DISSOCIATIVE 1 IDENTITY DISORDER PRESENTING AS HYSTERICAL PSYCHOSIS
Hamdi Tutkun, M.D. L. Ilhan Yargic, M.D. Vedat Sar, M.D.
Hamdi Tutkun, M.D., is a psychiatrist in private practice in livan, & Maltbie, 1979; OztiJrk, 1981). The term is sLill in Istanbul. During this project he was a residentat tlle Depart use, and papers about the subject conLinue to be published ment ofPsychiatry, Istanbul University Istanbul Medical Fac (Modestin & Bachman, 1992; van der Hart, Witztum, & Fried ulty, Istanbul. L. I1han Yargic, M.D., is a psychiatrist and man, 1993; Oztiirk, 1994). Books on the subject have also Coordinator of the Dissociative Disorders Program at the appeared (Maleval, 1981; Libbrecht, 1995). DepartnlentofPsychiatry, Istanbul University Istanbul Med From the descriptive standpoint, HP beginssuddenlyand ical Faculty, Istanbul. Vedat Sar, M.D., is Professor of Psy dramatically (Hollender & Hirsch, 1964). The onset is tem chiatry and Director of the Clinical Psychotherapy nit & porally related to an event or circumstance which has been Dissociative Disorders Program at Department of Psychia profoundly upsetting. The manifestations may take the form try, Istanbul University Istanbul Medical Faculty, Istanbul. of hallucinations, delusions, depersonalization or grossly unusual behavior. Affectivity is not usuallyaltered.1faltered, For reprints write Hamdi Tutkun, M.D., Istanbul Tip Fakiil it is in the direcLion of volatility but not flatness. Thought tesi Psikiyatri Klinigi, Capa TR-34390 Istanbul Turkey. disorders, when they do occur, are generally circumscribed and u·ansient. The acute episode in HP usually lasts one to ABSTRACT three weeks. The process recedes as suddenly and dramat ically as it began, leaving pracLically no residue, and, occa Dissociative identity disorder (DID), formerly known as multiple per sionally, with amnesia for the episode. sonality disorder (MPD), usually presents with associated symptoms HP has been considered for a long time in the context rather than with the main features ofthe disorder. It is necessaJy described by Hollender and Hirsch (1964) and has been dis for the clinician to keep it in mind as a diagnostic pl'Obability and cussed from a psychoanalytic perspective. Various theories to know its various presentations and associated symptoms inorder about the etiology and nature of HP have been proposed. to recognize it. We observed during long-term evaluation offour cases These patients, mostly women, were described as very dra ofhysterical psychosis (HP), that they had DID with long-term his malic, histrionic, attenLion-seeking, and seductive in their tories ofdissociative symptoms. Patients applyingfor care who man behavior. The clinical picture of HP has been regarded as ifest a single dissociative symptom, a dissociative disorder, a severe the endpointofa continuum beginningwith hysterical char acute dissociative synd1'011le with regressive featu1'es, or a dramatic acter. It has been considered as a disorder mostly seen in and therafrrresistant conversion symptom should be evaluated for women ,vith hysterical or histrionic personalities. An episode other dissociative symptoms and especially for their chronicity. In of HP has been considered as a simple or primitive type of our experience, one presentingform ofdissociative identity disorder wish fulfillment, a fantasy which may take a vivid and hallu is a hystmical psychosis, a type ofcrisis situation in the context of cinatoryform in patients who have hysterical characterstruc the longitudinal course ofthe dissociative identity disorder. ture. It has been thought thatat times these patients become so frustrated, so angry, so frightened that they lose control INTRODUCTION and behave in a psychotic fashion ,vithout ever manifesting the kind ofpervasive tllOught disorderor inappropriateness Hysterical psychosis (HP) which has been defined as a ofschizophrenia (Hollender & Hirsch, 1964; Langness, 1967; form of hysteria, was a popular term in Europe and ortll Richman & White, 1970; Martin, 1971; Mentzos, 1973; Cave Anlerica, early in this century. After a time of diminished nar et aI., 1979; Gift, Strauss, & Young, 1985; Modestin & interest in tlle psychiatric literature, Hollender and Hirsch Bachman, 1992). (1964) revived the concept and formulated a descriptive Some papers which have tried to explain tlle psychody definition. It has never been part of tlle standard nomen namics and precipitating environmental stresses associated clature butit has lived on without official sanction (Hollender with HP, here suggested intrafamilial relationships and & Hirsch, 1964; Hirsch & Hollender, 1969; Mentzos, 1973; environmental stress (Richman & White, 1970), disturbed OztiJrk & G6gi.is, 1973; Spiegel & Fink, 1979; Cavenar, Sul- marriages (Martin, 1971), an unwelcomed orwished for bur
