DIAGNOSIS OF
COVERT AND
SUBTLE FORMS
OF MULTIPLE
PERSONALITY
DISORDE R
Through Dissociative Sign
Jean Franklin, M .D.
Dr. Franklin practices psychiatry in Amherst, Massachusetts.
For reprints write jean Franklin, M.D., 274 North Pleasant Street
Amherst, MA 01002
ABSTRACT
There are different ones of multiple personality disorder (MPD )
that van' on a dissociative continuum fromsubtle forms in which the
altersare not very distinct or elaborated and oflcm influence each other
without assuming full urntrol, to patients with fully developed AIPD
whose alters are distinct, elaborated, assume full control, and emerge
overtly. Most MPD patients present covertly, and some patients wit h
covert presentations will later show overt classic symptoms, while those
with subtle forms will often remain mild and subdued . Mast MP D
patients hide or disguise their condition, while their alien express their
thoughts and feelings through subtle dissociative signs that occur whe
the alters influence each other . These signs
consist of s
and behaviors, transferences, developmental levels, and psychiatri c
symptoms, and marked discrepancies in memories, viewpoint, and atti-
tudes, which may indicate the possible presenceofalters and of MPD or
Dissociative Disorder Not Otherwise Specified ofMPD. Th e
case of a subtle form ofMPL) is presented which illustrates some of th
subtle signs of dissociation and other dissociative symptoms often see
in these patients.
It is becoming increasingly clear that overt presentations o f
multiple personality disorder (MPD) are more uncommon tha n
other presentations . MPD is difficult to recognize and diag-
nose, because it is a condition of hiddeness (Gutheil, cited i n
Kluft, 1985b). Most MPD patients do not present with classi c
symptoms like those of Sybil (Schreiber, 1974) or Eve (Thig-
pen & Cleckley, 1957), who had fully developed personalitie s
that emerged clearly and assumed full control . Instead, mos t
present covertly, suppressing or hiding their symptoms (Kluft ,
1985a, 1985b) , or are unaware of them, and many present with
a subtle form of the disorder in which the personalities are dif-
ficult to distinguish. Patients with both covert and subtle form s
of MPD often present with subdued dissociative signs, which, i
recognized, make it possible to suspect the diagnosis early i n
therapy (Franklin, 1985) .
MPD patients are also difficult to diagnose, because man y
of them present with symptoms of other disorders (see reviews:
Bliss, 1984, 1986 ; Kluft, 1984, 1985a, 1987h
Solomon & Solomon, 1982) . They are polysymptomatic (Bliss,
1984, 1986; Coons, 1984), and on the average, have receive d
three or four other diagnoses (Putnam, Guroff, Silberman ,
Barban, & Post, 1986) . They often present with symptoms of
depression (Coryell, 1983 ; Kluft, 1985a, 1985b .,
1986; Putnam, Loewenstein, Silberman, and Post, 1984), bor-
derline personality disorder (Greaves, 1980; Gruenewald, 1977;
Horevitz & Braun, 1984; Solomon & Solomon, 1982), schizo-
phrenia (Bliss, 1980, 1984, 1986 ; Bliss, Larson & Nakashirrra,
1983; Kluft, 1985b, 1987a ; Rosenbaum, 1980), somatic syrnp-
loms (Bliss, 1980; Coons, 1989, 1986,1988; Kluft, 1985b), dru g
abuse, or antisocial behavior (Coons, 1984) .
Almost all MPD patients (about 97%) have experience d
severe, repeated sexual, physical or psychological abuse or othe
traumas in early childhood (Coons & Milstein, 1984 ; Putnam ,
1985; Putnam, et al., 1986; Spiegel, 1986; Wilbur, I984a, 1985).
They use dissociation as a defense against their traumas (Braun,
1986; Kluft, 1985b; Spiegel, 1984; Young, 1988), and differen t
identities are formed to deal with the traumas and to preserv e
and handle other personality functions .
Most MPD patients hide or disguise their condition, be -
cause: (1) they may have been threatened or punished abou t
revealing their abuse, or blamed for their abuse and feel ashamed,
or punished when their personalities emerged ; (2) they hav e
strong rears associated with their traumas ; (3) they may h e
afraid they would be considered "eras'" or accused of lying i f
they revealed their symptoms (Coons, 1984; Kluft, 1984, 1985a
1987b); and (4) if their personalities came out clearly, the y
would expose their dissociative defense, thus obviating its use -
fulness. Sometimes they are not aware of their multiplicity an d
are amnestic for their traumas (Putnam et al ., 1986).
