MPD/DID - Education: History & Research

Multiple Personality Disorder History and Research

I completed the following senior thesis for my Theory and Systems class for my major in Psychology. The following sections correlate to the outlined format my professor wanted. The paper was written in 1997, so the "Current Research" section covered 1991 through 1997.

Historical Perspectives
Contemporary Persepctives
Recent Research
Overall Compare and Contrast Patterns, with Evaluation
References
DSM Criteria: Version III, III-R, and IV for MPD/DID
The Dissociative Experiences Scale (DES)

Historical Perspectives

Multiple Personality Disorder (MPD) and dissociation are two problems that have been addressed since the founding days of psychology as an independent science. The two problems were often thrown into the melting pot of symptoms which made up hysteria, or incorrectly labeled as somnambulism (sleep walking). In the late 1800's, three major theorists in psychology, who were leaders in their own early school of psychology, began to focus on dissociation and MPD. These were the functionalist, William James, the psychoanalytical Sigmund Freud, and Alfred Binet who was in a group known as the early experimental psychologists. Morton Prince's work is often mentioned by Binet, Freud, and James. Although he is fairly unknown today, his work has been found to be highly insightful and supported by the current research in the field.

William James believed that psychology should study the mental life, which he said included the stream of consciousness brought forth by experiences. To him, studying dissociation and MPD provided key information concerning the mental life in the rest of the population. James believed that all people had 'selves' which had different functions, desires, and activities. He often referred to examples such as the social self, the spiritual self, and the family self. What unified all these selves, which he stated were often in conflict and power shifts, was the feeling of ownership in regard to the stream of consciousness. To him, cases of MPD proved this belief, yet were abnormal because the stream of consciousness was affected (Heidbreder, 1993). James explained that normal people have a stream of consciousness that links together the memories and separate parts of the self. In abnormal people, such as those affected by MPD, dissociation of ideas creates different streams of consciousness that do not span across these different parts. He further states in the psychology textbook that he published, entitled The Principles of Psychology (originally published 1890), that in order for the states of personality to change so thoroughly, so abruptly, and with different memories, that the well-organized association paths in the brain must change and develop along with the alter states. He proposed that this physiologically affected neurological path model explained how different alters could be present at the same events, or be unaware of events that were occurring to other alters.

Sigmund Freud and Josef Breuer co-authored Studies on Hysteria (originally published 1895), in which they addressed dissociation and MPD as subsets of hysteria. Breuer's infamous patient, Anna O, was diagnosed as having MPD and her case sparked Freud's interest in the workings of MPD. Together, Breuer and Freud wrote that trauma which involved extreme emotional content was the cause of MPD and dissociation. Unlike James, they believed that dissociation of ideas that were inadmissible to the consciousness of the primary self created a splitting of the mind. Freud believed this because he thought that splitting of the consciousness was impossible. He pointed to the fact that an alter self could recall the information that was inaccessible to the primary self to prove that the information was still in the consciousness somewhere. Freud went on to say that the alters were defined by what memories they held that were inadmissible to the complete consciousness. He called for abreaction done with the assistance of hypnosis in order to bring those memories back into complete consciousness as the cure for MPD and dissociation. Breuer and Freud also brought forth the idea that alters could affect each other without direct contact, such as through emotional and memory leakage.

Alfred Binet wrote Alterations of a Personality (originally published 1896) in which he focused solely on MPD and dissociation. Binet witnessed and conducted research done MPD and dissociative patients, including tests of memory, hypnotizability, autonomic writing, and differences between alters' handwriting, speech, and intelligence. From this research he noted that there was a stable base of symptoms that linked MPD patients. First, he noted that each alter had characteristics that differentiated them from another alter. These included: memory recall; the state or disposition; and the state of sensibility, movement, mental capacity, and physical differences or problems. Some similarities he found in early cases were: headaches, loss/shift in appetite, body pains from psychological sources, being highly hypnotizable, experience loss of time and memory, and different pain thresholds for different alters. Binet felt that studying MPD and dissociative patients provided much information because "they magnify the phenomena that must necessarily be found to some degree in the case of many persons who have never shown hysterical symptoms" (89). Binet agreed with Freud and Breuer on the belief that different alter states could affect and interact with each other, either directly or indirectly. He felt that something more 'profound' than associationism must be working in the mind due to dissociation occurring even with frequently occurring memories or memories with strong affect/emotional content (269). According to Binet, the process of dissociation was creating different consciousnesses, which could be identified by character and memory.

