Dissociative Identity Disorder: The People Inside

George is the tough guy.
Sandi is the terrified four-year-old.
Joanne is the outgoing adolescent.
Elizabeth knows them all.
Julia - who is all of them - knows none.

Julia Wilson* keeps a clock in every room of her house. When she looks at her watch, she checks not only the time but the date, to make sure that she has not somehow lost an entire chunk of her life.

Julia is, in novelist Kurt Vonnegut's phrase, "un-struck in time." "Since I was three or four," she says, "I've lost time. I remember being in the third grade, for instance, and I remember going back after Christmas break, and the next thing I knew it was fall, around October, and I was in the fifth grade."

Recounting the story now, two decades later, there is bewilderment and not-quite-subdued panic in her voice. "I knew who my teacher should have been, and I wasn't in her classroom," she says. "Everyone was working on a report, and I had no idea what I was supposed to be doing.

"I remember another time, eleven or twelve years ago," she recalls. "I was sitting in a kind of scummy bar, the kind of place I don't frequent. And I was talking to this guy, I had no idea who he was, but he seemed to know me a whole lot better than I knew him. It was, 'Whoa, get me out of here.' Believe me, this is not a relaxing way to live."

The fear of falling down one of those memory holes has become a preoccupation. "I might go home today and find out that my daughter, who is nine, graduated from high school last week," she says. "Can you imagine living your life that way?"

Julia is only now finding out how she loses time, and why. Her story is so strange that she herself is alternately fascinated and appalled by it. Julia has multiple personalities: She harbors within herself scores of alter egos. Some are aware of one another; some are not. Some are friendly; still others are murderously angry with Julia and leave signed notes threatening to cut and burn her.

For centuries, doctors have written up case histories that sound uncannily like Julia's. But it was only in 1980 that the bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders, first recognized multiple personalities as a legitimate illness.

The condition is still far from the medical mainstream. Part of the problem is that it is too glitzy for its own good, too easy to write off as more suited to Hollywood and Geraldo Rivera than to serious clinicians and scientists: In a single human being, we are told, there might be both female and male personalities, right-handers and left-handers, personalities allergic to chocolate and others unaffected by it.

Just as the symptoms strain credulity, the cause, too, is almost beyond imagining. Nearly always, people who develop multiple personalities were subjected to horrifying abuse as children. Therapists recount one case after another of children tortured - for years - by parents, or siblings, or cults. The abuse is typically far worse than "ordinary" child abuse: These children were cut or burned or raped, repeatedly, and had no place they could see refuge.

Almost every therapist who has diagnosed a multiple personality was blinded at first by skepticism of ignorance. Robert Benjamin, a Philadelphia psychiatrist, recalls a woman he'd been treating ten months for depression. "Every now and again, she'd have slashed wrists. I'd ask how that happened, and she'd say, 'I don't know.'

"'What do you mean, you don't know?'
"'Well,' she'd say, 'I don't know. I certainly wouldn't do something like that. I'm a proper schoolteacher. And by the way, I find these strange clothes in my closet, outfits I wouldn't be cought dead in, and there are cigarette ashes in my car.'
"'What's so strange about that?'
"'I don't smoke,' she'd say, 'I'm on the Pennsylvania Turnpike halfway to Pittsburgh, and I don't know what I'm doing here.'

And then a couple of weeks later," Benjamin goes on, "a young woman walked into my office who looked like my patient, except she was dressed like a streetwalker, with a cigarette hanging out of her mouth. I knew my patient didn't smoke, and then I had my brilliant diagnostic moment. She looked at me and said, 'Well, dummy, have you figured out what's going on yet?"

He was so slow to catch on, Benjamin says, because he'd had drummed into him the old medical saying, "If you hear hoofbeats, think horses, not zebras. "But, precisely because the disorder is exotic, the diagnosis remains controversial. Even the harshest critics concede that some people have multiple personalities, but they insist that bedazzled therapists incorrectly slap the label on every confused patient who comes through the door.

