When Writing Book Reviews (post 3): You don’t need to know everything in the following posts on psychiatry, but you should read them to get up to date.
March 24, 2017
American Psychiatric Revolution of 1980: USA embraces Bipolar Disorder (British) and Multiple Personality (French), but abandons Psychoanalysis (Freud)
The third edition of the psychiatric diagnostic manual, DSM-III, was published in 1980. Whereas previous editions had used psychoanalytic terms (e.g., “neurosis”) and assumed the validity psychoanalytic concepts (e.g., “repression” and “the unconscious”), the 1980 edition prided itself on its scientific objectivity. Psychoanalytic terms were no longer used; psychoanalytic theory was no longer assumed; and all diagnoses now had diagnostic criteria (a list of specific signs and symptoms).
Prior to DSM-III in 1980 (and the 1970s leading up to it), USA psychiatry had had an overly broad concept of schizophrenia. Some patients who actually had bipolar disorder (aka manic-depression) or multiple personality had been misdiagnosed as having schizophrenia.
Two events, the introduction of lithium in 1970 (to treat bipolar disorder) and a study that compared British and USA psychiatric diagnosis, convinced USA psychiatrists that they had been misdiagnosing some patients as having schizophrenia, who actually had bipolar disorder.
Another medical awakening in the 1970s was the prevalence of child abuse. Until 1970, psychiatric textbooks had stated that, literally, only one child in a million was the victim of child abuse. But now it was found to be much more common than that.
USA doctors had had blind spots for bipolar disorder and childhood trauma.
Also in the 1970s, some psychiatrists, who may have wondered what else psychiatry had missed, began to recognize cases of multiple personality and its connection to childhood trauma. I was not one of those psychiatrists. My focus in the 1970s was on bipolar disorder. I did not realize that any of my patients had multiple personality until 1986.
The reason I give credit to French psychiatry for multiple personality is that the origin of its basic concept, dissociation, is most associated with French psychiatrists like Pierre Janet (1859-1947). Unfortunately, for most of the 20th century, Janet’s concept of dissociation was eclipsed by Freud’s concept of repression. Since Freud’s concept could not explain the occurrence of even one case of multiple personality, so long as Freud was popular, the diagnosis of multiple personality would likely be missed.
However, DSM-III (1980)—and subsequent editions of the American Psychiatric Association’s official diagnostic manual (the latest edition is DSM-5, published in 2013)—do have a chapter devoted to dissociative disorders, including multiple personality (aka dissociative identity disorder), but do not have a chapter for “repression disorders,” because Janet was right and Freud was wrong.
February 5, 2016
Must literary critics know any psychiatry? Are critics incompetent if they fail to note the unacknowledged multiple personality that is present in many novels?
Acknowledged Multiple Personality
When Alfred Hitchcock directed “Psycho” and Charles Dickens wrote “The Mystery of Edwin Drood,” they assumed that everyone watching the film or reading the book would know some psychiatry: When the character’s multiple personality was finally revealed, everyone would recognize it. And any critic who didn’t recognize it would be incompetent.
Unacknowledged Multiple Personality
Novels discussed in this blog illustrate that unacknowledged multiple personality is relatively common, much more common than acknowledged multiple personality. In these works, the author hadn't intended to raise the issue of multiple personality, and it is there only because it reflects the author’s own mind and own concept of ordinary psychology.
The Critic’s Responsibility
One of the traditional responsibilities of literary criticism is to explain why a novel has the impact that it does. Unacknowledged multiple personality gives characters and plots an aura of hidden meanings and psychological depth. It is one of the things that makes a novel “serious” and “literary.” Critics should know about this.
December 8, 2014
Schizophrenia, Bipolar Disorder, Multiple Personality: Objectively, Not Emotionally, Multiple Personality is the Least Controversial
Schizophrenia and Bipolar Disorder
For more than a hundred years—and now as much as ever—there has been a scientific controversy as to whether schizophrenia and bipolar disorder are, or are not, different diseases. The four main reasons for the controversy are:
1. genetics: studies show a large overlap for bipolar and schizophrenia.
2. medication: many of the same medicines are used to treat both.
3. heterogeneous symptoms: two persons diagnosed with schizophrenia may be quite different from each other; this may also be true of two persons diagnosed as bipolar.
4. overlap of symptoms: persons diagnosed with schizophrenia or bipolar disorder may have many of the same symptoms. This is sometimes such a problem that an intermediate diagnosis, schizoaffective disorder, is used.
Why, then, don’t news stories about schizophrenia begin: “In the latest study of schizophrenia, one of the most controversial diagnoses in psychiatry…”? The reason is that it is a controversy, about which, very few people get emotional.
