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Adolescent Multiple Personality Disorder: A Preliminary Study of Eleven Cases

Article in Journal of the American Academy of Child & Adolescent Psychiatry · June 1990
DOI: 10.1097/00004583-199005000-00005 · Source: PubMed

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 Adolescent Multiple Personality Disorder: A Preliminary Study of Eleven Cases

PA UL F . DELL, PH.D. , AND .J AMES W . EISEN HOWE R, L. C. S .W .

Abstract. T he diagnostic features and trea tment histor ies of II adolescents with multiple person a lity d isor der
(MPD) are presen ted . Clinical evaluation revealed that the maj ority of these adole sce nts manifested ex tre me ly
variable schoo l perform ance , disrup tive behavior, trances, amnesias. mood swings, sharp c hanges in perso nal ity ,
apparent lying , voices heard in the head, and depression . All had a history of childhoo d traum a: Sex ual abuse
(73%) , physical abuse (73%), and emo tional abuse (82%). Seve nty-three percent had a parent with a d iagnosab le
dissociative disorder ; 36% of the mothers had MP D. These ado lesce nts had a mean number of 24 . 1 alter per son alities
and appear to have become multiple at a mean age of 3 years, I month . All patients had angry protector alters ,
dep ressed alters , scare d alters , and child alter s. Fifty-four percent of these cases have integrated dur ing treatment
or are pro gressing toward integration . The rema ining eases dropped out of therapy. J. Am . /vcad. Child /vdolesc,
Psychiatry, 1990 , 29, 3:359- 366. Key Words: mult iple personality disorder , dissociation, traum a, adolescent,
psychotherapy.

Over the past decad e , there has been an acce lerating pro-
liferation of clinica l research on adult patients with multiple
personality disord er (M PD) . Yet , desp ite a research and
cl inical conse nsus that MP D is a childhood onset disorder
(American Psychi atric Associa tion, 1987) , there have been
rather few pub lished report s of MPD in childhoo d or ado -
lescence . At presen t, the literatur e on childhood M PD co n-
sists of a total of 10 case s of MP D (Despine , 1840 ; Fagan
and MeM ahon , 1984 ; Kl uft , 1984a , 1986b; Weiss et al.,
1985; Malcnbaum and Russell , 1987; Riley and Mead, 1988),
and an add itional three cases of " ineipient multiple per-
sonality in children " (Fagan and McM ahon , 1984). T he
literatu re on adolescent MPD co nsists of five cas e studies
(A lexander, 1956; Gruenwald , 1971 ; Horton and Miller,
1972 ; Fagan and Mc Ma hon, 1984 ; Bowman et al. , 1985)
and a brief overview of 16 teenage cases in Kluft ' s ( 1985b)
land mark paper on the natur al history of MPD .
Brief Overview of Multiple Personality Disorder
MPD is a severe dissociati ve disorder characterized by
disturbances in both ident ity and me mory (Nerniah , 1981).
It is best understood as a posttraum atic condition (Putn am ,
1985; Kluft, 1984b; Spiegel , 1984; Braun and Sachs , 1985;
Klu ft , 1988a; Putnam, 1989). T hat is , MPD is the adaptive ,
dissocia tive resp onse of a young child's mind to the fea r
and pain of overwhelming trauma-most co mmo nly abu se
(Putnam ct al. , 1986; Coo ns, 1988; Ross et al . , 1989b;
Schultz et al. , 1989; Ross et aI., in press). Once begun,
1\("("('l' t('t! .1</ 11/1(//)' /3 . I QC)() .
Dr . Dell is Prof essor of Psychiatry and Behavioral Scien ces and
Director oj the Dissociative Disorders Program at Eastern Virginia
Medical School . James (Ike ) Eisenhower is in pri vate practi ce with
Eisenhow er & Associates Psychotherapy Services .
An earlier version oj this paper was presented at the Sixth Inter-
national Conference a ll Multiple Personality/Dissociative States , Oc-
tober 14. 1989. in Chicago .
Reprints may be requestedfrom Dr . Dell , Department ofPsychia try
and Behavioral Sciences, Eastern Virginia Medical School, P .O . Box
1980, Norfl)lk, VA 2350 1.
0890-8567/90/2903-035 9$02.00/0 © 1990 by the American Academy
of Child and Adolescent Psychiatry.
however , this tactic of ada ptation (i.e., coping with trau ma
via splitting it off' into different "selves") may be repea ted
as often as the individual rinds it necessary or helpful in
dealin g with repeated incid en ts of fear, pain , or abuse .
Alter perso nalities have two basic fun ct ion s: ( I) to se-
quester trau matic affect, sensa tion, and memory so that the
host personal ity is protected from such ma terial , and (2) to
help cope with the env iro nment (both external and internal) .
As a consequece of those functions , each alter has " its ow n
relatively enduring pattern of perceivin g , relating to , and
thinking about the enviro nme nt and one's sc lf" (A me ric an
Psychi atric Association, 1987 , p . 1( 6). Crite rion A for MPD
in the DSlvl-l/I-R requ ires that two or more such dist inct
personalities or personality states be present. T he second
(and only add itional) criterion in DSM -Il/-R is that " At least
two of these personalities or person ality sta tes recu rrentl y
take full control of the person ' s beh avior " (p . 1( 6).
Although MPD was pre viously considered to be rare ,
rece nt research on the c linica l phenomenology of MPD
(Kluft , 1985b; Putnam et al ., J 986; Coons, 1988 ; Ross et
al, 1989b; Schultz et al. , 1989; Ross ct a!., in press) strongly
sugg ests that MPD is not so much rare as it is well -hidden .
Because MPD is characteristically an adaptation to a chro n-
ically dangero us and abusive chi ldhood environmen t, there
arc exce llent reaso ns why these patients and their alters keep
a low profile and delib erately try to hide their " switches "
and periods of amne sia .
Subjects and Method
Subjects
The suhjec ts of this st udy are the II adolescents see n by
the authors over the past 4 years , who were d iagnosed as
M PD , and who were the n followed in therapy . Eight of the
II were specificall y referred by the previous ther apist (or,
in one case, by the patien t' s MPD mo the r) for evaluation
of possible dissociative symptoms. The remaining three were
ge neral refer rals for psych oth erapy .
Procedures
All patient s anel thei r fami lies (to the extent that the latter
were accessible) were see n for standard clinical evaluat io ns;

