Continuum of Disease


Dynamics of Dissociation

The Personality System

Making the Diagnosis

Common Presentations of MPD



Nursing Implication

Cast Studies



Post Examination

Making the Diagnosis

Studies have shown MPD patients to be polysymptomatic with a combination of dissociative, affective, posttraumatic, and somatic symptoms.  This polysymptomatic presentation, along with certain core characteristics of MPD makes it an extremely difficult disorder to diagnose.  The average MPD patient receives three erroneous diagnoses, spends approximately seven years in therapy and has three of more hospitalizations before receiving an accurate diagnosis and appropriate treatment.

            Kluft (1991a) has gathered data from studies by several clinicians to demonstrate the polysymptomatic presentation of MPD patients.  The data depicts the percentage of MPD patients who experienced the following concomitant psychiatric or medical disorders:

Anxiety – psychopbysiological = 100%

                        Phobic = 60%

Panic attacks = 55%

Obsessive-compulsive = 35%

Affective symptoms – depressive = 90%

                                     High = range 15 – 73%

Allied dissociative symptoms – Amnesias = range 57 – 100%

                                                     Fugues = range 48 – 60%

Depersonalization = 38%

Somatoform symptoms – All = 90%

                                          Conversion = 60%

Sexual dysfunctions = range 60 – 84%

Suicide attempts = range 60 – 68%

Self-mutilation = 34%

Psychoactive substance abuse = 40 – 45%

Eating disorders = range 16 – 40%

Sleep disturbance = 65%

Symptoms suggestive of schizophrenia – depending on symptoms = 35 – 73%

Symptoms of posttraumatic stress disorder (PTSD) = 70 – 85%

Stigmata of borderline personality disorder = 70%

Overview of Characteristics

            The secrecy, denial and suppression so characteristic of the MPD patient make it extremely difficult to obtain an accurate history.  In most cases the individual, along with the alter personalities, are very committed to keeping the disorder hidden.  The secrecy can be attributed to shame around the abusive events, embarrassment about the dysfunctional behavior, or may parallel the secrecy enforced in the abusive dysfunctional family.  This is particularly rue of survivors of cult abuse, where the child was repeatedly programmed with threats not to divulge cult information or experience.

            The evasiveness of these individuals can also largely be due to the reluctance of uncovering painful memories of abuse, reliving them as they share them in therapy.

            Embarrassment over lost periods of time may lead the MPD patient to confabulate a history in order not to appear crazy.  They may even access the memories of a particular alter or several alters, without realizing they have done this.

            Concomitant Axis I and II diagnoses will further complicate the picture.  MPD patients present with such a varied cluster of behaviors and disorders that a clear diagnosis of MPD becomes difficult.  This accounts for the many years the typical MPD patient spends in the mental health system before receiving the correct diagnosis.

            Kluft also maintains that, given the cycles of covert versus overt behavior, there are windows of diagnosability when diagnosis can easily be made, otherwise it can be completely missed.  (Kluft, d)  These “windows” are periods of high stress which would provoke increased alter activity or conflict.

            Another contributing factor to the misdiagnosing of MPD is that different alters may present at different times to different therapists and each be given a different diagnosis.

            Individuals experiencing any level of dissociative disorder do not necessarily seek therapy because they are aware of the dissociative behavior.  In fact, they are often not aware of it at all.  It has been found that only five percent of MPD patients enter therapy self-diagnosed.  (Steele, 1989)  What they are aware of is simply not feeling right, or of feeling absolutely crazy without knowing why.  They may seek therapy because someone brings their bizarre behavior to their attention, or because other things in their lives are not going well.  Relationship or job conflicts, family issues, generalized stress or depression, or suicidal impulses may all lead MPD patients to seek professional help.

            Drug and alcohol abuse, as well as eating disorders, are often seen in individuals with MPD.  In fact, it is often after the addiction has been dealt with and the patient abstains from the addictive behavior that the multiplicity is seen for the first time.  Chemical addictions numb the psychic pain from the trauma and the internal conflicts of the personalities.  Once the patient is clean and sober the pain is acutely felt and the activities of the alters become more clear.  Individuals with MPD who are in recovery for substance abuse need an extreme amount of support and professional help to continue working through the trauma instead of resorting to the old defense mechanism of numbing through chemicals.

