BUT IT’S IN THE DSM

Since the material below was written, the DSM-V has been published. The changes in the DSM-V broadened the scope for the diagnosis of Dissociate Identity Disorder. In particular, the diagnosis has been expanded to "account for more diverse presentations of the disorder," such as "possession-form phenomena and functional neurological symptoms." Another criterion now specifically states that transitions in identity may be observable by others or self-reported. Finally, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences.

The FMSF Newsletter excerpts below continue to be relevant because the methodological and political issues that were present at the time of the DSM-IV publication remain today.

For a complete description of the changes in the DSM-V see:

American Psychiatric Association Highlights of Changes from DSM-IV-TR to DSM-5, 19

BUT IT’S IN THE DSM-IV (Parts 1 to 3)

(Part 1)

FMSF Newsletter, Vol. 7, No. 8, October 1998

Court documents show that one argument continues to be raised: ‘repression’ and multiple personality disorder must be real because ‘Dissociative Amnesia’ is in the Diagnostic and Statistical Manual-IV (DSM-IV) published by the American Psychiatric Association. There are, however, seven points -- statements either in the book or in the description of its construction -- that provide evidence that this argument cannot be supported.

1. THE DSM-IV URGES CAUTION: The Diagnostic and Statistical Manual was not written for use in forensic settings.

"When the DSM-IV categories, criteria, and textual descriptions are employed for forensic purposes, there are significant risks that diagnostic information will be misused or misunderstood. These dangers arise because of the imperfect fit between the questions of ultimate concern to the law and the information contained in a clinical diagnosis." (page XXIII)

2. THE DSM-IV MENTIONS THAT THERE IS CONSIDERABLE CONTROVERSY: The DSM-IV states that there is no consensus on the issue.

"In recent years in the United States, there has been an increase in reported cases of Dissociative Amnesia that involves previously forgotten early childhood traumas. This increase has been subject to very different interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been overdiagnosed in individuals who are highly suggestible." (page 479)

"There has been considerable controversy concerning amnesia related to reported physical or sexual abuse, particularly when abuse is alleged to have occurred during early childhood." (page 480)

3. THE DSM-IV NOTES THAT DISSOCIATIVE AMNESIA CANNOT BE DISTINGUISHED FROM MALINGERING (feigning symptoms for external gain):

"There are no tests or set of procedures that invariably distinguish Dissociative Amnesia from Malingering..." (page 480)

4. THE DSM-IV STATES THAT THERE IS A NEED FOR EXTERNAL CORROBORATION:

"There is currently no method for establishing with certainty the accuracy of such retrieved memories in the absence of corroborative evidence." (page 481)

5. THE DSM-IV WAS PUBLISHED IN 1993. Many significant clinical and research articles have since been published:

"New knowledge generated by research or clinical experience will undoubtedly lead to an increased understanding of the disorders included in DSM-IV, to the identification of new disorders, and to the removal of some disorders in future classifications. The text and criteria sets included in the DSM-IV will require reconsideration in light of evolving new information."(page XXIII)

6. THE DSM-IV WAS DEVELOPED BY COMMITTEE, NOT FROM SCIENTIFIC EVIDENCE:

"It must be noted that DSM-IV reflects a consensus about the classification and diagnosis of mental disorders derived at the time of its initial publication." (page XXIII)

7.THE DSM-IV WILL CONTINUE TO INCLUDE SOME DIAGNOSES BASED MORE ON CURRENT SOCIAL INTERESTS THAN ON SCIENTIFICALLY DERIVED AND VALIDATED PRINCIPLES:

Several books discuss this issue, including They Say You’re Crazy, by Paula Caplan, and The Selling of DSM: The Rhetoric of Science in Psychiatry, by Stuart A. Kirk and Herb Kutchins.

