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risk. THE CONCEPT OF "PERSONALITY" Behavioral expressions of humans and other complex social animals are defined by three psychological components: temperament, culture, and personality. Temperament is inborn and characterizes a specific animal species. A fox constantly runs about looking for food or mischief, but a lion sleeps twenty hours a day. Cows mainly rest or feed slowly, but dolphins are highly active, spending brief moments to feed and long hours to play. Humans devote long hours to work, rest, sex, learning, exploration, and entertainment. These biologically predetermined characteristics are resistant to change within the lifetime of an individual and define us as a species. Culture is a set of acquired traits and is learned in a social environment. Culture can dampen or enhance personal expression. Hispanics are generally vivacious, but Scandinavians are more reserved. Germans are private people, but Italians seem to expose their private lives in the streets. New Zealanders dress conservatively and the same way, but Americans dress to express their different tastes. Asian cultures suppress individualism, but Americans embrace it. Personality is a psychological concept that reflects acquired behavioral trends of individuals. We intuitively evaluate other people within the same culture and categorize them based on the overall impression they make on us. Although personality is difficult to define exactly, we intuitively know what personality is and do not hesitate to form our opinions about the mental, social, and behavioral traits of others. The above characterization of the psychological makeup of humans is largely correct, but neither an individual's impression nor psychology as a science are able to fully and correctly recognize the relationships between temperament, culture, and personality. Each of the three psychological components is produced by a complex system of neural structures, connections, and neurochemicals. Damage to even one attribute of the biological, neural, or psychological makeup of a person can produce subtle or major changes in behavioral expression. These issues are especially important in the multiple personality disorder, when all three psychological components of the human being interact and project the images of unique personalities (personas or alters) within a personality (persona or alter) system. The alternative labels persona and alter are used intentionally to indicate that the neuropsychological construct of a "personality" in the multiple personality disorder is not the same thing as the purely psychological set of traits known as personality. To understand the personas/personalities of people with multiple personalities, we need to learn about the overall neurocognitive makeup of the human brain. Only with this blueprint in our hands, can we reliably recognize what individual personalities consist of and what properties they have. Knowing and correctly applying the neurocognitive organization of the mind is not merely an academic exercise, but is critically important for our ability to identify personalities, evaluate their neurocognitive completeness or disintegration, recognize the underlying brain disorders, and devise appropriate treatment strategies. These issues are especially significant when personalities exhibits diverse ages, diverse cognitive abilities, or diverse physiology, handedness, blood pressure, sexual orientation, allergies, illnesses, or responses to drugs and medications. WHAT IS MULTIPLE PERSONALITY DISORDER? Multiple personality disorder is a complex neurocognitive condition. The diagnostic label of MPD was first used in France at the end of the nineteenth century [16]. A case of a split personality containing just two minds was already reported (based on hearsay) by Dr. S. L. Mitchill in 1816 [17]. Various other labels undoubtedly existed for patients in older times. In all likelihood, the doctors were only aware of a subset of the symptoms, and failed to acknowledge the full spectrum of the manifestations. Similar problems exist even today, and multiple personality is often simplified to some specific trait. The subjects are considered mentally deficient or abnormal, and hardly anyone cares to investigate their condition in depth. The first impression typically results in a "diagnosis" of some other disorder the doctor is familiar with. The unfamiliar is ignored, and the familiar is substituted for diagnosis, even though there are no facts to warrant such a false diagnosis. The problems of poor qualification of medical personnel already begin in medical schools, where professors teach students that MPD is a rare condition, meaning that the professors never saw one patient who had MPD. As a result, MPD appears just as exotic to doctors as it appears to the general public. Multiple personality disorder has only become widely recognized after the publication of Diagnosis and Treatment of Multiple Personality Disorder by Frank W. Putnam [1]. Since that time, many other professionals have confirmed his findings. Multiple personality disorder does exist and is much more common than anyone would believe. This brain disorder often arouses odd attitudes, and most people want to hear fantastic sounding stories about the expression of multiplicity, but show little concern with the real impact this severe neuropsychological illness has on the sufferers. Multiple personality is easiest to explain from the clinical viewpoint. Every person has various sides to her nature. She can become aware of her sides if she pays close attention to her moods. Sometimes she is happy, at other times she is sad. Sometimes she is reasonable, at other times she is demanding. Sometimes she is confident, at other times she does not know what to do. Occasionally, a person can have ambivalent feelings. Depending on the particular environmental stimuli, one of her moods happens to be dominant in a given situation. All the moods are in mutual contact, influence each other, and perceive themselves as one mind. This is totally normal, but when something causes these neuropsychological entities to become mutually isolated, multiple personality is produced. Multiple personality disorder (MPD), also known as dissociative identity disorder (DID), is a relatively permanent state of mind; the mind is split into partially or completely isolated neuropsychological modules. Each complete personality module has its own memories, emotions, and preferences, and behaves as a unique person. Some modules (called personalities or alters) are aware of the existence of other modules, whereas some personalities believe that they are the only mind in the body. In everyday life, only a few personalities emerge to interact with the environment. A woman with multiple personality disorder may activate only one personality at work, another personality at home, and another personality when she is with her friends despite having several dozen personalities in her arsenal. Her personalities may be awake at the same time and watch the behavior of the currently active personality. They can affect her behavior by letting her know how they feel. This may happen in silent ways, unbeknown to the personality in charge of the body, or by talking and producing "audible" internal voices the activated personality hears [1]. Multiple Personality Disorder is a good name for the described illness. Unfortunately, most health professionals have been unable to diagnose the disorder. After years of political maneuvering at the highest levels of the mental health system, the name was changed to Dissociative Identity Disorder. The new name might have been chosen to appease both the promoters and adversaries of the diagnosis, but the change has signaled a denial of multiple personality by the mental health system. In effect, the establishment decreed that the earth is the center of the universe and there is no proof otherwise. Anyone opposing this view is a heretic and will be dealt with by the system. Such attitudes are not caused by deliberate ill will of the deniers, but by a mental disorder called psychopathology. But then again, there is no proof that psychopathology exists either. On the personal level, multiple personality manifests a unique dissociative disorder. The mind of a multiple is permanently dissociated, which means that the mind is broken up into compartmentalized functional modules. Selection or suppression of these modules produces the phenomenon of multiple personality. In addition to MPD, there are several other dissociative disorders that lead to permanent dissociative states of the mind. These states may produce symptoms that are indistinguishable from MPD. By contrast, some dissociative modes are only temporary and selective, and a person is momentarily dissociating. The mind returns to normal operation soon after. Also during this mode of dissociation, the mind distances itself from certain functional parts. They are not personalities, but components of the overall united mind. For example, while danger lasts, some segments of the mind become inactive and allow a soldier to fight without experiencing fear. He is temporarily detached from his emotion, but can reactivate and even succumb to the emotional effects once the danger is over. The physiology of multiple personality and the identification of the neural structures involved in this illness are discussed in the eBook SPELLBOUND. As for the possible number of personalities the mind can have, this is a tricky topic. In theory, the number of personalities can be huge. In real life, personalities are only created in response to overwhelming traumas, and the same personality can be responding to all traumas of the same type. This is why repeated child rape does not produce a new personality during every episode of rape. Only when the environmental conditions change is there a need to form a new personality. Although most personalities are created as a direct result of a trauma, some personalities are created as a byproduct of such splitting. When two disagreeable neuronal areas split from each other, one or more smaller areas may be left behind. Also these areas of the neural substrate may become independent personalities if the neuropsychological conditions are right. The likely triggers (severe traumas) of permanent dissociation hint that the number of possible personalities could run in the dozens. In extreme cases, when the abuse is lifelong, several hundred personalities might be expected to exist. By contrast, according to MPD skeptics, thousands of personalities have reportedly been identified by some doctors. This claim is difficult to accept. It is unlikely that a psychotherapist would be able to encounter thousands of personalities and keep track of them. Most individuals can only identify a few thousand people in real life. The likelihood that a doctor doing two hours of therapy per week could discern a comparable number of personalities, which only emerge briefly and occasionally, is highly questionable. Dak reports that he was able to identify only a few personalities in most non-patient multiples, and only two dozen personalities in the most severe cases, which are more likely to become mental patients. Some of the subjects were studied for decades, but did not have dramatically higher numbers of personalities, relative to the non-patient multiples, who were studied just for several years. The clinical experience suggests that there could be up to several hundred personalities in a person in extreme cases, but identifying them all may not be achievable. Note: All Dak's subjects were evaluated in full consciousness and without the use of hypnosis. Hypnosis might reveal additional personalities of the unconscious mind, which can remain inactive during consciousness. HOW DOES A NORMAL PERSON GET MPD? Normal people do not get MPD. If a person exhibits multiple personality, his or her life must have been anything but normal despite superficial semblance of normalcy. Multiple personality disorder typically develops at a young age because of some kind of very traumatic experience, usually long-lasting and severe abuse in childhood. The earliest age when MPD can develop has not been clearly established, but seems to coincide with early infancy. Allison, who is an expert with extensive clinical