359
DELL i\N D E1SEN I IOWER

the famil ies actively par ticip ated (on a case by case basis T AllLE I . Symptoms Detected during the First Three Contacts with
to the extent deemed appropriate) in the therapy . A Behavior JJ Adolescent Patients with Multipl e Personality Disorder
Problem Checklist (BPC) (Fagan and McMahon , 1987) was
Cases
completed on each patient. Th e BPC is a 20 -ite m checklist Case No. with Symptom
of behaviors tha t arc common and typi cal for children and Symptoms 2 3 4 5 6 7 S 9 10 11 (%)
adolescents with MPD (Fagan and Mclvlahon, 1984) .
Depression x x x x x x x x x S2
All patients met strict D SM-fll-R crite ria for MPD. In
Voices x x x x x x x x x 82
addit ion, NIM H research standards for the dia gn osis were Amnesia x x x x x x x x x 82
also applied, Th us , diagnosis of multiple personality re- School Prob. x x x x x x x 82
quircd that the ther api st meet one or more distin ct alter Bchav. Prob. x x x x x x x x 73
person aliti es , on rep eated occ asions , in a patient with both Nightmares x x x x x x x 64
con tem porary amncsias and a history of arnnesias that pre- Headaches x x x x x x 55
dated the pat ient's entry into therapy with one of the auth ors. Drug Abuse x x x x 36
In an e laboratio n of Fa gan and McMahon 's ( 1984) cla s- Violent x x x x 36
sification system , the present study classified pat ient fam- Self-Muli!. x x x 27
ilies as ( I) fundam entally supportive, (2) narcissistic/re- Phobia x x IS
Eating Dis. x x 18
jecting, or (3) profoundl y abusive. Fund amentally supportive
fam ilies have parent s who arc empathic, cooperati ve , and
suppor tive . Th ere is little or no charac ter pa thology presen t
in the family , and the parent s arc willin g and helpfu l par- previou s diagn oses is 1.36 (range , 0 to 4). Th e mo st co m-
ticip ants in the therapy . Narcissistic /rejecting famili es have mon prior dia gn oses were mood d isorders (27 %), conduct
parents who are embattled with one anoth er, und ercmpathi c , disord er ( 18%) , and borderline person alit y disord er (18%).
emotionally abusive , and may be som ewhat ph ysically abu-
sive as well. T hey ea sily beco me angry and rejecting toward Beh avior Probl em Checklist (BPC)
thei r MPD ado lesce nt and arc underre spon sive to therapeutic The most co mmon beh av ior problem s (Table 3) in the II
input. Both the parent s and the MPD adolesc ent tend to MPD adolescents were extre me changeability in school pe r-
have sig nificant cha racter path ology . Profoundly abusive formance , majo r forgetful ness , and repe atedly going into a
Iamilics have parent s who arc inten sely angry, co ld , and daze or tranc e- behaviors manifested by over 90% of the
sad istic, or arc maj or enable rs of the spo use ' s unremitting patient s in this study . Over 80% were perceived a liars,
abuse . Th e emotional abus e in these fa milies is severe and exhibited big changes in personality, and perplexed the
chronic; entrenched se xual and /or ph ysical abuse may also teachers, counselors, principals, and therap ists who had been
be present as well. Both the pa rent s and the MPD adolescent dea ling with them . The mean BPC score attained by the
have major character pathologies . Such famili es tend to be patient s in this study was 12 .7 (range , 10 to 19).
highl y resista nt to treatment.
Traumatic!Dissociat ive H istory
Demograph ic Chara cteristics All pa tients rep orted a histor y of previous trauma (Ta ble
At the time of int ake, the mean age of the pati ents was 4) . Ten pati ent s (9 1%) reported a hist ory of abuse ; one
14 .7 years (range 12 .3 to 18 .8 yea rs). All patient s but one patient (9%) rep ort ed a traumatic hist ory that consisted on ly
were Cau ca sian ; on c was black . Seven patients (64 %) wer e of medi cal/surgical traum a . Eight pati ents (73 %) reported
female and four (36%) were male . Eight of the patients sexual abuse , eight patients (73 %) reported ph ysical abu se ,
(73 %) were trom mil itar y famili es . Th e occ upationa l cat- and nine patients (82%) report ed emo tio nal abu se . The mean
egori es of the paren ts of these patients were predo minantly num ber of different types of trauma (sexual abu se , ph ysical
cle rica l/sa les/technician (55%) and executi ve (27 %) . abuse, emotional abuse, injury, medi ca l/surgical trauma)
report ed was 2.4 (range , I to 4) . Although not all trauma
Presentin g Symp toms and abuse reported by these MPD patients could be ind e-
T he symptoms found dur ing the first three interviews are pendently veri fied , some ind epe ndent corroboration wa s ob-
listed in Tab le I. Th e mos t common symptom s were depres- tained in 73 % of the cases .
sion, sch ool problem s , auditory hallu cination s (voices heard Dur ing the co urse of therap y, the patients in this study
within the head ), am nesia, and beh avior problcm s-i-each reported that their first alter person ality wa s du e to abu se
o f which was rep orted by three-qu arter s of the patients in (82% o f ca ses) , med ical/sur gical trauma (9 % of ca ses) , or
this study . injur y (9% of cases) . Th e mean age at which the first alter
was produced was 3 years, 1 month (me dian = 3 ye ars ;
Prior Diagnoses (by Previ ous Therapists) range, I to 6 years of age).
Seven patie nts (64 %) had undergone a prev iou s course
of therapy . The mean number of prior ther apists seen by Patients' Families
the II patient s was 1.72 (range, 0 to 6) . Three patients had Si x o f the patient s (55%) were living with both natural
undergone a psych iatr ic hospit alizati on prior to comi ng to parents; three patient s (27 %) were living with their natural
one of the authors fo r treatment. Previou s diagnoses of the moth er and stepfathe r; one patient (9%) was ado pted before
I I patient s are listed in Table 2 . Th e mean number of the age o f one ; and one pati ent (9%) was livin g with paternal