Some patients hide their personalities by suppressing them ,
or their personalities disguise themselves by passing for on e
another (Kluft, 1987b), by blending their characteristics, b y
transferring personality elements to one another, or by funnel-
ing them through the presenting personality (Kluft, 1985a ,
1985b). Their personalities are difficult to distinguish whe n
they are suppressed or disguised, when they influence eac h
other without emerging or when they are similar .
CONCEPTSOF A DISSOCIATIVECONTINUU M
Several workers in the field have proposed concepts of dis-
sociative continua that range from normal or less pathologica l
dissociation to MPD . Ross (1985) has proposed a continuu m
of increasingly large amounts of dissociated ego which range s
from transient psychogenic amnesia to fugue states and deper-
sonalization to partial MPD to fully developed MPD. O'Brien's
(1985) continuum ranges from isolated traumatic experience s
and ego states to dissociative state syndromes to multiplicit y
syndromes, which include overt, covert, and latent forms o f
MPD.
The dissociative continuum described by the Watkinses (H .
2 7
DISSOCIATION, Vol . 1, No, :1 . 19M
II. Watkins, 1984a, 1984b;j . G. Watkins, 1978; Watkins &Wat-
kins, 1979-80, 1984) ranges from normal ego states (Federn ,
1952) to covert ego states (Hilgard, 1977) which influence th e
executive state (j . G. Watkins, 1984) to overt multiple person-
alities. Their continuum is quantitatively scaled by their defini -
tions. They define an ego state as "an organized system of '
behavior and experience whose elements are bound togethe r
by some common principle" and separated by more or les s
permeable boundaries (H . ii. Watkins, 1984a). The personali-
ties in MPD have rigid, impermeable boundaries and are inde -
pendent of and often unaware of other personalities (H . H . DIAGNOSTIC CRITERIA FOR MPD
Watkins, 1984h). According to J .G. Watkins (1984), the diag-
nosis of multiple personality should be given onlyif these states
emerge spontaneously without any hypnotic induction .
Beahrs' dissociative continuum ranges from fluctuations i n
moods to roles arid ego states, to MPD, in which there are alter
personalities that have more impermeable boundaries and ar e
beyond voluntary control (Beahrs, 1982) . He believes that ev-
eryone has multiple levels of consciousness and multiple enti-
ties similar to Hilgard's hidden observers (Hilgard, 1977) . Nor-
mally, there are various trains of simultaneous consciousnes s
that are kept somewhat separate from each other, that is, ther e
is a healthy co-consciousness . The degree of awareness an d
voluntary control of the different entities decreases from nor-
mals to patients with MPD, in whom the various entities ar e
kept separate by dissociative barriers (Hilgard, 1977) . A con-
tinuum of forms of MPD is reflected in Beahrs ' description o f
patients with ego state disorder o
have less rigid dissociative boundaries than MPD patients .
Khrft's view of a dissociative continuum is qualitative, i n
that he believes that " g hat is essential to multiple personalit y
across its many presentations is no more than the presenc e
within the individual of more than one structured entity with a
sense of its own existence" (Kluft, 1985b), and the "personali-
ties' overt differences and self concepts can range from mini-
mal divergence to extreme polarity " (Kluft, 1985a). He ha s
said that "overtness is not basic to the condition" (Kluft, 1985a),
because the personalities influence each other without assum-
ing full control and that their distinctness and elaboration ca n
be minimal, as they often are in childhood cases . He has ob-
served that there may be some personalities "which, were the y
the only other personality, would not have sufficient definitio n
to qualify the patient for a [DSM-III] diagnosis of MPD" (Kluft
1984). In his view, the term personality state could be used t o
include both personality and personality state, which are seen a s
varying only in degree of definition .
Braun's continuum (Braun, 1986 ,.1988), formulated un -
der DSM-III, includes other dissociative disorders as well a s
several categories of MPD, described in terms of his definitions
of personality and fragment . He defines a personality as having
a consistent, ongoing set of response patterns to given stimuli ,
a significant history, a range of emotions and a range of inten-
sity of affect for each emotion. This definition is a quantitativ e
one, based on specific, recurrently observable criteria that ar e
discrete and qualify as a fullpersonality. A fragment is an entit y
smaller than a personality, that has a consistent, ongoing set o f
response patterns to given stimuli and either a significant his-
tory or a range of emotions but not both to the same degree .
