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Home >> History, Ideology & Science >> Sociology & Psychology Dissociative Identity Disorder and the Cycle of Violence Marina Mazur - 11/20/2009 Dissociative Identity Disorder, formerly known as Multiple Personality Disorder, is one of the most controversial mental disorders. The questions of its etiology and epidemiology are omnipresent in the psychological community. Research concerning the disorder’s connection to aggressive and violent behaviors in society is only in its infantile stages. However, if dissociative identity disorder is accepted as a valid form of mental illness and its causes and treatments are understood, then some types of interpersonal violence and self-destructive behaviors can be recognized, alleviated and eventually cured. Dissociative Identity DisorderDSM-IV defines the criteria for diagnosis of dissociative identity disorder as the presence of two or more distinct identities or personality states that recurrently take control of the person’s behavior, inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness, and these symptoms are not due to direct effects of a substance or a general medical condition (Kluft, 2003). Alters develop as survival mechanisms in a stressed and struggling child that contain self-protective and adjusting features. The rationale, which is responsible for the creation of each alter, may command the modification and disturbance of identity and autobiographical memory (Kluft, 2003). Generally a person with dissociative identity disorder appears to possess more than one personality, but “there is a widespread misunderstanding of the essential psychopathology in this dissociative disorder, which is failure of integration of various aspects of identity, memory, and consciousness. The problem is not having more than one personality; it is having less than one personality” (David Spiegel as cited in Kennett & Matthews, 2002, p. 515). The central positions on the etiology of the dissociative identity disorder view the condition either as occurring naturalistically or as iatrogenic in origin, due to a diagnosis, manner and treatment of the helping professional. Some have argued that dissociative identity disorder is a manufactured object of excited clinicians who will a patient to manifest symptoms of the disorder, because they want to treat it. However, the majority of knowledgeable professionals agree that the full condition of dissociative identity disorder cannot be explained as an iatrogenic artifact, but they do believe that factors origination from the mental health professionals can exacerbate and complicate the condition (Kluft, 2003). There is a prevalent view that dissociative identity disorder is very rare, but recent studies suggest that it occurs in many countries roughly at the same rate in the psychiatric inpatient residences. Furthermore, on average a patient diagnosed with dissociative identity disorder has been in the mental health system for 6.8 years before being accurately diagnosed (Kluft, 2003). The skepticism of some mental health professionals regarding the existence of dissociative identity disorder and the belief in its rarity have forced this illness to be largely ignored, leaving its implications for the community unstated. Dissociation, one of the symptoms of dissociative identity disorder as well as other dissociative disorders, means to split apart or disengage essential factors that are somehow connected. Psychological dissociation is defined as a disruption of memory, consciousness, identity and awareness of the environment, but is also evident in an interruption of sensation, movement and other bodily occupations (Diseth, 2005). Most studies cite dissociation as a major component in violent and criminal behaviors. Moskowitz (2004) stated that based on previous research it is reasonable to conclude that nearly one quarter of convicted criminals serving a prison term have had, or are presently experiencing, dissociative symptoms. According to Tanay, a forensic psychiatrist, 70% of the 53 homicide offenders, who were evaluated by him over a 10-year period, had been in a “dissociative reaction” when they committed the crime (Moskowitz, 2004, p. 25). Signs of dissociation, however, can predict not only an existence of a dissociative identity disorder, but a myriad of other disorders as well, such as post-traumatic stress disorder and others. Thus, a clinician has to very careful in diagnosing a specific disorder. Causes and Prevalence in Criminal PopulationsGenerally causes of dissociative identity disorder are childhood physical and sexual abuse. Kluft (2003) stated that patients with dissociative identity disorder typically have an overwhelming array of negative childhood circumstances, characteristically involving child abuse. Foote, Smolin, Kaplan, Legatt and Lipschitz (2006) agreed that patients with a dissociative disorder are much more likely to experience childhood physical and sexual abuse. In addition, other childhood factors play a role in possible development of the dissociative identity disorder in adulthood. These factors include neglect, parental dysfunction and unavailability of caretakers (Draijer & Langeland, 1999). Patients, who demonstrate higher levels of dissociation and more dissociative identity disorder symptoms, report repeated abuse of a maternal figure during childhood (Simoneti, Scott & Murphy, 2000). However, keeping with the central position on causes of dissociative identity disorder, extreme childhood physical and sexual abuse will be recognized as the main basis in the development of the disorder. If these experiences cause a person to develop a dissociative identity disorder, one of the “personalities” might be a violent one. For example, authors of one study analyzed 12 convicted murderers with dissociative identity disorder and found that nine subjects, including one female, had violent male alternate personalities, which contained the painful aspects of a person’s experiences (Lewis, Yeager, Swica, Pincus & Lewis, 