Psychotherapy THE SIMULATION OF MULTIPLE

Psychotherapy

Volume 28/Summer 1991/Number 2

THE SIMULATION OF MULTIPLE PERSONALITIES: A CASE REPORT SUSAN S. BRICK AND JAMES A. CHU McLean Hospital I Belmont, Massachusetts

The realistic simulation of Multiple Personality Disorder (MPD) has become much more possible as a result of the recent proliferation of information about MPD in the professional and popular press. Such simulation has been documented most frequently as malingering in a forensic context. However, outside a forensic context where the motivation may not be obvious, the detection of simulated MPD can be a difficult task. Introduction Despite some ongoing professional skepticism, Multiple Personality Disorder (MPD) is a recognized disorder, and is a part of the American Psychiatric Association's DSM-III-R classification (1987). Since 1980, when the first comprehensive descriptions of MPD began to appear in modern psychiatric literature (Bliss, 1980; Coons, 1980; Greaves, 1980), there has been a rapid growth in the amount of professional information available to clinicians. The public has also been heavily exposed to information about MPD, beginning with books about MPD such as The Three Faces of Eve (Thigpen & Cleckley, 1957) and Sybil (Schreiber, 1973), more recent first-person accounts of sexual abuse and dissociation (Bass & Davis, 1988), and frequent appearances of both mental health professionals and patients on radio and television talk shows. As with any other diagnosis which captures public and professional attention, MPD may be simulated. This paper concerns instances where persons deliberately fabricate the signs and symptoms of Correspondence regarding this article should be addressed to James Chu, McLean Hospital, 115 Mill Street, Belmont, MA 02178.

MPD, as opposed to occasions where overly enthusiastic clinicians are overinclusive in diagnosis or iatrogenically influence their patients. Persons simulating MPD have been described in the literature, but primarily as malingering in a forensic context. The successful use of this disorder as the basis for a Not Guilty by Reason of Insanity defense in the Milligan case (Keyes, 1981) has apparently resulted in the use of MPD in a number of situations, most notoriously in the Bianchi case (Orne, Dinges & Orne, 1984; Watkins, 1984). However, even outside a forensic context, MPD may be simulated, although the motivation may not be obvious. In this paper, the authors present a case of an adolescent girl who successfully masqueraded as patient with MPD for over three months. The authors briefly review the literature on MPD and malingering, and discuss strategies to detect patients who are simulating MPD. Case Illustration The authors were asked by a community hospital to consult on a 15-year-old girl, Sarah, who was displaying signs and symptoms of MPD on their inpatient unit. The attending psychiatrist felt strongly that this patient did have MPD. However, as he did not have extensive experience with MPD, he wanted confirmation of the diagnosis and suggestions in regard to treatment and clinical management. The consultation with the patient and her parents, along with information provided by the hospital, yielded the following history which appeared highly suggestive of MPD. The patient was the oldest of three siblings in an intact family, and grew up in a small town in western Massachusetts. She was three when her nearest sibling was born. Because of serious complications in the birth of this sibling, the patient was separated from her mother who remained at the hospital for some time. This separation was very confusing for the patient who came to believe that she had caused the illness; the bond between mother and daughter was never re-established. A babysitter was hired and remained nine months while the mother convalesced and then returned to her work as teacher for disabled children. The patient later alleged that the babysitter's boyfriend would come to the house and would sexually molest her, lock her in closets, and engage in sexual relations with the babysitter in the next room. The patient was seen in grade school for what was seen as pathological lying and difficulties with peer relationships. She

