Ralph B. Allison: ON DISCOVERING MULTIPLICITY Dr Allison har i flera †r arbetat intensivt med en speciell typ av st”rning som kallas multipel personlighet. Under 6 †r har han behandlat mer „n 40 fall med goda resultat. Multipla personligheter „r l†ngt vanligare „n vad man tidigare trott, menar Dr Allison, men en terapeut, som inte anv„nder sig av hypnos, kan sv†rligen uppt„cka dem, kanske inte fler „n en eller tv† under en livstid. Dr Allison beskriver i denna artikel, den andra av tre, hur man n†r frarn till diagnosen multipel personlighet. (Den f”rsta artikeln var inf”ord i nr 6/77.) In the latter half of the 19th century, interest was high among the French and English hypnotherapists in that clinical oddity called multiple personality. Freud, however, in spite of all his early interest in the psychodynamics of hysteria, never wrote about a patient with this disorder, which I prefer to call multiplicity. Therefore, the major work on the subject in the United States was done by non-Freudian psychiatrists such as Morton Prince. (Prince, 1920) Since the first case was published in the United States in 1888, (Mitchell, 1888), there have been slightly over a hundred patients reported in the English literature. No doubt there have been many times that number treated by psychotherapists who did not publish their findings. Personally, I have seen over 40 cases in the past 6 years. I know of a psychiatrist in Honolulu who has seen 50 cases, and one in Phoenix who has seen 30. All of us use hypnosis extensively. Those therapists who do not use hypnosis may see one or two in a lifetime, usually the most obvious type. This may occur in a situation where a patient has been coming for sometime for therapy and then, one day, the same body arrives, but Jane says June is not coming today and she, Jane, is there to explain why June has been so depressed lately. This is a shocker for any therapist and many try to avoid that upset happening to them again by denying the signs presented by subsequent patients. Other therapists are interested or fascinated by such a peculiar mental aberration and may be only too willing to find symptoms of multiplicity in their patients. There are many figures of speech which could imply multiplicity, such as "my good self" and "when the bad me takes over. " Eric Berne's Transactional Analysis theory (Berne, 1964) uses terms like "child ego state" which are more likely to be accurate descriptions of the immature behavior of an adult patient. The "sub-personality" concept of psychosynthesis, as pioneered by Assagioli, (Assagioli, 1965) is another view which may be more correct in "normal neurotics. " Role playing accounts for a great deal of the different patterns of behavior we all show at different times. This is conscious, however, and the switching done by the multiple, before treatment, is done for unconscious reasons and therefore is, for the most part, beyond the control of the patient's conscience or social judgmental faculties. Therefore, I wish to confine myself to those persons who become psychotherapy patients, or we would not see them, the ones who use denial, repression, and dissociation as preferred ways to deal with emotional stress. In this way, they create, in the unconscious mind, a disconnected focus of unacceptable feelings, attitudes, and behavior patterns which can come forth as a personality under proper stimuli to control the body. The basic personality or ego is amnesic for this period of loss of control, since the purpose is to allow for the acting out of unacceptable impulses. Usually childhood anger towards a loved one is the first such feeling handled in this way. Next comes sexual feelings, especially if mixed with fear and anger following a childhood rape or molestation. Thus a pattern is established, of creating alter-personalities to act in the patient's behalf, all while the patient is consciously unaware of what is being done. This pattern creates its own troubles and encourages more denial, repression and dissociation. This may seem to the child to be the only way to cope with the pathological family members, and indeed, it may be. However, the child grows up and enters adult life with job, family and social responsibilities. Now the defensive pattern grossly interferes with life, and the patient seeks therapy, hoping to find a way out of the self made hell. The main interest in multiples has been so far in those in psychotherapy. But I have personally become acquainted with another group, those in prison. Eighty five per cent of my multiple patients have been women. Of those patients who had serious trouble with the law, two thirds were men. They told of other men they knew in prison who, like they, could not remember large segments of time when they had been acting violently. I suspect that many male multiples who get arrested and deny memory of the crime are sent to prison. The females who give the same story to male judges and prosecuting attorneys are more likely to be given probation and be referred to the local mental health clinic. What I am going to say on the subject of making a correct diagnosis cannot be applied to a person in prison, since anyone will manipulate and lie to a psychiatrist to try to get out of prison. It would also be hard to apply these ideas to one awaiting trial, since a prisoner's civil rights to privacy, in the United States, would be violated if a court appointed psychiatrist used hypnosis to probe his unconscious mind to find out if he had an alter-personality. Then there is the ethical problem of what the psychiatrist is to do if he finds an alterpersonality in a prisoner. Pandora's box had been opened and the psychiatrist cannot just walk out on a patient in such an unstable state of mind. Suicides have occurred when awareness of the truth came abruptly without emotional support and understanding. So let us get back to those who are in our care and see how we