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Dissociative Identity Disorder: Adaptive Deception of Self and Others

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Dissociative Identity Disorder: Adaptive Deception of Self and Others Dissociative Identity Disorder: Adaptive Deception of Self and Others John 0. Beahrs, MD Dissociative identity disorder (multiple personality) is increasingly diagnosed, often follows childhood trauma. and is characterized bv riqidification of phenomena that resemble hypnosis. To inteipret dissociated aspeck of selfhood as autonomous entities is a useful heuristic; but when taken too literally, it leads to three kinds of anomaly: (1) legal: dissociators remain culpable for misdeeds carried out beyond apparent awareness or control; (2) clinical: legitimization sometimes leads not to relief, but to escalating cycles of regressive dependency; and (3) scientific: the form of dissociated entities varies with how they are defined, in ways that are intrinsically motivated and clinically manipulable. These anomalies yield to an evolutionary perspective that views dissociative identity disorder as an evolved strategy of adaptive deception of self and others; e.g., a beaten subordinate avoids further retribution by "pleading illness." Such a deceit best avoids detection when fully experienced; through its intensity and persistence, it becomes real at a new level. One's basic competencies remain intact, however, and are the source of the anomalies described. They can be clinically accessed and empowered, providing the key to therapeutic change when dissociative processes are problematic. Overall, despite clear impairment in subjective awareness and volition, dissociative-disor- dered individuals are best held fully accountable for the consequences of their actions. When deviant behavior becomes unac- ately excused and "treated."' To be held ceptable, society classifies the offending liable for retribution, transgressors must agents in two groups. Those defined as (1) know what they are doing and why, "bad" (culpable, blameworthy) are sub- and (2) be able to choose otherwise. ject to retribution. Others, defined as These attributions correspond to "con- "mad" (sick, insane), are compassion- sciousness" and "volition," the sensory and motor aspects of subjective experi- John 0. Beahrs, MD is associate professor of psychiatry, ence.* Their absence, by contrast, pro- Oregon Health Sciences University, and staff psychia- trist at the Portland D.V.A. Medical Center, Portland, vides the cognitive and volitional prongs Oregon. This paper was presented at the 24th annual meeting of the American Academy of Psychiatry and of the insanity defen~e,~and also con- the Law, October 24, 1993, San Antonio, TX. The tributes to the defining features of the views represented in this article are the author's own, and not necessarily those of the Department of Veterans dissociative disorders. Affairs. Address correspondence to John 0. Beahrs, Dissociative identity disorder (DID) M.D. (I 16A-OPC), Portland D.V.A. Medical Center, P.O. Box 1036, Portland, Oregon 97207. relabels multiple personality in the new Beahrs DSM-IV.4 Positive criteria are the char- process: real, yet fundamentally decep- acteristic symptom patterns: (a) pres- tive. This further clarifies how excusing ence of two or more "entities" (person- from responsibility paradoxically rein- ality states), which can (b) "take control" forces the condition, whereas accounta- of one's behavior, accompanied by (c) bility, by contrast, can lead to its suc- "inability to recall . too extensive to cessful resolution. be explained by ordinary forgetfulness" (amnesia). If an alternate personality Multiple Personality as a Useful state takes over and commits a crime Approximation beyond awareness, control, or desire, There is little doubt that DID (multi- three factors provide a prima facie case ple personality) exists as defined by op- that afflicted patients should be excused erational riter ria.^.^^ It is increasingly from criminal retribution. Amnesia, a diagno~ed,~-~and a standard of care has cardinal symptom of DID4 and hypoth- recently been proposed for its treat- esized vehicle for dissociative bameq5, ment.28 Current consensus accepts a negates our usual concept of conscious traumatic etiology, usually catastrophic awareness. Nonvolition is implied when- child abuse or its equivalent. Thus, DID ever an alternate personality (alter) is a variant of posttraumatic stress dis- "takes over9' beyond a subject's control. order (PTSD).30,31 Although recent data External victimization is believed to be suggest significant differences that re- a primary etiology in more than 95 per- main to be clarified,32posttraumatic dis- cent of cases.7 Eminent treatabilit~~,~sociation remains closely linked with the suggests a practical reason that dissocia- dissociative phenomena of normal hyp- tive-disordered offenders should be n~sis.