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Letter to the Editor   |    
Dr. Coons and Dr. Chu Reply
PHILIP M. COONS , M.D.; JAMES CHU , M.D.
Am J Psychiatry 2000;157:1179-a-1180. doi:10.1176/appi.ajp.157.7.1179-a

In their report, Dr. Pope et al. revealed bias and unfamiliarity regarding the dissociative disorders. They implied a newly attained status of the disorders as of DSM-IV. However, the dissociative disorders have been nosological entities since DSM-II, with published reports extending back to 1791 (1). As DSM-IV work group advisors who considered these disorders, we can assure the authors that these disorders were thoroughly reviewed and discussed with four fellow members who are also on the scientific advisory board of the False Memory Syndrome Foundation.

The study by Dr. Pope et al. might be characterized as promoting an extremely polarized viewpoint, with examples of bias including the following:

  • The authors stated, "Only about one-third of respondents replied that dissociative amnesia and dissociative identity disorder should be included without reservations in DSM-IV…. Only about one-quarter of respondents felt that diagnoses of dissociative amnesia and dissociative identity disorder were supported by strong evidence of scientific validity" (p. 321). Using their own data, the authors could have said that only 9%–15% felt these diagnoses should not be included in DSM-IV and that only one-fifth felt that these diagnoses had little or no scientific validity.

  • No control questions about other dissociative disorder and other nondissociative disorder diagnoses were included in the questionnaire.

  • Four previous studies regarding belief in dissociative identity disorder were ignored (24, Hayes and Mitchell, 1994). Belief in dissociative identity disorder has increased to 80% (3).

  • The questionnaire respondent sample appeared biased toward older (55% were at least age 50), male (73%), biological psychiatrists. We would expect these psychiatrists to be biased because of a lack of recent training in dissociation.

  • This study promulgates the political and litigious viewpoint of the False Memory Syndrome Foundation. Two authors (Drs. Pope and Hudson) are on its scientific board. In the article’s extremely selective literature review, another two board members (F.H. Frankel and A. Piper) were cited. The False Memory Syndrome Foundation has lobbied against the diagnosis of dissociative identity disorder on the basis of unverified reports of a small number of retractors previously diagnosed with dissociative identity disorder. Although members of the False Memory Syndrome Foundation’s scientific advisory board label dissociative identity disorder a controversial diagnosis, they are in the minority. In the scientific literature criticizing dissociative identity disorder, nine past and present board members are responsible for the majority of the criticism, and four regularly write letters to the editor. None has published studies of patients with genuine dissociative disorders in a peer-reviewed journal.

  • The authors appeared to recognize their bias; otherwise, they would not have had a person unknown to the dissociative disorders field distribute their questionnaire.

  • The closure of "several major dissociative disorders treatment units" was cited as evidence of a controversy regarding dissociation. A few have closed because of litigation over therapeutic practices. However, the closure of other units was related to the diminishing rate of reimbursement for inpatient treatment and the rapid rise of managed care. Both general and specialized psychiatric treatment units have closed recently because of marketplace pressures. Presently, several major dissociative or trauma treatment units are flourishing—one at McLean Hospital—where all authors of this article have worked!

  • The authors are mistaken about "sharp shifts" in the diagnostic criteria for dissociative disorders between different versions of DSM. The majority of these shifts have been minor and were supported by the scientific literature.

This discussion should not be interpreted as a wish to stifle the debate concerning dissociative disorders. Informed scientific data serve to hone the accuracy of differential diagnosis. We believe the diagnostic criteria for dissociative identity disorder should reflect its polysymptomatic nature by the inclusion of affective, posttraumatic, and somatoform symptoms in addition to dissociative symptoms (5).

Goettman C, Greaves GB, Coons PM: Multiple Personality and Dissociation, 1790–1991: A Complete Bibliography, 2nd ed. Lutherville, Md, Sidran Press, 1994
 
Dell PF: Professional skepticism about multiple personality. J Nerv Ment Dis  1988; 176:537–538
[PubMed]
[CrossRef]
 
Dunn GE, Paolo AM, Ryan JJ, Van Fleet JN: Belief in the existence of multiple personality disorder among psychologists and psychiatrists. J Clin Psychol  1994; 50:454–457
[PubMed]
[CrossRef]
 
Mai FM: Psychiatrists’ attitudes to multiple personality disorder: a questionnaire study. Can J Psychiatry  1995; 40:154–157
[PubMed]
 
Nakdimen KA: Diagnostic criteria for multiple personality disorder (letter). Am J Psychiatry  1992; 149:576–577
[PubMed]
 
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References

Goettman C, Greaves GB, Coons PM: Multiple Personality and Dissociation, 1790–1991: A Complete Bibliography, 2nd ed. Lutherville, Md, Sidran Press, 1994
 
Dell PF: Professional skepticism about multiple personality. J Nerv Ment Dis  1988; 176:537–538
[PubMed]
[CrossRef]
 
Dunn GE, Paolo AM, Ryan JJ, Van Fleet JN: Belief in the existence of multiple personality disorder among psychologists and psychiatrists. J Clin Psychol  1994; 50:454–457
[PubMed]
[CrossRef]
 
Mai FM: Psychiatrists’ attitudes to multiple personality disorder: a questionnaire study. Can J Psychiatry  1995; 40:154–157
[PubMed]
 
Nakdimen KA: Diagnostic criteria for multiple personality disorder (letter). Am J Psychiatry  1992; 149:576–577
[PubMed]
 
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