DISSOCIATIVE IDENTITY
DISORDER: A CLINICAL
INVESTIGATION OF 20
CASES IN TURKEY
Hamdi Tutkun. M.D.
L. (Than Yargic, M.D.
Vedat Sal. M.D.
Hamdi Tutkun, M.D., and L. Ilhan Yargic, M.D., are resi-
dents in the Department of Psychiatry, Istanbul University,
Istanbul Medical School, in Capa, Istanbul, Turkey.
Vedat Sar, M.D., is Associate Professor and Chief of the Clinical
Psychotherapy Unit in the Department of Psychiatry, Istan-
bul University, Istanbul Medical School, in Capa, Istanbul,
Turkey.
For reprints write Dr. HamdiTutkun, Istanbul Tip Fakultesi,
Psikiyatri Anahilim Dali, Capa, 34390 Istanbul, Turkey.
ABSTRACT
This study describes the presentation and clinical features of disso-
ciative identity disorder (DID) in Turkey. The first twenty consecu-
tive patients in a dissociative disorders program of a university clin-
ic in Turkey who met the DSM-HI--R criteria for multiple personality
disorder (MPD) and DSM-IV criteria for DID were assessed with clin-
ical interviews, a structured evaluation form consisting of 126 items,
and the Dissociative Experiences Scale. Eighteen of the patients were
women in their twenties. The median number of alternate person-
alities was four. Eighty five percent of the patients complained severe
headache. All of the patients had at least one Schneiderian first-r
symptom. Childhood traumas were reported in 85% of the cases.
The mean DES score was 47.2. These results are remarkably similar
to findings from North America and Western Europe, suggesting the
validity of DID across cultures.
INTRODUCTION
We report data on 20 patients meeting DSM-III-R crite-
ria for multiple personality disorder (MPD) and DSM-IV cri-
teria for dissociative identity disorder (DID). This is the first
DID case series from Turkey. We describe the systematic assess-
mentof these patients, comparing them with case series report-
ed from North America. We particularly focus on clinical
history, phenomenology, symptom profiles, and histories of
childhood abuse and/or trauma.
Literature Review
Dissociative identity disorder (American Psychiatric
Association, 1994), formerly known as multiple personality
disorder (American Psychiatric Association, 1987) , is increas-
ingly understood as a complex and chronic post-traumatic
dissociative psychopathology closely related to child abuse
(Kluft, 1987a). Until recently, multiple personality disorder
was little understood and thought to be quite unusual. Various
standardized interview schedules (Ross, 1989a; Steinberg,
Rounsaville, Chiccetti, 1990) and self-rating scales (Bernstein
Putnam, 1986) were developed in order to diagnose chron-
ic dissociative disorders and proved to be valid and reliable.
Now multiple personality disorder is known to be more com-
mon than previously imagined (Ross, 1991).
Traditionally dissociative disorders have been associat-
ed with hysteria (Ellenberger, 1970). Various forms of "hys-
terical neurosis" have long been appreciated to be common
in Turkey. A series of the first methodologically adequate
epidemiological studies in the 1980s using the Present State
Examination showed a prevalence of 7.5 - 17.5% (Atakan,
1980; Demiriz, 1980; Hancioglu, 1981; Saher, 1981; Satir,
1981). It is one of the most frequent psychiatric disorders
seen in the emergency units of general hospitals and emer-
gency psychiatric wards. Such cases constitute 47.0% ofemer-
gency Turkish psychiatric admissions according to a repre-
sentative study in Turkey. (Salgirtay, 1979)
In a retrospective investigation of inpatient cases in a
university clinic diagnosed as any form of "hysteria" in the
1970s, 6% of the whole inpatient population in a ten-year
period, there was not a single case of multiple personality
disorder (Sar, 1983). The sole published Turkish article about
multiple personality disorder was a review which questioned
why it was not diagnosed in Turkey (Ozmen, Cigeroglu, 
Ertan, 1992). The first multiple personality disorder cases
in Turkey were reported by our research team recently (Tut-
kun, Yargic Sar, 1994; Yargic, Tutkun Sar, 1994a) . There
have been suspected cases, but they were not reported because
most Turkish psychiatrists do not accept this diagnosis or
have considered it as an epiphenomenon of schizophrenia,
affective disorders, or borderline personality disorder.
According to the responses to a questionnaire sent to the
senior psychiatrists in various institutions in our country, only
19% of them have had a patient with MPD (Sar, Yargic, 
Tutkun, in press).