~,~~Trauma often leads to stable transferred from the criminal justice to increases in hypn~tizability,~~.~~and the mental health system.lO, Predicta- spontaneous hypnosis occurs widely in bly, this occurs from time to time in the patients with DID.21,36 Dissociative bar- lower co~rts.'~-l~ riers are widely believed to be rigidified When such pleas reach the appellate through the aversive push of traumatic level, however, they uniformly affect.37,38 Despite undisputed impairment in con- Regarding other aspects of the disor- sciousness, volition, and recall, higher der, controversy reigns. Among these are courts have consistently ruled that these the questions of re~ponsibility,~~.23 iatro- patients remain legally responsible for genic artifact,39 veracity of traumatic the consequences of their action^.^',^^ mem~ries,~~-~~examiner bias,44and po- Although unfair from an intuitive per- tency of environmental shaping influ- spective, there are also dominating psy- ence~.~~-~~Among experienced practi- chotherapeutic reasons to enforce this tioners there is additional tension be- responsibility rigoro~sly.~~-~~This paper tween whether to emphasize dissociative explicates how such anomalies arise disorder as a pathological ~ondition~-~,48 from the very nature of the dissociative or as residing on a continuum with the 224 Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 Dissociative Identity Disorder complex consciousness of everyday despite appearances of temporal stabil- li~ing.~~-~~ ity, the form of psychological structures However we conceive these dilemmas, varies profoundly with the context in to think of human mentation at least as which they are defined.45Hypnosis re- if comprised of multiple part-selves has search suggests that physiological pa- extensive heuristic value. It helps to rameters may also be context-depend- make sense of otherwise inexplicable ent.60These anomalies will be discussed paradoxes in consciousness and in turn, before a new synthesis that re- volition2.6'2 1'37~49-53 and respects solves them at another level of abstrac- humankind's ubiquitous experience of tion. inner dialogue and conflict. To validate Legal Anomaly: Multiple Personali- part-selves' autonomous identities con- ties are Culpable for their Misdeeds tributes to the efficacy of ego-state ther- Barring major psychosis, courts are tra- a~y,'~configurational analysis,54 ges- ditionally reluctant to excuse wrong- talt,j5 and transactional analysis,56 as doers from responsibility because of well as treatment of multiple personali- claimed amnesia or subjective nonvoli- ties per See&9.37.5 1-53 These advantages tion. These are simply too intangible and hold, as long as we consider the concept difficult to validate.27 More important, of mental entities as either a useful ap- if convincing subjective reports could proximation or a he~ristic.~,21, 37 consistently exonerate antisocial of- fenders, this would undermine criminal Reifying Part-Selves: Three law's basic charge for the protection of Anomalies ~ociety.~'Further, such claims are no- When dissociated entities are taken toriously unreliable whenever high literally, reified, or confused with sub- stakes reward skillful de~eit.~~?~~When stantive reality, anomalies arise at legal, being accused, an almost universal hu- clinical, and scientific levels. Because man strategy is to claim lack of there is only one body that others can Surveys of homicide defendants indicate reward or punish, to allocate legal re- that 40 to 70 percent claim amnesia,64 sponsibility among part-selves is enig- and we lack methods to differentiate matic.16 When alters number into the reliably whether this is real or malin- tens or hundreds, it can lead to a reductio gered.65 Interview styles often used to ad absurdum.15When therapists validate uncover multiple personality disorder dissociative-disordered patients' impair- (MPD) are also known to bias naive ments at the expense of coexisting subjects toward assuming a dissociative strengths, we often see an escalating spi- pattern.45.46 ral of symptomatic distress, destructive These issues led to extensive debate behavior, and regressive unraveling of over the widely publicized "Hillside personality23,25. 263 373 57-59 rather than the Strangler" case. Some experts argued expected relief. Finally, scientific data that the accused committed homicide in from many diverse sources shows that a dissociated state beyond awareness or Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 225 Beahrs control66; others, that this was willful incompetency to stand trial. An often- fabrication by an incorrigible psycho- cited law review article noted that "some path.47The intensity of the debate partly amnesia is present in everyone," with reflected the tacit assumption that "real" effects similar to the information gaps dissociative disorder
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