1997). Since a child tries to forget bad experiences and represses one’s anger, during dissociation an alternate personality will take on the anger trait and express it. Violence is a growing problem in all communities. Even though, most criminals do not have dissociative identity disorder or other dissociative disorders, the ones that do have an illness should be helped so potential criminal acts could be prevented. People with dissociative identity disorder have been somewhat equated to the fictional story The Strange Case of Dr. Jekyll and Mr. Hyde (Moskowitz, 2004). However, real people are not able to fight their unwanted personality. The prevalence of dissociative disorders in criminal populations is much higher than would be expected. Moskowitz (2004) declared that several authors maintain that more than a dozen violent offenders were found in various prisons and were diagnosed with dissociative identity disorder. Additionally, two outpatient samples of men diagnosed with dissociative identity disorder found past incarceration rates of 28.6% and 47%. Howe (1984) stated that a forensic psychiatrist is unlikely to diagnose someone with dissociative identity disorder, because it is presumed to be extremely rare, but it may occur with a far greater incidence rate that is usually supposed. The central problem is legal system’s complete disregard of dissociative episodes that occurred in the process of the crime, because they are brushed of as a criminal’s effort to deny responsibility or minimize guilt. MalingeringIt is a common belief that criminals will feign mental illness to avoid punishment for their crime. It is possible that malingering is a big problem among criminal populations, but it is also possible that legal professionals do not want to waste time to check if a person is actually suffering from a mental illness, such as dissociative identity disorder. There are ways to differentiate between an actual illness and a malingering one. Howe (1984) recommended a way to evaluate a forensic patient. Firstly, the person would report having little or no memory of his crime. Secondly, history of self-mutilation or suicide attempts would be another clue. The patient might have scars that he/she is not able to account for or the history of suicide attempts may be vague or inconsistent. This might suggest a presence of an “assaultive” or “homicidal” personality, which wants to destroy the other personalities without comprehending that by destroying the body it would also destroy itself. Thirdly, physical symptoms are usually present. Headaches are common when the person is transitioning from one personality to another. Lastly, a range of psychological symptoms is also present. These include mood swings, anxiety and antisocial behaviors. Inability on behalf of the legal and mental health professionals to diagnose dissociative identity disorder in forensic psychiatric patients may allow a persistent survival of extremely aggressive dissociative identity states, and possible relapses into homicidal behavior (Nijenhuis, 1996). Malingering could also be differentiated from dissociative identity disorder not only by its symptoms, but also by the person’s reaction to them. Mental illness is still a taboo topic in our society. Criminals with dissociative identity disorder try to hide their problems and do not use them to avoid punishment or to gain some benefit. Regarding a forensic patient Nijenhuis (1996) stated that he was hiding his dissociative symptoms, just like many non-forensic patients with dissociative identity disorder, which showed that he did not seek legal or social gains. Criminals with dissociative identity disorder also are not able to fully divulge their childhood histories, because they do not remember them since they have dissociated during the traumatic experiences. “Contrary to the commonly held assumption that individuals facing the consequences of murder charges will exaggerate their childhood misfortunes, these murderers could barely remember anything about their childhoods” (Lewis et al., 1997, p.1709). Moskowitz (2004) refuted the idea that some offenders do not want to take responsibility by stating that it is common for persons, who do not remember committing a violent crime to plead guilty and express substantial aggravation that they cannot remember what they believe they must have done. Self-Destructive BehaviorsMoskowitz (2004) declared that some people with dissociative disorders are violent toward others, but many are violent to themselves, and others manage to avoid participating in any form of violent behavior. Self-destructive behaviors should also be explored in relation to dissociative disorders, since such behaviors are violent as well, but are directed against oneself. Somewhere between 34% and 80% of patients with dissociative identity disorder, engage in self-injurious behaviors (Saxe, Chawla & Van der Kolk, 2002). Similar to aggressive and violent behaviors the mechanism that connects childhood abuse and self-harming behaviors in people with dissociative identity disorder is dissociation. Patients with dissociative disorders harm themselves more often than other psychiatric patients. The extent of dissociation is related to the quantity of self-harm (Saxe, Chawla & Van der Kolk, 2002). Unfortunately, no research has addressed the possibility that self-destructive behavior in patients with dissociative identity disorder may change into aggressive behavior channeled toward others instead of oneself. Treatment for self-injurious behaviors has been to force patients to accept that the host/historical personality is responsible for the actions of all alternate personalities. Saxe, Chawla and Van der Kolk (2002) stated that patients must accept that all parts of the self must be held accountable for the behaviors of any given alter. “Holding a patient strictly responsible for his or her behavior, regardless of whether it was performed in a dissociative state of consciousness, is ultimately containing for the patient and, in our experience, results