Let’s hear once again from some people on an Internet discussion forum.

These reports seem so different from those written by people with schizophrenia, which you read earlier in this chapter. These people don’t report that God is speaking directly to them, that everyone else is a robot, or other such delusional beliefs. You might wonder what these stories about Megan, Skip, Kyle, and the others are even doing in a chapter on psychological disorders.

Here’s a hint: Megan doesn’t exist. Neither does Skip. The same goes for Kyle, Hera, and their friends. They don’t exist anywhere except within the minds of the writers (from http://www.psychforums.com/dissociative-identity). All these characters are alters —alternative personalities—invented by people with dissociative identity disorder.

In this section of the chapter, we’ll learn about the dissociative disorders and will then complete our coverage of psychological disorders by reviewing a puzzling syndrome known as conversion disorder.

Dissociative disorders are a category of psychological disorders in which people experience profound alterations in their sense of personal identity, their conscious experiences of events, or their memory of their own past. Clinicians have identified a range of dissociative disorders; they include dissociative identity disorder, depersonalization/derealization disorder, and dissociative amnesia and fugue.

DISSOCIATIVE IDENTITY DISORDER. In dissociative identity disorder, people experience more than one self; that is, more than one personality seems to inhabit their mind. (The disorder was formerly known as multiple personality disorder.) According to the DSM, people qualify as having the disorder when they experience two or more personalities that are distinct. The different personalities are experienced as possessing different behavioral styles, emotional experiences, and personal goals. An additional factor in diagnosis involves memory. People with dissociative identity disorder experience memory disruptions; when in one personality state, they report being unable to remember what they were doing when in another.

The disorder became well known in American society more than half a century ago thanks to a movie. The film The Three Faces of Eve (1957) told the story of Eve White, a modest woman with a wild alternative personality, as well as a third personality that was able to discuss the other two.

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There can be no doubt that dissociative identity disorder severely disrupts people’s lives. Yet substantial questions about the disorder are unresolved (Gillig, 2009). One concerns the alternative personalities. Are they really separate psychological beings, each with its own, independent mental life? Or are they just ways of talking about normal variations in emotion and behavior (Merckelbach, Devilly, & Rassin, 2002)? Everyone is in a good mood sometimes and a bad mood other times. Everyone is fun-loving and outgoing in some settings, and quiet and shy in others. These variations do not indicate that everyone has multiple personalities, but merely that people’s experiences and behaviors naturally vary from one situation to another. It can be difficult, then, to discern whether people with dissociative identity disorder truly have multiple personalities or simply observe variations in their own behavior, try to understand themselves, and, in so doing, create stories in which they describe themselves in terms of different characters.

A second question is the cause of dissociative identity disorder. Many clinicians have suggested that its causes lie in childhood (Gillig, 2009). Children who experience mistreatment, including sexual abuse, may cope with the trauma by convincing themselves that it happened “to somebody else”—an alternative personality. This was the explanation given in the famous case of Sybil (Schreiber, 1973), a woman whose multiple personalities reportedly were caused by physical abuse suffered at the hands of her mother (but see This Just In). Others, while recognizing the reality of the disorder, question whether evidence truly supports trauma-based explanations. They suggest, instead, that the disorder may develop through social processes in which people adopt different social roles that call for different types of behavior and gradually come to think of these roles as “selves” or “personalities” (Lilienfeld et al., 1999).

THIS JUST IN

There is no single, standard therapy strategy for treating dissociative identity disorder. Some therapists employ cognitive therapy designed to teach clients ways of coping with stress that are more adaptive than switching personalities (Gillig, 2009). Others use hypnosis (see Chapter 9) in an effort to help clients remain calm while focusing their attention on traumatic memories or feelings that may underlie their disorder (Kluft, 2012).

