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EVERYTHING YOU ALWAYS WANTED TO KNOW ABOUT
MULTIPLE PERSONALITY BUT WERE AFRAID TO ASK
Prepared for Presentation at the
Marin County Psychiatric Society
April 1982
by
Ralph B. Allison, M.D.
Retyped August 1988
During a ten year span of clinical psychiatric
practice, I had the opportunity to treat and observe over
60 patients, both male and female, who demonstrated the
presence of both primary and alter-personalities. All
were considered to possess the basic characteristics of
the histrionic personality disorder (formerly the
hysterical character disorder). However, their
clinical pictures did not necessarily follow that
portrayed in DSM III (1). They showed the basic pattern
described by Tupin (2) of an exaggeration of either male
or female stereotypical social behavior. They also
showed, when tested on the Minnesota Multiphasic Personality
Inventory or the California Psychological Inventory, the
preference for the psychological defense mechanisms
of denial, repression and dissociation. Their
management of hostile impulses was handled by dissociation
prior to any actual acting out behavior.
DEFINITION OF THE DISORDER PER DSM III
1. The existence within the individual of two or more
distinct personalities, each of which is dominant at a
particular time.
2. The personality that is dominant at any particular
time determines the individuals behavior.
3. Each individual personality is complex and integrated
with its own unique behavior pattern and social relationships.
INCIDENCE OF THE DISORDER
The true incidence in the population is unknown but
studies at NIMH currently underway by Frank Putnam, M.D.
will give more accurate data than is currently provided by
the currently popular method of counting the reported cases
in the literature. One experiment in Finland by Kampman
(3) showed that, of mentally healthy high school
students, only 8% could create an alter-personality under
hypnosis with specific instructions on how to do it.
Therefore, one could speculate that 8% of the population
might have the capacity to dissociate to the degree
necessary to manufacture such entities. This figure may or
may not apply to the mentally ill population. However,
case finding by Kluft (4) in Philadelphia, among chronically
suicidal patients in long stay hospitals and groups of
non-improving outpatients has shown multiplicity to be
frequently present as the reason for the lack of progress
in treatment. In his series of 70 cases treated, 73% were
female and 27% were male. In my cases, 80% were female
and 20% male. In the subsample of cases seen primarily
for legal evaluation, 75% were male and 25% female.
PSYCHOPATHOLOGY
1. The unconscious mental defense mechanisms of
denial, repression and dissociation are used as the
primary means of dealing with unpleasant stimuli,
instead of more socially appropriate learned coping
methods.
2. Instead of physical means, mental methods are used to
deal with both physical and emotional trauma, at least in the
initial phases of the period of trauma. Hateful thoughts
towards abusers are preferred to physical actions, such as
striking back or running away from home.
3. Hostile attitudes and feelings must be dissociated,
cannot be "owned," due to parental injunctions such as, "Thou
shalt not hate me, your parent, while I have the right to beat
you up."
4. The prime or original personality creates a
"persecutor" alter-personality for the purpose of first
handling anger, then for the feelings related to sexual
abuse. Then a "rescuer" alter-personality must be
created, followed by an organizer of the inner forces, an
entity I have christened the "Inner Self Helper" or ISH
(5).
5. If the first alter-personality is created before the age
of eight years, an additional type of alter-personality is
created, the "false front." This alter-personality may assume
all of the social functions and duties of the original
personality, which then remains "inside the mind" frozen in
emotional development at the age of the first dissociation.
There may be a series of false front personalities during
childhood, as each one becomes incompetent to handle
progressively more complicated duties. This
alter-personality is very fragile and can splinter into any
number of alter-personalities (third generation fragments or
ego states), often numbering between 10 and 50. In contrast,
if the first alter-personality is created after the age of
eight, the primary personality remains in charge. In
those cases seldom will more than six alter-personalities be
found to have ever been created.
ETIOLOGY
1. Psychological: The prime defect seems to be a failure
of the primary personality to learn by experience, a defect
which leads to antisocial behavior over a long period
of time, unchanged by punishment or the direct results of the
misbehavior.
