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I ain't got a clue as to  why the various font sizes and colors are different. Sorry.   

Words of wisdom from multiples, their friends & families  
  There are several scientific articles included. Though they may be long, and we don't agree with all of the information, they are for the most part, very enlightening and significant to us.
All articles and essays are owned by their writers.Copyrights may be involved.


Then... What Am I?by Jennifer Lee Combies
I talk about my existence as a whole separate person within a multiplicity system

The Klatch, Medication, and Death  by Julie Rae Combies
We were misdiagnosed with various mental illnesses and put on medication that harmed us
 
Things I Can't Stand   by Luna Diana CombiesI talk about the frustrating behaviors of singlets and other outsiders 

We Are Not DID Or MPD by Miakoda Celena Combies
I analyze the definitions of DID and MPD and i;llustrate how we do not fit either! 


Searching for Convergence 


What is activism by Mark & GY


One Brain, 2 Selves  


A new Model of DID 

A new (and hopeful) spin on Integration (thank you Hail of the Fall Family for finding this counter-integration link)

Integration-a-requirement-for-DID-therapy-or-not?-AWESOME!!!

Mirror writing and DID 

Probing the egnigma of Multiple personality 

Dissociation and Transformation 

Multiple Personality Disorder: an alternative theory’ 

 A New Focus on Multiple Personality

Sighted and blind in one person: a case report and conclusions on the psychoneurobiology of vision 

Multiplying models: Personal identity, dissociation and the possibility of healthy multiplicity 




Know Thyselves: Theorizing Multiple Personality through Social Movements


Alterity: Learning Polyvalent Selves, Resisting Disabling Notions of the Self 

Normal Dimensions of Multiple Personality Without Amnesia 

Towards a theoretical framework of the etiology and structures of multiple personality


Cultural-bound aspects of dissociation


Critiquing the requirements


An International Perspective


Fact or factious 


Exploring Multiple personalities

Woman with DID blind for over a decade regains sight-Brain decoder

Here's a quote I've seen several places, but I can't find the source. Can any body help?
"The treatment outcome that David Caul hoped for when working with people with multiple personalities would be applicable to all of us: "It seems to me (David Caul) that after treatment, you want a functional unit, be it a corporation, a partnership, or a one-owner business" (Kluft, 1987, p.370)"
                                             
 


Then What Am I? 
“Person ”
  
  - (Philosophy) a self-conscious or rational being.
  - the actual self or individual personality of a human being...
 
 What I know about “person”....

People feel. They can feel love. They feel hurt. They can feel angry. They can feel many many emotions.

 People dream. They dream about things they wish they could do. They dream about the future. They dream about so many many things.

 People think. People think about what they are. People contemplate the world around them. People think many things.

 What I know about myself...

 I feel. I have m y own emotions that are my own, all my own, and no one else’s. I can feel happy, I can feel angry, I can feel hurt.

 I dream. I have dreams of my own, all my own, and no one else’s. I dream someday being seen for who I am. I dream of beating all 3 USA Super Mario titles on the NES. I dream of not having to worry what outsiders want with me. I dream of many things.
 
 I think. I have thoughts that are my own, all my own, and no one else’s. I think about what I am. I think about who I am. I think about why people don’t see me as me. I think about why people have to go out of their way to tell me what I’m not.

 If I can do all those things, feel, dream, and think, then on what grounds do people insist I am not a person?

 Outsiders say I am part of a person, but I am not. I don’t think like the person I’m supposedly part of. I don’t feel like the person I’m supposedly part of. I don’t dream like the person I’m supposedly part of.

 Outsiders say   I am a symptom of some horrible disorder someone has. Symptom? A runny nose doesn’t have a will to live. An itchy eye doesn’t dream of anything. A fever doesn’t feel sad when you take flue medicine.

 If I’m not a person... then I ask you.... What am I?
 
 What makes me not a person?

 Jennifer Lee Combies
 The JC Klatch
 
© Copyright 2012 Jennifer Lee Combies (UN: particlechild at Writing.Com). All rights reserved. 
Jennifer Lee Combies has granted Writing.Com, its affiliates and syndicates non-exclusive rights to display this work.









 
The Klatch, Medication & Death  
 We are The JC Klatch. Our story begins at our body's birth. To the best of our knowledge, we were born multiple. We remember each other from as far back as any of us can remember. I won't be including our entire story here in this article. I will be discussing the effects erroneously prescribed medication had on us.

 When our body age was merely two, our mother claims to have witnessed us colliding in to walls at times, and rarely able to pay attention. The notion that we couldn't pay attention simply doesn't add up, as our mother also describes how we would spend hours upon hours at a time playing with Lego blocks. She also has told us about how she would approach to shut off a TV she was ab solutely sure we weren't actually watching, as we were busy with toys, only to be shocked to have the entire episode of "Bill Nye The Science Guy" she had just interrupted recapped back to her accurately. What she was witnessing was not a lack of attention. It was, instead, several people in the same body who each have different interests and the ability to co-front, with two or more persons paying attention to entirely unrelated things simultaneously. The colliding with walls, I'm sure was simply due to the fact that we hadn't yet learned to co-operate with our one shared body. Try having two people drive the same car in opposite directions at once, and you'll quickly learn what an air bag looks like.

 This lack of attention, along with other supposed "symptoms" such as hyperactivity lead us to being slapped with an overused diagnosis called Attention Deficit Hyperactive Disorder. We definitely do not, and did not, have A.D.H.D, but we were quickly put on medication anyhow. Medication doesn't always work the same on multiples as it does on singlets, and rarely has the intended affect on people who don't have the disease or disorder the medication is for. This was no exception. The medications we were forced to take over the course of our body's childhood and adolescent years included Ritalin, Dexadrine, Welibutrin, Zoloft, and one medication the name of which eludes me.

 The side effects of some of those medications included intrusive thoughts, and thoughts of suicide and even thoughts of homicide. Other side effects they had on our system was to almost entirely suppress our ability to switch. One of us in particular was front nearly 100 percent of the time. Only certain members of our system could come and go at all, but with great difficulty. The rest of us rarely saw the light of day.

 Being front nearly every moment of every day may sound normal to a singleton. If you are a singlet reading this, you're used to always being out front. For many multiples, if one member is front too much, he or she gets worn out, tired, burnt out. This constant feeling of exhaustion can take a toll on somebody, shortening their fuse, angering and frustrating them. After a while, this one system  member resented there were others in this system.

  When we were able to make our way front, no one ever heard us. We tried to tell outsiders we were here, and tell them the medications were hurting us. Our guidance counselors at school had spoken to Rebecca, and Jenn, but never acted or relayed anything to our mother. If any of us used our own names or spoke of others in our system, we were accused of lying. I had been front for several visits to psychiatrists. I, being mute, was always accused of just sitting there and not talking. I communicated, but they only listened for spoken words.

 When the body was 18, the medication was finally discontinued. You can't make an adult take medication. The damage, however, was done. We spent the next several years slowly regaining our strength within the system. Slowly but surely we were able to switch somewhat smoothly again.

 Fast forward to today. There are still permanent effects left from the medication we never needed. First and foremost, we are missing a member of our system. The medication lead to a member's death. We've been told members within a system can't individually die. That is untrue. We saw this one die and none of their memories were "recovered" when they died. This system member is gone. When we switch, our body twitches horribly, and if we switch too much, it will go into convulsions. Miakoda has an audible tic which tends to sound like a yelp or a shriek. Katelynn sometimes goes in to convulsions that are extremely terrifying for her. Insomnia is something we all frequently cope with. Spacing out plagues most of us at times. Short term and long term memory problems is another effect left from the medication.

  Medicating what isn't fully understood is never the answer unless a life really is at stake. I can hardly see how a "lack of attention" would have been life threatening. Our system will never again take any "mind" prescriptions.

 Julia Rae Combies
 The JC Klatch
© Copyright 2012 Julie Rae Combies (UN: curiouslymute at Writing.Com). All rights reserved. 
Julie Rae Combies has granted Writing.Com, its affiliates and syndicates non-exclusive rights to display this work.
 

Things That I Can't Stand 
 OR
 How Not To Treat Members of Multiplicity Systems

 It hurts when outsiders tell me I'm just an act. I think, I feel, I dream. I am real, by every sense of the word. 
 Nothing drives me crazy quite like people insisting one of us becomes another of us. No, I still exist when I'm not front. I'm inside, not dead.

 It really angers me when singlets use co-fronting, matching likes, or any other dumb thing as “proof” that we aren't multiple. Yes, Miakoda and I like similar music. Yes, you will hear two voices or a blend of voices if two of us co-front. Yes, Miakoda and Lilly are both allergic to carrots. These things prove nothing. Don't people like similar things to their friends? If two people talk in the same room, I hear both of voices. Don't health concerns run in families?

 I hate when outsiders insist on using our legal name despite knowing who's front! I have a name. I like my name. I would appreciate it if people didn't try to force another name on me. I'm fairly certain my headmates feel the same way about their names.

 It's infuriating when outsiders ignore me until the one they want to talk to is front. I'm a person too. Talk to me, I won't bite. I promise.

 I can't stand being asked “Who's the real one?”. Easy! ALL of us are real.

 I hate when singlets or even other multiples cram us in to a little box labeled “D.I.D.”.  We're not dissociating, we're not just a bunch of identities, and we function in quite an orderly fashion. We're farther from “Dissociative Identity Disorder” than most singlets I know. How can our mere existence as a group be a “disorder”? I have nothing against D.I.D. systems. I just don't like labels that don't belong to us being applied to us.

 It drives me up a wall when outsiders, including other multiples, insist our abuse is where we came from. We're in here, and have been in here the whole time we've been in here!  We're the best to know where we came from. It's as if we aren't valid if we existed first and were abused later. The abuse scarred us, but it certainly didn't make our system.  It also implies that a person is their abuse. 
 Sorry to dis appoint, but I was born here when the body was born.

 I can't stand being called an “alter”, a “personality”, or a “part”. I'm a person. I'm not somebody's “alternate personality”, and I am definitely not a “part” of somebody. I am a somebody entirely of my own. I am a person.
 The fastest way to enrage any one of us is to throw that god awful word “fragment” at any of us!
 In our system, these words are about as bad as any other slur. They're used by “normals” and therapists to convince the people in a multiple system that they are not people, just symptoms, so they won't object to being killed off in a process called “integration”.
The absolute worst excuse is the phrase, “But I need a way to differentiate you from real people”.

I am tired of “When will you go to a therapist?” and “Will you be integrating soon?”.
First off, if any of us did seek a therapist, it wouldn't be for being multiple and it wouldn't be any outsiders' business. Second, no, we have no intention of killing off all but one of us. Asking a question like that really just says “I can't stand that there are many of you. Fix it.”. That doesn't make any of us feel good at all.

 I can't stand singlets pitying me. “It must be so hard not knowing what's going on” or “It must be frustrating fighting for time outside” are some of the most degrading things frequently said to me and mine. Being one of many in a single body is all I've ever know. I've never been a singlet. Quite honestly, I can't imagine what it's like to have to be front 24 hours a day, 7 days a week, without one second of a break. I  can only guess it might be nice to dye your hair if you wish, but I can tell you it's a life saver to step away from a toothache for a while when waiting to get to the dentist. It's also an amazing experience to take my loved one out of that same toothache and give her a break.

 I hate when singlets assume my change in mood is a switch. No, if you just ticked me off and I got mad at you, I'm mad at you. That's just how life works. Make somebody mad, they're mad. Singlet or multiple, everyone has hot buttons and breaking points.

 It drives m e up a wall when people insult my headmates to me.
 My headmates are my family. Don't trash talk my family!

 So if I hate all these things, what is it I do like?

 I love it when somebody takes the time to ask me my name when meeting me the first time, especially if they had just initially met someone else in my system. This is the best first step in getting me to like you! If you don't recognize when I'm front, no biggie. You can ask.

 I love it when a friend not only misses me, but asks if I can come front. This really shows that I am worth something to somebody as an individual.

 I love it when singlets ask when they don't know or understand something.

 It really makes my day when somebody wants to talk to me and leaves a message with whomever was front at the time. If I can't come front for one reason or another, I can still get back to you later on. I'm a person, if I'm not here, I'll return later.

 It really brightens my day when somebody actually remembers something about me instead of only remembering my group.

 Phew. Glad to get all that off my chest.
 All I want from outsiders is to be treated like a person and valued as one. Why? Because I am a person.

 Luna Diana Combies
 of
 The JC Klatch

 

© Copyright 2012 Luna Diana Combies (UN: waxinglunacy at Writing.Com). All rights reserved. 
 Luna Diana Combies has granted Writing.Com, its affiliates and syndicates non-exclusive rights to display this work.

 

We are NOT DID or Mpd  
 
We claim we are multiple, yet not DID nor MPD. Let's take a moment to break this down, and let's take a more in depth look at that claim.

  First, let's start with MPD.
  
 
Multiple Personality Disorder.

 Multiple: Yes, we are multiple. There are more than one person living in this one, shared body.

 Personality: This is a grey area...
 per·son·al·i·ty
 noun, plural -ties.
 1. the visible aspect of one's character as it impresses others: He has a pleasing personality.
 2. a person as an embodiment of a collection of qualities: He is a curious personality.
 3.
 Psychology .
 a.the sum total of the physical, mental, emotional, and social characteristics of an individual.
 b. the organized pattern of behavioral characteristics of the individual.
 4. the quality of being a person; existence as a self-conscious human being; personal identity.
 5.The essential character of a person.

 In one definition, a personality is a collection of characteristics. We are more than collections of characteristics.
 In another definition, a personality is the state and quality of being a person. In that sense, we would be personalities.
 For the sake of this article, we'll say yes to this one. Personalities, ok.

 Disorder: We are not disordered!

 dis·or·der
 [dis-awr-d er] Show IPA
 noun
  - a disturbance in physical or mental health or functions; malady or dysfunction: a mild stomach disorder.

 A disturbance in physical or mental health or functions. Our multiplicity does not disrupt our abilities to think rationally, hold a job, interact in public, keep social relationships and friendships, conduct necessary business such as banking or keeping appointments, or even reacting to outside emergencies. It doesn't disrupt our daily life! Some of us, individual, have other issues that impede life at times (such as my PTSD symptoms), but the state of being multiple is not the cause of any of our daily life issues. Everyone has problems, we're no exception - but our multiplicity isn't one of those problems.

  Let's break down D.I.D.

Dissociative Identity Disorder

Dissociative: We don't consider ourselves dissociative.

dis·so·ci·ate
 [dih-soh-shee-eyt, -see-] Show IPA verb, -at·ed, -at·ing.
 verb (used with object)
 1. to sever the association of (oneself); separate: He tried to dissociate himself from the bigotry in his past.
 2. to subj ect to dissociation.
 verb (used without object)
 3. to withdraw from association.
 4. to undergo dissociation.

  dis·so·ci·a·tion¢
 [dih-soh-see-ey-shuhn , -shee-ey-] Show IPA
 noun
 4. Psychiatry . the splitting off of a group of mental processes from the main body of consciousness, as in amnesia or certain forms of hysteria.

 Let's pick these apart. To sever association of oneself. What would that even mean? I'm myself. I didn't sever anything to be myself.
 Ok, so the splitting off of a group of mental processes from the main body of consciousness. My consciousness, all of what makes me Miakoda, has always been as it is now. I didn't originally have the name Miakoda, but I have always been the I that I am! I've grown and matured as a person, but I am me. My headmates have each done the same. They've always been as they each a re, just growing and maturing as people. There was no "splitting off". We are as we are.
 ...With one single exception. Seventeen. He is not an original member of our system. He was added here later by an outsider for the purpose of manipulating those who were already here. Seventeen is made from Kate. If you would like to consider him a dissociation, we won't object. However, he will disagree. He considers himself something else.

 Identity: Another grey area, just like "personalities".

i·den·ti·ty
 [ahy-den-ti-tee, ih-den-] Show IPA
 noun, plural -ties.
 1.the state or fact of remaining the same one or ones, as under varying aspects or conditions: The identity of the fingerprints on the gun with those on file provided evidence that he was the killer.
 2. the condition of being oneself or itself, and not another: He doubted his own identity.
 3. condition or character as to who a person or what a thing is: a case of mistaken identity.
 4. the state  or fact of being the same one as described.
 5. the sense of self, providing sameness and continuity in personality over time and sometimes disturbed in mental illnesses, as schizophrenia.

 We think of ourselves as more than just identities.  I, Miakoda, being different than Jenn or Rebecca, is in no way shape or form the same as the other screen name, the other identity, I have on some web sites of a private nature.
 However, if you look at the definition "the condition of being oneself", I am definately one self myself, with other selves who are not part of me.
 Identity.... We consider ourselves more than just identities, we're people.

Disorder: Since  I already covered Disorder for M.P.D., I won't cover it again here. It means the same in both.

 Now let's take a peek at the criterion for D.I.D.: I will address each one seperately.

1. Disruption of identity characterized by two or more distinct personality states (one can be the host) or an experience of possession, as evidenced by discontinuities in sense of self, cognition, behavior, affect, perceptions, and/or memories. This disruption may be observed by others, or reported by the patient.

 This criterion assumes that a body should only have 1 "identity", 1 person in it. That's false right there.
 However, there are more than one distinct people in this body with their own senses of self, their own memories, etc. I'll mark this criterion as a yes for us.

 2. Inability to recall important personal information, for everyday events or traumatic events, that is inconsistent with ordinary forgetfulness.

 Each of us has our own memories. If I was front, I remember it within reason. If you ask about things I was not front for, I can ask my headmates for you if you are currently talking to me. We can each just ask whomever was front for the info.  This criterion is a NO!

3. Causes clinically significant distress and impairment in social, occupational, or other important areas of functioning.

 We love this criterion! This is unanimously our favorite criterion of all time for anything ever!
 We hold a job,  we have friends, we've dated (SEPARATELY!), we go out in public, WE HAVE A LIFE, A DECENT LIFE!
 Most of the people in our life know us individually! Here's the shocker... It has NO NEGATIVE IMPACT ON OUR DAILY LIFE! NONE!
 Our friends love us! Our clients at work like us! We're not lost in the middle of the city with no idea how we got there!
 We take not es if we need to keep continuity. We hand off information before we switch, such as where we are, where is our car if we brought it, who are we with, why are we where we are and why are we with who we're with!
 At work, our call sheet is marked so the next one front knows exactly what is done, what needs to be done, and where in our schedule we're currently at.
 In other words, when it comes to being multiple, we have our shit together!
 This is not to say we're perfect at it. Yes, some days we fail. However, our "bad days" are no worse nor more frequent than any singlet having an "off day".
 Even better, when we do have an error, we each know how to correct the situation and get back on track. The effect is minimal.
 In fact, our multiplicity has given us an advantage! At work, one of us is tired, switch. 2 computers at the same location? We can co-front and rip both apart simultaneously! One of us is stumped at work? There's a handful of additional minds to run the problem past!
 Our multiplicity is not a disruption of our daily life!

4. The disturbance is not a normal part of a broadly accepted cultural or religious practice and is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex partial seizures). NOTE: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

 Ok, well, we're not on drugs and we're not channelling other spirits, and these aren't imaginary friends. Number 4 is a yes.

 All that being said, we just do not fit D.I.D. or M.P.D.
 Does this make us better than systems who do? Absolutely not!
 We just feel our multiplicity is not something in need of repair. Just because our white car isn't the same color as the blue car next to it does not mean it's white paint is broken and needs to be fixed. The same here. Just because we aren't the same as other people does not mean we are broken and need help.
 We are multiple. We are happy being multiple. We are functional in our multiplicity.

© Copyright 2012 Hello Miakoda (UN: hellomiakoda at Writing.Com). All rights reserved. 
Hello Miakoda has granted Writing.Com, its affiliates and syndicates non-exclusive rights to display this work.

 

 

 Searching for Convergence 

 The Forensic Evaluation of Dissociation and Persons Diagnosed with Dissociative Identity Disorder: Searching for Convergence
 Psychiatric Clinics of North America - Volume 29, Issue 1 (March 2006) - Copyright © 2006 W. B. Saunders Company

 Arguably, some of the most interesting developments in the biology of DID come from brain imaging studies using positron emission tomography, MRI, and hexamethylpropyleneamine oxime single photon emission CT. Although many such studies concern single case presentations [36], [37], [38], an increasing number of studies examines larger cohorts of patients diagnosed with DID [39], [40], [41] and compares patients diagnosed with DID to simulators [40]. Results of these studies suggest that cerebral blood flow may vary for DIDs as a function of alternate personalities and that the reported cerebral blood flow differences may discriminate between DIDs and normal controls or simulators. Hypothesized blood flow differences in the temporofrontal cortex and structural differences in the hippocampus are reported [36], [3 7], [38], [39], [40].
 Neurobiologic studies of DIDs versus controls or simulators also demonstrate differential findings regarding alternate personalities [36], [37], [38], [39], [40], [41], “switching” between personalities [38], and amnesia between alternate personalities [42], [43], [44], [45], [46], [47]. In addition, there are studies of neurobiologic anomalies (eg, electroencephalogram abnormalities [48] and hypnotic capacity using the eye-roll technique [49]). Finally, neurobiologic studies have discriminated successfully between DID, seizures, and pseudoseizures [50], [51].
 [36]

 






 

 What is activism?  

