PRELIMINARY
OBSERVATIONS ON
MPD IN
PUERTO RICO
Alfonso Martinez-Taboas, M
Alfonso Martinez-Taboas, M .A., is a psychologist for the
Puerto Rican Society for the Assistance of Epileptic Patients.
For reprints write Alfonso Martinez-Taboas, M .A., 17 Street,
#1088, Villa Nevarez, Rio Piedras, Puerto Rico, 00927.
The author is grateful to Carlos S . Alvarado for comments on
an earlier draft of this article.
ABSTRACT
A considerable number of cases of multiple personality disorder
(MPD) have been reported by clinicians working in the continental
United States of America (USA) . However, there has never been a
documentation of MPD in a Latin American country . Here I report
three cases ofPuerto Rican patients with MPD whose symptom profile
and etiological background are strikingly similar to the ones reported
in the USA . It is recommended that Latin American mental health
professionals should become more aware of and clinically sensitive to
this increasingly recognized condition.
PRELIMINARY OBSERVATIONS OF MULTIPLE
PERSONALITY DISORDER IN PUERTO RICO
In the last 20 years there has been an upsurge of interest
in multiple personality disorder (MPD) . Following this trend,
a multitude of publications have discussed areas such as
psychophysiological investigations (Coons, 1988 ; Putnam,
1984) , diagnostic criteria (Coons, 1984 ; Kemp, Gilverston &
Torem, 1988 ; Schafer, 1986), different therapeutic modali-
ties (Braun, 1986 ; Kluft, 1984; Putnam, 1989), and various
theoretical frameworks (Bliss, 1986 ; Kenny, 1986 ; Kohlen-
berg, 1973).
Apparently, this renewed interest in the reporting of
patients with MPD is the product of a variety of factors . First,
many professionals in the mental health field are now more
acquainted with the clinical characteristics of the syndrome.
This process has been facilitated by clearer specifications of
the syndrome in DSM-III (American Psychiatric Association,
1980) and DSM-III-R (American Psychiatric Association,
1987) and by the numerous workshops and professional
publications on the subject . Second, there is evidence that
many of the risk factors that have traditionally been associ-
ated with the development of MPD (incest and physical
abuse) either are on the rise or at least are increasingly
recognized (Ammerman, Cassini, Hersen, & VanHasselt,
1986; Wolfe, Wolfe, & Best, 1988) . Third, many influential
authors are giving due weight to the dissociative aspects of
many psychopathologies (Bower, 1981 ; Hilgard, 1977;
Nemiah, 1984) . This shift in emphasis has given rise to more
careful attention to the impact of non-conscious processes
upon human emotion and behavior.
Nethertheless, some authors have objected to the use-
fulness of the diagnosis of MPD because it appears to be a
culture-hound syndrome confined primarily to the conti-
nental USA . As Fahy (1988) has noted : "Although support-
ers of the diagnosis can point to the wide distribution of cases
in time and place . . . this distribution no longer extends
outside the USA . Just one British case has appeared in the
literature over the past 15 years " (p. 601) . This impression
was confirmed to me by Coons (personal communication,
April, 1989) when he stated : ". .. some world experts believe
multiple personality disorder to be a culture bound syn-
drome of the continental United States and possibly Can-
ada ."
Reviewing the literature on MPD largely confirms those
impressions . So, although it is true that some cases of MPD
have been documented in various European countries (see
Ellenberger, 1970), nearly all of these were published in the
19th century or in the first decade of the 20th century . One
important exception is the case study reported by Varma,
Bouri, and Wig (1981) of a MPD patient in India.
The major purpose of this paper is to briefly record the
occurrence of various cases of MPD that the author has
studied in detail in Puerto Rico . It is important to highlight
that, as far as I know, this is the first publication that
documents the presence of MPD in a Latin American country.
ANALYSIS OF THE CASES
Characteristics of the patients
Between 1986 to the present the author has been work-
ing as a clinical psychologist at the Puerto Rican Society for
the Assistance of Epileptic Patients . Typically, the Society's
clinicians attend patients with a diagnosis of epilepsy or with
symptoms that suggest the possibility of a seizure disorder.
Our patients usually are persons of low socioeconomic and
educational status.
During the last two years I have diagnosed MPD in three
patients, using the DSM-HI criteria . Table I shows the reader
the clinical characteristics of these cases . It seems clear that
all of them conform to the general pattern that has been
documented in other clinical research in the USA (Coons,
Bowman, & Milstein, 1988 ; Putnam, Guroff, Silberman,
Barban, & Post, 1986) . Such symptoms as persistent head-
aches, hallucinated inner voices, recurrent and rapid affec-
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DISSOCIATION, Vol. II,1No. 3:September 1989
MARTINEZ-TABOAS
Live and expressive shifts and changes, psychogenic amnesia,
and psychogenic seizures are repeatedly encountered . Also,
from their history we find documentation of post-traumatic
stress disorder and of trauma that occurred during child-
hood . In all cases I have been able to corroborate the
patients' accounts from independent sources of informa-
tion .
In the case of Olga, whom I have seen for only five
sessions, there is apparently no history of physical or sexual
abuse . Nevertheless, one of the alter personalities was cre-
ated around the age of five years, when she witnessed a tragic
accident that occurred to her mother.
It is important in the context of transcultural observa-
tions to indicate that these patients had not been raised in
the continental USA and then relocated to Puerto Rico.
They were born and raised in Puerto Rico, and resided there .
Characteristics of the alters
As can be seen in Table 2, in nearly all cases the alters
demonstrated different tones of voices and different hand-
writings . What has impressed me most forcefully, however,
are the different bodily expressions of each alter . For ex-
ample, Diana has three other alters . One is of a child eight
years of age, another is a man, and the remaining one is a
woman a little younger than the patient . The child person-
ality always trembles from head to toe, constantly has a
bowed head, rubs her hands in a nervous way, and looks at
me a very fearful manner . Additionally, on occasions she
presents with a type of acute coughing attack that occurred
very frequently when Diana was a young child . The male
personality usually is very calm . He speaks in a very soft voice,
constantly looks at my eyes, and rarely blinks . Finally, the
younger woman never looks at the eyes of her interlocutor.
TABLE 1
Clinical Characteristics of the Patients
Migdalia
 
