The Diagnosis of Multiple

Personality Disorder
Joshua D. McDavid, M.D. , M.P.H .

Abstract
This pap er represents an att empt to facilitate the clin ician or psychiat rist in making a
diagn osis ofMultiple Personali ty Disorder, the most severe ofthe dissociat ive disorders. Emphasis
w ill be pla ced on detecting signs, symptoms, and information that occur within the consti tuent part s
ofa typical psychiatric int erview, and that are high ly suggest ive qfM PD even in the absence ofalter
presentation .

Although th e fr equ ency of th e di agnosis of Multiple Person ality Di sord er (M PD)

has incr eased in th e last several years psychiatric resid en cy training pro gra ms st ill
give littl e more than cu rso ry att ention to this area ( 1,2), a nd as a result , most
psychiatrists are not trained in syst ematic ass essm ent of th e dis sociative diso rd ers.
MPD is best con ceptualized as both a co m plex, chro nic dissociative d isorde r
cha rac te rized by disturbance of identity a nd m emory (3) a nd as a post -tra u ma t ic
co ndit ion initiating from a buse or traumatic child hood expe rie nces (4) .
It has been hypothesized that dissociative stat es d evelop as prot ecti on against
overwhelming negative stimu li. Given a necessary biological di ath esis, th e pot e nti al
for autohypnosis or dissociation, th e young, growing, child may form di scr e te an d
variably " discon nec te d" stat es wh en co nfro nt ed with overwhelming traum a . T hese
stat es a re perpetuat ed by continuing a bus ive or neglecting relation ships, part icul arly
in th e a bse nce of restorative expe rie nces with a sig nifica n t ot he r or ot hers (5) .
Initially as a kind of " successfu l" ad apt ation , th e dis sociative process insures or
increases th e like lihood of t he child's survival. In other dim ensions of th e survivor 's
life, and especia lly in adulthood, th e adaptability becom es a disabilit y, impairing t he
developm ent of a uniform self- con cept and att enuating th e formation of stabl e
int erpersonal relationships.
Th e importance of making th e di agnosis of MPD is more th an just a n academic
exe rcise . Failure to make th e diagnosis resu lts in substantial morbidity an d eve n
death. Pati ents who leave treatm ent prematurely do not cease ha vin g MPD nor do es
MPD remit spon ta neo usly (3). Though th e treatm ent ca n be a rd uo us , th e pot entia l
for resolution of symptom s and improvem ent of funct ioning is real. It is not

Joshua D. McDavid, M.D., M.P.H. is a n NIMH Clinical Research Fell ow a t

Psychi atric In stitut e a nd C linic of th e U nivers ity of Pitt sburgh.

29

t he

Western

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J EFFERSO N J O URNAL OF PSYCH IATRY

un common for patient s with MPD to have bee n previously di ag nosed with schizo ph renia a nd treat ed as suc h wit h high dose neu roleptics an d adjuvants ; occasionally an
MPD patient will be det ect ed in a chro n ic ca re faci lity or eve n th e ba ck ward s of a
state hospit al (6).
The purpose of this pape r is to aid clini cia ns and psychiatrists in det ecting,
prim arily in ad u lts, MPD, t he most cli nically co m plex and dramat ic of th e di ssociative di sorders. Althou gh th e di a gn osis of MPD re q uires th e identification of a lte rn a te
personaliti es (a lte rs) this pap er will highlight th ose a reas with in a typi cal initi al
psychiatric int ervi ew th at lend th em selves to discove ry of MPD in th e absen ce of alter
presentation by identifyin g th e sym pt oms cons t it u ti ng t he po lysymptomatic cons te llation fr equ ently as sociat ed with MPD.

DIAGNOSTIC CRITERIA

Besides "the pr esen ce of oth er personalities" th e DSM-III-R crite ria have not
offered mu ch in th e way of g uide line s for diagnosin g MPD (7). It has not address ed
th e post-traumatic nature of th e di sord er, a nd th e only opera t iona lized crite rio n is
one di sso ciative symptom , person ality change . Because of th e pa ucity of cri te ria
a r ticu la te d in th e DSM-III-R, clinicians have not learned to inqui re in a way th at will
ex trica te MPD from other synd ro mes.
Althou gh th e di a gn osis requires th e ide nt ification of d ist inct personaliti es, or
a lte rs, MPD cons ists of a co ns te lla tion of non- sp ecific sig ns a nd symptom s (pol ysymptom at ology) and is relat ively pleiomorphic (8,9,10, II ). In classic MPD as defin ed by
DSM-III-R, each pe rso na lity state, as a d ist inc t ent ity, ta kes fu ll control of th e
person 's beh avio r. Cl assic MPD is pr ob abl y not as commo n as less dramatic pr esent ation s wit h less th an full con t ro l a nd di st inctness (8, 12). Various authors have
atte m p te d to conce pt ualize th e subt le g rada t ions, ca lli ng them at ypical variant s, ego
state cha nges, co-prese nces, isom orphi sm s, a nd fragm ents (8, 11,12, 13).
DSM -IV cha nges th e nam e of MPD to Di ssociat ive Id en tit y D isorde r, and it now
elim ina tes th e requirem ent of " fu ll" co nt ro l as part of th e A crit e rio n. It introduces
th e requirem ent of a m nesia as a cri terio n fo r th e d ia gn osis since evide nce sugges ts
th at it is a sym pto m in 90% of pat ien ts with t he disord er. H oweve r, wh eth er MPD
pati ents expe r ie nce form al a mnesia re mains con t rove rsia l. A new crite rion for th e
DSM -IV is: "T he in ability to recall import ant pe rson al info r m at ion that is too
ex te nsive to be ex pla ine d by ord ina ry forgetfuln ess" ( 14,15, 16). A fourth crite rion
s tat ing th at "t he di stu rb a nce is no t du e to a Substa nce-In d uced Diso rd e r" has also
been in t rod uce d ( 16).
Th e DSM is not a lone in m inimally demarcating accompa nying signs a nd
symptoms of MPD. In t he new In te rn at ional C lassification of D iseases, or ICD-I O,
MPD has not bee n list ed for mally as a diagnostic e n t ry (17) , but is subsu me d und e r
"other dissocia tive d isorders" (18) .