Morton Prince published his book concerning MPD and dissociation, called The Dissociation of a Personality (originally published 1905). His cases are important not only because they offer information about MPD and dissociation, but they also offer an early cross-cultural study of these phenomena. Prince was much like James in his belief that studying cases of MPD offered knowledge about the normal functioning of the human mind. Prince noted that the alters had distinct characteristics, including different trains of thought, views, tastes, habits, memories, ideals, and temperaments. He argued that the term double or multiple personality should be changed to "disintegrated" personalities. For Prince, each of the alters merely made up the whole, normal self, which had undergone a process of the personal ego breaking apart. Prince stressed that this was a process of disintegration and separation, and not degeneration or destruction. Furthermore, he made the distinction that MPD patients were not insane, but "functionally dissociative" with their "elementary psychical processes" remaining normal. In addition, he said that since nothing was being destroyed in the process of dissociation, that the alters were "capable of being reassociated into a normal whole"(3).

Contemporary Perspectives

Ross (1989, 1997) and Duncan (1994) trace the history of MPD for the years of 1910 through 1980. Both authors see this as a time in which dissociation and multiple personality disorder fell from interest and research due to several concurrent factors. Duncan refers to this time as when the field reached its full maturity and then experienced an unfortunate decline, so severe that dissociation and MPD were eliminated almost completely.

First, the authors point to the changes within the schools of psychology as a cause of the rapid decline. Pavlov's theory and research on learning and conditioning ushered the behavioral movement to the foreground. This school of psychology repressed the study of dissociation and MPD as being irrelevant, unnecessary concepts. Furthermore, Freud broke away from Breuer and repudiated their earlier theory that childhood sexual trauma was the foundation and cause of hysteria. He insisted that the reports of incest and child abuse were really incestuous dreams and desires that women were having, which fit in to his theory of psychosexual development. In addition, Freud also took the stance that hypnosis was not a treatment modality.

Another cause of the great decline was the rise in attention given to schizophrenia. As Ross cited Rosenbaum's 1980 research on the issue, from 1914 to 1926 there were more diagnoses of MPD than schizophrenia. In the late 20's and early 30's, Rosenbaum says that the diagnosis of schizophrenia "caught on." He says this is due to the field becoming more physiological and biological in focus. A sign of this pattern was found by Hilgard (1987), as cited by Ross. Hilgard points out that 20 abstracts concerning dissociation and MPD appeared in Psychological Abstracts from 1927 to 1936, eight from 1937 to 1946, two from 1947 to 1956, and only three abstracts from 1957 to 1966. Duncan states that two MPD patients with the same symptoms would most likely be diagnosed schizophrenic or hysteric during this time frame.

Ross cites an article published by Taylor and Martin in 1944, in which the patterns found in 76 patients with MPD from the US, France, Britain, Germany, and Switzerland were analyzed. They found that 49 of the subjects had dual personalities, and that only six subjects had five or more alters. They claimed that the causes of MPD could be head injury, fatigue, intoxication, unbalanced urges, and excessive learning and forgetting. At that time, no mention of trauma surfaced in their study.

In the 1950's a personal account of MPD was published, and turned into a popular movie. The Three Faces of Eve appeared to present a rare case to the public eye, and some felt that Eve was the only living case of MPD at that time. Duncan recounts being instructed in graduate school in the late 60's that MPD was extremely rare, usually caused by incompetent therapists and attention seeking patients, and probably something many psychologists would never encounter directly.

An important psychologist hit the scene in the 501s as well, yet received little acknowledgment at the time for his work. George H. Estabrooks began to study the early literature that seemed to have been forgotten. Through his studies of Binet, Janet, Prince, Sidis and Goodhart, Estabrooks began to publish articles concerning hypnosis, trances, and MPD. Unlike the other psychologists who were also beginning to realize the vast amount of information that they had lost over the years, Estabrooks included Studies of Hysteria by Freud and Breuer into his library. He began to talk about trauma and its role in dissociation. Furthermore, in his 1957 edition of Hypnotism, Estabrooks presents case histories in which W.W.II personnel were placed through rigorous techniques in which MPD was artificially created. In order to facilitate infiltration and other top secret, dangerous operations for the government, the subjects were submitted to months of intensive conditioning, training, and hypnosis. One reason Ross feels that Estabrooks is very important to the field is the fact that he shows that iatrogenic MPD can occur. In contrast to the image of an overzealous, inadequate therapist with a suggestible, eager-to-please patient, Estabrooks stresses that the creation of MPD took an extreme amount of control, time, intent and effort.

The next major time period ranges from the 1970's to the 1990's in which dissociation and MPD began to be studied and taken seriously as their own entities once again. This period is marked by the publication of Hilgard's Divided Consciousness (1977). This book brought dissociation back to the research forefront. Two social influences that helped the resurgence were the attention to Post Traumatic Stress Disorder (PTSD) after the Vietnam War, and the attention to child abuse that the Women's Movement brought forth. The publication of Sybil in 1973 helped the public see not only the patient, but also the therapist, deal with MPD.