experience, believes that MPD predominantly develops before the age of 7 years [14]. Other clinical workers have reported dramatic age regression in their patients with MPD down to the toddler age. Such effects hint at the existence of multiple personality even in preschool age, but complex dissociative disorders could also produce an identical age regression. According to Dak's discoveries, the neural structure and cognitive organization of a personality already exist during the third month after birth, and repeated mental shocks should be able to break up the personality even at this early age. Abuse that leads to development of multiple personality can be emotional, physical, or sexual, or combinations thereof. In reality, all abuse is mental. The mind perceives and interprets the harmful acts as abusive. The aftereffects of childhood sexual abuse seem to be responsible for more than 90% of all MPD cases. By contrast, non-abusive traumatic events do not cause multiplicity. Multiple personality disorder only develops when a person is helpless and unable to escape her suffering or the threat of suffering, especially when the abuse is repetitive or lasting weeks, months, and years. A significant factor leading to the development of multiple personality is the dependence of the victim on the abuser and establishment of a personal relationship with him. He becomes an essential and psychologically inseparable part of her existence, but he is also her torturer in the mental sense. The cognitive substrate of the brain is unable to reconcile these dramatically opposing experiences and is forced to split into pieces. Some people wonder why fragmentation of the cognitive mind happens at all. It seems that the mind could live through traumas in one piece, and then develop the classical symptoms associated with post-traumatic stress disorder (PTSD). The reason for the splitting, relative to the consequences of PTSD, is given by different relationships and mechanisms between functional areas of the brain. In PTSD, dissociation is temporary and mainly affects processing of information in real time. Some areas of the neural circuitry are excluded from information processing, and the information is stored incorrectly. This fact alone produces the colorful manifestations of PTSD. The outcome is caused by a subset of mechanisms that lead to complex dissociative disorders. In multiple personality, the traumatic experience is remembered by a specific segment of the mind. The information is then shared with other areas of the brain. Information sharing is a spontaneous process, but this time the information is overwhelming. The other parts of the mind do not like the recorded experience. Mental tension develops between the traumatized and the unaffected brain segments. The discourse is intense and ongoing. Neurochemicals are produced by the unaffected brain segments, and all ties are severed with the traumatized segment, which is unable to separate itself from its memories. Car accidents or similar single traumatic events that occur suddenly and allow no opportunity to agonize do not produce multiple personalities. However, clinical investigators report that people who have experienced only one traumatic event can have multiple personalities. Such person's include witnesses of parent murder, or victims of rape by strangers, or survivors of sudden natural disasters. Whether or not such events cause multiple personality is questionable. The events certainly can produce posttraumatic stress disorder, time loss, repressed memories, and similar effects, but multiplicity is probably not the outcome. It seems that such single traumatic events mask previous traumas that were frequent and led to the creation of multiplicity even before the occurrence of the one-time traumas. By contrast, incestuous child rape by a parent, which is presumably a repetitive activity occurring several times a week and lasting years, causes constant fear and tension in the mind of the child, and unavoidably produces severe dissociation and multiple personality disorder. Dissociation takes place not only during the actual abusive episodes, but also during any future reminders of the abuse. Thus, dissociation is an ever-present process. The longer it goes untreated, the bigger damage it does to the mind, the brain, and the body. A grown-up person who is only abused in adulthood can develop multiple personality disorder, too, but her effects are likely to be less apparent, and her treatment may be easier. Incestuously abused children with multiple personalities may create additional personalities when they are re-abused in adulthood. Dak describes an incest victim with multiple personality disorder who started smoking at the age of 20, when she was violently raped. Incidentally, she developed a new personality "Smoker" who regularly smoked, but only in the privacy of her home. Even twenty years after the traumatic incident, some of her other personalities did not know about her existence, and the person was known to all her friends and colleagues as a nonsmoker. Dak also encountered a subject from an abusive relationship who developed a new personality at the age of 35 years. The personality exhibited normal adult behaviors, but had no awareness of life events that preceded her creation. These clinical examples suggest that traumas can produce new personalities at any age. PERSONALITY TYPES Clinicians working with multiples have identified various types of personalities. The categories describe behavioral manifestations and attitudes, which are driven by different memory contents personalities are associated with. In general, personalities manifest differences is cognitive and executive abilities. Some personalities are strong-willed and in charge of other personalities. Others are submissive and do not challenge the leaders. The leading personalities may often fight between themselves for control over the body. One personality type, known as the host, has been identified by clinicians and recognized for its dominant control over the body most of the time. By identifying the host personality type, experts have created a false impression in the minds of the public or less knowledgeable doctors. The host personality is no different than other personalities are and is controlled by the same neural mechanisms as they are. The significant trait of the host is that it naturally fits the everyday environment best of all personalities, and that is why the host is in charge of the body most often. Changes in daily routines (illness, vacation, business trip, seminar, relocation, etc.) may cause that other personalities emerge as dominant and stay in charge for days or weeks. During these times, the host personality controls the subject's behavior only sporadically. When daily life returns to normal, the host personality usually resumes its prominent role. It would require major disruption in lifestyle to dramatically reduce the participation of the host over a long period or permanently. The situation could occur if the need for the function of the host were abolished. For example, a stay-at-home mom would lose her children to illness or a car accident. Because of the change, the host personality would lose its purpose, and other personalities might emerge as better suited for the new social environment. WHO HAS MULTIPLE PERSONALITY DISORDER? The men and women in Dak's studies show equal prevalence and degrees of severity of multiple personality disorder, but there are significant differences in the manifestations. Multiple personality disorder is much easier to diagnose in women because they typically show dramatic emotional changes when they switch from one personality to another. Men are less likely to display emotions and usually switch to another personality in subtle, inconspicuous ways, but sometimes may suddenly change the focus of their interests. The findings in adults also seem to be fully applicable to girls and boys. Multiple personality disorder is more common and more severe among these people:
As for ethnic predisposition, multiple personality disorder has been labeled an American illness. The reasons are given by the different levels of awareness and the numbers of diagnosed cases in the USA versus the rest of the world. With the exception of a few industrialized countries, mainly in Europe, multiple personality is considered an American psychological invention. By contrast, Dak has found no substantial difference between the incidence of MPD in the USA and the incidence of MPD in other countries or cultures. His findings indicate roughly equal prevalence of MPD in subjects born and raised in the USA, Western Europe, Eastern Europe, Russia, Israel, China, and Southeast Asia. Despite the generally commensurable statistics, Dak reports that he found unusually high prevalence of high-degree MPD among Chinese women. IS MPD HEREDITARY? Multiple personality is a brain disorder produced by severe life experiences of an individual. So far, absolutely no indications have been found to suggest that MPD can be transferred through the genetic code. Contrary to this lack of impact on inheritance of MPD, victims of severe traumas often develop significant genetic mutations that often lead to serious illnesses and even deaths. Some of the genetic changes only affect an abused child, while others are hereditary and can propagate through multiple generations. Because of the genetic mutations, children of victimized parents are predisposed to having numerous illnesses. They are discussed in Dak's work. Interestingly, clinical experience suggests that genetic mutations alone are often not enough to produce the illnesses. Many children only develop the "hereditary illnesses" when the faulty genes are triggered by severe stress or environmental chemicals. This scenario is likely to happen because parents who are abused do unintentionally learn to be abusive. The values in the family of origin and the abusive experiences of the parents are permanently impressed in their memory and control their behaviors. These mental effects cause that abuse of children continues through countless generations. It commonly happens that abused children swear to themselves during their abuse that they will never harm a child when they grow up. Surprisingly, virtually all abused children become abusers. Not emotional abuse, not physical abuse, but sexual abuse is by far the dominant form of child abuse parents commit against their children. This form of abuse also has the highest likelihood of producing MPD. WHAT IS THE PREVALENCE OF MPD? In 1989, a top American expert Frank Putnam believed that there were only several thousand people with multiple personality disorder in the entire United States [1]. In 1991, Ross conducted a study and conservatively estimated that 1% of the general population in North America had MPD [2]. These data contrast the findings of Dak, who identified the following prevalence of MPD:
