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Identifyingdissociativeidentitydisorder:Aself-reportandprojectivestudy
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Journal of Abnormal Psycholog1998, Vol. 107, No. 2,272-28'
Copyright 1998 by the American Psychological Association, Inc.0021-843X/98/S3.00
Identifying Dissociative Identity Disorder:A Self-Report and Projective Study
Joe C. ScroppoAdelphi University
Sanford L. DrobNew York University Medical Center/Bellevue Hospital Center
Joel L. WeinbergerAdelphi University
Paula EagleColumbia University College of Physicians and Surgeons
This study compared 21 female adult psychiatric patients diagnosed with dissociative identity disorder(DID) with 21 female adult nondissociative psychiatric patients to determine whether DID patientsexhibit a distinguishing set of clinical features, and perceptual, attentional, and cognitive processes.Participants were assessed with the Dissociative Disorders Interview Schedule to assess diagnosticstatus. Group scores on the Dissociative Experiences Scale, Tellegen Absorption Scale, ChildhoodTrauma Questionnaire, Brief Symptom Inventory, and the Rorschach test were compared. DIDparticipants reported earlier and more severe childhood trauma, more dissociative symptoms, and agreater propensity for altered states of consciousness. The DID participants also exhibited increasedprojective and imaginative activity, a diminished ability to integrate mental contents, a complex anddriven cognitive style, and a highly unconventional view of reality.
Dissociative identity disorder (DID; formerly known as multi-
ple personality disorder) has existed under various names since
very early in recorded history (Ellenberger, 1970). Yet, despite
its lengthy history and its relatively long tenure in the official
diagnostic nosology, DID has been the subject of few experi-
mental investigations, and the mental health community remains
skeptical about the legitimacy of the disorder (North, Ryall,
Ricci, & Wetzel, 1993). This controversy has been spurred by
a recent dramatic increase in both the number of reported cases
and journal articles devoted to the disorder (North et al., 1993).
Skeptics generally maintain that DID is essentially an iatrogenic
phenomenon wherein therapists or influential others suggest dis-
sociative symptoms to vulnerable individuals (Merskey, 1992;
Spanos, 1994, 1996). They argue that the disorder is a con-
sciously or unconsciously enacted role and maintain that DID
patients do not share any consistent etiological or psychological
processes. Advocates, on the other hand, point out that no in-
stance of iatrogenically induced DID has been documented in
the literature (Ross, 1989) and refute many of the key assump-
tions of the iatrogenic model (e.g., Cleaves, 1996). They main-
Joe C. Seroppo and Joel L. Weinberger, Gordon Derner Institute ofAdvanced Psychological Studies, Adelphi University; Sanford L. Drob,Department of Psychiatry, New "fork University Medical Center/BellevueHospital Center; Paula Eagle, Department of Psychiatry, Columbia Uni-versity College of Physicians and Surgeons.
We gratefully acknowledge New "ibrk University Medical Center/Bellevue Hospital Center and Columbia-Presbyterian Medical Center fortheir cooperation in carrying ouf this study and Andrea Hessel, AmyMargolis, and Patrick Ross for their assistance throughout this project.
Correspondence concerning this article should be addressed to Joe C.Scroppo, Gordon Derner Institute of Advanced Psychological Studies,Adelphi University, Box 701, Garden City, New York 11530. Electronicmail may be sent to [email protected].
tain that DID typically emerges from the effects of severe child-
hood trauma on individuals predisposed toward a dissociative
coping style (Loewenstein, 1994). Advocates attribute the cur-
rent increase in cases to the development of coherent diagnostic
criteria, more accurate assessment instruments, and an increased
awareness of dissociative psychopathology (e.g., Kluft, 1984).
One approach to examining both the nature of DID and its
diagnostic validity consists of determining whether DID-diag-
nosed individuals exhibit a set of clinical features (i.e., psychiat-
ric history and symptomatology) and psychological processes
that differentiate them from non-DID-diagnosed individuals.
Using a recently developed self-report measure (i.e., Dissocia-
tive Experiences Scale, E. Bernstein & Putnam, 1986), research-
ers have begun to demonstrate that DID patients exhibit a
uniquely intense level of dissociation (Carlson et al., 1993)
and a clinically distinct set of dissociative symptoms (Waller,
Putnam, & Carlson, 1996). Similarly, researchers have begun
to recognize and quantify a set of clinical features shared by
most DID patients (e.g., episodes of partial or total amnesia,
history of childhood trauma, nonpsychotic hearing of voices,
subjective sense of being controlled by a foreign entity, and
alterations in identity, such as diary entries in different handwrit-
ings ) and have incorporated these characteristic features within
structured diagnostic interviews that exhibit promising specific-
ity and sensitivity (e.g., Ross, 1989; Steinberg, Cicchetti, Bu-
chanan, Hall, & Rounsaville, 1993). These self-report and inter-
view measures, however, suffer from some limitations. They
lack opacity (i.e., the requirement that items not be obvious in
their intent) and are thus vulnerable to exaggeration and feigning
(e.g., Gilbertson et al., 1992). They may also suggest the syn-
drome to susceptible or attention-seeking individuals. These in-
struments, moreover, are largely descriptive and do not assess
the underlying perceptual, cognitive, or affective processes that
create and maintain dissociative symptoms.
272
IDENTIFYING DISSOCIATIVE IDENTITY DISORDER 273
The advantage of opacity and the need to assess process-
oriented dimensions suggest that projective psychological tests
may be well suited to further investigate this disorder. Projective
tests may also be particularly appropriate because they assess
perception, attention, and imagination—the very psychological
processes considered most theoretically relevant to DID. Pierre
Janet's (1901/1977,1920/1965) still powerfully influential the-
ory of dissociation, for example, hypothesized that in response
to trauma, dissociatively disordered patients develop a set of
characteristic psychological processes that serve to keep some
experiences out of conscious integration with the bulk of mental
life. In Janet's model, dissociation occurs through a narrowing
of the internal and external perceptual field (such that many
aspects of experience recede from consciousness), combined
with a heightening of attention toward the remaining perceptual
field. This narrow but intensely focused attention greatly and
involuntarily amplifies mental contents (i.e., images, thoughts,
and feelings) such that they become overvalued, extremely com-
plex, and excessively realistic—a process that fosters imagina-
tion and fantasy over logic. Butler, Duran, Jasiukaitis, Koop-
man, & Spiegel (1996) suggested that this process is analogous
to watching an engrossing movie: ' 'attention is completely cap-
tured in the immediate narrow experience, and other self-reflec-
tive, perceptual, affective, and behavioral information" (p. 43)
becomes inaccessible. They maintained that this process dimin-
ishes higher order critical capacities and allows unattended or
unconscious material to exert an influence that is experienced
as uncontrollable or as imposed from without (accounting, at
least partially, for these individuals' sense of being influenced
by nonself entities). Modem dissociation theory continues to
focus on early developmental trauma and the role of fantasy
and imagination (Bowers, 1991; Ganaway, 1989, 1995; Lynn,
Rhue, & Green, 1988; Spiegel & Cardena, 1991).
