OSIRIS Complex, The

The author presents various case histories of multiple personality disorder. The purpose of this book is to provide understanding of the relationship between childhood trauma and serious mental illness.

TABLE OF CONTENTS

I. CASE HISTORIES OF MULTIPLE PERSONALITY DISORDER

1. The Case of Jenny Z
2. An Abused, Agoraphobic Housewife
3. The Woman Who Didn't Come Back
4. A Case of Polyfragmented MPD
5. A Psychic Helper
6. A Woman With Unusual Spells
7. A Woman in a Man's Body
8. Talking With A Dead Grandmother
9. A Chemical Dependency Problem
10. A Woman Who Decided Not To Remember
11. Request For a Sex Change
12. The Evil One
13. Checking With the Expert
14. Flash and the Destroyer
15. Electroshock Treatments
16. Temporal Lobe Epilepsy and Schizophrenia
17. A Little Girl Inside
18. A Foster Child
19. Anne Sexton

II. CASE HISTORIES RELATED TO MULTIPLE PERSONALITY DISORDER

20. A Man Who Wandered
21. A Bump on the Head
22. Something Out of the Exorcist
23. Indecent Exposure
24. Voyage to Didyma
25. The Stranger Within
26. Obsessions and Compulsions

  Introduction

I diagnosed my first case of multiple personality disorder (MPD) as a third year medical student in 1979. Over the fourteen years since then, my patients have been my greatest teachers: they have been creative, open, and honest, and their conversation has been real and intelligent. Day in and day out in my professional life since 1985, the year I started working intensively with MPD as a psychiatrist, I have had the privilege of participating in serious conversations about identity and the nature of the human mind. Many of the people I have conversed with have not been well educated, but they have had much to teach me, because they have a deep experience and understanding of life.

What is multiple personality disorder? As I say in my book Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment (Ross 1989), multiple personality disorder is a little girl imagining that the abuse is happening to someone else. The imaging is so intense and subjectively compelling, and is reinforced so many times by the ongoing trauma, that the created identities seem to take on a life of their own, though they are all parts of one person.

Two basic psychological manoueuvres form the foundation of multiple personality disorder. First, the little girl who is repeatedly sexually abused has an out-of-body experience: detached from her body and what is going on, she may float up to the ceiling and imagine that she is watching another little girl being abused. Since that unfortunate little girl on the bed below may have a different name and a different physical appearance, the abuse is not so terrifying and overwhelming because it is happening to someone else, and the child is buffered from the direct impact of the trauma. Second, an amnesia barrier is erected between the original child and the newly created identity. Now not only is the abuse not happening to the original little girl, she doesn't even remember it: this process is reinforced over and over as the abuse continues. Various identities may be created to deal with different aspects of the trauma, resulting in an eventual total of ten, twenty, or more alter personalities. Once the mind is in the habit of creating new identities in this way, alter personalities may be generated to cope with many non-trauma events, tasks, or functions in life, including going to school and dealing with peers.

Adult patients with MPD experience a number of core symptoms that should be enquired about in psychiatric assessments. These include voices in the head and ongoing blank spells or periods of missing time. The voices are the different personalities talking to each other, and to the main, presenting part of the person who first comes for treatment. The periods of missing time occur when different personalities take turns being in control of the body, and are attributable to the memory barriers between the personalities.

MPD patients also experience numerous other symptoms such as those associated with depression, anxiety, eating disorders, substance abuse, sleep disorders, sexual dysfunctions, and psychosomatic disorders, and symptoms that mimic those of schizophrenia. The assessment and treatment of multiple personality disorder must take this large array of trauma-related symptoms and problems into account. The complexity of the patients' symptoms often results in misdiagnosis and the institution of treatments that are not effective. In fact, in two different published research studies, MPD patients were found to spend an average of just under seven years in the mental health system before being correctly diagnosed (Putnam 1989; Ross 1989). During this time, they received many different diagnoses and treatments, none of which took the trauma into account.

Although MPD patients are, by definition, diagnosed as having more than one personality, they in fact don't. The different 'personalities' are fragmented components of a single personality that are abnormally personified, dissociated from each other, and amnesic for each other. We call these fragmented components 'personalities' by historical convention: much of the scepticism about MPD is based on the erroneous assumption that such patients have more than one personality, which is, in fact, impossible.

In order to correct misconceptions arising from use of the term 'personality' in this context, the official name of the disorder has been changed to Dissociative Identity Disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1993), which is the official diagnostic manual of psychiatry in North America. The term 'Multiple Personality Disorder' will be retained, in brackets, in DSM-IV, and thus may still be used diagnostically.

I decided not to cite references within the case-studies in this book in order not to detract from their immediacy, but will give a brief description of the literature on dissociation here. The literature on dissociative disorders is still relatively small and can be entered quite easily; however, it is growing at a rate that now makes it impossible for any one clinician to read everything that is being published. That was not so five years ago, when it was still possible to read pretty well everything published about MPD in the mental-health literature.

