Sybil's DID was Iatrogenic - Interesting story from NPR

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
I believe it's reasonably substantiated that nearly every index case of DID was either malingered, performative (brought on by expectations of the therapist), or iatrogenic in encouraging the naming of distinct feeling states as "personalities."

Memory is very malleable. Mix this with the suggestible, the histrionic, the factitious, and thus we have DID.

Yet even today DID is probably gonna stay in DSM-V.

http://skepdic.com/mpd.html
http://www.amazon.com/gp/product/1932594396/
 
Hmm looks like a very interesting book. Will order next time, thanks for the suggestion. DID is a diangosis that causes much controversy. Although many cases are proved to be a result of malingering, some could be left unexplained. Not so for DID (which could really not exist) but generally for the "repressed dissociative amnesia" stuff. I don't believe the traditional psychoanalytic repressed-memory stuff (sorry, but there is no evidence for it) but dissociation exists and maybe for different reasons than the ones thought by Freud (e.g. trauma. Kihlstrom's research has shown some people are more dissociative than others regardless of previous abuse). Maybe false memories are not only generated as a result of suggestions, hypnotherapy and associatve psychoanaltyic methods, but as a weird cognitive phenomenon of unknown aetiology
 
Members don't see this ad :)
nitemagi said:
I believe it's reasonably substantiated that nearly every index case of DID was either malingered, performative (brought on by expectations of the therapist), or iatrogenic in encouraging the naming of distinct feeling states as "personalities."

Memory is very malleable. Mix this with the suggestible, the histrionic, the factitious, and thus we have DID.

Yet even today DID is probably gonna stay in DSM-V.

http://skepdic.com/mpd.html
http://www.amazon.com/gp/product/1932594396/
Click to expand...

glad you posted mchugh's book. the book's great and addresses many things in psychiatry that generally go un-addressed or, more often, mis-addressed.
 
nitemagi said:
I believe it's reasonably substantiated that nearly every index case of DID was either malingered, performative (brought on by expectations of the therapist), or iatrogenic in encouraging the naming of distinct feeling states as "personalities."
Click to expand...

I don't recall where I read it, but I'd heard it more succinctly and more directly that there has never been a spontaneous case of DID - every single one, bar none, was after the patient had seen a psychiatrist.

Your response is more nuanced, and not as blunt as mine.
 
Apollyon said:
I don't recall where I read it, but I'd heard it more succinctly and more directly that there has never been a spontaneous case of DID - every single one, bar none, was after the patient had seen a psychiatrist.

Your response is more nuanced, and not as blunt as mine.
Click to expand...

Apollyon I would agree, with the replacement of psychiatrist with "therapist." A lot was induced by well meaning misguided "therapists" (MFT's, MSW's, Psychologists, some Psychiatrists) chasing the mythical repressed memories, never realizing how they were creating a self-fulfilling prophecy.

I mean even Freud abandoned the repressed memory abuse concept, chalking it up to fantasy or construct.
 
Last edited:
I've had a a few cases of alleged DID that I actually believed were real. I could be wrong. The reason why I chose to make the leap and believe they were real was because the patient sought no special attention due to their alleged condition and because I could not figure out any particular gain they could get for having it.

In these cases, I bluntly told the patients that DID is a diagnosis with plenty of controversy and that the majority of psychiatrists combined as a group either didn't believe it existed or didn't know if it did. I told them that with the known data on the disorder, I could not allow any excuses to be allowed concerning this disorder, and they never asked for anything such as a pass from work or anything else to that effect.

I've also seen dissocation that wasn't DID but I thought to myself that if you took it a step further, DID was a reasonable outcome.

But current opinion is that it does exist, but if you encounter it you have to be highly skeptical, and even if the person does have it, the data suggests you still hold the person responsible for actions from the other non-dominant personalities as a form of their treatment.

Yet even today DID is probably gonna stay in DSM-V.
Click to expand...

I'm finding some very highly questionable things with the DSM V including making ADHD even easier to diagnose. I'm of the opinion that the DSM V will allow even more children to be overmedicated. IMHO the DID issue should be an issue of hot debate for inclusion given the information I mentioned above. When less than 50% of the profession can't say they believe it exists, IMHO this begs substantiation as to why this disorder truly exists despite my own opinion.
 
whopper said:
I've had a a few cases of alleged DID that I actually believed were real. I could be wrong. The reason why I chose to make the leap and believe they were real was because the patient sought no special attention due to their alleged condition and because I could not figure out any particular gain they could get for having it.

In these cases, I bluntly told the patients that DID is a diagnosis with plenty of controversy and that the majority of psychiatrists combined as a group either didn't believe it existed or didn't know if it did. I told them that with the known data on the disorder, I could not allow any excuses to be allowed concerning this disorder, and they never asked for anything such as a pass from work or anything else to that effect.

