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0:00
>> I'll give you a quick introduction, I'll tell you quickly what I'm gonna go over, and it's divided into three sections, so I've got three sets of slides, and we'll take a break between each of those sections. And we're finishing at... 9:00 or 9:15?
0:18
9:15-- it's a little loose? >> We could go later if you-- >> 11:15, 12:00? (audience laughing) Uh, so, I'm a psychiatrist, born in Canada, grew up in Canada, went to medical school in Canada from '77 to '81. Did my psychiatry training in Canada from '81 to '85. Then, I was an academic psychiatrist in Canada, '85 to '91. And then, in '91, I moved to Dallas where I've been since, running a hospital-based trauma program. In '98, we opened a trauma program here at Forest View, and then, in 2000,
0:53
I kind of inherited a pre-existing trauma program at a hospital in LA. And in Dallas, I've-- I'm now at my third hospital. So the first hospital I was at is closed-- the corporation went out of business. Second hospital I was at closed temporarily, so we moved to a sister hospital in the Dallas area. So basically, I... help with oversight, overview, educating the staff, consulting to the staff. I do lots of writing, lots of talking, and I do, in Dallas, three groups a week in person.
1:35
Here in Michigan, I do two groups a week by video conference. I come up once a month for two days. And in LA, I do two groups a week by video conference, and go kind of intermittently to LA. So I'm actually hands-on involved in clinical work, not just a theory guy, sits at his desk and smokes cigars and plays golf sort of thing.
1:58
I decided to be a psychiatrist way back, and then kind of did a life detour around and about, got to medical school in '77, 100% intending to be a psychiatrist. But I learned fairly quickly in medical school that it's best to keep that a little bit quiet, because the surgeons and the internists generally didn't have a whole lot of respect for psychiatry, and were all disappointed if they heard you're going to psychiatry.
2:27
Didn't really have any particular thoughts about trauma, dissociation, multiple personality disorder, anything kind of in that ballpark at the beginning of medical school. Then in... early in...
2:42
Hey. For some reason, when you phoned me, I answered, I said, "Hello," but you weren't there. >> I was standing outside too long-- my phone fell asleep. (laughing) >> Oh, not to mention you. This is Jessica, who's the program director at the Forest View hospital. >> Hello. >> Feel free to sit somewhere. >> Okay. >> And so, early in the third year medical school, you start doing rotations, and... you do surgery, internal medicine, pediatrics obstetrics, gynecology and psychiatry.
3:13
And your basic job as a medical student is to get harassed by the nurses, try and stay out of the way, and do some kind of menial task that nobody else wants to do. And that involves taking a history, for one thing. So somebody comes in, and you have to go take a history and write it up in great detail, because the psychiatrists don't want to spend all that time asking all those questions or writing that stuff out. And as you're doing that, of course, then you learn, by asking questions,
3:40
talking to people, finding out what's going on. And so... kind of like a third of the way into the rotation, which was eight weeks, I was assigned to do an intake history on a woman who had been referred in by her family doctor. And she was late-ish 20s, and her story was-- so this is in Edmonton, in Canada-- her story was, a week previous to my talking to her, she had all of a sudden come to at the airport, and she had a blank spell of a week, and didn't know where she'd been.
4:14
Not even what city she was in, for a week. Then, from that point in time, going back, she had normal memory for a month, and at that point in time, she had come to at the airport, but that time she was missing a whole month. So that was kind of the puzzle of what's going on with this woman, and I'd read a little bit about hypnosis, so I was kind of practicing my hypnosis techniques with people who are... not really trauma people, just general adults, psychiatric in-patients
4:45
for help for sleep, help for relaxation, maybe a little anxiety reduction. Basically just practicing the rigmarole of hypnotizing somebody. So since she had amnesia, I thought, "Well, maybe I'll try hypnotizing her, "see if she can remember." She's very easy to hypnotize, and immediately she remembered that she had been in eastern Canada-- she was separated from her husband, she was in eastern Canada visiting her kids, on both occasions, and she had bought them a whole lot of presents.
5:18
Well, where did she get the money from, was the question. Well, where she got the money from was her pretty wealthy, high-spending construction guy boyfriend. And he wisely had decided to set up a joint account with her, and she had taken a whole bunch of money out of his account and put it in four different accounts, and then, during the period of time she didn't remember, she'd emptied out those accounts, used that to buy the plane ticket and buy a whole bunch of presents for her kids.
5:47
So is that true or did that really happen? So what we did is called the banks and went through a procedure, and a detective actually came in and interviewed her, because she had bounced a couple of checks. So all these bank accounts did in fact exist, the money in fact was spent. She was married-- or separated-- she did have kids. And so, that was interesting, as a third-year medical student. And my supervising psychiatrist was off on vacation for a couple of weeks,
6:14
so his replacement supervisor basically said, "Oh, yeah, whatever you wanna do." That was my supervision. And... after a couple of these hypnosis sessions, she said, "You know, sometimes, "I joke around with my boyfriend, "and I tell him, 'That wasn't me you kissed, "'that was Suzy,'" a different name. I said, "Yeah, okay, whatever." And then, I can't really remember why, but I decided after I had hypnotized her and she's all relaxed and everything,
6:43
to say, "Well, how are you feeling today, Suzy?" All of a sudden, 11-year-old Suzy's talking to me. She's the one who did all the money and the bank accounts and bought the ticket and went back and saw the kids, and the grown-up regular person didn't remember. So there I was with a case of multiple personality. Third-year medical student, know nothing about nothing. So my supervisor, by this point, had come back from his period of vacation, so I said,
7:12
"Well, I've got this multiple personality case." He's like, "Oh, yeah, okay." "Well, what should I read about that?" This is in 1979. He says, "I don't know. "Why don't you go to the library?" Good suggestion. So I go to the library. Started looking around in textbooks, and I find a couple of review papers, one from the '70s and one from the '60s, and I learn that this is the 200th case of multiple personality disorder ever diagnosed in the history of Western medicine. Huh.
7:48
So that's a little bit weird. And what are the odds of that? And so, I end up writing that case up and publishing it in the "International Journal "of Clinical and Experimental Hypnosis" in 1984. That was my first case-- that's how I got into it. And I thought, "Well, that was really interesting, "but obviously I'm never gonna see "another case again. "It's just a statistical fluke." Then, finished medical school, I'm in my residency program, and we have a long-term psychotherapy program
8:19
where each resident follows two people for as long as required. And every year, on each of those cases, you change supervisor. So you get a bunch of different cases and a bunch of different supervisors. So I'm working with this woman who's a pretty seriously battered spouse, depressed agoraphobic, anxious and lo and behold, she has a couple parts inside. So now I've got two cases. Then I finish my residency in 1985, and, um, at the end of the academic year, which is the end of June,
8:53
and in September, a woman comes to the emergency department, is assigned to me as a general in-patient psychiatrist, and lo and behold, I figure out that she has multiple personality disorder. So now, I've seen three cases. So at this point, I'm the leading expert in western Canada with the most publications of any psychiatrist in western Canada. Equals two. Three cases, two publications. So this is how I stumbled into this area. I had no idea, no attitudes, no thoughts,
9:23
and so, now, the puzzle gets even bigger. Well, wait a minute, if there's only been 200 cases, how come now I've got three all by myself? And the possible answers to this question are... "There's something very weird about Colin Ross-- "he makes people act like they have multiple personality, "and they just do that for whatever reason." Or, it must be much more common than just a couple hundred cases. And so, I'm gonna talk about the epidemiology, how common it is, how it can be diagnosed,
9:52
and, in '94, when "DSM IV" came out, the name was changed from "multiple personality disorder," MPD, to "dissociative identity disorder," DID, but it's the same basic thing. So multiple personality and dissociative identity disorder are the same thing. So jumping into some slides here, I'm gonna show you some data now and a little bit of the science of how all this works. If I can. Mmm. Oh, okay, this one.
10:28
Okay. So first of all, it's always good to define terms. So if you read the general psychology literature, psychiatry literature, you'll quickly find that there's people out there who don't believe in all this stuff. Psychologists, psychiatrists. And one of the things they say is that dissociation's an extremely vague thing, nobody knows what it is, nobody can define it, nobody can measure it. Well, that's true in their minds. But not in my mind. It's actually very clearly defined.
10:56
But the confusing point is that there's actually four different meanings of the word "dissociation" that are used in the literature, and people aren't always clear which meaning they're using, and people who are reading aren't always clear which meaning they're intending, so there is confusion. But it can be sorted out quite easily. So dissociation-- meaning number one is it's a general systems meaning of the word "dissociation." General systems theory is just a theory
11:23
of how systems in the universe operate, in general. Could be a solar system, could be a cell, could be an atom, could be an organization. So it's how systems operate. And in the general systems meaning, "dissociation" is the opposite of "association." So if two things are associated, they're connected, they're interacting, they've got something to do with each other. If they're dissociated, they're disconnected, not interacting, out of relation, split apart.
11:53
So dissociation basically means the same as "disconnected." And I'll come back to all these meanings as we go through it. Second meaning is it's a technical term in cognitive psychology. So this is guys who do experiments with rats and mice and all kinds of different animals. And there's thousands and thousands of papers published in psychology about all kinds of learning experiments and so on. So a typical experiment is, if you're looking at memory,
12:20
there's conscious memory, unconscious memory... which is declarative memory, or procedural memory... or explicit memory, implicit memory. They all kind of mean conscious, unconscious. And so, there's a famous guy who had brain damage, who... if you met him 50 times in the last month, every single time, he has no idea that he's met you before, it's a brand new thing, because he can't record any memories and store them. They just disappear automatically because of the damage to his brain.
12:55
And this guy's very well-studied and so on. And so, there's a whole bunch of different tasks that he was run through, and lo and behold, the more he did a task-- like there's a task where there's three pegs like this, and you stack blocks on them, and you have to re-stack them in a certain pattern, and like anything in life, the more you do it, the better you get at it. Well, his performance improved with practice at the same rate as normal college students, although he had no memory whatsoever
13:24
of ever being exposed to the task. Which shows that his-- part of his memory's intact and learning and recording, he just has no conscious record of it, which is part of piles of evidence that procedural memory, declarative memory are separate systems. You can knock one out, and the other can still be operating. And then, in human experiments, there's basically-- you take all these college students who are guinea pigs who get course credit and the professors crank out lots of papers,
13:58
so it's good for everybody. And you run them through all these different tasks. Well, one task is you memorize a list of word pairs, which are homophonic word pairs, meaning they sound the same, like R-E-E-D and R-E-A-D, but they have different meanings. So you have maybe 30 of these pairs of words, and you memorize them, and then a week later, you're asked to write down as many of them as you can remember. So pretty good chunk of people are not going to remember reed/read, consciously--
14:31
they don't write it down. So it's gone from their memory. And then, what you do is you give them a cue. So with spontaneous recall, the information isn't there. You give them a cue. "What's the name of a tall tubular plant "that grows in marshes?" And they're supposed to write down the answer. So the first group, like you guys on this side-- your word list included reed/read. Your word list did not. So you guys, when you're asked that question, you misspell R-E-E-D as R-E-A-D
15:09
much more frequently than you guys, who are never exposed to reed/read. Because the word read-- R-E-A-D-- is grumbling around in your brain somewhere. You can't consciously access it, you don't remember it was on the list, but it's affecting your output, your conscious verbal or written output, showing that you can have information in your brain that you can't access consciously, but it's affecting your behavior. And there's zillions of experiments like this.
15:39
So this means that the memory is dissociated. It's not in conscious memory. So the conscious-- I can remember my name and my address and my parents, etcetera-- that system, the information isn't there, it's dissociated and held in the other system. So that's a technical meaning of dissociation, and that kind of dissociation is experimentally proven over and over and over and over. It's a very rigorously proven thing. That's just how the mind operates. Which is just common human experience.
16:12
So there's all this controversy about whether this kind of dissociation and this kind of amnesia actually occurs... but if you think about it for a second, this is the way your mind operates all day every day. "So, what was that movie, okay? "Oh, yeah, yeah-- but what was the actor's name? "Well, yeah, he was in that other movie with Kevin Bacon, "and Kevin Bacon knew this guy "who knew that guy-- oh yeah, that's his name." So we're constantly doing these little...
