Sybil exposed
As a work of investigative journalism, Sybil Exposed is simultaneously fascinating and appalling. Through the eyes of a psychiatrist, it is scathing and occasionally overreaching. The account of Sybil’s abuse at the hands of her mother does not hold up well in the light of Debbie Nathan’s investigation. The book is not a work of science, but the criticism of the absence of scientific basis for Sybil’s treatment is not significantly diminished for it. Nathan documents so many accounts of blurred personal, professional, and financial boundaries, suggestive interview techniques, and atypical prescribing methods (most with clear citations), that it would be difficult to accept Shirley Mason’s treatment as representing appropriate psychiatric care.
Despite the well-founded concerns, the book presents an overly literal interpretation of psychoanalysis and perpetuates inaccurate stereotypes about electroconvulsive therapy. Nathan gives little context to seemingly antiquated psychiatric practices relative to developments in other specialties of medicine, and makes little distinction between “antiquated” and “never appropriate.”
Furthermore, embellishments such as the statement that Shirley Mason “spent her free time half-zonked on mind-bending medications,”2 are less compelling than describing that she was prescribed combinations of barbiturates, opioids, and stimulants. The revelation that Shirley Mason’s symptoms were actually a result of pernicious anemia also seems like an incomplete explanation. The irony is that drawing a superficially reasonable conclusion despite limited evidence is exactly the complaint Nathan levels against those who uncritically accepted the story of Sybil.
Still, perhaps the books suggests the need for a more systematic look at not just the case of Sybil, but also the diagnosis of dissociative identity disorder (DID).
The DID “state of the union”: A divide between “us and them”
Although studies of the psychological sequelae of trauma are prominent in the literature, DID does not seem to be a common focus for most psychiatrists. Sadly, there is no shortage of significantly impaired patients with a range of trauma-related pathologies, but DID itself is rarely featured in scientific journals or conferences. However, the International Society of the Study of Trauma and Dissociation (ISSTD) has made DID a regular subject of discussion. Their publication, Journal of Trauma & Dissociation, recently published guidelines for treating DID in adults.3
The ISSTD guidelines (“Guidelines”) clearly address appropriate boundaries between patients and psychiatrists, discuss medications, and discourage suggestive interview techniques. If Sybil’s treatment ever represented anyone else’s approach, the Guidelines are clear that such actions (eg, suggesting alternate identities, naming identities) are at odds with modern standards.
Much of the remainder of the document, however, suggests a divide between psychiatrists who diagnose and treat DID regularly and those who do not. The Guidelines cite a prevalence rate for DID of 1% to 3% in the general population.3 The authors explain why, despite this high prevalence, the disorder may go unrecognized.
Instead of showing visibly distinct alternate identities, the typical DID patient presents a polysymptomatic mixture of dissociative and posttraumatic stress disorder (PTSD) symptoms that are embedded in a matrix of ostensibly non-trauma-related symptoms (e.g., depression, panic attacks, substance abuse, somatoform symptoms, eating-disordered symptoms). The prominence of these latter, highly familiar symptoms often leads clinicians to diagnose only these comorbid conditions. When this happens, the undiagnosed DID patient may undergo a long and frequently unsuccessful treatment for these other conditions. Finally, almost all practitioners use the standard diagnostic interviews and mental status examinations that they were taught during professional training. Unfortunately, these standard interviews often do not include questions about dissociation, posttraumatic symptoms, or a history of psychological trauma.3
To say that “almost all practitioners” use standard diagnostic interviews that “often” do not ask about posttraumatic symptoms or psychological trauma is a surprising statement to make without offering a supporting citation.
Although the alleged traumas may not have happened to Shirley Mason, the idea that systematic and terrible traumas provide an important potential progenitor for DID remains in the Guidelines:
A substantial minority of DID patients report sadistic, exploitive, and coercive abuse at the hands of organized groups. This type of organized abuse victimizes individuals through extreme control of their environments in childhood and frequently involves multiple perpetrators. It may be organized around the activities of pedophile networks, child pornography or child prostitution rings, various “religious” groups or cults, multigenerational family systems, and human trafficking/prostitution networks. Organized abuse frequently incorporates activities that are sexually perverse, horrifying, and sadistic and may involve coercing the child into witnessing or participating in the abuse of others.3
These sources of trauma in a “substantial minority” of 1% to 3% of the general population once more suggest a divide between clinicians who focus on patients with DID, and those who do not.
This divide may continue down to the journal level. EigenfactorTM metrics offers quantitative measure of “[a] journal’s total importance to the scientific community.”4 The Journal of Trauma & Dissociation had an Eigenfactor of 0.000794. For comparison, Biological Psychiatry has an Eigenfactor of 0.104614, and Journal of the American Academy of Psychiatry and the Law has an Eigenfactor of 0.001682. A lower score is, of course, entirely reasonable for a more narrowly focused journal; these focused topics might risk being caught in an echo chamber of concurring opinion to the exclusion of broader attention.
The numbers suggest that DID has never been the topic of heavy research attention, and the attention it once had has waned. This count also includes studies that feature modern methodologies such as neuroimaging that either demonstrated no measurable differences between control and experimental groups or have been met with concerns regarding validity,5 in addition to results that conclude that DID is not a scientifically well-supported construct.6
The future
The DSM-5 process may limit rather than foster some of this discussion. The diagnosis of DID is under the purview of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group (Work Group). When a group of experts in existing diagnostic categories discuss the future of those diagnoses, there is some inherent conflict of interest. Indeed, more than one member of the Work Group has publications cited by the ISSTD Guidelines. That does not preclude them from reevaluating the available data, but those whose reputation of expertise rests on the diagnosis may not be entirely impartial.
A recent article regarding the DSM-5 features 2 members of the Work Group, as well as 4 authors of the ISSTD Guidelines.7 The article features suggested DSM-5 diagnostic criteria for DID. The proposed DSM-5 criteria in this document are identical to those on the DSM-5 Web site.8 The proposal includes several important changes from the DSM-IV-TR. Criterion A describes having “two or more distinct personality states,” that “may be observed by others or reported by the patient.” The DSM-IV-TR implied a requirement for direct observation of the personality states. The DSM-IV-TR Criterion B that the personality states “recurrently take control of the person’s behavior,” is slated for removal. The DSM-5 Web site also notes that the Work Group is considering whether a criterion requiring clinically significant distress or impairment in function is necessary.
Conclusion
Sybil Exposed1 makes the case that the book Sybil2 misrepresents the facts of Shirley Mason’s life, diagnosis, and treatment. It also points to concerns that extend beyond a single case, to the diagnostic concept of multiple personalities. Although some of the criticism and conclusions are over-reaching, there are some genuine and unaddressed issues that the rest of the profession must face.
Do new developments in DID receive the benefit of rigor from the broader debate? Occam’s Razor roughly translates to “entities are not to be multiplied beyond necessity.”9 The null hypothesis, as with all diagnoses, is that DID does not exist as a valid clinical entity. Science demands that a case must be built. If extraordinary claims require extraordinary proof, would DID be added to the DSM today?