His continuum goes from normal to dissociative episode ,
dissociative disorder, atypical dissociative disorder to atypica l
MPD to MPD to polyfragmented MPD . His MPD categories
also are quantitatively scaled by his definitions Atypical dissocia-
tive disorderincludes patients who dissociate frequently, but th e
dissociative episodes, though linked, do not qualify as person-
alities. In atypicalMPD, the patients' alters exchange factual in -
formation, so they have knowledge of their life history but lac k
the affective component of memory . In MPD, patients hav e
two or more personalities and may have some fragments . I n
polyfragrnentedMID, they have some personalities and numer-
ous fragments .
In DSM-III-R (American Psychiatric Association, 1987), the
criteria for MPD are that patients must have "two or mor e
distinct personalities or personality states (each with its ow n
relatively enduring patterns of perceiving, relating to and think-
ing about the environment and self)" and "at least two of these
personalities or personality states recurrently take full contro l
of the person 's behavior." A personality is a "relatively endur-
ing pattern of perceiving, relating to, and thinking about th e
environment and on e's self that is exhibited in a wide range o f
contexts. Personality states differ only in that the pattern is no t
exhibited in as wide a range of contexts ." In the present paper ,
the term alter will he used to mean either a personality or a
personality state.
The use of the terms personality and personality state rep -
resents an attempt to incorporate the quantitative and qualita-
tive concepts of the dissociative continuum into DSM-III-R defi
nitions. The term personality is quantitative by definition, wherea
personality state is a qualitative, fluid concept -
titative and qualitative views of the dissociative continuum for
the theoretical basis for DSM-III-R.
Those patients who show some of the symptoms of MP D
but do not meet all the criteria for this diagnosis are classifie d
in DSM-III-R as one form of "Dissociative Disorder Not Other-
wise Specified" or DDNOS: variants of MPD (American Psychi
atric Association, 1987). In DDNOS, there is "more than on e
personality state capable of assuming executive control of th e
individual, but not more than one personality state is suffi-
ciently distinct to meet the full criteria for Multiple Personalit y
Disorder, or cases in which a second personality never assumes
complete executive control ." This definition allows for th e
removal of the quantitative criterion of distinctness or of as-
suming executive control, again introducing the concept of a
qualitative continuum . If the childhood form has what is es-
sential to the condition (Kluft, 1985b) , this means that patient s
diagnosed as DDNOS: variants of MPD have the basic psychic
structure of MPD . Thus, MPD can be viewed as on a contin-
uum including a range of forms : from those resembling th e
childhood forms, that are more subtle, to the full-blown classi c
forms with two or more fully developed, distinct personalitie s
that take full control of the person's behavior .
FORMS OF MP
The criteria for MPD in DSM-III-R have been broadene d
from DSM-Ill (American Psychiatric Association, 1980), an d
with the inclusion of DDNOS: variants of MPD, now include a
range of forms of MPD : from overt classic forms to covert ,
subdued and subtle forms. Most patients present covertly (Kluft
I985b, 1987b), appearing in subdued forms with signs an d
28
 
DISSOCIATION, Vol . 1, No. 2 :June, 1988
symptoms that are reduced in intensity or degree .
In covert presentations, the alters hide by suppressing o r
disguising themselves or by influencing each other, but durin g
certain periods of their lives, some of these patients show overt.
symptoms of classic MPD (Kluft, 198:5) . Patients with subtl e
forms of MPD may also hide at times, but sometimes may only
appear to be hiding, because many of their alters are simila r
and not very distinct and are difficult to perceive or distin-
guish. The signs and symptoms of these patients tend to re -
main more mild and subdued .
Compared to subtle forms of' MPD, patients who presen t
covertly but later show symptoms of classic MPD have a greate
degree of dissociation among many of their alters, which hav e
more impermeable amnestic boundaries and more separat e
memories and distinct behavior patterns . Their alters are more
substantial and divergent and more distinct when they emerge .
Their divergence often leads to more conflict and pressure t o
emerge as one alter tries to express itself. Often their alters ar e
strongly suppressed or disguised and operate by influencin g
one another .
