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DEBATE FORUM Assistant Editor: Lenore C. Terr, M.D.

Resolved: Multiple Personality Disorder Is an Individually and


Socially Created Artifact
AFFIRMATIVE: PAUL R. McHUGH, M.D.

Where's hysteria now that we need it? With DSM-IV, to consult with experts, who examine the patient for
psychiatrists have developed a common language and esoteric disease. As the investigation proceeds, the pa-
a common approach to diagnosis. But in the process tient may become still more persuaded that an illness
of operationalizing diagnoses, we may have lost some is at work and begin to model the signs of disorder
concepts about patient behavior. The term "hysteria" on the subtle suggestions of the physician's inquiry.
disappeared when DSM-III was published; without it, For example, a patient with complaints of occasional
psychiatrists have been deprived of a scientific concept lapses in alertness might-in the course of investiga-
essential to the development of new ideas: the null tions that include visits to the epilepsy clinic and to
hypothesis. This loss hits home with the epidemic of the EEG laboratory for sleep studies, photic stimula-
multiple personality disorder (MPD). tion, and nasopharyngeal leads-gradually develop the
The work of Talcott Parsons (1964), David Me- frenzied thrashing movements of the limbs that require
chanic (1978), and Isidore Pilowsky (1969) taught the protective attention of several nurses and hospi-
psychiatrists to appreciate that phenomena such as tal aides.
hysterical paralyses, blindness, and pseudoseizures were Eventually, with the patient no better and the investi-
actually behaviors with a goal: achieving the "sick gations proving fruitless, a psychiatric consultant alert
role." Inspired by Parsons, Mechanic and Pilowsky to the concept of hysteria and its contemporary link
used the term "abnormal illness behavior" in lieu to the "sick role" might recognize that the patient's
of hysteria. Their approach eliminated the stigma of disorder is not an epileptic but a behavioral one. The
malingering that had been implied in hysteria and patient is displaying movements that attract medical
indicated that patients could take on such behavior attention and provide the privileges of patienthood.
without fraudulent intent. They were describing an Talcott Parsons, the Harvard sociologist, pointed
old reality of medical experience. out in the 1950s that medicine was an organized
Some people-experiencing emotional distress in component of our society intended to aid, through
the face of a variety oflife circumstances and conflicts- professional knowledge, the sick and the impaired. To
complain to doctors about physical or psychological accomplish this, certain individuals-physicians-are
symptoms that they claim are signs of illness. Sometimes licensed by society to decide not only how to manage
they display gross impairments of movement or con-
the sick, but to choose and distinguish the sick from
sciousness; sometimes the features are subtle and chang-
other impaired people. Such an identification can pro-
ing. These complaints prompt doctors to launch
vide these "sick" individuals with certain social privi-
investigations in laboratories, to conduct elaborate and
leges, i.e., rest, freedom from employment, and support
sometimes dangerous studies of the brain or body, and
from others during the reign of the condition. The
person given the appellation "sick" by the social spokes-
man-the physician-was assumed by the society to
Accepted August 17, 1994.
Dr. McHugh is Director 0/ Psychiatry, johns Hopkins University, School respond to these privileges with other actions, i.e.,
0/ Medicine, Baltimore, MD. Dr. Putnam is Chief, Unit on Dissociative cooperating with the intrusions of investigators of the
Disorders, Laboratorya/Developmental Psychology, National Institute ofMental
illness and making every effort at rehabilitation so as
Health, Bethesda, MD.
0890-8567/95/3407-0957$03.00/0 1995 by the American Academy to return to health. The hidden assumption is that
of Child and Adolescent Psychiatry. the burdens and pains of illness act to drive the patient