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Before 1980, when the condition made it into the psychiatrists' handbook, the total number of cases ever reported was about 200: the number of current cases in North America is about 6,000, according to one expert. Does that support the fad theory? Or does it reflect a new awareness that a real disorder was long overlooked, that sometimes what sounds like a horse really is a zebra?

Julia is 33, an articulate, college-educated woman. She is pretty, with delicate features and light brown hair pinned up on top of head. She seems nervous, though no more skittish than many people; this is a woman you would be glad to sit next to on the bus, or chat with in line for a movie.

We met at the office of her therapist, Anne Riley. Julia and I were at either end of a brown corduroy couch, with Riley in a chair in front of us. Julia sat smoking and drinking one Diet Pepsi after another, trying to convey to me some sense of what her days are like.

Listening to her was like reading a novel whose pages had been scattered by the wind and then hastily gathered up - the individual sections were clear and compelling, but chunks were missing and the rest hard to put in order. What was most disorienting was her feeling of not knowing firsthand about her own life. She is continually obliged to play detective.

"Sometimes I can figure out who's been 'out,'" she said. "Obviously, if I find myself curled up in a closet and crying, that's a pretty good indication it's somebody fairly young - but most of the time I just don't know what the hell's been going on. The little ones tend to do things with their hair. Sometimes I have braids or pigtails and I think, 'Patty.' If my hair is cut shorter, I know one of the guys has been out."

She recounted such stories with a kind of gallows humor, but occasionally her tone grew darker. "This gets into scary stuff," she said at one point. "I have some old scars, they've always been there, and I don't know where they came from."

Riley asked for details. "I can remember my father having razor blades," Julia said. "I remember once feeling like I was getting cut, but I'm real detached from it." Her voice had become quieter, slowing and drifting almost to a murmur.

She was silent for a moment and changed posture slightly. It was subtle and far from histrionic - she pulled a bit closer to the edge of the couch, turning slightly from me, drawing her legs under her a bit more closely, and holding both hands to her mouth. Several seconds went by.
"Who's here?" Riley asked.
A tiny voice. "Elizabeth."
"Were you listening?"
"Yeah." Long pause. "We got cut a lot, if that's what you're asking."
"You remember your dad cutting you?"
Julia shifted posture, stretching her legs out toward the coffee table and picking up her cigarettes. "He's not my dad," she spit out venomously. The voice was slightly deeper than Julia's, the tone far more belligerent.
"Who's there? George?" asked the therapist.
"Yeah." George is 33, the same age as Julia, and tough. And male.

"Can you explain what it's like for. George, being a guy?" Riley asked. "Whose body is it?"

"I don't think about it too much. I'm real glad I'm a guy. It somebody messes with me, I can hurt them more than a girl can."

George paused. "he" seemed jumpy. "People (Julia's personalities) are kind of close today. There's lots of us around.

Riley continued asking questions, but in the parade of names and references I lost track of which personality was speaking. Julia was talking in a tiny, childlike voice that I could barely pick up, though I was only three feet from her.

An ambulance in the distance sounded its siren. Julia jumped. "Why are those there?" she asked.

Riley explained, but the noise continued.

They're kind of loud," Julia whined. She seemed almost frantic.

The sirens faded, and Julia became a shade more composed. "You know what I wish?" the tiny voice asked. "I wish people would take better care of children. I don't think mommies and daddies should make 'em take off their clothes and do things. Not even if the children were bad."

"What makes you say you're bad?" Riley asked.

"I am bad. If you don't listen to people who are bigger than you, like moms and dads, that's bad."

"Sometimes you're right not to listen." Riley reassured Julia.

Then something - I'm not sure what - panicked her. She whipped her head toward me, wide-eyed like a cornered doe, and leapt off the couch we'd been sharing. She cowered on the floor in front of the office door, trembling, hands to her mouth. Her nose and cheekbones were beaded with sweat. On her face was a look of terror I'd never seen on anyone before. If this was acting, it was a performance that Meryl Streep would have envied.

