Lifetime Axis I and II Comorbidity and Childhood Trauma History in Dissociative Identity Disorder Joan W. Ellason, Colin A. Ross, and Dayna L. Fuchs ACCORDING to DSM-IV, dissociative identity disorder is characterized by the existence within the person of two or more distinctly different identities or personality states that from time to time take executive control of the person's body and behavior, with accompanying amnesia (American Psychiatric Associ- ation, 1994). By retrospective patient report, dissociative identity disorder usually occurs in conjunction with severe childhood trauma (Kluft 1985; Put- nam et al. 1986; Ross 1989; Ross et al. 1989a, 1990a). The disorder appears to be the most severe form of disturbance on the dissociative disorders continuum (Boon and Draijer 1993; Coons 1992; Ross 1985; Ross et al. 1992). There is evi- dence that dissociative identity disorder may be more prevalent than once be- lieved in the general population (Ross 1991) and among general adult psychiat- ric inpatients (Latz et al. 1995; Ross et al, 1991; Saxe et al. 1993). ‘The relationship between childhood physical and sexual abuse and psycho- pathology, as evidenced by dissociative identity disorder, has not yet been fully explored. Clearly, severe adulthood trauma leads to symptoms of posttrau- matic stress disorder (Carlson and Rosser- Hogan 1991; Mellman et al. 1992; Roszell et al. 1991; Shalev et al., 1993; Southwick et al. 1993), often accompanied by other comorbidity. In 48 Vietnam veterans di- agnosed with posttraumatic stress disor- der, for instance (Roszell et al. 1991), 64.6% of subjects showed evidence of a current major depressive episode. Be- tween 4.2% and.25% had anxiety disorder symptoms, including panic disorder, ago- W. Ellason, MA, LPC, is a Clinical raphobia, and social phobia; and lifetime drug and alcohol addiction was also sub- stantial (33.3% and 70.8%, respectively). Childhood trauma has been postulated. to be a precursor of borderline personality disorder (Goldman et al.. 1992; van der Kolk 1987; van der Kolk, et al. 1991). In particular, clinical studies have shown that physical and sexual abuse in early childhood, latency, and adolescence were significant predictors of self-mutilation and suicidality (van der Kolk et al. 1991). Among individuals with borderline pa- thology, there is often a high prevalence of reported childhood abuse (Braver et al. 1992; Coons et al. 1988; Goldman et al. 1992; Hurlbert et al. 1992; Nigg et al. in Joan ‘Researcher in Richardson, TX. TT ———————————————— ‘Dayna L, Pucks, PRD, is in Private Practice, For reprints contact: C research was supported wish to thank Drs. ey sarod ten Andrew Brylowald, Linda Richardson, TX. ‘A Nowe, MD. 1701 Gateway Suite 349, Richardson, TX ‘a grant from Charter Beh savioral Health Speen of Dla. ‘The authors .. Dennis Raymond, Art Arauzo, William W. Prater, ‘referrals. Hughes: and Jeroese Statonan for thar Beton PSYCHIATRY, Vol. 59, Fall 19961991; Ogata et al. 1990; Westen et al. 1990; Zanarini et al. 1989), neglect (Frank and Paris 1981; Paris et al. 1988; Zweig- Frank and Paris 1991), or a combination of both childhood abuse and (Gar- tner and Gartner 1988; Ludolph et al. 1990; Torgergen and Alnaes, 1992). In borderline personality disorder, the re- ports of childhood physical and/or sexual abuse have been as high as 75% to 81% (Herman et al. 1989; Perry et al. 1990). Clinical studies reveal that abused sub- jects manifest significantly more symp- toms of posttraumatic stress disorder, panic disorder, social and simple phobia, agoraphobia, major depression, and sub- stance abuse as compared to both non- abused general-population and psychiat- rie comparison subjects (Pribor and Dinwiddie 1992). On a self-administered instrument, completed by 98 adult female inpatients (Chu and Dill 1990), those who reported physical abuse histories en- dorsed significantly more severe interper- sonal sensitivity, anxiety, hostility, para- noid ideation, psychoticlike symptoms, and overall psychopathology than the pa- tients who reported no abuse history. Scores on a dissociative measure, in this study, were 32.4% higher among women reporting both a physical and a sexual abuse history than they were for the women who reported no abuse experi- ences. According to Kirby, Chu, and Dill (1993), severity and invasiveness of the sexual abuse, frequency of the physical abuse, and onset of abuse experiences have been linked to more severe dissocia- tive pathology. Anxiety, depression, dis- sociation (Briere et al. 1988; Anderson et al. 1993), and somatoform disorders (Roy- Byrne et al., 1993) have been documented throughout the clinical literature, regard- ing survivors of childhood trauma. Nonclinical studies show some similar- ity with the above findings also. In 2833 professional women, significant differ- ences were found between abused and nonabused subjects on anxiety, depres- sion, and dissociation (Elliot and Briere 1992), Moreover, regression analysis conducted on data from 502 general- ELLASON, ROSS, AND FUCHS population subjects showed that child- hood: hood physical and sexual trauma were sig- nificant predictors of Schneiderian first rank symptoms (Ross and Joshi 1992). The relationship between behavioral dysfunction and childhood abuse history has recently come under investigation (Briere 1992; Cavaiola and Schiff 1988; Goldman et al. 1992; van der Kolk et al. 1991). Individuals abused in childhood or adolescence exhibit problems with inter- personal relationships such as aggressive and manipulative behavior, distrust and ambivalence regarding closeness, sexual dysfunction, receipt and acceptance of vic- timization, avoidance behaviors (Briere 1992), and in extreme forms, self-mutila- tion and suicidality (Briere 1992; van der Kolk et al, 1991). One study revealed that abused adolescents were more likely