|Dual Personality, Multiple Personality,
Dissociative Identity Disorder - What's in a Name?
When I diagnosed my first case of MPD in 1972 (Janette in "Minds In Many Pieces"), I had had no professional training on the subject. I went to the Stanford Medical Library to look up articles on the subject since no computerized databases existed then. The book called "Index Medicus" was the only place one could start searching for published articles. There I found the listing of "Dual Personality."
In the 1970s, when I started meeting with other therapists of "multiples" (the term we all came to use for patients with MPD), we informally agreed to call the disorder "Multiple Personality Disorder" or MPD for short. I wrote to the editors of the Index Medicus to ask them to add Multiple Personality Disorder to the subject headings, and they did that.
At that time, a small group of us therapists were struggling with these patients, and we created our own networking methods. I published a newsletter, "Memos On Multiplicity," for one year as my way of trying to let such therapists know where fellow adventurers in this field were.
Eventually, the interest moved from the solo practitioner's office to the academic halls of learning. Some practitioners had teaching appointments in graduate schools where their opinions about MPD were not always greeted with acceptance. After all, the accepted dictums stated that people only were allowed one personality per body. Anyone claiming to have patients with two or more personalities had a difficult task convincing those in academia that such was possible.
This conflict of views between those therapists dealing daily with dissociated patients (some exhibiting dozens of alter-personalities, or "alters") and academic teachers who spent more of their days teaching and doing research than actually treating severely ill patients, came to a boil with the need to revise DSM III.
DSM I (Diagnostic & Statistical Manual of Mental Disorders, Version I) was created after WWI to provide a framework for labeling post-war psychiatric causalities. DSM II was written after WWII for the same purpose. Remember, these were written in the USA by American psychiatrists. However the same terms were accepted by the editors of the International Code of Diseases (ICD) through its present 9th edition.
When I met my first multiple, DSM II was in use. MPD was then a minor label under "Hysterical Dissociative Disorder." It did not even have its own code number.
DSM III was created while I was in the middle of my practice years. It recognized MPD as existing, gave it a code number, and defined its characteristics. We who treated these patients finally had found a degree of acceptance in officialdom. "If it is listed in here, it must exist."
Then the backlash began. There had always been doubters that such a disease really existed, and my struggles with critics are chronicled in "Minds In Many Pieces." Personally, I had withdrawn from public debates on the matter to deal with private matters, so I only know indirectly about the political battles behind the scene during the formulation of DSM IV, the current edition.
The field of "Dissociative Disorders" now had its own section. A committee of experts was appointed to decide what disorders should be listed in DSM IV. It was hoped that DSM IV would also be the psychiatric section of the new ICD-10, then in progress.
The committee was composed of two groups, psychiatrists whose primary role was as therapists and those whose primary roles were teaching and research. The therapists wanted to keep MPD much as it was in DSM III. The teachers wanted to eliminate MPD altogether, and replace it with "Dissociative Identity Disorder" or DID. I heard one of these teachers say in public, "Everybody is born with only one personality. Therefore, there can be no such thing as a Multiple Personality Disorder."
With this belief system, the teachers could not agree that MPD could be an accurate label for anyone. The treaters on the committee did not know how to explain that, in practice if not in theory, their patients acted as if they had other personalities. The teachers decided that the patients had the major mental problem of believing that they had more than one personality. The goal of therapy should not be integrating the various personalities, but getting the patients over their false belief (delusion) that they had other personalities at all. (Since I was not present for the deliberation, these ideas are only reasonable conclusions from what I heard from others who were there and position statements published about the debate.)
So the patients still had a problem, but it was redefined as a different problem than the one their therapists were treating them for. Instead of therapists trying to integrate "alters" into an original personality, they should now focus their attention on the patients "delusion" that they did not have a single identity. Now the teachers expected the treaters to treat the patients' "identity disorder," as no one could really have multiple personalities.
When the decision was reported out of committee, the teachers had won, and MPD suddenly ceased to exist. Now all our multiples had Dissociative Identity Disorder or DID.
However, the editors of the ICD did not accept DSM IV as their section on Mental Disorders. In the newest printing of ICD-9, they did add "Dissociative Identity Disorder" below MPD as a synonym. So, in the world outside the USA, MPD still exists. Only in the USA have all multiples been told they have a false belief that they have alters running their bodies.
But I know that, in the case of MPD, the patient's Original Personality (yes, teachers, the only one they have) goes "into hiding" at the time of a life threatening assault before the age of seven. Therefore, there is "no one home" to have the Disorder of Identity. The Original Personality is the only one capable of having such a "false belief," but she is not in executive control of the body or participating in social life at all. But the Allisonian ISH I met in these patients had created all sorts of alters to run the body in the absence of the Original Personality. Therefore, I could not honestly give up the accurate label of MPD and substitute an inaccurate label of DID.
