Both MPD and DID Should Be Listed In the Next DSM As Labels for Two Quite Different Groups of Patients with Alter-Personalities By Ralph B. Allison, M.D. PO Box 957 Paso Robles, CA 93447-0957 805/237-2665 ralfalison@charter.net Presented at the meeting of the International Society for the Study of Dissociation at Toronto, Ontario, Canada November 7, 2005 Abstract: Extensive clinical practice with dissociators has shown that there are two distinctly different groups of patients who have bona fide alter-personalities. The group for which MPD is an appropriate label created their first alter-personality before the age of six, have no resident Original Personality, and manifest dozens of alter-personalties. The group for which DID is appropriate created their usually single alter-personality after the age of six, have a resident Original Personality, and are usually quite socially able. Criteria for both MPD and DID will be presented, along with some theoretical underpinnings of this point of view. In 1972, while in private psychiatric practice in Santa Cruz, California, I identified my first patient with Multiple Personality Disorder (MPD). She was a clone of Eve, so I was able to do this, since I had no formal education on the subject of the dissociative disorders. All I knew at the time came from seeing the movie, "The Three Faces of Eve." At that time, DSM II called it "Personality trait disorder, dissociated (hysterical), multiple personality." In 1974, I wrote my first paper describing this patient, "A New Treatment Approach To Multiple Personality." Her most significant difference from Eve was her dissociated "Inner Self Helper" or ISH, something I spent the next several decades trying to understand. In 1987, I presented a paper in Ottawa called "Maybe Multiples in Courts and Corrections." This was my first attempt to tease out the differences between those outpatients of mine who dissociated and the dangerous felons I was evaluating for murder trials. The felons presented "other selves" which committed heinous crimes, and I just could not accept that they had the same problem as did my office patients with MPD. In 1996, in "The Allison Manifesto on MPD and DID," presented in Budapest, Hungary, I laid out how I thought the felons and my patients differed in what they showed as "other selves" and distinguished two groups of patients with bona fide alters, but which were created at different ages under different situations. Now I am trying again to present what I consider a valid point of view which differs from the present tendency to consider all persons showing "other selves" to be dissociators, and therefore all fitting into a one group we call Dissociative Identity Disorder (DID). During my earlier years in practice, DSM III was published, and MPD was recognized as a "real disorder" by being given its own code number. We clinicians were all delighted. However, a backlash occurred, and, in the mid 1990's, DSM IV was produced, and MPD was banished, to be replaced by DID. This was a political compromise, since many academic psychiatrists and psychologists thought MPD to be impossible to have. As one told me, "We all are born with one personality. Therefore, it is impossible for anyone to have multiple personalities." He just didn't understand how these patients came to be the way they were. Plato and Aristotle believed each human has a "rational soul" and an "irrational soul." Western philosophers have long spoken of each of us being made of "body, mind, and spirit." I agree. The problem is semantic, as we have not yet agreed on single terms for the "mind" (Plato's irrational soul) or the "spirit" (Plato's rational soul). For purposes of this talk, I will use the term "Personality" for the mind and "Essence" for the spirit. When DSM IV was published, I decided not to use DID for all former MPD patients of mine, as it was semantically incorrect. But I decided to appropriate DID to apply to a select number of my patients who clearly fell into a different group from those whom I still felt deserved the diagnostic label of MPD. Now I will describe and compare each clinical group. First, one must recognize that dissociators who make bona fide alter-personalities (alters) do so as a protective, survival mechanism. One also must understand that each alter is like a computer program, created and designed by the Essence to work on behalf of the Personality. Therefore, it is involuntarily made, from the point of view of the Personality. For a person to have MPD, the following factors are needed: 1. Predisposing factor: Grade V hypnotizable child (top 4% of the population) younger than age six. 2. Precipitating factor: Experiences life threatening trauma, usually in parental home, before the age of six. 3. Continuing factor #1: Polarized parents, with one seen as bad and the other as good and potentially protective, but the parents keep changing roles. Therefore, rescue is impossible. 4. Continuing factor #2: Polarized siblings. Only this child is so badly abused by her parents. Other children are treated much better. For a person to have DID, the following factors are needed: 1. Predisposing factors: Hypnotizability in the upper half of the population, age six or older. 2. Precipitating factors: Trauma which need not be life threatening, but is of such a nature that the child has had no training to know how to handle it. Typical traumas are rape for girls and physical assault for boys. 3. Continuing factors: No adult is available to teach the child how to cope with this specific stress. To develop the MPD syndrome, the first dissociation is the separation of the Essence from the Personality at the time of the life threatening trauma. This causes the Essence to take on the job of ISH, which is equivalent to Disaster Control Officer. The ISH immediately sends the Original Personality off to somewhere safe. She, the Original Personality, will not return until it is safe to do so. The ISH then makes and programs the first alter, a False Front Alter, so as not to anger the abusing parent. Otherwise, the parent might kill the infant. Since the False Front Alter is not programmed to handle anger, when further abuse does cause anger, the ISH then creates another alter who can handle anger, which I called the Persecutor Alter. When the Persecutor Alter makes a mess, the ISH makes a Helper Alter to clean it up. The process goes on and on, so dozens of alters are formed over time, each for a specific survival function. The resulting person comes for therapy in her twenties, brought in by her eldest False Front Alter, pushed by her ISH, and accompanied by numerous alters. No Original Personality is at home in her body. The development of the DID syndrome begins when the first dissociation is at age six or later, due to a rape or physical assault. One alter is created by the Essence, which does not dissociate from the Personality. This single alter is designed to deal with this one type of trauma. Assault to a boy will lead to a violently protective alter. Rape to a girl will lead to a sexually aggressive alter who wants to use sex in order to control men. The Original Personality is home in the body and may proceed with social and educational development. The Original Personality comes in for therapy, accompanied only by one alter. The therapy approaches for the two groups are different. With