Who was Sybil? The true story behind her multiple personalities

case study on multiple personality disorder

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The story of Sybil — a young woman who had been abused by her mother as a child and, as a result, had a mental breakdown and created multiple personalities — caused a sensation. Sybil was a bestselling book in the 1970s and was adapted as a 1976 television mini-series and a feature-length docudrama in 2007. Author Flora Schreiber and Sybil's psychiatrist, Dr. Cornelia Wilbur, became rich and famous as a result. Sybil also profited, but her true identity remained a secret until after all three women were dead.

Much of the sensational story was fabricated, according to journalist and author Debbie Nathan. She reveals the truth about the case in her  book, Sybil Exposed: The Extraordinary Story Behind the Famous Multiple Personality Case , which she discussed in on The Current .

In the original book, Sybil is portrayed as a young woman who started seeing a psychoanalyst in New York City in the early 1950s. Nathan described what happened after a few sessions, as detailed in the book: "She had a very dramatic moment when she started smashing windows, and split into another personality, into a little girl. And as she went into further therapy with the therapist, she developed many other personalities, a total of 16. The therapist assumed that something terrible must have happened to her when she was a child to create this kind of splitting in her consciousness. So she spent many years working with her. And ultimately Sybil remembered terrible, hideous sexual abuse and torture by her mother, and once she came to remember that, she reintegrated and was able to have a happy life after that. So the book had a happy ending."

Sybil's case generated widespread fascination both in the general public and the medical community, and a group of psychiatrists and psychologists successfully lobbied to have multiple personality disorder included in the DSM ( Diagnostic and Statistical Manual ). Once that happened, the disorder, which had been extremely rare, became a relatively common diagnosis. "In the entire history of Western civilization, there had been less than 200 [cases] over a period of centuries," Nathan said. "But after the book and film, suddenly there were hundreds and thousands. And by the late 1980s there were 40,000 cases diagnosed in the United States alone."

Sybil's real name was Shirley Mason, and she was brought up as a Seventh Day Adventist in rural Minnesota. The fundamentalist Christian sect taught that people shouldn't read fiction. But Shirley was a highly imaginative child, who loved to make up stories. "She lived in a fantasy world as a little girl," Nathan said. By the time Shirley was in college, she was having psychological problems, and she went to see Dr. Wilbur in the 1940s.

Dr. Wilbur had an interest in multiple personality disorder, and she recommended that Shirley read up on the subject; a mistake, in Nathan's view, as Shirley was so prone to fantasize. But it wasn't until a few years later, in the early 1950s, that Shirley returned to therapy and the multiple personalities emerged.

"One day Shirley just knocked on Dr. Wilbur's door and said, 'Hi, I'm Peggy,' a nine-year-old alter personality," Nathan explained. "Dr. Wilbur barely blinked an eye. She seemed very pleased that she now had a multiple personality disorder patient. She told Shirley she'd treat her for free, on credit, and she began giving her strong psychotropic drugs and barbiturates. Within a few weeks, [Dr. Wilbur] asked Shirley if she'd like to write a book with her about the case."

One of the drugs Dr. Wilbur administered was Thorazine, "an anti-psychotic that can have very, very strong side effects, including hallucinations," Nathan said. "And she gave her intravenous barbiturates, which can cause all kinds of fantasies which seem very real while the person's having them. They're like nightmares, but when you wake up from them, you believe that the material you fantasized really happened."

Nathan discovered the truth by poring over the papers of Flora Schreiber, the journalist who collaborated on the book. Her papers, which included thousands of pages of therapy material between Dr. Wilbur and Shirley Mason, had been sealed until 2001, because it wasn't until then that it was known whether Shirley was alive or dead.

Though Sybil ends happily, the woman who inspired the story did not. Shirley became a barbiturate addict, and was heavily dependent on Wilbur, who paid her rent, gave her clothes and money, and supplied her with drugs. Nathan likened the relationship to that of a junkie to her pusher.

Nathan speculates that Dr. Wilbur's motivations were based on the fact that she never had children. "From the 1930s to the 1950s, in psychiatry and the popular culture, you were not a fully realized woman unless you had children," Nathan explained. "And I think Dr. Wilbur wanted a daughter. And I think that was the real dynamic of the relationship."

In therapy, Shirley would imply that the personalities were generated because something terrible had happened to her. "The doctor would ask leading questions, which quickly came to focus on her mother," Nathan said. "Eventually there was a very detailed story of sexual torture by the mother, and that torture was supposed to have been so horrifying that Shirley the child, or Sibyl, just had to encapsulate that in different parts of her consciousness so she wouldn't remember it."

Journalist Flora Schreiber got involved because although Dr. Wilbur believed the case would make her famous, she wasn't a good writer. Eventually, as Schreiber started fact-checking the story, she began to doubt its veracity. But by then she had already been paid an advance, and when she confronted Dr. Wilbur and Shirley, they stuck by the story.

At the time the book was published, it was considered shaming to go to a psychiatrist, so Shirley tried to keep her identity secret. But some people did realize that Shirley Mason was Sybil. "Flora did very little to actually disguise Shirley's identity," Nathan pointed out.

Shirley had gotten a job teaching art at a college in the Midwest. But when she was effectively "outed" among colleagues, she ended up going into hiding and depending on Dr. Wilbur for support. "It was a sad ending to a very, very glittery beginning with that book," Nathan said.

Nathan went on to say that the case created a stir because it touched on issues that many women were dealing with at the time. "This was a woman's book, and the diagnosis that developed was a woman's diagnosis — 90 percent of people who have multiple personality disorder, or get diagnosed with the new name, dissociative identity disorder, are women."

Many young women wrote to Schreiber to say that Sybil's story struck a chord with them. They felt torn between the traditional female role and new opportunities that were opening up as a result of feminism. "Reading about this poor girl, who had developed all these personalities, and vanquished them, and put them all together and learned how to use them, well, that's the inspiration that I got from reading Sybil, that I can take all of my different selves and put them back together and lead a full life," Nathan said.

In Nathan's view, there are more constructive options for dealing with that tension. "To medicalize the sense of splitting and say that you are a woman who's very, very ill, because you are the ultimate victim, I think didn't do women any favours. And continues not to do them any favours."

The diagnosis of Dissociative Identity Disorder "clearly exists, when you have experts who are interested in finding it and they diagnose it," Nathan acknowledged. But she compares it to the Middle Ages, when it was assumed many people were possessed by devils. "Most women who went to the inquisitors during that period and said that they felt they had devils inside them weren't tortured to say that. They freely went to the inquisitors and the priests and said that they felt possessed."

Nathan added that it's not uncommon for people to "express their distress by feeling that there's something inside them, whether it's a demon or a spirit or a self, there's something inside them that doesn't really belong there. And depending on what's going on in the culture, and who's available to define that and treat it, you can get epidemics of that feeling, and you can get epidemics of diagnoses. So I think that that's what happened here."

She hastens to say that she isn't suggesting that people are faking their illness. "Once people get the diagnosis of Dissociative Identity Disorder, they have that diagnosis, and they act that out, not consciously, necessarily, at all," Nathan said. "So I think that asking whether it's true or it's false is not the helpful way to think of it." 

"Sybil: a name that conjures up enduring fascination for legions of obsessed fans who followed the nonfiction blockbuster from 1973 and the TV movie based on it — starring Sally Field and Joanne Woodward — about a woman named Sybil with sixteen different personalities. Sybil became both a pop phenomenon and a revolutionary force in the psychotherapy industry. The book rocketed multiple personality disorder (MPD) into public consciousness and played a major role in having the diagnosis added to the psychiatric bible, Diagnostic and Statistical Manual of Mental Disorders.

But what do we really know about how Sybil came to be? In her news-breaking book Sybil Exposed , journalist Debbie Nathan gives proof that the allegedly true story was largely fabricated. The actual identity of Sybil (Shirley Mason) has been available for some years, as has the idea that the book might have been exaggerated. But in Sybil Exposed , Nathan reveals what really powered the legend: a trio of women — the willing patient, her ambitious shrink and the imaginative journalist who spun their story into bestseller gold."

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Dissociative Identity Disorder: The woman who created 2,500 personalities to survive

  • Published 6 September 2019

Jeni Haynes

There was only one woman in the witness stand that day but out of her came six people prepared to testify about the extreme abuse she had suffered.

"I walked into court, I sat down, I made the oath, and then a few hours later I got back into my body and walked out," Jeni Haynes told the BBC.

As a child, Jeni was repeatedly raped and tortured by her father, Richard Haynes, in what Australian police say is one of the worst child abuse cases in the country.

To cope with the horror, her mind used an extraordinary tactic - creating new identities for her to detach from the pain. The abuse was so extreme and so persistent, she says she ultimately generated 2,500 distinct personalities to survive.

And in the landmark trial in March, Jeni confronted her father to present evidence against him through her personalities, including a four-year-old girl named Symphony.

It's believed to be the first case in Australia, and perhaps the world, where a victim with diagnosed Multiple Personality Disorder (MPD) - or Dissociative Identity Disorder (DID) - has testified in their other personalities and secured a conviction.

"We weren't scared. We had waited such a long time to tell everyone exactly what he did to us and now he couldn't shut us up," she said.

On 6 September Richard Haynes, now 74, was sentenced to 45 years in jail by a Sydney court.

Warning: Contains descriptions of violence and child abuse

'I wasn't safe in my own head'

The Haynes family moved from Bexleyheath in London to Australia in 1974. Jeni was four years old, but her father had already begun his abuse, and in Sydney this escalated into sadistic, near-daily violations.

Jeni Haynes, aged four

"My dad's abuse was calculated and it was planned. It was deliberate and he enjoyed every minute of it," Jeni told the court in a victim impact statement in May. She waived her anonymity rights, as a victim of abuse, so her father could be identified.

"He heard me beg him to stop, he heard me cry, he saw the pain and terror he was inflicting upon me, he saw the blood and the physical damage he caused. And the next day he chose to do it all again."

Haynes also brainwashed his daughter into thinking he could read her mind, she said. He threatened to kill her mother, brother and sister if she even thought about the abuse, let alone told them.

"My inner life was invaded by Dad. I couldn't even feel safe in my own head," Jeni said. "I could no longer examine what was happening to me and draw my own conclusions."

She composed her thoughts through song lyrics, to try to hide them:

"He ain't heavy/he's my brother" - when worrying about her siblings.

"Do you really want to hurt me/ Do you really want to make me cry" - when thinking about her ordeal.

Her father restricted her social activities at school to minimise other adult oversight. Jeni learnt to keep herself small and silent, because if she were to be "seen" - such as when her swimming coach approached her father to encourage her natural talent - she would be punished.

Richard Haynes sits on a couch with his three children including Jeni on the right

Jeni was also denied medical care for her injuries from beatings and sexual abuse, which have developed into serious lifelong conditions.

Now aged 49, Jeni has irreparable damage to her eyesight, jaw, bowel, anus and coccyx. These have required extensive surgeries including a colostomy operation in 2011.

The abuse would continue until Jeni was 11, when the family moved back to the UK. Her parents divorced shortly after, in 1984. She believes no-one, not even her mother, was aware of what she was going through.

'He was actually abusing Symphony'

Contemporary Australian experts refer to Jeni's condition as Dissociative Identity Disorder, and say it is heavily linked to experiences of extreme abuse against a child in what is supposed to be a safe environment.

"DID really is a survival strategy," Dr Pam Stavropoulos, a childhood trauma expert, told the BBC.

Jeni Haynes, aged four

"It serves as a very sophisticated coping strategy that is widely regarded as extreme. But you have to remember, it's the response to extreme abuse and trauma the child has undergone."

The earlier the trauma and the more extreme the abuse, the more likely it is that a child has to rely on disassociation to cope, leading to these "multiple self-states".

The first personality Jeni says she developed was Symphony, the four-year-old girl who, she says, exists in her own time reality.

"She suffered every minute of Dad's abuse and when he abused me, his daughter Jeni, he was actually abusing Symphony," Jeni told the BBC.

As the years went on, Symphony created other personalities herself to endure the abuse. Each one of what would be hundreds and hundreds of personalities had a particular role in containing an element of the abuse, whether it was a particularly horrifying assault, or a triggering sight and smell.

"An alter would walk out the back of Symphony's head and take on the distraction," Jeni told the BBC.

"My alters have been my defences against my father."

It's while discussing this that Symphony presents, about half an hour into our conversation. Jeni has warned this might happen, and there is a sign when it does - she struggles to articulate an answer before transitioning.

"Hello, I'm Symphony. Jeni's gotten into a pickle, I'll come tell you all about this if you don't mind," she says in a rapid burst.

Symphony's voice is higher, her tone brighter, more girlish and breathless. We talk for 15 minutes and her microscopic recollection of decades-old events around "Daddy's nastiness" is astounding.

"What I did was I took everything I thought was precious about me, everything important and lovely and hid it from Daddy so that when he abused me he wasn't abusing a thinking human being," Symphony said.

Presentational grey line

Some of the 'people' Jeni says helped her survive

Illustration of Jeni Haynes with her multiple personalities

  • Muscles - a teenager styled like Billy Idol. He is tall and wears clothes which show off his strong arms. He's calm and protective.
  • Volcano is very tall and strong, and clad from top to toe in black leather. He has bleached blond hair.
  • Ricky is only eight but wears an old grey suit. His hair is short and bright red.
  • Judas is short with red hair. He wears plain grey school trousers and a bright green jumper. He always looks like he's about to speak.
  • Linda/Maggot is tall and slender, wearing a 1950s skirt with pink poodle appliqués. Her hair is in an elegant bun and she has tapered eyebrows.
  • Rick wears huge glasses - the same sort Richard Haynes used to wear. They dwarf his face.

In March, Jeni was allowed to testify in court as Symphony and five other personalities, each of which would have shared different aspects of the abuse. The trial was heard by a judge only, because lawyers considered the case to be too traumatising for a jury.

