Print

Ralph B. Allison:
ON DISCOVERING MULTIPLICITY

Dr Allison har i flera †r arbetat intensivt med en speciell typ
av st”rning som kallas multipel personlighet.  Under 6 †r har
han behandlat mer „n 40 fall med goda resultat.  Multipla
personligheter „r l†ngt vanligare „n vad man tidigare trott,
menar Dr Allison, men en terapeut, som inte anv„nder sig av
hypnos, kan sv†rligen uppt„cka dem, kanske inte fler „n en eller
tv† under en livstid.  Dr Allison beskriver i denna artikel, den
andra av tre, hur man n†r frarn till diagnosen multipel
personlighet.
(Den f”rsta artikeln var inf”ord i nr 6/77.)

In the latter half of the 19th century, interest was high among
the French and English hypnotherapists in that clinical oddity
called multiple personality.  Freud, however, in spite of all
his early interest in the psychodynamics of hysteria, never
wrote about a patient with this disorder, which I prefer to call
multiplicity.  Therefore, the major work on the subject in the
United States was done by non-Freudian psychiatrists such as
Morton Prince. (Prince, 1920) Since the first case was published
in the United States in 1888, (Mitchell, 1888), there have been
slightly over a hundred patients reported in the English
literature.  No doubt there have been many times that number
treated by psychotherapists who did not publish their findings. 
Personally, I have seen over 40 cases in the past 6 years.  I
know of a psychiatrist in Honolulu who has seen 50 cases, and
one in Phoenix who has seen 30.  All of us use hypnosis
extensively. Those therapists who do not use hypnosis may see
one or two in a lifetime, usually the most obvious type.  This
may occur in a situation where a patient has been coming for
sometime for therapy and then, one day, the same body arrives,
but Jane says June is not coming today and she, Jane, is there
to explain why June has been so depressed lately.  This is a
shocker for any therapist and many try to avoid that upset
happening to them again by denying the signs presented by
subsequent patients.

Other therapists are interested or fascinated by such a peculiar
mental aberration and may be only too willing to find symptoms
of multiplicity in their patients.  There are many figures of
speech which could imply multiplicity, such as "my good self"
and "when the bad me takes over.  " Eric Berne's Transactional
Analysis theory (Berne, 1964) uses terms like "child ego state"
which are more likely to be accurate descriptions of the
immature behavior of an adult patient.  The "sub-personality"
concept of psychosynthesis, as pioneered by Assagioli,
(Assagioli, 1965) is another view which may be more correct in
"normal neurotics.  " Role playing accounts for a great deal of
the different patterns of behavior we all show at different
times.  This is conscious, however, and the switching done by
the multiple, before treatment, is done for unconscious reasons
and therefore is, for the most part, beyond the control of the
patient's conscience or social judgmental faculties.

Therefore, I wish to confine myself to those persons who become
psychotherapy patients, or we would not see them, the ones who
use denial, repression, and dissociation as preferred ways to
deal with emotional stress.  In this way, they create, in the
unconscious mind, a disconnected focus of unacceptable feelings,
attitudes, and behavior patterns which can come forth as a
personality under proper stimuli to control the body.  The basic
personality or ego is amnesic for this period of loss of
control, since the purpose is to allow for the acting out of
unacceptable impulses.  Usually childhood anger towards a loved
one is the first such feeling handled in this way.  Next comes
sexual feelings, especially if mixed with fear and anger
following a childhood rape or molestation.  Thus a pattern is
established, of creating alter-personalities to act in the
patient's behalf, all while the patient is consciously unaware
of what is being done.  This pattern creates its own troubles
and encourages more denial, repression and dissociation.  This
may seem to the child to be the only way to cope with the
pathological family members, and indeed, it may be.  However,
the child grows up and enters adult life with job, family and
social responsibilities.  Now the defensive pattern grossly
interferes with life, and the patient seeks therapy, hoping to
find a way out of the self made hell.

The main interest in multiples has been so far in those in
psychotherapy.  But I have personally become acquainted with
another group, those in prison.  Eighty five per cent of my
multiple patients have been women.  Of those patients who had
serious trouble with the law, two thirds were men.  They told of
other men they knew in prison who, like they, could not remember
large segments of time when they had been acting violently.  I
suspect that many male multiples who get arrested and deny
memory of the crime are sent to prison.  The females who give
the same story to male judges and prosecuting attorneys are more
likely to be given probation and be referred to the local mental
health clinic.

What I am going to say on the subject of making a correct
diagnosis cannot be applied to a person in prison, since anyone
will manipulate and lie to a psychiatrist to try to get out of
prison.  It would also be hard to apply these ideas to one
awaiting trial, since a prisoner's civil rights to privacy, in
the United States, would be violated if a court appointed
psychiatrist used hypnosis to probe his unconscious mind to find
out if he had an alter-personality.  Then there is the ethical
problem of what the psychiatrist is to do if he finds an
alterpersonality in a prisoner.  Pandora's box had been opened
and the psychiatrist cannot just walk out on a patient in such
an unstable state of mind.  Suicides have occurred when
awareness of the truth came abruptly without emotional support
and understanding.