Our curiosity in multiple personality disorder started
with our interest in so called "hysterical psychosis" (or pseu-
3
Di55OCt1TIO1.ll. CIII, No, I, larch 1995
DID: CLINICAL INVESTIGATION OF 20 CASES IN TURKEY
dopsychosis) which is afrequent diagnosis, especially in emer-
gency psychiatric units in Turkey- It is characterized by acute,
severe time-limited dissociative symptoms following a life stress,
and as its name implies, shows the phenomenology of a brief
reactive psychosis (Ozturk & Gogus, 1973; Ozturk, 1993; Ozturk
& Volkan 1971). Our first case was admitted to our emer-
gency psychiatric unit, with manifestations typical for pseu-
dopsychosis.
SUBJECTS AND METHODS
Subjects
The subjects of this study were the first 20 consecutive
. patients with multiple personality disorder who were seen
by the authors. All of the subjects were patients at the Medical
Center of Istanbul University, Istanbul Medical Faculty, a
general hospital including a psychiatric clinic with inpatient
and outpatient facilities. Our clinic is one of the referral cen-
ters for the metropolitan Istanbul area, with a population of
8 million, and for the whole country as well.
The patients, who were admitted to various units of the
psychiatric and neurologic clinics over a ten-month period
with symptoms of pseudopsychosis, psychogenic amnesia,
fugue and dramatical conversion symptoms, were referred
to our research team by their physicians. During the research
period, 63 patients were diagnosed as having some form of
dissociative disorder. They were called for follow-up. Twenty
patients among them were diagnosed definitely as multiple
personality disorder during successive interviews and were
included in this study. Twenty-four patients, who were diag-
nosed as "Dissociative Disorder Not Otherwise Specified, "
and whose relatives described different personalities in
detail, were not accepted for the study, because we could
not observe these personality states ourselves.
Methods
Because these are the first MPD cases detected in our
clinic, data collection for this study underwent a gradual evo-
lution, as our knowledge and experience increased. Newer
assessment techniques were added during the follow-up peri-
od. We developed an original unstructured clinical inter-
view technique with the aid of the American literature about
diagnosing MPD. We relied especially on the SLID-D (Structured
Clinical Interview for DSM-IV Dissociative Disorders) of
Steinberg (1993). The following data were gathered on admis-
sion: psychiatric and medical history, mental status exami-
nation, physical and neurological examination, EEG,
Rorschach's test, Stanford-Binet intelligence test, and neu-
ropsychological tests. A collateral interview with a family mem-
ber was obtained for all patients.
An evaluation form consisting of 126 items was devel-
oped to take information about demographic data, presenting
psychiatric and medical symptoms, psychological trauma, legal
problems, previous diagnoses, and any family history of psy-
chological disturbance. After the initial diagnoses, information
about symptoms of dissociation and MPD were gathered as
the follow-up continued. Because this evaluation form was
developed after our project began, it was completed retro-
spectively on four patients.
All patients except one were administered the Dissociative
Experiences Scale-DES (Bernstein & Putnam, 1986) after the
initial diagnoses of chronic, complex dissociative disorder
(MPD or E)DNOS). The Turkish version of this scale has a
high reliability and validity according to our data (Yargic,
Tutkun, & Sar, 1995) derived from a non-clinical and clini-
cal population in Istanbul.
All 20 patients were diagnosed according to the strict
diagnostic criteria of DSM-III-R. Seventeen of them also ful-
filled NIMH research diagnostic criteria; i.e., there was amne-
sia between at least two personalities and these personalities
were observed with full control during therapy sessions at
least three times. On the remaining three patients, who stayed
under our observation only for a short time, we could observe
personality switches two times instead of three, but the patients
and their relatives described separate personality states in
detail.
RESULTS
Patient Sources
The patients came from different sources. Eight patients
had been admitted to the emergency psychiatric unit for
amnesia (two) , pseudopsychosis (four) , fugue (one) and con-
version/blindness (one). Five patients had been hospital-
ized in a psychiatric unit with diagnoses other than disso-
ciative disorders. Four patients had been admitted to the
neurologic outpatient clinic for severe headaches when they
were detected. One patient was referred from the psychi-
atric outpatient unit with the diagnosis of chronic post-trau-
matic stress disorder (due to prolonged childhood sexual
abuse and incest). One patient was detected by one of the
authors during psychiatric consultation at the neurological
inpatient unit. One patient was referred by the psychiatric
outpatient unit with the initial diagnosis of MPD: she had
aggressive outbursts as chief complaint.
Demographic Characteristics of Patients
Eighteen patients (90%) were women in their twenties
or younger. The mean age of the patients was 20.0 (range
1 1 to 38 years) with an average education of seven years (range
0 to 11 years) . Seven female patients were married. One female
was living separately. Seven of the patients were employed.
