15-19 What are dissociative disorders, and why are they controversial?

Among the most bewildering disorders are the rare dissociative disorders, in which a person’s conscious awareness dissociates (separates) from painful memories, thoughts, and feelings. The result may be a fugue state, a sudden loss of memory or change in identity, often in response to an overwhelmingly stressful situation. Such was the case for one Vietnam veteran who was haunted by his comrades’ deaths, and who had left his World Trade Center office shortly before the 9/11 attack. Later, he disappeared on the way to work. Six months later, when he was discovered in a Chicago homeless shelter, he reported no memory of his identity or family (Stone, 2006).

647

Dissociation itself is not so rare. Any one of us may have a sense of being unreal, of being separated from our body, of watching ourselves as if in a movie. Sometimes we may say, “I was not myself at the time.” Perhaps you can recall getting up to go somewhere and ending up at some unintended location while your mind was preoccupied. Or perhaps you can play a well-practiced tune on a guitar or piano while talking to someone. When we face trauma, dissociative detachment may protect us from being overwhelmed by emotion.

A massive dissociation of self from ordinary consciousness occurs in dissociative identity disorder (DID), in which two or more distinct identities—each with its own voice and mannerisms—seem to control a person’s behavior at different times. Thus, the person may be prim and proper one moment, loud and flirtatious the next. Typically, the original personality denies any awareness of the other(s).

People diagnosed with DID (formerly called multiple personality disorder) are rarely violent. But cases have been reported of dissociations into a “good” and a “bad” (or aggressive) personality—a modest version of the Dr. Jekyll–Mr. Hyde split immortalized in Robert Louis Stevenson’s story. One unusual case involved Kenneth Bianchi, accused in the “Hillside Strangler” rapes and murders of 10 California women. During a hypnosis session, Bianchi’s psychologist “called forth” a hidden personality: “I’ve talked a bit to Ken, but I think that perhaps there might be another part of Ken that … maybe feels somewhat differently from the part that I’ve talked to…. Would you talk with me, Part, by saying, ‘I’m here’?” Bianchi answered “Yes” and then claimed to be “Steve” (Watkins, 1984).

Speaking as Steve, Bianchi stated that he hated Ken because Ken was nice and that he (Steve), aided by a cousin, had murdered women. He also claimed Ken knew nothing about Steve’s existence and was innocent of the murders. Was Bianchi’s second personality a trick, simply a way of disavowing responsibility for his actions? Indeed, Bianchi—a practiced liar who had read about multiple personality in psychology books—was later convicted.

Skeptics have raised serious concerns about DID. First, instead of being a true disorder, could DID be an extension of our normal capacity for personality shifts? Nicholas Spanos (1986, 1994, 1996) asked college students to pretend they were accused murderers being examined by a psychiatrist. Given the same hypnotic treatment Bianchi received, most spontaneously expressed a second personality. This discovery made Spanos wonder: Are dissociative identities simply a more extreme version of our capacity to vary the “selves” we present—as when we display a goofy, loud self while hanging out with friends, and a subdued, respectful self around grandparents? Are clinicians who discover multiple personalities merely triggering role playing by fantasy-prone people? Do these patients, like actors who commonly report “losing themselves” in their roles, then convince themselves of the authenticity of their own role enactments? Spanos was no stranger to this line of thinking. In a related research area, he had also raised these questions about the hypnotic state. Because most DID patients are highly hypnotizable, whatever explains one condition—dissociation or role playing—may help explain the other.

Skeptics also find it suspicious that the disorder has such a short and localized history. Between 1930 and 1960, the number of North American DID diagnoses averaged 2 per decade. By the 1980s, when the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) contained the first formal code for this disorder, the number exploded to more than 20,000 (McHugh, 1995a). The average number of displayed personalities also mushroomed—from 3 to 12 per patient (Goff & Simms, 1993). This disorder is much less prevalent outside North America, although in other cultures people may be said to be “possessed” by an alien spirit (Aldridge-Morris, 1989; Kluft, 1991). In Britain, DID—which some have considered “a wacky American fad” (Cohen, 1995)—is rare. In India and Japan, it is essentially nonexistent (or at least unreported).

648

Such findings, skeptics note, point to a cultural phenomenon—a disorder created by therapists in a particular social context (Merskey, 1992). Rather than being provoked by trauma, dissociative symptoms tend to be exhibited by suggestible, fantasy-prone people (Giesbrecht et al., 2008, 2010). Patients do not enter therapy saying “Allow me to introduce myselves.” Instead, charge the critics, some therapists go fishing for multiple personalities: “Have you ever felt like another part of you does things you can’t control? Does this part of you have a name? Can I talk to the angry part of you?” Once patients permit a therapist to talk, by name, “to the part of you that says those angry things,” they begin acting out the fantasy. The result may be the experience of another self.