In the present study, we gathered a sample of DID-diagnosed
patients and a control sample of mixed-diagnosis psychiatric
patients who had never been diagnosed with a dissociative disor-
der. We used a structured diagnostic interview to confirm the
DID diagnosis and to verify the absence of significant dissocia-
tive psychopathology in the control participants. We gathered
data on various clinical features and used the Rorschach test
(Exner, 1993) and the Tellegen Absorption Scale (Tellegen &
Atkinson, 1974) to assess perceptual, attentional, and cognitive
variables relevant to current dissociation theory. The Tellegen
Absorption Scale has been advanced as a measure of the ten-
dency toward fantasy-driven alterations in perception and cogni-
tion (e.g., Ganaway, 1989) and of the affinity for an attentional
style that heightens engagement with one aspect of internal or
external experience while markedly diminishing other aspects
(e.g., Crawford, Brown, & Moon, 1993; Roche & McConkey,
1990). We chose to use the Rorschach because it is one of the
most widely researched and administered of projective tests and
because of its demonstrated psychometric properties (e.g., Ex-
ner, 1993; Parker, Hanson, & Hunsley, 1988).
Rorschach studies of patients diagnosed with DID are scarce;
the entire published corpus consists of approximately seven in-
vestigations (Armstrong, 1991; Danesino, Daniels, & Mc-
Laughlin, 1979; Labott, Leavitt, Braun, & Sachs, 1992; Lovitt &
Lefkof, 1985; Wagner, Allison, & Wagner, 1983; Wagner &
Heise, 1974; %ung, Wagner, & Finn, 1994). For the most part,
these studies are difficult to compare with each other because
they used markedly different scoring systems and research de-
signs. The sample sizes were generally quite small; most studies
used less than 4 DID participants. These studies also exhibited
significant methodological weaknesses. All failed to include at
least one of the following components: a control group, an
assessment of the interrater reliability of the Rorschach scoring,
or a diagnostic procedure to verify the DID diagnosis. Further-
more, the degree of overall psychological impairment was not
generally assessed or held constant, even though differences on
this variable could have been responsible for the obtained re-
sults. A summary of the extant DID Rorschach literature yields
only two consistent findings. First, DID Rorschach protocols
tend to feature a large number of movement responses (e.g.,
"two women cooking"), a finding generally interpreted as re-
flecting a heightened imaginative tendency. Second, these proto-
cols tend to contain an elevated number of responses that depict
a dissociative or fragmenting process (e.g., "a woman being
split down the middle" or "a cell dividing down the middle").
Areas of disagreement, however, significantly outweigh areas of
agreement. In this study, we used Exner's (1993) psychometri-
cally sound Rorschach system and adopted rigorous procedures
to assess diagnostic status and to determine the interrater relia-
bility of the Rorschach scoring. We also assessed overall psycho-
logical impairment and controlled for this variable in comparing
the DID and the control groups. This increased the likelihood
that findings would reflect differences attributable to the pres-
ence of a dissociative syndrome rather than simply to differences
in gross psychopathology.
We hypothesized that the DID group would manifest a higher
score on the Tellegen Absorption Scale than would the mixed-
diagnosis control group. We also hypothesized that the DID
group would report greater childhood trauma than would the
psychiatric control group. We further hypothesized that the DID
group would respond to the Rorschach inkblots with compara-
tively greater imaginative activity, as measured by an increased
tendency to endow the blot with movement—a quality that the
blot clearly does not possess (Bendick & Klopfer, 1964; May-
man, 1977; Piotrowski, 1977). Consequently, we predicted that
the DID protocols would feature a greater total number of move-
ment (M + FM + m) determinants. We also hypothesized that
the DID group would use an attentional style that heightened one
perceptual area while simultaneously diminishing surrounding
areas (Armstrong, 1991). On the Rorschach, such a style would
tend to create figure-ground relationships and result in the per-
ception of depth or dimensionality. Consequently, we expected
a greater number of dimensionality (FD + Vista) determinants
in the DID protocols. We also hypothesized that the DID group
would tend to greatly amplify and become overinvolved with
their perceptual environment. On the Rorschach, this variable
is assessed by the Lambda score; we expected a comparatively
low Lambda (i.e., complex and inefficient) for the DID partici-
pants. Similarly, we hypothesized that the DID participants
would fail to appropriately integrate or unify distinct perceptual
details, as evidenced by both a comparatively greater number
of Incongruous and Fabulized (INCOM + FABCOM) combina-
tions (i.e., "penis with wings"; "chicken holding a basket-
ball"), a finding associated in the literature with various post-
traumatic clinical groups (Levin & Reis, 1996) and also by a
274 SCROPPO, DROB, WEINBERGER, AND EAGLE
greater number of responses depicting a dissociative or frag-
menting process (i.e., entities being split apart, torn in half,
etc.). Furthermore, given the relatively intense distortion of real-
ity implicit in this perceptual and cognitive style, we predicted
that the DID group would produce comparatively fewer re-
sponses that accurately conformed to conventionally denned
reality (i.e., decreased X + %). Previous research suggests that
an increased number of Blood, Anatomy, Fragmented-human,
and Morbid (i.e., damaged or dysphoric) percepts in the Ror-
schach protocol is often associated with a history of trauma
(Armstrong & Loewenstein, 1990; Nash, Hulsey, Sexton, Har-
ralson, & Lambert, 1993; Salley& Telling, 1984; van derKolk&
Ducey, 1984). Consequently, we hypothesized that the DID
group would exhibit a comparatively greater number of each of
these contents.
Borderline personality disorder (BPD) and posttraumatic
stress disorder (PTSD) have both been linked with DID (North
et al., 1993). Reports in the literature (e.g., Armstrong, 1991),
however, have suggested that although these diagnostic groups
may exhibit various descriptive similarities, they feature distinct
psychological processes. To determine whether DID can be dis-
tinguished from these closely related but presumably separate
clinical entities, we hypothesized that the DID group would
produce more movement and dimensionality responses and a
lower Lambda score than the published Rorschach norms for
both a BPD sample and a PTSD sample. In light of previous
research on the avoidant characteristics of many DID patients
(e.g., Gleaves, 1996), we also hypothesized that the DID group
would exhibit a more intellectualized and affectively constricted
style on the Rorschach (e.g., a higher score on the Intellectual-
ization Index) than that of the control group or of the BPD or
PTSD group.
