Growing not dwindling: international research on the worldwide phenomenon of dissociative disorders

LETTERS TO THE EDITOR Growing Not Dwindling International Research on the Worldwide Phenomenon of Dissociative Disorders To the Editor: n the December 2012 issue of the Journal, Joel Paris, MD, wrote an article about the current status of dissociative identity disorder (DID) and the dissociative disorder field in general. He suggests that DID is merely a ‘‘fad’’ and that there is no credible evidence to connect traumatic experiences with the development of DID. We refute several of the claims made by Dr Paris. Our biggest concern as nonYNorth American researchers is that Dr Paris does not reference a single international study related to dissociative disorders and DID, despite the considerable and increasing empirical literature from around the world. His speculation that DID is not diagnosed outside clinics that specialize in treating dissociation is not consistent with current data. DID and dissociative disorders have been reliably found in general psychiatric hospitals; psychiatric emergency departments; and private practices in countries including England, the Netherlands, Turkey, Puerto Rico, Northern Ireland, Germany, Finland, China, and Australia, among many others (e.g., Dorahy et al., 2006; Leonard et al., 2005; Lewis-Fernández et al., 2007; Lipsanen et al., 2004; Martı́nezTaboas, 2005; Martı́nez-Taboas et al., 1995, 2006; Middleton and Butler, 1998; Rodewald et al., 2011; Sar, 2006; Sar et al., 2007b, 1996; Tutkun et al., 1998). Much of the international research, using sophisticated epidemiological and clinical research methods, has replicated dozens of times the finding that dissociative processes and disorders (including DID) can be reliably detected in a wide spectrum of different societies. Epidemiological general population studies indicate that 1.1% to 1.5% meet diagnostic criteria for DID; and 8.6% to 18.3%, for any DSM-IV dissociative disorder (Johnson et al., 2006; Sar et al., 2007a). The international literature on DID and dissociative disorders has been widely published in mainstream journals of psychiatry and psychopathology and is inconsistent with Dr Paris’s conclusions. Similarly, with regard to treatment, almost 300 patients from 18 countries participated in the most recent prospective treatment study of DID and a closely related disorder, dissociative disorder not otherwise specified (Brand et al., 2012). Moreover, the authorship of the 2011 International Society for the Study of Trauma and Dissociation guidelines I The Journal of Nervous and Mental Disease for the treatment of DID included clinicians from North America, Europe, the Middle East, and Australasia. Dr Paris also opines that there is only a ‘‘weak link’’ between child abuse and psychopathology, quoting an article published 17 years ago. Current research illustrates a very different picture. Persons with early abusive experiences demonstrate increased illnesses (Green and Kimerling, 2004), impaired work functioning (Lee and Tolman, 2006), serious interpersonal difficulties (Van der Kolk and d’Andrea, 2010), and a high risk for traumatic revictimization (Rich et al., 2004). The Adverse Childhood Experiences Study, an American epidemiological study, has provided retrospective and prospective data from more than 17,000 individuals on the effects of traumatic experiences during the first 18 years of life. This large study demonstrated the enduring, strongly proportionate, and frequently profound relationship between adverse childhood experiences and emotional states, health risks, disease burdens, sexual behavior, disability, and health care costs, even decades later (Felitti and Anda, 2010). Specifically, child sexual abuse (CSA) has been related in various epidemiological studies to the subsequent onset of a variety of psychiatric disorders. For example, Molnar et al. (2001), using data from the National Comorbidity Survey, found that CSA was associated with 14 psychiatric disorders among women and 5 among men, even after controlling for other childhood adversities. Dinwiddie et al. (2000), using a large database of Australian twins (N = 5,995), found that individuals reporting CSA were much more likely to receive a psychiatric diagnosis and more likely to report suicide attempts than were those who were not sexually abused. In a populationbased sample of 1,411 female adult twins, Kendler et al. (2000) found that CSA was significantly related to eating disorders and drug problems. When the twin pairs were discordant for the CSA, the abused twin was at a higher risk for developing a psychiatric disorder. More recently, Jonas et al. (2011), using a sample of 7,403 individuals, demonstrated that every psychiatric disorder they evaluated was strongly related to CSA. The link between childhood relational trauma and dissociation is now solidly established in the empirical literature (e.g., Carlson et al., 2012; Dalenberg et al., 2012). In fact, stringently documented international research has made it almost impossible not to appreciate what happens psychologically to children who grow up being abused by the adults who were supposed to protect them (Kezelman and Stavropoulos, 2012; Middleton, 2013a, 2013b). Dr Paris devotes a whole section of his article to challenging a single case of reported DID, published in the popular press by a & Volume 201, Number 4, April 2013 journalist (i.e., Nathan, 2011; Schreiber, 