to diagnose and treat illness

1. Eur Psychiatry 1999 ; 14 : 270-7
´
© 1999 Editions scientifiques et médicales Elsevier SAS. All rights reserved
ORIGINAL ARTICLE
Dissociative Identity Disorder: diagnosis and treatment
in the Netherlands
H.N. Sno1, H.F.A. Schalken2
1
Department of Psychiatry, De Heel General Hospital, PO Box 210, 1500 Ee Zaandam, the Netherlands; 2 University
Department of Psychiatry, Academic Medical Center Amsterdam, the Netherlands
(Received 8 February 1999; final version 21 June 1999; accepted 30 June 1999)
Summary – Dissociative Identity Disorder (DID) is a controversial diagnosis and empirical data on the efficacy of
treatment modalities are scanty. The objective of this study was to explore the frequency of the diagnosis, the types and
efficacy of prevailing treatment practices, and to examine demographic data on patients in the Netherlands.
A questionnaire, including questions on one selected DID patient, was mailed to 1,452 Dutch psychiatrists. The
response rate was 46.7%. A total of 273 psychiatrists reported having made the diagnosis at least once. The diagnosis
was made in a statistically significant manner more frequently by female psychiatrists, by psychiatrists aged 50 years
or younger, and by those certified after 1982. No correlation was observed with primary theoretical orientation or the
type or topography of work facility.
The mean age of the selected patients was 33.2 and the male:female (M:F) ratio 1:9. The majority of patients were seen
once a week in an outpatient setting. Individual psychotherapy and adjunctive anxiolytic or antidepressant medications
were the most widely endorsed treatment modalities. Hypnosis was rarely used.
We conclude that the diagnosis of DID is not to be dismissed as a local eccentricity. It is warranted as an explanatory
framework in the context of a psychotherapeutic treatment. © 1999 ´ditions scientifiques et médicales Elsevier SAS
E
dissociation / dissociative identity disorder / Dutch psychiatrists / multiple personality disorder / survey
INTRODUCTION results of a questionnaire study by Dunn et al. [12] in
all veterans’ administration (VA) medical centers in the
The status of Dissociative Identity Disorder (DID) as a USA indicated that VA psychiatrists had more doubts
distinct clinical entity remains controversial. The psy- about the diagnosis than VA psychologists. Based on a
chiatric community seems to be split into impassioned survey among 294 psychiatrists in Canada, Mai [22]
protagonists [4, 19, 30, 32] and antagonists [7, 13, 23, concluded that the diagnosis was made by a small
26, 27]. In a letter to the editor, Chodoff [7] wrote that number of psychiatrists. Pope et al. [27] mailed a one-
in the 40 years of his psychotherapeutic practice, his page questionnaire to 367 board-certified American
experience with Multiple Personality Disorder (MPD) psychiatrists and concluded that there appeared to be
had consisted of one very doubtful case. An informal little consensus regarding the diagnostic status or scien-
poll of his colleagues revealed that most of them had tific validity of DID.
not seen more than one or two instances of this diag- The treatment of DID patients is based primarily on
nosis. A survey conducted by Dell [10] among 62 psy- clinical experience and anecdotal observations. There
chotherapists, showed psychiatrists as the most fre- have been no well designed empirical studies on the
quent purveyors of scepticism concerning MPD. The efficacy of any treatment modality. Clinical experts

2. Dissociative identity disorder in the Netherlands 271
advocate a long-term and intensive psychodynamic those who have not made the diagnosis. A significant P
psychotherapy facilitated by hypnotherapy [8, 14, 19, value was set as P < 0.05. The size of the study popula-
28]. To date, no specific pharmacotherapeutic agent tion varies due to missing data.
that cures the core dissociative symptoms is avail-
able [19, 34]. RESULTS
Because of this controversial status and the paucity of
treatment outcome data, a questionnaire was distrib- Psychiatrists and DID diagnosis
uted among Dutch psychiatrists to explore the fre-
quency of the diagnosis, the types and efficacy of cur- A total of 1,452 psychiatrists were approached: seven of
rent treatment practices, and to explore some of the them were deceased, two had moved abroad, and three
demographic information regarding the psychiatrists envelopes were returned to sender. Of the remaining
and the patients. In this paper, the results of the survey 1,441 psychiatrists, 661 completed and returned the
are described and compared with data from the litera- questionnaire, eleven called or wrote to say they had not
ture. completed it because of their age (65–88 years), retire-
ment, or prolonged sick leave. This produced a re-
METHODS sponse rate of 46.7% Three questionnaires were elimi-
nated because of incomplete information, yielding a
An anonymous one-page questionnaire with a stamped final cohort of 658 respondents (table I). On 1st Janu-
and addressed envelope was sent to all members of the ary 1996, a total of 1,565 psychiatrists were registered.