Method
Participants
DID participants were recruited from the flellevue Hospital Dissocia-
tive Disorders Clinic and from the dissociative disorders program of
the Columbia-Presbyterian Day Treatment Clinic. Information about the
study was presented to clinicians at these sites, and they were asked to
refer suitable patients to the study. Additional participants were obtained
through contacts with several clinician-led study groups devoted to the
investigation of dissociative disorders. Control participants were re-
cruited from the Bellevue Hospital Mental Hygiene Clinic, the Colum-
bia-Presbyterian Day Treatment Clinic, and from several other mental
health clinics. The basic inclusion criteria required that all participants
be at least 18 years old and in some form of ongoing psychotherapy.
DID participants were required to have been assigned the DID diagnosis
by their treating clinician; control participants were required to be free
from any dissociative-disorder diagnosis over their clinical history. Neu-
rological syndromes have been reported to closely mimic dissociative
disorders (Schenk & Bear, 1981); consequently potential participants
who reported a history of neurological disorder were excluded. All
participants were told that the purpose of the study was to improve the
efficacy of a set of psychological tests and were paid $10 to $35 for
their participation. All DID participants referred to the study were fe-
male; thus, only female control participants were recruited.
Procedure
All potential participants were screened over the telephone to deter-
mine whether they met the basic inclusion criteria. Participants who
passed this screening were scheduled for a face-to-face assessment,
which consisted of one 2 \- to 3-hour session. The assessments occurred
in the offices of Bellevue Hospital or in a private professional office.
Informed consent and demographic information were collected and four
self-report questionnaires (Tellegen Absorption Scale; Brief Symptom
Inventory; Dissociative Experiences Scale; Childhood Trauma Question-
naire) and a diagnostic interview (Dissociative Disorders Interview
Schedule) were administered, in that order. To qualify as a control partic-
ipant, an individual had to score 15 or less on the Dissociative Experi-
ences Scale and not qualify for any dissociative-disorder diagnosis. To
qualify as a DID participant, an individual had to meet the diagnostic
criteria for DID as assessed by the Dissociative Disorders Interview
Schedule ( DDIS). Although the DDIS criteria are based on the Diagnos-
tic and Statistical Manual of Mental Disorders (3rd ed.; DSM-1II;
American Psychiatric Association, 1980), they closely match the current
DSM-IV (4th ed.; American Psychiatric Association, 1994) DID crite-
ria. Ib apply the appropriate inclusion criteria, the evaluators began the
assessment with knowledge of the participant's presumptive group status
(DID versus control), although actual determination of that status did
not occur until all serf-report instruments and the diagnostic interview
were completed. Individuals who met the appropriate control or DID
criteria were immediately given the Rorschach test, which was audio-
taped. Prior to the Rorschach, all participants were presented with in-
structions similar to those used by Armstrong and Loewenstein (1990),
in which the person is encouraged to allow all self-aspects to participate
in the testing. Most of the assessments were carried out by the first
author, Joe C. Scroppo, though a few participants were assessed by
two master' s-level clinicians trained in the administration of all the
instruments. Twenty-two potential DID participants and 29 control parti-
cipants received a face-to-face assessment. One potential DID participant
was excluded because she reported a neurological disorder; 8 potential
control participants were excluded because they exhibited significant
dissociative psychopathology. The final sample consisted of 21 DID
participants and 21 control participants. At the time of assessment, 20
DID participants and 20 control participants were psychiatric outpa-
tients, and 1 DID and 1 control participant were psychiatric inpatients
(in the same hospital).
Instruments
Dissociative Experiences Scale (DES). The DBS is a 28-item self-
report measure of the frequency of various dissociative experiences (E.
Bernstein & Putnam, 1986). Scores on the DES range from 0 to 100,
with 0 representing the complete absence of dissociative experiences
and 100 representing constant dissociative experiences. Whereas various
nondissociative psychiatric groups exhibit slight to moderate elevations
on the DES, a score above 15 or 20 is suggestive of dissociative psycho-
pathology (Carlson et al., 1993). The reliability and validity of the DES
has been widely established (e.g., E. Bernstein & Putnam, 1986; Carlson
et al., 1993).
Dissociative Disorders Interview Schedule (DDIS). The DDIS
(Ross, 1989) is a 131-item structured interview schedule linked to the
DSM-II1 that allows for the diagnosis of all five dissociative disorders,
and major depression, substance abuse, and BPD. Additional items pro-
vide information about previous psychiatric history (hospitalizations,
psychiatric medications, number of therapists), childhood physical and
sexual abuse, dissociative symptoms, and First Rank Schneiderian
(FRS) symptoms (i.e., experiences in which entities or forces not ac-
knowledged as part of the self are felt to act on the individual, such as
believing that one's thoughts, feelings, or actions are controlled by
others, hearing voices, etc.; Ross, 1989). The DDIS has an overall
interrater reliability of 0.68; it has a specificity of 100% and a sensitivity
of 90% for the diagnosis of DID (Ross, 1989). Following the procedure
used by Sandberg and Lynn (1992), we slightly abbreviated the DDIS
IDENTIFYING DISSOCIATIVE IDENTITY DISORDER 275
to exclude the sections concerning somatization and paranormalexperiences.
Brief Symptom Inventory (SSI). The BSI is a 53-item self-reportinventory designed to assess the psychological symptoms of psychiatricand medical patients (Derogatis, 1993). Derogatis (1993) indicated thatreliability coefficients (internal consistency and test-retest) range fromr = 0.71 to 0.85 and reported on a range of studies that have establishedsatisfactory construct, convergent, and discriminant validity for the BSI.In this study, we used Derogatis's female outpatient standards TO norm
our data.Childhood Trauma Questionnaire (CTQ). The CTQ is a recently
developed 70-item self-report instrument intended to retrospectively as-sess experiences of childhood abuse and neglect (D. Bernstein et al.,1994; D. Bernstein, Ahluvalia, Pogge, & Handelsman, 1997). The CTQprovides scores on four empirically derived factors—Physical and Emo-tional Abuse, Emotional Neglect, Physical Neglect, and Sexual Abuse—and also generates an overall score. D. Bernstein et al. (1994,1995) havereported solid reliability coefficients for the CTQ and have established itsinitial validity through the CTQ's correlation with extensive interview-based assessments of childhood trauma.