Haynes initially faced 367 charges, among them multiple counts of rape, buggery, indecent assault and carnal knowledge of a child under 10. Jeni, in her personalities, would have been able to provide detailed evidence on every single offence in court. The separate identities have helped her to preserve memories that might otherwise have been lost to trauma.

Prosecutors had also lined up a range of psychologists and experts in DID, to give evidence about the condition and reliability of what Jeni would say.

"My memories as a person with MPD are as pristine today as they were the day they were formed," she told the BBC, before switching briefly to the plural. "Our memories are just frozen in time - if I need them, I just go and pick them up."

Symphony had intended to relive "in excruciating detail" the particulars of the crimes over the seven years in Australia. Muscles, a burly 18-year-old strongman, would have given evidence of physical abuse while Linda, an elegant young woman, would have testified on the impact on Jeni's schooling and relationships.

Black and white photo of the Haynes' family home in Greenacre, in western Sydney

Symphony "was hoping to use the testifying to grow up too", says Jeni. "But we only got through 1974 before he rolled over and showed his belly. He couldn't deal with it."

About two and half hours into Symphony's testimony on the second day of the trial, her father changed his plea to guilty on 25 charges - "the worst ones"- says Jeni. Dozens more were counted towards his sentencing.

'MPD saved my soul'

"It's a landmark case because, as far as we're aware, it's the first time in which the testimony of different parts of person with DID has been taken at face value into the court system and has led to a conviction," says Dr Cathy Kezelman, the president of Blue Knot Foundation, an Australian organisation helping survivors of childhood trauma.

Richard Haynes

Jeni first reported the abuse in 2009. It has taken 10 years for the police investigation to culminate in Richard Hayne's conviction and jailing.

He was extradited from Darlington in north-east England in 2017, where he had served a seven-year sentence for another crime. He had been living among Jeni's extended family, to whom he cast his daughter as a liar and manipulator.

Since learning of the abuse, Jeni's mother - who divorced Haynes in 1984 - has become her strongest supporter in her pursuit of justice.

But for decades, Jeni had struggled to receive help for her trauma. She says counsellors and therapists turned her away because her story sparked disbelief, or was so traumatic they could not deal with it.

Dissociative Identity Disorder

  • Disassociating - disconnecting from yourself or the world - is considered a normal response to trauma.
  • But DID can be triggered if a person, particularly a child, has to survive complex trauma over a long time.
  • Having no adult support - or an adult who says the trauma was not real - can contribute to developing DID.
  • A person with DID may feel they have multiple selves who think, act or speak differently, or even have conflicting memories and experiences.
  • There is no specific drug treatment - specialists will mostly use talking therapies to help DID patients.

Source: Mind

Despite being a widely accepted and evidence-backed diagnosis these days, DID commonly raises doubt among the general population and even some medical circles.

"The nature of the condition is such that it does generate disbelief, incredulity, and discomfort about the causes of it - partly because people find it hard to believe that children can be subjected to such extreme abuse," Dr Stavropoulos said.

"That's why Jeni's case is so important because it's bringing wider awareness of this very challenging but not uncommon condition that still isn't sufficiently realised."

Jeni says her MPD saved her life and saved her soul. But the same condition, and her underlying trauma, have also resulted in great hardship.

Jeni Haynes, in her 20s

She has spent her life studying, getting a masters and PhD in legal studies and philosophy but she has struggled to manage full-time work. She lives with her mother, both of them reliant on their welfare pensions to get by.

In Jeni's victim impact statement, she said she and her personalities "spend our lives being wary, constantly on guard. We have to hide our multiplicity and strive for a consistency in behaviour, attitude, conversation and beliefs which is often impossible. Having 2,500 different voices, opinions and attitudes is extremely hard to manage".

"I should not have to live like this. Make no mistake, my dad caused my Multiple Personality Disorder."

Jeni sat metres away from her father in court on 6 September to see him sentenced to 45 years. Haynes, who is suffering from poor health, will serve at least 33 years before he is eligible for parole.

Sentencing Judge Sarah Huggett said he would likely die in jail. His crimes were "profoundly disturbing and perverted" and "completely abhorrent and appalling", she said.

Judge Huggett said it was "impossible" for the sentence to reflect the gravity of the harm.

"I passionately want my story told," Jeni told the BBC before the sentencing. "I want my 10-year struggle for justice to literally have been the fire that ripped through the field so that people behind me have a much easier road.

"If you have MPD as a result of abuse, justice is now possible. You can go to the police and tell and be believed. Your diagnosis is no longer a barrier to justice."

You might also be interested in:

  • 'I feel like a weight has been lifted' - letters from abuse survivors

'My cruel gangster father made me have a nose job'

  • 'The story of a weird world I was warned never to tell'
  • 'Raised in a doomsday cult, I entered the real world at 15'
  • How I escaped my father's murderous polygamous cult

If you have been affected by sexual abuse or violence, UK-based help and support is available at BBC Action Line. In Australia you can contact Kids Helpline , Lifeline or Blue Knot Foundation .

More on this story

Why some abuse victims shunned Australia's apology

  • Published 22 October 2018

Silhouette of a young girl against a barren landscape

  • Published 27 August 2019

Margo Perin

Around the BBC

Mental health information and support

Dissociative Identity Disorder (Multiple Personality Disorder)

Reviewed by Psychology Today Staff

Dissociative identity disorder, formerly referred to as multiple personality disorder , is characterized by a person's identity fragmenting into two or more distinct personality states. People with this condition are often victims of severe abuse.

Dissociative identity disorder (DID) is a rare condition in which two or more distinct identities, or personality states, are present in—and alternately take control of—an individual. Some people describe this as an experience of possession. The person also experiences memory loss that is too extensive to be explained by ordinary forgetfulness.

DID was called multiple personality disorder up until 1994 when the name was changed to reflect a better understanding of the condition—namely, that it is characterized by fragmentation or splintering of identity, rather than by proliferation or growth of separate personalities. The symptoms of DID cannot be explained away as the direct psychological effects of a substance or of a general medical condition.

DID reflects a failure to integrate various aspects of identity, memory, and consciousness into a single multidimensional self. Usually, a primary identity carries the individual's given name and is passive, dependent, guilty, and depressed . When in control, each personality state, or alter, may be experienced as if it has a distinct history, self-image , and identity. The alters' characteristics—including name, reported age and gender , vocabulary, general knowledge, and predominant mood—contrast with those of the primary identity. Certain circumstances or stressors can cause a particular alter to emerge. The various identities may deny knowledge of one another, be critical of one another, or appear to be in open conflict.

According to the DSM-5, the following criteria must be met for an individual to be diagnosed with dissociative identity disorder:

  • The individual experiences two or more distinct identities or personality states (each with its own enduring pattern of perceiving, relating to, and thinking about the environment and self). Some cultures describe this as an experience of possession.
  • The disruption in identity involves a change in sense of self, sense of agency, and changes in behavior, consciousness, memory, perception, cognition , and motor function.
  • Frequent gaps are found in the individual’s memories of personal history, including people, places, and events, for both the distant and recent past. These recurrent gaps are not consistent with ordinary forgetting.
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Particular identities may emerge in specific circumstances. Transitions from one identity to another are often triggered by emotional stress . In the possession-form of dissociative identity disorder, alternate identities are visibly obvious to people around the individual. In non-possession-form cases, most individuals do not overtly display their change in identity for long periods of time.

People with DID may describe feeling that they have suddenly become depersonalized observers of their own speech and actions. They might report hearing voices (a child's voice or the voice of a spiritual power), and in some cases, the voices accompany multiple streams of thought that the individual has no control over. The individual might also experience sudden impulses or strong emotions that they don't feel control or a sense of ownership over. People may also report that their bodies suddenly feel different (like that of a small child or someone huge and muscular) or that they experience a sudden change in attitudes or personal preferences before shifting back.

Sometimes people with DID experience dissociative fugue in which they discover, for example, that they have traveled, but have no recollection of the experience. They vary in their awareness of their amnesia, and it is common for people with DID to minimize their amnestic symptoms, even when the lapses in memory are obvious and distressing to others.

In many parts of the world, possession states are a normal part of cultural or spiritual practice. Possession-like identities often manifest as behaviors under the control of a spirit or other supernatural being. Possession states become a disorder only when they are unwanted, cause distress or impairment, and are not accepted as part of cultural or religious practice. 

According to the Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition,  more than 70 percent of people with DID have attempted suicide at least once, and self-injurious behavior is common among this group. Treatment is crucial to improving quality of life and preventing suicide attempts for those with DID. 

Why some people develop dissociative identity disorder is not entirely understood, but they frequently report having experienced severe physical and sexual abuse during childhood .

The disorder may first manifest at any age. Individuals with DID may have post- traumatic symptoms (nightmares, flashbacks, or startle responses) or post-traumatic stress disorder. Several studies suggest that DID is more common among close biological relatives of persons who also have the disorder than in the general population.

Once a rarely reported disorder, the diagnosis has grown more common—and controversial. Some experts contend that because DID patients are highly suggestible, their symptoms are at least partly iatrogenic—that is, prompted by their therapists' probing. Brain imaging studies, however, have corroborated identity transitions.

There are other dissociative disorders, all of which concern an individual's disconnection with reality. The person who suffers dissociative amnesia, for example, has difficulty remembering who they are, where they live, and other important personal information. And the person who suffers depersonalized or derealization disorder is detached from their actions.

The primary treatment for dissociative identity disorder is long-term psychotherapy with the goal of deconstructing the different personalities and integrating them into one. Other treatments include cognitive and creative therapies. Although there are no medications that specifically treat this disorder, antidepressants , anti- anxiety drugs, or tranquilizers may be prescribed to help control the psychological symptoms associated with it. With proper treatment, many people who are impaired by DID experience improvement in their ability to function in their work and personal lives.

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A Multiple Personality Disorder Case Study

Multiple personality disorder is a serious personality disorder more commonly referred to as dissociative identity disorder. Genuine dissociated identity disorder is relatively rare, but it has appeared as a plotline in many films and books over the years, and one famous alleged example of a multiple personality disorder case study eventually became the subject of a book and two films.

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What exactly is dissociative identity disorder.

Patients suffering from the disorder develop several personalities, all of which are completely separate from the main identity. The “alters” can be different genders, ages, races, or even species, but the one thing that the “alters” have in common is that they usually appear as a result of severe emotional, sexual or physical abuse.

Shirley Ardell Mason

A famous example of a multiple personality disorder case study was Shirley Ardell Mason, otherwise known as Sybil, whose life was fictionalised in a book in 1973, and later in two films. Shirley Mason was the daughter of a schizophrenic mother. After suffering from blackouts and breakdowns for many years as an adult, she began having psychotherapy in an attempt to find a resolution to her emotional problems.

The account of Mason’s psychotherapy sessions with the psychologist, Cornelia Wilbur, later formed the basis for the book about her life, which revealed that she was alleged to have multiple personalities after suffering severe sexual abuse from her father.

The story of Shirley Mason received a great deal of publicity once the book was published. Many experts believed that Cornelia Wilber had made an incorrect diagnosis and Mason was in fact a suggestible hysteric as opposed to suffering from multiple personality disorder, but despite the controversy that persisted in the case of “Sybil”, her story was later made into a popular TV film in 1979 starring Sally Field and Joanne Woodward, and remade again in 2007.

Another example of a multiple personality disorder case study is that of “Paula”.

Paula was the daughter of extremely strict Baptist parents. Her mother subjected her to physical abuse on many occasions and from the time Paula was five years old, she began to suffer sexual abuse at the hands of her father. The abuse took a turn for the worse once Paula turned fifteen and she was later to recall several incidents in which she was raped, both by her father and by a neighbour.

As an adult, Paula fell into a series of dysfunctional relationships with men, but it was not until she began to suffer episodes of amnesia and intense headaches whilst studying at night school that she was referred for counselling by her professor. Although Paula was initially diagnosed with borderline personality disorder, following a hypnosis session, she was finally diagnosed with dissociative identity disorder.

Further sessions of therapy revealed three alters: Sherry, Janet and Caroline. Sherry had been created to help protect Paula from the sexual abuse, Janet manifested as an angry teenager, and Caroline was a five year old child. Another suicidal personality called Heather later appeared. This escalation of events prompted Paula’s psychologist to try and reintegrate the different personalities more quickly than he had planned, but unfortunately, Paula’s treatment was ultimately unsuccessful and she ended up being forcibly committed to a mental institution in order to protect her from further self harm.

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August 26, 2021 at 2:36 pm

My mother had multiple personality disorder. Being raised I have memories of her switching from one personality to another. Her voice changed and the feelings about her did too. Mom passed away 2 years ago and I found a journal written by the different personalities. Each one different from another. And some disturbing things are revealed in it. It is interesting read about others who suffered from the same disorder.

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Dissociative Identity Disorder and the Law: Guilty or Not Guilty?

Stefane m. kabene.

1 Department of Psychology, Canadian University Dubai, Dubai, United Arab Emirates

Nazli Balkir Neftci

Efthymios papatzikis.

2 Department of Early Childhood Education and Care, Oslo Metropolitan University, Oslo, Norway

Dissociative identity disorder (DID) is a dissociative disorder that gained a significant rise in the past few decades. There has been less than 50 DID cases recorded between 1922 and 1972, while 20,000 cases are recorded by 1990. Therefore, it becomes of great significant to assess the various concepts related to DID to further understand the disorder. The current review has a goal of understanding whether an individual suffering from DID is legally responsible for the committed crime, and whether or not he or she can be considered competent to stand trial. These two questions are to be raised in understanding DID, by first shedding a light on the nature of the disorder and second by examining the past legal case examples. Despite the very nature of the disorder is characterized by dissociative amnesia and the fact that the host personality may have limited or no contact with the alters, there is no consensus within the legal system whether the DID patients should be responsible for their actions. Further to that, courts generally deny the insanity claims for DID suffering patients. In conclusion, more studies in the field are suggested to incorporate primary data into research, as the extensive reliance on secondary data forces us to believe the conclusions that were previously made, and no opportunity to verify those conclusions is present.