One of the male patients was employed, the other one was
a student. Five patients were housewives. Two patients had
left their jobs, two had interrupted their education because
of their dissociative symptoms, two of the employed patients
had long periods of sick leaves and could not work regular-
ly. All of the employed patients worked at an occupational
4
DISSOCIATION. Vol.VIII. No. I. llarcli 1995
TUTKUN/YARGIC/SAR
TABLE 2
Characteristics of Alternate Personalities
Characteristics Number Percent
Personalities with different names 12 60
Child alternate personality 11 55
Suicidal alternate personality 9 45
Helper/protector alternate personality 6 30
Persecutor alternate personality 5 25
Opposite-sexed alternate personality 5 25
thoughts of passive influence. The mean number of
Schneiderian symptoms per patient was 4.0 (range, 1 to 7).
Thought withdrawal, thought broadcasting, and thoughtread-
ing were not experienced by any patient.
Alcohol or substance abuse was not present in any patient.
Previous Psychiatric Diagnoses
Nine (45%) patients had previous psychiatric diagnoses,
some of them had more than one. The most common pre-
5
TABLE 1
Types of Childhood Trauma Reported by Patients with MPD
Type Number Percent
Physical abuse 11 55
Sexual abuse (including incest) 11 55
Emotional abuse 10 50
Incest 7 35
Neglect 5 25
Extreme poverty 3 15
Witness to accidental death 1 5
level of semi-skilled or lower.
Onset of Illness
It was impossible to take uniform
information about the onset of illness.
Most of the patients had had their first
dissociative symptoms before the age of
10. Some of the patients could not give
reliable information because they had
amnesia about their childhood and ado-
lescence.
Diagnostic Procedure
The duration of our follow-up
ranged from two interviews to two years.
Six patients were followed for less than
one month, four patients were followed
between one to five months, six patients
were followed between five to 10 months
and four patients were followed for
more than 10 months. The four patients
who were followed longer than 10
months included two patients who were
diagnosed as MPD before this study
began, and two others who were followed
as chronic depression. The time spent
from intake until MPD was diagnosed
varied widely. Three patients were diag-
nosed (seeing personality switches and
intrainterview amnesia) during the first
interview, and five patients during the
second interview. Three patients were
diagnosed between six and 12 weeks,
and nine patients were diagnosed after
more than three months of follow-up.
Psychiatric Symptoms
All of the patients had depressive
symptoms. But because the depressive
symptoms were confined to specific per-
sonalities and they disappeared with per-
sonality switches, we did not consider
affective disorder as a definitive diag-
nosis for any patient.
Chronic and severe headache was
one of the most common complaints (17 patients, 85%).
Eight individuals (40%) had previous suicide attempts.
Eight patients had chronic self-abusive behavior other than
suicide attempt. Thirteen individuals (65%) had demonstrated
aggressive behavior.
All of the patients had at least one Schneiderian first
rank symptom. Auditory hallucinations expressed as inner
voices were detected by 19 individuals (95%). One patient
(age 11) did not have auditory hallucinations but had
DISSOCIATION, Vol.No. l. Mardi 1995
DID: CLINICAL INVESTIGATION OF 20 CASES IN TURKEY
vious diagnosis was schizophrenia or psychotic disorder (30%) .
The others were personality disorder (15%), post-traumat-
ic stress disorder (15%), depression (10%), and conversion
disorder (10%). Nine patients had either been hospitalized
before or during our follow up. Ten patients (50%) were
known to have consulted paramedical healers and clergy for
their symptoms.
History of Previous Trauma
Seventeen patients revealed that they had traumatic life
events before age 16. Ten patients had more than one kind
of psychic trauma. The types of childhood trauma experi-
enced by the patient sample are listed in Table 1. The mean
number of psychic traumas per patient was 2.1.
Only seven patients had alters who related their exis-
tence to a specific childhood traumas.
History of Legal Difficulties
None of our patients had legal problems. One of the
alters of a female patient introduced herself as prostitute,
but whenever she came to the point of sexual relationship
one of the host personalities emerged and escaped. Two
patients had committed assault and battery but they had not
been legally punished. One of the male patients, 11 years
old, was a well-mannered and hard-working student until his
dissociative symptoms made him unable to attend school.
We have very limited knowledge about the other male patient
(age 19) due to short follow-up.
Family History
The fathers of nine patients (45%) had either alcohol
abuse or excessive gambling or both. Chronic dissociative
disorders (DDNOS) were present in the first degree relatives
of four patients (20%). No cases of affective or psychotic dis-
orders were reported in any of the first degree relatives.
