Psychology, 1, 227-253.

Kihlstrom, J.F.  (2010).  Dissociative disorders.  In I.B. Weiner & W.E. Craighead (Eds.), The Corsini Encyclopedia of Psychology, 4th edition (Vol. 2, pp. 512-513). New York: Wiley.

Angiulo, M.J., & Kihlstrom, J.F. (2010).  Dissociative experiences in a college population.  Unpublished ms., University of Arizona.

Does DID Belong in the DSM?

In 2009, a "Group of Concerned Psychiatrists and Psychologists", disturbed over the excess of the DID industry and the recovered-memory movement, circulated a petition to the task force preparing the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-V), either that the diagnosis of Dissociative Identity Disorder (DID) should be removed from DSM "completely", or else removed to an appendix of "experimental criteria" subject to further investigation before being listed definitively as an official diagnosis.  

The Petition

DID is an extremely controversial diagnosis, and while I do not agree with it, the petition makes an extremely strong case against the diagnosis.  In the service of promoting better understanding of the debate, which has at least three sides, I quote from the petition below (those who originally wrote the document asked recipients to circulate it freely).

The evidence supporting this diagnosis as a distinct mental disorder is modest whereas much suggests it to be a behavioral artifact equivalent in nature to pseudo-epilepsy generated by suggestion in vulnerable people. Its identification as a special, separate diagnostic entity in DSM has harmed the practice of psychiatry and undermined its scientific credibility. Although it is important for us to provide evidence to support these statements, we wish to avoid excessive detail, given that such evidence has been documented widely in the published literature.

 

Origins

The notion of dual personalities was founded upon cases of bipolar illness (1) and was followed by the idea of extra personalities.  This expansion first occurred with the hypnotically-induced introduction of a second personality and the deliberate naming of those personalities as if they were separate entities (1).

 

Prevalence

Taylor and Martin (2) recognized a total of 76 cases occurring between 1816 and 1944—slightly more than one every two years; they thought a similar number might be unreported. In 1954 Thigpen and Cleckley (3) reported their case, which was published as “The Three Faces of Eve” in 1957. After a film was made of this case, the numbers of reported cases increased steadily; there was a further dramatic leap after the film of “Sybil”. By 1990 thousands of cases were being diagnosed; some authors identified more cases in their personal practices than had been described in the literature over an entire century.

 

Twentieth Century Suggestion

As is well known, Sybil, a patient of Dr. Cornelia Wilbur, was fully aware that her therapist wanted her to create extra personalities (4).  In 1973, Dr. Wilbur gave tape recordings of Sybil’s interviews to Schreiber [the journalist who reported Sybil as a case of multiple personality disorder (5)]. Schreiber made the recordings available to Ronald Rieber, a professor of psychology, who amassed evidence showing that at least some of the personalities were artifacts overtly created in treatment (6).

 

Etiology

Dissociative Identity Disorder is often alleged to result from repressing an experience of childhood sexual abuse. This claim has not received adequate scientific validation. For example, Piper and Merskey (7) reviewed all the studies that claimed to corroborate DID patients’ abuse recollections. These authors concluded that “no evidence supports the claim that DID patients as a group have actually experienced the traumas asserted by the disorder’s proponents” (7). 

Proponents of the DID diagnosis assert that horrific, repeated childhood physical and sexual abuse is the primary cause of DID.  Victims supposedly develop their multiple personalities as repositories for traumatic memories that the “host” personality is unable to tolerate consciously. The DID diagnosis thus relies on the concept of traumatic Dissociative Amnesia (DA or “repression”): the notion that the mind protects itself by banishing terrifying memories from awareness, rendering them inaccessible until the person feels psychologically safe to recall them, often years later.  There is no convincing evidence that victims can become incapable of recalling genuinely traumatic experiences, as the trauma theory of DID requires (8). Indeed, an extensive survey of the historical literature, including both fictional and non-fictional written works in multiple languages, found no written example of “dissociative amnesia” prior to 1786 (9).  Thus the notion of “repressing” a memory itself, like DID, appears to represent a recent culture-bound phenomenon, rather than a naturally occurring human psychological process.  

In a comprehensive analysis of studies of people with documented trauma histories, not a single mention of spontaneous amnesia for the traumatic event was found—unless the forgetting was attributable to either organic amnesia or childhood amnesia (10).  Finally, an examination of Freud’s original work gives reason to think that the evidence from psychoanalysis for repression is also very unsatisfactory (11, 12). 

 

Harmful Effects

Due to the assumption that trauma is a primary etiological factor, the DID diagnosis has resulted in wrongful accusations of sexual abuse on the basis of recovered memories, not only in North America but throughout the developed world (references). DID has caused mockery of psychiatry, and, for patients, has led to misdiagnosis (13), mismanagement (14) and inadequate treatment of depression (15).

 

Lack of Consensus

Canadian and American psychiatrists show little consensus regarding the diagnostic status and scientific validity of DID. In surveys of board-certified psychiatrists in the United States (16) and Canada (17) fewer than one-third of Canadian psychiatrists and 35% of American psychiatrists replied that DA & DID should be included without reservations in the DSM-IV; fewer than 1 in 7 Canadian psychiatrists and only 21-23% of American psychiatrists replied that there was “strong evidence of validity” for these disorders.  French- and English-speaking Canadians had similar opinions.

 

Conclusions

There are overwhelming reasons to question the validity of Dissociative Identity Disorder. We respectfully urge you as members of the Work Group and the Task Force to drop the category of dissociative disorders from the upcoming DSM-V: it is harmful to patients and their families, scientifically unjustified, and undermining the credibility of psychiatry.