Multiple Personality
In contrast to schizophrenia and bipolar disorder, the symptoms used to diagnose multiple personality are not found in any other psychiatric disorder.
And whereas schizophrenia and bipolar disorder have been recognized clinical entities, reported in the medical literature, for about a hundred years, multiple personality has been a recognized clinical entity, reported in the medical literature, for at least two hundred years.
This is not to say that what is now called schizophrenia and bipolar disorder did not always exist. They probably did—although some historians dispute that they did—but they had not been considered distinct diagnoses.
And this is not say that multiple personality has only existed for two hundred years. Previously called demon or spirit possession, it had been known since antiquity.
“Controversial”
So the next time you hear multiple personality referred to as “the most controversial diagnosis in psychiatry,” you should think, “The most controversial? Compared to what?”
And you should be aware of how the word “controversy” is being used. It is being used to refer to the fact that the issue makes some people emotional.
December 4, 2016
Hearing Voices: According to clinical psychiatry, the field that knows most about it, hearing voices is typical of only two conditions — psychosis and multiple personality.
When Charles Dickens mentioned to someone that he heard the voices of his characters, he was accused of being crazy. But more than a half century later, after author interviews had become common, it was found that most authors hear the voices of their characters.
And surveys have found that a substantial minority of the general public hears voices, too.
So public opinion on hearing voices has gone from one extreme to the other. Whereas it used to be thought that hearing voices always meant that you were psychotic, now many people think that hearing voices means nothing in particular.
Whose opinion on this should you trust? Not academics (psychologists or philosophers). The discipline with most expertise on hearing voices is clinical psychiatry (and clinical psychology, etc.). Clinicians have been asking people “Do you hear voices?” for generations, and the results are in DSM-5, the latest edition of the psychiatric diagnostic manual.
In short, hearing voices (auditory hallucinations) is typically found in two conditions: 1. schizophrenia (and other psychotic disorders), and 2. multiple personality (“dissociative identity disorder”), a nonpsychotic “dissociative disorder.”
Therefore, when nonpsychotic persons hear voices, the condition that they are most likely to have is multiple personality, in which the host personality hears the voices of alternate personalities.
January 30, 2015
Failure to diagnose dissociative identity disorder is inevitable with the interview taught in American psychiatry residency training programs
Psychiatric diagnosis depends on an interview called the Mental Status Examination (MSE). Psychiatrists are not able to diagnose a disorder if the MSE fails to elicit its symptoms, its Diagnostic Criteria.
The Diagnostic Criteria for dissociative identity disorder (multiple personality disorder), found in DSM-5 (the diagnostic manual), may be abbreviated as follows:
Criterion A: alternate identities
Criterion B: memory gaps
Interviewing the “Host” Identity
Since the psychiatrist will be interviewing the patient’s “regular” or “host” identity—who is unaware of any other identities—neither the psychiatrist nor the patient (the host identity) will suspect dissociative identity disorder.
Alternate Identities Hide and Remain Incognito
Alternate identities will usually hide during psychiatric interviews. But even if an alternate identity does come out during the interview, it will not give its name or identify itself. It will answer to the patient’s regular name in order to fool the psychiatrist.
Why? Because they didn’t make this appointment. They are not the patient. And they see the psychiatrist as being an ally of the host identity in the doctor-patient relationship. Moreover, they fear that if the psychiatrist knew about them, he would try to get rid of them, out of loyalty to the host identity, his patient.
Memory Gaps as Footprints
Therefore, since the psychiatrist will not see—or at least not knowingly see—alternate identities, the key to making this diagnosis is to screen for it by getting a history of memory gaps. The host identity is usually aware of having had memory gaps, and will give that history if asked, but only if asked, because the gaps are nothing new, and the host has always tried to ignore them.
If there is a history of memory gaps—and if they have no medical or neurological cause—then the gaps may be periods of time during which alternate identities have been “out.” So getting a history of memory gaps is like finding the footprints of alters, but not the alters themselves.
The MSE and Memory Gaps
Does the traditional MSE interview ask patients if they have a history of memory gaps? Unfortunately, it does not. It evaluates short-term memory and long-term memory. It does not ask about memory gaps.
If alcoholism is at issue, the traditional MSE may inquire about alcoholic blackouts. But it fails to inquire about nonalcoholic “dry” blackouts.
The Formal Diagnosis
The diagnosis of dissociative identity disorder is not made unless and until the clinician knowingly meets, and has conversations with, the alternate identities (Criterion A), and then finds that the host identity has amnesia (memory gaps) (Criterion B) for those conversations.