The right conditions mean several things: The evaluator is an expert who knows what she is looking for; the evaluator is capable of triggering switches in the patient; and the discussed topic is sufficiently sensitive to provoke dissociative switches. Dak reports that he is able to induce switches in many younger women, who sometimes fear him so much that they succumb to panic attacks, but he gets differential responses from older women, who usually like him and are less prone to switch to another personality. Nevertheless, Dak met several women in their 60's and 70's who exhibited stunning transformations and plenty of affect during switches between their personalities. Dak also met a 70-year-old man who switched to a personality of a seductive little boy when he was exposed to the topic of child sexual abuse. These clinical observations indicate that multiple personality disorder does not diminish with age. On the other hand, dissociation tends to become more pervasive with time, spread to additional parts of the brain, and lead to complex dissociative disorders, such as Bipolar Disorder, Borderline Personality Disorder, and reportedly even schizophrenia [7,8,9]. The discrepancy between the here reported prevalence of multiple personality disorder and the generally accepted numbers may shock many experts, but one has to keep in mind that reports about the prevalence of child sexual abuse met with similar disbelief. For example, Sandra Butler quotes a Dr. Weinberg's study published in 1955 [3]. According to the study, the extent of incest was 1.1 incest offenders per 1 million people in the USA in 1930. Hall and Lloyd quote Finkelhor's data [4] based on 13 studies in the USA between 1975 and 1985. The incidence of sexual abuse was from 6% to 62% for females; and from 3% to 31% for males. In her book Secret Survivors, E. Sue Blume writes, "More than half of all women were violated as children, most by someone they loved" [5]. Yet the true prevalence of sexual abuse can only be correctly assessed after recognizing the visible signs of incest. Dak's studies of the prevalence of child sexual abuse paint a far more sinister picture than mentioned above. Given the history of our awareness of child sexual abuse, it is not surprising that many mental health professionals in the United States believe that the "fad of MPD" will go away. The British psychiatric diagnostic system does not even acknowledge the existence of MPD [4]. WHAT ARE THE FOOL-PROOF SIGNS OF MPD? Many professionals still remain skeptical about the existence of multiple personalities. The doctors want confirmation, evidence, and proof. But these are ideological expressions that have no place in medical science. There are no symptoms of multiple personality that serve such purpose. The indicators are not accompanied by the labels confirmation, evidence, or proof. The symptoms are what they are. Nothing more. Incidentally, diagnosis of multiple personality disorder largely depends on a person's ability to interpret the observed symptoms. It is relatively easy to identify the physical symptoms of incestuous rape and say with near absolute certainty that a child has been raped. But confirming the existence of multiple personality disorder is more difficult. Several accompanying symptoms have been associated with this condition through extensive clinical work:
DIAGNOSIS OF MULTIPLE PERSONALITY DISORDER The easiest way to recognize multiple personality disorder is through direct contact with individual personalities. When a personality becomes activated in the body and says "I am Anna. Don't call me Maria. I hate her. She is a wimp," the statement is absolutely clear. But such open declarations rarely occur in everyday life. They are exceptions that are usually seen only in the therapeutic environment. It needs to be stressed that most subjects with multiple personality behave no differently than other people do. The behaviors are normal on the surface and do not arouse the notion that something might be out of the ordinary. It usually takes some major discrepancy between factual reality and the claims of the multiple to arouse the suspicion that something is not right. For example, the multiple may say that she never uses lipstick, but the therapist can see her painted lips. Or she may say that she cannot stand her husband, and later the therapist sees her to embrace him and passionately kiss him. Or the multiple says that she came to therapy by a bus, but the doctor saw her park a car in front of the office. Only after such obvious discrepancies occur, can the doctor recognize that something is not in order. The natural reaction is to think that the patient is not telling the truth. If she is confronted with her lie, she may say that she misunderstood or was not paying attention. But there will be many more cases of such lying and denial of reality. If the doctor gave the multiple a lie detector test about her true behaviors, her unaware personalities would pass it by denying the multiple's behaviors, by giving factually incorrect answers, or by producing completely confabulated answers. How the doctor handles the discrepancies between his observations and the multiple's statements is critical. If the multiple is blamed, confronted in a hostile manner, or is prematurely shown proof that she lacks awareness of what she does, she is likely to quit therapy. Interestingly, after the doctor finishes his questioning, exhausts all his skills to make the patient admit the truth, and fails in the process, the multiple may inconspicuously switch to her knowledgeable personality and voluntarily confirm all the disputed facts. A beginning mental health professional cannot expect to recognize multiple personality disorder the first time he sees it. The condition was only discovered some 100 years ago, even though it has probably existed throughout human history. For a long time, there were very few diagnosed cases. They were not the average multiples we daily meet in the supermarket. The prominent subjects manifested extreme behavioral inconsistencies, so that the incompatible behaviors became noticed by doctors. Such extreme cases are few even in today's world, but striking examples of abrupt behavioral changes are all around us. Dak presents several striking behavioral and reasoning anomalies that had gone unnoticed by the people who witnessed them. And even when the anomalies were pointed out to the bystanders, they did not find them abnormal, not even peculiar! Incidentally, subtle behavioral shifts and changes in affect will have no chance to be noticed by the common psychologist. There are two big obstacles that prevent mental health professional from recognizing multiple personality disorder. The first problem is caused by the general belief that multiple personality is a rare condition. This naturally leads to insufficient attention to this issue in medical schools, and a lack of focus on the topic by the already practicing doctors. The second problem causing poor diagnosability of the multiple personality disorder is attributable to mental disabilities of the health professionals. Because of childhood sexual abuse, their minds are dissociated and often incapable of recognizing changes in the patient's body language and affect. The therapists' attention only focuses on spoken words. This usually happens to male psychiatrists with precisely sculptured edgy goatees. The men have lost their emotional intelligence, have suffered permanent neuropsychological damage, and no amount of training or schooling can fix their mental deficits. Teaching them to recognize multiple personalities is just as futile as teaching a cat to tell the difference between red and green colors. The cat does not have the necessary neural circuitry, and neither do the dissociated psychiatrists. Naturally, doctors like these, who see no evidence of multiplicity, find no proof and disagree with the notion that the mind could have several entities that function independently of each other. Even when the psychiatrists encounter a person with multiple personality disorder and an expert explains to them what they see before their very eyes, they fail to recognize it or understand it. Incidentally, the purported phenomenon of MPD has been labeled by various psychiatrists as hysterical psychosis, psychotic neurosis, witchcraft, fiction, folie à deux, psychoheresy, attachment disorder, and even crock of dung. Also philosophers are having a hard time accepting that the brain could have several independent minds. That is not how they perceive the mind. But it also needs to be mentioned that they have been unable to explain how the healthy mind works. Expecting them to grasp the physiology of multiplicity is really too much. Another common objection to the existence of MPD is purely mathematical. There was almost no mention of the illness prior to 1970, but publications about the disorder flourished during the following decades. In the minds of skeptics, the sudden occurrence of books about the condition clearly shows that MPD is not real, but is a fad. About as big a fad as the theory of relativity is. Prior to 1916, there was nothing published about the topic. But hundreds of articles were published during the following decades. The theory of relativity is obviously another fad that will fade away once all the delusional theoretical physicists undergo psychotherapy with one of the skeptical psychiatrists. Interestingly, some mental health professionals do accept the existence of multiple personality, but attribute it to the wrong causes. Some people believe that MPD is a product of social construction that is caused by pure psychology, rather than by damage to the brain. Others contribute MPD to divine intervention during extreme traumas. Rejection of the existence of an illness is not restricted to multiple personality. During WWI, a phenomenon called the "shell shock" emerged. It was well-known to the troops in the trenches, who had first-hand clinical experience, but was officially dismissed by psychological theoreticians and bureaucrats who ran the mental health establishment. Only much later, the term post-traumatic stress disorder (PTSD) was accepted to account for the effects of traumatic experiences. A common problem among nonbelievers in MPD is that they approach the condition with minimal theoretical knowledge and with exaggerated expectations. Anyone who fits this description may end up disappointed because the sensational expectations may not materialize. Ideally, an evaluator should have rich experience with the suspected person. This takes weeks if not months of close and frequent interactions, preferably in various social and physical environments. Only comparison of the multiple's long-term trends with his or her current state can reveal whether or not a behavioral anomaly exists. Lack of understanding of this mechanisms causes skeptics to complain that proponents of MPD do not describe what a specific personality looks like and how should one recognize her. The clinical fact is that not every examiner has the ability and the time to activate alternative personalities. Manifestation of multiplicity depends on unconscious nonverbal interactions between a multiple and the observer, and not every person makes a multiple to switch. Furthermore, clinical experience has established that diverse personalities are likely to come out in numbers only when they trust the person with whom they interact. In such a case, angry, fearful, seductive, and vulnerable personalities can be expected to come forth. Dak Considers the Existence of MPD Detected when Certain Signs Occur: 1) The subject switches to another personality and shows an abrupt change in cognitive and/or emotional expression that can be explained by no other means but multiple personality disorder. The subject may change her adult seriousness to childish giddiness or anxiety, or she may show startling changes in semantic knowledge and the use of the knowledge. She may become unable to reason or evaluate a simple fact although she should be able to do so. She may not know that she has a college degree or won the Miss America pageant, Nobel Prize, Pulitzer Prize, or a $10 million lottery prize. Or, she may not know her job title, her marital status, or her address. Another common indicator in this group is that a young personality talks about the distant past lively and passionately as if the events were very recent. The observer gets the impression that the personality cares too much about the impact of the distant events on her present life. In reality, the personality stopped aging and is locked in the past. The past is the present for this personality. 2) The subject shows unbelievable gaps in episodic memory. A man with multiple personality disorder may not know that he had a car accident two days ago, that he got drunk at a party last week, or that he was pulled over by a state trooper and got a speeding ticket this morning. Many clinical workers treating incest victims often describe vast gaps in memory, when several years or entire childhood are inaccessible. These statements are too generic and do not strictly agree with thorough clinical investigations. Multiples can frequently remember stunning details from time periods that are believed by therapists to be repressed. The patients can remember events that happened just seconds before or after traumatic events, but the actual traumas are inaccessible. Multiples can also remember their immediate reactions to traumas, but incorrectly associate the responses with some innocent detail that occurred within the context of the peritraumatic experience. The usual outcome of this false association is misdirected anger at the detail or persons involved with the detail at the time of the traumas. Just as often, multiples misdirect their anger when the detail is brought up in therapy, but it is now the therapist who becomes the target of the patient's anger. 