244 DlSSOCLlTlOX.l'ol. IX. Xo. 4, December 1996 TUTKUN/yARGICjSAR
not forthcoming sexual advance (Cavenal" et al., 1979) and fol1owingcril,eria: a) tbc psychosis isembcdded in dissociati\'c oycradjustmcm to a restrictive environment (OZliirk & phcnomena; b) tbe psychosis itself can be seen as a disso GOglIS, 1973; Ow}rk, 1981) as etiological factors. Spiegel ciated state; c) a splitting or doubling of the mind has and Fink (1979) stated that 1-11' patients arc highly hypnoli occurrcd; d) subconscious phenomcna arc obscn'cd; and ntble and in conrrast to schizophrenics are curable with psy e) altered states of consciousness occur. Van der Han and chotherapy. Stcingard and Frankel (1985) obsel.....cd thatcer Spiegel (993), reviewing the studies of Breukink (1860 Ulin highly hypnotizable persons arc prOlle to experience 1928), explaincd the usagc of hypnosis in the differential rransient bm severe psychotic Slates. diabtTIosisand lreaUnenl ofl.rauma-induced Hr, Van der Hart Various forms of ~h}'sterical ncurosis- ha\"c long been et al. (1993) emphasized the essential role of traulllatically appreciated to be common in Turkey (Ow}rk & Volkan, induced dissociation in the genesis ofreaCli\'e psychosis, and 1971). Most clinicians in Turkey agree that there is also an they proposed a new category of psychopathology, reacth'e entity beSt described as HI' which is distinctly different from dissocialh'e psychosis, which integrates the classical features schizophrenic disorder (Ozlurk & GOglIS, 1973; Ozturk, ofHP with the most recent thinkingoll trauma-induced psy 199--1). It has been a frequent diagnosis in Turkey, especial chosis. Depending 011 the case presentations of HI' in thc lyin emergencyadmission unitsofpsychiau-yclinics. Accord literamre and their own cases, they beliC\'e that the cssen ing LO a retrospecth'e im'estigation of 227 consecuti\'c tial charaClcristic of HI' is nol. its short duration bUl. a paticnts hospitalized in the psychiatry clinic ofl.he HaceuL'" dissociative foundation (Breuer, 1895; janet, 1894; l'lock, pe University (Ankara, Turkcy) between 1970-1980, those 1868; Breukink, 1923; Hugenbolz, 1946; cf. van der Han et diagnosed as having some form ofMhysl.eria M constiLUted 6% aI., 1993). of the wholc inpaticlll. population ovcr that tcn-ycar pcri It has becn well known in Turkish mainstream psychia od. Ofthcsc, 7.8 were diagnosed as HI' (Sar, 1983). Accord try thatH!' has a dissociati\'c nature and, as such, it is qual ing to a more recent report, 5.8 % ofthe whole patient pop itatively different from schizophrenic disorder (Oztllrk & ulation hospitalized in anOl.her univcrsity psychiatry clinic Gogus, ]9i3). II. has been considcrcd as a Mpseudopsycho (Adana, Turkey) between 1985-1995 were diagnosed as 1-11' tic dissociation ~ (07.tllrk & Gi>giIS, 19i3; 07.tllrk, 1994) which (Ol.poyraz et a!., 1995). does not indicate a need for neuroleptic drug treaunem. The cril.cria in use for the differential diagnosis of HI' Oztllrk (198],1994) points out thaI. it should be held sepa in Turkey have been mainly in accordance with Hollender rate from acmc psychogenic psychosis and should rather be and Hirsch's descripl.ions (Ozturk & Gogus, 1973; Oztllrk, classified among dissociative disorders, Short-term hospi 1981; Ozturk, 1994). On the other hand, it has been appre talization, supportive psychotherapy, and especiall}' separa ciated in Turkey for a long time that many patients with the tion from a distressing family elwironment have been the traditional diagnosis of hysteria (including HI') usually do most useful measures for the managcment of the disorder. not manifest histrionic personality features (Ozturk & Hypnosis has been