Multiple Personalities and Responsibility

Multiple Personalities, now known as Dissociative Identity Disorder (DID), is the single most controversial diagnosis in the diagnostic manual.  Most would agree with that statement I think.

One of the most bizarre aspects of this diagnosis and its promoters is the wish to have their cake and eat it too.  Let me give you a few examples of what I am talking about.  These are composite examples that have been slightly altered, not pertaining to any individual patient, but the comments attributed to therapists essentially express comments I have heard at one point or another.

Patient A signed a legal contract and later wanted to back out.  Patient A's therapist states, without any sign of misgiving or embarrassment: "People just don't understand that [Patient A]'s part [alternate personality] signed the contract and [Patient A] can't be held responsible."  Why is this having and eating cake simultaneously?  Well, let me explain.  Both the patient and the therapist believe and strongly advocate for Patient A's right to live and act in the community as a fully fledged adult citizen, and yet, they both want the world hold Patient A free of all agreements and obligations that Patient A has selectively decided some other personality inhabiting her body is responsible for.  This sort of undermines the basic social contract doesn't it?  Either Patient A is mentally competent to make agreements and sign contracts and be held responsible for her obligations, or if she really cannot competently sign contracts and be held responsible due to her psychiatric condition she should not be allowed to and her her therapist needs to be working to develop a legal guardian who can actually make binding decisions on behalf of Patient A who is apparently not competent to do so on her own.

Patient B is granted Social Security Disability for a psychiatric condition.  His primary diagnosis is DID.  He then enters university and goes through to complete a graduate program.  Throughout, he continues to receive monthly disability payments intended for individuals who are too disabled to work.  Both he and his therapist maintain that Patient B is both entitled to disability and able to legitimately complete a graduate program in the field of economics because his parts switch only when he is at the school and he can temporarily maintain his "host personality."  When returning home or out in the community he "switches" to different personalities and is therefore disabled.  After receiving his degree in economics, he continues to receive monthly disability payments and his therapist continues to be paid by Medicaid.  Patient B is both disabled and yet he is not.  It seems to me an ethical and competent therapist would be working with Patient B to utilize his graduate degree in a productive manner to his own personal and financial benefit.  Instead, the therapist continues to promote the idea that in spite of earning a graduate degree Patient B is too disabled to work and must continue in therapy indefinitely.  It may be no coincidence that if Patient B earns wage income, he will ultimately lose both Social Security Disability and Medicaid and the therapist's cash cow with dry up.

Patient C commits a felony crime of posing as a property owner (which she is not), collecting deposits and rents from multiple prospective renters and then flees the scene.  She spends the money on a car, clothing and a purebred Pomeranian dog for herself.  When tracked down by detectives and arrested, Patient C, her therapist and her defense lawyer all maintain that Patient C cannot be held responsible for the crime.  None of them dispute that her physical body was present at the time of the crime and in fact committed the crime, but they claim her body was inhabited by a personality who believed it was the property owner, therefore person/body of Patient C (the only legal and biological entity in this case) cannot be held responsible.  The "host personality" of Patient C cannot be held responsible because she was dissociated and was not aware of what occurred and had no control over it.  Furthermore, the "property owner" personality cannot be held responsible either because he/she/it really believed it was a property owner and did not realize it was committing a crime.  What does the therapist and defense attorney request?  That Patient C be freed and allowed to continue the same therapy (that failed to prevent her criminal behavior in the first place) because this is what Patient C "needs."

DID patients, therapists and promoters seem to have a problem with responsibility.  Basically they can disavow responsibility for anything with negative consequences for the patient/client/consumer but otherwise expect the world to treat the DID patient as a completely competent and responsible citizen.  Does that sound just a little too convenient?  Most jurors find it pretty fishy, that's why it almost never succeeds as a legal defense, but that doesn't stop people from trying.

Here are some interesting facts about DID and crime.  A small study published in 1989 (Putnum, Diagnosis and treatment of multiple personality disorder) found that 35% of female DID patients reported committing crimes including 7% of which were homicides and 47% of men with DID reported committing crimes of which 19% had committed homicide.

In the end, you can't have your cake and eat it too.

Why Does Norway Want Breivik to Be Insane?

Anders Breivik bombed downtown Oslo and went about methodically murdering 77 people and injuring many more.  In his recent trial that came to a close last month he calmly described how he did it and discussed with detached curiosity the victims' various reactions or lack of reactions to his attacks.  Throughout, he taunted family members, survivors and the world with what can only be described as a psychopathic sneer.