3) The subject is "consistently inconsistent." He sets a course of action and demands adherence to his plan, but then completely reverses himself and eagerly pursues the new strategy. And then he may reject either approach and invent something entirely new. Frequently, his strategy may survive without any changes, but the reasons for the strategy may undergo a lengthy process of rationalization and contradictory justifications. Naturally, once multiple personality disorder is detected, it is much easier to notice such behavioral patterns in the future. This does not mean, however, that the recognition of the subject's disorder automatically leads to the identification of his or her personalities. Getting to know individual personalities takes many hours of focused therapy or other long-term interactions. A clinical evaluator of multiple personality disorder has to be careful not to confuse multiple personality disorder with complex dissociative disorders or with straight dissociation from the prefrontal cortex. All three conditions can exhibit dissociative switches and loss of emotional intelligence. And whenever multiple personality disorder occurs, complex dissociative disorders and straight dissociation from the prefrontal cortex may also emerge, but not all the time and not with all personalities. Straight dissociation from the prefrontal cortex typically leads to reduced intelligence and sometimes rash judgment. Inability to comprehend the connection between cause and effect is very common, particularly in the area of emotional intelligence. By contrast, multiple personality disorder leads to behavioral inconsistencies, emotional outbreaks, contradictory values, beliefs, and strategies, or just plain ignorance. A multiple may be told, "The London Bridge is falling down," throughout the day. Every time, she replies, "Do not try to scare people," and goes about her daily business. One minute before midnight, she suddenly switches between her personalities and exclaims: "The London Bridge is falling down!" and expects nothing less than miracles. After the detection of MPD, a process of confirmation is needed to make sure that the impression is real. Confirmation is usually simpler because the observer knows what to expect and is highly motivated to pay attention to the usual signs of switching. Manifestations of Multiple Personality Disorder From the viewpoint of observers, prominent symptoms of multiple personality are those that directly relate to the multiple's person.
One very frequent symptom of multiple personality is inconsistency during a dialog. The multiple may say that she has enough money to buy a new car. A minute later, she may declare that she is poor and cannot afford to buy a tricycle. And shortly after, she may say, "If I had enough money, I would buy a new car." Similar discrepancies often show in a court of law when a multiple is under oath. She may say that she received no money from the defendant. A moment later, she may disclose that she has received the money in question. She may also make a mistake regarding the amount of the money. First, she may say that she was supposed to get $200, but did not get any money. Later, she may claim that she received the $200, but was supposed to get $500. And a little later, the defendant produces a receipt stating that the multiple received the full owed amount of $200. With no written documentation, the whole matter is mysterious, particularly when both parties are multiples. There are two people before the judge. They claim two different things and keep changing their stories. And when even the judge is a multiple, you get a classical courtroom drama. Relatives and close associates of multiples are uniquely positioned to witness dissociative switches and manifestations of different personalities. The multiples are typically described as being moody or unpredictable. For example, a professor with MPD may abandon her usual calm and proper manners, and may curse and exhibit fits of anger when she teaches a specific subject. She may use unique vocabulary that is not normally part of her speech, may manifest careless behaviors, and may badmouth other professors. A common trait of people with multiple personality is avoidance of answers to direct questions. The multiples may reply in uncertain ways or may refuse to confirm harmless facts. These types of responses occur because most multiples know that something strange is going on in their minds. The subjects know that they sometimes hear internal voices and are afraid that the untamed entities might reveal personal secrets or do some inappropriate acts. For these reasons, it may be very difficult to talk multiples into doing hypnosis or similar therapeutic work that might access the unconscious mind. Most multiples are secretive and do not want to be known by others. An even bigger problem is that multiples do not want to know themselves and their internal neuropsychological world. The fear of the poorly known unconscious mind keeps many a multiple out of therapy. Self-diagnosis of Multiple Personality Disorder It is strange, but many people seem eager to self-diagnose themselves in the comfort of their homes and treat themselves over the weekend. These amateurs have no idea what they are facing. Self-treatment is not recommended. The subjects are not facing just multiple personality, but possibly other dissociative disorders. Most importantly, they may face their incestuous rape or other forms of childhood sexual abuse. The subjects are likely to fail in their "pursuit of happiness" and may cause themselves irreparable harm. Anyhow, in all likelihood, they will not be able to find anything abnormal with their minds. People with multiple personality usually do not diagnose themselves; they never consider the possibility that they may have a mental disorder. Their perception of reality seems normal to them. This is how the world has always been. When they attempt to diagnose their conditions, they are likely to fail. Sigmund Freud, who discovered the connection between childhood sexual abuse and hysteria, denounced his theory when he realized that he also had the symptoms of hysteria; that is the symptoms of incest. A person trying to detect her multiple personality disorder will probably, like Freud, dissociate and dismiss her findings. Anyway, for the adventurous souls, here are a few hints: Most of the time, only one personality is fully conscious and controls the body. Her existence, actions, and experiences are continuous while she is in charge, but the whole organism of the subject perceives the world in discontinuous ways. The nature of the experiences of a multiple is similar to dreams. In dreams, the scene may jump from a busy downtown area to the desert. There is no explanation for the change, no logic, and no time continuity. Likewise, the scenes in the real life of a multiple vary suddenly. For example, the multiple gets up in the morning and makes breakfast, and the next perception of this personality is coming home from work. The entire time between these two events is unknown, as if it had never existed. This is similar to movies, where scenes jump from one place to another. The difference is that in a movie, there is always some indication that a change will occur, and a hint what the next scene will be. The actor may say in his New York office, "I am going to Rio on vacation." The next scene shows him on the beach in Brazil. The experience of a multiple is different. Her "Employee personality" says in her New York office, "Bye, see you." And the next thing she knows is being back in her office the "next" day. She has no idea that she went on a three-week vacation to Rio and came back last night. The period of no registration is often called "lost time." The time is not truly lost; it is only unaccounted for by a specific personality. Some other personality that was activated during the period knows what happened, but other personalities do not. As far as they know, they are at one place one minute, and miles away an instant later. Oftentimes, the periods of dominance over the body are very brief, under one second. During these moments, a person may do or say something that is totally unacceptable to her nature. This can be done under the influence of other personalities, and the active personality does not understand why she behaves in a particular way. Or, a personality momentarily seizes control over the body and does an act that is unknown to the usually activated personality. For example, a multiple talks to her boss and is very polite. She suddenly blurts out, "You bastard, I have worked overtimes with no pay!" And then she returns back to her usual politeness as if nothing has happened. Her normally activated employee personality is unaware of the outburst. A person with multiple personality disorder may experience that people approach her and behave as if they knew her, but she has no idea who the people are. She may masks her lack of knowledge by being overly polite and by providing no or very generic answers to specific questions. She may also exhibit rapid changes in her attention. Instead of talking to the people who claim to be her close friends, coworkers, or neighbors, she just briefly greets them, steps aside, and often remains totally oblivious to their presence. These phenomena typically result from conflicts between environments. The multiple may switch to a personality of a vacationer while she travels, and she may have a difficulty dealing with known people she meets at an unknown place. Similarly, the multiple may bring her coworkers to her home when her family is present. She may exhibit numerous switches as her employee personality deals with her coworkers; her mother personality deals with her children; and her wife personality deals with her husband. The same level of switching may arise when she is concurrently in the company of her abusive parent and her psychotherapist who treats her for incest. A multiple may find photographs of herself, but she has no clue what events they depict. A mentally healthy adult should always be able to recognize a photograph of herself and associate it with an episode in her life. (Assuming that the photo shows sufficient contextual information.) A multiple is told by her children that she promised something, but now she (her other personality) is against it. The activated personality is unaware of making any such promises. She may discover new facts in her life. She wakes up one day and finds that she has holes in her ear lobes although she has never worn earrings. Or, she buys a pair of gloves because her hands are freezing. As she leaves the store, she discovers her old gloves in the pockets of the coat she is wearing. Or, she asks her children, "What happened to our cat? Where is it?" Unbeknown to her, the cat has been dead for three months. HOW TO DEAL WITH MULTIPLES? People occasionally discover that someone known to them has the symptoms of MPD. How should the discoverer handle the situation? The reaction depends on what is intended to be achieved. When you discover that your spouse has the signs of multiplicity, you may genuinely want to help him or her get better. By doing so, you are entering a dangerous territory. Most multiples are unaware of their illnesses and refuse to believe that they are sick. Giving them a book to read about the disorder is unlikely to help. The multiples may become resentful and may react in ways that are uncooperative or outright hostile. Breakup of marriage is a real possibility. Many laymen and also health professionals assume that people with MPD are dangerous and psychotic when they switch to other personalities. This is a wrong assumption. A multiple should be viewed as different people in the same body. The trouble is that a naive observer does not know who will emerge and when. This uncertainty raises fears and doubts whether it is safe to be in the multiple's presence. However, the same doubts could be activated when we meet an unknown person. Is he good or bad? Will he hurt me? Since he is a stranger, we should be prepared for anything. Sure, some personalities are unreasonable and belligerent. This