16:40
various mind tricks with ourselves, or we're just repeating the recall effort, and then the information's there. It wasn't there, and now it is there. So it's just an everyday universal human experience, that information can be in your brain, you can't find it, but with some sort of procedure or effort, it pops back. And there's lots of evidence showing that hypnosis and other research, that the memory that you can't access initially, and then it gets cued and you do remember it,
17:12
has the same rate of memory error as just memory-- regular memory you've remembered all along. So it's not more accurate, it's not less accurate. Then, there's a phenomenological meaning of dissociation. So when I went to medical school, I was taught if you use a bunch of big words, you sound really smart. So phenomenological meaning. That just means the symptoms that people report that are in all these different questionnaires and symptom measures that we'll get into in a bit.
17:40
So that's the actual symptoms that people experience are dissociative symptoms. Then, there's anxiety symptoms, there's depression symptoms, etcetera. There's nothing mysterious about it, it's just symptoms that people report that kind of cluster into this group, just like depression symptoms cluster into a group. And then, there's a postulated intrapsychic defense mechanism. So this is a theory about a dissociative defense mechanism that's operating in your brain.
18:09
So the funny thing is that this meaning of dissociation-- some sort of theory about what's going on in your brain, how your defense mechanisms work, is actually only one possible cause of the phenomenological symptom form of dissociation. So there may or may not be this defense mechanism called "dissociation"... but it's only one of many possible causes of the phenomenon of dissociation. You can see where we can get really confused really fast. One person's talking about this defense mechanism,
18:43
another person's talking about a symptom. But if you sort these meanings out and you keep them clear, here they are. There's also a lot of confusion about the difference between repression and dissociation that I'll come back to in the third segment. And "repression" being a Freudian term. And the best way to, uh, explain that is a guy named Hilgard who created something called "Neodissociation Theory." He talks about horizontal splitting and vertical splitting.
19:14
So this is just a diagram for the difference between repression and dissociation. Because people talk about repressed memories. It's sort of the same but not really the same as dissociative amnesia. So if there's a horizontal barrier in your mind, the theory of repression, as stated by Freud, is you have information in your conscious mind, your ego, and it's upsetting, you have conflict about it, you don't like it, so you push it down into your unconscious mind, or your id.
19:47
And there's a horizontal barrier. Your conscious mind's up here, your unconscious mind's down there. And when stuff is pushed into the unconscious mind, then it gets all involved with dreams and fantasy and unconscious mental processes and get it all elaborated and distorted, and things can happen to that memory that don't happen if the information's just stored in your conscious mind.
20:12
And there's actually two subtypes of repression. One subtype of repression is called "repression proper," where it's in your conscious mind, like something traumatic or conflictual happens... you can't deal with it and you push it down.
20:29
Primal repression is nothing to do with experience or memory-- that's where you have some impulse coming from your unconscious mind or your id, and it's trying to come up into your conscious mind-- say, some sexual impulse-- your conscious mind is all hung up about it and uneasy about it so it just keeps it squashed down. It never actually makes it up into consciousness. So there's these two subtypes of repression. That's Freudian Repression Theory.
20:59
Dissociation is different-- it's vertical splitting. In dissociation, nothing is pushed down into the unconscious, into this mysterious place that you can never exactly pinpoint or find. It's in a different compartment of the conscious mind. So the barrier, the split, is this way. There's conscious mind here, which doesn't remember, and conscious mind there that does remember. So it's kind of a different model and different theory. A lot of people who don't believe in dissociation,
21:31
who attack dissociation, and say you can't have repressed memories of massive trauma-- it's not possible, the mind doesn't work that way, also say that the dissociative disorders are based on all this bogus Freudian theory about repression. Which is just a scholarly error. Dissociation theory is a completely different thing from repression theory. It's a different set of mechanisms, even at the theory level. And in early Freud, like his studies on hysteria
22:01
published in-- just before the end of the 19th century, he, with his co-author Breuer, describes classical, classical multiple personality kind of cases. Whole series of women, tons of childhood sexual trauma, they come into therapy 30 years later, they've got all kinds of different symptoms, including amnesia and sometimes full or partial multiple personality. And when he was writing like that, he assumed that the memories were real and accurate and the incest really did happen.
22:33
So when repression theory-- when early Freudian theory applies, then it's really more dissociation he's describing, and the assumption is the incest really happened, the memories are accurate. Not perfectly accurate, but basically accurate. Then, in 1897-- so that's called the "seduction theory"-- they were seduced by adult pedophiles, and that's why they've got all these symptoms 20 or 30 years later-- that's seduction theory. In 1897, he repudiated the seduction theory.
23:08
He decided that the memories were false. In order to explain to himself why the memories are false, he developed repression theory. So repression theory is all based on the idea that these are false memories. Not maybe 100.0%, but substantially, mostly. So the people who attack the dissociative disorders make a couple of conceptual errors. They say that dissociation and repression are the same thing, which is not true. And then, they say that these are false memories,
23:41
because the therapists are basing their therapy on repression theory, which is completely bogus, and that's why they're cooking up all these false memories. Which is completely wrong and backwards. If you follow repression theory as stated by Freud, you assume the memories are false. You don't believe them. So the people who don't believe in dissociative disorders are accusing the therapists of believing false memories because they're making their therapy based on repression theory.
24:10
It's all just a big huge mix-up. So this is what goes on in my field. So now, we're gonna talk about the phenomenological meaning of dissociation, and symptoms. So there's the-- so I'm gonna guess this is the pointer. There we are. So there's the dissociative disorders interview schedule that I developed, that's a structured interview-- a bunch of standardized questions. And you'll see the dissociative experiences scale, which is a 28-item measure you fill out yourself,
24:43
you score it, and the total score can go from zero to 100. And then, there's the SCID-D, which is another structured interview for dissociative disorders developed by a woman named Marlene Steinberg. So in this project, in general adult psychiatric patients in a hospital in Dallas, we excluded anybody who already had a dissociative diagnosis, which is only like one or two people. So these are all people who don't think they have a dissociative disorder,
25:13
never been treated for a dissociative disorder, never been told they have a dissociative disorder.
25:22
And what we do is we give them the dissociative experiences scale, and an interviewer gives them the one structured interview. And then, a second interviewer who doesn't know the results of the dissociative experiences scale, or the DDIS, interviews them with the second structured interview. And then, we look at, "Well, what's the agreement rate here?" So this is just general adult psychiatric inpatients. And lo and behold, in basically a one-hour research interview, or even 45 minutes,
25:56
according to the one structured interview, 40%, according to the SCID-D, 44%, and then, the third arm of the study was... after all these people had done two structured interviews, I was randomly assigned 52 people by the research assistant, who are a combination of people who are negative for a dissociative disorder and positive for a dissociative disorder, and I had to decide how many had dissociative disorders, and I actually was the most conservative.
26:27
But if we look at DID... it's not a rare thing. So there's about-- there's 10 to 12 studies now in eight or nine different countries more or less set up like this. You get general adult inpatients, exclude anybody who has a dissociative diagnosis, give them the dissociative experiences scale, one or other of these structured interviews, sometimes a clinical interview, and the overall average of all these studies is 4.4% of general adult inpatients in psychiatric hospitals
27:02
have previously undiagnosed DID-- dissociative identity disorder. They don't think they have it, they don't claim they have it, they've never been told they have it, they've never had treatment for it, and it can be detected in a fairly simple research interview. So that's kind of the epidemiology of it. And then, in the mental health field, there's a thing called "inter-rater reliability." So it's-- if two psychiatrists, or 100 psychiatrists,
27:33
absolutely cannot agree who's depressed and who isn't, like it's game over, right? Doesn't matter what treatment you believe in or what genetic research you wanna do. If you can't degree who is and who is not depressed, it's just chaos. So the statistic for the rate of agreement is called "Cohen's kappa." Which varies from plus 1 to minus 1. So if Cohen's kappa is 1.0, then two different raters agree 100% of the time who's depressed, who is not. If it's minus 1, they disagree 100% of the time.
28:09
So it's perfect agreement, perfect disagreement. And then, random is right in the middle at zero. So here's the Cohen's kappas for DID. If we compare one structured interview to the other, my structured interview to the clinician, for some reason this number's a little low, using the dissociation scale, and there's a sort of sub-scale within it that you can analyze. So these are kappas ranging from 0.71 to 0.81. In the "DSM V" field trials-- so "DSM V" came out in 2013--
28:43
in the "DSM V" field trials, which is a lot of money spent, we're getting a large number of people to interview lots and lots and lots of patients, and they look at the Cohen's kappa for the different diagnoses, Cohen's kappa for depression was 0.28. Cohen's kappa for schizophrenia was 0.40. So psychiatrists are really lousy at deciding and agreeing on who is clinically depressed and who isn't, and the top of the scale in the DSM field trials was actually PTSD, which was in the--
29:17
I forget the exact number, it was around 0.72. So DID and PTSD actually have higher Cohen's kappas than most... of the major, well-known, regularly talked about psychiatric diagnoses. So that's good to know. And in my structured interview, there's all these different sub-sections. So... there's psychosomatic symptoms, Schneiderian psychotic symptoms, secondary features of DID, which is dissociative borderline personality disorder, ESP paranormal experiences, and then total score.
29:58
So, like on this scale, there's 16 items here. There's 11 here. There's 33 here. There's nine here. So all I did was just take the average score here and divide it by 9, multiply it by 100. Take this one, divide by 16, multiply by 100. So I converted them all to scales that go from 0 to 100. And then, I put them on this graph. And what we have here is DID. I don't know if we can-- oh, here we are. So this is DID. This is dissociative disorder not otherwise specified,
30:33
which is basically partial DID. And this is schizophrenia, and then we have... psychiatric adolescence, chemical dependency, GI clinic-- gastrointestinal clinic-- population, and the general population. So... I'll come back-- I'm gonna talk about this thing here. If I can get the pointer to show up. Well, I'm gonna talk about this in the next section. Why do people with DID have more psychotic symptoms, more symptoms of schizophrenia, than people with schizophrenia?
31:12
But leaving that aside, clearly, this structured interview, this kind of walking through all these symptoms, clearly differentiates people with DID from almost DID, and then from other groups. Which is part of showing the validity and the reliability of any disorder. You wanna be able to do that.
31:35
Okay, so one of the conundrums is... what's the relationship between dissociative identity disorder and borderline personality disorder? There's all kinds of controversy about it, all kind of attitudes, all kinds of academic fighting. Basically, the academic world is a bunch of-- it's like the Bloods and the Crips, basically. It's gang warfare at the intellectual level. So there's guys stabbing each other in the back, attacking each other, discrediting each other,
32:02
blocking promotions, intriguing.
32:08
Except, again, not here at GRCC, right?
32:13
So BPD and DID-- borderline personality disorder-- are really embroiled in a lot of controversy. And one of the skeptical things is, "Oh, those people with DID-- "they're just a bunch of borderlines." Well, so I did some research comparing a large sample of people with DID to a large sample of people with BPD, and what do we find? "Comorbidity" means all the other mental health problems that go along with your main problem, and what gets to be the main problem's kind of arbitrary.
32:46
So comorbidity's basically a whole mess of depression, anxiety, substance abuse, all kinds of different things. And lo and behold, the comorbidity profile of these two things are pretty similar. Basically everybody with DID and BPD, if you're in a psychiatric hospital, either is or has been depressed, has some kind of mood disorder. Lots of anxiety, lots of panic, lots of PTSD. So it's very similar, but the DID people are just a little bit more. That's the general pattern.
33:23
In terms of their dissociative disorders, well, amazingly, 100% of the people with DID have DID on the structured interview. (audience chuckling) But that's good to know that the structured interview is picking all these people up, not missing them. So the interesting thing, though, is the people with BPD, 11% also have DID. So the borderline personality disorder people have said in "DSM IV" and "DSM V," that dissociative symptoms in BPD are kind of minor.