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"Why is he here?" she whispered, gesturing toward me.

Riley recognized a personality named Sandi, a bright but terrified four-year-old. She explained who I was, and I mumbled a few words I hoped would be calming. A minute or two passed, and Sandi seemed more at ease. "Want me to write my name?" she asked timidly.

Still on the floor, on her hands and knees, Sandi painstakingly printed her name on a piece of paper. The letters were about half an inch tall, the stem of the a on the wrong side. "You know what?" she asked. "There's two ways to make a letter in my name." Underneath the lowercase n, Sandi carefully wrote N. "But you can't write both kinds of 'Sandi' at the same time."

After a few minutes more, Sandi ventured back to the couch to show me her writing. Riley told her that it was time to speak with Julia again.

I was taking notes, not watching, and I missed the switch. But there, sharing the couch with me again, was Julia. She seemed a bit befuddled, the way someone does when you wake her, but she knew me and Riley and where she was. "You've been gone a couple of hours," the therapist said. "Do you remember? No? Let me tell you what happened."

Frank Putnam, a psychiatrist at the National Institute of Mental Health and perhaps the leading authority on multiple personalities, lists three rules of thumb: The more abuse the patient endured, the more personalities: the younger the patient when another personality first appeared, the more personalities; and the more personalities, the longer the time needed in therapy.

Personalities, he explains, often see themselves as different in age, appearance, and gender, somewhat the way a woman with anorexia sees her skinny body as grotesquely fat. They seem unable to grasp that they share one body. Julia finds notes in her home, written in different handwriting and signed by various of her personalities: "I hate Julia so much. I want her to suffer. I'll cut her when I can. you can count on it."

A multiple may have as few as two and as many as hundreds of personalities. The average number is 13. Sybil, the woman portrayed in the movie by same name, had 16; Eve according to her autobiography, had not "three faces" but 22. Anne Riley says Julia has close to a hundred personalities. Multiples can sometimes control switches between personalities, particularly once they have become aware of their alter egos through therapy. Some switches are akin to flashbacks, panic reactions triggered by a particular memory or sight or sound, such as the siren that rattled Julia. Other switches are protective, as if one personality had handed off to someone better able to cope.

Surprisingly, many people with multiple personalities do fairly well in the workaday world. "There's a lot going on beneath the surface, but if it's so far beneath that it's not perceived, then for all practical purposes things are going along smoothly," says psychiatrist Richard Kluft of the Institute of Pennsylvania Hospital. A stranger would be unlikely to notice anything amiss. Spouses or children often think something is very strange, but have no explanation for what they see. "Once you've described the diagnosis to the family," says Putnam, "they call up for a week rattling off incident after incident that suddenly makes sense."

One multiple in six has earned a graduate degree. Some work as nurses, social workers, judges, even psychiatrists. Julia, who is not working now, was a drug abuse and alcoholism counselor for a time. In many cases, the personalities "agree" to cooperate, striking such deals as that the "children" will stay home and the "grown-ups" go to work.

In fact, personalities typically have specific roles and responsibilities. Some deal with sex, some with anger, some with child-rearing. Others are "internal administrators," deciding which personalities are allowed "out," which have access to various bits of information, and which are responsible for memories of trauma. Often, it is the administrator who holds down the person's job. The administrators, Putnam says, come across as cold, distant, and authoritarian, intentionally aloof to keep anyone from coming close enough to find out about the other selves.

All multiples have a "host," the personality they most often present to the world outside the workplace. The host usually does not know about the other selves, though there is often one personality who does. Julia is the host, and her memory is packed with holes, while Elizabeth, the first of Julia's personalities I met, knows everyone. Elizabeth once put together a list for Anne Riley headed "Inside People." It filled a sheet of notebook paper and read like the cast of a large play: Susan, 4, very timid; Joanne, 12, outgoing, deals with school: and so on. A few have last names, too, and some have only labels, such as "Noise."