Four patients had children. All of the children were
younger than 15 years of age. Only one of them (nine years
old) had had psychiatric admission, and she was diagnosed
as DDNOS.
Characteristics Alternate Personalities
The patients had a mean number of 5.1 personalities
(range 2 to 10, median 4, mode 4). Characteristics of alter-
nate personalities are shown in Table 2. In 13 patients (65%)
we have not met alter personalities who relate their appear-
ance to childhood trauma.
MedicalStatus and EEGs
Only one of the patients (5%) had a serious physical ill-
ness.She had been hospitalized in the neurological clinic
due to blurred vision. Optic neuritis was detected. Her mag-
netic resonance imaging (MRI) was normal. She was diag-
nosed as probable multiple sclerosis (MS). None of the patients
had epilepsy.
EEGs were completed on 17 patients (85%). Only one
of them was definitely abnormal. This was the patient with
optic neuritis. There was localized and nonspecific organi-
zational disturbance in the right hemisphere.
Psychological Testing and Standardized Measures of
Psychopathology
The 19 patients who received the DES (possible scores
0 to 100) had a mean score of 47.2 (SD = +-17.6, and a range
of 10.1 to 76.7).
Rorschach testing did not show overt psychotic features
in any patient. IQs (tested with WAIS method) of the patients
ranged from borderline to superior.
DISCUSSION
This study is the first series ofMPD cases presented from
Turkey. In spite of the relatively small sample size, it shows
that MPD is much more common than imagined in Turkey
(Ozmen et al, 1992; Sar et al., 1994). Coons gathered 50
patients in 13 years (Coons, Bowman, Milstein, 1988) . We
identified 20 patients in 10 months, probably because we are
one of the few centers giving psychiatric care to a large pop-
ulation in Istanbul.
This study has limitations. First of all, the duration of
follow-up was very short for some patients. Extensive and
reliable data-gathering was not possible in those cases fol-
lowed briefly. Also, only one patient could come to the level
of fusion during psychotherapy over the period of data col-
lection. Many patients still show clues suggesting that there
are additional unmet alter personalities. Unfortunately,
some patients dropped out of therapy. Our opinion is that
our data do not reflect the real number of alter personali-
ties and frequency of childhood trauma in our patients; rather,
they indicate the minimum. Our patients have not been dis-
covered in a representative population of Turkish psychi-
atric patients. Most of them were found with the efforts of
the authors. Therefore our results cannot be seen as defini-
tive of the true features of MPD in Turkey.
In our series the female to male ratio is 9:1. This is the
same proportion as the findings of Ross and his colleagues
in North America (Ross, Norton, Wozney, 1989). Our
patients are younger than the patients in other series
(Putnam, Guroff, Silberman, Barban, Post, 1986; Coons
et al., 1988; Ross et al., 1989). While some symptoms of the
patients in this study resemble closely the symptoms of patients
in several recent American reports, they are different in some
aspects (Coons et al., 1988; Ross et al. 1989; Putnam et al.,
1986). The incidence of depressive symptoms and suicide
attempts are quite similar. The mean number of personali-
ties of the patients in this study (5.1) is substantially lower
than the mean numbers reported by Putnam (13.3), Ross
(15.7) and Coons (6.3). The median number (4) is the same
with the Coons study but less than the Putnam (9) and Ross
6
DISSOCIATION. Vol. V111 Nu. I. March 3995
TUTKUN/YARGIC/SAR
(8) studies. The difference in means is probably due to two
factors. In this study the number of personalities was sam-
pled very early during the follow-up, perhaps before all of
the personalities had been discovered. Furthermore in all
of the other studies there were larger series, providing a greater
chance of including patients with large numbers of person-
alities, occur, could skew the mean upward.
Possession was reported to be the major clinical mani-
festation of dissociative disorders in India (Adityanjee,
Khandelval 1989) . We had only one case in 63 patients whose
history was typical for "demonic" possession.
Alcohol and substance abuse was reported to be frequent
in American studies (Coons et al., 1988; Ross et al., 1989;
Putnam et al., 1986). This was not true for our series. There
may be two reasons. Our sample is younger, and there is a
relatively lower ratio of substance abuse in Turkey, especially
among women (Ozturk, O.M., 1993).
The occurrence of headaches in MPD has been report-
ed by several investigators. Coons reported headache in 56%
of the 50 MPD patients and Putnam reported 65% (Coons
et al., 1988; Putnam, etal.,1986) . The incidence of headache
may have been over-represented in our study because of our
close collaboration with the neurological clinic in our hos-
pital. Headache was often worse either before or during and
sometimes after the transition from one personality to anoth-
er.This pattern is the same with the previous reports (Coons
et at, 1988; Putnam, 1984).