than nonabused adolescents to manifest or re- port suicidal ideation and attempts, homi- cidal ideation, legal problems, sexual act- ing out, runaway behavior, accidents, and cruelty to animals and other people (Ca- vaiola and Schiff 1988). Dissociative identity disorder, which is understood to be a disturbance resulting from severe childhood abuse (Kluft 1985, 1991; Putnam et al. 1986; Ross 1989; Ross et al, 1989a), presents with a wide range of psychopathology (Loewenstein 1991; Putnam et al. 1984), including Schneider- ian symptoms, particularly in the form of auditory hallucinatinos (Kluft 1987; Ross et al. 1990c, 1990d), severe depression and suicidality (Coons et al, 1988), phobic anx- iety, somatization, substance abuse (Nor- ton et al. 1990), and borderline features (Benner and Joscelyne 1984; Boon and Draijer 1993; Buck 1983; Clary et al. 1984; Horevitz and Braun 1984; North et al, 1993; Horevitz and Braun 1984; North et al. 1993; Ross et al. 1989b, 1990a; Solo- mon and Solomon 1982). Loewenstein (1991) has presented a comprehensive outline of symptom clus- ters found in dissociative identity disor- der. Among these clusters are process symptoms, which include alter activity and switching behavior; amnesia symp- toms, such as memory blanks, fluctuation PSYCHIATRY, Vol. 59, Fall 1996DISSOCIATIVE IDENTITY DISORDER in abilities, knowledge, and habits, and disremembered events or acquaintances; autohypnotic symptoms, such as deper- sonalization, hypnotizability, and trance states; PTSD symptoms, including recur- rent flashbacks, sensitivity to triggers, feelings of panic, startle responses, numb- ing and avoidance; somatoform symp- toms, involving body memories and other somatic disorders; and affective symp- toms, which include mood swings, depres- sion, and suicidality. The posttraumatic adaptation in dissociative identity dis- order is apparently complex (Loewen- stein 1991). Putnam and his colleagues (1984) point out that dissociative identity disorder patients may exhibit the entire gamut of psychiatric symptoms and re- ceive multiple diagnoses. Although many efforts have been made to study the comorbidity of dissociative identity disorder (Armstrong and Loewen- stein 1990; Coons and Sterne 1986; Loew- enstein 1991; North et al. 1993; Putnam, et al. 1984; Solomon 1983; Wagner et al. 1983), none have involved a large clinical sample with comprehensive structured in- terviews. It is our expectation that exam- ining the overall pattern of DSM Axis I and II comorbidity within dissociative identity disorder may provide further in- formation on the effects of childhood trauma, specifically physical and sexual abuse, on mental state and character de- velopment. Given the apparent relation- ship between childhood abuse and many forms of psychopathology, it is expected that any diagnostic category character- ized by high levels of severe childhood abuse will report extensive lifetime co- morbidity. METHOD Subjects A total of 135 inpatients at Charter Be- havioral Health System of Dallas were se- lected on the basis of having a clinical di- agnosis of dissociative identity disorder (DID). Patients were diagnosed clinically PSYCHIATRY, Vol. 59, Fall 1996 by trained physicians specializing in dis- sociative disorders, using DSM-III-R (American Psychiatric Association 1987) and the proposed DSM-IV (American Psy- chiatric Association 1994) criteria. A diag- nosis of dissociative identity disorder by clinical physicians required the presence of DSM-III-R criteria and the DSM-IV criteria for dissociative identity disorder, plus clear evidence of switching of personality states. In this sample, the Dissociative Disorders Interview Sched- ule (DDIS) and clinical interview diagno- ses (by separate interviewers) had a 99.1% agreement rate. One DDIS inter- view resulted in a false-negative diagno- sis, in which the patient initially denied DID symptoms but later confirmed them in a subsequent clinical interview, estab- lishing a positive clinical diagnosis of dis- sociative identity disorder. ‘The investigation was conducted over a period of 18 months at a free-standing pri- vate psychiatric hospital. Permission for patient participation was granted from the internal review board and the attenc ing physician, and through written ii formed consent obtained from each pa- tient. Patients were referred from the chemical dependency, sexual trauma adult recovery, general adult psychiatric, select, and dissociative disorders units. Geographically, our patients were current residents of locations throughout the United States and Ontario, Canada. Procedure The Dissociative Experiences Scale (DES-Bernstein and Putnam 1986) and the Dissociative Disorders Interview Schedule (DDIS-Ross et. al. 1989c) were administered to measure dissociation and childhood trauma, and to gather demo- graphic information. The DES is a 28- item self-report measure with good valid- ity and test-retest reliability of 0.84 (Bernstein and Putnam 1986). The DDIS. is a 131-item structured interview with an overall interrater reliability of 0.68, a sen- sitivity of 95%, and a specificity of 100% for the diagnosis of dissociative identitydisorder (Ross et al. 1989¢). The poe is also designed to assess history, specifically, physical ‘mad sexual abuse by family members, relatives, and strangers and/or nonrelatives. The post- traumatic stress disorder (PTSD) section of the Diagnostic Interview Schedule (DIS-Wittchen et al. 1985) was adminis- tered also, because the version of the SCID used does not diagnose PTSD. ‘The lifetime prevalence of Axis I and II disorders was measured by the Struc- tured Clinical Interview for DSM-III-R (SCID I & II—Spitzer et al. 1990). One ex- ception to SCID I rules for interview ad- ministration was made. In several sec- tions, the interviewer is instructed to skip over a diagnostic area if