Continuum of Disease


Dynamics of Dissociation

The Personality System

Making the Diagnosis

Common Presentations of MPD



Nursing Implication

Cast Studies



Post Examination

The Personality System

The average number of personalities for a person with MPD ranged from eight to thirteen.  However, there can be many more; some cases have reported up to 100 or more personalities.  The personalities may be referred to as alter personalities, alternates, or alters.  Collectively, they are referred to as a system.  They are experienced by the patient as distinct and separate individuals, with their own way of perceiving the world and responding to it.  Remember, they have been created in order to dilute the impact of the trauma on the abused child, and therefore will have different memories or perceptions of the abusive experience, or no memory of it at all.  They have been created to perform different functions of life, thus the various genders, ages, ethnic backgrounds, names, and character traits, which are dependent upon their particular role within the system.  Each personality may support its own style of dress, handwriting, speech pattern, mannerisms, walk, likes and dislikes, even eyeglass prescriptions, and responses to medications.  One alter may even have a disease that the others do not, for example diabetes or asthma.

Often alters are created who express impulses perceived as forbidden by the child, such as anger, defiance, promiscuity, or violence.

            The names of the alters often have a symbolic meaning.  For example, Melody might be the name of a personality who expresses herself through music.  Or the personality could be given the name of its function, such as “The Protector” or “The Perpetrator”.  The legal personality is the person with the legal name of the body, or the birth personality.  This is also called the original personality and is the identity from which the first other personality split off.  This may or may not be the same as the host personality.  The host is the personality who has executive control of the body the greatest percentage of time.  This host may have completely taken over the basic functions or daily life for a legal personality who is too overwhelmed to participate at all.  Or the host might be the only one perceived by the system as being able to keep the system under control and intact.

            The presenting personality is the one who presents for treatment.  This may or may not be the host.  This could be an alter whose immediate adult crisis, such as a relationship failure or problem at work, leads the body into therapy.  Or it could be an alter suffering from the behavior of another, such as an unduly scrupulous alter suffering from the behavior of a promiscuous one,  The most commonly found personality in the repertoire of the MPD is that of a child who is terrified and remembers the abuse.  The next most common is the persecutor who is usually modeled after the abuser.,  Because the individual feels incapable of integrating all the functions of life into one personality, alters are created to perform the various roles of maintaining a job, parenting, being sexually active, and any number of other functions.  The individual is broken down into components that when put together can rise to the complex demands of life.

            In referring to themselves, multiples often use the pronoun “we”.  In referring to the different personalities as a whole they may use such terms as the system, the family, the troops, my people, or the kids if there is a large number of child personalities.

The awareness of one personality to the others is called “co-consciousness” and exists in varying degrees.  Some may be totally unaware of the existence of the others.  Some may be aware of the existence of others but not have any interaction with them.  Only one personality interacts with the external environment at a given moment.  A personality is referred to as being “out” when they have executive control of the body at a given moment.  The others may or may not perceive or influence what is going on.  This is an important phenomenon for healthcare personnel to grasp.  Though one alter has met the assigned nursing staff, another may not have.  Don’t assume the patient knows your name, trusts you, or is familiar with a particular hospital routine.  Introductions and explanations may need to be made to each alter as they appear.  The personalities can become quite narcissistic, developing such an investment in their separateness that one or several alters ay try to kill others.  Because they see themselves as separate and distinct entities, they fail to understand that they share the same body.  Thus, they cannot grasp that killing one alter, kills the entire system.  This is often when the patient presents to the psychiatric professional for the first time.  Suicidal impulses and/or attempts, or self-mutilation will often bring the patient, who has been able to function fairly well in life, finally to the attention of those who can help.

            An alter may exert its influence without ever seizing executive control.  For example, if this alter is the persecutor, the patient may experience inward conflict without this alter ever presenting to the outside world.  It makes itself known to the patient through threats and insults, which are heard as command hallucinations.  Or the persecutor can take over the domain of motor control, perhaps telling the patient to drive off a cliff, but still has never presented to the onlooker. The personality in charge at the time will describe the experience as imposed rather than willed, which can be quite confusing and disconcerting, particularly to the individual who has no idea of his or her multiplicity.

            Transition from one personality to another is referred to as “switching.”  This usually occurs within seconds to minutes, but can also be gradual, taking hours or days to complete.  This is rarer.  Switching is often prompted by stress in the individual’s life, or by the person’s own intrapsychic conflict, such as vague memories of abuse.  Switching can also be brought on by alters who are in conflict with one another, which happens quite frequently.  They will have different ideas about the way life should be lived, relationships conducted, how much to trust someone, or whether or not to take a medication.

