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EVERYTHING YOU ALWAYS WANTED TO KNOW ABOUT MULTIPLE PERSONALITY BUT WERE AFRAID TO ASK Prepared for Presentation at the Marin County Psychiatric Society April 1982 by Ralph B. Allison, M.D. Retyped August 1988 During a ten year span of clinical psychiatric practice, I had the opportunity to treat and observe over 60 patients, both male and female, who demonstrated the presence of both primary and alter-personalities. All were considered to possess the basic characteristics of the histrionic personality disorder (formerly the hysterical character disorder). However, their clinical pictures did not necessarily follow that portrayed in DSM III (1). They showed the basic pattern described by Tupin (2) of an exaggeration of either male or female stereotypical social behavior. They also showed, when tested on the Minnesota Multiphasic Personality Inventory or the California Psychological Inventory, the preference for the psychological defense mechanisms of denial, repression and dissociation. Their management of hostile impulses was handled by dissociation prior to any actual acting out behavior. DEFINITION OF THE DISORDER PER DSM III 1. The existence within the individual of two or more distinct personalities, each of which is dominant at a particular time. 2. The personality that is dominant at any particular time determines the individuals behavior. 3. Each individual personality is complex and integrated with its own unique behavior pattern and social relationships. INCIDENCE OF THE DISORDER The true incidence in the population is unknown but studies at NIMH currently underway by Frank Putnam, M.D. will give more accurate data than is currently provided by the currently popular method of counting the reported cases in the literature. One experiment in Finland by Kampman (3) showed that, of mentally healthy high school students, only 8% could create an alter-personality under hypnosis with specific instructions on how to do it. Therefore, one could speculate that 8% of the population might have the capacity to dissociate to the degree necessary to manufacture such entities. This figure may or may not apply to the mentally ill population. However, case finding by Kluft (4) in Philadelphia, among chronically suicidal patients in long stay hospitals and groups of non-improving outpatients has shown multiplicity to be frequently present as the reason for the lack of progress in treatment. In his series of 70 cases treated, 73% were female and 27% were male. In my cases, 80% were female and 20% male. In the subsample of cases seen primarily for legal evaluation, 75% were male and 25% female. PSYCHOPATHOLOGY 1. The unconscious mental defense mechanisms of denial, repression and dissociation are used as the primary means of dealing with unpleasant stimuli, instead of more socially appropriate learned coping methods. 2. Instead of physical means, mental methods are used to deal with both physical and emotional trauma, at least in the initial phases of the period of trauma. Hateful thoughts towards abusers are preferred to physical actions, such as striking back or running away from home. 3. Hostile attitudes and feelings must be dissociated, cannot be "owned," due to parental injunctions such as, "Thou shalt not hate me, your parent, while I have the right to beat you up." 4. The prime or original personality creates a "persecutor" alter-personality for the purpose of first handling anger, then for the feelings related to sexual abuse. Then a "rescuer" alter-personality must be created, followed by an organizer of the inner forces, an entity I have christened the "Inner Self Helper" or ISH (5). 5. If the first alter-personality is created before the age of eight years, an additional type of alter-personality is created, the "false front." This alter-personality may assume all of the social functions and duties of the original personality, which then remains "inside the mind" frozen in emotional development at the age of the first dissociation. There may be a series of false front personalities during childhood, as each one becomes incompetent to handle progressively more complicated duties. This alter-personality is very fragile and can splinter into any number of alter-personalities (third generation fragments or ego states), often numbering between 10 and 50. In contrast, if the first alter-personality is created after the age of eight, the primary personality remains in charge. In those cases seldom will more than six alter-personalities be found to have ever been created. ETIOLOGY 1. Psychological: The prime defect seems to be a failure of the primary personality to learn by experience, a defect which leads to antisocial behavior over a long period of time, unchanged by punishment or the direct results of the misbehavior. 2. Social: Traumas in the family may include being unwanted by at least one parent, sexual and physical abuse by a parent or a parent substitute, polarized parents, mandatory secrecy of family problems, unresolved sibling rivalry and youthful marriage to a sadist (in the case of females). 3. Physical: These individuals appear to have nervous systems which are hypersensitive to the "vibes" of other persons, so that they can easily perceive the emotions of others around them, especially the negative ones. They are then very much influenced by the moods of those around them. Such persons are "emotional albinos." 4. Moral: Prior to therapy, they have not decided whether to be good or bad persons. The formation of alter-personalities is their method of demonstrating the moral ambivalence without developing a true sense of guilt, which might inhibit the acting out. CLINICAL PICTURE 1. Symptoms which are most prominent at the start of therapy are depression and amnesic spells, during which suicide attempts may be made. Physical complaints may include severe headaches, backaches, colitis, stammering, convulsions, alcoholism, drug addiction and sexual dysfunction. There are usually reports by family members and friends of complicated social behavior during amnesic spells, such as the taking of long trips, renting motel rooms, making dates and entering into illegal or immoral activities with other individuals. The hearing of accusatory voices inside the head may be admitted, if the patient is questioned in a non-threatening fashion. 