New Edition of MacKinnon, Michels, Buckley The Psychiatric Interview in Clinical Practice fails to integrate its new chapter on multiple personality

Having read the first edition of this book back when I was in psychiatric training, I was curious to see how it has evolved, especially since the new edition includes a chapter on multiple personality for the first time.

The first thing I noticed was that the three editors, who wrote most of the twenty-one chapters, had to get someone else to write the chapter on multiple personality. Evidently, their approach to the psychiatric interview has prevented them from having sufficient experience with this diagnosis.

Two problems with their approach are that they don’t ask patients if suicide attempts are remembered, and they don’t know that some nonpsychotic people, such as those with multiple personality, may hear voices.

Suicide Attempts

In the chapter on interviewing the multiple personality patient (by Brad Foote, M.D.), a case begins as follows:

“A single mother in her twenties presented for treatment after hospitalization for a suicide attempt…The clinician…noted that the patient was never able to give a detailed account of the attempt…” and further noted “subtle discontinuities in conversations in sessions in which the patient, who was intelligent and alert, would seem confused as to what was being discussed. Finally, at one of these junctures, the clinician asks the patient if she remembered what they had just been discussing. The patient replies ‘of course,’ but when the clinician follows up…she admits that she cannot remember” (1, p. 386). After discovering the patient’s memory gaps, her alternate personalities are eventually found and the correct diagnosis made.

The key to making the correct diagnosis was the clinician’s interest in whether the patient actually remembered her suicide attempt, or, instead, had a memory gap. This is something that the editors of this book (and most other psychiatrists) don’t ask about, as indicated by its omission from the editors’ chapter on interviewing the depressed patient (including suicidal issues).

You have to ask if the patient actually remembers, and doesn’t just know of, her suicide attempt. Patients may know of their suicide attempt by making inferences from circumstantial evidence (e.g., a bandage, or what other people have said). But does she actually remember all the details (both subjective and objective) that she would remember if she were the personality who did it?

You might wonder why, if a patient did have memory gaps, the clinician couldn't depend on the patient to complain about them. Why does the clinician have to ask? Because what happens during a memory gap is none of the “host” personality’s business. It is the business of the alternate personality who was out during that time. Moreover, the host personality has been having memory gaps since childhood; they make no sense to the host personality; nothing can be done about them; so they are just something that the host personality tries to ignore.

Hearing Voices

The editors say, “One would no more ask an obviously nonpsychotic patient if he hears voices than ask an obviously comfortable medical patient if he is in great pain” (1, p. 57). This is wrong in two ways. First, there are some psychotic patients whose psychosis will not be recognized unless you screen even seemingly nonpsychotic patients. Second, there are truly nonpsychotic people who do hear voices, such as people with multiple personality, who sometimes hear the voices of their alternate personalities speaking from behind the scenes. Indeed, one reason for a clinician to suspect multiple personality is the finding of superficially psychotic symptoms in a person who functions and relates too well to be psychotic.

In conclusion, I am happy to see a chapter on multiple personality in a book where it was previously ignored, but I hope that the next edition will integrate that chapter with the rest of the book.

1. Roger A. MacKinnon MD, Robert Michels MD, Peter J. Buckley MD. The Psychiatric Interview in Clinical Practice, Third Edition. Arlington VA, American Psychiatric Association Publishing, 2016.