Psychological Concepts and Dissociative Disorders

Raymond M. Klein, Benjamin K. Doane, Raymond M. Klein, Benjamin K. Doane

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780805805161
• Edition: 1
• eBook ISBN:
  9781134752294
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This book is based on a symposium that was inspired by the late Donald O. Hebb who, in his latter years while an Honorary Professor in the Department of Psychology at Dalhousie University, became very interested in the phenomenon of multiple personality and other dissociative states. Hebb was troubled by the lack of understanding of dissociative behavior and, through his discussions with basic science and clinical colleagues in psychology and psychiatry, he became convinced that the subject would be a figurative gold mine for psychological theory and experimentation. The purpose of the symposium was to bring together clinical and research scientists with an interest and expertise in dissociative phenomena such as multiple personality disorder, hysteria and hypnosis. This group would exchange ideas and findings, discuss theory, and lay the groundwork for an interdisciplinary research program into dissociative phenomena generally, and more specifically into multiple personality disorder and its principal precipitating factor -- physical and sexual abuse in children.

I

CLINICAL ANALYSIS

1

Multiple Personality Disorder: Observations on the Etiology, Natural History, Recognition, and Resolution of a Long-Neglected Condition

Richard P. Kluft

The Institute of Pennsylvania Hospital

Multiple personality disorder (MPD) is a complex chronic dissociative psychopathology characterized by disturbances of identity and memory (Nemiah, 1981). These disturbances are rather consistent. They change relatively slowly over time in the absence of clinical intervention or major life changes, but may be altered over the passage of many years (Kluft, 1985a, 1991a). The ongoing coexistence of relatively consistent but alternating separate identities (called personalities) associated with recurrent episodes of memory distortion, frank amnesia, or both (episodes that correlate with the alternation of the separate identities) distinguish MPD from all other mental disorders (Kluft, 1985b, 1987a; Putnam, Loewenstein, Silberman, & Post, 1984).

Until recently, MPD was not a major subject of concern to the mental health disciplines, either clinical or academic. MPD was considered quite rare, and its legitimacy as a naturalistically occurring mental disorder was openly doubted. Many psychotherapists and researchers considered it a virtual psychiatric dinosaur, a syndromic relic of a more naive era left behind long ago. Stengel offered the most drastic statement of this nature when, in 1943, he declared the condition extinct.

Over the course of a decade, however, MPD has once again entered the mainstream of North American psychiatry, and cases are being recognized and treated in Europe, Asia, Africa, and Australia (Coons, Bowman, Kluft, & Milstein, 1991). Clearly, Stengel’s obituary has proven somewhat premature.

It is the purpose of this chapter to comment briefly on the recent rise in recognition of MPD, and thereafter to offer a series of observations on the etiology, natural history, recognition, and resolution of this long-disregarded condition. These remarks are made from the perspective of a clinician-researcher who has worked with MPD patients for more than 20 years, interviewed over 2,000 patients who were under assessment for possible MPD, observed over 600 patients with this disorder, and treated over 140 patients to the point of integration. Consequently, they emerge from the more murky and roiled waters of clinical practice and lack the crisp and clean qualities of findings from the academic setting, in which the more detailed and controlled study of a smaller number of subjects can be carried forward. Hopefully, the loss in precision is somewhat compensated for by the likelihood that the sample that has been observed is much more representative of the overall population of MPD patients than a smaller series would be.

THE RECENT HISTORY OF MPD

The commonly accepted history of MPD is that a small number of cases were identified throughout the early and middle 19th century; that a good number of cases were reported in the era of Charcot and Janet and, in the United States, in the era of Morton Prince and Borus Sidis; and that then relatively few additional cases were reported prior to the 1980s. Articles from the early parts of that decade generally stated that the world’s literature consisted of approximately 200 to 300 cases. MPD was considered to be quite rare.

Unfortunately, this history is more than somewhat misleading. Fine (1988 and personal communication, 1986-1988) discovered that several large series of MPD patients in the French literature had remained unknown to most students of the condition, and there is reason to believe that experiences and databases of many European contributors of the last century continue to be unknown to contemporary scholars. It is dubious that MPD was terribly rare when clinicians were aware of it as a significant psychopathological entity. With the rise of Freudian concepts and with Bleuler’s declaring MPD a form of schizophrenia, and with the predominance of behaviorism in academic psychology, interest in dissociation and the dissociative disorders waned for nearly two generations. Case reports were few. The publication of Thigpen and Cleckley’s The Three Faces of Eve (1957) excited public interest in MPD, but the thrust of this account was that “Eve” was the only case of MPD recognized anywhere in the world. Hence, it did not create a higher index of suspicion for MPD among the mental health community. It is of interest that these authors, in near-total disregard of the contemporary literature, continue to insist that the condition is very rare and that they have seen only one additional genuine case (Thigpen & Cleckley, 1984).