Patients with subtle forms of MPD have less dissociatio n
among many of their alters, which have more permeable bounda
ries and share more memories and behavior patterns . Thei r
alters are, in general, less distinct and substantial . Some ar e
barely elaborated and have only enough intrapsychic dissocia-
tion to separate out their traumas and give them a sense o f
separate existence (Kluft, 198%) . Their alters are not very dis-
tinct, and usually influence each other without taking full con-
trol, and because they are less divergent, they have less conflict
and less need to emerge . Subtle cases have used intrapsychi c
dissociative defenses in childhood and have continued to us e
them to maintain their amnesia for their t raumas but have no t
elaborated their alters as they moved into adulthood .
Forms of MPD can be understood in terms of Kluft's con-
cept of a range of personality states that vary in degree of defi -
nition . On this continuum, subtle forms would range fro m
DDNOS: variants of MPD at the low end of the continuu m
through some forms of DSM-III-R multiple personality disor-
der, but would not reach classic forms at the high end of th e
continuum . Patients with subtle forms of MPD would at firs t
be diagnosed as DDNOS, and some will eventually be diag-
nosed as DSM-1II-R MPD d
at first be diagnosed as DDNOS : variants of MPD, but as the y
become more overt, their diagnosis could fall anywhere on th e
continuum .
The personality system of patients with classic forms of MP
would generally include relatively more substantial personali-
ties and fewer personality states, while patients with subtle form
would usually have more personality states and fewer person-
alities, or perhaps only personality states. Some multiples with
subtle forms could be complex multiples with 26 or more per-
sonalities and personality states (Kluft, 1988) or polyfragmente
multiples (Braun, 1986) .
SUBTLE SIGNS OF DISSOCIATIO
Patients with covert and subtle presentations do not sho w
overt symptoms of MPD, but often show a number of subtl e
signs of dissociation which suggest the presence of alters o r
their dissociated elements such as behaviors, thoughts an d
feelings. These subtle signs may be observed when the alters
express themselves by influencing each other, partly emerg-
ing, subtly switching, and fluctuating in and out .
MPD patients need to express the memories and feeling s
connected to their traumas, but are afraid to, because of th e
fear, pain, anger, and shame connected to them, of which the y
may not even be conscious . This conflict between expressio n
and hiding leads to a compromise in which the memories an d
feelings are expressed through subtle signs of dissociation. Thi s
process can be viewed as similar to the compromise leading t o
neurotic symptoms, except that in MPD, the subtle signs are a
return of the dissociated rather than a return of the repressed .
In addition, internal or external stresses may serve as trigger s
which activate memories of past events and the alters who contain
them (Loewenstein, Hamilton, Alagna, Reid, & DeVries, 1 .
The presence of different identities may cause patients t o
show subtle signs of dissociation in any of the following ways :
as subdued, sometimes sudden changes in affects, behaviors ,
thoughts, moods, and memories that are incongruous or dis-
connected f rom each other, or as sudden discrepant change s
in social relatedness, transferences, developmental levels an d
psychiatric symptoms. They may show many inconsistencie s
and contradictions that are expressions of alters who have dif -
ferent attitudes and viewpoints about the same person or prob-
lem area . They may also show other dissociative symptom s
which may or may not indicate the presence of alters, but whic
can lead one to suspect the presence of a dissociative disorder .
A case of multiple personality whose personality system was
basically covert and subtle will be presented, and excerpts from
her therapy will be used to illustrate the subtle signs of dissocia-
tion and other dissociative.symptoms observed in MPD patients
CASE HISTOR
The patient, Margaret (and M . or "sine"will he used to refe
to any of her personalities or personality states) was a 21-year -
old college student, the youngest of six children . When M . wa
two, her mother was hospitalized for depression for some months
and M. was cared for during the day by a woman who left whe
the mother returned . The father drank, and sometimes abuse d
the mother at night, which M . must have overheard, as he r
bedroom was next to theirs . The parents divorced when M .
was six, and the father remarried and rarely visited .
M. was severely teased, bullied, and depreciated by' her sib-
lings. She was not protected from these abuses and often hi d
in closets to feel safe . She remembered pretending to thro w
her stuffed animals and dolls into "a moat of boiling wate r
around her bed and rescuing them in a macerated condition ."
