November 1998, Vol. XV, Issue 11
Dissociative identity disorder (DID), known as multiple personality disorder until renamed in the DSM-IV (American Psychiatric Association, 1994), is a controversial diagnosis. Many highly regarded clinicians (Putnam, 1989; Ross, 1989) have built careers working with patients they believe to have DID. Other distinguished practitioners consider DID to be a bogus diagnostic tag.
McHugh (1992) argues vigorously that hysteria--what he sees as the DID patient's more or less unconscious effort to appear more significant to others and to be more entitled to their interest and support--along with the current social canonization of the victim, accounts for the fanciful behavior of those who claim to have multiple identities and personalities.
Merskey (1992) believes that the rise in DID diagnosis can be traced to the influence of the 1957 book The Three Faces of Eve and other books and films about DID, as well as the uncritical embracing of the DID diagnosis by a large number of mental health care professionals. He claims he could not identify a single uncontaminated DID case originating in a defensive response to trauma, the mechanism classically thought to underlie DID.
McHugh, Merskey and other critics of DID all essentially agree that the behavior named by this diagnosis is socially learned behavior. Highlighting the interaction of patient and culture, Merskey sees DID behavior as the manufacture of madness. Focusing on the role of the mental health care profession in this mislearning, McHugh calls the diagnosis a psychiatric misadventure (McHugh, 1992, 1995; McHugh and Putnam, 1995).
Perhaps some patients-but probably not most given this diagnosis-experience a trauma-induced, psychodynamically based dissociation and fragmentation of feeling, thinking and behavior sufficient to allow coalescence around two or more distinct identities. (DSM-IV bases diagnosis on behavior; the meaning of this behavior often remains unclear and unspecified.) Whatever the origin of their dissociated behavior, those who meet criteria for DID have frequent exacerbations of their symptoms, and they often come to the emergency room in crisis.
Nadine, age 23, acted in a way consistent with the supposition of dissociated identities to a greater degree than any other patient with whom I have worked. (How Nadine came to act this way and what her actions meant is ultimately unknown.) This was the third time I had been asked to see her in the ER. She was sitting on a royal blue mattress in the seclusion room, watched and comforted by a female technician who had a particularly gentle way with patients.
Nadine seemed to be holding court, alternately speaking English and Russian, a language she later told me she had studied seriously. Her speech was rapid and pressured, loud and emphatic. Much of what she said was intelligible, some was not. She wrote in a notebook as she spoke, making bold strokes that produced lines and, occasionally, a few words. Nadine was childlike in appearance and manner-short, slightly built, with short brown hair and thick glasses that seemed too big for her sharp-featured, feral face.
Nadine had come from the oncology unit upstairs. Proudly, she flashed a hospital badge with her picture and the word Volunteer printed in bold, black letters. She had two reasons for coming to the ER. She needed prescriptions for paroxetine (Paxil), trazodone (Desyrel) and levothyroxine (Synthroid); her psychiatrist was not due back from vacation for two weeks, and she had only enough medication for six days. The second reason was because, as she put it, the children started coming out. These children, as far as I could tell, were several of the more immature facets of her identity-the alters-who tended to cause trouble for the major identity, Nadine (a name she chose, not her legal first name).
Whoever was speaking for the ensemble of labile identities constituting the consciousness of this patient, ostensibly Nadine, gave an agreeable and often cogent interview. Much of what she said made sense, but some of what she said did not and was clearly bizarre. Both the cogent and the bizarre were put forward with equal conviction, making me think she could not distinguish one from the other.
Nadine was hyperalert, knew who she was (i.e., Nadine), the name of the hospital and the date. Her speech was rapid, had a stop-and-start quality and was loud with poor modulation. Asked about her mood, she said she felt sad, but denied any disturbance of sleep or appetite, weight loss, anhedonia, psychomotor retardation (she had been agitated earlier, most likely because of anxiety, but was relatively calm during the interview), extended disturbance of daily routine (she had come to us directly from her volunteer work) or thoughts of being better off dead. She denied any intent or plan to hurt herself or anyone else. She insisted that her father had abused her physically and sexually.
Four months earlier, Nadine had been discharged from a state mental institution following a one-year stay. She lived in a group home for two months after that, but was asked to leave when the staff could no longer provide the attention she needed (to control the children, she said, referring to the immature alters). Currently, she was living with a female friend.
Nadine told me she wanted to get the prescriptions for her medication and go home. She assured me she could manage on her own. She denied any history of alcohol or substance abuse (the toxicology screen was negative). Her physical health was currently good, she said, though she did have asthma and was taking Synthroid for hypothyroidism.
Almost parenthetically, Nadine let it be known that while she was in a bathroom just a few feet from the seclusion room a man shoved garbage up me. I did not take her claim literally, though I repeated the remark to a physician assistant, who immediately said No to her own unspoken thought of doing a pelvic examination.
When I finished the interview, I spoke with the ER attending physician, who agreed the patient could be given the prescriptions she asked for and discharged. We were busy that evening, and Nadine had to wait for me to write follow-up orders for her discharge form and for the attending doctor to sign it. She sat on one of the high stools that ring the nurses' station, taking her place among several of the ER staff, talking confidently with them.