Other researchers and clinicians believe DID is a real disorder. They find support for this view in the distinct body and brain states associated with differing personalities (Putnam, 1991). Handedness sometimes switches with personality (Henninger, 1992). Shifts in visual acuity and eye-muscle balance have been recorded as patients switched personalities, but not as control group members tried to simulate DID behavior (Miller et al., 1991). Abnormal brain anatomy and activity can also accompany DID. Brain scans show shrinkage in areas that aid memory and detection of threat (Vermetten et al., 2006). Heightened activity appears in brain areas associated with the control and inhibition of traumatic memories (Elzinga et al., 2007).

Both the psychodynamic and learning perspectives have interpreted DID symptoms as ways of coping with anxiety. Some psychodynamic theorists see them as defenses against the anxiety caused by the eruption of unacceptable impulses. In this view, a second personality enables the discharge of forbidden impulses. Learning theorists see dissociative disorders as behaviors reinforced by anxiety reduction.

Some clinicians include dissociative disorders under the umbrella of posttraumatic stress disorder—a natural, protective response to traumatic experiences during childhood (Putnam, 1995; Spiegel, 2008). Many DID patients recall being physically, sexually, or emotionally abused as children (Gleaves, 1996; Lilienfeld et al., 1999). In one study of 12 murderers diagnosed with DID, 11 had suffered severe, torturous child abuse (Lewis et al., 1997). One had been set afire by his parents. Another had been used in child pornography and was scarred from being made to sit on a stove burner. Some critics wonder, however, whether vivid imagination or therapist suggestion contributed to such recollections (Kihlstrom, 2005).

So the debate continues. On one side are those who believe multiple personalities are the desperate efforts of people trying to detach from a horrific existence. On the other are the skeptics who think DID is a condition constructed out of the therapist-patient interaction and acted out by fantasy-prone, emotionally vulnerable people. If the skeptics’ view wins, predicted psychiatrist Paul McHugh (1995b), “this epidemic will end in the way that the witch craze ended in Salem. The [multiple personality phenomenon] will be seen as manufactured.”

649

15-20 What are the three clusters of personality disorders? What behaviors and brain activity characterize the antisocial personality?

The disruptive, inflexible, and enduring behavior patterns of personality disorders interfere with social functioning. These disorders tend to form three clusters, characterized by

A person with antisocial personality disorder is typically a male whose lack of conscience becomes plain before age 15, as he begins to lie, steal, fight, or display unrestrained sexual behavior (Cale & Lilienfeld, 2002). About half of such children become antisocial adults—unable to keep a job, irresponsible as a spouse and parent, and assaultive or otherwise criminal (Farrington, 1991). (These people are sometimes called sociopaths or psychopaths.) They may show lower emotional intelligence—the ability to understand, manage, and perceive emotions (Ermer et al., 2012). When the antisocial personality combines a keen intelligence with amorality, the result may be a charming and clever con artist—or even a fearless, focused, ruthless soldier, CEO, or politician (Dutton, 2012).

Despite their remorseless and sometimes criminal behavior, criminality is not an essential component of antisocial behavior (Skeem & Cooke, 2010). Moreover, many criminals do not fit the description of antisocial personality disorder. Why? Because they actually show responsible concern for their friends and family members.

Antisocial personalities behave impulsively, and then feel and fear little (Fowles & Dindo, 2009). Their impulsivity can have violent, horrifying consequences (Camp et al., 2013). Consider the case of Henry Lee Lucas. He killed his first victim when he was 13. He felt little regret then or later. He confessed that, during his 32 years of crime, he had brutally beaten, suffocated, stabbed, shot, or mutilated some 360 women, men, and children. For the last six years of his reign of terror, Lucas teamed with Ottis Elwood Toole, who reportedly slaughtered about 50 people he “didn’t think was worth living anyhow” (Darrach & Norris, 1984).

