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trials in homeopathy because each patient is so different and may require a different homeopathic remedy. Fisher et al's study suggests that, with careful patient selection and appropriate clinical trial methodology, it is indeed possible to initiate double-blind controlled trials which satisfy both the conventional doctor and the homeopathic physician. In all these studies homeopathic medications were used that contained no material medicines; the dilutions were below that predicted by the Avagadroo number. The conclusion one draws from these three recent studies is that homeopathy does indeed have an effect greater than that of placebo alone. Furthermore, homeopaths are capable of initiating and completing complex clinical trials to a high scientific standard. However, these studies beg a number of questions. If homeopathy is as effective as these three studies would suggest, what is its mechanism of action? If we believe conventional chemistry is the sole repository of wisdom that underpins modern pharmacology, how can we accept homeopathy? Yet, if these clinical trials are correct, modern pharmacology may yet be rocked to its foundations by researchers working

Multiple personality disorder: where is the split? The human individual is neither unitary nor internally consistent, but complex, contradictory and divided. In some cases these contradictory attitudes and behaviours may become incompatible, thereby threatening the stability and integrity of the personality. On rare occasions, stability may only be preserved by a dissociation or splitting of the personality into more stable subunits. The first report of such a case of double consciousness was published by Dr S L Mitchill of West Point Military Academy in 18161. Mitchill's report was in fact little more than hearsay, as he heard about the case from a teaching colleague who told him the strange story of a young English woman Mary Reynolds who had emigrated with her family to a rural area of Pennsylvania. In her early twenties she suddenly entered an extraordinary mental state, forgetting all ofthe details ofher life and, with a personality which was different in attitudes and temperament, began to relearn many basic skills, gradually acquiring a sophisticated and well defined second 'personality' which alternated with her previous personality until her death. Such cases were very rarely reported during the first half ofthe 19th century, but by the tur ofthe century Morton Prince was able to review a collection of 20 patients and he later published his own detailed account of the case of Christine Beauchamp2. From this time onwards most cases were reported as having more than two personalities and the condition became known as multiple personality disorder (MPD). The

in the same field of fundamental research as Beneviste.

George T Lewith Centre for the Study of Complementary Medicine 51 Bedford Place, Southampton S01 2DG

References 1 Davenas E, Beauvais F, Amara J, et al. Human basophil d0granulation triggered by very dilute anti-serum against IgE. Nature 1988;333:816-18 2 Lewith G, Brown PK, Tyrell DAJ. Controlled study ofthe effects ofhomeopathic dilution of influenza vaccine on antibody titres in man. Complementary Med Res 1989;3;22-4 3 Reilly D, Taylor M, McSharry C, Aitschison T. Is homeopathy a placebo response? Controlled trial of homeopathic potency with pollen in hay fever as model. Lancet 1986;ii:881-5 4 Ferley J, Zimirou D, D'Adhemar D, Balducci F. A in the controlled evaluation ofhomeopathic p treatment of influenza-like syndrome. Clin Pharmacol

1989;27:329-35 5 Fisher P, Greenwood A, Huskisson EC, Turner P, Belon P. Effective homeopathic treatment on fibrositis (primary fibromyalgia). Br Med J 1989;299:365-6 6 Boiron J. Une annee de recherches bio pharmacologiques. Homeopathie 1988;5:13-18

diagnosis was heavily criticized from the first case descriptions. It was commonly held that these patients were clever and suggestible 'mythomaniacs' who were capable of impressing gullible clinicians3. The past 20 years have seen a second wave of interest in MPD, with the -number of reports in the literature increasing dramatically since 1970. Bliss estimates that 300 cases have been reported in the world literature, at least 79 occurring between 1970 and 1981, but only eight cases were identifiable in the 25-year period prior to this4. Some clinicians claim to have seen hundreds of cases in their clinics. This North American 'epidemic' can be traced back to the publication of several widely publicized biographical accounts of' MPD patients and alleged multiples. The first ofthese, written by a psychiatrist and a psychologist in -1957 gives a dramatic account of the presentation and treatment of their patient in The Three Faces of Eve5. Proponents of the diagnosis of MPD attribute the increase in case reporting to greater awareness ofthe condition among professionals and greater accuracy in diagnosis following clarification of the definition of schizophrenia by DSM-I11. In order to fulfil the diagnostic criteria for MPD a subject must possess two or more 'distinct personalities' or personality states, each with its own relatively enduring pattern of perceiving, relating to and thinking about the environment and self and at least two of these personality states must take full control of the person's behaviour recurrently. According to somecritics these brief criteria are excessively vague and lack a clear definition of 'personality'7. One of the most detailed descriptions of the phenomenology of the disorder comes from an uncontrolled survey of clinicians who had at least one