 Activism is fighting on when you don't feel like it, when you're too
 tired, too screwed-up in your own head to fight. It's admitting you're
 screwed-up in your own head. It's not for your vindettas or grudges.
 (We have trouble with this one.)
 It's not for your bitching out other members of the oppressed group.
 It's understanding that even in oppressed groups there is privilege,
 that some groups within the oppressed group have got more advantages
 than others, and acknowledging those instead of trying to shove them
 under the rug or flaunt them.
 It's to realizing if you have an advantage and trying to help someone
 who doesn't.
 Activism is standing up for yourself, understanding there's no damn
 way that you can please everyone.
 It's digging in your heels and refusing to be budged, but picking your
 battles wisely enough to know which ones to focus on.
 It's taking things tiny chunks at a time, and not forgetting to
 celebrate tiny victories.
 It's lighting a candle for the guy who offed himself in his bedroom
 before you got your head out your ass and realized that he was begging
 you for help thirty seconds too fucking late, after the words were
 already out of your mouth.
 It's realizing that text has tone and that everyone's words have power
 no matter how powerless you believe your own words to be.
 It's knowing when to use your words for a weapon and when to back down
 with grace.
 It's about not being afraid to say to someone "Calm down." and knowing
 when to say it.
 It's to free expression and to controlling yourself enough to act like
 civil adults.
 It's to realizing that sometimes no matter what you do, they're all
 going to think you're fucking insane.
 It's to realizing that sometimes a poorly chosen word can blow the
 whole shitpile sky-high.
 It's respecting the people who blazed a path before you, building off
 their ideas when you can, but never staying stagnant.
 It's to coming up with new ideas, new ways to reach out, to beating
 your head against the brick wall till you make a hole.
 It's to backing down when you can't.
 It's to breaking a window when you can't open a door.
 It's to being fucking glad for every tiny thing that gets your cause
 noticed, even if it's hidden in oppressor language.
 It's to giving everyone a voice but understanding that some of them
 will use it to give the whole fucking group a bad name and hoping
 there're enough that aren't jackasses to make it all fly.
 It's to never resting on your laurels. It's to knowing when to hang
 onto those reins for dear life, and when to let them lax so that
 someone else can pull the wagon for a while, but never giving up,
 because you are an inspiration, whether you signed up for that job or
 not.
 Activism is watching your own heart break over and over but still
 managing to pick up the pieces and rebuild it with other people's
 inspiration.
 And maybe most importantly, activism is building a shell to keep
 yourself safe, but not letting bitterness, jadedness and pure-ass
 spite, either toward yourself, your situation, other oppressed people
 or even toward the oppressors blind you to what truly is important.
 *We have difficulty with this one too.*
 And activism? is asking yourself what truly is important.
 Activism is also knowing when you need to quit or back down either
 temporarily or permanently, and not pushing beyond that point and
 taking care of yourself/ves and your safety/sanity first.

 If you read this, have cookies.

 -Mark and GY

 

 

  One Brain Two Selves 
 
DOI: 10.1016/j.neuroimage.2003.08.021 
 
Abstract:

 Having a sense of self is an explicit and high-level functional specialization of the human brain. The anatomical localization of self-awareness and the brain mechanisms involved in consciousness were investigated by functional neuroimaging different emotional mental states of core consciousness in patients with Multiple Personality Disorder (i.e., Dissociative Identity Disorder (DID)). We demonstrate specific changes in localized brain activity consistent with their ability to generate at least two distinct mental states of self-awareness, each with its own access to autobiographical trauma-related memory. Our findings reveal the existence of different regional cerebral blood flow patterns for different senses of self. We present evidence for the medial prefrontal cortex (MPFC) and the posterior associative cortices to have an integral role in conscious experience.

Citation:

 One brain, two selves.
 Reinders AA - Neuroimage - 01-DEC-2003; 20(4): 2119-25
 MEDLINE® is the source for the citation and abstract of this record

NLM Citation ID:
 14683715 (PubMed ID)

Full Source Title:
 NeuroImage

Publication Type:
 Clinical Trial; Journal Article; Research Support, Non-U.S. Gov't

Language:
 English

Author Affiliation:
 Department of Biological Psychiatry, Groningen University Hospital, The Netherlands. a.a.t.s.reinders@med.rug.nl

Authors:
 Reinders AA; Nijenhuis ER; Paans AM; Korf J; Willemsen AT; den Boer JA

 

 A New Model of Dissociative Identity Disorder 

Psychiatric Clinics of North America - Volume 29, Issue 1 (March 2006)  -  Copyright © 2006 W. B. Saunders Company  -  About This Journal Add Journal Issue Alert 
DOI: 10.1016/j.psc.2005.1Psychiatric Clinics of North America - Volume 29, Issue 1 (March 2006)  -  Copyright © 2006 W. B. Saunders Company  - About This Journal Add Journal Issue Alert 
DOI: 10.1016/j.psc.2005.10.013

IMPLICATIONS OF THE PRESENT STUDY FOR THE SOCIOCOGNITIVE MODEL OF DISSOCIATIVE IDENTITYDISORDERFor the last decade, proponents of the sociocognitive model[76], [77], [78], [79], [80], [81], [82] have argued that DID is caused by social influence:
DID is a socially constructed condition that results from inadvertent therapist cueing (eg, suggestive questioning regarding the existence of possible alters), media influences (eg, film and television portrayals of DID), and broader sociocultural expectations regarding the presumed clinical features of DID. For example, proponents of the sociocognitive model believe that the release of the book and film Sybil in the 1970s played a substantial role in shaping conceptions of DID in the minds of the general public and psychotherapists [77].
The sociocognitive model of DID is necessarily wed to the DSM-IV's model of classic DID. Why? Because the general culture's model of DID is classic DID. Classic DID is clearly reflected in Sybil. Classic DID has also been reflected in countless portrayals of DID in contemporary films and television programs. In short, the DSM-IV's essential phenomena of classic DID (ie, multiple personalities + switching + amnesia) are very familiar to the general culture.
Although not intended as such, the present findings refute the sociocognitive model of DID because 15 of the 23 subjective dissociative symptoms that were measured (the criterion A symptoms except for trance and the criterion B symptoms except for self-alteration; see Box 1) are invisible (ie, completely experiential), unknown to the media, unknown to the general public, and largely unknown to the mental health field. Nevertheless, these 15 subjective dissociative symptoms occurred in 83% to 95% of persons who had DID (Table 2). The pervasive presence of these symptoms cannot be explained (away) by the sociocognitive model's “usual suspects”—therapist cueing, media influences, and sociocultural expectations regarding the clinical features of DID. There can be no therapist cueing, media influences, or sociocultural expectations about dissociative symptoms that are invisible, unknown to the media, unknown to the culture, and largely unknown to the mental health field.
The sociocognitive model explains and predicts the classic signs of DID, but the sociocognitive model neither predicts nor can explain (1) most of the empirical literature's well-replicated dissociative symptoms of DID (Table 1), (2) most of the subjective/phenomenological dissociative symptoms of DID (Box 1), or (3) most of the findings of the present study. In contrast, the subjective/phenomenological model of DID predicts and explains all of the symptoms of classic DID, all 13 of the well-replicated empirical findings about DID (Table 1), all 23 of the subjective/phenomenological dissociative symptoms in Box 1, and all 23 of the dissociative findings of the present study (Table 2).
On the grounds of greater verisimilitude—most importantly, its ability to predict a large number of dissociative phenomena that cannot be predicted by either the DSM-IV model of DID or the sociocognitive model of DID—the subjective/phenomenological model of DID should be considered superior, and the sociocognitive model of DID must be judged to be refuted.
 

LIMITATIONS

The strength of the present study is limited by two aspects of its methodology. First, the study is primarily based on a clinically-diagnosed sample of DID cases (rather than a sample of DID cases that were diagnosed with a structured interview such as the SCID-D-R). Fig. 1, however, demonstrates that there is a remarkable resemblance between the 220 patients who had DID who were clinically diagnosed and the 41 who were diagnosed by the SCID-D-R. Still, the SCID-D-R was administered in a clinical setting by therapists who were not blind to the patients' presenting symptoms, and was not subject to reliability checks across raters. Second, the present study did not employ SCID-D-R-diagnosed comparison groups (eg, general psychiatric patients, nonclinical adults, patients who had other dissociative disorders). Gast and colleagues[70], however, did use SCID-D-R-diagnosed comparison groups in their investigation of the diagnostic efficiency of the German MID. Their results replicated those of the present study. In a sample comprised of patients who had DID, patients who had DDNOS-1, general psychiatric patients, and nonclinical adults, Gast and colleagues reported that the dissociative symptoms in Box 1 (as assessed by the G-MID) had a positive predictive power of 0.93, a negative predictive power of 0.84, and an overall predictive power of 0.89 for major dissociative disorder (DID or DDNOS-1).

Table 2 . Incidence of 23 dissociative symptoms in 220 persons who have dissociative identity disorder
MID scale SCID-D n = 41 Total sample n = 220 Outpatients n = 161 Inpatients n = 57
Mean number of symptoms 19.7 20.2 19.9 21.3
SD 4.7 4.5 4.8 3.2
Percent incidence of each symptom
General dissociative symptoms:
Memory problems (5/12)a 100 94 93 98
Depersonalization (4/12) 95 95 94 98
Derealization (4/12) 93 92 89 98
Posttraumatic flashbacks (5/12) 93 92 90 96
Somatoform symptoms (4/12) 83 83 81 88
Trance (5/12) 88 87 84 96
Partially-dissociated intrusions
Child voices (1/3) 95 95 94 95
Internal struggle (3/9) 100 96 95 98
Persecutory voices (2/5) 88 90 87 96
Speech insertion (2/3) 85 83 81 86
Thought insertion/withdrawal (3/5) 93 91 90 95
“Made”/intrusive emotions (4/7) 95 91 90 96
“Made”/intrusive impulses (2/3) 85 89 87 93
“Made”/intrusive actions (4/9) 98 95 93 98
Temp loss of knowledge (2/5) 90 82 80 91
Self-alteration (4/12) 98 95 94 98
Self-puzzlement (3/8) 98 95 93 98
Fully-dissociated intrusions (ie, amnesia)
Time Loss (2/4) 88 88 87 89
“Coming to” (2/4) 78 79 75 88
Fugues (2/5) 83 75 71 86
Being told of actions (2/4) 85 86 85 88
Finding objects (2/4) 61 74 72 77
Evidence of actions (2/5) 71 77 76 81

Table 2 . Incidence of 23 dissociative symptoms in 220 persons who have dissociative identity disorder
MID scale SCID-D n = 41 Total sample n = 220 Outpatients n = 161 Inpatients n = 57
Mean number of symptoms 19.7 20.2 19.9 21.3
SD 4.7 4.5 4.8 3.2
Percent incidence of each symptom
General dissociative symptoms:
Memory problems (5/12)a 100 94 93 98
Depersonalization (4/12) 95 95 94 98
Derealization (4/12) 93 92 89 98
Posttraumatic flashbacks (5/12) 93 92 90 96
Somatoform symptoms (4/12) 83 83 81 88
Trance (5/12) 88 87 84 96
Partially-dissociated intrusions
Child voices (1/3) 95 95 94 95
Internal struggle (3/9) 100 96 95 98
Persecutory voices (2/5) 88 90 87 96
Speech insertion (2/3) 85 83 81 86
Thought insertion/withdrawal (3/5) 93 91 90 95
“Made”/intrusive emotions (4/7) 95 91 90 96
“Made”/intrusive impulses (2/3) 85 89 87 93
“Made”/intrusive actions (4/9) 98 95 93 98
Temp loss of knowledge (2/5) 90 82 80 91
Self-alteration (4/12) 98 95 94 98
Self-puzzlement (3/8) 98 95 93 98
Fully-dissociated intrusions (ie, amnesia)
Time Loss (2/4) 88 88 87 89
“Coming to” (2/4) 78 79 75 88
Fugues (2/5) 83 75 71 86
Being told of actions (2/4) 85 86 85 88
Finding objects (2/4) 61 74 72 77
Evidence of actions (2/5) 71 77 76 81









 The Scope of Dissociative Disorders: An International Perspective  

Vedat Sar, MD

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Clinical Psychotherapy Unit and Dissociative Disorders Program, Medical Faculty of Istanbul, Istanbul University, 34390 Capa, Istanbul, Turkey 
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E-mail address:  vsar@istanbul.edu.tr

  PII S0193-953X(05)00090-0

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In contrast to the meaning that the unfortunate term “posttraumatic stress disorder” imposes, trauma is not identical with a noxious event [1]. It is a complex sociopsychologic process with subjective and objective components following traumatic experience that is embedded in past, present, and future. A comprehensive definition of psychic trauma is the loss of cohesion in internal world, in external reality, and between them; creating loss of psychic harmony in a given time point and across the life span. In that sense, trauma and dissociation are concepts that dissolve in each other [2]. An approach to trauma without understanding dissociation remains meaningless from both psychiatric and sociopsychologic point of views. Extracting dissociation from concepts and adaptations of everyday life or from general psychopathology empties its content and marginalizes it (ie, it is a disservice to both the traumatized person and the professional who wants to help them).
This issue includes a special article about culture-bound aspects of dissociation (see the article by Somer elsewhere in this issue). This article is concerned mainly with the documentation of the universality of dissociative disorders as presented by empirical studies conducted in various countries using standardized assessment instruments. The similarities between dissociative patients in various cultures are obvious[3], [4]. Cultural differences between perceptions and conceptualizations of researchers and mental health professionals in psychiatry are higher than those in any other medical specialty. This seems to be the main reason why dissociative disorders have been considered by some authors as culture bound syndromes; somewhat paradoxically, either as a merely North American disorder or a premodern phenomenon seen in exotic cultures, primitive societies, or mystic-religious communities. Modern pioneers of the field initiated a rising wave of dissociation studies in North America in the 1980s, to be slowed down in 1990s by the so-called “backlash” movement, which has been balanced by a steadily enlarging and emerging international research. Large-scale systematic studies on dissociative disorders in this initial period of international research flourished mainly in The Netherlands [3], Turkey [4], and Germany [5]. Case series also have been published from Switzerland [6] and Australia [7]. Case presentations and many other contributions continue to come from many countries throughout the world. This article does not claim to be an exhaustive one. Rather, to elucidate the way for future research, it tries to evaluate the key aspects of this mosaic of clinical and scientific endeavors.


EPIDEMIOLOGY OF DISSOCIATION: A COMMON PSYCHIATRIC DISORDERMost of the screening studies on dissociative disorders have been conducted in clinical settings (Table 1). Studies on dissociative disorders in Istanbul, Turkey, yielded prevalence slightly above 10% among psychiatric inpatients and outpatients [8], [9], [10]. Although still considerable, these rates were lower in The Netherlands [11], Germany [5], and Switzerland [6] among inpatients (between 4.3% and 8%). A Finnish study [12] reported higher rates for psychiatric outpatients (14%) and inpatients (21%). A study conducted among emergency admissions in Istanbul yielded the highest rate (35.7%) [13].





