Dissociative identity disorder in the Netherlands 271advocate a long-term and intensive psychodynamic those who have not made the diagnosis. A signiﬁcant Ppsychotherapy facilitated by hypnotherapy [8, 14, 19, value was set as P < 0.05. The size of the study popula-28]. To date, no speciﬁc pharmacotherapeutic agent tion varies due to missing data.that cures the core dissociative symptoms is avail-able [19, 34]. RESULTS Because of this controversial status and the paucity oftreatment outcome data, a questionnaire was distrib- Psychiatrists and DID diagnosisuted among Dutch psychiatrists to explore the fre-quency of the diagnosis, the types and efficacy of cur- A total of 1,452 psychiatrists were approached: seven ofrent treatment practices, and to explore some of the them were deceased, two had moved abroad, and threedemographic information regarding the psychiatrists envelopes were returned to sender. Of the remainingand the patients. In this paper, the results of the survey 1,441 psychiatrists, 661 completed and returned theare described and compared with data from the litera- questionnaire, eleven called or wrote to say they had notture. completed it because of their age (65–88 years), retire- ment, or prolonged sick leave. This produced a re-METHODS sponse rate of 46.7% Three questionnaires were elimi- nated because of incomplete information, yielding aAn anonymous one-page questionnaire with a stamped ﬁnal cohort of 658 respondents (table I). On 1st Janu-and addressed envelope was sent to all members of the ary 1996, a total of 1,565 psychiatrists were registered.Dutch psychiatric association. An introductory letter Our study population thus included about 42% of theexplained the purpose of the questionnaire and speci- Dutch psychiatric community.ﬁed the criteria for the diagnosis of DID (DSM-IV) There was a signiﬁcant correlation of diagnosis fre-and MPD (DSM-III-R). Four weeks later, a reminder quency with the psychiatrists’ age (chi-square test,was sent. The questionnaire contained twenty-ﬁve χ2 = 5.5, df = 1, P < 0.05), and years of clinical experi-questions formatted in checklists and rating scales. It ence (chi-square test, χ2 = 6.6, df = 1, P < 0.01).was intentionally kept short to enhance the response Younger (i.e., 50 years or younger) psychiatrists maderate. the diagnosis more frequently than their senior (i.e., The questionnaire was divided into four sections. older than 50) colleagues (45% vs. 36%). PsychiatristsThe ﬁrst nine questions focused on demographic and certiﬁed after 1982 reported making the diagnosis moreprofessional characteristics of the psychiatrist. The next frequently than those who completed their specialitysection consisted of two questions on the frequency of training earlier.DID diagnosis and the number of treated DID pa- Female psychiatrists made the diagnosis signiﬁcantlytients. In the last two sections, following the format more frequently (50% vs. 39%) (chi-square test,used by Putnam and Loewenstein , the questions χ2 = 6.1, df = 1, P < 0.01). The principal subspecialtyfocused on anonymous demographic and treatment and topography of the work site did not exert a statis-data of one patient. Respondents were asked to rank, in tically signiﬁcant inﬂuence on the frequency of theorder of effectiveness, all treatment modalities used diagnosis. Nor was a correlation observed with a pri-from a list of 12 therapeutic approaches. Medication mary theoretical orientation: psychiatrists with a psy-efficacy was evaluated per major medication class on a chodynamic frame of reference did not exhibit more ofsix-point scale, ranging from ‘worse’ to ‘excellent’ a tendency to make the diagnosis than biological orien-symptomatic improvement. Finally, the respondents tated psychiatrists. The psychiatrists who reported giv-were asked to specify the drug of choice for each medi- ing psychotherapy treatment did however make thecation class. diagnosis signiﬁcantly more frequently (47% vs. 22%, Statistical analysis was performed using the statistical chi-square test, χ2 = 28.1, df = 1, P < 0.001).product and service solutions 7 for Windows (SPSS).Pearson’s chi-square test and the binomial test were DID patients and treatmentemployed for nominal data and the Mann-Whitney Utest and the Kruskal-Wallis test were used for ordinal A total of 298 of the respondents had either made thedata. In calculations concerning the DID diagnosis, use DID diagnosis themselves or had treated patients diag-was made of a dichotomy: respondents who have versus nosed with DID (table II). The majority (59%) of these
