Philip M. Coons

The dissociative disorders : Rarely considered and underdiagnosed

A wide variety of dissociative disorders, including dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, and various forms of dissociative disorder not otherwise specified. In many instances, these disorders are either underdiagnosed or misdiagnosed secondary to the clinicians mistaken belief that dissociative disorders are rare. Recent research shows that dissociative disorders may comprise 5% to 10% of psychiatric populations. This article reviews the epidemiology and clinical symptomatology of these disorders. In addition, various screening and diagnostic instruments, such as the DES, Structured Clinical Interview for Dissociative Disorders, and MMPI, are discussed.

Patterns of dissociation in clinical and nonclinical samples

Research has consistently found elevated mean dissociation scores in particular diagnostic groups. In this study, we explored whether mean dissociation scores for different diagnostic groups resulted from uniform distributions of scores within the group or were a function of the proportion of highly dissociative patients that the diagnostic group contained. A total of 1566 subjects who were psychiatric patients, neurological patients, normal adolescents, or normal adult subjects completed the Dissociative Experience Scale (DES). An analysis of the percentage of subjects with high DES scores in each diagnostic group indicated that the diagnostic groups mean DES scores were a function of the proportion of subjects within the group who were high dissociators. The results contradict a continuum model of dissociation but are consistent with the existence of distinct dissociative types.

Multiple personality disorder. A clinical investigation of 50 cases.

To study the clinical phenomenology of multiple personality, 50 consecutive patients with DSM-III multiple personality disorder were assessed using clinical history, psychiatric interview, neurological examination, electroencephalogram, MMPI, intelligence testing, and a variety of psychiatric rating scales. Results revealed that patients with multiple personality are usually women who present with depression, suicide attempts, repeated amnesic episodes, and a history of childhood trauma, particularly sexual abuse. Also common were headaches, hysterical conversion, and sexual dysfunction. Intellectual level varied from borderline to superior. The MMPI reflected underlying character pathology in addition to depression and dissociation. Significant neurological or electroencephalographical abnormalities were infrequent. These data suggest that the etiology of multiple personality is strongly related to childhood trauma rather than to an underlying electrophysiological dysfunction.

Confirmation of childhood abuse in child and adolescent cases of multiple personality disorder and dissociative disorder not otherwise specified.

The diagnostic validity of multiple personality disorder (MPD) and its association to trauma have been questioned because corroboration of child abuse in studies of patients with MPD is scant. The purpose of this study was to determine on a retrospective basis whether external corroboration of child abuse could be found in a group of patients with MPD and dissociative disorder not otherwise specified. A group of child and adolescent psychiatric inpatients and outpatients was chosen because of the extensive number of collateral records collected on them in a tertiary care setting. This group was also chosen because of the intense interest paid by child protective services and courts to child abuse during the past 15 years. This retrospective chart review confirmed child abuse in eight of nine patients with MPD and in all 12 cases of dissociative disorder not otherwise specified. This study provides further evidence of the association of severe dissociative disorders with trauma, particularly child abuse. Future studies should be prospective and blinded to avoid the possibility of investigator bias, and should include a control group for comparison of base rate of child abuse.

Treatment progress in 20 patients with multiple personality disorder.

Attempts to follow the treatment Progress of patients with multiple personality havebeen limited to a few single case studies and, in the only large series, to those most successfully treated. This study followed the treatment progress of 20 patients for a mean of 39 months after intake. The study included a detailed history, neurological examination, and psychological testing on each patient. At follow-up each patient was interviewed and a questionnaire was completed by his or her therapist to assess treatment response. Although nine patients achieved partial or full integration, complete integration was maintained by only five. During therapy the unintegrated patients experienced emotional trauma at approximately twice the rate as did the patients who eventually became integrated. Psychodynamic psychotherapy and hypnosis were the most widely prescribed therapies. The improvement in multiple personality appeared to proceed in a stepwise fashion from acceptance of the diagnosis to integration. The progress of therapy was hindered most commonly by the overuse of the mental mechanisms of repression and denial, the continued utilization of secrecy, which began during child abuse, and the production of numerous crises. The most common countertransferences included anger, exasperation, and emotional exhaustion. Although the psychotherapy of patients with multiple personality is tedious and time consuming, it can be eminently successful if the patient and therapist persevere.