Introduction

Dissociative identity disorder (DID) is classified by DSM-V as “presence of two or more distinct identities or personality states, each with its own patterns of perceiving, thinking, and relating to the environment and the self” where “at least two of these identities or personality states recurrently take control of the person’s behavior” ( American Psychiatric Association, 2013 ). The fact that the DID patients’ multiple identities not only perform differently on personality tests, but also on IQ tests was long since discovered by the predecessor studies in 1950s. It has been also shown that the identities may also differ in age, gender, preferences, and even handwriting (see Figure 1 ; Thigpen and Cleckley, 1954 ). Such gigantic difference between the identities and the fact that some identities may not be aware of others’ doings raises the question of legal responsibility of a person suffering from DID should a law be violated by one of the identities within him.

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The letter sent to the psychiatrists involved in the case of Chris Sizemore by the patient, Mrs. Sizemore. The sudden change in the handwriting can be observed in the last paragraph of the letter.

Another legal issue concerned with DID is competence to stand trial. As minor identities may “come out” during the process of the trial, and the dominant identity may have no awareness and/or memory of the actions and events that took place under control of minor identities, it becomes unclear of whether the person under trials is able to completely understand all the happenings during the trials. If that is the case, the question may arise as of person’s competency to stand the trial, not even the legal liabilities that he must incur given the crimes committed. To this aim, the initial attempt will be the examination of the clinical and neuropsychological characteristics of DID by the screening of recent studies that contributed to a better understanding of the disorder. This will provide a foundation for the framework that would in its turn attempt to define whether DID should be in all instances considered a valid reason for the person’s incompetence to stand trial or the person’s legal non-liability for the crime. Subsequently, the current review will examine the existing cases in which the DID patients had to face trials and the sentences they were or were not given. The paper will also attempt to formulate the conditions under which such patients are proven insane, based on the above-mentioned cases. The paper will then analyze the existing materials covering the encounters of DID patients who have committed crimes with the courts and the law enforcement system in general. A further emphasis will be given to the criteria that the courts use when dealing with issue of calling an DID patient to the legal liability. The extent to which the existing laws protecting criminals with mental issues can be applied particularly to DID patients will constitute a part in the current paper. Based on the review performed, the comparison will be made on how well the suggested framework aligns with the current tendencies in law enforcement on sentencing or not sentencing patients suffering from DID.

Current review will only focus on the analysis of secondary data due to the rarity of legal cases concerning DID patients. Therefore, the amount of cases will be too limited to find distinctive patterns in the features of DID symptoms, and the framework suggested will not be as comprehensive, hence, it will not be able to provide reasonable suggestions to the users. Despite using the secondary data as a source of information for the analysis, it must be noticed that the amount of trials involving DID is still very limited. Therefore, another focus of the paper will be on finding the traits in the symptoms of the DID patients not violating the law and hence not standing a trial.

Dissociative Phenomenology and Dissociative Identity

Dissociative identity disorder, formerly called multiple personality disorder, was first classified in DSM-III-R ( American Psychiatric Association, 1987 ). As it has been seen more commonly in the past 20 years among patients, DID remained as an Axis I disorder in DSM-IV-TR with the renaming of multiple personality disorder to DID ( American Psychiatric Association, 2000 ). Both in DSM-III-R and DSM-IV-TR the diagnostic criteria were laud and clear for that times, but in the context of the current information regarding DID they seem quite sketchy. Unsurprisingly, in 1999, in a survey of board certified psychiatrists in the United States only 21% reported that there is an evidence for DID’s scientific validity ( Gharaibeh, 2009 ). Apparently, the lack of consensus was not an issue in the legal system but also among the mental health care professionals as well. In an effort to overcome this issue, in 2013, American Psychological Association Work Group has proposed slight changes in the diagnostic criteria for DSM-5, in which “the symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events” ( American Psychiatric Association, 2013 ). Furthermore, as time progressed, more scientific evidence is being provided by the recent studies scrutinizing the experience of dissociation and its manifestation as DID, leaving little room for any clinical disagreement.

Current definition of dissociation refers to a detachment from one’s sensory experiences, thoughts, feelings, sense of identity or personal history, that occur in reaction to a traumatic experience ( Pollock et al., 2017 ). Dialectical in nature, on one hand it serves as a coping strategy that allows individuals to distance themselves from a trauma that may otherwise be unbearable, on the other it prevents an integration between the trauma and personal narrative, which is a must for the recovery. By manifesting itself in various forms, in depersonalization and derealization an individual has difficulty in processing information about the self and the reality at the present time. In dissociative amnesia the traumatic memory is reserved away from one’s memories and can only be recalled by dissociative flashbacks. In DID, the traumatic information is stored in different parts of the identity, so called alters. Among the others DID manifests the most complex clinical portrait, that is predisposed by prolonged childhood trauma ( Ozturk and Sar, 2016 ). According to Loewenstein and Putnam (1990) , the stories of male and female patients had a root from the past where 60% of females had causes related to sexual abuse whereas, 17% of male patients suffered from violence or rape in childhood. In description, DID is characterized by the coexistence of the host and alter identities that are fragmented from each other with limited or no communication. A recent theory identified 13 alter identities, namely, the apparently natural, helper, persecutor, child, gay/lesbian, messenger, abuser (perpetrator), leader (guide, wise), objective (neutral), reversible, talented, suicidal-depressive and potent female, all of which have varying awareness by the host personality. Furthermore, three forms of awareness of the personalities by the host personality were identified: (1) mutual amnesic, (2) unidirectional amnesic, and (3) co-conscious. Although there might be a co-conscious awareness between an alter and the host personality, the degree of recognition between the alter personalities is quite limited. This is due to the fact that each alter contains varying degrees of awareness of the traumatic memories and experiences his or her subjective reality accordingly, resulting in a dissociative barrier ( Ozturk and Sar, 2016 ; Ozturk, 2021 ).

Several comorbidities are reported among patients with DID, including major depression, somatization disorder and borderline personality disorders, which are among the most commons. Auditory hallucinations, dissociative amnesia, flashbacks and childhood abuse/neglect are other features seen in patients with DID, which are overlapping with the symptoms of other conditions such as PTSD and Schizophrenia. Particularly, Schizophrenia and DID overlap in psychotic symptoms, Schneiderian first rank symptoms in particular, as well as in their traumatic antecedents. However, the differentiation between DID and schizophrenia can be made along several criteria. For instance, poor reality testing and insight of the disorder are observed in schizophrenia, whereas both reality testing and insight remains intact in DID. Unlike schizophrenia, visual hallucinations are quite rare among patients with DID. Schizophrenia is characterized by loose associations with inappropriate affect, however, DID patients manifest conjectural associations with appropriate affect. Still, many patients receive different diagnoses because of lack of awareness of this condition ( Tschoke et al., 2011 ). As for the etiopathology of DID very little is known and the studies in this field are just a few. However, there is recent evidence demonstrating neuroanatomical differences between DID patients and health controls. The research revealed that cortical and subcortical volumes in the hippocampus, amygdala, parietal structures that are responsible for perception and personal awareness as well as frontal structures, which is responsible for movement execution and fear learning were significantly smaller in DID patients. Furthermore, in DID patients larger white matter tracts were detected, which is involved in information communication between somatosensory association areas, basal ganglia, and the precuneus. It was concluded that such neuroanatomical differences might be responsible for some of the symptoms of DID such as host dissociation and neurotic defense mechanisms ( Blihar et al., 2020 ). Apparently, more studies need to be conducted in order to reveal the etiopathology of DID for the recognition of the disorder both legally and clinically.

Despite the complexity of its nature, there are promising treatment models proposed by various professionals, who have a long-standing experience with DID patients (e.g., Kluft, 1999 ; Pollock et al., 2017 ). Trauma Based Alliance Model Therapy (TBAMT), for instance, provides a detailed theoretical framework in conceptualizing DID and proposes an evidence-based psychotherapy intervention techniques with a detailed psychotherapy protocol. By proposing an eclectic approach, TBAMT highlights the critical importance of forming therapeutic alliance with the host and all of the other alter personalities. This is for the fusion of each of the alter with the host personality so as to neutralize the traumatic experience by integrating the trauma related autobiographical memories of the alters, which the degree and the content varies for each of them ( Ozturk, 2021 ).

As can be concluded, within the last decade, the scientific advancements in understanding of DID has improved significantly. Integration of the recent clinical findings in the legal system would contribute to a consensus regarding whether claims for NGRI-DID can be accepted. Still, there is an incomprehensible challenge in the forensic assessment of DID patients claiming for the reason of insanity for crimes based on a dissociated state ( Farrell, 2011a ).

Dissociative Identity Disorder in the Courtroom

In order to understand the complexities of DID and its relationship with law, one should start the examination by starting from its history ( Table 1 ). The first encounter with DID has taken its place in 1815, when a patient, Mary Reynolds, who, according to Rayna L. Rogers, “might sleep eighteen hours a day and then awaken with large discrepancies in her memory, penmanship and disposition” ( Rogers, 1991 ). The first case of DID that has attracted significant public attention was that of Chris Sizemore, a story of a female patient diagnosed with DID, presented in 1954 by Thigpen and Cleckley. In this case, patient suffering from DID had two very distinctive identities, named by the psychiatrists as Eve White and Eve Black. In Eve’s case, Eve White could be considered as a dominant personality, as Eve Black’s appearances were relatively rare prior to the beginning of the treatment. Eve White and Eve Black had remarkably different behavioral traits. Furthermore, Eve White had no memories of actions done by Eve Black, while Eve Black had a complete awareness of Eve White’s expriences. Thigpen and Cleckley (1954) discussed an event, recalled only by Eve Black and the patient’s relatives, on how Eve committed a prohibited act, specifically she was “wandering through the woods to play with the children of a tenant farmer.” In this particular act, Eve Black only appeared to commit the wrongdoing and let Eve White take on the punishment that followed. The case of Eve becomes an argument that would support protecting DID patients from facing the legal liability for the illegal actions committed. If the person (in the above case Eve White) has no memory of the wrongdoing that cannot be explained by the regular forgetfulness, she may not be considered liable for the crime. However, it must be noticed that while Eve White must be considered innocent, Eve Black could not be exempted from the liability, if we consider two of them as separate identities. Eve Black herself is a sane personality that could appreciate the wrongdoing and the consequences that would follow. During the years ahead, this method was proposed and adopted with some courts that have faced DID patients. These courts have classified the distinct identities of DID patient as separate identities, and therefore sentenced only one or several identities that were in a way or other committing to a crime. Steinberg et al. (1993) examined the results of DID patients facing trials and have demonstrated the reasoning applied by the Supreme Court of Hawaii, that deals with DID suspects in a way that “each identity may or may not be criminally responsible for its acts, each must be examined under the ALI (American Law Institute) Modal Penal Code competency test.”

Court cases where DID was claimed as a basis for NGRI.

This method of judging several identities, however, contradicts itself. On one hand, only the personality that has committed a crime will be sentenced to a punishment. However, as all the identities in case of DID share one common physical body including the innocent ones, are subject to the punishment given by the court. Saks (1995) has proposed a theory of general non-responsibility of individuals with DID. Saks’s theory treats identities within an DID patient as separate identities, and therefore claims that courts must not hold DID patients responsible for the crimes unless all the identities existing within a person are involved in a crime, meaning they were either committing a crime or could have interfered and prevent the crime but did not. As per Saks, such theory would correlate with the system of jurisprudence that holds that “ten guilty people should go free rather than one innocent person be jailed” ( Sinnott-Armstrong and Behnke, 2000 ). The research conducted by Farrell (2011a) suggests that courts in general do not accept NGRI-DID (not guilty by reason of insanity due to DID) as a justification for non-responsibility. The reasoning for the rejection of DID as a reason is based on several factors. First one is based on the reason that “scientific evidence failed to meet reliability standards.” Second, abnormal states of consciousness is an insufficient allegation to correspond to a mental disorder that could meet the criteria of M’Naghten Rules (i.e., defendants did not know the nature or quality of their actions or, if they did know, they did not know that what they were doing was wrong) ( Farrell, 2011b ). In response to this, Nakic and Thomas (2012) reported that the British courts that are more indulgent to the diagnosis of DID have used several approaches to assess criminal responsibilities of DID cases. The alter in-control approach is used to assess the mental state of the alter identity, who was in control when the crime was committed. In the each-alter approach all of the alter identities are assessed for their criminal responsibility. Finally, the host approach examines whether the host personality was unable to evaluate the nature and quality of the conduct committed by the alter. The utilization of the aforementioned approaches will be illustrated in some of the following case examples.

Getting back to the courtrooms, the case of Juanita Maxwell that took place in Florida in 1979 was considered as one of the most unusual at that time. Maxwell was working as a hotel maid and was arrested because of the blood on her shoes and a scratch. Apparently, one of the hotel guests, Inez Kelley, was brutally beaten, bitten, and choked to death. Later on, the murderer was diagnosed with DID where she had six identities. In addition, the identity who committed the crime was called Wanda Weston that was asked to stand trial. People were impressed because Juanita was a soft woman with calm behavior, however, Wanda seemed to be more aggressive and violent ( McLeod, 1991 ). Furthermore, she was even laughing when admitted that she killed a person. As she was a woman suffering from DID, the court found her non-guilty and sent the patient to a psychiatric hospital. In 1988, Maxwella was arrested again for committing two bank robberies and claimed that it happened due to not receiving a proper treatment. By that time, Maxwell had seven identities, but Wanda was still pinned as the culprit of the crimes. Finally, she pleaded “no contest” and was released from prison for time served ( Levy et al., 2002 ).