360 J. A m . Acad . Ch ild A do/esc . Psychia try, 29:3, Ma y 1990

 ADO LESCEN T MULTIPLE I'U~ S O N i\U T Y DISORDI\ R

T A BL E 2. Therapy or11 Adolescent Patients with Multiple Personality Disorder

Case Age at Pre sen ting Diagnosis of BPC Fam ily Months in
No . Diag nos is Sex Symptoms Prior T herap ist Sco re T ype T he rapy Ou tcom e
I 12 .4 M Suieid ., phob ., voices N /1\. 11 Suppor tive 31 Integratcd
2 12 .3 F Lying , am nesia, voices N/A 10 Nareis s.lRej ec!. 29 Integrated
3 17 .8 F Wa nted sex- cha nge 00 , !D , DD , 13 Narci ss .l Reject. 27 Integrated
G!D
4 16. 8 F Bul imic , dcpress ., violent Bulimia , DO 10 Narciss./ Rejec t. 20 Progr essing
5 15 .3 M Deli nq ., sub st . abuse N/A 14 Supportive 20 Progressing
6 14 .9 F Suicid .. violent BPD , CD 19 Narciss .lReject. 10 Failure
7 12 .8 F Voices , threats , suicid . BPD , AD P 12 Narc iss .l Rejec t. 7 Failure
8 18 .8 F Vio lent , am nesia AD , ADD 16 Profoundly ab usive 0 Fai lure
9 13.4 M Bcha v. sch ool prob s. CD , SOD 11 Pro foundly abus ive 0 Fa ilure
10 12 .7 M Dcprcss . , amne sia , voices DO 10 Nareiss.l Reje ct. 4 Progrc ssing
II 14.0 F Depress. N/A 14 Profound ly ab usive 3 Fa ilure
Note : Suicid. = suicid al; Phob. = phobi c; Threats = threats to kill; 00 op pos itional disor der; ID = identity diso rde r; DD = dysthym ic
disorder; GID = gen de r identit y disorder; BPD = borderline personality disorder; CD = co nduct disorder ; ADP = affecti ve di sorder with
psychot ic features; A D = adju st ment disord er; ADD = atyp ical dissoc iative d isorde r; SD D = spec ific deve lopmenta l disorder; a nd Narciss.l
Reject. = narcissistic/reject ing .

T ABLE 3. 1nciden ce of SYIIIPIOIllS 0 11 the Beha vior Problem fact that 73% of the eases were re ferred bec ause the pare nt
Checklist (BI'C) ill the Clinical Presenta tions of I I Ado lescents with or prior ther apist was noti cin g dissociat ive sy mptoms . Of
Multiple Personality Disorder the three remaining patien ts (who had not been refe rred for
Patients a dissociative evaluation) , suspicion of M PD wa s raised
with the when a stark amnesia was detected in two patient s and when
No . of Pat ients Sy mptom a sponta neo us switch was obse rved in another patient. Di-
Symptom with the Symptom (%) agnos is was faci litated not o nly by the detection of amnesia,
1. Schoolwor k ver y changeable II 100 but also by the patient s ' past histor ies , scores on the I3PC ,
2. Dazes , tra nces 1() 91 and by the presence of vo ices heard w ithin the head . At the
3. Major forgetfulness 10 91 time of d iagno sis , the host pers on aliti es of a ll I I pat ient s
4. Big chang es in personality 9 82 were totally unaware of the presence of alter pers onaliti es .
5. Lyi ng 9 82
0. Perplexes professionals 9 82 Concu rrent Diagnoses
7. Discipline is ineffect ive 8 73
8. Suicidal 7 64
All patients had f eatures of several additiona l d iagnoses
9. Stealing , destructi ve 7 64 and me t the full DSM -Ilf-R crite ria for at least one add itional
10. Illnesses/injuries 7 64 diagnosis (mea n = 1.8 ad ditio nal diagnoses; rangc = I to
II . Odd changes in physical skills 0 55 3); 64% had mood disord ers, 55 % had d isrupti ve be havior
12 . Behavior pro blem in school 0 55 disorders (36% = co nduct disord er; 36% = oppositiona l
13 . Stoi c in face of punishment 0 55 defi ant disorder) , 45% had posttrau matic stress dis order
14 . Uses more than one nam e 6 55 (PTSD), 18% had borderl ine perso na lity disord er, and 9 %
15. Aggressive/ho mic ida l 0 55 had bulimia anorex ia, spec ific deve lop me nta l disorder , or
16 . Hysteria 5 45 person ality disorder, NOS. It is impo rtant to note that ini-
17. Early sex 5 45
tially the authors did not co nside r any of these ado lesce nts
18. Se lf-injurio us 5 45
19 . Tru ancy 5 45
to have PTSD. Yet , as add itiona l data (so me of it previously
20. Lonely 4 36 dissoeiated or hidden ) we re gat hered, it becam e clear that ,
in fact , 45% of these MP D cases had PTSD that was present
but undetec ted at the time of their initia l eva luat ion . More-
relatives. All but three families were military . Fam ily types over , as is typical of ad ult cases of MP D , the major ity (82 (7'0)
are listed in Tab le 2: 18% of the families were supportive, of these adolesce nt patient s developed tlo rid PTSD du ring
55% narcissistic/reject ing , and 27% profoundl y abusive . In the uncoverin g! abre active stage of therapy .
73% of the families one or both parent s had a diagnosab le
dissoci ativ e disord er (Table 4) . Four of the moth ers (36%) Alter Personalities
were strict DSM-Ilf -R cases of MPD . In three cases , (27%), The patie nts had a mean numb er of 24. I alter pers ona lities
data was either unava ilable or insu ffi cient to determine (fem ales = 28 .7 and males = 16.0). In ea ch patient, only
whether one of the parents had a dissociati ve disord er. a handful of alters wer e we ll-deve loped persona lities that
frequ ent ly assum ed exe cutive co ntro l of the bod y. Th e re-
Diagnosis of MPD maining alters in eac h patien t typi call y we re less e laborated,
Each of the I I patients was suspected of being multiple "came out" in frequently , and (at the beginning of treat-
within the first three ses sions . In part , this was due to the merit ) tended to have relative ly litt le kno wledge o f the pa-

l .A m . A cad . Child A do/ esc .Psychiatry, 29:3 , May 19 90 36 1

DELL AND E ISENHO W ER

T A Il L E 4 . The Traumatic/Dissociative Histories of 1J Adolescent Patients with Multiple Personality Disorder