She ran away from home when she was five and was found b y
the police several miles away . She was frequently scolded fo r
losing and forgetting things .
Her mother depreciated and dominated her by telling he r
what to do and how she should feel and think, and M . would
%pace out "to shut her out. M. said, "My mother puts her ow n
thoughts and feelings onto me and totally wipes mine out ."
When she was 12, M. found her mother so difficult to live wit h
that she attempted suicide by taking an overdose of aspirin .
Then, on her own, she saw a series of seven psychotherapist s
over eight years with no improvement .
After high school, she went to New York to study art, live d
alone, and was depressed and dysfunctional . She saw a youn g
woman therapist, but presented her family as ideal, and th e
29
DISSOCIATION . Vol . 1. No. 2: 1unc, 1558
therapist did not recognize her dissociative symptoms, such a s
`blank outs" during sessions, which could have led her to sus-
pect MPD and early traumas .
The next year, M . entered college, and in her junior yea r
began therapy with inc . She presented with depression, anxi-
ety, bulimia, headaches, blank outs, and memory problems .
She did well in her courses, but found it hard to complete he r
work and worried about failing .
Though M . felt socially inept, she had several girl friend s
who were socially skillful and helpful . She was attractive an d
well-groomed, but felt panic around men and did not date an d
avoided talking about rrten or sex . Her extreme attitude mad e
me suspect that she might have been sexually abused as a child.
She once said in a low voice, "Maybe my mother and fathe r
raped me when 1 was four, but I don 't know if this is true."
Early in therapy, her transference feelings were that th e
therapist was projecting her own ideas onto her or was not .
helping her, because she did not tell her what to do or say . She
used her college work to shut out feelings, and at these time s
denied anything was wrong with her, because she felt 'nor-
mal ". At other times, she was overwhelmed with despair, lo w
self-esteem, and feelings of non-existence and failure . I Ier ear-
liest expression of affect in the transference was anger, whic h
was later directed at her mother . She alternated between ac-
cepting therapy and scornfully rejecting, depreciating and sabo-
taging it . When I used hypnosis, she broke trance twice an d
then refused further attempts .
During a year of therapy, her dissociative condition gradu-
ally unfolded . She showed many changes in mood, attitude ,
voice quality, and facial expression between and during ses-
sions. She alternated between tentative trust and deep mis-
trust, but eventually was able to express more of her feelings .
Although I suspected MPD in the first interview and tol d
her then that she had a dissociative condition, most of he r
alters showed minimal divergence and did not emerge clearly .
M. described herself as being like a collage in shades of brown,
with a little gray and black, rather than in reds, blues and yel-
lows like Sybil or Eve. Her dissociated states did not appear t o
be highly elaborated ; most were not distinct ; and she did no t
refer to them by names other than her true name and its dirni-
nuitive form, "Peggy". Eventually, I could distinguish four per-
sonalities which were similar in external appearance and onl y
slightly different in voice and facial expression, but were mor e
substantial than her other dissociative states, in that they had a
more distinct psychic structure in terms of attitudes, affect s
and functions and were more stably present .
They were : (1) Her presenting personality, who was de-
pleted, depressed, anxious, confused, subdued and had a soft ,
low-pitched voice; (2) a hostile personality, who was angry be -
cause her parents did not love or care for her properly ; (3) a
self-assertive, autonomous personality, who allowed her to ge t
her work done ; (4) an efficient personality, who had a slightl y
higher-pitched, brisk and clipped voice and who made definit e
plans for the future . These personalities sometimes influence d
and blended into one another before emerging .
She also had a number of personality states that emerge d
recurrently, but briefly . These states had certain functions o r
represented identifications or sides of conflicts or embodie d
certain defenses . A few showed distinct differences in body ap-
pearance and facial expression and switched clearly, such as
the child states and the mannequin state . The states were (1) a
superficial, conventional state, (2) a numb state, (3) a para-
noid state, (4) an identification with the abuser state, (5) a
hated, rejected state, (6) a superior, snobbish state, (7) a hope-
ful, positive young adult state, (8) a robot or mannequin state ,
(9) a defiant, rebellious state, and (10) several child states ; a
child with positive feelings, a fearful, unloved abandoned child,
and a dependent child .
M.'s behaviors and affects fluctuated as she changed states .