Nearly all multiples have child personalities, like Julia's Sandi, frozen in time at the age that some trauma occurred. Most have a protector personality, often a male if the patient is female, as in the case of Julia's George, who emerges in response to threats of danger. The threat could be real - a mugger - or it could be mistaken - a stranger innocently approaching to ask for directions.

Harder to understand, many multiples have a persecutor personality who is at war with them. Julia's threatening notes are written by persecutors. The danger is real. Most people with multiple personalities attempt suicide or mutilate themselves. Julia has "come to" to find herself bleeding from rows of self-inflicted razor wounds. "Multiples seem to teeter continuously on the brink of disaster." Putman says.

Strangely enough, some personalities seem to differ physically. For example, in a survey of 92 therapists who had treated a total of 100 multiple personality cases, nearly half the therapists had patients whose personalities responded differently to the same medication. A fourth had patients whose personalities had different allergic symptoms.

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"I once treated a man who in almost all his personalities, except one called Tommy, was allergic to citric acid." recalls Bennett Braun of Rush-Presbyterian-St. Luke's Medical Center in Chicago. "If Tommy drank orange or grapefruit juice and stayed 'out' for a couple of hours, there would be no allergic reaction. But if Tommy drank the juice and went 'in' five minutes later the other personalities would break out in itching and fluid-filled blisters. And if Tommy came back, the itching went away, though the blisters remained."

Some researchers have tried to verify such differences with controlled experiments. Scott Miller, a psychologist in Cathedral City, California, has just completed a careful, but limited, study of vision in multiple personalities. Miller recruited nine patients who were able to switch to any of three alternate personalities at will. His control group, nine normal volunteers, was sown the movie Sybil as well as videotapes of actual patients switching personalities, and told to fake the disorder.

An ophthalmologist, not told who was who, gave all 18 a standard eye exam. He held up different lenses, and each subject eventually settled on the best correction. Then the ophthalmologist left the room, the patient switched personality (or the faker faker pretended to), and the doctor returned to administer new tests.

When the real patients switched from one personality to another, they showed marked and consistent changes in vision. The fakers did not. Other findings were even more curious. One multiple had a four-year-old personality with a "lazy eye" an inward-turning eye. The problem is common in childhood and usually outgrown. The same women's 17 and 35-year-old personalities revealed no sign of the lazy eye, not even the residual muscle imbalances that one might expect. But Miller acknowledges that his findings are not airtight. He chose subjective measurements ("Is this better, or this?"), for example, rather than objective ones such as the curve of the cornea.

Putnam believes these physical differences may not be so inexplicable as they seem. "People look at the brain scans of multiples' personalities and say, 'See, they are so different they're like different people,'" he says. He draws a long, exasperated breath. "It's not true. They're not different people- they're the same person in different behavioral states. What makes multiples different is that they move between states so suddenly. Normal people might show similar abrupt physiological shifts, if you could catch them at the right times. "An example: You're calmly listening to your car stereo when a tractor trailer cuts in front of you on the freeway; you slam on your brakes and your blood pressure and adrenaline skyrocket.

But why all the personalities? "Their basic coping strategy has been 'divide and conquer,'" Putnam says. "They cope with the pain and horror of the abuse they suffered by dividing it up into little pieces and storing it in such a way that it's hard to put back together and hard to remember."

Multiple personality disorder is an extreme form of what psychiatrists call dissociation. The term refers to a kind of "spacing out," a failure to incorporate experiences into one's consciousness. At one end of the spectrum are experiences as common and innocuous as daydreaming or "highway hypnosis," where you arrive home from work with only the vaguest memory of making the drive. At the other extreme lie multiple personality and amnesia.