the patient tests positive for a psychosis. Because dissocia- tive disorders are not considered to be psychotic in nature (Solomon and Solo- mon 1982), a SCID I diagnosis of schizo- phrenia or any other psychotic disorder did not result in sections of the SCID I be- ing skipped, as they usually would, All other DSM-III-R and SCID I exclusion rules were followed. The Beck Mood Inventory (BMI-Gal- lagher et al. 1983), the Hamilton Rating Scale for Depression (HRSD~Rehm and O'Hara 1985), and the Symptom Check List-90—Revised (SCL-90-R — Derogatis 1992) were also administered. Although interviewers were not blind tothe primary Axis I diagnosis, they were initially blind to other Axis I and II co- morbid pathology and abuse histories of the subjects prior to administering the DDIS and SCID. Of the total sample, 135 subjects completed the DES, 130 com- pleted the DDIS, 107 completed the SCID 1, 103 completed the SCID II, and 72 com- pleted the PTSD section of the DIS; no subjects were omitted-from the study on the basis of missing test data. Data Analysis Demographic data and abuse history items were tabulated. Mean values were calculated on continuous variables, and the prevalence of Axis I and II disorders ELLASON, ROSS, AND FUCHS was tabulated as percentages of subjects positive. RESULTS Demographic Data There were 12 males (9.2%) and 118 fe- males (90.8%); 52 subjects (40%) were married, 42 (32.3%) were single, and the remainder were either divorced, separated or widowed. Slightly over half (n = 77, 59.2%) were unemployed. Trauma Histories ‘The total number of subjects reporting a history of physical abuse on the DDIS was 117 (90%), and of sexual abuse 120 (92.3%); and 125 subjects (96.2%) re- ported childhood physical and/or sexual abuse. The modal number of physical abuse perpetrators identified per subject was 4(n = 25, 19.2%) and 40 (31.0%) sub- jects identified from 5 to 9 perpetrators. Of the types of sexual abuse items ident fied, 99 subjects (76.2%) reported experi- encing four or more different types of sex- ual abuse. Self Report Psychopathology ‘The average SCL-90-R score was 2.11 (SD = 0.68). The average BMI score was 33.14 (SD = 11.91), the average HRSD score was 43.81 (SD = 11.20), and the av- erage DES score was 49.8 (SD = 19.1, NV = 135). Axis I and II Diagnoses Table | illustrates the SCID Idata(n = 107); 88 subjects (82.2%) received a diag- nosis of a severe mental disorder. Major depressive episode was found in 104 (97.2%) subjects, but only 12 (11.2%) sub- jects met the DSM-III-R hierarchical cri- teria for this diagnosis when exclusion rules for psychosis were applied. On the DIS, PTSD was identified in 57 (79.2%) of the subjects. PSYCHIATRY, Vol. 59, Fall 1996DISSOCIATIVE IDENTITY DISORDER Table 1 Axis I Comorsupiry In DissoctaTIve IDENTITY DisorDER on THE SCID-I (N = 107) Positive Diagnoses NN % Mood disorder Major depressive episode 104 97.2 Bipolar I 10 93 Bipolar IT 8 75 Dysthymia 1 09 ‘Some type of mood disorder 105 98.1 Psychotic disorder ‘Schizoaffective disorder 5849.5 ‘Schizophrenia 20 18.7 Psychotic disorder NOS Se: saa! Delusional disorder 2 19 Schizophreniform disorder 0 00 Brief reactive psychosis 0 00 Some type of psychotic disorder 8 74.3 Anxiety disorder Panic disorder 4 69.2 Obsessive-compulsive 6863.6 Social phobia 49 458 Simple phobia 30 28.0 Agoraphobia 17 15.9 Generalized anxiety 1 LO Some type of anxiety disorder 96 89.7 Substance abuse/dependence Drug dependence 6358.9 Alcohol dependence 5450.8 Both drug and alcohol 45 421 Some type of substance abuse/dependence 70 65.4 Somatoform disorder Somatization 44 4 Somatoform pain 30 28.0 Hypochondriasis 3 28 Undifferentiated somatic disorder 2 19 Some type of somatic disorder 47 43.9 Eating disorder Bulimia nervosa 29 27.1 Nonamenorrheic anorexia 16 15.0 Anorexia nervosa 9 8.4 ‘Some type of eating disorder al 38.3 Table 2 shows the SCID II (Axis II) re- sults (n = 103). Many subjects endorsed more than ome diagnosis in a cluster. Thirty subjects (29.1%) endorsed two cluster areas, withrCluster BC as the most common pattern(n = 15, 14.6%); over one third (x = 39, 37.9%) of the sample en- dorsed ail three cluster areas. Chi-square teste, conducted on the four most prevalent Axis II categories, re vealed no significant differences in the fre- PSYCHIATRY, Vol. 59, Fall 1996 quency of borderline personality disorder compared to avoidant (x* = 2.982, df = 1, P = .084) or self-defeating (x? = 1.91, df = .167) personality disorder. A significant difference was obtained, how- ever, in comparing borderline and para- noid personality disorders (x’ = 10.681, df = 1,p = 001), When DSM-III-R exclusion rules for psychosis were not applied, the median number of Axis I diagnoses was 7 and theTable 2 Axis II CoMoRBIDITY IN Dissociative IDENTITY DISORDER ON THE SCID-IT(N = 103) Dissociative Identity Disorder Axis II Diagnoses N % Borderline 58 56.3 Avoidant 50 48.5 Self-defeating 48 46.6 Paranoid 45 43.7 Dependent 41 39.8 Compulsive 37 35.9) Schizotypal 28 272 Antisocial 24 23.3 Passive-aggressive 13 12.6 Narcissistic 13 12.6 Histrionic 9 87 Personality disorder NOS 9 87 Schizoid 6 58 mean was 7.3 (SD = 2.5); the mode was 8, with 52 (48.6%) subjects testing positive for 8 or more SCID I disorders. Three or more character disorders were endorsed by 65 (63.1%) subjects. The modal num- ber of Axis II diagnoses was 3 (z = 3.6, SD = 2.5), resulting in an overall average of 10.9(SD = 4.1) Axis I and II disorders. ‘This did not include the diagnosis of dis- sociative identity disorder. which is not made by the SCID. Discussion Among the modal diagnoses were major depression, posttraumatic stress disor- der, panic disorder, obsessive-compulsive disorder, social phobia, simple phobia, and somatization disorder. Typically these disorders were current as well as chronic. Overall, mood disorders were the most