Objective Documentation of Child Abuse and Dissociation in 12 Murderers with Dissociative Identity Disorder

LCEHWAILImDS, JAY PBEsUAycSGhEEi aARtrN,y S D1W 5DI4CI:S1AS2,O, EDCTeI cAAeTmLI.bOeNr 1 I9N9 7MURDERERS Objective Documentation of Child Abuse and Dissociation in 12 Murderers With Dissociative Identity Disorder

Dorothy Otnow Lewis, M.D., Catherine A. Yeager, M.A., Yael Swica, B.A., Jonathan H. Pincus, M.D., and Melvin Lewis, M.B.B.S., F.R.C.Psych., D.C.H.

Objective: The skepticism regarding the existence of dissociative identity disorder as well as the abuse that engenders it persists for lack of objective documentation. This is doubly so for the disorder in murderers because of issues of suspected malingering. This article presents objective verification of both dissociative symptoms and severe abuse during childhood in a series of adult murderers with dissociative identity disorder. Method: This study consisted of a review of the clinical records of 11 men and one woman with DSM-IV-defined dissociative identity disorder who had committed murder. Data were gathered from medical, psychiatric, social service, school, military, and prison records and from records of interviews with subjects’ family members and others. Handwriting samples were also examined. Data were analyzed qualitatively. Results: Signs and symptoms of dissociative identity disorder in childhood and adulthood were corroborated independently and from several sources in all 12 cases; objective evidence of severe abuse was obtained in 11 cases. The subjects had amnesia for most of the abuse and underreported it. Marked changes in writing style and/or signatures were documented in 10 cases. Conclusions: This study establishes, once and for all, the linkage between early severe abuse and dissociative identity disorder. Further, the data demonstrate that the disorder can be distinguished from malingering and from other disorders. The study shows that it is possible, with great effort, to obtain objective evidence of both the symptoms of dissociative identity disorder and the abuse that engenders it. (Am J Psychiatry 1997; 154:1703–1710)

he diagnosis of dissociative identity disorder (for- symptoms nor the abuse engendering them have ever T merly called multiple personality disorder) is usu- been documented objectively in a group of dissociative ally not made until adulthood (1), long after the ex- identity disorder patients of any kind (children, adoles- treme maltreatment thought to engender the condition cents, adults, or murderers), both the diagnosis and its has passed. Therefore, although there is a consensus etiology in childhood maltreatment have met with criti- that the most common cause of the disorder is early, cism ranging from skepticism to scorn (8–15). ongoing, extreme physical and/or sexual abuse (2–6), The diagnosis in felons is doubly suspect. The pros- accounts of such abuse are usually provided retrospec- pect of facing the consequences of a serious offense tively by the patient and lack objective verification. As invites malingering (16, 17). Dinwiddie and col- Putnam (1) said, “In most reports, including the NIMH leagues (18) asserted that the disorder, especially in survey, there is no outside verification that any trauma forensic cases, could not be distinguished from malin- actively occurred.” gering. Orne and colleagues (19) suggested that the Coons (7) recently attempted to verify abuse histories most objective means of making the diagnosis in foren- in a group of 19 children and adolescents through in- sic cases was through interviews with family members terviews with families and “collateral reports from nu- and others who had observed the characteristic be- merous sources.” The extent to which abuse was docu- havioral changes in the individual before he or she mented in each case was unclear. Because neither the had committed a particular offense. To date, however, there have been no such systematic studies of groups of felons with dissociative identity disorder or, for that Received April 5, 1996; revisions received March 24 and July 7, matter, of any other series of adult patients with the 1997; accepted July 31, 1997. From the Department of Psychiatry, disorder. Carlisle (20) described 13 murderers suffer- Division of Child and Adolescent Psychiatry, New York University School of Medicine. Address reprint requests to Dr. Lewis, Depart- ing from multiple personality disorder but provided ment of Psychiatry, New York University School of Medicine, 550 few objective data to support the diagnosis or its etiol- First Avenue/New Bellevue 21 South 14, New York, NY 10016. ogy. Coons (21) collected information on a group of

Am J Psychiatry 154:12, December 1997 1703 CHILD ABUSE AND DISSOCIATION IN MURDERERS