1973). This degree of attention to a single popular press case is out of place in a serious academic review and also ignores another work in the same popular press genre that came to the opposite conclusion about that case (Suraci, 2011). Given the scientific topic under discussion, it would have been preferable for Dr Paris to base his thesis on peer-reviewed, empirical-driven, scientific data rather than on a journalistic investigation in the popular press. He insistently refers to seven popular books or sensational press releases in his attempts to sustain some of his arguments. In conclusion, Dr Paris’s assessment of the supposedly dwindling fad of DID and dissociative disorders is not in keeping with current peer-reviewed international research. The dissociative disorder field has been producing solid and consistent evidence that provides guidance to clinicians and researchers about the epidemiology, phenomenology, diagnosis, and treatment of DID (and closely related conditions). We agree that more research efforts should be dedicated to DID and to dissociative disorders overall, along with the impact of dissociation on the entire spectrum of psychiatric disorders (Sar and Ross, 2006). The epidemiological, laboratory, neurobiological, psychophysiological, and psychometric research on dissociative disorders is abundant and impressive. For whatever reasons, this research is inadequately represented in Dr Paris’s article. This body of international researchers (from four nonYNorth American continents) refutes Dr Paris’s claims. Alfonso Martı́nez-Taboas, PhD Department of Psychology Carlos Albizu University San Juan, Puerto Rico Martin Dorahy, PhD Department of Psychology University of Canterbury Christchurch, New Zealand Vedat Sar, MD Department of Psychiatry Istanbul University Istanbul, Turkey Warwick Middleton, MD Department of Psychiatry University of Queensland St Lucia, Australia Christa Krüger, MD Department of Psychiatry University of Pretoria Pretoria, South Africa DISCLOSURES The authors declare no conflicts of interest. www.jonmd.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 353 The Journal of Nervous and Mental Disease Letters to the Editor REFERENCES Brand BL, McNary SW, Myrick AC, Loewenstein RJ, Classen CC, Lanius RA, Pain C, Putnam FW (2012) A longitudinal, naturalistic study of dissociative disorder patients treated by community clinicians. Psychol Trauma. doi:10.1037/a0027654. Carlson EB, Dalenberg C, McDade-Montez E (2012) Dissociation in posttraumatic stress disorder part 1: Definitions and review of research. Psychol Trauma. 4:479Y489. Dalenberg CJ, Brand BL, Gleaves DH, Dorahy MJ, Loewenstein RJ, Cardeña E, Frewen PA, Carlson EB, Spiegel D (2012) Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull. 138:550Y588. Dinwiddie S, Heath AC, Dunne MP, Bucholz KK, Madden PAF, Slutske WS, Martin NG (2000) Early sexual abuse and lifetime psychopathology: A co- twin-control study. Psychol Med. 30:41Y52. Dorahy MJ, Mills H, Taggart C, O’Kane M, Mulholland C (2006) Do dissociative disorders exist in the Northern Irish psychiatric population?: A blind diagnosticstructured interview assessment. Eur J Psychiatry. 20:172Y182. Felitti VJ, Anda RF (2010) The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: Implications for healthcare. In Lanius RA, Vermetten E, Pain C (Eds), The impact of early life trauma on health and disease (pp 77Y87). New York: Cambridge. Green BL, Kimerling R (2004) Trauma, posttraumatic stress disorder, and health status. In Schnurr PP, Green BL (Eds), Trauma and health: Physical health consequences of exposure to extreme stress (pp 13Y42). Washington, DC: American Psychological Association. International Society for the Study of Trauma and Dissociation (2011) Guidelines for treating dissociative identity disorder in adults, 3rd revision. J Trauma Dissociation. 12:115Y187. Johnson JG, Cohen P, Kasen S, Brook JS (2006) Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. J Psychiatr Res. 40:131Y140. Jonas S, Bebbington P, McManus S, Meltzer H, Jenkins R, Kuipers E, Brugha T (2011) Sexual abuse and psychiatric disorder in England: Results from the 2007 Adult Psychiatric Morbidity Survey. Psychol Med. 41:709Y719. Kendler KS, Bulik CM, Silberg J, Hettema JM, Myers J, Prescott CA (2000) Childhood sexual abuse and adult psychiatric and substance use disorders in women. Arch Gen Psychiatry. 57:953Y959. Kezelman C, Stavropoulos P (2012) Best practice guideline for complex trauma (trauma specific) and trauma informed care and practice. Sydney, Australia: Adults Surviving Child Abuse (ASCA). Lee S, Tolman R (2006) Childhood sexual abuse and adult work outcomes. Soc Work Res. 30:83Y92. Leonard D, Brann S, Tiller J (2005) Dissociative disorders: Pathways to diagnosis, clinician attitudes and their impact. Aust N Z J Psychiatry. 39:940Y946. Lewis-Fernández R, Martı́nez-Taboas A, Sar V, Patel S, Boatin A (2007) The cross-cultural assessment of dissociation. In Wilson JP (Ed), Cross-cultural assessment of post-traumatic stress disorder and trauma (pp 279Y317). New York: Springer. Lipsanen T, Korkeila J, Peltola P, Järvinen J, Langen K, Lauerma H (2004) Dissociative disorders among psychiatric patients: Comparison with a nonclinical sample. Eur Psychiatry. 19:53Y55. Martı́nez-Taboas A (2005) From obscurity to daylight: The study of dissociation in Puerto Rico. J Trauma Pract. 