Table 1 . Summary of dissociative disorder prevalence studies among psychiatric patients in four countries: Turkey, Switzerland, Germany, and The Netherlands
Dissociative experiences scale score
Study % Inclusion rate Number of subjects Diagnostic instrument Cutoff on dissociative experiences scale % Rate of dissociative identity disorder Rate of dissociative disorder mean SD > %DESb
Psychiatric inpatients
Tutkun et al [8] 63.6 166 DDIS 30 5.4a 10.2a 17.8 14.9 14.5
Modestin et al[6] — 207 DDIS 20 0.4 5 13.7 13.5 12
Gast et al [5] — 115 SCID-D 20 0.9 4.3 — — 21.7
Friedl and Draijer [11] 50.4 122 SCID-D 25 2 8 20 18.1 29.5
Psychiatric outpatients
Sar et al [9] 81.5 150 DDIS 30 2a 12a 15.3 14 15.3
Sar et al [10] 79.5 240 SCID-D 25 2.5 13.8 20 18.9 27.9
Psychiatric emergency unit
Sar et al [13] 43.3 44 SCID-D 25 13.6 35.7 23.3 19.1 38.6
Abbreviations: DDIS, Dissociative Disorders Interview Schedule; DES, Dissociative Experiences Scale; SCID-D, Structured Clinical Interview for Dissociative Disorders.
a  Clinically confirmed diagnosis. 
b  Percentage of patients with a Dissociative Experiences Scale score above cutoff point. 
Two large-scale studies conducted in the general population of Sivas, Turkey, provided detailed information about the prevalence of all dissociative disorders in the community. The first one was conducted on a representative sample of 994 participants from both genders [14]. Although there was no difference in average Dissociative Experiences Scale (DES) scores between genders, there were two times more women than men among high scorers. The second study was conducted on a representative female sample of 648 participants in the same city using a structured diagnostic interview (ie, the Dissociative Disorders Interview Schedule)[15]. The overall prevalence of dissociative disorders was 18.3%. The largest group was Dissociative Disorder not Otherwise Specified (DDNOS) (8.3%). A total of 7.3% of the population reported having had dissociative amnesia at least once throughout their life. The prevalence of depersonalization disorder was 1.4%, whereas 1.1% of the population had Dissociative Identity Disorder (DID). Conditions based primarily on presence of distinct personality states (ie, DID and allied forms of DDNOS) together built up a prevalence of 5.2%. Only one proband (0.2%) had dissociative fugue as a solitary phenomenon; when present it was usually part of a more complex dissociative disorder (DID or DDNOS).
In The Netherlands, 378 subjects from a nonclinical population were screened using the Dissociation Questionnaire, a self-rating scale of European origin [16], [17]. A total of 2.1% of the participants had a score above the cutoff point (score of 2.5), and 0.5% had a score comparable with those of patients with dissociative disorders (scores of 3 or higher). Of the eight high scorers, seven were women. A total of 2.9% of the women and 0.7% men had scores above the 2.5 cutoff, a ratio of 4 to 1. In a large general psychiatric population in Germany [18], there were no significant gender differences in the distribution of high dissociators.
In Germany, a screening study was conducted on 51 male criminal offenders admitted to a medicolegal institution by the court so as to understand diminished or lack of responsibility for the offense because of psychiatric disorder, including a large group of persons with substance-use disorders [19]. Using the Structured Clinical Interview for Diagnostic and Statistical Manual (DSM)-IV Dissociative Disorders [20], a high prevalence of dissociative symptoms and disorders (23.5%), mostly DDNOS, were demonstrated. A total of 22.6% of the group had a DES score 20 or higher. In Turkey [21] 26.8% of 108 male prisoners in a regular correctional center had a DES score 20 or above. This rate was 18.5% for DES scores 30 or above. According to the Structured Clinical Interview for DSM-IV Dissociative Disorders, 15.7% of the subjects had a dissociative disorder, either DDNOS (N = 10) or dissociative amnesia (N = 7). Interestingly, only 2.8% of the prisoners fit the DSM-III-R borderline personality disorder criteria, whereas this rate was 28% for antisocial personality disorder and 66.4% for lifetime posttraumatic stress disorder diagnosis [21].
Overall, independent studies from various countries clearly demonstrate that dissociative disorders constitute a common mental health problem not only in clinical practice but also in the community. The lack of dissociative disorder sections in commonly used general psychiatric screening instruments has led to the omission of dissociative disorders in large-scale epidemiologic studies. Although studies using specific instruments have began to correct this perception, the inclusion of dissociative disorders in general psychiatric screening studies will help to gather detailed information about comorbidity issues (see the article by Sar and Ross elsewhere in this issue). Differences between rates obtained in various settings may be related to differences in treatment-seeking behavior and in mental health delivery systems. In particular, the relatively high prevalence of DDNOS both in clinical settings and in the community points to the necessity for a thorough revision in the DSM-IV dissociative disorders section.
Critiquing the Requirement of Oneness over Multiplicity: An Examination of Dissociative Identity (Disorder) in Five Clinical Texts.  
Kymbra Clayton (kclayton@psy.mq.edu.au)
Department of Psychology, Macquarie University,
North Ryde, Sydney, 2109, Australia
Abstract
In the health professions there is widespread agreement
that dissociative identity is dysfunctional and needs to be
cured. This position is based on the assumption that the
healthy self is unitary and therefore multiplicity must be
disordered. The cure, a requirement of oneness, is
integration: the multiple selves must be unified into a
single, integrated personality. To uncover themes and
assumptions of this dominant approach to dissociative
identity, five main texts were examined. From the many
discourses identified, two central discourses were
selected for further exploration. This paper explores how
the identified discourses construct individuals with
dissociative identity and how they inform and limit
psychological theory and practice. Being exploratory,
this paper offers a platform for further in-depth
deconstruction and critical evaluation of the underlying
assumptions and implications.
Keywords:
Dissociative Identity; Clinical Psychology,Integration.
Shall my cure be a far greater burden
Than the one I now bear on my own?
For when the battle is won
You will go home
And it is I who must continue alone.
(Anon)
A concept which continues to arouse interest and
controversy in psychological circles is that of
dissociative identity, previously known as multiple
personality disorder (MPD).
This phenomenon is best
understood and examined in the context of one’s notion
of self. Mainstream psychology tends to view the self
as individuated and autonomous, that is, as having core
properties that are universal, bounded, atomic and
somewhat detached from its
cultural, social and
historical moorings. Many psychology and psychiatry
professionals rely on the traditional idea of a ‘true’ or 'core’
 self, a self which is individual, rational,
authentic, consistent and the origin of its own actions.
From this perspective, it is expected that a well-
integrated, healthy person should have a strong and
unitary self (O’Connor & Hallam, 2000).
This concept is in contrast to pre-enlightenment and
post modern thought that problematises the notion of
the unitary self. [For recent
conceptions of the self in
psychological literature, see
Lester, (1994) and Stam
(2004).] Those who embrace an alternate view of self
offer the concept of an inherently plural, fluid, flexible,
fragmented and decentred self, formed and constrained
by social processes. From this perspective a plural self
consists of a multiplicity of positions, voices, states of
mind and functions (Neimeyer & Raskin, 2000); each
self “
is a source of differing interpretations of the
world, based on differing interpretive schemes
” (Lester,
1994, p. 312). This self “
has a plural personality, she
operates in a pluralistic mode
” (Anzaldúa 1987, p.79).
For those who view the self as inherently unitary, two
main positions or groups regarding dissociative identity
can be identified. The first group either does not believe
that dissociative identity exists at all or believes that it
can exist but is extremely rare. This group views those
who present with multiple selves either as fakes or as
holding false beliefs of multiplicity that have been
created iatrogenically by misguided therapeutic
techniques (Spanos, 1994). The second group
acknowledges individuals’ use of dissociation as a
common response to trauma and/or neglect and reports
that there is a significant (perhaps around 1%) group of
individuals whose lived experience is one of multiple
selves or different identities (Kluft & Fine, 1993; Ross,
1997). As a result of this group’s efforts, dissociative
identity has become more recognized and was included
in the Diagnostic and Statistical Manual (DSM),
editions III and IV, published by the American
Psychiatric Association. The DSM is regarded as
providing the medical and social definition of mental
disorder and is a main diagnostic reference used by
psychiatrists and psychologists.
However, reflecting this second group’s perspective
that a healthy person requires an integrated and
essentially unitary self, the DSM-IV presents
dissociative identity as a disorder (DID) and describes
it as “
a failure to integrate various aspects of identity,
memory and consciousness
” (American Psychiatric
Association, 1994, p. 484). The criteria for diagnosis
according to the DSM are “
the presence of two or more
distinct identities or personality states
(Criterion A)
that recurrently take control of behavior
(Criterion B).
There is an inability to recall important personal
information that is too extensive to be explained by
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
10
ordinary forgetfulness
(Criterion C).
The disturbance is
not due to the direct physiological effects of a substance
or a general medical condition
(Criterion D). The
distinctive assumption is that identity, memory and
consciousness should be integrated into a unitary self.
An alternative position in relation to dissociative
identity, partially informed by a post-modern notion of
self is that it is not a disorder per se (Rowan & Cooper,
1999), but rather an alternate and potentially functional
and adaptive way of being. This position invites a
deconstruction of the addition by the DID proponents
of the concept “
disorder
” to dissociative identity. In
agreement with this, Hacking (1995) is also wary
about the term ‘
disorder
’. He purports that it is “
loaded
with values and is code for a vision of the world that
ought to be orderly.
” (p. 17). Such an addition of the
term ‘
disorder
’ contributes to discourses on
dissociative identity which are then disseminated by
subsequent generations of practitioners as the truth.
They inform how practitioners perceive clients with
multiplicity and shape a whole treatment approach.
The purpose of this paper is not to detract from the
valuable role played by prominent members of the DID
field in fostering a greater recognition of multiplicity.
Neither is the purpose to imply that such practitioners
have negative intent towards people who experience
multiplicity. Rather, the intention is to identify the
discourses of the DID proponents and to consider their
implications for working with people who experience
dissociative identity. In this paper, multiple self-states
are referred to not as ‘DID’
but rather as dissociative
identity or multiplicity, spelt
without capitals. This is
done to avoid either automatically pigeonholing the
experience as inherently disordered or objectifying
those who experience it.
Method
The texts chosen are from three of the most well
known psychiatrists in the field of dissociative identity,
namely Richard Kluft, Frank Putnam, and Colin Ross.
Each has published recognized texts and numerous
articles on ‘DID’ and all contributed to the recognized
treatment guidelines of the International Society for the
Study of Dissociation (ISSD) (Barach, 1994). To explore
a counter position, a text by a more recent specialist in
multiplicity, Margo Rivera, is included. The texts
examined were:
Clinical Perspectives on Mu
ltiple Personality Disorder
(Kluft & Fine, 1993) and articles by Kluft (period of
1983-1996).
Diagnosis and Treatment of Multiple Personality
Disorder
(Putnam, 1989).
Dissociative Identity Diso
rder: Diagnosis, Clinical
Features, and Treatment
(Ross, 1989, 1997).
International Society for the Study of Dissociation (ISSD)
Treatment Guidelines
(Barach, 1994).
More Alike than Dissociative: Treating Severely
Dissociative Trauma Survivors
(Rivera, 1996).
To describe and analyze the power structures,
ideologies, images and messages within these texts, a
variety of qualitative analytical
methods were applied as
part of a larger study which explores the clinical literature
more fully. As a precursor to a more thorough critical
discourse analysis or post modern critique, this paper
examines the texts from the point of view of content and
language, teasing out assumptions and attitudes
concerning DID and those who experience it. This paper
also offers a brief glimpse into how the identified
discourses construct individuals and diagnoses, and how
they inform and limit psychological theory and
therapeutic practice
Texts are segments of meaning reproduced in any form
that can be given an interpretive slant (Parker, 1992). A
discourse can be defined as “
sets of statements that
construct objects and an array of subject positions
”
(Parker, 1994, p. 245). “
Discourse is a practice not just
of representing the world, but of signifying the world,
constituting and constructing the world in meaning
”
(Fairclough 1992, p. 64). Fairclough (1992) argues that it
is important that this relationship is understood
dialectically.
A dialectical perspective emphasizes that
discourse is a way to study both explicit language and the
material anchoring of language.
Discourses can be found ‘
performing’
in texts. This
paper sets in motion the process of exploring the
“connotations, allusions, and implications which the texts
evoke” (Parker, 1992, p.7). The questions that are posited
are “how are descriptions produced so that they will be
treated as factual?
” and “
how are these factual
descriptions put together in ways that allow them to
perform particular actions?
” (Potter, 1996, p. 6).
Language is often a reflection of the attitudes and
assumptions of much of society at large. Critical analysis
of language used in the dissociative field, heightened
awareness of its implications, and considered choice of
new and different language to frame the experience of
those with DI, can have a major impact on the future
directions of therapy in this field.
Analysis and Discussion
From the many discourses discovered in the texts, two
central discourses were chosen for exploratory analysis.
These were:
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
11
1. ‘Single’ is necessary but not sufficient for health
2. Therapist knows best.
Exploring Discourse No. 1: ‘Single’ is Necessary...
but not Sufficient for Health.
Single’ is Necessary. ...All the texts initially adopt an
egalitarian stance towards dissociative identity by
acknowledging and praising the functional aspects of
dissociation in helping individuals to cope with the
experiences of abuse. “
Creating other children inside is
an excellent short-term solution to the abused child’s
problems
” (Ross, 1989, p.128). “
At one time, usually in
early childhood, dissociation was a highly adaptive
response to overwhelming trauma
” (Putnam, 1989, p.
137).
Descriptions such as “excellent” and “highly adaptive”
express admiration for the processes involved. However
the implied praise is qualified: the solution is only “
short-
term
” (Ross, 1989, p. 128), the processes only adaptive
“
at one time
” (Putnam, 1989, p. 137). The assumption is
that a strategy that worked well in childhood is no longer
functional in adulthood.
All the texts, excluding Rivera’s, make much stronger
assertions that multiplicity for adults is dysfunctional,
maladaptive, and, in line with the Western medical
model, pathological: “
The problem with adult DID is
that, like any survival strategy gone wrong, it creates
more problems than it solves
” (Ross, 1997, p. viii). “
The
person needs to be fixed so that he/she can be effective
rather than powerless in the face of the MPD
psychopathology and life events
” (Kluft, 1993, p. 291).
“(Adults) require ‘symptom stabilisation’, ‘control’ of
their behaviour and ‘restoration of functioning
’ (Barach,
1994, section II).
The implications of the ISSD Guidelines are twofold.
First, individuals with dissociative identity incur a
process of medicalisation, through which “
non-medical
problems become defined and treated as medical
problems
” (Conrad, 1992, p. 209). In this process the
concept of disease, for wh
ich a biological cause is
required is often misaligned with the concept of disorder.
Disorders do not have clear
aetiologies, yet the practice
of psychiatry is still underp
inned by the medical and
therefore disease model. Second, individuals with
multiple selves are further positioned as unstable, out of
control and dysfunctional respectively.
These implications are broadened in most texts to a
conflation of multiplicity with
undesirable be
haviour and
disease:
The desire for intense dissociated states is built into
our DNA ... such states are wonderful, desirable, and
healthy in their natural form ... but there is nothing
wonderful about the chemical ecstasy of the heroin-
addicted ghetto prostitute. This is why there is
psychiatry of dissociation, the goal of which is to
substitute healthy, normal altered states for self-
destructive, painful ones
(Ross, 1989, p. 187).
The emotive language in this extract implies an almost
inevitable link between dissociation, drug addiction and
prostitution. This is further developed by Ross:
MPD is directly linked to sexuality ... In our 236
cases, 19.1 percent had worked as prostitutes. Many
of these people would potentially stop prostituting if
they were diagnosed and treated for the MPD. The
connection between MPD, childhood sexual abuse,
prostitution, sexual promiscuity, and venereal
diseases including AIDS, makes MPD a major
unrecognised public health problem
(Ross, 1989, p.
94).
Statistical data from one sample is used by Ross to
factualise a conflation of multiplicity, prostitution and
associated diseases such as
AIDS and venereal diseases.
Although some individuals with multiplicity have these
health issues, the language used constructs ‘MPD’ as the
primary problem. However, it is disease that is a major
public health problem, not multiplicity. There is no doubt
that some people who experience multiple selves are
dysfunctional and/or live outside of society’s standards,
and in some cases a causal relationship could be
reasonably argued between multiplicity and
dysfunctionality. However, no evidence has been
published that dissociative identity inevitably causes
dysfunctional and socially
unacceptable behaviour or
disease.
The assumption of automatic dysfunctionality in
dissociative identity is central in the DSM. “
Diagnosis
can be made in the absence of significant objective
dysfunction
” (Summerfield, 2001, p. 97). Other
diagnoses such as Schizophrenia, Major Depression and
Post-traumatic Stress Disorder include in their diagnostic
criteria that “
the symptoms cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning
” (APA, 1994, p. 327).
However, no such criteria ar
e included for “Dissociative
Identity Disorder
”.
Whether or not there is distress or
impairment is irrelevant. Unlike other disorders,
dissociative identity is deemed a disorder and thereby
dysfunctional, purely on the basis that those who
experience it have a self that is not singular.
There may be in the general population a large
number of people with MPD who are high-
functioning, relatively free of overt psychopathology,
and no more in need of treatment than most of their
peers. They may not have abuse histories and may
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
12
have evolved a creative and adaptive multiplicity. If
these people exist, virtually nothing is known about
them.
(Ross, 1989, p. 97)
The phrase “
if these people exist
” expresses some
doubt that there can be “
high-functioning
” individuals
with multiple selves, continuing the discourse of
dysfunction. However the phrase also highlights a gap in
the scientific research. Functional individuals who live
with multiplicity are most lik
ely not documented because
of the very fact that they
are
functional and do not seek
therapy. At present, the only documented cases of
functional multiplicity are self-documented, for example
on internet pages. Although this is not persuasive
evidence for the scientific community, such data cannot
be summarily dismissed simply to hold to the dominant
discourse.
A construction of dissociative identity as inherently
disorderly and dysfunctional, in conjunction with many
therapists’ world view that a unitary self is normal and
best, leads to the assumption that multiplicity needs to be
cured
: “
The goal of treatment of MPD is not palliation. It
is cure
” (Ross, 1997, p. 204). “
Integration as an overall
treatment goal
” (Barach, 1994, section IIIA). “
It usually
becomes essential to replace dividedness with unity ... for
any treatment to succeed
” (Kluft, 1984a, p. 11).
The prescription for cure is integration to oneness as
accepted and unquestioned practice. According to this
view, multiple selves must be integrated into a unitary
identity. “
My model of therapy is no more than this: the
patient has developed chroni
c trauma disorder with
MPD in response to childhood abuse. She needs to
integrate
” (Ross, 1997, p.294). “
This carries the seeds of
a prescriptive rigidity, one which might also serve to
confirm an illusion that it is possible to develop a set of
principles or codes which can be invariantly applied
irrespective of context
” (Gergen, 1992, p.181). In
advocating integration, the
texts support the traditional
understanding of the self as a unitary psychological
construct.
The unified, coherent se
lf thereby becomes the
regulative norm. One of the ways in which a normative
prescription such as unitary oneness operates is through
the construction that dissociative identity is deviant.
“
Those who lack ‘rightness’ help define what is ‘right’.
Some modes of living become accountable while others
remain unexceptional and taken for granted.
” (Reynolds
& Wetherell, 2003, p. 490).
Alternatively, a position that constructs the self as
inherently plural and multiple in nature has the potential
to present a very different view of dissociative identity.
On first reading, Rivera’s text appears to do this, largely
due to the markedly positive language used throughout.
Multiplicity and dissociation are presented as not only
potentially functional, but also real strengths:
Multiplicity is not a problem; it is a wonderful
thing, individually, socially, and culturally. The
problems from which multiples suffer do not derive
from the existence of their personality states, their
many ways of being in the world. That is their
strength
(Rivera, 1996, p. 41).
The different voices with different perspectives no
longer have to be silenced or devalued. The
individual who is now in
a position to bear an
awareness of the depth, breadth, complexity and
contradictory nature of her life experience, can now
call all of those voices “I”, accepting none as the
whole story, but embracing them all. This is the
multiplicity at the heart of all of us. It transcends
categories
(Rivera, 1996, p. 48).
However, a careful reading of
the Rivera text reveals
that multiplicity is ultimately not equated with functional
living but instead is presented
as a problem that needs to
be addressed. Rivera falls
back on discursive resources
that situate dissociative identity within the Western
medical model:
You have a serious problem that used to be called
multiple personality and is now called dissociative
identity disorder. There is good news and bad news
about this condition. The good news is that is
treatable. Many people who have this problem get
completely better. The bad news is that the treatment
takes a long time and is very stressful
(Rivera, 1996,
p. 79).
In some respects Rivera also
prescribes integration to
oneness:
The more deeply parts of the individual connect
with the therapist; the more important it is for the
therapist to remember that the client is one person.
As the therapist does this, the individual aspects of
the system or personalties will gradually transform.
They will not be stuck in rigid and repetitive patterns,
and the early stages of a fluid responsive self will
begin to emerge
(Rivera, 1996, p. 122).
“
She can now call all of those voices ‘I
’” (Rivera,
1996, p. 48). Rivera appears to
fall back on the traditional
concept of encapsulating all parts into a single identity.
There has to be an “I”; she does not contemplate an
identity as ‘we’. She presents a mixed message: it is not
necessary for individuals with multiplicity to be directed
towards integration, but if they are left alone the parts
will integrate by themselves.
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
13
Although in some ways Rivera’s text tries to offer a
new approach, it really only removes itself to the margins
of the medical model. She takes issue with the position of
the DID proponents, but does not really establish a clear
alternative position of functionality as a “we”. If one
were to adopt such a
position it would not only
acknowledge the possibility of a functional multiplicity
but also encompass a multi-facet
ed identity that could use
“we” as a description of “self”.
The plural self (we) is seen as being consistent with the
historical and social condition of pre-enlightenment and
post-modernity. The self is formed and performed
through interactions in specific and cultural contexts.
Hermans (1997) theorised the self as a constellation of
dialogically structured pos
itions, each with their own
worldview and landscape, in relations of intersubjective
exchange and dominance. The “I” moves between
positions in an imaginal landscape, depending on time,
place and situation, resulting in a multi-voiced self. The
self as plural consists of a multiplicity of positions,
voices, states of mind, functions etc. (Rowan & Cooper,
1999). This self, therefore is never ultimately bound by a
set role but is constantly in the making; it is a self-in-