Dutch psychiatric association. An introductory letter Our study population thus included about 42% of the
explained the purpose of the questionnaire and speci- Dutch psychiatric community.
fied the criteria for the diagnosis of DID (DSM-IV) There was a significant correlation of diagnosis fre-
and MPD (DSM-III-R). Four weeks later, a reminder quency with the psychiatrists’ age (chi-square test,
was sent. The questionnaire contained twenty-five χ2 = 5.5, df = 1, P < 0.05), and years of clinical experi-
questions formatted in checklists and rating scales. It ence (chi-square test, χ2 = 6.6, df = 1, P < 0.01).
was intentionally kept short to enhance the response Younger (i.e., 50 years or younger) psychiatrists made
rate. the diagnosis more frequently than their senior (i.e.,
The questionnaire was divided into four sections. older than 50) colleagues (45% vs. 36%). Psychiatrists
The first nine questions focused on demographic and certified after 1982 reported making the diagnosis more
professional characteristics of the psychiatrist. The next frequently than those who completed their speciality
section consisted of two questions on the frequency of training earlier.
DID diagnosis and the number of treated DID pa- Female psychiatrists made the diagnosis significantly
tients. In the last two sections, following the format more frequently (50% vs. 39%) (chi-square test,
used by Putnam and Loewenstein [28], the questions χ2 = 6.1, df = 1, P < 0.01). The principal subspecialty
focused on anonymous demographic and treatment and topography of the work site did not exert a statis-
data of one patient. Respondents were asked to rank, in tically significant influence on the frequency of the
order of effectiveness, all treatment modalities used diagnosis. Nor was a correlation observed with a pri-
from a list of 12 therapeutic approaches. Medication mary theoretical orientation: psychiatrists with a psy-
efficacy was evaluated per major medication class on a chodynamic frame of reference did not exhibit more of
six-point scale, ranging from ‘worse’ to ‘excellent’ a tendency to make the diagnosis than biological orien-
symptomatic improvement. Finally, the respondents tated psychiatrists. The psychiatrists who reported giv-
were asked to specify the drug of choice for each medi- ing psychotherapy treatment did however make the
cation class. diagnosis significantly more frequently (47% vs. 22%,
Statistical analysis was performed using the statistical chi-square test, χ2 = 28.1, df = 1, P < 0.001).
product and service solutions 7 for Windows (SPSS).
Pearson’s chi-square test and the binomial test were DID patients and treatment
employed for nominal data and the Mann-Whitney U
test and the Kruskal-Wallis test were used for ordinal A total of 298 of the respondents had either made the
data. In calculations concerning the DID diagnosis, use DID diagnosis themselves or had treated patients diag-
was made of a dichotomy: respondents who have versus nosed with DID (table II). The majority (59%) of these

3. 272 H.N. Sno, H.F.A. Schalken
Table I. Characteristics of psychiatrists and DID diagnosis.