It has been suggested that the dissociation in MPD is a
manifestation of chronic limbic epilepsy or an interictal phe-
nomenon of temporal lobe epilepsy (Mesulam, 1981; Schenk
Bear, 1981). (Coons, et al., 1988) reported 10% epilepsy
in 50 MPD patients, and concluded that it is extremely unlike-
ly that this hypothesis is accurate. It was also demonstrated
that there is no etiological relationship between temporal
lobe dysfunction and dissociation (Loewenstein Putnam,
1988) . In our series, there was only one patient with an abnor-
mal EEG and she had not had any seizures. It would be unsci-
entific and speculative to consider her three complex alter
personalities with different social relationship patterns to be
an ictal manifestation. Our data suggest that dissociative expe-
riences in our patients did not have an epileptic origin.
The high incidence of childhood trauma in this study
is consistent with the results of previous studies (Coons et
al., 1988; Ross et al. 1989; Putnam etal.,1986). Coons reports
68% sexual abuse in 50MPD patients, and this is more com-
mon than our findings (55%). But emotional abuse which
was noted in 10% of the Coons study patients is more fre-
quently reported (50%) in our patients. The childhood trau-
mas in our series generally were not as brutal as the ones in
American literature (Putnam, 1989; Ross, 1989b). We
acknowledge that the lower incidence of trauma in our patients
may be due to shorter duration of follow-up and in this series,
with consequent incomplete exploration of their alter sys-
tems.
In our series 30% of MPD patients had a previous diag-
nosis of a psychotic disorder. Eleven of thepatients had the
first psychiatric consultation in their lives by the authors dur-
ing this study. When we exclude these patients, having a pre-
vious diagnosis of a psychotic disorder rises to 66%. This fig-
ure confirms reports by otherinvestigators that suggest that
MPD is frequently misdiagnosed as schizophrenia (Coons et
al., 1988; Ross et al. 1989; Putnam et al.,1986) . The low num-
ber of previous psychiatric admissions is probably due to the
less frequent utility of psychiatric facilities (especially for psy-
chiatric disorders other than psychotic states) in Turkey. Half
of the patients had consulted paramedical healers and
prayers.
The high frequency of Schneiderian first-rank symptoms
in MPD patients confirms that these symptoms are not spe-
cific for psychotic disorders. In our series the average num-
ber of Schneiderian symptoms per patient was 4.0 (range, 1
to 7). It was reported as 4.54 and 3.4 in two different previ-
ous studies (Ross et al., 1989, Kluft, 1987b). Ross reported
that the most common Schneiderian symptoms in MPD patients
are voices arguing (71.1%) and voices commenting (66.1%)
(Ross et al., 1989). Auditory hallucination of commenting
voices was the most common one in our series (95%). These
were typically described as "inner voices" (Coons etal.,1988).
PatientslQs in this study were found to range from bor-
derline to superior and are consistent with results found pre-
viously (Coons et al., 1988).
MPD was proposed to have a familial tendency in previ-
ous studies (Ross et al., 1989; Putnam et al., 1986) . Ross report-
ed that the mean number of MPDs is 0.69 in the first degree
relatives of 236 cases. In our series, four patients (20%) had
DDNOS in their first degree relatives. Two of them were moth-
ers, one was a sister, and the other was the daughter of a
patient.
The mean DES score was 47.2, very close to the mean
DES scores of MPD patients reported in other studies (Carlson
Putnam, 1993).
CONCLUSIONS
The present study has described the clinical phe-
nomenology observed in 20 consecutive cases of MPD in Turkey.
The clinical phenomena of the patients in our series are very
similar to those reported from North America. This suggests
that there is a stable set of core phenomena found in MPD
patients across various cultures. This patient population is
largely composed of female outpatients who reported his-
tories of significant childhood trauma.
In many patients, pseudopsychosis ("hysterical psy-
chosis"), although self-limited, did not occur only once in
life, as considered earlier. It is usually a manifestation of a
more chronic and complex dissociative disorder, MPD or
DDNOS. These patients suffered from severe headaches and
were mostly misdiagnosed as having psychotic disorder. 
7
DISSOCtiTION, Vol. VIII. No. 1, March 1995
DID: CLINICAL INVESTIGATION OF 20 CASES IN TURKEY
The authors wish to thank Salih Zoroglu, M.D., Leyla Alkas,
M.D., and Kaan Kora, M.D.,
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