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Section 21
Mystery & Confusion in Diagnosis & Treatment

Question 21 | Test | Table of Contents


Various forms of dissociative disorders have been the focus of the misdiagnosis and incomplete treatment of TRS (Trauma Reenactment Syndrome) clients. In the late nineteenth century, Freud’s treatment of women who were survivors of childhood sexual abuse and other doctors’ hypnosis work with dissociative manifestations of early trauma represented the medical establishment’s view that women with dissociative behaviors and communications were to be diagnosed as suffering from hysteria. While this was an improvement over seeing these women as possessed by demons, it still unduly stigmatized the victim of childhood trauma. Until recently, dissociative episodes were likely to result in diagnoses such as schizophrenia, manic-depression, or other forms of major mental illness. Now that childhood trauma has been understood to stimulate dissociative patterns in children that last into adult life, there has been significant development in the mental health field. The trauma researcher and psychiatrist Bessel van der Kolk has developed a new diagnostic category to assess the various types of dissociation related to early trauma not specified as part of other diagnoses. While this is a hopeful step toward more precisely understanding and describing the effects of trauma on dissociative phenomena, there is still much mystery and confusion in this area of diagnosis and treatment.

Multiple Personality Disorder (MPD), also referred to as Dissociative Identity Disorder, an extreme form of dissociation, has become enormously interesting to clinicians and the public over the past few years. Many women whose behavior seems relatively normal yet who are strangely withdrawn, isolated, or difficult to relate to are now being diagnosed as suffering from this disorder. The MPD client has several distinct personalities, or alters, as a result of dissociative patterns developed during trauma experiences in childhood. These parts of herself are split off from each other and have separate, fully developed personae. One personality may be a child; another may be an adult woman very different from the woman as she is known to the world; another may be a male alter; and so on. The alters do not necessarily communicate with each other. The primary task of healing is generally assumed to be the integration of these various parts of the self into a more unified and better functioning whole self, or at least improvement in coordination of the various selves.

Women with this disorder are being seen in therapy far more frequently today than in years past. The discovery that MPD seems more prevalent than professionals had assumed seems directly linked to the recent evidence that child sexual abuse is more widespread and more damaging than had been thought. There is increasing pressure to believe the mental health professionals who say that Multiple Personality Disorder is a relatively common response to severe abuse.

Treatment of MPD is still evolving and there is no “usual” protocol for working with this disorder. It is generally accepted that rather lengthy individual psychotherapy is necessary. The therapist and client work together to bring forth as many of the personalities as possible, getting acquainted with each part of the fragmented self. They then begin the work of integrating the alters, so that the client can have a more cohesive self and manage her life more effectively. Not much is yet known about how medications or support groups may work to aid the psychotherapy treatment.

MPD women can include Trauma Reenactment Syndrome among their problems. They are likely to engage in self-destructive behaviors, ranging from self-mutilation to addictions and eating disorders. They are slightly more complicated than other TRS women in how they communicate, however, because only some alters seem to be responsible for the self-destructive behavior. Theoretically, this factor could make treatment much easier, because the particular part of the self that does the damage to the body has already been split off and identified. One could work directly with this alter on the self-harming patterns and then either persuade the alter to stop the behavior or integrate the alter with the parts of the self where there is more capacity for self-protection. In practice, however, this is not easy. The destructive alters are more accountable for the self-harmful behavior than the Abuser—Victim—Nonprotecting Bystander fragments of the Triadic Self, but they are not easy to communicate with or to neutralize. The non-MPD TRS woman may be less aware of the conflict within herself than the MPD woman. However, once she develops an understanding of how the Triadic Self operates, she generally has an easier time developing a Protective Presence to stop the Abuser’s self-harm.

A positive factor in connecting the MPD diagnosis with TRS is that the problem of dissociation resulting from childhood trauma takes center stage. All those who work with, or are in any form of relationship with, the TRS woman need to become familiar with the centrality of dissociation and fragmentation. The problems of the fragmented self for TRS women are on a continuum. MPD is at one end of the continuum; at the other end is the Triadic Self, a less severe form of fragmentation. The attention being given to MPD should make the road smoother for a better understanding of all TRS women and their problems with fragmentation and dissociation. The preoccupation with MPD can get in the way, however; because they are distracted by the novelty and drama of MPD clients, clinicians and other experts may lose sight of the fragmentation problems presented by other trauma victims. Professionals may also exaggerate the simpler triadic version of fragmentation so that it becomes a false MPD diagnosis.
- Miller, Dusty; Women who Hurt Themselves: A Book of Hope and Understanding; Basic Books: Massachusetts; 1994

Promoting Self-Regulation in Adolescents and Young Adults:
A Practice Brief

- Murray, D. W. & Rosanbalm, K. (2017). Promoting Self-Regulation in Adolescents and Young Adults: A Practice Brief. OPRE Report #2015-82. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

Personal Reflection Exercise #7
The preceding section contained information about self-injury behavior in Multiple Personality Disorder. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Association of Psychiatric Services Referral and Attendance
Following Treatment for Deliberate Self-harm With Prospective
Mortality in Norwegian Patients

- Qin, P., Stanley, B., Melle, I., & Mehlum, L. (2022). Association of Psychiatric Services Referral and Attendance Following Treatment for Deliberate Self-harm With Prospective Mortality in Norwegian Patients. JAMA psychiatry, 79(7), 651–658. https://doi.org/10.1001/jamapsychiatry.2022.1124


Peer-Reviewed Journal Article References:
Ennis, C. R., Tock, J. L., Daurio, A. M., Raines, A. M., & Taylor, J. (2020). An initial investigation of the association between DSM–5 posttraumatic stress disorder symptoms and nonsuicidal self-injury functions. Psychological Trauma: Theory, Research, Practice, and Policy.

Harmon-Jones, C., Summerell, E., & Bastian, B. (2018). Anger increases preference for painful activities. Motivation Science, 4(4), 301–314.

James, K., & Stewart, D. (2018). Blurred boundaries—A qualitative study of how acts of self-harm and attempted suicide are defined by mental health practitioners. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(4), 247–254.

QUESTION 21
According to the author, what is a positive factor in connecting MPD with Trauma Reenactment Syndrome? To select and enter your answer go to Test.

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