This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.
Dissociative Identity Disorder: How the Media Created a Diagnostic Fad by Amy Brewer
When you hear the term “multiple personality disorder,” something from the media probably springs to mind. Most people have seen or heard of the story of Sybil from the movie starring Sally Field. Many other movies give a portrayal of a person with this disorder, but to name to them would be to spoil them for some people who are behind on their movies. A simple Google search will take you to long lists of movies where this disorder is the central plot. These types of story lines began inundating the cinema, particularly in the 1970’s and 80’s. At the same time, there was an upsurge in diagnosis of multiple personality disorder, or what is now referred to as Dissociative Identity Disorder (DID). As is normally the case, movie and television writers have given the general public some misconceptions, particularly that psychologists and psychiatrists in the field routinely diagnose this disorder and that it is prevalent around the world. Furthermore, many believe that DID has been researched with robust empirical methods and can be successfully treated by means of integration of personalities. Though these ideas are still prevalent, there is a lot more evidence to the contrary.
The DSM-5 defines Dissociative Identity Disorder as a person having two or more distinct personality states and who feel that their behavior and feelings are not under their control. It is also marked by gaps in memory of daily events and is often precipitated by childhood trauma, most often sexual or physical abuse.
The made for TV movie Sybil is based on a book written in 1973 about Shirley Mason, who as a result of years of child abuse was shattered into 16 different personalities. The book gives the account of her diagnosis and treatment by psychiatrist Cornelia Wilbur. Interestingly, new information surfaced years later uncovering that the diagnosis was fabricated. The book Sybil Exposed by Debbie Nathan in 2011 discusses how this diagnosis was built from sessions in which Shirley was injected with sodium pentothal before psychoanalytic treatments to discuss past traumatic events. Dr. Wilbur had a growing fascination with the disorder and asked leading questions, pressing Shirley into producing names for her “personalities.” These interviews led to tales of abuse that later were revealed to be memories of a tonsillectomy. Shirley would later deny the stories of trauma she once disclosed to Wilbur, saying she adhered to the stories because wanted to please her psychiatrist with whom she had grown close.
Though much of the original story of Sybil was conjecture, the number of people diagnosed with the disorder after its publication soared. Prior to 1970, there were only 79 documented DID cases worldwide. In 1986, the number of cases in the literature increased to over 6000 cases in the United States alone. There were more cases reported from 1981-1986 than in the preceding two centuries. Some researchers will argue that the prevalence of DID has not increased, but the diagnostics are just better at recognizing the disorder. Skeptics dispute this argument, stating that the numbers are more indicative of faddish over-diagnosis.
There is still much controversy over Dissociative Identity Disorder in the field. Within this debate, there are two opposing models. The posttraumatic model, which is still present in much of the literature, states that DID stems from a childhood trauma and is a resourceful survival method where a person splits off into alter personalities in order to cope. The sociocognitive model is gaining much ground and in contrast reasons that DID is an iatrogenic artifact that is created through the psychotherapy process, such as in the case of Sybil. According to this model, therapists are often giving clients suggestive notions of alternate personality states and shaping their clients’ behavior through differential reinforcement. Though the posttraumatic model is still present in the literature, the sociocognitive model fills in many of the questionable gaps about the diagnosis of this disorder.
Sociocognitive theorists believe that the numbers rocketed in the early 1980’s partly due to this iatrogenic effect. When the disorder gained popularity in the media, people, particularly victims of childhood abuse, began looking for the symptoms in themselves. Furthermore, therapists also began watching for the signs in their clients, implicitly prompting them into thoughts of possessing multiple personalities. This is also due in part to demand characteristics, where the client may interpret the direction the therapist is going and change their behavior to fit that interpretation.
These two theoretical models also differ in terms of DID treatment. Much of the mainstream literature of the post-traumatic model still proposes that the treating psychologist must make direct contact with all the instate identities in order to repair fragmentation of identity states which would in turn decrease episodes of amnesia. They suggest that the client must be lead to map through the network of personalities in order to integrate them. This method is misleading because it works under the assumption that these “alters” are discrete entities within a person. In addition, though there are studies that suggest a decrease in symptoms with this method, these reports come from uncontrolled case studies. Many psychologists who oppose this approach were monumental in the APA’s alteration of multiple personality disorder” to “dissociative identity disorder “ in the DSM-IV. This maneuver moves away from the rationale that a person can fragment into many personalities and moves toward a more accurate concept of a person having difficulty integrating the different aspects of their personality.
Although sociocognitive theorists believe that much of DID is a product of iatrogenesis, they are not suggesting that these clients are not in distress or not in need of care. On the contrary, they propose that cognitive behavioral therapy (CBT) can aid in reduction and stabilization of trauma symptoms. They believe that making contact with the “instate identities” only aids in reinforcing the client’s belief of their existence. Instead, therapists using CBT treatments encourage clients to let go of unhelpful beliefs and work with the trauma that is resulting in the behavior. Rather than placing emphasis on the perceived identities, CBT therapists focus attention on the client’s dysfunctional schemas that are leading to their belief in the altered identity states.
It is important to realize that the theories and subsequent hype about DID that arose in the 1970’s and 80’s were socially constructed. Though some of these theories are still present in the literature, much of the field has shifted its thinking. Unfortunately, there are still many misconceptions about this disorder in the public view. Where it is still essential to try to meet the needs of people who meet DID criteria, it is also imperative to have a clear understanding and healthy skepticism of the realities of its diagnosis and treatment.