avoided for a long time in Turkish main GOgiIS, 1973; OZlllrk, 1981; Sar, 1983; Sal' & Savasir, 1984; stream psychiatry and has unfortunatcly nC\'er becn uscd Oztiirk, 1994; Sar, Yargic, & Tutkun, 1995). Ozturk and for thedifferemial diagnosis and treatrncmofHP in Turkey. GOgiis (1973) pointed out, referring to Hollenderand Hirsch Although \'3n del' Hart and Spiegcl (1993) considercd hyp (1964), that these patients uSllally havc Man abilil)' to accom nosis an CffCClivc tool for I.hese purposes, it rcmains outside modate readily to the expectations or requiremcnts ofoth the mainstrcam ofTurkish practice. M ers- which they called Muysal uyum (complaisant O\'erad~ Dissociati\'C idcntity disorder (DID), formerl)' known as justJl1CIlI.), unaccompanied, however, by histrionic feaLUrcs. multiplc pcrsonalilY disorder (American Psychiau'ic Ass0 Sarand Savasir (1984) linked this aspect to a hisLOry ofmul ciation, 1994) has followed a route rather parallel to HI' tiple frustrations, negligelll. parents, and a restrictive fami throughout psychiatric hisLOry. Interest in it diminished dur ly el1\'ironmclll. (Sar, 1983) and concludcd, referring to ing I.he early twentieth centuf)' but il. becomc popular again Marmor (1950), that in Turkey hysteria is based rather on beginning ....ith the so-<:alled ncoknepelinian period after oral characteristics in personality I.han on oedipal conflicts. 1980. Previously, DID W,lS IittJe understood and tJlOught to They did not pUl. I.heir conceptualization into today's trau be quitc unusual. Various sl.andardi7.cd intcrvicw schedules ma paradigm. (Ross, 1989a; Steinberg, Rounsmille, & Chicceui, 1990) and Van der Han and his colleagues, reintroducing Janet sclf-ratingscales (Bernstein & Pumam, 1986) wercdeveloped and Breukink's forgoucn works on 1-11' and drdwing upon in order to diagnose chronic dissociati\'c disorders and lheir own experienccs, put the concept of HI' in a perspec proved to be\'3lid and reliable. Now DID is knO\\'J"IlO be more ti\'e different from that ofHollender and Hirsch's (van der common than previously imagined (Ross, 1991).lt is increas Ilart & Friedman, 1989; V"dn der Hart & Spiegel, 1993; van ingly understood as a complex and chronic post-tr.llImatic del' Hart et aI., 1993). Van der Hart et al. (1993) quoted dissociative psychopathology often closely relaled to child Janet, who s..... id thaI. for a psychosis to be hysterical, its dis abuse (Kluft, 198ia). 'iOCiative nature should be cstablished, as idcntified by the DID usually presents with associated symptoms mther
245 D1ssomTIO:.i, loL IX. ;';0. t ~bcr 1996 • DID PRESENTING AS HYSTERICAL PSYCHOSIS
than with main features ofthe disorder. Therefore it is nec had been overlooked previously. One of d1em (Case 3) essary forthe clinician to keep itin mind as a diagnostic prob reached fusion between heralter personalities after two years ability and to know its various presentations and associated of psychotherapy. The od1ers dropped out for various rea symptoms in order to recognize it. Kluft (1987b) reported sons. that DID patients can have many first-rank Schneiderian symptoms. The majority of DID patients experience audi CASE PRESENTATIONS tory and/orvisual hallucinations. These patients may appear to have profound thought disturbances and delusions. But Sema DID patients do notshow a true sustained thought disorder, Sema, a 15-year-old female high school smdent, was such as is often found in schizophrenia (Putnam, 1989). brought to d1e emergency unitofourgeneral psychiatryclin Some famous cases ofhysteria, (e.g., Anna O. and Emmy ic by her parents. She was laughing and crying inappropri von 1 .), who also manifested HP (Hollender & Hirsch, 1964), ately. She had horrific \~sual hallucinations. She said that are now considered as ha\~ng had chronic complex disso she heard d1e voice of a man who d1reatened to kill her if ciative disorder (Ross, 1989b). Van der Hart and van der she did not kill her parents. She was answering this voice Velden (1987) stated about one of the first historical cases loudly, sometimes tearfully, sometimes ironically. Herspeech ofHP, Rika van B., that 'Janet (1909, 1910) would probably was childish and exaggerated. She was not oriented to time also have characterized Rika