I've also seen dissocation that wasn't DID but I thought to myself that if you took it a step further, DID was a reasonable outcome.

But current opinion is that it does exist, but if you encounter it you have to be highly skeptical, and even if the person does have it, the data suggests you still hold the person responsible for actions from the other non-dominant personalities as a form of their treatment.
Click to expand...

I definitely believe that dissociation as a phenomenon exists. DID I doubt. Sometimes the benefit isn't a secondary gain. Sometimes it's an identity (pardon the pun) as being someone with a dramatic or interesting disorder (for a medical provider, family members, friends), financial, excuses from work, an excuse for any brief aberrant behavior, and sometimes people just like getting seen for anything. I've seen several previously dx'd DID cases, and even with extensive hospital stays there was never evidence for more than a Borderline PD. Which itself can have some dissociation. Given these are only snapshots. But I have yet to see anyone with a diagnosis of DID who was dx'd in the last 10-15 years.
 
Singularz said:
Not only I don't think DID exists, I don't think "dissociation" does either. I mean, what is it? It doesn't explain anything, just labels it. It's like saying that the paperwork did not get done because I was daydreaming. But why was I daydreaming, why did I not do it, how does that happen, etc? Of course, most of psychological/psychiatrist concepts aren't real in the sense that an infection is real. So we judge them on their usefulness, explanatory power, and real world application. I don't find "dissociation" to be as useful as certain other concepts like anxiety or regression.
Click to expand...

Care to inform the group as to your level of training/location, etc?

I find dissociation has a fair amount of utility in explaining phenomenon like conversion disorder, as well as alternative types of "psychosis" such as AH in Borderline PD or even PTSD individuals. Ignoring phenomenology lessens your ability to discern subtypes amongst the vague complaints that patients may volunteer or that a standardized questionnaire may ask, and thus to give inappropriate treatment. This approach IMO leads to excessive overdiagnosis of psychosis, for example.

Now I agree many hypotheses are exactly that. They're constructs. Dissociation is quite different than daydreaming. Though a trance state which people may move in or out of can have a dissociative component.
 
Members don't see this ad :)
Singularz said:
If insurance companies pay for something, the person is much more likely to receive the medication or get labeled.
Click to expand...

Non sequitur. Insurance companies pay for whatever you write down. If I say you have ADHD because you like pizza, I code that, give you stimulants, and that's that. I don't have to document six symptoms in both categories as agreed upon across two settings. I'm unethical in that case, but I'm no more or less ethical because of what the DSM said.

Either the kid is so impaired by hyperactive, impulsive, or inattentive symptoms that medications are necessary to prevent them from falling behind developmentally, or not. Either you're a conscientious prescriber who weighs risks and benefits appropriately, or not. The DSM is important in many cases. In the case of ADHD, it's not really.

Whopper, like most adult psychiatrists, has the bias that children are over-medicated and that parents are looking to drug their children and avoid therapy. It's not an uncommon bias. It's the bias of most adult psychiatrists. Most parents. Most media outlets. It is not the bias of child psychiatrists, who far more often see parents doing the best they can and really struggling with the decision to use pharmacotherapy in children even when entirely appropriate.

For support, see Judith Warner's We've Got Issues.
 
I agree that dissociation happens and is a useful construct. I've really done an almost complete 180 on the subject of DID. I used to think DID was real and underdiagnosed, but having spent some time now in the field and having seen what types of folks tend to gravitate toward making these diagnoses along with having more clinical experience myself, I'm now a lot more skeptical. I'm willing to believe it might exist, but that if it does, it's probably very rare. And that most cases you hear about are usually due to something else entirely.
 
I think this discussion raises an interesting point about the nature of the DSM classifications and reminds me of a very illustrative example one of my best psychiatry professors brought up.

He was arguing in favor of moving towards an etiological (vs. descriptive) classification system, and as a comparison he referred to aortic aneurisms. As of now, we can perfectly describe the diameter, thickness of the vessel walls, flow, turbulence, presence of atherosclerotic plaques, etc., but the exact same aneurism is a very different animal in the context of hypertension, Marfan syndrome, or syphilis, with all the consequences this brings to medical management. I wish he had, or hope we achieve in the future, something like that in psychiatry.

Oh yeah... after that, he told me: "Man who catch fly with chopstick accomplish anything..." 😱
 
spaceboy said:
I think this discussion raises an interesting point about the nature of the DSM classifications and reminds me of a very illustrative example one of my best psychiatry professors brought up.