33:58
But actually, in fact, they're complex, chronic, and major. And there's lots of 'em. Lots of eating disorders. A little bit more in the DID group. And this is what we see clinically all the time. When you're treating DID, you're always treating a whole bunch of other stuff at the same time. And then, in terms of the personality disorders, again, astoundingly, 100% of the borderlines are borderline. But so are over half of the people with DID.
34:26
And they have lots of these other personality disorders as well. So personality disorders are very overlapping things. They're not clear, simple, discrete categories. And if you have borderline personality disorder, you're likely to meet criteria for two or three others, at least.
34:44
But, yet again, the patterns, they're very similar, but overall, the DID people tend to be more. So they're more similar than they are different.
34:56
Well, I wasn't satisfied with that, so I did another study. With inpatients again, and now we've-- using the structured interview, we've divided them into people who have both DID and BPD, only DID, only BPD, and neither. And the data-- like if I decided I was gonna fake some data so it would look good, I'd just make it look like this. It doesn't get any better. It's perfect-- it fits with exactly what I predicted.
35:26
Which the people who have both are the most severe. The people who have neither are the least severe. And these two groups are in between. So there's a total trauma score, and then duration of sexual abuse in years, number of different abusers, number of types of sexual abuse, duration of physical abuse in years, number of physical abusers. It just goes down, down-- I mean, it's not perfect, it bumps up and down a little bit. But basically, it's just a line like this.
35:56
So when you have both, you're worse off than if you have only one of those two diagnoses, and if you have either one, you're worse off than somebody who has neither.
36:08
In terms of different diagnoses... same thing. You're more depressed, you're more substance abuse, more psychosomatic symptoms, more amnesia, fugue-- that's another dissociative diagnosis-- depersonalization dissociative disorder, now, though I specified. So not surprisingly, these guys have the most, these guys have not so much, and these guys are in between. But the people with just DID-- this is supposed to be under here-- have more dissociation than the people who have just BPD,
36:41
which makes sense, which fits, which is logical. So basically, the message here is-- we've got lots of research on this. We're not just walking around with opinions. And then, uh... all these different symptoms clusters that were on that graph-- so the people with DID have the most, these guys are intermediate, these guys are the least. And all these different symptoms clusters are serious mental health trouble. Okay, well, that's sort of interesting.
37:13
So we actually have a whole body of literature showing-- using the same rules that you use for depression, dissociation, psychosis, substance abuse, anxiety, so same rules, same sort of methodology, we've shown that our diagnoses perform as well, are as reliable, are as valid, hang together as well, as any other set of diagnoses. Which is cool, but who cares? Because the only thing that really counts is treatment. So I'm gonna show you a couple of treatment outcome studies
37:47
now, where we give a bunch of questionnaires on admission to the program-- this is in Dallas. Then, we repeat the questionnaires at discharge. And then, one study at three months, another study, that's just an analysis now, at up to 10 months, another study two years. So what happens when all these dissociative people come into the hospital and we treat them? This is a typical sample, so most-- it's 90% women, average age is usually in the 30s. You can't be an adolescent in our program.
38:19
The federal government won't let adolescents be mixed in with adults. Average length of stay, which is a combination of inpatient and stepping down to the day program-- average length of stay in the program overall is 18 days. What happens to their symptoms? Well, before I tell you that. So they have lots and lots of sexual abuse. Lots of depression, lots of borderline personality disorder, lots of psychosomatic symptoms, half are DID, half have substance abuse problems.
38:52
Very typical of our population. So it's a typical sample. And lo and behold, in this 18 days, the Beck depression inventory's the most used depression inventory. Drops by close to 50%. The "how suicidal they are" drops to close to 50%. How hopeless they are, pushing 50%. And the dissociation score doesn't significantly change. So this is the targets that we address in the inpatient setting. "You're here basically because you're suicidal." It's more or less a suicide program.
39:27
We could call it all kinds of things. The best name would actually be the "Dealing with Your Feelings" program, but that doesn't quite have the marketing ring to it. And I don't think the manage care companies would be thrilled by that name. But the depression, the hopelessness, and the suicide-- those are the targets of the treatment. And that's a very nice drop in scores, and the dissociation takes much longer to treat.
39:52
So we take the dissociation into account, and we work with it, but we're not really targeting it-- that's not our main treatment target.
40:03
Uh, another study. Same concept. 50 people this time, admission and discharge. The SCL-90 is a whole hodgepodge of different symptoms, all across the board. The Beck score goes down, suicide, hopelessness. Dissociation doesn't change. So we got several replications of this.
40:24
And, um, what you see-- this is just a list of the references here, which, if any of you want copies of the slides, you can provide, right? >> Say that again? >> You can provide these slides to anybody who wants them? >> I could, if that's all right with you. >> Yeah, yeah, absolutely. >> I'll post them on-- >> They're only 50 bucks a set, so it's a pretty good deal. (audience laughing) So this is just showing that, you know, I've published a bunch of outcome studies.
40:49
And what happens at three months is it's not that-- okay, it's nice to be in the hospital, we give you some TLC, you improve, and then, two weeks later, you're right back to where you were. Those gains are sustained at three months, 10 months, two years, and, in fact, the symptom levels keep going down, down, down. So here's a study I did, published in the '90s, where we interviewed a bunch of people in the program in '93. They're there for a few weeks.
41:21
Then, we re-interview them two years later in '95. And here, we're asking about, this point in time, going back for a year. Here, we're asking two years later going back for a year. Using standardized diagnostic interviews here. And the number of active diagnoses-- depression, substance abuse, eating disorders, schizophrenia, etcetera DID-- is dropped by 50%, and the number of personality disorders active in the preceding year has dropped by 50%. And all these people meet criteria
41:53
for borderline personality disorder. But they're a sub-group. Everybody in this study met criteria for multiple personality disorder. I just pulled out the 25 who met criteria for borderline, as well. And what we have is really nice treatment outcome, two years later. Their psychosomatic symptoms are dropping, their psychotic symptoms, dissociative symptoms, their borderline has dropped by a third, basically. Paranormal experiences, which we can talk about more if anybody's interested.
42:25
How suicidal they are, how many suicide attempts. Their dissociation score now, in two years, has dropped substantially. Their depression score-- and this is just another depression measure. So lots of different kinds of problems dropping down substantially. And this is an interesting thing, in terms of their abuse histories. So there's-- the people who hate dissociative disorders and think they're all bogus are always accusing us of cooking up all these false memories out of nowhere.
42:59
So this is the duration of physical abuse in years-- child physical abuse, up to age 18. Number of perpetrators, duration of sexual abuse in years, number of perpetrators, and number of types of sexual abuse. So that's a whole list of different sexual things one person can do to a kid. And lo and behold, when we asked them exactly the same questions two years later, there's no statistically significant increase. There's a little bit of an increase in a couple of 'em, not really here,
43:28
not really here, not really there. So two years later, after more of this "false memory therapy," they're not reporting more trauma memories than two years previously. Which is pretty good evidence that we're not just pulling fake memories out of nowhere.
43:48
So that's... the first talk.
43:55
Thank goodness for water. And so, the summary point here is-- and so, this whole thing could be extended to a half day. And I could go into so much detail you'd all probably be suicidal yourselves. (scattered chuckling) But basically, the point is, there's a whole bunch of research, it's a substantial body of literature, it's replicated in many different countries. There's good psychometrics to it, so... there's all these different statistics that are used
44:23
to see how solid and strong a measure is. We've used all of those. One of the studies I did was actually a series of six or seven papers-- one's called "Trauma and Dissociation in China," in the "American Journal of Psychiatry," which was the official journal of the American Psychiatric Association. So I worked with people in Shanghai, at Shanghai Mental Health Center. Basically, I talked to them and they did all the work. And so, multiple personality is never diagnosed,
44:53
it's not in their diagnostic manual, it's not taught, it's not in their popular culture, it's not in movies or on TV or... they don't have soap operas with people with multiple personality. And it was quite readily detected in our research protocol. And that's important, because that's a culture where the multiple personality can't be explained by contamination, or "I picked it up from the radio," or "I picked it up from TV," or "I picked it up from my therapist." So just a lot of research,
45:23
and the quantity of research is smaller than for depression or schizophrenia, but the quality is about equal. I rest my case. Here is the stereotype that dominates the field-- "Schizophrenia is a biological brain disease. "It's genetic." Of course, the environment can sort of color the symptoms a little bit, so if you have schizophrenia and you're somewhere in the jungles of New Guinea, you're not gonna think that the CIA or the FBI are after you, because you've never heard of them.
45:55
But the basic form of the disease, how common it is, it's a universal genetic brain disease. Hear that from the American Psychiatric Association, National Alliance for the Mentally Ill. If you just search schizophrenia on the web, you'll get told over and over and over it's a genetic brain disease. Not all the time, but a fair bit of the time, they'll explain-- (clearing throat) excuse me-- that schizophrenia is not split personality. Not multiple personality.
46:26
There's people out there who are confused. And they think that schizophrenia and split personality are the same thing. But we professionals who are physicians, who treat biological brain diseases, know that that's not the case. It's very clear. It's a totally separate category. And it's kind of this fluffy, neurotic light thing that's highly suspicious, maybe not even genuine at all. Schizophrenia... it's just like cancer. And schizophrenia is not caused by bad parenting.
46:58
Just like arthritis or cancer are not caused by bad parenting. And dissociative identity disorder is a reaction to the environment. So everybody's agreed on this. People who don't believe in it think it's a reaction to bad therapy. People who do believe in it think it's a reaction to childhood trauma. But everybody's agreed-- it's not an internal biological disease that you're genetically born with. It's a reaction to the environment. And you don't treat it with medication.
47:31
Although people with DID are frequently on medication because they're also depressed and also anxious and so on. But the DID, the dissociation itself-- there's no medication for that. And everybody's agreed on that point. So you treat it with an environmental intervention, not with medication. And if you believe in it, you treat it with psychotherapy. If you don't believe in it, you treat it with "benign neglect," which, if you don't feed into it, you don't reinforce it, you don't talk about it,
47:58
it just kind of fizzles out. And this you get stated in professional journals and books and so on. So totally separate compartments. Genetic brain disease, reaction to the environment. Never the twain shall meet. They have nothing to do with each other. So if I was a regular biological psychiatrist, I would've just cleared that up for you, end of discussion. I actually just got back from this year's American College of Psychiatrists meeting, which also, funnily, was also in Puerto Rico.
48:35
Sad to say I was stuck on the beach for two afternoons. >> (faux concern) Ohh! (audience laughing) >> So each year, there's a Dean award lecture, where some top researcher in schizophrenia gets an award for his lifetime work-- or her lifetime work on schizophrenia. And they basically give a talk describing their lifetime work on schizophrenia. So this guy Kenneth Kendler got that award, and he's pretty well "top dog" guy in schizophrenia and genetics. And it's kind of a catchy talk
49:05
with a catchy title. "The Genetics of Schizophrenia-- "Toward the Identification "of Individual Susceptibility Loci." That sounds kind of scientific. Kind of like some big shot talking. And he is a big shot. And oh... whoop...
49:25
Oh, there it goes, okay. A little tricky. He doesn't look like Dr. Evil, right? He's a kindly academic looking kind of guy. And this is a quote from the talk based on his lifetime of research on genetics. "Most, if not all of the reason "why schizophrenia runs in families "is due to shared genes and not shared environment." Most, if not all, of the reason why schizophrenia runs in families is genetics. It may not be all... but it could be all. But if it's not all, it's most, if not all.
50:03
So in other words, it's predominantly, "major big league" a genetic disorder. That's his conclusion from his lifetime of research. So... what are the facts? What's the research that supports this conclusion? Well, there's a methodology called "twin concordant studies." Which are a little bit old-fashioned now. The reason they're old-fashioned now is because of what the data are, which we'll get to in a second. So basically, there's identical twins, non-identical twins.
50:35
Identical is MZ-- monozygotic-- one egg. Fraternal, non-identical twins are DZ-- dizygotic-- two eggs. And what you wanna look at is concordance. So if the first identical twin is female, how often is the second-- this is a quiz question. If the first identical twin is female, how often is the second identical twin female? 100% of the time, right? If the first identical twin has red hair, always red hair. Etcetera. So some traits clearly are purely genetically controlled.
