WHY IT WASN’T “PATRICIA” Dissociative identity disorder: misconceptions, malingering and the media
| By Gaby FitzGerald |
Photo 1: Photo courtesy of James McAvoy on Instagram, photo illustration by Karina Zapata
Even if you’ve never seen the film Split (2016), you most likely know the viral meme it produced. James McAvoy plays Kevin, a man who apparently hosts 24 different personalities. A clip of him saying “that wasn’t me, that was Patricia” went viral as the punchline for jokes denying responsibility for some social infraction or another. For purely academic purposes, I’ll insert a particularly elegant example at the bottom of this article.
Now as much as I’d love to talk about the psychology of viral humour, that’s not why I bring this up. What Split highlights, and as has been pointed out by movie critics and psychologists alike, is the many misconceptions about dissociative identity disorder (DID), formerly termed multiple personality disorder. This is not helped by the fact that DID is largely used as a plot device in psychological thrillers or horror movies, which play on outdated understandings of the disorder and manipulate the symptoms for dramatic effect. While making for excellent entertainment, it doesn’t help us understand this psychological condition. This is particularly relevant to DID as Dr Simone Reinders, a specialist on the subject, notes: “There’s already a lot of stigma and scepticism concerning [DID]”. Indeed, an open letter was written and signed by many DID patients to the director of Split, arguing that the film goes so far as to make them targets of violence. They say that “Split represents yet another gross parody of us based on fear, ignorance and sensationalism …”. I suggest that these are the voices that should be amplified, and the stories that should be told, rather than misinformation that makes for a gripping movie.
So much for the poetic license which often informs popular entertainment, let’s now focus on the reality of DID, based on current diagnostic definitions, and anecdotal insights from professionals in the field. The reason DID was renamed in 1994 was to reflect an updated understanding of the condition, in that it reflects a fragmentation of a person’s personality into differing states, rather than the growth of separate personalities altogether. A look at the Diagnostic and Statistical Manual’s (DSM-5) most recent definition of DID can help. There are five key diagnostic criteria for DID. The first is amnesia. This means that a person cannot remember significant features of their personal history, a symptom not attributable to normal levels of forgetting. The second is a disruption to their identity, characterized by two or more distinct personal states. Note the use of the term personal states rather than personalities here, as it provides insight into our current understanding of the condition. The next three criteria are that it leads to significant distress or impairment in the patient’s ability to go about their daily life; the disturbance is not a part of a normal cultural practice such as a child having an imaginary friend; and the symptoms cannot be explained physiologically, such as substance abuse or head injury.
A person with DID’s different personality states are often referred to as “alters”, and are widely accepted from a clinical perspective as being a fragmentation of a person’s identity, separated from the other parts by a defensive mechanism. DID usually occurs in conjunction with severe childhood trauma, and actually exists on the extreme end of the continuum of dissociative disorders. It is suggested that the condition occurs after childhood trauma, where depersonalisation and derealisation, combined with amnesia, help to protect one identity from the effects of the abuse so that the child is not completely overwhelmed. The fact that this kind of abuse is frequently a root cause of DID makes it singularly inappropriate to sensationalize the disorder in a way that upsets those living with it, especially when the dramatization suggests that these personalities are violent, malicious or threatening. This short summary of the definition and diagnostic criteria strongly suggests that DID does not reflect a person who is inhabited, as often claimed in media references, by multiple personalities with independent agendas. One can see why this perception may arise, as a potential symptom of DID is a change in affect, which encompasses an individual’s experience of emotion. The apparent change in a person’s identifying characteristics, combined with the fact that they feel detached from the people and objects around them and their own personal history, can be confusing for others. DID is ultimately a highly complex posttraumatic stress disorder, and the overdramatization of characters with alters in media is deeply damaging to patients living with the condition.
Another intriguing topic related to DID, which Dr Shiloh and Dr Scott bring up in their forensic psychology podcast, L.A. not so confidential, is malingering. This is the production of fictitious or exaggerated symptoms with an external aim such as reduced responsibility for criminal charges. In the DSM-5, DID is the only diagnosis for which the manual provides specific criteria to evaluate whether the patient is feigning their symptoms. Reviews of the clinical features of those diagnosed with true DID, as opposed to those simply malingering, have identified a few key inconsistencies that expose the lie. Many of these fall into the category of what you could describe as “plot holes”. These include alleged abuse being inconsistent with medical history, having obvious secondary gain from the diagnosis, and being able to remember a sequential personal history. Other more subtle differences include a lack of co-morbid post-traumatic stress disorder symptoms, using the first person over a range of affect and being able to competently express strong negative affect. Although studies such as this and DSM-5 criteria make it progressively easier to spot malingerers, it’s a challenging tightrope to walk, as Shiloh and Scott point out. An accusation of malingering instead of diagnosis of a significant mental health condition are two very opposite ends of a spectrum, and for either to be accepted by a court the presenting psychologist must have strong evidence to support their case. Discussion of this topic brings up all kinds of moral and ethical questions that face forensic and clinical psychologists on a daily basis. Is it really ‘better to be safe than sorry’? What margin of error is acceptable when giving out standardized diagnoses to unique individual cases? And how many of these malingerers do we actually catch?
On those ominous notes I’ll leave you with a brief summary of my view on DID, the misconceptions about it, its portrayal in the media, and its ties to malingering. When dramatizing a mental health disorder for public consumption, it is vital that we hold the industry to a higher standard - a higher standard of care for those whose stories it is exploiting, and a higher standard of accuracy about scientific fact. Psychology, while powerful in its capacity to fascinate and I hope thus powerful in its ability to change lives, should not be used to extract that which deviates from our perception of ‘normal’ and sensationalize it. Instead, we ought to focus on the issues faced by professionals in the field, and on the only people who can truly tell us how it feels to live with this condition. Media must put real people at the forefront, not just in psychology, but in all communication of scientific advances and professional work.
(And as a parting gift, the promised example of why this particular screenshot went viral)
Photo 2: Retrieved from: www.knowyourmeme.com
Gaby FitzGerald is in her 2nd year of studying Experimental Psychology at Corpus Christi College
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Beahrs, J. O. (1988). Kluft, Richard P.(Ed.),(1985). Childhood antecedents of multiple personality. Washington, DC: American Psychiatric Press.
Depersonalization/Derealization Disorder. (2020). Retrieved 10 November 2020, from http://traumadissociation.com/depersonalization.html
Ellason, J. W., Ross, C. A., & Fuchs, D. L. (1996). Lifetime axis I and II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry, 59(3), 255-266.
Multiple Authors (2016). Open Letter to the Director. Retrieved 6 November 2020, from https://splitmoviehurts.com/letter-to-director/
Rose, S. (2020). From Split to Psycho: why cinema fails dissociative identity disorder. Retrieved 10 November 2020, from https://www.theguardian.com/film/2017/jan/12/cinema-dissociative-personality-disorder-split-james-mcavoy
Shiloh & Scott (2018), L.A. not so confidential, Episode 12 - Multiple Personality Disorder isn’t a thing, produced by Crawlspace Media
Split, Directed by M. Night Shyamalan, Universal Pictures, 2016
Swica, Y., Lewis, D. O., & Lewis, M. (1996). Child Abuse and Dissociative Identity Disorder/Multiple Personality Disorder: The Documentation of Childhood Maltreatment and the Corroboration of Symptoms. Child and Adolescent Psychiatric Clinics of North America.
Thomas, A. (2001). Factitious and malingered dissociative identity disorder: Clinical features observed in 18 cases. Journal of trauma & dissociation, 2(4), 59-77.