J. AM. ACAD. CHILD ADOLESc:. PSYCHIATRY, 34:7, JULY 1995 957


DEBATE fORUM

toward these cooperative actions with the physicians of prompting a search for and treatment of the troubles
and thus to be happy to relinquish the few small in the personal life.
pleasures that can be found in being treated as a victim All this became embedded in the concept of hysteria
of sickness. and needs to be reapplied in the understanding of
However, because there are advantages to the sick MPD. The patients I have seen have been referred to
role, there are some situations in which a person might the Johns Hopkins Health System because elsewhere
seek this role without a "ticket of admission," a disease. they have become stuck in the process of therapy. The
This is hardly a remarkable idea as almost anyone has histories are similar. They were mostly women who
noticed the temptation to "call in sick" when troubles in the course of some distress sought psychiatric assis-
are afoot. But in some patients-those with emotional tance. In the course of this assistance-and often early
conflicts, weakened self-criticism, and high suggestibil- in the process-a therapist offered them a fairly crude
ity-this temptation can be transformed, usually with suggestion that they might harbor some "alter" person-
some prompting, into the conviction that they are alities. As an example of the crudity of the suggestions
infirm. This kind of patient may, in fact, use more to the patient, I offer this published direction of how
and more information from the medical profession's to both make the diagnosis and elicit "alters":
activities to amplify the expression of the infirmity.
The sine qua non of MPD is a second personality who ar some
Psychiatrists have known about these matters of rime comes out and takes executive control of the patient's behavior.
social and psychological dynamics for more than 100 It may happen that an alter personality will reveal itself to you
years. They were brought vividly to attention by the during this [assessment] process, but more likely it will not. So
you may have fa elicit an alter personality... .To begin the process
distinguished pupil of Jean-Martin Charcot, Joseph of eliciting an alter, you can begin by indirect questioning such
Babinski (he of the plantar response). Like Sigmund as, "Have you ever felt like another part of you does things that
Freud and Pierre Janet, Babinski had observed Charcot you can't control?" If she gives positive or ambiguous responses,
manage patients with, what Charcot called, "hystero- ask for specific examples. You are trying to develop a picture of
what the alter personality is like.... At this point, you might ask
epilepsy." But Babinski was convinced that hysteroepi- the host personality, "Does this set of feelings have a name?"
lepsy was not a new disorder. He believed that the Occasionally you will get a name. Often the host personality will
women at Charcot's clinic were being persuaded-and not know. You can then focus on a particular event or set of
behaviors and follow up on those. For instance, you can ask, "Can
not so subtly-to take on the features of epilepsy
I talk fa the part of you who is taking those long drives to the
by the interest Charcot and his assistants expressed country? (Buie, 1992, p. 3).
(Babinski and Frornent, 1918). Babinski also believed
that these women were vulnerable to this persuasion Once the patient permits the therapist to "talk to
because of distressing states of mind provoked in their the part ... who is taking those long drives," the
life circumstances and their roles as intriguing patients patient is committed to having MPD and is forced to
and the subject of attention from many distinguished act in ways consistent with this role. The patient is
physicians who offered them a haven of care. then placed into care on units or in services-often
Babinski was bringing the null hypothesis to Charcot titled "the dissociative service"-at the institution. She
and with it, not a rejection of these women as legitimate meets other patients with the same compliant responses
victims of some problem, but an appreciation that to therapists' suggestions. She and the staff begin a
behaving as if epileptic obscured reality and made continuous search for other "alters." With the discovery
helping their actual problem difficult. Babinski wrote of the first "alter," the barrier of self-criticism and self-
that just as hysteroepilepsy rested on persuasion, so a observation is breached. No obstacles to invention
form of counterpersuasion could correct it. He demon- remain.
strated that these patients improved when they were Countless numbers of personalities emerge over time.
taken from the wards and clinics where other afflicted What began as two or three may develop to 99 or
women-epileptic and pseudoepileptic-were housed 100. The distressing symptoms continue as long as
and when the attention of the staff was turned away therapeutic attention is focused on finding more alters
from their seizures and onto their lives. These mea- and sustaining the view that the problems relate to
sures-isolation and countersuggestion-had the ad- an "intriguing capacity" to dissociate or fractionate
vantage of limiting the rewards for the behavior and the self.