Antisocial personality disorder is woven of both biological and psychological strands. Twin and adoption studies reveal that biological relatives of people with antisocial and unemotional tendencies are at increased risk for antisocial behavior (Frisell et al., 2012; Tuvblad et al., 2011). No single gene codes for a complex behavior such as crime. Molecular geneticists have, however, identified some specific genes that are more common in those with antisocial personality disorder (Gunter et al., 2010). The genetic vulnerability of people with antisocial and unemotional tendencies appears as a fearless approach to life. Awaiting aversive events, such as electric shocks or loud noises, they show little autonomic nervous system arousal (Hare, 1975; van Goozen et al., 2007). Long-term studies have shown that their levels of stress hormones were lower than average when they were youngsters, before committing any crime (FIGURE 15.12). Three-year-olds who are slow to develop conditioned fears are later more likely to commit a crime (Gao et al., 2010). Other studies have found that preschool boys who later became aggressive or antisocial adolescents tended to be impulsive, uninhibited, unconcerned with social rewards, and low in anxiety (Caspi et al., 1996; Tremblay et al., 1994).

650

Traits such as fearlessness and dominance can be adaptive. In fact, some argue that psychopaths and heroes are twigs off the same branch (Smith et al., 2013). If channeled in more productive directions, fearlessness may lead to star-level athleticism, adventurism, or courageous heroism (Poulton & Milne, 2002). One analysis of 42 American presidents showed that they scored higher than the general population on such traits as fearlessness and dominance (Lilienfeld et al., 2012). Consistent with evidence that such traits can run in families, two of the most fearless and dominant presidents were distant cousins with the same last name: Roosevelt. (Two of the least fearless and dominant presidents were a father and son, John Adams and John Quincy Adams.) Lacking a sense of social responsibility, the same disposition may produce a cool con artist or killer (Lykken, 1995).

Genetic influences, often in combination with child abuse, help wire the brain (Dodge, 2009). In people with antisocial criminal tendencies, the emotion-controlling amygdala is smaller (Pardini et al., 2013; Yang et al., 2010). The frontal lobes are also less active, as Adrian Raine (1999, 2005) found when he compared PET scans of 41 murderers’ brains with those from people of similar age and sex (FIGURE 15.13). This area of the cortex helps control impulses. The reduced activation was especially apparent in those who murdered impulsively. In a follow- up study, Raine and his team (2000) found that violent repeat offenders had 11 percent less frontal lobe tissue than normal. This helps explain why people with antisocial personality disorder exhibit marked deficits in frontal lobe cognitive functions, such as planning, organization, and inhibition (Morgan & Lilienfeld, 2000). Compared with people who feel and display empathy, their brains also respond less to facial displays of others’ distress, which may contribute to their lower emotional intelligence (Deeley et al., 2006).

A biologically based fearlessness, as well as early environment, helps explain the reunion of long-separated sisters Joyce Lott, 27, and Mary Jones, 29—in a South Carolina prison where both were sent on drug charges. After a newspaper story about their reunion, their long-lost half-brother Frank Strickland called. He explained it would be a while before he could come see them—because he, too, was in jail, on drug, burglary, and larceny charges (Shepherd et al., 1990). The genes that put people at risk for antisocial behavior also put people at risk for substance use disorders, which may help explain why these disorders often appear in combination (Dick, 2007).

Genetics alone do not tell the whole story of antisocial crime, however. In another Raine-led study (1996), researchers checked criminal records on nearly 400 Danish men at ages 20 to 22. All these men either had experienced biological risk factors at birth (such as premature birth) or came from family backgrounds marked by poverty and family instability. The researchers then compared each of these two groups with a third biosocial group (people whose lives were marked by both those biological and social risk factors). The biosocial group had double the risk of committing crime (FIGURE 15.14). Similar findings emerged from a famous study that followed 1037 children for a quarter-century: Two combined factors—childhood maltreatment and a gene that altered neurotransmitter balance—predicted antisocial problems (Caspi et al., 2002). Neither “bad” genes alone nor a “bad” environment alone predisposed later antisocial behavior. Rather, genes predisposed some children to be more sensitive to maltreatment. Within “genetically vulnerable segments of the population,” environmental influences matter—for better or for worse (Belsky et al., 2007; Moffitt, 2005; Pluess & Belsky, 2013).

651

With antisocial behavior, as with so much else, nature and nurture interact and the biopsychosocial perspective helps us understand the whole story. To explore the neural basis of antisocial personality disorder, neuroscientists are trying to identify brain activity differences in criminals who display symptoms of this disorder. Shown emotionally evocative photographs, such as a man holding a knife to a woman’s throat, criminals with antisocial personality disorder display blunted heart rate and perspiration responses, and less activity in brain areas that typically respond to emotional stimuli (Harenski et al., 2010; Kiehl & Buckholtz, 2010). They also have a larger and hyper-reactive dopamine reward system, which predisposes their impulsive drive to do something rewarding despite the consequences (Buckholtz et al., 2010; Glenn et al., 2010). Such data provide another reminder: Everything psychological is also biological.