When I brought her the discharge form to sign, Nadine repeated what she said during the interview about garbage being inserted into her while she was in the bathroom. When I did not respond, she quickly become agitated and refused to sign the form. You promised to help me with this, she said, not saying who made the promise. Later, she insinuated it was the technician who had spoken to her in the seclusion room.
Agitation quickly gave way to hysterics. The patient (whatever facet of her dissociated, fractured identity was paramount now, possibly not Nadine) was screaming, and drawing the attention of the ER staff, as well as other patients being evaluated or waiting to be seen. In a few seconds, she went from what appeared to be a composed young woman (Nadine?) to a hysterical child, (one of the children who started coming out just before she came to the ER? Or, alternatively, simply an hysterical adult), screaming that we were not giving her the attention she needed and was promised.
When Nadine left the ER area, she was followed by a male technician, and wandered past the radiology waiting room. She then started down a hall leading to the south hospital. She was clearly out of control now, but eventually took our suggestion to go back to the waiting room. She refused several chairs in the empty room, choosing instead to sit in a corner, legs pulled up, head down. After about 15 minutes, she was calm enough to coax back to the seclusion room.
Having seen part of this display, the ER attending insisted that Nadine be admitted to the hospital's psychiatric unit. Loudly objecting, she became agitated again and said she wanted to go home. I suggested we wait to see if she would regain her composure, and then reevaluate. But the consensus was for admission, and I did not disagree strongly enough to pursue the point.
Nadine called her therapist from a phone at the nurses' station, and spoke intently for some time. I went back to the office to work on my report, which had to be finished before she could be taken upstairs to the psychiatric unit. Then I got a call from Nadine's therapist, who told me that as far as she was concerned, Nadine had been certifiable all week; that Nadine sometimes did insert objects into her vagina; and that she would fight being hospitalized tooth and nail.
On the chance that the patient (whoever she was now-Nadine or one of the children) might have become more rational in the half-hour it took me to finish writing the report, I decided to ask her to sign herself into the psychiatric unit voluntarily, hoping to save the extra time and labor involved in the certification process. She was sitting in a chair just a few feet down the hall from the office, talking to a young male patient who was sitting on a gurney, legs over the side. In the few seconds I had to survey the situation, it seemed they were communicating rationally and happily.
I will sign a voluntary, she said before I could get a word out, anticipating my request. I just need a day or two in the hospital. I don't want to cause any trouble. Nadine was back, or so it seemed.
Two days later, I called the attending psychiatrist who accepted Nadine into the inpatient unit. The gynecology department had been asked for a consult. A gynecologist did a pelvic examination and removed a quantity of debris from her vagina that could have come from an ER bathroom wastebasket.
During an ER visit several months earlier, while she was waiting to be seen, Nadine had specifically asked for a female attending physician to take out objects that, she said, had been placed in her vagina by a hostile alter. A 10-inch piece of rubber tourniquet hose, a bent straw and a tampon that Nadine said had been soaked in bleach were removed. She later told me that the hostile alter who put these objects into her vagina was also trying to poison her by mouth. Up here I have control, she said, pointing to her mouth. Down here, indicating the genital area, she implied that her control was tenuous.
During this visit, Nadine's claim that a man shoved garbage up me first struck us as a delusion. Considering the history of physical and sexual abuse by her father, and following the DID dynamic model, one could ask whether a hostile alter (a part of her consciousness not under her control) may have reenacted her father's original violation. In her panoply of dissociated identities, where the father's trauma was not integrated into the structure of one personality, could one alter have taken on the role of the intrusively violating parent? Alternatively, could Nadine, deceiving herself, have done what her culture and the mental health care professionals she worked with told her that a hostile alter of someone with DID would be expected to do?
Many mental health care professionals who believe in the DID diagnosis insist the main personality (for this patient, Nadine) is a borderline personality. Taken as one person and one identity, Nadine does come off as thoroughly borderline. Indeed, some who do not acknowledge the validity of the DID diagnosis claim that DID patients are really just severe borderlines. But clearly, even borderline patients who are very labile do not have emotions and behaviors that coalesce around strikingly different identities to the extent of many patients diagnosed with DID, including Nadine.
If someone with DID can ultimately be considered borderline, he or she must be seen as a very different kind of borderline-perhaps one with hysterical features severe enough to warrant the diagnosis of hystrionic personality disorder.
In the attempts to distinguish one mental disorder from another, a point is sometimes reached when the notion of diagnostic specificity itself is pushed to the limit. This may be the time to quit trying to fit a patient's symptoms to one set of diagnostic criteria or another so that the more fundamental question of why a patient's life is being lived as it is-i.e., the meaning of the pathological behavior-can be asked more directly and concretely.
Dr. Muller works for the Crisis Intervention Service at Union Memorial Hospital in Baltimore, Md. His books include The Marginal Self: An Existential Inquiry into Narcissism (1987), Alembics: Baltimore Sketches, Etc. (1992) and Anatomy of a Splitting Borderline: Description and Analysis of a Case History (1994). His most recent book, Beyond Marginality: Constructing a Self in the Twilight of Western Culture, has just been published by Praeger.
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