958 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 34:7. JULY 1995


DEBATE FORUM

At Johns Hopkins, we see patients in whom MPD of DSM-IV. It provides a way in which a diagnosis
has been diagnosed because symptoms of depression can be reliably applied to a patient, but it does not
have continued despite therapy elsewhere. Our referrals in any way validate the existence of the condition or
have been few and our experience, therefore, is only negate a null hypothesis about it.
now building, probably because our views-that MPD Charcot had quite reliable ways of diagnosing hyster-
may be a therapist-induced artifact-have only recently oepilepsy. It just did not exist as he thought it did,
become generally known in our community (McHugh, but rather it was a behavior seeking the sick role.
1995) . We seem to challenge the widely accepted view It is my opinion that MPD is another behavioral
and to "turn back the clock." The referrals that come disorder-a socially created artifact-in distressed peo-
to us often arrive with obstacles to our therapeutic ple who are looking for help. The diagnosis and subse-
plans. Patients and their referring therapists often wish quent procedures for exploring MPD give them a
to stay in regular contact (two to three times weekly) coherent posture toward themselves and others as a
and to continue their work on MPD. At the same particular kind of patient: "sick" certainly, "victim"
time, we at Hopkins are expected to treat the depression possibly. This posture, if sustained, will obscure the
or some other supposed "side issue." We, however, real problems in their lives and render psychotherapy
following the isolation and countersuggestion approach, long, costly, and pointless. If the customalY treatments
try to bring about, at least temporarily, a separation of hysteria are provided, then we can expect that the
of the patient from the staff and the support groups multiple personality behaviors will be abandoned and
that sustain the focus on "alters." We refuse to talk proper rehabilitative attention can be given to the
to "alters" but rather encourage our patients to review patient.
their present difficulties, thus applying the concept of Hysteria as a concept has been neglected in DSM-
"abnormal illness behavior" to their condition. III and DSM-IV, but it offers just what it has always
The advocates for MPD are in the same position offered: a challenge to proposals of new entities in
as Charcot was when Babinski offered his proposal of psychiatry. Some diagnoses survive and others do not.
the null hypothesis. As in any scientific discussion, it MPD has run away with itself, and its proponents
is not the responsibility of the proposers of the null must now deal with this challenge. Charcot took such
hypothesis to prove its likelihood. That hypothesis a challenge from his student. Everyone learned in
simply claims that nothing special has been discovered. the process.
I claim the same in this debate. The investigators
proposing a new entity must demonstrate that the null REFERENCES
hypothesis should be rejected.
Babinski J, Frorncnr J (I918), Hysteria or Pitbiatism and Reflex Nervous
In most of the discussions by champions of MPD Disorders in the Neurology of War. Rollcsron JD, trans; Buzzard EF,
just the opposite occurs. Not only is the null hypothesis cd. London: University of London Press
Buic SE (I 992), Introduction to the diagnosis of multiple personality
discarded without any compelling reason, but nonrele- disorder. Grand Rounds Rev (4):1-3
vanr information is presented to justify a uniqueness McHugh PR (I995), Witches, multiple personalities, and other psychiatric
artifacts. Nature Med 1: II 0-114
to MPD. Perhaps the most common proposal is that Mechanic D (1978), Effects of psychological distress on perceptions of
MPD must exist in the way proposed because it is physical health and lise of medical and psychiatric facilities. J Hum
Stress 4:26-32
included in DSM-IVand operational criteria are avail- Parsons T (1964), Social Structure and Personality. New York: Free Press
able to make the diagnosis. This is a misunderstanding Pilowsky I (1969), Abnormal illness behaviour.13rJ Med PsyhcoI42:347-351

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 34:7, JULY 1995 959


D EBAT E PORUM

NEGATIVE: FRANK W. PUTNAM, M.D.