Diana Olga
History of sexual abuse
 
+
 
+ ?
History of physical abuse
 
+
 
+ ?
Post-traumatic stress disorder
during childhood
 
+
 
+ +
Use of fantasy as a coping mechanism
 
+
 
+
Tendency to repress feelings
 
+
 
+ +
Psychogenic amnesia
 
+
 
+ +
Psychogenic seizures
 
+ +
Recurrent and persistent headaches
 
+
 
+ +
The hearing of hallucinatory voices
 
+
 
+ +
Rapid and recurrent changes of
affect and expression
 
+
 
+ +
Previous unsuccessful psychiatric
treatment
 
+
 
+ +
TABLE 2
Characteristics of the Alter Personalities
Migdalia
 
Diana Olga
Number of alters
(including host personality) 4 4 3
Child personalities present + + +
Depressed personalities present + +
Anger personalities present + + +
Different handwritings + +
Opposite gender personalities + +
Different tones of voice + + +
Different facial expressions + + +
Protector personalities present + + +
She usually likes to smoke one cigarette
after another, and has a constant tremor in
her hands.
In all cases, there is at least one per-
sonality who displays much anger, another
who reports severe depression, and a child-
like personality.
Case illustration
I will briefly discuss the case of Migdalia
to illustrate some of the clinical characteris-
tics of my caseload . Migdalia is a 30 year old
woman with only a sixth grade school educa-
tion . During her childhood years there were
frequent and violent quarrels in her family
that usually included physical aggression.
On various occasions her father beat her so
strongly that he disfigured her nose and
broke some bones in her chest . Also, she was
sexually attacked on two different occasions
by an uncle . She usually coped with the
abuse by imaging that deep inside her was a
strong and forceful man who can handle
any difficult situation . She named this per-
sonage "Pedro ." In her adolescent years she
noted that when her father attacked her,
she suddenly and uncon trollably responded
in a violent way . Sometimes she had no
consciousness or memory of her aggressive
actions.
When she first came to my attention she
was very depressed and exhibited suicidal
ideation . During administration of the The-
matic Apperecention Test (TAT) she in-
sisted that she didn't want to see the cards
because some of them brought back memo-
ries of her unhappy childhood . Unexpect-
edly, while she was looking at card #6, she
bowed her head for some seconds . When
she lifted it, she told me in a forceful voice:
"Why do you want to make her suffer?" I
didn 't understand her remark and I said so.
This time she said : "You want her to suffer
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DISSOCIATION, Vol. 11 . 3:September 1989
MPD IN PUERTO RICO
but I will not permit that . And I am not Migdalia . I am Pedro.
I am here to protect her against people like you!"
Pedro's principal function is to protect Migdalia from
suffering any external or internal stressful situation that
might provoke emotional instability in her . He describes
himself as rude and stern . Fortunately, he has usually been
quite cooperative in the psychotherapy process.
During the last months, two other alter personalities
have made their appearance . One is of a woman (Maria)
who is constantly crying . She says that she hates Migdalia and
her family, but Pedro does not permit her to take any
harmful action toward them . Maria is usually weak and says
that she takes a more dominant role when Migdalia is suffer-
ing from some disappointment or depression . In those
instances she can influence Migdalia in a more marked way.
Lastly, there is a very little girl (Vicki) who only likes to play
and who refuses to talk about Migdalia 's family.
During the last year I have seen this patient about twenty-
five times . My approach has been akin to that described by
Caddy (1985) and until now has mainly consisted of ampli-
fying her coping skills and of confronting her with the past.
On October 28, 1988 in collaboration with Dr . Luis
Rivera Reyes, a neurologist, Migdalia was admitted to a
video-EEG monitoring unit . The reason for this admission
was to try to establish whether the patient and her alters have