In 1980 the Diagnostic and Statistical Manual of Mental Disorders (DSM) III officially considered Multiple Personality Disorder to be a diagnosis in the field of Psychiatry and Psychology. During this time the amount of literature on the field greatly increased. Trauma, especially childhood abuse, began to be looked at once again as the cause of the dissociation and MPD. In 1984 the first major conference on MPD was held in Chicago by the International Society for the Study of Multiple Personality and Dissociation (ISSMP&D). This society continued, and in 1994 was renamed the International Society for the Study of Dissociation (ISSD). In 1983 and 1984 major journals published special issues on MPD, which Ross cites: American Journal of Clinical Hypnosis, International Journal of Clinical and Experimental Hypnosis, Psychiatric Annals, and Psychiatric Clinics of North America.

Researchers began to notice that Freud and Breuer had been correct in their hypothesis that trauma was the cause of MPD and dissociation. More research began to appear to illustrate that. For example, Hilgard published a second edition of Divided Consciousness in 1986. In that edition, Hilgard says that MPD was an effort to cope with a very difficult childhood. Hilgard also pointed out that "violent and excessive punishment, overt sexual assaults in childhood, unbalanced parental roles, one parent occasionally sadistic, the other rather passive and aloof" (40) occurred very frequently in the childhood history reports of MPD patients.

In 1988, the leaders in the field of MPD were Bennett Braun and Richard Kluft. In addition to the large amounts of literature they produced, they established the first dissociative disorders psychiatric unit and the first journal devoted exclusively to dissociative disorders, entitled Dissociation. In 1989 two books for clinicians were published concerning the diagnosis and treatment of MPD, which marked the field coming back full circle as an important division of psychology.

Recent Research

Currently, the field of dissociation and MPD has no lack of research. In my search of the Psychological Abstracts from 1991 to 1997, there were over 400 abstracts listed under MPD/DID alone. I have chosen to focus on the articles that deal with MPD/DID, and have more than 5 subjects. This has narrowed my scope of recent research down to 56 articles. I have arranged them into the following categories:

Those research articles that focus on:
-The Continuum of Dissociation (3)
-General Information and Treatment of MPD (9)
-Beliefs of Mental Health Care Professionals on MPD (3)
-Cross-Cultural Studies (7)
-Tests and Measurements for MPD (11)
-Comparative Studies (9)
-Secondary Aspects of MPD (7)
-Rarities in MPD (7)

The idea that dissociation runs along a continuum, with some forms of dissociative disorders being higher or lower on the continuum, is one that has been researched in the past few years. Colin Ross and his associates interviewed 166 people who were diagnosed with MPD and 57 people who had the diagnosis of Dissociative Disorder not otherwise specified (DDNOS). They found that there seemed to be a spectrum of dissociation, with increased complexity and symptoms related to increased severity of childhood trauma (Ross & Anderson et al., 1993). Ira Brenner also came to the conclusion that there was a continuum of dissociation and defensive altered states after interviewing and reviewing 100+ cases of suspected MPD (1994). Research done in 1996 by Waller, Putnam, and Carlson also indicates that the dimensional and typological models of dissociation that use the idea of a continuum are supported by research. They applied taxometric methods for distinguishing typological from dimensional constructs to the Dissociative Experiences Scale (DES) data gathered from 228 MPD and 228 normal subjects. The taxometric findings suggest that there are 2 types of dissociative experiences which can be empirically justified. They label these two forms as pathological dissociative experiences, which are manifestations of a latent class variable, versus nonpathological, which is a dissociative trait.

