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.

Treatment

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.

REFERENCES
Balhan, Krystle. “Lecture: Dissociative Disorders.” 2015.
Discovery Fit and Health Writers. “5 Myths About Dissociative Identity Disorder.” http://health.howstuffworks.com/mental-health/mental-disorders/5-dissociative-identity-disorder-myths.htm
Sue, David et alia. Understanding Abnormal Behavior Tenth Edition. 2013.

Recovery

Fifteen years after diagnosis, I think I'm beginning to understand how recovery works after the "loss of self." One must first work one's way through the onion of denial with respect to the scope of the loss. This can be very difficult with cognitive damage because even the experts don't really understand the extent of the damage. It took my years to recognize that I cannot write complex pieces of work in a timely fashion, owing to how easily I get lost, due to the short-term recall problem. I was very attached to that skill. So much was this the case, I couldn't believe it was gone, because I couldn't imagine myself without it. This is the first difficulty.

Then, following the loss of the ability, one must mourn the loss of the values and ideals that one must relinquish as impractical. Simply put, one cannot live up to the value, owing to the loss of capacity. As these values were core parts of one's identity and one is, by definition, attached to that sense of self, one must mourn. One cannot lose a core value that one believed was a matter of choice without grief. True, there may be some solace in the fact that one cannot be accountable for doing something one is not able to do. That said, high-performance individuals frequently over-emphasize their individual agency to remain highly motivated. Accepting the reversal of this position causes a great deal of cognitive dissonance. Moreover, often society emphasizes the chosen aspect of the behavior with the exact same reasoning as individuals apply to their own behavior. Society wishes to motivate higher levels of discipline and repeatedly emphasizes it as a moral choice to expand its ability to discipline those it sees as failing to self-discipline. Society's desire to motivate the person does not disappear, as society is loathe to adapt to individual needs. The function of social norms is obviously to limit individual variance in favor of cooperation with a single pattern. But finally, in a sense, one has lost some of that divine spark of ability that makes us human, rather than an animal. This is extremely painful to acknowledge. Such a loss must be grieved, owing to depth of the humiliation involved.

One especially cannot contemptuously skip steps, scorning the process of grief as a waste of time, moving directly to acceptance. After all, in many cases, that capacity to use the will to "just skip it" is itself what has been lost. One must grieve, or one simply won't let go of the values, otherwise. This leads to a feedback loop, where one tries to move on, but fails, because one hasn't actually engaged the process of recovery fully. One keeps trying to recover the skill that was lost and, through that process, live up to the impractical value. The super-ego responds to these repeated failures by whipping the carcass of the dead horse. This creates a long-term loop of suffering. Because while one's skills and intelligence have become like a dead horse, one's soul still lives and feels the lash of the whip each time. This creates a mental state of crushing contempt for the self. We are not designed to live well in such a mental state.

Breaking the cycle leaves a person with what has proven, for me at least, to be a singularly difficult task. One must find something to like about what the disease has left you. If the disease has practically eviscerated very important values, this leaves one some rather slim pickings. One must truly learn to find value where you would not have found value under any other circumstances. You must dream up an identity that you would have dismissed before as being suboptimal and, then, find value in that life. Moreover you must learn not to mind that others find this task senseless, because they like you as you are and see nothing wrong with you. We all like people who we would never volunteer to be. That said, most would-be empathizers have never done this sort of thing before, and frankly, it's rather too abstruse for daily imagination. They're not going to get it. Finally, you must work hard every day to relinquish the old values and align yourself with values that develop what you can become with what's left. Who you were may have died, but that doesn't mean that there isn't a human being left who needs to find a way to live. You owe it to him to put grief aside and help him. It starts by finding a way to like him.

Beyond Dominoes and Billiard Balls

Josiah Narog has been known to get me thinking. He asked what I thought about the Arab Spring. Remarkably, I had an opinion.

Dear Josiah,

Forget dominoes. It stinks of international relations theory. That sort of metaphor makes you try to conceive of the political as being akin to the physical. Instead assume that you are dealing with humans.

Maintaining a relationship of abusive domination requires the dominator to cultivate intense fear in the dominated. Typically the goal of this fear is to economize on the use of violence. Anyone who really understands politics understands that balances of power are not like a lever teetering on a fulcrum. Rather, it’s a great deal more like football. No matter how good one team and how bad the other, on any given Sunday you can win or lose. The trick of the dominator is to avoid losing by minimizing the number of games he or she has to play. Each game is a playoff game. If you lose once, you’re out of the game or will at least have to renegotiate the terms of domination. To stay in the game, the dominator has to win and preferably, win big. Abused people have to believe that they have no hope of resistance if they are to willingly bear the costs of abuse. Hope is the wellspring of the will to fight. Hope must be eliminated in the dominated if the dominator plans on making the abuse a foundation of his or her rule.

Demonstration effects are possible because the experience of seeing resistance work in a context that you see as much like your own is inspiring. It restores hope. Plus, there are young people. Young people differ from old people in that they have very limited experience of how difficult it can be to bear the costs of failure. Naturally the young will seize an opportunity when they are inspired. This is the essence of the demonstration effect. Most will lag behind to “see if it works.” If it looks like resistance is possible, more will join. Dennis Chong is right--it’s basically a tipping game. It needs inspiration (charisma), however to get it started. That said, losses dampen the will to fight. Recall that every charisma lives from success to success and with each passing hour grows nearer and nearer to its own death. Seeing resistance crushed is also psychologically powerful.

