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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 scroppo@panther.adelphi.edu.

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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