Finding+themselves+and+the+truth-+the+controversy+surrounding+dissociative+identity+disorder

media type="youtube" key="BT_IFLCxYWI" height="315" width="420" Alexandra Fitzgerald 8093547 Tutor: Judith Meiklejohn

**Artefact:** //Identity// (2003) is an American mystery thriller film, and is based around ten individuals trapped in a motel, where various characters are killed. Meanwhile, Malcolm Rivers is awaiting the death sentence for several murders which he allegedly committed. It is later revealed (as seen in the youtube clip) that Malcolm in fact suffers dissociative identity disorder (DID- previously referred to as multiple personality disorder), by which he created the ten different personalities and the motel scene all in his mind.

DID is a mental illness affecting approximately 1% of the world’s population (International society for the study of trauma and dissociation, 2011). An individual who suffers from DID perceives themselves as at least two different individuals (however there are often many more) and although the same ‘core’ body is always present, the different individuals living in the mind all possess unique personalities (Disability information and resource centre, 2008). The public health issue that this artefact represents is the overwhelming predisposition that portrays DID sufferers as violent, murderous and ‘mad’ (this is also observed in relation to many other mental illnesses). The controversy surrounding questionable diagnosis, as well as the stigma associated with DID (including lack of understanding of the disorder) will be the main focus points throughout this assessment piece.
 * Public health issue:**

Before diving head first into the misunderstanding and ignorant portray that is often given to DID, the aetiology of this disorder needs to be addressed, along with the controversy that surrounds both the cause and validity of this particular disorder. Identity disorders have been largely controversial since their discovery in the early 19th century. It is this controversy, in conjunction with the fascination of such a disorder that has been the focus for many research articles and media over many years (more so in the last 20 years) (Dunn, 1992). Dunn (1992) and Traub (2009) agree that the existence of DID as a genuine disorder has been proven by the Diagnostic and Statistical Manual of Mental Health, however both sources question not the existence of the disorder, yet the diagnosis, criteria for diagnosis and presenting aetiology. Dunn (1992) adds that it can be especially difficult to differentiate between disorders where similar symptoms exist.
 * Literature review:**

The American psychiatric association define dissociative identity disorder as ‘At least two...identities or personality states recurrently taking control of the person’s behaviour. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness and not due to the direct affects of a substance or a general medical condition... Patients with DID report having severe physical and sexual abuse, especially during childhood. There is controversy around these reports, because childhood memories may be exposed to distortion and some patients with DID are highly hypnotizable and vulnerable to suggestive influences.’ (2000).

At present, there is much debate surrounding whether DID is caused primarily by a traumagenic influence or iatrogenic influence, or a mixture of both. In fact, it is one of the biggest controversies surrounding contemporary clinical psychology (Lilienfeld, Kirsch, Sarbin, Lynn, Chaves, Ganaway, Powell, 1999). According to Sinason (2011) the aetiology of DID has been evaluated and in 90% of all known cases, it has found to be traumagenic. David Gleaves is a key theorist and has conducted a large amount of investigation into DID, and supports the notion that DID is in fact a traumagenic condition (Gleaves, 1996). According to Gleaves (1996) the traumagenic aetiology evolves from severe childhood abuse, often referred to as trauma, where a child is subject to horrific sexual, physical and psychological abuse. Used a survival technique, different identities are formed to try to cope with the pain and fear attached to such abuse. Lilienfeld et al (1999) quotes Ross (1996) to give us a different perspective of traumagenic DID- “MPD [DID] is a little girl imagining that the abuse is happening to someone else” (p. 59). Although conducted over twenty years ago, one of the few DID studies performed claimed that the aetiology of DID is traumagenic. Conducted by Coons, Bowman and Milstein (1988) the study focussed on fifty patients diagnosed with DID, who were all assessed via clinical history, psychiatric interview, neurological examination, intelligence testing, along with varying psychiatric rating scales. These tests more than often linked women with depression, suicidal traits, amnesia and a significant history of childhood abuse with DID. Ruling out a significant presence of neurological impairment, Coons et al (1988) suggested that the underlying cause of DID was due to severe childhood trauma. More recent theorists corroborate this study, with Stickley and Nickeas (2006) noting the constant thoughts of death and ‘sleeping’ or ‘dreaming’ long periods of time away (resulting in amnesia) are often present in DID patients, resulting from childhood trauma (often sexual). Traub (2009) highlights that although certain theorists maintain that DID exists as a mental illness caused by severe childhood abuse, studies are yet to determine why, in adults who have been traumatised as children, this disorder continues to be apparent.