T HE DIAGNO SIS O F MULTIPLE PERSO NALITY DISORDER

31

C LINICAL PRESENTATION
General Considerations

Th e conce pt of " windows of d iagnosability" has be en applied to MPD becau se of

its cove r t ness a nd th e tend en cy of patients wit h th e di sord er to dis simulat e (5). Age,
ge nder, d evelopm ental hist o ry, subject ive ex perie nces, pr evious experiences with
m ent al health workers, a nd th erapi st ex pe r t ise will a ll influ ence th e express ion of
sym pto ms during a n int e rview. For exa m ple, wh e reas young children may be t he
most susce pt ible and least resist ant to early recognition of t he disorder, th eir
dissociative sym pto ms a ppea r more vague a nd fr equ ently seem to have other possibl e
di a gn oses (15,19, 20) . Ad olescents see m to be th e most complex and diverse of
pati ents with MPD a nd least like ly to reveal alt er person alit ies ( 15).
Kluft (8,15 ) rep orts th at a mo ng adults 20% of th ose with MPD resis t det ection;
50% have su st ained periods of sym pto m quiescen ce lasting so m e times a year or mor e;
a nd only a sma ll minority, 6%, are ex hibitionistic about th e disord e r. In th e co nte xt of
a risin g suspicion for th e diagnosis, he recomm ends an ex te nde d inte rview, since
spo n tane ous symptoms of dissociation may eve nt ually e me rge with fatigu e and
st ress. Ne ve r t he less, th e di a gn osis fr equ ently requires pati e nce on t he pa rt of th e
clini cian . Proper di a gn osis during th e first int ervi ew is th e exc e pt ion, an d diagnosis
m ay require week s, if not months, to det ermin e.
If MPD is sus pec te d or a polysymptom atic prese n tatio n occurs , most experie nce d clinicia ns recomm end t ha t q ues t ions pe rt ai ning to t he pr esen ce of alte rs be
rel egat ed to th e end of th e sess ion once so me rapport has been est ablished (1,9), in
orde r not to fri ght en a patient who ofte n will be revealing t he mu lti plicit y for th e first
tim e to anot he r. These patient s often suffer a pr ofoun d se nse of personal co nfus ion,
in fe riority, and wort hless ness a nd view th e worl d as fr ightening, overwhelming, a nd
unsy m pa t he t ic. Revel at ion of t he ir int ern al disorganizat ion to ot hers ca uses g rea t
distress (4) . Reluct ance t o reveal th e se lf sys te m a lso may reso nat e with the child hood
fea r of being threat ened o r bla m ed if th ey reveal th e a buse or of being accu sed as lia rs
( I I). In th e more classic form of MPD th e host or pr im ary person ali ty may not eve n
be aware of th e presen ce of alte rs a nd will d en y th eir exist e nce, a nd such a revel ation
to th e host ca n in it sel f be traum atic a nd fr igh te ning.
If th e pati ent resp onds to probing qu esti on s in a pu zzli ng or ou t of cha rac te r
way, as king if a no t he r " pe rso nality" is pres ent is th e prop e r in t e rve ntion (15) . A
negative response, however, m ay reflect denial a nd no t necessarily t he absence of
MPD. A positive resp on se sugges ts furth er inq uiry give n ade q uat e t ime a nd recog niti on th at th e disclosure co uld be de-st abilizin g a nd fri ght en ing to th e patient.
If a pol ysymptomatic pr ese nt ation occ urs t hat is suggestive of MPD th en t he
clinicia n ca n go farthe r a nd as k qu estion s a bo ut th e pr ese nc e of other "personali ti es ." T he prese nce of alters usually sett les th e diagnosis unl ess th ere is sus picio n of a
malinge ring or fact itious pa tient. Alters are more likely to em erge spont an eou sly
wh en th e pati ent is in crisis or if th e d iagnos is has been made previo us ly (9).

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The followin g qu estions a bo ut o t he r a lte rs ca n be directl y asked: H ave you eve r

been told by others th at yo u see m lik e a different person ? Have you eve r referred to
you rse lf by different nam es? Or, have you eve r ac te d in a co m ple t ely different
manner?
A cave a t to asking que stions about MPD is th e real co nce rn abo u t iatrogenesis,
suggesting or even e nc ou ra ging th e formation of alte rna te person aliti es. Al though
th ere is some evid en ce th at iatrogen esis ca n occur (3), particul arly as a result of
hypnosis , th e clinician must gu ard a gainst being too aggress ive as we ll as being to o
pa ssive in th e qu estioning. In st ead of as king pati ent s if th ey have ot her personaliti es
o r nam es, as king a bo ut wh ether th ey have oth er as pects o r parts with contradictory
or see m ing ly unknown affect s a nd ex pe rie nces m ay help to guard against thi s
dil emm a .
THE PSYCHIATRIC INTERVIEW