Based on lecture to Section of Hypnosis & Psychosomatic Medicine, 6 November 1989

0141-0768/90/ 090544-03402.00/0 © 1990 The Royal Society of Medicine

Journal of the Royal Society of Medicine Volume 83 September 1990 545 case in therapy8. Ninety-two of 100 cases were female, their average age at diagnosis was 31 years and the average number of personalities was 13. In 85% of cases one of these personalities was that of a child. Many had personalities who were self destructive, violent, ciminal or sexually disinhibited. Amnesic barriers frequently separated personalities. The great majority of cases have complex and lengthy psychiatric histories. The average interval between first psychiatric presentation and diagnosis of MPD was 7 years. During this time patients had presented with a great variety of psychiatric and physical symptoms, including depression, anxiety, eating disorders, auditory and visual hallucinations and somatic complaints. About half had a history of 'hysterical' or 'dissociative' symptoms, including psychogenic amnesia, conversion symptoms and fugue episodes. Borderline personality disorder has been diagnosed in up to 70% ofcases. In Bliss' series of 21 DSM-m multiples, 76% qualified for designation as Briquet's syndrome or somatization disorder. Putnam acknowledges that a large number of his cases also bear a resemblance to Briquet's syndrome, but like other investigators, he proposes that once the diagnostic criteria for MPI) are satisfied, MPD should be considered the superordinate diagnosis, since working with the alternates can provide an important therapeutic device9. The complex nature of MPD has been demonstrated in results from a small number of experiments which involve serial psychological and physical investigations of cases as they change personalities. Although no specific neuroanatomical or physiological anomalies have been demonstrated, it is claimed that these investigatioiis show alternates to display variations in characteristics that are as different as those observed between separate individuals, for example, on rating scales measuring quantitative differences in mood9. Others have studied the amnesic barriers between personalities. In one such study of a patient with four personalities it was found that emotionally neutral material generalized to other personalities by a practice effect, but emotionally laden words generalized less well, implying that the different personalities were relatively independent in emotionally relevant areas'0. Prince and Peterson found variations in skin resistance response to emotionally laden words between alternates". Other differences between alternates have been found on EEG recordings (differing muscle tension and alpha background frequency), patterns of divergent eye movement12, P100, N120 and P200 components of the visual evoked response13 and in optical

functioning'4. Detailed enquiries into the background of MPD cases have provided more useful hints about aetiology than psychological or physiological investigations. Very high rates of sexual or physical abuse and neglect have been found in several studies of large numbers of patients. However, these studies have not included matched control groups. Bliss, in a series of 70 patients, estimated that 60% had been victims of sexual abuse and 40% were victims of other types of physical abuse during childhood4. Ninetyseven of Putnam's 100 patients reported a similar

experience8. How these traumatic experiences might lead to a presentation of MPD in later life is unclear. The effects of exposure to situations of extreme

ambivalence and abuse in early childhood may be coped with by an elaborate form of denial and by the protective mechanism of psychological splitting or repression. This process may be facilitated in childhood, a time when there is a rich fantasy life, often including imaginary companions. Traumatic experiences in childhood may enhance the individual's ability to dissociate. A positive correlation has been found between reporting of strict discipline and punishment in childhood and hypnotizability in adults5.- Usually hypnotizability diminishes with age, but in MPD traumatic experiences may preserve high chil-dhood scores. The role of hypnosis in the genesis of MPD remains a topic for heated debate. Bliss proposes that the MPD patient reflexly undergoes a rapid, unpremeditated withdrawal into a hypnotic trance when faced with an anxiety-provoking situation'. Putnam found that hypnosis was used to facilitate first revelation of the alternates in a minority of cases-(23%)8. However, there is scanty evidence to suggest that short-term exposure to hypnosis alone can induce well developed alternates. Experimentally induced personalities tend to be transitory and their presence does not extend beyond the hypnotic experience'6. The effects of longterm exposure to hypnosis within a clinical setting remains unknown, but there is little evidence that the therapeutic use of hypnosis is directly responsible for the disorder. Since the earliest case descriptions of dual consciousness, critics have suggested that the presentation could be strongly influenced by the clinician through selective reinforcement of certain symptoms. The scepticism of critics and the frustration of proponents of MPD were recorded by Taylor and Martin in 194417 and seem as apposite today. The issue of iatrogenicity remains unresolved. Although supporters of the diagnosis can point to the wide distribution of cases in time and place, this distribution no longer extends outside North America. Patients undoubtedly present with dual behaviour occurring before contact with a therapist and without experience of hypnosis. This behaviour, which includes mood swings, psychogenic amnesia and alterations in behaviour and attitudes, cannot easily be dismissed as a consequence of diagnostic fashion or the influence of the therapist, especially when the behaviour antedates contact with the clinician. To account for the complex presentation witnessed in these cases, an equally sophisticated theoretical framework is demanded which recognizes the importance of innate prdisposing factors, precipitating events and cultural influences which mould the final clinical presentation. The innate predisposing factors may include a greater dissociative potential, which is reflected in hypnotizability ratings. Traumatic experiences in early childhood disturb personality development and reinforce the dissociative tendency as a mechanism for resolving conflicting needs and emotions. The final presentation is a product of psychodynamic and extrinsic factors including psychosocial influences. The culture bound nature of MPD can only be adequately accounted for by recognizing the effects of the promotion ofthe disorder in the media and the subtle and possibly inadvertent reinforcement which may take place within the doctor-patient relationship. The practice of interviewing the alternates at length may add to the complexity of the disorder, as alternates acquire

