Reflections on the Psychotherapy of a Patient with Multiple Personality Disorder

Abstract

H istoricall y, th e di agnos is of Multiple Perso nali ty Disorder (MP D) has generate d cur ios ity, fasc ina t io n, ske p t icism , a nd d isbe lie f. From th e first reported cases in th e ea r ly nin eteenth ce n tu ry , controversy has abounded about th e plausib ilit y o f th e many d ramati c man ifestations of the illn ess, its pathoge nesis, and appropriate approach es to its trea tment ( I) . From the m idst o f scien tifi c co ntroversy and debate , a more refined co ncep tua liza tion of th e illness is be ing developed , particularly since th e recent inclusio n of the d iagnosis in DSkl-Ill (2). Noteworthy among th ese ad vances are the th eo ri es of pathoge nesis described by Klu ft (3), and Br aun and Sach s (4) wh ich em phas ize a prerequisite biological dis sociative potential in co m binatio n with ex treme environmen tal stress, a nd Sp e igel's (5) formul ation framin g MPD as a post-t raumatic st ress di so rder. Despite th ese ad vances, many long rejected and sc ientifica lly inva lid no tions about th e illn ess co n tin ue to play a part in the cli n ica l assessment and trea tm ent of MPD. Misin formati on ha s led to delays in acc ura te diagnosis. A recent study has sho wn that th e ave ra ge length of time to reach th e d iag nosi s of MPD is 6 .8 years (6), with preliminary d iagnoses ranging from schizophrenia to borderl ine personality di sorder. T he use of hypnosis as a n adju nct in both diagnosi s and treatment of multiple personali ty di sorder has further co mplicated the picture , inspiring questions about th e role o f suggestion and th e possibility o f a n iatrogenic e t io logy. One assumption has been that MPD is the unfo rt unate crea tion of an over zea lous psychiatrist e ngaged in a foli e a deux with a highly suggestib le pati ent. These qu esti ons and co ncerns have clear effect s o n th e treatment a nd management o f pati ents di agnosed with MPD as well as with th e other DSM-III Dissociative Disorders. As a medical studen t a nd subseq ue nt ly as a resident, I have had occas ion to work with MPD pat ients and have been struc k by th e man y complex attitudes and e mo tio ns th ese pati ents inspire . When I was ass igned to adm it Ms. S to ou r unit, I fo und m ysel f in th e cur io us positi on of ha vin g to sort out th e man y qu estions raised in di scu ssions with co lleagues . As one in te rv iew grew into man y and m y qu estions multiplied, I so ug h t th e supervisio n of Ms. S's a ttend ing