So let us get back to those who are in our care and see how we
can determine whether or not they suffer from multiplicity,
which is the tendency to create alter-personalities under
stress.  The traditional approach taught in medical schools,
regarding all diseases, is also appropriate here.  First, what
are the presenting signs and symptoms ? Forty per cent of my
patients came to me because of depression and or suicidal
attempts, A typical story is that of a young lady who is brought
to the emergency room of the hospital with longitudinal slash
wounds of both forearms.  She states that she had been on the
phone arguing with her boy friend, who wanted to break up with
her.  Then she blacked out and woke up in the ambulance.  A
bloody knife was found in her sink.  A hypnotic interview,
within the day, to find out what happened during the amnesic
period, reveals the existence of the alter-personality who did
the foul deed.  The alter-personality's reason was that the
patient was again letting a man degrade her and needed to be
punished for her weakness.  So the alter-personality turned the
anger on the body of the main personality to punish her.

Other reasons for seeking help were hysterical physical
complaints such as backaches, headaches, colitis, stammering,
and convulsions.  Other complaints were alcoholic bouts, sexual
problems, auditory hallucinations and a belief in being
possessed.  In addition to these, a common complaint is sudden
mood changes.  This may be accompanied by a change in
handwriting when in a different mood.  One lady's bank kept
refusing to cash her checks because a different signature kept
showing up on the checks.  A simple complaint of amnesia is
rare, since these patients may have had so many amnesic spells,
they consider it normal.  But please be suspicious when the
patient asks you, as one did me, "What happened to the month of
January? The last thing I knew was going to a New Years Eve
party and now it is the first week in February, And I've moved
during that time into a new apartment in a different town.

On looking into the details of the present illness, you must
inquire about lost time gently, since these patients, not being
psychotic, believe that if they complain of lost time or of
hearing voices, they may be committed to a mental hospital as
schizophrenics.  So one has to ask about amnesia and voices in a
very off-hand casual way as if they were no more important
symptoms than a rash o r a hangnail. They frequently will admit
to amnesia after drinking but have to be quizzed further before
admitting amnesia also occurs at times when they are sober. 
Finding themselves in strange places, being told they used
different names, is a common story.

The voices of good and bad alter-personalities sometimes are
heard inside the head.  They know these are their own thoughts,
yet they are separate.  They are not projected onto an outside
source.  The bad voice will be urging suicide or homicide, and
the good one will be encouraging and directive in how to solve
today's problems.  Unfortunately, the patient rarely pays any
attention to the good voice.  There is often a history of poor
impulse control, with violent rages toward rejecting lovers and
near murderous acting out.  There may have been chronic physical
complaints and prolonged pain after back surgery.  The back pain
never clears up with any type of treatment, and the recurrent
"migraine" headache brings the patient to the emergency room
every night for a narcotic injection, to everyone's dismay. 
Addiction to narcotics is common, as is a history of bouts of
excessive drinking of alcohol.

The childhood family situation can best be characterized as
"terrible." The child was unwanted at birth.  The parents became
polarized in the child's view, as saintly or evil, but the child
could never be sure which parent was which way.  Frequently the
favored parent left the home before the age of six, leaving the
child with the one she couldn't stand.  The child was taught the
importance of keeping family secrets, supporting the positive
value of repression.  The girls all had a very unpleasant first
sexual experience, either rape or molestation.  Sibling rivalry
was intense but never recognized or dealt with by the parents. 
The adolescent years were full of conflict with the parents, so
the child ran away from home, the girl to get married, the boy
to the military.  The girls usually married a mate unsuitable
for anyone, sadistic, unfaithful, alcoholic, and so on.  None
finished college, although several bright ones got within one
year of graduation.  The men showed marked job instability
because of intervening arrests and imprisonment.  Still they
were very talented at what they did and could always get another
job.

On examination of the patient, who will most frequently be
female, you might notice the glistening, smooth texture of the
face.  This is because she never stays in one personality long
enough to develop wrinkles.  When she gets depressed, she
switches to her fun loving one and looks happy.  There might be
a number of recently healed longitudinal scars from the wrists
to the antecubital fossae on both forearms.  If you have samples
of the patient's handwriting over a period of time, you might
find three different hand writings on the same page, as the
subject matter changes.  If the patient is very unstable, she
might switch right in front of you, talking in one voice, with
one facial expression for a while; then the eyes close for 30
seconds and, on opening, you note a totally different
expression.  The demeanor may change from one appropriate to a
ten year old school girl to an 18 year old seductress, all in a
30 year old body.  Or you might have been seeing the patient for
some time and one day she comes in and announces she has another
name and can tell you all about "your patient" since she herself
needs no psychotherapy but "she", the other one, certainly does.
Those are the easy kind.

There is a spot midway between the eyebrows which is very
sensitive in multiples.  If you touch one there, she may switch
personalities, or at least get mentally upset.  For some reason,
this is a trigger point which the therapist can use to help the
patient make a switch when desired.  