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names, dates of birth and more elaborate patterns of behaviour. Whatever quibbles may be expressed about the diagnostic validity of MPD, there is undoubtedly a qualitative difference between the experiences reported by these patients and those internally inconsistent attitudes and behaviours which are a feature of all of our personalities. The pattern of episodic dissociative behaviour which is characteristic of MPD provides a fascinating opportunity to study the organization of consciousness. Future research will need to be motivated by more ambitious goals than recording an ever greater number of alternate personalities. An increasing body of evidence points to the importance of right hemispheric activation during imagery, hypnosis and dreaming'8. EEG and psychological testing have shown that the ability voluntarily to change and hold qualitatively different states of consciousness was associated with a state dependent shift in functional lateralization in a case which bore a resemblance to MPD19. Similar studies in MPD cases may advance the understanding of the physiological or neurological mechanisms of hysteria.

Thomas Fahy Lecturer in Psychiatry Institute of Psychiatry De Crespigny Park London SE5 8AF

References 1 Mitchill SL. A double consciousness, or duality of person inthe same individual. The Medical Repository 1816;3:185-6 2 Prince M. The dissociation of a personality. New York: Longmans, 1905 3 Ellenberger HF. The discovery of the unconscious. New York: Basic Books, 1970 4 Bliss EL. Multiple personality, allied disorders, and hypnosis. Oxford: Oxford University Press, 1986 5 Thigpen CH, Cleckley H. The three faces of Eve. London: Secker & Warburg, 1957

6 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. Washington DC: American Psychiatric Association,

19$0 7 Ludolph PS. How prevalent is multiple personality. Am J Psychiatry 1985;142:1526-7 8 Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM. The clinical phenomenology of multiple personality disorder: review of 100 recent cases. J Clin Psychiatry 1986;47:285-93 9 Putnam FW. Multiple personality disorder? J Clin Psychiatry 1987;48:174 10 Ludwig AM, Bradsma J, Wilbur C. The objective study of a multiple personality. Arch Gen Psychiatry 1972; 26:298-310 11 Prince M, Peterson F. Experiments in psychogalvanic reactions from co-conscious ideas in a case of multiple personality. J Abnorm Psychol 1908,3:11431 12 Condon WS, Ogston WD, Pacoe LV. Three faces of Eve revisited: a study of transient microstrabismus. J Abnorm Psychol 1969;74:618-620 13 Putnam FW. The scientific investigation of multiple personality disorder. In: Split minds split brains: historical and current perspectives. New York: New York University Press, 1986 14 Miller SD. Optical differences in cases of multiple personality disorder. J Ment Nerv Dis 1989;177:480-91 15 Nash MR, Lynn SJ, Givens DL. Adult hypnotic susceptibility, childhood punishment, and child abuse: a brief communication. Int J Clin Exp Hypnosis 1984;32:6-11 16 Kampman R. Hypnotically induced multiple personality: an experimental study. Int J Clin Exp Hypnosis 1976;3:215-27 17 Taylor WS, Martin MF. Multiple personality. JAbnorm Soc psychol 1944;39:281-300 18 Gabel S. The right hemisphere in imagery, hypnosis, rapid eye movement sleep and dreaming. J Nerv Ment Dis 1988;176:323-31 19 Gott PS, Hughes EC, Whipple K. Voluntary control of two lateralized conscious states: validation by electrical and behavioural studies. Neuropsychologia 1984;22: 65-72

Multiple personality disorder: where is the split?

544 Journal of the Royal Society of Medicine Volume 83 September 1990 trials in homeopathy because each patient is so different and may require a di...
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