is an expectable consequence of abuse. But for the most part, multiples are average people and are able to bring the most extreme personalities under internal control. The discovery of multiplicity by the healthy spouse and the revelation of the fact to the multiple are likely to activate personalities that have been dormant or largely inactive until now. The multiple may engage in harmful addictions, may commit illegal acts, may become reckless, or may disappear for days at a time. Whatever the future brings, the healthy spouse can expect stormy seas ahead. Failure of the relationship is more likely than a success is. Treatment of the multiple, if it ever starts, is more likely to fail than to bring positive results. The same dynamics exist between children and parents. Love or devotion are usually unable to positively influence the outcome. Families may fall apart, and the multiple may end up much worse off than he or she was before the revelation of the illness. A different situation exists at work. What should you do when you discover that your boss has MPD? The usual revealing sign is this scenario: The boss says, "Move these boxes to the other room." You start working as told. The boss looks at you and asks, "What are you doing?" "I am moving the boxes to the other room, as you have told me." "No, that is not what I have told you. I have told you to leave these boxes here and sweep the floor in the other room." Exchanges like these will likely occur several times within a month. The boss says one thing, denies it a minute later, and substitutes a different instruction for the original one. Also common is the boss's forgetfulness. He sends you to do something, and he momentarily does not know where you are and what you are doing. What can you do with such a boss? Your reaction should be in agreement with your goal. Do you want to get fired by your boss? Go ahead. Tell him or her about multiplicity. Do you want to bring it to the attention of your boss's boss? Go ahead. Get fired that way. Middle and upper managers tend to hire people like themselves; that is multiples. The higher manager may feel that you are indirectly accusing him or her of being mentally ill. If being fired is not enough for you, tell others and get ready for an expensive lawsuit. Your revelation, whether true or false, is libel per se. You will lose. If the multiple is in a position where other lives are at risk because of the boss's multiplicity, you still will not win. Even if the boss is sent for mental evaluation, chances are high that the examining doctor will have MPD, too, and will find nothing wrong with your boss. Now you will look like a paranoid or mentally deranged, and will ruin your career. The best approach to dealing with a boss with MPD is to accept the fact and live with it, or find yourself a new job. Hopefully, your new boss will not have MPD. But do not bet on it, because multiples love working in managerial positions. NEUROCHEMICAL ASPECTS OF MPD Multiple personality disorder breaks up the mind into isolated but functional parts (personalities). Personalities behave almost normally just like a whole person, with the difference that instead of a unified mind, there are several neuropsychological entities. Break up of the mind into personalities is triggered by severe mental traumas and is achieved by producing neural chemicals that cause disintegration of the brain and mind. Which chemicals cause such a disintegration is not easy to determine because personality consists of multiple neural structures. Each structure uses unique combinations of chemicals to carry out its normal functions. Incidentally, disintegration of the original personality and formation of isolated subpersonalities require different chemicals in different neural structures. Despite these differences, the total number of all the chemicals that are needed to break up a personality is not overwhelming. Interestingly, disintegration of just one neural structure can be enough to produce clinical manifestations of multiplicity. In fact, this is the usual trigger that sets in motion the process of personality disintegration. It is important to correctly understand what neurochemicals do. Most brain researchers believe that chemicals cause this or that, but fail to consider the effects of cognition. The brain uses two important types of chemicals. One type of chemicals sustains contact and long-term communication between brain structures, and another type mediates transmission of the cognitive content. In MPD, the mind modulates both chemicals by means of a third type of chemicals that is produced in response to the outcome of cognitive processes. Interactions between the three variables can result in dissociation. More about the functions of the human brain can be found in Dak's work. DIFFERENCES BETWEEN MPD AND SCHIZOPHRENIA Clinical experience shows that doctors frequently confuse MPD with schizophrenia. Unlike MPD, schizophrenia is an illness characterized by intermittent or permanent loss of rational thought and emotional intelligence. In schizophrenia, the brain and mind are damaged, fragmented, and the neocortex shows striking hypoactivity in the frontal lobe. The reason behind the usually permanent demise of parts of the brain is purely biological and is not affected by personal experiences. There is strong evidence that schizophrenia is associated with DNA corruption and tends to be hereditary to some degree. In schizophrenia, the ability to recognize the relationship between cause and effect or to respond in socially appropriate ways is poor, almost nonexistent. For example, schizophrenics lack the most basic skills in communication and turn taking. They may exhibit the perseveration phenomenon. They may talk about a topic in hair-splitting detail and with great interest long after the issue is considered of no concern to others. Schizophrenics may also manifest indifference or inappropriate behaviors when dealing with very significant issues. Death in the family may be of no concern to a schizophrenic. He may joke about it or may start laughing as others describe how the person died. Although schizophrenia is often associated with a lack of emotions and understanding of emotional valence, subjects with multiple personality disorder are usually lively, emotionally sensitive, extremely sociable, and are able to effortlessly blend into any situation. According to Dak, very few cases of insanity might start as multiple personality disorder that later leads to schizophrenia, but multiplicity is much more likely to be a precursor to Alzheimer's disease. Interestingly, Read and Hammersley have reported that they found very strong association between physical/sexual child abuse and schizophrenia. The manifestations mainly show as auditory hallucinations and flashbacks [7,9]. Similar association was identified by Lysaker et al. [8]. Do these studies mean that severe childhood abuse typically leads to both multiple personality disorder and schizophrenia? Probably not. Putnam specifically points out the frequent misdiagnosis of multiple personality as schizophrenia [1]. Schizophrenia and multiplicity differ in their onset, brain areas they affect, illness progression, behavioral and cognitive manifestations, and the underlying neural mechanisms. Although some clinical traits of schizophrenia may be confused with multiple personality disorder and vice versa, the neurophysiological mechanisms of these two illnesses are usually totally different. However, schizophrenia may produce the same manifestations as those found in complex dissociative disorders and other conditions. The different illnesses affect different neural substrates that just happen to support the same mental function. In such cases, it is possible to recognize that schizophrenia and complex dissociative disorders have not only a lot in common, but also show subtle differences. In other cases, the affected neural substrates are different from those of schizophrenia in the beginning of an illness, and the functional impairment is different from the symptoms of schizophrenia. As the illness progresses, it can damage neural substrates that are also involved in schizophrenia. The illness is diagnosed as schizophrenia despite different mechanisms leading to the same neural damage. Some personalities may occasionally become biologically corrupt and may acquire a neuropsychological organization that is identical to that of a schizophrenic. When this happens, both the fragmented personality of a multiple and the whole mind of a schizophrenic exhibit schizophrenic-like behaviors, and the illnesses are indistinguishable because the behaviors are produced by the same neural structures. The difference is that a multiple may switch to a different personality and become normal again. Schizophrenic-like behaviors of either a multiple or a true schizophrenic are strange. The subjects show peculiar reasoning qualities and unshakable beliefs, and yet these behaviors correspond to periods when the subjects behave "normally." From time to time, either subject can have a psychotic episode, which shows as an inability to logically and socially respond to the environment, and typically involves a busy irrational activity. Most schizophrenics may enter this mode for tens of minutes, while multiples usually do not stay in this mode more than a few seconds or minutes. But multiples may enter this mode repeatedly during the same day. Because of the reversible temporal changes and identical operating modes in both illnesses, schizophrenia could be considered a dissociative illness. In fact, schizophrenia represents a special case of biologically triggered complex dissociative disorders. Contrary to common complex dissociation, which only lasts briefly and the mind then returns to its normal function, schizophrenia is usually a non-recoverable or long-lasting condition. The inability to restore normal brain function is attributable to biological decay and malfunction of cortical structures. At least 5 years before schizophrenia results in any identifiable symptoms, the subject may engage in nonconforming behaviors or may do things his way. He fully knows what he is doing, and he understand that the acts are improper, but he does them in spite of social norms and expectations. He may appear to be nonconforming, defiant, or disobedient. Occasionally, he may engage in seemingly psychopathic behaviors when relating to animals or people. He may sleep with his boss's young wife, or do strange and harmful things to animals. He may tie cans to the dog's tail and let it run about, or close the cat in the oven and turn on the heat. Or, while eating in a restaurant, he may provocatively get up and start running after he notices that the police have entered the room and are looking for a suspect. The misguided behaviors often lack focus and emotional desire. They are more like quest for fun and excitement, or they are reenactments of events seen on television or in the environment. The externally motivated behaviors can be good or bad. However, the external influence on the schizophrenic's behavior and the lack of internal censorship of bad behavior are recurrent problems with schizophrenics. A typical example would be grabbing a person's genitals as the budding schizophrenic saw it done by Paul Hogan in the movie Crocodile Dundee. These abnormal acts are rare at first. They may only occur once a year and do not raise any notion that the subject has a mental illness. Schizophrenia seems to affect more males than females and usually shows the first cognitive manifestations between 18 and 22 years of age. In the earliest stage of schizophrenia, the illness mainly affects emotional intelligence, and the subject engages in silly behaviors regularly. He shows clear deficits in the understanding of the relationship between cause and effect in the area of social relations and personal well-being. Within a year, reasoning and executive functions begin to exhibit deficits in the understanding of the relationship between cause and effect in all areas of logic. As the illness progresses, the subject loses emotion but is not depressed. He starts hearing voices, may become philosophical or narcissistic, and may experience the alien hand syndrome, believing that his hand is moving without his will, as if it were controlled by some