C ase No . Age Whe n fi rst First A lte r Ot her Dissociati ve
No . o f A lters Alter Produced Du e To Ab use A bu sers Parcnt(s)?
I 5 I Y, Medical trauma None N/A M PD
2 48 2 Sexual abu se Phys .zcmot . M gfa ; Bro . MPD
3 24 3 Sex ua l ab use Emo tion al Unc le; parents DO
4 33 3 Phys ./e mot. abuse Se xua l/rape Fa . ; boyfrien d DO
5 9 6 Phys .zemot . ab use Sex ual Mot her M PD
6 69 I Se xual ab use Phys ./e mot. Mgfa; Fa . ; Bro . MPD
7 (j 3 Injury Rape Ba by sitter Unk now n
8 8 2 Sex ual ab use Phys./emot. Fa . ; Bro . ; Pg fa Unknow n
9 25 ? Phys ical abuse Emo tiona l Une . ; Fa . ; Stepbro . DO
10 25 (j Phys .le mot. abuse Non e Father DO
11 13 3 Se xual abuse Phys .lemot. Father Unknown
Note: DD = d isso c iative d isord er ; Mgfa = mate rn al gra ndfathe r; and Pgfa = paternal gra ndfather.

tient' s life histor y. Nevertheless , all personaliti es had the
ability to ass ume full exec utive contro l of the body- usually
with the host personality being fully amn esic for their ac-
tivities. Almost eve ry alter personality encountered in these
I I patien ts has , during the course of therapy , recalled and
abreacted a specific eve nt or situation that app eared to be
the po int of origin or cause for the exis tence of that particular
alter.
The types of alter personaliti es enco untered in these I I
patients were quite similar fro m case to case . All patients
had child alters, scared alters , depressed alters, and angry
protector alters. Persecutors and internal help ers were found
in 82% of the cases. Alters of the opposi te sex from the
patient were found in 73% of the cases , violent alters in
64% of the cases, sexualized alters in 55% of the cas es ,
and suicidal alters in 50 % of the cases.
Th erapy
The therapy was conducted on an outpatient basis, but
four patients (36%) requi red varyi ng peri ods of inpatient
care durin g their treatment. Half of the cases req uired eith er
the involv ement of child protect ive servi ces or temporary
foster placement in order to provide a sec ure environment
for the patient.
All cases that did not dro p out of therapy are either in
the process of integra tion (27 %), or have fully integra ted
and arc con tinuing in postintegration therapy (27% ). Th e
remaining 45% of the cases quit ther apy and are co nsidered
to be treat ment failures. All cases from supportive families
have done well in therapy and all cases from profoundly
abusive fam ilies have done poo rly . The mean length of time
in therap y has varie d directly as a function of treatment
outcome: failures (6 .4 month s), progressing, but not yet
integrated ( 14.7 month s), and integrat ed and continuing in
postintcgrati on therapy (29 .0 months).
All cases that dropped out of the rapy with the authors are
classified as treatm ent failures. Follow- up on the five cases
that dropped out reveals that three of the five (60% ) have
since been hospitalized (mea n = 2. 67 times; range, I to
6), one or the five (20%) has been in da y hospit al , and four
of the five (80%) have had other co urses of therapy . At
present, one patie nt is in therapy for MPD , one is in therapy
for a different diagnosis, one is in day hospi tal bein g treated
for a different diagnosis , and one is in a detenti on ce nter.
T he Process of T herapy
In keepi ng with the step-by-s tep approaches advocated
by Fagan and Mc Ma hon (19 84), Braun (19 86), and Kluft
(l986b), the thera py of the I I adolescents was und ertaken
in a methodical , systematic fashio n. Once the diagnosis of
MPD had been mad e , the init ial tasks of the therapy were:
(I ) to deto xify the patient ' s environment by stopping all
forms of abuse ; (2) to stabilize the pati ent, the famil y , and
the patien t' s sys tem of alters; and (3) to devel op a thera -
peutic alliance with the patient , the family , and the patient ' s
alter personalities. These tasks see m to constitute the foun-
dation for the therapy. Failure to successfully lay this foun-
dation led to therapies that were difficult , chaotic , and prone
to failure .
Detoxificati on , Stabilizati on and A lliance-B uilding . Th e
achieve ment of detoxification , stabiliza tion, and alliance-
buildi ng required an active, interventionist style of therap y .
Detoxification of the adolescent' s environment necessitated
the use of famil y therapy (seven cases), notifi cation of child
protect ive services (six cases), use of temporary fos ter place -
ment (three case s) , and alternat ive edu cational arra nge ments
such as hom ebound instru ct ion , day hospital , or changi ng
schools (seve n cases). With persistence, it was possible in
most cases to stop all use of corporal punishm ent. Emo-
tiona lly abusive parent ing , ho wever, was much more dif-
ficult to neut ralize-s-especi ally in the nar cissistic/reject ing
and profoundl y abusive families .
Psychoeducation , Detoxification , stabilization, and alli -
ance-building were , to a sign ifica nt degree , accomp lished
by means of a psycho-education al appro ach. Pati ents , alters,
parent s , and sib lings were sys te matically educated abo ut
traum a , dissociation , MPD , the functio n of alters, and the
dynam ics of flashb acks and other posttraum atic reen act-
ments.
Wheneve r possible , pare nts and siblings were introduced
to alters durin g family thera py sessio ns. The se expli cit en-
counters between alters and fam ily memb ers help ed to foster
the developm ent of relation ships between the family and
the alters. Educa tion and alliance-building was also fur-

