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Commentary CONTROVERSIES IN PSYCHIATRY

Dissociative identity disorder:
Time to remove it from DSM-V?
Examining the logic behind
arguments todperpetuate
ia
M
a controversial e diagnosis
e a lth
d e n H only
® Do
w ehat is it about dissociative identity disorder
s (DID) that makes it a polarizing diagnosis?
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Fo
t
igh erson
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a l
and
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Why does it split professionals into believers
nonbelievers, stirring up heated debates, high emo-
tions, and fervor similar to what we see in religion?
The DID controversy is likely to continue beyond
the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-V), slated for publication
in 2012. Proponents and opponents claim to have the
upper hand in arguments about the validity of the
DID diagnosis and benefits vs harm of treatment.
This article examines the logic of previous and new
© images.com / VEER

arguments.

1. The fallacy of equal-footing arguments
Numan Gharaibeh, MD When 301 board-certified U.S. psychiatrists were sur-
Staff psychiatrist
Department of psychiatry
veyed in 1999 about their attitudes toward DSM-IV
Danbury Hospital dissociative disorders diagnoses:
Danbury, CT • 35% had no reservations about DID
• 43% were skeptical
• 15% indicated the diagnosis should not be included
in the DSM.1
Only 21% believed there was strong evidence for
DID’s scientific validity. On balance, published papers
appear skeptical about DID’s core components: disso-
ciative amnesia and recovered-memory therapy.2

Dr. Gharaibeh is a an attending psychiatrist on the inpatient unit at Danbury
Hospital in Danbury, CT. He teaches psychiatric residents from New York
Current Psychiatry Medical College during their rotation in Danbury Hospital and physician
30 September 2009 assistant students from Quinnipiac University, Hamden, CT.

For mass reproduction, content licensing and permissions contact Dowden Health Media.

30_CPSY0909 30 8/17/09 11:05:23 AM
DID skeptics are sometimes accused of Box 1
“denial” or “reluctance” to accept this diag-
nosis. Informed skepticism is acceptable— Bertrand Russell’s ‘celestial
even encouraged—in making a diagnosis teapot’ analogy on religion
of malingering, factitious disorder, some
personality disorders, substance abuse, and
psychotic states, to name a few. Why is in-
I n 1952, British philosopher Bertrand
Russell used the analogy of a teapot in
space to illustrate the difficulty skeptics
formed skepticism about DID frowned on? face when questioning unfalsifiable claims.
In medical and surgical specialties, in- Russell’s argument involved religious belief,
formed skepticism is encouraged so that the but it is valid for other belief systems relying
practitioner challenges his or her assump- on faith. Here is the celestial teapot analogy:
tions about a possible diagnosis through a
“If I were to suggest that between Earth and
methodical process of inclusion, exclusion, Mars there is a china teapot revolving about
and hypothesis testing. I argue that little or the Sun in an elliptical orbit, nobody would
no skepticism is substandard practice, if not be able to disprove my assertion provided
negligence. I were careful to add that the teapot is
Bertrand Russell’s celestial teapot parable too small to be revealed even by our most Clinical Point
powerful telescopes. But if I were to go
(Box 1)3 exposed the fallacy of equal-footing An extensive review
on to say that, since my assertion cannot
arguments (ie, in any debate or argument be disproved, it is intolerable presumption found no proof that
that has 2 sides, the 2 sides are not necessar- on the part of human reason to doubt it,
ily on equal footing). Russell’s argument is I should rightly be thought to be talking DID results from
valid for any belief system relying on faith. nonsense. If, however, the existence of such childhood trauma
a teapot were affirmed in ancient books,
Now that DID is in the “ancient book” or that DID cases in
taught as the sacred truth every Sunday,
(DSM-IV), the burden of proof by some and instilled into the minds of children at children are almost
magical logic has shifted to “nonbelievers.” school, hesitation to believe in its existence
In law that is called precedent, but law is would be a mark of eccentricity and
never reported
even less scientific than psychiatry and not entitle the doubter to the attention of the
the best example to follow. A mistake made psychiatrist in an enlightened age or of the
Inquisitor in an earlier time.”
100 years ago is still a mistake.
Source: Reference 3