external (alien) force. Many schizophrenics also have difficulty with sensory integration and assembly of a mosaic from small pieces. They may fail to recognize an item or living thing if they see only a fragment of the image. In this advanced stage, patients also have psychotic episodes. They become more frequent as time goes on and manifest no understanding of the relationship between cause and effect, which is the core symptom of schizophrenia in advanced stages. The subjects have no memories of the psychotic episodes after they pass. Although the patients are usually not psychotic between episodes, they still manifest grossly distorted belief-based reasoning and profound loss of touch with reality. Surprisingly, they may be positive that their beliefs are reality. For example, a schizophrenic may say that he grew up in France and traveled the world as an ambassador, even though he was born in Iowa and never left the state. If his claim is questioned, he may say very seriously that he knows who he is. And he may produce another confabulated "fact" to support his false claim. This creation of false positives distinguishes schizophrenia from non-schizophrenic multiple personality. By contrast, personalities of a multiple tend to show the opposite effect. They fail to recognize known objects, places, or people. Unlike schizophrenia, multiple personality disorder is predominantly noticeable in women. The onset of multiple personality disorder takes place shortly after an abusive episode. The person appears normal at first. She only has a gap in her knowledge about the violation. But who would be looking for the record of her rape by Dad? No one even suspects such a possibility. And even if someone did, that someone would not want to find out. Further child abuse creates additional gaps in memory and the associated neural substrates. Biological chemicals and various neurotransmitters are produced in unregulated fashion. There is too much or too little of them. Under the influence of the chemical effects, the neuropsychological unity of the brain (and even the body) gradually disintegrates, and personalities occur. Maintenance of the dissociative boundaries requires constant production of the necessary chemicals, which leads to further neural damage and more complex dissociative disorders. The typical symptoms of multiple personality include isolated knowledge about events, different quality and level of emotional expression, and slightly reduced intelligence. Multiples may appear to lack education, knowledge, or the reasoning power to comprehend certain things. As a whole, emotional intelligence of multiples is slightly reduced, and most adult personalities will show no reasoning deficits during common everyday interactions. Younger personalities and personality fragments often exhibit psychopathology as a result of very poor emotional intelligence. Unlike in schizophrenia, understanding of the relationship between cause and effect is usually preserved in non-emotional areas. The most noticeable deficit is lack of knowledge. The missing knowledge can involve isolated facts, procedures, skills, periods of life, and biographical memories of specific people or places. The gaps pertain to both recognition (identification of a known person or item) and remembering (recall of biographical experience or a public event learned about from the news media). Unlike schizophrenics, who confabulate and "make up" fantastic stories all the time, multiples usually say things that are true or confabulate relatively infrequently. In addition, multiples appear to be rational. When they say something that is not true, their false beliefs are often attributed to normal forgetting or mistakes, rather than to a mental illness. As for the alleged symptoms of schizophrenia in the above mentioned studies [7,9], the symptoms appear to be closer to those of multiple personality disorder. Some of the hallucinations seem to be produced by multiple personality disorder, and some are probably caused by complex dissociative disorders. Hallucinations in complex dissociative disorders are very similar to those occurring in schizophrenia, but are not the same. There are differences in cognitive quality and in the neural substrates that generate the hallucinations. It appears that the scientists incorrectly attributed the observed hallucinations to schizophrenia. But then again, a lot depends on the definition of schizophrenia. Dak has defined schizophrenia based on the cognitive architecture of the brain, while others associate schizophrenia with behavioral manifestations. Because of these differences, schizophrenia in Dak's model is associated with specific neural structures, rather than with apparent psychosis. Dak's definition is narrow and specific, while irrational clinical manifestations lead to diagnoses of diverse types of schizophrenia . Hallucinations of schizophrenics typically produce ideas and voices that arrive from an unspecified direction or from some distant place outside the subject's mind, and only rarely involve a particular person. For example, the subject experiences various voices coming from a group of people in a neighboring building. The building, and not the individual people, is the source of the voices. The subject may also hear or mentally register an instruction seemingly arriving from a satellite or from a distant town. The voices of schizophrenics are marked by no or very poor interactions with the subject and by no or very poor interactions among themselves. The voices usually do not stay for long, but are different every time. If an isolated voice repeats the same brief statement in the same manner, this activity can reflect schizophrenia or complex dissociative disorders. The message coming from the same source may exhibit minor changes, but the core of the message remains unchanged. Most importantly, the voices and mental intrusions in schizophrenics lack the emotional traits experienced by normal people. Voices and ideas of a schizophrenic do not get upset or joyful. They just comment or issue instructions, but give no feedback in case of no response by the subject. For example, a single voice or several voices say, "You will obey us" and repeat the same message without ever changing the phrase or tone of voice. The voices tend to occur out of context and typically reflect no continuity with the past or the future. The voices almost never state: "I told you yesterday that you have to do this" or "Ask Jack what he thinks about it" or "What do you plan to do this weekend?" There is a potential problem with the manifestations of internal voices, and a health professional dealing with a subject who hears voices has to make sure what is happening. A child may repeat the same sentence or word and give the impression to have schizophrenia. The deciding factor is not what the child says, but what the voices inside the child's mind say and how they behave. Even a healthy child may repeat an expression she hears in the environment. The repetition may occur many times a day and may persist for a week. This is absolutely normal. The young child is learning, and unusual behaviors of adults may not be easily understood by the child. The repetition reflects this fact and stops when the child incorporates the unique experience into the preexisting cognitive schemes. This behavioral mode is particularly pronounced in traumatized children. They repetitively react to traumas through language and behaviors. Also autistic children tend to do repetitive activities. They manifest a struggle of the mind with the cognitive material. The information is difficult for the autistic children to explain and incorporate into cognitive schemes. By contrast to schizophrenics, hallucinatory experiences of multiples can be easily recognized based on the number of the voices involved and based on their interactions. If two or more voices talk among themselves or include the subject in their conversation, the voices manifest MPD. If an individual voice instructs the subject to do something, and the voice comments about the personal qualities or faults of the subject, and if the voice emerges repetitively and has something new to say every time, this also reflects MPD. Almost universally, the voices of multiples get emotional when their requests, ideas, orders, or suggestions are ignored. In some cases, the voices can be accompanied by visual hallucinations. The other personalities are "seen" (in the mind) as real persons who talk to the subject. If the visualized persons interact among themselves or with the subject, the case typically manifests MPD. Interaction does not mean pursuit of a common goal. Interaction involves exchange of ideas, looks, gestures, feelings, and consideration of the viewpoint of the other personality. In addition to the above scenarios, it is possible that a person has both multiple personality and schizophrenia. He may develop MPD in response to childhood traumas, and may become a schizophrenic later in life. Such a subject is schizophrenic in brain function, mentation, and behavior, and all observations of the subject are consistent with the qualities of schizophrenia. On top of that, individual personalities may show unique preferences, knowledge, reactions, and abilities. The coexistence of MPD and schizophrenia is possible because the illnesses affect different areas of the brain or affect the same areas in different ways. Unfortunately, this theoretical conclusion is only based on the physiology and cognitive architecture of the brain, and is next to impossible to confirm clinically. Furthermore, a schizophrenic with MPD may also exhibit the manifestations of complex dissociative disorders. To determine whether or not sexual abuse causes schizophrenia, Dak evaluated six preteen schizophrenics for the symptoms of childhood sexual abuse. Five subjects had the primary visible signs of childhood abuse, and one subject had no obvious symptoms. The prevalence of the primary symptoms was 60% higher than in the general public, but the quality or quantity of the symptoms was less than average. Likewise, the subjects had very few secondary symptoms of abuse. Only one subject had exceptionally prominent secondary symptoms of abuse. As a whole, the symptomatology is a mixed bag, and the findings sharply contrast other dissociative illnesses, which produce very striking quality and quantity of child abuse symptoms. The discrepancy is doubly surprising because schizophrenia should produce the strongest symptomatology of any illness or disorder that is caused by abuse. The reasoning goes like this: There are three basic dissociative modes. The mildest forms of abuse only lead to reduction in emotional intelligence. More severe abuse causes multiplicity. The most severe abuse gives rise to complex dissociative disorders. Complex dissociation typically includes diverse dissociative modes and the accompanying illnesses. At least two of the illnesses are conceptually similar to schizophrenia. If the illnesses were more profound, schizophrenia would result. The interesting thing about the three dissociative modes is that they are very common, and so is childhood abuse. By contrast, schizophrenia only affects about 1% of the total population. The numbers suggest that dissociation that produces schizophrenia should be something special, way beyond the relatively mild dissociative disorders seen in multiples. In turn, the accompanying symptoms of any traumatic experiences that produce schizophrenia should be very strong. This is not the case. Because of the inconclusive results, schizophrenia cannot be associated with childhood sexual abuse at this time. Nevertheless, the increased prevalence of primary symptoms of child abuse in schizophrenic calls for a large study to resolve the inconsistency. It is clear from Dak's studies that the manifestation of visible symptoms of sexual abuse does not always correspond to the level of abuse or to the level of the psychological reaction. Many victims who were abused in the most severe ways show only mild or no obvious symptoms. By contrast, the mind is usually affected in proportion to the level and duration of abuse. Unfortunately, this assessment takes time and direct interaction with the evaluated subject. Schizophrenia enormously complicates the process because of defective reasoning. The illness