            Environmentally triggered cues, or “triggers”, can also provoke switching.  A musty smell may remind a patient of being locked in a dark, damp closet as a child.  Or eating red mean could trigger a response in the survivor of cult abuse who remembers rituals involving cannibalism.  The individual might then switch ito the abused and helpless child alter, or the persecutor, or even a strong and aggressive alter who becomes violent and fights the abuser in a way the child never could.

            During times of high stress or provocation of whatever sort, switching can be so rapid that the individual becomes depleted and confused.  This is a time when nursing staff can take the patient aside to a quiet place to do a reality check and to help the patient feel safe and comforted.
In psychotherapy, switching is sometimes encouraged by the use of hypnosis, with or without the use of a sedative called amobarbital (amytal).  This helps the therapist to access all alters, particularly those who are reluctant to come out, and thereby work with the system as a whole.

            The individual with MPD may have cycles in his or her life where the actual overt behavior of multiplicity is not seen.  These cycles of overt versus covert behaviors are quite typical.  For example, a common motive or task may render alter activity covert temporarily, until the task is complete.  Motherhood is an example.  The alters may collaborate to raise the child, with no overt signs of MPS for several years,.  However, when the child is grown and has left home, or become more independent, the alters once again diverge into their separate identities and purposes, and may suddenly appear in a more covert manner.

            Some may be more overt in behavior due to secondary gain.  If the behavior is reinforced and exploited by others, or if the behavior suddenly brings them the attention and nurturing they missed as a child, for example in hospitalization, they may be encouraged to be more overt.  (Kluft, 1991a)

            However, Kluft maintains that “dramatic external differences are not the core of MPD.”  (Kluft, 1991a).  If the alters influence each other by inner dialogue, there may never be overt signs of MPD.  If this communication is in the form of inner threats, the presentation can appear psychotic.  If in their influence they do so by seizing complete executive control, the classic overt signs or MPD may be this time be seen, with obvious switching and differences between alters.

            The amnestic barrier is also a determinant of overt versus covert behavior.  If the alters share the same contemporary memories, one can easily discount their overt differences because of the consistent descriptions of their lives.  However, if they have their own separate versions of their contemporary lives, the observer will see the presence of dissociative phenomena.  If alters are similar it will diminish the overt signs of MPD.  The signs of MPD are not as obvious as one might think, and may only be apparent to those who know the patient very well.  Though different personalities exist, the differences may be very subtle.  Kluft has found from his experience that approximately 20% of MPD patients spend most of their adult lives in an overt MPD presentation..  Of these, approximately only 6% make an overt presentation on an ongoing basis and try to draw attention themselves.  The remaining 14% are overtly MPD on an ongoing basis, but do not call attention to themselves and try to keep their condition covert.  Forty percent show signs that could alert a skilled clinician and the remaining 40% are highly disguised.  (Kluft,1991a)

            These statistics from Kluft help us to understand then, the difficulty in diagnosing a disorder that one might erroneously believe to be so dramatic that it would be obvious to anyone in the patient’s presence.  It is well to remember that this is a disorder of intense secrecy, and the alters may have a firm pact to remain hidden.  The patient will often vehemently deny the suggestion of MPD if confronted.


Child and adolescent alter personalities

            These are the most common types of alter personalities and are often the first discovered during therapy.  (Fike, 1990a)  Child and adolescent alters emerged to endure the abuse that the original personality could not tolerate or to handle feelings that were unacceptable to the original personality.  Child alters will often say that they do not know how to play, that they feel unloved and that they d not have any friends.  In a sense, this is exactly their experience.  Since their access to the body was usually during the abuse, this is the only experience they know.  Even though the original child personality may have had friends and played as any child would, the child alter was created for the purpose of handling the abuse only.  To the original personality, it is the child alter who is experiencing the abuse.  The child thinks, “It is happening to her, not to me”, so she can therefore be relieved of the pain and emotional anguish over her participation in the abusive experience.  Art and play therapy are ways the child alters can be reached and encouraged to express themselves, just as one might work with a true child of stated age.

