Dissociative identity disorder: Time to remove it from DSM-V?
Examining the logic behind arguments to perpetuate a controversial diagnosis
What is it about dissociative identity disorder (DID) that makes it a polarizing diagnosis? Why does it split professionals into believers and nonbelievers, stirring up heated debates, high emotions, and fervor similar to what we see in religion?
The DID controversy is likely to continue beyond the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), slated for publication in 2012. Proponents and opponents claim to have the upper hand in arguments about the validity of the DID diagnosis and benefits vs harm of treatment. This article examines the logic of previous and new arguments.
1. The fallacy of equal-footing arguments
When 301 board-certified U.S. psychiatrists were surveyed in 1999 about their attitudes toward DSM-IV dissociative disorders diagnoses:
- 35% had no reservations about DID
- 43% were skeptical
- 15% indicated the diagnosis should not be included in the DSM.1
Only 21% believed there was strong evidence for DID’s scientific validity. On balance, published papers appear skeptical about DID’s core components: dissociative amnesia and recovered-memory therapy.2
DID skeptics are sometimes accused of “denial” or “reluctance” to accept this diagnosis. Informed skepticism is acceptable—even encouraged—in making a diagnosis of malingering, factitious disorder, some personality disorders, substance abuse, and psychotic states, to name a few. Why is informed skepticism about DID frowned on?
In medical and surgical specialties, informed skepticism is encouraged so that the practitioner challenges his or her assumptions about a possible diagnosis through a methodical process of inclusion, exclusion, and hypothesis testing. I argue that little or no skepticism is substandard practice, if not negligence.
Bertrand Russell’s celestial teapot parable (Box 1)3 exposed the fallacy of equal-footing arguments (ie, in any debate or argument that has 2 sides, the 2 sides are not necessarily on equal footing). Russell’s argument is valid for any belief system relying on faith. Now that DID is in the “ancient book” (DSM-IV), the burden of proof by some magical logic has shifted to “nonbelievers.” In law that is called precedent, but law is even less scientific than psychiatry and not the best example to follow. A mistake made 100 years ago is still a mistake.
Bertrand Russell’s ‘celestial teapot’ analogy on religion
In 1952, British philosopher Bertrand Russell used the analogy of a teapot in space to illustrate the difficulty skeptics face when questioning unfalsifiable claims. Russell’s argument involved religious belief, but it is valid for other belief systems relying on faith. Here is the celestial teapot analogy:
“If I were to suggest that between Earth and Mars there is a china teapot revolving about the Sun in an elliptical orbit, nobody would be able to disprove my assertion provided I were careful to add that the teapot is too small to be revealed even by our most powerful telescopes. But if I were to go on to say that, since my assertion cannot be disproved, it is intolerable presumption on the part of human reason to doubt it, I should rightly be thought to be talking nonsense. If, however, the existence of such a teapot were affirmed in ancient books, taught as the sacred truth every Sunday, and instilled into the minds of children at school, hesitation to believe in its existence would be a mark of eccentricity and entitle the doubter to the attention of the psychiatrist in an enlightened age or of the Inquisitor in an earlier time.”
Source: Reference 3
2. Illogic of causation
- no proof that DID results from childhood trauma or that DID cases in children are almost never reported
- “consistent evidence of blatant iatrogenesis” in the practice of some DID proponents.
One can easily turn the logic around by claiming that a DID diagnosis causes memories of childhood sexual abuse.
As for patients’ presumed reluctance to report childhood abuse, I witnessed in every one of my 15 alleged cases of DID (all female) not reluctance but a strong tendency to flaunt their diagnosis and symptoms and an eagerness to re-tell their stories with graphic detail, usually unprovoked. Patients with a DID diagnosis seem to have a “powerful vested interest”—to borrow Paul McHugh’s expression6—in sustaining the DID diagnosis, symptoms, behaviors, and therapy as an end in itself.
DID proponents acknowledge that iatrogenic artifacts may exist in the diagnosis and treatment. However, they almost immediately insinuate that DID patients’ “subtle defensive strategies” generate these artifacts. Greaves’ discussion of multiple personality disorder7 acknowledged that overdiagnosis may be driven by therapists’ desire to “attain narcissistic gratification at ‘having a multiple [sic] of their own’” but blamed this on “neophytes.”
3. Tautology in DID’s definition
DSM-IV’s criterion A for DID is in fact a definition: “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).”8 Together, criteria A and B show circularity and redundancy. If A is met, then B must be met because “a person’s behavior” is part of her or his identity and personality state, which was established in A.
Tautology is a major shortcoming of the descriptive system for psychopathology in general. Of greater clinical value are observing a patient’s actions, listening to his or her words, learning his or her history, studying his or her expressions, and noting his or her relationships.9
4. Bewitchment by language
Psychiatrists could spend hours over strong cups of coffee arguing the meanings of terms such as “dissociation,” “presence,” “identity,” “personality state,” etc. Psychiatry has been targeted unfairly regarding where it falls on the subjectivity-objectivity axis, but it has not fared that differently from other medical specialties.10 Psychiatry, however, depends much more on language.