prevalent form of comorbidity in this sample, The high lifetime prevalence of major depressive episode is consistent with other studies of subjects of reported childhood abuse (Anderson et al. 1993; Briere et al. 1988; Pribor and Dinwiddie 1992) and prior studies of dissociative ELLASON, ROSS, AND FUCHS identity disorder (Boon and Draijer 1993; Coons et al 1988; Putnam et al. 1986; Ross et al. 1989a, 1990b). The patients re- ported auditory hallucinations that had no apparent relation to depression or ela- tion, and that maintained running com- mentaries on their behavior. Many of them reported delusional beliefs that his or her subculture would regard as totally implausible. These included systematized delusions of reference, persecution, so- matic changes, control, and guilt. These findings are consistent with the high prevalence of psychotic diagnoses in his- torical records of patients with dissocia- tive identity disorder (Coons et al. 1988; Putnam et al. 1986; North et al. 1993; Ross et al. 1989a, 1990b, 1990d; Solomon and Solomon 1982). Patients with dissociative identity dis- order report a greater number of Schnei- derian first rank symptoms than do schizophrenics (Ross et al. 1990d). How- ever, the Schneiderian symptoms in dis- sociative identity disorder are understood differently from those in psychotic disor- ders (Ross et al. 1990d; Solomon and Solo- mon 1982; van Benschoten 1990). For ex- ample, the voices inthis sample were clinically identified as arising from alter personalities and were capable of partici- pating in psychotherapy. Clinical experi- ence has demonstrated that upon integra- tion, the auditory hallucinations of dissociative identity disorder disappear. The patient's delusions appeared to be di- rectly related to the specifics of the child- hood trauma. Other factors differentiate dissociative identity disorder from psychotic disor- ders. Typically, as in our sample, the nar- ratives of patients with dissociative iden- tity disorder do not have the disintegrated quality that schizophrenics tend to ex- hibit (van Benschoten 1990). The patient with dissociative identity disorder will also demonstrate mutual contact with the interviewer and will usually be oriented to person, place, time, and situation (Solo- mon and Solomon 1982). As well, in our sample, although prodromal and residual symptoms of schizophrenia were present, PSYCHIATRY, Vol. 59, Fall 1996DISSOCIATIVE IDENTITY DISORDER there was no evidence of incoherence, loos- ening of associations, flat or grossly inap- iate affect, or marked motor anoma- lies. Our clinical understanding of these patients is ‘that in the majority of cases their psychotic diagnoses on the SCID are false positives generated by the inability of the SCID and the DSM system to dif- ferentiate psychosis and dissociation. Anxiety disorders were very common in this group, which is also consistent with previous studies (Boon and Draijer 1993; North et al. 1993; Ross et al. 1989a, 1990b; Solomon 1983). PTSD was the most common anxiety disorder, followed by panic disorder, obsessive-compulsive disorder, and social phobia. Simple phobia and agoraphobia were intermediate in fre- quency, whereas generalized anxiety was the least common, occurring at a fre- quency no different from the general pop- ulation (Robins et al. 1984). As in other studies (Coons et al. 1988; Putnam et al. 1986; Ross et al. 1989a), al- cohol and drug addiction occurred in a large proportion of our patients. In many of these cases the drug abuse was severe. Many patients reported incipient drug or alcohol abuse in adolescence, and a num- ber alleged drug or alcohol use with an on- set in early childhood. Some who endorsed pervasive abuse of several substances al- leged quitting abruptly without interven- tion from a treatment program. Somatoform and eating disorders were also common. Nearly half of this sample suffered from some type of somatoform disturbance. Our results are in agreement with previous studies on somatic symp- toms of sexual abuse survivors (Anderson et al, 1993; Boon and Draijer 1993; Coons 1984; Coons et al. 1988; North et al, 1993; Ross et al. 1989a, 1990b). The most common comorbid Axis II di- agnoses in these patients were borderline, avoidant, and self-defeating personality disorders. There has been considerable overlap between borderline personality disorder and other Axis II disorders in other clinical samples (Nurnberg et al. 1991; Widiger et al. 1986). The pattern of overlap depends on the nature of the sam- PSYCHIATRY, Vol. 59, Fall 1996 ple, base rates of diagnoses in the sample, assessment methods, and other method- ological factors (Nurnberg et al. 1991). Pa- tients in our sample were equally as likely to have avoidant or self-defeating disor- ders as they were to have borderline diag- noses. Borderline diagnostic criteria may be overinclusive and nonspecific (Zanarini et al, 1991). Interpretations of dissociative identity test data as borderline phenom- ena may lack specificity and may result in missed information regarding important underlying dynamics (Armstrong 1991). The dissociative criterion listed in DSM-IV (American Psychiatric Associa- tion 1994) for borderline personality dis- order distinctly differs in its dynamics, process, and structure from that of dissoc- iative symptoms in DID (Marmer and Fink 1994), Although splitting is the pri- mary defense in both, dissociative split- ting in DID is used to create amnesiac barriers and compartmentalize traumatic memory and overwhelming emotion. In borderline personality disorder, dissocia- tive experiences are fleeting and transi- tory, whereas in dissociative identity dis- order they are an underlying, pervasive symptom, Our sample showed some degree of over- lap of schizotypal and borderline criteria. Consistent with previous borderline sam- ples (Zanarini et al. 