Should dissociative identity disorder be in DSM-V?
Dr. Henry Nasrallah’s editorial, “Should psychiatry list hubris in DSM-V?” (From the Editor, Current Psychiatry, December 2008), touches upon an important subject related to psychiatry’s place among medical specialties and the respect—or disrespect—our field gets. I shudder to think that “Excessive Nose Picking” could be listed in DSM-V with a fancy name such as “Rhinotelexomania” or “Excessive Nail Biting” with a sexy label such as “Onychophagia.” Psychiatry has been under attack for being pseudoscientific and not worthy of the respect that other medical specialties command. There is no need to add insult to injury.
Dissociative identity disorder (DID) is another controversial diagnosis that may have been very appealing to Hollywood moviemakers but does the field, patients, and their families a great disservice. Although DID is listed in DSM-IV-TR, criterion A—the presence of 2 or more distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self—is a definition rather than a useful guideline. Who, when, and how does this “presence” become present? What is the clinician’s role in the face of the first-person authority?
In other medical specialties, it is recommended—rather strongly encouraged—that the practitioner constantly challenge his or her basic assumptions about a possible diagnosis through a methodic process of inclusion, exclusion, and hypothesis testing. Gullibility, lack of scrutiny, lack of skepticism, and not having a high index of suspicion are signs of poor clinical practice. To use Donald Davidson’s words, the skeptic’s attempt to investigate dissociative phenomena—especially DID—is bound to break on the rocks of the first-person authority.1
The antipsychiatry movement, despite its excesses, helped psychiatry do some introspection and look at its own excesses. It helped the field evolve from pseudoscientific psychoanalytic traditions to the evidence-based practices of today. The polarizing DID diagnosis is not only a difference of opinion between proponents and opponents, nor is it a harmless abstract controversy or just about “opinion” or “belief.” Patients and families are harmed by the diagnosis and the practice of its proponents.
For economy, I refer readers to the 2-part, 2004 review of DID in the Canadian Journal of Psychiatry, which came to following conclusions:
- there was no proof that DID results from childhood trauma
- DID could not be reliably diagnosed
- DID cases in children were almost never reported, and
- consistent evidence of blatant iatro genesis appeared in the practice of DID proponents.2,3
The DID controversy is not a symmetrical argument of personal opinion vs another or 1 dogma vs another. Rather, it is like the Celestial Teapot parable of Bertrand Russell. An almost impossible belief persists because it can’t be proven wrong.
Numan Gharaibeh, MD
Western Connecticut Mental Health Network
1. Davidson D. Subjective, intersubjective, objective. New York, NY: Oxford University Press; 2001.
2. Piper A, Merskey H. The persistence of folly: a critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept. Can J Psychiatry. 2004;49(9):592-600.
3. Piper A, Merskey H. The persistence of folly: critical examination of dissociative identity disorder. Part II. The defense and decline of multiple personality or dissociative identity disorder. Can J Psychiatry. 2004;49(10):678-683.