The case of Thomas Huskey that took a place in Knoxville, brought up a broader question of whether DID is a valid defense for the crime. The man viciously killed four women after forcing them to have sex. In addition, he audiotaped himself with a loud and angry voice during the murder. Lawyers claimed that even though Huskey may have been speaking, the words were coming from an alter ego that took control of his actions ( Haliman, 2015 ). Moreover, the defense attorneys claimed that the tape of other personality so-called Kyle is not a proof that Thomas – a soft-spoken and calm man – committed any crime. Prosecutors asked an expert, Dr. Herbert Spiegel, to evaluate the presence of multiple identities and how each could impact the actions made by one human. Interestingly, the vocabulary, tone, and manner of talking were completely different in both identities when the professionals agreed it was the voice of the same person. One of the psychiatrists claimed Huskey was just a good actor and had an incredible ability to manipulate people ( Appalachian Unsolved, 2017 ). The court had only two options: whether find him guilty of the crime or non-guilty due to DID and signs of insanity. No matter how attorneys tried to defend Huskey, the majority of jurors came to a conclusion that he needs punishment for his crimes, and he is currently serving a 64-year sentence.

Speaking of “alter approach” (the approach under which the courts decide on person’ responsibility based on sanity or insanity of the alter in control during the crime), many courts have judged based on these criteria. In case of Grimsley, a woman accused of drunk driving and pleading for NGRI-DID, the court have concluded that “there was only one person driving the car and only one person accused of drunken driving. It is immaterial whether she was in one state of consciousness or another, so long as in the personality then controlling her behavior, she was conscious, and her actions were a product of her own volition. The evidence failed to indicate that Jennifer was unconscious or otherwise acting involuntarily” ( Sinnott-Armstrong and Behnke, 2000 ).

A possible reason that can explain the courts’ tendency to reject the NGRI-DID is the social response to the successful defenses based on that reason. The case in 1978, at which the defendant, Billy Milligan, who was a serial rapist, was found innocent for the reason of insanity (NGRI-DID), found an extreme outrage in the society. Since then, it was a very rare phenomenon to see courts accepting DID as a justification for insanity. Undeniably, the social response to DID hinders the objective judgment of DID-diagnosed patients for their legal responsibility. Certain psychiatrists do not believe in the DID at all, and there is a great suspicion over the ease of malingering DID in order to plead for insanity. The reason behind the thinking is the extreme complexity of symptoms that leads to the difficulty in the scientific evaluation of the patient’s disease.

The research conducted by Nakic and Thomas (2012) presents the case of Goering Orndorff, a woman who has killed her husband and altered a crime scene in a way that the scene presented her actions as a self-defense. During the process of the trials, specialists were asked to evaluate her competency to stand the trial due to the existence of dissociative symptoms. Some of the experts have agreed on DID diagnosis being applied to Mrs. Orndorff and presented their opinions during the trial. However, it was later revealed that the crime scene was intentionally altered, and that Mrs. Orndorff has told her cellmate that she attempts to malinger the DID in order to plead for insanity defense. With the account of all these facts, the court has found her guilty and sentenced her to 32 years of imprisonment. The later motions for new hearing proposed by the defense, were rejected by the courts.

Even though the people diagnosed with DID seem as no danger to the society at first, the statistics conducted by clinicians shows that nearly half of the patients had violent behavior ( Webermann and Brand, 2017 ). Since there is a sign of aggressiveness, the probability of committing a crime is relatively high and hard to be prevented due to a dissimilar behavior under each of the identities. At the same time, psychiatrists claimed that criminals tend to malinger DID in order to be defended by the law of insanity ( Saks, 1995 ). However, faking DID is considerably difficult because the person should be able to completely separate characters and fully control the actions and mind over a prolonged time. According to the case of Ms. Moore, there were two identities that acquiesced in the crime and found responsible for their actions. First of all, Billy Joel was a personality that actually terrorized a group of children and even ended up beating one of them to death. Then, there was the other identity so-called Marie Moore that would actually call herself pretending it is Billy with children’s daily instructions. Moreover, she even deflected the police when under suspicion. In this case, Ms. Moore could not be diagnosed with DID because both of her identities knew about the crime and actually took an action. Apparently, she was not mentally stable and could still have some mitigation but her claim of suffering from DID was completely rejected ( Moore, 1988 ).

Nevertheless, people diagnosed with DID can put not only themselves in trouble but also confuse the others around them by an abnormal change of mood and behavior. The case of Mark Peterson took place in Oshkosh in 1990, however, the psychiatrists found a progressive disorder where the number of identities was increasing and even represented changes of age in the majority of them ( Possley, 2014 ). Mark Peterson was a victim of dealing with a woman diagnosed with DID where she agreed to have intercourse with a 29-year-old man. The identity that emerged during that time was 20 years old when the other 6-year-old identity was watching from a different perspective. Later on, Mark was charged and convicted of second-degree sexual assault because it is illegal to have an intercourse with someone who is mentally ill. In addition, at the time of the incident in June woman had 21 identities, when later during the trial in November prosecutors discovered that this number has increased to 46. Even though Peterson was never retried for the crime after the overturned a month later verdict, the case brought up questions about how to deal with DID victims that claim to be assaulted during the presence of one of the identities.

Another cause of concern, as in the case of Peterson, is taking into consideration how to deal not only with DID patients who committed a crime but also how to punish the people who were interacting illegally and harmed one of the identities ( Possley, 2014 ). The action can be done by one identity and it will be considered acceptable when the other identity will look at that as a crime. However, the same human might not remember doing any of these since the switch of the identities happens naturally and the memory of past actions usually do not interfere with one another. Meanwhile, the prosecutors tend to end the trial faster in order not to put the victim in the position of psychological trauma all over again.

Discussion and Analysis

The literature review suggests a general tendency from the courts’ side not to accept the DID propositions and hence exempt the person from the responsibility on the basis of NGRI-DID. The major reasons for the tendency were lack of reliability of scientific methods in diagnosing DID, the possibility of a suspect to malinger DID in such a way that certain specialists will give the desired diagnosis (Ms. Orndorff’s case), the social response to the successful defense based on NGRI-DID, and the immaterial fact of DID, as related to the legal responsibility (the alter in control being sane and competent to stand the trial). Moreover, the case of Maxwell clearly showed that the person can commit the crime again when the society will hardly accept the decision of non-guiltiness. Therefore, the prosecutors tend to find criminals responsible due to the past experience and research done on DID.

The complexity of DID is also supported through the differences in the opinions on the reliability of the tests administered with the purpose of diagnosing DID. It has been suggested by Steinberg that the introduction of Structured Clinical Interview for DSM-III-R (SCID) and the Schedule for Schizophrenia for Affective Disorders and Schizophrenia (SADS) has increased the reliability in diagnosing disorders such as DID ( Steinberg et al., 1993 ). The case of Ms. Orndorff, however, has happened in 2000 and suggests that the diagnostic capabilities in terms of DID were still lacking and hence insufficient to accurately diagnose DID.

As was mentioned before, the courts do have a tendency to deny the NGRI-DID claims for the DID patients that commit crimes. However, it becomes interesting to check on whether similar illnesses, such as epileptic seizures, face the same level of denials in the courts. Epileptic seizures resemble DID in terms of legal responsibility in a way that during a seizure, a person may engage in “actions such as picking at the clothes, trying to remove them, walking about aimlessly, picking up things, or mumbling” ( Farrell, 2011b ). Of greater importance is the fact that “following the seizure, there will be no memory of it” ( Farrell, 2011a ). As the actions performed during a seizure are involuntary, the person is unable to appreciate the actions or the consequences that follow, and has no memory of the events, not explained by the regular forgetfulness, the court should consider the person insane at the moment of committing a crime. Farrell elaborates on three cases of successful defenses on the basis of “non-insane automatism” (the definition under which courts nowadays classify epileptic seizures). In all cases, the courts have declared the defendants not guilty of the crimes, as their actions were involuntary, and the defendants had no memory of the events.

It is interesting in the light of above-mentioned cases to see the drastic difference in the courts’ opinions about the similar illnesses in terms of legal responsibility. In both cases, the defendants have no memory of the actions committed. However, it must also be presented that DID patients generally have an identity within them that was aware of the wrongdoing and also carries the memory of that wrongdoing, while under epileptic seizures there is not a single trace that would suggest that the defendant has a memory of a wrongful conduct. One could also argue that while considering the epilepsy-suffering patient, we are concerned with a single identity that is a subject to a biological illness and therefore, it becomes easy to say that the person’s actions were indeed involuntary, while considering the DID, we are talking about totally different identities with their own mindset within a single individual with a very limited information regarding its etiopathology. It means that the court can be reasonably confident in the reliability of epilepsy truly belonging to an individual, while an DID patient can potentially malinger the illness. Even though a few studies have emerged within the last a few years investigating the neurological correlates of DID, the research in this domain is still in the stage of infancy.

Taking a look at the root causes of the DID, it is found that severe psychological trauma or prolonged abuse in the childhood are the most possible reasons that cause the brain to trigger the self-defense mechanisms and protect itself through the dissociation of identities. As the effect of DID is not happening on its own and is occurring following a severe trauma, it should be considered a mental illness and thus be a sufficient reason for claiming the person to be not guilty by the reason of insanity (NGRI-DID). Moreover, both genders can be exposed to any kind of assault or negative experience in the childhood and the tendency of being diagnosed with DID of those victims is correlated. Both men and women showed similar types of identities and behavior that leads to the conclusion that crimes can be done by anybody regardless of their sex ( O’Boyle, 1993 ). Therefore, the framework of how to justify or punish the person who committed wrongdoings should be the same for both male and female.

Many psychiatrists tend to question whether the person is really suffering from DID or trying to pretend in order to have NGRI-DID. However, involving only one specialist might not be enough as we all are human beings and think subjectively based on our past experience and beliefs. The case of Thomas Huskey was advised by the psychiatrist that already had strong beliefs that the murderer is just a great actor, therefore, he did not attempt to search for the root cause of the behavior that was hard to explain at that time ( Haliman, 2015 ). Moreover, involving a few professionals is no longer enough since the opinion can differ based on individual observation, however, even the final judgment can be affected by groupthink. Based on the case of Ms. Moore, it was easier to find her guilty since both identities were directly involved in the action, so even the presence of other minor identities would not justify her wrongdoings. In particular, she was not even diagnosed with DID during the trial and was found responsible regardless of her mental illness ( Moore, 1988 ).

Regarding the doubts over the reliability of measures for the assessment of DID, there are so far very few mechanisms available to psychiatrists that can be used in an attempt to evaluate patient’s dissociative disorders. It has been found that the long interviews used during the evaluation allow for emerging of different identities present within an individual. The long aspect of the interviews and evaluation also reduce the possibility of patient malingering the diagnosis. Kluft (1999) stated that “simulated DID presents crude manifestations of the disorder, such as stereotypical good/bad identity states and a preoccupation with the circumstances individual hopes to avoid by obtaining an DID diagnosis.” Kluft also suggested that it is difficult for the individual to maintain the voice, set of body gestures, and memory for every personality that he or she is trying to simulate. Hence, it can be suggested that the actual possibility of malingering DID is extremely challenging, and that cases of malingered DID will be very rare compared to correctly diagnosed DID.

Speaking of suggesting the framework for deciding on person’s liability on the basis of DID, the diagnosis has proven itself to be so complex that no universal method can actually be applied. However, there is a set of actions that should be done in order to assess the responsibility for the crime committed. Initially, an evaluation of the patient should be performed by several independent psychiatrists. The DID in our opinion should only be considered valid when all the psychiatrists involved agree on the opinion that the defendant is suffering from DID. Based on the diagnosis, the question of competency to stand trial must be answered. Then, the court should select the appropriate method for assessing the responsibility. The “host-alter” method is best when there is a dominant personality present, and the crime was committed by the alter identity. The “alter-in-control” method should be used when there is no clear evidence of the dominant identity. If the method used provides a result that supports the fact that the identity evaluated is insane at the time of committing a crime, the defendant should be considered not guilty.

Limitations

The paper does carry certain limitations. The main limitation lies in the fact that no primary sources of data were used. The nature of literature review exempts researchers from direct interaction with the patients. This is even true for the previous research that our paper is based on. The existing literature primary deals with evaluating the cases that have already happened, and not evaluating the currently open cases. It brings us to the need to believe the judgments of previous psychiatrists involved in the cases, not being able to actually see the patients and whether or not the researchers would agree on the diagnosis and the responsibility with the psychiatrists involved. The suggestion for future research that arises from this limitation is to attempt to conduct the study that would be based on the primary data by conducting interviews with specialists and patients involved or conducting observations. Case study method could be suggested.

Secondly, the paper primary deals with the cases from the Western region. It raises the question of the ability to generalize the results to the other region, as different cultures have different approaches toward legal judgments. It would hence be interesting to see the results of similar studies in the Asian and Eastern regions to compare whether these regions possess the similar views on the topic of multiple personality disorder. The future research on the above-mentioned areas of the world will therefore be of importance and value to the field of literature currently available.

Recommendations

The research has identified few critical areas in the field of DID that have not yet been addressed by the previous research and are also not addressed by our research. Previous research has either involved case studies of non-criminal DID patients, or analysis of criminal DID patients that was done after the trials have been concluded. However, it is of great importance to conduct the study that would examine the criminal DID patients while trials and evaluations are still ongoing. Such study would tackle the limitations present in our paper, as well as ones from previous research.

Future researchers are also encouraged to compare the courts’ views on DID with other disorders, similarly to our paper’s comparison of DID to epileptic seizures. Such studies are of interest to the field of psychology, as they may change the opinions on the diagnosis from the law enforcement agencies, if they see that similar disorders are treated differently, just like DID and epileptic seizures. Moreover, the research paper was focused on the cases that happened in the West and under its legal environment. The further research is suggested to look at the wider aspect of countries and nationalities, however, the availability of secondary source data as of now is really limited.

Dissociative identity disorder is a complex and controversial disorder which has seen opposing opinions on the existence of the disorder itself and concepts associated with it, such as the legal responsibility of the defendants suffering (or appearing to suffer) from multiple personality disorder.