51:12
And if you take one of these identical twins-- let's say you have a set of Chinese identical twins, you take one out of the family at birth and put 'im in an English-speaking family, they're gonna grow up speaking English. Whereas the one that stayed in the Chinese Chinese-speaking family is gonna speak Chinese. So from that, we know that what language you speak isn't coming from your genes, it's coming from your environment. But incredibly, when you're-- a Chinese kid
51:41
is adopted into a Caucasian family, they don't become Caucasian. So now we know that being Caucasian, or being female, or having dark hair, is genetic, and it's not modified by the environment. So the first thing you wanna do is look at the concordance rate. If the concordance rate is very, very low, then you know that it's not really genetic. If it's purely genetic, then the concordance rate's going to be 100%. But what's the concordance rate for speaking Chinese
52:12
versus speaking English in identical twins? It's almost 100%, right? So you, the concordance rate doesn't prove it's genetic, it just means it very well could be. Then, you've gotta go look at adoption and do some other strategy. So the concordance rate is kind of the first pass. So you wanna look at the concordance rate for cystic fibrosis in identical twins. It's 100%. If the first twin has cystic fibrosis, other twin always has it. First twin doesn't have it, other twin never has it.
52:44
It's a purely genetic disease, totally proven medically, nobody doubts it. So what's the story with schizophrenia? Which is mostly, if not all, genetic? Well... to find out, we should go to the expert, Kenneth Kendler. So in this same talk, he's presenting his data, which supported the conclusion that schizophrenia's mostly, if not all, genetic. And he looked at this 16,000 pair of twins, and he looked at the concordance rate for schizophrenia.
53:17
So what do we think-- like if I was gonna take a poll here, to support the conclusion it's mostly genetic, what kind of concordance do you think we would want? It's not likely to be 100%, because the mental health field's kind of like fuzzy. But we'd want some kind of high number, right? So if the concordance rate was 90%, then I'd go, "Yeah, it very well could be "mostly, if not all, genetic." 80%? Eh, that's still mostly, if not all. 70%-- well, that's getting away from "if not all,"
53:49
but still mostly. 60%-- well, that's just barely mostly. So what was the actual concordance rate that he observed and published in his research that got him the award for demonstrating that schizophrenia is mostly genetic?
54:06
Anybody wanna take a guess? >> 32. >> (laughing). That's a good guess.
54:15
In his own sample-- and this is actually higher than the real actual average number, if you add together all the best studies. In his own data set, when the first twin has schizophrenia, the other identical twin does not have it 70% of the time.
54:34
That simple fact, by itself, proves conclusively, scientifically, medically, biologically, beyond a shadow of a doubt, no other possibility, that schizophrenia could be at most only a little bit genetic. And this result-- which the numbers bounce around from study to study, but when you add together the best-designed studies, and the most recent studies, it actually comes out more in the low 20s, like 22%.
55:03
So what's up with my field? How, how does this myth get perpetuated? So you go to these academic meetings, and the top expert in the world, comes and gives his award speech and says it's mostly genetics, 31%, and everybody goes... (scattered laughing) "Good talk." There's something really wrong. I mean, it's just absolutely not possible. So I have a letter in press, letter to the editor, at a journal called "Psychosis," which is edited by a friend of mine who's very skeptical
55:37
about all these "genetic biological schizophrenia" guys. So he liked my letter. So the letter is...
55:46
Something like January 29th, or something like that. There's, in the journal "Nature," which is-- "Nature" and "Science" are the two top science journals in the world. So if you're-- if you figure out the structure of DNA for the first time in human history... and your name is Watson or Crick, where do you publish your paper? "Nature." I mean, it is top, top journal. So in this journal "Nature," there's a paper published in January, and there's a write-up--
56:18
I just talked about the write-up in the "New York Times." There's numerous other write-ups in many other media outlets. This is the biggest, most important, fundamental advance in the study of the biology of schizophrenia ever. We've really, for the first time, started to tap into the underlying genetic causation of schizophrenia. We're really starting to figure it out. We've really got our hands on something for the first time. That's what the author said, all these different commentators.
56:54
What was the research? So there's like 39-- some huge number-- 39,000 people with schizophrenia, 28,000 controls. And this is a schizophrenia genetics consortium, which has pulled together all of these studies where they do genome-wide analysis, which is they-- they can just basically throw your blood in a machine, and it'll scan your entire genome. Because now, thanks to the Human Genome Project-- and this is getting cheap enough now that they can do these gigantic numbers.
57:27
So that's millions of dollars of research money. And what they zoned in on was a single nucleotide polymorphism, which means little variations in one ATGC base pair. And they looked at a specific gene called the "C4 complement gene." And they looked at four-- out of all these genes that they scanned, they finally found one somewhere that had some sort of statistical significance to it, and it turned out to be the C4 complement gene. And there's four variations
58:03
of this single nucleotide polymorphism. For the first three they looked at, there was no increased risk of schizophrenia at all. But the fourth one, this is where they found this fundamentally new insight into the underlying genetic biology of schizophrenia. Which is now gonna open up this revolution in psychiatry.
58:26
So if you have this gene variant... how much does your risk of schizophrenia go up? This fundamental breakthrough finding. The most significant, profound finding in the history of schizophrenia and genetics. What would you think it might be? The answer is your odds of developing schizophrenia sometime in your life go up from 1% to 1.27%. That's it! It's just-- it's like being at the Mad Hatter's tea party or something. I mean, it's just ridiculous. It doesn't make any sense.
59:06
It's massive over-hyping of this result, which then generates more grants, more motions, more interests, more excitement, and diverts money away from studying maybe something in environment that's causing people to go crazy. Like child abuse, for instance. So this is dominating the field all the time, this kind of thinking. Okay, so, just jumping over to DID now, just to refresh you a little bit. What is DID? What's a typical description of it? Well, here's-- this is the--
59:42
so we're in the category now of neurotic reaction to the environment, totally different box from genetic brain disease, which isn't even, in fact, a genetic brain disease, which we've known scientifically for decades, but we keep saying that it is.
59:58
Little side detour-- back to the American College of Psychiatrists meeting in Puerto Rico last week, the mood disorders award was a lecture given by a woman who's actually in University in Galveston, not too far away from me. Top handful of childhood depression experts in the world, presenting all her research. And she's talking about how effective anti-depressants are for children. And she's very pro-anti-depressants. Because genetic brain disease, medication, are all part of a package.
1:00:34
That package is promoted as a package. Okay, so we can diagnose depression in children. So this is an hour talk. It turns out that the FDA has only approved two anti-depressants for kids under 18. Fluoxetine, which is Prozac, and escitalopram. For Prozac, there's two studies. For escitalopram, there's one. Showing positive results. She didn't mention how many studies there are where there's no difference between drug and placebo. In the FDA, you could have 10 different studies of Prozac.
1:01:11
They only require that two show a difference between the drug and a placebo. If there's eight other studies that show no difference at all, they don't care, doesn't matter, gets approved, goes to market. That's how the whole thing operates. Then, there's a whole bunch of other anti-depressants on the list where all of the studies failed to show any other-- any difference at all between the drug or the anti-depressant and the placebo for depressed kids.
1:01:38
But we got two drugs, a total of three studies. So then, she averages together all the literature on anti-depressants in kids. Thousands and thousands and thousands and thousands of kids. And she says, "How many kids respond to anti-depressants "compared to placebo?" Where "response" is defined as your depression score drops by 50% or greater. So being a responder doesn't mean you're better, it just means you're at least half better. So not a very tough definition of "responder."
1:02:14
Overall, when you add the whole world's literature on anti-depressants in children, you add it together, 60% respond to the anti-depressants and 50% respond to placebo. That's it. It's not too impressive. And so, there's this whole room full of 500 psychiatrists, and they're all, "Uh-huh, yeah, good, "great talk, here's your award." There's something fundamentally wrong here. Okay. But at least we know that dissociative identity disorder and schizophrenia are separate things.
1:02:48
So here's a classical-- it's a little bit older text. You'll see the language is a little bit archaic, but, you know, typical case description of dissociative identity disorder. "The delusion of being possessed is very commonly seen "as a specific type of 'double personality.' "Single emotionally charged ideas or drives "attain a certain degree of autonomy, "so that the personality falls to pieces. "These fragments can exist side by side, "and alternately dominate the main part
1:03:14
"of the personality, the conscious part of the patient. "However, the patient may also become "a definitely different person from a certain moment onwards." It's completely consistent with the entire DID literature. "Naturally, such patients must speak of themselves "in one of their two versions, "or they may speak in the third person of the other two, "usually he designates himself by one of his several names. "The splitting of the psyche into several souls
1:03:39
"always leads to the greatest inconsistencies. "In a few cases, the 'other' personality "is marked by use of different speech and voice. "Thus, we have here two different personalities "operating side by side."
1:03:53
Extremely clear definition of DID. "When specific 'persons' speak through the patients "in various cases of automatic speech, "each person has his own special voice "and distinct manner of speech. "Thus, the patient appears to be split "into as many different persons or personalities "as they have complexes." Complexes is not talked about that much now. It's a late 19th, early 20th century term. "The blocking of the recall of memories "is a common occurrence during the examination
1:04:20
"of these patients." So they have lots of amnesia.
1:04:26
Okay. So this would be from some classical textbook on dissociative identity disorder, right? This is clearly not schizophrenics. This is people with split personalities. Different voices, names, ages, amnesia. What book is this from?
1:04:45
There we go.
1:04:49
This is a book by Eugen Bleuler, published in 1911. He's the guy who coined the term "schizophrenia." It used to be called "dementia praecox" before that, which means "early onset dementia." This is the guy who invented the term "schizophrenia," writing one of the classical 20th century's textbooks on schizophrenia, describing a substantial chunk of his caseload.
1:05:15
It's exactly the same thing as "DSM IV," "DSM V" dissociative identity disorder. In great minute detail. And he says that splitting is the fundamental thing going on in schizophrenia. And he says that splitting is exactly the same thing as dissociation, which is Pierre Janet's term for the same thing as he calls splitting, and Pierre Janet is kind of the father of dissociation theory. So the guy who originally coined the term "schizophrenia"-- every psychiatrist knows that--
1:05:47
most psychiatrists, of course, don't read the book-- is completely confused about the difference between DID and schizophrenia. And many people that he's calling "schizophrenic" clearly have DID. So there's actually, in fact, mass confusion in the profession... I'm sad to say.
1:06:09
I might turn around and chortle for a second but... I'm very sad to say that. Okay, so let's look at this relationship between dissociation, psychosis, and some research. Genetic brain disease. Oh, by the way, the woman who was giving the talk about anti-depressants in children for an hour didn't mention child abuse, childhood trauma, PTSD, or anything like that, once. In an hour. That's how relevant all that stuff is to childhood depression. Which we're treating with anti-depressants
1:06:42
that don't work any better than placebo because it's a biological disease. Okay, so this is general population in Canada. Team knocked on people's doors and interviewed them with the standardized dissociative disorders interview schedule, dissociative experiences scale. So this is people in the general population. Not in treatment. And I divided them into 397 people who had no psychotic symptoms at all and 35 who reported three or more. Simple. I mean, this is not rocket science, right?
1:07:17
And look at the difference in their abuse histories. Physical or sexual abuse, or both, 8.1% if you have no psychotic symptoms. 45% if you have three or more. From this, you might consider the possibility that physical and sexual abuse have got something to do with psychosis. You would think. So... your rate of having psychosis goes up from 8% to 45%, not 1% to 1.27%. I mean, that's a massive finding compared to the strongest finding in all of schizophrenia genetics ever
1:07:56
after they've spent literally a billion dollars or whatever they've spent.
1:08:04
Same people. Much higher dissociative experiences scale scores, more somatic symptoms, secondary features of DID, more borderline criteria, more ESP paranormal. This is starting to look like the same pattern as when I compared DID to borderline personality disorder. It's all the same kind of comorbidity.