2. Illogic of causation to have a “powerful vested interest”—to
Piper and Merskey’s extensive literature re- borrow Paul McHugh’s expression6—in
view4,5 examined the presumed association sustaining the DID diagnosis, symptoms,
between DID and childhood abuse (mostly behaviors, and therapy as an end in itself.
sexual). They found: DID proponents acknowledge that iatro-
• no proof that DID results from child- genic artifacts may exist in the diagnosis
hood trauma or that DID cases in chil- and treatment. However, they almost im-
dren are almost never reported mediately insinuate that DID patients’
• “consistent evidence of blatant iatro- “subtle defensive strategies” generate these
genesis” in the practice of some DID artifacts. Greaves’ discussion of multiple
proponents. personality disorder7 acknowledged that
One can easily turn the logic around overdiagnosis may be driven by therapists’
by claiming that a DID diagnosis causes desire to “attain narcissistic gratification at
memories of childhood sexual abuse. ‘having a multiple [sic] of their own’” but
As for patients’ presumed reluctance blamed this on “neophytes.” ONLINE
to report childhood abuse, I witnessed in ONLY
every one of my 15 alleged cases of DID Discuss this article at
(all female) not reluctance but a strong 3. Tautology in DID’s definition http://CurrentPsychiatry.
tendency to flaunt their diagnosis and DSM-IV’s criterion A for DID is in fact a blogspot.com
symptoms and an eagerness to re-tell their definition: “the presence of 2 or more dis-
stories with graphic detail, usually unpro- tinct identities or personality states (each
Current Psychiatry
voked. Patients with a DID diagnosis seem with its own relatively enduring pattern of Vol. 8, No. 9 31

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Table the concept that these terms try to com-
municate make speaking a common lan-
A meaningless word? guage extremely difficult. To borrow from
‘Dissociation’ is used Wittgenstein, psychiatrists’ intellect is be-
to describe many things witched by language.11
Words fail to communicate experiences
Daydreaming or fantasizing
such as the taste of red wine or the feeling
Dissociative Memory lapses caused by benzodiazepines of sand beneath bare feet. It is almost futile
identity Preoccupation with everyday worries to try to define dissociation, identity, per-
disorder Preoccupation with internal stimuli (such as
sonality states, etc., using words or even
auditory hallucinations or delusional thoughts) pictures. More definitions and agreement
on stricter definitions would not provide
Poor attentiveness
greater clarity or solve the problem of first-
Histrionic/theatrical behavior to avoid upsetting person authority.
the patient or to provide a face-saving
An example is found in DID’s criterion
explanation
B: “at least 2 of these identities or person-
Clinical Point Daydreaming while driving (‘highway ality states recurrently take control of the
dissociation’ or ‘highway hypnosis’)
DSM-IV criteria A person’s behavior” [italics mine]. “Posses-
Getting engrossed/captivated by a novel, a sion” seems to be a fitting word! Whether
and B for dissociative movie, or a piece of radio journalism or music it is an alter or the devil taking control is a
identity disorder technicality. Even more acceptable would
show circularity perceiving, relating to, and thinking about be possessed by inconsolable anger, pos-
and redundancy; if the environment and self).”8 Together, sessed by fierce jealousy, possessed by
criteria A and B show circularity and re- lust, possessed by hatred and vengeance,
criterion A is met,
dundancy. If A is met, then B must be met possessed by and obsessed with love, pos-
then B must be met because “a person’s behavior” is part of sessed by cocaine, etc.
her or his identity and personality state, Dissociation is used to describe so many
which was established in A. things that it has become almost meaning-
Tautology is a major shortcoming of the less (Table). I refer not only to definitional
descriptive system for psychopathology in imprecision but also to a lack of consensus
general. Of greater clinical value are ob- on the nature of the concept itself.
serving a patient’s actions, listening to his The word “control” is another term on
or her words, learning his or her history, whose meaning almost no 2 psychiatrists
studying his or her expressions, and not- agree. Consensus on definitions is elusive
ing his or her relationships.9 when words become divorced from the
concepts they were intended to describe.

4. Bewitchment by language
Psychiatrists could spend hours over strong 5. Validity of first-person authority
cups of coffee arguing the meanings of terms The skeptic’s attempt to investigate a subjec-
such as “dissociation,” “presence,” “identi- tive phenomena—especially DID—is bound
ty,” “personality state,” etc. Psychiatry has to break on the rocks of the first-person
been targeted unfairly regarding where it authority, to borrow Donald Davidson’s
falls on the subjectivity-objectivity axis, but words.9 To support reliability and validity
it has not fared that differently from other of the diagnosis, dissociation researchers
medical specialties.10 Psychiatry, however, rely on “scales” and “instruments” to give
depends much more on language. the impression of objectivity, empiricism,
Consider slippery terms such as person- and “science” hard at work. However, a
ality, identity, self, dissociation, integration, quick look at some of the questions on these
alters, ego, ego states, trance states, person- “instruments” reveals their assault on rea-
ality states, unconscious, etc. Lack of preci- son and intellect (Box 2, page 35).12
sion, variability in use of words and their Proponents who claim DID is “suffi-
Current Psychiatry
32 September 2009 meaning, and variability in understanding ciently validated for inclusion in the current
continued on page 35