process (Ortega, 1991).
Although psychological discourse does not encourage
discussion about separate selves in ordinary speech
(Heinimaa, 2000) many people in today’s post-modern
world would describe themselves as having multiple
parts or senses of self, cons
tantly changing and evolving.
They would see this as an appropriate response to the
multifaceted demands of contemporary society, in which
flexibility and horizontal integration are valued as
subjective qualities over stability and hierarchical
organisation (Rappoport, Baumgardner, & Boone,
1999). Our language also holds an underlying
‘multiplicity’. When describing individuals we use words
such as balanced and well-roundedness. We often use
phrases such as “part of me wanted to and part of me
didn’t” or “I didn’t feel like myself”. This “plurality in all
of us” Rivera believes, is experienced as a “unity”. “
The
unmentioned or hidden ‘multiplicity’ in all of us
comprises the many distinct and separate facets of a
person’s personality, the many ways of being, which
make up the ‘whole’ individual called ‘I’
.” (Rivera, 1996,
p. 48). Perhaps it is as Erdelyi (1994) describes, “
when
the self-system is in dis
harmony, however, the multiplicity
of self-systems tends to be more obvious
” (Rivera, 1996,
p.99).
It may also be that “
fragmentation is a way of living
with differences without turn
ing them into opposites, nor
trying to assimilate them out of insecurity
” (Trinh, 1992,
p.156). Rather than focus on
the issue of multiple self
“disorder”, an alternative approach could explore the
notion of functionality in conjunction with the
individual’s experience. This approach could explore
whether the individual experiences their inner and outer
world as safe, functional, happy, productive, and as an
acceptable way of being in th
e world. Similarly it could
explore whether the extern
al world experiences the
person as safe, functional,
happy, as productive, and
sufficiently consistent in presentation (in all guises) that
others can relate to the person. In this way the
“diagnosis” of disorder, if one was to be made at all,
would be linked with the individual’s views on multiple
aspects of both internal and external functioning.
Therapeutic goals would vary depending on which of
these different aspects of functionality were to be focused
on. One issue might be the degree of communication and
co-consciousness between pa
rts thought necessary for
one’s definition of functional. While therapeutic work on
developing co-consciousness and communication has
frequently been promoted by DID therapists, this has
only been portrayed as a step along the way towards
integration (Kluft, 1993). Rivera’s stance (p. 41 & p.
122) moves towards seeing communication and co-
consciousness as a therapeutic end in itself, but still with
the goal of developing a functional “I”. If the goal is
functionality as “we”, two approaches are possible.
Either therapy works toward
s a co-ordinated internal
system, involving communication and co-consciousness
between parts, or the possibility could be explored that
functionality can be gained wit
hout all parts of the system
becoming aware of other parts and able to communicate
with them. In Bromberg’s (1993) view “
Health is not
integration. Health is the ability to stand in the spaces
between realities without losing any of them
” (p. 379).
Continuing Discourse No. 1: ... But not Sufficient
for Health.
Although the texts promote integration as
being the cure for dissociative identity, they then state
that more is needed to achieve health; that is, integration
is necessary but not sufficient for health: “
Treatment does
not end with fusion/integration; it only enters a new
phase
” (Putnam, 1989, p. 302). There is also the tacit
message that on this path to “true health” the “patient”
will develop further psychological problems: “
The initial
euphoria that accompanies the achievement of unity
rapidly gives way to a profound depression
” (Putnam,
1989, p. 318). “
When you complete the multiple
personality part of the treatment and the person has
achieved integration, you are
then dealing with a person
with single personality disorder
” (Kluft, 1993, p. 89;
1994)
These problems may even be “
untreatable
”:
After the final alter personality has been
integrated, there is still a lot of work to do. Others
make a transition from MPD to PTSD in a single
personality. Such patients may have intense
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
14
flashbacks and continue to be suicidal, unstable in
their mood and self-destructive in their manner of
living for a long period of time post integration. For
some the outcome may be resolution of their MPD,
with an untreatable personality disorder
(Ross, 1989,
p. 220).
In no other area of the DSM does the eradication of
one disorder inevitably lead to the diagnosis of another
disorder. This brings into question the validity of the
prescription for integration to oneness, and also reflects
the power of social expectations. Individuals must move
from socially unaccepted mu
ltiplicity to a socially
tolerated single disorder.
The texts go on to address the problems of integration:
“
Even though the patient may be enormously distressed
after integration because they have lost their ability to
dissociate, this is still an ideal goal
” (Putnam, 1989, p.
141). Kluft (1995) also notes
that many multiples have
very unrealistic expectations about how good it feels to
be unified. “
The patient may always be tempted to return
to the divided state and may even mourn the loss of the
alter selves. Vigilance is essential
” (Putnam, 1992, p. 36).
These quotes attribute post-integration problems to the
client. The possibility that it is the treatment that is
problematic is not questioned and the fact that an
individual experiences ongoing distress is viewed as a
necessary sacrifice for the ach
ievement of the therapist’s
ideal of a singleton self. “
The multitude of voices are thus
reduced to a ‘systematically monologized whole
”
(Bakhtin, 1997, p. 9).
Alternatively, if internal and external functionality as
“we” is the goal, then iatrogenic distress would be
avoided. The therapist’s task would be simply to explore
what each part of “we” needs in order to experience
health.
Exploring Discourse No. 2: Therapist Knows Best.
Representations of the relationship between therapist and
‘patient’ in the texts function to promote a further
discourse embedded in the dominant medical model: that
the therapist knows best. The
texts initially advocate the
ideal collaborative nature of the therapeutic relationship
when dealing with dissociative identity, but quickly go
on to stress the importance of the power of the therapist:
“
Treatment will be a collaboration but not democratic.
The patient is the patient and I am the doctor. We are not
friends, and I am the only one getting paid
” (Ross, 1997,
p. 302).
This extract highlights that
real collaboration is
impossible, stressing the chas
m between the doctor as the
all-knowing professional and the patient as the unwell
one simply paying for the doctor’s expertise. The
therapeutic process theref
ore becomes one where the
dominant goals of the all-knowing professional are
imposed despite the client:
There is no need to be apologetic for commitment
to the goal of integrati
on and the specific techniques
that help the patient get there. The patient will stall
and resist the work to
ward interpersonality
integration in countless ways
(Ross, 1989, p. 245).
It is most important to decline to engage in
arguments over integration with the patient, because
this course of action almost inevitably heightens
narcissistic investment in the wish to avoid
integration and introduces an adversarial tension in
to an already difficult treatment. My personal style is
to encourage a wait-and-see attitude. Usually by the
time integration becomes an issue, it is in the process
of occurring and perceived as inevitable. The
argument is then irrelevant
(Kluft, 1993, p. 109).
The word “
argument
” shapes the client as an adversary
and their desire to discuss the issue of integration before
committing to it as unreasonable and antagonistic. First,
the therapist is constructed as entitled to refuse to discuss
the issue of integration b
ecause he is right and knows
what is best for the client. Second, the text condones a
therapeutic approach of subterfuge that disguises, under
an apparently easy-going style of “
wait-and-see
”, the use
of a process that will lead to an “
inevitable
”
predetermined outcome. “I
encourage their (the alters’)
communication and teamwork, all of which is in the
service of eroding narcissistic investments in uniqueness
and separateness and promoting integration
.” (Kluft,
1993, p. 34)
Ironically, while a commitment to maintaining one’s
identity would be considered a normal and healthy life
force in a singleton, the selves (alters) of an individual
with dissociative identity are represented as having a
“
narcissistic investment
” when they attempt to preserve
their existence, rather than yielding to the therapist’s
demands.
“
The medical field holds the power and it sets the
agenda
” (Parker, 1995, p.2). The power of authoritative
knowledge is not that it is correct but that it counts
(Coates & Jordan, 1997). In the face of the expertise of
the medical fraternity, which is both sanctioned by and
informs society, the “patient” with multiplicity is
rendered powerless.
As part of this power asymmetry, the “patient” with
multiple selves is constructed as a child and the therapist
as a parent. In the role of
“child”, the “patient” is
represented as unable to assess his/her own needs or
goals, incapable of equality with a professional person,
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
15
and requiring rules and discipline to manage out of
control behaviour:
Handling MPD patients is often like handling
misbehaving children. Limits, toughness, strict rules
and consistent enforcement are the kindest and most
effective treatment. Not everyone agrees with that
parenting approach, but the patients will eventually
teach it to most therapists who are committed to
effective efficient therapy
(Ross, 1989, p. 224).
With this combination of a belief in the primacy of the
therapist’s knowledge, a minimising of the client’s wants,
and the adoption of a parent/child approach, it is only a
short step to justifying the us
e of coercion in therapy with
clients who experience multiplicity:
Initially, confrontation shoul
d be kind, firm, matter
of fact, and incorruptible. Once it is clear that the
patient understands what is required but behaves
inappropriately nonetheless, more forthright
confrontation may have a role. This may be
especially forceful if the issue concerns cooperation
with therapy
(Kluft, 1993, p. 43).
A double standard is sanctioned: the therapist can
adopt an authoritarian approach involving force but the
client must exhibit “appropriate” behaviour and
democratic cooperation. Indeed, a state of siege initiated
by the therapist is prescribed:
The strategic integration therapist focuses more
specifically on undermining the dissociative defenses
that support the multiplicity; this erosion is ongoing
and relentless so that the dissociative structure
collapses from within
(Fine, 1993, p. 137).
The easiest outcome of this war is for the client to
submit, to surrender. If not, more invasion is prescribed:
“
Sodium amytal should be considered when other
techniques have failed or when temporary access to an
unavailable alter is required... it is a battering ram. It
gets you into the system
” (Ross, 1997, p. 363).
The medieval war image of the battering ram has
echoes of rape and thus could be seen as highly
insensitive in light of evidence that a history of prior
abuse is common in multiplicity (Kluft, 1990; Ross,
1989). Nowhere within these texts is there an
acknowledgement of the possi
bility that these breaking-
down processes may replicate and perpetuate abuse
dynamics, further harming the client. It is possibly
because of the invasive for
cefulness advocated in such
therapy that client resist
ance becomes an issue.
Again and again the patient must be educated and
reminded of his or her role and duties in the therapy.
... Unless the therapist takes such steps he or she will
find it difficult to confront the MPD patient who is
resistant and/or nonc
ompliant. Confr
ontation will be
met with protestations of helplessness and wounded
innocence
(Kluft, 1993, p. 33).
Resistance to invasion is portrayed as troublesome and
constructed as a manipulative overreaction. Critics of this
traditional view point out that resistance has been, and in
some cases still is, seen as an obstacle that must be
circumvented or overcome (Rowe, 1996) and arises
from a patronising position that clients “
just don’t know
what is in their own best interests
” (Amundson, Stewart,
& Valentine, 1993, online version).
An alternative view is that resistance is a positive
instinct. “
Resistance to violence and oppression is both a
symptom of health and health inducing
” (Wade, 1997, p.
24). From this perspective, clients could be seen as
exhibiting a healthy response to the invasion of the
therapist. Such resistance is
not unexpected, given that
multiplicity is itself a: “
Creative and courageous
resistance, the refusal by women and children to be
destroyed
” (Rivera, 1996, p. 18).
Perhaps the therapeutic goal for people who are
experiencing dysfunctional
multiplicity should be to
recognise the creative instinct to resist past abuse, to
develop resistance to the legacies of previous and current
abuse, including invasions by traditional therapists.
Instead, the majority of th
e texts examined depict
therapy as a site of conflict. The therapist’s role is seen as
the holder of knowledge, “
the expert who diagnoses the
client’s problem and applies treatment
” (Bohart, 2000, p.
143), with an entitlement to us
e force in order to change
the patient. These power relations between therapist and
patient “
grant powers to some and delimit the powers of
others, enable some to judge and some to be judged,
some to cure and some to be cured, some to speak truth
and others to acknowledge its authority and embrace it,
aspire to it, or submit to it
” (Rose, 1996, p. 175).
Rivera’s text acknowledges the importance of a more
collaborative relationship between therapist and client as
a more effective basis for growth and change:
Although the therapist has the training and the
experience that give her more responsibility for the
effectiveness of the treatment, it is crucial that the
client not lose control over this part of her life.
Therapy is always a partnership, and unless both
partners respect the roles and responsibilities of both
themselves and the other, the relationship is likely to
undermine the client’s strengths rather than
contribute to her growth
(Rivera, 1996, p. 82).
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
16
Although Rivera emphasises the notion of
“partnership” the growth is still portrayed as occurring on
one side only. Perhaps a more equal collaborative client
therapist relationship would demonstrate and
acknowledge that often the therapeutic relationship is a
mutual process of growth and learning.
General Discussion
This analysis does not purport to be a thorough
discourse analysis or the only possible interpretation of
the texts explored. It is important to note that what we
accept as possible interpretations
of a text are determined
by our “
horizons of understanding
” (Gadamer, 1975, p.
273) and as such these texts are open to other readings,
other possible interpretations.
Indeed there are as many
possible interpretations as ther
e are readers of the texts.
However this brief exploration offers a glimpse into the
ambiguities, contradictions
and complexities involved in
the language used to describe
dissociative identity. It also
demonstrates the need for further qualitative research into
the area of dissociative identity.
The present analysis raises many issues, some of which
will be discussed here. A prominent issue which has been
long recognised in the psychologi
cal literature is that of
defining self. The literature on
‘the self’ is huge and there
is no claim here to cover the numerous ways in which the
term has been used in modern and postmodern writings.
However when looking at how the authors of the five
examined texts viewed the se
lf within the dissociative
identity context, the majority
proposed the unitary self as
the goal of therapy. However when one looks beyond the
five texts, there is an
acceptance of multiplicity, the
multiple self and polypsychism within the psychological
literature (see Hermans, Rappoport, Ross, Shotter, &
Watkins in Rowan & Cooper, 1999). Mair (1977)
proposed the mind to be a ‘community of selves’ while
Stone (1998) states that the belief that only one “
I
” could
belong to one body, or even that only one “
I
” could be
present at one time, was: “
a kind of a story we told each
other
” (p.85). “
For the post-modern practitioner a
multiplicity of self-accounts is
invited, but a commitment
to none
” (Gergen, 1992, p.180).
Within the views that
embrace multiplicity, however,
there appear to be varying degrees of acceptance of
multiplicity. Ross (1999) takes the position that, while
MPD is a psychiatric pathology or psychiatric
polypsychism, polypsychism is the “
normal state of the
human mind
.” (Rowan & Cooper, 1999, p. 193). Ross
defines polypsychism (rarely obtained) as “
a degree of
healthy, fluid integration of sub-selves
” (p. 194) and that
MPD and polypsychism are distinguished, he explains by
“
the difference in the degree of personification of the ego
states, the delusion of literal separateness of the
personality states, the conflict, and the degree of
information blockage in the system
”(p.193). Although
polypsychism may be an ideal
, Ross states that what “
we
call normal in our culture is actually pathological
pseudounity
” (p. 194). He states that “DID
is a
psychiatric disorder while pathological pseudounity is a
cultural sickness
” (p. 195). “
The integrated DID patient
is better off having no DID, even though he or she may
now exhibit pathological pseudounity
” (p. 195)
So, is the requirement for oneness necessarily healthy
and helping the client? The texts explored indicated that
this may not always be so. In general integration was
expected to result in further problems (eg. Putnam,
1989). The possibility that the tr
eatment is problematic is
not questioned within the texts. Instead the problems
resulting from treatment are individualised to the client
and at best are seen as a sacrifice that the client has to
pay. This highlights issu
es of power, responsibility,
control and agency which will be covered in a further
paper.
If treatment is problematic and yet remains
unquestioned by the therapist, then does the therapist
really know best? This was the second discourse
explored within the texts. It was found that the texts
placed the client in a subser
vient role; he or she was
required to comply with the therapist or be labelled
recalcitrant or possibly not treatable. This type of
therapeutic paradigm requires the client to take on board
the therapist’s world view a
nd become how the therapist
thinks he or she should be, rather than how he or she
would choose to be. This also raises an issue of what
Hacking (1999) calls “
false consciousness
” (p. 266). The
fear concerning false consciousness is the sense that the
end product of therapy is a thoroughly crafted person.
Not a person with self knowledge, but a person who is
worse for having a glib patter that
simulates an understanding of herself (Hacking, 1999)
Towards a More Open Stance.
I have selected
extreme extracts because
these may highlight the
underlying beliefs that inform the texts. But the texts
themselves are not extremes. Indeed these are the most
common and widely used texts practitioners read to learn
about and inform their practice relating to dissociative
identity. These texts both reproduce and produce the
discourses that construct dissociative identity at the
present time.
Discourses can inform or misinform understanding of
multiplicity and therefore enhance or hamper
understanding of self/selves. Some beliefs about the self
which are most widely shared
are the least easy to see;
this is because they
are
shared and therefore go
unquestioned. By failing to que
stion these beliefs we are
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
17
complicit in promoting them: “
there is a tacit and almost
heedless allegiance. We influ
ence that which we observe,
as much as we are influenced by it
” (Radden, 1996, p. 8).
Wearing (1994) determined that there is a professional
dominance of psychiatry and nosographic language of
medical discourse used to classify and treat illness and
syndromes within the health
system. However there are,
in contrast to this, many therapists who use and promote
alternative “
therapies of resistance
” (Guilfoyle, 2005, p.
101) such as narrative approaches. These approaches not
only privilege the client rather than expert accounts, but
also bring to the fore the situation of their client and their
problems in respect of societal domination or
marginalisation. (e.g. Albee, 2000; Ali, 2002; Gilligan,
Rogers, & Tolman, 1991; Kaye, 1999). Nevertheless
many health professionals are still required to adhere to
the rigid and objectified set of categories of illness found
within the DSM. The DSM becomes professional
knowledge and diagnosis, the language of psychiatry, the
“
social representation of psychiatric knowledge, as well
as the psychiatric profession’s presentation of self
”
(Brown, 1990, p. 389). Moreover, Parker (1995) states
“
When the categories from
the DSM-IV are used, they
become charged with an emotional force which has far-
reaching consequences for those who are labelled
” (p.2).
It is important to recognise that “
discursive practices
are ways of talking, thinking, feeling and acting that,
when enacted, serve to reinforce, reproduce or support a
given discourse and at the sa
me time deny, disqualify or
silence that which does not fit the discourse
” (Law, 1999,
p. 119). The texts explored here indicated both symbolic
and real violence toward
s those who experience
dissociative identity. Through the setting down of
ideological boundaries and inclusion/exclusion of
single/multiple and healthy/not healthy, those with
dissociative identity who do not conform to the expected
way of being (by completing treatment) are marginalised.
The limitations of the mainstream approaches towards
dissociative identity become apparent when the
assumptions and norms implic
it in these approaches are
uncovered: that the self is ideally unitary, that the
experience of multiple selves is pathological, and the
professional has the authority to impose goals and
processes on the client, to define any signs of resistance
as a problem and to over-power such resistance.
This analysis of traditional psychotherapeutic discourse
in relation to dissociative identity raises some important
questions. Does the traditional view of dissociative
identity empower the client or does it individualise
oppression and pathologise their experiences? Does the
therapy offer space for clients to develop new forms of
subjectivity or does it confirm them within their current
restrictive positions and castigate them for their
resistance? How are the power relations embodied in
certain specific kinds of tec
hniques, for example the use
of a metaphorical battering ram?
If we recognise that personal constructions are shaped
and constrained by culture or by the “
shared language
and meaning systems that d
evelop, persist, and evolve
over time
” (Lyddon, 1995, pp. 69-92), and that
knowledges, discourses, and power are interrelated, and
that some discourses are legitimated as proper
knowledges while others are subjugated (Foucault, 1980,
1983), then how do individuals experiencing a “we”
identity negotiate the expectations of the majority? Do
they adopt or resist the different discourses? How does
the “we” find their voice wh
en faced with powerful
traditional professions such as psychiatry and
psychology? How is the “we” identity constituted in
relation to the dominant discourses of the DID group and
the psychological community?
The analysis undertaken indicates that a resistant
reading of the texts is possible. It could be that other
practitioners and theorists can also be resistant to these
texts. The texts themselves do not necessarily indicate
what actually goes on in practice. The relation between
texts and the practices that might be informed by them
needs to be explored.
Although it is not possible at the present time to
answer all the questions and issues raised in this paper,
further research explori
ng these issues and the
phenomenology, the lived experience, of dissociative
identity from the client’s point of view is being
undertaken by this writer. This may aid in creating a
space for individuals with di
ssociative iden
tity to speak
with their own voices and their own discourses.
It is likely that there will be some resistance to the
adoption of more open discourses on dissociative identity
into the mainstream. This is
because by its very nature
dissociative identity challenges and disrupts the dominant
views held by the psychological community and society
at large. Adopting a more open view of multiplicity
depends on and informs a major shift in notions of the
self, therapeutic research
and practice, and social
attitudes in general. Adopting this view may well cause
considerable discomfort in the mainstream
psychiatry/psychological communities. However it is
perhaps this discomfort that has blocked more open
views on dissociative identity, rather than anything
inherent in multiplicity itself.
Adopting a different therap
eutic stance that embraces
the possibility of a functional multiplicity in relation to
dissociative identity might allow new discourses to
develop. Instead of the notion that single is necessary
but not sufficient for health, a dissociative identity
therapist could also convey the message that
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
18
multiplicity is an alternative, valid and potentially
highly functional way of being, but internal
communication might be necessary for health. Rather
than promoting the concept that the therapist knows
best, dissociative identity th
erapy could be underpinned
by the idea that therapist and client work best together,
with transparency, honesty and mutual learning being
paramount, and with “resistance” valued as a healthy
survival instinct.
Acknowledgments
I would like to thank Fran, Doris, Daf, Alison, and
Sue for their thoughts on this paper. I would also like to
thank the anonymous reviewers for their helpful
comments.
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23, 1-8.