van B. as a double personality and place. She remembered nod1ing about herself except of the dominating somnambulism (somnambulisme domi her name. Sometimes she attacked her parents physically. nateur) type - in his view, the prototype oIlhe multiple per She had had several fainting fits, usually lasting a few min sonality disorder." Van der Hart and Spiegel (1993) con utes. Her symptoms started the day before admission, after sidered both HP and DID to be trauma-induced severe a \~sit from her friends. She had been suffering decreased dissociative disorder. However, they did not mention a pos vision for three months. This had started gradually, and she sible overlap between the two. became totally blind for 20 days. Detailed neurological and Our curiosity about DID started with our interest in HP. opthalmological investigations had not revealed any physi We observed that in some patients, HP was a transient man cal cause. She had had similar symptoms intermittendy for ifestation ofan underlying unrecognized chronic complex six mond1s periodically after her brod1er's drowning when dissociative disorder, usually DID or DO 0 , according to she was 11 years old. u1e diagnostic criteria of DSM-1V. The current paper is u1e Serna was hospitalized wid1 d1e diagnosis of HP. Wiu1 first indicating the overlap between HP and DID. outany medication hersymptoms, including blindness, sud Indeed we detected our first DID case (Case 1 of this denly disappeared two days later and she returned to her paper) among HP patients in 1992 during long-term evalu premorbid state. She was amnesic for d1is d1ree-day period. ation after the acute picture had subsided. This observation Sudden and spontaneous remission of d1ese acute dramat gave way to the studies which led to d1e publication of the ic symptoms supported our diagnosis of HP. first case series from Turkey (Tutkun, Yargic, & Sar, 1995). A few days later, ema was sent home for d1e weekend. Among our first consecutive 36 cases ofDID patients, nine Upon her return she again suffered d1e symptoms she had of them (25%) were diagnosed as HP in the emergency previously had, except for d1e hysterical blindness. We admission unit of our general psychiatl)' clinic (Yargic, d10ught that HP had recurred. The patient also said some Tutkun, Sar, & Zoroglu, 1995). We concluded that HP is one thing that was very strange for us: She said d1at she had no ofd1e main causes ofpsychiatric admissions for DID patients name, and d1atshe hadjust been born; she was illiterate and in Turkey manifesting itselfas an acute crisis situation in the did not know the names ofobjects. AldlOUgh we insisted d1at context of the underlying chronic complex dissociative dis her name was Serna and she was 14 years old, she refused order. Here four cases are presented, which were referred to believe us. During her hospitalization, she told us that to the clinic as HP and were diagnosed by our team as hav her parents passed through the wall at night and beat her ing DID concurrendy after the HP had subsided. recurrendy. She was hallucinating her parents, crying, and In all these four cases the HP disappeared sponta calling nurses for help at night. As the authors were on hol neously or after supportive u'eaUnent in a few days and the iday, Serna was taken in hand by anod1er team. The opin patients said that they did not have any further complaints. ion ofd1e possibilityofa schizophreniform psychotic episode However, detailed psychiatric examination for dissociative led this team to administer 15 mg ofu'ifluphenazine per day. symptoms revealed d1at they had had amnesias, voices There was no improvement in three weeks. Meanwhile d1e inside their heads, unexplained changes in behavior and aud10rs returned and took back the responsibility of d1e affect, and feeling d1at d1ere was someone else inside d1em. patient. We insisted on our first diagnosis and decided to These experiences had waxed and waned over time fqr many apply electroconvulsive therapy (ECT) which is considered, years. The patients did not mention d1em spontaneously. in Turkey, as u1e last choice of symptomatic treaunent for. Thus we could diagnose in d1ese patients classical DID which HP, even if administered only a few times (Oztl.rk, 1994).
