Continuum of Disease


Dynamics of Dissociation

The Personality System

Making the Diagnosis

Common Presentations of MPD



Nursing Implication

Cast Studies



Post Examination


            In 1889 Pierre Janet, a French psychiatrist, wrote that “certain happenings would leave indelible and distressing memories – memories to which the sufferer was continually returning and by which he was tormented by day and by night.”  (Van der Kolk, 1989) Janet understood over 100 years ago what lay at the very core of dissociation.  Dissociation is defined as a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.  Freud felt that dissociation was a process of defense which would remove threatening or overwhelming thoughts from a person’s awareness.

            This same idea is supported by today’s professionals.  Dissociation is seen as a coping mechanism and develops when normal coping mechanisms are depleted or over-taxed.  In this weakened state the individual withdraws consciousness, or dissociates from the event, while the brain then encodes the event in a different fashion so that the intense shock can be split off and thereby not completely experienced by the individual.

            The most extreme level of dissociation is called Multiple Personality Disorder, or MPD.  Multiple Personality Disorder is described as chronic dissociative posttraumatic stress psychopathology (Braun, 1990).  It is the result of trauma which is far greater than normal stress and surpasses the individual’s ability to cope.  In these cases the individual is so traumatized that the young developing mind fragments, or splits off, into different selves.  The psyche creates a separate consciousness, or personality, in which it absorbs the overwhelming trauma and stores the information.  Often there are several of these other personalities.  Each of the personalities then responds to the traumatic information in a different way.  With the information about the trauma split up, the child is then better able to cope with it.  It is the same idea as sharing a problem with friends.  Once the burden is shared, it becomes easier to bear.

            MPD begins in childhood, between the ages of two and eight.  Because the very nature of children’s dependence upon adults renders these incapable of “fight or flight” they will instead flee inward, thereby abandoning the sense of involvement or responsibility for the situation.  Otherwise, the feelings of guilt and terror would be overwhelming.  Without this coping mechanism, the child might perish under the pressure, either through suicide or psychotic break.

            Childhood physical or sexual abuse is commonly found in the history of someone with MPD.  It has been found that 97-98% of MPD’s have experienced child abuse in some form – physical, sexual, or psychological mistreatment and neglect.  (Talbott, 1988).

            Approximately two percent of MPD’s report no incidence of child abuse, but have experienced a trauma often perceived as life-threatening, such as near drowning or witnessing the violent death of another person.  (Steele, 1989).

The traumas could be a single event, such as a case of rape, although the chronic dissociation seen in MPPD patients is, in most cases, the result of repeated severe or inhuman abuse, rather than an isolated experience (Steele, 1989).

            The child is usually from an environment where not only has trauma occurred, but also where the necessary protection to prevent the trauma re-occurring, or the nurturing to enable the child to resolve the trauma is nonexistent.

            Though the disorder begins in childhood it may remain undiagnosed for many years.  Not all individuals with MPS are as obvious as Hollywood would have us believe.  Sometimes the switching, or changing to other personalities, is very subtle and can only be detected by those who know the person very well.  Because of amnestic barriers the individual may be unaware of the presence of other personalities.  It may only come to the person’s attention after others have remarked about unusual behavior.  Often people with MPD will find articles among their personal belongings that seem to belong to someone else.  This may lead them to think they are going crazy.

            The person with MPD may feel that something is terribly wrong, but have no idea about the multiplicity.  This is a condition which can be hidden for long periods of time and only show itself during stressful situations, such as problems with work or relationships.

            Females represent 75 – 90% of reported cases.  This is most likely due to the different manner in which men and women respond to emotional trauma.  Women tend to act out in harmful ways against themselves and find their way into treatment after self-mutilation or suicide attempts.  Self-mutilation includes such behavior as cutting superficially without suicide intent, burning the skin with a cigarette, and banging the head against a wall.  Men, on the other hand, have been found more likely to respond to psychic paid by committing violent crimes against others and ending up in the criminal justice system.  (Talbott, 1988)

FIGURE 2 The 3-P model of multiple personality disorder (Braun & Saches, 1985) SDL = state dependent learning.  Note.  From Treatment of Multiple Personality Disorder (p.6) by B.G. Braun (Ed.) 1986, Washington, DC: American Psychiatric Press.  Copyright 1986 by American Psychiatric Press.  Printed by permission.

Etiological Models

            Kluft offers the following etiological model.  He suggests that these four factors must be present in order for an individual to develop MPD:


Factor 1:


The individual possesses a predisposition for dissociation, seen by a high degree of hypnotizability.


Factor 11:


Normally adaptive capacities are overwhelmed by traumatic events, such as severe child abuse,  so that the organism dissociates as a defense mechanism.


Factor III:


The unique combination of psychological substrates occurring in each individual provides the building materials for specific alternate personality formations.  These shaping influences include self=object constancy, cognitive structures of separateness, developmental lines, and normal dissociative phenomena.


Factor IV:


An absence of nurturing, soothing, and restorative experiences which might enable the child to recover from the trauma.  Also, the failure of significant others to protect the child from further trauma.  The trauma is repeated over and over again.  (Steele, 1989)

Braun and Sachs suggest the 3-P model as an explanation of the development of MPD.  It is a similar model to Kluft’s in etiological framework.  (See Figure 1)  This model consists of predisposition, precipitation, and perpetuation:

Predisposition – The biopsychological capacity to disassociate and the child’s exposure to an environment in which server abuse was meted out unpredictably by parents and other caregivers repeatedly.

Precipitation – An overwhelmingly traumatic event that indicates the first use of dissociation as an escape or coping mechanism.

Perpetuation – The continuing abusive phenomena link subsequent dissociative episodes with a common affective theme, eventually resulting in separate memories for each.  Over time, the patient begins to experience discrete life histories for each set of memories.  (Braun, 1990)

Kluft’s and Braun’s model are similar.  The difference is in Kluft’s specific mention of the absence of a nurturing environment where the child might have the opportunity to heal.  This is implied in Braun’s “Perpetuation”.

Essentially, the literature all points toward a common theme in the etiological background of patients with MPD.  This is an individual with a predisposition to dissociate, who grows up in a highly abusive environment where there is no opportunity for respite or escape, and the abuse is ongoing.  Braun reports that an estimated prevalence of MPD in the United States is 0.1% (Braun, 1990).  MPD has also been found to span generations (Kluft, 1991b).

Next: Dynamics of Dissociation