Her states did not seem to be connected to each other, an d
when she was in one state, she sometimes seemed unaware o f
the others, but at other times she was co-conscious for mor e
than one state . She was often not aware of her conflicts whe n
each side was expressed by a different alter . Her personalit y
states led her to show many subdued and subtle signs of disso-
ciation throughout her therapy .
CASE ILLUSTRATIONS OF THE SUBTLE SIGNS O
DISSOCIATION
FLUCTUATIONS IN AFFECTS AND TRANSFERENCES
In MPD, each personality or personality state has a specific
transference arising out of its needs, functions and develop -
mental level (Wilbur, 1984h, 1986,1988) e
switches, or partial emergence of the alters cause these pa-
tients to show marked fluctuations in their transferences an d
affects, within or between sessions, that may be the first evi-
dence of the presence of alters.
M. showed many such fluctuations . hi one early session ,
when she was feeling dependent and helpless and that every -
thing was out of her control, her hostile state influenced her ,
and she suddenly turned her head away and said angrily ,
"Therapy is a waste of my valuable time"and got up and starte d
to leave. just before college graduation, her hopeful, positiv e
young adult alter came in, saying that she had decided to go t o
New Y rk to live with her friends and find an interesting jo b
and was sure she could make it with the support and help o f
her friends . Two days later, her efficient, realistic alter, influ-
enced by her dependent child alter, called, saying she coul d
not count on her friends and should continue in therapy a
while longer .
FLUCTUATIONS IN DEVELOPMENTAL LEVEL
MPD patients often show sudden changes in facial expres-
sion, voice and vocabulary and level of emotional expression .
Many may behave at times in ways suggestive of a young child,
or show magical or polarized thought typical of young chil-
dren . M .'s facial expression sometimes changed to that of a
frightened child, or she would hang her head in shame like a
small child . Her dependent demands to be told what to d o
and say alternated with expressions of autonomy, willful defi-
ance, and anger .
FLUCTUATIONS IN PSYCHIATRIC SYMPTOM
The psychiatric symptoms of MPD patients sometimes vary
markedly from day to day (Coons, 1988 ; Kluft, 1985a, 1985b,
19871) ., 1984) ; for example, they may chang e
from depression to acting out or to psychosomatic symptoms ,
and sometimes these variations may indicate a change to a
different alter . M . would suddenly become depressed or bu-
limic when she visited her mother or felt that. her friends di d
30
 
DISSOCIATION, Vol. I, No : lime, 1988
FRANKLIN
not pay enough attention to her, but these symptoms woul d
suddenly disappear when she changed to another state, suc h
as her autonomous state .
INCONSISTENCIES AND CONTRADICTIONS IN VIEW -
POINTS AND ATI:'I I CDE
M. often showed striking inconsistencies and contradictions
in her viewpoints and attitudes between and within sessions .
When she was beginning to open up imm therapy, she said ,
"Therapy is making me feel worse. I can 't work. Everything is
hopeless. No one ever helped me ."A few days later, she said,
"I' 've been in m y
whole life ." She was fearful about sex and associated it wit h
sadism, yet said she was looking forward to having pleasurable
sexual relations . She alternated between saying she loved an d
hated her mother and her mother loved and hated her . Sh e
once said in a normal voice, "I've got to stop seeing mother,"
and then in a muted . younger voice, "hut I'm not sure I can do
it..,
EVIDENCE OF SWITCHING
Patients with covert and subtle forms of MPD usually sho w
subtle switches rather than the obvious switches seen in classic
multiples in which a distinct personality emerges and takes full
control. In a subtle switch, one alter may influence and mi x
into another before it emerges . Subtle switches are smoot h
transitions that may pass unnoticed if one is not looking fo r
them ; for example, one facial expression may blend into an -
other . Before they occur, a patient may pause, look blank, o r
turn away, or there may be no sign . M . often turned her hea d
away so that her transitions were hard to see . They could b e
inferred from subtle changes in her voice and facial expression
or from incongruous changes in her viewpoints, attitudes, an d
feelings.
INFLUENCES OF ALTERS ON EACH OTHER
The personalities and personality states of patients with cover
and subtle forms of MPD usually influence each other rathe r
than emerging overtly . They may influence each other by talk-
ing to or transferring thoughts and feelings to one another o r
by imposing themselves on, dominating or suppressing eac h
other.
