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The syndrome commonly known as Multiple Personality Disorder but now called Dissociative Identity Disorder (American Psychiatric Association, 198) might be thought of as a recent phenomenon. The diagnostic literature shows the definition of multiple personality as evolving significantly over the editions of the Diagnostic and Statistical Manual of Mental Disorders. In the DSM-1, these behaviors were called dissociative reaction, (American Psychiatric Association, 1952), which came to be called hysterical neurosis, dissociative type in the DSM-II (American Psychiatric Association, 204).
In each of these, multiple personality was not seen as a distinct disorder but was grouped with somnambulism, amnesia, and fugue states.
Only in the DSM-III does Multiple Personality Disorder appear as a separate diagnostic category, with a definition of this behavior. This disorder’s defining features were argued to be “the existence within the individual of two or more distinct personalities, each of which is dominant at a particular time” (American Psychiatric Association, 257).
The DSM-IIIR of 1987 gave nearly identical defining features as “the existence within the individual of two or more distinct personalities or personality states” (American Psychiatric Association, 269).
The defining features evolved further in the DSM-IV where this behavior pattern came to be termed Dissociative Identity Disorder. Its features became “the presence of two or more distinct identities or personality states that recurrently take control of behavior” (American Psychiatric Association, 484).
This subtle change is significant; distinct personalities were no longer seen as existing within the person or as a part of the person, but the behaviors displayed different states or identities. This definition is less organismic and more behavioral-environmental in theory than earlier versions.
With the readers’ extrapolation, the personality is variable behavior or as “topographical subdivisions of behavior, occasioned by discriminative stimuli and controlled by reinforcement contingencies. Here, the personality is showing more variability than that of the “average or normal” individual; the individual lacking one coherent personality displays a personal repertoire of behaviors which is very diverse, with large variability in the relationship between antecedents and responses. The antecedents, that is, people, places, events, and so forth, of the individual in question occasion more responses of an idiosyncratic nature which are maintained by reinforcement contingencies unique to that individual.
Along t his approach, one writer took the new definition to mean that the individual displaying these behaviors could no longer be described as having more than one personality. Instead, the person should be viewed as having less than one whole, coherent personality (Sapulsky, 95). Similarly, Kohlenberg and Tsai (82) observed that these individuals may have not developed all the characteristics of a stable, single personality. History Multiple personality was first recognized and described by the French physician Pierre Janet the late 19th century. In the year 1982 psychiatrists were talking about “the multiple personality epidemic.
Yet those were early days as multiple personal¬ity became an official diagnosis of the American Psychiatric As¬sociation only in 1980. Ten years earlier, in 1972, multiple personality had seemed to be a mere curiosity. “Less than a dozen cases have been reported in the last fifty years. ” You could list every multiple personality recorded in the history of Western medicine, even if experts disagreed on how many of these cases were genuine as the word for the disorder was rare. Ten years later, in 1992, there were hundreds of multiples in treat¬ment in every sizable town in North America.
Even by 1986 it was thought that six thousand patients had been diagnosed. After that, one stopped counting and spoke about an exponential increase in the rate of diagnosis since 1980. Clinics, wards, units, and entire private hospitals dedicated to the illness were being established all over the continent. Maybe one person in twenty suffered from a dissociative disorder. Clinicians were still reporting occasional cases as they appeared in treatment. Soon the number of patients would be¬come so overwhelming that only statistics could give an impression of the field (Modestin, 88-92).
Public awareness of the disorder increased in contemporary times after a case was the subject of The Three Faces of Eve (1957). In the 1980s and early 90s, such factors as recognition of child abuse, public interest in memories recovered from childhood (whether of actual or imagined events), allegations of so-called satanic ritual abuse, and the willingness of many psychotherapists to assume a more directive role in their patients’ treatment, led to what came to be regarded as a rash of overdiagnoses of multiple personality.
Causes The cause of multiple personality is not clearly understood, but the condition seems almost invariably to be associated with severe physical abuse and neglect in childhood. It is believed that amnesia the key to formation of the separate personalities occurs as a psychological barrier to seal off unbearably painful experiences from consciousness. The disorder often occurs in childhood but may not be recognized until much later. Social and psychological impairment ranges from mild to severe.
The fairly-necessary-condition evolved together with the characterization of multiple personality disorder (MPD). According to Cornelia Wilbur and Richard Kluft, “MPD is most parsimoniously understood as a posttraumatic dissociative disorder of childhood onset. ” Here the childhood onset and the presence of trauma are not parts of an empirical generalization or a statistically checkable fairly-necessary-condition. They are part of the psychiatrists` understanding of multiple personality disorder, part of what they mean by “MPD. ” There is nothing methodologically or scientifically wrong with this.
I warn only against having it both ways. There is a tendency (a) to define the concept “MPD” (or dissociative identity disorder) in terms of early childhood trauma, and (b) to state, as if it were a discovery that multiple personality is caused (in the sense of fairly-necessary-condition) by childhood trauma (Horton and Miller, 151-159). Moreover, child sexual abuse became part of the prototype of multiple personality. That is, if you were giving a best example of a multiple, you would include child abuse as one feature of the example.