            Eating disorders, as well, can be seen as a defense mechanism against the chaos of the internal system.  The core component of an eating disorder is the issue of control.  The individual can control this one aspect of his or her life in a world that feels totally out of control.  Eating disorders can also be experienced as punitive, denying or punishing the shameful child who participated in the abuse and who now lives a secret life.  A study by Demitrack et al found that the self-destructive and suicidal behavior in eating disorder patients could be linked to dissociation rather than to impulsivity or depression.  (Kluft, 1991b)

            The MPD patient is often in an abusive relationship.  This keeps the individual reliving the abusive past which he or she has not yet come to terms with.

            The amnesia and loss of periods of time can be explained by the alter activity.  If there is no-co-consciousness the host personality has no idea when other alters are out.  When the host returns, the patient will experience a gap of time which can’t be explained.  This causes confusion and disorientation.

A fairly classic presentation of an MPD patient is the depressed and depleted female between the ages of 20 to 50, who is often intelligent and accomplished, with persistent somatic complaints that are unresponsive to usual treatment modalities, and who has been exposed to psychiatric treatment without success.

Signs and Symptoms of MPD

            The behaviors, complaints and histories of the MPD patient will provide much information that could lead a clinician to suspect MPD.  A careful history taking and observation of the MPD patient will yield many of the following signs and symptoms (Kluft, 1989a; Braun, 1990):

  • Prior treatment failure
  • Three or more prior psychiatric or medical diagnoses
  • Concurrent psychiatric and somatic symptoms – severe headaches, anxiety, chest pain/palpitations, fluctuations in pain threshold, dizziness, nausea without pregnancy, gastrointestinal problems, menstrual and gynecological irregularities, fear of dying depression, mood swings, phobias, unpredictable responses to medication (e.g., sudden alterations in insulin requirement)
  • Body memories – unexplained somatic complaints which is the body relieving physical pain from an abusive experience (e.g., numbing of the hands from a patient whose wrists were tied up during the childhood abuse episodes; choking sensation with a patient who was forced into oral sex as a child)
  • Fluctuating symptoms and level of function
  • Time distortion or time lapses
  • Amnesia – particularly in large gaps of childhood
  • Being informed of behaviors the patient does not remember
  • Inconsistencies in physical behavior – voice changes, changes in facial expression, switching in right or left handedness, substantial differences in clothing worn on the first and subsequent visits, differences in hair style and facial makeup on different visits
  • Discovery of productions, objects, or handwriting in one’s possession that one cannot account for or recognize
  • The hearing of voices ( > 80% experienced as within the head), experienced as separate urging toward some good or bad activity.
  • The use of “we” in a collective sense
  • The elicit ability of other alters through hypnosis and/or amytal
  • A history of child abuse, or of a family history of dissociative disorders (there is evidence that MPD is transgenerational)
  • The sense that one’s mind and/or body are being influenced or changed – feeling in a daze, confused, going into a trance, thoughts out of control, disoriented, vocalizing words one did not think to speak, difficulty understanding others

Differential Diagnosis

            The most common differential diagnoses are schizophrenia and borderline personality disorder.  Because the MPD patient hears voices, he or she may appear to have the auditory hallucinations of psychosis.  However, the schizophrenic patient will experiences vices heard outside the head most of the time, whereas the MPD patient usually hears them inside the head.  MPD’s are oriented to reality and their perceptions of the world are logical and intact.

Schizophrenics, on the other hand, have a skewed sense of reality where there are no clear boundaries or delineations between the various elements of their world.  Because MPD patients sometimes feel they are possessed or controlled by another being, this can appear to be delusional material of a psychotic disorder.

            The switching of personalities can be mistaken for the instability of mod, self-image, and interpersonal behavior that characterizes borderline personality disorder.  This disorder can, however co-exist with MPD.