There have been a number of studies done to find general traits of MPD and information about the treatment process involving MPD patients. Loewenstein and Putnam compared the clinical history, phenomenology, symptom profile, history of violence and the involvement with the criminal justice system of 210 male and 128 female MPD patients. They discovered that both groups had extensive childhood abuse histories of sexual and physical abuse. The men tended to have more alcoholism and antisocial behaviors. The men also showed more subtle MPD clinical presentations and fewer alters than the female group of subjects (1990). Ross studied 484 general adult psychiatric inpatients over a two year period, excluding those who had previous diagnosis of MPD. He administered the DES to all subjects, and the Dissociative Disorders Interview Schedule (DDIS) to subjects that scored above 20 on the DES. The results indicate that MPD is relatively common in inpatients, affecting at least 5% of the individuals admitted (Ross & Anderson, et al., 1991). Ross also interviewed 102 MPD patients across 4 centers using the DDIS to study the prevalence of abusive childhood histories. Sexual abuse was reported 90.2%, physical abuse 82.4%, and both were reported by 95.1% of the subjects. Over 50% said the abuse started before the age of five, and the average duration was ten years, with several perpetrators. Ross concludes that MPD appears to be a response to chronic trauma during childhood (Ross & Miller et al., 1991). Philip Coons reviewed the case files and medical files of 31 child and adolescent psychiatric inpatients and outpatients and found that 18 subjects were found to have DDNOS or MPD and documentation of abusive childhoods (1994). A study of 305 various mental health professionals showed that individual psychotherapy facilitated by hypnosis was uniformly endorsed as the primary treatment modality for MPD clients. Adjunct drug therapies with antidepressants and antianxiety medications were also highly supported (Putnam & Loewenstein, 1993). Anne Mills surveyed 46 private practitioners who offered art therapy on an outpatient basis for MPD patients and found that most of the subjects felt that treating MPD was a clinical specialty. The practitioners were both primary and adjunct therapists, and often met with the client once a week. They used art to help with pacing, containment, managing chronic suicidal tendencies of the clients, and enhancing self-efficacy of the client (1995). Richard Kluft compared 31 MPD patients in treatment with ten MPD patients just entering treatment along 12 dimensions of therapeutic progress. He found that MPD patients are far from uniform in their response to treatment, even in cases where the nature, orientation, and experience of the therapist are constant (1994). Latz, Kramer, and Hughes conducted a study done on 175 women admitted to a state hospital over a 5.5 month period and found that those who met the DES and DDIS criteria for MPD scored significantly higher on the DES, and were younger than the non-MPD group. They also found that there was no difference in the length of hospital stay or admission status in the two groups (1995). Ellason and Ross studied the effects of integration after a two year period and found that integration provided the patient with significant improvements of scores on the self-defeating, borderline, anxiety, dysthymia, avoidant, passive-aggressive, and major depression scales of the Millon Clinical Multiaxial Inventory-II. They conclude that MPD presents with polysymptomatology yet much treatment progress can be achieved through the process of integration (1996).

A few studies have been conducted to see how mental health care professionals view MPD as a diagnosis. Dunn and his associates surveyed 644 psychologists and 456 psychiatrists and found that 97.5% believed in dissociative disorders, while 80% reported a belief in MPD, 12.3% did not believe in MPD, and 7.7% were undecided. Younger professionals with less experience in the field, as a whole, believed in MPD more than older, more clinically experienced professionals. Furthermore, those who had previous experience with MPD clients tended to be more accepting of MPD (1994). Hayes and Mitchell conducted a study on 207 mental health professionals and found that skepticism and knowledge about MPD are inversely related, with moderate to extreme skepticism expressed by 24% of the sample. They also found that MPD is diagnosed with less accuracy than schizophrenia and that the misdiagnosis can be predicted by the skepticism of the professional (1994). Francois Mai interviewed 180 Canadian psychiatrists in three cities and found that 27.8% doubted the existence of MPD and blamed the media and inept psychiatrists for the diagnosis of MPD. Again, younger psychiatrists were more likely to diagnose and believe in MPD, which the researcher says may be due to the introduction of MPD in the DSM-III (1995).

Cross-cultural studies have been done on the prevalence and symptomotology of MPD to try to validate MPD as a diagnosis in the psychological field. In Japan, 489 psychiatric inpatients over a five year period were interviewed and none of them met the DSM-III MPD criteria, although seven subjects who were diagnosed as schizophrenia claimed a change in identity. The disparity between the number of cases in Japan and the United States, according to Takahashi, may be due to very low incidence rates of child abuse in Japan, as well as their cultural emphasis on interdependence rather than self-dependence (1990). In Canada, a survey of 454 adults from the general population found that MPD related to childhood abuse affected about 1%, with 10% having a DSM-III-R dissociative disorder of some kind, and the lifetime prevalence of a major depressive disorder affecting 21.1% of the general population. Ross sees these figures to indicate that pathological dissociation is about as common as anxiety, mood and substance abuse disorders (1991). Martinz-Taboas found that Puerto Rican cases of MPD had striking parallels with those of Canada and the US, and concluded that MPD can emerge in a social and cultural setting quite different from that of the US. In addition, he states that the development and manifestation of MPD are dependent on some environmental and idiosyncratic personal characteristics, such as severe childhood abuse (1991). A survey of 770 Swiss psychiatrists found that 3% were currently treating one or more DSM-III criterion MPD patient at the time of survey, and 10% had seen MPD clients at some time before the survey. MPD appeared to be a rare yet genuine diagnosis (Modestin, 1992). The Dutch DES, Structured Clinical Interview of DSM-III-R Dissociative Disorders (SCIDD), and the Structured Trauma Interview were given to 71 patients. The results showed 94.4% had a history of abuse in childhood, 8.2 years in the mental health system before correct diagnosis, 80.6% criterion rate for PTSD diagnosis, and a history of past psychiatric or neurological diagnosis. Boon and Draijer believe that their data indicated that patients with MPD have a stable set of core symptoms throughout North America and Europe (1993). Tutkun, Vedat, and Yargic have done two studies with Turkish populations on MPD. Using the DSM-III-R criteria for MPD and the DSM-IV criteria for Dissociative Identity Disorder (DID, as the DSM-IV renamed and changed the criteria for MPD), they found that the median number of alters was four. Also, 85% of the subjects suffered from severe headaches, all subjects had at least one Schneiderian first ranked symptom, and 85% reported childhood abuse (1995). Using the DES and DDIS, they found further data that supports the belief that MPD/DID has a set of stable, consistent set of features throughout North America, the Netherlands, and Turkey (1996).

