Dissociative Identity Disorder
Dissociative Identity Disorder: Medicolegal Challenges
Helen M. Farrell, MD
Persons with dissociative identity disorder (DID) often present in the criminal justice system rather than the mental health system and perplex experts in both professions. DID is a controversial diagnosis with important medicolegal implications. Defendants have claimed that they committed serious crimes, including rape or murder, while they were in a dissociated state. Asserting that their alter personality committed the bad act, defendants have pleaded not guilty by reason of insanity (NGRI). In such instances, forensic experts are asked to assess the defendant for DID and provide testimony in court. Debate continues over whether DID truly exists, whether expert testimony should be allowed into evidence, and whether it should exculpate defendants for their criminal acts. This article reviews historical and theoretical perspectives on DID, presents cases that illustrate the legal implications and controversies of raising an insanity defense based on multiple personalities, and examines the role of forensic experts asked to comment on DID with the goal of assisting clinicians in the medicolegal assessment of DID in relation to crimes.
J Am Acad Psychiatry Law 39:402– 6, 2011
Dissociation is a general term that refers to the sepa- ration of any normally integrated psychological pro- cesses, encompassing both dissociative amnesia and the dissociative state. The first case of multiple per- sonality disorder, now known as dissociative identity disorder (DID), was described by Paracelsus in 1646.1 After a steady rise in DID symptom reports during the 19th century, interest in DID waned in the early 20th Century because of a variety of factors, including the death of Jean-Martin Charcot, reports of patients faking DID, and affairs between patients and therapists. According to Index Medicus, between 1903 and 1978 there was a decline in dissociative reports and a rise in Eugene Bleuler’s newly identi- fied disorder, schizophrenia.2
Media attention and popular culture later resur- rected interest in dissociative symptoms. For exam- ple, Mary Shelley’s Frankenstein and Robert Louis Stevenson’s Strange Case of Dr. Jekyll and Mr. Hyde, intriguingly illustrated individuals with multiple per- sonalities. Movies such as Sybil and The Three Faces of Eve also resurrected popular interest in the phenom- enon.3 In the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III),4 disso-
ciative disorders were labeled as Axis I. Controversy, however, spiked with media attention.5 The reliabil- ity of the DID diagnosis, the lack of childhood cases, and consistent evidence of blatant iatrogenesis in the practice of DID proponents have called the diagnosis into question.6
Causes and Pathology
Today, it is generally agreed that a required ante- cedent of dissociation is a traumatic event.7 Theoret- ically, harm by a trusted caregiver forces one to split off awareness and memory of the trauma to survive the relationship. These memories and feelings recede into the subconscious and emerge later in the form of a separate personality. This process happens repeat- edly at different times, so that different personalities develop, containing different memories and per- forming different functions that are helpful or de- structive. Later, dissociation becomes a coping mech- anism for individuals when faced with further stressful situations.8
Constitutional predisposition for development of a dissociative disorder includes personality traits, such as being easily hypnotized, mental absorption, suggestibility, and a tendency to fantasize.9 Co-mor- bidities with dissociation include posttraumatic stress, borderline personality, somatoform, and eat- ing and substance-abuse disorders.10
Dr. Farrell is an Instructor, Harvard Medical School, and Staff Psychi- atrist, Beth Israel Deaconess Medical Center, Boston, MA. Address correspondence to: Helen M. Farrell, MD, 173 Commonwealth Ave- nue, #5R, Boston MA 01116. E-mail: hfarrell@bidmc.harvard.edu.
Disclosures of financial or other potential conflicts of interest: None.
402 The Journal of the American Academy of Psychiatry and the Law
A N A L Y S I S A N D C O M M E N T A R Y
DID may also result from co-morbid mental ill- ness or other medical conditions, including complex partial seizures. While it is beyond the scope of this article to provide an in-depth review of neuropsycho- logical and neuroanatomical studies of personality and memory, advances in neuroimaging techniques serve to remind us that much remains to be learned in the area of neurobiology.9
Dissociative pathology, despite the renaming of multiple personality disorder (MPD) to DID, re- mains an Axis I disorder in the DSM-IV-TR.11 Al- though the American Psychiatric Association Work Group has proposed new diagnostic criteria for DSM-5, scheduled to be published in May 2013,12
its current criteria are listed in Table 1. The purpose of the DSM-IV-TR is to provide clear descriptions of diagnostic categories to enable clinicians and investi- gators to diagnose, communicate about, study, and treat people with various mental disorders.13
NGRI and DID
Utilization of the DSM, however, becomes chal- lenging in legal situations. The DSM influences, but does not control, the definition of mental disorder in the test of criminal responsibility.14 Ultimately, the judge or jury decides whether the accused has proven that he suffered from a mental disorder that meets the statutory requirement(s), often including inabil- ity to appreciate the nature and quality of the action in question.15
In cases of NGRI with multiple personalities, the astute defense attorney will utilize one of three legal approaches.16 The alter-in-control approach, which is the prevailing defense, considers the key question to be what alter (personality) was in control at the time of the offense and whether the alter meets the insanity standard. The each-alter approach considers whether each personality meets the insanity stan- dard. Finally, the host-alter approach considers the key issue to be whether the dominant or primary personality meets the insanity standard.