leads to false positives and an impression of excessive abuse in comparison with the general population. The reason is that schizophrenics have minimal moral or mental blocks, and easily volunteer information about their sexual abuse. Non-schizophrenic incest victims hide their abuse to the utmost and do not admit it even to themselves. The investigator may conclude that they were not abused and that schizophrenia is caused by sexual abuse in childhood. DIFFERENCE BETWEEN MPD AND HYSTERIA Multiple personality disorder and hysteria occur together. Hysteria could be considered a special trait of multiple personality. Hysteria only occurs in severe cases of MPD and reflects the disruption of the main control mechanisms in the brain. The uniqueness of hysteria is that it last for a sufficiently long time to be reliably noticed, and that it frequently affects somatic abilities. Or, looking at the condition from another perspective, hysteria manifests disrupted switching between personalities. An uncooperative personality asserts its will and blocks normal switching between personalities or blocks a normal function of the personality in charge. The subject may become paralyzed on one side despite no obvious damage to the body or the brain. The problem may last hours or days before everything returns to normal. At other times, the willful personality may produce hysterical laughter, or may urinate on the spot, or may do some other outrageous act, and no other part of the brain is able to stop her. CAN A PERSONALITY BE EXORCISED OR CREATED IN THERAPY? Not in the supernatural sense. Personalities are complex neuropsychological entities. Some parts of these entities can be banned from reaching consciousness. The usual way to do this is through hypnosis. The mechanism does not work in a healthy conscious mind. Dissociation of some sort, either temporary (hypnosis) or permanent (MPD), is required to enable the suppression of an inconvenient segment of a personality structure. The approach only works with certain types of personalities, particularly those that are incomplete and fragmented. Suppression of the undesirable personality can be achieved through direct appeal to the personality to stop interacting with the world, with others, or with the mind, and stay forever dormant. This approach works even when the hypnotist makes the request in religious terms. The fragment does not care whether God, Satan, President, or the patient's dog wants him to disappear and never come back. The factual meaning of the request, and not the supernatural overtone, is what suppresses the personality. Similarly, the suppressed personality fragment can be reactivated in the future by an appeal to become active again. But the personality cannot be erased from the records of the memory forever. This would require destruction of the neural substrates that host the personality. So, in a sense, the personality fragment is like software that is permanently programmed into the neural substrate. The information cannot be overwritten because it is encoded by means of stable, nonerasable biological synapses. The corresponding neuropsychological entity can only be banned from participation in mental processes or it can be combined with other cognitive parts of the brain. Some personality fragments are difficult to ban after a simple order or request. In such a case, other parts of the brain can be recruited to block the unwanted personality fragment. The blocking can be done by other personalities or by the Internal Self Helper [10]. By means of a similar mechanism that leads to the suppression of a personality fragment, a psychological entity can be programmed into the mind of a hypnotized subject. This propensity of the brain to accept certain psychological content or entities into the dissociated mind is manifested as posthypnotic suggestion, when the subject acts on a suggestion made during hypnosis after he regains consciousness. The creation of a multifaceted psychological entity that is comparable to a personality can occur in a similar way, but requires special techniques. They are not mentioned for reasons of possible misuse. Psychotherapists working with MPD patients routinely meet adult patients who have several adult personalities, child personalities, and some doctors even report personalities of the opposite gender. Exceptionally, the reports about the types of personalities also include animals [12], God, Satan, stuffed animals, and people thousands of years old or from another dimension [11]. These claims immediately arouse laughter and disbelief in laymen with zero clinical experience in MPD and zero understanding of how the brain works. The laymen do not accept the possibility that the claims might be true and that a personality might sincerely believe to be an animal, alien, 1000-year-old man, God, Satan, or person of the opposite sex. But if such beliefs are genuine — and clinical experience indicates that — then it is important to explain how the entities are generated and what they represent in the neuropsychological sense. The answers to these questions are provided in Dak's work and will not be revealed here. However, it is useful to consider a similarly striking condition of anosognosia. The patients may deny that their left arms belong to them and confabulate some irrational explanation why they have dysfunctional left limbs attached to their bodies [13]. These are also cases of false claims and unbelievable behaviors, but the conditions can be readily tested by seeing the patients' limbs and hearing the irrational confabulated answers. It turns out that both multiple personality and anosognosia share some neural substrates that are responsible for such "internal realities." The clinical possibility of creating a psychological entity in the mind should not lead to the idea that therapists can and do create multiple personalities in their patients. Creating some artificial entity that behaves like a personality is not that simple. In addition, a therapist is unable to program complex neuropsychological characteristics at will. By contrast, stage hypnosis reveals that people can be "programmed" to play certain roles. A hypnotized person can be told to become a weather reporter. At the hypnotist's command, she gets up, appears awake and conscious, and starts reciting a seemingly realistic weather forecast. She does not make an actual weather forecast. It may be freezing outside, and she forecasts a warm and sunny day. The discrepancy does not bother her. There may be an earthquake happening at the moment, but she ignores it and proceeds with her report. She is just fulfilling a demand in a state of mind when she is unable to critically censor her behavior and evaluate reality. The unnatural acts show disagreement between explicit behavior and body language. A true and complete personality exhibits cognitive drives and emotional reactions that are proportional to environmental stimuli. She judges reality, acts voluntarily, and her body language manifests the state of her body and her mind. A hypnotized subject or a personality fragment lacks these properties. When disbelieving doctors encounter personalities in a hospital, the discovery does not indicate that the personalities were created by some monstrous psychotherapist or that the patient is playing roles that are unwittingly rewarded by the hospital staff. The patient behaves as she does even when she is not rewarded, and even when she suffers. It is the physical and social environment of the hospital that preferentially activates certain personalities. Loss of interest in the patient or punishment of the patient for "playing roles" changes the patient's behavior and may reduce personality switching. But this state never lasts long. Other personalities emerge and exploit the opportunity to come out when more powerful personalities withdraw in response to the acts of the ignorant hospital staff. HOW DOES MPD AFFECT A MULTIPLE'S LIFE? Multiple personality disorder creates discontinuous life experiences that start and end abruptly. The victim's life is unstable and seemingly out of control. She has extremely limited ability to learn from her past experiences, and uses unproductive ways of coping with problems. She is often unable to recognize or avoid danger. Even worse, she is unconsciously drawn to dangerous situations. She may like the action, the thrill, and the excitement. When making decisions, she is likely to focus on one positive attributes and ignore all negatives, disadvantages, and dangers. Because of her poor emotional reasoning, she is prone to get into trouble. But instead of dealing with problems, she tends to switch to other personalities, and her problems stop to exist in her activated consciousness. For example, instead of paying a speeding fine, she may ignore the ticket until she is in very big trouble. Then she fails to show up for a court hearing and does not respond to court letters or phone calls. She is digging herself deeper and deeper into problems and appears nonchalant about the possible consequences. Her inability to change her life leads to depression, and sometimes even suicide. The success rate for completed suicides is not that high. By contrast, thinking about suicide is very common, and suicidal attempts can become repetitive in seriously mentally damaged patients. In addition to splitting into personalities, the mind of an incest victim also dissociates from the prefrontal cortex, which is involved in higher mental functions [6]. The inaccessible knowledge of the dormant personalities and the reduced reasoning ability because of dissociation from the prefrontal cortex make the activated personality stupid. Although stupidity is as yet unrecognized consequence of dissociation, the affected person suffers dearly. Dissociative stupidity mainly shows in lifestyle, values, religion, politics, and social interactions (which are modulated by emotional intelligence), but also in semantic knowledge. Dissociative stupidity and psychopathology are caused by the malfunction of the same neural networks. The distinction between these two disorders is rather scholastic than practical. Dissociative stupidity is an inability to comprehend things because of poor emotional intelligence. Psychopathology occurs when a person acts under the control of his or her dissociative stupidity. This can produce harmful behaviors that are directed toward self or others. For example, a person who believes that he is a descendant of aliens who live at a far away star has poor emotional intelligence. By contrast, a person who devotes his life to establishing a contact with such a believed civilization exhibits psychopathology. Despite diminished emotional intelligence, the affected subjects may be geniuses in science, manual skills, games, and similar unemotional endeavors. Dak suggests that dissociative stupidity and/or psychopathology is the most widespread mental illness, affecting more than 90% of the general population. But such a claim, similarly as the claim about the existence of multiple personality disorder, sounds truly outlandish. Not many people will believe it. But what else can do people who have no theoretical knowledge, no clinical experience, and also have insufficient emotional intelligence? They can only believe or disbelieve what others report. There are several dissociative modes that have nothing to do with multiple personality, but often accompany this condition. The modes are produced by activation of specific mechanisms of the brain. One of the mechanisms leads to depersonalization, fuge, dreamlike experiences, dreams, hypnotic trance, false associations, and fantasy. Any healthy person can enter this operating mode at times, but a person who has suffered severe childhood traumas enters this mode often, and sometimes it becomes the dominant operating mode of the brain. More information about this dissociative mode is on the webpage Repressed Memories in the EMDR section. A frequent problem of persons with MPD is a failure to mention important facts to significant others. The multiple appears to have selective knowledge, particularly when she deals with a sensitive topic. She may be accused of being unfair, selfish, or dishonest. But she also exhibits such selective knowledge even when she is not affected in any way. For example, a multiple may fail