Tellegen Absorption Scale (TAS). The TAS is a 34-item self-report,true-false scale (Tellegen, 1982; Tellegen & Atkinson, 1974). Tellegen(1982) reported an internal reliability of r = .88, and a 1-month test-retest reliability of r - .91. The TAS measures "absorption," a multidi-mensional construct that has evolved since the scale's inception. Highscores on the TAS correlate with the capacity for self-altering experi-ences (Finke & MacDonald, 1978), fantasy proneness (Lynn & Rhue,1988), and the ability to inhibit aspects of the attentional field (Davidson,Schwartz, & Rothmau, 1976).
The Rorschach Test (Exner's Comprehensive System). The Ror-schach Test assesses the perceptual, cognitive, and emotional characteris-tics that influence personality and social functioning. Exner (1993) re-ported acceptable test-retest reliability for his scoring system (0.70 to0.90 for most of the variables considered in this study) and has validatedhis interpretative hypotheses with large-sample studies of various clinicaland nonclinical groups.
Dissociative-content Rorschach scoring system. To differentiate be-tween DID and non-DID Rorschach protocols, Labott et al. (1992)developed and empirically tested a system that assesses Rorschach re-sponses for the presence of dissociative content. There are two types ofDissociative-content responses: responses of human, animal, or abstractentities that feature division or splitting (e.g., people torn apart or beingseparated, animals cut down the center, or cells dividing) and responsesthat feature entities seen through a mist or fog so that people and objectslook unclear, blurry, or far away.
Results
Interrater Reliability of the Rorschach Scoring
Thirty-eight percent (n = 16) of the Rorschach protocols
were randomly selected and scored blindly by a clinical psychol-
ogist. As recommended by Exner (1991), reliability was calcu-
lated as percent agreement for each of the nine major scoring
categories: Location = 88%, Developmental Quality = 90%,
Determinants = 74%, Pairs = 92%, Contents = 69%, Populars
= 90%, Z Score = 89%, and Special Scores = 72%. Percent
agreement for Dissociative-content responses (scored according
to Labott et al.'s, 1992, system) was 80%. To further assess
interrater reliability, we calculated the raw correlation between
scorers for all of the Rorschach variables featured in our hypoth-
eses. Corrected with the Spearman-Brown formula, these cor-
relation coefficients ranged from r = .82 to .96.
Demographic Variables
The DID group and the control group did not differ signifi-
cantly with regard to age (DID: M = 39.38 years; control:
M = 35.95 years), income (DID and control: median annual
household income = $30,000-44,000), or education (DID and
control: median = 4 years of college). Consequently, the two
groups were broadly equivalent with respect to major demo-
graphic variables.
Clinical Features
Clinical features were obtained from the items on the DDIS.
Excessively skewed variables were corrected with a natural-
log transform. We computed a multivariate analysis of variance
(MANOVA; using the Pillais criterion) for the continuous vari-
ables in our DDIS dataset (see Table 2) and obtained an exact
f(8, 32) = 57.41,p < .001. Given the statistically significant
multivariate test, we proceeded with univariate comparisons.
For the three continuous variables applicable only to participants
reporting a history of childhood abuse (age at onset of physical
abuse, age at onset of sexual abuse, and index of the number
of separate incidents of sexual abuse), we used a Bonferroni
post hoc contrast procedure (p < .02) to control for multiple
pairwise comparisons. The obtained values for the clinical-fea-
tures variables are presented in Tables 1 and 2, with a statistical
comparison between the two groups. A large proportion (i.e.,
a57% for all variables) of the DID group reported a positive
history of childhood physical abuse, childhood sexual abuse,
substance abuse, and suicide attempts. They also evidenced a
sizable total number of nondissociative psychiatric diagnoses
(combined Axis I and Axis n), a large total number of FRS
symptoms, a large number of DDlS-assessed dissociative fea-
Table 1
Chi-square and Percentage of Dissociative Identity Disorder
(DID) and Control Groups Endorsing Selected Clinical
Features on the Dissociative Disorders Interview Schedule
Group
Variable '
Childhood physicalabuse
Childhood sexual abuseHistory of substance
abuseHistory of suicide
attempt(s)History of sleepwalkingHistory of trance(s)Borderline personality
disorder diagnosis'
DID(%, n = 21)
76.1985.71
76.19
57.1457.14
100.00
61.90
Control(%, n = 21)
23.8128.57
19.05
19.050.00
38.09
4.76
X2U)
9.55**14.00***
13.75***
6.46*16.80***18.83***
15.43***
d"
1.081.41
1.40
0.851.631.80
1.52
Note. Percentages reflect positive responses. All p values based onFisher's exact probability test, two-tailed." Cohen's measure of effect size. b Diagnosis was assessed through aneight-item set of questions corresponding to criteria of the Diagnosticand Statistical Manual of Mental Disorders (3rd ed.).*p<.05. **/?<.01. ' ***/>< .001.
276 SCROPPO, DROB, WEINBERGER, AND EAGLE
Table 2
Means for the Dissociative Experiences Scale (DBS), the Tellegen Absorption Scale (TAS),
and Selected Clinical Features From the Dissociative Disorders Interview Schedule, With
Both Simple ANOVA and ANCOVA Covarying Global Psychological Impairment
Feature
DBS score*MSDn
TAS score'MSDn
Nondissociative psychiatricdiagnoses
M
SD
n
First Rank Schneiderian
symptomsM
SD
n
Dissociative symptomsMSDn
Psychiatric hospitalizationsMSD
n
Index of total no. of currentpsychiatric medications
MSDn
Index of no. of separateincidents of sexual abuse
Msnn
MedianNo. of therapists, lifetime
MSD
n
Age at onset of physical abuseM
SD
n
Age at onset of sexual abuseMSD
n
Group ANOVA
DID Control F d"
45.97
18.2721
25.387.65
21
3.291.19
21
6.432.69
21
10.522.34
21
4.384.94
21
1.43
0.3120
3.690.63
13>50
6.524.61
21
2.802.15
15
3.282.47
18
6.213.97
2118.32*** 1.35
16.76
5.1621
36.72*** 1.921.430.75
21
87.42*** 2.960.481.12
21316.84*** 5.63
0.860.85
2119.27d*** 1.35
0.290.90
21
9.49** 0.971.17
0.2321
28.30*** 1.541.671.0361-5
16.65d*** 1.292.861.56
212.46 0.50
4.331.636
&.1S"** 0.908.835.356
ANCOVA
F d'
4.23* 0.63
12.92*** 1.15
34.31*** 1.88
141.56*** 3.81
14.36"** 1.17
4.83* 0.70
14.84** 1.23
18.10'*** 1.36
2.68 0.52
4.61"* 0.69
Note. DID = dissociative identity disorder.a Cohen's measure of effect size.b Between-group statistical comparison was not carried out because valueswere constrained by inclusion-exclusion criteria. c The TAS has a range of 0-34. d Raw data were trans-formed into natural logarithms to reduce skewness before the use of the ANOVA or ANCOVA.*P < .05. **p < .01. ***p < .001.