In spit e of th e lack of guid elines for diagnosing MPD th ere a re several broad
fa ctors that suggest MPD; these factors derive from th e natural loci of th e psychiatric
int ervi ew though th ey may em erge during a ny ph ase of th erapy. Th ese cons t ituent s
of th e int ervi ew includ e th e history of pr esent illn ess, psychi atric, medical , social a nd
developm ental hist ory, sig ns and sym pto ms, a nd th e ment a l stat us exa m .
Loewenst ein ( I) has d evised th e "sym p to m clus te r m e th od " for assessing MPD
and Dissociative Di sord ers. H e divides MPD sym pto ms into six di ffe re nt ph enom enological ca te gories . Process sym p to ms (i.e. switc h ing), co re aspec ts of a pati ent 's
multiplicity, refer to th ose sympt om s that reflect alte r transi t ion s or int eractions
between alt ers. The other clu st ers a re more familiar, though not necessarily attribut ed to MPD by clinicians unfamiliar with MPD sym pt om ex pressio n. They include
amn esia, autohypnotic, post-traumatic, somatoform, and affec tive sym pto ms .
This paper will e m phasize th ose aspect s a nd sym pto ms of MPD tha t fall within
th e fr am ework of a traditional psychi atric int ervi ew (see tabl e I).
Us ually th e clini cian or psychiatrist will not have received any advance d ir ect
indication that a patient m ay have MPD . A co m pos ite pa ti ent profile that fr equ ently
characte rizes t he pr esent ation of a " typical" MPD patient is as follows:
A 30 year old d epressed fe male with sym pto ms of a m nes ia, recurren t
suicidal ideation , se lf destructi ven ess, a hist o ry of sex ual ab use, many
psychiatric diagnoses a nd fail ed treatm ent s.
Su ch a profil e is unusual in un complicat ed a ffec t ive a nd a nx ie ty d isord er s and
psych osis. Some patient s with person ality diso rd e rs, particul arly borderli ne personality di sord er or a " hys te rica l" person ality style ca n a pproac h t he co mposi t e, a nd su ch a
profile wa r ra n ts co ns ide ra t io n of a nd investigation int o th e poss ibility of MPD .
Patient Identification and H istory ifPresent Illness

Th e sign s a nd sym pto ms of th e co m posite which j us tify pa rticula r a tte n t ion

includ e a m nes ia without obvious orga nic ex p la na t ion, cu r re n t o r past sui cid al or

T HE DIAGNOSIS OF MULTI PLE PERSO NALITY DISORDER

TABLE 1.

Factors Suggesting MPD that are Part of a Typical Psych iat ric Interview
H istor y of Presen t Illness
Sui cide a tt empts
Self-mu t ilat ion of Se lf-d est ru ction
" D espe ra te Dep re ssio n" or At ypic al a ffec t ive symptoms
Symptoms
Amn es ia
Fugue
Aud ito ry ha llucinations
Sch neide ria n symptoms
PT SD Sym ptoms (detachment, avoid an ce, re experien cin g of traum a, ni gh t m a res)
Concurrent somatic a nd psychiatric symptoms
" H yste ria "
Psych iatric Hi story
Numero us previous d iagnos is a nd treatment fa ilures Prior or C onc u r re nt Disorde r :
PT SD
Bord erline personality d isorder
Eat ing disorders
Psychoti c disorders unr esponsive to m edi cations
Somatoform disord er
Substance or Alco ho l ab use
G ender identit y di sord er
Transs exualism or Transvestism
M edical History
H ead a ches
Numerous physical co m pla in ts of sexual natur e
Un explai ned pa in , part icu la rly gyn ecologic or gas t ro in tes t ina l
Conversion ph enomenon
Fear of physical exams or rej ection of ca re
Family History
C haot ic famil y situation
Social and Developm ental H istory
Sex ual, psycho logi ca l a nd phys ica l abuse , espec ia lly rep etitive a nd fr om an ea rly a ge
History of neglect
Grossly distort ed upbringing and impov erished social network in th e a bsence of psychosis
Cu lt invo lvem en t as a young ch ild
Ego-dys tonic sexual impu lses and acting out
M ental Status Ex am
Appearance
Signs of se lf-injury
Behaviors
Int ra- in t erview amnesia
Sp ells
Spon taneo us regression
Catatonia
Odd beh avio r despit e a n apparent rel at edness to the in te rviewe r
T he us e of " we "
Spontaneo us voice or a ccent cha nges
Sudden invo luntary movements
C hanges in fac ia l mu sc ulature
Changes in ha nd ed ness

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JEFFE RSON JOURNAL O F PSYCHIATRY

TABLE 1.

Factors Suggesting MPD that are Part of a Typical Psychiatric Interview (Con t.)
Flu ctuation s in crea t ive a bilities or sty les
Handwriting cha nges
Affect a nd Mood
Dr am ati c shifts in a nxie ty o r mood
Thou ght Pro cess a nd conte nt
Pseudod elu sion s
Abn orm al se lf-co nce pt
Abnorm al bod y conce pt or image
Obsessive ideation
Marked ph ob ias
Pe rception s
Pseudoh allu cin ation
Nega t ive hallu cin ation s
Sc h ne ideria n sym pto ms
Illu sions, flashbacks , revivificati on s
D ep ersonali zation / der eali zation / marked det achm en t
Cognit ion
Psych ogen ic a mnesia
Abstracti on despi t e a ppa rent psych osis

self-d estructive behavior, a hist ory of sex ua l or ph ysical a buse, an d ext e nsiv e psychiatric hist ory . A sympt om profil e whi ch includ es so matic co m pla in ts with con comitant
psychi atric sym pt oms , or a profile sugge sting Po st-Traum atic St ress Disorder (PTSD)
with det achm ent , psychi c numbing, avoidance, incr eased a ro usal, an d flashbacks,
deserves a tte n t ion. Extrem e negative se lf-evalua t ion, di stu rba nce of in terpersona l
relation ships, co m pulsive sex uality, m anipul ativen ess, reenactmen ts, and adversari ality a re also fre q ue n t e piphe nome non of NfPD a nd severe post sexual abuse tra um a
(2 1,22).

