Application of Clinical Psychology

56 Chapter 4 The Dissociative and Sleep Disorders

The most common diagnoses initially given are major depression and schizophrenia. Most multiples are identified as such only after some extended contact with mental health specialists who eventually observe one or more of the alternates in vivo.

A history of having suffered amnesia or other dissociative experiences or borderline personality disorder pattern is mildly predictive of a future multiple personality disorder (Chu, Frey, Ganzel, & Matthews, 1999), as is a history of physical or sexual abuse (especially repeated traumatic incest). In a 2010 study, Ross and Ness suggested that the symptom patterns in dissociative identity disorder likely represent a normal human response to severe, chronic childhood trauma. Stress and/or significant personal loss is an important precipitating factor, as are difficult developmental or social transition points. New personalities are usually a crystallization into a personality of opposite facets from the original one.

Anna 0. is critical to the development of psychoanalytic theory and then the later psychodynamic therapies; indeed, she is considered the first patient of psychoanalysis. Specifically, she is the first patient with whom the cathartic method was employed. In light of the evolution of modern diagnostic concepts, it is increasingly evident that Anna 0. suffered from MPD, in addition to or instead of the traditional diagnosis of Anna as "hysteric" (Weissberg, 1993).

Also, although many professionals believe Anna 0. was a patient of Freud's, he never saw her. Rather, she was a patient, for about 18 months between November 1880 and June 1882, of Josef Breuer, Freud's early mentor and collaborator. Breuer and Freud both viewed Anna 0. as a classic case of hysteria. However, Weissberg (1993) has argued persuasively that although there are hysteric components, Anna 0. is most accurately seen as a multiple personality, with the possibility that the MPD was at least in part induced by Breuer's treatment. Some difficulties in assessing this case stem from the fact that Breuer did not write up the case until 10 years after he had terminated treatment with her.

CASE STUDY

THE CASE OF ANNA 0.

Anna (actually Bertha Pappenheim), an unmarried 21-year-old woman from a prominent Jewish family in Vienna, first consulted with Breuer at the end of November 1880 with the initial complaint of a persistent cough. Breuer used hypnosis to elicit memories to reconstruct the events that led up to referral. This included Anna's reaction to childhood and, more recently, to her distress around caring for her father while his health gradually failed. In July 1880, he developed a pleuritic abscess, probably caused by tuberculosis—the possible cause of Anna's symptoms as well.

As is often the case with seriously disordered individuals, any success and/or acceptance of the initial complaint allows elaboration into numerous

allied symptoms—in Anna's case, vision and hearing problems, neck weakness, headaches, and anesthesia of her right arm and leg. She then became mute for two weeks, and soon thereafter revealed two distinct personalities that apparently switched back and forth without warning. Anna's first, or usual, personality was a bit melancholy, in part because, as is common with MPDs, she experienced gaps in consciousness, mood swings, and even possible hallucinations. As is also often the case with MPDs, the second personality has a more antisocial quality, what Anna termed "naughty." It was also often abusive toward others, and occasionally generated odd, rebellious behaviors, such as tearing buttons off of bedclothes.

Case Studies in Abnormal Behavior, Ninth Edition, by Robert G. Meyer and Christopher M. Weaver. Published by Pearson. Copyright © 2013 by Pearson Education, Inc.

Chapter 4 The Dissociative and Sleep Disorders 57

After Anna's father's death on April 5, 1881, she (1) stopped recognizing anyone except Breuer, (2) would communicate only in English (her sec­ond language), and (3) would eat only if fed by Breuer. As is evident, this first Freudian was hardly orthodox in his therapeutic technique. Each and every day, Anna would become somnolent in the afternoon (probably autohypnotically), and after sunset, Breuer would formally hypnotize her or she would do the autohypnosis, and would then recount her hallucinations/dreams of that day and then awaken "calm and cheerful."

Yet, Anna's condition worsened, and she became suicidal. On June 7, 1881, she was moved to a house outside Vienna, where she could be monitored more closely. Breuer now visited her most days, occasionally resorting to pleading to get her to talk. She would sometimes talk only after thoroughly feeling Breuer's hand to make sure it was him, asserting she could not recognize him visually. Though her symptoms had at first worsened, they now calmed somewhat—Anna attributed this to the "talking cure" of reliving her memories under hypnosis—and Anna moved back to Vienna.

However, Anna's personalities again changed more dramatically, and Breuer could now elicit a personality shift by showing her oranges (the only food she would eat during the first part of her illness). It was in this period that after avoiding water for six weeks, Anna, while hypnotized, recalled her disgust when she saw a dog drink from a water glass. When she awoke from the hypnosis, her hydrophobia disappeared. Breuer now had the insight to recognize this as catharsis, a basic principle of psychoanalytic technique, and systematically used it on her many other symptoms. Most disappeared, and in the process Breuer discovered they had all started the summer her father fell ill. Breuer and Freud later theorized that Anna's feelings about this had been "strangulated" (later termed "repressed"), only to come out later in her various symptoms, and then relieved by "insight" as well

as "working through" by analyzing dreams and talking into "abreaction," and eventual catharsis, bringing a cure.

