Transient psychotic episodes may occur in multiple personality [11]. Hallucinations during such episodes are usually of a complex visual nature indicating an hysterical type of psychosis. Sometimes a personality will hear the voices of other personalities. These voices, which occasionally are of a command type, appear to come from inside the head, and should not be confused with the auditory hallucinations of the schizophrenic which usually come from outside the head. Most often stress precipitates the transition between personalities. These transitions may be dramatic or quite subtle. In a clinical situation the transition may be facilitated by asking to speak to a particular personality or by the use of hypnosis. The switching process usually takes several seconds while the patient closes the eyes or appears to look blank, as if in a trance.

The onset of multiple personality generally occurs in childhood, although the condition is not usually diagnosed until adolescence or early adulthood. The sex incidence is about 85% female [11]. This increased incidence of multiple personality in women may occur because sexual abuse and incest, which are strongly associated with multiple personality, occur predominantly in female children and adolescents. The degree of impairment in multiple personality may vary from mild to severe. Although multiple personality was thought to be quite rare, recently it has been reported to be more common [8].

Types Of Child Abuse Experienced By Multiple Personality Victims

Trauma has long been recognized as an essential criterion for the production of dissociative disorders including multiple personality [12]. The various types of trauma include childhood physical and sexual abuse. rape, combat, natural disasters, accidents, concentration camp experiences, loss of loved ones, financial catastrophes. and severe marital discord [12]. As early as 1896, Freud recognized that early childhood seduction experiences were responsible for 18 female cases of hysteria, a condition closely associated with dissociative disorders [13]. In the famous case of Dora. the patient's complaint of a sexually seductive adult was corroborated by other family members [14. 15]. In another famous case of hysteria, Anna O, who suffered from dual personality, the initial trauma was the death of Anna O's father [16. 17].

It was not until the publication of Sybil in 1973 that childhood physical and sexual abuse became widely recognized as precipitants of multiple personality [5]. Since 1973 numerous investigators have confirmed the high incidence of physical and sexual abuse in multiple personality [6, 18, 19]. In 100 cases Putnam found an 83% incidence of sexual abuse, 75% incidence of physical abuse, 61% incidence of extreme neglect or abandonment. and an overall 97% incidence of any type of trauma [20]. In Bliss' series of 70 patients, of whom only 32 met the DSM-111 criteria for multiple personality, there was a 40% incidence of physical abuse and a 60% incidence of sexual abuse in the female patients [21]. Coons reports a 75% incidence of sexual abuse. a 55% incidence of physical abuse, and an overall 85% incidence of either type of abuse in a series of 20 patients [10]. The types of child abuse experienced by victims of multiple personality are quite varied [22]. Sexual abuses include incest, rape, sexual molestation. sodomy. cutting of the sexual organs, and inserting objects into the sexual organs. Physical abuses include cutting, bruising. beating, hanging. tying up, and being locked in closets and cellars. Neglect and verbal abuse are also common.

The abuse in multiple personality is usually severe, prolonged. and perpetrated by family members who are bound to the child in a love-hate relationship [IO, 22, 23]. For example, in one study of 20 patients. abuse occurred over periods ranging from 1 to 16 years. In only one instance was the abuser not a family member. The abuses included incest. sexual molestation, beating, neglect, burning and verbal abuse.

Multiple Personality Disorder In Children

No cases of childhood multiple personality disorder were reported between 1840 and 1984 [24]. In 1840 Despine Pete reported the first case of childhood multiple personality in an Il-year-old girl [2]. Since 1984 at least seven cases of childhood multiple personality disorder have appeared in the literature [24-27]. The reported cases range in age from 8 to 12 years.

From these first few reported cases the symptoms characteristic of childhood multiple personality begin to emerge and reveal some marked differences when compared to adults [25]. In the childhood form of multiple personality the difference between personalities are quite subtle. In addition the number of personalities is fewer. So far an average of 4 (range 2-6) personalities have been reported in children. while the average number of personalities reported in adults is about 13 (range 2 to 100+). Symptoms of depression and somatic complaints are less common in children but the symptoms of amnesia and inner voices are not decreased. Perhaps most importantly, the therapy of children with multiple personality is usually brief and marked by steady improvement. In adults therapy may last anywhere from 2 to over 10 years. while in children therapy may only last a few months. Kluft believes this shorter therapy time is due to the lack of narcissistic investment in separateness [25].

Kluft and Putnam have derived a list of symptoms characteristic of childhood multiple personality disorder [24]. The main characteristics include the following:

1. A history of repeated child abuse.
2. Subtle alternating personality changes such as a shy child with depressed. angry. seductive. and/or regressive episodes.
3. Amnesia of abuse and/or other recent events such as schoolwork. angry outbursts, regressive behavior. etc.
4. Marked variations in abilities such as schoolwork. games. and music.
5. Trance-like states.
6. Hallucinated voices.
7. Intermittent depression.
8. Disavowed behaviors leading to being called a liar.