But, I had met other dissociating patients who were of the "dual personality" type. They had never shown an ISH, and they manifested far fewer alters. Could I apply this new label to them? Yes, I decided I could.
So, personally, I came to realize that both MPD and DID can be considered accurate labels, but for two different groups of dissociators. Here is how I now use these acronyms in my writings.
The key differentiating criteria is the age of the first dissociation, with the seventh birthday being the approximate cut-off point for MPD, and the earliest date for DID to appear. This is the age the child's mind must mature to so that it can "hold it all together" when severely traumatized. After age seven, it may dissociate and form alters, but it will not dissociate into its two component parts, the Intellectual Self (ISH/Essence) and the Emotional Self (Original Personality).
The concept that the human mind originally consists of two parts is not a clear part of American/European psychological theory. Root words to express this concept do not exist in European languages. Again, "if we don't have a word for it, maybe it doesn't exist."
But I learned from my foreign friends that root words for these two parts of the mind do exist in Middle Eastern and Oriental languages. My favorite is Japanese, which calls the Intellectual Self the "Risei" and the Emotional Self the "Kanjou." The Japanese recognize that we are constantly switching from being controlled by our Kanjou and being controlled by our emotions, to letting our Risei take over to solve our problems rationally.
In TV "literature," the same story is repeatedly played out by "Mr. Spock" on the original Star Trek series. Leonard Nemoy played the role to the Intellectual Self very well. He sounds close to the way the ISHs talked to me when I was doing therapy with multiples. In "Star Trek, The Next Generation," Lt. Cmd. Data, an "android," plays the same role. In one show, he shows what happens when emotions are added to his brain with the insertion of a new chip, which makes him able to emote for the first time.
Now, after learning how dissociation occurs in a human before age seven, I realized that all humans have a bipartite mind (not to be confused with a two-hemisphered brain). When the mind is integrated, as is the usual case, it might be analogized as a coin with two faces, Heads and Tails. The Emotional Self (Kanjou) is the Tail side and the Intellectual Self (Risei) is the Head side. Normally, we are operating somewhere between 99% intellectually and 99% emotionally. Both are there, ready to be used. Neither one is good or bad. How much we use of which one depends on the situation and the goal we have at the time.
To avoid unwarranted assumptions, I wish to note that, for trauma to split (dissociate) the Risei from the Kanjou, it requires certain preconditions to be present. Just being traumatized before age seven will not always cause the child to develop MPD. In other types of people, in different settings, the same trauma may cause other types of psychopathology. The situation is not that simple.
Yes, there must be life threatening trauma before the age of seven for anyone to develop MPD. But another condition is that the Emotional Self (aka Birth Personality, Original Personality, Kanjou) must be Grade V hypnotizable on the Stanford Scale. The ability to age regress by revivification is a trait needed to qualify one for being in Grade V. This ability is invaluable in participating in effective therapy.
Grade V hypnotizability is a characteristic of the Emotional Self and is a trait given to it at birth. This trait is accompanied by other characteristics, such as psychic abilities, exquisite sensitivity to the emotions of others, fantasy proneness, flamboyance, and "hysterical" traits of all kinds.
In women, this may be seen as typical hysterical female behavior (pardon the sexist connotations). In men, the same traits may be seen as antisocial behavior. In American society, girls learn to internalize their problems, and boys learn to externalize them. So women with MPD tend to develop emotional and physical problems, while the men tend to act out antisocially.
Another factor needed to bring about MPD is polarization of the parents, the usual caretakers of infants. One parent is seen by the child as good and the other as bad. What often happens is that the parents flip from role to role. But if the parents are together in matters of discipline, MPD will not be likely to occur. Usually one parent is the primary abuser, while the other one screams or deserts. The non-abusive one does not rescue the child or the damage could have been reversed.
The other factor needed for MPD is polarization of the siblings. This child must be the only one in the family to be abused. This child was seen as "different" from the other children, and therefore somehow "deserving" of abuse the other children did not get. "Equal Opportunity Abuse" is bad enough in its own right, but it creates in the children a different clinical picture.
So, in our view, MPD is still a valid diagnosis for a clinical picture, but it requires these preconditions:
1. Life threatening trauma before the age of seven. (Minor trauma is not enough. The child must fear for his or her life.)
2. Grade V hypnotizable Emotional Self.
3. Polarized parents - one good and one bad.
4. Polarization of siblings. Only this one is abused. The others are treated decently.
What does this produce clinically?
The first effect is dissociation of the Intellectual Self from the Emotional Self. The Intellectual Self (aka Essence, Risei) then sends the Emotional Self (aka Original Personality, Kanjou) into hiding somewhere in Thoughtspace, so the Original Personality abdicates executive control over the physical body.