Mean age (n = 658) 49.6 Mean clinical experience (n = 656) 15.3
– SD 9.7 – SD 9.6
– range 33–80 – range 2–50
Gender (n = 651) n % Region (n = 637) n %
– male 491 74.8 – north Holland 179 28.1
– female 165 25.2 – east Netherlands 91 14.3
– five other regions range between 68–77
Primary work site (n = 654) n % Theoretical orientation (n = 648) n %
– psychiatric hospital 170 26 – psychodynamic model 277 42.7
– private practice 145 22.2 – biological model 119 18.4
– general or university hospital 105 16 – system theory 30 4.6
– community mental health center 95 14.5 – cognitive-behavioral model 23 3.5
– child psychiatry setting 81 12.2 – other 199 30.7
– other 58 8.9
Principal subspecialty (n = 652) n % Psychotherapy (n = 652) n %
– psychotherapy 241 37 – yes 517 79.3
– social psychiatry 87 13.3 – no 135 20.7
– clinical psychiatry 79 12.1 + number of patients (n = 509)
– child psychiatry 74 11.3 – mean 11.8
– biological 30 4.6 – SD 12.7
– forensic 30 4.6 – range 1–90
– geriatric 22 3.4 – less than ten a week 289 56.7
– consultation-liaison 21 3.2 – 10–19 a week 109 21.4
– other 68 10.4 – 20–39 a week 81 16
– 40 or more a week 30 5.9
+ duration (n = 507)
– short-term (less than one year) 155 30.6
– long-term (one year or more) 352 69.4
DID diagnosis (n = 653) n % Treatment of DID patients (n = 652) n %
– never 380 58.2 – never 414 63.5
– once 83 12.7 – once 76 11.7
– 2–5 times 136 20.8 – 2–5 times 125 19.2
– 6–10 times 28 4.3 – 6–10 times 15 2.3
– 10–25 times 21 3.2 – 10–25 times 21 3.2
– more than 25 times 5 0.8 – more than 25 times 1 0.2
patients were in the 20–40 year age category and 21 A total of 239 (36.3%) respondents reported having
(7%) below the age of 18. In comparison with demo- treated patients with DID (table III).There was a non-
graphic data on the Dutch general population (Central significant trend for women (Mann-Whitney U-test,
Statistics Office 1997), the selected DID patients ex- U = 1627, Z = –1.543, P > 0.05) and for higher edu-
hibited an over-representation of women (binomial cated patients (Kruskal-Wallis test, χ2 = 2.5, df = 3,
test, Z = 12.9, P < 0.001), the 20–39 year age category P > 0.05) to have been in treatment longer. There was
(chi-square test, χ2 = 114.2, df = 4, P < 0.001), people a significant relation with income level (Kruskal-Wallis
who live alone (binomial test, Z = 10.9, P < 0.001), test, χ2 = 11.0, df = 2, P < 0.01). The treatment dura-
well-educated people (chi-square test, χ2 = 83.32, tion of low income was shortest. The treatment dura-
df = 3, P < 0.001), unemployed people (χ2 = 241.4, tion and frequency were not influenced by the psychia-
df = 2, P < 0.001), and people with a low income (chi- trists’ gender. The psychotherapeutic approach was
square test, χ2 = 570.3, df = 2, P < 0.001). There was ranked first by 131 respondents whereas 17 ranked it
no significant difference as regards marital status. second: 17 respondents ranked medication first and 99

4. Dissociative identity disorder in the Netherlands 273
Table II. Characteristics of DID patients.
Mean age (n = 271) 33.2 Gender (n = 270) n %
– SD 11.1 – male 27 10
– range 10–76 – female 243 90
Living situation (n = 271) n % Cultural background (n = 274) n %
– with others 174 64.2 – Dutch 247 90.1
– alone 97 35.8 – non-Dutch 27 9.9
Marital status (n = 272) n % Education (n = 267) n %
– unmarried 133 48.9 – lowa 35 13
– divorced/widowed 109 40.1 – middleb 104 39
– married 30 11.0 – highc 106 39.7
– university 22 8.2
Employment status (n = 264) n % Income bracket (n = 238) n %
– employed 59 22.4 – lowd 141 59.2
– unemployedd 113 42.8 – middlee 73 30.7
– othere 92 34.9 – highf 24 10.1
a
Special school, primary school, lower vocational school; b Secondary school O levels, middle level vocational school; c Secondary school A
levels, higher vocational school; d Lower than minimum wage; e Between minimum wage and public health insurance level; f Higher than
public health insurance level.
Table III. Characteristics of treatment.