4:271Y285. Martı́nez-Taboas A, Camino R, Cruz-Gartúa A, Francia M, Gelpı́ E, Rodrı́guez-Cay J (1995) What a group of 354 www.jonmd.com clinicians have learned about multiple personality disorder in Puerto Rico. Rev Puertorriq Psicol. 10:197Y213. Martı́nez-Taboas A, Canino G, Wang MQ, Garcı́a P, Bravo M (2006) Prevalence and victimization correlates of pathological dissociation in a community simple of youths. J Trauma Stress. 19:439Y448. Middleton W (2013a) Parent-child incest that extends into adulthood: A survey of international press reports. J Trauma Dissociation. 14:184Y197. Middleton W (2013b) Ongoing incestuous abuse during adulthood. J Trauma Dissociation. 14:184Y197. Middleton W, Butler J (1998) Dissociative identity disorder: An Australian series. Aust N Z J Psychiatry. 32:794Y804. Molnar BE, Buka SL, Kessler RC (2001) Child sexual abuse and subsequent psychopathology: Results from the National Comorbidity Survey. Am J Public Health. 91:753Y760. Nathan D (2011) Sybil exposed. New York: Simon & Schuster. Rich CL, Combs-Lane AM, Resnick HS, Kilpatrick DG (2004) Child sexual abuse and adult sexual revictimization. In Koenig LJ, Doll LS, O’Leary A, Pequegnat W (Eds), From child sexual abuse to adult sexual risk (pp 49Y68). Washington, DC: American Psychological Association. Rodewald F, Wilhelm-GöQling C, Emrich HM, Reddemann L, Gast U (2011) Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. J Nerv Ment Dis. 199:122Y131. Sar V (2006) The scope of dissociative disorders: An international perspective. Psychiatr Clin North Am. 29:227Y244. Sar V, Akyüz G, Dogan O (2007a) Prevalence of dissociative disorders among women in the general population. Psychiatry Res. 149:169Y176. Sar V, Koyuncu A, Ozturk E, Yargic LI, Kundakci T, Yazici A, Kuskonmaz E, Aksüt D (2007b) Dissociative disorders in psychiatric emergency ward. Gen Hosp Psychiatry. 29:45Y50. Sar V, Ross CA (2006) Dissociative disorders as a confounding factor in psychiatric research. Psychiatr Clin North Am. 29:129Y144. Sar V, YargN0 LI, Tutkun H (1996) Structured interview data on 35 cases of dissociative identity disorder in Turkey. Am J Psychiatry. 153:1329Y1333. Schreiber FR (1973) Sybil. New York: Henry Regnery. Suraci P (2011) Sybil in her own words: The Untold Story of Shirley Mason, her multiple personalities and paintings. New York: Abandoned Ladder Press. Tutkun H, Sar V, YargN0 LI, Özpulat T, YanNk M, KNzNltan E (1998) Frequency of dissociative disorders among psychiatric inpatients in a Turkish university clinic. Am J Psychiatry. 155:800Y805. Van der Kolk BA, d’Andrea W (2010) Towards developmental trauma disorder diagnosis for childhood interpersonal trauma. In LaniusRA, VermettenE, PainC (Eds), The impact of early life trauma on health and disease (pp 57Y68). New York: Cambridge University Press. Disinformation About Dissociation Dr Joel Paris’s Notions About Dissociative Identity Disorder To the Editor: e write to record our objections to both the form and the content of Dr Joel W & Volume 201, Number 4, April 2013 Paris’s recent article entitled The Rise and Fall of Dissociative Identity Disorder (Paris, 2012). His claim that dissociative identity disorder (DID) is a ‘‘medical fad’’ is simply wrong, and he provides no substantive evidence to support his claim. From the mistaken identification of Pierre Janet as a psychiatrist in the first line (Janet was the most famous psychologist of his day), it is replete with errors, false claims, and lack of scholarship and just plainly ignores the published literature. Dr Paris provided a highly biased article that is based on opinion rather than on science. His review of the literature is extremely selective. Of 48 references, Dr Paris cites exactly 7 peer-reviewed articles published from 2000 onward (7/48 references equals 14%) and only 8 peer-reviewed, data-driven articles from before 2000 (8/48 equals 16%). Rather than relying on the recent peer-reviewed, scientific literature, Paris relied almost entirely on the nonYpeer-reviewed books, including a popular press book written by a journalist whose methods and conclusions have been strongly challenged. He claims that interest and research in DID have waned, yet he fails to cite the multitude of studies that have been conducted about it. In fact, Dalenberg et al. (2007) documented evidence of the exact opposite pattern described by Paris: ‘‘A search of the PILOTS database offered by the National Center for Posttraumatic Stress Disorder for articles on dissociation reveals 64 studies in 1985Y1989, 236 published in 1990Y1994, 426 published in 1995Y1999 and 477 in the last 5-year block (2000Y2004)’’ (p. 401). Dr Paris seems unaware of the depth and the breadth of research about dissociation yet made sweeping generalizations about it. For example, he fails to review the neurobiological and clinical research that has led to the addition of a dissociative subtype of posttraumatic stress disorder (PTSD) in the DSM-5. He fails to cite cutting-edge research on dissociation including a recent study by 2012) in Biological Psychiatry that found evidence of the dissociative subtype of PTSD in about 14.4% of 25,018 individuals in a World Health Organization sample involving 16 countries. The dissociative subtype was associated with male sex, a history of high exposure to previous traumatic events and childhood adversities, subsequent onset of PTSD in childhood, histories of separation anxiety disorder and specific phobia, severe role impairment, and suicidality. Dr Paris fails to cite a review article in 2010 