IDENTIFYING DISSOCIATIVE IDENTITY DISORDER 277
tures, a comorbid diagnosis of BPD, and a positive history of
suicide attempt(s). For all of these variables, the values for the
DID group were significantly higher than for the control group.
The age of onset of physical abuse was not significantly different
between groups, but the DID group reported a significantly
earlier age of onset of sexual abuse and a larger total number
of separate incidents of sexual abuse. Virtually all of the effect
sizes associated with these differences were large (d >: 0.80).
The DID group reported a very high level of dissociative symp-
tomatology (M = 45.97) on the DBS.
The DID group also reported a greater number of psychiatric
hospitalizations, a higher score on an index of current psychiat-
ric medication use, and contact with a greater total number of
therapists over their lifetime (see Table 2). On the BSI, a mea-
sure specifically designed to assess psychological impairment,
the DID group reported significantly greater symptomatology
than did the control group on all nine subscales as well as on
the global symptom severity scale, and these differences were
all large-sized effects. Statistics (reported as standard scores)
for the BSI global scale were as follows: for the DID group, M
= 56.24, SD = 8.72; for the control group, M = 39.86, SD =
7.60; /(40) = 6.49; and Cohen's d = 2.05.
Given the difference between the two groups in the level of
overall psychological impairment, we decided to use, whenever
possible, the BSI global symptom severity scale as a covariate
in all statistical comparisons of the two groups to control for
this difference. Even when global symptom severity was held
constant in the two groups, the DID group continued to show
significantly more psychiatric-medication use, a greater number
of hospitalizations, contact with a larger number of therapists,
a larger total number of nondissociative psychiatric diagnoses,
and more FRS symptoms; most of these differences were large-
sized effects (see Tables 1 and 2).
Type and Level of Childhood Trauma
Whereas a general history of reported childhood physical
abuse, sexual abuse, or both were determined through a set of
questions embedded within the diagnostic interview, a more
fine-grained analysis of early trauma was obtained by means of
the CTQ. We computed a MANO\A (using the Pillais criterion)
for the CTQ's five subscale variables (see Table 3) and obtained
an exact F(5, 36) = 19.75, p < .001; because the CTQ Global
score is wholly composed of the subscale scores, it was not
included in the multivariate test. We then proceeded with univari-
ate comparisons. The DID group reported greater trauma than
did the control group on all four subscales as well as on the
Global scale, and these were all large-sized effects (see Table
3). When global psychological impairment was held constant,
the DID group continued to manifest significantly higher levels
of reported trauma on all CTQ indices, and the effect sizes
remained large.
Tellegen Absorption Scale
The DID group manifested a higher score on the TAS than
did the control group, and it was a large effect (see Table 2).
When global psychological impairment was held constant, the
DID group continued to have a significantly higher score than
did the control group, and the effect was moderate.
Table 3
Mean Childhood Trauma Questionnaire (CTQ) Subscale and Global Scores, With Simple
ANOVA and ANCOVA Covarying Global Psychological Impairment
Group ANOVA ANCOVA
CTQ variable DID (n = 21) Control (n = 21) d"
Weighted emotional abuseM
SDWeighted physical abuse
MSD
Weighted sexual abuseMSD
Weighted emotional neglectM
SD
Weighted physical neglect
MSD
Weighted global traumaMSD
4.160.65
3.14
1.19
3.841.16
3.780.55
2.230.76
17.153.26
2.461.00
1.671.07
1.410.71
2.270.67
1.280.34
9.092.69
42.12*** 2.05 24.95***
17.89*** 1.34 17.58***
67.24*** 2.59 29.82***
64.16*** 2.53 20.86***
27.35*** 1.65 18.07***
76.39*** 2.76 41.66***
1.60
1.34
1.75
1.46
1.36
2.07
Note. CTQ data reported as summary scores ranging from 1 (minimum) to 5 (maximum). The scales areweighted for the number of items endorsed. DTD = dissociative identity disorder." Cohen's measure of effect size,***/? ^ .001.
278 SCROPPO, DROB, WEINBERGER, AND EAGLE
Rorschach Hypotheses (DID Versus Control Group)
Rorschach variables often tend to feature distributions skewed
enough to violate the normality assumption of parametric statis-
tical tests; thus, following the recommendations of Viglione
(1995), we transformed markedly skewed data into natural loga-
rithms. We computed a MANOV\ (using the Pillais criterion)
for the Rorschach variables that were the focus of our hypotheses
and obtained an exact F(10, 31) = 2.82, p < .05. We then
carried out a simple univariate comparison between the DID
and control group, as well as a univariate comparison after
covarying global psychological impairment (see Table 4). In
the simple comparison, the DID group exhibited significantly
(i.e., p < .05) greater movement responses; Incongruous and
Fabulized combinations; Blood, Anatomy, Morbid, Fragmented-
human, and Dissociative-content responses; and a significantly
lower X+% score. Although the DID group exhibited greater
dimensionality determinants, the difference closely approached
(p = .06, d = 0.62) but did not reach the conventional signifi-
cance level. All of these differences {both significant and nonsig-
nificant) were large effects in the simple comparison, except
for movement and dimensionality, which were moderate effects.
For two variables (Lambda and Dissociative-content) the cor-
rection for skewness was not fully satisfactory, and we used a
nonparametric (i.e., Mann-Whitney U) test to compare the
groups. The descriptive and inferential statistics for Lambda
were as follows: for the DID group, M = 0.18, SD = 0.13, sum
of ranks = 383; for the control group, M = 1.43, SD = 0.31,
sum of ranks = 520; U = 152; p -= .08; Cohen's d = 0.69.
The statistics for Dissociative-content were as follows: for DID
group, M = 1.43, SD = 1.72, sum of ranks = 556; for the
control group, M = 0.24, SD = 0.54, sum of ranks = 347; U
- 116; p = .003; Cohen's d = 1.21.