Protective or rescuer alter personalities

            These alters were created to save the original or other personalities from intolerable conditions.  They may have intervened by fighting or defending themselves through trickery, pretense, or running away.  Protective alters can be of any age group and are generally much tougher and braver than the original personality.  (Fike, 1990a)  The other weaker personalities often feel a sense of shame in comparison to the Protective alter..  “He is so strong and I am so weak.  I couldn't’t take care of myself.”  They may feel shame that the abuse happened to them, but that the personalities can be helpful during therapy, but can become resistant or hostile if they feel that their job of protecting is being threatened.  (Fike, 1990a)

Persecutor alter personalities

            These alters are modeled after the abuser.  The perspective behavior can be demonstrated in different forms.  Patients report taunting and negative messages that they hear inside their heads, blaming the patient for abuse, condemning, threatening to hurt the patient, and telling them they need to die, or to pay for succumbing to the abuser.  Often the host will act on these messages and this is commonly when the patient becomes introduced to the mental health system.  They may cut or burn themselves in self-mutilation, or may actually make a serious suicide attempt.  During therapy the patient may become terrified because the persecutor is threatening to kill the host for sharing information about the abuse or the personality system.  The host and alters are sometimes very frightened by the feelings and/or ideas of another alter, in as much as they feel they have no control over, or protection from, the other’s actions.

            Though difficult to understand at times, self-injury does sin fact serve a certain purpose.  Patients report a sense of relief after self-mutilation.  They often feel they deserve to be punishment and will temporarily feel better because they have paid for being bad.  Self-mutilation can also be seen as a protective mechanism; MPD patients believe they are avoiding more grotesque harm from the abuser, because they have instead hurt themselves.  (Fike, 1990a)

            It is important to see that these alters were originally created as a defense mechanism.  Though this mechanism might have kept the child alive in the past, in adult life it only serves as a negative influence.  Understanding the rationale for self-abuse is essential for cessation of the behavior.  The persecutor personality must begin to understand that, though this behavior was important to survival in the past, it is no longer helpful.

Perpetrator alter personalities

            Perpetrator alters, like persecutors, are modeled after the original abuser, and like persecutor personalities.  Unlike persecutor alters however, perpetrator alters seldom direct their abusive behavior inward to injure other personalities shared by the body.  Rather, perpetrators direct their behavior outward towards others.  No matter how unacceptable their behavior may be, it is essential to remember that perpetrator alters were essential to the survival of the child who was abused.

            There are two types of perpetrator alter personalities.  The first is the personality created to handle the abhorrent behavior demanded by a cult.  Upon paid of death or torture, cult members are expected to participate in hideous acts of cannibalism, group sex, and violence.  For the children of members there is no escape but an inward one.  To emotionally survive this type of experience an alter must be created who participates, otherwise the terrified child could not survive such an extraordinary experience.  This first type of perpetrator alter is the one who was forced by the abuser to abuse others, but no longer participates in such abuse.  In therapy it is important to help these alters to understand their earlier behavior as a survival mechanism and begin to develop a more positive self-image.  (Fike, 1990a)

            The second type of perpetrator personality is one who continues that earlier abusive behavior in adult life.  These are the men whose violent crimes, such as rape or child molestation, eventually find them in the criminal justice system.  Women who have an active perpetrator tend to abuse their children in ways that were similar to their own abuse.  (Fisk, 1990a)

Avenger Alter Personalities

            The avenger holds the rage from the childhood abuse and may attempt to avenge themselves or seek retribution from the abuser.  They express the anger of the entire system and can be very hostile and negative.  However, this is a personality that therapists often like to work with, because the avenger expresses the anger that the therapist also feels.  A goal of therapy with the avenger is to find ways to express the anger I a satisfying and yet socially acceptable manner.

Self-destroyer Alter Personalities

            “Self-destroyer alter personalities are considered special purpose fragments rather than full alter personalities and are generally found only in survivors of cult abuse.”  (Fike, 1990a)  Although suicidal alters are certainly present in most patients with multiple personality disorder, the self-destroyer is different in that it was created by the cult for the sole purpose of destroying the body should the individual disclose secrets of the cult.  This alter was created through the use of abuse or torture, and explains the extreme secrecy of these patients.  The internal conflict for these patients in therapy is great, and it is very difficult for the therapist to obtain a true history of the abuse.  It is only after a great trust has been established that the patient is able to disclose cult information in therapy, and then it is with great fear.

            Often the self-destroyer does not become evident until a suicide attempt has been made and it can be related to recent disclosure of cult activities.  It is then important to do whatever is necessary to protect the patient from further self-harm.