The paper has examined the existing literature on the topic of multiple personality disorder and has found a general courts’ tendency to not accept DID as a reason to justify the defendant’s insanity and hence not to exempt the person from the legal responsibility. In part, such tendency is explained by the negative social reaction to the cases where defendants were found not guilty by the reason of insanity (see Milligan’s case). Another explanation for the tendency is the controversial and subjective nature of DID and differences in the opinions held by psychiatrists when evaluating a person on whether DID diagnosis could be given.

Based on the existing literature, the paper has suggested the basis for the framework on which the legal systems can standardize their approach toward DID. It has to be noted, however, that the framework still cannot be made universal, because the symptoms and traits existing differ from one patient to another (for example, the existence of the dominant personality). The induction of hypnosis during the course of treatment makes the issue even more complex, as we have seen from the case of Eve, where Eve White was a dominant personality until hypnosis sessions began and Eve Black learned to emerge at her will.

Based on the found secondary source data, the progress of developing the legal framework has improved when the awareness of DID keeps increasing, respectively. The courts tend to find DID criminals responsible for their actions due to the social factor and previous evidence. The approach of judgment is not related to the gender of the person since both male and female share the same types of identities. Even though the evaluation of DID is done by the psychological measures, the questions whether some people actually fake this disease keep appearing. Therefore, the involvement of the latest methods and a group of psychiatrists during the trial showed a positive effect on the final judgment.

Author Contributions

SK: conceptualization and supervision. SK and NB: data curation and writing – original draft. SK, NB, and EP: methodology and writing – review and editing. All authors have read and agreed to the published version of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

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Billy Milligan case brought attention to multiple-personality disorder

Billy Milligan, shown in 1985, was diagnosed with 24 personalities.

The shocking case of Billy Milligan, who died last week at a Columbus nursing home, helped propel the mental-health diagnosis of multiple-personality disorder from obscurity to instant notoriety.

Before Columbus police charged Milligan with kidnapping, robbing and raping three women in the Ohio State University area in 1977, mental-health professionals rarely diagnosed the disorder.

During his trial, a psychiatrist testified that Milligan had 24 personalities, including a Yugoslavian man named Ragen and a lesbian named Adalana who had taken over during the crimes. He was found not guilty by reason of insanity and became the first person in the U.S. to successfully use multiple-personality disorder as a defense for a violent crime.

Two years later, in 1980, the American Psychiatric Association formally recognized the disorder, and almost overnight, the number of reported cases jumped from fewer than 100 to thousands. People flocked to TV talk shows to discuss their multiple identities and how they had been abused as children.

But just as quickly as the phenomenon grew, propelled through books, movies and TV shows, the hype around the condition — now called dissociative identity disorder — seems to have waned.

“It was somewhat of a fad to say you had multiple personalities during the 1970s and '80s and remains one of the most misunderstood and controversial diagnoses today,” Henry Thompson, a Chicago-area psychiatrist, said yesterday.

The disorder gained public attention with the 1957 book and film The Three Faces of Eve and later, a 1973 book about a woman named Sybil (later identified as Shirley Ardell Mason) who had 16 personalities. Sybil was made into two movies, one in 1976 and again as a TV movie in 2007.

“It seemed to get a lot of attention in the media after that and a certain sense of legitimacy,” said Terry Kukor, director of forensic and specialized assessment services at Netcare Access, a 24-hour mental-health and substance-abuse crisis-intervention service for Franklin County residents.

“People started talking about multiple-personality disorder and wondering if they had it, and mental-health professionals began diagnosing it more.”

Kukor likened it to the rapid rise of disorders such as bipolar and attention-deficit hyperactivity. For example, a 42 percent increase in cases of ADHD has been reported since 2003, according to a Centers for Disease Control and Prevention-led study published in the Journal of the American Academy of Child and Adolescent Psychiatry .

Not so clear is whether cases of these disorders are increasing because there truly are more or because doctors have gotten better at recognizing symptoms or are overdiagnosing.

Because of new scientific knowledge, the American Psychiatric Association renamed multiple-personality disorder in 1994 and set clearer, more delineated guidelines, resulting in fewer people being diagnosed, said David Lowenstein, a German Village psychologist.

“I think some people were being mis- and over-diagnosed,” he said.

During the late 1990s, several patients diagnosed with multiple-personality disorder sued their therapists for planting false memories of abuse and won in court, Kukor said. That caused many mental-health professionals to be more cautious about diagnosing the disorder.

People with dissociative disorder and other mental illnesses often seek treatment earlier and, as a result, don't get as sick as they used to, Lowenstein said.

“Treatment and medication can help stabilize them and fuse their multiple personalities before it causes a problem,” he said.

John Baughman, a retired school superintendent in Lancaster in Fairfield County, can't help but wonder if Milligan's life would have turned out differently if he had received treatment before he had kidnapped and raped the three women.

Baughman was a brand-new teacher when he taught Milligan in the sixth grade. He remembers being perplexed when the 11-year-old vehemently denied doing anything wrong, even when Baughman caught him in the act.

Concerned, Baughman said he talked to Milligan's mom about having a school-district psychologist meet with the boy. But he doesn't think that ever happened.

“Learning about his case after he was arrested helped explain some of his behavior,” Baughman said yesterday.

[email protected]

@EncarnitaPyle

Multiple personality. A case study

  • PMID: 7437999
  • DOI: 10.1177/070674378002500706

This paper presents a single case study of multiple personality that developed from traumatic experiences in early childhood and adolescence. The paper discusses how the therapist's attention can reinforce the development of new personalities. Hypnosis, psychotherapy and advancing age all have an effect on the resolution of multiple personality. In this case, there was only partial success in resolving all the personalities, because of earlier reinforcement.

Publication types

  • Case Reports
  • Child Abuse
  • Dissociative Identity Disorder / diagnosis*
  • Dissociative Identity Disorder / etiology
  • Dissociative Identity Disorder / therapy
  • Psychotherapy

CASE REPORT article

Schema therapy for dissociative identity disorder: a case report.

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Commentary: "Schema therapy for Dissociative Identity Disorder: a case report"

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\r\nNathan Bachrach,

  • 1 Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
  • 2 GGZ-Oost Brabant, Department of Personality Disorders, Helmond, Netherlands
  • 3 Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
  • 4 Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
  • 5 Department of Experimental Psychotherapy and Psychopathology, University of Groningen, Groningen, Netherlands

Treatment for Dissociative Identity Disorder (DID) often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation. The percentage of patients that reach the third phase is relatively low, treatment duration is long, and the effects of this treatment on the core DID symptoms have been found to be small or absent, leaving room for improvement in the treatment of DID. Schema Therapy (ST) is an integrative psychotherapy that has been proposed as a treatment for DID. This approach is currently being investigated in several studies and has the potential to become an evidence-based treatment for DID. This case report presents an overview of the protocol adaptations for DID ST treatment. The presented case concerns a 43-year-old female patient with DID, depressive disorder (recurrent type), PTSD, cannabis use disorder, and BPD. Functioning was very low. She received 220 sessions of ST, which included direct trauma processing through Imagery Rescripting (ImRs). The patient improved in several domains: she experienced a reduction of PTSD symptoms, as well as dissociative symptoms, there were structural changes in the beliefs about the self, and loss of suicidal behaviors. After treatment she was able to stop her punitive mode, to express her feelings and needs to others, and to participate adequately in social interaction. This case report indicates that ST might be a viable treatment for DID, adding to a broader scope of treatment options for this patient group.

Introduction

Dissociative Identity Disorder (DID) is a highly disabling disorder, associated with high levels of impairment, high risk for self-harm, multiple suicide attempts, high mortality, and very high societal costs ( 1 ). The main diagnostic criterion for DID is the perceived presence of two or more distinct identities, accompanied by a marked discontinuity in the sense of self and agency, and alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. Also, patients often report recurrent gaps in the recall of important personal information, everyday events, and traumatic events ( 2 ). The estimated 12-month prevalence of DID is 1.5% in the general American population ( 2 ), and around 5% in psychiatric settings ( 3 ).

Treatment for DID often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation ( 4 ). The percentage of patients who reach the third phase of treatment is relatively low [17–33%, ( 5 )] and treatment duration is long, on average 8.4 years ( 6 ). The effectiveness of this treatment has been examined in several non-controlled studies ( 6 – 8 ) and one Randomized Controlled Trial [RCT; ( 9 )]. The results indicated that, although the general functioning of patients improved, the effects of this treatment on the core symptoms (i.e., dissociative symptoms) are small or absent. Hence, there is ample room for improvement in the treatment of DID.

Schema therapy (ST) has been introduced as a viable alternative treatment for DID ( 10 – 12 ). ST is thought to be applicable to and effective for DID for several reasons. First, ST as a whole, as well as its trauma processing component, Imagery Rescripting (ImRs), are effective for disorders that result from interpersonal trauma in childhood, including complex PTSD and personality disorders [e.g., ( 13 – 17 )]. Secondly, ST was found to reduce dissociative symptoms in patients with Borderline Personality Disorder (BPD) ( 18 ). Thirdly, perceived shifts between identities in people with DID are understood as shifts between modes (temporary states of mind) and compartmentalization is not assumed ( 19 ). Extreme shifts in emotions, cognitions, and behaviors that are present in DID also appear in other disorders that are related to severe and prolonged childhood abuse, such as BPD; ST delivers tools for dealing with these shifts ( 20 ). Fourthly, a recent RCT ( 15 ) investigating the effectiveness of ImRs in people with PTSD as a result of early childhood trauma showed that trauma treatment is highly effective and can be performed safely without a stabilization phase. As a first illustration of this new approach to the treatment of DID, this case report presents an illustration of the application of an adapted form of ST for DID.

Case description

Ella (fictitious name) is a 43-year-old patient with an extensive psychiatric history, who was referred to a specialized mental health center in the Netherlands to participate in a study on the treatment of DID with ST. Ella experienced nightmares and flashbacks about past traumatic experiences, and reported 17 identities, as well as dissociative amnesia (i.e., memory gaps for daily life events and traumas). Several identities were obsessed with self-hatred and self-punishment and repeatedly gave orders to hurt or kill herself. She broke her arm once by force, repeatedly cut herself on her arm, and attempted suicide several times. According to the patient's report, traumatic experiences involved recurrent sexual abuse by her father during her childhood (4–11 years), as well as several times by a teacher and a peer from secondary school. Her mother denied the abuse and behaved in a guilt-inducing way. Moreover, during her training as a dentist assistant after graduating from high school, a manager tried to sexually abuse her, after which she mentally broke down. She was hospitalized numerous times due to parasuicidal behavior and suicide attempts. She also received CBT for 3 years. This treatment focused on depressive and anxiety symptoms, (para)suicidal behaviors, and cannabis addiction. It was delivered in individual as well as group format and did not result in long-lasting results. Previous treatment in this case did not include trauma stabilization therapy. She met her husband 14 years ago and has a son who is 6 years old. She feels insecure about the upbringing of her son and feels unconnected to her partner. At the start of therapy, she was not able to work.

The patient gave informed consent for participation in the study and for the publication of this case report. The Structured Clinical Interview for DSM disorders Dissociative disorders-Revised [SCID-D-R; ( 21 )], SCID-I, and SCID-II ( 22 , 23 ) were used to assess the presence of clinical disorders by an independent experienced clinician. Ella was diagnosed with DID, depressive disorder, PTSD, cannabis use disorder, and BPD, and her Global Assessment of Functioning ( 2 ) score was 25. Table 1 shows the results of the baseline assessment. This case is part of a non-concurrent multiple baseline design study among 10 DID patients ( 10 ).

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Table 1 . Results of baseline measures.

The treatment consisted of 160 sessions twice per week, followed by 40 weekly sessions. Thereafter, she received 6 monthly booster sessions which were aimed at reconsolidation and generalization of ST insights and skills learned during the active treatment. Each session lasted 50 min. ST for DID follows the same theoretical framework and makes use of therapeutic interventions as originally developed by Young et al. ( 25 ), though ST for DID is personalized to each patient as they present with different symptoms. Furthermore, several important adaptations to ST were made to meet the needs of DID patients. These will now be discussed.

Case-conceptualization and establishing a shared definition of problems in schema therapy language

At the start of treatment, the diagnosis of DID as well as the main problems of the patient were discussed. Ella was educated on the rationale of ST for DID with regards to basic needs and how frustration of these needs leads to schemas, modes, and psychopathology. To manage expectations, conditions of treatment were explained, such as treatment length (3.5 years), frequency of sessions, need for active participation, whom to contact in case of crisis, and the availability of the therapist. Much effort was put into building a working alliance throughout treatment by validating thoughts and emotions and being present, available, and consistent. Being really determined in finding solutions to deal with severe and persistent symptoms, not giving up but instead delivering hope and power is very important in working with DID patients. She was educated on how DID is understood in terms of schema theory (as modes), and identity states were thereafter translated into modes by clustering identities by their function and reformulating and merging them into a mode (see Table 2 ). There was no pressure to share all identities; the therapist worked with states that were present. Together with Ella a mode model was made (see Figure 1 ), containing the most prevalent modes: punitive and demanding mode (e.g., internal demanding and punitive messages), the vulnerable child mode (painful feelings, PTSD symptoms), the detached protector (e.g., withdrawing and disconnecting), avoidant protector (active avoidance behaviors), and self-soother (using cannabis and auto-mutilation to deal with painful feelings). This idiosyncratic model was consistent with the results of a recent empirical study into the most prevalent modes in patients suffering from DID ( 26 ). Moreover, (para)suicidal behaviors, coping mechanisms, and supportive relatives were assessed (level of parasuicidal behaviors was high and healthy coping mechanisms low), after which a basic safety plan was made in which Ella agreed to try to perform helpful behaviors (e.g., talking to my neighbor, talking to my husband, talking with my therapists) before harming herself (see Figure 2 ). This plan was used whenever basic safety became an issue, evident for example by the patient sending an appeal for help by e-mail or phone. She e-mailed texts like “ Death must be met with dignity. It is the only dignified thing left to do. I am never going to recover and if you really get to know me you would see how bad we are. I don't deserve to live .” Yet, it was possible to reassure her and prevent self-harm through email and short phone calls.