In the covaried comparison, the DID group exhibited signifi-
cantly greater dimensionality responses; Incongruous and Fabu-
lized combinations; Blood, Anatomy, and Morbid responses; and
a significantly lower X+% score. Although the DID group exhib-
ited greater movement responses, the difference closely ap-
proached (p — .098, d - 0.54) but did not reach the conventional
threshold of significance. These differences (both significant and
Table 4
Mean Scores on Selected Rorschach Variables, With Both Simple ANOVA and ANCOVA
Covarying Global Psychological Impairment
Group ANOVA ANCOVA
Variable
Movement determinants (M + FM + m)MSD
Vista (FV + VF + V) + FD determinantsMSD
Incongruous + Fabulized combinationsMSD
X+% scoreMSD
Morbid responsesMSD
Blood responses (primary or secondarycontent)
MSD
Anatomy responses (primary or secondarycontent)
MSD
Fragmented-human responses (Hd + (Hd);primary or secondary content)
MSD
DID(n = 21)
14.817.24
4.103.33
3.902.97
0.390.11
3.483.06
1.951.94
2.952.60
5.763.40
Control(n = 21) F
5.02"*10.143.72
3.72"2.291.74
8.94**1.571.99
9.92**0.49
0.1013.62"**
1.141.74
19.45"**0.330.58
6.92b*1.14
1.28
9.73**2.862.56
<*'
0.71
0.61
0.95
1.00
1.14
1.39
0.83
0.99
F
2.88"-'
4.52b*
4.86*
7.48**
7.45b**
5.65'*
4.55'*
0.54
d'
0.54
0.68
0.71
0.88
0.87
0.76
0.68
0.24
Note. DID = dissociative identity disorder; M = human-movement determinants; FM = animal-movementdeterminants; m = inanimate-movement determinants; FV = Form-Vista determinants; VF = Vista-Formdeterminants; V = pure Vista determinants; FD = Form-Dimension determinants; Hd = human-detailcontents; (Hd) = fictional/mythological human-detail contents.a Cohen's measure of efffect size. b ANOVA or ANCOVA applied to logarithmically transformed raw data.> = .098. d p = .06.*p < .05. **/? < .01. ***/? < .001.
IDENTIFYING DISSOCIATIVE IDENTITY DISORDER 279
nonsignificant) in the covaried comparison were moderate ef-
fects, except for X+% score and Morbid responses, which were
large effects. One variable, Fragmented-human responses, exhib-
ited a very small effect size and was nonsignificant.
Rorschach Hypotheses (DID Group Versus BPD
Normative Data)
Exner's (1986) normative Rorschach data for a BPD-diag-
nosed sample is the largest (N = 84) and most carefully assem-
bled dataset for this clinical group; consequently, we compared
these norms with the scores of our DID group. The hypotheses
that the DID group would produce more movement and dimen-
sionality responses and a lower Lambda score than those of the
BPD-diagnosed group were supported (see Table 5). The effect
sizes associated with these findings, moreover, were all large.
Rorschach Hypotheses (DID Group Versus PTSD
Normative Data)
There are four extant PTSD Rorschach studies that have used
a relatively large number of participants (N > 20) and a system-
atized scoring approach (Hartman et al., 1990; Levin, 1993;
Sloan, Arsenault, Hilsenroth, Harvill, & Handler, 1995; Swan-
son, Blount, & Bruno, 1990). To most rigorously test for differ-
ences, we compared our DID sample to the PTSD sample (Sloan
et al., 1995), whose values on the target variables were most
similar to those for our DID group. The hypotheses that the
DID group would produce more movement and dimensionality
responses were supported, and the effect sizes were large ones
(see Table 5). The hypothesis that the DID group would produce
a lower Lambda score was not supported.
Discussion
This study has several important methodological strengths in
comparison to other DID studies. The DID participants were
recruited from different sites, which minimized the possibility
that the findings are specific to a particular therapist, clinic,
treatment approach, or other site-specific variable. The investi-
gators who collected the data did not have a clinical relationship
with any of the participants, which has not been the case in
many other DID studies. Rirthermore, whenever possible, we
controlled for differences in overall psychological impairment
in comparing the DID and control groups. This substantially
increased the likelihood that the obtained differences are
uniquely attributable to the presence of a dissociative syndrome
rather than simply to differences in gross psychopathology. This
study also had a significant methodological weakness. To apply
the appropriate inclusion criteria, the evaluators were not blind
to the participant's presumptive group status. It is unlikely, how-
ever, that knowledge of the participant's presumptive group sta-
tus biased the assessment. The self-report instruments were sim-
ply filled out in the examiner's presence, and the structured
diagnostic interview required mostly "yes-no-unsure" an-
swers. All Rorschach protocols were administered according to
Exner's (1993) highly standardized procedure, which dictates
the precise wording of the first and most important query, and
the audiotaping and verbatim transcription of the test served as
a rigorous check on the quality of the administration and entailed
a scoring based on the entire and unedited proceedings. A blind
scoring of approximately 40% of the Rorschach protocols served
as a further check. Nevertheless, experimenter bias, expectancy
effects, or both cannot be completely ruled out as validity
threats. Future studies would benefit significantly from a fully
Table 5
Mean Scores and One-Sample t Tests for Selected Rorschach Variables, Comparing the DID
Group With Normative Data for BPD-Diagnosed and PTSD-Diagnosed Individuals
Group Compared with DID
BPD PTSD
VariableDID BPD norm' PTSD normb
(n = 21) (n = 84) (n = 30)
Movement determinants(M + FM + m)
MSD
LambdaM
SDVista (FV + VF + V) +
FD determinantsMSD
14.81 8.337.24
0.18 0.570.13
4.10 2.073.33
4.10** 1.83 3.20** 1.439.76
-13.81*** 6.18 -4.85*** 2.170.32
2.79* 1.25 -0.10 0.044.17
Note. Variance estimate taken from the DID sample; df = 20 for all tests. DID = dissociative identitydisorder; BPD = bipolar disorder; PTSD = posttraumatic stress disorder; M = human-movement determi-nants; FM = animal-movement determinants; m = inanimate-movement determinants; FV = Form-Vistadeterminants; VF = Vista-Form determinants; V = pure Vista determinants; FD = Form-Dimensiondeterminants.* Normative BPD data taken from Exner (1986). b Normative PTSD data taken from Sloan et al. (1995).* Cohen's measure of effect size.* p < .05. **p<.01. ***/)< .001.
280 SCROPPO, DROB, WEINBERGER, AND EAGLE
blinded approach. Our exclusively female sample may also seem
to limit the generalizability of our findings; nevertheless, the
literature suggests that in clinical settings the overwhelming
majority of DID patients are female (Loewenstein, 1994).
Do the DID Participants Exhibit a Distinguishing Set
of Clinical Features?
The DID sample in this study showed many of the clinical
features reported in other empirical studies of DID patients
(e.g., Boon & Draijer, 1993; Fink & Golinkoff, 1990; Kemp,
Gilbertson, & Torem, 1988; Lauer, Black, & Keen, 1993; Ross
et al., 1990). These clinical features were present in the DID
group at a significantly greater level than they were in the mixed-
diagnosis psychiatric control group, and the effect sizes associ-
ated with these differences were almost all large (i.e., d ^ 0.80).