2. Social: Traumas in the family may include being unwanted
by at least one parent, sexual and physical abuse by a parent
or a parent substitute, polarized parents, mandatory secrecy
of family problems, unresolved sibling rivalry and youthful
marriage to a sadist (in the case of females).
3. Physical: These individuals appear to have nervous
systems which are hypersensitive to the "vibes" of other
persons, so that they can easily perceive the emotions of
others around them, especially the negative ones. They are
then very much influenced by the moods of those around
them. Such persons are "emotional albinos."
4. Moral: Prior to therapy, they have not decided
whether to be good or bad persons. The formation of
alter-personalities is their method of demonstrating
the moral ambivalence without developing a true sense
of guilt, which might inhibit the acting out.
CLINICAL PICTURE
1. Symptoms which are most prominent at the start of
therapy are depression and amnesic spells, during which
suicide attempts may be made. Physical complaints may
include severe headaches, backaches, colitis,
stammering, convulsions, alcoholism, drug addiction and
sexual dysfunction. There are usually reports by
family members and friends of complicated social
behavior during amnesic spells, such as the taking of
long trips, renting motel rooms, making dates and
entering into illegal or immoral activities with
other individuals. The hearing of accusatory
voices inside the head may be admitted, if the
patient is questioned in a non-threatening fashion.
2. Signs may include an incongruity between the
atrocious history which is obtained and the calm,
unweathered facial and bodily appearance presented by the
patient. Longitudinal scars on the forearms may
be present from repeated self-mutilations. Rarely is
the spontaneous switching of personalities seen on an
initial interview. If it does occur, that is, of
course, the basic clinical requirement for the diagnosis.
The patient, in such a situation, may suddenly act
like a young child, or becomes very seductive or
violent. Patients with multiplicity usually have a
sensitive spot in the middle of the forehead which,
when touched by the therapist, will facilitate the
switching from a hostile to a helping alter-personality.
LABORATORY TESTS
1. The MMPI and the CPI (when interpreted by the
Behaviordyne, Inc. computer program), usually will show a
high hysteria score (over 55) and the diagnosis
of dissociating hysterical personality disorder as one
of the preferred diagnoses.
2. Rorschach test findings, per Wagner's criteria (6),
may be the most reliable test results, regardless of
the differences between responses of the different
alter-personalities. Wagners' five guidelines indicate
that a goodly number of movement responses must be
present, at least two of the movement responses must be
qualitatively diverse, at least one of the movement
responses must reflect a feeling of being oppressed,
there should be at least three color precepts and at
least one color percept should be "positive" and another
"negative."
3. Neurophysiological evaluations at NIMH have so far
shown definite differences between patients and normal
subjects, but variations between patients are too great to
allow any one test to be a reliable indicator of the
diagnosis (Putnam, personal communication, 1982).
Specifically, "the visual evoked potential component
differences among the alternate personalities of
individuals with Multiple Personality Disorder are
significantly greater than among the simulated alternate
personalities of normal controls. This was noteworthy
on the evoked potential component, P-100, previously
associated with individual differences in
personality. obsessive-compulsive alternate
personalties of individuals with MPD show the same
amplitude differences that obsessive-compulsive patients do."
USE OF HYPNOSIS IN MAKING THE DIAGNOSIS
In non-forensic cases, hypnosis is usually needed to
confirm or deny the diagnosis when there is a suspicious
history. But the hypnotic examiner must be completely open
minded and looking only for the true explanations for
the patient's amnesia or strange behavior. The
examiner must not suggest that some other entity might be
responsible. A recent amnesic episode about which
the patient is anxious can be an excellent place to
start the exploration for the truth. Recall of the time
just before that episode, with recitation of events
leading into the amnesic period and a reliving of the
feelings occurring at the start of the episode, can be a
powerful trigger for activating the already existing
alter-personality which was responsible for that
particular episode. In California, as of April 1982,
hypnosis is forbidden in forensic cases, since any
witness who has been hypnotized during the
investigation of the crime will be considered to be
subsequently giving "tainted" testimony. Any approach
to a criminal defendant who is suspected of being a
multiple will have to be in a manner which avoids the
appearance of inducing hypnosis.
