LETfERS

then patient illness on therapist misconduct advances neither the goals of treatment nor feminism any further than the biases unjustifiably attributed to Dr. Gutheil. As a colleague and coauthor for more than a decade, I speak with some confidence about the lack of foundation for the accusations made against Dr. Gutheib.

REFERENCES 1. Jordan JV, Kaplan A, Miller JB, et al: More comments on patient-therapist sex (letter). Am J Psychiatry 1990; 147:129-130 2. Gutheil TG: Borderline personality disorder, boundary violations, and patient-therapist sex: medicolegal pitfalls. Am J Psychiatry

1989;

HAROLD

J. BURSZTAJN, Cambridge,

M.D. Mass.

EDITOR

dance with social stereotypes, they cultivate a “waif-like demeanor,” “manipulative skills,” and so on, which they ultimately use to their own detriment. To diminish the importance of the psychopathology involved in self-oppression, as Dr. Jordan and her colleagues do, is also to diminish the recognition of the harm experienced by women in a sexist society and, ultimately, to weaken the legitimate claims of feminists. Given this, Dr. Gutheil’s unflinching description of the role that some women patients play in becoming their own oppressors can be viewed as strengthening feminist anguments. He should be celebrated rather than scorned. PATRICIA

146:597-602

3. Illingwonth P: AIDS and the Good Society. London, Routledge, 1990 4. Reiser SJ, Bursztajn HJ, Appelbaum PS, et al: Divided Staffs, Divided Selves: A Case Approach to Mental Health Ethics. London, Cambridge University Press, 1987 S. Bursztajn HJ, Feinbloom RI, Hamm RM, et al: Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope With Uncertainty. London, Routledge (in press)

TO THE

Dr.

Gutheil

ILLINGWORTH, Montreal, Que.,

PH.D. Canada

Replies

SIR: I am delighted that at beast one reader-bike myself, feminist in orientation-has grasped the point I was driving at. While I could not have expressed the point with Dr. Illingworth’s clarity, cogency, or conceptual force, I quite agree with the implication that the critics she mentions seem insufficiently attuned to the antifeminist dimensions of their argument.

SIR: I write with respect to the recent correspondence concemning Dr. Gutheib’s article on patient-therapist sex. As a philosopher, ethicist, and feminist, I believe it is worth noting that Dr. Jordan’s view that Dr. Gutheib is guilty of blaming the victim is unfounded. Whether or not Dr. Gutheil’s descniptive claims about patients are true, it does not follow from them (logically) that he blames patients. For Dr. Gutheil to be blaming patients, he would have to add premises to his descriptive account, premises of a very different kind from the descriptive ones that he has advanced. He would have to add evaluative (normative) premises, such as 1) women patients who behave in seductive ways with their therapists act wrongly, and 2) women patients who act wrongly in therapy are blameworthy. On my reading of his article, he claims neither. To infer from his descriptions of patients that he is blaming the victim is to attribute to him views for which there is no evidence that he holds. Were we to saddle Dr. Jordan and her colleagues with the same line of reasoning that they deploy in their attack on Dr. Gutheil, the same moral indignation could be directed at them as they have directed at Dr. Gutheil. Consider the foblowing. They suggest that Dr. Gutheil should “think more about the difficulty these women have in protecting themselves from revictimization.” White South Africans defend apartheid on the grounds that black South Africans cannot take care of themselves. A similar line of reasoning was used to justify slavery in America. Furthermore, much sexism is based on the assumption that women are unable to take care of themselves. The alleged inability of people to take care of themselves has frequently been invoked to justify oppressing them. I am certain that Dr. Jordan and her colleagues do not wish to oppress the victims of sexual misconduct, but this is only because I do not infer from their descriptive claim-that the victims of sexual misconduct experience difficulty taking cane of themselves-a prescriptive claim-that their wishes ought to be discounted. Finally, it is worth mentioning that one of the points which feminist theorists have repeatedly made about sexism is that it is particularly successful in oppressing women precisely because women internalize the messages conveyed by a sexist society and become their own oppressors. That is, in accon-

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1990

THOMAS

Differential

Diagnosis

of Multiple

Personality

G. GUTHEIL, Boston,

M.D. Mass.

Disorder

SIR: In an exchange of letters to the Editor (1), J.M. Rathbun, M.D., and P.K. Rustagi, M.D., pointed out that the DSM-III-R criteria for schizophrenia can bead to the misdiagnosis of patients with multiple personality disorder because both disorders have auditory hallucinations, and Kenneth S. Kendler, M.D., and associates replied that multiple personality should be added to schizophrenia’s differential diagnosis in DSM-IV but rejected any modification of schizophrenia’s diagnostic criteria because, they said, multiple personality is a relatively rare disorder. However, it was not so long ago that child abuse was considered rare, and we might be making the same mistake with regard to multiple personality. Although most psychiatrists still think of multiple personality as a disorder that is rare but obvious, clinicians familiar with it say it is not rare, only rarely obvious (2, 3). What is indisputably rare is the psychiatrist who ever considers the diagnosis. Before I learned about multiple personality disorder, I had treated a number of these patients for years without realizing that they were examples of multiple personality. Some of them met the diagnostic criteria for schizophrenia, a disorder whose supposed prevalence has had a reciprocal relationship with the recognized prevalence of multiple personality (4). Others of these misdiagnosed patients with multiple personality seemed to have a mood disorder with psychotic features or borderline personality disorder-the other two disorders that, along with schizophrenia, appear in the DSM-III-R differential diagnosis of multiple personality. I am happy to see that Dr. Robert Spitzer, who chaired the DSM-III-R task force, thinks that multiple personality, even if assumed to be rare, belongs in the DSM-IV differential diagnosis of disordens with which it may be confused. Maybe then, with more than a rare psychiatrist considering the diagnosis of multiple personality, we’ll get a better idea of its true prevalence.