362 l. Am . Acad. Child Adolesc. Psychiatry , 29:3, May 1990


thered by minor hypn oti c inter ventions (e .g ., safe roo m
technique , ego stre ng thening, hypnotic sleep, self-hypnos is ,
and silent abreacti on s) in orde r to ca lm distres sed alters and
increase the pati ent ' s sen se of se lf-contro l.
Contracting . Th e next major task o f the therapy was
contractin g: ( I ) w ith each alter for co mmitment to the proj ect
of thera py , and (2) with the family for a commi tme nt to
therapy and to non abu siv e d isciplinary procedures . Thi s was
usuall y the turnin g point of the therapy and was often dif-
ficult to accomplish. Contracting required rep eated expl a-
nation , negotiation , fear reduction , and steady confrontation
of defen ses , charac ter path ology. and dysfuncti on al patt ern s
of interactio n am on g parents and patien ts , and among the
alter person aliti es as wel l. In so me case s , negot iation ove r
contracts was pro longed, co nflictua l, and was only achi eved
after und ergoing the disc omfort of various cris es and real-
izing the ut ility of the cont ract bein g soug ht by the therapist.
In othe r cases, however , these same sorts of crises led not
to co ntracts, but to the rejec tion of the therapy (three cases),
and/or the rejection of the ado lesce nt by the parents (two
cases), and/or thc rej ection of the parents by the adolescent
(one case) .
Abreaction and working through. Onl y whe n co ntracting
had been successfully accomplishe d was it relativel y safe
to proceed to the most affec tively charged stage of therapy:
ex ploration of the traumatic pas t, abreacti on , workin g
through, achieveme nt of new und erstandings about the pa st,
and gri d wo rk . Pat ient s and alters frequ entl y were reluctant
to address pas t traumata , parti cul arl y when the adolescent
was not in acute distress . Sy mpto matic distress (e .g ., flash-
back s, self-injuri ng, suicide attem pts) and blunt enco unters
with the disadvan tages of being multiple often we re need ed
in order to motivate the adolescent to face his or her painful
past. Hypn os is wa s used ex tensively during this stage of
therapy to struc ture, fac ilitat e , and titr ate abreactions , and
to provide so me ca lm ing and soo thing afte rwards. T he fa m-
ily ' s und erstanding of flashbacks , dissociati on , and the
abreactive process was an invaluable support for this dif-
ficult work . In some cases (the yo unger adolesce nts), one
or both parent s attended abrea eti ve sess ions and achieved a
remarkab le degree of understanding and skill in help ing their
adolescent at hom e bet ween sessions .
Crises . Crises were common dur ing th is stage of the rapy,
but were often easil y handled via coaching , hypnotic inter-
.vcntions ove r the telephon e , and /or the prompt scheduling
of an ex tra thera py sess ion . Cri ses were less stressful than
they migh t have bee n bec ause earli er educat ional wo rk made
the crises co mprehe ns ible to the famil y. In tho se fa milies
where cri ses neces sitated a psy chi atric hospitalization (four
cases), the situation often became more difficult. The hos-
pital staff's discomfort and unfam iliarity wi th MPD tend ed
to ge nerate skepticism abo ut the diagn osis , cou nter-pro -
du cti ve and even abusive therapy approaches, and power
stru ggles with the pa tient, the parents , and the outpatient
therapist (Dell, 1988a, b ; Kluft, 1988b) .
Integration . Integration is a natural con comitant and out-
gro wth of abreac tion and wo rking throu gh. As eac h alter
fini shed metabol izing his/h er trau matic history , and was no
longer needed to ca rry out some crucial functio n, he/she
l.Am .Acad. Child Ado/esc. Psychiatry, 29:3. May 1990
ADOLESCEN T MULTI PLE PERSONALITY DISORDER
was helped ( I) to reco nc ile with other alte rs and (2) to
integrate with the host personalit y (or another alter) by means
of a hypn oti c fusion ritual.
Post integration , Postintegrat ion therapy (four ca ses ) has
focused on (1) additional working thr ough , (2) rest oration
of function al boundaries and co mmunication in the famil y
and the marri age, (3) regul ar chec king of the stabi lity of
the integrati on (Kluft, 1985c) , and (4) continual alertness
for the presen ce of hereto fore hidd en alters . Th ese latter
check-ups will continue during period ic foll ow -up ses sions
for the next sev eral years .
Discussion
The data in this study eme rged from clin ical practic e
rather than from a caref ully planned research de sign. As
such , the study is som ewhat limited by the abs ence of con-
trol gro ups and standardized measures of psych opathology .
The sa mple size is sma ll and is dra wn fro m a dem ograph-
ica lly unique popu lation (heavily mil itar y) . It is uncl ear to
what ex tent these factors ma yor may not have biased the