32_CPSY0909 32 8/17/09 11:05:35 AM
continued from page 32
and future versions of DSM” are to be com- Box 2
mended for adding “much more research is
needed in several areas.”13 Piper and Mer- Sample statements from
skey’s review4,5 concluded that DID could the Adolescent Dissociative
not be reliably diagnosed. Experience Scale (A-DES)*
A-DES: I get so wrapped up in watching TV,
reading, or playing a video game that I don’t
6. Does a DID diagnosis do harm? have any idea what’s going on around me.
Webster’s14 defines iatrogenic as: “Resulting
Comment: Although this item seems like a
from the activity of a physician. Originally joke, it is not meant as one. It is meant to be
applied to a disorder or disorders inadver- part of the serious business of science. Isn’t
tently induced in the patient by the manner that what any ‘normal’ human would do if he or
of the physician’s examination, discussion, she has enough attention and concentration?
or treatment, it now applies to any condi- A-DES: People tell me I do or say things
tion occurring in a patient as result of medi- that I don’t remember doing or saying.
cal treatment, such as a drug reaction.” I get confused about whether I have done
A DID diagnosis has been blamed for something or only thought about doing it. Clinical Point
misdiagnosis of other entities,15 patient I can’t figure out if things really happened Even when DID is
mismanagement,16 and inadequate treat- or if I only dreamed or thought about them.
treated with the
ment of depression.17 Even when DID is People tell me that I sometimes act so
treated with the best of intentions, unde- differently that I seem like a different person. best of intentions,
sired negative effects may result from psy- Comment: These items are crafted in a way undesired negative
chotherapy, and some patients experience to encourage false positives. First, ‘people effects may result
worsening of symptoms and/or deteriora- tell me’ does not qualify as an ‘experience.’
Second, one wonders why the scale was from psychotherapy
tion of functioning.18,19
made up of declarative statements instead
In Creating Hysteria, Acocella20 cites exam- of questions. Third, ‘I seem like a different
ples of harm done to [alleged DID] patients person’ is a leading statement.
and their families, including 2 high-profile
A-DES: I am so good at lying and acting
cases under the care of a member of the that I believe it myself.
DSM-IV work group on dissociation.
Comment: This should be an immediate
tip-off that the reporter is unreliable.

7. How is self-deception possible? A-DES: I feel like my past is a puzzle and
some of the pieces are missing.
The ability to self-deceive has advantages
Comment: Isn’t this the human condition?
and disadvantages,21 and widespread de-
ception is possible. Richard Dawkins’s The *A-DES statements are italicized; comments by Dr. Gharaibeh
are in plain text
God Delusion,22 Christopher Hitchens’s God Source: Reference 12
is Not Great,23 and Michael Shermer’s Why
People Believe Weird Things24 are recent ex-
posés of how self-deception and deception Proponents also allege that part of the
by charismatic figures occurs despite the reason for “professionals’ reluctance” to
progress “reason” has made. embrace DID is the “subtle presentation
As with other belief systems that be- of the symptoms.”25 In other words, it is
come entrenched in the face of criticism, not reluctance; it is ignorance, with the
DID proponents accuse critics of denial, re- insinuation that nonbelievers or skeptics
luctance, and adopting “defense[s] against are not smart enough to pick up on the
dealing with the reality of child abuse in subtle clinical presentation. I can’t see
North America.”20 One wonders why just why professionals would be ignorant
North America! Why not Africa, with its when it comes to dissociation as opposed
children in Sudan, Somalia, Zimbabwe— to schizophrenia, depression, bipolar dis-
to name a few—enduring enough abuse order, and almost all DSM-IV disorders.
to spread around the world several times Why this selective ignorance exists re-
Current Psychiatry
over? mains unexplained. Vol. 8, No. 9 35
continued

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8. Experts and conflict of interest
DSM-V’s guidelines on conflict of inter- Related Resources
est are very welcome. One hopes conflict • Borch-Jacobsen M. Making minds and madness: from
hysteria to depression. New York, NY: Cambridge University
of interest does not refer only to financial Press; 2009.
relationships with pharmaceutical compa- • Memory and reality. False Memory Syndrome Foundation.
nies. Conflicts of interest can exert unseen www.fmsfonline.org.