A sneer, micro or macro, is the universal expression of contempt

Is he insane?  This was the central question the recent trial revolved around.  Prosecutors want him to be insane, even though they now admit their doubt on the subject.  Prosecutor, Svein Holden, is quoted by the BBC as stating, "We are not convinced or certain that Breivik is insane but we are in doubt."  And yet, they continue to argue he should not be imprisoned but should instead be committed to a psychiatric institution.

Here, insane is more or less defined as psychotic.  Is he psychotic (insane) or psychopathic (sane but very very bad)?  That is the question.  Technically the defense is on a fool's mission to explain his actions as justified, but that is beyond absurd.  One wonders if the defense attorneys have undergone cognitive deficiency testing themselves--if not, perhaps they should.  While there is little if any evidence of actual psychosis there is a strong desire to place Breivik in that category, or maybe more to the point, to place him outside the categories of normal or sane.

Other than the fact that Norway has one of the most lenient and forgiving criminal justice systems on the planet, I know too little of that place and culture to fully understand their reasoning.  I can only surmise it gives some comfort to hold a belief that a man capable of doing what Breivik did cannot be normal or sane.  In a lay sense, what Breivik did makes him, by definition, insane.  This creates a safe psychological boundary between him and us.

It is an understandable sentiment, I'm sure.  But what does it say about a criminal justice system where prosecutors are not motivated by truth but by the outcome that makes them the most comfortable?

Can a man like Breivik be helped by psychiatric care?  If he were in fact psychotic, there are drugs that may (or may not) help.  Add some cognitive-behavioral whatnot and sometimes we see improvement, even dramatic improvement at times.  Conversely, if he is a straight up psychopath (as is likely the case), there is very little help possible if we want to be honest about it.

The Norwegian prosecutors fail to recognize the collateral impact of their strategy is to add more fear and stigma to the actual insane, the 1% or so of the world's population with a form of psychosis at some point in their lives.  Granted there have been plenty of psychotic shooters and killers over the years, and we may very well have experienced another one in Colorado just this month, but the vast majority of people with psychotic experiences, 1% of the world's population, are as non-violent as anyone else.  Some psychotic individuals can be dangerous, but lets not pin everything too horrific to comprehend on them just to make us feel a little more removed from the human potential for evil.

They Want Us to Believe

There is a ubiquitous use of tense in mental health treatment, and curiously, it highlights an interesting contrast with the evangelists of multiple personalities.

In working with people on the more severe end of the spectrum of mental health disease (or "disease" in quotations if you prefer) we usually find that we cannot directly challenge beliefs we believe are delusive without threatening to lose the relationship, the precious rapport, that is often our only hope of helping, and yet we don't want to reinforce the delusion just in order to maintain rapport as that would also be counterproductive, so we try to ease our way through the dilemma with a little play of tense.  The client speaks in the indicative, "I have an implant in my neck that Richard Nixon speaks to me though." It is a solid fact.  Meanwhile, we clinicians reflect in the subjunctive, "You believe . . .", "You said . . .", or you might even risk a "I believe you believe . . ."  We leave it in an open and conjectural mood to show understanding, and thereby avoiding conflict, but without reinforcing.

Changes in tense are also important in the strictly professional side of mental health when we take our professionally sanctioned beliefs and apply them in the real world.  The ultimate document of professional belief, the Diagnostic and Statistical Manual, The DSM, is written entirely in the indicative tense.  Every mental health diagnosis is a fact and every criterion of every diagnosis is a fact.  These facts are immutable immobile objects with crisp edges.  The DSM is seemingly free from conjecture or uncertainty, much less fantasy and make believe.  Here we find ourselves in another dilemma because most clinicians (and researchers too I would guess) do not believe the diagnostic categories handed down from on high are factual at all.  Most of us handle these interesting but crude objects with healthy skepticism.  They are all works in progress that may or may not hold up long enough for the next edition.  The clients we work with are individual people who do not always so easily fit these models.  We are well aware they are just that, models.  Is Schizophrenia really a single disease entity or several that happen to look similar?  No one really knows for the time being.  So, we think and talk about these things in the subjunctive manner even though Medicaid forces us to write out our final diagnoses in the indicative.