Consider slippery terms such as personality, identity, self, dissociation, integration, alters, ego, ego states, trance states, personality states, unconscious, etc. Lack of precision, variability in use of words and their meaning, and variability in understanding the concept that these terms try to communicate make speaking a common language extremely difficult. To borrow from Wittgenstein, psychiatrists’ intellect is bewitched by language.11
Words fail to communicate experiences such as the taste of red wine or the feeling of sand beneath bare feet. It is almost futile to try to define dissociation, identity, personality states, etc., using words or even pictures. More definitions and agreement on stricter definitions would not provide greater clarity or solve the problem of first-person authority.
An example is found in DID’s criterion B: “at least 2 of these identities or personality states recurrently take control of the person’s behavior” [italics mine]. “Possession” seems to be a fitting word! Whether it is an alter or the devil taking control is a technicality. Even more acceptable would be possessed by inconsolable anger, possessed by fierce jealousy, possessed by lust, possessed by hatred and vengeance, possessed by and obsessed with love, possessed by cocaine, etc.
Dissociation is used to describe so many things that it has become almost meaningless (Table). I refer not only to definitional imprecision but also to a lack of consensus on the nature of the concept itself.
The word “control” is another term on whose meaning almost no 2 psychiatrists agree. Consensus on definitions is elusive when words become divorced from the concepts they were intended to describe.
A meaningless word? ‘Dissociation’ is used to describe many things
Daydreaming or fantasizing
Memory lapses caused by benzodiazepines
Preoccupation with everyday worries
Preoccupation with internal stimuli (such as auditory hallucinations or delusional thoughts)
Histrionic/theatrical behavior to avoid upsetting the patient or to provide a face-saving explanation
Daydreaming while driving (‘highway dissociation’ or ‘highway hypnosis’)
Getting engrossed/captivated by a novel, a movie, or a piece of radio journalism or music
5. Validity of first-person authority
The skeptic’s attempt to investigate a subjective phenomena—especially DID—is bound to break on the rocks of the first-person authority, to borrow Donald Davidson’s words.9 To support reliability and validity of the diagnosis, dissociation researchers rely on “scales” and “instruments” to give the impression of objectivity, empiricism, and “science” hard at work. However, a quick look at some of the questions on these “instruments” reveals their assault on reason and intellect (Box 2).12
Proponents who claim DID is “sufficiently validated for inclusion in the current and future versions of DSM” are to be commended for adding “much more research is needed in several areas.”13 Piper and Merskey’s review4,5 concluded that DID could not be reliably diagnosed.
Sample statements from the Adolescent Dissociative Experience Scale (A-DES)*
A-DES: I get so wrapped up in watching TV, reading, or playing a video game that I don’t have any idea what’s going on around me.
Comment: Although this item seems like a joke, it is not meant as one. It is meant to be part of the serious business of science. Isn’t that what any ‘normal’ human would do if he or she has enough attention and concentration?
A-DES: People tell me I do or say things that I don’t remember doing or saying.
I get confused about whether I have done something or only thought about doing it.
I can’t figure out if things really happened or if I only dreamed or thought about them.
People tell me that I sometimes act so differently that I seem like a different person.
Comment: These items are crafted in a way to encourage false positives. First, ‘people tell me’ does not qualify as an ‘experience.’ Second, one wonders why the scale was made up of declarative statements instead of questions. Third, ‘I seem like a different person’ is a leading statement.
A-DES: I am so good at lying and acting that I believe it myself.
Comment: This should be an immediate tip-off that the reporter is unreliable.
A-DES: I feel like my past is a puzzle and some of the pieces are missing.
Comment: Isn’t this the human condition?
*A-DES statements are italicized; comments by Dr. Gharaibeh are in plain text
Source: Reference 12
6. Does a DID diagnosis do harm?
Webster’s14 defines iatrogenic as: “Resulting from the activity of a physician. Originally applied to a disorder or disorders inadvertently induced in the patient by the manner of the physician’s examination, discussion, or treatment, it now applies to any condition occurring in a patient as result of medical treatment, such as a drug reaction.”
A DID diagnosis has been blamed for misdiagnosis of other entities,15 patient mismanagement,16 and inadequate treatment of depression.17 Even when DID is treated with the best of intentions, undesired negative effects may result from psychotherapy, and some patients experience worsening of symptoms and/or deterioration of functioning.18,19
In Creating Hysteria, Acocella20 cites examples of harm done to [alleged DID] patients and their families, including 2 high-profile cases under the care of a member of the DSM-IV work group on dissociation.
7. How is self-deception possible?
The ability to self-deceive has advantages and disadvantages,21 and widespread deception is possible. Richard Dawkins’s The God Delusion,22 Christopher Hitchens’s God is Not Great,23 and Michael Shermer’s Why People Believe Weird Things24 are recent exposés of how self-deception and deception by charismatic figures occurs despite the progress “reason” has made.
As with other belief systems that become entrenched in the face of criticism, DID proponents accuse critics of denial, reluctance, and adopting “defense[s] against dealing with the reality of child abuse in North America.”20 One wonders why just North America! Why not Africa, with its children in Sudan, Somalia, Zimbabwe—to name a few—enduring enough abuse to spread around the world several times over?