If the patient reports an internal voice talking to
him/her, the examiner may ask the patient to talk out loud
to that voice, while in a light, self-induced trance.
The instructions might include, "Go back to just behind
your eyeballs, so that you two occupy the same space. Then
talk to the source of that voice out loud so that I
will know what you are saying." Sometimes the; examiner
will get exactly what is asked for, but sometimes the
alter-personality will come out to object to the examiner
doing anything at all, giving the examiner an excellent
chance to interview the alter-personality.
DIFFERENTIAL DIAGNOSES
1. Play Acting or Conscious Simulation: This would be
unlikely: in a non-legal case but exposure to a genuine
multiple and questions by a patient as to whether or not the
therapist thought the patient was a multiple would be
suspicious signs in a questionable case. Genuine multiples
strongly deny that they might have such a disorder and
would rather have an organic disease to explain their
symptoms. Yet, some actors and actresses may be
dissociating in the course of playing historical roles or
character parts, but they have no amnesia. The
distinction may be unclear between the disease of
multiplicity and the mental state of the over-involved character
actor, except for the absence of amnesia and the ego
syntonic reason for the personality changes.
2. Unconscious Simulation: Just as anyone with the need
and histrionic character traits can unconsciously mimic any
physical symptom, as in a conversion disorder, so can a
histrionic patient mimic a multiple, if previously exposed to a
genuine multiple, as might occur in a psychiatric hospital
setting. The difference would be in the lack of a
history of amnesias or sudden personality changes and the
lack of symptoms meeting specific psychological needs, such
as the management of anger. The course of the illness would
differ in that "fusion" of the "alter-personalties" would
occur only when the secondary gain is accomplished, not
with effective psychotherapy.
3. Dissociation After Arrest: In legal cases, some degree
of dissociation may be suspected during a crime spree
by an otherwise non-criminally oriented defendant because the
defendant seemed to be playing two roles for a period of
time. One role might be the good worker and family man during
the day, and the other role would be the fiendish, sadistic
rapist at night. Upon arrest, the defendant would claim
at least some degree of amnesia, such as the lack of
recognition of some of the victims. Yet there was no
witnessed history of amnesic spells or personality
changes in childhood or early adulthood. Upon arrest and the
sudden confrontation with such revolting illegal
activity, the defendant may, with any suggestion at all, create
a psychic entity which accepts responsibility for the crimes,
uses another name, ridicules the defendant and is the very
embodiment of evil itself. Yet there is no solid evidence
that this entity existed prior to the arrest, and it never
appears in jail after sentencing, if at all. The
psychiatric examiner may quite naturally assume that this
evil entity did indeed exist at the time of the crime
spree, yet it may have only been a part of the defendant's
mental apparatus when the crimes occurred, only to split
off under hypnosis when the psychiatrists were called in by
the defense attorney. At that point, the defendant, who may
have had retrograde amnesia for his ego dystonic crimes,
unconsciously allows this evil portion of his mind to
crystallize into an entity which confesses for him. When he
is confronted with this entity on videotape, he is able
to let 'him' take the emotional responsibility for the
crimes and provide him with the basis for an insanity plea,
which is rarely successful. After conviction, this entity
disappears, never to be seen in prison, without the
benefit of formal psychotherapy.
4. Spirit or Demonic Possession: In most of the world
outside of the USA, spirit possession is considered a reality
and a more likely explanation for the presence of
alter-personalities than is any psychological diagnosis. In
the USA, public opinion polls indicate that 40% of the
population believe in spirit possession and 5% believe that
they, themselves, have been possessed at some time in the
past. Sixty percent do not believe in possession as a
reality. Therefore, if the examiner, who most likely
sides with the majority, finds entities who claim to be
demonic, under the control of archdemons, and with no
point of psychological origin, he/she has a real problem
in making a psychiatric diagnosis. One option is
to call this state an Atypical Dissociative Disorder
called The Possession Syndrome. This can be defined as
a state of mind in which the patient has no conscious
belief in possession (which would be considered a
delusion by the skeptical majority), but shows evidence
of an unconscious belief in being possessed by entities
from a supernatural source. The patient's behavior is
determined by the form these beliefs take in his/her mind.