It has recently struck me, however, when it comes to therapists who are wont to diagnose and promote Dissociative Identity Disorder (or Multiple Personality Disorder), the above outlined patterns do not hold.

Firstly, there is no distance between the belief of the clinician and the belief of the client.  They become fused in a shared belief.  A shared fantasy.  A shared dramatic enactment.  Between clinician and client, the belief system is spoken of in the indicative.  Changes of mood are distinct personages inhabiting a single body.  The clinician pronounces it.  The client reflects it and gradually comes to act it and be it.  The reality that DID becomes depends on the indicative mood.  The clinician and client must truly believe and always speak of it in the most confident and unwavering language.  Any doubt may cause the mirage to waver and blow away in the wind.  The clinician is on stage also, enacting the role of professional therapist, but it is an "as if" that only looks like therapy.  In fact, it is therapy in reverse, rather than curing or ameliorating, with this therapy the symptoms of the client strangely increase in strength and definition over time and eventually become cemented facts.

Secondly, there is no healthy skepticism on the part of the clinician in the professional realm.  Always these therapists use the same indicative tense used in the DSM whenever discussing their one cherished true diagnosis of DID.  They are believers who want us to believe in it too.  To convince themselves and us, they don't use the language of belief, they use the language of hard facts.  There are no maybes or uncertainties.  The facts of DID are proven and true.  Professionals who doubt run the risk of being called closed-minded or ignorant of the facts, or finally when we fail to align we are told we are invalidating toward their clients--spoken as if it is the worst possible insult.  It always strikes me that the selfsame therapists who want so hard to believe in the fact of DID are often the most doubtful of just about any other diagnosis in the DSM.  I have been told by a straight faced bearded therapist that many cases of Schizophrenia are actually DID.  There are many many people out there with mood fluctuations who have DID and don't even know it.  Or so I'm told.  I suppose the right therapist can skillfully draw out the symptoms and turn annoying mood fluctuations into a disabling condition and Medicaid will reward the therapist for many years to come.

It may be no coincidence the only other people I have experienced such a hard sell from, miraculously turning uncertainties into facts, are car salesmen and preachers.  I can't say that I've ever knowingly been part of a cult, but I imagine cult leaders also are inclined toward an indicative mood.

Bipolar Paradigm Swings

But seriously folks, there really is a problem with the trauma fad.  Just the other day, I had a therapist tell me, without blinking an eye, that 95% of mental illness is caused by trauma.  And, as you might imagine, coming from a therapist, the statement was made with the upmost in self-important tones with flavor highlights of virtuous condescension.

Yes, obviously, she read it off a brochure, or somewhere in all that blather on the web that has taken the place of brochures.  But where did this “fact” originate in the first place?

Looking back to the mid-20^th century, there were any number of theorists who promoted the idea that schizophrenia was caused by trauma, or at least, early childhood events and social environment.  Generally speaking, dating back to this era, we have the idea that a child bonds with a parent (the word “attachment” is quite chic at the moment), the parent psychologically hurts the child’s sense of self—typically through abuse, neglect or ambivalence (this is the basic trauma)—and, the child ultimately develops schizophrenia or just about any other diagnosis you can think of for that matter.  Here we have the infamous “schizophrenicgenic” mother who relates to her child in an ambivalent or abusive manner and causes the child to become insane in adulthood.  The theoretic underpinning is the (now dated) belief that schizophrenia is a result of a weak ego that disintegrates and is overwhelmed by the id when the subject is faced with the challenges and pressures of adult life.

Essentially, childhood trauma perpetrated by an adult (to who the child is bonded) results in the development of a weak ego.  A weak ego results (later in life) in flooding of impulses and internal stimuli emanating from the subconscious.  Hence, insanity.  Neat little theory and it was quite the rage in the 50’s but slowly declined in subsequent decades and by 1990 had very little following in professional circles.

You can dig even deeper into the intellectual history of psychology.  Freud comes to mind and he had his antecedents in previous beliefs about the causes of insanity going all the way back to Plato and Hippocrates.  Hippocrates, as you might imagine, saw insanity as caused by an imbalance of humors in the body, but Plato interpreted it as reason being overwhelmed by emotion (but before you get too excited keep in mind that Plato also advocated that people who were sick and not likely to contribute should simply be killed).  This is just to point out the old nature versus nurture or, more correctly, mind (or spirit) versus body debate goes way back to ancient times and has been with us ever since.