The Essence takes on the role of Inner Self Helper (Damage Control Officer) and has to go to work making the first False-Front Alter-Personality to run the body. The ISH designs and programs all alters to do whatever is necessary to keep the child alive.
Each alter is designed to do a job and only that job. It is endowed with characteristic traits which the Original Personality would have taken on, if it were in charge. The situation can be viewed as operating a doll factory, with only the outfits of clothes being produced. The doll, itself, is not present. The alters are the sets of clothes, but there is no doll inside any of them. Therefore, they cannot grow and change. They can only do what the ISH has programmed them to do.
There is no way that this condition can be called "Dissociative Identity Disorder." There is no Original Personality to have any disorder. The ISH is busy making alters to run the body. The Original Personality has been removed from executive control. There are multiple personalities alternating control of this body, awaiting the end to the abuse and the arrival of a therapist who can work with the ISH to bring the Original Personality back in charge. This is truly MPD.
So, when is DID an appropriate diagnosis? When the trauma occurs after the age of seven to a highly hypnotizable person. Then there is no dissociation of the Intellectual Self from the Emotional Self. The Emotional Self (aka Original Personality) is still in charge and available to have an Identity Disorder.
The social situation is different, as the child is now often out of the parental home and in school. The abuser is often someone outside the birth family. The trauma situation need not be long lasting or life threatening, more likely some situation the child was too immature to cope with. One of my cases of "dual personality" was created by the rape at age 9, by a cousin. The girl created an angry female alter who became a prostitute. She used sex to humiliate and control men, like her Original Personality had been humiliated by her cousin. This woman could well be said to have a Dissociative Identity Disorder.
Treatment would be effective if she, the Original Personality, learned better ways of handling sexually abusive men and other humiliating situations. She would need to learn better ways of coming to grips with the sexual conflicts she had. If she succeeded, her prostitute alter would become obsolete and might "die" of disuse atrophy. This clinical course is much different from that seen with someone who had MPD, as we have defined it here.
To provide you with the official definition of DID, here is what it says in DSM IV:
300.14 Dissociative Identity Disorder (formerly Multiple Personality Disorder)
The essential feature of Dissociative Identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due to the direct physiological effects of a substance or a general medical condition (Criterion D). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play.
Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, one at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations.
Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may be gradual. The number of identities reported ranges from 2 to more than 100. Half of reported cases include individuals with 10 or fewer identities.
In my first case of MPD, I was introduced to a psychic entity who was normal, all knowing of personal history, and helpful to me in doing therapy. After I had met similar entities in other severely dissociated patients, I came to call it the Inner Self Helper or ISH. By following psychologically integrated patients for several decades, I learned what the ISH does after the disorder is corrected. It then prefers to be called the Essence of "my charge," another name for the Intellectual Self, Kanjou, or Hidden Observer of Hilgard at Stanford University. It has many useful functions. As a matter of fact, without it present, the person is in need of life support systems.
But, during therapy of a patient with MPD, by my definition, the ISH is a highly necessary co-therapist to any ethical therapist, no matter how talented in psychotherapy. The ISH observes and intervenes on the inside while the therapist attends to matters on the outside. Between the two of them, effective therapy can be done in a much shorter time. In my most complicated case of MPD, it only took me three years of twice a week therapy to achieve integration of 70 alters into the Original Personality. With the time limitations of the public clinic in which I worked, only because of the guidance of the ISH did I get the integration done the day before I departed that employment. Therefore, I highly recommend therapists of true MPD patients should be happy to meet the ISHs in their patients and listen to what they have to say. Not to do so is like the surgeon ignoring the advise of his hospital's radiologist and laboratory pathologist.
Characteristics of the Inner Self Helper (ISH)
A. Prime Directive of the ISH is to keep patient alive until her Life Plan is completed and fulfilled. The ISH will prevent suicide in any way possible.
B. Has no date of origin; has always been present.
C. Can only agape love; is incapable of hatred.
D. Has awareness of and belief in "The Creator."
E. Is aware that the Celestial Intelligent Energy (CIE) put her in charge of teaching this person how to live and move forward properly.
F. Is able to work on the inside of the patient's mind, as co-therapist, while the human therapist works on the outside.
G. Knows all about history of patient and can predict short term future.
H. Possesses no personal sense of gender identity, but will assume either gender the therapist is comfortable with.
I. Talks intellectually instead of emotionally, carefully chooses precise words, speaks in short concise sentences; prefers to answer questions; gives enigmatic instructions. ("Teach her humility today.")
J. Avoids using slang; does not have the capacity for put-downs or guilt-trips.
K. Is aware of patient's past lifetimes.