 

REFERENCES

1.      Merskey, H. (1992a). The manufacture of personalities. The production of multiple personality disorder.  Brit. J. Psychiat., 160:327-340.

2.      Taylor W.F. & Martin M.F. (1944) Multiple personality.  J. Abnormal & Soc. Psychol., 39:281-330.

3.      Thigpen, C.H. & Cleckley, H.M.  (1957). The Three Faces of Eve.  New York : McGraw-Hill.

4.      Spiegel, H.  (1993) Mistaken Identities: Toronto .  Canadian Broadcasting Corporation.  The Fifth Estate, 9 November 1993.

5.      Schreiber, F.R. (1973) Sybil.  Chicago : Henry Regnery.

6.      Rieber, R.W. (2006) The Bifurcation of the Self.  The History and Theory of Dissociation and Its Disorders.  New York : Springer Science.

7.      Piper, A., Merskey, H., (2004). The persistence of folly: a critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept. Can J Psychiatry 49 (9): 592-600.

8.      McNally, R. J. (2003) Remembering Trauma. Belknap Press/Harvard University Press: Cambridge , MA .

9.      Pope, H.G. Jr., Poliakoff, M.B., Parker, M.P., Boynes, M.D., & Hudson , J.I. (2007)   Is dissociative amnesia a culture-bound syndrome?  Findings from a survey of historical literature.  Psychol. Med., 37(2):225-233.

10.  Pope, H. G. Jr., Oliva, P., Hudson , J.I.: (2005) Repressed memories. The scientific status of research on repressed memories, in Modern Scientific Evidence: The Law and Science of Expert Testimony—Social and Behavioral Science, 2005-2006 Edition. Edited by Faigman D, Kaye D, Saks M, Sanders J. Eagen, MN, West Group, pp 408-447.

11.  Esterson, A. (1993) Seductive Mirage.  Open Court: Chicago .

12.  Crews, F. (1998) Unauthorized Freud: Doubters Confront a Legend.  New York : Viking.

13.  Freeland, A., Manchanda, R., Chiu, S., et al. (1993) Four cases of supposed multiple personality disorder: evidence of unjustified diagnoses.  Can. J. Psychiat., 23: 245-247.

14.  McHugh, Paul R. (2008) Try to Remember: Psychiatry’s Clash over Meaning, Memory, and Mind. Chapters 4 &5. Dana Press.

15.  Fetkewicz, J., Sharma, V. & Merskey, H. (2000) A note on suicidal deterioration with recovered memory, treatment.  J. Affect. Dis., 58:155-159.

16.  Pope, H.G., Jr., Oliva, P.S., Hudson, J.I., Bodkin, J.A. & Gruber, A.J. (1999) Attitudes toward DSM-IV Dissociative Disorders Diagnoses among Board-Certified American Psychiatrists.  Am. J. Psychiat., 2000; 157:1179-1180.

17.  Lalonde, J.K., Hudson , J.I., Gigante, R.A. & Pope, H.G. Jr.  (2001) Canadian and American psychiatrists’ attitudes toward Dissociative Disorders diagnoses. Can. J. Psychiat., 46(5): 407-412.

I have a lot of sympathy with this point of view, but do not agree that DID (or, indeed, any of the other dissociative or conversion disorders) should be removed from the psychiatric nosology.

My Reply

I replied as follows:

I'm sorry, but I won't be able to join your petition to remove Multiple Personality Disorder/Dissociative Identity Disorder, or indeed any of the dissociative or conversion disorders, from DSM-V.  Nor can I support a "compromise" position to move MPD/DID to Appendix B.

I am, of course, completely aware of the mischief incident to the MPD "epidemic" of the 1980s.  And I share your view that the vast bulk of these cases have been misdiagnosed.

I agree that it is an exceedingly rare syndrome (though I believe that the "epidemic" began with Sybil, which was a fairly clear case of clinician enthusiasm run amuck, rather than with Eve, who was rather carefully and skeptically diagnosed). 

And I agree completely that there is no good evidence, and in fact only the very worst kind of clinical evidence, favoring the claim of some clinicians that MPD/DID has its etiology in repressed or dissociated childhood sexual abuse -- which means that I am also opposed to any proposed reclassification of MPD/DID as a variant on PTSD. 

But we observe "dissociations" of the kind implicated in the dissociative and conversion disorders every day in the hypnosis laboratory, so it is clear that profound divisions of consciousness are possible.  And if they are possible for college sophomores, it is possible for those same dissociative processes to go awry, leading to (rare) cases of dissociative and conversion disorder.  So, however rare it might be, and I believe that all the evidence indicates that it is very rare indeed, there is no question in my mind that MPD/DID is a valid diagnosis.  This is why I have written extensively, positively if appropriately skeptically, about the dissociative and conversion disorders, and the functional amnesias.  See, for example, the reviews collected on my website, http://socrates.berkeley.edu/~kihlstrm/DissDisMaster.htm.

If your objection were simply to the official acceptance (in DSM-V) of the trauma theory of MPD/DID, or its reclassification as a variant on PTSD, I should be very happy to sign on.  Either move would be a grave mistake for a field of medicine that purports to be based on science, and put the mental health professions on track for another 30 years of mischief.  But given that the objection is to the diagnosis in the first place, there is an irreconcilable difference between us, and I just can't join you.

This page last revised 01/17/2011 06:56:51 PM.