Mean duration (years) (n = 209) 2.8 Practice/institution setting (n = 214) n %
– SD 2.7 – psychiatric hospital 51 23.8
– range 1 month–16 years – private practice 45 21.0
– male patients (n = 22) 2.1 – general or university hospital 45 1.0
– female patients (n = 185) 2.9 – community mental health center 35 16.4
– low educational level 2.3 – child psychiatry setting 16 7.5
– middle 2.7
– high 3.0 Outpatient/inpatient setting n %
– university 3.3 – exclusively outpatients 92 43.2
– low income 2.3 – outpatients with hospitalizations 56 26.3
– middle income 3.6 – inpatients 41 19.3
– high income 3.4 – partial hospitalization settings 24 11.2
Adjunctive medication (n = 239) n %
Treatment frequency (n = 194) n %
– yes 173 72.4
– once a week 96 49.5
– no 38 15.9
– twice a month 49 25.3
anti-depressants (n = 124)
– more than once a week 27 13.9
– estimated efficacy: moderate to good 75 60.5
– once a month or less 22 11.3
anxiolytics (n = 124)
– estimated efficacy: moderate to good 73 60.8
Treatment modalities (n = 239) n %a
neuroleptics (n = 111)
– individual psychotherapy 154 64.4
– estimated efficacy: moderate to good 53 47
– medication 160 67.0
: none or inverse 17 15.3
– hypnotherapy 28 11.7
anticonvulsant (n = 15)
– art therapy 41 17.2
– estimated efficacy: moderate to good 7 46.7
– family therapy 35 14.6
lithium (n = 15)
– group therapy 22 9.2
– estimated efficacy: slight or none 11 73.3
– cognitive-behavoural 29 12.1
– ECT 2 0.8
a
Since more than one modality may have been used, the total percentage adds up to more than 100%.

5. 274 H.N. Sno, H.F.A. Schalken
ranked it second. Hypnotherapy was ranked first by our study, 273 (41.8%) psychiatrists noted having
two respondents and 17 ranked it second. made the diagnosis, and the predominance of respon-
Fluoxetine and paroxetine were the most frequently dents from the north of Holland corresponds with the
reported serotinin reuptake inhibitors, whereas clomi- high ratio of psychiatrists to population in this region.
pramine and amitriptyline were the most frequently No topographic relation could be detected. This is
used tricyclic antidepressants. The most frequently re- substantially more than in Switzerland, where 63
ported anxiolytics were oxazepam, alprazolam, cloraze- (10%) psychiatrists in Modestin’s study [24] reported
pate, and diazepam. Pimozide, haloperidol, thior- having seen a DID patient at one time or another. It is
idazine, and zuclopentixol were the most frequently however less than the 119 (66.1%) psychiatrists in
reported neuroleptics. As for anticonvulsants, carbam- Mai’s [22] study, who expressed the belief in the valid-
azepine was prescribed in eight cases. Lastly, three ity of the diagnosis. Mai [22] nonetheless concluded
respondents prescribed naltrexone. The estimated effi- that a substantial minority of the psychiatrists do not
cacy was slight to moderate. make it as a new diagnosis. Due to the low response rate
of 24%, the finding of Dunn et al. [12] that 81.9% of
DISCUSSION 456 VA psychiatrists acknowledged DID as a separate
clinical identity, is of limited value.
In spite of the limited number of questions and the The significant relation observed in our study be-
anonymity, the response rate was rather disappointing. tween the psychiatrist’s gender and the frequency of
In addition to survey fatigue, the low response rate may making the diagnosis differs from the findings of
have been due to the psychiatrists’ resistance to the Modestin [24] and Dunn et al. [12], who did not ob-
DID diagnosis. Our response rate is comparable to the serve any significant relation of either diagnosing or
52% reported by Dell [10], and to the 49% docu- believing in DID with the gender of the psychiatrist.
mented by Putnam and Loewenstein [28] in two sepa- Our finding that the diagnosis was more frequently
rate studies among 120 and 637 members of the inter- made by female psychiatrists may be explained by the
national society for the study of multiple personality preference of the predominantly female patients for
and dissociation. In addition, the response percentage psychotherapists of the same sex, or by the possibility
was higher than the 31.3% recorded by Dunn et that female psychiatrists are more open to the effects of
al. [12] among 3,600 VA psychiatrists and psycholo- traumata.