DEPERSONALIZATION/DEREALIZATION DISORDER. A second dissociative disorder is depersonalization/derealization disorder, which is defined by a change in people’s conscious experiences. In depersonalization/derealization disorder, people do not feel fully involved in their own experiences. They go through their day with strange detachment, as if they are merely observing the day’s events rather than taking part in them (Sierra, 2009). According to DSM-5 criteria, a person is classified as having depersonalization/derealization disorder (previously known as depersonalization disorder) based on the persistent presence of either (or both) of these two key symptoms:

Adam Duritz, lead singer of the band Counting Crows, describes—from personal experience with depersonalization/derealization disorder—what it’s like to have this particular dissociative disorder. It “makes the world seem like it’s not real, as if things aren’t taking place. It’s hard to explain, but you feel untethered. … Because nothing seems real, it’s hard to connect with the world or the people in it because they’re not there. You’re not there … you feel like you don’t exist” (Duritz, 2008).

Not all cases of depersonalization are alike; there is a range of severity (Sierra, 2009). For some people, feelings of detachment occur only rarely and do not substantially disrupt their lives. For others, depersonalization/derealization experiences are nearly continual, and personal well-being is severely impaired.

DISSOCIATIVE AMNESIA AND FUGUE. The third dissociative disorder we’ll review disrupts memory. In dissociative amnesia, people are unable to remember significant personal information—facts and experiences that normally would be highly memorable. Some people with dissociative amnesia forget specific personal experiences that were highly stressful or traumatic. Others’ memory loss is more widespread; they may forget major aspects of their own life history.

On rare occasions, individuals with dissociative amnesia experience dissociative fugue, which is a complete loss of memory for one’s own personal identity. Fugue states, when they occur, commonly prompt unexpected travel (the word fugue, in Italian, means “escape” or “take flight”). People move to a new location and may establish a new identity. When they recover memory of their original, true identity, they may have no memory of the fugue period. Cases of dissociative fugue are rare but have been documented, including among well-known people.

Case study evidence shows what it’s like to experience dissociative amnesia and fugue. Consider these two cases:

These two cases are particularly interesting in that they were reported by neuroscientists who used brain-imaging techniques to identify the biological bases of the men’s psychological problems. The men were found to have lower than normal activity in the hippocampus, a brain region known to be involved in the formation of new memories (Kikuchi et al., 2010).

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CULTURAL OPPORTUNITIES

Dissociative identity disorder raises not only psychological questions, but also moral and legal concerns.

Sometimes we condemn behavior as immoral. We do this when the behavior violates a moral rule. What about behavior that violates a rule, but is performed by an alter —an alternative personality that seizes control of the actions of someone suffering from dissociative identity disorder? One sufferer writes, “One of my alters (a 17-year-old sexual deviant) went and had sex with someone a few times over multiple years. … Logically I understand that my body went and had sex with someone that was not my husband. … Logically he understands that the person that had the affair was not his wife. … But emotionally we’re a bit of a mess” (http://www.psychforums.com/dissociative-identity/topic24140.html).

A similar question arises in legal settings (Farrell, 2011). Suppose a crime is committed, but the criminal, a person with dissociative identity disorder, reports the following: “I would never do that. I don’t even remember any of the criminal behavior. The crime wasn’t done by me. It was done by my alter.” Does this individual, who suffers from a severe mental illness, have the same legal responsibility as someone without a mental illness who planned and intentionally committed a crime?

Legal scholars have addressed this issue. Elyn Saks (featured in this chapter’s opening vignette) explains that a standard legal principle is the following: People are found innocent of acts if they “did not have the capacity … not to act” (Saks, 1991, p. 431; emphasis added). In other words, people with no control over their behavior cannot be found guilty. Imagine someone who is sleepwalking. If the person sleepwalks into a store and walks out without paying, she can’t be found guilty of shoplifting. Because she was asleep, she had no control over her behavior—she was not able “not to act.” Lawyers defending a person with dissociative identity disorder may argue, similarly, that their client had no control over the actions of an alter.

The psychologist John Kihlstrom (2005) notes a different legal circumstance. Suppose a person insists on his innocence in a criminal case, but one day an alter confesses to the crime. Should the legal system convict the person based on the confession of his alter?