1990) were the pres- ence of odd thinking such as supersti- tiousness, magical thinking, telepathy, clairvoyance, and overvaluation of ideas, Borderline-schizotypal subjects report visual illusions in the mirror, as well as de personalization, derealization, paranoid ideation, ideas of reference (Zanarini et al. 1990), and social anxiety (Kavoussi and Siever 1992). Similar patterns of Axis II comorbidity can be seen in other groups of trauma sur- vivors. For example, men reporting child- hood abuse endorsed borderline pathol- ogy as the most common form of character disturbance, followed by para- noid and avoidant personality disorders (Raczek 1992). Cluster B and C personal- ity disorders have been understood to be 261associated with developmental factors (Fink 1991). The high prevalence of avoid- ant responses in our subjects, was consis- tent with studies of chronic po: stress disorder (Davidson et al 1991). The childhood trauma histories in our subjects were established by retrospec- tive patient report without external cor- roboration. We cannot confirm the accu- racy of these trauma histories, and the possibility of memory error and confabu- lation must be borne in mind. However, in one study (Coons and Milstein 1986), abuse histories could be corroborated in 85% of 20 adult dissociative identity dis- order patients. In a second study (Coons 1994) the trauma history was confirmed in 58% of 31 adolescents with dissociative identity disorder or dissociative disorder not otherwise specified. Therefore, the ex- isting data, though not definitive, suggest that the reported abuse in the main proba- bly has actually occurred. ‘Likewise, early developmental experi- ences of paranoid (Cluster A) individuals have been said to involve rigid, harsh fam- ily systems, often with a parental figure who is hostile, rejecting, and cruel (Ja- nosko 1977). Development of paranoia also involves brutality inflicted in an at- mosphere of harsh authoritarianism, lead- ing to a negative self-concept and malevo- lent attitudes that become projected onto others (Sisler 1987). One can understand these dynamics from a trauma model per- spective. Items frequently endorsed in the paranoid section of the SCID II can be un- derstood as trust issues arising from abuse. The most commonly endorsed items by our patients were: “unreasonable suspicion of harm, disloyalty, or exploita- tion by others” (endorsed by 77 patients, 74.8%), and “reluctance to confide in oth- ers for fear of incrimination” (endorsed by 64 patients, 62.1%). Clinical observations have shown that childhood trauma may create problems with trust in the form of paranoid traits (Raczek 1992; Sebold 1987), avoidant be- havior (Briere 1992; Cavaiola and Schiff 1988; Janus et al. 1987; Leitenberg et al. 1992), sensitivity to rejection, inhibition ELLASON, ROSS, AND FUCHS (Raczek 1992), self-destructive behavior (Briere 1992; Cavaiola and Schiff 1988; van der Kolk 1987, van der Kolk et al. 1991), and dissociative symptoms (Allison and Swartz 1980; Brende 1987; Briere 1992; Paley 1988; Putnam et al. 1984, 1986; Ross 1989; Ross et al. 19892, 1990a; van der Kolk 1987). The high of avoidant, paranoid, and borderline per- sonality disorders in this sample is consis- tent with many observed behaviors and experiences of other abuse survivors (Briere 1992; Deblinger et al. 1989; Rac- zek 1992; Southwick et al. 1993; van der Kolk 1987), implying that these character- istics are part of the trauma response (Briere 1992; Paley, 1988; van der Kolk 1987, 1989; Westen et al. 1990). A noteworthy finding is that only 8.7% of the 103 subjects interviewed with the SCID-II met criteria for histrionic person- ality disorder. This is lower than the re- ported frequency of DSM-IV (American Psychiatric Association 1994) histrionic personality disorder among general adult psychiatric inpatients. Unless method- ologically adequate disconfirmatory data are replicated and published on large num- bers of subjects in the future, our findings provide a powerful counter to the stereo- type of dissociative identity patients as hysterics, In fact, a histronic personality style is uncommon in this population. Likewise, it is not possible to dismiss dissociative identity disorder patients as “really just borderlines” because in fact 30-44% of subjects in three series, includ- ing the present one, do not meet criteria for borderline personality disorder (Hore- vitz and Braun, 1984; Ross et al. 1990c). The low prevalence of dysthymia and generalized anxiety disorder in our pa- Bente is due to the SCID exclusion rules regarding the presence of a preempting mood disorder. Nevertheless, an impor tant rule of thumb for the practitioner is to consider dissociative identity disorder as a possibility when encountering pa- tients who manifest numerous current or previous diagnoses. Because it is absurd. to consider that one individual could have 7.3 independent lifetime Axis I and 3.6 in- PSYCHIATRY, Vol. 59, Fall 1996DISSOCIATIVE IDENTITY DISORDER dependent lifetime Axis II diagnoses, it is not clear how to understand these data. One interpretation of our findings could be that they are an artifact of a positive response bias in dissociative identity dis- order patients. This interpretation.is not supported by the fact that different disor- ders are endorsed at widely differing fre- quencies, nor is it consistent with the counterstereotypic low rate of endorse- ment of histrionic personality disorder criteria. ‘Another hypothesis is that these pa- tients are in fact psychotic, and that this is their primary problem. This does not appear to be so clinically, and no other studies of chronically psychotic patients report this level of comorbidity. ‘An alternative view, one consistent with the large body of research reviewed in this paper, is that the high level of life- time comorbidity