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S. S. Brick & J. A. Chu felt she was an "outcast" and had few friends. Approximately ten months prior to the consultation she told her friends that her father had burnt her with cigarettes, and showed burn marks to prove this. Her father, a respected attorney, denied this, and an investigation by the Department of Social Services failed to reveal any evidence of abuse. She began individual psychotherapy shortly after this, and was subsequently hospitalized due to her reports that she cut and hurt herself, once showing the therapist the word "DIE" scratched onto her forearm. The patient was hospitalized for a period of four months, with only one brief return home during which she deliberately put her fist through a window. During the course of this hospitalization she began to tell her therapist about the existence of other personalities. The patient's given name was Sarah, and Sarah was described as the original or core personality who knew little or nothing about the existence of other personalities. She performed much of the day-to-day activities, but was empty, depressed, and easily overwhelmed by stress. "Madeleine" was described as a four-year-old personality who was split off from Sarah as the result of the incidents of early sexual and emotional abuse. She also reported feeling that she was "bad" because she had planted a "bad seed" in her mother's belly, which caused her mother to get sick when her sibling was born. She felt that the abuse from the babysitter's boyfriend was her punishment for this. "Eric," aged ten, was a boy who stuttered as Sarah did when she was a child, and who was therefore shy and refused to speak. "Jeannie," aged eight, seemed to carry the feelings of jealousy toward her siblings who she felt got better parental attention. "Julie," aged twelve, described all the personalities, and seemed to have executive control of the system, deciding who was able to be "out" and when. She had little emotion, and tried to control Sarah's self-destructive behavior, but was not always successful.

Prior to the consultation, most of the above background material was presented by the family and the referring psychiatrist. In the interview, the various personalities appeared quite easily, reportedly as "told to" by "Julie." Only the Sarah personality did not appear since, as explained by "Julie," she had been badly frightened the previous evening and was very anxious about the interview. There were clear differences between the personalities, and each personality was consistent with the descriptions of the referring psychiatrist. The switches appeared to be genuine, each with a brief pause and a suggestion of an eye-roll. The patient was felt to have MPD, and she was subsequently transferred to the author's inpatient unit, and began an individual evaluation with one of the authors. The plan was for a brief hospitalization and transition to outpatient treatment. Evaluation In the initial therapy session, Sarah, the "core" personality appeared, and professed to not remembering ever having met the therapist. She

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appeared somewhat withdrawn, but seemed most cooperative and eager to know about her personalities. The therapist discussed the link between childhood abuse and MPD. Curiously, the patient had no disbelief about her newly discovered personalities or abuse. She was concerned from the start that she be told what happened when her other personalities were "out." For the most part, the therapist met with only one of the personalities during each session; the personality who participated in the session was usually "out" and waiting for the therapist and remained "out" until after the session. The patient made it quite clear, through the majority of the personalities, that she did not wish to return home. The therapist spent considerable effort in questioning the reason for this, half suspecting that some form of abuse might be occurring at home. Although there were certainly some problems concerning boundaries among family members, and difficulties with family communications, no evidence of abuse was discovered. The therapist's first suspicions that the patient was not a true case of MPD surfaced around the issue of her history of pathological lying. It is well known that patients with MPD have often been accused of lying. In childhood, this is typically due to the switching of personalities and amnestic barriers; when a personality denies what she does not remember doing (which was actually done by another personality) she is accused of being a liar. In other situations, one personality who is hostile to another personality may contrive situations to embarrass or humiliate the other personality by making the appearance of lying. In the case of this patient, however, the lies were about events which never occurred, and appeared to be consistently to gain adult attention. One such event was the invention of a story about a close girlfriend who had died from cancer. This friend never existed. The lies were well thought out as to content and to whom they were disclosed. Another factor which made the therapist actively question the MPD diagnosis involved the personalities themselves. The original five personalities had brief biographical sketches produced by "Julie." Shortly before the transfer to the authors' unit, two additional personalities emerged. One was a boy, "Mark," who seemed to embody much intense rage. The other was "Loretta," a 78-yearold woman. In contrast to the biographical sketches of the original five personalities which included names, birthdays, origins and major functions,