He was arguing in favor of moving towards an etiological (vs. descriptive) classification system, and as a comparison he referred to aortic aneurisms. As of now, we can perfectly describe the diameter, thickness of the vessel walls, flow, turbulence, presence of atherosclerotic plaques, etc., but the exact same aneurism is a very different animal in the context of hypertension, Marfan syndrome, or syphilis, with all the consequences this brings to medical management. I wish he had, or hope we achieve in the future, something like that in psychiatry.

😱
Click to expand...

Agree that etiology is important. One can say that the exact same (same symptoms) psychosis is a very different animal in the context of Syphilis, functional psychiatric illness (schizophrenia), or genetic syndrome (such as Wilson's)
 
splik said:
Actually there is fairly good neuroimaging data backing up a neurobiological basis for dissociation. For example in conversion disorder where a patient has the inability to move their left arm fMRI studies show that if you ask them to recall the inciting traumatic event, there is increased activity in the amygdala and concomitant decreased activity in the right motor cortex.

So dissociation is not just a psychological construct, it is one that has external validity. These patients are in my experience often highly hypnotizable (often a marker of dissociation) and and I have had some good results with hypnosis in conversion disorder. The neurobiology of hypnotic phenomena and dissociation are similar, so the concept of dissociation has been very useful for me, as the management of conversion disorder is an evidence-free zone.

I have never seen DID/MPD but I do believe something like it exists beyond iatrogenesis as we see something similar in other cultures but it gets labelled as 'spirit possession' etc. Obviously there is always some bandwagon and in the 80s it was DID, in the last decade it was pediatric bipolar disorder, who knows what the next diagnosis du jour will be? But that doesn't mean there isn't something to it - there are deffo some children with bipolar it is just a fraction of those who get diagnosed as such.
Click to expand...

I think trance episodes exist in many cultural contexts, but can still be filtered based on expectations. Trance state (the state aspect of hypnosis if you buy into that side of the state vs. trait debate) involves the three components of concentration, relaxation, and dissociation.

Conversion pt's are definitely highly hypnotizable, as well as highly suggestible, though you could argue they are more like individuals with a state aspect of being able to manifest hypnotic phenomenon (don't have to be "put into" a trance to manifest many of them). Furthermore conversion d/o pt's are the only group of somatoform pt's in which reassurance (i.e. suggestion) is effective in eliminating symptoms.
 
I don't think "dissociation" does either.
Click to expand...

Dissociation does exist. Anytime you're at a dentist or undergoing anything painful and you try to not think about it and imagine you're somewhere else, that's dissociation to a degree though not pathological.

As mentioned above, there is good scientific evidence it exists.

The problem, however, and I don't mean to speak for Singularz because maybe that's what he/she meant, is that it's very difficult to quantify and measure. That makes this phenomenon difficult to deal with on a clinical level.

Unfortunately, I find this disorder underdiagnosed, and instead it's called psychosis. Doctors tend to get trapped in a mental box and only diagnose what they can treat. While we should be equiped to treat dissociative disorders, the bottom line is it's easier to call it psychosis, throw an antipsychotic, and go to the next patient. Meds aren't a mainstay treatment for this problem. I'm seeing the same problem with borderline PD. Doctor's don't know how to do DBT so many are calling it bipolar disorder even when they consciously know the person's problem is borderline and not bipolar disorder.

I've seen a few patients that dissociated to a pathological degree and were medicated with strong stuff that just made their situation worse because they where misdiagnosed. When someone is dissociating pathologically, the last thing they need is a medicaiton that's going to zonk them out. Heck, if anything is going to be given pharmacologically, maybe it should be smelling salts. I remember being a resident, seeing this happen, telling the attending what was going on, and the attending just added even more antipsychotic.

By the way, I have now (only after years) had enough patients with a dissociative disorder to the degree where I have something of a handle on it besides what is read in books. I got a patient now who dissociates when she drives and as a result gets lost on the order of once a month. In some cases, she ends up in locations being literally hours away from where she intended to be. She was severely abused by her mother for years, has a very severe case of PTSD.
 
Last edited:
It's the bias of most adult psychiatrists.
Click to expand...

Actually, from my experience, it's the bias of too many psychiatrists to overmedicate in all areas. This is coming from a guy who has patients with psychosis to the degree where they're literally on 5-6 meds total. You tend to see this thing as actually common in long-term and forensic facilities where the severity of psychosis is much worse than in a regular inpatient unit.

If say 10% of psychiatrists I thought were overmedicating, I wouldn't have this opinion. I'm of the opinion, after seeing regular practice in 4 states, that this is on the order of about 1/2 the doctors out there.