1:08:26
Okay, different study. This is 83 people in Canada. Long, stable, clinical diagnoses of schizophrenia. Most of them have been diagnosed as having schizophrenia for 10 years or more. Same dissociative experiences scale score, same dissociative disorders interview schedule, I divide them into people say they were abused physically or sexually or both in childhood, and people who say they were neither physically nor sexually abused. Lo and behold, if you have a longstanding stable diagnosis
1:09:00
of schizophrenia, and you answer "yes" to a very simple question-- "Yes, I was either physically or sexually abused or both," you have much more dissociation, more somatic symptoms-- this is another set of dissociative symptoms. You're more borderline. You have more of all this stuff. You have more schizophrenia. You're twice as many psychotic symptoms as the person with schizophrenia without an abuse history. And those Schneiderian symptoms-- named after Kurt Schneider, a German psychiatrist--
1:09:30
are the hardcore symptoms that are everywhere in the schizophrenia literature and in the DSM criteria.
1:09:41
Whole different measure of standardized thing that's used in tons of research. Whole list of different types of psychotic symptoms. Lo and behold, the abused schizophrenics has way more of those than the non-abused schizophrenic. Ideas of reference is... uh, "That message on the side of the bus "is deliberately meant for me. "They put it on the bus to let me know." That's an idea of reference. Voices, paranoid ideation, thought insertion is thoughts being stuck in your mind that aren't your own.
1:10:12
Hallucinations, reading someone else's mind.
1:10:20
So in schizophrenia, the symptoms are divided into positive symptoms and negative symptoms. The positive symptoms-- and they're measured by this thing called the PANSS, "positive and negative syndrome scale," and by lots of other scales. They're everywhere in the entire schizophrenia literature. Negative symptoms are the things you should have that you're missing. So that's kind of burned out, empty, no social connectedness, no life, no spontaneity, no desire for anything.
1:10:48
The positive symptoms are things that are there that you shouldn't have, like being agitated, mixed up, jumbled up thoughts, hallucinations, delusions. And lo and behold, the abused schizophrenics got more positive symptoms and fewer negative symptoms. And the composite score is just when you add the two together. So now, we're starting to see that "Wait a minute..." we can see-- take a whole bunch of-- say everybody in this room has schizophrenia,
1:11:15
I go, "All you guys who have physical and sexual abuse "in childhood sit on this side, "all you guys who don't sit on this side." You guys over here are gonna have way more negative symptoms, fewer positive. You guys are gonna have more positive, fewer negative. And these symptoms have a lot to do with how well you respond to medication, what your treatment needs are, what your housing needs are, what your relationship qualities are like, and what your prognosis is like.
1:11:41
We can make this major differentiation into a much more treatable treatment response group, much more difficult, simply by asking a couple of questions. But that is nowhere in the standard schizophrenia literature, until the last few years. Starting to creep in now. Okay, so now we've got 160 people with multiple personality, 83 people with schizophrenia. Let's compare them. So they're not matched demographically so it's not perfect research. Ideally, it should be the same average age,
1:12:15
same percentage of female, and so on. But this is a first look.
1:12:25
Oh, wow... what do you know? People with multiple personality have twice as much childhood abuse as people with schizophrenia. But people with schizophrenia have way more than the base rate in the general population.
1:12:39
People with MPD have-- by all these different indicators, much more severe abuse. They don't just have more "yes" answers, they have much more severe abuse.
1:12:52
They have more dissociative disorders. Not surprising. But wait a minute here, these are people with schizophrenia, 25% of them are coming up meeting criteria for MPD, DID, on a standardized interview. So it's not like these are really clear, distinct separate groups. They're all overlapping, confusedly mish-mashed together. Substance abuse about the same. More depression, more borderline personality. So by and large, this is the same pattern, whether you compare abused schizophrenics
1:13:25
to non-abused schizophrenics, people with DID to people without DID. And the common theme is the trauma.
1:13:36
Some more dissociative symptoms.
1:13:41
Higher dissociation score, more somatic symptoms, dissociative symptoms, borderline. Here we are again. Well, that's interesting, but take a look at this line. Yet again, the people with multiple personality have more symptoms of schizophrenia, on average, than people with schizophrenia. So these symptoms of schizophrenia cannot possibly be specific to schizophrenia. They may not even have anything to do with brain disease at all. They might be trauma dissociation symptoms
1:14:13
that the person wouldn't have if they weren't abused as a kid.
1:14:18
Okay.
1:14:21
Well, we've got all these clinicians out there who can tell the difference between schizophrenia and dissociative identity disorder-- they never diagnosed dissociative identity disorder, they just know it's rare and iffy. So if that was actually true, what would we think we would see in large series of people who have a diagnosis of multiple personality or are in psychotherapy for it? We wouldn't see previous clinicians saying they had schizophrenia. But in these two series, 40%, a quarter,
1:14:51
had previous diagnoses of schizophrenia from other clinicians, half had been treated with antipsychotics, and a bunch had had electroconvulsive therapy, shock therapy. Which tells us that the previous clinicians thought these people were seriously, seriously, seriously mentally ill, needed the most heavy-duty treatments for major serious mental illness that we had, and a half of the time, or a quarter of the time, got an actual diagnosis of schizophrenia,
1:15:20
proving that most clinicians cannot tell the difference. And these are people who are participating in, you know, high-level, hardworking, cognitively functioning psychotherapy.
1:15:36
This is the PANSS, that positive and negative syndrome scale. This is the norms for schizophrenia in the manual. And this is the DID series. Yet again, DID people are more positive, less negative. So... This is just my research. These findings have been replicated in multiple samples with multiple different measures. Okay, so we all know that hearing voices is... a sign of psychosis and very typical of schizophrenia. So... This is the Schneiderian symptoms of schizophrenia,
1:16:09
which include several different forms of hearing voices. What's the percentage of people with schizophrenia who have at least one Schneiderian symptom? This guy Kurt Schneider said, "These are the hardcore symptoms "of schizophrenia." Well... this is published series in the literature. Only a third of the people in this published series of schizophrenia cases had any of the core symptoms of schizophrenia. That's a little weird.
1:16:44
So if you total these 12 or so series, there's 2,500 people, only just over half had any of these Schneiderian symptoms, which are the core, defining symptoms of schizophrenia, in theory.
1:16:58
On the other hand, if you have multiple personality, 87% have one or more symptoms. So again, there's like multiple ways of looking at it, multiple sources of data, same pattern over and over and over. What gets called "psychosis" is actually more typical of people who are dissociative than of people who are psychotic. So I took this same series-- 1993, '95-- now, I pulled out the people who had psychotic diagnoses on the structured interview. Schizophrenia or schizoaffective,
1:17:29
which are the two major, heavy duty psychotic diagnoses. So these people all, in fact, had multiple personality, all were getting treated with psychotherapy. But... 36 of them met standardized DSM structured interview criteria for psychotic diagnosis in '93. In '95, they're on fewer medications and lower doses, and their primary treatment's been psychotherapy, and now instead of 100% met criteria in the previous year, only a quarter did. Their Axis I diagnoses are dropping.
1:18:03
Same pattern as we saw when we pulled out the borderline people. And the same thing over and over. Their thought disorder scores, this other measure, the-- (mic cuts out). Thought disorder, psychosis, depression's dropping down, all different things are dropping down.
1:18:28
Another measure of psychotic symptoms, in my structured interview-- dropping, dropping, dropping dropping, dropping. So all kinds of symptoms, including the psychotic symptoms, are going down, which is a good thing. The positive symptoms are going down. Also the negative symptoms are going down. The dissociation score dropped dramatically. Depression, Hamilton depression, the SCL-90s-- the all across the board different symptoms. Then, there's a psychosis sub-scale.
1:18:56
So we've got four different measures of dissociation-- of psychosis, rather, all following the same pattern.
1:19:04
So we're successfully treating-- "oh, wait a minute, what are we treating again? "Oh, yeah, borderline personality disorder. "No no no, schizophrenia. "No, I mean, actually we're treating depression. "No, no, we're treating anxiety disorder. "Wait a minute, we're treating..." We're treating this whole pot of different diagnoses. And the typical clinician who sees these people, says they have schizophrenia, schizoaffective, bipolar, some heavy duty diagnosis,
1:19:28
gives them meds, maybe ECT, and no psychotherapy. This is just the way the field operates.
1:19:36
Which I think is a sad story.
1:19:43
There's probably, I actually just read a paper this morning-- or this afternoon, while I was sitting at the airport, waiting for three hours... (scattered chuckling) which was handy, because I got lots of emails done and stuff. Um, it's a summary article, and they were talking about 15 different studies published. None of these existed 10 years ago. Mostly in the last five years. They're studies with like 5,000 people, 7,000 people, 3,000 people in the general population.
1:20:13
Or large collections of schizophrenia patients, psychotic patients, like, hundreds and hundreds, and there's multiple studies like this. Just asking about childhood physical abuse, sexual abuse, neglect, bullying, family violence, a whole bunch of different forms of trauma, and lo and behold, it's way up there in people with psychosis. So having a history of severe, chronic childhood trauma increases your risk for psychosis in many, many, many studies, in many different samples,
1:20:44
by like, 20-fold, 40-fold. There's a study called the "Adverse Childhood Experiences" study, which is done in a Kaiser Permanente population in San Diego. So they had 17,000 people who were all in the Kaiser Permanente system, and they gave 'em this adverse childhood experiences scale, and then they reviewed all of their medical psychiatric records, because they owned them all. And the adverse childhood experiences scale has 10 different questions, and you either say "yes" or "no,"
1:21:18
and the total score ranges from zero to 10. So, "Yes, I was sexually abused, "Yes, I was physically abused, family violence, "parent with substance abuse, parent went to jail," different forms of childhood trauma. And one of the guys who's the core guy in the study, is an epidemiologist from the CDC, so he's spent his whole life looking at the statistics of disease at the Center for Disease Control. And this guy says in talks, and says in papers,
1:21:50
"Most epidemiologists never get a finding like this "in their entire careers." What was the specific finding? The specific finding is, if your ACE score-- "adverse childhood experience" score-- is 4 or higher, compared to zero, your risk of IV drug use goes up 1,400 times. That's kind of a big finding. That's a little bigger than 1% to 1.27%. And so, ACE scores go up dramatically... in conjunction with all kinds of different physical and mental health problems. The higher your ACE score,
1:22:32
the more psychotic symptoms you have. More suicide attempts. More depression. Hearing voices. Being admitted to psych hospitals. Okay, that's all kind of understandable. But other things that go up dramatically with ACE score include cardiovascular disease, funnily enough, having Cesarean sections, cancer, lung disease. There's a whole bunch of health outcomes that go up dramatically with childhood trauma. Childhood trauma is driving a lot of billions of dollars of healthcare costs
1:23:12
in the United States per year. What is one of the things-- so when you see the graph, it's like, "ACE score, 1 through 10," what's your likelihood of having a body mass index above 30, which is the low end of being obese? People who are obese in our program, they have BMIs like 45 and 50.
1:23:33
A score of 1, 2, 5. It goes just like this-- (whooshing noise). So what's the healthcare costs of cardiovascular disease, high blood pressure, high glucose, on and on and on and on, heart attacks, in our culture? Billions of dollars per year. That's just the financial cost, let alone the human cost. And a significant, major driving contributing factor is childhood trauma. So we did a study which... we're just doing the analysis on now, but we got kind of, like, the preliminary analysis--
1:24:11
67 people admitted to the hospital in Dallas for, basically, for being suicidal. So they're admitted to a psych hospital. But they've all had bariatric surgery, weight loss surgery. And most of them are kind of like a couple years out... and so we looked at-- number one, they're all inpatients, they all have serious mental health problems, they're obviously not doing well psychiatrically. Most of them have lost a ton of weight. What are their depression scores, their dissociation scores?
1:24:43
And we did several different eating disorder measures. Nothing really stood out that much except their ACE scores. These people had amazing ACE scores, these 67 people. There's many, many people with 6, 7, 8, 9. Whereas the general population is like zero, 1. And so, that's one sample. But what we're looking at is people who've had bariatric surgery, they've lost a ton of weight, but they're still doing horribly psychiatrically. And what is the one thing that stands out about them?