Critiquing the Requirement of Oneness
over Multiplicity: An Examination of
Dissociative Identity (Disorder) in Five Clinical Texts.
Kymbra Clayton (
kclayton@psy.mq.edu.au
)
Department of Psychology, Macquarie University,
North Ryde, Sydney, 2109, Australia
Abstract
In the health professions there is widespread agreement
that dissociative identity is dysfunctional and needs to be
cured. This position is based on the assumption that the
healthy self is unitary and therefore multiplicity must be
disordered. The cure, a requirement of oneness, is
integration: the multiple selves must be unified into a
single, integrated personality. To uncover themes and
assumptions of this dominant approach to dissociative
identity, five main texts were examined. From the many
discourses identified, two
central discourses were
selected for further explorati
on. This paper explores how
the identified discourses construct individuals with
dissociative identity and how they inform and limit
psychological theory and practice. Being exploratory,
this paper offers a platform for further in-depth
deconstruction and critical evaluation of the underlying
assumptions and implications.
Keywords:
Dissociative Identity; Clinical Psychology,
Integration.
Shall my cure be a far greater burden than the one I now bear on my own?
For when the battle is won you will go home
And it is I who must continue alone.
(Anon)
A concept which continues to arouse interest and
controversy in psychological circles is that of
dissociative identity, prev
iously known as multiple
personality disorder (MPD).
This phenomenon is best
understood and examined in the context of one’s notion
of self. Mainstream psychology tends to view the self
as individuated and autonomous, that is, as having core
properties that are universal, bounded, atomic and
somewhat detached from its
cultural, social and
historical moorings. Many psychology and psychiatry
professionals rely on the traditional idea of a ‘
true
’ or
‘
core
’ self, a self which is individual, rational,
authentic, consistent and the origin of its own actions.
From this perspective, it is expected that a well-
integrated, healthy person should have a strong and
unitary self (O’Connor & Hallam, 2000).
This concept is in contrast to pre-enlightenment and
post modern thought that problematises the notion of
the unitary self. [For recent
conceptions of the self in
psychological literature, see
Lester, (1994) and Stam
(2004).] Those who embrace an alternate view of self
offer the concept of an inherently plural, fluid, flexible,
fragmented and decentred self, formed and constrained
by social processes. From this perspective a plural self
consists of a multiplicity of positions, voices, states of
mind and functions (Neimeyer & Raskin, 2000); each
self “
is a source of differing interpretations of the
world, based on differing interpretive schemes
” (Lester,
1994, p. 312). This self “
has a plural personality, she
operates in a pluralistic mode
” (Anzaldúa 1987, p.79).
For those who view the self as inherently unitary, two
main positions or groups rega
rding dissociative identity
can be identified. The first group either does not believe
that dissociative identity exists at all or believes that it
can exist but is extremely rare. This group views those
who present with multiple selves either as fakes or as
holding false beliefs of multiplicity that have been
created iatrogenically by misguided therapeutic
techniques (Spanos, 1994). The second group
acknowledges individuals’ use of dissociation as a
common response to trauma and/or neglect and reports
that there is a significant (perhaps around 1%) group of
individuals whose lived experience is one of multiple
selves or different identitie
s (Kluft & Fine, 1993; Ross,
1997). As a result of this group’s efforts, dissociative
identity has become more recognised and was included
in the Diagnostic and Statistical Manual (DSM),
editions III and IV, published by the American
Psychiatric Association. The DSM is regarded as
providing the medical and social definition of mental
disorder and is a main diagnostic reference used by
psychiatrists and psychologists.
However, reflecting this second group’s perspective
that a healthy person requires an integrated and
essentially unitary self, the DSM-IV presents
dissociative identity as a disorder (DID) and describes
it as “
a failure to integrate various aspects of identity,
memory and consciousness
” (American Psychiatric
Association, 1994, p. 484). The criteria for diagnosis
according to the DSM are “
the presence of two or more
distinct identities or personality states
(Criterion A)
that recurrently take control of behaviour
(Criterion B).
There is an inability to recall important personal
information that is too extensive to be explained by
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
10
ordinary forgetfulness
(Criterion C).
The disturbance is
not due to the direct physiological effects of a substance
or a general medical condition
(Criterion D). The
distinctive assumption is that identity, memory and
consciousness should be integrated into a unitary self.
An alternative position in relation to dissociative
identity, partially informed by a post-modern notion of
self is that it is not a disorder per se (Rowan & Cooper,
1999), but rather an alternate and potentially functional
and adaptive way of being. This position invites a
deconstruction of the addition by the DID proponents
of the concept “
disorder
” to dissociative identity. In
agreement with this, Hacking (1995) is also wary
about the term ‘
disorder
’. He purports that it is “
loaded
with values and is code for a vision of the world that
ought to be orderly.
” (p. 17). Such an addition of the
term ‘
disorder
’ contributes to discourses on
dissociative identity which are then disseminated by
subsequent generations of practitioners as the truth.
They inform how practitioners perceive clients with
multiplicity and shape a whole treatment approach.
The purpose of this paper is not to detract from the
valuable role played by prominent members of the DID
field in fostering a greater recognition of multiplicity.
Neither is the purpose to imply that such practitioners
have negative intent towards people who experience
multiplicity. Rather, the intention is to identify the
discourses of the DID proponents and to consider their
implications for working with people who experience
dissociative identity. In this paper, multiple self-states
are referred to not as ‘DID’
but rather as dissociative
identity or multiplicity, spelt
without capitals. This is
done to avoid either automatically pigeonholing the
experience as inherently disordered or objectifying
those who experience it.
Method
The texts chosen are from three of the most well
known psychiatrists in the fi
eld of dissociative identity,
namely Richard Kluft, Frank Putnam, and Colin Ross.
Each has published recognised texts and numerous
articles on ‘DID’ and all contributed to the recognised
treatment guidelines of the International Society for the
Study of Dissociation (ISSD) (Barach, 1994). To explore
a counter position, a text by a more recent specialist in
multiplicity, Margo Rivera, is included. The texts
examined were:
Clinical Perspectives on Mu
ltiple Personality Disorder
(Kluft & Fine, 1993) and articles by Kluft (period of
1983-1996).
Diagnosis and Treatment of Multiple Personality
Disorder
(Putnam, 1989).
Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment(Ross, 1989, 1997).
International Society for the Study of Dissociation (ISSD)
Treatment Guidelines
(Barach, 1994).
More Alike than Dissociative: Treating Severely
Dissociative Trauma Survivors
(Rivera, 1996).
To describe and analyse the power structures,
ideologies, images and messages within these texts, a
variety of qualitative analytical
methods were applied as
part of a larger study which explores the clinical literature
more fully. As a precursor to a more thorough critical
discourse analysis or post modern critique, this paper
examines the texts from the point of view of content and
language, teasing out a
ssumptions and attitudes
concerning DID and those who experience it. This paper
also offers a brief glimpse into how the identified
discourses construct individua
ls and diagnoses, and how
they inform and limit psychological theory and
therapeutic practice
Texts are segments of meaning reproduced in any form
that can be given an interpretive slant (Parker, 1992). A
discourse can be defined as “
sets of statements that
construct objects and an a
rray of subject positions
”
(Parker, 1994, p. 245). “
Discourse is a practice not just
of representing the world, but of signifying the world,
constituting and constructi
ng the world in meaning
”
(Fairclough 1992, p. 64). Fairclough (1992) argues that it
is important that this relationship is understood
dialectically.
A dialectical perspective emphasises that
discourse is a way to study both explicit language and the
material anchoring of language.
Discourses can be found ‘
performing’
in texts. This
paper sets in motion the process of exploring the
“
connotations, allusions, and implications which the texts
evoke
” (Parker, 1992, p.7). The questions that are posited
are “
how are descriptions produced so that they will be
treated as factual?
” and “
how are these factual
descriptions put together in ways that allow them to
perform particular actions?
” (Potter, 1996, p. 6).
Language is often a reflec
tion of the attitudes and
assumptions of much of societ
y at large. Critical analysis
of language used in the dissociative field, heightened
awareness of its implications, and considered choice of
new and different language to frame the experience of
those with DI, can have a major impact on the future
directions of therapy in this field.
Analysis and Discussion
From the many discourses discovered in the texts, two
central discourses were chosen for exploratory analysis.
These were:
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
                                   Clayton: Critiquing the Requirement of Oneness Over Multiplicity. 11. ‘Single’ is necessary but not sufficient for health 2. Therapist knows best.
xploring Discourse No. 1: ‘Single’ is Necessary...
but not Sufficient for Health.
Single’ is Necessary. ...All the texts initially adopt an
egalitarian stance towards dissociative identity by
acknowledging and praising the functional aspects of
dissociation in helping individuals to cope with the
experiences of abuse. “
Creating other children inside is
an excellent short-term solu
tion to the abused child’s
problems
” (Ross, 1989, p.128). “
At one time, usually in
early childhood, dissociation was a highly adaptive
response to overwhelming trauma
” (Putnam, 1989, p.
137).
Descriptions such as “
excellent
” and “
highly
adaptive
”
express admiration for the processes involved. However
the implied praise is qualified: the solution is only “
short-
term
” (Ross, 1989, p. 128), the processes only adaptive
“
at one time
” (Putnam, 1989, p. 137). The assumption is
that a strategy that worked well in childhood is no longer
functional in adulthood.
All the texts, excluding Rivera’s, make much stronger
assertions that multiplicity for adults is dysfunctional,
maladaptive, and, in line with the Western medical
model, pathological: “
The problem with adult DID is
that, like any survival strategy gone wrong, it creates
more problems than it solves
” (Ross, 1997, p. viii). “
The
person needs to be fixed so that he/she can be effective
rather than powerless in the face of the MPD
psychopathology and life events
” (Kluft, 1993, p. 291).
“(Adults) require ‘symptom stabilisation’, ‘control’ of
their behaviour and ‘restoration of functioning
’ (Barach,
1994, section II).
The implications of the ISSD Guidelines are twofold.
First, individuals with dissociative identity incur a
process of medicalisation, through which “
non-medical
problems become defined and treated as medical
problems
” (Conrad, 1992, p. 209). In this process the
concept of disease, for wh
ich a biological cause is
required is often misaligned with the concept of disorder.
Disorders do not have clear
aetiologies, yet the practice
of psychiatry is still underp
inned by the medical and
therefore disease model. Second, individuals with
multiple selves are further positioned as unstable, out of
control and dysfunctional respectively.
These implications are broadened in most texts to a
conflation of multiplicity with
undesirable be
haviour and
disease:
The desire for intense dissociated states is built into
our DNA ... such states are wonderful, desirable, and
healthy in their natural form ... but there is nothing
wonderful about the chemical ecstasy of the heroin-
addicted ghetto prostitute. This is why there is
psychiatry of dissociation, the goal of which is to
substitute healthy, normal altered states for self-
destructive, painful ones
(Ross, 1989, p. 187).
The emotive language in this extract implies an almost
inevitable link between dissociation, drug addiction and
prostitution. This is further developed by Ross:
MPD is directly linked to sexuality ... In our 236
cases, 19.1 percent had worked as prostitutes. Many
of these people would potentially stop prostituting if
they were diagnosed and treated for the MPD. The
connection between MPD, childhood sexual abuse,
prostitution, sexual promiscuity, and venereal
diseases including AIDS, makes MPD a major
unrecognised public health problem
(Ross, 1989, p.
94).
Statistical data from one sample is used by Ross to
factualise a conflation of multiplicity, prostitution and
associated diseases such as
AIDS and venereal diseases.
Although some individuals with multiplicity have these
health issues, the language used constructs ‘MPD’ as the
primary problem. However, it is disease that is a major
public health problem, not multiplicity. There is no doubt
that some people who experience multiple selves are
dysfunctional and/or live outside of society’s standards,
and in some cases a causal relationship could be
reasonably argued between multiplicity and
dysfunctionality. However, no evidence has been
published that dissociative identity inevitably causes
dysfunctional and socially
unacceptable behaviour or
disease.
The assumption of automatic dysfunctionality in
dissociative identity is central in the DSM. “
Diagnosis
can be made in the absence of significant objective
dysfunction
” (Summerfield, 2001, p. 97). Other
diagnoses such as Schizophrenia, Major Depression and
Post-traumatic Stress Disorder include in their diagnostic
criteria that “
the symptoms cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning
” (APA, 1994, p. 327).
However, no such criteria ar
e included for “Dissociative
Identity Disorder
”.
Whether or not there is distress or
impairment is irrelevant. Unlike other disorders,
dissociative identity is deemed a disorder and thereby
dysfunctional, purely on the basis that those who
experience it have a self that is not singular.
There may be in the general population a large
number of people with MPD who are high-
functioning, relatively free of overt psychopathology,
and no more in need of treatment than most of their
peers. They may not have abuse histories and may
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
12
have evolved a creative and adaptive multiplicity. If
these people exist, virtually nothing is known about
them.
(Ross, 1989, p. 97)
The phrase “
if these people exist
” expresses some
doubt that there can be “
high-functioning
” individuals
with multiple selves, continuing the discourse of
dysfunction. However the phrase also highlights a gap in
the scientific research. Functional individuals who live
with multiplicity are most lik
ely not documented because
of the very fact that they
are
functional and do not seek
therapy. At present, the only documented cases of
functional multiplicity are self-documented, for example
on internet pages. Although this is not persuasive
evidence for the scientific community, such data cannot
be summarily dismissed simply to hold to the dominant
discourse.
A construction of dissociative identity as inherently
disorderly and dysfunctional, in conjunction with many
therapists’ world view that a unitary self is normal and
best, leads to the assumption that multiplicity needs to be
cured
: “
The goal of treatment of MPD is not palliation. It
is cure
” (Ross, 1997, p. 204). “
Integration as an overall
treatment goal
” (Barach, 1994, section IIIA). “
It usually
becomes essential to replace dividedness with unity ... for
any treatment to succeed
” (Kluft, 1984a, p. 11).
The prescription for cure is integration to oneness as
accepted and unquestioned practice. According to this
view, multiple selves must be integrated into a unitary
identity. “
My model of therapy is no more than this: the
patient has developed chroni
c trauma disorder with
MPD in response to childhood abuse. She needs to
integrate
” (Ross, 1997, p.294). “
This carries the seeds of
a prescriptive rigidity, one which might also serve to
confirm an illusion that it is possible to develop a set of
principles or codes which can be invariantly applied
irrespective of context
” (Gergen, 1992, p.181). In
advocating integration, the
texts support the traditional
understanding of the self as a unitary psychological
construct.
The unified, coherent se
lf thereby becomes the
regulative norm. One of the ways in which a normative
prescription such as unitary oneness operates is through
the construction that dissociative identity is deviant.
“
Those who lack ‘rightness’ help define what is ‘right’.
Some modes of living become accountable while others
remain unexceptional and taken for granted.
” (Reynolds
& Wetherell, 2003, p. 490).
Alternatively, a position that constructs the self as
inherently plural and multiple in nature has the potential
to present a very different view of dissociative identity.
On first reading, Rivera’s text appears to do this, largely
due to the markedly positive language used throughout.
Multiplicity and dissociation are presented as not only
potentially functional, but also real strengths:
Multiplicity is not a problem; it is a wonderful
thing, individually, socially, and culturally. The
problems from which multiples suffer do not derive
from the existence of their personality states, their
many ways of being in the world. That is their
strength
(Rivera, 1996, p. 41).
The different voices with different perspectives no
longer have to be silenced or devalued. The
individual who is now in
a position to bear an
awareness of the depth, breadth, complexity and
contradictory nature of her life experience, can now
call all of those voices “I”, accepting none as the
whole story, but embracing them all. This is the
multiplicity at the heart of all of us. It transcends
categories
(Rivera, 1996, p. 48).
However, a careful reading of
the Rivera text reveals
that multiplicity is ultimately not equated with functional
living but instead is presented
as a problem that needs to
be addressed. Rivera falls
back on discursive resources
that situate dissociative identity within the Western
medical model:
You have a serious problem that used to be called
multiple personality and is now called dissociative
identity disorder. There is good news and bad news
about this condition. The good news is that is
treatable. Many people who have this problem get
completely better. The bad news is that the treatment
takes a long time and is very stressful
(Rivera, 1996,
p. 79).
In some respects Rivera also
prescribes integration to
oneness:
The more deeply parts of the individual connect
with the therapist; the more important it is for the
therapist to remember that the client is one person.
As the therapist does this, the individual aspects of
the system or personalties will gradually transform.
They will not be stuck in rigid and repetitive patterns,
and the early stages of a fluid responsive self will
begin to emerge
(Rivera, 1996, p. 122).
“
She can now call all of those voices ‘I
’” (Rivera,
1996, p. 48). Rivera appears to
fall back on the traditional
concept of encapsulating all parts into a single identity.
There has to be an “I”; she does not contemplate an
identity as ‘we’. She presents a mixed message: it is not
necessary for individuals with multiplicity to be directed
towards integration, but if they are left alone the parts
will integrate by themselves.
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
13
Although in some ways Rivera’s text tries to offer a
new approach, it really only removes itself to the margins
of the medical model. She takes issue with the position of
the DID proponents, but does not really establish a clear
alternative position of functionality as a “we”. If one
were to adopt such a
position it would not only
acknowledge the possibility of a functional multiplicity
but also encompass a multi-facet
ed identity that could use
“we” as a description of “self”.
The plural self (we) is seen as being consistent with the
historical and social condition of pre-enlightenment and
post-modernity. The self is formed and performed
through interactions in specific and cultural contexts.
Hermans (1997) theorised the self as a constellation of
dialogically structured pos
itions, each with their own
worldview and landscape, in relations of intersubjective
exchange and dominance. The “I” moves between
positions in an imaginal landscape, depending on time,
place and situation, resulting in a multi-voiced self. The
self as plural consists of a multiplicity of positions,
voices, states of mind, functions etc. (Rowan & Cooper,
1999). This self, therefore is never ultimately bound by a
set role but is constantly in the making; it is a self-in-
process (Ortega, 1991).
Although psychological discourse does not encourage
discussion about separate selves in ordinary speech
(Heinimaa, 2000) many people in today’s post-modern
world would describe themselves as having multiple
parts or senses of self, cons
tantly changing and evolving.
They would see this as an appropriate response to the
multifaceted demands of contemporary society, in which
flexibility and horizontal integration are valued as
subjective qualities over stability and hierarchical
organisation (Rappoport, Baumgardner, & Boone,
1999). Our language also holds an underlying
‘multiplicity’. When describing individuals we use words
such as balanced and well-roundedness. We often use
phrases such as “part of me wanted to and part of me
didn’t” or “I didn’t feel like myself”. This “plurality in all
of us” Rivera believes, is experienced as a “unity”. “
The
unmentioned or hidden ‘multiplicity’ in all of us
comprises the many distinct and separate facets of a
person’s personality, the many ways of being, which
make up the ‘whole’ individual called ‘I’
.” (Rivera, 1996,
p. 48). Perhaps it is as Erdelyi (1994) describes, “
when
the self-system is in dis
harmony, however, the multiplicity
of self-systems tends to be more obvious
” (Rivera, 1996,
p.99).
It may also be that “
fragmentation is a way of living
with differences without turn
ing them into opposites, nor
trying to assimilate them out of insecurity
” (Trinh, 1992,
p.156). Rather than focus on
the issue of multiple self
“disorder”, an alternative approach could explore the
notion of functionality in conjunction with the
individual’s experience. This approach could explore
whether the individual experiences their inner and outer
world as safe, functional, happy, productive, and as an
acceptable way of being in th
e world. Similarly it could
explore whether the extern
al world experiences the
person as safe, functional,
happy, as productive, and
sufficiently consistent in presentation (in all guises) that
others can relate to the person. In this way the
“diagnosis” of disorder, if one was to be made at all,
would be linked with the individual’s views on multiple
aspects of both internal and external functioning.
Therapeutic goals would vary depending on which of
these different aspects of functionality were to be focused
on. One issue might be the degree of communication and
co-consciousness between pa
rts thought necessary for
one’s definition of functional. While therapeutic work on
developing co-consciousness and communication has
frequently been promoted by DID therapists, this has
only been portrayed as a step along the way towards
integration (Kluft, 1993). Rivera’s stance (p. 41 & p.
122) moves towards seeing communication and co-
consciousness as a therapeutic end in itself, but still with
the goal of developing a functional “I”. If the goal is
functionality as “we”, two approaches are possible.
Either therapy works toward
s a co-ordinated internal
system, involving communication and co-consciousness
between parts, or the possibility could be explored that
functionality can be gained wit
hout all parts of the system
becoming aware of other parts and able to communicate
with them. In Bromberg’s (1993) view “
Health is not
integration. Health is the ability to stand in the spaces
between realities without losing any of them
” (p. 379).
Continuing Discourse No. 1: ... But not Sufficient
for Health.
Although the texts promote integration as
being the cure for dissociative identity, they then state
that more is needed to achieve health; that is, integration
is necessary but not sufficient for health: “
Treatment does
not end with fusion/integration; it only enters a new
phase
” (Putnam, 1989, p. 302). There is also the tacit
message that on this path to “true health” the “patient”
will develop further psychological problems: “
The initial
euphoria that accompanies the achievement of unity
rapidly gives way to a profound depression
” (Putnam,
1989, p. 318). “
When you complete the multiple
personality part of the treatment and the person has
achieved integration, you are
then dealing with a person
with single personality disorder
” (Kluft, 1993, p. 89;
1994)
These problems may even be “
untreatable
”:
After the final alter personality has been
integrated, there is still a lot of work to do. Others
make a transition from MPD to PTSD in a single
personality. Such patients may have intense
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
14
flashbacks and continue to be suicidal, unstable in
their mood and self-destructive in their manner of
living for a long period of time post integration. For
some the outcome may be resolution of their MPD,
with an untreatable personality disorder
(Ross, 1989,
p. 220).
In no other area of the DSM does the eradication of
one disorder inevitably lead to the diagnosis of another
disorder. This brings into question the validity of the
prescription for integration to oneness, and also reflects
the power of social expectations. Individuals must move
from socially unaccepted mu
ltiplicity to a socially
tolerated single disorder.
The texts go on to address the problems of integration:
“
Even though the patient may be enormously distressed
after integration because they have lost their ability to
dissociate, this is still an ideal goal
” (Putnam, 1989, p.
141). Kluft (1995) also notes
that many multiples have
very unrealistic expectations about how good it feels to
be unified. “
The patient may always be tempted to return
to the divided state and may even mourn the loss of the
alter selves. Vigilance is essential
” (Putnam, 1992, p. 36).
These quotes attribute post-integration problems to the
client. The possibility that it is the treatment that is
problematic is not questioned and the fact that an
individual experiences ongoing distress is viewed as a
necessary sacrifice for the ach
ievement of the therapist’s
ideal of a singleton self. “
The multitude of voices are thus
reduced to a ‘systematically monologized whole
”
(Bakhtin, 1997, p. 9).
Alternatively, if internal and external functionality as
“we” is the goal, then iatrogenic distress would be
avoided. The therapist’s task would be simply to explore
what each part of “we” needs in order to experience
health.
Exploring Discourse No. 2: Therapist Knows Best.
Representations of the relationship between therapist and
‘patient’ in the texts function to promote a further
discourse embedded in the dominant medical model: that
the therapist knows best. The
texts initially advocate the
ideal collaborative nature of the therapeutic relationship
when dealing with dissociative identity, but quickly go
on to stress the importance of the power of the therapist:
“
Treatment will be a collaboration but not democratic.
The patient is the patient and I am the doctor. We are not
friends, and I am the only one getting paid
” (Ross, 1997,
p. 302).
This extract highlights that
real collaboration is
impossible, stressing the chas
m between the doctor as the
all-knowing professional and the patient as the unwell
one simply paying for the doctor’s expertise. The
therapeutic process theref
ore becomes one where the
dominant goals of the all-knowing professional are
imposed despite the client:
There is no need to be apologetic for commitment
to the goal of integrati
on and the specific techniques
that help the patient get there. The patient will stall
and resist the work to
ward interpersonality
integration in countless ways
(Ross, 1989, p. 245).
It is most important to decline to engage in
arguments over integration with the patient, because
this course of action almost inevitably heightens
narcissistic investment in the wish to avoid
integration and introduces an adversarial tension in
to an already difficult treatment. My personal style is
to encourage a wait-and-see attitude. Usually by the
time integration becomes an issue, it is in the process
of occurring and perceived as inevitable. The
argument is then irrelevant
(Kluft, 1993, p. 109).
The word “
argument
” shapes the client as an adversary
and their desire to discuss the issue of integration before
committing to it as unreasonable and antagonistic. First,
the therapist is constructed as entitled to refuse to discuss
the issue of integration b
ecause he is right and knows
what is best for the client. Second, the text condones a
therapeutic approach of subterfuge that disguises, under
an apparently easy-going style of “
wait-and-see
”, the use
of a process that will lead to an “
inevitable
”
predetermined outcome. “I
encourage their (the alters’)
communication and teamwork, all of which is in the
service of eroding narcissistic investments in uniqueness
and separateness and promoting integration
.” (Kluft,
1993, p. 34)
Ironically, while a commitment to maintaining one’s
identity would be considered a normal and healthy life
force in a singleton, the selves (alters) of an individual
with dissociative identity are represented as having a
“
narcissistic investment
” when they attempt to preserve
their existence, rather than yielding to the therapist’s
demands.
“
The medical field holds the power and it sets the
agenda
” (Parker, 1995, p.2). The power of authoritative
knowledge is not that it is correct but that it counts
(Coates & Jordan, 1997). In the face of the expertise of
the medical fraternity, which is both sanctioned by and
informs society, the “patient” with multiplicity is
rendered powerless.
As part of this power asymmetry, the “patient” with
multiple selves is constructed as a child and the therapist
as a parent. In the role of
“child”, the “patient” is
represented as unable to assess his/her own needs or
goals, incapable of equality with a professional person,
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
15
and requiring rules and discipline to manage out of
control behaviour:
Handling MPD patients is often like handling
misbehaving children. Limits, toughness, strict rules
and consistent enforcement are the kindest and most
effective treatment. Not everyone agrees with that
parenting approach, but the patients will eventually
teach it to most therapists who are committed to
effective efficient therapy
(Ross, 1989, p. 224).
With this combination of a belief in the primacy of the
therapist’s knowledge, a minimising of the client’s wants,
and the adoption of a parent/child approach, it is only a
short step to justifying the us
e of coercion in therapy with
clients who experience multiplicity:
Initially, confrontation shoul
d be kind, firm, matter
of fact, and incorruptible. Once it is clear that the
patient understands what is required but behaves
inappropriately nonetheless, more forthright
confrontation may have a role. This may be
especially forceful if the issue concerns cooperation
with therapy
(Kluft, 1993, p. 43).
A double standard is sanctioned: the therapist can
adopt an authoritarian approach involving force but the
client must exhibit “appropriate” behaviour and
democratic cooperation. Indeed, a state of siege initiated
by the therapist is prescribed:
The strategic integration therapist focuses more
specifically on undermining the dissociative defenses
that support the multiplicity; this erosion is ongoing
and relentless so that the dissociative structure
collapses from within
(Fine, 1993, p. 137).
The easiest outcome of this war is for the client to
submit, to surrender. If not, more invasion is prescribed:
“
Sodium amytal should be considered when other
techniques have failed or when temporary access to an
unavailable alter is required... it is a battering ram. It
gets you into the system
” (Ross, 1997, p. 363).
The medieval war image of the battering ram has
echoes of rape and thus could be seen as highly
insensitive in light of evidence that a history of prior
abuse is common in multiplicity (Kluft, 1990; Ross,
1989). Nowhere within these texts is there an
acknowledgement of the possi
bility that these breaking-
down processes may replicate and perpetuate abuse
dynamics, further harming the client. It is possibly
because of the invasive for
cefulness advocated in such
therapy that client resist
ance becomes an issue.
Again and again the patient must be educated and
reminded of his or her role and duties in the therapy.
... Unless the therapist takes such steps he or she will
find it difficult to confront the MPD patient who is
resistant and/or nonc
ompliant. Confr
ontation will be
met with protestations of helplessness and wounded
innocence
(Kluft, 1993, p. 33).
Resistance to invasion is portrayed as troublesome and
constructed as a manipulative overreaction. Critics of this
traditional view point out that resistance has been, and in
some cases still is, seen as an obstacle that must be
circumvented or overcome (Rowe, 1996) and arises
from a patronising position that clients “
just don’t know
what is in their own best interests
” (Amundson, Stewart,
& Valentine, 1993, online version).
An alternative view is that resistance is a positive
instinct. “
Resistance to violence and oppression is both a
symptom of health and health inducing
” (Wade, 1997, p.
24). From this perspective, clients could be seen as
exhibiting a healthy response to the invasion of the
therapist. Such resistance is
not unexpected, given that
multiplicity is itself a: “
Creative and courageous
resistance, the refusal by women and children to be
destroyed
” (Rivera, 1996, p. 18).
Perhaps the therapeutic goal for people who are
experiencing dysfunctional
multiplicity should be to
recognise the creative instinct to resist past abuse, to
develop resistance to the legacies of previous and current
abuse, including invasions by traditional therapists.
Instead, the majority of th
e texts examined depict
therapy as a site of conflict. The therapist’s role is seen as
the holder of knowledge, “
the expert who diagnoses the
client’s problem and applies treatment
” (Bohart, 2000, p.
143), with an entitlement to us
e force in order to change
the patient. These power relations between therapist and
patient “
grant powers to some and delimit the powers of
others, enable some to judge and some to be judged,
some to cure and some to be cured, some to speak truth
and others to acknowledge its authority and embrace it,
aspire to it, or submit to it
” (Rose, 1996, p. 175).
Rivera’s text acknowledges the importance of a more
collaborative relationship between therapist and client as
a more effective basis for growth and change:
Although the therapist has the training and the
experience that give her more responsibility for the
effectiveness of the treatment, it is crucial that the
client not lose control over this part of her life.
Therapy is always a partnership, and unless both
partners respect the roles and responsibilities of both
themselves and the other, the relationship is likely to
undermine the client’s strengths rather than
contribute to her growth
(Rivera, 1996, p. 82).
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
16
Although Rivera emphasises the notion of
“partnership” the growth is still portrayed as occurring on
one side only. Perhaps a more equal collaborative client
therapist relationship would demonstrate and
acknowledge that often the therapeutic relationship is a
mutual process of growth and learning.
General Discussion
This analysis does not purport to be a thorough
discourse analysis or the only possible interpretation of
the texts explored. It is important to note that what we
accept as possible interpretations
of a text are determined
by our “
horizons of understanding
” (Gadamer, 1975, p.
273) and as such these texts are open to other readings,
other possible interpretations.
Indeed there are as many
possible interpretations as ther
e are readers of the texts.
However this brief exploration offers a glimpse into the
ambiguities, contradictions
and complexities involved in
the language used to describe
dissociative identity. It also
demonstrates the need for further qualitative research into
the area of dissociative identity.
The present analysis raises many issues, some of which
will be discussed here. A prominent issue which has been
long recognised in the psychologi
cal literature is that of
defining self. The literature on
‘the self’ is huge and there
is no claim here to cover the numerous ways in which the
term has been used in modern and postmodern writings.
However when looking at how the authors of the five
examined texts viewed the se
lf within the dissociative
identity context, the majority
proposed the unitary self as
the goal of therapy. However when one looks beyond the
five texts, there is an
acceptance of multiplicity, the
multiple self and polypsychism within the psychological
literature (see Hermans, Rappoport, Ross, Shotter, &
Watkins in Rowan & Cooper, 1999). Mair (1977)
proposed the mind to be a ‘community of selves’ while
Stone (1998) states that the belief that only one “
I
” could
belong to one body, or even that only one “
I
” could be
present at one time, was: “
a kind of a story we told each
other
” (p.85). “
For the post-modern practitioner a
multiplicity of self-accounts is
invited, but a commitment
to none
” (Gergen, 1992, p.180).
Within the views that
embrace multiplicity, however,
there appear to be varying degrees of acceptance of
multiplicity. Ross (1999) takes the position that, while
MPD is a psychiatric pathology or psychiatric
polypsychism, polypsychism is the “
normal state of the
human mind
.” (Rowan & Cooper, 1999, p. 193). Ross
defines polypsychism (rarely obtained) as “
a degree of
healthy, fluid integration of sub-selves
” (p. 194) and that
MPD and polypsychism are distinguished, he explains by
“
the difference in the degree of personification of the ego
states, the delusion of literal separateness of the
personality states, the conflict, and the degree of
information blockage in the system
”(p.193). Although
polypsychism may be an ideal
, Ross states that what “
we
call normal in our culture is actually pathological
pseudounity
” (p. 194). He states that “DID
is a
psychiatric disorder while pathological pseudounity is a
cultural sickness
” (p. 195). “
The integrated DID patient
is better off having no DID, even though he or she may
now exhibit pathological pseudounity
” (p. 195)
So, is the requirement for oneness necessarily healthy
and helping the client? The texts explored indicated that
this may not always be so. In general integration was
expected to result in further problems (eg. Putnam,
1989). The possibility that the tr
eatment is problematic is
not questioned within the texts. Instead the problems
resulting from treatment are individualised to the client
and at best are seen as a sacrifice that the client has to
pay. This highlights issu
es of power, responsibility,
control and agency which will be covered in a further
paper.
If treatment is problematic and yet remains
unquestioned by the therapist, then does the therapist
really know best? This was the second discourse
explored within the texts. It was found that the texts
placed the client in a subser
vient role; he or she was
required to comply with the therapist or be labelled
recalcitrant or possibly not treatable. This type of
therapeutic paradigm requires the client to take on board
the therapist’s world view a
nd become how the therapist
thinks he or she should be, rather than how he or she
would choose to be. This also raises an issue of what
Hacking (1999) calls “
false consciousness
” (p. 266). The
fear concerning false consciousness is the sense that the
end product of therapy is a thoroughly crafted person.
Not a person with self knowledge, but a person who is
worse for having a glib patter that
simulates an understanding of herself (Hacking, 1999)
Towards a More Open Stance.
I have selected
extreme extracts because
these may highlight the
underlying beliefs that inform the texts. But the texts
themselves are not extremes. Indeed these are the most
common and widely used texts practitioners read to learn
about and inform their practice relating to dissociative
identity. These texts both reproduce and produce the
discourses that construct dissociative identity at the
present time.
Discourses can inform or misinform understanding of
multiplicity and therefore enhance or hamper
understanding of self/selves. Some beliefs about the self
which are most widely shared
are the least easy to see;
this is because they
are
shared and therefore go
unquestioned. By failing to que
stion these beliefs we are
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
17
complicit in promoting them: “
there is a tacit and almost
heedless allegiance. We influ
ence that which we observe,
as much as we are influenced by it
” (Radden, 1996, p. 8).
Wearing (1994) determined that there is a professional
dominance of psychiatry and nosographic language of
medical discourse used to classify and treat illness and
syndromes within the health
system. However there are,
in contrast to this, many therapists who use and promote
alternative “
therapies of resistance
” (Guilfoyle, 2005, p.
101) such as narrative approaches. These approaches not
only privilege the client rather than expert accounts, but
also bring to the fore the situation of their client and their
problems in respect of societal domination or
marginalisation. (e.g. Albee, 2000; Ali, 2002; Gilligan,
Rogers, & Tolman, 1991; Kaye, 1999). Nevertheless
many health professionals are still required to adhere to
the rigid and objectified set of categories of illness found
within the DSM. The DSM becomes professional
knowledge and diagnosis, the language of psychiatry, the
“
social representation of psychiatric knowledge, as well
as the psychiatric profession’s presentation of self
”
(Brown, 1990, p. 389). Moreover, Parker (1995) states
“
When the categories from
the DSM-IV are used, they
become charged with an emotional force which has far-
reaching consequences for those who are labelled
” (p.2).
It is important to recognise that “
discursive practices
are ways of talking, thinking, feeling and acting that,
when enacted, serve to reinforce, reproduce or support a
given discourse and at the sa
me time deny, disqualify or
silence that which does not fit the discourse
” (Law, 1999,
p. 119). The texts explored here indicated both symbolic
and real violence toward
s those who experience
dissociative identity. Through the setting down of
ideological boundaries and inclusion/exclusion of
single/multiple and healthy/not healthy, those with
dissociative identity who do not conform to the expected
way of being (by completing treatment) are marginalised.
The limitations of the mainstream approaches towards
dissociative identity become apparent when the
assumptions and norms implic
it in these approaches are
uncovered: that the self is ideally unitary, that the
experience of multiple selves is pathological, and the
professional has the authority to impose goals and
processes on the client, to define any signs of resistance
as a problem and to over-power such resistance.
This analysis of traditional psychotherapeutic discourse
in relation to dissociative identity raises some important
questions. Does the traditional view of dissociative
identity empower the client or does it individualise
oppression and pathologise their experiences? Does the
therapy offer space for clients to develop new forms of
subjectivity or does it confirm them within their current
restrictive positions and castigate them for their
resistance? How are the power relations embodied in
certain specific kinds of tec
hniques, for example the use
of a metaphorical battering ram?
If we recognise that personal constructions are shaped
and constrained by culture or by the “
shared language
and meaning systems that d
evelop, persist, and evolve
over time
” (Lyddon, 1995, pp. 69-92), and that
knowledges, discourses, and power are interrelated, and
that some discourses are legitimated as proper
knowledges while others are subjugated (Foucault, 1980,
1983), then how do individuals experiencing a “we”
identity negotiate the expectations of the majority? Do
they adopt or resist the different discourses? How does
the “we” find their voice wh
en faced with powerful
traditional professions such as psychiatry and
psychology? How is the “we” identity constituted in
relation to the dominant discourses of the DID group and
the psychological community?
The analysis undertaken indicates that a resistant
reading of the texts is possible. It could be that other
practitioners and theorists can also be resistant to these
texts. The texts themselves do not necessarily indicate
what actually goes on in practice. The relation between
texts and the practices that might be informed by them
needs to be explored.
Although it is not possible at the present time to
answer all the questions and issues raised in this paper,
further research explori
ng these issues and the
phenomenology, the lived experience, of dissociative
identity from the client’s point of view is being
undertaken by this writer. This may aid in creating a
space for individuals with di
ssociative iden
tity to speak
with their own voices and their own discourses.
It is likely that there will be some resistance to the
adoption of more open discourses on dissociative identity
into the mainstream. This is
because by its very nature
dissociative identity challenges and disrupts the dominant
views held by the psychological community and society
at large. Adopting a more open view of multiplicity
depends on and informs a major shift in notions of the
self, therapeutic research
and practice, and social
attitudes in general. Adopting this view may well cause
considerable discomfort in the mainstream
psychiatry/psychological communities. However it is
perhaps this discomfort that has blocked more open
views on dissociative identity, rather than anything
inherent in multiplicity itself.
Adopting a different therap
eutic stance that embraces
the possibility of a functional multiplicity in relation to
dissociative identity might allow new discourses to
develop. Instead of the notion that single is necessary
but not sufficient for health, a dissociative identity
therapist could also convey the message that
E-Journal of Applied Psychology: Clinical Section. 1(2): 9-19 (2005)
Clayton: Critiquing the Requirement of Oneness Over Multiplicity.
18
multiplicity is an alternative, valid and potentially
highly functional way of being, but internal
communication might be necessary for health. Rather
than promoting the concept that the therapist knows
best, dissociative identity th
erapy could be underpinned
by the idea that therapist and client work best together,
with transparency, honesty and mutual learning being
paramount, and with “resistance” valued as a healthy
survival instinct.
Acknowledgments
I would like to thank Fran, Doris, Daf, Alison, and
Sue for their thoughts on this paper. I would also like to
thank the anonymous reviewers for their helpful
comments.
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Fact or fictitious? 