is best understood as part of an overall response to chronic, se- vere childhood trauma. Although the dis- orders are all separate entities by DSM-IV rules, they are perhaps better un- derstood as elements of one inclusive su- perordinate syndrome (Putnam et al. 1984). It is essential for modern psychis try to give serious consideration to the trauma-driven aspects of psychopath ology. Tf one accepts that the psychotic diag- noses on the SCID are mostly false posi- tives, and due to the inability of the diag- nostic system to differentiate psychosis and dissociation, the data pose a profound problem for differential diagnosis and suggest the need for extensive revisions of DSM rules. It is our view that the data are strong enough for this possibility to be taken seriously and investigated fur- ther. Since dissociative identity disorder is a chronic condition with childhood onset, all the disorders diagnosed on the SCID are truly comorbid with it. However one understands the data, it appears to be well established that dissociative identity dis- order patients meet criteria for many dif- ferent diagnoses, and that much of this co- morbidity needs to be considered in treatment planning and any future treat- ment outcome research. REFERENCES ALLISON. R., and SWARTZ, T. Minds in Many Plec New York: Rawson, Wade Publishers, 1980. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic ‘and Statistical Manual of Mental Disorders (3rd ed. rev.), APA. 1987. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disordars (4th od.), APA. 1994, ANDERSON, G., YASENIK, L., and Ross, C. A. Dis- sociative experiences and disorders among women who identify themselves as sexual abuse survi- vors. Child Abuse & Neglect (1993) 17:677-86. ARMSTRONG, J, The psychological organization of ‘multiple personality disordered patients as re- vealed in psychological testing. Psychiatric Clin- ics of North America (1991) 14:533-48. ARMSTRONG. J. G., and LOEWENSTEIN, R. J. Char acteristics of patients with multiple personality and dissociative disorders on psychological test- ing. Journal of Nervous and Mental Disease (1990) 178:448-54. BENNER, D. G., and JOCELYNE, B. Multiple person- ality as a borderline disorder. Journal of Nervous and Mental Disease (1984) 172:98-104. BERNSTEIN, E. M., and Purwam, F. W. Develop- PSYCHIATRY, Vol. 59, Fall 1996 ment, reliability, and validity of a dissociation seale. Journal of Nervous and Mental Disease (1986) 174:727-33. BOON. S., and DRAWER. N. Multiple Personality in the Netherlands, Amsterdam: Swets & Zeitlinger, 1993. BraveR. M., BuMBERRY. J., GREEN, K., and RAW- SON, R. Childhood abuse and current psychologi- cal functioning in a university counseling center population. Journal of Counseling Psychology (1992) 39:252-7. BreNpé, J. O. Dissociative disorders in Vietnam combat veterans. Journal of Contemporary Psy- chotherapy (1987) 17:77-86. Briers, J. N. Child Abuse Trauma, Sage Publica- tions, 1992. BRIERE, J.. EVAN. D.. RuNTZ, M., and WALL, T. Symptomatology in men who were molested as children. American Journal of Orthopsychiatry (1988) 58:457-61. Brown, G. R., and ANDERSON, B. Psychiatric mor bidity in adult inpatients with childhood histories of sexual and physical abuse. American Journal of Psychiatry (1991) 148:55-61. Bux, O. D. Single case study: Multiple personalityas a borderline state. Journal of Nervous and Men- tal Disease (1983) 171:62-5. CaRison, E.B., and RosseR-HOGAN, R, Trauma ex- periences, posttraumatic stress, dissociation, and depression in Cambodian refugees. American Jour nal of Psychiatry (1991) 148:1548-51. CAVAIOLA. A. A., and SCHIFF, M. Behavior sequelae of physical and/or sexual abuse in adolescents. Child Abuse & Neglect-(1988) 12:181-88. Cu, J. A., and Dit, D. L. Dissociative symptoms in relation to childhood physical and sexual abuse, American Journal of Psychiatry (1990) 147:887-92. Ctany, W. F, BURSTIN, K. J. and CARPENTER, J. ‘S. Multiple personality and borderline personality disorder.- Psychiatrie Clinics of North America (1984) 12:825-35, Coons, P. M. The differential diagnosis of multiple personality: A comprehensive review. Psychiatric Clinies of North America (1984) 7:5 Coons, P. M. Confirmation of childhood “abuse in child and adolescent cases of multiple personality disorder and dissociative disorder not otherwise specified. Journal of Nervous and Mental Disease (1994) 182:461-4. Coons, P. M, Dissociative identity disorder not oth- erwise specified: A clinical investigation of 50 cases with suggestions for typology and treat ment. Dissociation (1992) §:187-95. Coons. P. M., BOWMAN, E. S., and MILSTEIN, V. Multiple personality disorder: A clinical inveatiga- tion of 50 cases. Journal of Nervous and Mencal Disease (1988) 176: 517-27. Coons, P. M.. and MILSTRIN, V. Psychosexual dis- turbances in multiple personality: Characteristics, etiology, and treatment. Journal of Clinical Psychi- cacry (1986) 47:108-10. Coons, P. M.. and STERNE, A. L. Initial and fok low-up psychological testing on a group of pa tients with multiple personality disorder. Psycho- logical Reports (1986) 58:43-9, DAviDsoN, J. R.. HUGHES. D., BLAZER. D. G.. and Georce. L. K. Post-traumatic stress disorder in the community: An epidemiological study. Psy- chological Medicine (1991) 21:713-21. DEBLINGER. E., MCLEER, S. V., ATKINS, M. S, Rate PHE. D., and Foa, E. Post-traumatic stress in sex- ually abused. physically abused, and non abused children, Child Abuse & Neglect (1989) 13:1403-8, DeRocaris, L. R. SCL-90-R Administration, Scor ing, and Procedures Manual I. Towson, MD: Clin- ical Psychometric Research, 1992. Eutior, D. M.. and BrteRs, J. Sexual abuse trauma among professional.. women: Validating the Trauma Symptom Check List-40 (TSC-40). Child Abuse & Neglect (1992) 16:391-8. Fin, D. The comorbidity of multiple personality disorder and DSM-IIL-R Axis