Since it is highly unlikely that any two persons will
agree as to just what it is like to be possessed, there is
no typical clinical picture. The only common thread
is the belief in being possessed by evil entities which
come from outside. It would be expected that cultural
stereotypes will be used in creating the details of the
experience of being possessed.
TREATMENT
1. The Goal: The long term goal of treatment is
personality integration so that only one personality
inhabits the body thereafter. This goal is supported
by the view that what has actually happened is personality
splitting or disintegration, not the creation of truly
separate entities who need to be taught to share time in
the body. If the therapist's goal is that teaching time
sharing is best, this indicates an ill trained and
unimaginative therapist. A comparison to surgery is
appropriate. The therapist should do all he/she can,
with the patient's assistance, to put the pieces all
back together again. If the therapist cannot, only then
should he/she help the patient to learn to live with the
condition. But the therapist should try all he/she can to
cure the basic defect first, and the defect is in the lack
of unity within the mind. The basic method for doing that
is to have the patient recall to consciousness all of
the traumatic situations which have led to the dissociations.
The presently active primary personality must become
aware of the feelings generated by those traumatic
events and must accept those feelings as naturally
occurring and his/her own. With the help of the
therapist and the inner Self Helper, the primary
personality must replace hostile feelings with
neutral or positive ones, thus eliminating the need for
an alter-personality to act out in a destructive fashion.
Each patient will demonstrate a unique style for
accomplishing this goal.
2. The Plan; Personality integration appears to
follow the following steps. They are not necessarily
sequential, but usually overlapping. Details can be found
in my article (7).
a. Recognition of the existence of the alter
personalities: The patient must be fed back all of
the data which the therapist receives which
indicates who the alter- personalities are, what they
do and why they exist.
b. Intellectual acceptance of having multiple
personalities: The patient comes to accept, on a
superficial basis, the truth of what the therapist
is showing and telling him/her, even though he/she
does not really believe the information deep down.
This allows the psychotherapy to begin, usually
utilizing age regression under hypnosis, with
sequential review of the causes of the creation of the
negative alter-personalities.
c. Coordination of alter-personalities: The therapist
must assign duties, if necessary, to helper
alter-personalities in such areas as suicide
prevention, child care, work and marriage, so that
all life sustaining functions are maintained while
therapy proceeds.
d. Emotional acceptance of being multiple: This comes
about as the result of some incident which no one
could have possibly staged for the patient's benefit,
an event which convinces the patient of the accuracy
of what the therapist has been trying to get across for
some time. This marks the turning point from the
patient grudgingly cooperating in treatment to a whole
hearted commitment to becoming one, no matter the
cost.
e. Elimination of persecutor alter-personalities: The
alter- personalities which are activated by
hostility and aggressive sexuality are the most
dangerous ones and, therefore, should be first on
the therapist's list for neutralization. After
psychotherapy reveals their origins, various imagery
methods can be used to either reform such entities into
helpers or to eliminate them entirely from the patient's
psychic structure. For each persecutor alter-
personality, there may be one rescuer alter-personality,
which will then have nothing to do and will disintegrate
from disuse atrophy.
f. Psychological fusion: When all of the persecutor
alter-personalities have been neutralized, all of the
resultant fragments will come together automatically. In
the case of a patient with over 10 personalities, clusters of
personalities may fuse prior to the grand integration,
thus removing the casualties from the scene of battle. As
two or more alter-personalties become more alike In
function and attitudes, they may fuse spontaneously.