The connection between abuse and multiplicity became stronger and stronger during the 1970s, just when the meaning of “child abuse” moved from the prototype of battered babies through the full range of physical abuse and gradually centered on sexual abuse. As a point of logic it is useful to see how concepts are used to lift themselves up by their own bootstraps. Those sounds highly figurative, but consider this. In a 1986 essay Wilbur wrote, “In discussing the psychoanalysis of MPD, Mershkey (330) pointed out that childhood trauma is central and causal. ” In fact he ended his prize winning essay by posing some questions.
He said that in recent previous reports of multiplicity “childhood trauma is central and causal” (327-340). The connection between multiple personality and real, not fantasized, child abuse was cemented in clinical journals throughout the 1990s. By 1992 there were vivid musterings of data about the relationship between incest and multiple personality. Philip Coons (299) had stated in his classic 1994 essay on differential diagnosis of multiple personality, he wrote that “the onset of multiple personality is early in childhood, and is often associated with physical and sexual abuse. At that time no child multiples were known.
But the hunt was on. The first in what is now a long series of books of contributed papers about multiple personality had a fitting title: Childhood Antecedents of Multiple Personality (311-315). Prevalence The number of different personalities per MPD patient has shown a substantial increase since the 19th century. During the 19th century, most cases involved only two personalities. Since 1944, however, almost all cases have involved three or more personalities.
Modern cases average from 6 to 16 personalities per patient (Coons 305). For instance Modestin (89) reported that 44% of 74 MPD patients each had more than 10 personalities and 8 of these patients had more than 20 personalities each. North, Ryall, Ricci, and Wetzel (2003) plotted the mean number of MPD per patient as a function of year, between 1989 and 2000. In 1989, the average MPD patients manifested just fewer than 10 personalities; by 1999, MPD patients displayed an average of just under 25 personalities per patient.
At the present time, MPD appears to be culture-bound syndrome. The explosion of cases since 1970 has thus far remained largely restricted to North America. The diagnosis is very rarely made in modern Europe, despite its turn-of-the-century prominence as a center for the study of MPD. It is also very rare in Great Britain (Modestin,90). Modestin (92) surveyed all of the psychiatrists in Europe concerning the frequency with which they had seen patients with MPD. Depending on how it was calculated, the prevalence rate ranged between . 5% and 1. 0%.
More interesting, Modestin noted that 90% of the respondents had never seen a case of MPD, whereas three psychiatrists had seen each seen more than 20 MPD patients. Hence, the frequency of multiple personality has been debated over time. There were some descriptions of these behaviors early in this century, but from the 1920s to the early 1970s, there was a surprising dearth of cases (Spanos, 145). Kohlenberg (138) termed it relatively rare while other reports saw it as very numerous in number; more cases were reported from the mid-1970s to the mid-1980s than in the previous two-hundred years.
The tremendous increase in reported cases has occurred almost exclusively in North America (Spanos, 147). This behavior pattern is rarely reported in Great Britain, France, and Russia; no case has ever been reported in Japan (Spanos, 160). In both North America and Switzerland, most diagnoses are made by a small minority of professionals while the vast majority of professionals rarely if ever see such a case (Modestin, 90-91). The dramatic increase in the reported numbers of cases has been attributed to differing factors.
Possibly, cases which were undiagnosed in previous decades are now being diagnosed because of greater awareness of this condition; it has also been proposed that the condition is now being overdiagnosed in individuals whose behaviors are readily suggestible (American Psychiatric Association, 94). It is probably safe to conclude that the prevalence of Dissociative Identity Disorder is in dispute at this time; some may also dispute the validity of this diagnosis as the DSM-IV, unlike earlier versions of the DSM, does not provide any diagnostic reliability information (American Psychiatric Association, 99). Diagnosis
On balance, with the behaviors labeled Dissociative Identity Disorder or DID hereafter, the variability between behavioral repertoires is very high, possibly so extreme that the repertoires do not compose one stable personality (Sapulsky, 64). The person himself or herself may even report being a different person, complete with a different name or “identity. ” Although the behavioral variability is more extreme here, it is still on a continuum with the average person; we all can exhibit several personalities and there are circumstances under which any person might claim to be a different person (Sackeim & Devanand, 21).
Among the behaviors correlated with a diagnosis of DID, self-report is less controlled by public, environmental events and more controlled by events which are private to the person providing the self-report (Kohlenberg & Tsai, 139). The most apparent question is: What type of experiences could account for this extreme behavioral variability, in the self-report of being a different person, with differences in sex, age, race, physical appearance, and so forth.
Some writers report that this disorder may only become apparent to a professional or others when “different people” attend meetings, interviews, or therapy; that is, the same individual attends but with a different self-report of identity, memories, and personality (Sackeim & Devanand, 25). In so doing, individuals displaying these behaviors can receive a great deal of reinforcing attention from professionals for engaging in these behaviors. Individuals displaying behaviors correlated with a diagnosis of DID may be reassured of no further abuse and may be encouraged to try to “be themselves” in as many ways as they can.