These influences take the form of co-presence, co-consciousnes s
and passive influence, which often overlap. In co-presence, a n
alter influences the behavior or affective state of another with -
out assuming control (Kluft, 1984) ,
1906), an alter is aware of the feelings, actions and thoughts o f
another . In passive influence, patients feel that impulses, act s
and affects are imposed on them, that their body is influence d
by some force, that thoughts are withdrawn from their mind ,
or that their mind is influenced by thoughts they ascribe t o
others (Kluft, 1985h, 1987a).
Co-presence leads some patients to say they are ` tossessed'
and co-consciousness causes some to hear their alters' voices in
their head . M . heard `murmurs " and received 'signals abou t
the pain of her childhood ". She showedpassive influence when
she felt helpless to control what happened to her and was lik e
a 'robot" or `mannequin" . She once said, "When I talk, I
don 't know what's going to come out . It 's like pulling some -
thing out of a hat ."
ATYPICAI D
DISSOCIATIVE EXPERIENCE
MPD patients often make atypical and metaphorical refer-
ences to self aspects and dissociative experiences that are evi-
dence of their dissociative condition . M. described herself as a
'zombie "and said that a `ghost was buried in her '.. Some pa-
tients use descriptive terms fin- their alters or say that thei r
states ` "or `come out ".
M. said many things that suggested multiplicity . She said ,
"Many years ago, there were a lot of little 'Peggys' that got pu t
on the shelf and got dusty ," and "I have two sets of eves; inner
eyes that see had things and outer eves that see what's happen -
ing outside ." Early in therapy, she described her dissociatio n
by saying, "Sometimes when I'm upset, I call block myself ou t
totally."
SIGNS AND SYMPTOMS COMMON TO OTHE
DISSOCIATIVE DISORDER
Because they were traumatized, MPD patients often sho w
other dissociative signs and symptoms. Like patients with post -
traumatic stress disorder, they sometimes have flashbacks, sleep
disturbances and out-of-body experiences (Spiegel, 1984, 1986)
M. described an out-of--body experience by saying she felt like
she was "floating in outer space." She described her trance-lik e
states as being in a "twilight state"She had amnesia for most o f
her childhood and showed minor amnestic episodes (Fran-
klin, 1985) or microamnesias (Kluft, 1985b), often forgettin g
what she or the therapist had said within or between sessions .
She also showed depersonalization, once saving, "When I tal k
to people, sentences come out that don 't mean anything . I
come to a cliff- a big empty space . I can 't think. I'm afraid al l
the bad things will come out . I lose a sense of myself."
CASE SUMMAR
I will now summarize how I suspected that M . had MP D
from her history and from some of the dissociative signs I ob-
served during the first interview. (1) The first thing M . did, was
to look out the window and in a subdued voice and say : " I
came to you for hurt, " instead of saying help" . I saw this as
possibly indicating leakage of feeling from a traumatized chil d
alter to her presenting personality . (2) She asked me to repea t
many of my questions, indicating microamnesia . (3) She kep t
her eyes focused on her key ring, apparently to keep herself i n
one steady state. (4) She kept her head lowered and talked i n
a very soft voice, behaviors Kluft (1985a) has found to be com-
mon in MPD patients trying to hide their condition . In addi-
tion, lxer presenting symptoms of depression, headaches,` k
outs' ; amnesia for her childhood and the fact that she ha d
been treated by many psychotherapists with no improvemen t
made me suspect the possibility of MPD (Kluft, 1985a ,
et al., 1986).
M. continued to show many subtle signs of dissociation ,
and I could gradually distinguish different personalities an d
personality states. Sometimes, younger alters would sugges t
themselves by briefly coming out, but they did not speak, an d
when her presenting personality returned, she often seeme d
unaware of what had happened .
Later in therapy, M . had told me, "There were younge r
forms of me that got stunted in their growth, and that's when I
3 1DISSOCIATION, Vol,
1,No . 2 : Tune, 1988
began to see psychiatrists." She described her intrapsychic dis-
sociation by saying, "I have imcmalized `hiding in the closet, '
and now 1 can find a safe place in my rnind to go to . I don 't
make connections that are relevant to each other . I have dis-
parate minds, and that's why Fin so confused . Maybe I hav e
over 100 pieces . 1 live in separate minds, and I don 't kno w
about it . I live multiple lives, and I 'rn not real ."