2 246 D1SS0Clmo:,\, \'01. IX. :'\0, 4, December 1996 TUTKUNjYARGICjSAR
After only a single adminislration arEeT, Serna had returned remembered were hearing a commanding male \'oice in her to lhe premorbid stale "'hen she woke up. She was amnesic head and suffering a severe headache, for her hospital slay and her previous S)'lnptoms. This obser \Vhen the Ill' completely resolved and Gllla)' remrned \"alion also supported our diagnosis of HP, to ~norma1.~ we e' 247 DI!\SOCLmO\. \oL IX. \0. 4. Drmnber 1!I9li • I DID PRESENTING AS HYSTERICAL PSYCHOSIS Halime Two identities had been formed from childhood imag Halime, a 45-year-old housewife, was brought to the inary playmates: "Pamuk Prenses" (Snow White) and "Kral emergency psychiatric unitby hercousin with the complaints ice" (the Queen). They bod1 enjoyed partiesat nights where ofamnesia, headache, talking to herself, visual and audito the Queen looked after, protected, and controlled d1e young ry hallucinations, inappropriate laughing and Clying, and "Pamuk Prenses" and enviously competed with her at the talking childishly. Hersymptoms had started suddenlywhen same time. she found herselfwith the cousin in a hotel room partially During the interviews different identities and person amnesic for the previous night. She knocked her head against alityfragments took full control spontaneouslyand they had the wall in the emergency unit. She said thatshe had a severe various degrees ofamnesia for one another's activities and headache and heard voices in her head which ordered her different degrees of knowledge about one another. These to kill herself, her husband, herolderbrother, and heraunt's identities also executed many aspects ofthe patient's life for husband. She saw herdead father in front ofher. She claimed which host was amnesic (e.g., extramarital relations, travel that her father controlled her. Sometimes she gazed at a ling to several places). This patient reached fusion after two point and talked to herself. She did not answer questions years ofpsychotherapy including inpatient treatment ofsix when in thatstate. Suddenly she became veryjoyful and was months oftotal duration spread over these admissions. Post amnesic for the time and place and why she had come to fusion treatment of the patient is under progress. the emergency psychiatric unit. After talking for a few min utes she began to cry and shake. She became disoriented Ipek again and fearfully said that there were insects on her. She 1pek, a 21-year-old single female clerk, had been hospi was struggling as if she were trying to get rid of the insects. talized and diagnosed as HP one year ago in our clinic by a Then she calmed down and became amnesic to this and the team other than the authors'. From the charts itwas learned rest of the interview. She did not know why she was there. that she had suddenly had auditory hallucinations which She said she had enjoyed herself the previous night. Ten commanded her to harm herselfand others, and to escape minutes later she began to cry and shake again. She from her home. She talked to these voices. She also had a screamed, "leave me, it aches very much." When she was visual hallucination of a hanged man. Occasionally she asked, she said thatshe was six years old, in her aunt's house, became excited and tried to harm herself. After the com and her uncle was doing bad things to her. Meanwhile she plete remission ofthese acute symptoms in 20 days, she had was tearing her clothes with one hand and trying to cover amnesia for the episode. Itwas noteworthy that during her her body with her other hand. hospital stay, she usually remained in bed during the day These acute symptomsofvisual hallucinations and com complaining ofanhedonia, weakness, and headache. How mand auditory hallucinations, rapid affective and behavioral ever, it was noted that she sang and danced merrily in the changes, her believing she was controlled by her father, evenings. She denied this behavior when questioned in the trance states, flash-backs lasted for six days, waxing and wan morning. ing. When they resolved completely she remembered these 1pek did not have psychiatric follow-up. The experiences six days only partially. The patient said that she had had a with the three cases presented above led the audlOrs to make similar episode for two weeks, seven years ago. contact,vith another three patientswhom they knew to have Psychotherapy began once weekly. Twenty-one identi had the same diagnosis before. Only Ipek accepted a follow ties and personality fragments were identified. The hostwas up interview. She had had a similar episode six months before a depressive person who suffered flashbacks ofsexual abuse she was contacted and had been hospitalized in anotherinsti by her uncle when she was six years old (including vaginal tution. During the first interview she complained of head penetration), by her two older brothers from nine to 12 ache, fainting, nightmares which frequendy interrupted her (including anal penetration), being placed in an orphan sleep, nervousness, selfmutilation, blank spells, voices inside age at age six, and various emotional and physical abuses. her head, and seeing frightening images. She said that she She was amnesic to the other personalities. "Happy" Hal felt as if there were someone inside her head, commanding ime liked traveling, dressing, went out for entertainment at her to hurt herself and commenting about her. She some nights, and did notworry about the