For more than a century, the existence of multiple hypnosis. Since MPD appears in many patients with
personality disorder (MPD) has provoked heated de- no histo ry of hypnotic interventions, the misuse of
bate. That both the diagnosis and the controversy are hypnosis apparently is not responsible for the syndrome.
still with us says something about the resiliency of The second allegation, that MPD is induced by
both sides of the question. The similarities between media portrayals, ignores extensive research on the
the charges leveled in the cur rent debate and those in effects of the media on beh avior. More than 30 years
the historical record suggest th at things, unfortunately, of research on the relation of television viewing to
have not changed very much in IOO years. It is unlikely violence informs us of ju st how difficult it is to find
that this exchange will resolve the matter, but perhaps clear-cut effects produced by exposure to specific media
we can move the question along to a higher level. imagery. Certainly there are media effects, but these
The criticisms leveled at MPD are not credible when effects are not simple and direct identifications. Rather
examined in the light of what we know about the th ey are indirect, cumulative, and heavily confounded
etiologies of mental illness . Debate can be advanced by individual and situational variables (Friedlander,
by critiqueing the validity of MPD in the same manner 1993). The depiction of violence in the media is vastly
in which the validity of other psychiatric diagnoses more com mon (perhaps it is even the norm for movies
are assessed . and television) than the portrayal of MPD. Yet, the
What are the criticisms of MPD ? There are three crit ics ofMPD would have us believe that the minuscule
basic criticisms made against this diagnosis. The first percentage of media time devoted to MPD is directly
is that MPD is an iatrogenic disorder produced in responsible for the increase in diagnosed cases. This
patients by their psychiatrists. The seco nd is that MPD would be an extraordinarily specific and powerful ef-
is produced by its portrayal in the popular media. The fect-far, far beyond anything found by the thousands
third is that the numbers of MPD cases are increasing of stu d ies on violence conducted by media researchers.
expo nent ially. The first and seco nd charges are often The first and second accu sations beg an important
lumped together and viewed as being responsible for qu estion. Why this disorder? If these individuals are
th e thi rd . so suggestible, wh y don't they develop other disorders?
The first accusation is historically the oldest and the Why should suggestion effects be unique to MPD?
most serious because it alleges th erapeutic misconduct Psychiatrists inquire about and exhibit interest in other
of the gravest nature. The psychiatrist's fascination sym ptoms. We do not believe that asking about halluci-
with the patient's symptoms supposedly reinforces the nations produces them in a patient. Why should asking
behavior and produces the syndrome. A variation of about the existence of "other parts" of the self produce
thi s accusation charges that the condition is produced alte r personalities? What is so magical about this ques-
by the improper use of hypnosis. In either instance, tion? With respect to media portrayals of mental illness,
the fact is that there are no cases reported in wh ich a random channel-walk through the soap opera and
the full clinical syndrome of MPD was ind uced either talk show circuits will con vinc e one that many other
by fascination or by hypnosis. Experiments by Nicholas sym ptoms and d isorders fill th e airwaves. Eating d isor-
Spano s are sometimes cited as exam ples of the creation ders, obsessive-compulsive disorder, bipolar illness, as-
of MPD by role-playing stu dents (Spanos , 1986). The so rted phobias, sexual dysfunctions, autism, chronic
reader is invited to compare th e verbal responses of fatigue syndrome, etc. , erc., are discussed in graphic
undergraduates responding to a staged sit uation with detail and glamorized after th eir own fashion. Why
the psychiatric symptoms of MPD patients reported don't suggestible individuals identity with these condi-
in the clinical literature. Two clinic al stu d ies examined tio ns? Truly, if there is such a high degree of suggestive
the effects of using hypnosis on th e sym pto ms and specificity to MPD, it is worthy of intensive
behaviors of MPD patients (Putnam et al., I986; Ross, investigation.
1989). T here were no significant differences between T he third accusation, that cases of MPD are increas-
MPD cases diagnosed and treated with or without ing "e xponentially" or " logarithm ically," shows little

