A Patient with Dissociative Identity Disorder 'Switches' in the Emergency Room

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.