TABLE 1. Child and Adult Symptoms and Signs of Dissociation and Sources of Confirmatory Data for 12 Murderers With Dissociative Identity Disorder

Age Symptoms and Signs Symptoms and Signs Corroboration Subject Sex (years) in Childhood in Adulthood of Symptoms

1 M 40 Considered “possessed”; vivid Trances; vivid imaginary companions; voice Mother, sister, aunt; police imaginary companions; auditory changes/switches to foreign-sounding records; legal assistant’s hallucinations; dramatic language; different names/handwritings; notes; handwritten demeanor changes command hallucinations; amnesias; two documents and letters male personality states identified 2 M 32 Trances (“phasing out”) since age Trances; voice, accent, demeanor changes; Mother, brother, wife, 15 months; called “possessed”; different names/signatures; wrote different teacher, housemates; vivid imaginary companions; ages on forms; auditory hallucinations; am- handwritten documents auditory hallucinations; episodic nesias; three male personality states and letters shaking with eyes open; identified considered epileptic 3 M 41 Trances; fugue states; called Trances/“conscious blackouts”; voice and Wife, brother, sister, friends, “possessed”; vivid imaginary demeanor changes; regression to small neighbors, co-workers; companion; auditory child; legally changed name to that of most court records of legal name hallucinations; amnesias powerful alternate personality; different change to that of alternate signatures/handwritings; auditory personality; handwritten hallucinations; amnesias; three male documents and letters personality states identified 4 M 33 Trances (“glassy eyed”); fugues Trances/time loss; vivid imaginary com- Mother, father, brother, (age 8, found across town; age panions; voice and demeanor changes/ friends, cell mates; pros- 14, found in distant state); vivid dresses and sounds female; different ecution psychiatrist inter- imaginary companions; audi- clothing (sizes, sexes); different names/ viewed alternate person- tory, visual, and tactile hallucin- handwritings; auditory hallucinations; alities; trial transcripts; ations; amnesias; falling and shak- amnesias; two female and four male police audiotapes; hand- ing episodes; considered epileptic personality states identified written documents and letters 5 M 30 Fugues; vivid imaginary com- Trances (i.e., “astral projection”); fugues/ Mother, brother, aunt, uncle, panion; auditory hallucinations; time loss; voice and demeanor changes/ stepmother, stepfather, amnesias; wore girls’ panties dresses as a female; different names/sig- childhood friend; adult and and sanitary napkins natures/handwritings; different visual child psychiatric/psycho- acuities; auditory hallucinations; amnesias; logical records; school two female and four male personality records; handwritten states identified documents and letters 6 M 22 Trances; fugues; vivid imaginary Trances (i.e., “astral projection”); fugues/ Mother, siblings, cousin, companions; auditory and blackouts without alcohol; vivid imaginary schoolteacher, prison visual hallucinations; considered companions; voice and demeanor changes; psychiatrists; handwritten epileptic different names/signatures/handwritings; documents and letters different drawing styles; different visual acuities; auditory hallucinations; amnesias; one female and three male personality states identified 7 M 21 Trances; vivid imaginary com- Trances/blackouts without alcohol; fugues; Mother, father, panion; auditory hallucinations vivid imaginary companions; voice and de- grandmother, sister; meanor changes; different names/signa- handwritten documents tures/handwritings; auditory halluci- and letters nations; feels controlled from outside; amnesias; two female and five male personality states identified 8 M 46 Vivid imaginary companions; hos- Trances/blackouts without alcohol; voice Mother, ex-girlfriend, wife, pitalized for two episodes of and demeanor changes; regression to baby relatives hysterical paralysis (ages 9 and talk; different names; auditory hallucina- 10); talked to self as if to tions; amnesias; one female and two male someone else personality states identified 9 F 36 Vivid imaginary brother; auditory Time loss; voice and demeanor changes/ Parents, child, teenaged hallucinations dresses and sounds male; different names; accomplice, housemates; auditory hallucinations; amnesias; neurologist’s report diagnosed/treated for alleged psychomotor epilepsy (normal EEG); one other male personality state identified 10 M 43 Auditory hallucinations; Trances/dreamlike states; fugues/time loss; Mother, aunt, friends; amnesias; dizziness, falling vivid imaginary companions; voice and handwritten documents spells; considered epileptic demeanor changes; different names/signa- and letters tures/handwritings; refers to self in third person; command hallucinations/hears voices arguing; visual hallucinations; amnesias; four male personality states identified (continued on next page)