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Table 2 . Overview of parts and the corresponding modes.

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Figure 1 . Schema mode model of the patient.

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Figure 2 . Safety plan of the patient.

Dealing with dissociation and working with the detached protector

Specific adaptations in ST were made to address dissociative responses. Ella was educated on dissociation, stressing that it is a natural reaction to extreme and ongoing stress, especially when (biologically) sensitive to stressors. Furthermore, dissociative behaviors such as detachment or being unresponsive to stimuli from the environment were framed as behaviors that once had a clear survival function, but at present were mainly maladaptive. A strip of fleece was used to make a literal connection between Ella and the therapist, and to gain control over what was happening during the session. Whenever Ella zoned out or started to dissociate, the therapist gave the fleece a slight tug to have her stay connected and more present. Also, Ella could tug the fleece whenever she was in need, e.g., when the pace of the therapist was too high. At the beginning, the tugging and exploration of what triggered the disconnection was mainly initiated by the therapist, but gradually Ella became more active in tugging and exploring. Other techniques that were used to stop disconnection were grounding, such as the “Stop, Freeze, and Breathe” exercise ( 27 ), naming five things you see, throwing a small ball, or pinching some things hard (a shell or a sharp wooden stick). Also, the therapist and Ella found out that a dog clicker helped Ella to orient in the present whenever she got overwhelmed by flashbacks. She used the clicker when she sensed that she was (about to) reexperience traumatic events. The clicker helped her to feel in control over flashbacks and reorient to the present. Moreover, chair exercises, such as interviews with the detached protector, validating its protective function in the past, asking it to be less present, and setting the chair more aside in order to connect and reparent the vulnerable child, were used to reduce detachment.

Working with the avoidant protector

Avoidance behaviors are highly prevalent in DID patients and are a strong maintaining factor. Therefore, in ST for DID there is a constant alertness for avoidance behavior shown by the various identities. Dependent on their function they are reframed as a coping mode. Because the avoidance behavior can be intense and strong, creative solutions on how to deal with it are needed.

Ella had a strong avoidant protector (interpersonal and situational avoidance). She tended to avoid multiple situations (e.g., talking to other mothers at the schoolyard, attending other social situations, or discussing shameful past situations with the therapist). Her awareness of avoidance increased by teaching her to identify the behaviors of the avoidant protector and turn her attention toward avoidance behaviors in and outside the sessions via homework assignments (mode awareness work sheets). Avoidance patterns were targeted by chair work [dialogue with the avoidant protector, validation of the protective function in the past, asking the mode to make space for healing of the vulnerable part, and empathic confrontation (e.g., confronting her with the fact that avoiding trauma processing maintains PTSD, and not going along with avoidance)]. Creative solutions were used to break through her avoidance (e.g., picking her up from the parking lot and outside the building when she was afraid to enter the health center building and using telehealth when she wanted to cancel a therapy session combined with discussing her avoidance). In addition to cognitive interventions such as exploring the pros and cons of avoidance, she was stimulated to exercise approach behaviors at home (e.g., sharing feelings with partner or talking to other moms). Gradually, Ella became more able to diminish her tendency to avoid in therapy, as well as in daily life situations.

Working with the self-soother

DID patients frequently use alcohol, drugs, or medication to avoid dealing with intense negative emotions. In ST for DID these behaviors are reframed as the self-soother mode. The patient is made responsible for her behavior instead of going along with her tendency to attribute her behavior to an identity over which she has no control.

In the case of Ella, her cannabis use was framed as an avoidance strategy; she used cannabis daily to avoid painful feelings from past traumatic experiences. After several attempts to reach abstinence of cannabis through CBT techniques for addiction used in the context of ST, an additional clinical detox at her request helped Ella to stop her cannabis use completely. During this detox she expressed that she did not get overwhelmed by flashbacks and painful feelings, which helped her to continue abstinence, because sedation was not necessary anymore.

Trauma processing

In ST for DID, trauma processing is seen as a crucial part of therapy, which needs to start as soon as possible (usually several weeks to a few months). In ST for DID there is no stabilization phase in which skill and emotion regulation strategies are taught nor is stabilization of symptoms a prerequisite for trauma processing, whilst trauma processing in itself is found to have a stabilizing effect in patients suffering from severe childhood traumas [e.g., ( 17 )]. Trauma processing is done by ImRs, a technique that aims to change the dysfunctional meaning of early aversive experiences. It consists of prompting patients to rescript painful autobiographical memories in line with their unmet needs ( 28 ). To adapt ST to the specific needs of DID patients, the use of ImRs has been broken down in steps, to customize the pace of trauma processing and level of trauma exposure to what patients are able to deal with, gradually increasing the level of exposure and the involvement of the healthy adult part of the patient. In the case of Ella, trauma processing started after 8 weeks. This was possible due to several factors such as raising her commitment, the good working alliance, not avoiding trauma work but carrying it out at a level that was manageable for her, performing it in small steps, and the high frequency of treatment sessions. Imagery work was built up slowly, starting with a neutral experience (imagining skiing together with the therapist), whereafter mild negative (soothing of her crying as a child or being excluded at school) and more adverse negative experiences were processed (neglect and abuse experiences by father, teacher, and peer). ImRs was performed in small steps in which first the therapist rescripted, whereafter Ella was motivated to gradually participate in the rescripting (“ what would you like to say to him, okay just say that ”), and finally carrying out the rescripting herself. In the first 2 years, trauma work often disrupted her, because it activated the punitive part, sometimes leading to (para)suicidal behaviors. Therefore, in ST for DID one frequently oscillates between trauma work and working with the punitive part. At these moments, the safety plan was used and if necessary we worked with the punitive mode in the next session. In Ella, the punitive part told her she was bad and faulty and it was not worth living, making it very difficult to take care of the needs of the vulnerable child. The therapist interspersed ImRs with punitive mode work (see next paragraph) and stimulating adult healthy perspectives on feelings and needs of people. At the start the therapist kept the trauma work short (5 min) and gradually increased the duration of trauma processing (to about 30–40 min in one session). Over time, Ella thus increasingly tolerated trauma work and gained power over the traumatic experiences.

It took a long time and many repetitions before she was able to comfort and fulfill the needs of her vulnerable child. Only in the 3rd year she was able to adopt a healthier perspective on who was guilty and responsible for the abuse. In the last year she was able to rescript on her own. As a tool for performing the rescripting at home, she made a collage for each individual person who abused her to visualize the rescripting. It contained pictures of actions to stop the abuser (hitting him with a baseball bat, stabbing him with a knife, or setting fire to the house/school where the abuse took place). Additionally, it contained messages to say to the abuser ( shame on you, you're bad ), actions to bring the vulnerable child to safety (bring her to the hospital, wrapping her in warm blankets, or bringing her to a new safe home), and sentences to emphasize the innocence of the child and to build her self-worth (“ it is not your fault, there is nothing wrong with you ”).

Banishing the punitive part

In ST for DID, aggressive, punitive, and highly demanding identities are reframed as the punitive and demanding mode. Repeated, persistent, and creative ways of fighting their messages and banishment are needed to reduce the impact on the patient. ST aims to stop these messages and to increase control over them by replacing them with realistic, healthier messages.

In Ella the punitive and demanding modes (e.g., telling her she was bad, guilty, worthless, and incapable) were highly prevalent and persistent, and had a profound impact on her quality of life. They played an important role in eliciting and maintaining strong negative feelings and thoughts, self-harm (e.g., damaging her arm), and suicide attempts (by auto-intoxication). In those moments, the safety plan was initially used, followed by punitive mode work. Early in therapy, Ella felt that getting rid of the punitive mode was invalidating, because she felt that it was a part of her, and she was afraid of losing other identities as well. Repeated education and exploration of the impact of the punitive and demanding modes was necessary to work on banishing the punitive and demanding modes. Through time, and after numerous repetition of these exercises, the impact of the punitive mode was diminished. Numerous ST techniques were used in this process, such as balloon techniques (e.g., putting an imaginative protective balloon around herself to shield her from the negative messages and blowing punitive messages into a balloon after which the balloon was released). Other techniques used were imaginative muting of the mode (using a remote control to diminish the volume or using duct tape to silence the voice), shrinking the punitive mode to a smaller size, incarcerating it, chair work (e.g., putting the punitive mode on a chair, ordering it to stop, and placing it outside the room), and rituals such as burying and burning the images and messages of the punitive mode. A major breakthrough was achieved during a clinical admission due to a suicide attempt induced by the punitive mode. At this moment in time, the therapist had become really fed up with the punitive mode, and authentically and very strongly directly addressed this mode: “ I want you to get out of Ella's life, you are making her life miserable. You must leave .” Thereafter, the therapist motivated Ella to take back control and to bid farewell to the punitive mode once and for all. During an imagery exercise that followed, she imagined the punitive mode to change into a statue whereafter she shrank it, and chopped it into a thousand pieces. In the sessions that followed, Ella reported that the punitive part did not return, but she felt an empty hole within herself. The therapist and patient filled this hole with helpful messages for her vulnerable child.

Healing the vulnerable child mode

In ST for DID, child identities are conceptualized as vulnerable child modes. The therapist frequently and repeatedly reparents the vulnerable child, using imagination exercises to fulfill the needs of the vulnerable child, and gradually stimulating the healthy adult part of the patient to participate in healing the vulnerable child. Ella did not show her vulnerable side during the first treatment sessions. She feared maltreatment by the therapist. It was possible to gain her trust by creating a sense of safety within the therapy, after which she was able to let the therapist get in contact with the vulnerable child. The high treatment frequency, repeated validation of feelings and needs, and availability of the therapist might have all contributed to the relatively quick formation of a good working alliance. The therapist reparented the vulnerable child by validating and comforting Ella, but also by educating her on universal basic rights and needs of children, and responsibilities of parents as well as by recurrent rescripting of traumatic events that contributed to her negative self-image and guilt and shame feelings.

Stimulating autonomy

In ST for DID there is a strong focus on the stimulation of autonomy and taking responsibility for changing lifelong patterns throughout the treatment, because of the high levels of learned helplessness in DID patients. Ella often felt overwhelmed by her symptoms and unable to cope with most aspects of her life. Right at the start of treatment, personal goals were formulated to increase commitment and take responsibility for direction of the treatment. Also, homework exercises were given, in which Ella was asked to make summaries of each session, and was stimulated to express feelings and needs within sessions and at home (“ What does your little child mode think, feel, and need, and what does your healthy adult mode want to say to your father? ”). Especially in the last year of therapy, instead of doing the work for her, the therapist stimulated Ella to become more personally active in interventions. Autonomy and mastery were also stimulated by building a clear identity, figuring out what her likes and dislikes were, and which societal goals she wanted to pursue. In the last few months of treatment, the therapist and patient made a mode management plan together, in which all the helping interventions were included.

Review of successes

Because of a persistence of symptoms and strong feelings of helplessness, continuous focusing on the strengths of the patients and the progress they make is very important. Every 6 months, successes were reviewed by both the therapist and Ella by looking back at the positive steps she made (e.g., “ You completely stopped using cannabis for 6 months now ”, “ Lately, you were able to stay present during each entire session ”, and “ You were able to rescript yourself ”), and by looking at changes in the Mode Pie Chart [a pie chart in which the relative attendance of each mode is estimated; see ( 27 )].

The effectiveness of ST for DID is currently being investigated in two non-concurrent multiple baseline design studies in the Netherlands ( 10 ). This case report is one of the first descriptions of the practical application of ST for DID [also see ( 12 , 29 )], and illustrates that ST might be a viable and effective treatment for DID. Ella reported dissociative amnesia for traumatic experiences at the start of treatment. However, during therapy she shared that she was able to access traumatic experiences but feared confrontation and thus tried to avoid them. ImRs helped her to gradually process these traumas. ImRs was adapted to the limitations of Ella; it started as soon as possible (after several weeks), was built up gradually, and was performed continuously during the course of treatment. Furthermore, she was able to go along with a new conceptualization of the self in terms of modes instead of identities.

Ella showed strong improvement in psychiatric symptoms; there was a strong reduction of dissociative symptoms, PTSD, and depression symptoms including absence of suicidal behaviors, and abstinence from cannabis. She improved in social interaction and societal participation: she now takes care of her son and dog, her relationship with her husband has improved, she is meeting with friends, and sings in a choir. She also works as a volunteer for a needy elderly person and is applying for a job as a dentist assistant. These results are in line with studies into the effectiveness of ST and ImRs in adjacent populations ( 17 , 30 ). Ella found the termination of treatment very difficult, especially saying farewell to her therapist. Working so closely together during several years created a strong attachment bond, and ending of treatment can be difficult for both therapist and patient. Furthermore, because of the descriptive nature of this case report, no conclusion can be drawn about the evidence base of ST for DID; follow-up assessments were performed but cannot be presented because this case is part of a non-concurrent multiple baseline design study amongst 10 DID patients which is not yet finalized, so the results of individual participants cannot be shared ( 10 ).

This case report shows how ST can be applied to DID and suggests the possible effectiveness of ST for DID in general. An important next step is to systematically investigate the effectiveness of ST for DID in methodologically well-designed treatment studies, possibly leading to evidence-based treatments that go beyond stabilization of symptoms.

Patient perspective

Ella reported that ST for DID was and still is hard work. She has learned tools with which she can take and keep more control over modes and flashbacks. Where she used to avoid many situations and places, she now has the confidence to know that she can manage these on her own.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving human participants were reviewed and approved by the Ethics Committee of the Faculty of Behavioral and Social Sciences of the University of Groningen (EC-GMW). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

NB wrote the first draft of the manuscript. All authors read, commented on, and approved the manuscript.