272 H.N. Sno, H.F.A. SchalkenTable I. Characteristics of psychiatrists and DID diagnosis.Mean age (n = 658) 49.6 Mean clinical experience (n = 656) 15.3– SD 9.7 – SD 9.6– range 33–80 – range 2–50Gender (n = 651) n % Region (n = 637) n %– male 491 74.8 – north Holland 179 28.1– female 165 25.2 – east Netherlands 91 14.3 – ﬁve other regions range between 68–77Primary work site (n = 654) n % Theoretical orientation (n = 648) n %– psychiatric hospital 170 26 – psychodynamic model 277 42.7– private practice 145 22.2 – biological model 119 18.4– general or university hospital 105 16 – system theory 30 4.6– community mental health center 95 14.5 – cognitive-behavioral model 23 3.5– child psychiatry setting 81 12.2 – other 199 30.7– other 58 8.9Principal subspecialty (n = 652) n % Psychotherapy (n = 652) n %– psychotherapy 241 37 – yes 517 79.3– social psychiatry 87 13.3 – no 135 20.7– clinical psychiatry 79 12.1 + number of patients (n = 509)– child psychiatry 74 11.3 – mean 11.8– biological 30 4.6 – SD 12.7– forensic 30 4.6 – range 1–90– geriatric 22 3.4 – less than ten a week 289 56.7– consultation-liaison 21 3.2 – 10–19 a week 109 21.4– other 68 10.4 – 20–39 a week 81 16 – 40 or more a week 30 5.9 + duration (n = 507) – short-term (less than one year) 155 30.6 – long-term (one year or more) 352 69.4DID diagnosis (n = 653) n % Treatment of DID patients (n = 652) n %– never 380 58.2 – never 414 63.5– once 83 12.7 – once 76 11.7– 2–5 times 136 20.8 – 2–5 times 125 19.2– 6–10 times 28 4.3 – 6–10 times 15 2.3– 10–25 times 21 3.2 – 10–25 times 21 3.2– more than 25 times 5 0.8 – more than 25 times 1 0.2patients were in the 20–40 year age category and 21 A total of 239 (36.3%) respondents reported having(7%) below the age of 18. In comparison with demo- treated patients with DID (table III).There was a non-graphic data on the Dutch general population (Central signiﬁcant trend for women (Mann-Whitney U-test,Statistics Office 1997), the selected DID patients ex- U = 1627, Z = –1.543, P > 0.05) and for higher edu-hibited an over-representation of women (binomial cated patients (Kruskal-Wallis test, χ2 = 2.5, df = 3,test, Z = 12.9, P < 0.001), the 20–39 year age category P > 0.05) to have been in treatment longer. There was(chi-square test, χ2 = 114.2, df = 4, P < 0.001), people a signiﬁcant relation with income level (Kruskal-Walliswho live alone (binomial test, Z = 10.9, P < 0.001), test, χ2 = 11.0, df = 2, P < 0.01). The treatment dura-well-educated people (chi-square test, χ2 = 83.32, tion of low income was shortest. The treatment dura-df = 3, P < 0.001), unemployed people (χ2 = 241.4, tion and frequency were not inﬂuenced by the psychia-df = 2, P < 0.001), and people with a low income (chi- trists’ gender. The psychotherapeutic approach wassquare test, χ2 = 570.3, df = 2, P < 0.001). There was ranked ﬁrst by 131 respondents whereas 17 ranked itno signiﬁcant difference as regards marital status. second: 17 respondents ranked medication ﬁrst and 99
Dissociative identity disorder in the Netherlands 273Table II. Characteristics of DID patients.Mean age (n = 271) 33.2 Gender (n = 270) n %– SD 11.1 – male 27 10– range 10–76 – female 243 90Living situation (n = 271) n % Cultural background (n = 274) n %– with others 174 64.2 – Dutch 247 90.1– alone 97 35.8 – non-Dutch 27 9.9Marital status (n = 272) n % Education (n = 267) n %– unmarried 133 48.9 – lowa 35 13– divorced/widowed 109 40.1 – middleb 104 39– married 30 11.0 – highc 106 39.7 – university 22 8.2Employment status (n = 264) n % Income bracket (n = 238) n %– employed 59 22.4 – lowd 141 59.2– unemployedd 113 42.8 – middlee 73 30.7– othere 92 34.9 – highf 24 10.1a Special school, primary school, lower vocational school; b Secondary school O levels, middle level vocational school; c Secondary school Alevels, higher vocational school; d Lower than minimum wage; e Between minimum wage and public health insurance level; f Higher thanpublic health