Psychiatric H istory

The psychi atric hist ory ca n offer va luable infor ma tio n for cons ide ri ng MPD . The
two most import ant indicators a re a hist ory of many prior diagnoses and multipl e
trea tm ent fa ilu res. N u me ro us psychi at ri c hospital izat ions, us ua lly great er th an
three, a nd refract or in ess to co nventional treatm ent also may reflect undiagn osed
MPD.
A previous diag nosis of PTSD , borderline personality disorder, ge nde r iden ti ty
d isord er, intract a ble su bs tance or alco ho l ab use, sc hizoaffec t ive di sord e r, o r sch izophre nia , es pecia lly in a pa tie nt who a ppea rs to rela te well int erpe rso nally, does not
res po nd to treatm e nt, a nd ha s a hist ory of sex ua l a buse sho u ld prompt th e clin ician
to co ns ide r MPD in th e di fferential di a gn osis.

T HE DIAGNO SIS O F MULTIPLE PERSO NALITY DISORDER

35

M edical H istory

Numero us ph ysical co mplai nts ofte n accompany !\,I PD. Th e most co m mon
com pla in t is head ach es. Gas t ro int esti nal a nd sex ual symptoms, co nve rsion ph enom enon, and unex pla ine d pai n syn dromes a lso a re quit e com mo n (9). C oon s (6)
report ed th at 50% of his pa t ient s with MPD were observed with hyst erical co nversion
reacti on s. No t un com monly pat ie n ts will reex perie nc e the ph ysical se nsa tions th at
some m ist reatme n t had in still ed with out a ny co nsc ious awareness of th eir origin (3) .
These patient s ofte n have chro nic m edi cal illnesses, and they will ofte n not
pu rsu e or resist pr op e r t reatmen t. Many of th ese pati en ts will often fear ph ysical
exams a nd a re prone to vasovagal e pisodes a nd panic attacks eit he r in relation to t he
exam or ve nipu nc t ure. Th e clinicia n sho uld qu estion a ny pat ient who demonstrat es a
m arked reluct ance o r dread of a ph ysical exam.
Family H istory

Though very non-sp ecific, a pr es ent or past chaot ic fam ily si tua tion is th e most
sugges tive indicat or of MPD within th e family hist ory. I t is not unco m mo n for th ese
pati ent s to have families wit h im poverish ed rel a ti on ships an d communication net wo r ks. H eavy a nd fre q ue n t substance a buse, a crimi na l record, sexual , e mo t iona l,
a nd ph ysical a buse , infidelity, di vorce, m ulti-agency involve m e nt , and un employm ent
m ay a ll be m ani fest ation s of t he chaos . Co nverse ly, descript io ns of " t he perfect
fami ly" t hat see m too goo d to be be lievable ra ise suspicion (23) .

S ocial and Developmental H istory

Patien ts wit h MPD invariabl y have had a gross ly d istort ed upbringing, generally
wit hou t ade q ua te or consis ten t support. Int e rviews sho uld be sensitive to less
commonly ide n tified traum a tic expe rie nces such as lo ng confin em ents, excessive
e ne m as, a nd m ed ical pro cedures occurring at a n ea rly age. Kl uft (15) hypothesiz es
th at m ost of th ese pati ents while growing up had no one with whom to sec ure a
nurturing bond. Qu esti on s co nce rn ing a buse a nd neglect are mandatory parts of an y
psyc hia t ric eva lua tio n. Th e prese nce of ph ysical or sexual abuse invites inquiry into
th e pr esen ce of MPD a nd co nversely, t he pr esen ce of MPD demands inquiry int o
t raum a. Att entive obse rva tio n of pa tie nts whil e inquiring a bout ab use history is very
import ant since m an y pati ents with MPD or a n abuse history will " give th emselves
away" whe n as ked a bo u t th ese a reas . It is not un com m on to get st ra ng e or unu sual
a nswe rs to th e qu est ion s or to see incr easin g a nx ie ty, a sh udder , tremor, or a star t le
when d iscuss ing th ese a reas. Less commonly, dissociative ph enom ena su ch as switching, m icro-am nesia, or eve n spo n taneo us a lte r em e rg ence occurs. It is best not to as k
about a buse directl y as t his e licit s unwarran ted defensiven ess, but an indirect
inquiry, like, " How was discipline hand led in your famil y? How were you punish ed?
What was th e wors t thing t ha t eve r happened to you in childhood?" may elicit mo re
ge rman e informatio n. T he eva lua t or should conside r a lte r na t ive qu estions and less
direct qu es tions if a negat ive answer suggests deni al. Det ail ed qu estions ab out a bus e