15-21 What are the three main eating disorders, and how do biological, psychological, and social-cultural influences make people more vulnerable to them?

Our bodies are naturally disposed to maintain a steady weight, including stored energy reserves for times when food becomes unavailable. But sometimes psychological influences overwhelm biological wisdom. This becomes painfully clear in three eating disorders.

652

A U.S. National Institute of Mental Health-funded study reported that, at some point during their lifetime, 0.6 percent of the Americans studied had met the criteria for anorexia, 1 percent for bulimia, and 2.8 percent for binge-eating disorder (Hudson et al., 2007). So, how can we explain these disorders?

Eating disorders do not provide (as some have speculated) a telltale sign of childhood sexual abuse (Smolak & Murnen, 2002; Stice, 2002). The family environment may provide a fertile ground for the growth of eating disorders in other ways, however.

Those with eating disorders often have low self-evaluations, set perfectionist standards, fret about falling short of expectations, and are intensely concerned with how others perceive them (Brauhardt et al., 2014; Pieters et al., 2007; Polivy & Herman, 2002; Sherry & Hall, 2009). Some of these factors also predict teen boys’ pursuit of unrealistic muscularity (Ricciardelli & McCabe, 2004).

Heredity also matters. Identical twins share these disorders more often than fraternal twins do (Culbert et al., 2009; Klump et al., 2009; Root et al., 2010). Scientists are now searching for culprit genes, which may influence the body’s available serotonin and estrogen (Klump & Culbert, 2007). In one analysis of 15 studies, having a gene that reduced available serotonin added 30 percent to a person’s risk of anorexia or bulimia (Calati et al., 2011).

But these disorders also have cultural and gender components. Ideal shapes vary across culture and time. In impoverished areas of the world, including much of Africa—where plumpness means prosperity and thinness can signal poverty or illness—bigger seems better (Knickmeyer, 2001; Swami et al., 2010). Bigger does not seem better in Western cultures, where, according to 222 studies of 141,000 people, the rise in eating disorders in the last half of the twentieth century coincided with a dramatic increase in women having a poor body image (Feingold & Mazzella, 1998).

Those most vulnerable to eating disorders are also those (usually women or gay men) who most idealize thinness and have the greatest body dissatisfaction (Feldman & Meyer, 2010; Kane, 2010; Stice et al., 2010). Should it surprise us, then, that when women view real and doctored images of unnaturally thin models and celebrities, they often feel ashamed, depressed, and dissatisfied with their own bodies—the very attitudes that predispose eating disorders (Grabe et al., 2008; Myers & Crowther, 2009; Tiggeman & Miller, 2010)? Eric Stice and his colleagues (2001) tested this modeling idea by giving some adolescent girls (but not others) a 15-month subscription to an American teen-fashion magazine. Compared with those who had not received the magazine, vulnerable girls—defined as those who were already dissatisfied, idealizing thinness, and lacking social support—exhibited increased body dissatisfaction and eating disorder tendencies. Even ultra-thin models do not reflect the impossible standard of the classic Barbie doll, who had, when adjusted to a height of 5 feet 7 inches, a 32–16–29 figure (in centimeters, 82–41–73) (Norton et al., 1996).

653

There is, however, more to body dissatisfaction and anorexia than media effects (Ferguson et al., 2011). Peer influences, such as teasing, also matter. So does affluence, increased marriage age, and especially, competition for available mates.

Nevertheless, the sickness of today’s eating disorders stems in part from today’s weight-obsessed culture—a culture that says, in countless ways, “Fat is bad,” that motivates millions of women to be “always dieting,” and that encourages eating binges by pressuring women to live in a constant state of semistarvation. One former model told the story of how her anorexia caused her organs to fail (Caroll, 2013). Starving from not having eaten for days, she walked into a meeting with her modeling agent, who greeted her by saying, “Whatever you are doing, keep doing it.”

If cultural learning contributes to eating behavior, then might prevention programs increase acceptance of one’s body? Reviews of prevention studies answer Yes. They seem especially effective if the programs are interactive and focused on girls over age 15 (Beintner et al., 2012; Stice et al., 2007; Vocks et al., 2010).

***

A growing number of people, especially teenagers and young adults are being diagnosed with psychological disorders. Although mindful of their pain, we can also be encouraged by their successes. Many live satisfying lives. Some pursue brilliant careers, as did 18 U.S. presidents, including the periodically depressed Abraham Lincoln, according to one psychiatric analysis of their biographies (Davidson et al., 2006). The bewilderment, fear, and sorrow caused by psychological disorders are real. But, as this text’s discussion of therapy shows, hope, too, is real.

654