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LE1TERS

TO THE

EDITOR

REFERENCES 1. Rathbun JM, Rustagi PK: Differential diagnosis of schizophrenia and multiple personality disorder; reply of KS Kendler et al (letters). Am J Psychiatry 1990; 147:375 2. Nakdimen KA: Asking patients about symptoms of multiple personality (letter). Am J Psychiatry 1989; 146:682-683 3. Ross CA: Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment. New York, John Wiley & Sons, 1989 4. Rosenbaum M: The role of the term schizophrenia in the decline of diagnoses of multiple personality. Arch Gen Psychiatry 1980; 37:1383-1385 KENNETH

A. NAKDIMEN, M.D. New York, N.Y.

ity disorder or possession-is adequate to explain all the varieties of these phenomena. William James’s statement that a serious study of these phenomena is one of the greatest needs in psychology (2) still holds true. However, we believe that our present diagnostic classification is not adequate for a comprehensive study of these multiple identity phenomena and therefore should be revised. We also want to point out that there was a case of multiple personality reported from India (5) which was not mentioned in Dr. Adityanjee and associates’ article, bringing the total number of such cases before their own to three, instead of two as they stated.

REFERENCES Multiple

Personality

Disorder

in India

SIR: In their recent article entitled “Current Status of Multiple Personality Disorder in India” (1), Adityanjee, M.D., and associates commented on the rarity of multiple personality disorder in India, where the possession syndrome is commonly reported. In the Western world the reported incidence of these syndromes is reversed. One reason given by Dr. Adityanjee and associates for this variance is that in the West, possession syndromes may be “lumped together” with multiple personality disorder. This is probably true. Indeed, the main differences in these dissociative syndromes seem to be only in terminology and cultural and scientific beliefs. In the West the phenomenobogical similarity of possession and multiple personality disorder has bong been appreciated (2). When belief in possession was strong, cases of multiple personality disorder were probably diagnosed as possession (3). It was only when belief in possession subsided at the end of the eighteenth century that case histories labeled as multiple personality disorder began to appear in mesmerist writings and later in the medical literature (3). After this change, when nonpsychotic persons exhibited signs of possession and believed they were possessed by a spirit or other entity, they were diagnosed as having multiple personality disorder if they otherwise met criteria for this diagnosis. What then is the difference, if any, between possession and multiple personality disorder? Oestemreich (4) said that the most striking characteristic of possession is that “the patient’s organism appears to be invaded by a new personality; it is governed by a strange soul.” This description generally fits multiple personality disorder as well (3). In this disorder the personalities frequently believe that they are distinct and separate persons or entities (spirits, demons, etc.) which somehow occupy the same body. It is not uncommon for the personalities to explain this odd occurrence by the belief that they on other personalities are entities (spirits etc.) that have “possessed” the body. Furthermore, possession is subdivided into two types: lucid and somnambulistic (the person has no memory of the episode). It may be overt (manifest) or latent, involuntary (spontaneous and unwanted) or voluntary (deliberately produced and wanted). Examples of the voluntary type are some practices of shamans and spinitists/mediums (4). These terms, with the possible exception of voluntary possessive states, apply equably well to multiple personality disorder (3). Therefore, the only fundamental difference between multiple personality disorder and so-called possession may be in the voluntary type. Since it only reflects whatever belief systern happens to be current, neither term-multiple personal-

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1 . Adityanjee, Raju GSP, Khandelwal 5K: Current status of multiple personality disorder in India. Am J Psychiatry 1989; 146: 1607-1610 2. James W: The Principles of Psychology, vol 1. New York, Henry Holt, 1890 3. Ellenberger HF: The Discovery of the Unconscious. New York, Basic Books, 1970 4. Oesterrcich TK: Possession and Exorcism. Edited by Ibberson D. New York, Causeway Books, 1974 S. Stevenson I, Pasnicha 5: A case of secondary personality with xenoglossy. Am J Psychiatry 1979; 136:1591-1592 JOHN DOWNS, SHARON K. DAHMER, ALLEN 0. BATFLE, Memphis,

M.D. M.S. PH.D. Tenn.

SIR: Dr. Adityanjee and colleagues attempted to provide a valuable cross-cultural prospective on dissociative disorders. Unfortunately, the attempt failed because of a lack of diagnostic rigor. Of the three cases they presented, the second and third clearly did not meet the DSM-III-R criteria for multiple personality disorder because there was no repeated alternation of control. These cases appear appropriate for the diagnosis of dissociative disorder not otherwise specified. Given our fragmentary state of knowledge regarding the dissociative disorders, careful attention to diagnostic rigor seems indicated. J.M.

Dr.

Adityanjee

RATHBUN, Fort Wayne,

M.D. Ind.

Replies

SIR: My coauthors and I thank Dr. Downs and associates for their useful and interesting comments on differences between multiple personality disorder and the possession syndrome. Their views, indeed, are a reiteration of our earlier opinion that these syndromes reflect parallel dissociative disorders with similar etiologies despite some differences in dinicab profiles. We agree with their assertion that our present diagnostic classification is inadequate for a comprehensive study of these multiple identity phenomena and therefore needs revision. The current ambiguity is beautifully demonstrated by the position taken in DSM-III-R, which states that the belief that one is possessed by another person, spirit, or entity may occur as a symptom of multiple personality disorder. In such cases the complaint of being “possessed” is actually the experience of the alternate personality’s influence on the person’s behavior and mood. Such a position

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