Abstract
Background

Dissociative identity disorder (DID) is a disputed psychiatric disorder. Research findings and clinical observations suggest that DID involves an authentic mental disorder related to factors such as traumatization and disrupted attachment. A competing view indicates that DID is due to fantasy proneness, suggestibility, suggestion, and role-playing. Here we examine whether dissociative identity state-dependent psychobiological features in DID can be induced in high or low fantasy prone individuals by instructed and motivated role-playing, and suggestion.

Methodology/Principal Findings

DID patients, high fantasy prone and low fantasy prone controls were studied in two different types of identity states (neutral and trauma-related) in an autobiographical memory script-driven (neutral or trauma-related) imagery paradigm. The controls were instructed to enact the two DID identity states. Twenty-nine subjects participated in the study: 11 patients with DID, 10 high fantasy prone DID simulating controls, and 8 low fantasy prone DID simulating controls. Autonomic and subjective reactions were obtained. Differences in psychophysiological and neural activation patterns were found between the DID patients and both high and low fantasy prone controls. That is, the identity states in DID were not convincingly enacted by DID simulating controls. Thus, important differences regarding regional cerebral bloodflow and psychophysiological responses for different types of identity states in patients with DID were upheld after controlling for DID simulation.

Conclusions/Significance

The findings are at odds with the idea that differences among different types of dissociative identity states in DID can be explained by high fantasy proneness, motivated role-enactment, and suggestion. They indicate that DID does not have a sociocultural (e.g., iatrogenic) origin.

Citation: Simone Reinders AAT, Willemsen ATM, Vos HPJ, den Boer JA, Nijenhuis ERS (2012) Fact or Factitious? A Psychobiological Study of Authentic and Simulated Dissociative Identity States. PLoS ONE 7(6): e39279. doi:10.1371/journal.pone.0039279

Editor: Jerson Laks, Federal University of Rio de Janeiro, Brazil

Received: March 5, 2012; Accepted: May 16, 2012; Published: June 29, 2012

Copyright: © 2012 Reinders et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: AATSR is supported by the Netherlands Organization for Scientific Research (www.nwo.nl), NWO-VENI grant no. 451-07-009. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Despite its inclusion in the Diagnostic Manual for Mental Disorders [1], the genuineness of dissociative identity disorder (DID) continues to be disputed. Supporters of the diametrically opposed trauma-related and non-trauma-related views have been engaged since decades in a passionate debate regarding its validity as a mental disorder, and whether it is related to traumatization or to fantasy proneness, suggestibility, suggestion, and simulation [2]–[10].

The non-trauma-related position [2], [3], [7], [11]–[13], also referred to as the sociocognitive model of DID [14]–[16], holds that DID is a simulation caused by high suggestibility and/or fantasy proneness [17]–[21], suggestive psychotherapy and other suggestive sociocultural influences (e.g., the media and/or the church). According to this model, “[t]he rules for enacting the [DID] role […] are as follows: (a) Behave as if you are two (or more) separate people who inhabit the same body. (b) Act as if the you I have been addressing thus far is one of those people and as if the you I have been talking to is unaware of the other coinhabitants. (c) When I provide a signal for contacting another coinhabitant, act as though you are another person. To the extent that patients behave in terms of these rules, the “classic” symptoms [of DID] follow by implication and do not have to be taught through direct instruction or further suggestion”, Spanos (p.239 [15]). Fantasy proneness and suggestibility are highly correlated [18], [22]–[25], and dissociative symptoms were found to be correlated with fantasy proneness, heightened suggestibility, and susceptibility to pseudomemories [11], [26].

To date, the position that DID is caused by sociocultural factors and personal features such as fantasy proneness has not been tested in studies involving DID patients, and evidence that the complex phenomenology and psychobiology of DID can be created and sustained over time by these factors is lacking [27]–[30]. Despite this lack of empirical support, the sociocognitive and fantasy based model of DID is influential in contemporary psychiatry and there have been proposals to prevent the inclusion of DID in the DSM-V [31].

The trauma-related perspective entails that DID is related to a combination of factors that include chronic emotional neglect and emotional, physical, and/or sexual abuse from early childhood, insufficient integrative capacity, attachment disorder, and lack of affect-regulation by caretakers [27], [32]–[35]. In this view DID is thought to be at the far end of the spectrum of trauma-related psychiatric disorders, i.e. being a severe form of post-traumatic stress disorder (PTSD) [33], [36].

Holders of the trauma-related view acknowledge that: some features of dissociative identity states can be influenced by sociocultural factors [33], that false positive cases of DID have evolved in a treatment setting, and that some psychiatric patients imitate DID [37]. However, they also note that there are differences between authentic and imitated DID and that there is no evidence that DID can (sub-)consciously be created by sociocultural factors [27]. Furthermore, even if DID symptoms can be created iatrogenically or enacted [14] this does not mean that genuine trauma-related DID does not exist[38].

According to the DSM-IV [1], DID is characterized by, among others, the presence of two or more distinct `identities’ or `personality states’. Different proposed labels include `different emotional states’, `alters’, `dissociative parts of the personality’ [33], and `dissociative identity states.’ Following previously used descriptions and terminology [39], [40]different types of dissociative identity states are indicated here as neutral identity states (NIS) and trauma-related identity states (TIS). These indicators are derived from the terms ‘apparently normal part of the personality (ANP)’ and ‘emotional part of the personality (EP)’ respectively, which are used in the theory of structural dissociation [33], [41]. This theory defines dissociation as a division of personality into different types of subsystems, each with their own first-person perspective, that is, their own point of view as to who they are, what the world is like, and how they relate to that world [42]. As NIS DID patients concentrate on functioning in daily life, commonly try to hide their pathology, and have not sufficiently integrated (e.g., have partial or complete amnesia) traumatic memories. That is, NIS fails to relate the trauma-related nature to its self [39]. In contrast, TIS does have conscious access to these memories, recalls them as personal experiences and is bodily and emotionally affected by them. That is, as TIS the patients are fixated in traumatic memories and engage in defensive actions such as freeze and flight, when they are or feel threatened [41], [43], thereby activating fast subcortical response routes in the brain [40], [44]. TIS who engage in active kinds of physical defence (e.g., freeze, flight, fight) would involve dominance of the sympathetic nervous system, whereas those who engage in total submission (i.e.,playing dead) would be primarily mediated by the dorsal vagal branch of the parasympathetic nervous system [45].

Proponents of the sociocognitive view have argued that the different patterns of subjective, psychophysiological, and neural activity for NIS and TIS in response to a trauma-memory script that Reinders et al. [39], [40] documented, might be due to fantasy proneness, suggestion and role-playing, and that they do not prove a traumagenic origin of DID. Obtaining independent proof of childhood traumatization in adulthood is most difficult. However, the claim that the previously reported results constitute effects of fantasy proneness, suggestion, and role-playing is open to test. Thus, the present study involves a psychobiological comparison between NIS and TIS engaging in active kinds of physical defence in DID patients (i.e., the DID identity states from Reinders et al. [39], [40]), and simulated NIS and TIS in high and low fantasy prone mentally healthy women who do not report a trauma history and who are instructed and motivated to role-play these different identity states (i.e., simulated identity states).

The a priori hypotheses of the current study were: (i) important previously found psychophysiological and neurobiological differences between NIS and TIS engaging in active kinds of physical defence in DID patients [39], [40] are upheld when controlling for fantasy proneness, suggestion, and instructed and motivated role-playing, and (ii) the upheld psychophysiological and neurobiological differences for NIS and TIS in DID patients include higher sympathetic nervous system activation (e.g. higher heart rate and systolic bloodpressure) and subcortical activity (e.g. the amygdala and caudate nucleus) for TIS in DID, and (iii) hyperactivation of the cortical multimodal posterior association areas (e.g. the intraparietal sulcus and (pre-)cuneus) for NIS in DID when listening to personal trauma scripts.

Results

Twenty-nine subjects participated in the brain imaging study: 11 patients with dissociative identity disorder (DID), 10 high fantasy prone DID simulating controls, and 8 low fantasy prone DID simulating controls. The controls were instructed to enact the two DID identity states: a neutral identity state (NIS) and a trauma-related identity state (TIS). Brain imaging data, autonomic (systolic and diastolic blood pressure, discrete heart rate and heart rate variability (HRV)) and subjective (controls’ subjective sensorimotor and emotional experiences) reactions were obtained. DID patients, as well as high fantasy prone and low fantasy prone controls were studied in the two different types of identity states during a memory script (MS) driven (neutral or trauma-related autobiographical texts) imagery paradigm. The brain imaging data of the three groups was statistically analyzed in SPM5 in a three-by-two-by-two factorial design which allows for the assessment of various effects, e.g., main effects and simple subtraction analyses (within and between identity state) within and between the three groups.

Autonomic and Subjective Reactions

Statistical results of the autonomic and subjective reactions analyses between the three groups are presented in Table 1. Mean values and the direction of the responses are depicted in Figure 1. Significant differences were found for most of the measured variables between the DID patients and both control groups (see for details Table 1) for dissociative identity state (DIS), DIS*group, MS, MS*group, DIS*MS, and DIS*MS*group.[thumbnail]
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Table 1. Between group: Subjective and autonomic reactions.doi:10.1371/journal.pone.0039279.t001
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Figure 1. Graphical representation of averages and direction of subjective emotional experiences, subjective sensori-motor experiences, and cardiovascular responses.

The dashed line depicts the response of the neutral identity state (NIS) when listening to the neutral or trauma-related memory script (MS). The solid line depicts the response of the traumatic identity state (TIS) when listening to the neutral or trauma related MS. All three groups are presented per variable: the dissociative identity disorder patients (DID) in pink, the high fantasy prone DID simulating controls (CH) in cyan and the low fantasy prone DID simulating controls (CL) in blue. SeeTable 1 for the statistical values.

doi:10.1371/journal.pone.0039279.g001

Regional Cerebral Blood Flow Changes
Covariate data.

T-tests were used to test if a significant (p<0.05) difference in regional cerebral bloodflow (rCBF) variance between the DID and control groups was explained by the subjective or objective covariates (i.e. the principal components (PC), see below). No brain areas for which a significant difference was present between the DID patients and the high or low fantasy prone controls respectively were found.[thumbnail]
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Table 2. Main effects.

doi:10.1371/journal.pone.0039279.t002

Comparing Simulated and Pathological Identity States
Main effects and conjunction analyses.

Results for the within DID group re-analyses and for the two between group comparisons of the dissociative identity states (DIS) main effects, both TIS and NIS, are given in Table 2. Significant differences in rCBF changes between the DID and both the high and low fantasy prone groups were found, i.e., text independent effects. These findings are shown in Figure 2. Commonalities in brain activation between patients and controls were found (data not shown).[thumbnail]
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Figure 2. “Glass brain” renderings showing the dissociative identity state main effects, both for the trauma-related identity state (TIS) and for the neutral identity state (NIS), for the dissociative identity disorder (DID) group (left) and the comparison of this group to the high (middle) and low (right) fantasy prone DID simulating controls (CH and CL respectively).

See Table 2 for the specific areas.

doi:10.1371/journal.pone.0039279.g002

Trauma-related MS effects within identity state.

Trauma-related MS effects within both TIS and NIS are given in Table 3. TIS showed significant regionally specific increases and decreases in cerebral blood flow, when processing the trauma-related MS as compared to the neutral MS, between the DID and both the high and low fantasy prone control groups. These findings are depicted in Figure 3 and 4.[thumbnail]
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Table 3. Memory script effects within dissociative identity state.

doi:10.1371/journal.pone.0039279.t003

Trauma-related MS effects between identity state.

Trauma-related MS effects between DIS are given in Table 4. Different rCBF patterns were found for NIS and TIS, when processing the trauma-related MS, between the DID and both the high and low fantasy prone control groups. These differential rCBF patterns are shown in Figure 5 and 6. The results indicate that, for some areas (e.g. the parahippocampal gyrus in the comparison NISt-TISt or the caudate nucleus in the comparison TISt-NISt), the difference in blood flow between patients and controls is larger than the difference between the DID identity states.[thumbnail]
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Figure 3. “Glass brain” renderings show differences in the processing of the trauma-related text (indicated with a small ‘t’) and the neutral text (indicated with a small ‘n’) within the trauma-related identity state (TIS).

Differences in regional cerebral blood flow patterns for the dissociative identity disorder (DID) group (left) and the comparison of this group to the high (middle) and low (right) fantasy prone DID simulating controls (CH and CL respectively) are depicted. See Table 3 for the specific areas.doi:10.1371/journal.pone.0039279.g003
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Figure 4. The brain areas indicated with the blue cross (i.e. the peak voxel) are (from top left to bottom right):

the left amygdala, the left insula, the left precuneus, and the right occipitotemporal sulcus. These areas have the most significant rCBF differences between the dissociative identity disorder patients and high and low fantasy prone DID simulating controls (CH and CL respectively) and is shown both in directionality, i.e. the bar graphs, and location, i.e. shown on a coronal overlay (left in the picture is left in the brain). Results show the differential processing of the trauma-related text versus the neutral text within the TIS, when comparing the DID groups to the high fantasy prone control group (left) and low fantasy prone control group (right).doi:10.1371/journal.pone.0039279.g004
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Table 4. Memory script effects between dissociative identity states.

doi:10.1371/journal.pone.0039279.t004

Discussion

The present study was performed to examine whether earlier reported results [39], [40] for DID hold after correcting for potential iatrogenic and other sociogenic effects. To this end, we tested whether these findings can be simulated by motivated role-enactment and/or is facilitated by a high level of fantasy proneness [18] by re-investigating the patient population from Reinders et al. [39], [40]. Results of a sub-study (see Methods and Supporting Information S1) show that DID patients have a fantasy proneness score of 9.83 (SD 5.25), which approximates the normal population, indicating that fantasy proneness might not play a major role in DID. This finding is consistent with the current psychobiological results. Neither high nor low fantasy prone healthy controls, instructed and motivated to simulate two different types of dissociative identity states in DID (i.e., NIS and TIS), mimicked previously observed psychophysiological and neural reactions that are associated with these identity states in DID [39], [40], which is supportive of our first a priori hypothesis.[thumbnail]
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Figure 5. “Glass brain” renderings show differences in the processing of the trauma-related text (indicated with a small ‘t’) between the trauma-related identity state (TIS) and the neutral identity state (NIS).