However, as explained above, the diagnostic process usually starts with Criterion B (memory gaps), and eventually leads to Criterion A (alternate identities).
“But I never see that.”
When told that a colleague has made the diagnosis of dissociative identity disorder, most American psychiatrists wonder why, if it’s real, they never see it. The reason is that the traditional MSE fails to ask patients if they have a history of memory gaps.
Except for the rare cases in which alternate identities are overt in the initial interview, it is only after getting a history of memory gaps, and then finding out what caused the memory gaps, that a psychiatrist will make this diagnosis.
Most American psychiatrists think that they never see such cases, because they do not routinely ask their patients if they have a history of memory gaps.
In conclusion, to make the MSE capable of screening for dissociative identity disorder, its evaluation of memory must include memory gaps. This would require the addition of one word to the outline of the MSE taught to psychiatrists:
Traditional MSE
Memory: short-term, long-term
Revised MSE
Memory: short-term, long-term, gaps
December 6, 2013
Two Key Clues to Hidden Presence of Multiple Personality (Dissociative Identity): The Person’s Puzzling Inconsistencies and Unreported Memory Gaps
Puzzling Inconsistencies
Real people are not perfectly consistent and predictable. So fiction writers make sure to add a little inconsistency and unpredictability to help turn a “flat” two-dimensional character into a “round” three-dimensional character.
Nevertheless, real people do not act randomly. They are fairly consistent and have reasonable predictability, which is the basis for our concept that a person has a personality.
So what should we make of it if a person has puzzling inconsistencies? One possibility is that we really don't know the person very well, and they have things going on in their life that we don't know about, and these things, once known, will easily explain the inconsistencies. But what if we do know the person very well and we still find their inconsistencies puzzling?
Unreported Memory Gaps
Most people assume that if a person had memory gaps they would complain about it. And that is a safe assumption if the memory gaps are something new. But what if the person has had memory gaps since childhood? It is part of the fabric of their life. It is nothing new. For all they know, everyone else has the same thing. And so it just seems to them like something that is best to ignore. If you don’t ask them about it, they will never tell you.
Psychiatric News
American Psychiatric Association
May 04, 2007
Mental Status Exam
Kenneth A. Nakdimen, M.D.
The standard mental status exam's assessment of memory has a blind spot. It doesn't ask patients if they've had recurrent sober memory gaps (dissociative amnesia), which is often the only clue that a patient might have dissociative identity disorder (DID). It leaves it to patients to raise the issue.
Why don't undiagnosed DID patients bring up the subject of their memory gaps? First, they don't know its clinical significance (that these might be times that other identities were "out"). Second, they are generally unaware that they've lost time, except when something embarrassing, confusing, or disturbing confronts them with the fact, and they don't like to think about it. Third, they're afraid that telling people they have memory gaps—periods of time they don't remember and when they're not in control of their own behavior—might make people think they're "crazy."
Why do clinicians need a "clue" (memory gaps) to the presence of DID? What's the mystery? When DID is present, isn't it obvious? If you've ever seen an interview of a known DID patient, weren't the switches from one identity to another something you couldn't miss?
Actually, what you see in such an interview is the postdiagnosis picture, not how DID presents. Prediagnosis, alternate identities usually answer to the patient's regular name, because they prefer to remain incognito. They lose that reticence once diagnosis has blown their cover, but all that you would have found prediagnosis (if you had inquired) were memory gaps.
Once you discover that your patient does have a history of memory gaps, you can ask about these episodes. For example, after some gaps, a patient finds poems. She agrees that nobody else could have written these poems (which she found among her personal papers), but she doesn't remember writing them; they don't express her views, and they're not even in her handwriting.
Keeping the interview focused on these poems will eventually cause a switch to the identity who wrote them. You might ask this identity why she writes poems, her age, and her name. If you then turn the focus away from the poems, or simply address the patient by her regular name, you will prompt a switch back to the regular identity, who has amnesia (a memory gap) for your conversation with the poetry-writing identity.
The standard mental status exam does not now, but should, screen for memory gaps (dissociative amnesia). Otherwise, when it comes to diagnosing DID, the clinician will be clueless.
May 6, 2017
Harvard Review of Dissociative Identity Disorder (Multiple Personality): Not Fad, Not Cultural, Not Rare, Not Iatrogenic, Not Borderline, Not Temporary.
Harvard Review of Psychiatry. 2016 July; 24(4): 257-270.
“Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder”
Bethany L. Brand, PhD, Vedat Sar, MD, et al.
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