In outpatient, regularly, I see patients who've been literally put on several meds for something such as borderline PD, gained 100 lbs, became addicted (not just dependent) on opioids or benzos, all thanks to their doctors who believed in pushing pills on disorders where they were not the best or first recommended treatment choice.

I of course believe that kids with ADHD need to be medicated if appropriate, that is they truly have ADHD, the risk/benefit ratio favors medication, and it's not being used to simply zonk out a troublesome kid whose parents don't want to put the time into raising the kid right.

Depending on your specific clinical scenario, you will see a bias. E.g. a not guilty by reason of insanity plea is rare, yet I've had dozens of patients with it because where I work they are transferred here if they are found NGRI. Without the proper training, a doctor could believe that it's actually a fairly common verdict. It's not. It's rare for people to pursue it, and when it is, it rarely works, but if you're in the place where all the ones in the lower 1/2 of the state are diverted, perspectives could change.

But from my non-child psychiatry perspective, I do see a lot of kids medicated when they should not be. My proof? I take them off meds and they're no worse, in fact often times they're actually better, then when you read their histories, their behaviors are within a cultural norm for someone in that situation. Perhaps in yours it's different.

Someone I know is a leading physician in the country and is a child psychiatrist. Pretty much every single time he ordered psychotropic medication for a child as far as I know, I thought he was doing good practice. I'm sure from your posts that you are likely giving them good care as well. On the other hand, a guy who works a few miles from where I do in private practice is readily diagnosing every child with bipolar and ADHD and giving them Risperdal even an age of two years and this guy is not a child psychiatrist, and I know for a fact that he's doing poor care as the norm.
 
Last edited:
I'm wondering if there's anything to getting someone out of dissociation by giving a sharp and painful or near painful stimuli. Problem here is doing a study will require several subjects that are confirmed to dissociate and that's difficult to find.

I've only encountered perhaps about 20-30 patients that I was confident had a real dissociative disorder during my entire length of training and practice. That's another reason why I believe psychiatrists often overlook it, because in residency they might have had no patients with this phenomenon ever and are not prepared to identify it.

IMHO anyone with a significant history of trauma as a child needs to be screened for PTSD, cluster B disorders, and a dissociative disorder.
 
whopper said:
IMHO anyone with a significant history of trauma as a child needs to be screened for PTSD, cluster B disorders, and a dissociative disorder.
Click to expand...

love this topic because it all comes down to the way we conceptualize various observations.

dissociation, like some have said, is likely something we all do, and it's on a spectrum - from daydreaming in a boring class all the way to a fugue.

regardless, dissociation is probably best looked at as a behavior. dissociation is likely a natural way of coping with boredom or stress or trauma that we learn to either do more or less often based on reinforcements. so DID would be an example of a VERY maladaptive coping strategy that may be best replaced by offering patients better skill sets.

I do not think DID is 'an entity unto itself,' a neurobiological sequelae of particular types of trauma in particular types of persons. It's maladaptive behavior in a highly suggestible person who has been unable to cope.
 
Last edited:
Truddi Chase's case of DID hasn't been disproven yet, has it?
 
F0nzie said:
DID makes me want to groove to this song:
Click to expand...

Couple weeks ago a student working with me coined a new diagnosis:
In my opinion she has, well, is there such a thing as "Over the Borderline?"
 
cara susanna said:
Truddi Chase's case of DID hasn't been disproven yet, has it?
Click to expand...

I haven't heard that it has and I don't know that it will now that I think everyone involved in her case (including Truddi) have passed on. But I do remember hearing that her "memories" were "recovered" under hypnosis and that is hugely red flaggy.
 
cara susanna said:
Truddi Chase's case of DID hasn't been disproven yet, has it?
Click to expand...

Well she fits all the classic problems -- memories brought up by a hypnotherapist (I say this as a psychiatrist that practices hypnosis). Never any corroborative evidence that the abuse actually happened. Unfortunately she died. I'm not aware of any independent examinations to eval for DID.

Plus she developed quite a celebrity out of the whole thing.
 
Yep, she sure did. And she brought her therapist, who encouraged her to write the book, with her to all of her many engagements. Like I said, red flaggy.
 
You must log in or register to reply here.

Similar threads

P
Interesting PRN job
Replies
16
Views
1K
Merovinge
Merovinge
StilgarMD
Interesting update on HealthyGamerGG (Dr. K)
Replies
16
Views
5K
neglect
neglect
MrFlyGuy
Let go from post-fellowship job before starting
Replies
7
Views
792
Merovinge
Merovinge
J
  • Locked
Psychiatry under fire from the White House
2
Replies
98
Views
5K
GoSpursGo
GoSpursGo
N
Negligence accusation story.
Replies
34
Views
2K
whopper
whopper
Top