The implication that the change in nomenclature from “Multiple Personality Disorder” to “Dissociative Identity Disorder” means the condition has been repudiated and “dropped” from the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association is false and misleading. Many if not most diagnostic entities have been renamed or have had their names modified as psychiatry changes in its conceptualizations and classifications of mental illnesses. When the DSM decided to go with “Dissociative Identity Disorder” it put “(formerly multiple personality disorder)” right after the new name to signify that it was the same condition. It’s right there on page 526 of DSM-IV-R. There have been four different names for this condition in the DSMs over the course of my career. I was part of the group that developed and wrote successive descriptions and diagnostic criteria for this condition for DSM-III-R, DSM–IV, and DSM-IV-TR.While some patients have been hurt by the impact of material that proves to be inaccurate, there is no evidence that scientifically demonstrates the prevalence of such events. Most material alleged to be false has been disputed by someone, but has not been proven false.Finally, however intriguing the idea of encouraging forgetting troubling material may seem, there is no evidence that it is either effective or safe as a general approach to treatment. There is considerable belief that when such material is put out of mind, it creates symptoms indirectly, from “behind the scenes.” Ironically, such efforts purport to cure some dissociative phenomena by encouraging others, such as Dissociative Amnesia.
Among DID individuals, the sharing of conscious awareness between alters exists in varying degrees. I have seen cases where there has appeared to be no amnestic barriers between individual alters, where the host and alters appeared to be fully cognizant of each other. On the other hand, I have seen cases where the host was absolutely unaware of any alters despite clear evidence of their presence. In those cases, while the host was not aware of the alters, there were alters with an awareness of the host as well as having some limited awareness of at least a few other alters. So, according to my experience, there is a spectrum of shared consciousness in DID patients. From a therapeutic point of view, while treatment of patients without amnestic barriers differs in some ways from treatment of those with such barriers, the fundamental goal of therapy is the same: to support the healing of the early childhood trauma that gave rise to the dissociation and its attendant alters.Good DID therapy involves promoting co­-consciousness. With co-­consciousness, it is possible to begin teaching the patient’s system the value of cooperation among the alters. Enjoin them to emulate the spirit of a champion football team, with each member utilizing their full potential and working together to achieve a common goal.Returning to the patients that seemed to lack amnestic barriers, it is important to understand that such co-consciousness did not mean that the host and alters were well-­coordinated or living in harmony. If they were all in harmony, there would be no “dis­ease.” There would be little likelihood of a need or even desire for psychiatric intervention. It is when there is conflict between the host and/or among alters that treatment is needed.
The case of a patient with dissociative identity disorder follows:Cindy, a 24-year-old woman, was transferred to the psychiatry service to facilitate community placement. Over the years, she had received many different diagnoses, including schizophrenia, borderline personality disorder, schizoaffective disorder, and bipolar disorder. Dissociative identity disorder was her current diagnosis.Cindy had been well until 3 years before admission, when she developed depression, "voices," multiple somatic complaints, periods of amnesia, and wrist cutting. Her family and friends considered her a pathological liar because she would do or say things that she would later deny. Chronic depression and recurrent suicidal behavior led to frequent hospitalizations. Cindy had trials of antipsychotics, antidepressants, mood stabilizers, and anxiolytics, all without benefit. Her condition continued to worsen.Cindy was a petite, neatly groomed woman who cooperated well with the treatment team. She reported having nine distinct alters that ranged in age from 2 to 48 years; two were masculine. Cindy’s main concern was her inability to control the switches among her alters, which made her feel out of control. She reported having been sexually abused by her father as a child and described visual hallucinations of him threatening her with a knife. We were unable to confirm the history of sexual abuse but thought it likely, based on what we knew of her chaotic early home life.Nursing staff observed several episodes in which Cindy switched to a troublesome alter. Her voice would change in inflection and tone, becoming childlike as ]oy, an 8-year-old alter, took control. Arrangements were made for individual psychotherapy and Cindy was discharged.At a follow-up 3 years later, Cindy still had many alters but was functioning better, had fewer switches, and lived independently. She continued to see a therapist weekly and hoped to one day integrate her many alters.
Treating Abuse Today (Tat), 3(4), pp. 26-33Freyd: I see what you're saying but people in psychology don't have a uniform agreement on this issue of the depth of -- I guess the term that was used at the conference was -- "robust repression."TAT: Well, Pamela, there's a whole lot of evidence that people dissociate traumatic things. What's interesting to me is how the concept of "dissociation" is side-stepped in favor of "repression." I don't think it's as much about repression as it is about traumatic amnesia and dissociation. That has been documented in a variety of trauma survivors. Army psychiatrists in the Second World War, for instance, documented that following battles, many soldiers had amnesia for the battles. Often, the memories wouldn't break through until much later when they were in psychotherapy.Freyd: But I think I mentioned Dr. Loren Pankratz. He is a psychologist who was studying veterans for post-traumatic stress in a Veterans Administration Hospital in Portland. They found some people who were admitted to Veteran's hospitals for postrraumatic stress in Vietnam who didn't serve in Vietnam. They found at least one patient who was being treated who wasn't even a veteran. Without external validation, we just can't know --TAT: -- Well, we have external validation in some of our cases.Freyd: In this field you're going to find people who have all levels of belief, understanding, experience with the area of repression. As I said before it's not an area in which there's any kind of uniform agreement in the field. The full notion of repression has a meaning within a psychoanalytic framework and it's got a meaning to people in everyday use and everyday language. What there is evidence for is that any kind of memory is reconstructed and reinterpreted. It has not been shown to be anything else. Memories are reconstructed and reinterpreted from fragments. Some memories are true and some memories are confabulated and some are downright false.TAT: It is certainly possible for in offender to dissociate a memory. It's possible that some of the people who call you could have done or witnessed some of the things they've been accused of -- maybe in an alcoholic black-out or in a dissociative state -- and truly not remember. I think that's very possible.Freyd: I would say that virtually anything is possible. But when the stories include murdering babies and breeding babies and some of the rather bizarre things that come up, it's mighty puzzling.TAT: I've treated adults with dissociative disorders who were both victimized and victimizers. I've seen previously repressed memories of my clients' earlier sexual offenses coming back to them in therapy. You guys seem to be saying, be skeptical if the person claims to have forgotten previously, especially if it is about something horrible. Should we be equally skeptical if someone says "I'm remembering that I perpetrated and I didn't remember before. It's been repressed for years and now it's surfacing because of therapy." I ask you, should we have the same degree of skepticism for this type of delayed-memory that you have for the other kind?Freyd: Does that happen?TAT: Oh, yes. A lot.