1:25:17
Their massive amount of childhood trauma.
1:25:21
Clinically, we have people in the program all the time. So, it's not like in psychoanalysis where you've gotta spend like 30,000 hours digging down into the unconscious and interpreting stuff. People just tell you. And I don't know how many dozens and dozens and dozens and dozens of-- like, 250- to 350-pound women I've talked to who consciously, deliberately, are keeping themselves overweight so that perpetrators won't be interested in them. And then, when they have either big weight loss
1:25:53
or they have bariatric surgery, and their weight goes down, they get overwhelmingly terrified, because guys start hitting on them, and perpetrators are going to come after them. It's-- you don't have to dig around, you just ask. "What's going on? "Why do you keep your weight up there?" In combination with, it's basically comfort food. They're self-soothing-- that's their drug of choice. They eat, they eat, they feel full. They're distracted, they're focused on that.
1:26:21
All the bad feelings are gone.
1:26:24
So this is... obviously not the total cause of obesity, but it's a significant, major contributing factor, with costs of billions of dollars. And it's the same thing-- you read the obesity literature or general medical literature, child abuse just doesn't get mentioned. Like it doesn't exist. So the analogy I came up with is... this is like being an expert on lung cancer and giving a one-hour talk on lung cancer and never mentioning cigarette smoking once. It's just-- "wait a minute."
1:26:57
Cigarette smoking's kind of an important topic in the causation of lung cancer. It doesn't cause every case, but if we could stop the cigarette smoking, we would drop off so many cases of lung cancer. That's the one thing we know can make a difference. Same thing with childhood trauma in the mental health field. So try actually accomplishing it. But if you could wave a magic wand and there was no more physical abuse, sexual abuse, family violence, the amount of mental health would drop down--
1:27:27
(whooshing noise). So I was kind of hemming and hawing about whether I should go into this in exhaustive detail or not, or... do a short version of this and just wander through other mental health issues, so I'm still kind of undecided. So I'll probably compress it down some. So basically... this is like the drive-by shooting bullets that get sent my way in the gang war in academia. This is the stuff that skeptical people say about DID, and the main point is-- it's just a really, really,
1:28:03
really low-level of logic and scholarship. I mean, just basic errors of logic, discourse, analysis. In a philosophy department, you'd just get laughed out of the department if you did this kind of stuff. So... very commonly, arguments are applied to DID that could just as well be used against all other psychiatric disorders. So DID is not real because... and fill in the blank. But the same thing applies to all the other psychiatric disorders, but that's never said about them.
1:28:37
So it's this kind of double standard, goes on all the time. Which I'll give you some examples of. Skeptics also over-generalize from biased samples. So in cognitive therapy, which is a very well-studied, tons of outcome studies, method of therapy, originally for depression, and then expanded to a lot of other stuff. In cognitive therapy, you look for cognitive errors. So people who have been abused as kids, kids always blame themselves, so they think,
1:29:06
"I'm bad, I'm unworthy, I'm causing it, I deserve it, "it's my fault," and then that gets reinforced and ingrained, reinforced and ingrained. 30 years later, they come to our program. "I'm bad, I deserved it, I caused it, it's my fault. "I deserved to be abused by my husband. "I deserved to be abused by myself. "I'm not even a member of the human race. "I'm a disgrace," etcetera. All the time, all the time, all the time, all the time.
1:29:30
So one of the methods of therapy we applied to this is cognitive therapy, so we look at this as a cognitive error, an incorrect belief, because no child deserves to be abused or causes abuse. So it's an error in thinking. And then, we have a whole bunch of strategies and techniques we do to try and get them to see that, "No, that's not true. "It's never true of any human being. "You deserve to be treated well. "The only reason you weren't was just bad luck.
1:29:57
"It's all about your parents, not about you." So... in the cognitive therapy literature-- I'll take your question just in a second-- there's some basic sort of categories of cognitive error. There's "all or nothing," "black and white" thinking. So... that dominates presidential debates. You see this "all or nothing," "black and white" thinking. "This guy's gonna destroy America!" "This guy's the only hope for America!" So it's extreme, polarized "black and white,"
1:30:25
without looking at all the subtleties in between. And it dominates discussion in the culture of all kinds of different issues all the time. But "all or nothing," "black and white" thinking is supposed to be typical of borderline personality disorder. So it's a form of mental illness that we treat with psychotherapy. Another cognitive error is catastrophization. So the example I use when I'm teaching it to a patient or client is... woman's upstairs,
1:30:55
she's in her bedroom, she's about to go to sleep. All of a sudden, she hears a sound downstairs. She thinks to herself, "If that dog knocks over his water bowl "one more time, I'm really gonna be mad at him." Then, she goes to sleep. Down the street, there's another woman who's upstairs in her house. She hears exactly the same sound. She goes, "I think a serial killer "just broke into the house." Okay, so, the thinking that you have is going to generate
1:31:21
some very different emotional reactions, right? The woman-- the woman's who's kind of, "Eh, hmm," go to sleep. The other woman's in full panic. So your thinking kicks up all this "fight/flight," catastrophe, adrenaline, and then the counter to that is to de-escalate, talk yourself down. So this is catastrophization. Another cognitive error that mental patients do all the time is over-generalization. So, "My uncle abused me, "therefore all men are pedophiles."
1:31:54
Well, unfortunately, our colleagues do that all the time. They over-generalize from biased samples. So they might see one case of DID diagnosed by somebody else where there was lousy treatment and the person got worse, and then they conclude that all the treatment is 100% harmful. This happens all the time. "DID is not valid because its treatment "has not been proven effective." Okay, well, so, we just got rid of cancer of the pancreas. There's no effective treatment for cancer of the pancreas,
1:32:24
so therefore, it's not a valid disorder, right? You can't say this in general medicine. Everybody'd just look at you like, "What?" But you can say it about DID. So if it was true that the treatment of DID has never-- has no evidence basis, never been proven to be helpful, that would tell us zero about whether it's a legitimate disorder or not. Go back 200 years, we didn't-- there's no effective treatments for hardly anything in all of medicine. That doesn't mean all the diseases were not real.
1:32:55
So the absence of an effective treatment tells you nothing about the validity of the disorder. But on top of it, there in fact is a bunch of treatment outcome evidence. So that's an example of you can say that about DID, but you couldn't possibly say it about cancer of the pancreas, because everybody would just think you should have your license removed. Sorry, you were gonna ask something? >> Yeah, um, I was... when we were talking about childhood abuse,
1:33:23
now, things like-- I don't know, like, uh, parents divorced, or other experiences that, you know, you could qualify as psychological trauma, but it was not intended. Is that something you guys keep in account when you guys do your research, like, "Oh, we asked this question-- have you ever-- "were you abused as a child?" The person might not think about it as, "I was not abused," but, you know, there was certain experience that would, uh, be considered as trauma.
1:33:56
You know, think like, "Oh, my parents got divorced," but, you know, it's not-- >> So this was an excellent question. And, of course, it's really complicated. Nobody's got all the answers. Because... there aren't really any measures that ask about every single kind of upsetting or traumatic thing that can happen. And so, the focus is often on physical abuse, sexual abuse-- you know, big, obvious clear stuff. But actually in the patients who come to the program,
1:34:25
half the trauma comes from good things that should have happened that didn't. Namely bonding, connecting loving unconditional love, nurturing, protection. And so, they felt very scared, small, sad, lost, lonely. But nothing happened. Nobody fired a gun. Nobody hit you. So a lot of trauma is actually things that never even happened. And then, there's kind of like mild trauma, and then medium trauma, and obvious, huge trauma, and then there's... some people can run faster,
1:34:58
some people are better at math, some people are a little tougher at surviving trauma. Maybe two people have the same amount of trauma, but one's got a fairly okay parent and one's got two not-okay parents. So the one with the one okay parent got the same amount of sexual abuse, or they had a good aunt, or they had something to counterbalance the effect of the trauma. So there's all these different things that kind of come into play. And measuring it all is like pretty complicated and hard to do.
1:35:28
But there's-- like a recent literature started to grow showing very clearly that childhood bullying has lots of serious mental health consequences. 10 years ago, there was nothing about bullying in the mental health literature. And then, divorce, it all depends, because sometimes, the amount of family pathology and the amount of trauma goes down because of divorce, because you got rid of the not-so-good parent. Other times, it goes up. So there's not just one pattern.
1:36:01
I don't know if that answers your question. >> No, yeah-- yeah, definitely. Makes sense-- so you would think that in your field, that's probably one good area where more research could build up on, like, trying to measure some of these variables, like-- >> Yeah, absolutely. We always need more research. So of course, my opinion is, we should take a billion dollars from all this genetic research that's going nowhere and put it into this kind of research.
1:36:26
Because there isn't an infinite pot of money. And so, being able to study all this stuff, we're getting robbed by all the money being diverted over in that direction.
1:36:40
You look like you still have another thought there. >> No, no, no, I'm fine. >> Okay. (chuckling) So, uh, "DID is not a disease "because it is influenced by culture." So this gets published in psychiatry journals.
1:36:54
Okay so... hold on a second here, so you're telling me that there's actually psychiatric disorders that are not influenced by culture? It's an absurd proposition. Every anthropologist in every anthropology department in the whole planet would laugh his head off at you, or her head. It's ridiculous. There's no culture-free psychiatric disorder at all. So the fact that something is influenced by culture... tells you nothing about nothing, in terms of the validity of the disorder.
1:37:24
But sort of lurking in behind there is this idea that, "Oh, it's not influenced by culture, "because it's a biological brain disease." "The absence of cases outside North America "proves DID is a North American artifact." So we've accumulated lots of cases from outside North America, so that one's kind of starting to drop off now. But let's just say it-- well, it was a fact, if we go back 30 years, 25 years. There's a lot more cases being diagnosed in North America than outside North America.
1:37:57
So what does that prove? Well, there's two competing hypotheses to explain it. So I'm talking about DID here, but I'm actually illustrating kind of the logic of how the mental health system works, and what arguments are, and how you prove things and disprove things, and... which could be applied to all kinds of different disorders. So the two competing hypotheses are-- well, it's just being diagnosed more often in North America because the clinicians have become aware of it
1:38:25
in North America, and everybody else hasn't got up to speed yet. That's one hypothesis-- and it's a real, legitimate disorder, and if we do research in other countries, we'll find lots of DID all over the place. The second hypothesis is... it's just a hysterical fad kicked up by these crazy therapists... one of whom is me. And that's why it doesn't occur outside of North America, because they aren't as hysterical in the rest of the world. So the fact that in the '80s, DID was being diagnosed
1:38:57
a lot more inside North America, was a fact. But it's equally consistent with both hypotheses. But the skeptical people use the fact to prove their theory. But that's not how science works. What you do is you have an observation, a fact, then you construct a theory to explain the fact, and then you have to test your theory to see if it's right or not. You don't just go, "Well, here's the fact, "here's my theory, the fact proves my theory." No scientist operates like that.
1:39:29
So what you have to do is do some research and do some studies and find out, "Okay, "are there no cases outside North America? "Yes or no?"
1:39:39
So it's this completely unscientific kind of intellectual function. "Increase of diagnoses of DID in the '90s "is evidence of its artifactual nature"-- same idea. Also, going back in time, DID was rarely diagnosed-- (mic cuts out) and that proves it's just a fad in the 20th century, which is unfortunately persisting into the 21st century. But it's the same two theories. It's always been around, going back for thousands of years, we just haven't gotten up to speed on it until...
1:40:13
into the 20th century, versus, "no, we've created a fad in the 20th century." So the fact that there's more cases diagnosed 1980 to '90 than all of the 18th and 19th centuries doesn't prove which theory is correct. But the skeptics use the fact to prove their own theory. "Skeptics make appeals to authority." So appeal to authority is... "Oh, by the way, I know this is true, because Freud said so." So you just-- "Freud, you can't argue with Freud." That's an appeal to authority.