Carole Goettman, George Greaves, and Philip Coons have produced a comprehensive bibliography of the MPD literature, entitled Multiple Personality and Dissociation, 1791-1990: A Complete Bibliography. It is available for purchase in updated versions from George Greaves, Ph.D., at 529 Pharr Road, Atlanta, Georgia, 30305. Two other entries into the literature are Frank Putnam's Diagnosis and Treatment of Multiple Personality Disorder (1989), and my Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment (1989). Both include extensive bibliographies and literature reviews, indentifying the key references in the field up until the late 1980s.

The journal Dissociation, published quarterly since its founding in 1988, is edited by Richard Kluft, and is available from the Ridgeview Institute, 3995 South Cobb Drive, Smyrna, Georgia, 30080. The articles and references in this journal will keep the reader current with the dissociative-disorders literature. Other essential reading is the September 1991 special issue of Psychiatric Clinics of North America on MPD, edited by Richard Loewenstein and published by W.B. Saunders Company, The Curtis Center, Independence Square West, Philadelphia, Pennsylvania, 19106.

I highly recommend Multiple Personality Disorder From the Inside Out, edited by Barry Cohen, Esther Miller, and Lynne W. This collection of anonymous poems and writings by people with MPD is published by the Sidran Press, 211 Southway, Baltimore, Maryland, 21218. Besides the wonderful material from the contributors, it contains lists of resources, support networks newsletters, and suggested readings.

The professional society for study of MPD, of which I was the 1993-4 president, is the International Society for the Study of Multiple Personality and Dissociation, which is based at 5700 Old Orchard Road, First Floor, Skokie, Illinois, 60077. Besides conducting an annual meeting, the society publishes a newsletter and a membership directory, and has component societies and study groups throughout North America.

These sources of information are sufficient to lead the interested reader into both the professional and lay literatures on MPD. Research papers of mine published since 1989 can be found in the May 1990, November 1990, and December 1991 issues of The American Journal of Psychiatry. Other psychiatric journals to which I have contributed and which could be scanned for recent MPD publications include Hospital and Community Psychiatry, General Hospital Psychiatry, The Journal of Nervous and Mental Disease, The American Journal of Clinical Hypnosis, The International Journal of Clinical and Experimental Hypnosis, Comprehensive Psychiatry, The American Journal of Psychotherapy, and Psychiatry.

Over the last ten years, the MPD literature has evolved from prescientific to scientific status, although this transition isn't yet fully appreciated by the majority of mental health professionals. The quality of the data supporting the reliability and validity of the diagnosis is as good as for any other psychiatric disorder, though the quantity of literature is still relatively small.

Most of the quantitative research on MPD has been conducted using the Dissociative Experiences Scale (DES), the Dissociative Disorders Interview Schedule (DDIS), and the Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D). Data on and discussion of these three measures can be found in several 1991 issues and the January 1992 issue of the American Journal of Psychiatry; the relevant references are cited in those papers. The DES is a self-report measure of dissociation developed as a screening tool for dissociative disorders. It consists of 28 items, can be completed and scored in 15 minutes, and yields an overall score ranging from 0 to 100. The factor structure of the DES has been replicated in a number of studies, large-N general population norms are available, and the ability of group median scores on the DES to differentiate MPD from other diagnostic groups has been replicated. Using a computer algorithm based on weighted item scores, the DES can predict with a high rate of sensitivity and specificity who in a large pool of clinically heterogeneous psychiatric patients has a clinical diagnosis of MPD. The performance of the DES in this regard is as good as that of any other self-report measure used to screen for any other disorder, and it has been translated into many different languages. Among the several other self -report measures of dissociation, particularly promising is a scale developed in Europe by Vanderlinden. This scale has been translated into English, and studies using it in North America are underway. State-of-the-art discussion of the self-report measurement of dissociation now deals with subtle questions about variations in the factor structure of the DES in different populations, correlations of DES factors with other measures, and similar concerns. Whether the DES is reliable and valid as a screening tool for MPD is no longer a research question, but an established fact.

The DDIS and SCID-D are structured interviews developed for making dissociative-disorder diagnoses in both research and clinical settings. Both have established validity and reliability, but further studies with larger numbers of subjects are required in order to irrefutably establish their diagnostic validity in terms of MPD. Research projects are underway in which the interrater agreement of these two methods of diagnosing MPD is being determined, and I expect that the level of agreement between the two interviews will be as good as the structured-interview reliability for any other psychiatric disorder. Both the DDIS and the SCID-D have been translated into a number of different languages.

MPD is the most important and interesting disorder in psychiatry, which is why I study it. I believe it to be the key diagnosis in an impending paradigm shift in psychiatry, because MPD best illustrates the characteristic response of the human organism to severe psychosocial trauma, and because trauma is a major cause of mental illness, from a public health point of view. Trauma, I believe, is a major underlying theme in much mental illness, including depression, eating disorders, personality disorders, substance abuse, psychosomatic illness, and all forms of self-abuse and violence. Biological psychiatry might obtain more clinically meaningful results if it focused on the psychobiology of trauma and abandoned the search for causality in genes and endogenous chemical derangements. Since MPD patients have experienced the most extreme childhood trauma of any diagnostic group, they exhibit the psychobiology and psychopathology of trauma to an extreme degree.

