Issues in the Psychotherapy of Multiple Personality Disorder

Edited by: Bennett G. Braun, M.D.
Director, Dissociative Disorders Program, Rush-Presbyterian-St. Luke's Medical Center

Multiple personality disorder (MPD) has been reclassified by the American Psychiatric Association (APA; 1980) in its Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) as one of four dissociative disorders. The essential feature of all such disorders is "a sudden, temporary alteration in the normally integrative functions of consciousness, identity, or motor behavior" (p.253). The specific criteria that differentiate MPD from other dissociative disorders are 1) the existence within the individual of two or more distinct personalities, each dominant at different times; 2) the personality that is dominant at any particular time determines the individual's behavior; and 3) each individual personality is complex and integrated with its own unique behavior patterns and social relationships. In addition, I proffer that each of these criteria should be observed on more than one occasion (that is, there should be consistency over time) before the formal diagnosis of MPD is made (Braun 1985a).

Although diagnoses of MPD were frequent around the turn of the century, a dramatic decrease in the reported incidence of this disorder appeared after 1910. Rosenbaum (1980) speculated that Bleuler's introduction of the term schizophrenia around 1911 led to misdiagnosis of many MPD patients as schizophrenic. Indeed, in their recent study of 100 consecutive MPD cases, Putnam et al. (1983) reported that some were previously misdiagnosed as schizophrenic. Multiple personality disorder patients have been misdiagnosed as suffering from a variety of other psychiatric problems as well.

Another attempt to account for the post-1910 decline in the incidence of MPD is Larmore, Ludwig, and Cain's (1977) proposal that because MPD was identified most often through hypnosis, the disorder could be an artifact of hypnotic suggestion. If it were, it did not merit classification as a genuine diagnostic entity. However, it has been argued (Braun 1984b; Kluft 1982) that although MPD is not a by-product of hypnotic suggestion, some superficial symptoms of MPD can be elicited in highly hypnotizable subjects. Indeed, several investigators have observed that MPD patients tend to be significantly more hypnotizable than normal subjects or other clinical groups (Bliss 1983; Lipman, Braun, and Frischholz 1984). These findings suggest that tests of hypnotizability may be useful in the differential diagnosis of MPD.

In 1944 a review of the literature by Taylor and Martin found only 76 documented cases of MPD. However in the last decade the number of reported MPD cases has increased more than tenfold (Braun 1984c). This raises a new question: Why the dramatic increase in the incidence of MPD over the last decade?

One factor that has been associated with the increase in the number of reported MPD cases is a growing public awareness and popular fascination with this disorder. For example, the film The Three Faces of Eve and the books about Sybil and Billy Milligan are widely known. In addition, improved diagnostic criteria for MPD may have facilitated diagnostic precision. In contrast to its classification as one of the hysterical neuroses in DSM-11 (APA 1968), its current classification (DSM-111; APA 1980) as a dissociative disorder is much more specific. The credibility of this explanation is supported by the finding of Putnam et al. (1983) that it takes an average of 6.8 years after first entry into the mental health system before the typical MPD Patient is accurately diagnosed. I have observed a similar figure (6.88 years) in a study of 126 cases by different therapists (un-published data, October 1985).

Although we are now beginning to be able to reliably identify MPD, we still do not clearly understand what causes and maintains the symptoms of this disorder. Unfortunately, most theories about MPD formed before 1944 were based on clinical observation of only a few cases or a single case study. However, during the last decade, a number of investigating practitioners have systematized their observations on a large number of MPD cases (Bliss 1980; Braun 1980, 1984c, 1985; Fagan and McMahon 1984; Kluft 1984a, 1984b; Putnam et al. 1983). Although most of these clinicians have not yet formulated a comprehensive theory about MPD, they have made some important observations about some of its distinguishing features.

Two recent theories about MPD have been useful in identifying the unique therapeutic needs of patients suffering from this disorder. The first of these is Kluft's (1984a) four-factor theory, which attempts to identify the various factors associated with the initiation and course of MPD. The other theory has been called the 3-P model of MPD (Braun and Sachs 1985) because it focuses on the predisposing, precipitating, and perpetuating factors that are associated with development of the syndrome. Because the 3-P model forms the basis for the 13 psychotherapeutic considerations I introduce later in this chapter, a brief description of the model is in order.

The 3-P Model Of MPD

The 3-P model of MPD is diagrammed in Figure1. Two predisposing factors are hypothesized to be necessary: 1) an inborn biological/psychological capacity to dissociate that is usually identified by excellent responsivity to hypnosis and 2) repeated exposure to an inconsistently stressful environment. The inconsistency is in the patient's receiving love and abuse for the same behavior, at unpredictable times. An abusive family environment has been the source of this inconsistent stress in the vast majority of MPD cases studied so far. However, other events such as the death of a family member, frequent geographic relocation, and cultural dislocation can also be identified as sources of stress. Both of these predisposing factors are necessary for MPD to develop. Neither alone is sufficient.