These partial fusions will leave those
un-neutralized alter-personalities to the attention of the
therapist, so that he/she need only focus on those
still active.
g. Spiritual fusion: When all of the alter-personalities
have blended together, in whatever way the patient may
do this, the primary personality, or a new version
thereof, will co-exist with the Inner Self Helper, who
will then function primarily as a mental teacher. In
the months following the psychological fusion, the ISH
will be teaching principles of healthy living to the
primary personality. When all of these lessons have
been learned, and there is no essential difference
between the two in thought patterns, they become one,
in a quiet spontaneous process.
h. Post-fusion experiences: After fusion, the patient
usually feels that he/she will never again have
problems. The reality is that the problems the
patient now faces are modern versions of those the
patient, as a child, mishandled by creating
alter-personalities. Now the patient has a second
chance to use newly learned coping skill in dealing
with those old problems. Another major experience
the patient may have is the experiencing of normal
emotional reactions to making good decisions regarding
major problems. Patients usually believe that they will
always feel good if they have make the right choice
in a difficult situation. But now the patient feels
miserable after having made the correct decision, since
the previous ambivalence could not be maintained. The
patient may be surprised to learn that to gain
something, one may have to lose something else. In
the process of this loss, pain is felt.
MORBIDITY
Multiplicity is not a self-limited disease. once
initiated, an alter-personality can well continue to exist into
old age, and several patients over 50 years of age have
been treated by the writer. In the process, they can well
exhaust parents, spouses, children, employers, friends,
physicians and anyone else who has ever cared for them.
Suicidal acting out may be viewed by others as only an
attention getting device, but, for the patient, he/she often
wants to die. Survival is possible because of the inherent
ambivalence manifested by the rescuer
alter-personalities. Children can be abused, mentally and
physically by an alter-personality who does not consider
herself to be the mother of the children. Individuals
who really do physical harm to these patients may, if
not natural parents, be victims of serious
physical assault or even murder by an alter-personality
who believes it is protecting the patient from death.
About 80% of the marriages of multiples in treatment
ended In divorce after the patient improved, since the
spouse was now sicker than the patient, and no recovered
patient wants to stay married to a disturbed mate.
In my series, there were many suicide attempts but only
one successful suicide, that one being due to desertion of
the patient's husband after she had left
therapy, which was incomplete. One other patient was
declared a suicide by the coroner, after fusion, but
all evidence pointed to the possibility that the
patient was accidentally killed trying to settle a fight
between two men in the house. one patient died of unknown
caused, with no clarification at autopsy.
A number of patients were involved in homicidal
acts. One patient reported killing her stepfather and his
two friends after they had tried to kill her. One male
multiple killed his wife with no more reason than that she
nagged him one time too often. One male killed a lone woman
after raping her and then killed a man after they had had
homosexual activity together.
After treatment, which varied in length from one
week to three years, averaging 18 months, most of the
patients moved from the location of treatment, where they
were too well known to the helping agencies, to other
towns where they were not known. There they have faded
Into anonymity, leading quiet and very average lives.
REFERENCES
1. American Psychiatric Association, Diagnostic and
Statistical Manual of Mental Disorder, Third
Edition, Washington, DC, APA, 1980
2. Tupin, J. Psychiatric Grand Rounds, UC Davis
School of Medicine, Sacramento, CA, Jan. 1981
3. Kampman, R. Hypnotically induced multiple
personality: An experimental study. International
Journal of Clinical and Experimental Hypnosis, 1976,
24, 215-227
4. Kluft, R.P. varieties of hypnotic interventions
in the treatment of multiple personalities.
American Journal of Clinical Hypnosis, 1982 ,in press,
5. Allison, R.B. A new treatment approach for
multiple personality. American Journal of Clinical
Hypnosis, 1974 17, 1 5- 3 2
6. Wagner, E.E. & Heiss, M. A comparison of Rorschach
records of three multiple personalities. Journal
of Personality Assessment, 1974, 38, 308-331
7. Allison, R.B. A rational psychotherapy
plan for multiplicity. Svensk Tidskrift for Hypnos,
1978, 3-4, 9-16
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