NPR: Therapists Split on Multiple Personalities
Continuing on with my critical analysis of current approaches to treating the highly controversial diagnosis, Dissociative Identity Disorder (DID, formerly known as Multiple Personality Disorder or MPD), here and here are links to a November 2009 NPR program, Science Friday (although some may opine that this episode seemed more like pseudoscience Friday) that featured a debate on the topic of DID.
The debate featured on the supporter of DID therapy side, Clinical Nurse Specialist and psychotherapist Cathy Steele, President of the International Society for the Study of Trauma and Dissociation and on the critical side was Numan Gharaibeh, MD, Staff Psychiatrist at Danbury Hospital in Danbury, CT. Both parties are practicing clinicians.
The host, Ira Flatow, began by referring to the recent portrayal of DID in the cable series The United States of Tara and noting that the diagnosis is controversial. He then introduced the guests and addressed his first question to Ms. Steele:
IF: Tell us exactly what Dissociative Identity Disorder is?
CS: Well, in spite of some of the things that have been portrayed in the media, it’s actually clinically a quite different process for the most part and what we’re actually looking at are different senses of selves across time and context, such that a person experiences themselves as completely different. Now, any one of us can do that, but the difference in Dissociative Identity Disorder is that there appears to be a sense of ownership and agency to that different self that experiences itself from the perspective of not me, so you have a self that’s me and a self that’s not me.
This rather vague description involves a person’s subjective perception of him/herself and anyone who has studied the processes of social influence will recognize that it is quite easy to influence a person’s self perception and sense of identity. As Ms. Steele correctly points out, all of us can indeed have very different senses of ourselves in different contexts. My own analysis of this is that if someone is also having some kind of psychological challenge such as experiencing depression or going through some type of stressful life experience, and then happens to go to a therapist who believes in DID, it would not be difficult to, whether intentional or not, impose this on the client seeking help. Therefore there is a controversy as to whether DID actually exists or if it is created through therapist suggestion and other suggestion that is implicit in popular media portrayals of DID.
The interview continues:
IF: Do you get like we see in Sybil or the news show, do you have actually people changing? I want to speak to so and so now or so and so comes out as a different personality?
CS: Well, that can happen but it so rarely looks like what’s on TV. Of course, that’s greatly exaggerated and less than 3 to 5% of people with DID actually have that kind of presentation. It’s generally much more subtle than that.
This is an interesting and most telling statement. If it’s so “subtle” one has to wonder if normal role identity shifts in people who also happen to be experiencing emotional distress are not being interpreted as “DID” by therapists. There are plenty of people who have complex, multi-faceted personalities and may very well behave differently in different situations and contexts, but do we really need to turn this into a disorder? One of the arguments is that people experiencing the disorder are experiencing distress and impaired functioning in life, but that would also hold true from people suffering from depression, the aftereffects of a trauma or who are grieving a major loss. These are common problems for which people seek therapy. However, if they seek therapy from a DID-oriented therapist, they may end up with a DID diagnosis.
When the topic of research evidence came up, Ms. Steele made vague references to “a huge amount of data from neuroscience” that shows the brain functions in very unique ways in dissociation on the topic over the past decade. This is highly debatable and unwarranted extrapolations from neuroscience are common among certain clinicians who promote DID therapies.
Although Ms. Steele claimed there were “hundreds of articles on dissociation as it relates to post traumatic stress disorder” [note she said “dissociation” not just DID] provided no specific citations (even though Ira Flatow had asked her for citations) and she provided no critical analysis of what these publications actually consisted or evidence that any of these publications actually provided what would be considered valid evidence. While it is true that there are probably hundreds of such articles, they do not all fit the theories endorsed by Ms. Steele.
On the contrary, many of these studies and critical reviews (and no, a critical review is not just an “opinion piece” or “polemic” as true believers love to portray them) have actually challenged what clinicians have long believed to be true about trauma and dissociation. For a very specific review of this research that does provide specific discussion and citation of specific studies in the area of trauma, PTSD and dissociation, I highly recommend The Clinician’s Guide to Posttraumatic Stress Disorder, published in 2010 by John Wiley and Sons, edited by Gerald M. Rosen and Christopher Frueh. I also recommend the following critical analysis of the literature, full text available online:
Giesbrecht, T., Lynn, S.J., Lilienfeld, S.O., & Merckelbach, H. (2008). Cognitive processes in dissociation: An analysis of core theoretical assumptions. Psychological Bulletin, 134, 617-647.
The closest Ms. Steele came to anything specific was mentioning (without specific citation) brain scan studies that showed personality shifting resulted in changes in brain scan changes that could not be produced by the control group. This, in and of itself, however, is not necessarily evidence that DID is a valid diagnosis. Many questions need to be asked such as:
How many people were studied? How large was the sample? How was the sample selected?
Were there control groups? [note that in this type of study random assignment would be impossible as people cannot be randomly assigned to have DID or not so any control would actually have to be a comparison group, not an actual control group]
If so, who and what did the controls/comparisons consist of? What was the control condition?
None of this was discussed or challenged in this debate (although to be fair to Dr. Gharaibeh, there probably wasn’t time to get into this type of discussion and so I in no way mean for this to reflect poorly on him). Fortunately, as Michael Anestis recently pointed out, blogs provide the opportunity to get into more of an in-depth analysis than radio programs or even sometimes journal exchanges will allow for due to time and space limitations.
The fMRI and PET scan studies on DID are largely ones that either had no comparison group or if they did, the control condition was people who were healthy controls, for example, in this study which had a control group of people with no history of childhood trauma, depressive or dissociative disorders. There can be all kinds of explanations other than DID for between people who are in distress to the extent that they have sought therapy and received a diagnosis and people who had no history of any kind of childhood trauma, depressive or dissociative disorders. So yes, while there have been a number of brain scan studies, I have yet to find one that presents any kind of strong evidence to support the validity of DID. Having a control group of DID simulators is also hardly convincing evidence. All such a study would show is that people diagnosed with DID are not faking it, something that would hardly come as a surprise to anyone. Most critics would readily acknowledge that for the most part, DID patients are not deliberately faking their symptoms and strongly believe that they do have the disorder. Strong beliefs (e.g. placebo effects and religious beliefs), in and of themselves can produce dramatic physiological changes including changes in brain scans. If someone truly believes they are shifting “personalities” it is hardly surprising this would show up on a brain scan.
As an aside, I would be very interested in seeing the brain scans of practicing Scientologists who are doing advanced levels where they believe that they are dealing with what they believe to be separate spirits in their bodies known as body thetans that are believed to be separate identities. I would predict we would see some marked changes in their brain scans. Although it is highly unlikely that people who are still within the main organization of the Church of Scientology would agree to participate, there are people who have left and still embrace this belief who might participate in such a study. If my predicted result turned out to be the case, would that mean that these people all have DID or would it simply be a reflection of their belief that they had separate entities residing in their bodies with separate personalities and experiences?
In general, we need to be very cautious and skeptical when hearing claims based on brain scan (fMRI, PET scan) studies since all too often they are open to misinterpretation and claims that go far beyond what they actually show. All too often, although people who cite them may be sincere, such references turn out to be nothing more than ways to give a shaky claim or diagnosis the superficial appearance of science when it is anything but.