can determine whether or not they suffer from multiplicity, which is the tendency to create alter-personalities under stress. The traditional approach taught in medical schools, regarding all diseases, is also appropriate here. First, what are the presenting signs and symptoms ? Forty per cent of my patients came to me because of depression and or suicidal attempts, A typical story is that of a young lady who is brought to the emergency room of the hospital with longitudinal slash wounds of both forearms. She states that she had been on the phone arguing with her boy friend, who wanted to break up with her. Then she blacked out and woke up in the ambulance. A bloody knife was found in her sink. A hypnotic interview, within the day, to find out what happened during the amnesic period, reveals the existence of the alter-personality who did the foul deed. The alter-personality's reason was that the patient was again letting a man degrade her and needed to be punished for her weakness. So the alter-personality turned the anger on the body of the main personality to punish her. Other reasons for seeking help were hysterical physical complaints such as backaches, headaches, colitis, stammering, and convulsions. Other complaints were alcoholic bouts, sexual problems, auditory hallucinations and a belief in being possessed. In addition to these, a common complaint is sudden mood changes. This may be accompanied by a change in handwriting when in a different mood. One lady's bank kept refusing to cash her checks because a different signature kept showing up on the checks. A simple complaint of amnesia is rare, since these patients may have had so many amnesic spells, they consider it normal. But please be suspicious when the patient asks you, as one did me, "What happened to the month of January? The last thing I knew was going to a New Years Eve party and now it is the first week in February, And I've moved during that time into a new apartment in a different town. On looking into the details of the present illness, you must inquire about lost time gently, since these patients, not being psychotic, believe that if they complain of lost time or of hearing voices, they may be committed to a mental hospital as schizophrenics. So one has to ask about amnesia and voices in a very off-hand casual way as if they were no more important symptoms than a rash o r a hangnail. They frequently will admit to amnesia after drinking but have to be quizzed further before admitting amnesia also occurs at times when they are sober. Finding themselves in strange places, being told they used different names, is a common story. The voices of good and bad alter-personalities sometimes are heard inside the head. They know these are their own thoughts, yet they are separate. They are not projected onto an outside source. The bad voice will be urging suicide or homicide, and the good one will be encouraging and directive in how to solve today's problems. Unfortunately, the patient rarely pays any attention to the good voice. There is often a history of poor impulse control, with violent rages toward rejecting lovers and near murderous acting out. There may have been chronic physical complaints and prolonged pain after back surgery. The back pain never clears up with any type of treatment, and the recurrent "migraine" headache brings the patient to the emergency room every night for a narcotic injection, to everyone's dismay. Addiction to narcotics is common, as is a history of bouts of excessive drinking of alcohol. The childhood family situation can best be characterized as "terrible." The child was unwanted at birth. The parents became polarized in the child's view, as saintly or evil, but the child could never be sure which parent was which way. Frequently the favored parent left the home before the age of six, leaving the child with the one she couldn't stand. The child was taught the importance of keeping family secrets, supporting the positive value of repression. The girls all had a very unpleasant first sexual experience, either rape or molestation. Sibling rivalry was intense but never recognized or dealt with by the parents. The adolescent years were full of conflict with the parents, so the child ran away from home, the girl to get married, the boy to the military. The girls usually married a mate unsuitable for anyone, sadistic, unfaithful, alcoholic, and so on. None finished college, although several bright ones got within one year of graduation. The men showed marked job instability because of intervening arrests and imprisonment. Still they were very talented at what they did and could always get another job. On examination of the patient, who will most frequently be female, you might notice the glistening, smooth texture of the face. This is because she never stays in one personality long enough to develop wrinkles. When she gets depressed, she switches to her fun loving one and looks happy. There might be a number of recently healed longitudinal scars from the wrists to the antecubital fossae on both forearms. If you have samples of the patient's handwriting over a period of time, you might find three different hand writings on the same page, as the subject matter changes. If the patient is very unstable, she might switch right in front of you, talking in one voice, with one facial expression for a while; then the eyes close for 30 seconds and, on opening, you note a totally different expression. The demeanor may change from one appropriate to a ten year old school girl to an 18 year old seductress, all in a 30 year old body. Or you might have been seeing the patient for some time and one day she comes in and announces she has another name and can tell you all about "your patient" since she herself needs no psychotherapy but "she", the other one, certainly does. Those are the easy kind. There is a spot midway between the eyebrows which is very sensitive in