The Importance of Skeptical Inquiry in Matters of Dissociative Identity Disorder
Description of Topic
Dissociative Identity Disorder (DID) is described in the DSM-IV (I paraphrase here) as the presence of two or more enduring and distinct identities or personality states, at least two of which recurrently take control of a person’s behavior, and between which memory is partitioned such that memories are not equally shared by all personality states. We certainly can encounter people, in life and in therapy, who fit these criteria to the best of our discernment. There is some argument, however, as to the source of these personalities, specifically regarding recent increases in diagnosed cases of DID and the fact that there appears to be some inflation in the numbers of identities within each person. Earlier cases recount two or three personalities while more recent cases are attributed alters numbering in tens or hundreds. These trends have inspired no small amount of skepticism regarding the validity of current diagnostic methods and the suspicion that therapists themselves may be accountable for some number of alters encountered during therapy.
Arguments of First Author
Frank W. Putnam begins by addressing criticisms of Dissociative Identity Disorder, specifically, that DID is an iatrogenic disorder induced by therapists, that DID is produced by exposure the popular media, and that we’ve seen an exponential increase in diagnoses of DID. He points out that there have been no documented cases of inducement of DID in patients as a result of hypnosis or fascination and that DID has been diagnosed in patients without a history of hypnotherapy, thus demonstrating reasonably that therapist intervention is not alone sufficient to produce DID.
The second case, that of media contribution to the incidence of DID diagnosis, is addressed by Mr. Putnam by pointing out the quantitative disparity between portrayals of violence in the media and portrayals of multiple personalities. He points out that, if the media can be attributed the power to induce behavioral changes in its consumers, we should have seen a media-induced surge in violence far greater than the observed increase in diagnosed cases of DID. Putnam asks why the media effects should be so powerful and so specific to the case of DID when there has been no similarly robust linkage to other behaviors. Putnam’s third argument from mathematics can be largely ignored as semantic- or at least will be ignored in this response as such. Outside the physical and biological sciences it is generally understood that an ‘exponential’ increase can refer to any increase in incidence which deviates from linear and is positive.
Putnam states that the validity of DID as a diagnosis should be assessed in terms of content validity, criterion-related validity and construct validity. He asserts that striking symptom similarities between patients in systems utilizing different methodologies and the establishment of developmental criteria for DID satisfy requirements for content validity. Criterion-related and construct validity are, he says, supported by our ability to objectively assess dissociative disorders and to reliably discriminate DID from other dissociative disorders. He concludes that denial of the existence of the disorder or blaming the media for the disorder is not productive in terms of treating the disorder.
Arguments of Second Author
Paul R. McHugh begins his argument with an example from somatization disorders in which patients may be reinforced by ongoing physical-therapeutic interventions due to attention from doctors and care-giving responses from loved ones. He points out cases of “hysteroepilepsy” as encountered by Charcot and how they were eventually remedied not by continuing care in the facility, but rather by removing patients and placing them in a less reinforcing environment. A parallel is then drawn to diagnosis and treatment of Dissociative Identity Disorder, in which troubled patients may encounter the suggestion that alternate personalities may be implicated, and in which enthusiastic pursuit of those alternate personalities may ensue. Therapist zeal is attributed to subsequent multiplicity of personalities as a therapist may strive to ferret out additional alternates and in so doing encourage their creation.
McHugh gives examples from his own practice: of therapists seeking to continue visits with patients who have been transferred to his care, describing these lingering entanglements as barriers to treatment. In McHugh’s experience patients begin to improve only after they have been extricated from their former therapists, at which time, as in the case of “hysteroepilepsy,” removing a source of reinforcement precipitates successful treatment.
McHugh ends his argument by underscoring the importance of the null hypothesis, placing the burden of proof on those making positive claims. He points out that Charcot’s diagnostic criteria for “hysteroepilepsy” were certainly reliable, but that diagnostic reliability is not sufficient to demonstrate that a disorder exists.
