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Dissociative identity disorder: Time to remove it from DSM-V?

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Examining the logic behind arguments to perpetuate a controversial diagnosis


 

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What is it about dissociative identity disorder (DID) that makes it a polarizing diagnosis? Why does it split professionals into believers and nonbelievers, stirring up heated debates, high emotions, and fervor similar to what we see in religion?

The DID controversy is likely to continue beyond the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), slated for publication in 2012. Proponents and opponents claim to have the upper hand in arguments about the validity of the DID diagnosis and benefits vs harm of treatment. This article examines the logic of previous and new arguments.

1. The fallacy of equal-footing arguments

When 301 board-certified U.S. psychiatrists were surveyed in 1999 about their attitudes toward DSM-IV dissociative disorders diagnoses:

  • 35% had no reservations about DID
  • 43% were skeptical
  • 15% indicated the diagnosis should not be included in the DSM.1

Only 21% believed there was strong evidence for DID’s scientific validity. On balance, published papers appear skeptical about DID’s core components: dissociative amnesia and recovered-memory therapy.2

DID skeptics are sometimes accused of “denial” or “reluctance” to accept this diagnosis. Informed skepticism is acceptable—even encouraged—in making a diagnosis of malingering, factitious disorder, some personality disorders, substance abuse, and psychotic states, to name a few. Why is informed skepticism about DID frowned on?

In medical and surgical specialties, informed skepticism is encouraged so that the practitioner challenges his or her assumptions about a possible diagnosis through a methodical process of inclusion, exclusion, and hypothesis testing. I argue that little or no skepticism is substandard practice, if not negligence.

Bertrand Russell’s celestial teapot parable (Box 1)3 exposed the fallacy of equal-footing arguments (ie, in any debate or argument that has 2 sides, the 2 sides are not necessarily on equal footing). Russell’s argument is valid for any belief system relying on faith. Now that DID is in the “ancient book” (DSM-IV), the burden of proof by some magical logic has shifted to “nonbelievers.” In law that is called precedent, but law is even less scientific than psychiatry and not the best example to follow. A mistake made 100 years ago is still a mistake.

Box 1

Bertrand Russell’s ‘celestial teapot’ analogy on religion

In 1952, British philosopher Bertrand Russell used the analogy of a teapot in space to illustrate the difficulty skeptics face when questioning unfalsifiable claims. Russell’s argument involved religious belief, but it is valid for other belief systems relying on faith. Here is the celestial teapot analogy:

“If I were to suggest that between Earth and Mars there is a china teapot revolving about the Sun in an elliptical orbit, nobody would be able to disprove my assertion provided I were careful to add that the teapot is too small to be revealed even by our most powerful telescopes. But if I were to go on to say that, since my assertion cannot be disproved, it is intolerable presumption on the part of human reason to doubt it, I should rightly be thought to be talking nonsense. If, however, the existence of such a teapot were affirmed in ancient books, taught as the sacred truth every Sunday, and instilled into the minds of children at school, hesitation to believe in its existence would be a mark of eccentricity and entitle the doubter to the attention of the psychiatrist in an enlightened age or of the Inquisitor in an earlier time.”

Source: Reference 3

2. Illogic of causation

Piper and Merskey’s extensive literature review4,5 examined the presumed association between DID and childhood abuse (mostly sexual). They found:

  • no proof that DID results from childhood trauma or that DID cases in children are almost never reported
  • “consistent evidence of blatant iatrogenesis” in the practice of some DID proponents.

One can easily turn the logic around by claiming that a DID diagnosis causes memories of childhood sexual abuse.

As for patients’ presumed reluctance to report childhood abuse, I witnessed in every one of my 15 alleged cases of DID (all female) not reluctance but a strong tendency to flaunt their diagnosis and symptoms and an eagerness to re-tell their stories with graphic detail, usually unprovoked. Patients with a DID diagnosis seem to have a “powerful vested interest”—to borrow Paul McHugh’s expression6—in sustaining the DID diagnosis, symptoms, behaviors, and therapy as an end in itself.

DID proponents acknowledge that iatrogenic artifacts may exist in the diagnosis and treatment. However, they almost immediately insinuate that DID patients’ “subtle defensive strategies” generate these artifacts. Greaves’ discussion of multiple personality disorder7 acknowledged that overdiagnosis may be driven by therapists’ desire to “attain narcissistic gratification at ‘having a multiple [sic] of their own’” but blamed this on “neophytes.”

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