to mention to her husband that her lifelong friend has died, that her mother has been taken to the hospital after suffering a heart attack, that their bank account has been frozen, that their child is being investigated by the police for buying illegal drugs, or that their neighbor has been murdered inside his house. It may take weeks or months before the multiple mentions such facts in passing, and she is surprised when she learns that her husband does not know. The same forgetful behavior can also show in patients with other brain disorders, such as frontal lobe syndrome or frontotemporal degeneration. For example, a person with these conditions may say that she does not know where her close childhood friend is, and one day she may suddenly remember that her friend died 10 years ago. Multiples often face psychosomatic illnesses because living as a multiple is stressful for the organism. There can be undue physical stress and inability to stay in touch with the body. The person also makes bad choices in life and needlessly exposes herself to stressful situations and lifestyle. Such problems are easily avoided in normal people. Their brains are used fully and all the time. The people get tired and thus protect their bodies against exhaustion. A multiple's mind only employs some parts of her brain at a time while most of her neural circuits rest. But her body never gets a rest and has to meet the mental and physical demands of several personalities. It is not uncommon for multiples to run in the marathon when they are seriously ill or have a physical injury. SHOULD PERSONALITY SWITCHING BE INFLUENCED? The simple fact is that a multiple does switch under naturally occurring environmental influences. She switches between her personalities regardless of external encouragement. The switching happens unconsciously. The multiple has extremely limited ability to chose whether she switches or not. She can resist the temptation to switch, but when the environmental stimuli become strong, the switch occurs, and she is unable to prevent it. But is it a good idea to encourage her to switch more or less often? That depends on what the people in the multiple's life wish to achieve. Encouragement of switching through exposure to further traumas, stressful lifestyle, or intentional abuse will result in more switching and possible creation of additional personalities. The mental health of the multiple can become damaged more than it already is. Similarly, a therapist who encourages a multiple to "come out" and switch in a safe manner so that her personalities can be identified and worked with makes it easier for the multiple to switch. She will manifest the existence of more personalities and give the impression to outsiders that the personalities were created by the psychotherapist. But this situation is different from traumatically induced switches. The personalities come out from hiding because they feel safe and are recognized. This process needs to be encouraged if a psychotherapist ever hopes to combine the personalities into one mind. As for discouragement of multiples to switch, this is not a good idea. This strategy, whether wished for by another person or by one of the powerful personalities of the multiple, can backfire. External pressure not to switch can result in the opposite effect. The multiple may fight against restrictions of her internal life and may manifest her freedom through increased switching and acting out. Harmful, criminal, antisocial, and inappropriate acts that would not have occurred earlier thanks to censorship by more prudent personalities are now possible. The mature personalities may not only ignore what the other parts of the mind do, but may even encourage such behaviors to show the external oppressive authority that they will do as they please. A different situation exists when one or more mature personalities try to rule over the rest of the mind and prevent the younger or less powerful personalities to be in charge of the body. The censorship will never be absolute, and the less prominent personalities will find ways to let their presence be known. This can happen through brief seizures of the body and acting out one's will. Or it can happen as internal struggle between personalities. The dominant personalities, which control the body for large parts of the day, will hear complaining or angry voices, threats, and disrespectful comments. Also visual flashbacks of childhood traumas can emerge and haunt the strong nonabused personalities. Constant medication may become the only way out of the turmoil. Who wins the struggle is not certain, but the fighting and the medication will surely cause more severe mental and neural damage to the patient's brain. The person may develop bipolar disorder, borderline personality disorder, neurodegenerative disorders, psychosomatic illnesses, or psychotic personalities that mimic true schizophrenia. Similarly, some personalities may mimic bipolar disorder or borderline personality disorder. Telling the difference between these disorders may not be possible during a brief encounter with a patient. Only a comprehensive evaluation over the course of days or weeks can determine which illness or illnesses are involved. This is so because the illnesses have not only overlapping symptoms, but also may involve the same neural structures. The fight between personalities may produce no victor in the end. The subject may die or spend the rest of her life locked up in a mental institution. IS MPD TREATABLE? Depends who you ask. Some doctors incorrectly associate multiple personality disorder with moodiness or role playing and report almost absolute success rate of MPD treatment. This is not surprising. The patients either had no MPD or their MPD was not recognized and treated by the doctors. Apart from such doctors who cannot tell the difference between MPD and normal behaviors, many qualified professionals treat MPD with mixed results. In theory, multiple personality disorder is "treatable." Unfortunately, this disorder is seldom recognized by mental health professionals, who often exhibit multiplicity themselves. The doctor and the patient are blind to the indicators or take them for normal human traits. If multiple personality disorder is diagnosed by a true expert, the victim may be unwilling to explore her childhood. She often leaves therapy before any progress is made. Even in a successful treatment, the outcome may be far from what the therapist may desire. Dak proposes that only few incest victims are diagnosed with multiple personality disorder, fewer start treatment, and even fewer finish. After all, therapy for multiple personality disorder involves dealing with the trauma of childhood sexual abuse. Not many people can face the pain. Nonetheless, some healers occasionally report merging of personalities into a unified mind. Kluft, who is one of the top experts in the world, reports an incredibly high success rate [10]. But merging of personalities into a single mind sounds better than it really is. The unity of the mind is more apparent than real. Although the doctor believes that the personalities merged, the manifestation is only superficial. According to Dak's discoveries of the physiology and cognitive architecture of the brain, restoration of the mind to the pre-dissociation form and function is not possible. Significant aspects of the mind have been excluded from merging or have been lost forever through deafferentation and neuronal deaths. A serious problem of MPD patients is their brain damage. Similarly as schizophrenics, many multiples do not believe that there is anything wrong with their brains and minds. The subjects refuse to see a doctor. Other multiples, those who hear voices, are afraid to face this reality. They hide the existence of such voices from themselves. The subjects tend to deny the voices, suppress them with loud music, or make themselves believe that the voices are not as bad and frequent as they are. Other multiples are afraid to mention that they hear voices because this would be interpreted by most doctors as schizophrenia. Chances are that the multiple would be exposed to frequent injections of mind-altering drugs, electroconvulsive shocks, and other criminal activities that are routinely perpetrated by the medical establishment. Whatever brain damage the multiple has already suffered would be made much worse by doctors. Hiding the experiences of one's multiplicity often becomes a matter of survival. The chances that a multiple would find an expert doctor who knows what he is doing are slim, practically nonexistent. Most multiples spend years being treated with misunderstanding and harmful medications by leading psychiatrists who do not have the foggiest what is going on in the patients' minds. But even when a multiple does find a qualified doctor, there is no guarantee that she will be able to tolerate the necessary psychotherapy. A multiple who stays in MPD therapy may greatly benefit from her treatment. The treatment takes years, and complete healing should be considered a scientific curiosity, and not the expected outcome. Most people affected by this disorder will have to live as multiples for the rest of their lives. This is not so because of a failure of the therapists. The trouble is that the best therapeutic measures have no major impact on the damaged neural substrates or on the restoration of emotional intelligence. Values and bad habits can be changed in therapy, but damaged neural circuits respond poorly. This is particularly true in complex dissociative disorders. Between these two extremes is a gray zone. Some neural damage can be corrected through therapy if the process starts early. But a multiple who has lived with her condition for 30 or more years will always have some permanent neural and functional damage. Luckily for her, she is not conspicuous. She is just an average member of the human race. REFERENCES [1] Diagnosis and Treatment of Multiple Personality Disorder by Frank W. Putnam, pages 47, 55, and 155. 1989 Guilford Press, A division of Guilford Publications, Inc. Printing No 8, ISBN 0-89862-177-1 [2] Dissociative Experiences Scale (DES). Web page http://www.rossinst.com/des.htm 1996-99 by the Colin A. Ross Institute [3] Conspiracy of Silence the Trauma of Incest by Sandra Butler, page 14. 1996 Volcano Press ISBN 1-884244-12-2 [4] Surviving Child Sexual Abuse by Liz Hall and Siobhan Lloyd, pages 24 and 76. 1993, The Falmer Press, Taylor and Francis Inc. Second edition, ISBN 075070 153 6 paper [5] Secret Survivors by E. Sue Blume, page 292. 1990 by John Wiley & Sons, Inc. First Ballantine Books edition: March 1991. Tenth Printing: April 1993, ISBN 0-345-36979-3 [6] The Central Nervous System Structure and Function by Per Brodal, page 608 1992, 1998 Oxford University Press, Inc. Second edition, ISBN 0-19-511741-7 [7] J. Read & P. Hammersley, Child sexual abuse and schizophrenia [Electronic version]. The British Journal of Psychiatry (2005) 186: 76 [8] Paul H. Lysaker, Ph.D., Piper S. Meyer, M.S., Jovier D. Evans, Ph.D., Catherine A. Clements, M.S. and Kriscinda A. Marks, M.S. Childhood Sexual Trauma and Psychosocial Functioning in Adults With Schizophrenia. Psychiatr Serv 52:1485-1488, November 2001. [9] Child Abuse Can Cause Schizophrenia, Conference Told, ScienceDaily (Jun. 14, 2006). Retrieved April 7, 2008 from http://www.sciencedaily.com/releases/2006/0606141206.htm [10] Kluft, R. P. (1994). Treatment Trajectories in Multiple Personality Disorder. Retrieved May 2, 2008 from http://www.empty-memories.nl/dis_94/Kluft_94.pdf [11] Skeptical Inquirer May/June 1998. Retrieved May 23, 2008 from http://www.csicop.org/si/9805/witch.html [12] Stanley G. Smith https://scholarsbank.uoregon.edu/dspace/bitstream/ 1794/1415/1/Diss_2_1_8_OCR.pdf [13] Sandra Blakeslee, SCIENTIST AT WORK: Vilayanur Ramachandran; Figuring Out the Brain From Its Acts of Denial. January 23, 1996. The New York Times (May 24, 2008.) [14] http://www.dissociation.com [16] Faure, Henri; Kersten, John; Koopman, Dinet; Hart, Onno van der, 1941. Dissociation : Volume 10, No. 2, p. 104-113 (June 1997): The 19th century DID case of Louis Vivet: new findings and re-evaluation. [17] T. Fahy, Multiple personality disorder: where is the split? J. R. Soc. Med. 1990, September, 83(9):544-546 | |
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