2. Signs may include an incongruity between the atrocious history which is obtained and the calm, unweathered facial and bodily appearance presented by the patient. Longitudinal scars on the forearms may be present from repeated self-mutilations. Rarely is the spontaneous switching of personalities seen on an initial interview. If it does occur, that is, of course, the basic clinical requirement for the diagnosis. The patient, in such a situation, may suddenly act like a young child, or becomes very seductive or violent. Patients with multiplicity usually have a sensitive spot in the middle of the forehead which, when touched by the therapist, will facilitate the switching from a hostile to a helping alter-personality. LABORATORY TESTS 1. The MMPI and the CPI (when interpreted by the Behaviordyne, Inc. computer program), usually will show a high hysteria score (over 55) and the diagnosis of dissociating hysterical personality disorder as one of the preferred diagnoses. 2. Rorschach test findings, per Wagner's criteria (6), may be the most reliable test results, regardless of the differences between responses of the different alter-personalities. Wagners' five guidelines indicate that a goodly number of movement responses must be present, at least two of the movement responses must be qualitatively diverse, at least one of the movement responses must reflect a feeling of being oppressed, there should be at least three color precepts and at least one color percept should be "positive" and another "negative." 3. Neurophysiological evaluations at NIMH have so far shown definite differences between patients and normal subjects, but variations between patients are too great to allow any one test to be a reliable indicator of the diagnosis (Putnam, personal communication, 1982). Specifically, "the visual evoked potential component differences among the alternate personalities of individuals with Multiple Personality Disorder are significantly greater than among the simulated alternate personalities of normal controls. This was noteworthy on the evoked potential component, P-100, previously associated with individual differences in personality. obsessive-compulsive alternate personalties of individuals with MPD show the same amplitude differences that obsessive-compulsive patients do." USE OF HYPNOSIS IN MAKING THE DIAGNOSIS In non-forensic cases, hypnosis is usually needed to confirm or deny the diagnosis when there is a suspicious history. But the hypnotic examiner must be completely open minded and looking only for the true explanations for the patient's amnesia or strange behavior. The examiner must not suggest that some other entity might be responsible. A recent amnesic episode about which the patient is anxious can be an excellent place to start the exploration for the truth. Recall of the time just before that episode, with recitation of events leading into the amnesic period and a reliving of the feelings occurring at the start of the episode, can be a powerful trigger for activating the already existing alter-personality which was responsible for that particular episode. In California, as of April 1982, hypnosis is forbidden in forensic cases, since any witness who has been hypnotized during the investigation of the crime will be considered to be subsequently giving "tainted" testimony. Any approach to a criminal defendant who is suspected of being a multiple will have to be in a manner which avoids the appearance of inducing hypnosis. If the patient reports an internal voice talking to him/her, the examiner may ask the patient to talk out loud to that voice, while in a light, self-induced trance. The instructions might include, "Go back to just behind your eyeballs, so that you two occupy the same space. Then talk to the source of that voice out loud so that I will know what you are saying." Sometimes the; examiner will get exactly what is asked for, but sometimes the alter-personality will come out to object to the examiner doing anything at all, giving the examiner an excellent chance to interview the alter-personality. DIFFERENTIAL DIAGNOSES 1. Play Acting or Conscious Simulation: This would be unlikely: in a non-legal case but exposure to a genuine multiple and questions by a patient as to whether or not the therapist thought the patient was a multiple would be suspicious signs in a questionable case. Genuine multiples strongly deny that they might have such a disorder and would rather have an organic disease to explain their symptoms. Yet, some actors and actresses may be dissociating in the course of playing historical roles or character parts, but they have no amnesia. The distinction may be unclear between the disease of multiplicity and the mental state of the over-involved character actor, except for the absence of amnesia and the ego syntonic reason for the personality changes. 2. Unconscious Simulation: Just as anyone with the need and histrionic character traits can unconsciously mimic any physical symptom, as in a conversion disorder, so can a histrionic patient mimic a multiple, if previously exposed to a genuine multiple, as might occur in a psychiatric hospital setting. The difference would be in the lack of a history of amnesias or sudden personality changes and the lack of symptoms meeting specific psychological needs, such as the management of anger. The course of the illness would differ in that "fusion" of the "alter-personalties" would occur only when the secondary gain is accomplished, not with effective psychotherapy. 