People charged with crimes have the legal option of pleading not guilty by reason of insanity. In the insanity defense, people admit to committing the crime—to being the physical agent who caused the crime to occur—but claim that, due to mental illness, their physical behavior was out of their control. For example, people might claim that they suffer from dissociative identity disorder and that, at the time of the crime, their behavior was controlled not by themselves, but by an alter.

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How successful is this defense? Not very. The claim of insanity due to dissociative disorder rarely has produced not-guilty verdicts (Farrell, 2011). Sometimes courts are not convinced that the defendant really is mentally ill. Other times they accept the claim of mental illness, but judge that it is not an excuse; for instance, a court may decide that whatever the defendant’s personality at the time of a crime, that personality had the responsibility to tell right from wrong. Either way, the insanity defense fails (Fouche & Klesty, 2011).

The last psychological disorder we will review, conversion disorder, is among the first to be studied systematically. Freud saw patients with the disorder in the late nineteenth century and based much of his psychoanalytic theory of personality on ideas about how conversion disorder develops and how it can be cured.

PHYSICAL SYMPTOMS AND EMOTIONAL DISTRESS. Conversion disorder is a psychological disorder in which people experience physical symptoms that cannot be explained by any medical condition. A person might report paralysis of a hand or arm, or difficulty seeing or hearing, without there being any detectable biological cause. Most editions of the DSM, including DSM-5, have suggested that the physical symptoms may have an emotional basis, with psychological stress or trauma triggering the disorder. Treatment of the disorder is particularly difficult because patients commonly believe they are afflicted by a malady that is physical, not psychological, and thus may resist psychological therapy (Krull & Schifferdecker, 1990).

Freud explained such cases through his theory of the unconscious. The unconscious mind, according to the founder of psychoanalysis, holds repressed ideas that the physical symptoms symbolically represent. A repressed traumatic memory that involved the use of one’s hand, for example, might cause a hand paralysis.

Today, most psychologists do not endorse Freud’s explanation of the disorder. In fact, some question the entire existence of conversion disorder. They say patients might be faking their symptoms to get attention from others, or might be overly sensitive to minor physical symptoms with ordinary medical causes. Recent brain-imaging evidence, however, may quiet the skeptics.

CONVERSION DISORDER AND BRAIN RESEARCH. Researchers (Voon et al., 2010) studied patients with motor conversion disorder, in which the symptoms are motor movement disorders (e.g., muscular shaking) with no medical explanation. They compared them with a control group of psychologically healthy individuals lacking any sign of conversion disorder. The researchers took brain images while participants responded to a series of pictures displaying either fearful or happy human faces. Afterward, they conducted analyses to determine not only which brain regions were active during the task, but also how different regions of the brain interacted with each other during task performance.

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The results provided remarkable brain-level insight into conversion disorder. Compared with psychologically healthy participants, in the brains of people with conversion disorder there was more communication between two regions of the brain: (1) the amygdala, which is involved in the detection of emotionally relevant stimuli (see Chapter 10), and (2) the motor cortex, which controls the planning and execution of muscular movements (Voon et al., 2010). These links between emotion and motor-movement centers of the brain may be a biological basis for the unusual physical symptoms experienced by emotionally distressed people with conversion disorder.

OTHER PSYCHOLOGICAL SOMATIC DISORDERS. In DSM-5, conversion disorder is part of a broader category of disorders in which psychological factors substantially affect the experience of one’s body and potential physical illness. This broader category also includes somatic symptom disorder and illness anxiety disorder.

In somatic symptom disorder, people are excessively distressed about a physical symptom. Unlike conversion disorder, the cause of the physical symptom may be known; it may have a clear medical basis. The psychological problem is the person’s degree of reaction to the symptom. For example, a heart attack victim who has a medical prognosis predicting full recovery, but who obsessively worries about having another heart attack and substantially restricts work and social activities to avoid one, would be exhibiting somatic symptom disorder.

In illness anxiety disorder, a person is excessively distressed about his or her physical well-being even in the complete absence of physical symptoms. The disorder is present when people are highly anxious about their health and frequently check themselves for signs of illness, despite being physically fit.