1:40:44
Or if you're a philosopher, "Wittgenstein said so." Or if you're an English literature person, you might say something about Dickens. So the skeptics prove that they're correct by referencing their friends and their co-authors. Over and over and over and over and over. So there's a little group of guys who belong to the club, and everybody in the club agrees, therefore the club is correct. It's just not science. Validity can be inferred from anecdotal
1:41:13
short-term treatment outcome, which I measured-- talked about before. So if you find a couple of cases that did poorly... you can then conclude that all treatment of all cases of DID is bad and wrong. You just, you couldn't say this about schizophrenia. You know, a couple of people with schizophrenia came to the hospital and they got some sort of crazy treatment and they did badly, therefore schizophrenia is not real? You just cannot say that anywhere in the mental health field.
1:41:42
But you can say it about DID. Bad therapeutic practices call the validity of DID into question. Okay, so you go to Mexico to get Laetrile for cancer and you die at exactly the same date as you would've if you didn't go to Mexico, proving that cancer's not real. It just doesn't make any sense. "Diagnostic criteria for DID are vague, "therefore DID is not valid." Okay. That could be true. If it was true, that the diagnostic criteria are vague.
1:42:18
But how are we gonna find out if the diagnostic criteria are vague? Well, we've got to do inter-rater reliability studies and look at the Cohen's kappa. So we actually have evidence that the criteria for DID are less vague-- like they're-- the DID-- depending on if you wanna go up or down on the scale, either the criteria for depression are twice as vague as the criteria for DID, or the criteria for DID are half as vague as the depression criteria, based on the Cohen's kappas.
1:42:50
So why are we saying that DID is vague when it's actually demonstrably much less vague than depression?
1:42:59
And what is the-- how do you diagnose substance abuse, according to the "DSM V"? Well, obviously you've got to take a bunch of some kind of substances. But you have-- all the wording is things like "clinically significant."
1:43:16
So what's "clinically significant"? There's no number for that. It's kind of a vague term. To be depressed, you have to be depressed, down, sad, blue, most of the time for at least two weeks. Yeah, but how much most of the time? It's completely undefined. It's literally just "most of the time."
1:43:37
So this is one of the reasons why the agreement level is so low. So we're applying this argument of vagueness to DID, which applies more to other diagnoses. "Lack of proven physiological differences "between alters invalidates DID."
1:43:54
There's no proven physiological difference between any mental disorder and any other mental disorder. So this applies to all mental disorders. We don't have-- and this is according to "DSM V"-- we don't have a blood test, we don't have a brain scan, for diagnosing any "DSM" disorder.
1:44:13
"If repression is not proven, DID is not real." Did that earlier. "Diagnosis of DID encourages irresponsible behavior." It could. It doesn't in my treatment programs. I hold people with DID responsible for all their behavior, and they get the natural consequences of their behavior just like anybody without DID. So just because-- you can use DID to go, "Oh, I can't help it-- little Joey inside did it," but you don't have to. So if we had a rule in the mental health system
1:44:46
that if you're depressed, you get half as long a prison sentence as somebody who's not depressed, how many people would be depressed all the time? Everybody. If we had a rule that said depressed people get double the sentence, everybody would be, "I'm not depressed." So you can totally manipulate it by the rules of the system. It's not inherent in the disorder or the diagnosis.
1:45:08
Uh... "They're really just borderlines"-- went over that. "It's an artifact of suggestibility "and highly hypnotizable individuals." So this is one of the common things. You just hypnotize these people and suggest to them that they have a canary living in their left ear. All of a sudden, they have a canary living in their left ear. It's a very chauvinistic, demeaning, belittling view of women, because most of the people in treatment are women, that they're "so impressionable,"
1:45:35
you just tell them, "Oh, you have somebody inside." "Oh, yes, I have somebody inside!" I mean, it's like women don't even know their own minds. It's a very belittling model. And we actually have all kinds of research. People with DID who've never been hypnotized don't really differ in their symptom profiles from people who have been hypnotized. "It's impossible to have more than one personality "in the same body, therefore it's not a real disorder." Well, of course it's impossible to have
1:46:02
more than one personality in the same body. Nobody's saying there's literally different people living in there. And I explain this to patients all the time. I call it the "central paradox of DID." So it took a while to figure this out. Because if you say this the wrong way, the person goes, "Oh, you're telling me it's not real? "I'm just making it up, it's all in my head? "I might as well go kill myself right now." So you've gotta be careful how you deliver it.
1:46:25
So it took me a while to figure out how to state the central paradox of DID, which is it's both real and not real at the same time. And I've given this explanation to hundreds and hundreds of people with DID. What do I mean by that? Well, on the one hand, it's not literally concretely real. So if we took an X-ray of your head, we wouldn't see all these little skeletons in there. And if there really were little skeletons running around inside your brain,
1:46:51
your brain would be just all mashed up and you'd be dead. And nobody goes, "Oh, yeah, there's skeletons in there." Everybody goes, "Oh, that's cute-- little skeletons." So nobody debates the point. So it's not literally, concretely true (indistinct) people, personalities in there. But on the other hand, it's completely psychologically true. And very subjectively compelling. And people really do open up their closets, and there's like three outfits-- so this was a...
1:47:18
very conservative 39-year-old married housewife, and there's like 16-year-old party girl stuff. She doesn't remember buying it. There's the receipt, her credit card, sort of like her signature, and she can't remember from 2 PM to 4 PM yesterday, because her teenage alter went shopping. These experiences actually happen. They're very psychologically real. They're just not literally real. So this whole thing about it's not possible to have more than one personality is, like completely irrelevant.
1:47:52
"A few clinicians are making all the diagnoses." Uh, that was true... in 1980. It's not true today. But so what? At one point in time, a small number of clinicians were making all the AIDS diagnoses. What does that prove? There's people who see-- have clinics every week where numerous people with cystic fibrosis come to see them, and there's other pediatricians who don't see any cases at all. Well, that's because these guys specialize in cystic fibrosis. It's completely ordinary.
1:48:28
It's unsurprising. Nobody says, "Oh, a few clinicians are seeing "most of the cases of this disorder, "therefore it's not real." They just go, "Oh, those guys specialize in that."
1:48:39
"Incorrect references are indicative of careless research "in the skeptical literature." So the skeptical guys do a really lousy job on their references. They even get like the wrong references. Or they quote a reference supporting a point that doesn't even support that point. So just lousy scholarship. "DID has been created experimentally, "which proves it's not valid." Hmm... okay. So there's nothing worse in medicine than having an animal model of a disorder. Right?
1:49:13
So biological cancer researchers never want to study mice that have cancer.
1:49:21
Well, of course they do. These are called "animal models." All of medicine is based on things in test tubes and things in animals that are a model of the disease in humans, so we can study how it works, whether it's the immune system or arthritis or cancer. So animal models, or experimental models of something, don't disprove it. They help us to study how it works. So nowhere else in medicine is an experimental version of the disorder used to invalidate the disorder.
1:49:51
What are the experiments where people created DID that proves it's not valid? It's so preposterous. You wouldn't believe that this stuff could get in the literature if it wasn't in almost all of the major psychology textbooks as evidence that DID is not valid. So the experiment is, you get a whole bunch of undergraduates, such as you guys. I bring you in. I give you a... little bit of training for an hour or two about what DID is, what it looks like. I teach you about child alter personalities.
1:50:30
And then, I ask you to come back next week and act as if you have multiple personality, and a little girl comes out and talks and she's so cute, and she doesn't remember what happened a long time ago.
1:50:43
So you do that. The reason you do that is, you get course credit for it. And this is the proof that multiple personality can be created experimentally-- literally. They get college students to act as if they have multiple personality, after they give them a little training on how to do the acting. That's it. Do any of these people have multiple personality for another year? Or go to the counseling center and say, "I can't remember what happened yesterday?" None.
1:51:14
So what if we got you guys together and we said, "Okay, I'm gonna teach you about back pain. "You're all gonna act like you've got lumbar disc pain, "and you're gonna be going, 'Oh, oh,' "and you're gonna ask the doctor for some painkillers, "and maybe you need to take a week off of school. "And you can't hand in your paper this week." And so, you all start going, "Oh, oh, oh." This proves that disc pain isn't a real thing? So teaching people to fake something temporarily
1:51:47
in order to get course credit tells us nothing about whether the thing they're faking actually happens in the world or not. But it's-- I'm not kidding, like the majority of undergraduate psychology textbooks cite these experiments as compelling, conclusive evidence that DID is a fake disorder. Which, again, if you did that with depression, everybody'd just go, "Well, they're just faking depression. "They don't actually have it. "It stops as soon as the experiment's over."
1:52:17
>> What about "BLUEBIRD"? (indistinct). >> This guy's read too many of my books here for his own good. So another line of argument, which I was not gonna get into, but it's a whole 'nother half-day talk, is one of my books originally was called "BLUEBIRD," but I reissued it as "The CIA Doctors." It's about 15,000 pages of documents that were declassified in the '70s, plus a ton of papers from medical journals from the '50s and '60s about CIA mind control experimentation,
1:52:51
all totally documented, done at major institutions, Ivy league schools. Closest place where MKUltra top secret experimentation was done to here would be Ionia State Hospital in Michigan. The experiment there was five or six military psychiatrists who had severed in the Vietnam war who were now back working at the state mental hospital in Michigan, cleared at top secret by the CIA, knowing it was CIA funding, were interviewing incarcerated sex offenders,
1:53:29
and giving them barbiturates, marijuana, and hallucinogens, to see if they could get them to confess to crimes they'd never been charged with. That seems a little dicey. That doesn't, no, I don't think that would exactly pass the proper ethical review board. You've got incarcerated sex offenders, you're giving them street drugs to see if you can get them to confess to things, and then you're not going to bother reporting that to the police at all. And it's cleared at top secret.
1:53:58
So these are the documented types of experiments that were done, including creating Manchurian candidates, which is artificial multiple personality, which is the movie "The Manchurian Candidate." This is fact, not fiction, described extensively in documents, that if you take somebody, you don't just go, "Hey"-- it's the same as creating a suicide bomber. You don't just walk up to somebody on the street and go, "Hey, would you like to blow yourself up next week?"
1:54:27
You've gotta recruit them, you've gotta work on them, you've gotten soften them up a little, you've gotta give them some rewards. 72 virgins in heaven-- pretty good reward. Not sure if it's a real reward. So to get somebody to kill themselves, I mean, it's a project. You've got to have a susceptible person, and you can't choose like the head of the government's son, and they've gotta be kind of desperate, and they've gotta be kind of adrift in life, and then you've gotta work on them,
1:54:54
work on them, work on them. If you take somebody such as a marine and you work on them for a period of months with all kinds of interrogation techniques and brainwashing techniques, you can create artificial multiple personality, and use the person in the background to go on missions, and the person out front doesn't remember, and this is described in great detail in documents going back to the second World War. So what I do with that is, I say, "That proves the reality of civilian
1:55:27
"clinical multiple personality." If you control somebody, traumatize them, threaten them, manipulate them enough, this is how the human mind reacts. Not in all people. But a sub-group of people. So if you react to brainwashing by creating a new alter personality, why wouldn't you react to childhood abuse by creating a new alter personality?
1:55:55
Oh, "DID must be completely unconscious to be genuine."
1:56:00
I don't know where these guys even came up with this. They say that people like me believe that DID is totally unconscious. Nobody in the DID field has ever said that. They just kind of invent that out of nowhere, and then they argue that, "Well, "since it's not completely unconscious, it's not genuine." Which doesn't make any sense-- I mean, who ever comes in and says, "I'm here, doctor, "because I'm completely unconscious "of being depressed." (audience chuckling)
1:56:26
It just doesn't make any sense. Uh, "Satanic ritual abuse and alien abductions "are not real, so neither is DID." Okay so... wait a minute, what's that got to do with anything?
