3. Tautology in DID’s definition
DSM-IV’s criterion A for DID is in fact a definition: “the presence of 2 or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).”8 Together, criteria A and B show circularity and redundancy. If A is met, then B must be met because “a person’s behavior” is part of her or his identity and personality state, which was established in A.
Tautology is a major shortcoming of the descriptive system for psychopathology in general. Of greater clinical value are observing a patient’s actions, listening to his or her words, learning his or her history, studying his or her expressions, and noting his or her relationships.9
4. Bewitchment by language
Psychiatrists could spend hours over strong cups of coffee arguing the meanings of terms such as “dissociation,” “presence,” “identity,” “personality state,” etc. Psychiatry has been targeted unfairly regarding where it falls on the subjectivity-objectivity axis, but it has not fared that differently from other medical specialties.10 Psychiatry, however, depends much more on language.
Consider slippery terms such as personality, identity, self, dissociation, integration, alters, ego, ego states, trance states, personality states, unconscious, etc. Lack of precision, variability in use of words and their meaning, and variability in understanding the concept that these terms try to communicate make speaking a common language extremely difficult. To borrow from Wittgenstein, psychiatrists’ intellect is bewitched by language.11
Words fail to communicate experiences such as the taste of red wine or the feeling of sand beneath bare feet. It is almost futile to try to define dissociation, identity, personality states, etc., using words or even pictures. More definitions and agreement on stricter definitions would not provide greater clarity or solve the problem of first-person authority.
An example is found in DID’s criterion B: “at least 2 of these identities or personality states recurrently take control of the person’s behavior” [italics mine]. “Possession” seems to be a fitting word! Whether it is an alter or the devil taking control is a technicality. Even more acceptable would be possessed by inconsolable anger, possessed by fierce jealousy, possessed by lust, possessed by hatred and vengeance, possessed by and obsessed with love, possessed by cocaine, etc.
Dissociation is used to describe so many things that it has become almost meaningless (Table). I refer not only to definitional imprecision but also to a lack of consensus on the nature of the concept itself.
The word “control” is another term on whose meaning almost no 2 psychiatrists agree. Consensus on definitions is elusive when words become divorced from the concepts they were intended to describe.
Table
A meaningless word? ‘Dissociation’ is used to describe many things
| Daydreaming or fantasizing |
| Memory lapses caused by benzodiazepines |
| Preoccupation with everyday worries |
| Preoccupation with internal stimuli (such as auditory hallucinations or delusional thoughts) |
| Poor attentiveness |
| Histrionic/theatrical behavior to avoid upsetting the patient or to provide a face-saving explanation |
| Daydreaming while driving (‘highway dissociation’ or ‘highway hypnosis’) |
| Getting engrossed/captivated by a novel, a movie, or a piece of radio journalism or music |
5. Validity of first-person authority
The skeptic’s attempt to investigate a subjective phenomena—especially DID—is bound to break on the rocks of the first-person authority, to borrow Donald Davidson’s words.9 To support reliability and validity of the diagnosis, dissociation researchers rely on “scales” and “instruments” to give the impression of objectivity, empiricism, and “science” hard at work. However, a quick look at some of the questions on these “instruments” reveals their assault on reason and intellect (Box 2).12
Proponents who claim DID is “sufficiently validated for inclusion in the current and future versions of DSM” are to be commended for adding “much more research is needed in several areas.”13 Piper and Merskey’s review4,5 concluded that DID could not be reliably diagnosed.
Sample statements from the Adolescent Dissociative Experience Scale (A-DES)*
A-DES: I get so wrapped up in watching TV, reading, or playing a video game that I don’t have any idea what’s going on around me.
Comment: Although this item seems like a joke, it is not meant as one. It is meant to be part of the serious business of science. Isn’t that what any ‘normal’ human would do if he or she has enough attention and concentration?
A-DES: People tell me I do or say things that I don’t remember doing or saying.
I get confused about whether I have done something or only thought about doing it.
I can’t figure out if things really happened or if I only dreamed or thought about them.
People tell me that I sometimes act so differently that I seem like a different person.
Comment: These items are crafted in a way to encourage false positives. First, ‘people tell me’ does not qualify as an ‘experience.’ Second, one wonders why the scale was made up of declarative statements instead of questions. Third, ‘I seem like a different person’ is a leading statement.
A-DES: I am so good at lying and acting that I believe it myself.
Comment: This should be an immediate tip-off that the reporter is unreliable.
A-DES: I feel like my past is a puzzle and some of the pieces are missing.
Comment: Isn’t this the human condition?
*A-DES statements are italicized; comments by Dr. Gharaibeh are in plain text
Source: Reference 12