            An MPD patient can be misdiagnosed with psychogenic fugue or psychogenic amnesia.  Though these are often features of MPD, these disorders in and of themselves are usually limited to a single brief episode and do not demonstrate the repeated identity changes characteristic of MPD.

            Not only is the diagnosis difficult based on how the patient presents, but critics in the mental health community have made the validity of the disorder an issue.  Because of the increase in reported cases in the past decade, clinicians have been accused of overzealousness in making the diagnosis, or of iatrogenesis.  It is suggested that clinicians respond with curiosity and interest when patients reveal potentially dissociative qualities, thus the patient is encouraged to continue and expound on dissociative behavior when,, in fact, it may not exist.  There is also concern that malingering may be encouraged because the patient receives so much secondary gain free sharing traumatic childhood material.

Concomitant Axis I and Axis II Diagnoses

            It is common for the MPD patient to have other co-existing psychiatric pathology.  Some of the most common of these are borderline personality disorder and affective disorders.  A study by Horevitz and Braun found that 70% of MPD patients also fit the DSM-III-R criteria for borderline personality disorder.  (Kluft, d)  Depression is the most common chief complaint among MPD patients, documented in over 90% of cases.  Many MPD patients are thought to be bipolar, due to the rapid cycling seen during periods of high stress and/or extreme conflict between alters.

Diagnostic Tools

            Direct questioning about traumatic events or amnesia can be very threatening, or may not even be known by the presenting personality.  Also, when asked about amnesia or time losses, the patient is embarrassed or fearful of being labeled crazy.

            Indirect questioning is more appropriate and productive.  Questions about unexplained objects in one’s possession, relationships, presence of skills or writing that is not familiar will often yield helpful information.  In history, taking, sudden and inexplicable changes in behavior or performance can be quite telling.  For example, an honor student who suddenly fails a test, or the secretary who is always conscientious but has turned slovenly and disinterested might suggest alternate personality activity.
Suggesting the MPD patient write in a diary for thirty minutes per day can provide considerable information.  Different personalities will interrupt and different writing styles and content will be noted.

            Hypnosis can be very helpful in making the diagnosis.  Dissociative patients are extremely susceptible to undergoing hypnosis.  In this state alter personalities can easily be drawn.  If the patient does not have MPD there will be no forthcoming alters.

            Amytal is a sedative hypnotic drug which is often used during hypnosis to help the patient relax enough to undergo this type of interview process.

            In the past few years specific diagnostic tests have been developed to aid in the diagnosis of MPD.  They should be used as an adjunct to the taking of a careful and in depth history, and to the observations the clinician makes of repeated visits.  These diagnostic tests are not definitive for MPD by themselves.  The diagnostic tests include:

  • The Dissociative Experiences Scale (DES)
  • The Dissociative Disorders Interview Schedule (DDIS)
  • The Hypnotic Induction Profile (HIP)
  • The Structured Clinical Interview for DSM-III-R

Dissociative Disorders (SCID-D)  (the author of this test, Marlene Steinberg, M.D. describes  it as “more than 90% sensitive for true known MPD.” (Kluft, 1991a).


            Due to the secondary gain a non-MPD patient might gain from the diagnosis of MPD, malingering becomes quite problematic.  A diagnostic tool in this instance would be to remember the innate secrecy and embarrassment of a true MPD patient.  A patient too eager to share traumatic childhood material should raise a margin of suspicion in the clinician.

            Malingerers will generally follow a pathological course they have learned from lay sources, overstate their case in an attempt to convince the therapist they have MPD, and demonstrate inconsistencies in the presentation of alters.

            If malingering is suspected hypnosis can be very helpful.  As stated above, these individuals will be inconsistent in the presentations of alters, and often overly dramatic based on how they believe such a patient would behave.  A true MPD patient under hypnosis will demonstrate alters whose behavior is consistent with repeated hypnotic sessions.

            A diagnosis of malingering can also be substantiated by checking past hospital and police records.

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