Sunday, May 10, 2015

Not Two-Face—A Genuine Face of Dissociative Identity Disorder

All too often, our view of mental health is shaped by the popular media. Certainly, Batman’s Harvey Dent/Two-Face has been a popular image of dissociative identity disorder. But to be frank, Batman’s Two-Face is a better symbol of poor popular understanding of this mental illness than it is a representation of that illness. I propose that, as a public service, we examine the two faces of the disease and explain why both images fail our understanding or the compassionate treatment of those suffering the illness. The first face, that of sensational fiction, depicts someone with dissociative identity disorder as a possible psychopathic criminal of the sort that poor Harvey Dent became as a result of trauma. The second face is that of pure confabulation. Neither image is a fair appraisal of this illness. Finally, we will discuss the existing treatment modalities for the illness.
Harvey Dent: Least Likely Candidate for Dissociative Identity Disorder
The first major problem for our fictional image of Two-Face as an example of dissociative disorder is that Harvey Dent, Gotham City’s steely district attorney, is a terrible candidate for this illness. Sue, Sue, Sue and Sue draw on Kluft’s 1987 model to suggest four factors necessary for the development of dissociative identity disorder. These are:
1. Exposure to overwhelming childhood stress, such as traumatic physical or sexual abuse
2. The capacity to dissociate
3. Encapsulating or walling off of experience
4. Developing different memory systems (p. 205)
The first difficulty is that there is no childhood trauma in this case. Harvey Dent’s major traumatic stressor came as an adult with a very well-articulated personality. His origin story, in Detective Comics #66 (1942) is that his face was hideously scarred during a trial when gangster Sal Marconi threw acid at him, burning off the left side of his face. Adult post-traumatic stress disorder may well be a likely outcome of such an encounter. It would further account for Two-Face’s fixation with random outcomes. Harvey Dent, a man who believed he made his own luck, used to flip a two-headed coin to emphasize his “heads, I win” attitude. I could imagine him easily scratching off one of the heads after such an injury. That said, this is an adult trauma.
The capacity to dissociate is also unlikely in this case. Sue, Sue, Sue and Sue stress that dissociation occurs “[w]hen complete repression of these impulses is not possible because of the intensity of the impulses or poor ego strength” (p. 205). Harvey Dent was a tower courage who fought to clean Gotham City of the mafia, an honest man capable of fighting to rise to elected office under the most sinister circumstances. Ego strength was not his problem. His personality was very well articulated. Again, the stimulus of having half of one’s face burned off was intense, but PTSD seems a much more likely outcome under these circumstances.
In the absence of the first two conditions, it seems unlikely that encapsulation or walling off of experience and the developing of different memory systems is likely. What we know of this disease suggests that the radical transformation of Harvey Dent into a criminal is rather unlikely.
Confabulation: The Other Face of Dissociative Identity Disorder
The other image that society often picks up of this illness is that it is hysterical confabulation and attention-seeking. It is critical to understand that even those scholars who hold that the illness has cultural origins, nonetheless believe it is a real mental illness, even if it is caused buy unwitting therapists. Let us first review the case for this illness being an iatrogenoic disorder and then explain why it nonetheless requires treatment.
Sue, Sue, Sue and Sue review several sources to suggest that the mass media has a strong influence on the etiology of this illness. To start with, an examination of cases of this condition between 1800-1965 suggest that cases during that time period reflected “fewer personalities (an average of three versus twelve), a later onset of first dissociation (age twenty as opposed to eleven in the 1980s), a greater proportion of males, and a much lower prevalence of child abuse” (Sue, p. 201 drawing on Goff and Simms, 1993). Cases seemed to spike after the case of Sybil was made into a popular book and film in the 1970s (p. 202). While it is likely that there is a clear cultural impact on the illness, this may govern the form of dissociation in response to trauma. It does not suggest that the dissociation or the causing trauma are simply a figment of the imagination.
Moreover, there is evidence to suggest that therapists are often unwitting agents in determining the shape in which trauma is expressed. Ironically, clients who are the most sensitive to the illness are the most sensitive to a therapist’s “selective attention, suggestion, reinforcement, and expectations.” Indeed, Sue, Sue, Sue and Sue (p. 207) provide the following startling revelation:
The authenticity of one well-known case of DID, Sybil (mentioned earlier), has actually been questioned (Borch-Jacobsen, 1997). Herbert Spiegel, a hypnotist, worked with Sybil and used her to demonstrate hypnotic phenomena in his classes. He described her as a "Grade 5" or "hypnotic virtuoso," something found in only 5 percent of the population. Sybil told Spiegel that her psychiatrist, Cornelia Wilbur, had wanted her to be "Helen," a name given to a feeling she expressed during therapy. Spiegel later came to believe that Wilbur was using a technique in which different memories or emotions were converted into "personalities." Sybil also wrote a letter denying that she had multiple personalities and staring that the "extreme things" she told about her mother were not true. Tapes of sessions between Wilbur and Sybil indicate that Wilbur may have described personalities for Sybil (Rieber, 2006).
The form of dissociation may be affected by cultural narratives. That said, there is good reason to assume that the dissociation in response to trauma is real. The Discovery Fit and Health Writers state flatly that “Studies have found that ‘alters’ (secondary personalitiers) have different heart rates and blood pressures than the main personality.” Sue, Sue, Sue and Sue elaborate that
A number of studies using PET scans and MRIs on individuals diagnosed with DID have found variations in brain activity when comparing different personalities (Reinders et aI., 2003; Sheehan, Sewall, & Thurber, 2005; Tsai et al., 1999). Switching between personalities is associated with activation or inhibition of certain brain regions, particularly the hippocampus (Tsai et al., 1999), an area involved in memories and hypothesized to be involved in the generation of dissociative states and amnesia (Staniloiu & Markowirsch, 2010; Teicher er aI., 2002). Differences in temporal lobe activity have also been found among different personalities within an individual. This is interesting because temporal lobe seizures sometimes involve altered states of consciousness (Sheehan et al., 2005).
Sue, Sue, Sue and Sue are quick to elaborate that it is unclear what this means, but it does suggest that something is afoot, even if awareness of this disease is used at times as artful manipulation.
Krystle Balhan suggests three phases of treatment in such cases. The first stage involves creating an atmosphere of safety and stability in individual therapy with the client and patiently mapping the personality system. Common personality types include:
“Managers”: Good at anticipating problems before trouble arises. Run the everyday life of an individual. Help keep the individual safe and functional.
“Exiles”: Parts that are locked away by the managers. Typically young parts that experienced trauma and carry emotional memories of humiliation, pain, and debasement. When in control, can make the individual feel vulnerable and fragile.
“Firefighters”: Become active when the individual is distressed. They 'extinguish' the feelings of the exiles. Typical firefighter behavior includes impulsivity, and binging on drugs, alcohol, food, and sex.
“Self”: The core identity with leadership qualities. Should direct the work of the other parts.
The second stage of treatment focuses on the resolution of traumatic memories. Finally, therapy proceeds to integrating the alters, focusing particularly on creatinga personality capable integrating the parts and existing independently.
In conclusion, the two faces of this illness are not the faces of the split personalities, but the faces of drama created by fiction writers and disdain for those who suffer the illness as “fakers.” Harvey Two-Face is a better symbol of the ugliness of the public views of the disease than it is a representative of the illness itself.
Balhan, Krystle. “Lecture: Dissociative Disorders.” 2015.
Discovery Fit and Health Writers. “5 Myths About Dissociative Identity Disorder.”
Sue, David et alia. Understanding Abnormal Behavior Tenth Edition. 2013.

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