Dissociation is a well-known reaction to trauma. In memoirs recalling his experiences as a prisoner in Dachau and Buchenwald, for example, the psychologist Bruno Bettelheim wrote of his and his companions' reaction after being forced to stand outdoors through a night so cold that 20 men dies. "The prisoners did not care whether the SS shot them: they were indifferent to acts of torture.... It was as if what was happening did not 'really' happen to oneself. There was a split between the 'me' to whom it happened, and the 'me' who really did not care and was just a vaguely interested, but essentially detached, observer."

In multiple personality cases, the trauma is most often child abuse of a sort that is far more sadistic and bizarre than usual. Some children exposed to overwhelming violence in wartime have also developed multiple personalities. Cornelia Wilbur, the psychiatrist who treated Sybil, reported one case, for example, where a man buried his nine-year-old stepson alive, with a stovepipe over his face so he could breathe. The man then urinated through the pipe onto the boy's face.

According to Julia's therapist Anne Riley, both Julia's mother and father, and a brother, abused her physically and sexually for many years. Riley doesn't go into details. "I don't consider that I've led a sheltered life - for six years I was a Washington, D.C. cop, specializing in child abuse - but I had no inkling that anything like this existed."

Age is a key to multiple personality. The trauma at its roots occurs during a window of vulnerability that extends to about age 12. One proposed explanation of why age makes a difference is that it takes time for infants and children to develop an integrated personality. They have fairly distinct moods and behaviors and make abrupt changes from one to another - a happy baby drops his rattle and instantly begins howling in misery. "We all come into the world with the potential to become multiples," Putnam suggests, "but with hallway reasonable parenting, we learn to smooth the transitions and develop an integrated self. These people don't get a chance to do that."

Another part of Putnam's theory holds that the personalities are outgrowths of the imaginary companions of childhood. Think of the incentive for a trapped and tormented six-year-old to try to foist the pain onto an imaginary companion. The child could tell herself, in effect, "This didn't really happen to me. It happened to her." Then because the abuse occurs again and again, the child may come to depend on these alter egos. In time, the personalities might take on "lives" of their own.

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Originally, the "splitting" into different personalities helps the child survive. But as it becomes the routine response to crisis, even in adult life, what was formerly life-saving becomes life-threatening.

Some Therapists believe that the incidence of the disorder has been wildly exaggerated. They propose a simple explanation - faddism - and a more complex one: They say the multiple personality diagnosis represents self-deception on the part of both patient and therapist. "We're all different people in different situations," says Eugene E. Levitt, a clinical psychologist at the Indiana university School of Medicine. "You're one person with your wife, an entirely different person with your mother, still another person with your boss.

"A person may be unaware that he turns different facets of his personality to different people," Levitt says. "The man who comes home and domineers over his wife doesn't realize or doesn't want to realize, that he cringes before his boss."

The goal of therapy, Lefitt says, is to help patients discover and face up to the sides of their characters that they would rather deny. But some patients' personalities as if each were a separate person. And this can unwittingly encourage patients to believe there are independent "personalities" that are beyond their control. Levitt also points out that the overwhelming majority of therapists have never encountered a multiple personality, while a few diagnose such cases regularly.

One skeptic says, "It's the cop-out of the eighties. It used to be, 'The devil made me do it,' and 'Demon rum made me do it.' Psychiatry had gotten away from demons, and now we've got'em back."

The defenders of the multiple personality diagnosis concede that everyone has many sides and many moods. That's why "you're not yourself today" is a cliché. The difference between healthy people and multiples, they say, is that healthy people have little problem accepting that they're sometimes angry, sometimes sad, and so on. We have a continuous stream of memories that provides a feeling that all those selves are "me".

People with multiple personalities, in contrast, have disowned parts of themselves. "If you've been raped daily by your daddy," says Robert Benjamin, the Philadelphia psychiatrist, "you can't feel just normally ambivalent about your father. you either say. 'My father is a monster,' which is unacceptable, because it shatters your image of your family, or you say, "I can't think anything but good about my father, and the parts of me that think my father is a monster, I don't want to hear from.'"