Bear in mind that age plays a role also for the dominator. Most people including a good many dictators, are not what I called psychopaths and what you called sociopaths: individuals who are incapable of feeling sympathy and, as a result, can objectify others with no psychological costs. Abuse has a psychological cost for the psychologically normal dominator, as does the will to savagery and cruelty. The dominator is not able to bear these psychological costs uniformly throughout his or her life. As one ages, one loses these capacities. Mubarak was a very old and feeble man in this round. He was leaning on JIMMY for Christ’s sake. What does that tell you about his sense of real politik?

This analysis, bear in mind, is very simplified. Recall that Tunisia, Egypt, Syria and Yemen are all facing remarkably different situations of domination and remarkably different domestic problems. But they weren’t dominoes. One falling over does not guarantee the next falling over. If I have tried to teach you anything at all, it’s been to stop thinking of states as a system. There are some loose regularities that characterize the states on this planet; this is true. But you’re never going to get more than loose regularities owing to the lack of uniformity in institutions and the personalities who run them. Billiard balls and dominoes are of no practical use to us here.

Merry Christmas, brother! Commend me to your wife. Let me know if you ever get the time to grab that beer.

Cheers!

Talal

The New Food Plan

Frans wanted to know what I was doing for my food plan. There are the meals:

The Fiber One cereal is because, well, I’m descended from the goodly folks of the Mediterranean Basin and am pushing 40. A cup and a half of Fiber One and I’m perfect. Other folks may not need as much. Obviously cereal needs milk, so there’s the cup of 1%. Perhaps I should use skim, but I’m not that strong. The eggs are hard-boiled to save on frying calories (ostensibly) and to save precious morning time (really). I have a latte in the morning because I am Seattlite. I sweeten with sucralose. That took the most getting used to.

For lunch and dinner, right now I’m having 6 ounces of shish tawouk (chicken kebabs for the uninitiated) and a very large salad. My salad is a cup of a salad mixture I create at the beginning of the week (6 bell peppers of multiple colors, 3 English cucumbers, two onions—all diced—yes, I am a Levantine), half a Romaine heads, chopped finely (about 4 oz) and a diced roma tomato. Kraft fat-free Italian is only 15 calories per tablespoon and doesn’t taste bad at all. I imagine I’ll have to develop a few alternatives, as even I can’t bear this much repetition for weeks on end. I’m throwing in 6 oz of roast, which actually has fewer calories than the chicken this week. I’m also looking at a black bean and corn salsa to alternate with the salad.

Snacks are pivotal to this plan, as I eat something every two hours. This way the body is always digesting and, hence, burning more calories. Moreover, this way I avoid hunger. Weight Watchers is clever about rating hunger on a scale on 1-5, where 1 is ravenous and 5 is stuffed. You eat at 2 (hungry, but not like a wolf) until you get to 4 (approaching full, but not there yet) so that you spend most of your day at 3 (neutral—not hungry, but not full, not engaged with food). Mine are pretty plain:

The apple treat probably won’t work for most folks, but I like it. I dice an apple and crush an ounce of walnuts and throw them in a bowl. I then sprinkle with 4 packets of sucralose, liberal amounts of ground cinnamon and a light sprinkling of nutmeg. Cloves are nice if you have them, but I’m out. I have a serious sweet truth and this gets me close to desert without breaking the diet or creating refined carb cravings.

The total caloric intake is roughly 1969 calories. I often have a second latte in the afternoon, so I’m hovering below 2100. As I weigh about 210, 2100 is my goal (10 calories per pound I weigh). Maintenance is supposed to be 15 calories per pound I weigh. I’m doing my pathetic version of weight lifting, so hopefully I pack on some muscle and don’t lose much weight, but just burn some fat. I’ll keep you guys posted.

McCarthy's Big Moment

Listen to The Bears Still Suck Polka from Chicago Bears

Let's hope he doesn't blow it, eh?

For Dinur and Shawn

Mike McCarthy

This is from Coach McCarthy’s press conference on Monday:

(How can you use a win like that? The flip side, the season’s not over if you lose and fall to 3-4, but then you’ve lost four games by three points each and things are pretty tough around here. What kinds of things can you take from a win like this and build off of and try to create some momentum?)

I’m the point man of this deal. I don’t swing left to right like that. I’m out in front. I do not change. It’s not my personality. I believe it’s ineffective to swing with the emotion, the criticism, even on the other side of it. When something everybody feels extremely positive is happening, I don’t think you run around with your pom-poms this week. That’s the last thing that I’m going to do. Everybody had a chance to enjoy the win last night, and I’m sure everybody feels good today. It was easier coming to work today than it was last week. That’s our business. Winning is important. A lot of good things come off of winning. But it’s onto the next one. It’s a simple as that. I wish I had some fancy words up here to make you feel better, I could answer your question better. But that’s what you’ve got and that’s what I am.

(You are that way, but you have 25-year-old kids who are more emotional and might look at it differently. How do you make sure that they use it in a positive way?)

Well, it’s all part of how you, you have to set the tempo and the plan every week. A big part of coaching is you’re a teacher and a salesman. You have to sell that plan, sell that path every single week. You can’t just go up and give a good speech at the beginning of the year and roll the ball out there. It doesn’t work that way. Today’s athlete is different. I think they’re very educated, they’re very in tune. The social networking is unbelievable. Some things I don’t even know how to work. But I’m in tune with what’s out there. It’s important for us to stay focused on the next opponent, and that’s our approach.

McCarthy is in awe of twitter (?!). I'll let that pass. But in his own words, the man is a technocrat. He isn’t a leader. I’ll be genuinely surprised if we beat the Jets come Sunday. But Brent limped off the field last Sunday. If we can beat the Bears come Christmas, I'll say the season turned out alright. Or as well as could be, our coaching situation considered.