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ca n a nd sho u ld be d e ferred until a mo re tru sting and sus tained r e lationship d evelop s.
It is import an t to m ention that during th erapy once a t he rapeutic a lliance ha s been
es ta blishe d qu estion s a bo u t a b use d eserve r epeat ed inquiry even if initia l negative
r esponses see med a p p ro p ri a te. Pati ent s d eny a buse for m any reasons: fear, amnesia ,
or becau se of misund erstanding abou t th e d efinition of abuse .
Finally, a na log ous to th e dil emm a di scussed a bove a bo u t as king pati ent s if t hey
hav e se para te id entiti es a nd iatrogenicall y ca us ing MPD is t he concern a bo u t
"coachi ng" a pati ent int o admitting , fal sel y or exagge ra ting, a histo ry of abu se .
Althou gh a lmos t too obvio us to sta te, coe rc io n a nd eve n suggestio n have no pla ce in a
psychi atric int ervi ew . As import ant as a n a b use histo ry may be to a pati ent 's
psych ology a nd behavior it sho u ld not be fo rgott en that a h ist ory of abuse d oes not by
it self imply pathology o r MPD , a nd ab use sho uld not be th e th e ra pis t 's prim ary focu s
or age nda without co ns ide r ing o t he r fact ors su ch as presen ti ng com pla in t, int erperso nal re la t ions hips a nd behavior, a nd th e pat ien t 's ow n pe rce ption of the issu es t hat
require focus. It m ay be impos sibl e to prevent o r imm ediat el y d et ect the patient who
d eceiv es, exa gge ra tes, or di stort s but th e probl em ca n be r educed in t he co n te x t of a
se ns it ive a nd non-judgm ental eva lua t ion, by a clinician wh o ca n ca ll on expe r ie nce
a nd judgment.

Mental Status Exam

Appearance: As a ge neral rul e d uring th e firs t interview MPD pati ent s do not
a p pear unusu al or diffe rent fr om the gre a t m aj o r it y of pa t ie n ts. T he re is a s ubse t
that m ay a p pear odd or wear mi sm atch ed o r ina p prop ria te clo t hes. On occa sion th e
clinician will obse rve ove r t sig ns o f se lf-inj ury.
O ver subse q ue n t se ssions cu r io us cha nges in a p peara nc e m ay be r ecogni zed :
sig nifica n t ly different styles of clo t h ing, hair, m ak eup , g lass es, pos tu r e, and j ew elry.
M ost of th ese cha ng es a re su bt le a nd not dram atic so clini ca l se nsitivity to s uc h
cha nges will increa se th e lik elihood of recogn it io n ( I).
B ehaviors: Facia l cha nges, bod y shifts, vo ice tones, ac cen ts, cha nge in hand edn ess,
eye cha ng es, invol u nt a ry m ove m ent s, and th e us e of " we " are less su b t le sig ns , a nd
a r e m ore lik ely t o be ca p t u red during in it ia l in tervi ews . Even so, an initi al int erview
wit ho ut such behavior is common. Pert in ent beh avio ral man ifestations ca n occur a ny
t im e du ring the int erview: int ra-in terview am nesia, m arked or spont an eou s reg ression, spe lls, catato nia, a nd hysteria . Th ese sho uld be sugges tive cl ue s t ha t warrant
s pecific qu estion s a bo u t bla ck outs, tim e loss, di ssociation a nd th e ex ist ence of alt ers.
In the eve n t of th e a p peara nce of an a lter, th e focus on th e d iagnosis beco m es
p r ed o min ant a nd the reaso ns fo r e me rge nce sho uld be ex plo re d.
A.ffect and Moo d: As m ention ed , a frequ en t prese nt a tio n of MPD is in th e co ntex t
of a n affec t ive illness or a nx ie ty disorde r. T hou g h a ffec t and mood cha nges a rc
non-s pecific , t hey te nd to be exa gge ra ted . Dr a m a t ic shifts in affect during th e
inte rview or between sessions ca n re flect sw itching behavior. Incr easing anxi et y in
re la tio n to qu estion s co ncern ing no n-specific symptoms or a bo u t MPD directly sho uld
raise th e suspicio n of th e di a gn osis.

THE DIAGNOSIS OF MULTIPLE PERSO NALITY DISORD ER

37

Thought Process: In th e con te x t of a crisis pr es entation, a pa ti ent 's st rea m of