1704 Am J Psychiatry 154:12, December 1997 LEWIS, YEAGER, SWICA, ET AL.

TABLE 1 (continued) Age Symptoms and Signs Symptoms and Signs Corroboration Subject Sex (years) in Childhood in Adulthood of Symptoms 11 M 41 Counseling regarding sexual Time loss; voice and demeanor changes/ Aunt, co-workers, acquaint- behaviors (age 13); listed dresses and sounds female; different ances; handwritten docu- different names at different names/signatures/handwritings; auditory ments and letters times for parents hallucinations; amnesias; two personality states, one female and one male, identified 12 M 15 Trances; rapid changes of de- Trances/blackouts without alcohol; different Mother, brother, mother’s meanor, mood, and behavior names/signatures/handwritings; friend, uncle, great-aunt, noted (age 6); vivid imaginary voice/accent changes; command grandmother, jail guard; companion; talked to self as if hallucinations; observed hitting self, psychiatric hospital record to someone else; drew person yelling at self; amnesias; one other male (age 6); other psychiatric/ with seven or eight ears, two personality state identified, three more social services records; mouths, split in half (age 6) suspected police reports and witness statements; handwritten documents, letters, drawings

18 murderers alleged to have suffered from multiple symptoms have been described elsewhere (22–25). During these psy- personality disorder; his data were gleaned in great chiatric evaluations, dissociative phenomena were explored in detail and included questions about trances, time loss, fugues, amnesias, measure from newspaper accounts and legal decisions. imaginary companions, rapid mood shifts, auditory/visual hallucina- For lack of objective documentation of symptoms or tions, fluctuations in skills, being blamed for disavowed acts, sound- abuse, in most instances the diagnosis was disbelieved. ing/acting like a different person, and using different names/signa- Given the dearth of objective documentation of dis- tures/handwriting. Records of these neuropsychiatric evaluations and of any previous evaluations were reviewed for the presence or absence sociative symptoms and the antecedent abuse that en- of the above-mentioned signs and symptoms. Handwriting samples genders dissociative identity disorder, we welcomed the (e.g., old journals, letters) were also examined. These written materi- opportunity to present objective data on dissociation als were produced before the subjects’ psychiatric evaluations and and abuse in 12 murderers suffering from the disorder. thus were not influenced by the examiner. In all cases, affidavits, testimony, and/or reports of interviews with family members, friends, As will be discussed, we believe that our findings are neighbors, childhood acquaintances, teachers, probation officers, po- also relevant to cases of the disorder in adults who have lice, and clergy were reviewed for mention of the signs and symptoms not committed violent crimes. and for any indications of abuse and neglect. At the time of publication of this article, clinical data regarding symptoms and abuse histories were in the public domain (i.e., in trial transcripts, exhibits, appeals briefs, newspaper articles, and books); METHOD hence, informed consent to tabulate data was not necessary. Never- theless, out of respect for the privacy of the subjects and their families, During a 13-year period in the 1980s and 1990s, the first author we have not identified the subjects by name. (D.O.L.) had the opportunity to do psychiatric evaluations of ap- proximately 150 murderers. Of these murderers, 29 were subjects in a study of death row inmates. The majority of the rest were evaluated RESULTS at the request of individual defense attorneys. Several others were evaluated at the request of the court, of prosecutors, or of family members. Of these murderers, 14 met the DSM-IV criteria for disso- Signs and Symptoms of Dissociative Identity Disorder ciative identity disorder. We were able to obtain objective documentation of both child abuse and long-standing dissociative signs and Table 1 presents the subjects’ dissociative symptoms symptoms in 11 of these 14 individuals and of early dissociative signs and symptoms in a 12th. This report focuses on the 12 murderers in childhood and adulthood and the corroborative with dissociative identity disorder for whom objective, confirmatory documentation. Among the most common symptoms data on child abuse and/or long-standing dissociative symptoms and signs were trances, amnesias for circumscribed pe- could be verified. There were 11 men and one woman. Their ages at riods of time and/or particular behaviors, changes in the time of their offenses averaged 28 years (range=15–44). Eight voice and demeanor, and auditory hallucinations. were white and four were black. The subjects’ psychiatric, neurologic, medical, social service, wel- As can be seen in table 1, the amounts of information fare, school, probation, police, prison, and military records were re- available on the subjects’ childhoods varied. We were viewed, and in eight cases social service, medical, psychiatric, mili- able to obtain objective evidence that during child- tary, court, or police records pertaining to parents were also reviewed. hood, eight of the 12 subjects had trances and amne- Any evidence of abuse, neglect, and/or dissociative signs and symp- sias, nine had experienced auditory hallucinations, and toms was noted and tabulated. All 12 subjects had been evaluated psychiatrically by the first 10 had vivid and long-standing imaginary companions author (D.O.L.), a board-certified psychiatrist. Nine had been exam- who seemed to be precursors of their alternate person- ined neurologically by one of the authors (J.H.P.), a board-certified ality states. neurologist; a 10th was examined by another board-certified neuro- Ten subjects experienced trance-like states in adult- logist. An 11th, at age 2, had been evaluated by a neurologist, at hood that were also observed by others. Two described which time an EEG was performed. The psychiatric and neurologic reports of these evaluations were reviewed. The nature of the psychi- their ability to remove themselves from situations as atric and neurologic evaluations and the criteria for specific signs and “astral projection.” Others described their trance-like