Acknowledgments

We thank Ella for her participation in the study and her consent for the publication of this case report. We also thank Ida Shaw for her supervision of this ST trajectory.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: schema therapy, Dissociative Identity Disorder, case report, PTSD, personality disorder

Citation: Bachrach N, Rijkeboer MM, Arntz A and Huntjens RJC (2023) Schema therapy for Dissociative Identity Disorder: a case report. Front. Psychiatry 14:1151872. doi: 10.3389/fpsyt.2023.1151872

Received: 26 January 2023; Accepted: 04 April 2023; Published: 21 April 2023.

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Copyright © 2023 Bachrach, Rijkeboer, Arntz and Huntjens. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Nathan Bachrach, n.bachrach@tilburguniversity.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

  • Open access
  • Published: 19 February 2024

How changes in depression severity and borderline personality disorder intensity are linked – a cohort study of depressed patients with and without borderline personality disorder

  • John J. Söderholm 1 ,
  • J. Lumikukka Socada 1 ,
  • Jesper Ekelund 1 &
  • Erkki Isometsä 1 , 2  

Borderline Personality Disorder and Emotion Dysregulation volume  11 , Article number:  3 ( 2024 ) Cite this article

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Borderline personality disorder (BPD) is often complicated by comorbid major depressive episodes (MDEs), which can occur as part of major depressive disorder (MDD) or bipolar disorder (BD). Such comorbidity is related to worse outcomes in both disorders. Subsyndromal features of BPD are also common in depression. However, studies of simultaneous changes in BPD and depression severities are scarce, and their interactions are poorly understood.

Studying the associations between changes in BPD and depression symptoms over the course of an MDE.

In a 6-month naturalistic cohort study of MDE/BPD, MDE/MDD, and MDE/BD patients ( N  = 95), we measured change in BPD features between baseline and six months with the Borderline Personality Disorder Severity Index (BPDSI), an interviewer-rated instrument quantifying recent temporal frequency of BPD symptoms. We examined changes in BPD severity and their correlation with depression severity and other clinical measures and compared these across patient groups.

There were significant reductions in BPD severity, both in number of positive BPD criteria (-0.35, sd 1.38, p  = 0.01672) and in BPDSI scores (-4.23, SD 6.74, p  < 0.001), reflecting mainly a reduction in temporal frequency of symptoms. These were similar in all diagnostic groups. In multivariate regression models, changes in depression severity independently associated with changes in symptoms in the BDSI. This relationship was strongest in MDE/BPD patients but was not found in MDD patients without BPD.

Conclusions

In the six-month follow-up, BPD features in MDE patients alleviated mainly by decreasing temporal symptom frequency and intensity. In BPD patients with comorbid MDE, changes in both conditions are strongly correlated.

Introduction

Major depressive episodes (MDEs) can occur as part of major depressive disorder (MDD) or bipolar disorder (BD) [ 1 ]. Borderline personality disorder (BPD) is associated with a significantly increased risk of these mood disorders, with lifetime prevalence rates of MDD around 70% and BD around 20% [ 2 , 3 , 4 ]. Conversely, in MDE patients, comorbid BPD is common, with rates around 10% in MDD and 20% in BD [ 5 ]. Comorbid BPD in depression is correlated with a less favourable prognosis, increased risk of relapse, and increased risk of suicide attempts, affecting treatment [ 6 , 7 , 8 , 9 , 10 ]. Hence, the course of comorbid BPD is relevant for the prognosis and treatment of depression patients, and vice versa.

The reciprocal relationship between BPD and mood disorders

According to several long-term cohort studies, BPD is not a static condition, instead the symptoms of BPD tend to ameliorate over time, with the great majority of patients reaching symptomatic remission in long-term follow-up, although functional impairments seem more persistent [ 11 , 12 , 13 , 14 , 15 ].The prevalence of depression in BPD also tends to decline over time but remains relatively high in follow-up, and relapses are common [ 16 ].Over long-term follow-up of patients diagnosed with both mood disorders and BPD, there is evidence of bidirectional negative effects on outcome in MDD/BPD but less robustly in BD/BPD [ 7 ]. A previous prospective cohort of MDD patients found a significant correlation between decline in depression severity and number of positive personality disorder (including but not limited to BPD) criteria and self-reported neuroticism [ 17 , 18 ]. The factors underlying these relationships are likely to be complex. For instance, since a diagnosis of BPD is usually based on information obtained in a diagnostic interview, it can, in a depressed patient, be influenced by such factors as autobiographical, attentional, and emotional cognitive biases related to depression [ 19 ], with BPD symptoms seeming more pronounced during an MDE and less severe during remission. The DSM-5 recognizes this issue and explicitly warns against misdiagnosis of BPD in these circumstances: ”Because the cross-sectional presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar disorder, the clinician should avoid giving an additional diagnosis of borderline personality disorder based only on cross-sectional presentation without having documented that the pattern of behaviour had an early onset and a long-standing course” [ 1 ]. Still, PD diagnoses made during an MDE seem to have important prognostic implications, and a BPD diagnosis can be made also during an acute MDE, ascertaining that BPD symptoms have been present also when the patient is not acutely depressed [ 20 ]. How the symptomatology of BPD changes over the course of an MDE is not well known, however, and more detailed study of this issue would deepen our understanding of how these commonly comorbid disorders influence each other.

In longitudinal follow-up, BPD exhibits both trait-like (i.e. temporally stable) and state-like (more dynamic) features, with the stable component, or BPD proneness , closely correlated with Five Factor Model traits (i.e. descriptive normative personality traits), such as neuroticism, previously linked to BPD [ 21 ]. Examining how BPD feature severity changes over time and whether this change correlates with changes in depression severity in different patient groups (such as depression patients with and without BPD) would illuminate these issues further.

Categorical and dimensional aspects of BPD

There is long-standing discussion on whether personality disorders are best described using categorical or dimensional diagnoses [ 22 , 23 ]. BPD is still conceptualized as a categorical diagnosis in the main DSM-5 model, but the DSM also includes an alternative, hybrid approach that takes both traits and level of functioning into account [ 24 ], and ICD-11 utilizes a primarily dimensional approach based on functioning, with trait-based descriptors (including borderline pattern ) being optional [ 1 , 25 ]. Thus, attempts have been made to reconcile categorical diagnosis with more theoretically, and perhaps prognostically, valid dimensional evaluation.

One approach to quantifying BPD severity is according to the number of positive DSM-5 diagnostic criteria or otherwise measured symptoms, with more symptoms signifying higher severity [ 12 , 15 ]. However, since the rating concerns long-standing patterns apparent from (at least) young adulthood, these are by design not very sensitive to change over the short or even medium-term (weeks to months), and quick changes in these might reflect a change in recall and other cognitive biases rather than personality change. More accurate methods are also available; the Borderline Personality Disorder Severity Index (BPDSI) is an interviewer-rated, valid, and reliable instrument for quantifying recent BPD symptom frequency (mostly, in 8 of 9 symptom domains by rating how often symptoms occur) in greater detail [ 26 ], and has been used as a measure of treatment efficacy in trials of psychotherapeutic, pharmacological, and neuromodulatory treatment of both BPD and persistent depressive disorders [ 27 , 28 , 29 , 30 ]. Consistent with the view of BPD as a dimensionally occurring phenomenon that may increase the risk of mood disorders, subsyndromal symptoms of BPD are more common in depression than in the general population. For example, the non-BPD participants in this study had a significantly higher BPDSI score at baseline than previously found in healthy controls [ 31 , 32 ]. Nonetheless, to the best of our knowledge, there are no studies comparing the changes in dimensionally measured BPD feature severity in depression patients with MDD or BD, and with and without BPD, over time. A diagnosis of BPD, according to the DSM-5, is made based on established (retrospective) symptom patterns of high pathology, pervasiveness, and persistence over adult lifetime. Therefore, one might reasonably assume that prospectively assessed BPD symptom frequency and severity (measured, for instance, with the BPDSI) may be more temporally stable in BPD than non-BPD patients; however, this has not been previously investigated using methods precisely quantifying symptom frequency and severity.

Aims of the study

We evaluated the changes in BPD feature severities over the course of an MDE in MDD and BD patients, including patients with and without comorbid BPD. We hypothesized, firstly, that frequency and intensity of BPD symptoms, measured by the BPDSI and BPD criteria, would ameliorate over the course of the MDE, correlating with attenuation of depression severity. Secondly, BPD symptoms were hypothesized to be more stable in BPD patients than in others. If a correlation between the changes in BPD symptom and depression severities emerged, we intended to explore whether such a relationship was also present for anxiety and BPD symptoms.

This naturalistic cohort study with a follow-up of at least 6 months is based on the Bipolar – Borderline Depression (BiBoDep) cohort.

Recruitment and sampling

Our recruitment process has been described in more detail elsewhere [ 31 , 33 ]. We recruited patients with depression starting outpatient treatment at one of two psychiatric care clinics of the City of Helsinki, Finland, with a total catchment area of 234 000 adults.

We aimed to include adequate numbers of MDE patients with MDD, BD, and/or comorbid BPD, applying stratified randomized sampling to achieve this. Based on information in the referrals, we divided all incoming depression referrals ( n  = 1655) into six preliminary strata by (i) sex and (ii) probable diagnosis: (a) MDD, (b) MDE in BD, (c) MDE with comorbid BPD. We prioritized patients in strata that were underrepresented in our sample at that time. If there were multiple possible recruits within the preferred stratum, recruitment order was determined randomly with a random number generator available online at random.org. Patients were contacted by phone, and those providing preliminary consent were met and given additional oral and written information about the study.

Consenting patients were then interviewed with the Structured Clinical Interview for DSM-IV, i.e. SCID-I and SCID-II [ 34 , 35 ]. The diagnostic interviews were thorough, lasting around three hours per patient at baseline, and the diagnostic evaluation was also based on information in patients’ clinical charts. Diagnostic reliability, assessed with independent rating of videos of these interviews, was found to be excellent, with a Cohen’s kappa of 1.00 for MDD, 0.90 for BD, and 0.89 for BPD. We examined current depression severity with the Montgomery Åsberg Depression Rating Scale (MADRS) [ 36 ].

Inclusion and exclusion criteria

Inclusion criteria were a current MDE, a MADRS score of 15 or more, and age of 18–50 years. Exclusion criteria have been described in more detail previously [ 31 , 33 ], but included psychotic illness or ongoing psychotic symptoms, active substance use disorders, antisocial personality disorder, lacking proficiency in the Finnish language, and significant neurocognitive or sensory impairments.

Sample and subcohort assignment

Altogether 124 patients were included in the study at baseline. Our patients were divided into three subcohorts, such that all patients with MDD without BPD belonged to one subcohort (MDD, n  = 50), patients with BD belonged to the second subcohort (MDE/BD, n  = 43), and patients with comorbid BPD belonged to the third subcohort (MDE/BPD, n  = 31). BD patients with comorbid BPD were assigned to the BD subcohort if they had type I BD, otherwise we assigned them to either the MDE/BD or the MDE/BPD subcohort depending on main clinical picture at and preceding baseline. Unclear cases were discussed in the study group, and a consensus decision of subcohort assignment was reached.

Baseline evaluation

In addition to the diagnostic interviews and MADRS, we also asked study participants to complete the Beck Depression Inventory II (BDI II) [ 37 ] and the Overall Anxiety Severity and Impairment Scale (OASIS) [ 38 ].

  • Borderline personality disorder severity index

We evaluated severity of recent BPD symptom severity with the BPDSI [ 26 ]. The BPDSI rates 70 items, comprising occurrence frequency (for 8/9 symptoms) and severity (the identity disturbance symptom) of instances of the 9 DSM-IV (and 5) symptoms during the preceding 3-month period, yielding a total sum score measuring overall BPD severity, as well as symptom level subscores. In rating the BPDSI, we also had access to patients’ clinical charts, with information regarding possible suicide attempts and other relevant information. The BPDSI interviews lasted around 1 h per patient.

We had a follow-up period of at least 6 months, after which we met with patients again, repeating the SCID, MADRS, and BPDSI. Altogether 95 patients were available for follow-up. Remission from the MDE was achieved by 56.8% of patients, with no significant differences between cohorts: MDE/MDD 56.4%, MDE/BD 60.6%, and MDE/BPD 52.2%, p  = 0.8196 [ 10 ]. In assessing clinical course (relevant for e.g. the BPDSI and SCID), we had access to clinical charts as well as a biweekly online follow-up questionnaire consisting of an expanded version of the Personal Health Questionnaire-9 [ 10 ]. Of note, the focus of both SCID-II interviews was whether PD criteria were currently met, based on information regarding participants’ lifetimes. As previously reported, we found no significant differences between drop-outs and non-drop-outs in subcohort or clinical data [ 10 ].

Data were assembled into a database using SQLite, version 3.35.5 (SQLite Team, www.sqlite.org ) and analysed with R version 4.2.2 (R Foundation, www.r-project.com ) on PC computers running Microsoft Windows 11. We used parametric and non-parametric tests as appropriate, analysis of variance testing, and linear regression models. Significance testing of changes over time was done with paired samples t-tests comparing baseline and later scores, and change magnitude between groups was examined with ANOVA comparisons of the change in scores.

Demographic and clinical characteristics of the cohort and the subcohorts at baseline and follow-up are reported in Table  1 .

Changes in categorical BPD diagnoses

For the vast majority of patients, there was no change in their BPD diagnostic status at follow-up (i.e. most BPD diagnoses were still valid, and most patients not meeting BPD criteria at baseline did not meet them at follow-up either). Only two patients diagnosed with BPD at baseline did not meet diagnostic criteria at follow-up, whereas two other patients who had not met BPD criteria at baseline now did so; thus, there was no change in the net sum of BPD patients. The patients no longer meeting full BPD diagnostic criteria at follow-up were MDD patients sorted into the BPD subcohort, who had met 5 (the diagnostic minimum) of the BPD diagnostic criteria at baseline and 3 and 4, respectively, at follow-up, one of them had achieved remission from MDE as well. Patients with new BPD diagnoses were BD subcohort patients with type II BD, meeting 3 and 4 BPD criteria at baseline and 3 more (i.e. 6 and 7) at follow-up, respectively, one of them having achieved remission from MDE.

