Discussion

Recalling the Lessons of the Past

The diagnosis of DID has a short history but a long ancestry. Historically, dissociative and somatoform disorders were grouped together as subtypes of hysteria. Beginning with DSM-III (APA, 1980), these conditions were dissociated from each other, and the overarching construct of hysteria was eliminated entirely (Hyler & Spitzer, 1978). This decision was understandable, largely because the concept of hysteria was imprecise and ill defined. Nevertheless, the SCM suggests that the dissociation of dissociative and somatoform disorders may have been an error (see also Kihlstrom, 1994). These superficially different groups of disorders may reflect phenotypically different expressions of a shared diathesis (Good- win & Guze, 1996: Lilienfeld, 1992). The underlying nature of this diathesis (e.g., fantasy proneness, absorption), however, remains to be determined. Slater (1965) similarly noted that many conditions that would today be subsumed under the rubric of somatoform and dissociative disorders can assume a variety of superficially different manifestations across individuals.

Moreover, the behavioral expression of these conditions may be shaped substantially by cultural and historical factors. [*9]

[*9] Gleaves (1996) cited data indicating that DID had recently been diagnosed in the Netherlands and other European countries and invoked these data to dispute Spanos's (1994) contention that DID is a culture-bound condition. Nevertheless, without additional information regarding the accessibility of information about DID to the general public in such countries, these findings are difficult to interpret. In the Netherlands, for example, the writings of several well-known researchers (e.g., van der Hart, 1993; van der Kolk, van der Hart & Marrnar, 1996) have resulted in greatly increased media and professional attention to DID.

For example, latah, a condition characterized by sudden and transient episodes of profanity, command obedience, trancelike states, and amnesia, is limited primarily to women in Malaysia and Indonesia (Bartholomew, 1994). Conversion disorders were prevalent at the end of the 19th century but are apparently much rarer now (Jones, 1980). In moving from one fin de siècle to the next, DID may have replaced conversion disorders as the disorder in vogue (see Hacking, 1995). Although further research using external validating variables (e.g., family history, course and outcome, biological variables) is necessary to corroborate the hypothesis that DID, latah, and conversion disorders are expressions of the same underlying etiology, this hypothesis has the potential to unify a large number of disparate observations.

Veith (1965) argued that tile manifestations of somatoform and dissociative conditions have changed dramatically over time in accord with prevailing cultural conceptions. For example, she observed that Victorian England in the 19^th century experienced a marked increase in the prevalence of dramatic and unexplained somatic symptoms (e.g., paralyses, aphasias), which were subsequently displaced by less florid episodes of fainting ("the vapors"). Veith pointed out that

the manifestations of [these conditions] tended to change from era to era much as did the beliefs as to etiology and the methods of treatment. The symptoms, it seems, were conditioned by social expectancy, tastes, mores, and religion, and were further shaped by the state of medicine in general and the knowledge of the public about medical matters. ... Thus we have seen departures from and returns to the generalized convulsion, the globus hystericus, the loss of consciousness, the cessation of breathing. We have watched the

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acting-out of demonic posession and the vast variety of delusions related to it. (p. 209)

Most proponents of the PTM have not explicitly attempted to explain the cross-cultural and cross-historical manifestations of multiple role enactments and have instead focused primarily or exclusively on the etiology of DID per se. This is especially true of Gleaves's (1996) exposition of the PTM, which dethrones multiple identity enactment as the essential feature of DID and instead largely emphasizes secondary features (e.g., Schneiderian symptoms, depersonalization) not commonly found in other conditions characterized by multiple role enactments (e.g., transvestism, glossolalia; see Spanos, 1994).

The existence of social, cross-cultural, and historical influences on the manifestations of multiple role enactments may not in principle be incompatible with the PTM (Castillo, 1994) and may in fact represent one potential area of common ground between the PTM and the SCM. Ross (1997), for example, acknowledged that social psychological factors (e.g., therapist expectations) often play a role in the etiology and maintenance of DID (e.g., p. 81) and suggested that demonic possession may be a culture-bound variant of DID.

In contrast, Gleaves's (1996) categorical rejection of the SCM (p. 54) leaves little room for the incorporation of socio-cultural and historical influences into the PTM. To integrate such influences into the PTM, proponents of this model need to clearly articulate how the etiological variables (e.g., iatrogenesis, media influences) postulated by the SCM could interact with childhood trauma to produce DID, as well as how cultural and historical factors might differentially shape the phenotypic expression of multiple role enactments. As Bronowski ( 1978) noted, a number of the most significant advances in science stem from the demonstration that phenomena previously believed to be distinct are in fact interrelated. From this perspective, the SCM represents a step forward in the effort to address the puzzling question of why certain individuals display markedly different identities at different times.

By focusing primarily or almost exclusively on the overt manifestations of DID rather than on its commonalities with other conditions, many modern DID practitioners may unwittingly be repeating many of the errors of the past. For example, in the 1880s, Charcot believed that he had identified a new disease, "hystero-epilepsy", characterized by fluctuations in consciousness, seizures, and fainting spells. Charcot frequently displayed hystero-epileptics at conferences and accorded them special attention. Nevertheless, one of Charcot's students, Joseph Babinski, convinced Charcot that hystero-epilepsy was the inadvertent product of his mentor's creation. He persuaded Charcot to isolate hystero-epileptics from each other and from epileptics (they had originally been housed with epileptics and had begun to mimic their seizures) and to withhold attention from their dramatic symptomatic displays. Babinski's prescription worked (McHugh, 1993).

By reinforcing the multiplicity of DID patients, many modem therapists may be recapitulating Charcot's error. Moreover, by underemphasizing the possibility that DID is a forme fruste of the same psychological disposition underlying other multiple role enactrnents, Gleaves and some other proponents of the PTM may have erroneously reified one variant of a broader constellation of multiple role enactments into a distinct nosological entity (Fahy, 1988).

When viewed in historical context, the current epidemic of DID cases (Boor, 1982) may be neither as inexplicable nor as surprsing as it appears. This epidemic does, however, impart a valuable lesson to today's psychotherapists. The well-replicated finding that psychotherapy, although generally effective (Wampold et al., 1997), can be harmful in a select number of cases (Strupp, Hadley, & Gomes-Schwartz, 1978) serves as a needed reminder that the clinician qua diagnostician and treatment provider can be the creator as well as the discoverer of psychopathology.

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