current findings about the clinical phenomenol ogy and treat-
ment of adolesce nt pati ents with MPD . With the exception
of the gre ater number o f alters per patient, all data on the se
I I cases are highl y co ngrue nt with previou s reports abo ut
child , ado lesce nt , and adult MPD .
Presenting symptoms. The present ing symptom s of the se
adolesce nts with MPD are highly simil ar to those previously
reported for adults with MPD : depression (Bliss , 1980 ; Blis s
et aI. , 1983; Horevitz and Braun , 1984 ; Kluft , 1985b ; Put -
nam et al. , 1986; Coons , 1988; Ross et aI. , 1989b ) ; vo ices
(Bliss , 1980 ; Bliss et aI., 1983; Kluft , 1985b ; Putnam et
al. , 1986; Coons , 1988 ; Ross et aI. , 1989b ); and amnesia
(Bliss , 1980; Kluft, 1985b; Putnam et aI. , 1986; Co ons ,
1988 ; Ross et al.. 1989b ) .
Th e presenting sy mp toms and beh avior probl em s arc also
quite co nsistent with those previou sly reported in children
with MPD: depres sion (Des pinc, 1840; Fagan and Mc-
Mahon, 1984; Kluft, 1985a; M alenbaum and Russell, 1987),
voices (Des pine , 1840 ; Fagan and McMahon , 1984 ; Kluft ,
1985a; Male nba um and Ru ssell , 1987 ), amn esia (Des pine ,
1840 ; Fagan and McM ahon, 1984; Kluft , 1985a ; W eiss et
aI., 1985 ; Riley and Mead , 1988) , sc hoo lwork very change-
able (Fagan and McM ahon, 1984; Kluft , 1985a), and tra nces
(Despine, 1840 ; Fagan and McMahon , 1984; Kluft, 1985a;
Weiss et al. , 1985 ; Rile y and Mead, 1988) .
The sy mptoms of the patient s in this study also correspond
to those prev iou sly report ed in adolesce nts with MPD :
de press ion (G rue nwa ld, 1971 ; Ho rton and Miller , 1972 ;
Kluft , 19R5h), vo ice s (G ru enwa ld , 1971; Bowman et al.,
1985), amnesia (Alexander , 1956; Gru enwald , 1971 ; Hor-
ton and Mill er , 1972 ; Bowman et aI. , 19 85 ; Kluft , 1985b ) ,
and sudde n shifts of mood and behavior (A lexande r, 1956 ;
I-lorton and Miller , 1972 ; Fag an and McMahon , 1984 ; Bo w-
man et al, 1985; Klu ft , 1985b ) .
In short, the adolesce nt MP D pati ents in th is study pre-
se nted with elini cal symptoms that are typical o f pre viou sly
rep orted cas es of child , ado lescent, and adult MPD .
Prior diagnoses. T wo of the thre e most co mmon diag-
noses made by previou s therapists (moo d disorder and bor-
363
D ELL A N D EI SEN HO W ER
derline personality) arc typical of adults with MPD. Putnam
et al. (19 86) reported that ov er 70% of the MPD eases in
their sample had previou sly been given depressiv e dia g-
noses. Both Hore vit z and Braun ( 198 4) and Coon s ( 1988 )
noted that a large percent age of their ivIPD pati ent s also met
the dia gnostic cr iteria fo r bord erline person alit y disord er.
Concurrent dia gnoses . Th e mo st co mmo n con current di -
agnoses in these MPD patients (i.e . , mo od disorder , PTSD,
conduct disorder, oppositiona l defiant disorder, and bor-
derline person alit y disorder) are frequ ent cl inical concom-
itants o f ab use and trauma . Thi s link between traum a and
these concurrent diagnoses is highlighted by the fact th at
all five cases who had PTSD at the outset of therap y also
met the d iagnostic criteria for a disrupti ve beh avior d isorder.
Moreover , thei r disru ptive beh avior wa s subsequently found
to be controlled by alter personal ities wh o were experiencing
aeute flash backs and/or respon din g angrily to the ab use of
others. Othe r researchers have also not ed that children with
PTSD typicall y are initia lly di agnosed as having a disru ptive
behav ior diso rde r (Green , 198 3; Doyle and Bauer , 1989)
or a mood d isord er (G reen, 1983) . Accord ingly, the authors
bel ieve that , in most case s , MPD and PTSD should be
understood to be di agnosticall y superordinate to moo d dis-
order, co ndu ct dis order , oppositional defiant disorder, at-
tention deficit hyp eractivit y disord er , and borderline per-
sonality disorder. The authors agree with others who advocate
a co ncept of trau ma-spectrum d isor de rs (va n de l' Kol k , 1988 ;
Herman et al., 1989 ; Ross , 1989) and sugg est tha t childre n
and adolescent s who manifest disruptive beh aviors should
be very ca refully evaluated for a histor y of trau ma and the
possible presence of PTSD and /or diss ociative disorder.
Hist ory of traum a and dissociation . The 100% incidence
of childhoo d traum a and abuse in thi s sa mple is virtually
identical to all recent dat a on adult MPD patien ts . Putnam
ct al, ( 1986) , Coo ns ( 198 8) , Ross et al. , ( 198 9) , and Sch ultz
et al. , ( 1989) have re ported a 96 to 98 % incide nce of abuse
and trauma . Alth ou gh two ado lescent case report s clearly
document abuse (Gru enwald , 1971; Bowman et al. , 1985) ,
thc liter ature on adolescent MPD is so sparse and sketchy
that the incide nce of abuse in that pop ulation ca nnot be