3. Dissociation After Arrest: In legal cases, some degree of dissociation may be suspected during a crime spree by an otherwise non-criminally oriented defendant because the defendant seemed to be playing two roles for a period of time. One role might be the good worker and family man during the day, and the other role would be the fiendish, sadistic rapist at night. Upon arrest, the defendant would claim at least some degree of amnesia, such as the lack of recognition of some of the victims. Yet there was no witnessed history of amnesic spells or personality changes in childhood or early adulthood. Upon arrest and the sudden confrontation with such revolting illegal activity, the defendant may, with any suggestion at all, create a psychic entity which accepts responsibility for the crimes, uses another name, ridicules the defendant and is the very embodiment of evil itself. Yet there is no solid evidence that this entity existed prior to the arrest, and it never appears in jail after sentencing, if at all. The psychiatric examiner may quite naturally assume that this evil entity did indeed exist at the time of the crime spree, yet it may have only been a part of the defendant's mental apparatus when the crimes occurred, only to split off under hypnosis when the psychiatrists were called in by the defense attorney. At that point, the defendant, who may have had retrograde amnesia for his ego dystonic crimes, unconsciously allows this evil portion of his mind to crystallize into an entity which confesses for him. When he is confronted with this entity on videotape, he is able to let 'him' take the emotional responsibility for the crimes and provide him with the basis for an insanity plea, which is rarely successful. After conviction, this entity disappears, never to be seen in prison, without the benefit of formal psychotherapy. 4. Spirit or Demonic Possession: In most of the world outside of the USA, spirit possession is considered a reality and a more likely explanation for the presence of alter-personalities than is any psychological diagnosis. In the USA, public opinion polls indicate that 40% of the population believe in spirit possession and 5% believe that they, themselves, have been possessed at some time in the past. Sixty percent do not believe in possession as a reality. Therefore, if the examiner, who most likely sides with the majority, finds entities who claim to be demonic, under the control of archdemons, and with no point of psychological origin, he/she has a real problem in making a psychiatric diagnosis. One option is to call this state an Atypical Dissociative Disorder called The Possession Syndrome. This can be defined as a state of mind in which the patient has no conscious belief in possession (which would be considered a delusion by the skeptical majority), but shows evidence of an unconscious belief in being possessed by entities from a supernatural source. The patient's behavior is determined by the form these beliefs take in his/her mind. Since it is highly unlikely that any two persons will agree as to just what it is like to be possessed, there is no typical clinical picture. The only common thread is the belief in being possessed by evil entities which come from outside. It would be expected that cultural stereotypes will be used in creating the details of the experience of being possessed. TREATMENT 1. The Goal: The long term goal of treatment is personality integration so that only one personality inhabits the body thereafter. This goal is supported by the view that what has actually happened is personality splitting or disintegration, not the creation of truly separate entities who need to be taught to share time in the body. If the therapist's goal is that teaching time sharing is best, this indicates an ill trained and unimaginative therapist. A comparison to surgery is appropriate. The therapist should do all he/she can, with the patient's assistance, to put the pieces all back together again. If the therapist cannot, only then should he/she help the patient to learn to live with the condition. But the therapist should try all he/she can to cure the basic defect first, and the defect is in the lack of unity within the mind. The basic method for doing that is to have the patient recall to consciousness all of the traumatic situations which have led to the dissociations. The presently active primary personality must become aware of the feelings generated by those traumatic events and must accept those feelings as naturally occurring and his/her own. With the help of the therapist and the inner Self Helper, the primary personality must replace hostile feelings with neutral or positive ones, thus eliminating the need for an alter-personality to act out in a destructive fashion. Each patient will demonstrate a unique style for accomplishing this goal. 2. The Plan; Personality integration appears to follow the following steps. They are not necessarily sequential, but usually overlapping. Details can be found in my article (7). a. Recognition of the existence of the alter personalities: The patient must be fed back all of the data which the therapist receives which indicates who the alter- personalities are, what they do and why they exist. b. Intellectual acceptance of having multiple personalities: The patient comes to accept, on a superficial basis, the truth of what the therapist is showing and telling him/her, even though he/she does not really believe the information deep down. This allows the psychotherapy to begin, usually utilizing age regression under hypnosis, with sequential review of the causes of the creation of the negative alter-personalities. c. Coordination of alter-personalities: The therapist must assign duties, if necessary, to helper alter-personalities in such areas as suicide prevention, child care, work and marriage, so that all life sustaining functions are maintained while therapy proceeds. d. Emotional acceptance of being multiple: This comes about as the result of some incident which no one could have possibly staged for the patient's benefit, an event which convinces the patient of the accuracy of what the therapist has been trying to get