The dissociative state has emerged as an impor- tant consideration in numerous legal cases.17 Legal and mental health commentators are divided about whether dissociative disorder warrants an acquittal for insanity. Complexities arise when ev- idence of a dissociative state or dissociative amne- sia is offered in court. One such complexity con- cerns how each phenomenon relates to personal control over behavior. Arguments have been made for excusing those with DID from responsibility. Some experts believe that a person with DID is a single person in the grip of a very serious mental disorder and that such a person is unable to fulfill the ordinary conditions of responsible agency (au- tonomy and self-control).18
In support of DID’s being exculpatory, an argu- ment can be made that since courts have acquitted defendants who show evidence of automatism, a dis- sociative state,19 –21 the same should be the case for DID. The Canadian case R v. Stone,22 conversely, held that exculpation hinges on whether criminal behavior is involuntary, regardless of the state of consciousness.23
The recognition of MPD as a mental illness that would excuse criminal responsibility did not occur until Billy Milligan was declared insane in 1978 (State v. Milligan).24 In that case, the argument for application of the insanity defense to the case of DID was that the defendant did not have an integrated personality. Rather, coexisting within the same indi- vidual were both criminally responsible and nonre- sponsible personalities. Public outrage was extraordi- nary, given that this serial rapist was not held culpable, and afterward, most DID defenses did not hold up, as shown in Table 2. For example, when Nathan Darnall25 was charged with murder, he pleaded insanity due to multiple personalities. The court found that he was most likely malingering his alters, and even if alters did exist, having alter person- alities was not a mental disease that would preclude having responsibility for the murder.
Table 1 DSM-IV-TR DID Criteria11
The presence of two or more distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self.
At least two of these identities or personality states must recurrently take control of the person’s behavior. Patients have an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. The disturbance must not be due to the direct physiological effects of a substance . . . or a general medical condition.
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The defense used in State v. Grimsley26 was insan- ity due to multiple personalities. The court ruled that it was immaterial what state of consciousness or per- sonality the defendant was in as long as the person- ality controlling the behavior was conscious and aware of his actions. The defense in Kirkland v. State27 also asserted an insanity defense based on a psychogenic fugue. The court found that the law adjudges criminal liability of the person according to the person’s state of mind at the time of the act, and the law will not inquire whether the individual pos- sesses other personalities, fugues, or even moods in which he would not have performed the act. State v. Jones28 found William Jones guilty of murdering a woman he met at a bar, despite expert testimony that his multiple personalities “paralyzed” him and hin- dered from knowing right from wrong.
More recently, courts have rejected the admissibil- ity of DID evidence, including expert testimony, be- cause the scientific evidence fails to meet reliability standards and therefore is not ultimately useful to the judge or jury. In State v. Greene,29 the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Wash- ington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.
Similarly, in State v. Lockhart,30 Mr. Lockhart contested his conviction of first-degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The
West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards of evidence.
DID and the Forensic Expert
Admission of expert testimony into court regard- ing DID is an ongoing debate that involves forensic psychiatrists.31 While some courts have allowed tes- timony on dissociative disorders, others have denied the validity of dissociations or acknowledged the lack of scientific information available on the diagnosis. Evidence of dissociation in accused persons during acts of severe violence is highly problematic because of the legal significance of dissociative symptoms.32
When a report of dissociation emerges in a crimi- nal case, the stakes are high. A major consideration is the possibility of malingering alter personalities to evade responsibility. If malingered symptoms were mistakenly viewed as valid evidence of a dissociative state (a false-positive error), the court could unjustly adjudicate the defendant NGRI.