However, not all theorists are in support of the claim that the aetiology of DID is childhood trauma. Piper and Merskey (2004) present very conflicting views on the diagnosis and aetiology of DID. Piper and Merskey’s journal article ‘//The persistence of folly: a critical examination of dissociative identity disorder. Part one. The excesses// //of a an improbable concept//’ (2004), reassess a number of studies completed by theorists who are advocates of traumagenic DID, and conclude that there is simply not enough evidence to justify that childhood abuse (even though it may be present in a patient) is the primary cause of DID. The journal articles opening quote “When ideas go unexamined and unchallenged for a long time. . . they become mythological, and they become very, very, powerful”, gives the reader a brief idea of the direction of the theory. Piper and Merskey (2004) claim that trauma cannot be labelled as the primary cause of DID because there is a lack of evidence to support trauma, including a lack of eye witness accounts; confessions from perpetrators; photographs; and any medical, social or court records confirming that the child was subject to trauma. Providing reason for the quote, Piper and Merskey (2004) added that the accounts from the victims/patients could be entirely accurate and truthful, or could be completely fanciful. This uncertainty can lead to misdiagnosis as therapists have no way of differentiating between the two. Piper and Merskey (2004) also criticise Coon, Bowman and Milstein’s study (previously mentioned), claiming that the authors fail to include the duration and frequency of abuse, nor gave a definition to the type of abuse that the participants endured. This iatrogenic formulation of DID concept claims that the cause of DID is due to the role of the psychotherapist in legitimizing the perception of multiple identities, formulating symptoms in the patient through hypnosis, and proceeding to shape the patients behaviour (Gleaves, 2006). Piper and Merskey (2004) concluded their paper by ruling out the suggestion that the aetiology of DID is primarily trauma based, and allege that DID is an often iatrogenic condition. In an attempt to prove this theory (in conjunction with their claim that a lack of trauma based evidence is made available for diagnosis), Piper and Merskey (2004) state that the number of reported cases of DID increased enormously in the 1980’s. However, the rate of childhood abuse did not (nor were there any major wars, famine or disasters). The theorists’ claim that if the primary cause of DID was trauma, then this would consequently have to increase as well. Piper and Merskey (2004) argue that misdiagnosis by physicians due to lack of proper diagnostic techniques and evidence contributes to the reported cases of DID. (The controversy surrounding this topic is so large that there are a number of theorists that have responded to and critiqued this article). **Cultural and Social Analysis:** As mentioned earlier, much research and media attention surrounding DID has become overwhelmingly prevalent for at least the past twenty years. But how much of this ‘spot light’ attention is misleading, and how does this contribute to the perception of DID suffers by lay people? As well as various research articles, DID has prevailed in many media sources, particularly being portrayed in many movies and television shows. Although it may not be commonly recognised among lay people, movies such as //Identity//; //Sybil//; //The Secret Window;// //Hide and Seek//; //Me, Myself and I//; and popular US television show //United States of Tara// are just a few of the many popular media sources that depict the life a person living with DID. But which of these depictions are accurate, and how does this type of media impact on the understanding and redressing of DID? According to Hodder-Fleming (2005), lay people generally associate DID patients with ‘evil’, purely due to the formation the media have given to the disorder. Often movies will portray basic theory, but fail to represent a DID patient with complete accuracy, much like the film and artefact, //Identity//. The evil, murderous, mad portrayal given to the main character gives no consideration to accurate portrayal; rather it is uses DID to add thrill and psychological twist to enhance the genre of the film (Hodder-Fleming, 2005). Again, the aetiology of the DID in //Identity// was sacrificed for a thriller genre and although childhood trauma was briefly mentioned during the film, there was not a proper established link between this aetiology and dissociation (Hodder-Fleming, 2005). Hodder-Fleming (2005) concludes the journal article by suggesting that the treatment of the main characters dissociation (briefly mentioned in the artefact) was dependant on violence and that the film “uses DID in a fictitious manner, to form the core of a psychological thriller, possibly sacrificing some theoretical accuracy for the sake of adrenaline impact” (p. 113). Wall, Reeves and Wall (2005) corroborate Hodder-Fleming, stating that the film blatantly misrepresents and misinterprets DID, which could consequent in the perception that this disorder leads to violent acts towards others. Not only does this create stigma aligned with negative views, the recently high media coverage that has been associated with DID may (hypothetically) increase the actual creation of DID within an individual, because movies and television shows alike have given the general public a basic idea of the way a person suffering DID acts (Gleaves, 2005). Those that oppose DID is a legitimate diagnosis claim that media influence encourages a small portion of the mental health community to illegitimatise the presence of DID (Traub, 2009). According to Spanos (1994), the patients enter a type of role play, whereby they use the mental disorder as a way of concealing personal flaws. Furthermore, Spanos (1994) states that “At present, MPD appears to be a culture-bound syndrome” (p. 152). He claims that the increased rate of DID cases are due to multiple self enhancements that occur in North America. These multiple self enhancements are often referred to as spirit possessions, whereby the body of an individual is temporarily controlled by spirits. Spanos (1994) states that reported cases have often been localised to North America, since their increase in the 1970’s, due to the strong predisposition to DID in individuals that experience multiple self enhancements. **Analysis of artefact and learning reflection:** This artefact provides us with a great representation of the perception of DID that is put right in front of our faces, without giving it a second look. The common unfamiliarity of this mental disorder (to the lay person) allows the media to influence and shape our perspective of a patient suffering from DID. The fact is that, even psychotherapists and theorists have only touched to tip of the iceberg with this disorder, and are still to uncover many of the various aspects associated with DID. Yet, popular media has taken advantage of the disorder to use for their personal gain, perhaps stigmatising the disorder along the way. The film //Identity// and the clip provided is just one of the many popular media sources contributing to this kind of stigmatisation. My interest in this topic stemmed from a story that was aired on A Current Affair (channel nine) recently. Prior to viewing this story, I was unaware of that this disorder even existed. It was difficult to grasp the concept that an individual was capable of possessing many different and unique alters, all controlling the one core body through the mind. No matter the debate surrounding the aetiology of the disorder, in future practice (both as a professional and personally) I believe I have gained the knowledge and perception to be able to treat people (whether mentally ill or otherwise) with nothing more than respect, not allowing the stigma attached to many mental disorders to cloud my view of any individual. **References:** American Psychological Association (2000). Diagnostic and statistical manual of mental disorders. Retrieved from [] Disability information and resource centre (2008). Dissociative identity disorder: formerly multiple personality disorder. Retrieved from [] Dunn, G. (1992). Multiple personality disorder: a challenge for psychology. //Professional psychology: research and practice, 23(1),// 18-23. Retrieved from [] Gleaves, D. (2006). A sociocognitive model of dissociative identity disorder: a re-examination of the evidence. //Psychological Bulletin, 120(1)//, 42-59. doi: 10.1037/0033-2909.120.1.42 Hodder-Fleming, L. (2005). Sybil, voices within and identity. //Australian Journal of Clinical and Experimental Hypnosis, 33(1),// 112-115. Retrieved from [] International society for the study of trauma and dissociation (2011). Frequently asked questions: dissociation and other dissociative disorders. Retrieved from [] Lilienfeld, S., Kirsch, I., Sarbin, T., Lynn, S., Chaves, J., Ganaway, G. & Powell, R. (1999). Dissociative identity disorder and the sociocognitive model: recalling the lessons of the past. //Psychological bulletin, 125(5),// 507-523. doi: 10.1037/0033-2909.125.5.507 Piper, A & Merskey, H. (2004). The persistence of folly: a critical examination of dissociative identity disorder. Part one. The excesses of a an improbable concept. //Canadian journal of psychiatry, 49(9),// 592-600. Retrieved from [] Ross, C. (1996). Epidemiology of dissociation in children and adolescence: extrapolations and speculations. //Child and adolescent psychiatric clinics of north America, 5(2),// 273-284. Retrieved from [] Sinason, V. (2011). //Attachment, trauma and multiplicity: working with dissociative identity disorder// [Internet]. Hove, East Sussex: Routledge. Spanos, N. (1994). Multiple identity enhancements and multiple personality disorder: a sociocognitive perspective. //Psychological Bulletin, 116(1),// 143-165. doi: 10.1037/0033-2909.116.1.143 Stickley, T. & Nickeas, R. (2006). Becoming one person: living with dissociative identity disorder. //Journal of psychiatric & mental health nursing, 13(2),// 180-187. Retrieved from [] Traub, C. (2009). Defending a diagnostic pariah: validating the categorisation of dissociative identity disorder. //South African journal of psychology, 39(3)//, 347-356. Retrieved from [] Wall, J., Reeves, R. & Wall, D. (2005). Entertaining an identity: an artistic approach. //American Psychological Association, 50(10)//. doi: 10.1037/041014