gists, but lower than the 66% observed by Modes- In concert with the findings of Dunn et al. [12] and
tin [24] among 1,273 Swiss psychiatrists, the 61.2% Mai [22], the diagnosis was made more frequently by
Mai [22] noted among 294 Canadian psychiatrists or younger psychiatrists. The relation between diagnosis
the 82% reported by Pope et al. [27]. The M:F ratio of frequency and clinical experience is not unequivocal. In
our respondents coincides with Modestin’s [24] find- Modestin’s [24] study, the diagnosis was made signifi-
ings. The mean clinical experience (15.3 years) is lower cantly more frequently by the more experienced psy-
than in Modestin’s [24] (17.5 years) or in the studies of chiatrists. This finding is consonant with the hypoth-
Putnam and Loewenstein studies [28] (23.4 years). esis that the total number of patients a psychiatrist has
Due to the anonymity of the questionnaire, it was seen in his or her career, which is assumed to be roughly
impossible to describe the non-responders. The M:F proportional to the years of clinical experience, will
ratio, the mean age, and the topographic distribution of affect the number of DID patients that the psychiatrist
our respondents however, coincides with the data Hut- had the opportunity to see. Dunn et al. [12] however
schemaekers et al. [17] gathered on all Dutch psychia- noted more of a tendency on the part of hospital
trists in 1992. In 1997, the M:F ratio of the members of psychiatrists with fewer years of experience to believe in
the Dutch psychiatric association was 69.3%:30.7% the validity of the DID diagnosis. In our study, the
(personal communication 1998). Despite the disap- diagnosis was made significantly more frequently by the
pointing response rate, our cohort of respondents less experienced psychiatrists. The findings concerning
would seem to be representative for the Dutch psychi- age and clinical experience suggest a link with the
atric community. timing of speciality training. Psychiatrists who were
The conjecture that in the Netherlands a DID diag- confronted with the diagnosis before or during their
nosis is mainly made by a small number of psychiatrists training tended to make the diagnosis more frequently
in and near Amsterdam [9] has not been confirmed. In than those who did not learn of it until afterwards. One

6. Dissociative identity disorder in the Netherlands 275
explanation might be the influence of he DSM classifi- percentages of psychiatrists who reported using psycho-
cation system on the psychiatrists’ diagnostic practices. therapy (95%) and hypnotherapy (70%) in the study
Simultaneous with the introduction of the MPD diag- by Putnam and Loewenstein [28] was probably associ-
nosis in 1980, the concept of hysteria – which the DID ated with a dissimilarity in the study populations. In
diagnosis was hitherto classified as a symptom of – was addition to psychiatrists, the respondents in their study
eliminated from the DSM-III. It is not inconceivable included psychologists, social workers, and psycho-
that the psychiatrists who were certified before 1980 therapists who were members of the international soci-
prefer the hysteria diagnosis to dissociative identity ety for the study of multiple personality and dissocia-
disorder. tion.
Of the 298 patients, 239 were treated by the respon- As was found in previous studies [3, 24, 28, 30], our
dents. This cohort of patients is somewhat smaller than study shows that most of the patients were mainly
the cohort of 305 patients in the study by Putnam and treated as outpatients. This finding is consistent with
Loewenstein [28]. The predominance of women is in the notion that treatment should be given on an outpa-
agreement with the ratios noted in the literature, which tient basis, and that the indications for hospitalization
range from 3:1 to 9:1 [1]. The M:F ratio and mean age are similar to those for non-dissociative conditions [15,
of the patients concur with the findings of Putnam and 16, 19, 20, 25]. In 49.5% of the cases, the treatment
Loewenstein [28]. frequency was once a week. The mean treatment fre-
The ‘bulge’ in the 20–30 age distribution category quency was thus lower than the twice a week advised by
coincides with previous observations that MPD usually Coons [8] and the mean frequency of 1.94 sessions a
manifests itself in early adulthood and before the age of week reported by Putnam and Loewenstein [28].
40 [1, 19]. The findings on mean age, educational level, A majority of the patients were treated with adjunc-
and work situation of the patients also concur with the tive medications. Since no medication has yet demon-
data of other authors [3, 28]. The percentage of people strated a specific impact on dissociative psychopathol-
who live alone is somewhat higher than in the 100 ogy, the pharmacotherapy is evidently symptom-
patients described by Putnam et al. [29]. The age dis- oriented or palliative [19, 28, 34]. Several of the
tribution of the patients indicates that juvenile patients methodological difficulties described by Putnam and
can be diagnosed with DID: patients below the age of Loewenstein [28] limit the interpretation of our find-
10 have been described. Riley and Mead [31] reported ings on the type and efficacy of the prescribed medica-
the treatment of a 3 year old girl. The percentage below tions. At most, the results render a tentative outline of
the age of 21 is somewhat smaller than the 11% the medication regimens of psychiatrists during the
Kluft [18] noted as being diagnosed with DID before psychotherapeutic treatment of DID patients.