Initial and Follow-up Psychological Testing on a Group of Patients with Multiple Personality Disorder:

The Minnesota Multiphasic Personality Inventory (MMPI) and Wechsler Adult Intelligence Scale (WAIS) were administered to the host personality of 18 patients with multiple personality prior to therapy. The MMPI was readministered a mean of 39 mo. later. The MMPI appears to be a valuable aid in diagnosing multiple personality. Characteristic MMPI protocols include (1) high F and Sc scales, (2) technically invalid profiles, (3) numerous critical items, (4) critical items indicating dissociation, (5) a poly-symptomatic picture, (6) wide discrepancy between obvious and subtle scores, (7) lack of blatant psychosis, (8) and infrequently elevated Hs scales. Individuals with borderline to superior IQs may have multiple personality.

Multiple personality in adolescence: relationship to incestual experiences.

Children who are physically and/or sexually abused may develop multiple personality. Dissociation provides an effective way to cope with the strong affects evoked by abuse and is a predictable defense for young children whose natural development involves fluid role changes as part of fantasy life. This paper presents a case of multiple personality in an adolescent and discusses the relationship between abuse and dissociation in children. Guidelines are offered for treatment of an adolescent multiple personality.

Child abuse and multiple personality disorder: review of the literature and suggestions for treatment.

The syndrome of multiple personality is associated with a high incidence of physical and/or sexual abuse in childhood. Occasionally those with multiple personality abuse their own children. Multiple personality is difficult to diagnose both because of the nature of the syndrome and because of professional reluctance. Although multiple personality is most difficult to diagnose during childhood because of the subtlety of the syndrome, the much higher morbidity found in adult cases makes it imperative that it be diagnosed and treated early in order to avoid further abuse and greater morbidity and to shorten treatment time. This review describes the history, clinical features and treatment of multiple personality, particularly in children, in addition to exploring the professional reluctance to make the diagnosis.

A Comprehensive Bibliography of Literature Pertaining to Multiple Personality

The reported incidence of patients with multiple personalities has increased dramatically during the 1970s. It has become important for therapists and researchers to have available a comprehensive bibliography of the literature pertaining to this increasingly important disorder, especially since much of that literature is in sources that are difficult to locate through typical procedures for literature search. This paper presents a comprehensive bibliography of 350 references relating to multiple personality. The articles, books, and paper presentations included in this bibliography are classified into 11 categories: reviews, general references, diagnosis and differential diagnosis, psychological testing, etiology, case reports, biographical and autobiographical accounts, treatment, experimental investigations, medico-legal aspects, and psychophysiological aspects. References that might be especially useful to the reader new to the multiple personality literature are identified.

Multiple Personality Disorder

Multiple personality disorder (MPD), which has been described elsewhere (Coons, Bowman, & Milstein, 1988; Kluft, 1991b; Putnam, 1989; Putnam, Guroff, Silberman, Barban, & Post, 1986; Ross, 1989), is a polysymptomatic disorder which most often presents in women who report histories of long-standing and severe physical and sexual abuse beginning in early childhood. Depression most commonly overlies the more subtle dissociative symptomatology. Loewenstein (1991a) best articulated the polysymptomatic nature of MPD by dividing the syndrome into symptom clusters, including process, amnesic, autohypnotic, posttraumatic, somatoform, and affective symptoms. The dissociative symptoms will be described first, even though they are more subtle and have prompted one expert to call for a radical change in the way MPD is diagnosed (Nakdimen, 1992).