in the American Journal of Psychiatry identifying a neurobiological and psychophysiological profile of the dissociative subtype of PTSD (Lanius et al., 2010). These individuals respond to traumatic scripts with hyperfrontality and limbic inhibition on functional magnetic resonance imaging, in contrast to those with the hyperarousal type, who have hypofrontality and limbic activation. * 2013 Lippincott Williams & Wilkins Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. The Journal of Nervous and Mental Disease In addition, he fails to cite a variety of neurobiological and psychophysiological studies of DID documenting similar brain morphology abnormalities in patients with DID to those of other traumatized patients (Reinders et al., 2006; Vermetten et al., 2006). Despite failing to review this and other relevant research, Dr Paris made the claim that ‘‘Neither the theory behind the diagnosis nor the methods of treatment are consistent with the current preference for biological theories’’ (p. 1078). Furthermore, he fails to cite any research that has been done by researchers outside North America. For example, Vedat Sar, MD, in Turkey has published more than 70 articles and chapters on dissociative disorders and trauma (http://vedatsar.com/ index_2.htm), but Dr Paris failed to mention a single one. Dr Paris seems unaware of the research on child abuse and its consistent link with adult psychopathology. He stated incorrectly that ‘‘Child abuse is only a weak risk factor for the development of adult psychopathology’’ (p. 1078). To make this claim, he had to overlook a broad range of research including large-population and prospective, controlled studies, such as the National Comorbidity Study Replication (Scott et al., 2010), documenting that early life trauma and maltreatment show a dose-response relationship with higher rates of depression, substance abuse, suicidality, selfdestructiveness, problems with relationships, work impairment, revictimization, and dissociation and number of DSM-IV-TR diagnoses, among many others, including the leading causes of death from serious medical disease (Cicchetti, 2004; Felitti and Anda, 2010; Trickett et al., 2011). Dr Paris’s puzzling and incorrect claim has been carefully examined and refuted in the scientific literature (Dallam et al., 2001). At the least, contrary published information should be discussed. A recent review in Psychological Bulletin by 2012) found strong support for the etiological relationship of trauma and dissociation. These included several large meta-analyses, some of which focused on patients with DID. Dalenberg et al. (2012) found an effect size of r = 0.52 and 0.54 for the relationship between childhood physical abuse and sexual abuse, respectively, in studies that compared individuals with dissociative disorders with those without dissociative disorders. In addition, Dalenberg et al. (2012) tested eight different predictions of the trauma versus the fantasy (sociocognitive/iatrogenic) model of dissociation. On each, careful of reviews of the literature, including meta-analyses, on memory, suggestibility, and neurobiology, among others, Dalenberg et al. (2012) found minimal scientific evidence to support the fantasy model. Further, reviews have shown that there are no research studies in the literature in any population studied to support the iatrogenic/sociocognitive etiology * 2013 Lippincott Williams & Wilkins & Volume 201, Number 4, April 2013 of DID promulgated by Dr Paris (Brown et al., 1999; Loewenstein, 2007). Dr Paris makes claims that are far afield from what can be scientifically substantiated by current research. For example, he states that ‘‘I the treatment recommended [for DID] was never shown to be successful’’ (p. 1078). Dr Paris ignores studies that have found that treatment of DID is associated with improvements in a range of outcomes, including substantially reduced dissociation, PTSD, depression, general distress, suicidality, and self-destructive behaviors, among others. For example, he failed to cite a prospective study of almost 300 therapists and patients from around the world (Brand et al., 2009b, 2012). The 30-month follow-up data showed that patients showed decreased dissociation, PTSD, general distress, depression, suicide attempts, self-harm, dangerous behaviors, drug use, physical pain, and hospitalizations as well as improved functioning and higher Global Assessment of Functioning scores. Furthermore, more patients progressed from early stages of treatment to more advanced stages than regressed from an advanced to early treatment stage. Despite citing a recent review of DID treatment, Dr Paris did not make clear that every study described in the review by Brand et al. (2009a) showed that patients with DID benefit from phase-oriented treatment specific to DID. Further, meta-analyses found medium to large effect sizes across a range of outcomes including decreased symptoms of dissociation, PTSD, depression, and anxiety as well as reduced self-harm and suicidality (Brand et al., 2009a). Indeed, data show that failure to treat DID results in significant iatrogenic worsening of these patients (Kluft, 1989). Dr Paris notes that ‘‘random controlled trials’’ have not been performed on patients with DID. However, randomized controlled trials (RCTs) for complex disorders such as BPD and DID may be not be feasible, especially across all phases of a long-term treatment (Brand et al., 2009a; Westen et