IT disorders. Psy- chiatric Clinics of North America (1991) 14:547~ 66, FRANK. H., and PARIS, J. Recollections of family ex- perience in borderline patients. Archives of Gen- eral Psychiatry (1981) 38:1031-4. GALLAGHER, D., BRECKENRIDGE, J., STEINMETZ, ELLASON, ROSS, AND FUCHS J., and THOMPSON, L. The Beck Depression Inven- tory and research diagnostic criteria: Congrunce i population. Journal of Consulting and Clinical Psychology (1983) 51:945-6. Gantwer, A. F., and GARTNER, J. Borderline pa- thology in post-incest fernale adolescents. Bulletin. of the Menninger Clinic (1988) 52:101~13. GOLDMAN, S. J., D’ANGELO, E. J., DEMASO, D. R., and Mezzacarra, E. Physical and sexual abuse histories among children with borderline person- ality disorder. American Journal of Psychiatry (1992) 149:1723-6. HERMAN, J. L., PERRY, J.C., and VAN DER KOLK, B. ‘A. Childhood trauma in borderline personality dis- order. American Journal of Psychiatry (1989) 146: 490-5. Horevirz. R. P. and BRauN, B. G. Are multiple personalities borderline? Psychiatric Clinics of North America (1984) 7:69-87. Hyavserr, D. F., art. C., and WHITE, LC, Anem- pirical examination into the sexuality of women with borderline personality disorder. Journal of Sex and Marital Therapy {1992} 18:231-42, JANOSKO. R. E. M. The paranoid condition revisited. Psychiatry Digest (1977) 17-25, Janus, M-D., BURGESS, A. W., and McCoRMAcK, ‘A. Histories of sexual abuse in adolescent male runaways. Adolescence (1987) 22:86. Kavouss!. R. J.. and SIEVER, L. J. Overlap between borderline and schizotypal personality disorders. Comprehensive Psychiatry (1992) 33:7-12. Kinpy, J. S., CHU. J. A.. and DILL, D. L. Correlates of dissociative symptomatology in patients with physical and sexual abuse histories, Comprehen- sive Psychiatry (1993) 34:258-63, KLUFT.R.P.(ed,j.Childhood Antecedents of Multiple Personality. American Psychiatric Press, 1985. Kur, R. P. Unsuspected multiple personality dis- order: An uncommon source of protracted resis- tanee, interruption. and failure in psychoanalysis. The Hillside Journal of Clinical Psychiatry (1987) 9:100-15, KLUFT. R. P. Clinical presentations of multiple per- sonality disorder. Psychiatrie Clinics of North America (1991) 14:608-29. Larz. T.T.. KRAMER, S, Land HUGHES, D. L. Mul- tiple personality disorder among female inpa- tients in a state hospital. American Journal of Psy- chiatry (1996) 152: 1343-8, Le1TeNBERG, H.. GREENWALD, E., and CADO. S. A retrospective study of long-term methods of cop- ing with having been sexually abused during childhood. Child Abuse & Neglect (1992) 16:399- 407. LoeWeNsTEIy, R. J. An office mental status exami- nation for complex chronic dissociative symptoms and multiple personality disorder. Psychiatric Clinics of North America (1991) 14:567-604, LupowpH, P. S., WESTEN, D., MISLE, B., JACKSON, ‘A., Wixom, J., and Wiss, F. C, The bordertine agnosis in adolescence: Symptoms and develop- mental history. American Journal of Psychiatry (1990) 147:470-6. PSYCHIATRY, Vol. 59, Fall 1996DISSOCIATIVE IDENTITY DISORDER. Maraer, S. S. and FINK, D. Rethinking the com- parison of borderline personality disorder and multiple personality disorder. Psychiatric Clinics of North America (1994) 17:743~71. MELLMAN, T. A. RANDOLPH, C. A., BRAWMAN- MinTzER, O., FLORES, L. P., and MILANEs, F. J. Phenomenology and course of psychiatric disor- ders associated with combatrelated posttrau- matic stress disorder. American Journal of Psychi- try (1992) 149:1568-74. Nica, J. T., SILK, K. R., WESTEN, D.. LOHR, N. E.. GoLb, L. J., GooDRICH, S.. and OGATA, S. Object abused borderline patients. American Journal of Psychiatry (1991) 148:864~9. ont, C. S., RYALL, J. M., Ricci, D. A.. and Wer zEL, R. D, Multiple Personalities, Multiple Disor ders. Oxford Press, 1993. Norton, G. R., Ross, C. A., and Novorny, M. F. Factors that predict scores on the Dissoci Experiences Scale. Journal of Clinical Psychology (1990) 46:273-7. Nurwaere, H. G., RASKIN, M., LEVINE, P. E., POL- LACK, S., SEIGEL, O., and Prince, R. The comor- bidity of borderline personality disorder and other DSM-IILR Axis II personality disorders. Ameri- can Journal of Psychiatry (1991) 148:1371-7. Gata. $. N., SILK, K. R.. GOODRICH, S.. LOHR, N. E., Westen, D., and Hit, E. M, Childhood sex: ual and physical abuse in adult patients with bor- derline personality ‘American Journal of Psychiatry (1990) 147:1008-13. PALEY, AM. N. Growing up in chaos: The dissocia- tive response. American Journal of Psychoanaly- sis (1988) 48:72-43. Pants, J. NowLts, D.. and Brown, R. Develop: ‘mental factors in the outcome of borderline per sonality disorder. Comprehensive Psychiatry (1988) 29:147-50, Perry, J.C., HERMAN. J. L.. und VAN DER KOLK, B. ‘A. Psychotherapy and psychological trauma in borderline personality disorder. Psychiatric An- nals (1990) 20:33-43, Prigor, E. F., and Dinwinote, S. H. Psychiatric correlates of incest in childhood. American Jour nal of Psychiatry (1992) 149:52-6. Putnam, F. W., LOEWENSTEIN, R. J. SILBERMAN. E. J., and Post. R, M. Multiple personality disor- der in a hospital setting. Journal of Clinical Psychi- atry (1984) 45:172-5. Purwam, F. W., GuroFF, J. J. SILBERMAN. E. K. BARBAN, L., and Post. R. M. The clinical phenom- enology of multiple personality disorder: Review of 100 recent cases. American Journal of Psychia- ‘try (1986) 47:285-93. RACZEK, S, W. Childhood abuse and personality dis- orders, Journal of Personality Disorders (1992) 6: 109-16. ReHM, L. P, and O'HARA. M. W. Item character istics of the Hamilton Rating Scale for Depres- sion, Journal of Psychiatric Research (1986) 19:31- 9. Rosins, L. N., HELZER, J. E., WEISSMAN, M. M., PSYCHIATRY, Vol. 59, Fall 1996 Onvascuet, H., GRUENBERG, E., BURKE, J. D.. In, and REGIER, D. A. Lifetime prevalence of spe- cific disorders in three sites. Archives of General Pshychiatry (1984) 