Please forgive the length of this 5 part post. The intention is to summarize some of what I have written before as well as to add some additional points of refinement.
Robert Oxnam, author of A Fractured Mind, described how his psychiatrist came to the diagnosis of his MPD (now known as DID). This was quite similar to my experience of the diagnosis of Joan, the patient described in the first chapter of Engaging Multiple Personalities Volume 1. An alter came out and spoke with me and sneered as she called me “stupid.” It was clear at the end of the session, when that altered had disappeared, that the host personality had no recollection of what was said – the amnestic barrier remained completely in place.
It is unusual for a patient to call his psychiatrist stupid during a session, especially when the patient is depressed and seeking help. At the time I wrote my first Volume, I had not read Oxnam’s book. That his psychiatrist had almost the exact same experience leads me to believe that a therapist may face this kind of unexpected interaction on first meeting an alter. Hence, the importance of maintaining an appropriate index of suspicion with respect to the several possible diagnoses to consider when patients arrive trying to deal with depression, anger, and trauma.
How a therapist first comes to the diagnosis of DID is likely different from case to case. When the therapist has gained some experience in DID treatment, the realization of the correct diagnosis is usually quite evident and definite. In my own case, when I first met an alter – regardless of how they spoke to me – I usually had an unmistakable chilling sensation down my spine that the person with whom I was speaking had left the conversation and I was suddenly speaking to someone else, an alter.
I never experienced that sensation when dealing with the usual patients who had depression and anger. In the case I refer to, the alter is clearly one who is not the same age as the host. A professional well educated person in her forties would not call her psychiatrist “stupid” in the psychotherapy session!
Inexperienced therapists may worry that the patient is faking, that perhaps we are cheated by the patient or that perhaps we are anxious to meet an alter as a result of our own preconceived mindset. Psychiatrists who assert that they have never seen a case of DID are mostly fearful that making that diagnosis is the result of misdirecting and creating a case of DID (iatrogenesis) because they believe the disorder simply doesn’t exist. I believe those worries and fears are inappropriate, that they lead to missing the true underlying issue of DID – that it is the result of early childhood trauma impacting the patient on an ongoing basis.
Personally, I cannot think of any reason why a patient would deliberately try to fool me into believing he/she is suffering from DID. The only circumstance might possibly be in criminal matters. Claiming an alter did the criminal deed, is not going to excuse the crime. Nevertheless, there may indeed be a logic for someone in prison without DID to mimic DID symptomology to get a temporary reprieve from their prison cell to a mental hospital. However, whether it is a short or long term reprieve is not usually in the control of the prisoner.
It is clear to me that I have missed many cases of DID. Decades later, I came to the realization that my fault was thinking DID was a rare phenomenon. As a result I discounted the likelihood of seeing such a case or cases. In other words, it did not register in my general index of suspicion as might bipolar disorder, borderline personality disorder, or schizophrenia – even though studies show that DID is as common as schizophrenia.