Internal Self-helpers

            These alters can be extremely helpful in therapy, if they exist.  Not every patient with MPD has an internal self-helper.  Also referred to as observers, advisors, or organizers, they are the rational part of the system, with either controlled or non-existent emotions.  This alter is able to watch all the other personalities, report what the others are doing and how they are reacting to certain situations.  They are able to assist the therapist in providing the appropriate intervention to each alter.

Opposite Sex and Opposite Sexual Preference Personalities

            It is common for individuals with MPD to have alters of a different sex or opposite sexual preference than the host personality.  These personalities are often created to express feelings or behaviors that the host feels are unacceptable.  For example, a female patient may create a strong aggressive male avenger personality because she doesn’t feel capable of expressing those qualities herself, or she may feel those qualities are unacceptable to society as a whole.

            These personalities can also be created to play a specific role demanded by the abuser during the abuse experience.  If a boy were forced to dress and act as a little girl, he may create a female sister to play that role.

            These alters can present difficulties as they relate to society in the body of the host.  Opposite sex alters and alters that prefer a different sex than the host can present difficulties in relationships.  These alters also create conflict when an opposite sex alter takes over in actions that would be socially incorrect for the sex of the host,  For example, a little boy alter of a female host who wants to remove his shirt when he’s hot or use a public restroom for men.

            In therapy the opposite sex alters are brought to an agreement about socially acceptable behaviors for the host.

Alter Personalities of a Different Race/Ethnicity

            Different race alters are generally created for the stereotypic or imagined qualities of that race, as experienced or perceived b the host personality.  Fike gives the example of a Caucasian patient with a Native American alter personality who represented spirituality and other-worldliness.  Another example is that of a Caucasian woman with a black male child protective alter.  As a child she had a Black classmate who she described as “the toughest kid on the block.” (Fike, 1990a)

            These alters can even speak a different language than the host.  For example, a Spanish speaking female self-helper was created by a Caucasian female, because the only love or nurturing she received as a child was from the Spanish-speaking housekeeper.  The host personality may not know a single word of Spanish.

Older Alter Personalities

            Often this type of alter is created to serve a nurturing or parenting role, thus serving as a protector.  However, sometimes the age is related to taking on the identification of the abuser, and can therefore take on any of the other more hostile roles.

Nonhuman Alter Personalities

            Though these alters can seem unbelievable, they are actually quite common among patients with MPD.  The two types of nonhuman alters most commonly seen are animal alters and demonic/mythological alters.  An example of an animal alter is a young woman who would bark like a dog whenever she felt threatened and did not want to answer questions.  Since a dog cannot make itself understood in human terms, by sending this alter out there was certainly no way a therapist could pry for information.  Once again we see a very fine tuned defense system.

            It is important to remember than when an animal alter is out, to the host body this is actually and in reality, a dog.  With this in mind anyone working with the patient should be careful about touching the patient when an animal alter is out, in the event this is an unfriendly animal, or perhaps one who functions as a protector.

            In some cases, what presents as an animal is really a child alter acting as an animal.  This is found in cases where the abused child was forced to act as an animal, usually a dog, and may have included sexual acts with dogs.  These alters will speak as a human and will demonstrate confusion over whether they are an animal or a child.  In these cases the therapist reinforces the humanity of the alter and will address the alter as a child, rather than as an animal.  To treat this alter as an animal would be to reinforce the abuse and identify with the abuser.  (Fike, 1990a)  Demonic alter personalities are found in victims or satanic cults, while mythological god alter personalities are common in patients with fanatic religious backgrounds.  These alters are described by patients as all-powerful and all-knowing, and may have either good or evil qualities.  The role of these alters is to protect the body.  Though the therapist must acknowledge the existence of these demonic or mythological alters, they should not reinforce the patient’s belief in the power of these alters.  The therapist might say something like, “I know you believe you control all things, but I do not believe I am controlled by anyone.  I believe I can make my own choices.  (Fike, 1990a)

            All of the above alter personalities can present in a variety of combinations together.  For example, the patient is a middle-aged Caucasian female. She may have a black male child alter, a lesbian protector, an older male perpetrator, an older female goddess-like rescuer, and a wise Chinese female self-helper, to name only a few of the many personalities that may emerge.

            Though the manifestation of these alter personalities can seem fantastic and unbelievable, it is important to remember that the patient sincerely believes each one to be a separate and real entity, with its own experiences, thoughts and ways of interacting with the world.  Each personality must be recognized and respected for who they are in order to treat the whole patient.

Next:Making the Diagnosis