Treatment for Multiple Personality Disorder: At What Cost?

By Piper, August, Jr. | American Journal of Psychotherapy, Summer 1994 | Go to article overview

Treatment for Multiple Personality Disorder: At What Cost?


Piper, August, Jr., American Journal of Psychotherapy


AUGUST PIPER, Jr., M.D.*

* Attending Psychiatrist, Department of Psychiatry, Providence Medical Center, Seattle, WA. Mailing address: Cabrini Medical Tower, 901 Boren, Suite 701, Seattle, WA 98104.

INTRODUCTION

North America is in the grip of what has been described as an epidemic of multiple personality disorder (MPD).(1-3) By 1980, a total of just 200 cases had been accumulated in the entire world literature, and only eight had appeared between 1960 and 1970.(4) By 1986, however, Coons(5) estimated that in North America alone, 6,000 people had been given the diagnosis, while Ross(6) claimed that at least one per cent of the population of the United States and Canada was suffering from "dysfunctional MPD requiring specific psychotherapy."

In some parts of the United States, MPD appears to have become a psychiatric "growth industry"(7): numerous conferences and workshops on the disorder are held every year, and several hospitals market themselves at least partially on their ability to treat patients with MPD. Because costs of psychiatric care have recently risen twice as fast as those of general medical care,(8) it seemed reasonable to examine the economic aspects of the surge in patients diagnosed with MPD.

In a recent paper, Ross and Dua(9) assert that the financial burden on the mental health system is lightened if patients with MPD are diagnosed and treated correctly. They examined the psychiatric costs for fifteen patients before and after the diagnosis of MPD was made; projecting these into the future, they concluded that diagnosing and treating MPD resulted in significant savings. Their thesis: reaching an accurate diagnosis opens the door to psychotherapy that is both cost-effective and specific for MPD. The authors claim that this therapy effectively treats the disorder; the resulting improvement reduces the time patients spend in the mental health system, and thus, significant financial savings occur. In fact, the writers say that if their findings could be generalized to other MPD patients, "the psychotherapy of MPD would then be demonstrated to be the most cost-effective mental health intervention known." This paper examines the evidence supporting these assertions.

Six kinds of evidence show there can be little doubt that the MPD diagnosis invites ballooning mental health costs. First, numerous patients satisfy the nonspecific diagnostic criteria for MPD. Second, the condition is almost certainly overdiagnosed. Third, it is unclear that psychotherapy of MPD produces results in a reasonable time, because almost no outcome data have been published. Fourth, the writings of major exponents of the condition certainly do not suggest that it can be treated in a timely manner. Next, few clinicians are likely to duplicate the results claimed by the leading contributors to the MPD literature. Finally, my experience casts doubt on the idea that treatment of MPD is cost-effective. Each of these arguments is discussed in this paper.

NONSPECIFIC DIAGNOSTIC CRITERIA

The DSM-III lists these criteria for a diagnosis of MPD:

(A) The existence within the person of two or more distinct personalities, each of which is dominant at a particular time.

(B) The personality that is dominant at any particular time determines the individual's behavior.

(C) Each individual personality is complex and integrated with its own unique behavior patterns and social relationships.

The DSM-II-R criteria for MPD are:

(A) The existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

(B) At least two of the personalities or personality states recurrently take full control of the person's behavior.

It has been pointed out several times by others(7,10-12) and by me(13) that these criteria are vague, poorly elaborated, overinclusive, and excessively dependent on interpretation. …

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