al., 2004). In addition, the need to individualize treatment of complex disorders with many comorbidities and high risk for suicide attempts and/or self-destructive behavior may lead to adverse outcomes without modifying the usual RCT structures or using alternative designs (Brand et al., 2009a). In addition, by trivializing a psychiatric disorder that research shows affects 1% to 3% of the general population and that is common in both inpatient and outpatient settings (Akyuz et al., 1999; Foote et al., 2006; Johnson et al., 2006; Ross, 1991), articles such as that of Dr Paris add to the burden of stigma for these highly traumatized patients with serious psychiatric illness. Indeed, studies have shown that patients with DID have high rates of impairment, significant rates of treatment in more restrictive levels of care, and high rates of suicidality, leading to a significant burden of disease and cost Letters to the Editor to the mental health system (Johnson et al., 2006; Loewenstein, 1994; Mansfield et al., 2010; Mueller-Pfeiffer et al., 2012). The trauma-focused, phasic treatment model cited above is associated with significant clinical improvement. In addition, studies have also shown significant cost savings to the mental health system if correct treatment is provided for these patients (Loewenstein, 1994; Ross and Dua, 1993). Dr Paris gives one of us (D. S.) undeserved credit for dissociative disorders being in the DSM-5. They are there because the literature and clinical experience support it and our colleagues in American psychiatry (as well as the World Health Organization in the International Classification of Diseases) know that these are prevalent and persistent psychiatric disorders. Inclusion in the DSM-5 required extensive review and approval by the following: a) The Work Group on Anxiety, ObsessiveCompulsive, Trauma-Related and Dissociative Disorders (including many researchers from outside the dissociative disorders field), b) The Scientific Review Committee, c) The Clinical and Public Health Committee, d) the DSM-5 Task Force as a whole, and e) the Board of Trustees of the American Psychiatric Association. Dr Paris could have given input at any point in this process, including commentary on the www.DSM5.org Web site, which, for months, listed the proposed diagnostic criteria for dissociative disorders in DSM-5, and invited commentary. Indeed, all of the online comments were brought to the attention of the Work Group members during the DSM-5 process. In his critique, Dr Paris cites the review by Spiegel et al. (2011) of dissociative disorders for DSM-5, at the same time claiming that modern theories of dissociation are based solely on antecedent trauma, not genetic or biological factors. However, he ignores the full discussion in that article of the genetic data on dissociation (including his own articleVJang et al., 1998), citing, specifically, the interaction of genetic and environmental factors (e.g., traumatic experiences) that may lead to expression of a clinical dissociative disorder. In addition, that article reviews in depth the neurobiological data on dissociative disorders. Despite this, he claims that the dissociative disorders field has neglected neurobiological or genetic factors in understanding the process of dissociation and the dissociative disorders. Dr Paris also misrepresents David Spiegel’s late father Dr Herbert Spiegel’s opinion of Sybil. Dr Spiegel thought that Dr Cornelia Wilbur was pushing Sybil toward more fragmentation, so he disagreed with her treatment technique and concluded that Sybil had dissociative disorder not otherwise specified rather than dissociative identity disorder. One of us (D. S.) wrote the introduction to the book about the Sybil case cited www.jonmd.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 355 The Journal of Nervous and Mental Disease Letters to the Editor REFERENCES Brand BL, Classen C, McNary SW, Zaveri P (2009a) A review of treatment outcome studies for dissociative disorders. J Nerv Ment Dis. 197:646Y654. Brand BL, Classen CC, Lanius RA, Loewenstein RJ, McNary SW, Pain C, Putnam FW (2009b) A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians. Psychol Trauma. 1:153Y171. Brand BL, McNary SW, Myrick AC, Loewenstein RJ, Classen CC, Lanius RA, Pain C, Putnam FW (2012) A longitudinal, naturalistic study of dissociative disorder patients treated by community clinicians. Psychol Trauma. doi: 10.1037/a0027654. Brown D, Scheflin AW, Hammond DC (1998) Memory, trauma, treatment, and the law. New York: Norton. Brown DW, Frischholz EJ, Scheflin AW (1999) Iatrogenic dissociative identity disorder: An evaluation of the scientific evidence. J Psychiatry Law. 27:549Y638. Cicchetti D (2004) An odyssey of discovery: Lessons learned through three decades of research on child maltreatment. Am Psychol. 59:731Y741. Dalenberg C, Loewenstein R, Spiegel D, Brewin C, Lanius R, Frankel S, Gold S, Van der Kolk B, Simeon D, Vermetten E, Butler L, Koopman C, Courtois C, Dell P, Nijenhuis E, Chu J, Sar V, Palesh O, Cuevas C, Paulson K (2007) Scientific study of the dissociative disorders. Psychother Psychosom. 76:400Y401. Dalenberg CJ, Brand BL, Gleaves DH, Dorahy MJ, Loewenstein RJ, Cardena E, Frewen PA, Carlson EB, Spiegel D (2012) Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull. 138:550Y588. Dallam SJ, Gleaves DH, Cepeda-Benito A, Silberg JL, Kraemer HC, Spiegel D (2001) The effects of child sexual abuse: Comment on Rind, Tromovitch, and Bauserman (1998). Psychol Bull. 127:715Y733. Felitti V, Anda R (2010) The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior. In Vermetten E, Lanius RA, Pain C (Eds), The hidden epidemic: The impact of early life trauma on health and disease (pp 77Y87). Cambridge: Cambridge University Press. Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D (2006) Prevalence of dissociative disorders in psychiatric outpatients. Am J Psychiatry. 163:623Y629. International Society for the Study of Dissociation, Chu JA, Dell PF, Somer E, Van der Hart O, Cardeña E, Barach PM, Loewenstein RJ, Brand B, Golston JC, Courtois CA, Bowman ES, Classen C, Dorahy M, Sar V, Gelinas DJ, Fine CG, Paulson S, Kluft RP, Dalenberg CJ, Jacobson-Levy M, Nijenhuis ERS, Boon S, Chefetz R, Middleton W, Ross CA, Howell E, Goodwin G, Coons PM, Frankel AS, Steele K, Gold SN, Gast U, Young LM, Twombly J (2011) Guidelines for treating dissociative identity disorder in adults, third revision. J Trauma Dissociation. 12:115Y187. Jang KL, Paris J, Zweig-Frank H, Livesley WJ (1998) Twin study of dissociative experience. J Nerv Ment Dis. 186:345Y351. Johnson JG, Cohena P, Kasena K, Brook JS (2006) Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. J Psychiatr Res. 40:131Y140. Kluft RP (1989) Iatrogenic creation of new alter personalities. Dissociation. 2:83Y91. Lanius RA, Vermetten E, Loewenstein RJ, Brand BL, Schmahl C, Bremner JD, Spiegel D (2010) Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry. 167:640Y647. Akyuz G, Dogan O, Sar V, Yargic LI, Tutkun H (1999) Frequency of dissociative identity disorder in the general population in Turkey. Compr Psychiatry. 40:151Y159. Loewenstein RJ (1994) Diagnosis, epidemiology, clinical course, treatment, and cost effectiveness of treatment for dissociative disorders and multiple personality by Dr Paris (Rieber, 2006), explicitly disputing its conclusions. We disagree with almost every paragraph in Dr Paris’s article, from his inadequate discussion of the history of Janet, Freud, and the issue of traumatic memory in psychoanalysis to his one-sided discussion of the modern ‘‘false memory’’ legal cases and the complex medicolegal, forensic, and historical factors that led to them and to their cessation (Brown et al., 1998; Simeon and Loewenstein, 2009). We dispute his discussion of the role of hypnosis in DID treatment; indeed, expert consensus in the DID field is that hypnosis is primarily used for attenuation of severe symptoms, including severe PTSD flashbacks and intrusive symptoms, not for memory recovery (International Society for the Study of Dissociation et al., 2011). The strength of Dr Paris’s conclusions is not matched by a comparably strong empirical foundation and even includes ad hominem attack. Disagreement about important issues in our field is important and vital. However, this level of scholarship would not be considered acceptable in the discussion of the psychotic disorders, mood disorders, personality disorders, or any other disorder in psychiatry. It is time that the same minimum standard of scholarship be provided for discussion of the dissociative disorders. In summary, disagreement is healthy for our field. However, Dr Paris’s article does not provide scholarly criticism based upon peerreviewed research, scientific data, or accurate discussion of the history of psychiatry. His point of view is incorrect and outmoded. It is the so-called false-memory, iatrogenesis model of the dissociative disorders that is the fallen fad, buried under the weight of rigorous data that contradict it. Dissociative disorders have not risen and fallen. These existed before the fields of psychiatry and psychology did. These are, alas, here to stay but are amenable to better understanding and improved treatments. Bethany Brand, PhD Department of Psychology Towson University, MD Richard J. Loewenstein, MD The Trauma Disorders Program Sheppard Pratt Health System Baltimore, MD Department of Psychiatry University of Maryland School of Medicine Baltimore David Spiegel, MD Department of Psychiatry and Behavioral Sciences Stanford University School of Medicine CA 356 www.jonmd.com & Volume 201, Number 4, April 2013 disorder: Report submitted to the Clinton administration task force on health care financing reform. Dissociation. 7:3Y11. Loewestein RJ (2007) Dissociative identity disorder: Issues in the iatrogenesis controversy. In Vermetten E, Dorahy M, Spiegel D (Eds), Traumatic dissociation (pp 275Y299). Washington, DC: American Psychiatric Press. Mansfield AJ, Kaufman JS, Marshall SW, Gaynes BN, Morrissey JP, Engel CC (2010) Deployment and the use of mental health services among U.S. Army wives. N Engl J Med. 362:101Y109. Mueller-Pfeiffer C, Rufibach K, Perron N, Wyss D, Kuenzler C, Prezewowsky C, Pitman RK, Rufer M (2012) Global functioning and disability in dissociative disorders. Psychiatry Res. 200:475Y481. Paris J (2012) The rise and fall of dissociative identity disorder. J Nerv Ment Dis. 200:1076Y1079. Reinders AA, Nijenhuis ER, Quak J, Korf J, Haaksma J, Paans AM, Willemsen AT, den Boer JA (2006) Psychobiological characteristics of dissociative identity disorder: A symptom provocation study. Biol Psychiatry. 60:730Y740. Rieber R (2006) The bifurcation of the self. New York: Springer. Ross CA (1991) Epidemiology of multiple personality disorder and dissociation. Psychiatr Clin North Am. 14:503Y517. Ross CA, Dua V (1993) Psychiatric health care costs of multiple personality disorder. Am J Psychother. 