multiples. If you touch one there, she may switch personalities, or at least get mentally upset. For some reason, this is a trigger point which the therapist can use to help the patient make a switch when desired. Laboratory tests are usually not helpful. An electroencephalogram should be done to rule out temporal lobe epilepsy. One multiple showed EEG abnormalities at the start of treatment and symptoms of physical imbalance improved on diphenylhydantoin. At the end of therapy, her EEG was completely normal. Another patient had a normal EEG but symptoms of psychomotor epilepsy. She was totally controlled on diphenylhydantoin and relapsed into a severely depressed, confused state whenever she stopped it. However, when her demanding, asthmatic daughter left the home, she stopped the drug without incident. At the University of Kentucky, Dr. Ludwig and his staff (Ludwig, et al, 1972; Larmore, et al, 1977) have been finding that the visual evoked response on the computer-analyzed EEG is different for each alter-personality. This has not yet been confirmed by any other experimenters but is a promising approach to confirming clinical opinions. Glucose tolerance tests may show both a hypoglycemic low and a diabetic high. These patients tend to be malnourished due to poor eating habits, and then they exhaust themselves trying to deal with their many problems. A hypoglycemic diet can be helpful in improving this state of affairs, if they will eat it. On mental status examination, the first thing you may notice is your own sense of incongruity between the terrible story the patient tells you and her bland, composed appearance. You just can't believe this person could have gone through all those awful experiences and come out with so little evidence of wear and tear. These people are great actors and actresses when it comes to looking normal. DON'T YOU BELIEVE IT. THEY ARE NOT. They may appear very depressed or only complain of depression without even looking sad. It lakes a long time for them to learn to be honest in expressing their feelings in physical ways, such as with tears. They think the therapist might not like them if they show they are not doing just beautifully. It is very easy to underestimate the suicidal or homicidal danger. How to respond without giving too little or too much attention to threats of violence is a most difficult judgment to make. I personally tend to underestimate the danger, and then they arrive at the hospital emergency room brought in by family members or police. Then I know for sure that I cannot count on them to control their own behavior for a while. Also, they will act helpless and may want you to tell them how to spend the next weekend. But anything you suggest will be ignored in favor of alcohol and pills. They complain they have no friends, yet you may get phone calls from their best friend who wants to help them. They attract friends easily, but drive them away with their unpredictable behavior. Eventually, they do literally have no friends, except for sick spouses and relatives. Psychological testing with the usual battery of tests prior to the clinical demonstration of alter-personalities has not been very helpful to me. It takes time to do any battery of tests and the patient may shift from one personality to another in the midst of the test, totally invalidating the results. But I have found a good predictor is the California Psychological Inventory as computer interpreted by Behaviordyne, Inc. of Palo Alto, California. A colleague of mine, Mr. John Orfield, by analyzing the CPI answers of 25 multiples, devised a scale which the computer can now use to identify a multiple with 90% accuracy. Without this test, one can still pick out the suspicious ones, by noting those described as highly hysterical, having an hysteria scale of over 55, and with one of the preferred diagnoses being dissociating hysterical personality disorder. The use of hypnosis in diagnosis is primarily for finding out what happened during amnesic periods. While in trance, the patient may become aware of the existence of the alter-personality, see her, talk with her and know her thoughts. This is terrifying to the patient and must be accompanied by a very kind and supportive behavior on the part of the therapist. It is impossible for the patient to accept the reality of what you see for some time after you are convinced of its genuineness. It is not wise to go too fast looking for more entities. Census taking is not your goal, therapy is. All you need to really know are the ones who are most dangerous at that time, the ones that could kill the patient, her husband, or even you. I left until last the most important diagnostic factor - you, the therapist. Only if you realize the disease exists, will you diagnose it. if you, like many, are afraid to find it, you never will, as these patients are very sensitive to other's feelings and never want to upset their therapist. But if you are open minded to the possibility of multiplicity, the patient will then feed you the clues. You will then have to apply the diagnostic tests mentioned here to clear up the mystery of why those strange things have been happening to your patient. When you understand the mental dynamics involved, working out the therapy plan becomes much easier. Then therapy can be initiated and eventually the goal of personality fusion can be realized. REFERENCES Assagioli, R. Psychosynthesis. New York, Viking Press, 1965. Berne, E. Games people play. New York, Grove Press, 1964. Larmore, K. , et al. Multiple personality - An objective case study. British Journal of Psychiatry, 1977, 131, 35-40. Ludwig, A. M. ,et al. The objective study of a multiple personality. Archives of General Psychiatry, 1972, 26, 298- 310. Mitchell, S. W . Mary Reynolds: A case of double consciousness. Transactions of the College of Physicians of Philadelphia 

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