thought ca n be m arked ly loose, rapid, illogical , a nd without goa l di rect ed ness. Su ch
th ou ght processes ca n represent rapid alte r switc h ing o r co nflicted "int ernal di alog ue " among alt ers that " spill o u t" (8,9). At bas eline or not in cr isis, MPD pati ent s
do not have a form a l t houg h t disord er or tho ught process dysfunction.
Abnorma l thou ght co nte n ts (p seudod elu sions, ph obias, obsessions, abnorm al
self-co nce p ts) do occur and a re more likely to persist ove r t ime. Und er usual
cond it io ns MPD pati ent s do not suffe r or dem on strat e psych o tic id ea tion. Und er
seve re stress th ey m ay displ ay " m icro -psycho tic episodes" sim ila r to so me pe rso na lity
disorders. However, eve n during periods of rel ative qui escen ce th ese pati ent s oft en
display symptoms that clos ely res emble psychotic ideation . Three of th e more
co m mo n pseudode lusions are th e beli ef th at alt ers a re se pa rate en t it ies, that on e
alte r ca n do harm to a no t her without suffering conse q ue nces , a nd that one is being
con t ro lled . Oft en o nce th e dyn amics of th e delusions are und erst ood what appears as
a del usion usually is a reflect ion of int ernal conflict a mo ng a lte rs , particula rly in
relation to th e host or primary person ality (9). Further, t hese d elu sio ns rarely
present as a beli ef that a n ex te rnal age ncy is persecuting t he m or sending th em
m essa ges throu gh th e media, sym p to ms more co m monly see n in tru e psych oti c
illn ess.
Similarly, obs ess ive or co m pulsive ideation or behavior ca n m ani fest in MPD and
may reflect a lt ers in conflict, " ca nce ling out " each oth ers' th ou ght s o r be haviors or
inserting intrusive thought s (8) .
Th ese pati ents oft en have sig nifica n t phobias, particul arly in re lat ion to th em es
of pr evious traum a . C ertain socia l situation s, words, objects, o r e mo tio na l stat es ca n
cue switc hing behavior that may manifest as phobic behavior (9) .
Perception: It is not at a ll unusual for MPD pati ents to re po rt pe rce ptu al
di sturbances: hallucinations (bett er characte rized as pseudoh allu cin atio ns), ne ga tive
hallu cin ation s, illu sion s, ou t of body expe rie nces, a nd dep erson ali za ti on a nd derealization . If th e clinician acce pts su ch e ndorse me n t without furt he r inq ui ry, it is easy to
co nfuse th e sym pto ms wit h true psychotic illn ess. Oth er sym p to ms, including sev ere
regressive be havior a nd flash backs or revivificat ions, ca n be easily confused wit h
ca ta to nia a nd visual hallucinations, resp ectively.
Schneid erian first -r ank sym p to ms a re ofte n report ed , e.g., mad e phe nom enon :
made impulses, feelings , a nd volition al act s (24) . Pati ents wit h MPD ofte n describe
hearing voices arguing and making co m me n ts about th eir th ou ght s (25) . T hese
symptoms are bett er understood as ps eudoha llu cinations than true loss of reality
testing; passive in flue nce ph enom enon and int ernal voices m ay represe nt cove r t
conflict a mo ng alte rs for co nt ro l. If amnestic ba rri ers be twee n a lters become more
fluid th e lik elihood of first-rank symptom s ma y diminish (8,9).
The following a ppro ac h to a ud itory hallu cin ation s sho u ld be t ak e n to dissect
tru e psychosis from MPD . Inq uiry sho uld focu s on wh ether th e voices resid e in the
pati ent 's head and wh eth er th e voices will speak with th e clinician . Only infrequ e n tly,
about 20% of MPD patient s rep ort a ud ito ry hallucination s ou ts ide of th eir heads (8).
Asking th e pati ent if it is possibl e to talk to his or her voices ca n lead to emergence of

38

J EFFERSON J O URNAL OF PSYCHIATRY

a lte rs or give th e clinician so m e se nse of th e d epth of psychosi s. Voices th at are

chao t ic, in coh erent , or irration al probabl y represe nt manifest ations of psych osis
wh erea s alt er voices, th ou gh dram a tic, ca n be unde rst ood throu gh di al og ue ( 10).
Truly psychotic vo ices resp ond to m edication and will becom e quiescent for pe riods of
tim e. The voices of patient s with MPD persist a nd gen erally do not respond to
m edi cation (9, 15).
The so ca lle d " nega t ive sym pto ms" of schi zophrenia usu all y do not cha rac te riz e
MPD (6 ); however, oddness a nd bizarreness ca n be a tt ribu ted to so me alte r pe rsonali ti es. G en erall y, MPD pati ents rel at e int erperson all y m uc h bett e r t han pat ient s wit h
sc hizop hre nia . Pe rce pt ual disturban ces suc h as illu sion s, visio ns, flashbacks a nd
revivifications ca n occ u r during initial eva lua t ions o r as princip le motivation s for
see king psychiatric ca re if m emori es, exte rnal cues, or st im uli rekindle im a ges of
trauma.
Cognitive Exam: Th e constitue n ts of th e cog nit ive exa m-a tt e n tion , lan gu age,
pr axis , visuospatial fun ctions, ca lcula t io ns, a nd a bst ract reasoning-are ge nerally
intact in pa tients with MPD (9). Charact erization of m emory impai rm e nt in t hese
patients is com plex . The typ e of amnesia th ey suffer is psych oge nic a nd freq ue n tly
cha rac te rized by asymm etry; th e primary personality is un aware of a lte rs bu t no t vice
versa (4) . G en erally, shor t t erm m emory a nd m emory for skills, info rm a tio n, fact s,
co nce p ts, and vocabulary, th e so ca lled implicit se man t ic memory, remain in tact (26),
but th ere a re notable exce pt ions (27 ), particul arly across a lte rs wit h rigid a m nes t ic
barriers. Discr et e gaps in lon g t erm m em ory, particul arly involvin g a utobiog ra ph ica l
m at eri al a nd child hoo d eve n ts , is co m m on. It is import ant to rem ember t hat memory
d eficit s in patient s with MPD a re not ge ne ra lly s tru ct ural, may be "s ta te depend e nt "
to th e traum a, a nd a re pot entially reversibl e, resolvin g whe n t he ant eced ent s to t he
a m nesia a re a breacte d or und erst ood (28).
Il\IPRE SSIO NS O N THE EVALUAT O R

C linicia ns unaccu st om ed to treating o r eva lua ti ng MPD may find t hese pa t ie nts
perpl exing, st ra nge , bizarre, or eve n fri ght ening. It takes t ime to ge t over th e initial
fascination or negative reacti on s that may develop. Sinc e ma ny of t hese pati ent s
pres ent in crisis th e in itial co n ta ct ca n be quit e int ense. It is not unusu al for clini cian s
to expe rie nce som e of th e di ssociative ph enom en on th at th e pati en t does , for
exa m ple, mild in t ra-int e rview amn esi a or eve n tim e loss. Suc h dat a sho uld be used
for ass essment a nd ca n point tow ards th e diagnosis ( I). In th e author 's expe rie nce,
d espit e chao tic pres entations, mo st MPD pati ents re lat e well a nd a re likea ble.
ASSESSMENT TOOLS AND INSTR UME NTS
Hyp nosis