Fast forward:  Prozac was approved by the FDA in 1987.  One of the first atypical antipsychotics, Clozaril, was made available in 1989.  The schizophrenicgenic mother idea had been on the decline for a very long time and the biomedical model was on the rise, driven by pharmaceuticals and helped along by National Alliance for the Mentally Ill, an advocacy group whose core mission was to combat the blame-the-parents stigma resultant from the schizophrenicgenic mother hypothesis.

All this is really to point out the pendulum swing in mental health ideology.  The biomedical approach was on a high in the 1990’s, most famously expressed in the NAMI slogan, “Mental Illness Is a No-Fault Brain Disease.”  At the height of it, you couldn’t use the word trauma without being jumped on and re-educated on the biological basis of mental illness.

My, how things change.  In 15 years, things have more or less reversed, and clinicians are barraged with trademarked treatment models and consumer activists and mental health reform all aimed at eradicating what we were training people in 15 years ago.  Even key players in the designing of the DSM-III and IV are coming out publicly to denounce the very basis of psychiatric diagnosing.   Now the only word that matters is trauma.  Trauma is the cause of mental illness and the only possible cure is to understand and validate the trauma.  We seem to have come full circle.  Attachment theory again finds the source of all psychopathology to emanate from problems in early attachment and early developmental trauma.  We are pretty much back to the schizophrenicgenic mother concept in all but name.*

I exaggerate only slightly for emphasis.

The, I hope obvious, problem with all this is that these bipolar paradigm swings are not based on advances in knowledge so much as fickle swings in popular sentiment.

We are simply replacing one reductionist model (mental illness is a no-fault brain disease) with another reductionist model (95% of mental illness is caused by trauma).  Not that reductionism is all bad.  Even Stephen J. Gould pointed out the crucial importance of reductionism in the scientific process.  Newton described gravity with a simple but elegant formula.  Darwin reduced all that complex biological diversity down to a few core principles of evolution.  But, this is not what we are seeing in mental health.  Although it wears the cloak of empiricism, it looks a lot more like political ideology or hopeful religious beliefs.  It all comes down to wishful thinking.  People build treatment models and cherry pick research results, all in order to bolster what they already believe or what they want to believe.

The mental health field would be a much more healthy and functional endeavor if we all just decided to be honest with ourselves and each other.  We want to help people, but we don’t really know what the hell we are doing.

* Of course, as gender beliefs have changed over the years, it is now more likely that we will see the father as the source of trauma/abuse/neglect/ambivalence as opposed to the mother.

The Trauma Bandwagon

Gee whiz.  Is it just me, or is there a "trauma" jihad going on?  I can't open my eyes without seeing the word "trauma" in bold headlines in newspapers and journals and in 4H newsletters.  Do I see a new line of Hallmark "Trauma Condolence and Get Well" Cards on the way?

Don't get me wrong now.  I fully support the idea that psychological trauma is bad and can lead to bad things, and supporting people who have experienced trauma is a good thing, but let's try to have some perspective here people.  There is a mob mentality going on.  Is it a competition?  Is that it?  That would explain why people seem to think they're going to get a special treat if they use the word "trauma" more often and louder than anyone else.  A kind of self-satisfied glow appears on people's faces every time they use the word.

Maybe I'm just an old stick-in-the-mud Scrooge.  Bah-humbug.

Two New Mental Disorders?

Researchers are forever trying to link existing mental disorders with some kind, any kind, of brain structure “abnormality.”  Even the weakest of links send people into hysterical excitement and soon we see flashy headlines claiming Researchers Find Neurological Cause . . .” for, well, just fill in the blank yourself with your favorite mental disorder.

So, this is just what I was thinking about when I came across this flashy brain structure study, published in Current Biology, which found a significant link between anatomical brain differences and certain identifiable behaviors.  It’s a headline grabber for sure.

Of course, any researcher who has an actual college degree and took Statistics 101, would never, never assume that correlation equals causation, but this doesn’t stop people from doing endless correlational studies that grab headlines and are statistically significant but are of no use diagnostically.

If you don’t know what I’m talking about, you can see for yourself.  Go to Google and do a search for:  “brain structure” +adhd

ADHD happens to be a favorite target for useless correlational brain structure studies that might be interesting but give us no immediately useful knowledge because the differences they find can never be clearly separated out from the background noise of human variation.