Differences in regional cerebral bloodflow patterns for the dissociative identity disorder (DID) group (left) and the comparison of this group to the high (middle) and low (right) fantasy prone DID simulating controls (CH and CL respectively) are depicted. See Table 4 for the specific areas.doi:10.1371/journal.pone.0039279.g005
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Figure 6. The brain areas indicated with the blue cross (i.e. the peak voxel) are (from top left to bottom right): the right caudate nucleus (dorsal part) (2x), the left precuneus, and the right occipitotemporal sulcus.

These areas involve the most significant rCBF difference between the dissociative identity disorder patients and high and low fantasy prone DID simulating controls (CH and CL respectively) and is shown in both directionality, i.e. the bar graphs, and location, i.e. shown on a coronal overlay (left in the picture is left in the brain). Results show the differential processing of the trauma-related text between the TIS and the NIS, when comparing the DID groups to the high fantasy prone control group (left) and low fantasy prone control group (right).

doi:10.1371/journal.pone.0039279.g006

From results shown in Figures 2, 3, and 5 a general feel of the effects can be obtained. Figures 2 and 5 and the top row ofFigure 3 show that in the high fantasy prone control group more of the original DID rCBF patterns are apparent, while the low fantasy prone control group show less similarities with the original DID rCBF patterns, for example the disappearance of the left amygdala activation. Less similarities between patients only and patients versus controls means more overlap in rCBF patterns. In other words the less differences in the rCBF patterns between patients only and patients versus controls, the better the controls simulate DID. Thus, relatively speaking, low fantasy prone controls simulated the performance of DID patients better than high fantasy prone controls. This result is the opposite from the direction indicated by holders of the sociocognitive and fantasy based model of DID [17], [19]–[21], [46]. As patients and controls were scanned in a highly similar experimental setting and because controls were highly motivated to simulate DID, commonalities in brain activation between patients and controls were expected. Despite the overlap in brain activation between patients and controls important previously found psychophysiological and neurobiological differences between NIS and TIS in DID patients were upheld when controlling for fantasy proneness, suggestion, and instructed and motivated role-playing, which is supportive of our first a priori hypothesis.

The activated areas seem to be subdivided in two distinct neural networks, where the NIS activates areas in the cerebral cortex, while the TIS mainly activates subcortical areas (e.g., see Table 2 and Figure 2). The Tables show a detailed listing of all the brain areas involved. The brain areas marked with a II in the Tables are brain areas non-specific to DID as they disappear after comparing to a control group, i.e. these areas share commonalities between patients and controls. The brain areas marked with a III and IV in the Tables are brain areas specific to DID. The areas in the latter group are areas that were not reported earlier as they were “subtracted out” in the within group comparisons.

Our findings support the cortico-limbic inhibition model of trauma-related dissociative disorders [41], [47]. Results of both the NISt-TISt comparison and the main effect of NIS show significant overlap with the activated network of brain regions during emotional memory suppression of unwanted memories in mentally healthy individuals [48], for example in frontal areas (BA 4/6/8/10/47), cingulate cortex (BA 32), and intraparietal sulcus (BA 7/40). Anderson et al. [48] did not find all of these brain areas. There is significant overlap between our study and their study, but the brain areas involved in the modulation of access to trauma-related memory in our patient population are of larger number. This might be an indication that, when functioning as NIS, in DID patients different cortical processes are involved that modulate conscious and subconscious perception of trauma-related information. These areas, e.g. (pre-)cuneus (BA 7/39, 18/19), fusiform gyrus (BA 18/19/37), lingual gyrus (BA 18), occipital gyrus (BA 18/19/37), and the parahippocampal gyrus (BA 35/36), are located in the posterior association areas (PAA) and have been indicated to be involved in multimodal [49], [50] somato-sensory integration [51], [52] of information, especially in relation to attention and perceptual awareness [49]. Hyperactivation of cortical multimodal association areas for NIS in DID when listening to personal trauma scripts constituted our third a priorihypothesis. We thus propose that for emotional memory suppression, or NIS’ mental avoidance [41], of unwanted memories in DID the PAA fulfils a pivotal role.

There are notable similarities in the patterns of brain activation for DID patients, as revealed in the main effect TIS and the TISt-NISt comparison, and mentally healthy individuals unsuppressed memory retrieval [48]. Both groups had increased activation of the insula (BA 13) and parietal operculum (BA 40/43). We did not find the hippocampus to play a role in memory retrieval in DID patients, despite the fact that this area has been indicated in memory processing in mentally healthy individuals [48]. Instead we found that the caudate nucleus was activated when DID patients listened to the trauma-memory scripts as TIS. Acute stress can be associated with a shift from hippocampal involvement to caudate nucleus involvement [53], [54]. Thus, acute stress is linked with caudate nucleus-dependent stimulus-response type reactivity at the expense of hippocampal dependent spatial learning and memory [53]. According to the theory of structural dissociation[33], [41] listening to a description of a personal traumatic memory in an experimental setting constitutes a consciously experienced acute stressor for TIS, because as this dissociative identity state DID patients do not manage to mentally avoid the relevant memory. When DID patients as TIS are confronted with reminders of traumatic memories, they may initiate a caudate mediated reflex-like flight-fright-freeze response [55], [56] which reaction is also supported by an accompanying amygdala activation [44], [57]. Another, but compatible, explanation for increased caudate and amygdala activation in DID patients as compared to controls is a heightened memory sensitivity for negative valanced information [58]. These findings for TIS are supportive of our second a priori hypothesis.

To date, experimental research of inter-identity amnesia in DID has produced mixed results. One study [59] demonstrated evidence for inter-identity amnesia, which is in line with the current findings. Other studies [60]–[65] found inter-identity transfer of newly learned non-autobiographical stimuli, even though the “amnestic” identity reported subjective amnesia for these stimuli. Several principles might explain the inconsistent findings: (i) Inter-identity amnesia may only exist for stimuli that have personal relevance for the “amnestic” identity. In the cited studies [59]–[65], it was not assessed if or to what degree the applied stimuli had autobiographical meaning for the tested “amnestic” and “mnestic” dissociative identities. Our study included traumatic memories that were subjectively autobiographical for TIS but not for NIS, and found that NIS and TIS had different subjective, psychophysiological, and neural reactions to a description of the involved traumatic memories. We also found that as a NIS, DID patients did not relate these traumatic memories to themselves [39]. These results indicate the importance of using autobiographical information when investigating inter-identity amnesia in DID. (ii) Inter-identity amnesia may predominantly exist between different types of dissociative identities, particularly between neural and trauma-related identity states.This has been clinically observed, theoretically proposed [33], [41] and is in line with our results. Unfortunately, in most studies [59]–[66] it was not assessed what types of dissociative identities participated, e.g. NIS or TIS. Therefore, we strongly recommend that in future research in DID the types of dissociative identities are verified and reported and that test material is used that is subjectively autobiographical for one dissociative identity, but not for another.

The sociocognitive view of DID entails the idea that this disorder can be easily and readily created in motivated suggestible individuals and that few suggestions would suffice to generate the symptoms of DID [15] (see Supporting Information S2). Still, one might argue that the current brief practice of DID simulation is insufficient to simulate the psychobiological profiles of NIS and TIS. Even if years of practice could generate these profiles, our findings suggest that fantasy proneness is not the driving factor because low fantasy prone controls simulated the performance of DID patients better than high fantasy prone controls. This result is the opposite from the direction indicated by holders of the sociocognitive and fantasy based view. Therefore we feel that our study provides an important contribution to the etiology discussion.

For the first time, it is shown using brain imaging that neither high nor low fantasy prone healthy women, who enacted two different types of dissociative identity states, were able to substantially simulate these identity states in psychobiological terms. These results do not support the idea of a sociogenic origin for DID.

Methods
Participants
Controls.

Mentally healthy females were recruited by local newspaper advertisements. Respondents were sent a letter in which the study was explained and in which they were invited to complete three questionnaires: (i) the Traumatic Experiences Checklist (TEC) [67], a self-report questionnaire assessing potentially traumatizing events such as physical abuse and emotional neglect, (ii) the Somatoform Dissociation Questionnaire (SDQ-20 [68]–[70], a self-report questionnaire evaluating the severity of somatoform dissociative symptoms, e.g., analgesia, anesthesia, motor inhibitions), and (iii) the Creative Experiences Questionnaire (CEQ) [18] which measures fantasy proneness. Exclusion criteria were the presence of medical, neurological or psychiatric problems in the past or the present, the use of psychotropic medication 15 days prior to examination, participation in a positron emission tomography (PET) or other study that involved administration of radiation in the year prior to this study, and pregnancy. A total of 18 healthy controls participated in the study, which was approved by the Medical Ethical Committee of the University Medical Center Groningen.

After inclusion, written and oral information on dissociative identity states (i.e. NIS and TIS) in DID and instructions on how to simulate these dissociative identity states was given to the controls. It was checked whether the controls understood this information. A template for training themselves in switching between the simulated identity states was provided. Controls were then questioned about how they constructed the two identity states, whether they encountered difficulties and if so, they were given support to improve their roles as NIS and TIS. To help the controls simulate NIS and TIS, they were asked to recall two experiences they had had earlier in their life, an emotionally neutral experience and an emotionally painful experience. Controls were asked to provide their most painful memory to serve as an analogue for the patients’ personal trauma memories, as well as a neutral personal episodic memory. Controls were subsequently instructed how to write the autobiographical analogue neutral and “trauma” memory scripts. For the experiment they had to train themselves in being in a neutral state, the NIS who is unresponsive or under-responsive to the painful experience, and in being in a state in which they re-experience the painful memory, the TIS. The consecutive and final check on the capability to simulate the two different dissociative identity states consisted in checking whether their description of their neutral and painful experiences (that was to be casted in an audiotape recording) met the instructions on how to enact a DID patient.

In the two or more weeks preceding the PET scans, candidate control subjects practiced simulating NIS and TIS, as well as alternating between NIS and TIS using detailed role instructions. One of the investigators (H.V.) contacted the candidates per telephone during this preparatory phase to ensure that they followed the instructions and to offer further suggestions for optimizing their role performance. One candidate felt unable to simulate the roles satisfactorily, and was therefore excluded. Prior to the actual PET scanning, H.V. checked if the candidates experienced and judged that they were able to simulate the roles of NIS and TIS. During the actual scanning, he checked if they engaged in the requested simulations, and immediately after the role performances, he checked if the controls generally felt they had simulated the roles of NIS and TIS effectively. All controls passed these various checks. In addition, immediately after each text condition, H.V. administered a detailed questionnaire that inquired after the controls’ subjective sensorimotor and emotional experiences during their role performance. This questionnaire was identical to the one in the patient study [39], [40], which was administered by the patients’ therapist, and debriefed six subjective emotional experiences (fear, sorrow, sadness, anger, shame and disgust) and ten sensorimotor experiences (visual, kinesthetic, auditory, olfactory + gustatory reactions, pain, physical numbness, body stiffening, paralysis and restlessness) were debriefed. In addition, the presence of the identity state under investigation and the interference among identity states were also debriefed. Using this questionnaire, H.V. or the patients’ therapist could structurally evaluate if the intended NIS or TIS had been present during the experimental condition. Statistical analyses of the simulation performance in terms of their subjective experiences, i.e. the subjective sensorimotor perception and emotional response, during the scanning by the two control groups are provided in Supporting Information S2.

As we did not have CEQ values for the patients (see also Supporting Information S1) we could not control for fantasy proneness by including a covariate. Therefore, the controls were divided into two groups based on their CEQ scores resulting in a high fantasy prone group (n = 10, age 38.2 (SD 10.9), TEC 0.7 (SD 1.3), SDQ-20 22 (SD 2.4)) with CEQ 13.7 (SD 3.2) and a low fantasy prone group (n = 8, age 42.5 (SD 10.1), TEC 0.4 (SD 0.5), SDQ-20 20.9 (SD 1.5)), with CEQ 3.9 (SD 1.6). A CEQ cut-off for high fantasy proneness of 10 was used, which the developers of the CEQ recommended for the current sample[71].

Patients

A detailed description of the DID patients can be found elsewhere [39], [40]. In short: Eleven patients (all female, age 41.0, SD 6.1) participated: (i) whose treatment had progressed to Phase II [72], which involves therapeutic exposure to trauma-related memories, (ii) who met criteria for DID, as operationalized in the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D [73]), and (iii) had at least one TIS and one NIS that they could activate on demand [33] and (iv) the involved TIS had displayed signs of sympathetic nervous system dominance under perceived threat in clinical situations.

To establish the CEQ values in DID patients an independent and representative sample of DID patients (n = 42) completed the CEQ. Details regarding this substudy can be found in the Supporting Information S1.

Stimulus Scripts

During scanning, patients and controls listened to descriptions of the neutral episodic memories and memories of traumatizing or most painful events that only TIS experienced as a personal memory [74]. These memories were cast, prior to the PET session, by the therapist or one of the principal investigators (H.V.) in terms of stimulus descriptions, and were subsequently audio-taped in a neutral tone of voice as 120 second scripts for playback during the PET investigation.

PET Procedure

The PET (Siemens/CTI ECAT HR+) procedure for the controls was close to identical to the patients [39], [40]. In contrast to patients the controls did not habituate to the PET environment prior to the investigation as anxiety levels were expected to be low. Approximately two hours prior to the PET investigation the continuous ECG registration was started, obtaining the five frequency and time domain variables [75], [76]. No urine samples were obtained for the control groups, both medication and drugs use were verbally debriefed according to standard control research practice.

For the controls one extra set of the four conditions was added to increase statistical power. The scanning sequence was therefore NISn, NISt, TISn, TISt, TISn, TISt, NISn, NISt, TISn, TISt, NISn and NISt. The last minor character (n or t) denotes the content of the memory script (MS: neutral or trauma-related). For patient comfort considerations, i.e. minimizing the number of identity state switches, a fixed condition order was used, which was also used for the controls to minimize methodological differences.

Immediately following the end of each script, blood pressure (systolic and diastolic) and discrete heart rate frequency were measured and the six subjective emotional and ten sensorimotor experiences were debriefed. Finally, the presence of the identity state under investigation and the interference among identity states were also debriefed.

Image Acquisition and Data Processing

Data acquisition, reconstruction, attenuation correction, spatial transformation, spatial smoothing (isotropic Gaussian kernel of 12 mm) and global normalization were performed as usual [39], [40], [77]. SPM5 (www.fil.ion.ucl.ac.uk/spm) was used for spatial transformation to the MNI template (using heavy regularization) [78], [79] and statistical analysis [80] of both patient and control data.

Data Analysis: Autonomic and Subjective Reactions

Statistical analysis, missing value analysis and principal components (PC) analysis were performed with SPSS-PC 15.0 (2006) in an identical manner as was done for the patient data [39], [40]. Results with p<0.05 are reported as significant. Within SPSS two two-by-two-by-two factorial design were defined with the first factor Group, consisting of the levels DID and the high fantasy prone controls or the low fantasy prone controls, a second factor identity state, consisting of the levels NIS and TIS, and the third factor was MS, consisting of the levels neutral and trauma-related. For one high fantasy prone and one low fantasy prone subject heart rate variability (HRV) data could not be obtained. In addition, the data, including the PET data, from two NISt conditions was removed as the control subjects reported not to be able to maintain as a NIS. One TISn condition was removed from the low fantasy prone data as the subject reported not to be able to maintain a TIS. Bonferoni correction to correct for multiple testing was applied.

Data Analysis: PET-data

The patient PET data included in the current study is identical to the data as included and described in our previous publications [39], [40]. This study assessed various effects, e.g., main effects and simple subtraction analyses (within and between identity state) within the DID group using SPM99. This data was re-analyzed in SPM5 and is referred to as the “within DID only” analyses.

From the 10 high fantasy prone healthy controls the PET data of one subject was lost due to storage failure at the PET center. The data of the three groups was statistically analyzed in SPM5 in a three-by-two-by-two factorial design [81]–[84]. The general linear model (GLM) consisted of the three factor main effects, the four conditions and a group by condition interaction.

In addition, the subjective reactions and the autonomic reactions were included as group specific covariates of interest after PC analysis [39], [40]. The variance in the subjective ratings could be described with the first two, six, and five PC for the DID, high and low fantasy prone groups respectively, explaining 64%, 68%, and 72% of the variance. The variance in the autonomic reactions could be described with the first three PC for each of the DID, high and low fantasy prone groups, explaining 85%, 82%, and 87% of the variance respectively. Finally, the global cerebral blood flow (CBF) was included as a nuisance covariate (AnCova by subject).

Hypothesis Testing

Previously reported significant findings were tested using a between group subtraction of the within group results (e.g. DID(TISt-NISt)-Control(TISt-NISt)). Commonalities in brain activation between patients and controls were tested using global null conjunction analyses [83].

Statistical Inference and Reporting

Our a priori hypothesis was that earlier findings would still hold after the correction for non-trauma-related factors. Both whole brain and a priori region of interest (ROI) multiple comparisons correction were performed on the basis of false discovery rate statistics [85]. Statistical parametric maps were thresholded using an uncorrected threshold of p<0.001 [40],[86] and explored for a priori hypothesized brain areas. If an a priori hypothesized brain area did not survive whole brain multiple comparison correction, multiple comparisons correction was performed within the a priori region of interest (ROI). For subcortical located ROI and ROI in the cerebellum a sphere with a volume of 3054 mm3 [87] was used. For larger corticala priori hypothesised ROI a sphere with a volume of 6108 mm3 was used. Note: in line with previously used statistical thresholds [40] voxels surviving significant levels only uncorrected for multiple testing for the whole brain, i.e. p<0.001 [40],[86] were reported as well, but for comparison purposes only. Only clusters larger than eight voxels are reported taking into account the spatial resolution of the PET camera. In contrast to the earlier publication [40], this time all peak voxels are reported for a more accurate comparison between groups.

The coordinates were converted from MNI space to Talairach space [88] to be defined in Brodmann areas (BA) using both the Talairach atlas [79] and Deamon [89], [90]. Activations in sulci was defined using Brain Tutor [91]. The location was anatomically compared to and described using a second brain atlas [92].

Supporting Information

Supporting_Information_S1.doc

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Fantasy proneness in dissociative identity disorder.

Supporting Information S1 .

Fantasy proneness in dissociative identity disorder.

doi:10.1371/journal.pone.0039279.s001

(DOC)

Supporting Information S2 .

How well are the dissociative identity disorder simulating healthy controls doing?

doi:10.1371/journal.pone.0039279.s002

(DOC)

Acknowledgments

The authors are greatly indebted to all the participants: thank you for participating. They also would like to thank Margo Jongsma for her assistance and participant recruitment. Jaap Haaksma is thanked for the HRV data collection and Marc van Ekeren for help during data collection and pilot analyses. Finally, Borden Armstrong is thanked for psychophysiological data-analysis support and proof reading.

Author Contributions

Conceived and designed the experiments: AATSR ATMW JAB ERSN. Performed the experiments: AATSR HPJV. Analyzed the data: AATSR ATMW. Wrote the paper: AATSR ATMW HPJV JAB ERSN.

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Exploring Multiple Personality Disorder
Feyza Sancar

In popular culture, Dissociation, and Dissociative Identity Disorder (previously known as Multiple Personality Disorder--MPD) is considered a very exotic, rare and enigmatic psychological phenomenon (11). It seems that, especially in the media and entertainment, multiple personality disorder is stigmatized by a number of quite florid and nearly hysterical symptoms. Clinically, however, Multiple Personality Disorder has been recognized for centuries and is currently estimated to exist in 1% of the general population (1,8), and as much as 7% of the population may have suffered from a dissociative disorder at some point in timem (9). Currently, DID (MPD) is most generally defined as a disturbance in the normally integrative functions of memory, identity, and consciousness (1,7,9). Most simply stated, MPD/DID is manifest as an inconsistent sense of self or "I" (7). Interestingly, it has been established that MPD/DID is actually one of many dissociative disorders and falls on a continuous spectrum of dissociation which ranges from normal/common dissociative episodes to "poly-fragmented" DID(1,9).

Researchers and clinicians believe that dissociation is a very common and naturally occurring defense mechanism, which results from early childhood trauma. Full blown DID or poly- fragmented DID (more than 100 personalities) is characteristically a result of severe, and prolonged occurrences of physical, sexual, or emotional abuse occurring before the age of 12 (and often before the age of 5) (1,8,11). In theory, the developmental processes behind DID are a result of resorting to mental 'escape' from the traumatic situation (8). This is essentially achieved when neither fleeing nor fighting is a viable defense option, which leads the individual to distance themselves from the incident to retain control (11). This distancing mechanism is characterized by detachment from the self or surroundings, excluding or loosing unwanted or unneeded feelings from awareness, and partial or total amnesia for the emotions and cognitions associated with the traumatic event.

Such distancing mechanisms are very powerful modes of defense and serve to escape the emotional and physical pain of the event by compartmentalizing the cognitions, sensory inputs, and behavioral enactment of the traumatic experience (12). These compartmentalized elements are essentially fragmented experiences, which fail to become integrated into an explicit narrative. In essence, this process allows the individual to separate the traumatic memories from ordinary consciousness to preserve some areas of healthy functioning (8,12). This entire process is referred to as dissociation.

Dissociation serves as a temporarily adaptive function, as it allows the individual to escape from the traumatic event while it is underway (9). However repeated reliance on dissociative defenses can lead to the inability to properly process information from past events and possibly future events into a narrative (explicit memory) form (12). It is theorized that the repeated use of dissociation can lead to the development of a series of separate entities or mental states which may eventually take on an entity or identity of their own (8). These entities may become internal "personality states" which reflect different states of consciousness (8). Furthermore, these entities or personality states are frequently created to contain or house the fragmented memories related to different traumatic incidents (12).