My Reactions, Thoughts, and Opinions
Unfortunately for Putnam, McHugh makes some very persuasive points which did not seem to be countered very effectively in Putnam’s response. Putnam came close to directly addressing the issue of iatogenicity, but only refuted hypnosis as a source for iatogenically induced DID and thus failed to account for more subtle influences which might be exerted upon a patient by overzealous therapists. It isn’t at all difficult to imagine that a patient suffering from a Dissociative Disorder might be particularly vulnerable to the suggestion of multiple identities. They already feel as if they are not themselves at times, so it might seem reasonable that they are, at those times, someone else. In light of our human tendency to confabulate, and considering that patients will only tend to seek therapy when already in a state of distress, therapists employing proactive diagnostic methods as outlined by McHugh may indeed be doing their patients a grave disservice and aggravating preexistent conditions. By actively seeking alternate personalities in patients with a Dissociative Disorder, by asking questions such as, “Have you ever felt like another part of you does things that you cannot control?” and “Does this set of feelings have a name?” therapists are certainly making suggestions. Can we reasonably maintain that a person in distress who has gone to a therapist for answers and assistance will not latch onto any suggestion which might serve to explain their distress? For all that Dissociative Identity Disorder is a daunting diagnosis for a patient to deal with, the relief obtained from any diagnosis may be greater than the stress of an exotic disorder and patients may work, perhaps subconsciously, to reify their diagnosis in hope of obtaining assistance.
The null hypothesis and the scientific method should certainly be given more weight when it comes to diagnosis of psychological disorders in general and Dissociative Identity Disorder specifically. Putnam pointed out in the opening paragraph of his response that both sides in this issue have robust support. In science, this is taken to mean that we cannot conclude anything at all- that the burden of proof is upon those making the positive claim and that the null hypothesis cannot be discarded. Certainly this means that those making positive claims must work harder to demonstrate their cases and that we must often wait longer before benefiting from technologies or treatments which are eventually derived from research. Requiring a positivist bias from our sciences is not only a barrier to progress, though- it is also a protection from applying erroneous theory prematurely and in so doing harming those we seek to help.
Summary of Additional Journal Articles That Support My Position
Piper and Merskey (2004), citing Putnam as an example of iatogenic influence in the diagnosis of Dissociative Identity Disorder, outline several ways that therapist intervention may induce the creation of multiples in patients. Among this litany of poor practices are included the tendency to look for lists of behaviors without a protocol for exclusion below a certain threshold, directly asking to speak to alternate personalities prior to diagnosis with DID, and structuring therapy sessions in order to fatigue patients- tailoring these encounters to prevent patient breaks or opportunities to regain composure- with the intent of forcing them to reveal alternate personalities. Many of these practices surpass accusations of subtle suggestion and enter a realm frighteningly reminiscent of interrogation techniques employed by law enforcement. There is little doubt that these practices are successful in inducing the emergence of hidden personalities- as they might in an otherwise healthy person under the control of a trusted authority.
According to Piper and Merskey (2004) the initial revelation of an alternate personality does not demarcate an end to the process. After up to six months of concentrated effort to expose an initial alternate personality, therapists are often eager to look for others. The resultant years of psychotherapy may become a cycle of reinforcement for established patterns as well as reward for each additional personality revealed. The serpent dines upon its tail.
Kluft (2005) concludes his article Diagnosing Dissociative Identity Disorder by stating, “The typical differential diagnosis for DID includes other dissociative disorders, psychoses, affective disorders, borderline personality disorder, partial complex seizures, factitious disorder and malingering…. When the diagnostic criteria for DID are met, without definitive proof of factitious disorder or malingering, the DID diagnosis should be made. The underdiagnosis and misdiagnosis of DID are well-documented findings, and characteristically lead to years of suboptimal treatment and excess morbidity. The overdiagnosis of DID certainly can occur, but there is no solid evidence (despite strongly-voiced opinions) that it is a widespread phenomenon.” Kluft also documents the procedures outlined by Piper and Merskey regarding therapeutic methods for discerning the presence of alternate personalities in patients. This source can be considered an important contribution to my argument in that it represents confirmation of the charges of detractors by an author who does not share their bias. That DID can be diagnosed following such arduous therapy sessions and without excluding other dissociative disorders- or even unrelated disorders- which may have increased patient vulnerability to therapeutic suggestions should give pause to all but the most obstinate practitioners.
References
Piper, A., & Merskey, H. (2004). The Persistence of Folly: Critical Examination of Dissociative Identity Disorder. Part II. The Defense and Decline of Multiple Personality or Dissociative Identity Disorder. Canadian Journal of Psychiatry, 49, 678-683.
Kluft, R.P. (2005). Diagnosing Dissociative Identity Disorder. Psychiatric Annals, 35: 8, 633-643.