960 J . AM . ACAD. CHILD ADOL ESC . PSYC H IAT RY. 34:7. JULY 19 9 5
DEBATE FORUM

understanding of basic mathematics. Critics often cite symptoms of MPD patients across different sites and
inflated numbers of cases without any support for their investigational methodologies (Coons et a!', 1988, Put-
figures. I have plotted the numbers of published cases nam et a!', 1986; Ross et a!', 1990). They should
year by year, and while it is true that they have increased convince the interested reader that a specific, unique,
significantly compared to prior decades, the rise in the and reproducible clinical syndrome is being described.
slope is not nearly as dramatic as the critics' hyperbole A small but growing body of literature on childhood
suggests. Over the same period, other disorders, e.g., and adolescent MPD links the adult syndrome with
Lyme disease, obsessive-compulsive disorder, and childhood precursors, establishing a developmental
chronic fatigue syndrome, have shown equal or faster continuity of symptoms and pathology (Dell and Eisen-
rises in the numbers of published cases. This reflects hower, 1990; Hornstein and Putnam, 1992). The well-
a basic process in medicine associated with the compila- delineated, well-replicated set of dissociative symptoms
tion and dissemination of syndromal profiles. When that constitute the core clinical syndrome of MPD
symptoms that were once viewed as unrelated are satisfies the requirements for content validity.
organized into a coherent syndromal presentation and MPD and its core pathological process, dissociation,
that information is widely disseminated, physicians can be detected and measured by reliable and valid
begin to identity the condition more frequently. The structured interviews and scales (Carlson et a!', 1993;
rapid rise in the number of cases of "battered child Steinberg et al., 1991). Published data on validity
syndrome" following the classic paper by Kempe and compare very favorably with accepted psychological
his colleagues is a very relevant example of this process instruments and satisfy the reliability requirement im-
in action. A related criticism is that a few clinicians posed by Robins and Guze for the inclusion of psycho-
are responsible for most of the diagnosed MPD cases. logical tests as measures of criterion validity. These
Again, a review of the MPD literature demonstrates a instruments have been translated into other languages
healthy diversity of authorship comparable with that and proven to discriminate MPD in other cultures.
found for other conditions. Discriminant validity studies have been conducted for
The crucial question raised by this debate is: How the Dissociative Experiences Scale and the Structured
should the validiry of a psychiatric diagnosis be judged? Clinical Interview for DSM-III-R-Dissociative Module,
Considerable thought has gone into this question. both of which show good receiver operating characteris-
(For a more complete discussion, see The Validity of tic curves, a standard method for evaluating the validity
Psychiatric Diagnosis by Robins and Barrett, 1989.) of a diagnostic test (Carlson et a!', 1993; Steinberg
Many psychiatrists endorse the model of diagnostic et a!', 1991). MPD is well discriminated from other
validity put forth by Robins and Guze in 1970 and disorders by reliable and valid tests and thus has good
subsequently amplified by others (Robins and Barrett, criterion-related and construct validates.
1989). This model requires that psychiatric diagnoses Multiple personality disorder has been with us from
satisfy aspects of three basic forms of validiry: content the beginnings of psychiatry (Ellenberger, 1970). At
validity, criterion-related validity, and construct valid- present we conceptualize this condition as a complex
ity. Content validity is probably the most fundamental form of posttraumatic dissociative disorder, highly asso-
form of validity for psychiatric diagnosis. It requires ciated with a history of severe trauma usually beginning
that the diagnostician be able to give a specific and at an early age. I believe that research demonstrates
detailed clinical description of the disorder. Criterion- that the diagnosis of MPD meets the standards of
related validity requires that laboratory tests, e.g., chem- content validity, criterion-related validity, and con-
ical, physiological, radiological, or reliable psychological struct validity considered necessary for the validity of
tests, are consistent with the defined clinical picture. a psychiatric diagnosis. The simplistic argument that
Construct validity requires that the disorder be de- MPD is individually and socially caused "hysteria"
limited from other disorders (discriminant validity). evades the much more important question of what is
The clinical phenomenology ofMPD has been delin- the best approach to helping these patients. Denying
eated and repeatedly replicated in a series of studies its existence or blaming psychiatrists and television for
of more than 1,000 cases. A review of the best of MPD patients' symptoms is not constructive. It is
these studies demonstrates striking similarities in the important to move beyond debate about the existence