Hypnotizabilit y has bee n docum ent ed as a n a tt ribute of a nd a u to -hypnosis as a

pot en t ial m aj or fact or of MPD ( 14). MPD pat ient s ra pid ly and eas ily fa ll in to
hypn oti c (t ra nce) states, a nd have high sco res on m ea sures of hypn oti za bilit y

THE DIAGNO SIS OF MULTIPLE PERSO NALITY DISORDER

39

(28,29,30) . During psych oth erapy sess ions it is com mo n to observe pati ents e nte ri ng
wh at a ppear to be tran ce (hypno t ic) sta tes if on ly for br ief periods or seconds.
H ypn osis has several a pplica t ions in MPD which ca n be divided into th erap eutic
an d di ag nost ic. The fo rm er uses incl ude rel ief of anxi ety and distress , e na bling th e
pat ien t to use se lf-hyp nos is as a way of m ast e ring int ernal chaos, retrieval of
re pr essed hist ori cal inform ation , a nd as a m ean s to obtain abreacti ve expe rie nces
(5,9). As a di a gn osti c tool hypn osis fac ilitates emergen ce of a lt ers and person ality
fr a gm ents, and sho uld ge ne rally be used only a fte r a sig nificant trust has develop ed
bet ween a pati ent a nd th e rapist.
H ypn osis is m ost propitiou sly used a fte r ot he r mean s of m aking th e diagn osis
have been tried a nd so me g ro u ndwor k has been es ta blishe d to pre pa re th e pati ent for
wha t ca n be a di scon ce rting o r traumatic recognition (30) . H ypn osis of MPD pa ti en ts
is ge ne ra lly sa fe a nd easy to induce but do es require investi ga tion int o wh ether th e
pati ent has expe rie nce d formal hypn osis in th e past , th e qu ality of t hat expe rie nce,
a nd a n in-d epth underst andin g of th e pat ient's cu r re n t feel ings about hypnosis. As
with an y diagnosti c or th erap eutic procedure, clearl y a r t iculated object ives will
e ns u re a successful ou tco me . Pr eviou s negative ex pe riences , cu r re n t misg ivings o r
fears require add it iona l ca u tion a nd postpon em en t. H ypn osis is no t without un towa rd effec ts. The re are rare patients wh o becom e ext re me ly d istra ug ht or hyst eri cal
followin g inducti on . As a r ule, early in treatm ent th e most important principl e is th e
co n t in uity of a therape u t ic a llia nce and ens uring t he pat ient's se nse of sec u rity. In
any eve n t, initi all y, hypn osis shou ld be use d ca ut iously.
Drug Facilitated Interviews

The use of me d icat ion, eit he r sod ium a my tal or sodium pentothal, in dia gn osti c
in terviews has been described by Put na m (9). Med ica t ion s accomplish m an y of th e
sa m e goals as hypn osis but wit h th e add it ion of side effec ts such as sedation. The
res t rai n ts and precaution s me n tio ne d a bove for hypnosis, also ap ply to dru g fac ilitat ed int e rviews. Ex cept for th e pati ent wh o refuses, hyp nosis shou ld probably be th e
procedure of cho ice .
Self-Report Instrum ents

Th e Dissociative Experi en ces Scal e (DES) is a twenty-eight qu esti on self-r eport

sc ree ning instrument th at rat es di ssociative sym pto ms a nd experie nces (3 1). It is
most efficie nt ly used wh en given to t hose patients with sus pecte d dissocia tive
sym pto ms or a hist ory of a buse . In th e newly revised ve rs ion (32), th e pa ti ent
indicat es ag ree me n t by circling a percent a ge from 0% (no t a t a ll) to 100% (all t he
time). Scoring is calcula te d by t aking th e su ms of t he 28 sco res a nd ave raging. Th e
ope ra t ing cha racte rist ics of th e test have bee n d efin ed using a cu toff of 30 to scre e n
for cases of di ssociation , giving a sensi tivity a nd spe cificity of 80% (33) . Pati ents with
MPD ge ne rally sco re a bove 40, but a high percen tage of pati ents with PT SD and
ot her di ssociat ive di so rd ers sco re high e r th an 30 . A pos it ive score d emarcat es t he
need to pu rsu e a m or e th orou gh evalua tio n.

40

JEFFERSO N J O URNAL OF PSYCHIATRY

S tructured Interviews

The Disso ciative Di sord ers Int erview Sch edule (D DIS) and the Structured
Clinical Int erview for Di ssociative Disorders (SC ID-D) a re two assessm ent tools that
ca n be us ed to clarify th e dia gn osis . Both are tim e cons um ing, re qu iring from 45
minut es to three hours to com ple te, a nd ge ne rally a re used in resea rch settin gs
rath er th an clini call y (9).
Th e DDIS whi ch con tains 131 it ems was developed for t he DSM -Ill. It diagnoses
dissociative disorders, som atization disorders, m aj or d ep ression , and bord erlin e
person ality di sorder and as ks a bo u t child hood se xual a buse. It is repor t ed to have a
high se ns it ivity and spec ificity for di agnosing MPD (34) .
The SCID-D requires sp ecial t raining, is ex te ns ive an d tim e cons uming, but is
highl y sensitive to MPD a nd abl e to det ect a ll five Di ssociative Di sord ers (35) .