influence, which—if made clear—would Disclosure
Dissociative have a direct bearing of the reliability and Dr. Gharaibeh reports no financial relationship with any
company whose products are mentioned in this article or
identity trustworthiness of the published literature. with manufacturers of competing products.
disorder Strong adherents have a lot to gain from
perpetuating DID. Nonbelievers, skeptics,
and opponents would gain nothing if DID 4. Piper A, Merskey H. The persistence of folly: a critical
examination of dissociative identity disorder. Part I. The
disappeared from DSM today or in 2012. excesses of an improbable concept. Can J Psychiatry.
The first potential conflict of interest 2004;49(9):592-600.
5. Piper A, Merskey H. The persistence of folly: critical
for DID “experts” is financial gain. For ex- examination of dissociative identity disorder. Part II. The
ample, a psychologist saw 1 of my patients defense and decline of multiple personality or dissociative
identity disorder. Can J Psychiatry. 2004;49(10):678-683.
Clinical Point (before I came to the scene) for 5 years for 6. McHugh PR. Multiple personality disorder (dissociative
identity disorder). Available at: http://www.psycom.net/
Strong adherents 3 sessions a week (2 for adult alters and 1 mchugh.html. Accessed August 5, 2009.
for childhood alters), with annual earnings 7. Greaves GB. Observations on the claim of iatrogenesis of
have a lot to gain MPD: a discussion. Dissociation. 1989;2(2):99-104.
of nearly $20,000. A self-declared expert
from perpetuating would need only 10 patients to be better off
8. Diagnostic and statistical manual of mental disorders, 4th ed.
Washington, DC: American Psychiatric Association; 1994.
DID; skeptics would than most psychiatrists. 9. Davidson D. Subjective, intersubjective, objective. New York,
NY: Oxford University Press; 2001:15.
gain nothing if DID The second potential conflict of interest 10. Pies R. Psychiatry clearly meets the ‘objectivity’ test.
is personal gain in the form of narcissis- Psychiatric News. 2005;40(19):17.
were to disappear 11. Sluga H, Stern DG. The Cambridge companion to
tic gratification, as mentioned above. Al- Wittgenstein. New York, NY: Cambridge University Press;
from DSM in 2012 though DID proponents blame neophytes, 1966.
12. Armstrong JG, Putnam FW, Carlson EB, et al. Development
“teachers” are no less prone to narcissistic and validation of a measure of adolescent dissociation: The
gratification. Under this umbrella falls the Adolescent Dissociative Experience Scale. J Nerv Ment Dis.
1997;185:491-497.
DID experts’ interest in recognition, fame, 13. Gleaves DH, May MC, Cardeña E. An examination of the
diagnostic validity of dissociative identity disorder. Clin
and easily acquired expertise. One may Psychol Rev. 2001;21(4):577-608.
argue that self-arrogated expertise in this 14. The new Webster’s international comprehensive dictionary of
the English language. New York, NY: American International
realm is much ado about nothing. Press; 1991.
The third potential conflict of interest is 15. Freeland A, Manchanda R, Chiu S, et al. Four cases of
supposed multiple personality disorder: evidence of
the very process of becoming an “expert.” unjustified diagnoses. Can J Psychiatry. 1993;23:245-247.
The bias of this process is evident because 16. McHugh PR. Try to remember: psychiatry’s clash over
meaning, memory, and mind. Washington, DC: Dana Press;
if one does not accept a priori the presence 2008.
of DID, he or she will never be admitted to 17. Fetkewicz J, Sharma V, Merskey H. A note on suicidal
deterioration with recovered memory treatment. J Affect
the exclusive club of “DID experts.” To at- Disord. 2000;58:155-159.
tain the status of authority or expert on this 18. Hadley SW, Strupp HH. Contemporary views of negative
effects in psychotherapy. An integrated account. Arch Gen
subject, one must be a believer. Otherwise, Psychiatry. 1976;33(11):1291-1302.
how would one claim to have diagnosed 19. Bergin AE. The deterioration effect: a reply to Braucht. J
Abnorm Psychol. 1970;75(3):300-302.
and treated hundreds of DID cases? It is a 20. Acocella J. Creating hysteria: women and multiple personality
feedback loop that can’t be broken. disorder. San Francisco, CA: Jossey-Bass Publishers; 1999:81.
21. Nasrallah HA. Self-deception: a double-edged trait. Current
Psychiatry. 2008;7(7):14-16.
References
22. Dawkins R. The God delusion. Boston, MA: Houghton
1. Pope HG Jr, Oliva PS, Hudson JI, et al. Attitudes toward DSM- Mifflin; 2006.
IV dissociative disorders diagnoses among board-certified
American psychiatrists. Am J Psychiatry. 1999;156(2):321- 23. Hitchens C. God is not great: how religion poisons
323. everything. New York, NY: Twelve/Hachette Book Group;
2007.
2. Pope HG Jr, Barry S, Bodkin A, et al. Tracking scientific
interest in the dissociative disorders: a study of scientific 24. Shermer M. Why people believe weird things: pseudoscience,
publication output 1984-2003. Psychother Psychosom. superstition, and other confusions of our time. New York,
2006;75:19-24. NY: W.H. Freeman and Company; 1997.
3. Russell B. Is there a God? Available at: http://www.cfpf. 25. Coons PM. Child abuse and multiple personality disorder:
org.uk/articles/religion/br/br_god.html. Accessed June 25, review of the literature and suggestions for treatment. Child
2009. Abuse Negl. 1986;10(4):455-462.
Current Psychiatry
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