1:56:41
Only two or three people with DID who describe alien abduction experiences... out of thousands. So... so a few people with schizophrenia think they were abducted by aliens, therefore schizophrenia's not real? It's just not-- again, absolutely makes no sense whatsoever. Satanic ritual abuse-- well, let's assume that all the Satanic ritual abuse memories, which is a sub-group of people with DID, are not real. Well, okay, so, hello, these people are psychiatric patients
1:57:11
in a mental hospital-- they're a little mixed up. Who's surprised by that? Nobody says, "Oh, these schizophrenics have delusions, "therefore their schizophrenia isn't real." It just... over and over and over, this logic just doesn't make any sense. And then, the "extreme case escalation tactic" is just a term I invented. So they'll take the most extreme, out-there case, and use that to be typical of the entire population of DID. And so they-- they'll always do that--
1:57:42
escalate up to the extreme situation. So if you go to... I don't know the exact percentage, but over three-quarters of undergrad-- (mic cuts out)-- or even graduate abnormal psychology textbooks, you get the anti-DID approach, and you'll hear them talking about the Hillside strangler case in Los Angeles in the 1970s. Which is a serial killer who was convicted, who... not 100% for sure, but probably was faking DID. And that is overwhelming, powerful evidence that DID is not a legitimate disorder.
1:58:19
One case of one guy who's a serial killer-- we're gonna rely on them? Who tried to get out of responsibility by faking DID proves what about everybody else? It's just so far in outer space, it's hard to believe, but it's in the majority of abnormal psychology textbooks as powerful evidence that DID is not real. Textbooks written by, like, the top professors. This is what I deal with. Okay, so this is now my favorite part of the whole thing. So...
1:58:52
and so, this book was not published that long ago. Well, let me skip that one-- sorry. I'll just-- because we're a little short on time. Here we are at my favorite one. So this book was not published all that long ago. "Sibyl Exposed." By this woman Debbie Nathan, who sees herself as a feminist, she's a journalist. And Shirley Mason was-- is the real person who was in the novel and the movie, "Sibyl." So the two big books and novels before "DSM III" came out in 1980
1:59:33
where multiple personality got an official slot, the two big books and movies were "The Three Faces of Eve" and "Sibyl." And... Chris Seizmore, who's the real Eve from "The Three Faces of Eve," I know personally-- amazing woman-- has been integrated since 1975, highly gifted artist, wonderful person. Has been well for decades. Shirley Mason, who's Sibyl, I never met, and she died. But in this book, this Debbie Nathan uses the Sibyl case to establish conclusively
2:00:08
that Sibyl really didn't have DID-- it was just a crazy therapist, Cornelia Wilbur, which then makes us know pretty well for sure that all the cases are ridiculous and not real. But let's look at her analysis here. This is all from her book.
2:00:23
So... she's born in 1923, died in 1998. She had five sessions with Dr. Cornelia Wilbur-- who I knew, who is now deceased-- in 1945. So five sessions. She functioned well with no signs of DID from 1945 until she started seeing her again in 1954. So these are the facts according to Debbie Nathan. The symptoms of DID began after the therapy re-started, and were caused by the bad therapy by Cornelia Wilbur. Okay, but in the book, Debbie Nathan
2:00:59
describes symptoms prior to first contact with Dr. Wilbur, described to her by many people in Shirley Mason's hometown, who she interviewed directly. Many different people. Family members and non-family members. The symptoms from before first contact included fugue states, which means going somewhere and not remembering who you are for a period of time. Blank spells-- so clearly defined chunks of missing time. Spending hours playing with imaginary companions with names
2:01:33
far beyond the age that this occurs in non-traumatized children. Pretending to be Vickie, one of her imaginary companions at times. Her mother calling her by the names of alter personalities later identified in adult therapy. Talking in a high, childish voice when she was no longer a child. Numerous symptoms consistent with somatoform dissociation, which means psychosomatic symptoms. Going to bars to drink with men, and not remembering afterwards, although she hadn't consumed that much alcohol.
2:02:03
Suddenly going comatose in public. Suddenly acting dramatically out of character. All of these behaviors, described by many observers in her hometown, going back into her childhood for years before first contact with Cornelia Wilbur. Yet, the analysis is all the DID symptoms were caused by the therapy. This is a huge... amount of symptomatology consistent with pre-existing DID. But then, she goes on to say that all these symptoms that existed before contact with Cornelia Wilbur,
2:02:40
were caused by pernicious anemia, a form of anemia.
2:02:46
Well, a little minor problem... pernicious-- she never had a pernicious anemia diagnosis. No doctor ever diagnosed her with that. It's just made up out of nowhere. If the symptoms were caused by pernicious anemia-- which she didn't have-- why did those symptoms go into remission from 1945 to 1954? So Debbie Nathan says she had all these symptoms here before seeing Cornelia Wilbur, caused by pernicious anemia, which doesn't cause those symptoms anyway and which she didn't have.
2:03:18
And then, all those symptoms stop for nine years, although she wasn't diagnosed or treated, and pernicious anemia never goes away, and then they suddenly started up again and were caused by Cornelia Wilbur. Like, who's gonna believe this? This book gets published, gets reviewed favorably all over the places, it's cited by all the skeptics. It'll be in the psychology textbooks soon. "Debbie Nathan wrote this compelling analysis."
2:03:49
And the... final nail in the coffin of DID is that Debbie Nathan points out that Shirley Mason denied having MPD herself.
2:04:07
Once, in one letter. Okay, so you treat somebody with chronic, severe alcoholism, for a long period of time, and once they write you a letter saying that they don't have a drinking problem, that's it, they clearly don't have a drinking problem? (audience laughing) It's just-- again, it's just this outer space, Mad Hatter's tea party... doesn't make any sense. It's impossible. It's so far below any kind of... high school debating clubs could do way better than this in their level of scholarship,
2:04:39
argument, weighing the evidence. So then, that raises the question, "Well, why?" Why is this all going on in the field? What's the deal here? Why do all these, like, high-ranking professors have all this bad attitude and all these crazy arguments that make no sense? And my answer is I don't know for sure. But I think there's multiple sort of factors contributing to this. One is, uh, "My professors never taught me about that. "I was taught that it's rare. "My professors can't be wrong.
2:05:16
"I can't be wrong. "It'd be too shameful to admit that we've all been wrong "for all these decades." So there's this sort of egotism, professional reputation. Another thing is if it's actually true, then in the ballpark of 1 out of 25 inpatients in all the psych hospitals in the country has undiagnosed DID, and we're missing all those cases? That doesn't make us look like very sharp diagnosticians. So therefore, we have to say it's not real.
2:05:42
Another thing is, if there's all these people with DID-- full DID-- plus a whole bunch of people with kind of half, three-quarters, a quarter DID, maybe a lot of us are a little more DID-ish than we would like to admit to. So maybe, "I don't wanna look at them "because I don't wanna have to look at myself. "Maybe my behavior's sometimes a little inconsistent "and doesn't exactly mesh together in a healthy fashion." Which doesn't mean that I have DID. I'm talking "I" the skeptic.
2:06:13
"Maybe I, the skeptic, "have an unresolved childhood trauma history "and I don't want anybody talking about that stuff." So therefore... when Colin Ross goes to the American College of Psychiatrists meeting, hears a whole hour talk by a top expert on childhood depression-- not a mention of childhood abuse of any kind once. Then, listens to another talk about another expert, not a mention of childhood trauma once. Another talk by another expert, still no mention of childhood trauma.
2:06:44
Maybe they just don't wanna talk about it. Maybe they're uncomfortable. Maybe it's something to do with personal histories. Next hypothesis. Remember when sexual abuse was just kind of coming out of the closet? In 1980, the 3rd edition of the comprehensive textbook of psychiatry was published, that I used in my residency from '81 to '85. There's three volumes, it's 3,300-and-something pages, two columns each page. Everything you need to know in psychiatry was in there.
2:07:14
Way at the back, after the important stuff, like depression and schizophrenia, and drugs, genetics, was a section called "Topics of Special Interest." Which really means irrelevant stuff that we just stuck in at the end because, you know, gotta be comprehensive. In there was a short chapter called "Incest." In the chapter on incest was one paragraph talking about how common incest is, with a reference to a 1955 study saying it's one family out of a million in the United States.
2:07:45
Those are the scientific, academic, medical facts during my training. That's the level of denial. Institutional denial. It's been in place in psychiatry for a century. It's actually more than one family out of 100, not one out of a million. In this same era, the mid-'80s, there's several surveys where, surprisingly female psychiatrists got interested in childhood sexual abuse, which is mostly, but not exclusively, girls. It's about two to three times as much with girls as with boys.
2:08:19
And they did mail-out surveys to different types of physicians, psychiatrists, psychologists, and I think in one survey, social workers-- can't remember for sure. But all different types of physicians. Have you ever had sex with somebody who's currently in treatment with you? And a bunch of other questions. They got back-- they described in their article, published in a leading journal-- angry, scrawling, you know, F bombs and the whole works, from physicians, swearing at them,
2:08:51
accusing of being this, that, and the other, and not filling out the questionnaire. And 10% of respondents said yes-- anonymous respondents, said, "Yes, "I have had sex with somebody who's currently in treatment "with me in my practice." So 10% admitted. So what do we think the real rate is? So do we think there's pedophiles in the Catholic church? Do we think there's any in the Boy Scouts? Do we think there's any in the medical profession? Do we think there's any in psychiatry? There has to be.
2:09:23
There's pedophiles everywhere. So part of the whole deal is pedophiles don't want anybody talking about that stuff. Then, the other part of it is... biological brain disease model. If the genetics and the biology of the brain are the big drivers of mental illness, we can't allow it to be true that childhood trauma that's the major driver. It's just not allowed. So you have to discredit it. And any diagnoses that are linked to it, discredit. So to me, that's what's going on in the profession.
2:09:56
You look like you had a question. >> Yeah. Approximately, what's the ratio of skeptics to, you know, clinicians who believe in DID? >> There's actually surveys by skeptics, funnily enough, who then conclude that DID is not valid, should be taken out of the "DSM," and in those surveys, about, uh... it's a little tricky how they word the question. So sometimes the question is, "Should the criteria be modified?" And the answer is "yes," and then they say, "Well, see, it's a bogus diagnosis."
2:10:30
Well, hello, the criteria for schizophrenia just got modified between "DSM IV" and "DSM V." So of course we have to fine-tune stuff, and that proves nothing. But it comes out about... bouncing around from survey to survey, hardcore skeptics are somewhere between 5% and 15%. Half to two-thirds think it's a legitimate disorder, needs more research, maybe needs some fine-tuning, sometimes questionable. That's kind of the ballpark. So, but the very small group of really vociferous--
2:11:02
I mean, they're like the jihadists, right? They're the anti-DID jihadists. They're very vocal, very energized, very active. And have control of undergrad psychology textbooks, by and large.
2:11:18
>> What about the actual lit-- (clearing throat) sorry, the actual literature? Is there like a lot of literature-- you know, you presented us a little of the literature you've done on this topic, but is there, like, a lot of literature that says the opposite of what you're saying? >> Well, the literature that says the opposite just says it, but doesn't have any evidence. So these guys, like the guys who do the experiments to create multiple personality in college students,
2:11:45
they never once describe interviewing a single person with a clinical diagnosis of DID. So they do no treatment, and they don't even talk to people to say, "Hey, "tell me about your experience here." So it's totally armchair quarterbacks, and they don't have any solid designed research studies proving any of their points. >> So there's not, I mean, like, actual, empirical research from their side? It's mostly just reviews of-- >> Reviews and opinions. And false reasoning.
2:12:18
>> And sometimes, stereotyped by inaccurate descriptions of what they're even rejecting. >> Yeah, right. We were talking about this before, so the stereotype of what somebody with DID is supposed to look like. "So they're like flamboyantly, extremely obvious. "They're right in your face with it. "They're claiming no responsibility for anything. "They're trying to get all kinds of special treatment "and privileges. "And there's no evidence for any DID before from anywhere." That's the stereotype.
2:12:50
Which simply is just not reality.
2:12:54
Of course, we know that everybody from Grand Rapids is actually a Martian wearing a human costume. Well, we don't really have evidence for that, but we know it's true. It's kind of like that.
2:13:08
Anyone else with a thought, comment, question? About anything in the mental health field?
2:13:17
Or anything to do with college hockey, that I know a lot about? (all chuckling) Okay, well, thanks for listening. Thanks for spending some time. (applause)
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