But, back to the topic at hand . . . this write-up from Current Biology, found a strong link between brain structure and behavior that gives us a greater neurological understanding of this behavior than we have of many mental disorders.  What I don’t understand is why the authors didn’t make that leap and suggest a couple new diagnoses.  Does it make any difference that the behavior they looked at was political identification?  Honestly, I don’t know why it should make any difference; it seems to me we have two new perfectly good mental illness labels with some statistically significant data to back it all up.  All we need to do now is develop some psychopharmacological interventions and some evidence based psychotherapies.  Then we’re in business.

Kanai, et al., found that people who say they are liberal (gee, does anyone really do that anymore?) have thicker anterior cingulated cortexes.  On the other hand, people who go around using the word conservative in reference to themselves have inflated right (wing) amygdalas.  So, the authors interpret this to mean that liberals are able to cope with conflicting information (in other words, they’re spineless elitist smarty-pants who can’t make decisions) while conservatives are more able to recognize threats (which I interpret just a little further as meaning they are neurologically closer to highland gorillas than they are to homo sapiens sapiens).

Well, that’s all very cute, but let’s turn this into a real money maker.  It’s simple.  All we have to do is turn the glass-half-full language into glass-half-empty language.  Like this:

Liberalism Not Otherwise Specified is linked to smaller than average amygdalas resulting in impaired ability to recognize threats leading to being taken advantage of by freeloaders and traumatized by bullies and obstinate foreign powers.

Conservatism With or Without Paranoid Delusions is linked to withered anterior cingulates resulting in impaired ability to process complex information leading to reactive, bellicose and sometimes violent behaviors when confronted with multifaceted ideas and situations.

See? That wasn’t so hard, was it now?  Is it too late to get them added to the DSM-5?

Reference:  Ryota Kanai, Tom Feilden, Colin Firth, Geraint Rees.  Political Orientations Are Correlated with Brain Structure in Young Adults.  Current Biology, 07 April 2011 DOI: 10.1016/j.cub.2011.03.017

There are Psychiatric Diagnoses and Then There is Reality

Reality is a hard thing to pin down sometimes.  Why do the stars spin in a circle overhead?  Why are the people born under the constellation of Scorpio always such jerks?

I suppose the scientific method comes in there somewhere.  But let’s face it, our empirically grounded bodies of knowledge have their limits.  We can be hopeful that we will continue to expand our horizons of knowledge, but knowing what we really know and how we know it is probably a good thing.  I mean, isn’t that part of the whole scientific endeavor?

Well, I know you agree with me, but can someone help me understand how this message got so mixed up in the field of psychology?  In psychology, “scientific findings” and diagnostic labels seem to be thrown around with about as much critical scrutiny as a gibbering glossolalic soliloquy might receive in the midst of a writhing Pentecostal congregation.

Among practitioners, it seems to me, that the diagnostic categories of the DSM are typically taken with several cobblestone-sized grains of salt.  Not so among journalists or among the ubiquitous faceless internet-based free-advice-givers with their pop-up ad business models.  Doubly not so among purveyors of “evidence-based” therapies who use flashy headlines from the world of scientific research to prove their wares (acupuncture, Blood-LettingÒ, Eye Movement Desensitization Reprogramming, etc.).

It bothers me, not a little, that DSM labels are thrown around the way they are and it troubles me that so many researchers build their research designs as if these committee-written categories are unquestionable real-world phenomena.  Does anyone really believe that there is a discrete Major Depressive Disorder that is a distinct and separate process from Dysthymia?  Even that most archetypal of mental disorders, Schizophrenia, is quite fuzzy around the edges, and there continues to be some question as to whether we are dealing with a single disease process or multiple phenomena with similar and overlapping symptoms.

It is a truism that, in young disciplines, where there is a dearth of causal understanding, we tend to fall back on simple categorization of observable phenomena.  That, in fact, accounts for every single mental health diagnosis now in use.  These are loose categories based on our sad attempts to group complex human behaviors into digestible and palatable portions that we can pretend to understand and try to get the insurance companies to swallow without puking all over us.

With the upcoming DSM-V we are going to realign our categories by shifting our bullet-item-symptoms from one list to another and rebranding our labels, but still we will end up with somewhat arbitrary diagnostic descriptions authored by compromising, wordsmithing  committees and deeply confounded by cultural assumptions, political correctness and insurance driven language games.

Some day, maybe, we will have our grand synthesis of psychology, neurology and genetics, but we are not there yet people.  Please let’s stop playing pretend.