Laboratory tests are usually not helpful.  An
electroencephalogram should be done to rule out temporal lobe
epilepsy.  One multiple showed EEG abnormalities at the start of
treatment and symptoms of physical imbalance improved on
diphenylhydantoin.  At the end of therapy, her EEG was
completely normal.  Another patient had a normal EEG but
symptoms of psychomotor epilepsy.  She was totally controlled on
diphenylhydantoin and relapsed into a severely depressed,
confused state whenever she stopped it.  However, when her
demanding, asthmatic daughter left the home, she stopped the
drug without incident.  At the University of Kentucky, Dr.
Ludwig and his staff (Ludwig, et al, 1972; Larmore, et al, 1977)
have been finding that the visual evoked response on the
computer-analyzed EEG is different for each alter-personality. 
This has not yet been confirmed by any other experimenters but
is a promising approach to confirming clinical opinions.

Glucose tolerance tests may show both a hypoglycemic low and a
diabetic high.  These patients tend to be malnourished due to
poor eating habits, and then they exhaust themselves trying to
deal with their many problems.  A hypoglycemic diet can be
helpful in improving this state of affairs, if they will eat it.

On mental status examination, the first thing you may notice is
your own sense of incongruity between the terrible story the
patient tells you and her bland, composed appearance.  You just
can't believe this person could have gone through all those
awful experiences and come out with so little evidence of wear
and tear.  These people are great actors and actresses when it
comes to looking normal.  DON'T YOU BELIEVE IT.  THEY ARE NOT. 
They may appear very depressed or only complain of depression
without even looking sad.  It lakes a long time for them to
learn to be honest in expressing their feelings in physical
ways, such as with tears.  They think the therapist might not
like them if they show they are not doing just beautifully.  It
is very easy to underestimate the suicidal or homicidal danger. 
How to respond without giving too little or too much attention
to threats of violence is a most difficult judgment to make.  I
personally tend to underestimate the danger, and then they
arrive at the hospital emergency room brought in by family
members or police.  Then I know for sure that I cannot count on
them to control their own behavior for a while.

Also, they will act helpless and may want you to tell them how
to spend the next weekend.  But anything you suggest will be
ignored in favor of alcohol and pills.  They complain they have
no friends, yet you may get phone calls from their best friend
who wants to help them.  They attract friends easily, but drive
them away with their unpredictable behavior.  Eventually, they
do literally have no friends, except for sick spouses and
relatives.

Psychological testing with the usual battery of tests prior to
the clinical demonstration of alter-personalities has not been
very helpful to me.  It takes time to do any battery of tests
and the patient may shift from one personality to another in the
midst of the test, totally invalidating the results.  But I have
found a good predictor is the California Psychological Inventory
as computer interpreted by Behaviordyne, Inc. of Palo Alto,
California.  A colleague of mine, Mr. John Orfield, by analyzing
the CPI answers of 25 multiples, devised a scale which the
computer can now use to identify a multiple with 90% accuracy. 
Without this test, one can still pick out the suspicious ones,
by noting those described as highly hysterical, having an
hysteria scale of over 55, and with one of the preferred
diagnoses being dissociating hysterical personality disorder.

The use of hypnosis in diagnosis is primarily for finding out
what happened during amnesic periods.  While in trance, the
patient may become aware of the existence of the
alter-personality, see her, talk with her and know her thoughts.
This is terrifying to the patient and must be accompanied by a
very kind and supportive behavior on the part of the therapist. 
It is impossible for the patient to accept the reality of what
you see for some time after you are convinced of its
genuineness.  It is not wise to go too fast looking for more
entities.  Census taking is not your goal, therapy is.  All you
need to really know are the ones who are most dangerous at that
time, the ones that could kill the patient, her husband, or even
you.

I left until last the most important diagnostic factor - you,
the therapist.  Only if you realize the disease exists, will you
diagnose it. if you, like many, are afraid to find it, you never
will, as these patients are very sensitive to other's feelings
and never want to upset their therapist.  But if you are open
minded to the possibility of multiplicity, the patient will then
feed you the clues.  You will then have to apply the diagnostic
tests mentioned here to clear up the mystery of why those
strange things have been happening to your patient.  When you
understand the mental dynamics involved, working out the therapy
plan becomes much easier.  Then therapy can be initiated and
eventually the goal of personality fusion can be realized.

REFERENCES

Assagioli, R. Psychosynthesis.  New York, Viking Press, 1965.
Berne, E.  Games people play.  New York, Grove Press, 1964.
Larmore, K. , et al.  Multiple personality - An objective case
study.  British Journal of Psychiatry, 1977, 131, 35-40.
Ludwig, A. M. ,et al.  The objective study of a multiple
personality.  Archives of General Psychiatry, 1972, 26, 298- 310.
Mitchell, S. W . Mary Reynolds: A case of double consciousness. 
Transactions of the College of Physicians of Philadelphia