It may be impossible to know whether therapists are over diagnosing multiple personality, but it is known that people have fooled therapists by faking the illness. In the most notorious case, Kenneth Bianchi, the Hillside Strangler, tried unsuccessfully to beat a murder rap on the grounds that he shouldn't be held responsible because he had an alternate personality who had done the killing. Four therapists examined him: three decided he wasn't a multiple, but one still believes he is. Police evidence eventually showed that he is not.

Under any circumstances, the diagnosis can be hard to make because people with multiple personalities work so hard to cover up. Patients wander through the mental health system for an average of seven years before being accurately diagnosed. On the way, they pick up one label after another - schizophrenic, depressive, manic depressive.

During her teens Julia saw a psychiatrist for depression. "He just told me that all teenagers have their issues and that I came from a very upstanding family," she says. She tried to commit suicide at 15, by swallowing sleeping pills. She steered clear of the mental health system after that, but was finally diagnosed about five years ago, after she checked herself into a hospital, hallucinating that she was being chased by neon orange spiders. A resident made the diagnosis when, in the middle of an interview, Julia suddenly said, "I can tell you some things about what's going on, I'm Patty."

Most cases, like Julia's, are diagnosed at around age 30. It's not clear why things go wrong then. It may be that the person becomes more conscious of episodes of lost time; it may be that the multiple's defense system erodes when he or she is finally safe, away from abusive parents. In many cases, some new trauma precipitates a breakdown. A rape, for example, may trigger a flashback to childhood abuse. Often, the death of an abusive parent unleashes a welter of conflicting emotions and leaves the multiple in chaos.

For both patients and therapists, treatment is a long and harrowing ordeal. The first hurdle is that patients with multiple personalities all had their trust violated when they were young, and are therefore wary of confiding in any authority figure. They have had a lifetime's practice in keeping secrets from themselves and others, and that practice is hard to change. And the treatment itself is painful: the key, says Putnam, is exhuming, reliving, and accepting the original trauma, and that obliges the patient to confront terrifying, repulsive, and deeply hidden memories.

Patients have two or three sessions a week of therapy, usually for three years or more. Hypnosis is useful, especially in dredging up painful memories. The goal is to transfer the traumatic memories across the boundaries separating the personalities, to make the pain more bearable by sharing it.

If that happens, the separate personalities can fuse together, with the more similar ones being the first to merge. But nothing is simple. Often when the therapist thinks he or she has met all the personalities, new ones seem to emerge, as if from hiding. And once they are fused, more therapy is needed to develop some way other than "splitting" to cope with problems.

The prognosis for multiple personality is fairly encouraging, though few good follow-up studies of treatment have been carried out. Kluft, one of the most esteemed therapists in the field, has reported a success rate of 90 percent in a group of 52 patients. He calls treatment successful if a patient shows no signs of multiple personality in the two years following the end of therapy.

After bad experiences with another therapists, Julia has been seeing Riley for two and a half years. She talks about the prospect of integrating her various personalities wistfully, but without much hope. "In my better moments I say, 'You should be damned proud you've survived, don't let the bastards win now,'" she says, "But my idea of myself is very disjointed and that's really frightening.

"I don't have a history," she goes on. "Not just for the bad things, but for the accomplishments, too. I was in the National Honor Society in high school, I had a very good college record, but I don't have any sense of pride, any feeling that I did it."

She talks as if she is at the mercy of someone with a remote control channel-changer who keeps zapping her out of one scene and into another. "If I could just lose less time," she says plaintively. "If I could just have - I hate the word - 'normal' reactions to things.

"Do you know my idea of heaven? A little room with no doors and no windows, and an endless supply of cigarettes and Diet Pepsi and ice.

No more surprises, ever.

Edward Dolnick is a contributing editor.
Hippocrates July/August 1989

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