I believe that the traumatized subgroup of any given diagnostic category has a distinct phenomenology, response to psychotherapy and psychopharmacology, set of biological markers, pattern of family transmission, course, and prognosis. Until the confounding effects of trauma are taken into account and properly controlled for, it may not be possible to detect a gene for depression because the etiological influence of trauma is likely to swamp out any genetic effect, or any pedigrees in which a genetic cause is predominant. MPD patients have taught me that virtually all symptoms in psychiatry are potentially trauma-driven and dissociative in nature. The purpose of this book, then, is not simply to present interesting stories or provide a window into current goings-on in the dissociative-disorders field. It is to help foster an understanding of the relationship between childhood trauma and serious mental illness. The MPD literature is heading inevitably in the direction of a general trauma model of psychopathology. The model will produce a paradigm shift out of the two dominant schools of thought of twentieth century psychiatry, the psychoanalytical and the biomedical-reductionist: the case-studies in The Osiris Complex illustrate the clinical roots of this paradigm transformation.

In the pages of this book, I can portray only a shadow of the intense reality of MPD therapy. I have disguised the identities of all the patients except Anne Sexton: all the information about her is a matter of public record, and is contained in the biography by Diane Wood Middlebrook (1991). Some of the patients are Canadian, and some are people I have met since moving to Texas.

Each chapter has a specific purpose. Each case of MPD illustrates a different facet of the dissociative response to trauma; together they depict the range and variability of the disorder. The cases of psychogenic fugue and dissociative disorder not otherwise specified in Part II were also included because they illustrate the full range of dissociative disorders, of which MPD is the extreme, and because each case raises a problem about the nature of identity and memory, or defines an aspect of my work with the dissociative disorders. I have written this book primarily for a mental health audience, but it should be of interest to the general educated reader as well. At times I have explained certain details about medications or symptoms on the assumption that the reader is not a psychiatrist, and I have deliberately avoided professional jargon as much as possible.

Why have I chosen The Osiris Complex as the title of this book? I coined the term in my previous book, Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment. The Osiris complex designates what I believe is the most important motif in psychopathology: the fragmentation of the self in response to external trauma. In the Isis-Osiris myth from ancient Egypt, Osiris is murdered by his jealous brother Set, who cuts him into pieces and scatters them far and wide. Isis then gathers her brother Osiris's fragments together, reintegrates them, and resurrects Osiris in a new form: this healing of the traumatized self is my task as a therapist. Fathered by Ra, Isis and Osiris were siblings who married and begot a son Horus, who in turn defeated his uncle Set in battle. The idea communicated by the phrase 'the Osiris complex' is that incest and other psychosocial trauma are at the root of much psychopathology, and can be a direct and overwhelming cause of serious mental illness.

Institutional, social, and economic barriers stand in the way of traumatized children and their recovery, in our society and throughout the world. Like many forms of inflammation, MPD is a normal human response to trauma that has become self destructive. MPD is an autoimmune disorder in which the psyche has become confused about the distinction between self and non-self, and has learned to turn its destructive mechanisms on the self, mistaking it for a foreign invader. Fortunately, over the last thirty years, a specific and effective method for treating this condition has been created through the joint effort of many clinicians.

To the people with dissociative disorders who have taught me, I dedicate this book.

Reviews
From Rosemary Dinnage - The Times Literary Supplement
In the United States for some years there has been a growing movement--growing, but opposed by many-to reassert the importance of MPD (Multiple Personality Disorder) as a psychiatric diagnosis, in conjunction with the renewed awareness of child sexual abuse. . . . ]Ross is the] author of a text-book on MPD as well as a number of research papers. The Osiris Complex . . . is evidently the popularized spin-off from the text-book, a series of case-histories without index or references. . . . There is an interesting chapter on the American poet Anne Sexton.

From Booknews
Psychiatrist Ross believes that multiple personality disorder (MPD) is "the key diagnosis in an impending paradigm shift in psychiatry, because MPD best illustrates the characteristic response of the human organism to severe psychosocial trauma, and because trauma is a major cause of mental illness, from a public health point of view." This collection of case studies, then, is intended not only to present interesting stories or provide a window into the current dissociative- disorders field, but to help foster an understanding of the relationship between childhood trauma and serious mental illness. The only case identified by real name is that of poet Anne Sexton. Paper edition (unseen), $17.95. Annotation c. Book News, Inc., Portland, OR (booknews.com)

From Warren C. Johnson - Readings
The title of this volume of 26 case histories comes from the Ancient Egyptian myth in which Isis reassembles the parts of her murdered brother, Osiris,and revives him. The first case involves 7 personalities integrated by Ross,relieving the patient of depression, anxiety, dangerous self-destructive behavior, alcoholism, and prostitution--according to Ross, 20% of prostitutes suffer from multiple personality disorder (MPD). . . . Taking up the suicide of the poet Anne Sexton, Ross suggests that Sexton might have had a better treatment outcome if she had been treated for MPD. . . . The excellent case examples represent both successes and failures--a rare trait in the literature.