across for some time. This marks the turning point from the patient grudgingly cooperating in treatment to a whole hearted commitment to becoming one, no matter the cost. e. Elimination of persecutor alter-personalities: The alter- personalities which are activated by hostility and aggressive sexuality are the most dangerous ones and, therefore, should be first on the therapist's list for neutralization. After psychotherapy reveals their origins, various imagery methods can be used to either reform such entities into helpers or to eliminate them entirely from the patient's psychic structure. For each persecutor alter- personality, there may be one rescuer alter-personality, which will then have nothing to do and will disintegrate from disuse atrophy. f. Psychological fusion: When all of the persecutor alter-personalities have been neutralized, all of the resultant fragments will come together automatically. In the case of a patient with over 10 personalities, clusters of personalities may fuse prior to the grand integration, thus removing the casualties from the scene of battle. As two or more alter-personalties become more alike In function and attitudes, they may fuse spontaneously. These partial fusions will leave those un-neutralized alter-personalities to the attention of the therapist, so that he/she need only focus on those still active. g. Spiritual fusion: When all of the alter-personalities have blended together, in whatever way the patient may do this, the primary personality, or a new version thereof, will co-exist with the Inner Self Helper, who will then function primarily as a mental teacher. In the months following the psychological fusion, the ISH will be teaching principles of healthy living to the primary personality. When all of these lessons have been learned, and there is no essential difference between the two in thought patterns, they become one, in a quiet spontaneous process. h. Post-fusion experiences: After fusion, the patient usually feels that he/she will never again have problems. The reality is that the problems the patient now faces are modern versions of those the patient, as a child, mishandled by creating alter-personalities. Now the patient has a second chance to use newly learned coping skill in dealing with those old problems. Another major experience the patient may have is the experiencing of normal emotional reactions to making good decisions regarding major problems. Patients usually believe that they will always feel good if they have make the right choice in a difficult situation. But now the patient feels miserable after having made the correct decision, since the previous ambivalence could not be maintained. The patient may be surprised to learn that to gain something, one may have to lose something else. In the process of this loss, pain is felt. MORBIDITY Multiplicity is not a self-limited disease. once initiated, an alter-personality can well continue to exist into old age, and several patients over 50 years of age have been treated by the writer. In the process, they can well exhaust parents, spouses, children, employers, friends, physicians and anyone else who has ever cared for them. Suicidal acting out may be viewed by others as only an attention getting device, but, for the patient, he/she often wants to die. Survival is possible because of the inherent ambivalence manifested by the rescuer alter-personalities. Children can be abused, mentally and physically by an alter-personality who does not consider herself to be the mother of the children. Individuals who really do physical harm to these patients may, if not natural parents, be victims of serious physical assault or even murder by an alter-personality who believes it is protecting the patient from death. About 80% of the marriages of multiples in treatment ended In divorce after the patient improved, since the spouse was now sicker than the patient, and no recovered patient wants to stay married to a disturbed mate. In my series, there were many suicide attempts but only one successful suicide, that one being due to desertion of the patient's husband after she had left therapy, which was incomplete. One other patient was declared a suicide by the coroner, after fusion, but all evidence pointed to the possibility that the patient was accidentally killed trying to settle a fight between two men in the house. one patient died of unknown caused, with no clarification at autopsy. A number of patients were involved in homicidal acts. One patient reported killing her stepfather and his two friends after they had tried to kill her. One male multiple killed his wife with no more reason than that she nagged him one time too often. One male killed a lone woman after raping her and then killed a man after they had had homosexual activity together. After treatment, which varied in length from one week to three years, averaging 18 months, most of the patients moved from the location of treatment, where they were too well known to the helping agencies, to other towns where they were not known. There they have faded Into anonymity, leading quiet and very average lives. REFERENCES 1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorder, Third Edition, Washington, DC, APA, 1980 2. Tupin, J. Psychiatric Grand Rounds, UC Davis School of Medicine, Sacramento, CA, Jan. 1981 3. Kampman, R. Hypnotically induced multiple personality: An experimental study. International Journal of Clinical and Experimental Hypnosis, 1976, 24, 215-227 4. Kluft, R.P. varieties of hypnotic interventions in the treatment of multiple personalities. American Journal of Clinical Hypnosis, 1982 ,in press, 5. Allison, R.B. A new treatment approach for multiple personality. American Journal of Clinical Hypnosis, 1974 17, 1 5- 3 2 6. Wagner, E.E. & Heiss, M. A comparison of Rorschach records of three multiple personalities. Journal of Personality Assessment, 1974, 38, 308-331 7. Allison, R.B. A rational psychotherapy plan for multiplicity. Svensk Tidskrift for Hypnos, 1978, 3-4, 9-16