A multiple personality or DI will frequently and permanently isolate aspects of their "fragmented" traumatic experience into similarly "fragmented" alter egos. These created personalities are then likely to serve as mechanisms for coping with situations and events dealing with one particular aspect of the traumatic experience-- i.e.- when the individual feels rage, an angry personality is conjured to display this temperament and deal with these emotional issues. This loss of continuity in memory and consciousness (in the form of "alter egos") leads to an inability to establish a unified control system (9). In a sense, these personalities are themselves fragments and represent many incomplete selves, instead of a proliferation of selves (9). The development of "alter egos" can become extensive enough so that it is not uncommon to witness alters which display differences in gender, age, religion, handedness, handwriting, voice and even cerebral blood flow and brain electrical activity (9,14).

Although this theoretical framework provides a logical explanation for the development of DID/MPD, it does not provide any insights into the physiological, biological and neurological underpinnings of the phenomenon. There are many co-occurring symptoms and disorders that are associated with DID/MPD that first implicated the prominent neurobiophsysiological abnormalities underlying the pathology. Firstly, it has been consistently observed in clinical settings that MPD patients also suffer from recurrent depression, anxiety, panic, phobias, anger, rage, low self-esteem, substance abuse, eating disorders (bulimia, anorexia, compulsive overeating), sexual dysfunction, time loss, memory gaps, sense of unreality, flashbacks, intrusive thoughts and images of trauma, hypervigilance, and sleep disturbances (1,13). Furthermore, it has been documented that 80-100% of people diagnosed with DID also have a secondary diagnosis of PTSD (posttraumatic stress disorder).

Some organic causes of dissociation are both known and suspected. For example, many experts believe that temporal lobe epilepsy may lead to a dissociative disorder. Other physical conditions which can lead to some level of dissociation are sleep loss, sensory deprivation, strokes, encephalitis, and Alzheimer's disease. Even more interesting, the unity of self can be disrupted when the corpus callosum (the commissure that joins the two hemispheres of the cerebral cortex) is severed (9). This particular instance of disruption of self has been historically described as a "Jekyll and Hyde" type experience where the left and right hemispheres act as two independent and seemingly different entities (4,5,6). It has been these findings that have ultimately spurred research on the possible neurobiological etiology of MPD (3).

Given the prevalence of the concurrence of PTSD and MPD, it seems appropriate to briefly explore the possible neurobiological ramifications of PTSD, and how they may serve to segue into full dissociative identity disorder. It seems that the most salient pathogenic mechanism related to PTSD is the previously mentioned fragmentation of trauma related events. Consistent research has displayed how declarative or explicit memory functioning is seriously effected by patients suffering from PTSD (12). Characteristically, PTSD patients will recall, or reference the traumatic event only in the form of implicit or perceptual information, such as visual images, olfactory, auditory, or kinesthetic sensations, or intense waves of feelings (12). Recent neuroimaging studies have supported this clinical observation. During provocation of traumatic memories, it has been reported that activity in Broca's area (a portion of the central nervous system that is involved in the transformation of subjective experience into speech) is markedly suppressed (2). Simultaneously, the areas in the right hemisphere that are thought to process visual images and intense emotions were highly activated (2) .

These imaging studies seem to support the theoretical claims of the sequestering of fragmented information. It would seem that the neural memory traces that hold the specifics of the trauma (imagery, sensory input, sound, smell, etc.) are isolated from one another. They are in essence compartmentalized. This implies that in fact small portions of the brain are isolated or compartmentalized. The only way in which these memories could retain their fragmented and isolated status is if the areas of the brain that housed and retained the information were not connected to one another to form a coherent whole.

As it is known, one area of the brain cannot integrate its information with another area unless there is a means of communication. In turn, the communication between neurons necessary for this type of integration of information cannot occur unless the neural traces are physically connected (i.e.--the law of physical contiguity). The mere nature of trauma seems to lend itself to the physical isolation of neural networks within the brain. It could be imagined how repeated and conditioned compartmentalization could lead to deeply rooted and plastic changes in neural circuitry. As such, it can be seen how the isolation of neural traces could in and of itself lead to the propensity of split brain/MPD phenomena.

The traumatic and stressful nature of the experience also plays an important role in the mediation of neurochemicals, hormones, and modulatory substances in the body. Uncontrollable and extreme stress which has been experience for long periods of time in both PTSD and MPD patients has lead researchers to question the chronic effects these chemical substances released during stressful episodes. It has been determined that stress is related to the increased production of several neurotransmitters, neuropeptides, including norepinephrine, corticotropin releasing factor, as well as cortisol, opiates, dopamine and serotonin (2). Although the marked increase the release of these substances in beneficial for short-term survival, the long term or chronic effects of these substances are detrimental (2). Most generally, chronic stress related substance secretion causes the death of neurons.

In many cases, cortico- steroids released chronically and continuously due to frequent exposure to stressful events can act as neurotoxins, causing the death of neurons specifically in the hippocampus. Interestingly, it is the hippocampus that serves to unify memory elements from diverse neocortical areas (2). In one study, patients who had suffered from abuse displayed 12% smaller hippocampal volume as compared to matched controls (2). This abnormal function of the hippocampus caused by degeneration may further account for the fragmentation of traumatic memories, as well as the clinical phenomenon related to MPD of dissociative amnesia. The amnesic episodes may further serve as a barrier between certain subsystems or isolated neural networks previously mentioned. In the extreme case of MPD, these separations may be sufficiently pronounced and contain enough disparate information so that these subsystems or isolated neural networks could possibly take on a 'personality' of their own. But how does this occur?

Firstly, it seems important to consider the developmentally vulnerable age at which the trauma is experienced. In most common approaches to development, it is assumed that the evolution of the 'self', 'I', or unitary conscious state is in fact dynamic. Particularly in early childhood, it is conventionally assumed that the idea of the self or I is underdeveloped and quite malleable. Especially in the western traditions, the unitary conscious self is very much a learned phenomenon, which requires a period of experiential development. This seems to coincide with the knowledge that the neural structure of the developing brain is most fluid and subject to growth in the earlier stages of life. As such, the effects of traumatic events in childhood are most probably neurobiologically detrimental enough to induce such extreme dissociative patterns that later constitute MPD. In this sense, the dissociative phenomenon is proliferated by the neurobiological susceptibility of the developing brain.

Furthermore, the fact that the child has not developed an entrenched 'I' function would make the brain much more susceptible to fragmentation. With the continual compartmentalization of emotional, cognitive, and behavioral states, the I-function is not given the chance to form into a unitary whole. In order to make sense of scattered and disjoint experiences, it seems that the brain has no choice but to create separate I-functions which are relevant to each isolated neuronal trace or 'island'. This could also explain why PTSD and traumatic events experienced in adulthood do not normally cause MPD. This is probably due to the fact that the I-function or reference point is so rigidly intact, that it is more probable that the traumatic memories become continually more intrusive until they are integrated into the already entrenched schema. In other words, with no preexisting structural reference, stress induced states are more likely to result in a more disorganized or fragmentary state (entropy).

The dissociation of the I function could be viewed in another way as well. The I-function serves as a reference point to the environment and provides the capability to imagine oneself as an object that can be moved from one place to another. With this in mind, an alternate or additional etiology for MPD could be constructed. It could be proposed that the isolated neural components could potentially house many different perspectives or 'ideas' of a reference point. With disjoint memories, it seems that one could have many different reference points at the same time, since the emotions and cognitions are not actually recognized as being a part of the same point in time and space. Hence if there are different perceived reference points at any given time, there could be different 'I' functions as well.

Given the information presented, it would seem that MPD could be developed from a mixture of developmental susceptibility as well as detriments of chronic stress. It is clear that MPD is a product of structural deficits and degeneration as well as adaptive mechanisms. Its seems that the adaptive mechanism is first employed in a healthy manner, to avoid distress, but is then exacerbated by the influences of chronic stress. This chronic stress seems to encourage the original dissociative behavior by providing neural deficits as well. In a sense, the entire process lends itself to a positive feedback loop, where an initially adaptive mechanism becomes maladaptive due to extensive conditioning and entrenchment of chemical abnormalities as well as neural degeneration.

To impose some sort of logic to the increasing disorganization, the brain seems to make the most of its intrinsic variability (adaptability) by associating fragmented neural patterns to differing reference points or I-functions. In this instance, the brain's mechanisms are similar to those that occur in dreaming. However, instead of trying to make sense of random brain stem signals as in the Dream State, in MPD, the brain tries to place meaning and context to the disjoint memories. This results in the most logical choice which would be to assign reference points/I-functions to each fragment, and then use these reference points to both adapt to and deal with past and future traumatic situations.

WWW Sources

1)The Spectrum of Dissociative Disorders: An Overview of Diagnosis and TreatmentBy, Joan A. Turkus, M.D.

2)The Neurobiology of Traumatic Stress: Relevance to Posttraumatic Stress Disorder and the So-called "False Memory Syndromes, By J. Douglas Bremner, M.D.

3)Article: The Mind Body Connection, By Patricia D. McClendon

4)Splitting the Human Brain, By Paul Pietsch

5)Split Brain Paper with Funnel and Gazzaniga

6)Unity of Consciousness

7)Multiplicity and Victimization, By Patricia D. McClendon

8)Dissociative identity Disorder (Multiple Personality Disorder)

9)Dissociation and Dissociative Disorders

12)Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study, By Bessel A. van r Kolk and Rita Fisler

13)The Effects of DID on Children of Trauma Survivors, By Esther Giller

Additional Interesting Articles:

10)Dissociation

11)Questions About Multiple Personality

14)Child Abuse and Multiple Personality Disorder, By Philip M. Coons, M.D.

15)ISSD-Guidelines for Treatment


Exploring Multiple Personality Disorder 
Feyza Sancar

In popular culture, Dissociation, and Dissociative Identity Disorder (previously known as Multiple Personality Disorder--MPD) is considered a very exotic, rare and enigmatic psychological phenomenon (11). It seems that, especially in the media and entertainment, multiple personality disorder is stigmatized by a number of quite florid and nearly hysterical symptoms. Clinically, however, Multiple Personality Disorder has been recognized for centuries and is currently estimated to exist in 1% of the general population (1,8), and as much as 7% of the population may have suffered from a dissociative disorder at some point in timem (9). Currently, DID (MPD) is most generally defined as a disturbance in the normally integrative functions of memory, identity, and consciousness (1,7,9). Most simply stated, MPD/DID is manifest as an inconsistent sense of self or "I" (7). Interestingly, it has been established that MPD/DID is actually one of many dissociative disorders and falls on a continuous spectrum of dissociation which ranges from normal/common dissociative episodes to "poly-fragmented" DID(1,9).

Researchers and clinicians believe that dissociation is a very common and naturally occurring defense mechanism, which results from early childhood trauma. Full blown DID or poly- fragmented DID (more than 100 personalities) is characteristically a result of severe, and prolonged occurrences of physical, sexual, or emotional abuse occurring before the age of 12 (and often before the age of 5) (1,8,11). In theory, the developmental processes behind DID are a result of resorting to mental 'escape' from the traumatic situation (8). This is essentially achieved when neither fleeing nor fighting is a viable defense option, which leads the individual to distance themselves from the incident to retain control (11). This distancing mechanism is characterized by detachment from the self or surroundings, excluding or loosing unwanted or unneeded feelings from awareness, and partial or total amnesia for the emotions and cognitions associated with the traumatic event.

Such distancing mechanisms are very powerful modes of defense and serve to escape the emotional and physical pain of the event by compartmentalizing the cognitions, sensory inputs, and behavioral enactment of the traumatic experience (12). These compartmentalized elements are essentially fragmented experiences, which fail to become integrated into an explicit narrative. In essence, this process allows the individual to separate the traumatic memories from ordinary consciousness to preserve some areas of healthy functioning (8,12). This entire process is referred to as dissociation.

Dissociation serves as a temporarily adaptive function, as it allows the individual to escape from the traumatic event while it is underway (9). However repeated reliance on dissociative defenses can lead to the inability to properly process information from past events and possibly future events into a narrative (explicit memory) form (12). It is theorized that the repeated use of dissociation can lead to the development of a series of separate entities or mental states which may eventually take on an entity or identity of their own (8). These entities may become internal "personality states" which reflect different states of consciousness (8). Furthermore, these entities or personality states are frequently created to contain or house the fragmented memories related to different traumatic incidents (12).

A multiple personality or DI will frequently and permanently isolate aspects of their "fragmented" traumatic experience into similarly "fragmented" alter egos. These created personalities are then likely to serve as mechanisms for coping with situations and events dealing with one particular aspect of the traumatic experience-- i.e.- when the individual feels rage, an angry personality is conjured to display this temperament and deal with these emotional issues. This loss of continuity in memory and consciousness (in the form of "alter egos") leads to an inability to establish a unified control system (9). In a sense, these personalities are themselves fragments and represent many incomplete selves, instead of a proliferation of selves (9). The development of "alter egos" can become extensive enough so that it is not uncommon to witness alters which display differences in gender, age, religion, handedness, handwriting, voice and even cerebral blood flow and brain electrical activity (9,14).

Although this theoretical framework provides a logical explanation for the development of DID/MPD, it does not provide any insights into the physiological, biological and neurological underpinnings of the phenomenon. There are many co-occurring symptoms and disorders that are associated with DID/MPD that first implicated the prominent neurobiophsysiological abnormalities underlying the pathology. Firstly, it has been consistently observed in clinical settings that MPD patients also suffer from recurrent depression, anxiety, panic, phobias, anger, rage, low self-esteem, substance abuse, eating disorders (bulimia, anorexia, compulsive overeating), sexual dysfunction, time loss, memory gaps, sense of unreality, flashbacks, intrusive thoughts and images of trauma, hypervigilance, and sleep disturbances (1,13). Furthermore, it has been documented that 80-100% of people diagnosed with DID also have a secondary diagnosis of PTSD (posttraumatic stress disorder).

Some organic causes of dissociation are both known and suspected. For example, many experts believe that temporal lobe epilepsy may lead to a dissociative disorder. Other physical conditions which can lead to some level of dissociation are sleep loss, sensory deprivation, strokes, encephalitis, and Alzheimer's disease. Even more interesting, the unity of self can be disrupted when the corpus callosum (the commissure that joins the two hemispheres of the cerebral cortex) is severed (9). This particular instance of disruption of self has been historically described as a "Jekyll and Hyde" type experience where the left and right hemispheres act as two independent and seemingly different entities (4,5,6). It has been these findings that have ultimately spurred research on the possible neurobiological etiology of MPD (3).

Given the prevalence of the concurrence of PTSD and MPD, it seems appropriate to briefly explore the possible neurobiological ramifications of PTSD, and how they may serve to segue into full dissociative identity disorder. It seems that the most salient pathogenic mechanism related to PTSD is the previously mentioned fragmentation of trauma related events. Consistent research has displayed how declarative or explicit memory functioning is seriously effected by patients suffering from PTSD (12). Characteristically, PTSD patients will recall, or reference the traumatic event only in the form of implicit or perceptual information, such as visual images, olfactory, auditory, or kinesthetic sensations, or intense waves of feelings (12). Recent neuroimaging studies have supported this clinical observation. During provocation of traumatic memories, it has been reported that activity in Broca's area (a portion of the central nervous system that is involved in the transformation of subjective experience into speech) is markedly suppressed (2). Simultaneously, the areas in the right hemisphere that are thought to process visual images and intense emotions were highly activated (2) .

These imaging studies seem to support the theoretical claims of the sequestering of fragmented information. It would seem that the neural memory traces that hold the specifics of the trauma (imagery, sensory input, sound, smell, etc.) are isolated from one another. They are in essence compartmentalized. This implies that in fact small portions of the brain are isolated or compartmentalized. The only way in which these memories could retain their fragmented and isolated status is if the areas of the brain that housed and retained the information were not connected to one another to form a coherent whole.

As it is known, one area of the brain cannot integrate its information with another area unless there is a means of communication. In turn, the communication between neurons necessary for this type of integration of information cannot occur unless the neural traces are physically connected (i.e.--the law of physical contiguity). The mere nature of trauma seems to lend itself to the physical isolation of neural networks within the brain. It could be imagined how repeated and conditioned compartmentalization could lead to deeply rooted and plastic changes in neural circuitry. As such, it can be seen how the isolation of neural traces could in and of itself lead to the propensity of split brain/MPD phenomena.

The traumatic and stressful nature of the experience also plays an important role in the mediation of neurochemicals, hormones, and modulatory substances in the body. Uncontrollable and extreme stress which has been experience for long periods of time in both PTSD and MPD patients has lead researchers to question the chronic effects these chemical substances released during stressful episodes. It has been determined that stress is related to the increased production of several neurotransmitters, neuropeptides, including norepinephrine, corticotropin releasing factor, as well as cortisol, opiates, dopamine and serotonin (2). Although the marked increase the release of these substances in beneficial for short-term survival, the long term or chronic effects of these substances are detrimental (2). Most generally, chronic stress related substance secretion causes the death of neurons.

In many cases, cortico- steroids released chronically and continuously due to frequent exposure to stressful events can act as neurotoxins, causing the death of neurons specifically in the hippocampus. Interestingly, it is the hippocampus that serves to unify memory elements from diverse neocortical areas (2). In one study, patients who had suffered from abuse displayed 12% smaller hippocampal volume as compared to matched controls (2). This abnormal function of the hippocampus caused by degeneration may further account for the fragmentation of traumatic memories, as well as the clinical phenomenon related to MPD of dissociative amnesia. The amnesic episodes may further serve as a barrier between certain subsystems or isolated neural networks previously mentioned. In the extreme case of MPD, these separations may be sufficiently pronounced and contain enough disparate information so that these subsystems or isolated neural networks could possibly take on a 'personality' of their own. But how does this occur?

Firstly, it seems important to consider the developmentally vulnerable age at which the trauma is experienced. In most common approaches to development, it is assumed that the evolution of the 'self', 'I', or unitary conscious state is in fact dynamic. Particularly in early childhood, it is conventionally assumed that the idea of the self or I is underdeveloped and quite malleable. Especially in the western traditions, the unitary conscious self is very much a learned phenomenon, which requires a period of experiential development. This seems to coincide with the knowledge that the neural structure of the developing brain is most fluid and subject to growth in the earlier stages of life. As such, the effects of traumatic events in childhood are most probably neurobiologically detrimental enough to induce such extreme dissociative patterns that later constitute MPD. In this sense, the dissociative phenomenon is proliferated by the neurobiological susceptibility of the developing brain.

Furthermore, the fact that the child has not developed an entrenched 'I' function would make the brain much more susceptible to fragmentation. With the continual compartmentalization of emotional, cognitive, and behavioral states, the I-function is not given the chance to form into a unitary whole. In order to make sense of scattered and disjoint experiences, it seems that the brain has no choice but to create separate I-functions which are relevant to each isolated neuronal trace or 'island'. This could also explain why PTSD and traumatic events experienced in adulthood do not normally cause MPD. This is probably due to the fact that the I-function or reference point is so rigidly intact, that it is more probable that the traumatic memories become continually more intrusive until they are integrated into the already entrenched schema. In other words, with no preexisting structural reference, stress induced states are more likely to result in a more disorganized or fragmentary state (entropy).

The dissociation of the I function could be viewed in another way as well. The I-function serves as a reference point to the environment and provides the capability to imagine oneself as an object that can be moved from one place to another. With this in mind, an alternate or additional etiology for MPD could be constructed. It could be proposed that the isolated neural components could potentially house many different perspectives or 'ideas' of a reference point. With disjoint memories, it seems that one could have many different reference points at the same time, since the emotions and cognitions are not actually recognized as being a part of the same point in time and space. Hence if there are different perceived reference points at any given time, there could be different 'I' functions as well.

Given the information presented, it would seem that MPD could be developed from a mixture of developmental susceptibility as well as detriments of chronic stress. It is clear that MPD is a product of structural deficits and degeneration as well as adaptive mechanisms. Its seems that the adaptive mechanism is first employed in a healthy manner, to avoid distress, but is then exacerbated by the influences of chronic stress. This chronic stress seems to encourage the original dissociative behavior by providing neural deficits as well. In a sense, the entire process lends itself to a positive feedback loop, where an initially adaptive mechanism becomes maladaptive due to extensive conditioning and entrenchment of chemical abnormalities as well as neural degeneration.

To impose some sort of logic to the increasing disorganization, the brain seems to make the most of its intrinsic variability (adaptability) by associating fragmented neural patterns to differing reference points or I-functions. In this instance, the brain's mechanisms are similar to those that occur in dreaming. However, instead of trying to make sense of random brain stem signals as in the Dream State, in MPD, the brain tries to place meaning and context to the disjoint memories. This results in the most logical choice which would be to assign reference points/I-functions to each fragment, and then use these reference points to both adapt to and deal with past and future traumatic situations.

WWW Sources

1)The Spectrum of Dissociative Disorders: An Overview of Diagnosis and TreatmentBy, Joan A. Turkus, M.D.

2)The Neurobiology of Traumatic Stress: Relevance to Posttraumatic Stress Disorder and the So-called "False Memory Syndromes, By J. Douglas Bremner, M.D.

3)Article: The Mind Body Connection, By Patricia D. McClendon

4)Splitting the Human Brain, By Paul Pietsch

5)Split Brain Paper with Funnel and Gazzaniga

6)Unity of Consciousness

7)Multiplicity and Victimization, By Patricia D. McClendon

8)Dissociative identity Disorder (Multiple Personality Disorder)

9)Dissociation and Dissociative Disorders

12)Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study, By Bessel A. van r Kolk and Rita Fisler

13)The Effects of DID on Children of Trauma Survivors, By Esther Giller

Additional Interesting Articles:

10)DissociatioI ain't got a clue as to  why the various font sizes and colors are different. Sorry.   

Words of wisdom from multiples, their friends & families  
  There are several scientific articles included. Though they may be long, and we don't agree with all of the information, they are for the most part, very enlightening and significant to us.
All articles and essays are owned by their writers.Copyrights may be involved.I ain't got a clue as to  why the various font sizes and colors are different. Sorry.   

Words of wisdom from multiples, their friends & families  
  There are several scientific articles included. Though they may be long, and we don't agree with all of the information, they are for the most part, very enlightening and significant to us.
All articles and essays are owned by their writers.Copyrights may be involved.n

11)Questions About Multiple Personality

14)Child Abuse and Multiple Personality Disorder, By Philip M. Coons, M.D.

15)ISSD-Guidelines for Treatment                                                                                                                                                  




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