BUT IT’S IN THE DSM-IV

(Part 2)

But It’s in the DSM-IV (Part 2), FMSF Newsletter October 1998

A Lesson from History

"The witch-craze of the 16th and 17th centuries made clear that validation means something much more than proposing ways -- even consistent ways -- to make the diagnosis even of something that does not exist. That is, the witch hunters received explicit and operational ways of identifying witches. They taught each other and wrote their procedures in a large and influential book. This book, entitled Malleus Maleficarum or the Hammer of Witches, spelled out in exquisite detail the kinds of behaviors that characterize the witch and identify the evidence on her body of congress with devils, incubi and succubi. The Malleus had as its epigraph: Haeresis est maxima opera maleficarum non credens (to disbelieve in witchcraft is the greatest of heresies).

"What was learned from this that might illuminate practices with repressed memories? The fact that there is a manual telling how to recognize the manifestations of repressed memories does not confirm them. It is an exercise in creating a consistent approach to the diagnosis amongst therapists -- a uniformity of diagnostic practice -- and does not validate the presumed abusive experience...

"The issue for repressed memories is validation -- and validation in every case when it appears...To treat for repressed memories without any effort at external validation is malpractice pure and simple; malpractice on the basis of standards of care that have developed out of the history of psychiatric service -- as with witches -- and malpractice because a misdirection of therapy will injure the patient and the family."

--Paul McHugh, M.D. Chief of Psychiatry, Johns Hopkins Hospital Paper presented at Memory and Reality Conference, April 1993

BUT IT’S IN THE DSM-IV

(Part 3)

Professional Skepticism of Multiple Personality Disorder

Cormier, J.D. and Thelan, M.H., Professional Psychology: Research and Practice, 1998, Vol 29, No 2, 163-167.

The authors in 1994 randomly selected 1,000 doctoral level clinicians from members of the American Psychological Association and mailed them a cover letter, questionnaire, and a self-addressed stamped envelope. They received 425 responses (43 percent) and no follow-up mailing was reported. Participants were presented with criteria for MPD as defined in the DSM-IV and then answered 16 questions on a five-point scale that reflected their beliefs about MPD, their skepticism, and their familiarity with the MPD literature. The authors concluded that the majority of psychologists believed MPD to be a valid but rare clinical diagnosis. They note that "clinicians should not hesitate to assess dissociative symptomatology out of concern that it might be feigned." (p. 166)

There are a number of concerns raised by this report. Most significant is the 43 percent response rate. The authors do not mention that such a low rate introduces the problem of selection bias: people who are passionate about MPD may have been more likely to return the questionnaire than those who are not interested in the topic.

Another concern pertains to the content of the cover letter that was mailed to participants along with the questionnaire. Did it disguise any bias? Was it personally signed?

This is relevant because the authors reveal their bias when they state that "the onset of MPD is often related to extreme abuse that is perpetrated on females by male caretakers." (p.166) There is no scientific evidence that this assertion is valid. The authors also assume that "numerous, nationwide, and consistent" (p.163) clinical reports are sufficient to consider MPD a valid diagnostic category, but we should have learned from the witchcraft trials of the Middle Ages that this is not sufficient evidence.

Finally, even with all the methodological issues raised, the results of this study indicate that more than half, 54 percent, of the participants expressed at least some skepticism about MPD.

Additional Reading:

American Psychiatric Association. ( 2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. American Psychiatric Publishing, Incorporated.

Frances, A. (2014, January 30) Multiple Personality -- Is It Mental Disorder, Myth, or Metaphor? Huffington Post

Pope, H. G., Oliva, P.S., Hudson, J.I., Bodkin, J.A. & Gruber, A.J. (1999). "Attitudes toward DSM-IV dissociative disorders diagnoses among board-certified American psychiatrists." American Journal of Psychiatry, 156:2, Feb. 1999. 321-323. American Journal of Psychiatry, February 1999

Stern, R. and McDonald, M. (2013). Diagnosing dissociation or why measuring multiple personalities doesn’t work. Skeptic, 18(4), 40-43.

Last Updated: February 26, 2014