A number of tests have been studied to see how well they can help diagnose MPD and other dissociative disorders. The Questionnaire of Experiences of Dissociation (QED) was given to 18 people with MPD, 18 controls, 18 male alcoholics, and 15 patients with PTSD and substance abuse disorders. The QED correctly identified all of the MPD subjects as needing further screening, and only one of the alcoholics were incorrectly identified by the test (Dunn & Ryan, 1993). Coons and Fine tested the accuracy of the Minnesota Multiphasic Personality Inventory (MMPI) on 63 psychiatric patients and found that the test identified 68% of the MPD patients correctly (1990). Armstrong administered the Rorschach test to 14 subjects with MPD and PTSD and found that MPD subjects had more complexity, introspectiveness, and intellectuality of their responses (versus emotionality) than the PTSD group (1991). Labott, Leavitt, and Braun tried to replicate the study and found that the Rorschach was not a good indicator for MPD, but that greater diagnostic accuracy was obtained when using frequency of splitting and dissociative responses (1992). In 1994, 11 MPD subjects were matched with 22 controls and given the Rorschach and the Hand Test. The researchers found the combination to yield 91% correct MPD identifications with no false positives (Young, Wagner, & Finn). The DES has been tested numerous time to test the reliability and validity of the instrument as a way of identifying dissociative disorders and MPD. The test has been put through test-retest patterns and found to be internally valid with subject pools as large as 1,051 people (Frischholz & Braun et al., 1990; Carlson, Putnam, & Ross et al., 1993). The results have been put through ANOVA1s and Cronbach1s alphas and also proven highly valid (Dubester & Braun, 1995). The DES has also been tested and found to be very accurate in other countries, such as Puerto Rico with the Spanish version (Martinez-Taboas, 1995). In addition, other forms of the DES have been made due the high rates of success with the DES as a diagnostic tool. Studies have been done to show that the DES-II is just as accurate as the DES (Ellason & Ross et al., 1994). The DES was created for adults and a form was created to help asses children, called the Child Dissociative Checklist (CDC). A test was done with 131 children who fell into groups of normal, sexually abused, DDNOS, and MPD. The reliability and validity were checked through test-retest and one year test-retest measures, and found to be highly valid and reliable (Putnam, Helmers, & Trickett, 1993).

Another way researchers have been trying to prove that MPD does exist is by comparing MPD subjects against subjects with other disorders. It is not surprising that after decades of diagnosing MPD patients as schizophrenics that there is still research going on trying to see if there are differences between the two disorders. Ellason and Ross compared 108 MPD patients with 240 schizophrenic patients with the Positive and Negative Syndrome Scale (PANSS), which was developed to differentiate schizophrenic subtypes. They found that the positive symptom scores were more severe in the MPD group, while the negative symptom scores were more severe in the schizophrenic group. Consequently, depending on which end of the scale is being focused on by the diagnosing professional, misdiagnosis can occur for either diagnosis (1995). Steinberg et al., utilized the SCID-D as given by the DSM-IV, and found that it correctly differentiated the MPD subjects from the schizophrenic subjects (1994). Schneiderian first rank symptoms were also used to diagnose schizophrenia, but research has shown that MPD subjects present more Schneiderian symptoms than schizophrenics. A comparison of 1739 schizophrenics with 368 MPD patients found that schizophrenics averaged 1.3 symptoms, while MPD subjects averaged 4.9 (Ross & Miller et al., 1990). Lauer, Black, and Keen compared 14 MPD and 13 borderline personality disorder (BPD) subjects with the SCID-D, DES, and Beck Depression Inventory. The results showed considerable overlap, and the researchers conclude that possibly they are different aspects of the same disorder (1993). Fink and Golinkoff used the MCMI, MMPI, and DES to see if what differences could be seen between MPD, BPD, and schizophrenia. They found that MPD was differentiated from schizophrenia on most measures, but not from BPD on the MMPI or the MCMI. They stated that MPD and BPD could be differentiated by using clinical features, such as past history of physical and sexual abuse and dissociative experiences (1990). Boon and Draijer looked at the differences between DDNOS, MPD, BPD, and/or histrionic personality disorder. They found that severity of childhood abuse, defensive reactions, and dissociation symptoms were the greatest indicators for differentiation (1993). Ross, Fast, and Anderson compared the somatic symptom reports of MPD versus multiple sclerosis (MS) groups of subjects and found that MPD subjects reported an average of 14.5 somatic symptoms, while MS subjects averaged 3.0. They also found that MS subjects often reported muscle weakness and paralysis, while MPD subjects reports genitourinary and gastrointestinal symptoms (1990). A study done by Kluft in 1990 compared 20 therapists who had MPD with MPD patients and found that the therapists had fewer signs of psychopathology then the MPD subjects in general. Hughes compared trance channelers to MPD subjects with the DDIS and the DES and found that while the dissociative processes underlying both phenomena may be similar, etiology, function, control, and pathology all differentiate between the two groups (1992).