Am J Psychiatry 154:12, December 1997 1705 CHILD ABUSE AND DISSOCIATION IN MURDERERS

FIGURE 1. Writings Discovered in the Diaries of Subject Number 6 FIGURE 2. Signatures From the Letters of Subject Number 6

FIGURE 3. Writing Samples From the Letters of Subject Number 10 FIGURE 4. Signatures From the Letters of Subject Number 7

states as blanking out, spacing out, or transporting at different times, not in the context of avoiding arrest themselves to imaginary places in their heads. Seven re- or responsibility. Writing samples obtained from 10 ported being able to block out physical pain. subjects revealed markedly different handwritings. Fig- All 12 subjects, as adults, had impaired memory for ures 1–4 are examples of the different signatures and both violent and nonviolent behaviors. For example, handwritings of three of these 10 subjects. subject 5 pulled out his own toenails at night and, in the All 12 subjects had histories of experiencing auditory morning, did not know how this had happened. Sub- hallucinations that, during psychiatric evaluation, were jects 4, 5, and 11, all of whom had female alternate recognized by the examiner as being voices of alternate personalities, found women’s clothing in their posses- personalities. Seven experienced severe headaches when sion and did not know how it got there. Subject 4, at they heard arguments in their heads among alternate trial, insisted that the bloodstained suit he had been personalities. Subject 1 pulled out his own teeth in an wearing at the time of his arrest belonged to someone unsuccessful effort to cure his excruciating headaches. else because it was too big to be his. In all cases, examiners were able to speak with at least All 12 subjects were described by others as having one alternate personality. The subjects averaged three voice changes and/or marked changes of demeanor. For to four personality states (the range was one to seven). example, three people reported that subject 9, the only These figures may be underestimates because of the lim- woman in the study group, periodically sounded like an ited time available for evaluations. Nine subjects (in- aggressive male, and male subjects 4 and 11 at times cluding our only female subject) had violent male alter- reportedly sounded like women. Subjects 5 and 6 were nate personalities, most of whom said they “took the noted to have alternate personality states with different pain.” Six male subjects had older female alternate per- visual acuities, and the lawyers for subject 4 reported sonalities whose functions were caretaking, comfort- that he did not recognize his own voice on tape-re- ing, and protecting. Of note, five subjects had alternate corded police interviews and insisted it was the voice of personalities who were embodiments of parents or rela- someone else. All 12 subjects had used different names tives; two had abusive father personalities, one had an