J. AM. ACAD. CIIII.D ADOI.FSC. PSYCIlIATRY, 34:7, JULY 1995 961


DEBATE FORUM

In: Children and Violence, Reiss D, Richters JE, Radke-Yarrow M,


of the condition to more serious discussions of thera-
Scharff 0, eds, New York: Guilford Press, PI' 66-81
peutic issues. Hornstein NL, Putnam FW (1992), Clinical phenomenology of child and
adolescent dissociative disorders. J Am Acad Child Adolesc Psychiatry
31:1077-1085
Putnam FW, Guroff J], Silberman EK, Barban L, Post RM (1986), The
clinical phenomenology of multiple personality disorder: review of 100
REFERENCES recent cases. J Clin Psychiatry 47:285-293
Robins LE, Barrerr JE, cd. (1989), The Validity of Psychiatric Diagnosis.
Carlson EB, Putnam FW, Ross CA ct al, (1993), Validity of the Dissociative New York: Raven Press
Experiences Scale in screening for multiple personality disorder: a Ross CA (1989), Effects of hypnosis on the features of multiple personality
multicenter study. Am J Psychiatry 150:1030-1036 disorder. Am J Clin Hypn 32:99-106
Coons PM, Bowman ES, Milstein V (1988), Multiple personality disorder: Ross CA, Miller SO, Bjornson L, Reagor 1', Fraser G, Anderson G (1990),
a clinical investigation of 50 cases. J Nerv Ment Dis 176:519-527 Structured interview data on 102 cases of multiple personality disorder
Dell PF, Eisenhower JW (1990), Adolescent multiple personality disorder. from four centers. Am J Psychiatry 147:596-601
JAm Acad Child Adolesc Psychiatry 29:359-366 Spanos Nl' (1986), Hypnosis, nonvolutional responding, and multiple
Ellenberger HF (1970), The Discovery of the Unconscious: The History and personality: a social psychological perspective. !'rog Exp Pers Res 14:1-62
Evolution of Dynamic Psychiatry. New York: Basic Books Steinberg M., Rounsaville B, Ciccherri 0 (1991), Detection of dissociative
Friedlander BZ (1993), Community violence, children's development, and disorders in psychiatric patients by a screening instrument and a
mass media: in pursuit of new insights, new goals and new strategies. structured diagnostic interview. Am J Psychiatry 149:1050-1054.

AFFIRMATIVE REBUTTAL: McHUGH

Dr. Putnam makes two claims: (1) that MPD is vali- would dismiss as "simplistic." I would say that his lists
dated and (2) that a treatment program that rejects of validating methods are more smoke than substance
that claim will be incoherent. when their application to this issue is carefully
To his first claim, the point of contention is not appraised.
whether patients exist with a set of complaints that To his second claim, I agree that an important
are internally consistent and match the criteria for question-perhaps, though, not a "more important
MPD published in DSM-IV. The issue is whether this question"-is how to help these patients. Rational
collection of complaints and behaviors represents a treatment depends on the nature of the condition from
natural product of mental life or a socially constructed which the patient suffers. A psychological artifact is
artifact generated in the interaction between patient not treated in the same way as a natural psychological
and therapist. By an artifact I mean something forged condition, such as depression, grief, or demoralization.
by an artisan rather than by nature. For example, an It has to be removed, not cured. In fact, the treatment
arrowhead differs from a glacially scoured triangular of the artifact, MPD, has two aspects: First, attention
stone by being the product of the hand of a human to its peculiar features should cease. Stop talking to
being. alters, naming alters, eliciting alters, charting alters,
All examples of MPD that I have seen give evidence wiggling fingers at patients, and keeping patients with
of the "hand of an artisan" both in the way they these behaviors together on "dissociative units." Sec-
emerged during therapy and the features they presented. ond, turn one's clinical attention toward the contempo-
Since MPD exists in the same way that any artifact rary distress of the patient and its likely origin in either
exists, tests for content validity and criterion validity are life conflicts or particular mental disorders. Isolation
satisfied as they represent assessments of the elements of from suggestive influences, counterattention to other
the artifact and say nothing about its nature. concerns, treatment of any underlying conditions, and
Dr. Putnam knows that construct validation is a social/familial rehabilitation constitute the proper and
task that is never "done" but depends on the construct long-established sequences of treatment of medical and
surviving repeated challenges to its nature. Behavioral psychiatric artifacts in general and MPD in particular.
artifacts such as MPD succumb to the challenges that In our hands this program leads quickly to the abandon-
the concepts of the sick role and hysteria provide. ment of MPD and progress toward overall recovery
These are the counterconstructs that I am proposing that ultimately depends on the actual condition of the
here, that are seldom addressed, and that Dr. Putnam patient. This treatment program is not an interminable

962 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:7, JULY 1995


DEBATE FO R U M

process, a fact worth noting as ano ther feature valida ting consume months to years of th erapy, sustaining behav-
MPD as a psychological ar tifact. If tr eated as though ioral invalidism. D em ysti fy it and it disappears.
it were a natural mental cond ition, an art ifact will