Though she had made all these statements, she did no t
appear to have two or more personalities with sufficient defini -
tion "that were complex and integrated with unique behavio r
patterns and social relationships" as was then required by DSM-
III for a diagnosis of MPD, and a certain vagueness remained .
It did seem clear, however, that many alters were present i n
partial or full control, though N6diout antic.h distinctness or di-
vergence among them . At that tirtre, she would have met DSM
III-R criteria for MPD.
Eventually, in barbiturate-facilitated sessions, a child alte r
clearly emerged and recounted some of her early history, in-
cluding a memory of sexual abuse . In a child voice filled with
emotion, M . said, "I 'm with my mother in front of the fire -
place, and her boyfriend is there, and my mother poked m e
inside with her finger and showed the boyfriend how I wa s
made ." Then she paused, and irr all adult voice said, ` :She
made a specimen of me., and I was so mortified!"Although thi s
child alter had appeared briefly several times before, this wa s
the first time it had spoken and described a memory of sexua l
abuse.
CONCLUSION
In conclusion, it should be stressed that : (1) MPD patient s
do not have the internal colresiveness and consistency one see s
in other patients ; (2) there is a range of forms of 1111'D wit h
many different patterns and permutations of personalities an d
personality states ranging from overt classic forms to those that.
are more subtle ; (3) the majority of MPD patients present cov-
ertly in a subdued form and hide or camouflage their symp-
toms; (4) although most conceal their condition, many wil l
show subtle signs of dissociation that may be evidence of alters
Clinically, it is these dissociations whictl cause them to sho w
frequent, sometimes rapid fluctuations in thoughts, moods ,
and behaviors and to have discrepant memories and feeling s
about the same situation or person . These fluctuations and in -
consistencies are often the first suggestive evidence of MPD. I t
is the presence of int r e
out mental entities and their associated traumas from aware -
ness, that is the sine qua non for suspecting the existence of '
covert and subt.lc forms of MPD. What is essential to all form s
of MPD is the intrapsychic dissociation that separates out an d
maintains multiple concepts of self, object, and the world withi
the same person .
While some fluctuations are observed during flit therapi ?
of most patients, the changes shown by M. were clearly beyond
what. is usually seen ; as in her case, some dissociative symp-
toms such as arniresias, trance-like states, out-of-hotly experi -
ences, and depersonalization are present in addition to th e
subtle signs of dissociation and evidence of traumas, the pres-
ence of MPD should be suspected . When one observes man y
dissociative signs that appear to indicate the presence of alters ,
but the alters do not . emerge because of the strength of th e
resistances, and the diagnosis remains uncertain for long peri-
ods of time, hypnosis can be used (Braun, 1980, 1984x, 1984b ;
Kluft, 1982, 1985a). If there are major resistances to hypnosis ,
one earl consider using barbiturates .
Several scales measuring dissociation, such as the Dissocia-
tive Experience Scale (DES) of Bernstein and Putnam (1986) ,
the Structured Clinical Intertiiew for Dissociative Disorders (SCID
D) of Steinberg, Howland, and Cicchetti (1986), and the Per-
ceptual Alteration Scale (P .AS) of Sanders (1986) are bein g
developed and used to.screen for dissociative symptoms an d dis
orders and will help in suspecting the hidden forms of this
condition .
Kluft (1985b) has obser v D
patients present overtly. In a study of 73 cases (Kluft, 1984), h
found that 40% showed subtle hints of dissociation, and 40 %
were highly disguised (Kluft, 1985a), which indicates that many
more multiples exist than are now being diagnosed . In m y
own practice, an awareness of these subtle lints of dissociatio n
has led me to suspect the possibility of MPD in seven previously
undiagnosed patients, and the diagnosis was confirmed in six ,
by the exploration of what underlay the subtle signs, throug h
uncovering techniques or hypnosis .
The structure and process of the intrapsychic dissociatio n
described in the case of M. highlights the fact that the patien t's
use of intrapsychic dissociation as a defense is central in sus-
pecting the diagnosis . The fluctuating presentations over tim e
(Kluft, 1985a) and the variety of forms and structures of MP D
make an openness in conceptualizing its diagnostic criteri a
necessary if some cases are not to be missed . DSM-III-R now
allows for the recognition and inclusion of subtle, complex ,
and covert forams of MPD under MPD or DDNOS : variants of
MPD.
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