Simulation of Multiple Personalities the patient produced a two-page biography about the 78-year-old woman that delved not only into her life, but also into the lives of her children, one of whom froze to death in a snowstorm. Although it is common for additional personalities to surface during the course of the therapy of MPD patients, the elaborate account of this particular personality exceeded the authors' experience of even their most imaginative MPD patients. Was this patient truly dissociative, or simply becoming more engrossed in her own fantasies, or was this deliberate simulation? In that true MPD patients often have histories of being disbelieved, it was felt to be potentially destructive to confront the patient at this point. The therapist learned that during the patient's first hospitalization she had befriended a girl who had been sexually abused, and since then had been doing a great deal of reading of first person accounts written by sexual abuse survivors. One of the books mentioned that MPD could result from being sexually abused, and the patient sent away for more information about MPD. She reported that she had read the book and had seen the movie Sybil. She presented the therapist with drawings she had made. Some of these drawings, such as ones of question marks, knives, hands, and picture frames seemed typical of drawings done by patients with MPD, but were also reminiscent of the drawings which appeared in Sybil. In the fourth week of the hospitalization, the patient mentioned that she kept a journal over the past several years. The therapist asked if she might read it. By the following session yet another personality had emerged. This personality claimed to be paraplegic and was lying on the floor outside the therapist's door. After dramatically crawling into the office, she presented the therapist with a 31-page typewritten journal. A note attached by the patient explained that it had been typed because there were embarrassing parts the patient did not want the therapist to read. The journal writings strongly suggested that the patient was feigning MPD. Although there was mention of the other personalities, there was little to suggest any fragmentation of experience. Instead, the journal was full of the patient's chronic difficulty with relationships, and her use of role playing, lies, shams, and manipulation in an effort to gain some kind of relatedness, attention, and physical contact. Some examples follow: Sometimes I wonder if it's just a bad habit making up all these stories. I also wonder why I want to be held like a baby.

Maybe I am one. Is it because no one at school likes me any more? I'm getting to be a pretty good actress; although I was never crying I could convince people I was. Eyedrops need careful timing, but I got pretty good at it. . . . Remember when I said I only dealt with non-professionals? Well that was when I was a novice actress. Now I'm good enough to convince anyone of anything. Remember how I said I was staging a collapse? Well today was the day. I reeled into Mrs. Peter's room and said the room was spinning and then passed out. It was hard to keep my eyes shut and miss everyone's reaction. I'm torn between the truth and going back to lies.

When the therapist confronted the patient with her suspicions about the simulation of multiple personalities, the patient readily admitted that this was the case. In contrast to true MPD patients who often deny their multiplicity in a "flight into health," this patient was convincingly able to relate how she had set out to fabricate her stories. She seemed relieved to be found out and, in retrospect, it appeared that she kept on making her presentations more and more unbelievable until she was confronted. That she voluntarily surrendered her journal also supported the idea that she wished to let her therapist know the truth. The patient also admitted that she had fabricated the stories about early childhood abuse. However, it did seem to the treatment team that she had been affected by the disruption of her relationship to her mother during a very important time. Overall, the patient seemed a bit relieved, but had little remorse or sense of how her behavior affected others. In many ways, the uncovering of the hoax seemed to make the clinical picture even more complex and difficult. The trauma and the defensive structure of MPD would have been a place to start the unraveling of the problems of this patient's life. Instead, there was the difficult task of beginning to cope with her empty shams, her impoverished sense of self, and her lack of empathy for others. Given the absence of external motives for her behavior, this patient was considered to have Factitious Disorder with Psychological Symptoms. As noted in the DSM-III-R (American Psychiatric Association, 1987), this patient seemed to have the "psychological need to assume the sick role" (p. 315) and we assumed the existence of an underlying severe personality disorder. On follow-up one year later, the patient had shown no signs or symptoms of MPD or a dissociative disorder, and appeared to be improving in individual psychotherapy and a structured program.

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S. S. Brick & J. A. Chu Discussion The DSM-III-R (American Psychiatric Association, 1987) diagnostic criteria for MPD are quite straightforward: A. The existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). B. At least two of these personalities or personality states recurrently take full control of the person's behavior. However, making the diagnosis of MPD is often quite complex. Most frequently, patients with MPD present with secondary associated symptoms rather than showing overt evidence of separate personalities. This may well be the result of the history of childhood abuse which is nearly universal in MPD patients (Kluft, 1985; Putnam etal., 1986). As Coons (1980) notes, patients from abusive families may be reluctant to trust and may be afraid of "being judged crazy" (p. 335) if they report their internal experiences. In addition, the secrecy of the abuse and the patient's efforts to block out both the abuse and the existence of alternate personalities may confuse the clinical presentation. The clinical presentation of MPD, including the common associated features of MPD, is now well described in the literature. Putnam and his colleagues (1986) studied the prevalence of some of these common associated features: Virtually all MPD patients report a history of significant childhood abuse, which often begins at an early age and occurs on multiple occasions. MPD patients show evidence of amnesia, partial or complete for the abuse experiences, and continue to manifest evidence of continuing periods of amnesia in their adult life. Presenting complaints are commonly depression, mood swings, suicidality, insomnia, psychogenie amnesia, and sexual dysfunction. MPD patients often have had multiple previous diagnoses and have often been involved in the mental health system for many years prior to an MPD diagnosis. MPD patients commonly have personalities which could be described as core, child, angry, functional and observing.