NEGAT IVE REBUTTAL: PUTNAM

Dr. McHugh's plaintive question , " W here's hysteria to put forth supporting scie nti fic data in th e same
now tha t we need it?" spea ks volumes about the failu re fashion demanded of all ot her scient ific hypotheses.
of our reductionistic diagnostic system to adequately Published research has repeated ly tested the MPD
co nceptu alize these complex patients. The short answe r constru ct against many forms of the null hypothesis
is th at hysteria rapidly beca me more of an epithet an d found that these patients are significantly different,
than a diagnosis and th e con struct was ultimately bot h quantitatively and qu alitatively, on standardized
dismembered by the DSMinto the d iagnoses of border- psychological measures, stru ctu re diagnostic interviews,
line personality disorder; th e various somatoform dis- clini cal phenomenology, stud ies of cent ral and auto-
o rders, particularly co nve rsio n an d somatizatio n nom ic nervou s system activity, and stud ies of memory
d isorders; and, of course, mult iple person ality disorder. and cog ni tio n. As I outl ine above, MPD fulfills the
What we now know abo ut th is gro up of patients is standards of diagnostic valid ity applied to other psychi -
th at numerou s studies show th at th ey have sign ificantly atr ic diagnoses.
higher rates of child hood tr auma then psychiatric pa- I believe that th e critical questio n is not whethe r
tients in general or nonclinical samp les. A century ago, th ese patients have " hysteria" or MPD , but wh at can
Briquet comm ent ed on th e cru cial role of childhood we do to alleviate their distress and to help th em
tr auma in hi s classic tr eati se on hysteria (Loew- become more function al? Whatever one wishes to call
en stein , 1990 ). th em , th ere still exist a substa nt ial number of patients
Multipl e personality disorder is not a "s ick role" with co mplex posttraumatic disorders associated with
enacted to red uce life stress. It is a complex, childhood- histori es of child hoo d trauma. T hese patients ha ve a
onset, posttraumati c dissociati ve d isorder. A review of range of disturban ces in self-re presentatio ns, probl em s
the clinical literature dem on str ates that, as a group , with modulation ofaffect, elevated levels of patholo gical
MPD pat ients do not require th e diagnosi s of MPD dissociation , anxie ty, soma tization , and high rates of
as a " ticket of admission " to the sick role. In fact , suicide. The modern diagn ostic construct of MPD is
they typically average more th an 6 years of psychiatric associated with a specific treatment model. The real
and medical care under other diagnoses before the question is: Is this model more or less efficacious than
diagnosis of MPD. Their uni nt egrated , multiple repre- th e treatment model proposed by critics of MPD? This
sentations ofself, manifest in th e form of alter personali- is th e question that should be th e focus of future
ties, are an extreme example of a range of disturbances debat e and, mo re impo rta ntly, clin ical outcome
of "s elf" found in m any victims of child hoo d mal- research.
treatment (C ole and Putnam , 1992 ).
D r. M cHugh sets up th e straw man arg ument th at REFERENCES
MPD is iatrogenic hysteria induced by asking about Co le PM, Purnam FW (I 992), Effects of incest on self an d social functio n-
alter personalities. H e th en atte m pts to duck the need ing: a develop ment al psychopathology perspective. j Consult Clin Psychol-
to back his argum ent with actua l dat a by speciously vsr 60 : 17 "'- 18 '"
Loewenstein RJ (I 990) , Soma roform disord ers in victim s of incest and
labeling it th e " n ull" hypothesis. There are no scientific child abuse. In: Incest-Related Sy ndromes ofAdult Psychopathology, Klufr
dat a th at Dr. McHugh can cite th at dem on strate th at RP, ed. W ashingto n, D C: American Psych iatr ic Press, pp 75- 112

th e full clinical syndro me of M PD can be induced by


The debaters ill this section were asked to respond to the resolution from
asking abo ut the existen ce of an alter personality. If
the respective uietopoints; the opinions they exp ress may not necessarily reflect
Dr. McHugh really believed th at MPD is created de their true positions nor do they reflect the opinion of the Journal. Readers are
novo by asking a certain qu estion , then he is obligat ed encouraged to submit their comments about these issues as Letters to the Editor.

J. AM. ACA D. CHILD ADOI. ESC. PSYCHI AT RY. 34:7. JULY 199 5 963

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