Multiple-Personalities — Rare, but they happen

I was in my psychiatric training.  My supervisor and clinic director had booked me to see a patient.  I was often booked for some very difficult patients, because I am good at this sort of thing.  But he warned me about this particular patient.

“She is not a patient we want to follow in this clinic.  Just see if she needs medicines, and give her a little bit.  The psychologist will do the work.”

I thought he had to be kidding, as I prided myself on being an all-around psychiatrist, and I wanted to take care of everything psychiatric.  Especially while in training, under the malpractice coverage of the University, with their supervision.

“They say she has multiple personality disorder.  We don’t believe in that diagnosis.  We leave it, as much as we can, to the psychologists that do.  This patient is a mess.  Lots of commitments, lots of suicide attempts, lots of restraining orders.  Let the psychologist do it.  Stabilize her quickly on medication, and get her out of here, with monthly checkups, then bimonthly.

We didn’t believe in this diagnosis.  It had been constructed by psychologists, who were thus blessed with “career patients;” a stable source of income, as he had never heard of anyone with this diagnosis getting better.

I was confused, but had to abide by his wishes.  The patient was a pleasant and charming woman in her 20’s, who told me she had a dozen or so “alters,” different personalities with names who had very different characteristics.  A couple were even male.  As fascinating as her stories were, I was grateful when she told me none of them were about to “come out” just then, so I stuck with the medication management.  A tiny bit of an antidepressant that had helped in the past.  Check a blood level, to make sure it was not toxic.  Do my general blood work, as she had not had any for a bit and it sounded like a good idea.

Of course, I talked to the psychologist on the phone, ran to the books, did everything a good student would do.

Then there was a thing known as being “on call.”  I don’t remember how it happened, that I found myself covering at an institution where I had never set foot.  Same patient, same medications.  Her name was “Ellen,” and as in most such cases, the personality of her name was the main personality.  The same psychologist “on call.”  I was doing Saturday morning rounds.  The nurses at the desk said that she was not doing well, some alters had come out, and she had thrown a chair.

“Albert” was the personality who had thrown the chair. There was a security guard at the desk.  I had to see her.

When I think back, I was young and foolish beyond description.  I asked the security guard to wait outside the door, as I went in alone.

I would not be far from the door.  The door would be open.

I was very direct.

“Albert, go away.  You have no right to throw a chair.  I need to talk to Ellen.  Now.”

She put down the chair and Ellen was sitting on the bed, crying.  That was it.  I told Albert to get out of there and I told Ellen to come and it happened.  I tried not to look too shocked at my own power.  I did ask that the door be left open, and the security guard be not too far away.  I called the psychologist and she seemed grateful.  What I had done might help Ellen get out of the hospital faster.

Although amnesia in any patients I have ever seen may not be what it is in movies or novels, it exists.  Dissociative disorders exist.

People do indeed have spells when they forget who they are and what they are doing.  Then they “snap back.”  I do see these people because such episodes are often brought on by pharmacology of one sort or another; often, recreational.  The most common dissociative symptom, far and away, is the alcoholic blackout.

In most patients who have this sort of symptom, there is a history of trauma and abuse.  So some kind of psychotherapy is very important.

Some medication can help, but is usually not the only thing it takes by any means.  Recovery from the trauma or abuse is important.

Since I saw that first person, I have been involved with several others.  My strategy is to keep medication at a minimum.  I have actually seen some cases where patients have had medication-induced dissociation.

Because of the trauma history, there are sometimes dangerous physical threats involved.  Since I enjoy doing legal work, with testimony in court, I have testified in cases of dissociative disorder.  These histories are often hard for courts to believe since they sound strange, but I am convinced of their reality and have seen some strange behaviors with my own eyes.  It is important to be neither afraid nor fascinated.

I can certainly see how a therapist, willing or unwilling, could have endorsed the idea of multiple personality disorders or “alters” and thus made  them happen in a fragile or traumatized person.

Since I have learned more advanced therapy techniques, I have been increasingly involved in “integrating” dissociative symptoms back into a whole human.  Although it has traditionally been done with hypnosis, Neurolinguistic Programming and similar types of therapies have worked well.

No, I never saw Ellen again.  I finished at that institution and moved on.  The psychologist seemed grateful and sincere.  Based on the statistics available at that time, she did indeed have several years of work ahead of her.  She also had permanent 24/7 call, probably with lots of threats and lots of restraining orders.  If this was job security, I was not particularly interested in it at that time.  There were great controversies about the existence of the diagnosis.

I care as little as possible about diagnostic nomenclature.  Most of the people I see who have dissociative symptoms simply have a history of drug-induced blackouts, so I tell them where and how they ought to stop the drug.

Often drug-free people simply find something in their closet they do not remember buying, or do something they do not know that they did until somebody else tells them about it.  It is often a young woman, not involved with drug abuse, with a history of psychological trauma.  We figure out what is going on and why and dig in to heal the psychological trauma.  I do not see whole personalities with “names” who I need to yell at.  If I did, and they were dangerous, they would be in a hospital.

For each person, the complete and careful history cannot be replaced.

The important part here is to realize that plenty of patients simply do not know their complete history and it will come out later in bits and pieces that do not make sense at first.

The doctor’s listening must not be allowed to stop, or even allowed to relax; it must be constantly vigilant.