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The evaluation of patients with possible MPD should include careful consideration of both the essential and commonly associated features of MPD. The presentation of just the essential features is not usually sufficient to rule out the possibility of deliberate simulation of this syndrome. Information about MPD is widespread, and as noted by Spanos, Weekes and Lome (1985, p. 372), "when given the appropriate inducements, enacting the multiple personality role is a relatively easy task. . . . Following the rules for being a multiple means remembering which experiences, behavior, and preferences go with Identity A and which go with Identity B." It is the authors' experience with dozens of cases of MPD, that the deliberate simulation of multiplicity is quite rare. However, such a possibility should be carefully considered in the differential diagnosis of possible MPD patients, both as malingering in forensic settings, and as factitious disorder in clinical settings. How can a clinician approach the task of sorting through potential fiction? In addition to the careful examination presenting features, Kluft (1987) suggests other areas of differences between true MPD patients and malingerers: Malingerers generally were unable to manifest consistent alternate personalities over time in terms of memory, affect, and personal characteristics. Malingerers were generally unconvincing about any evidence of dividedness in the distant past. Malingerers did not have histories of prior unsuccessful treatments. Malingerers tended to have stereotyped good/bad personalities, while true MPD cases commonly showed a "tetrad configuration of depleted host, persecutors, traumatized alters, and protectors" (P- H2). True MPD patients rarely "played up" their symptoms and tended to "minimize public manifestations of their disorder" (p. 112). Kluft and others have suggested that the use of a prolonged initial interview may also make it difficult for the patient to maintain a contrived role (Resnick & Quinn, 1985; Kluft, 1987). Other techniques may be used such as asking leading questions that are usually not consistent with the syndrome (Resnick & Quinn, 1985).

Simulation of Multiple Personalities In the case presented above, the major consideration in the differential diagnosis was whether or not the multiple personality presentation was genuine. The patient did not seem to have a psychotic disorder (which is a common misdiagnosis), nor did she appear to have another dissociative disorder or an organic state such as temporal lobe epilepsy. Her clinical presentation initially appeared to meet the diagnostic criteria for MPD, but as the evaluation progressed, there began to be doubts as to whether she fit the overall usual picture for MPD. For example, it was noted only well into the evaluation that there were not prominent indicators of early amnesia or blackouts. When this was mentioned to the patient, she began to talk and write about alleged blackouts, which actually only increased suspicions that she was feigning MPD. The patient did appear to have some of the common associated features of MPD. She did present with self-destructive behavior, and had been in the mental health system for many years with multiple diagnoses. In addition the patient did seem to have a convincing constellation of personalities, but there was some blurring of roles and characteristics between the different personalities which was greater than our usual clinical experience. We also found it quite unusual for the patient to have a personality so much older than her chronologic age. In other MPD patients, we have seen older personalities infrequently and such personalities have been either modeled on real older people or have represented some kind of important psychological function (e.g., wisdom, peace). In this case, the older personality did not seem to have either role. Perhaps most inconsistent with true MPD was the patient's comfort with the MPD diagnosis and her willingness to talk about her personalities and past trauma. Even in situations where patients "spill" information about their personalities early in treatment, there always seems to be a price to pay, usually in the form of a negative therapeutic reaction. In this case, there was no reluctance about the patient revealing her "personalities" and she expressed much curiosity about her condition. She seemed quite positively gratified by ongoing progressive revelations with no evidence of any negative reaction. One final consideration in this case was the availability of information about MPD, which is another issue that should be carefully considered