in reduced self-injury” (Saxe, Chawla and Van der Kolk, 2002, p. 318). Moral and Legal ResponsibilityOnce the diagnosis has been established and the crime has been committed an important question to address involves the responsibility of a person with dissociative identity disorder for his/her crime. Contrary to the responsibility model accorded to patients with dissociative identity disorder, who are involved in self-injurious behaviors, Kennett and Matthews (2002) favored the Single Person Thesis, which views someone with dissociative identity disorder as a complete individual whose symptoms are perceived as self-delusion. An alternate personality is the same person in an altered state of mind and is deluded about who he/she is. Since the alternate state is not a separate entity in and of itself, then the character of the disorder provides an excusing clause for moral responsibility. The individual should be perceived as criminally insane at the time of acting (Kennett & Matthews, 2002). Since the individual suffers a loss of autonomy, cannot remember the actual events that took place and is incapable of making rational decisions and commitments when in an altered state, then that person cannot be held responsible for his/her actions at the time that the crime took place. These actions cannot be viewed as their own decisions, thus they cannot be held accountable (Kennett & Matthews, 2002). Cycle of ViolencePresently there is new evidence that suggests that dissociation, which arises in an individual from experiences of childhood abuse, may also place such an individual at a higher risk of being abusive to others (Moskowitz, 2004). It is usually assumed that people that have been abused as children are more likely to abuse their own children than those people that were not abused in childhood. However, another variable might be involved in abuse and violence – dissociation. Lewis et al. (1997) in their study evaluating 12 murderers established a linkage between early severe childhood abuse and dissociative identity disorder. The authors further explained that the illness forced these individuals to commit murder. They were not malingering in their evaluations, because they denied childhood abuse and the diagnosis afforded them by the clinicians. They took responsibility for their actions and the consequences that followed. Moskowitz (2004) reiterated that there new evidence is emerging that proposes that dissociation may drive the cycle of violence; that is individuals who were abused and in turn developed dissociative symptoms are significantly more likely to abuse their children than those who, despite having been abused, did not develop such symptoms. People with dissociative identity disorder are the most at risk for exhibiting aggression, because there is some evidence to imply that dissociative symptoms are especially predictive of violent behavior (Moskowitz, 2004). Treatment and PreventionPeople with dissociative identity disorder, who commit crimes, should be treated for their illness, and not imprisoned for their crimes. Imprisonment does not afford treatment and also exacerbates the symptoms of the disorder. Treatment may vary, but the general consensus involves steps of psychotherapy. Firstly, the therapist should foster an attitude of respect of each personality for each other. Secondly, a therapist should establish meaningful conversation with as many personalities as possible without siding with any one of them. Lastly, the therapist should help the personalities to merge together to become one complete integrated personality (Howe, 1984). Dissociative identity disorder does not cure itself, thus treatment is extremely important. Spontaneous recovery in dissociative disorders is unlikely, thus forensic patients that are not properly diagnosed and treated have a greater risk of relapsing into criminal behavior (Nijenhuis, 1996). However, offenders with dissociative identity disorder are more responsive to treatment and this difference could provide a rationale for creating a separate legal status for these criminals (Howe, 1984). Based on current research some precautions should be taken within the legal and mental health systems. Inmates and psychiatric patients should be screened for dissociative symptoms and offered appropriate treatment on a regular basis. Staff at prison and psychiatric institutions should be educated to be able to differentiate the signs and symptoms of dissociation, with the hope of limiting violent episodes (Moskowitz, 2004). Safety measures should also be directed toward families and children. Elementary and middle school staff should also be educated and be able to differentiate signs and symptoms of dissociation and seek to identify adolescents who might be at risk for aggressive behaviors. However, efforts should also be targeted toward managing dissociative symptoms in parents with traumatic childhoods who may be at risk for abusing their own children (Moskowitz, 2004). Violence can be prevented if potential aggressors are identified before they strike and could be treated for their dissociative disorders. In conclusion, the cycle of violence is made up of three major components, which are severe childhood abuse, dissociation that is used to help children deal with the abuse and adult aggression and violence. Close attention should be paid to criminals committing violent offenses to differentiate between crimes committed during a dissociative episode and crimes committed for other reasons. Criminals diagnosed with dissociative identity disorder need to be treated for the mental illness, instead of serving a prison term, to prevent future violent outbursts and criminal actions. Hopefully, future research will accord us more proof regarding the cycle of violence and will force us to accept the existence of dissociative identity disorder, its causes and its potential for extremely violent behaviors, as well as treatment options and a better look at the criminal justice system.
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