the same EEG pattern . The results indicated the "during the
transition from Migdalia to `Pedro' no abnormal electrical
activity was observed and the background activity remained
unaltered except for increased muscular activity ." This re-
sult is entirely consistent with the EEG study of Cocores,
Bender and McBride (1984) : "Our investigation demon-
strates that the EEG is not changed by the dissociation in the
multiple personality case studies . Although electrical arti-
facts were often present as a result of the muscle activity . . ."
(p . 437).
Iatrogenesis?
Some critics of the diagnosis of MPD contend that the
disorder is subtly shaped by the psychotherapist, especially
when the use of hypnosis is involved (Fahy, 1988 ; Kenny,
1986) . I contend that in the cases of Migdalia, Diana, and
Olga this sort of criticism is improbable . First, I have never
used hypnotic techniques in Migdalia's case . I used them
once in the case of Olga, and very sporadically in Diana's
case . In other words : over 90% of my communications with
the alter personalities were not mediated by the use of
hypnosis . Second, and as can be seen in Table 1, when the
patients came under my care, all of them were already
suffering from recurrent psychogenic amnesias, "blackouts,"
and other clinical signs that are usually associated with the
appearance of MPD prior to its clinical recognition . Third,
in the case of Migdalia the alter personality contacted me in
the very first session in a totally unexpected manner . In the
case of Olga she was continuously having a rare variety of
psychogenic seizures in which her character and behavior
changed in a dramatic way . Hours later, she woke up totally
confused and with no memory of her actions . Also, in
Diana's case it was after six months of an unsuccessful
behavioral intervention for her anxiety/depression that I
suspected MPD . The turning point in this case was a session
in which the patient suddenly changed her expression and
tone of voice and discussed in detail many traumatic memo-
ries of her childhood years . At the next session, the patient
had absolutely no memory of talking to me about that aspect
of her life.
Consequently, I am confident that the iatrogenic hy-
pothesis is neither a reasonable nor a sufficient explanation
for the cases that I am reporting in this communication.
DISCUSSION
The question ofwhy there is an "epidermic " (Boor, 1982)
of MPD in the continental USA and not in other countries
is not an easy one to answer . I think that part of the answer
may lie in the fact that many clinicians from other countries
do not diagnose MPD because they have not become suffi-
ciently sensitized to the disorder to recognize its varied and
subtle manifestations . For example, the patients discussed in
this paper have had previous psychiatric treatments . In all
cases they received the diagnosis of major depression and
were treated with a wide variety of antidepressants . In fact,
when one of Olga's former psychiatrists saw the personality
changes in his office, he merely instructed her husband in
methods to extinguish such behavior, without searching for
its meaning or exploring its dynamics . He appears to have
been unable or unwilling to identify the phenomena more
thoroughly, even though he had observed them quite clearly.
Although the report of these three cases in and of itself
cannot prove that MPD is a transcultural disorder, I think
that it highlights the fact that : a) MPD does occur beyond the
continental USA ; and that, b) the clinical configuration of
the Puerto Rican cases is strikingly similar to that of cases
reported in the American literature.
Admittedly, what we need is a series of transcultural
studies in which mental health professionals are trained to
detect MPD in their native settings and among high risk
populations . I am heartened to learn that some preliminary
efforts of this nature are underway (Kluft, personal commu-
nication, June 1989) and look forward eagerly to their
findings . a73
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MARTINEZ-TAB OAS
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