The accurate determination of the credibility of symptoms in defendants is difficult because the pri- mary source of information is self-report.33 There are motivations for malingered alters in criminal offend- ers. Feigned symptoms may serve to support a legal defense of NGRI to elicit sympathy, to raise doubt about the person’s involvement in the crime, or to avoid using the much more risky and cognitively taxing approach of explicit deception.34 A motiva-
Table 2 Using Dissociative Identity Disorder* as a Basis for Not Guilty by Reason of Insanity
Case Year Charge Defense Court Ruling
State v. Milligan 24 1978 Rape NGRI-MPD Lack of an integrated personality meant the defendant was not culpable
State v. Darnall 25 1980 Murder NGRI-MPD Multiple personalities do not preclude criminal responsibility
State v. Grimsley 26 1982 Drunken driving NGRI-MPD; primary personality had no control over the “alter”
State of consciousness or personality of defendant is immaterial
Kirkland v. State 27 1983 Bank robbery NGRI-psychogenic fugue Law does not inquire about other personalities, fugue states, or moods in cases of criminal liability
State v. Jones 28 1988 Murder NGRI-MPD Alter personalities will not be an excuse for inability to distinguish right from wrong
State v. Greene 29 1998 Murder NGRI - DID; primary personality was “unconscious”
Evidence of DID, including expert testimony, was not admissible because it did not meet reliability standards
State v. Lockhart 30 2000 Sexual assault NGRI-DID DID was not allowed into evidence by the West Virginia Court due to lack of scientific evidence
* Dissociative identity disorder formerly was referred to as multiple personality disorder.
Dissociative Identity Disorder
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tion to malinger in psychopathic offenders may sim- ply be pathological lying or even “duping delight.”35
In a medicolegal context, forensic experts who are asked to evaluate such a claim, should conduct a thorough investigation using multiple hypotheses and techniques.36 While DSM-IV-TR criteria are a useful tool, all relevant information, including clini- cal history and assessment, collateral information, and past and present behavior should be considered in a primary diagnosis. Experts must be suspicious of malingered alter personalities that manifest as exag- gerated details of alter states.37
Historically, specific techniques used to evaluate a report of DID have included polygraph and symp- tom suggestion. The polygraph depends on the as- sumption that a person will show an emotional or physiological response when being deceptive, reflect- ing a fear of detection or guilt about lying.38 How- ever, the polygraph is prone to false-positive errors and can also be fooled by means of countermeasures such as drugs or mental imagery.39
Experts now must use a multidisciplinary and multitechnique approach. An evaluation of the indi- vidual’s verbal and nonverbal behaviors that could indicate malingering should be undertaken during interviews regarding the event in question. Self-re- port questionnaires such as the Structured Inventory of Malingered Symptomatology40 can be used to evaluate the tendency to exaggerate memory com- plaints (indicative of malingering). The Dissociative Experiences Scale41 can be employed as a screening instrument for dissociative symptoms, and struc- tured interviews such as the Dissociative Disorders Interview Schedule42 can be used to assess whether the individual has a dissociative disorder.
It is important to recognize that converging evi- dence indicates that dissociative amnesia in defen- dants is authentic in some cases, despite the general skepticism from legal decision makers. Further, it can be concluded that dissociation is malingered in some cases, causing a significant challenge in medi- colegal contexts.
Conclusions
DID and the insanity defenses are controversial, with clinical and legal implications. Truly experienc- ing a dissociative state could decrease an individual’s capacity to control his actions and therefore diminish criminal responsibility. Defendants who claim DID, nevertheless, are usually regarded as having limited
credibility because of the inherent possibility of ma- lingering. Undoubtedly, some feign alter personali- ties in an attempt to evade punishment. However, genuine dissociation is seen in clinical practice, and remains an Axis I disorder.
When a defendant claims that an alter personality committed the crime, the court can have consider- able difficulty in formulating a decision. Wrongful decisions regarding the authenticity of an individu- al’s state at the time of the offense can be very costly, with the outcome that lighter or harsher sentences are given than is just.
In accepting evidence supporting the validity of claims of alter personalities, it seems clear that the important concern should be determining how to distinguish between genuine dissociation and malin- gering. Also, there should be validity testing and a better consensus on what is admissible in court testi- mony. The ultimate issue of DID as exculpatory for a criminal act remains a decision for the court.
As it stands, the forensic assessment of individuals who claim they should be acquitted by reason of insanity for crimes based on a dissociated state rep- resents a most interesting challenge. A review of the literature and previous cases indicates that even when testimony is admissible and points to an individual’s having distinct personalities that control his behav- ior, an insanity defense rarely has been successful.
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