Taken together, these findings strongly support the assumption
that DID patients exhibit a set of clinical features that differenti-
ates them from nondissociative psychiatric patients. Examined
qualitatively, these clinical features suggest that DID patients
frequently undergo alterations of consciousness. They reported,
for example, a very high rate of substance abuse even in compar-
ison to nondissociative psychiatric patients. Similarly, a very
large proportion reported a history of trance states and sleep-
walking, and these behaviors occurred at a dramatically higher
rate than among the control participants. Their very high rate
of suicidality may similarly indicate a prevailing and powerful
impulse to escape from unbearable states of consciousness. Fur-
thermore, the extremely elevated number of FRS symptoms in
the DID group (a difference of over 5 SD units) suggests that
these individuals experience a need to escape a sense of control
and ownership over many of their impulses and actions—a
need that manifests itself in feeling controlled or acted on by
seemingly external entities.
Even when overall psychological symptom severity was held
constant, our DID group continued to exhibit significantly
greater impairment. In other words, the DID group is character-
ized not simply by a more severe and extensive symptomatology
but also by a disproportionate tendency toward multiple hospi-
talizations, multiple diagnoses, multiple psychiatric-medication
trials, and multiple courses of therapy. These disproportionate
tendencies may stem from the fact that DID patients often do
not report their dissociative symptoms and behaviors when pre-
senting in clinical settings (e.g., Kluft, 1984)—a situation that
may lead to increased numbers of inaccurate diagnoses, unpro-
ductive therapeutic treatments, and elevations on measures of
psychological impairment. When DID patients do report or ex-
hibit dissociative phenomena, such phenomena may be inter-
preted as signs of a purely psychotic process, which may account
for their disproportionate tendency toward psychotropic medica-
tions and multiple diagnoses. In this study, for example, the
DID participants reported an average of 6.5 FRS symptoms,
which places them above schizophrenics on this variable. These
symptoms may impel clinicians toward a "psychosis" diagnosis
and a treatment aimed at reducing psychotic symptoms. In the
course of the assessment, however, the behavior of almost all
of the DID participants was generally coherent and goaldirected,
despite occasional reports of ongoing dissociative phenomena.
Childhood Trauma
The DID participants reported dramatically higher levels of
trauma than did the psychiatric control group. The large majority
specifically reported experiencing childhood sexual and physical
abuse, and many more DID participants reported a history of
such abuse than did control participants. Consonant with the
proposed etiology of the disorder, which links DID to particu-
larly severe and invasive early trauma, the DID group reported
an earlier onset and a much greater total number of episodes of
sexual, but not physical, abuse. Overall, these results indicate
that DID patients report a level and pattern of childhood trauma
that powerfully distinguishes them from nondissociative psychi-
atric patients. The meaning of these reports, however, is ambigu-
ous in light of the retrospective nature of the assessment and in
the absence of independent verification. These reports may result
largely from the influence of external forces (e.g., suggestions
from therapists or media accounts; also, see discussion of iatro-
genesis in the Discussion section). Alternatively, DID partici-
pants may be accurately reporting on their experience. Finally,
DID patients may, as a consequence of their fantasy-driven cog-
nitive style, defensively embellish or distort actual but relatively
prosaic traumas (Ganaway, 1989). Whatever the case, DID pa-
tients unequivocally experience themselves as victims of severe
childhood abuse.
Tellegen Absorption Scale
The DID group obtained a significantly higher score on the
TAS than did the control group, and their mean score fell ap-
proximately one standard deviation above the average (M = ±
18.5) for female nonclinical samples (Tellegen, 1982). This
finding suggests that the DID group exhibits a marked tendency
toward a fantasy-based pattern of perceptual and cognitive dis-
tortion that distinguishes them both from psychiatric controls
and from the average person. Tellegen (cited in Kihlstrom,
Glisky, & Angiulo, 1994, p. 120) has pointed out that high TAS
scores may reflect a tendency for ' 'psychological states that are
characterized by marked restructuring of the phenomenal self
and world." Among DID patients, this restructuring tendency
may constitute a primary mechanism for creating and main-
taining dissociative states. In a broader sense, this finding sup-
ports the existence of a relationship between fantasy and dissoci-
ation. Lynn et al. (1988), for example, asserted that the forma-
tion of alter personalities is essentially a creative, fantasy-based
activity, and they speculated that fantasy proneness, when com-
bined with the experience of early trauma, increases the likeli-
hood of an eventual DID diagnosis. Among nonclinical individu-
als, Rauschenberger and Lynn (1995) have found high levels
of fantasy proneness to be associated with the presence of dis-
sociative symptoms.
DID and the Rorschach
Our Rorschach findings suggest that as a group, DID-diag-
nosed patients can be differentiated from non-DID-diagnosed
patients on the basis of specific perceptual and cognitive vari-
ables. Of primary significance, the DID group exhibited a com-
paratively greater use of imaginative and projective operations.
IDENTIFYING DISSOCIATIVE IDENTITY DISORDER 281
inasmuch as they tended to mentally generate and endow the
inkblot with features (movement, dimensionality, morbidity)
that notably exceeded its manifest characteristics (shape, color,
shading; Exner, 1989). This extensive use of imagination and
projection is consistent with the phenomenology of DID, in
which discrete "entities" are imaginatively created and en-
dowed with disowned psychic qualities and experienced as sepa-
rate (i.e., projected) from the self. DID participants also tended
to perceive and attend to the inkblots in a way that resulted in an
increased impression of depth or dimensionality. This increased
tendency may reflect a perceptual phenomenon, often reported
in acute dissociative states (Bellak & Faithorn, 1981), in which
percepts are seen as far off or unnaturally distant (i.e., reports
of floating above a traumatic experience or viewing the environ-
ment as though from the wrong end of a telescope). The percep-
tion of depth is also consistent with a heightened but narrow
attention to one aspect of the blot (i.e., the figure or foreground)
and a concurrent diminished attention to other aspects (i.e., the
background). Janet (1901/1977, 1920/1965) and Spiegel and
Cardena (1991) proposed that such an attentional style is char-
acteristic of dissociatively inclined persons and results in the
loss of contextual information and eventual disturbances in
memory and identity.
DID participants also tended to become psychologically over-
involved with their perceptual environment as evidenced by their
proclivity to offer complicated, inefficient, and very elaborate
responses—a state that Exner (1993) characterized as an inabil-
ity to back away from experience. The inkblot seems to trigger
an automatic and complex flow of associations, an apparently
uncontrolled but intense process that these individuals may attri-
bute to an external agency or entity. This finding is consistent
with Janet's hypothesis that dissociatively inclined individuals
experience uncontrollable amplifications of their psychic life
that they experience as separate from their perceived self.