childhood traumas. She times found herself in anod1er part of the city and did not had had two extramarital relationships aboutwhich the host remember when and why she went there. Occasionally she was notaware. Halime also had alter personalitieswhich con had spells of complete amnesia for one to two hours and sidered themselves to be 16, 18, and 23 years old. Theywere tried to hide d1em from others. She had profound deper amnesic to other personalities and each other. They had their sonalization. own relatively enduring pattern of perceiving, relating to, Ipek was interviewed ten times for follow-up. During and thinking about the environmentand d1emselves,. There this evaluation, three alter personalitieswere detected which were six child personalities which were formed during trau were amnesic to each od1er. Although their names and age~ mas, and two male persecutory alters. were the same, d1eir perception about themselves and the 248 DISSOClHIO:\. Yol. IX, :\0. 4. December 1996 TUTKUNjYARGICjSAR ell\;ronmclll. their life Stories. their w 249 DID PRESENTING AS HYSTERICAL PSYCHOSIS , patients, HP, although self-limited, did not occur only a few nostic window" (Kluft, 1985) for DID. times in life, as considered earlier (Hollender & Hirsch, As in the case ofdissociative amnesia and fugue, HP can 1964). It is occasionally a manifestation of a more chronic occur as a "symptom" during tl1e course of DID, but it can and complex dissociative disorder (DID or DO OS). We do also occur separately as a diagnostic entity ofits own. There not claim that HP is always embedded in a DID or DONO , fore, we do not consider HI' simply as an epiphenomenon but it is possible that HP points to a chronic, and perhaps of DID. If HI' is a condition willi a dissociative foundation subtle, dissociative disorder and to tl1e existence of child which develops understressful circumstances, tl1en llie prob hood traumatic experiences. This requires further study. ability ofdeveloping it maybe especially high in persons who Hollender and Hirsch (1964) refer to an undated pes have llie most severe dissociative experiences, as in the case onal communication from Brill, who has described tl1e of DID. thought disorders in HI', even though characterized at times DSM-Nlacks a categorywhich corresponds to HI'. We re by delusions, as rather simple distortions of reality, which commend llie introduction oftl1is category in classification disappear when emotional control is achieved, more like systems among dissociative disorders and agree willi van der those seen in the very angty or fearful child than the more Hartetal. (1993) on a new label as "reactive dissociative psy complex, autistic, and chronic thought disorders of the chosis" (as former HI') which refers to its etiology and phe schizophrenic patient. We think that Brill's observation of nomenology more accurately. On tl1e ollieI' hand, tl1e devel the "very angry and fearful child" assumes a new meaning opment of studies on DID makes the reevaluation and in today's perspective. This type of behavior and thinking redefinition of HI' possible. The borders between HI', OlD, appears to originate from flashbacks ofchildhood traumatic and acute stress reaction should be redefined. This resolu experiences, age regressions, and child alters in DID and tion, however, will require furllier prospective research inves DONaS patients. tigating the relationship of HI' to DID. There are two different approaches to HI' in literature. The category ofHI' is still used traditionally by clinicians Hollender and Hirsch (1964) described HP depending only who are aware of the difference between an acute on clinical phenomenology. On the other hand, van derHart schizophrenic episode and psychotic-like dissociative ("hys et al. (1993), reviewing Hoek, Breukink, andJanet, empha terical") syndromes but who are not familiar willi DID and sized tl1e dissociative foundation and traumatic etiology of its incomplete forms (DO OS). The concept of HI' would HI'. Hollenderand Hirsch's definition required a shortdura be one oftl1e starting points for recognition ofDID in coun tion of no longer than three weeks and emphasized amne tries where professionals are more familiar witl1 more tra sia for the episode. Van der Hart et al. (1993) argue against ditional categories ofmental disorders.• the criterion ofshort duration. Their own case had longer duration and did not have amnesia for tl1e HP episode. Van der Hart et al. 's conception defines probably a broader cat egory which includes the former. HP lasted less than tl1ree REFERENCES weeks in all of our cases, congruent with Hollender and Hirsch's description. Total or partial amnesia for the episode, American Psychiauic Association (1994). Diagnostic and statistical and recurrent episodes ofshort duration in our cases could manualofmental disorders (4th ed.). Washington, DC: American Psy be a critical feature which points to the probability of a chiatric Association. chronic complex dissociative disorder underlying the acute Bernstein, E.M., & Putnam, P.W. (1986). Development, reliability episodes of HI'. and validity of a dissociation scale. Joumal ofNervous and Mental We believe that HP in DID patients i a result ofdecom Disease, 174,727-735. pensation after an acute stressful life event tl1at leads to a struggle for control and influence among alter identities car Cavenar,j.O.Jr., Sullivan,j.L., & Maltbie, A.A. (1979). 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