by Paul R. McHugh
When this essay was written, Paul McHugh, MD, was Henry Phipps Professor of Psychiatry and Director of the Department of Psychiatry and Behavioral Science at the Johns Hopkins Medical Institutions in Baltimore.
Prompted by the unexpected flourishing of this extraordinary diagnosis, students often ask me whether multiple personality disorder (MPD) really exists. I usually reply that the symptoms attributed to it are as genuine as hysterical paralysis and seizures and teach us lessons already learned by psychiatrists more than a hundred years ago.
Consider the dramatic events that occurred at the Salpetriere Hospital in Paris in the 1880s. For a time the chief physician, Jean-Martin Charcot, thought he had discovered a new disease he called “hystero-epilepsy,” a disorder of mind and brain combining features of hysteria and epilepsy. The patients displayed a variety of symptoms, including convulsions, contortions, fainting, and transient impairment of consciousness. Charcot, the acknowledged master of Parisian neurologists, demonstrated the condition by presenting patients to his staff during teaching rounds in the hospital auditorium.
A skeptical student, Joseph Babinski, decided that Charcot had invented rather than discovered hystero-epilepsy. The patients had come to the hospital with vague complaints of distress and demoralization. Charcot had persuaded them that they were victims of hystero-epilepsy and should join the others under his care. Charcot’s interest in their problems, the encouragement of attendants, and the example of others on the same ward prompted patients to accept Charcot’s view of them and eventually to display the expected symptoms. These symptoms resembled epilepsy, Babinski believed, because of a municipal decision to house epileptic and hysterical patients together (both having “episodic” conditions). The hysterical patients, already vulnerable to suggestion and persuasion, were continually subjected to life on the ward and to Charcot’s neuropsychiatric examinations. They began to imitate the epileptic attacks they repeatedly witnessed.
Babinski eventually won the argument. In fact, he persuaded Charcot that doctors can induce a variety of physical and mental disorders, especially in young, inexperienced, emotionally troubled women. There was no “hystero-epilepsy.” These patients were afflicted not by a disease but by an idea. With this understanding, Charcot and Babinski devised a two-stage treatment consisting of isolation and counter suggestion.
First, “hystero-epileptic” patients were transferred to the general wards of the hospital and kept apart from one another. Thus they were separated from everyone else who was behaving in the same way and also from staff members who had been induced by sympathy or investigatory zeal to show great interest in the symptoms. The success of this first step was remarkable. Babinski and Charcot were reminded of the rare but impressive epidemic of fainting, convulsions, and wild screaming in convents and boarding schools that ended when the group of afflicted persons was broken up and scattered.
The second step, countersuggestion, was designed to give the patients a view of themselves that would persuade them to abandon their symptoms. Dramatic countersuggestions, such as electrical stimulation of “paralyzed” muscles, proved to be unreliable. The most effective technique was simply ignoring the hysterical behavior and concentrating on the present circumstances of these patients. They were suffering from many forms of stress, including sexual feelings and traumas, economic fears, religious conflicts, and a conviction (perhaps correct) that they were being exploited or neglected by their families. In some cases their distress had been provoked by a mental or physical illness. The hysterical symptoms obscured the underlying emotional conflicts and traumas. How trivial a sexual fear seemed to a patient in whom convulsive attacks produced paralysis and temporary blindness every day!
Staff members expressed their withdrawal of interest in hysterical behavior subtly, in such words as, “You’re in recovery now and we will give you some physiotherapy, but let us concentrate on the home situation that may have brought this on.” These face-saving countersuggestions reduced a patient’s need to go on producing hysteroepileptic symptoms in order to certify that her problems were real. The symptoms then gradually withered from lack of nourishing attention. Patients began to take a more coherent and disciplined approach to their problems and found a resolution more appropriate than hysterical displays.
The rules discovered by Babinski and Charcot, now embedded in psychiatric textbooks and confirmed by decades of research in social psychology, are being overlooked in the midst of a nationwide epidemic of alleged MPD that is wreaking havoc on both patients and therapists. MPD is an iatrogenic behavioral syndrome, promoted by suggestion, social consequences, and group loyalties. It rests on ideas about the self that obscure reality, and it responds to standard treatments.
To begin with the first point: MPD, like hystero-epilepsy, is created by therapists. This formerly rare and disputed diagnosis became popular after the appearance of several best-selling books and movies. It is often based on the crudest form of suggestion. Here, for example, is some advice on how to elicit alternative personalities (alters, as they have come to be called), from an introduction to MPD by Stephen E. Buie, M.D., who is director of the Dissociative Disorders Treatment Program at a North Carolina hospital:
“It may happen that an alter personality will reveal itself to you during this [assessment] process, but more likely it will not. So you may have to elicit an alter… You can begin by indirect [sic] questioning such as, ‘Have you ever felt like another part of you does things that you can’t control?’ If she gives positive or ambiguous responses ask for specific examples. You are trying to develop a picture of what the alter personality is like…At this point you may ask the host personality, “Does this set of feelings have a name?”…Often the host personality will not know. You can then focus upon a particular event or set of behaviors. ‘Can I talk to the part of you that is taking those long drives in the country?'”
Once patients have permitted a psychiatrist to “talk to the part…that is taking these long drives,” they are committed to the idea that they have MPD and must act in ways consistent with this self-image. The patient may be placed on a hospital service (often called the dissociative service) with others who have given the same compliant responses. The emergence of the first alter breaches the barrier of reality, and fantasy is allowed free rein. The patient and staff now begin a search for further alters surrounding the so called host personality. The original two or three personalities proliferate into 90 or 100. A lore evolves. At least one alter must be of the opposite sex (Patricia may have Penny but also must have Patrick). Sometimes it is even suggested that one alter is an animal. A dog, cat, or cow must be found and made to speak! Individual alters are followed in special notes for the hospital record. Every time an alter emerges, the hospital staff shows great interest.
The search for fresh symptoms sustains the original commitment while cultivating and embellishing the suggestion. It becomes harder and harder for a patient to say to the psychiatrist or to anyone else, “Oh, let’s stop this. It’s just me taking those long drives in the country.”
The cause of MPD is supposed to be childhood sexual trauma so horrible that it has to be split off (dissociated) from the host consciousness and lodged in the alters. Patient and therapist begin a search for alters who remember the trauma and can identify the abusers. Thus commitment to the diagnosis of MPD is enhanced by the sense that a crime is being exposed and justice is being done. The patient now has such a powerful vested interest in sustaining the MPD enterprise that it almost becomes an end in itself.
Certainly these patients, like Charcot’s, have many emotional conflicts and have often suffered traumatic experiences. But everyone is distracted from the patient’s main problems by a preoccupation with dramatic symptoms, and perhaps by a commitment to a single kind of psychological trauma. Furthermore, given that treatment may become interminable when therapists concentrate on fascinating symptoms, it is no wonder that MPD is regarded as a chronic disorder that often requires long stretches of time on dissociative units.
Charcot removed his patients from the special wards when he realized what he had been inventing. We can do the same. These patients should be treated by the same methods Charcot used–isolation and countersuggestion. Close the dissociation services and disperse the patients to general psychiatric units. Ignore the alters. Stop talking to them, taking notes on them, and discussing them in staff conferences. Pay attention to real present problems and conflicts rather than fantasy. If these simple, familiar rules are followed, multiple personalities will soon wither away and psychotherapy can begin.