The DID group also exhibited a failure to appropriately sepa-
rate and synthesize diverse mental contents, as indicated by their
comparatively greater tendency to perceive highly incompatible
relationships ("a creature with a dragonfly's head and a human
body'') in the inkblots. This absence of logical integration is
likely to reflect the contradictory and incoherent personality
organization that defines DID. Similarly, the DID group exhib-
ited a comparatively greater tendency to perceive fragmentation,
splitting, and physical division ("an alligator with two heads
pulling it apart''). DID participants presumably lack a sense of
the continuing integrity of their physical and psychic selves
and thus tend to perceive parallel breakdowns in the unity and
wholeness of their perceptual environment (Cardena, Lewis-
Fernandez, Beahr, Pakianathan, & Spiegel, 1996). Compared
with the psychiatric controls, the DID group also tended gener-
ally to form highly atypical percepts, indicating an unwilling-
ness or a substantially impaired ability to perceive conventional
reality. This atypical translation of perceptual experience is con-
sistent with a highly imaginative, complex, and nonintegrative
style and suggests that this style may lead to significant distor-
tions of reality.
The DID group also generally exhibited more traumatic
(Blood, Anatomy, Morbid, or Fragmented-human) contents than
did the psychiatric control group. Elevations on these variables
have been associated with intense somatic concern, a preoccupa-
tion with physical integrity, and exposure to trauma (Arm-
strong & Loewenstein, 1990; Exner, 1993; Nash et al., 1993;
Salley & Teiling, 1984; van der Kolk & Ducey, 1984). For the
DID group, these elevations are consistent with both a lack of
internal coherence and their self-reported childhood trauma.
Even after controlling for global psychological impairment, all
of these differences remained at least medium-sized effects.
Given the magnitude of these differences and the fact that these
variables assess major psychological attributes (Exner, 1993),
it is likely that these findings have clinical relevance.
The hypothesis that DID participants would manifest affective
and interpersonal constriction in comparison with die psychiat-
ric control group was not supported in this study. The DID
group was not significantly different from the control group
on the Rorschach variables usually associated with affective or
interpersonal inhibition.
Comparison of DID Rorschach Scores to Published
BPD and PTSD Scores
The high comorbidity rale of BPD among the DID partici-
pants (i.e., 65%) is consistent with that found in other studies.
Some investigators (Manner & Fink, 1994) have maintained
that the high rate is an artifact of poorly differentiated diagnostic
criteria and that whereas both disorders may feature affective
instability, identity confusion, dissociative symptoms, and unsta-
ble relationships, DID and BPD exhibit distinct characteristics
and processes. Others have maintained that DID may constitute
a special case of BPD or that the two disorders fall on a spectrum
of dissociative posttraumatic disorders where DID is the more
complexly symptomatic disorder (North et al., 1993). This
study tested a set of hypotheses that posited specific differences
between the obtained DID Rorschach protocols and published
normative Rorschach data for BPD and PTSD. These compari-
sons should be interpreted cautiously: The published norms are
based on protocols collected under different circumstances from
those of this study. Nevertheless, these comparisons may provide
rough estimates of some differences between these clinical
groups. All three of the hypotheses concerning differences be-
tween the DID and normative BPD data were supported and
were large effects. Two of the three hypotheses concerning dif-
ferences between the DID and the normative PTSD data were
supported, and both were large effects. The results support the
assumption that DID is at least partially distinguishable from
BPD and PTSD on the basis of the Rorschach protocol, and
that DID may thus constitute a relatively distinct diagnostic
entity. In comparison with both the BPD and PTSD samples,
the DID group manifested a much more imaginatively based
and cognitively complex response style. These findings suggest
that whereas DID patients may tend to defensively elaborate on
and imaginatively alter their internal and external experience,
BPD and PTSD patients may tend to simplify and minimize
their engagement with such experience, instead adopting a more
action-oriented approach. Although these findings suggest that
genuine differences exist between DID and these other clinical
groups, direct comparisons with samples of DID, BPD, and
PTSD participants is necessary to more definitively determine
the differences and similarities among these diagnostic entities.
282 SCROPPO, DROB, WEINBERGER, AND EAGLE
DID and latrogenesis
Our findings indicate that DID patients exhibit fairly consis-
tent features over a relatively wide range of domains. Further-
more, the chronic and relatively severe history of psychological
impairment found among our DID sample participants argues
against an entirely iatrogenic etiology, especially given that indi-
viduals ultimately diagnosed with DID exhibit significant, often
severe, psychological impairment several years before DID diag-
nosis (e.g., Putnam, Guroff, Silberman, Barban, & Post, 1986).
Nevertheless, it is conceivable that whereas some common set
of characteristics and experiences may predispose a group of
individuals toward dissociative symptoms, the stereotypic final
manifestation of the disorder (e.g., fully elaborated and distinct
alter personalities) may be shaped through external forces. Inas-
much as DID patients exhibit increased imaginative activity and
a propensity for altered states of consciousness, they may be
particularly vulnerable to the implicit demands of particular
therapists, self-report assessment procedures, or even media ac-
counts. Yet, whereas some of our findings are in accord with
widely held notions about DID, others are not (e.g., increased
absorption, increased substance abuse and suicidality), indicat-
ing that DID patients share more than just the surface features
of the disorder. Furthermore, it is not easy to imagine partici-
pants being iatrogenically or otherwise externally influenced to
produce Rorschach responses that are consistent, both in content
and in style (e.g., form quality, dimensionality, complexity),
with extant dissociation theory. Our findings generally indicate
that DID participants do exhibit a distinct set of psychological
characteristics at both a surface and depth level. Whether these
characteristics are entirely responsible for the unique character
of the disorder, or whether they merely constitute a necessary
(but not sufficient) substrate, is a question that is beyond the
scope of this study. Future research might profitably focus on
identifying individuals who exhibit high levels of dissociation,
fragmentation, and childhood trauma, but who have not been
diagnosed with, nor consider themselves to have, DID. Such
individuals may represent "pure types" who can be usefully
compared with those already diagnosed with the disorder.
Conclusions
The DID participants reported a common set of clinical fea-
tures that distinguished them from nondissociative psychiatric
patients. The DID participants also exhibited a distinctive and
theoretically consistent set of perceptual and cognitive character-
istics on the Rorschach test that at least partially differentiated
them from both a nondissociative psychiatric control group and
from the published norms for two closely related clinical groups
(BPD and PTSD). Although DID is a controversial diagnosis,
there is reason to believe that genuine, distinctive, and theoreti-
cally consonant psychological processes underlie this disorder.
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Received October 9, 1996
Revision received July 9, 1997
Accepted November 15, 1997 •
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