1706 Am J Psychiatry 154:12, December 1997 LEWIS, YEAGER, SWICA, ET AL. abusive mother personality, one had a powerful aunt sexual abuse sustained at the hands of his grandpar- personality, and one had a sister personality. The na- ents. The affidavit of a cousin who lived with him dur- ture and function of these alternate personalities and ing childhood—a document discovered by one of the their relevance to the crimes committed will be de- authors (D.O.L.) after the subject had been executed— scribed in a subsequent paper. revealed that his grandmother had dressed him as a girl Table 1 lists the sources of information confirming and given him to his grandfather to be used for sexual evidence of dissociative identity disorder in each sub- gratification. ject. As can be seen, documentation regarding subjects’ Before evaluation none of the subjects was aware that dramatic changes of voice and/or demeanor came not he or she suffered from dissociative identity disorder, just from family members but also from police records, and most remained ignorant of their condition after notes of a legal assistant, observations of a jail guard, their psychiatric evaluations. Even after some were told observations of a prosecution psychiatrist, and subjects’ of their condition, they tended to disbelieve it. For ex- co-workers, roommates, acquaintances, and friends. ample, when subject 4 learned of his diagnosis at a As mentioned, objective documentation of personality court hearing, his response was, “I think you’re full of changes in the form of different handwriting and signa- shit.” Of note, in this case, because of his dramatically tures could also be found in the journals, letters, and changing demeanor during incarceration, the subject’s documents of 10 subjects. fellow prisoners had made the diagnosis of multiple personality disorder years before the psychiatrist ever The Nature of Maltreatment in Childhood saw him.

Because the histories of abuse of both patients with dissociative identity disorder and murder suspects are DISCUSSION often questioned, we call special attention to table 2, which presents objective documentation of the nature Our ability to interview subjects’ family members and and extent of physical and sexual abuse of 11 of our 12 friends, our access to their past psychiatric, social, and subjects. The term “abuse” does not do justice to the educational records, and our access to their personal quality of maltreatment these individuals endured. A letters and diaries enabled us to document evidence of more accurate term would be “torture.” For example, long-standing dissociative symptoms in all 12 of our subject 4 was deliberately set on fire by his parents. Sub- subjects and to obtain objective evidence of extreme ject 6 was used in child pornography by stepfathers and abuse of 11 of them. Rarely, if ever, do psychiatrists was deeply scarred from anus to mid-buttock from hav- have the opportunity to obtain this quantity and quality ing been made to sit on a stove burner. At 3 years of of confirmatory data about adults with dissociative age, subject 2 had his penis scalded and “circumcised” identity disorder. It was only because of the time-con- by his father. Subject 5 was tied down by his step- suming investigations conducted in the course of the mother, given enemas allegedly containing blood, and, legal representation of these murderers that we could to stanch the blood, had tampons inserted into his rec- amass these kinds of data. tum, thus simulating menstruation. This subject was re- Contrary to Dinwiddie and colleagues (18), we have moved from one foster family because he had been demonstrated that dissociative identity disorder can be caught molesting other children and wearing girls’ un- differentiated from malingering and other disorders. derwear and sanitary napkins. The evidence of strikingly different handwriting styles We were surprised to find that in their usual person- antedating the murders in question, plus the documen- ality states, most subjects denied or minimized child- tation of amnesias and of changes in voice, demeanor, hood maltreatment. Four of them, for whom documen- and appearance observed by family members and oth- tation of extraordinary abuse was discovered, totally ers before our subjects’ crimes, settles once and for all denied any physical or sexual abuse. Seven others who the issue of malingering in these cases. To have malin- had been severely physically and/or sexually abused gered, our subjects would have to have planned their had but fragmentary memories of the abuse. None at- murders long in advance and feigned their early symp- tempted to use histories of abuse to enlist the sympathy toms in anticipation of some day committing a violent of jurors or to excuse their violent acts. Since in their crime, a highly unlikely scenario. In short, with ade- usual personality states most of the subjects had no idea quate data, it is possible to distinguish dissociation of the kinds of maltreatment they had sustained, they from malingering and from other disorders. For exam- could not use histories of abuse to manipulate clinicians ple, although dissociative identity disorder shares cer- or anyone else. tain symptoms with schizophrenia, bipolar disorder, Histories of maltreatment were obtained primarily and other syndromes, none of these other disorders is from old records, accounts provided by first-degree characterized by the voice, demeanor, and handwriting relatives, and the reminiscences of childhood friends. changes and amnesias characteristic of dissociative For example, subject 3 had no recollection of his inces- identity disorder, as documented in our study group. tuous relationship with his mother; information regard- The question remains: to what extent are our 12 mur- ing incest was gleaned from the social service records of derers with dissociative identity disorder representative his brother. Similarly, subject 6 knew nothing of the of other adults with the disorder? After all, most pa-