when a patient is suspected to be feigning MPD. It appears normative for true MPD patients to seek out information about their disorder. However, patients who wish to contrive the appearance of MPD seem to seek out information in a relatively secretive manner, looking in the public media as well as researching the scientific literature. The recent proliferation of self-help groups for sexual abuse survivors and patients with dissociative disorders has also given rise to the dissemination of information about these topics. Contacts with persons with true MPD through these channels or in hospitalizations may also provide models of behavior to patients who wish to simulate MPD. In the case presented here, it was discovered that during a previous hospitalization the patient was acquainted with another patient who had been sexually abused. In addition, the patient had done considerable reading about these subjects and she continued to search for more information. Of great importance was that the patient was hospitalized which enabled monitoring of what materials she was seeking. Had she been outside of the hospital this would have been much more difficult, if not impossible. Conclusions The thoughtful scrutiny of patients who are suspected of simulating MPD is likely to yield definitive information, particularly if careful attention is paid to the history, phenomenology, and presentation, as well as the availability of information about MPD. The ability to observe such a patient over a period of time, whether on an outpatient basis or sometimes on an inpatient basis, is also helpful in differentiating true versus simulated MPD. Clinicians need to be extremely careful to try to separate out those who have true MPD, those who have related disorders, and those who have no such disorder at all. To diagnose inaccurately a patient as having MPD when this is not the case is to do a disservice to them, as well as to those who genuinely have MPD. Confusion about what is really MPD contributes, as Kluft (1987) suggests, "to the credibility problems suffered by many MPD patients" (p. 114). This case is unusual in the authors' clinical experience. Most cases which strongly suggest MPD usually turn out to be MPD or some related disorder. It is important to note, however, that the discovery of simulation in this case and others like it does not eliminate or reduce the need for

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S. S. Brick & J. A. Chu treatment. Orne et al. (1984) suggest that when a patient with no obvious secondary gain presents himself for treatment, even if simulating a disorder, that patient is deserving of treatment, and "it is the therapist's responsibility to help the patient understand what he is doing, and to cope with the stressors that have made it necessary for him to act in this fashion" (p. 164). It is paradoxical to note that just like patients with true MPD who are often incorrectly diagnosed and who may not receive appropriate treatment for extended periods of time, those who simulate MPD must also be correctly diagnosed before appropriate treatment can begin. References American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorder, third edition, revised. Washington, DC: Author. BASS, E. & DAVIS, L. (1988). Courage to heal. New York: Harper and Row. Buss, L. (1980). Multiple personalities. Archives of General Psychiatry, 37, 1388-1397. COONS, P. M. (1980). Multiple personality, diagnostic considerations. Journal of Clinical Psychiatry, 41, 300-336.

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GREAVES, G. B. (1980). Multiple personality. Journal of Nervous and Mental Disease, 168, 577-596. KEYES, D. (1981). The minds of Billy Milligan. New York: Random House. KLUPT, R. P. (ED.) (1985). Childhood antecedents of multiple personality. Washington, DC, American Psychiatric Press. KLUFT, R. P. (1987). The simulation and dissimulation of multiple personality disorder. American Journal of Clinical Hypnosis, 30(2), 104-118. ORNE, M. T., DINGES, D. G. & ORNE, E. C. (1984). On the

differential diagnosis of multiple personality in the forensic context. International Journal of Clinical Experimental Hypnosis, 32, 118-169. PUTNAM, F. W., GUROFF, J. J., SILBERMAN, E. K., BARBAN,

L. & POST, R. M. (1986). The clinical phenomenology of multiple personality disorder, a review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-293. QUINN, K. M. & RESNICK, P. J. (1985). Meet the malingerer. Audio-Digest, 14, #24. RESNICK, P. J. (1984). The detection of malingered mental illness. Behavior Sciences and the Law, 2, 21-37. SCHREIBER, F. R. (1973). Sybil. Chicago: Henry Regnery. SPANOS, N. P., WEEKES, J. R. & LORNE, D. B. (1985).

Multiple personality: a social psychological perspective. Journal of Abnormal Psychology, 94(3), 362-367. THIGPEN, C. H. & CLECKLEY, H. M. (1957). The three faces of Eve. New York: McGraw-Hill. WATKWS, J. G. (1984). The Bianchi (L.A. Hillside Strangler) case: Sociopath or multiple personality? International Journal of Clinical Experimental Hypnosis, 32, 67-101.