Dissociative Disorders

43-6 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. Six months later, when he was discovered in a Chicago homeless shelter, he reported no memory of his identity or family (Stone, 2006).

Dissociation itself is not so rare. Any one of us may have a fleeting sense of being unreal, of being separated from our body, of watching ourselves as if in a movie. 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 the person’s behavior. 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.

UNDERSTANDING DISSOCIATIVE IDENTITY DISORDER Skeptics have raised serious concerns about DID. First, they 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).

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Second, note the skeptics, DID varies by culture. It is much less prevalent outside North America. 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). Such findings, skeptics have noted, point to a disorder of suggestible, fantasy-prone people created by therapists in a particular social context (Giesbrecht et al., 2008, 2010; Lynn et al., 2014; Merskey, 1992).

Third, skeptics have asked, 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 the varied “selves” we normally present—as when we display a goofy, loud self while hanging out with friends, and a subdued, respectful self around grandparents? If so, say the critics, clinicians who discover multiple personalities may merely have triggered role playing by fantasy-prone people. After all, clients do not enter therapy saying “Allow me to introduce myselves.” Rather, 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. Like actors who lose themselves in their roles, vulnerable patients may “become” the parts they are acting out. 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). People with DID exhibit heightened activity in brain areas linked with the control and inhibition of traumatic memories (Elzinga et al., 2007). Abnormal brain anatomy can also accompany DID. Brain scans show shrinkage in areas that aid memory and detection of threat (Vermetten et al., 2006).

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 unacceptable impulses. In this view, a second personality could allow 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. In this view, DID is 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 abuse, even torture, in childhood (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 skeptics who think DID is 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.”

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43-7 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

ANTISOCIAL PERSONALITY DISORDER 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 violent 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). 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 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).

UNDERSTANDING ANTISOCIAL PERSONALITY DISORDER 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). There may be a genetic predisposition toward a fearless and uninhibited life. The genes that put people at risk for antisocial behavior also increase the risk for substance use disorder, which helps explain why these disorders often appear in combination (Dick, 2007).

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Genetic influences, often in combination with negative environmental factors such as childhood abuse, family instability, or poverty, help wire the brain (Dodge, 2009). In people with antisocial criminal tendencies, the emotion-controlling amygdala is smaller (Pardini et al., 2014). The genetic vulnerability of people with antisocial and unemotional tendencies appears as low arousal. Awaiting events that most people would find unnerving, such as electric shocks or loud noises, they show little autonomic nervous system arousal (Hare, 1975; van Goozen et al., 2007). Long-term studies show that their stress hormone levels are lower than average in their early teens, before they have committed any crime (FIGURE 43.3). And children who are slow to develop conditioned fears at age 3 are in later years 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).

Traits such as fearlessness and dominance can be adaptive. If channeled in more productive directions, fearlessness may lead to athletic stardom, adventurism, or courageous heroism (Poulton & Milne, 2002; Smith et al., 2013). 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). Lacking a sense of social responsibility, the same disposition may produce a cool con artist or killer (Lykken, 1995).

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, scientists are trying to identify brain activity differences in antisocial criminals. 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). One study compared PET scans of 41 murderers’ brains with those from people of similar age and sex. The murderers’ frontal lobes, an area that helps control impulses, displayed reduced activity (Raine, 1999, 2005; FIGURE 43.4). The reduced activation was especially apparent in those who murdered impulsively. In a follow-up study, researchers found that violent repeat offenders had 11 percent less frontal lobe tissue than normal (Raine et al., 2000). This helps explain another finding: People with antisocial personality disorder fall far below normal in aspects of thinking such as planning, organization, and inhibition, which are all frontal lobe functions (Morgan & Lilienfeld, 2000). Such data remind us: Everything psychological is also biological.

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43-8 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:

A U.S. National Institute of Mental Health-funded study reported that, at some point during their lifetime, 0.6 percent of Americans 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?

UNDERSTANDING EATING DISORDERS Eating disorders are not (as some have speculated) a telltale sign of childhood sexual abuse (Smolak & Murnen, 2002; Stice, 2002). The family environment may influence eating disorders in other ways, however. For example, anorexia patients’ families tend to be competitive, high achieving, and protective (Berg et al., 2014; Pate et al., 1992; Yates, 1989, 1990). 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; Yiend et al., 2014). 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). Data from 15 studies indicate that having a gene that reduces available serotonin adds 30 percent to a person’s risk of anorexia or bulimia (Calati et al., 2011).

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But eating disorders also have cultural and gender components. Ideal shapes vary across culture and time. In impoverished countries—where plumpness means prosperity and thinness can signal poverty or illness—bigger often 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).

There is, however, more to body dissatisfaction and anorexia than media effects (Ferguson et al., 2011). Peer influences, such as teasing, also matter. Nevertheless, the sickness of today’s eating disorders stems in part from today’s weight-obsessed culture—a culture that says “Fat is bad” in countless ways, that motivates millions of women to diet constantly, and that invites eating binges by pressuring women to live in a constant state of semistarvation. One former model recalled walking into a meeting with her agent, starving and with her organs failing as a result of anorexia (Caroll, 2013). Her agent’s greeting: “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).

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The bewilderment, fear, and sorrow caused by psychological disorders are real. But as our next topic—therapy—shows, hope, too, is real.