Though many of these symptoms cleared, Anna's alter personality appeared again in the spring of 1881, something Breuer called a "disagreeable event." Breuer last saw her in June 1882 and stated that she now enjoyed "complete health." But, possibly reflecting his Victorian ethics, or his pride, or his reported panic, or all three, he neglected to note that in their last session, Anna had told him she was pregnant with his baby. After calming her down by inducing a hypnotic trance, Breuer arranged for his own immediate departure to Venice with his wife for a second honeymoon. Anna was not pregnant. Freud later used his belief that Breuer had misunderstood Anna's sexual attraction to Breuer to develop his concepts of transference and countertransference.

She "was institutionalized for a year following her therapy with Breuer" (Larson, Graham, & Baker, 2007). Documents were later obtained from Anna's file at the Bellevue Sanatorium in Kreutizlingen, where she had been hospitalized in July 1882 for morphine addiction, indicating periodic inability to speak German (her first language), absences of consciousness, and feelings of "time missing." Anna also showed two separate personality states at least five years after termination.

Consistent with the concept that abuse is often (though not always) found in the histories of those who later manifest MPD, there were indications that Anna had been sexually abused, and that she was certainly emotionally abused by her mother. As an adult, she showed a consistent preoccupation with as well as active efforts in her social work career against Jewish men who abused women. Some believe that Anna was also generally emotionally abused, in that her needs to be independent were stifled by her father, by the family's Orthodox Jewish practices, by her mother and brother who eventually excluded her even from the care of her dying father, and

(Continued)

Case Studies in Abnormal Behavior, Ninth Edition, by Robert G. Meyer and Christopher M. Weaver. Published by Pearson. Copyright @ 2013 by Pearson Education, Inc.

58 Chapter 4 The Dissociative and Sleep Disorders

(Continued)

by society's repressive reaction at that time toward bright and intellectually curious women. Ironically, Anna maintained a lifelong disdain for psychoanalysis, and the Nazis later used Anna's journalistic expose of wealthy Jewish slave traders as anti-Jewish propaganda.

However, Anna did eventually recover and overcome her addiction. In 1895, she became the director of a Jewish orphanage in Frankfurt, Germany. She went "on to a successful career as Germany's first social worker, an author of

short stories, a playwright, and a champion of women's rights" (Larson et al., 2007, p. 274). In 1904, she founded a League of Jewish Women, the first organization of its kind. And in 1907, she began a home for unwed mothers. Committed to the causes of women and children, she can be considered an early feminist. She wrote, "If there is any justice in the next life, women will make the laws and men will bear the children!" In 1954, the West German government issued a commemorative postage stamp in her honor.

MPD Controversies

Most experts believe there are true MPDs, with these qualifications (Dell & O'Neil, 2008; Spanos, 1996; Thigpen & Cleckley, 1984; Weissberg, 1993):

· Although a few therapists seem to come up with many "multiples" in their practice, most therapists seldom see such cases.

· Not only have there been significantly more reports of cases of MPD, but also in recent decades, MPDs report a significantly greater number of secondary personalities, or "alters."

· The diagnosis of MPD is to some degree culture bound, and the great bulk of cases have been observed in the United States.

· The diagnosis has another possible culture-bound bias in that the vast majority of MPD cases are female.

· In the majority of cases, the diagnosis of MPD emerges only after a period of therapy, usually employing hypnosis (and often self-hypnosis) and with a therapist who is sympathetic to (if not an active advocate for) the idea of multiples.

· Many proponents of MPD argue that separate "alters" (or personalities) may influence the MPD's general behavior without actually emerging or being observable to others, thus making any kind of independent corroboration impossible. If so, the concept of MPD must be placed in the realm of philosophy or religion rather than of science.

· As in the case of Anna 0., the great majority of information derives from anecdotal testimony and case reports, and remains unverified by scientific methods. However, much of this information is repeated often enough to take on the veneer of truth.

· Some of the supposed scientific findings about MPD that are commonly repeated by believers are spurious. For example, advocates consistently assert that different personalities show different physiological patterns (e.g., in EEG patterns and in psychological test response patterns). However, normals can show similar differences when they are in different emotional states, and persons who attempt to simulate different personalities show EEG differences similar to those found in different MPD personalities. Also, some scientific findings—for example, that many MPDs report a history of childhood abuse—are generalized to the point of becoming inaccurate (e.g., "many" becomes "most" or even "virtually all"; or a history of abuse becomes specified as a history of sexual abuse).

Case Studies in Abnormal Behavior, Ninth Edition, by Robert G. Meyer and Christopher M. Weaver. Published by Pearson. Copyright CD 2013 by Pearson Education, Inc.