Changes in number of positive BPD criteria

The mean number of positive BPD criteria was 3.12 (sd 2.34) at baseline and 2.77 (sd 2.42) at follow-up in the whole cohort, signifying a mean change of 0.35 (sd 1.38), which was statistically significant ( p  = 0.017); the effect size was small (Hedge’s g = 0.14). Subcohortwise, the criteria sums were 1.64 (sd 1.56) and 1.15 (sd 1.39) in MDD, 2.61 (sd 1.34) and 2.45 (sd 1.80) in MDE/BD, and 6.35 (sd 1.15) and 5.96 (sd 1.22) in MDE/BPD subcohorts, respectively, with no significant differences between the cohorts in the amount of change ( p  = 0.59). We did not find evidence of significant differences in magnitudes of change between diagnostic groups (BPD vs. non-BPD, BD vs. non-BD).

BPDSI total and subscores

Changes in BPDSI total and subscores are reported in Table  2 . The effect size for total BPDSI change was moderate (Hedge’s g = 0.5).

Grouping patients into diagnostic groups, BPD patients (regardless of subcohort) had a significant mean total BPDSI score change of -4.91 (sd 7.32, p  = 0.017) and bipolar patients − 5.18 (sd 7.54, p  < 0.001). There were no significant differences in the amounts of change between BPD and non-BPD patients ( p  = 0.674) or between BD and non-BD patients ( p  = 0.328).

The mean change in BPDSI score was − 3.21 (sd 6.82) in patients who still fulfilled MDE criteria at follow-up, whereas those who were in a state of remission from MDE had a mean change of -5.02 (sd 6.66); the difference between remitted and non-remitted patients was non-significant ( p  = 0.2385).

Correlates of change in BPDSI

We examined the correlations between changes (from baseline to follow-up) in BPD feature severity (as measured by the BPDSI) and depression severity (as measured by the MADRS) in the whole sample and in the subcohorts graphically (see Figs.  1 and 2 ) and numerically; the correlation in the whole cohort was small but significant ( r  = 0.28, 95% cl 0.06–0.47, p  = 0.01185). The correlation was strong and significant in the MDE/BPD subcohort ( r  = 0.73, 95% CI 0.38–0.90, p  = 0.02) but non-significant in the MDE/BD ( r  = 0.37, 95% CI -0.006–0.65, p  = 0.055) and MDD subcohorts ( r  = 0.07, 95% CI -0.25–0.39, p  = 0.660). When analysed by diagnostic groups (i.e. all BPD or BD patients grouped together regardless of subcohort assignment), the correlations were significant for both groups: BPD patients ( r  = 0.67, 95% CI 0.27–0.87, p  = 0.004) and BD patients ( r  = 0.42, 95% CI = 0.09–0.67, p  = 0.016). There was also a significant correlation between changes in BPDSI and BDI-II ( r  = 0.31, 95% CI 0.06–0.53, p  = 0.018). Changes in OASIS were not correlated with BPDSI changes ( r = -0.047, 95% CI -0.266–0.178, p  = 0.685).

figure 1

Correlation between changes in BPDSI and MADRS during study in whole cohort

figure 2

Correlation between changes in BPDSI and MADRS during study by subcohort

We examined the robustness of the correlation between change in BPDSI and MADRS through linear regression models. When controlled by age, sex, change in OASIS score, and BPD and BD diagnostic status, the MADRS change remained a significant predictor of BPDSI change ( p  = 0.007), which the other variables were not; however, this model was not significant in itself (F 1.858 on 6 and 71 df, p  = 0.1001). Stepwise dropping of non-significant variables yielded a significant (F 4.251 on 2 and 75 df, p  = 0.01784) model in which MADRS change was significantly (estimate 0.240, SE 0.083, 95% CI 0.074–0.406, p  = 0.005) correlated with BPDSI change when controlled by OASIS change (the correlation of the latter being non-significant: estimate − 0.269, SE 0.17711, 95% CI -0.622–0.084, p  = 0.132).

Main findings

In this 6-month cohort study of major depressive patients with and without borderline personality disorder (BPD), we found that BPD feature severity decreased significantly over time both in BPD patients and in patients with subsyndromal BPD features. This was noted both in reduced number of positive BPD criteria in repeated diagnostic interviews and in a lower BPD severity index (BPDSI) score, reflecting lower frequency and intensity and of borderline symptoms. Whereas the effect size for the change in number of positive BPD diagnostic criteria was small, the effect size for change in BPDSI scores was moderate, indicating that this instrument was more sensitive to changes in the occurrence frequencies of symptoms. There were no significant differences in the amelioration of BPD symptoms over time between unipolar and bipolar depression patients, nor between BPD and non-BPD-patients. Changes in BPD feature severity were significantly correlated with changes in depression severity. Interestingly, this correlation was significantly stronger in BPD patients than in others, and was non-significant in MDD patients without comorbid BPD. Put differently, even MDE patients without a BPD diagnosis had significant BPD features at baseline, which became less marked during follow-up; however, in contrast to BPD patients, there was no evidence of this amelioration being correlated to how much their depression symptoms diminished.

BPD outcome after follow-up

No net change occurred in BPD point prevalence over time, supporting earlier reports that diagnostic change seems faster in mood disorders than in BPD [ 15 ]. Thus, our time frame might have been too short to detect such changes on a categorical diagnostic level. The changes in number of BPD criteria were also less marked than those in BPDSI scores. These findings thus might reflect the aim of the SCID-PD interview, which is primarily to evaluate the significance of symptoms over patients’ entire lifespans, rather than only recently. Our findings are not in conflict with the prevailing view of BPD as a partly dynamic disorder with a clear tendency toward symptomatic amelioration over time [ 14 , 21 ], as there was a significant, although modest, reduction in BPD feature severity measured with BPDSI scores (corresponding to symptoms occurring less frequently or strongly) as well as with BPD criteria. As a concrete example of the magnitude of changes in this time period, at baseline the score for the affective hyperreactivity category in the MDE/BPD subcohort was approximately 7 (rounded from 7.3), signifying that the average patient had experienced these symptoms weekly, and after follow-up the mean score was around 6 (6.1), which corresponds to symptoms in this domain occurring twice every three weeks. This dynamic seems to be valid both for depressive patients meeting the full BPD criteria and for those with subsyndromal symptoms, in line with viewing BPD as a dimensionally occurring phenomenon, rather than a categorical entity.

Correlations between changes in BPD and depression severity

Changes in depression and BPD severity were linked also when controlled for other relevant factors (such as anxiety and main diagnoses). However, when examining how changes in BPD symptom severity are correlated with changes in depression severity, we found marked differences between depressive patients with and without BPD; the correlation in BPD patients was significant and moderately high, but we found no evidence of a correlation in MDD patients without BPD. Considering the large difference between correlations (r 0.67 vs. 0.07), this seems unlikely to be simply an inferential (type II) error. This finding was contrary to our a priori hypothesis and warrants further study, but we wish to offer some possible explanations. Depression confers negative cognitive biases [ 19 ], and BPD patients might potentially be more affected by these biases than others, perhaps as a function of what has been described as BPD proneness or personality features, such as neuroticism [ 21 ], which would increase the correlation between the two. Interestingly, changes in anxiety (as measured by the OASIS) and BPDSI change did not correlate in any subgroup; attentional and cognitive biases in anxiety are more related to perceived external threats than to the self [ 39 ], and thus, changes in these may not influence the experience and occurrence of BPD symptoms as strongly (or, indeed, aet all). This difference in correlations may also reflect a difference in the unmeasured precipitants of depression. For example, the role of external triggers of symptomatic decline (such as adverse life events) might differ for BPD and non-BPD patients. In addition to potential differences in these triggers per se, BPD patients might, due to their affective hyperreactivity, have a tendency to react to these triggers more strongly, which would also explain differences in symptom change correlations. Another possibility is that (fullblown, syndromal) BPD is a cause of MDE, and that depression symptoms alleviate when BPD features alleviate in these patients, but not in others. Emotional dysregulation is closely linked to the BPD phenotype, and has been shown to mediate the effect of childhood maltreatment on risk of later depression [ 40 ], and decline in emotional dysregulation might thus explain both alleviation of depression and BPD symptoms. Alternatively, as the relationship of depression and borderline features may be reciprocal and bidirectional [ 7 ], this observed pattern might be conceptualized as an alleviation of a more global illness process rather than of two discrete disorders [ 41 ].

BPD symptom subdomains

In addition to an overall alleviation of BPD symptoms, we found significant reduction in five (out of nine) of the DSM symptom subdomains: identity disturbance, suicidality/self-harm, identity disturbance, feelings of emptiness, and difficulties in anger control; all, but the last, were highly significant. A reduction in suicidality is to be expected, as depression (generally) lessened over time and has indeed been reported in this cohort (using other methods and measures) previously [ 9 ]. In one earlier cohort study of BPD symptomatic change, the results were somewhat different, as impulsivity was the first to change and affective symptoms the last, with interpersonal and cognitive symptoms lying between the two [ 15 ]. Another study found amelioration in impulsive, affective, and interpersonal symptoms, but not in cognitive symptoms, and a third reported approximately similar rates of decline in all of the DSM-5 symptom domains of BPD over 10 years [ 13 ]. Differences in time frames and instruments used and, perhaps most importantly, our focus being on MDE patients may contribute to the variability of results.

Strengths and limitations

Strengths of this study include the clinically and theoretically relevant comparative design of three central depressive groups of treatment-seeking psychiatric care patients, the prospective study design, and the use of valid and reliable dimensional measures of BPD symptomatology and other symptom severity. The study also has some limitations. The follow-up time of 6 months was chosen in order to examine change over the course of an MDE but precludes drawing longer term conclusions. Since the research interviews were done by the same researcher for each patient, they were not blinded to diagnoses when assessing, e.g. the BPDSI. Although inter-rater reliability was excellent for main diagnoses, it was not assessed for all measures, including the MADRS and the BPDSI. Our sample size was moderate, but even so, we made significant new findings. Since we investigated outpatient psychiatric care patients, confirmation of our results in other settings is required. We focused on MDD patients, and the relationships between BPD and depression severities might conceivably be different in persons with minor depression or subsyndromal depression symptoms. Although we found interesting and suggestive relationships, the study design precludes drawing firm conclusions about causal relationships – for instance, we did not assess the possible role of psychosocial stressors as triggers for MDE, and thus, any changes in these,or other common causes of both BPD and MDD, such as emotional dysregulation, over the follow-up-period could explain changes in both depression and BPD severity. Alternatively, some features of BPD and depression may overlap at least indirectly or otherwise influence each other (for instance depressive dysphoria increasing the risk of anger and/or self-harm, and BPD-linked interpersonal problems might worsen depressive symptoms); the precise mechanisms of such reciprocal effects were largely beyond the scope of this study. The BPDSI instrument mostly focuses on symptom frequency, which was detectable; however, other mechanisms by which BPD feature severity may decrease, not identified using these methods, are also possible. What we see is thus dependent on what is being sought. Still, we would argue that the BPDSI is a methodological improvement over less detailed methods used in earlier research, such as number of positive BPD criteria in the SCID-PD, and quite specific for the DSM symptoms of BPD. Use of other dimensional assessment models of personality pathology, such as the DSM-5 alternative model and the ICD-11 are likely to illuminate these issues further, and could be combined with BPDSI or other measures for detecting changes in symptoms in future research.

In conclusion, we found interesting similarities, but also some differences, between changes in BPD severities over the course of an MDE in patients with MDD, BD, and/or BPD. The view of BPD as a partially dynamic phenomenon with both trait- and state-like components is refined by a deepened understanding of the relationship of frequently co-occurring BPD and depression. Specifically, the frequency and severity of BPD symptoms tend to ameliorate when recovering from depression, and one way in which this change takes place is through a lessening in frequency of both observable and subjective symptoms of BPD. Change in BPD and depression symptom severities seem to correlate in BPD patients, but not in non-BPD patients; this phenomenon warrants replication and further investigation. Seeing change in BPD is partly dependent on using instruments (such as the BPDSI) calibrated to detect change over the relevant period.

Data availability

Due to European (GPDR) and Finnish national data privacy legislation, and lack of participant consent for data sharing, we are unable to provide patient-level data. Group-level data are available from the authors upon reasonable request.

Abbreviations

Bipolar Disorder

Beck Depression Inventory II (BDI II)

Borderline Personality Disorder

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Acknowledgements

We gratefully acknowledge the statistical advice and valuable comments on the manuscript provided by PhD Tom H. Rosenström and the language editing provided by Ms Carol Pelli.

Open Access funding provided by University of Helsinki (including Helsinki University Central Hospital). This research has been supported by grants from the Helsinki and Uusimaa Hospital District (TYH2022305).

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The study was designed by authors EI, JE, JJS, and JLS. JLS and JJS recruited and interviewed patients and compiled the research database. Data were analysed by JJS. The first draft of the manuscript was written by JJS and revised multiple times after critical reviews, comments, and editing by all authors. The writing was supervised by EI. All authors have approved the final draft of the manuscript and agree to be accountable for all aspects of the work.

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Söderholm, J.J., Socada, J.L., Ekelund, J. et al. How changes in depression severity and borderline personality disorder intensity are linked – a cohort study of depressed patients with and without borderline personality disorder. bord personal disord emot dysregul 11 , 3 (2024). https://doi.org/10.1186/s40479-024-00247-2

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  • Borderline personality disorder
  • Major depressive disorder
  • Bipolar disorder
  • Major depressive episode
  • Personality disorder
  • Cohort study

Borderline Personality Disorder and Emotion Dysregulation

ISSN: 2051-6673

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