Some of the research in recent years has looked at how MPD may affect other aspects of life, or may appear through other clinical symptoms. Glover, Lader, and Walker-O1Keefe administered the Glover Vulnerability Scale to a group of inpatients and found that women with a trauma related diagnosis, such as MPD, scored high on this scale. Furthermore, the higher the exposure to trauma or childhood abuse, the higher the score on the scale (1995). Rossini, Schwartz, and Braun found no significant difference between MPD and DDNOS patients on the Wechsler Adult Intelligence Scale Revised (WAIS-R). They did find that a significant subgroup of the MPD subjects manifested abnormal interest scatter scores on the verbal subtests, which they indicate may be due to the memory/distractibility factor. In addition, they believe that this trend may show a need to evaluate MPD subjects for Attention Deficit Disorder (1996). Miller and Blackburn et al., compared 20 MPD subjects with 20 control subjects instructed to behave as if they were MPD on visual tests and discovered that MPD subjects experienced more differences across visual measurements (1991). Yank compared handwriting samples of different alters in MPD subjects and found that there was more variability between alters1 handwriting than would be expected in different samples given by the same person (1991). Artwork has also been evaluated to see if there were any differences to be found between MPD subjects and control subjects who were age regressed under hypnosis to the ages of 5, 9, 12, and 16. A comparison of the art samples found that MPD subjects showed greater diversity, with all six staged of artistic growth being represented in their art samples. This trend was not apparent in the control group, despite instructions to simulate art of that age group and the use of age regression hypnosis (Fuhrman, Zingaro, & Kokens, 1990). Barrett evaluated the dreams of 48 MPD patients and found that for most, the recovery of repressed memories was the most frequent dream activity. Also, alters appeared in dreams, alters could orchestrate the dream content, and sometimes alters even integrated in dreams (1994). Education problems of MPD subjects during grade school and throughout post-graduate school were investigated by Hobbs and Coons. The subjects reported severe dissociative symptoms usually on a daily basis beginning in grade school, which increased in severity over time. Also, many reported behavioral and conduct problems. Nearly all reported significant problems with school performance (1994).

The last category of research that has been done in recent years covers those aspects which do not occur frequently in MPD cases. Torem speaks of research done on eating disorders which found that five of the women who met the DSM-III-R criteria for anorexia nervosa or bulimia really had MPD, and that the eating disorder could not be alleviated until the MPD was dealt with (1990). Bergu et al., interviewed 44 women who were inpatients for eating disorders in Japan and discovered that nine met the criteria for MPD and six more were either MPD or PTSD (1994). Research has also been done with over 500 mental health professionals on the prevalence of diagnosing MPD and/or ritual abuse. No differences were found between ritual abuse or MPD diagnosis rates of Christian and non-Christian therapists (McMinn & Wade, 1995), or across disciplines or licenses (Bucky & Dalenberg, 1992). The effects of religious exorcisms has also been researched in recent years. Almost all of the subjects who had been exorcised reacted negatively, created new alters to deal with the exorcism, experienced PTSD and depressive symptoms following the exorcism, and felt their spirituality/religious fervor numb or cease (Fraser, 1993; Bowman, 1993). Hendrickson, McCarty, and Goodwin studied five women who had one of more alters that were animals. They traced the creation of these animal alters to childhood trauma involving the death, killing, or mutilation of animals, exposure to acts of bestiality, and being forced to live or act as if an animal. They suggest that therapeutic work with animal alters may be helpful and necessary in order to retrieve the underlying memories that lead to the creation of the animal alters (1990).

