Hippocrates first rule of medicine states" Primum, non
nocere," or "First, do no harm." To the conscientious prac-
titioner of every healing art it stands as a constant reminder
of the weighty responsibilities involved in rendering care to
the ill and the injured, and the necessity of evaluating every
aspect of what is done in the course of their care for possible
adverse as well as beneficial impacts.
When viewed purely in terms of their denotative mean-
ings, the words "iatrogenic" and "iatrogenesis" are relatively
neutral, and indicate that something has occurred as the
result ofa healer s interventions. However, the connotations
of these words, which determine their common usage and
most widely applied definitions, are largely negative. They
conjure up the image of something being clone by the healer
that is wrong or erroneous, with adverse consequences for
the patient.
As an indication of this, neither the emergence of a
transference neurosis (which may be encouraged to unfold
by a therapist s way of conducting treatment), nor a surgical
incision, nor the felicitous outcome of a medical blunder
that serendipitously proves helpful, nor the successful cure
of a patient are commonly referred to as iatrogenic, al-
though all clearly result from the interventions of a healer.
Conversely, the patient worsening in the course of treat-
ment, complications that ensue in the course of therapy,
accidental mishaps and errors, and the untoward outcomes
of healer efforts (be they thoughtful or inappropriate) may
well yield outcomes that become described as "iatrogenic."
Working within the context of the usual negative com-
plications of the term "iatrogenic," it is useful to return to the
commonplace distinctions made between errors of commis-
sion and errors of omission; i.e., errors that stem from steps
that are taken and prove to be incorrect, and errors that stem
from actions that are withheld, and the failure to act proves
to have been incorrect. Concerns about the possibility of the
iatrogenic creation or the iatrogenic worsening of multiple
personality disorder (MPD) are far from new; they have
been an ongoing theme in the modern history of this
condition. An interest in the iatrogenic illness and/or
complications that follow from the absence of healing ef-
forts in connection with MPD is, in contrast, a relatively new
concern.
It is a curious fact that despite the absence of any hard
data for the iatrogenesis of MPD, the vocal insistence that
MPD is an iatrogenic disorder remains a widely held and
"respectable" point of view. Many of our colleagues who
freely admit that they have no clinical experience with MPD
and have not read the literature of thisfield nonetheless feel
quite secure in maintaining that the condition is an artifact,
or merely a social-psychological phenomenon. It remains
commonplace for colleagues to attack the efforts of those
who attempt to work with MPD patients, an indication that
the disregarding of newer findings and approaches is widely
sanctioned.
Conversely, despite a wealth of studies demonstrating
that the MPD diagnosis is made on the average only after the
patient has spent many years misdiagnosed within the mental
health care delivery system, it remains commonplace for
both skeptics and scientific investigators within the field to
caution against energetic efforts to reach diagnostic clarity,
for fear of inducing artefacts. Even many major contributors
to the dissociative disorders literature appear rather defen-
sive and apologetic in this respect. Reports that indicate
MPD patients as a group can do well in appropriate therapy
have not yet resulted in a widespread effort within the
mental health community to identify MPD patients as
promptly as possible and to offer them or guide them toward
appropriate psychotherapy.
The publication of the David Gaul Memorial Sympo-
sium papers represents a milestone in the study of the
dissociative disorders. These contributions represent a
conscientious effort to address and explore those unfortu-
nate situations in which the MPD diagnosis is or is thought
to he worsened by treatment. Because these papers discuss
the issue of iatrogenesis with a focus on situations that
generally speak to actual or apparent errors of commission,
it seems appropriate to offer in the balance some brief
remarks on the iatrogenic aspects of errors of omission.
The phenomenon of nescience with regard to MPD
remains a major impetus to iatrogenic misadventure by
virtue of omission. Nescience is not a word used in everyday
conversations. It means a lack of knowledge, or complete
ignorance. While we attempt to study those incidents in
which patients suffer as a result of the misapplication of the
MPD diagnosis or of treatment interventions that are de-
signed for use with MPD, we must begin to assemble as well
systematic documentation of the consequences of the fail-
ure to make the diagnosis of MPD because of a lack of skill
and knowledge on the part of the healer. Nescience is not
without its consequences.
As I note in my own contribution to the David Gaul
Memorial Symposium, David Gaul and I never really dis-
cussed the topic about which I wrote. I can only hope that in
some serendipitous manner I did justice to his ideas about
the iatrogenic creation of new alter personalities. However,
over the course of nearly a decade, David and I spentmany
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DISSOCIATION, Vol. If,
hours in conversation about the plight of the MPD patient
whose diagnosis is made only after that patient spersonal
resources have been exhausted, her insurance squandered
on ineffectual treatments, the trajectory of her life unaltera-
bly distorted by the loss of years and the foreclosure of
opportunities, and her most treasured relationships, dreams
and talents devastated, if not destroyed. We often discussed
how much of this could and should be described as iatro-
genic. I would begin to talk about nescience --David would
smile indulgently and encourage me to find "a real word that
real people could understand."
It is because the iatrogenic consequences of nescience
are so crucial to appreciate that the David Caul Memorial
Symposium papers and the companion piece by Ross, Nor-
ton, and Fraser are joined in this issue by Halls tragic and
thought-provoking case study and by Batson and Stephens
article on integrating a dissociative disorders curriculum
into a residency training program. These latter two papers
respectively illustrate the problems that may follow in the
wake of nescience, and point the way toward their resolution
by educators. They are ample food for thought..
latrogenic excess morbidity as a sequel to nescience
remains a major public health problem with regard to MPI).
Before turning my attention to this editorial I attended a
case conference in which an MPD patient was being pre-
sented. She had been an outstanding student until she
began to show signs of mental disturbance. Since then, she
had been in state hospitals and residential settings continu-
ously for the last decade. The diagnosis of MPD had been
suggested on the basis of very solid clinical evidence early in
the course of her treatment, but was disregarded. The
patient was treated as paranoid schizophrenic, and several
reports in her file disparaged the possibility of an MPD
diagnosis. Instead of being given appropriate treatment in
her early twenties, she finally will receive it in her mid-
thirties. Perhaps some sage will coin a term for the iatrogenic
loss of over ten years of young womanhood, perhaps not.
Some food for thought digests less well than others. 
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DISSOCIATION, Vol. II, No. 2: June 1989