41:949-67. Ross, C. A. DSM-III problems in diagnosing partial forms of multiple personality disorder: Discussion paper. Journal of the Royal Society of Medicine (1985) 78:933-6, Ross, C. A. Multiple Personality Disorder: Diagno- sis, Clinical Features, and Treatment, John Wiley & Sons, 1989. Ross, C. A. Epidemiology of multiple personality disorder and dissociation, Psychiatric Clinics of North America (1991) 14:503-17. Ross, C. A., and Josut, S. Schneiderian symptoms ‘and childhood trauma in the general population, Comprehensive Psychiatry (1992) 33:269-73. Ross, C. A., NORTON. G. R., and WozNeY. K, Multi- ple personality disorder: An analysis of 236 case: Canadian Journal of Psychiatry (19898) 34:413-8. Ross, C. A., HEBER. S. NORTON. R., and ANDER: SON. G. Differences between multiple personality disorder and other diagnostic groups on struc- tured interview. Journal of Nervous and Mental Disease |1989b) 177:487-91., Ross, C. A.. HEBER, S., NORTON. G. R., ANDERSON, G., and Baxcitet, P. The Dissociative Disorders Interview Schedule: A structured interview. Dis- sociation (1989e) 2:169-89. Ross. C. A., JOsHt, S., and Cunnie, R. Dissociative experiences in the general population. American Journal of Psychiatry (19908) 147:1547-52. Ross, C. A. MILLER, S, D., BIORNSON, La, REAGOR, and ANDERSON, G. Abuse hit tories in 102 cases of multiple personality disor- der. Canadian Journal of Psychiatry (1990b) 36: 97-101. Ross, C. A.. MILLER, $. D.. REAGOR, P., BJORNSON, L., FRASER, G. A.. und ANDERSON. G. Structured interview data on 102 cases of multiple personal- disorder from four centers. American Journal of Psychiatry (1990c) 147:596-601. Ross, C. A., MILLER. S. D., REAGOR, P., BJORNSON, La, FRASER, G, A., and ANDERSON, G. Schneider- ian symptoms in multiple personality disorder and schizophrenia. Comprehensive Psychiatry (1990d) BU:IL1-B. Ross, C. A.. ANDERSON. G... and FLEISCHER, W. P. ‘The frequency of multiple personality disorder among psychiatric inpatients. American Journal, of Psychiatry (1991) 148:1717-20. Ross, C. A.. ANDERSON. G.. FRASER. G.. REAGOR, P., BJORNSON. L.. and MILLER. S. D. Different ing multiple personality disorder and dissociative disorder not otherwise specified. Dissociation (1992) 5:87-90. Roszett, D. K.. MCFALL, M. E., and MALAS, K. L. Frequency of symptoms and concurrent psychiat- ie disorder in Vietnam veterans with chronic PTSD. Hospital and Community Psychiatry (1991) 42:293-6. Roy-Bvane, P. P., JEMELKA, R. P. Histories of sexual victimization and Russo, J. patients withirritable bowel syndrome or inflammatory bowel disease. American Journal of Psychiatry (1983) 150:1502-6. Saxe, G. N., VAN DER KOLK, B. A., BERKOWITZ, R. CHINMAN, G. HALL K., LIgBERG, G., and Scuwantz, J. Dissociative disorders in paychiat- ric inpatients. -American Jounal of Psychiatry (1993) 150:1037-42. SeBOLD, J. Indicators of child sexual abuse in males. Social Casework (1987) 68:75-80. SHALEY, A. Y., SCHREIBER, S., and GALAL, T. Early psychological to traumatic injury. Jour “nal of Traumatic Stress (1998) 6:441-50. StsteR, G. C. The concept—‘paranoid’ Canadian Psychiatric Association Journal (1987) 12:183~7. SOLOMON, R. Use of the MMPI with multiple per sonality patients. Psychological Reports (1983) 53:1004-6. " ‘SOLOMON, R. S...and SOLOMON, V. Differential diag- nosis of the multiple personality. Psychological Reports (1982) 51:1187-94, SOUTHWICK, S. M., YEHUDA. R., and GILLER, E. L, Personality disorders in treatment seeking combat veterans with posttraumatic stress disorder. American Journalof Psychiatry (1993) 150:1020-3. Sprrzer, R. L., WILLIAMS, J. B. W., GIBBON. M. and First, M. B. Users Guide for the Structured Clinical Interview for DSM-IIER. American Psy- chiatric Press, 1990. TORGERGEN, S.. and ALNAES, R. Differential per- ception of parental bonding in schizotypal and borderline personality disorder patients. Compre hensive Psychiatry (1992) 33:34~8, VAN BENSCHOTEN, 8. C. Multiple personality disor dor and satanic ritual abuse: The isaue of credibil- ity, Dissociation (1990) 3:22-30. VAN DER KOLK, B. A. Psychological Trauma. Amer ‘can Psychiatric Press, 1987. VAN DER KOLK, B. A. The compulsion to repeat the trauma. Psychiatric Clinics of North America (1989) 12:389-411, ELLASON, ROSS, AND FUCHS VANDER KOLK. B. A., PERRY, J.C.,.and HERMAN, J. L, Childhood origins of self-destructive behavior. American Journal of Psychiatry (1991) 148:1665~ 71. WaaneR, £. E., ALLISON, R. B.. and WAGNER, C.F. Diagnosing multiple personalities with che Ror schach: A confirmation. Journal of Personality Disorder (1988) 21-36. Westen, D., LUDOLPR, P., MISLE, B., RussINs, S., and Buocx. J. Physical and sexual abuse in adolee- cent girls with borderline personality disorder. American Journal of Orthopsychiatry (1990) 60: 55-56. WiniaER, T. A., SANDERSON, C., and WARNER, L. ‘The MMPI prototypal and borderline personality disorder. Journal of Personality Assessment (1986) 50:540-53. Wirrenen, H. U., SEMLER, G., and VON ZERSSEN, D, A. Comparison of two diagnostic methods. Ar- chives of General Psychiatry (1985) 42:677-84. ZANARINI, M. C., GUNDERSON. J. G.. MARINO, M. F, Scuwarrz. E. O., and FRANKENBURG, F. R. Comprehensive Psychiatry (1989) 30:18-25. ZANARINI, M. C., GUNDERSON, J. G., arid FRAN: KENBURG. F. R. Cognitive features of borderlin personality disorder. American Journal of Psychi- try (1990) 147:57-63. ZANARINI, M. C., GUNDERSON, J. G.. FRANKEN: BuRG, F. R., CHAUNCEY, D. L., and GLUTTING. J. H. The face validity of the DSM-III and DSM- TIER criteria sets for borderline personality diso~ der. American Journal of Psychiatry (1991) 148: 870-4. Zwetc-FRANK, H.,and Pants, J. Parents’ emotional neglect and overprotection according to the recol- lections of patients with borderline personality disorder. American Journal of Psychiatry (1991) 148:648-51. PSYCHIATRY, Vol. 59, Fall 1996-