Overall Compare and Contrast Patterns, with Evaluation

Over the years the research on MPD and dissociation has remained fairly constant in a number of ways. Throughout the entire history of MPD and dissociation psychologists have questioned the validity of the two phenomena. Prince claimed that somnambulism was the underlying disorder for MPD and dissociation. Freud believed that MPD was a rare subset of the disorder hysteria. In the contemporary period, many believed that the diagnosis of schizophrenia was the problem, with MPD being a false entity. Currently, much research has been done comparing MPD subjects with other subjects with disorders including schizophrenia, borderline personality disorder, DDNOS, and histrionic personality disorder. The results of the current research show striking differences between the groups, indicating that MPD is a separate diagnosis and not merely a part of another disorder. Early psychologists lacked standardized tools to help them diagnosis MPD and dissociation. Today, the DES appears to be one of the most useful diagnostic tools available for practitioners. Other tests and measurements, such as the MMPI, the SCIDD, and the DDIS have all been found to be highly accurate and useful in the field. Further trends that have stayed throughout the years have been the set of clinical characteristics of MPD patients and the treatment modality preferred by mental health professionals. Binet noted that cases of MPD shared symptoms such as headaches and somatic symptoms. Freud and Breuer noted that cases of MPD appeared to be caused by childhood trauma. Current research by Putnam, Ross, Loewenstein, and Coons has supported these patterns. Freud and Breuer called for abreaction done with the assistance of hypnosis, while Prince spoke of “reassociation�? of the ideas and memories that had been dissociated. Current research shows that integration of alters provides significant improvements for the patient (Ross, & Ellason, 1996). A survey of mental health professionals also shows that most believe that hypnosis combined with psychotherapy to be the treatment method of choice for MPD and dissociation (Putnam, & Loewenstein, 1993).

There appear to be two trends that do seem to have faded over time. The first trend is trying to justify studying dissociation and MPD. James, Binet and Prince all suggested that the processes involved in MPD and dissociation needed to be studied in order to shed light on the normal human mind functioning. Freud and Breuer felt that the processes were pathological and occurred due to trauma. Current researchers seem to believe both; they accommodate for the normal and pathological levels of dissociation by the use of the Dissociation Continuum. It seems as though the problems of MPD and dissociation have reached a point in which they can be studied without fighting for the right to be taking up time in the psychological world. The other trend that has faded is the argument of whether MPD and dissociation are psychological, physiological, or a combination of the two. The problem of lacking the appropriate technological equipment to study the question is still a problem today. Although tests have been done to look at EEG1s and PET Scans in the late 801s, technology is still not able to answer that debate. For now, researchers seem content to focus on other factors. Another possibility for this trend fading may be the incredible amounts of research which point to the extremely high percentage of MPD cases involving severe early childhood abuse. This could be answer enough for many in the field.

The study of MPD and dissociation does not appear to have changed much through the years. It is sad that Freud and Breuer discovered such a huge element involved in MPD and dissociation, only to throw it away in the face of opposition. They were the first to truly stress that trauma in childhood had life-long ramifications. Binet and Prince both offered optimistic view points, believing that dissociation and MPD were functional, normal responses to abnormal factors. James believed that MPD was simply one step away from normalcy, and that the change in ownership of the stream of consciousness was the only thing that separated MPD from the normal functioning of the human mind. Furthermore, these early psychologists all noted past cases of MPD and found them to be consistent with the cases they were seeing. Now, a century later, the pattern continues. MPD and dissociation may seem rare, but they are not fake nor are they new phenomena.

References

Armstrong, Judith. (1991). The psychological organization of multiple personality disorder patients as revealed in psychological testing. Psychiatric Clinics of North America, 14, 533-546.

Barrett, Deidre. (1994). Dreams in dissociative disorders. Dreaming: Journal of the Association for the Study of Dreams, 4, 165-175.

Bergu, Douglas, Saito, S., Ono, Y., & Tezuka, I. et al. (1994). Dissociation and child abuse histories in an eating disorder cohort in Japan. Acta Psychiatrica Scandinavia, 90, 274-280.

Binet, Alfred. (1896/1903). Alterations of a Personality. New York: Appleton & Co.

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Diagnostic and Statistical Manual of Mental Disorders (DSM) Criteria

DSM-III Criteria for Multiple Personality Disorder: (Ross, 1989)
A. The existence within the individual of two or most distinct personalities, each of which is dominant at a particular time.
B. The personality that is dominant at any particular time determines the individual1s behavior.
C. Each individual personality is complex and integrated with its own unique behavior patterns and social relationships.
D. Two or more alter personalities must exhibit individually distinct and consistent alter personality-specific behavior on at least three occasions.
E. There is evidence of some type of amnesia or combinations of types of amnesia among alter personalities (e.g., one-way amnesia, mutual amnesia, etc.). the amnesia does not have to include all of the alters.