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TABLE 2. Nature and Documentation of Childhood Maltreatment of 12 Murderers With Dissociative Identity Disorder

Subject Physical Abuse Sexual Abuse Documentation Informants Scars

1 Severe beatings by Sexual abuse by Trial testimony regarding father’s Mother, sister, Head, back mother, father; tied up mother; incest incarceration for violence to his aunt and beaten by mother; with sisters family; neglect petitions; mother neglect declared unfit; children removed from home 2 Thrown into wall by Sexual abuse by Childhood hospital records document Mother, brother Head, back, father (ages 14 father, including numerous injuries, losses of con- chest months and 3 years), “circumcision” sciousness, “seizures”; father’s causing indentation of (age 3) military records indicate court skull; leg fractured by martial and dishonorable discharge father (age 5); tied up for beating subject’s 7-month-old naked and beaten by sibling; father’s medical records mother; set afire by document fist traumas coincident siblings with subject’s unexplained injuries 3 Severe beatings by Sexual abuse by Neglect petitions; petition for term- Brother, child- Head, face, mother, father; neglect mother; incest ination of parental rights; brother’s hood friend, back, chest with sister, brother social work, welfare records neighbor, wife reveal subject’s incest with mother; school records report father’s violence 4 Severe beatings by Sexual abuse, Hospital records document several Mother, father, Head, back, father; scalded by including sodomy admissions starting at age 2 for brother chest, arms, mother; set afire by with bizarre ob- “convulsions” and loss of con- thighs, but- parents jects, by father; sciousness; police reports call father tocks, penis sexual abuse by “highly emotional and erratic” older brother 5 Severe beatings by Sexual abuse by Child medical, psychiatric, and foster Mother, aunt, Head, back, mother, father, step- stepmother, in- care records document abuse by uncle, child- chest mother; burned and cluding sodomy father, mother, stepmother; mother hood friend thumbs pulled out of with bizarre obj- declared unfit, children removed sockets by stepmother; ects, being tied from home; police records docu- locked in closets and down and given ment stepmother’s violence basement by step- blood enemas; mother; abandoned dressed as a girl by mother by stepmother 6 Severe beatings by Sexual abuse by Removed from home by court order; Mother, siblings, Head, back, mother, stepfathers, mother, grand- social service records, juvenile pro- cousin, neigh- chest, but- grandparents; burned parents; prosti- bation records, parole records docu- bors, teacher, tocks; deep 2- by grandmother, step- tuted by step- ment family dysfunction; cousin’s two priests inch burn father; locked in base- fathers; dressed as affidavit documents sexual abuse by from left ments and attics by a girl by grand- grandparents buttock to anus grandmother; neglect mother 7 Daily severe beatings by None reported Emergency room records report Mother, father, Head, face, father severe headaches beginning in third childhood back, legs grade friend, aunt, maternal and paternal grand- mothers 8 Locked in closet, hit on Sexual abuse by Child medical records indicate Mother (denied Back head with skillet by mother, aunt hospitalizations (ages 9 and 10) for all abuse), wife, mother; beaten by hysterical paralysis girlfriend father 9 None reported Sexual abuse by Medical records of treatment for Father—refused None noted father hysterical seizures to allow mother to be inter- viewed alone (parents denied abuse) 10 Beaten while naked Suspected sexual Mother charged as unfit Mother, aunt, Back with belt, switches, abuse by father, childhood whips, until bleeding, grandfather, great- friends by mother and her grandfather (slept boyfriends; aband- with them in same oned by mother bed and com- plained of fre- quent anal pain as a child); sexual abuse by aunt; (continued on incest with sister next page)

