The phenomenology and treatment of extremely complex multiple personality disorder.

Cor temporary reports indicated that the average number of personalit.es in recently reported patients with multiple personality disorder (MPD) is larger than that reported in the older literature. A minority of tnese recent patients demonstrate extreme complexity. A group of 26 patients with 26 or more personalities and under observation for a n inimum of three years was studied. Their presentations, the rev ons that appeared to underlie their complexity, and their courses of /zeatment are reviewed. Findings indicate that this group of pat: ents is diverse, with some proving readily treatable, and others proving quite refractory. Observations that appear constructive for the 'reatment of such patients are offered. The concept of personality is d'scussed and an alternative description is explored. The usefulness of the paradigms and metaphors of splitting and division as heuristics for the understanding of MPD is challenged, and a paradigm/metaphor of redoubling and reconfiguration is offered for fun her study. In recent years multiple personality disorder (MPD) has been recognized, reported, and studied with increasing frequency. The recent DSM-III-R, (American Psychiatric Association, 1987) no longer describes MPD as rare. Cohorts of MPD patients have become available for study, and publisl-. ed collections of data from groups of MPD patients are slowly superseding the single case studies that had dominated the literature of the field for the majority of the twentieth century. One of the most consistent findings across the newer explorations of MPD is that the cases being encountered by con temporary clinicians and being reported in the modern scientific literature tend to have more personalities than those described prior to the 1970s. Most cases in the older literature had relatively few personalities. Forty-eight of the 76 cases reviewed by Taylor and Martin in 1944 were dual personalities; another 12 had three personalities. Only one individual, a patient with 12 pe-sonalities, had more than 8. "Sybil, " with 16 personalities, reported in 1973 (Schreiber), was the first of the modern more complex cases to be described. Within the sar-te decade it was revealed that the celebrated "Eve" had 22 rather than 3 faces (Sizemore & Pittillo, 1977), and Billy Milligan, with 24 personalities, became a cause celebre in the media (Keyes, 1981). As scientific investigators encountered increasing numbers of MPD patients, their estimates of the average number of personalities in such patients has increased. In 1979 I indicated that the number of alters in a series of 70 MPD patients clustered around a "modal range" of eight to thirteen alters; 55.7% had between two and ten, and 44.3 percent had eleven and more (Kluft, 1984b). In 1984 (a) I reported that a group of 33 successfully treated MPD patients had had an average of 13.9 alters. This group included nine patients with 20 or more alters; one had had 86. In 1985 a survey by Schultz, Braun, and Kluft (1989) of 355 MPD patients each reported by a different therapist, the patients had an average of 15.8 alters. Putnam, Guroff, Silberman, Barban, and Post (1986) found an average of 13.3 personalities per patient in their series of 100. In the same year I published an expanded series of 52 successfully treated MPD patients. This group averaged 15.4 alters. There were thirteen cases with over 20 alters, and patients with as many as 110 alters were included. Newer and unpublished additions to this research cohort include several successful treatments of patients with over 100 alters. Among the more recent series, Coons, Bowman, and Milstein (1988) are unique in reporting a mean of 6.3 personalities. They explain their findings by noting that their series was smaller than the others reported and that they sampled the number of alters "very early in therapy. " In contrast, I (1979, 1984a, 1986) had included only enumerations of alters from the records of patients who had been treated to the point of stable integration. My experience with very complex cases began in 1975. I was asked to see in consultation a woman who was believed to have three personalities. After a series of therapeutic misadventures she suddenly appeared to manifest 21 additional entities. My explorations convinced me that they were not conventional personalities, but were instead dramatic efforts to encapsulate the impact of imprudent therapeutic interventions. In essence, they were iatrogenic phenomena. A single hypnotic intervention reduced the complement of alters back to three. I had not anticipated any further contact with this patient, but, following several months of further therapeutic mishaps, she was transferred to my care. After a year during which she tested me extensively, a protector personality that had not emerged previously did so, told me that she decided I could be trusted and revealed a total roster of 33 alters. No outward sign had suggested such complexity.