With the publication of Sybil in the lay literature (Schreiber, 1973) and “The objective study of a multiple personality” (Ludwig, Brandsma, Wilbur, Bendfeldt, & Jameson, 1972), it became evident that a clinician knowledgeable about MPD could identify a number of contemporary cases. Cornelia B. Wilbur, whose successful treatment of “Sybil” was the basis for the popular book of that name, diagnosed several MPD patients, and became a valuable resource to an increasing number of mental health professionals who were confronting patients with MPD and looking for guidance as to how to proceed. Her influence is discussed in a recent text (Kluft & Fine, 1993). Ralph B. Allison reported experience with a series of over 30 MPD patients in the 1970s (Allison, 1974, 1978). Unfortunately, some of Allison’s rather idiosyncratic ideas and unconventional conceptualizations have obscured the recognition that many of his clinical observations have proven very useful and sound.

Allison, in collaboration with Wilbur and other pioneers such as the late David Caul, organized the first American Psychiatric Association courses on MPD in 1978. These courses, which continue to the current day under the direction of Richard P. Kluft, and Bennett G. Braun, became a major resource for the education of mental health professionals about MPD; the faculty and students of these courses became major figures in spreading knowledge about this condition across the United States and Canada.

By the late 1970s, a rising interest in MPD could be noted and this was expressed by the publication of a number of important articles on MPD in the professional literature in 1980. Of these, George Greaves’ 1980 study, “Multiple personality: 165 years after Mary Reynolds,” is of particular significance. Greaves received over 6,000 requests for reprints. This astonishing response indicated that a large number of clinicians had reason to be interested in MPD. It also inspired Dr. Greaves to begin the ancestor of what has become the 2,800-plus member International Society for the Study of Multiple Personality & Dissociation. In the same year, DSM-III (American Psychiatric Association, 1980) listed MPD as a freestanding member of a new class of mental disorders, the dissociative disorders, and provided useful diagnostic criteria and descriptive text.

In 1984, several special journal issues on MPD were published (American Journal of Clinical Hypnosis, 26:2, Oct. 1983 [not mailed until 1984]; Psychiatric Annals, 14:1, Jan. 1984; Psychiatric Clinics of North America, 7:1, 1984; International Journal of Clinical and Experimental Hypnosis, 32:2, June 1984), and the foundation of a credible scientific literature on MPD had been established. An increasing number of articles on MPD entered mainstream psychiatric journals and, in 1988, Kluft and Fine began Dissociation, a journal dedicated to the study of dissociation and the dissociative disorders.

This increase in the discussion of MPD within scientific publications and forums was matched by a rise in the number of clinical reports of contacts with large series of such patients. Between 1974 and 1987, at least 11 investigators or groups had reported experience with 10 or more MPD patients (Kluft, 1987a), and as many large series again have been reported at the First through Fifth (1984 1988) International Conferences on Multiple Personality/Dissociative States. A particularly significant series of 50 MPD patients was published by Coons, Bowman, and Milstein in 1988. This mounting number of reported cases led to the removal of the designation “rare” from the description of MPD in DSM-III-R (American Psychiatric Association, 1987). More recently additional large series have been reported by Ross, Norton, and Wozney (1989), Ross et al. (1990), and Schultz, Braun, and Kluft (1989).

It is appropriate to ask why this exponential increase in interest and reporting has occurred. Having demonstrated it, what drives it? Although many skeptics dismiss it as a faddish preoccupation, more substantial reasons may be offered. The following attempt to explain these upsurges is far from comprehensive, but it addresses several important considerations.

The progress of psychopharmacology and biological psychiatry has generated many powerful organic approaches to the understanding and treatment of mental disorders. With effective medications for so many major disorders, the patients who fail to respond to adequate treatment for the conditions that they first appeared to have often receive more careful scrutiny. A history of treatment failure for a major (and usually drug-responsive) mental disorder is a characteristic of the backgrounds of MPD patients. The phenomenologic orientation of the DSM-III and DSM-III-R, under the direction of Robert L. Spitzer, was instrumental in effecting a realization that MPD was not a form of hysteria, schizophrenia, or borderline personality disorder. Once correctly classified and adequately described (despite minor difficulties), a firmer foundation was laid for its clinical recognition and scientific study.

Historically, periods in which hypnosis is studied intensely are periods in which MPD is recognized and studied with greater frequency. Hypnosis has been enjoying a renaissance since the 1970s. This has been a mixed blessing, however. Many outstanding authorities in hypnosis have extrapolated from their own areas of expertise to reach pronouncements about MPD that are nearly devoid of connection to the clinical reality of the condition, and/or offered wide-reaching generalizations on the basis of quite limited data.

Lay attention to MPD has been extensive. It captures the imagination of the public. Often, the very drama of the condition has made it appear a subject more fit for soap opera than for science. Few long-standing television series have failed to exploit the sensationalistic aspects of MPD. It is a simple historical fact that MPD was rarely discussed in depth in the training programs of the mental health professions for over two generations, and still has not entered the curricula of the mental health disciplines in many areas. Consequently, until the last few years, the average mental health professional gained most of his or her vicarious knowledge about MPD from lay sources. Of these lay sources, Sybil (Schreiber, 1973) was the most influential. For better or for worse, the media has made MPD part of today’s popular culture.