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TABLE 2 (continued) Subject Physical Abuse Sexual Abuse Documentation Informants Scars 11 Beatings by father with Sexual abuse by Child psychiatric records of treatment — Chest, back, belts, extension cords, older male for excessive masturbation and arms, legs brooms relatives problems relating to father 12 Severe beatings by Sodomized by older Psychiatric hospital records, Mother, brother, Chest, back, mother (e.g., hit with male relatives; psychiatric outpatient records; social mother’s friend arms, ankles wrenches, vases); sexual abuse by service records (age 6) report father shot at grandmother; mother placed child with state mother—bullet grazed given biweekly because she was injuring him; nine subject (age 5); beaten enemas by reports of neglect and “possible with belt and whip by grandmother sexual abuse” since age 1; court uncle; neglect records; mother’s psychological reports/records tients with the disorder do not commit murder. On the encourage lying, especially in dissociative patients, of other hand, most patients with the disorder do have ag- our 12 subjects, not one produced false memories or gressive, protector personality states (1, 5). However, lied after inquiries regarding maltreatment. On the con- relatively few commit violent crimes, reflecting, at least trary, our subjects either denied or minimized their in part, the fact that most recognized cases of dissocia- early abusive experiences. We had to rely for the most tive identity disorder occur in women (1, 26, 27), and part on objective records and on interviews with family women as a group are far less violent than men (28). and friends to discover that major abuse had occurred. Whereas Loewenstein and Putnam (26) reported that Even if the subjects had been able to provide memo- similar percentages of men and women among their ries of maltreatment and even if they had been aware of subjects with multiple personality disorder had “homi- their diagnosis, because we were dealing with two cidal alters” (35% versus 32%), 19% of the men and problematic issues—murder and dissociative identity only 7% of the women reported actually having com- disorder—it was vital that we document from outside mitted murder. In our own clinical experience, we sources as much objective evidence as possible of disso- found that among the male outpatients seeking treat- ciative symptoms and childhood maltreatment. We ment for dissociative identity disorder at our clinic, a did this. In every case, three or more outside sources substantial percentage (64%) had demonstrated rageful provided independent evidence of subjects’ marked behaviors that came just short of homicide. In fact, one changes in voice, demeanor, and behavior, and in 11 patient reported spending time in a reformatory after cases abuse was also verified objectively. Furthermore, committing murder, and two others had been arrested in 10 cases handwriting samples produced before the for attempted murder. A much smaller percentage of offenses in question documented changes in writing the women in our clinic group (9%) were similarly ag- styles and signatures. Thus, the diagnosis of dissociative gressive. One had attempted to shoot her adult son, and identity disorder and the history of abuse did not rest another had tried to push her father in front of a car. exclusively or even primarily on reports obtained from The majority of the males with dissociative identity a subject. disorder that we have seen have not been clinic outpa- The extent to which it was possible in these murder tients but, rather, have been examined in prisons, where cases to review old records, interview families, and ob- they were incarcerated for violent crimes. On the basis tain objective documentation of symptoms and early of our clinical experience, we suspect that the diagnosis abuse was, of course, unusual. In most cases of disso- of dissociative identity disorder is overlooked in males ciative identity disorder, this degree of verification is more often than it is in females because the violent be- not possible. Nevertheless, our experience with these 12 haviors of the protector alternate personality states of murder cases illustrates that with sensitivity, diligence, men go unrecognized and their violence is regarded in- and appropriate resources, corroborative external evi- stead as “sociopathy.” As a result, males with the dis- dence of prior dissociative symptoms and of early, ex- order are far more likely than their female counterparts treme abuse in adult patients with dissociative identity to be arrested and incarcerated. disorder is there to be found. We may not always be The 12 murderers in our study were unaware of their able to obtain this extensive a body of documentation psychiatric condition. They also had partial or total for all of our patients, but we must try. amnesia for the abuse they had experienced as children. Such is the nature of dissociative identity disorder. 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