DSM-III-R Criteria for Multiple Personality Disorder: (Ross, 1989)
A. The existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring patterns of perceiving, relating to, and thinking about the environment and self).
B. At least two of these personalities or personality states recurrently take full control of the person1s behavior.

DSM-IV Criteria for Dissociative Identity Disorder: (Ross, 1997)
A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person1s behavior.
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

The Dissociative Experiences Scale (DES)

(Copied from The Ross Institute's Web Page)

The Dissociative Experiences Scale (DES) was developed by Eve Bernstein Carlson, Ph.D. and Frank W. Putnam, M.D. The overall DES score is obtained by adding up the 28 item scores and dividing by 28: this yields an overall score ranging from 0 to 100. The DES is posted on this Web page with permission of Dr. Putnam. It is in the public domain and can be copied and used without further permission.

DIRECTIONS
This questionnaire consists of twenty-eight questions about experiences that you may have in your daily life. We are interested in how often you have these experiences. It is important, however, that your answers show how often these experiences happen to you when you are not under the influence of alcohol or drugs.
To answer the questions, please determine to what degree, the experience described in the question applies to you and circle the number to show what percentage of the time you have the experience.
[Each question was followed by the direction to: Circle a number to show what percentage of the time this happens to you. An answer grid followed each question, which has also been removed to save space, of:
(NEVER) 0 10 20 30 40 50 60 70 80 90 100 (ALWAYS)]

1. Some people have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don't remember what has happened during all or part of the trip.

2. Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was said.

3. Some people have the experience of finding themselves in a place and having no idea how they got there.

4. Some people have the experience of finding themselves dressed in clothes that they don't remember putting on.

5. Some people have the experience of finding new things among their belongings that they do not remember buying.

6. Some people sometimes find that they are approached by people that they do not know who call them by another name or insist that they have met them before.

7. Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something and they actually see themselves as if they were looking at another person.

8. Some people are told that they sometimes do not recognize friends or family members.

9. Some people find that they have no memory for some important events in their lives (for example, a wedding or graduation).

10. Some people have the experience of being accused of lying when they do not think that they have lied.

11. Some people have the experience of looking in a mirror and not recognizing themselves.

12. Some people have the experience of feeling that other people, objects, and the world around them are not real.

13. Some people have the experience of feeling that their body does not seem to belong to them.

14. Some people have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event.

15. Some people have the experience of not being sure whether things that they remember happening really did happen or whether they just dreamed them.

16. Some people have the experience of being in a familiar place but finding it strange and unfamiliar.

17. Some people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other events happening around them.

18. Some people find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them

19. Some people find that they sometimes are able to ignore pain.

20. Some people find that that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time.

21. Some people sometimes find that when they are alone they talk out loud to themselves.

22. Some people find that in one situation they may act so differently compared with another situation that they feel almost as if they were two different people.

23. Some people sometimes find that in certain situations they are able to do things with amazing case and spontaneity that would usually be difficult for them (for example, sports, work, social situations, etc.).

24. Some people sometimes find that they cannot remember whether they have done something or have just thought about doing that this (for example, not knowing whether they have just mailed a letter or have just thought about mailing it).

25. Some people find evidence that they have done things that they do not remember doing.

26. Some people sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember doing.

27. Some people sometimes find that they hear voices inside their head that tell them to do things or comment on things that they are doing.

28. Some people sometimes feel as if they are looking at the world through a fog so that people and objects appear far away or unclear.

SCORING

(This is taken from the Ross site, and explains a bit about the scoring of this test. This is part of a much longer clinical paper concerning the DES and it's clinical validity.)

As reviewed in Chapter Six, the higher the DES score, the more likely it is that the person has DID. In a sample of 1,051 clinical subjects, however, only 17% of those scoring above 30 on the DES actually had DID (Carlson et al., 1993). The DES is not a diagnostic instrument. It is a screening instrument. High scores on the DES do not prove that a person has a dissociative disorder, they only suggest that clinical assessment for dissociation is warranted. This is how we report DES scores in our consults, as within or not within the range for DID, and as consistent or not consistent with the clinical and DDIS diagnosis of DID. DID subjects sometimes have low scores, so a low score does not rule out DID. In fact, given that in most studies the average DES score for a DID patient is in the 40s, and the standard deviation about 20, roughly about 15% of clinically diagnosed DID patients score below 20 on the DES.