patients with MPD, hospitalization for suicide attempts is often needed. Outpatient hypnotherapy with age revivification is the most efficient method of treatment. Only the angry Persecutor Alters need "treatment" so that they become willing to give up their "anger-energy." The other alters need social work and encouragement to cooperate with each other. When all the anger-energy is gone, the Original Personality is allowed back into the body by the ISH, who then supervises the Psychological Integration of the alters into the Original Personality. When this psychologically integrated patient has enough experience solving problems using non-dissociative methods, the ISH/Essence integrates into the Original Personality, a process called Spiritual Integration. During treatment of DID, the Original Personality is in charge. He has to learn to cope in an adult manner with the type of trauma he could not handle in his youth. Education in coping skills is needed so the Original Personality can grow and assume all the duties of adult life. The alter atrophies with disuse and integrates into the Original Personality when no longer needed. There are many variations on this theme. One important fact to remember is that "IMAGINATION IS NOT DISSOCIATION." Dissociation has become a favorite buzz word in psychology to cover many mental processes which can be otherwise explained. Dissociation is a survival mechanism, as when used to create alters. The process involves the ISH getting the native personality traits out of what might be called the patient's "Personality Parts Warehouse" so that another alter can be created from them. Therefore, the alter will be able to integrate into the Original Personality at a later date. All the pieces of the jig saw puzzle came from the same box, so to speak. There are at least two types of imagination, Inspirational and Emotional. Inspirational Imagination is used by the Essence and the Personality to create great works of art and valuable inventions. It is the most powerful ability of the human mind. But the Personality can also use Emotional Imagination. One-third of college students report having had a childhood imaginary playmate. When lonely, they used their Emotional Imagination to create a wonderful playmate. When they went to school and had human friends, they mentally destroyed it. One man on trial for murder had created an Internalized Imaginary Companion (IIC) at the age of four when his mother's boyfriend locked him in a closet while the boyfriend sexually abused the boy's sisters. Consumed with hatred of this man, the boy created an IIC whose goal was to kill the man. But, at the age of four, he couldn't do much about it. But 20 years later, he killed an innocent victim, an act for which he was subsequently sent to Death Row. So great confusion can develop when one of these persons commits an antisocial act and then shows "another self" to explain what happened. "It's not my fault; Joe did it." Such people are too often thought to have DID, since the current DSM IV does not provide any way to discriminate between a product of dissociation (an alter) and a product of emotional imagination (an IIC). In reality, they are very different. Alters are designed for survival of the person. Attacking others is not a good survival mechanism, as police sometimes shoot them, and Death Row is still operating in most states. Alters are always under the ultimate control of the ISH who created them, but IIC are under no control by anyone and have no social judgement or conscience. Both IIC and alters can be designed to hold hostile emotions. IIC are created by the Personality to manage otherwise unmanageable emotions. Alters are created by the ISH to handle anger the False Front Alter was not designed to manage. However, alters are angry at someone who maliciously attacked them personally. IIC are often made because of the child's anger at some adult who displeased or angered them in some way, but who did not really endanger them. Alters who behave badly can be recalled from duty by the ISH and reprogrammed. IIC who behave badly have no conscience or social judgement. They can be extremely dangerous as they are under no one's control. They are like military "smart bombs" as they have a hefty payload of explosives but only a simple targeting mechanism with no recall method. Alters can be reformed by the removal of their anger-energy, and they then become Helper Alters. They have a structure which stays intact. IIC who give up their anger-energy disappear. They were "only anger" in the first place. They have no structure. Alters will stick around in the background and can be called out under hypnosis. They cannot be destroyed by an act of will of the patient. IIC can be destroyed by an act of will of the patient. This often happens voluntarily when the cost/benefit ratio tips too far in the direction of cost. Once the insanity phase of the murder trial is over with, the IIC is nowhere to be found in the convicted felon, even when sought for under hypnosis. Unfortunately, combination cases occur all to frequently. Hypnotizability is a life-long trait we all have to varying degrees. We all range from zero to Grade V. I am about a Grade II. A Grade V hypnotizable person has a certain set of personality characteristics, one of which is being an "emotional albino." They are highly sensitive to the moods and emotions of all those around them. So they are easily hurt emotionally, even when no intent to do harm exists in the other persons. The ability to use emotional imagination readily and often is called Fantasy Proneness. Research has shown that hypnotizability and fantasy proneness are not coupled together. One may be high on one trait and low on the other, low on both, or high on both. When we therapists face a patient who is high on both traits, we are seeing a patient who is the challenge of our career. They have certainly livened up my professional life, by creating chaos and confusion in my mind. It is highly possible for a person with MPD, who has made dozens of alters, to also create any number of IIC. This is because she is both Grade V hypnotizable and highly Fantasy Prone. One of these patients of mine decided to punish her husband by making a couple of new "other selves" every night, just to bedevil him. When she showed them in my office the next day, I wasted our therapy time trying to deal with them, thinking they were new alters. Finally, I wised up and realized that they were IIC she deliberately created via emotional imagination, to pay back her now-reformed husband for all the beatings he had given her in the early days of their marriage. I told her to "Turn off the Barbie Doll factory," and she did, solving that problem. This combination of having both alters and IIC acting up is a common situation with patients with MPD. Knowing which is which is essential so the therapist can intelligently decide what to do next. Each one requires a different approach. If in doubt, the therapist can always ask the patient's ISH, who knows the identity of each and every psychic entity in that patient's mind. Summary MPD and DID can both be used as labels for two quite separate groups of patients who manifest bona fide alters. But we should apply neither label to those who use emotional imagination to create other entities who can inhabit their bodies.