estimated . Klufr ' s data on the inc ide nce of trauma and abuse
in child MPD is virtua lly ide ntical to the presen t dat a on
adolesce nt MPD .
Alter personalities . T he mean age (3 . I ye ars) and median
age (3 years) at w hich the se patients produc ed thei r first
alter per sonality is similar to Kluft 's (l 985a) chil d sample
(me an = 4 . I years; median = 3 yea rs) and somewhat
yo unge r than that rep orted by Bliss ( 198 0) (mean = 4 .8
years; med ian = 5 years), Coo ns ( 1988) (mean = 6.7
years), and Putn am et al. (19 86) (mea n = 5 .98 yea rs ; me-
d ian = 4 yea rs). Co ons , however , not es that his data on
alter personalities were coll ect ed fa irly ea rly in the ther ap y
process and may have omitted alters that would later be
uncovered. The dat a of Bliss and Putnam et al . wer e col -
lectcd at a tim e wh en therapi sts were less sophistica ted in
thei r awaren ess of the cli nical features of MPD (Schu ltz et
al. , 1989) and, as a result , may have ov eres tima ted the age
at which the ir cases firs t becam e multip le .
Hum an memory is a rec on stru cti on rather than a verid ica l
364
replaying of an immutab le memory trace. As such , recall
of trauma nec essarily contain s some degree of inaccuracy.
No ex haustive effo rts were mad e to ver ify the age or det ails
of tra umat ic events that were reli ved during abrcactio ns .
That would be ap pro pr iate to a for ensic evalua tio n, hut not
to a co urse of psych oth erapy . On the othe r hand , pa tients '
recall of tra uma wa s di scu ssed with the famil y (to the ex te nt
deemed appro priate) as part o f the process of normalizati on ,
working through, and int egration of traumatic ex perience .
Such discussion with the family frequ ently elicited corro-
borative or supportive data: (I) report s that the alleged abuser
had access to the child at the appa re nt tim e of the trauma ;
(2) repor ts of sudden changes in the child 's behav ior at that
time ; (3) witnes sing of the actual abu se (or simi lar behavior)
by the ab user; (4 ) reports that the sexual abuse wa s not
witn essed, but that the abu ser had sexually abu sed the ad-
olescent' s moth er as a ch ild ; (5) direct corrob oration of
inj ury or surgery; and (6) direct corrobo ra tion by the abu sive
alter person alit y (of the adol escen t' s MPD parent ) who had
assaul ted the child .
Putn am ( 1989) has recentl y co mmented on the interest ing
phen omenon of stead ily greater numbers of a lter s be ing
reported in MPD eases sin ce the turn o f the ce ntur y . Du al
personalities were frequent then, with se ldom more than a
total of three or fo ur alters . Mod ern se ries of MPD cases
have reported stead ily greate r numbers of alters : A lliso n
( 1978) (mean = 9 .7) , Bliss (198 0) (mean = 7 .7) , Kluft
( 1984b) (me an = 13. 9), Putn am et al. ( 1986) (mea n 13 .3) ,
Ross ct al. ( 1989 b) (mean = 15.7) , and Sc hultz et al. (1989)
(me an = 17). Th e numhe r of alters in the present study
(mean = 24.1) appears to co ntinue th is trend. Putnam sug-
es ts that " (p)art of the explanation may be that modern
therapi sts are mu ch more willing to seek out and identi fy
alters who do no t declare them sel ves overtly" (pp .39 -40).
In a simi lar vein , Schultz et a!. (I n9) sug gest that the trend
to rep orting more alters is occu rr ing be ca use " thera pists are
bec om ing more sophisticated in their aw are ness of the clin-
ical features of multiple personality " (p. 48).
Some clinician s have been concern ed about the possibl e
iatrogen ic creatio n of alter pers onalities-s-especially wh en
hypn osis is employed. Exte nsi ve co nsideration of iatroge-
nesis is bey ond the scope of thi s paper , but several po ints
ca n be outlined br iefl y . F irst , research has show n that MPD
pati en ts who were treated with hypn osis do not ha ve more
alters than MPD patient s treated without hypnosis (Putnam
et aI., 1986; Ro ss and Norton, 1989). Se cond, ex perts wh o
treat MPD do not find mo re alters in their pat ient s than are
found by Canad ian general psychiatrists who have treated
only a few MPD patients (Ross et al. , 1989 a) . Th ird , j us t
as the tre atme nt of sexual abuse is typi call y characteri zed
by a pattern of unfolding discl osure of abuse eve nts , so too
is the treatm ent of MPD typi call y characte rized by a pattern
of unfolding disclosure of add itiona l alters (wh o harbor the
knowled ge of additional abuse ev ent s) . This natural and
charac teristic process of unfolding disclosure of the presen ce
of more alte rs is sometimes misunder stood as a process o f
iatro gen ic crea tio n of new alters (K luft, 1989 ). Fo urth , MPD
patient s ca n (and wi ll) pr odu ce new alters during treatment
if the therapist makes technical errors or retraum atizes the
l.Am .A cad. Child Adolesc. Psychiat ry , 29:3, May 1990