The striking, albeit preliminary descriptions of the psychophysiologic expressions of the several personalities, and of the differences among them, have attracted considerable attention. Here, the work of Putnam (1984, 1991a, 1991b) is most noteworthy. Despite the interest shown in Putnam’s research, few have appreciated the cautions that Putnam has repeatedly expressed about the risks of overinterpreting his findings.

The efforts of dedicated teachers to spread information about MPD have been important. Before articles on MPD became readily accessible, it was the work of this relatively small group, many of whom were very charismatic individuals whose clinical expertise was readily apparent, who shared their knowledge with others and established what Kluft (1984a) described as the “oral literature” of work with MPD.

The two most important factors prior to 1984, however, are none of the aforementioned—they are feminism and the aftermath of Vietnam. Prior to feminism and the increasing importance of women in the mental health professions, one could speak of allegations of sexual abuse and incest as if they were the fantasies of hysterical females without encountering substantial challenge. In fact, this attitude was quite prevalent. It may be hard to realize today that, in the 1970s, major psychiatric texts were stating that the true incidence of incest was one in one million (e.g., Henderson, 1975). The consciousness raising of the feminists and the infusion of more women into the mental health disciplines have made it increasingly difficult to deny the unconscionable prevalence of the sexual abuse of women, and of children of both genders. Now it is appreciated that the true incidence of broadly defined incest is that close to 16% of female children are thusly affected (Russell, 1986), and that their allegations can be substantiated in the vast majority of cases (Herman & Schatzow, 1987). When one addresses an auditorium full of mental health professionals such as those who attended the Hebb Symposium that inspired this book, one does so in appreciating that one is likely to be addressing colleagues who are survivors of the very experiences that were discounted as fantasies not very long ago. Because MPD is largely a disorder of sexually victimized women, a new awareness of the prevalence of sexual abuse and a new freedom to discuss it have spurred a new acceptance of MPD.

Among the terrible legacies of Vietnam were a delayed but finally implemented study of posttraumatic stress disorder (PTSD) and a recognition that the capacity to commit atrocities is far from rare. As scientific investigators and clinicians struggled to learn about PTSD and to treat it, it became clear that many of the symptoms of PTSD are dissociative, and that dissociation is commonly associated with trauma. Putnam’s masterful review (1985) clearly demonstrated the connection of dissociation with traumatic experiences, and Spiegel (1984, 1986a, 1991) was the first to publish what many were observing—that MPD is closely allied to and may be a form of PTSD. The cross-fertilization of progress in studying PTSD and MPD has been impressive. Many professionals who had no difficulty in accepting the PTSD findings but who were most skeptical about MPD became able to understand and accept MPD when they realized that its similarity to PTSD was compelling.

The factors just noted explain a large part of the rising interest in MPD that developed in the late 1970s through the mid-1980s. More recently, the major influences have included: (a) the fact that increasing numbers of clinicians, sensitized by the aforementioned, have encountered their first MPD patients or have learned that a respected colleague has done so; (b) the increasingly substantial and accessible literature in the field; and (c) the rise of cognitive psychology, which, with its interest in the mind’s processing of information, finds many of its principles consistent with the clinical phenomenology of MPD.

THE ETIOLOGY OF MPD

On a clinical and descriptive level, MPD is, intrinsically, no more exotic than a brutalized child’s whimpering in the night and wishing with desperate earnestness that he or she were someone else, somewhere else, and that what had befallen him or her had befallen someone else. Most parsimoniously put, MPD appears to be a dissociative posttraumatic condition of childhood onset (Kluft, 1987a, 1991B). Throughout any discussion of MPD it is important not to lose sight of the fact that most “fascinating” cases of MPD, like beautiful cultured pearls, no matter how lustrously they shine and how wondrous they are to behold, are the organism’s attempt to wall off and survive a deliberately inflicted and totally unnecessary traumatic insult.

Over 90% of studied cultures have dissociative syndromes in which another entity takes over control of the body and behaves in a different manner. Some of these conditions appear related to unique social stressors within those societies, some to the life experiences of the victims. These syndromes are often described as possession, and MPD appears to be the secular expression of the Judeo-Christian possession state (Ellenberger, 1970). It is indeed ironic that those who have studied the literature on the witches and witchhunts indicate that one of the frequent “chief complaints” of those who were declared to be witches and later burned at the stake was that their father had lain with them. Because this was deemed to be impossible, or at least unlikely in a patriarchal society, the prevailing theory became that the devil or one of his minions had assumed the guise of the father and had lain with the woman. It was therefore assumed that she was possessed, and it naturally followed that she should be destroyed, and, pari passu, the threat to the social order that was posed by the woman’s allegations was relieved (J. Goo...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• Preface
• Introduction Demystifying Dissociative Phenomena
• I Clinical Analysis
• II Psychological Concepts
• III Scientific Analysis
• IV Round Table Discussion
• Name Index
• Subject Index