Discussions-
1. Through The Looking Glass

Hi Jack,

Firstly, your wiki was very well written, appropriate to the topic and covered various interesting facts and views on mental illness. I was particularly fascinated to discover that areas where mental illness is rather prevalent (as mentioned- in prisons, homeless communities, aged care), that the rate of monitoring of mental illness is rather low. I found it quite ironic that although a contributor to predisposal of mental illness is isolation, that, particularly in areas such as prisons and homelessness (where isolation is prevalent), are not as closely monitored for mental illness as the wider community is.

I’d also just like to briefly comment on Durkheim’s theory. Very interesting and makes you think twice about when a mental illness is described as ‘idiopathic’, yet most of them are thought to be linked to genetics. Much more research and many more studies seem rather essential for the future of mental health.

Great work Jack!

Ali Fitzgerald

2. Mental health treatment - from dark till dawn

Hi Tory,

Thanks for your really interesting insight into lobotomies. You covered the topic really efficiently and relevant facts and issues were covered. It was interesting to read about institutionalisation and how horrifically the patients were treated. You would have to think that the treatment of their illness (easily compared to that of unwanted animals) had much to do with only the heightening of their disorder and nothing to do with recovery. I totally agree with your reflection about lobotomies and believe that the complete ignorance of society had a lot to do with the acceptance of this horrible form of so called ‘treatment'.

Well done, great job!

Ali Fitzgerald