47: 103Y112. Scott J, Varghese D, McGrath J (2010) As the twig is bent, the tree inclines: Adult mental health consequences of childhood adversity. Arch Gen Psychiatry. 67:111Y112. Simeon D, Loewenstein RJ (2009) Dissociative disorders. In Sadock BJ, Sadock VA, Ruiz P (Eds), Comprehensive textbook of psychiatry (9th ed, Vol 1, pp 1965Y2026). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Spiegel D, Loewenstein RJ, Lewis-Fernandez R, Sar V, Simeon D, Vermetten E, Cardena E, Dell PF (2011) Dissociative disorders in DSM-5. Depress Anxiety. 28:824Y852. Trickett PK, Noll JG, Putnam FW (2011) The impact of sexual abuse on female development: Lessons from a multigenerational, longitudinal research study. Dev Psychopathol. 23:453Y476. Vermetten E, Schmahl CG, Lindner S, Loewenstein RJ, Bremner JD (2006) Hippocampal and amygdalar volumes in dissociative identity disorder. Am J Psychiatry. 163:630Y636. Westen D, Novotny CM, Thompson-Brenner H (2004) The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychol Bull. 130:631Y663. Response to Dissociative Identity Disorder Letters From Martı́nez-Taboas et al. and Brand et al. To the Editor: t must be difficult to acknowledge that one has spent a great part of one’s career promoting an illusion, particularly one that has been destructive to patients’ lives. However, that is the position that the proponents of I * 2013 Lippincott Williams & Wilkins Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. The Journal of Nervous and Mental Disease dissociative disorders find themselves in. The good news is that most psychiatrists ignored dissociative identity disorder, even at the height of the fad. The defeat of this idea helps to explain their furious onslaught on an article that only describes the current scientific consensus. The highly selective nature of their review of other published articles will be apparent to anyone who knows this literature. Unfortunately, neither Brand et al. nor Martinez-Taboas et al. have sufficient scientific training to be skeptical about one of the most absurd fads in the history of medicine. They are true believers, and that is what makes them dangerous. They fall back on personal attack, including the claim that I do not understand the impact of childhood abuse (despite my 20 years of research on the subject). Evidently, it has not occurred to them that the impact of adversity needs to be studied prospectively (or with independent validation), not by misguided therapists who insist that patients must have experienced abuse, whether they remember it or not. The larger tragedy is that once a category gets into DSM, it is almost impossible to remove it. When manufacturers produce defective products, they apologize for errors and carry out recalls. However, when psychiatrists invent diseases, and when they have friends in high places, they suffer no consequences other than long-term reputation. Our profession lacks oversight and regulation. The responsibility for this fiasco, which has done much to make our specialty look ridiculous, lies with the American Psychiatric Association and the editors of the various DSM editions, who allowed it to happen. Joel Paris, MD Department of Psychiatry McGill University Montreal, Quebec, Canada Do Fads Ever Die? To the Editor: r Joel Paris’s article, The Rise and Fall of Dissociative Identity Disorder, in the December issue of the JNMD is timely. The multiple personality disorder/dissociative identity disorder (MPD/DID) craze within psychiatry and clinical psychology that crested in the 1990s, and that was discredited in courts of law, has shown regenerative signs that need a prompt rebuke. CrazesVparticularly medical crazesV follow the course Penrose (1952) described in his book On the Objective Study of Crowd Behavior. A few enthusiasts start a craze as did the followers of Cornelia Wilbur and Sybil with this one. A craze catches on by D * 2013 Lippincott Williams & Wilkins & Volume 201, Number 4, April 2013 attracting susceptible followers, usually by means of ‘‘scientific’’ claims about illuminating ideas and new mechanisms that ultimately lead to clinical and public confusion and an immunity to its allure in most other physicians. The craze then retreats, only to return when the veteran enthusiasts presume that ‘‘the dust has settled’’ and, perhaps, the old ideas and methods can work their magic again. Dr Paris correctly notes that as long as official psychiatry credits categories such as MPD/DID, where a theoretical conception is embedded in the criteria, then ‘‘the way of return’’ for ‘‘repressed and recovered memory therapy’’ stays open. Simply look at the ‘‘criteria’’ for dissociative amnesia in DSM-IV, in which the psychological symptoms that have the same behavioral, artifactual nature as the physical symptoms of conversion disorder are given a diametrically opposite interpretationV that is, assumed to be genuine rather than pseudoimpairments of faculties. This mistaken view about the nature of the condition is at the root of these enterprises. Critics of Dr Paris’s article ignore his basic arguments and expend effort identifying ‘‘scientific, peer-reviewed literature’’ about childhood traumas and adverse experiences that they claim he overlooks. However, the issue is not ‘‘science’’; it is ‘‘practice.’’ The practices derived from the MPD/DID scientific presumptions have produced countless casualties among patients treated and families affected. A chaos of claims, counterclaims, court judgments, financial settlements, and general discredit of psychiatric coherence depicts the history of the early and mid-1990s, when this craze hit its peak. Recovered memory therapy became a byword for psychiatric mistreatment in many circlesVboth professional and lay. No one can deny the casualties and the chaos, although some champions of MPD/ DID have tried. Let me list a few that, being on the public record, can be consulted by any party reflecting on and wondering about the relevance of Dr Paris’s article. The craze-initiating text Sybil, describing a patient with MPD (who was suspected, by an experienced psychiatrist, to be a ‘‘game playing hysterical patient with role confusion’’; Borch-Jacobsen, 1997), was based, Nathan (2011) reveals, upon a fraudulent misdirection of practice and opinion. However, Sybil is hardly the worst example or the person who suffered the most from this kind of treatment. The Donna Smith case, fought out in the courts of Maryland, displayed the efforts of psychiatrists to send an innocent man to prison on the basis of the false recovered memories of his vulnerable daughter evoked into MPD with hypnosis and Amobarbital-advanced suggestions. For these wrongful practicesV when the daughter retracted her memories and was discovered to have Graves’s diseaseVthe Letters to the Editor psychiatrist and his hospital paid a large financial settlement for damages to the family. The popular press revealed many of the grim details (Taylor, 1994). In the Patty Burgus case at Chicago’s Rush Medical Center, one of the psychiatric founders of the International Society for the Study of Multiple Personality and Dissociation and a leader of the MPD/DID therapies carried out a wild, mistaken, misdirected treatment program with Ms Burgus based on the view that she and her children were being abused and controlled by disciples of a ‘‘satanic cult’’ arising from Transylvania in the Middle Ages. When this patient ultimately regained her coherence by withdrawing from the intense inpatient therapeutic regimen that included hypnotic treatments, group pressures, and intoxicating medications, she sought and received a malpractice settlement of 10 million dollars. The psychiatrist lost his medical license in Illinois. In addition, there is the Jack Quattrocchi case in Rhode Island, in which, again, academically distinguished advocates of MPD/DID and repressed memories testified and advocated sending this man to prison for more than 20 years all on the basis of the responses to psychotherapeutic pressure again by a psychologically vulnerable young woman who protested against the claim that she had been sexually abused by Quattrocchi until she was subdued by the prejudices and claims of this ‘‘science of the mind’’ advanced by her therapist on the basis of the writings and the views of these very advocates. These three cases are but a sample from a long list of other patient and family casualties that includes examples of suicide, bankruptcy, false imprisonmentVbut it is a sample with a public record that anyone can consult and study right down to the records from hospital clinics and the statements of protagonists and defendants in the cases. These psychiatrists were not ‘‘undertrained’’ therapists but the very leaders of this movement. In no case did anybody hold himself/ herself to account for being so grievously and shamefully wrong. The peer-reviewed literature does not speak to the practice. It is clear that there is a need for ‘‘peer-reviewed practice,’’ especially those practices of the leading proponents of MPD/DID. Interested parties should examine just how the psychiatrists and the psychologists who promoted MPD/DID have behaved in the past when faced with these casualties. They dismissed them out of hand. They condemned every honest effort, including those made by me, to bring to their attention the suffering victims. They presumed such efforts to be in bad faith and ones defending incestuous pedophiles. In addition, they never identified in their later publications or teaching what pitfalls into which they themselves had www.jonmd.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 357 The Journal of Nervous and Mental Disease Letters to the Editor fallen (and had to pay damage settlements) or just what dangers the loose assumptions about repressed memories bring when promoted for general psychotherapeutic practice. Dr Paris’s article is important and thoughtful. Do not dismiss it with trivial criticisms. Certainly, if you are thinking of importing MPD/DID therapy into your country from the United States, beware of just what you will likely deliver to your fellow citizensVa chaos of 358 www.jonmd.com fraught claims, family injuries hard to repair, and mistrust in the professional integrity of psychiatrists. Paul McHugh, MD Department of Psychiatry and Behavioral Sciences Johns Hopkins School of Medicine Baltimore, MD & Volume 201, Number 4, April 2013 REFERENCES Borch-Jacobsen M (1997) SybilVThe making and marketing of a disease: An interview with Herbert Spiegel. In Dufresne T (Ed), Freud under analysis (p 190). Northvale, NJ: Jason Aronson. Nathan D (2011) Sybil exposed. New York: Simon & Schuster. Penrose LS (1952) On the objective study of crowd behavior. London: HK Lewis. Taylor J (1994) Lost daughter. Esquire Magazine. 121:76. * 2013 Lippincott Williams & Wilkins Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.