pati ent (Kluft, 1982 ; Brau n , 1984 ; Fine, 1989 ; Kluft , 1989 ;
Totem , 1989 ) , but the overw he lming majority of a lters that
surface durin g ther ap y arc pr ee xistin g , heretofore hid den
o nes ( K luft , 1989 ) . Fina lly , these concerns (about exte ns ive
iatro geni c proliferati on of alters) may prove to be simply a
tran sient stage in psychiat ry's le arn ing abo ut the power and
effective nes s of di sso ciati ve copi ng . Afte r all, it seems quite
likel y that thos e children (w ith sub stantial d issoci ative ab il-
ity) who are rep eatedl y abus ed wou ld, in turn , re pe ate d ly
use the most e ffec tive co ping mech ani sm at their d isposal
(there by produc ing more and mo re a lters) .
Th e adolescent w ho had no history o f abu se (Case I ) is
informative in thi s regard . He sp lit as a result of medic al!
surg ica l trauma in very ea rly childho od and proceded to
form addi tiona l alters in the absence of abuse. The authors
have seen this same phenomen on in two childhood cas es of
MPD (ages 6 and 10) as well. T hus, it seems clear th at
abuse, while virtually ubiquitou s in th e histories of MPD
ca ses , is not a sine qua non for M PD . Moreover, the fac t
that add itional product io n of alters ca n occur (in the ab sen ce
of eit he r frank abuse o r an y furthe r major trauma) sug ges ts
that pati ent s find thi s di ssoci ati ve defen se to be a psych o-
logicall y e ffec tive mean s fo r handling even nont raumati c
life difficulties. Thus , the reports of inc rease d num bers of
a lter s may not o nly be a conseq uen ce of therapi sts ' greater
cl iniea l se ns itivity to the p res e nce of hi dden alters , but may
a lso ea ll fo r a great appree iatio n of th e prim itive and com-
pe lling effectiveness of d issoci ation . O nce begun, the d is-
soc iat ive productio n of alters may become a cha ractero-
logical or preferred st yle of proble m so lv ing in bo th those
situat ions that are trau mat ic , and those that arc merel y un -
co mfor table .
Gender. Pre viou s research o n ad ult pati ent s ha s co nsi st-
e ntly indicated that MPD females outnu mber MPD mal es
by a 9 : I ratio (Putna m et ul., 1986 ; Ros s et al., 1989b ;
Sc hultz et al ., 1989). On the other hand , the femal e to male
ratio among reported child MPD ca ses is 2:3, and the ratio
amo ng reported adolescent MPD ca ses is 4: 1. Given thi s
trend for increasing age to be co rre lated with fewer rep or ts
of male MPD cases, the fe ma le to m ale ratio of the pr es ent
study (7:4) does not app e ar to be ano m alo us. It seem s pro b-
ab le that troubled and trou blesome boys are muc h more
likel y to be bro ug ht to th e atten tion of ther api sts than is the
case w ith men. Accord ing ly , the adult fe male to male rat io
of 9 :1 is more likel y an art ifact of c ulture and sex ro le
beh avior tha n a n acc ura te portraya l of the pre valen ce of
MPD in wome n and men .
Fami lies . Of the e ig ht fa mi lies where sufficie nt data we re
ava ilable to be able to ma ke a dia g no stic dete rmi nation , on e
or both parent s was d issoc iat ive in 100 % of the case s. In
four of these fa milies th e mother was a strict D SM-l/I-R
ca se of MPD . This appare nt ly tran sgc ncrat ional natur e of
dissociat ive sy mpto ms and M PD is supported by severa l
other stud ies (Braun, 1985 ; Coons, 1985 ; Kluft , 1985a;
Malenbaum and Ru ssell , 1987 ; Ross e t al . , 1989b ).
Therapy . Becau se MPD requires long-term therapy (Braun,
1986 ; Coons, 1986 ; Klu ft , 1986'1, 1988 c ; Putnam , 1989) ,
the treatment data pro vided in th is study can only be co n-
side red to be a prelim inary sna ps ho t of ongoing trea tm ent
l .Am. Acad. ChildAdolesc . Psych iatry , 29:3 , May 1990
ADOLES CENT M UI.TIPl.li PERSONA LITY DI SORDI ] {
progress o r failu re . Ne verthe less , the dat a arc strong ly
suggest ive of ce rta in trends : a ll pa tients who d id not d rop
out arc ei ther integrat ed or prog ressing in the process of
integ ratio n. All patie nts from profou nd ly ab us ive fami lie s
are treatment fai lures. A ll patient s from narciss istic / rejecting
famili es were d ifficul t to treat , w ith 40 % dropp ing o ut of
therap y . Th e rejection and emotio na l abuse in thes e lat te r
fami lies are not to be und erestimated beca use these paren tal
be havi ors are ex tre me ly to xic and highl y resis ta nt to c ha nge .
Emotiona l abuse and reject ion imme asu rabl y co mplic ated
the therapy of these MPD ado lesc e nts.
T he rapy w ith ad olescents is a del icate and ad ventu rou s
undertaking at the best of times . Because o f their stro ng
nee ds for autonomy , ind ividu at ion, and sel f-control , the
pace and intensity of the therapy with these MPD ad oles-
cents was typically slower and more modulated than with
ad ult patients. The author s fo un d it necessary to fun cti on
simultaneously as ther apist , coach, che erleader, and Dut ch
un cle . T eenage crises had to be negotiated , w aited o ut,
a fforded av uncu lar consultatio n , and intersp ersed w ith MPJ)
therapy. Similarl y, ad van ces in the MPD therap y itse lf o fte n
had to awa it sympto ma tic c rises and pa inful lessons lea rned
in life ' s sc hool o f hard kno ck s .
Fam ily ther ap y was qu ite helpful in most c as es , but a
substa ntia l m inor ity of ad olescen ts were e ngaged in suc h
thorn y intera ctio ns w ith thei r fa mi lies tha t, for lo ng per iods
of time, paren ta l counsel ing w as more useful tha n fami ly
therapy . Hypnosis was an invaluable ther apeuti c tool but
had to be offe red in a wa y th at gave spec ial atten tion to the
adolescent' s need for a utonomy , mastery , a nd sel f-d irec-
tion . In fa m ilies that we re supportive (o r not too rej ecting),
hypn osis and fam ily ther ap y we re able to be co mb ined .
Although the symptoms o f these ado lesce nts bear a marked
si mi lar ity to those of both M PD c hild re n and MPD ad ults ,
the therapy of these ad olescent s mor e closely resem bles th at
of ad ults than children . Th e alters of these adolescents are
more distinct and e laborated tha n those of most child re n .
A s a consequence, th ese ado lescents required long hours o f
abre ac tio n , working throu gh , and the eventual usc of hy p-
noti c fusion rituals to integrate a lte rs (as opposed to the
quick abre actio ns and - often spo nta neo us- integ ra tio ns of
alters in chi ldren with M PD).
Co n cl us ion
Adolescent MPD is appa rently not a rare clini cal ph e-
no men o n. In these II ca ses , M PD typicall y occurred in the
co ntex t of o ne or mo re co nco mi tant ab use/tra uma- re lated
d iagn oses (mood d isorder, PT SD , d isrupti ve be hav ior d is-
o rde r , a nd /o r b orderl in e pe rso na l ity d iso rde r) . Carefu l
sc ree ning fo r di ssoc iation in adolescents who sho w th ree or
more of the fo llowing sympto ms will frequentl y lead to the
un covering of a heretofore und iag nos ed case o f M I'D :
dep ression , di srupt ive be havior, mood swings , the he ar ing
of vo ices , sur prisi ng forge tti ng , ap pa re nt lying , trancing
out, and sharp c hange s of beh avio r. The treatment data
indicate that ado lesce nt M PD pat ients arc similar to ad ult
MPD pa tients and , in a sig nifica nt percentage o f c ases ,
respond quite well to an ac tive , structure d therapy fo r MP D .
Th e major predictor o f tre atment fa ilure was the cont inuing
365
 DELL AND EISENHOWER
presence in the home of any form of abuse; even emotional
abuse had a major deleterious impact on treatment outcome.
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