The different self-reports and personalities become a source of gratification (self-reinforcement) for the formerly abused victims and the professional alike (Spanos, 153). The danger here is that a person with degrees of behavioral variability could be shaped iatrogenically to reporting to be a divergent person by professionals zealously looking for this disorder (Merskey, 329) To quote one skeptic, “the procedures used to diagnose MPD often create rather than discover multiplicity” (Spanos, 153).
Pain complaints, paralysis, blindness, and so forth, also consist of a self-report of a private event. Each of these may be accompanied by publicly observable events such as wincing, reluctantly moving, reporting or appearing to be unable to move or see ( Skinner) Both the self-reports and the public evidence for these differences are under stimulus control of the different personality repertoires in cases of these behaviors. When such an individual displays a specific personality, the self-report of pain or other symptom comes or goes with the other behaviors.
Originally, the public signs of pain were authentic afflictions in the past as the result of abuse; months or years later, such indications could be self-produced, rule-governed behavior as part of the personality repertoire. These pains and related behaviors could be reinforced and shaped into a “real” affliction by well-meaning others as the verbal behavior acquired differential stimulus control of operant pain behavior. The rep orts of pain and related behaviors can persist as operant behavior maintained by its consequences in the absence of the original painful stimuli (Bonica and Chapman, 732).
As for the reports in the literature of allergic and other responses being present in some personalities and not others, these too can potentially be accounted for via verbal behavior mechanisms. There are reports that individuals can develop rashes, a wound or a burn or other physiological symptoms in response to another’s verbal suggestions, that is, under hypnosis, although it has been argued that many of these symptoms are likely self-inflicted when observers are not present (Johnson, 298).
Actual reports of hypnotically induced dermatological changes are difficult to substantiate; such effects are difficult to produce and are not as common an occurrence as often reported (Johnson, 302). These reports are not all due to the acts of the person showing the symptoms; instead, these symptoms may be due to an interaction of verbal behavior and conditioning mechanisms. Verbal behavior can also facilitate the development of stimulus control via respondent or operant conditioning (Skinner).
If an experimenter were to flash a light in your eyes and then shock you, the experimenter would expect you to come to recoil to the light after some number of such pairings. If the experimenter were to tell you that he or she was going to shock you after every light flash, then it would be expected for you to recoil to the light sooner. Relating this to the differential presence of symptoms is not a big leap. Here, the individuals who display the divergent personalities have self-instructed and subsequently conditioned themselves to display symptoms when performing different behavioral repertories.
Over time, the symptoms may come under the stimulus control of the emotions displayed, in addition to the person’s verbal behavior, and appear spontaneous to the person himself or herself. To support the argument for conditioning mechanisms producing somatic symptoms, Smith and McDaniel (69) showed that a hypersensitive cellular response to tuberculin was modulated by respondent conditioning. Individuals can also exert control over a variety of autonomic functions as diverse as dysmenorrhea to seizure activity, via biofeedback . Treatment
From the foregoing assumptions, therapy for persons displaying the behaviors in question must consist of extinguishing a reasonable share of the behavioral variability in the repertoire and reinforcing behavioral stability and generalization; literally, to shape one personality. Kohlenberg (138) reported being able to increase the frequency of specific behaviors composing one personality of an individual who exhibited DID-like behaviors by differential reinforcement of that personality. When placed on extinction, these behaviors returned to baseline frequencies.
Other techniques might involve the client role-playing and rehearsing several social interactions and experiencing some situations expected to produce “normal” emotional behaviors. Kohlenberg (139) reported success at “reintegrating” the personalities in a dual personality individual by teaching assertiveness skills via role playing. Caddy (268) also used assertiveness training and shaping in reintegration. The therapist might videotape client s as they behave, to use for feedback and in shaping and instructing more “cohesive” behavior.
There might also have to be a way of teaching the client to engage in more “social-referencing,” or seeking public feedback in more instances of what is acceptable behavior. Whereas you or I might ask, “Did you see (or hear) something? ” when we are unsure of seeing or hearing, individuals whose behaviors are consistent with the label of DID may have to learn to ask, “Am I still behaving as me? ” The therapist could not answer this question alone but family members and significant others could.
This process would have to continue until the person reports being the same individual with the same experiences, and has less observable variability in his or her personal repertoire. Even if a therapist were to try to undertake such an intervention, and most would probably not, this process could be long and arduous, due to the multiple sources of control that would require adjustment, and the possibly well-meaning sabotage by those who attend to and reinforce the variability.
Indeed, based on this account, control of the behaviors in this pattern would be difficult for anyone to establish. Even the therapist who encourages variance is not exerting control unless unpredictable behavior is the target behavior. As a result, these individuals may have been and will likely be in therapy for years (American Psychiatric Association).
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