the age of 20. A substantial number of patients treated with medi-
The mean (2.9 years) and the longest (16 years) cation were given anti-depressant or anxiolytic medica-
duration of treatment correspond with the findings in tions. In a majority of these cases, the reported efficacy
previous studies. [8, 28, 29] Studies by Coons [8] and was moderate to good. Ancillary anti-depressant or
by Putnam and Loewenstein [28] demonstrated that anxiolytic medications were indicated in the event of
approximately 95% of the patients were treated with concomitant anxiety, somatoform, and depressive
psychotherapy, and 80 and 90% respectively with hyp- symptoms [19, 21, 30, 32, 34]. Contrary to the find-
notherapy techniques. However, in the Netherlands ings of Coons [8], in 66.7% of nine patients treated,
hypnotherapy techniques were used by a minority neuroleptics were reported to have had no effect or an
(11.7%) of the psychiatrists. The divergence is indis- inverse effect in 15.3% of the patients. This finding is
putably based on a dissimilarity in the respondent striking, since neuroleptics are alleged to reinforce dis-
populations; it probably also reveals an omission in the sociation, which is a reason not to prescribe them [28].
psychiatric speciality training. Our observation that In agreement with Loewenstein’s view [21],
psychotherapy is the most frequently used (64.4%) Torem [34] stressed that neuroleptics should only be
treatment approach and that it was viewed by a major- prescribed in cases of severe agitation or in cases where
ity of the respondents as the most effective treatment anti-depressant or anxiolytic drugs were ineffective.
method, is probably linked to the finding that the DID A small number of patients had been treated with
diagnosis was more frequently made by psychiatrists anticonvulsants. For most of them, the estimated effi-
who treated patients with psychotherapy. The higher cacy was moderate to good. A similarly small number of

7. 276 H.N. Sno, H.F.A. Schalken
patients had been treated with lithium. For most of concept can serve as a legitimate explanatory and con-
them, there was slight or no estimated efficacy. This ceptual framework for the treatment of complex psy-
finding confirms the opinions of Loewenstein [21] and chological phenomena and psychiatric symptoms.
Ross [32] that lithium should not be prescribed to treat Ross [32] rightly notes that therapists can lose sight of
DID. The prescription of anticonvulsants and lithium reality during the therapy and forget that ‘altered per-
is based on the assumed post-traumatic etiology and the sonalities are not people. They are not even personali-
speculated influence on limbic system kindling and the ties. (.....) The patient is acting as if she is more than one
GABA system [35]. The treatment with anticonvul- person, but she isn’t.’ Descriptions in the media or in
sants is also based upon an assumed association with novels similarly exhibit a tendency towards literal inter-
epilepsy [2, 11]. pretations. This is in fact quite understandable if one
None of the respondents prescribed clonidine or bears in mind the intricacy of translating psychological
propanolol. According to Braun [6], the combination phenomena into words. One of the difficulties here is
of clonidine, which inhibits the central noradrenergic the influence of very subtle semantic differences. The
activity of the locus coeruleus, and a high dose of semantic influence is, for example, illustrated by the
propanolol, which influences the peripheral sympa- difference between the English translation and the Ger-
thetic system, is effective in treating hyperarousal, anxi- man and Dutch translation of Stendhal’s French ‘deux
ety, impaired impulse control, disorganized thinking, têtes’ (i.e., two heads) in ‘le Rouge et le Noir’ [33]: “Julien
and rapid switching of identities. As few as three re- rit de bon cœur de cette saillie de son esprit. En vérité,
spondents prescribed naltrexone with a slight to mod- l’homme a deux têtes en lui, pensa-t-il. Qui diable
erate effect. The prescription of this opiate antagonist is songeait à cette réflexion maligne ?” The English ver-
based upon the hypothesis that the endorphin system is sion refers to ‘two separate beings’, and the German and
activated in DID patients [5]. Loewenstein [21] Dutch respectively to ‘zwei Seelen’ and ‘twee zielen’ (i.e.,
stressed however, that treating patients with naltrexone ‘two souls’).
should be viewed as experimental, and Torem [34]
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