Biological S tudies

There a re no biological t est s th at a id in makin g th e di a gn osis of MPD . Despite a

high er than expecte d fr equ en cy of abnormal EEGs with non -sp ecific changes (36) ,
EEGs a re of littl e utility exce pt in differentiating th e case of a pati ent suspect ed with
partial com plex seizures from MPD. Drug scr eens ca n be ve ry helpful in identifying
co m or bid subs tance a buse a nd th e occasional patient wh ose pr esen tation is co nfuse d
with a dissociative disord er.

CO MO RBIDITY

Como rbid diagn oses exist a longs ide th e prim ary ide n t ified d iagnos is, and som etim es th e two nearly ove rla p (i.e ., MPD a nd PTSD). Affecti ve diso rd e rs fr equ ently
pla gu e pati ent s with MPD a nd a re prin cipal instigators of prese nt ati on to t he mental
health syste m (9,3 7), but do not typi call y co nfuse clinicia ns per se; t he exc ept ion to
this ge ne ra liza t ion is bip olar disorder (38 ). Besid es a ffec t ive di sord e rs, t he most
co m mo n co mo rbid diagnoses a re anxiet y disorders, subs tance a buse a nd de pe nd e nce,
ea t ing di sorders, and person ality disorders. Mo st expe rts beli eve th at MPD shou ld be
treat ed as a superordin at e diagnosis th at has a pletho ra of possibl e pr esen tat ions
(1,9,15) . An y psychiatric diagnosis may co-e xist with MPD (23), but pra ctica lly
sp eaking, th e list is finit e.

DIFFERENTIAL DIAG NOSI S

What is most s t riking a bo u t th e differenti al di a gn osis for MPD is t he prepondera nce of psych otic sp ectrum disord ers in a n illn ess th at ge nerally does not exhibit tru e
psych oti c sym pto ms (see tabl e 2). This distinction has to do wit h th e protean nature
of MPD, but is al so a reflecti on oflack of training on th e part of clinicians who are not
acc usto me d to cond uc t ing a n int erview for investigating th e di a gn osis.

THE DIAGNO SIS OF MULTIPLE PERSO NALITY DISORD ER

41

T ABLE 2.

Differential Diagn os is of MPD

Di ssociative Disorders
Psychogeni c a m ne sia
Psychogeni c fugu e
Dissociative di sorde r NOS
Dep erson ali zation di sorder
Organi cit y
T empor al lob e e pile psy
Alcohol Abuse and Dep enden ce
Substance Abu se a nd Dep enden ce
Psych oti c Disorders
Sc hizo ph re nia
Sc hizoaffcct ive di sorder
Bri ef Reactive Psych osis
Delusion al disord e r
Mood D isorders
M aj or Depression with psych ot ic featur es
Bipolar di sord e rs
Per son ality Disorde rs
Borderline person alit y di sorder
Mix ed Person alit y di sor der
Ma lingering a nd Fa ctitiou s di sorder
Posses sion St at es

C ONCLUS ION

As an adapt ion to sus tained se xua l, ph ysica l, e mo tio na l a buse o r neglect MPD
ha s as a co nse q ue nce for th e adult profound negative intrapsychi c an d in terperson al
effec ts . The expressio n of th ese effec ts oft en m asqu erad es as ot her psyc hia tric illne ss.
MPD as a pol ysymptomatic, pl eiom orphic, a nd " hidd e n " cond ition is not necessarily
easy to d et ect and is fr equ ent ly denied by patients a nd ove rloo ked by cli nicians.
Because of th e variability of its symptom atic expre ss ion it requires patien ce on th e
part of th e clinician to di agn os e, bu t th e rewards a re sig nifica nt if dia gn osis leads to
proper treatm ent disp osition .
Qu estion s pe rt aining to th e non- sp ecific sym pto ms of MPD mu st now be ask ed
of all pa ti ent s during th e typi cal psychi atric int ervi ew: blackouts, hist ory of sexu al
and ph ysica l a buse, a nd PTSD symptoms. Other sym p toms requ ir e additional
qu estioning to di ssect out th e di a gn osi s: a ud itory hallucin ation s, Sc hneide rian symptoms, a m nesia, and behavioral cha nges. No sym ptoms a re pa th og no mo nic, a nd it is
not always possibl e to mak e a conclus ive d ia gn osis early in trea tm ent , but th e
pr esen ce of a co uple of symptoms shou ld rai se th e clinician 's ind ex of sus p icion. The
ident ification or e me rge nce of a lt ers co mes very close to a definitive dia gn osis of
MPD . In th ose cases that a re sugges t ive but not d efinitive th ere arc now several
instrum ent s th at ca n facilit at e in th e det ecti on of dissocia tiv e processes .
While th e focu s has been on t he psych ia tric int e rview and th e symptom
expressio n of MPD in ad ults , th e import an ce of di a gn osis in child re n, who are usu all y

42

JEFFERSON JOURNAL OF PSYCJ-lIAT RY

easier to treat ( 15), shou ld be e m phasized . For many cases MPD ca n be preven ted
altogether by effec tive child prot ection int erventions. Wh en child a buse has a lr ead y
occurred, long term treatm ent by expe rie nce d clinician s ca n a me liora te dissocia tive
pathology. Preve n tion and attenuation of traumatic st re ss di sord ers, MPD bein g a
very severe form, are crucial fronti ers of preventive psychiatric m edi cin e .

ACKJ'\IOWLEDGEMEi\'T

T he author wou ld like to thank Kathy Reilly, M.A. a nd Ka th y Paj e r, M. D.,

M.P.H. for t heir helpful comments a nd suggestions .

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