insurance level.Table III. Characteristics of treatment.Mean duration (years) (n = 209) 2.8 Practice/institution setting (n = 214) n %– SD 2.7 – psychiatric hospital 51 23.8– range 1 month–16 years – private practice 45 21.0– male patients (n = 22) 2.1 – general or university hospital 45 1.0– female patients (n = 185) 2.9 – community mental health center 35 16.4– low educational level 2.3 – child psychiatry setting 16 7.5– middle 2.7– high 3.0 Outpatient/inpatient setting n %– university 3.3 – exclusively outpatients 92 43.2– low income 2.3 – outpatients with hospitalizations 56 26.3– middle income 3.6 – inpatients 41 19.3– high income 3.4 – partial hospitalization settings 24 11.2 Adjunctive medication (n = 239) n %Treatment frequency (n = 194) n % – yes 173 72.4– once a week 96 49.5 – no 38 15.9– twice a month 49 25.3 anti-depressants (n = 124)– more than once a week 27 13.9 – estimated efficacy: moderate to good 75 60.5– once a month or less 22 11.3 anxiolytics (n = 124) – estimated efficacy: moderate to good 73 60.8Treatment modalities (n = 239) n %a neuroleptics (n = 111)– individual psychotherapy 154 64.4 – estimated efficacy: moderate to good 53 47– medication 160 67.0 : none or inverse 17 15.3– hypnotherapy 28 11.7 anticonvulsant (n = 15)– art therapy 41 17.2 – estimated efficacy: moderate to good 7 46.7– family therapy 35 14.6 lithium (n = 15)– group therapy 22 9.2 – estimated efficacy: slight or none 11 73.3– cognitive-behavoural 29 12.1– ECT 2 0.8a Since more than one modality may have been used, the total percentage adds up to more than 100%.
274 H.N. Sno, H.F.A. Schalkenranked it second. Hypnotherapy was ranked ﬁrst by our study, 273 (41.8%) psychiatrists noted havingtwo respondents and 17 ranked it second. made the diagnosis, and the predominance of respon- Fluoxetine and paroxetine were the most frequently dents from the north of Holland corresponds with thereported serotinin reuptake inhibitors, whereas clomi- high ratio of psychiatrists to population in this region.pramine and amitriptyline were the most frequently No topographic relation could be detected. This isused tricyclic antidepressants. The most frequently re- substantially more than in Switzerland, where 63ported anxiolytics were oxazepam, alprazolam, cloraze- (10%) psychiatrists in Modestin’s study  reportedpate, and diazepam. Pimozide, haloperidol, thior- having seen a DID patient at one time or another. It isidazine, and zuclopentixol were the most frequently however less than the 119 (66.1%) psychiatrists inreported neuroleptics. As for anticonvulsants, carbam- Mai’s  study, who expressed the belief in the valid-azepine was prescribed in eight cases. Lastly, three ity of the diagnosis. Mai  nonetheless concludedrespondents prescribed naltrexone. The estimated effi- that a substantial minority of the psychiatrists do notcacy was slight to moderate. make it as a new diagnosis. Due to the low response rate of 24%, the ﬁnding of Dunn et al.  that 81.9% ofDISCUSSION 456 VA psychiatrists acknowledged DID as a separate clinical identity, is of limited value.In spite of the limited number of questions and the The signiﬁcant relation observed in our study be-anonymity, the response rate was rather disappointing. tween the psychiatrist’s gender and the frequency ofIn addition to survey fatigue, the low response rate may making the diagnosis differs from the ﬁndings ofhave been due to the psychiatrists’ resistance to the Modestin  and Dunn et al. , who did not ob-DID diagnosis. Our response rate is comparable to the serve any signiﬁcant relation of either diagnosing or52% reported by Dell , and to the 49% docu- believing in DID with the gender of the psychiatrist.mented by Putnam and Loewenstein  in two sepa- Our ﬁnding that the diagnosis was more frequentlyrate studies among 120 and 637 members of the inter- made by female psychiatrists may be explained by thenational society for the study of multiple personality preference of the predominantly female patients forand dissociation. In addition, the response percentage psychotherapists of the same sex, or by the possibilitywas higher than the 31.3% recorded by Dunn et that female psychiatrists are more open to the effects ofal.  among 3,600 VA psychiatrists and psycholo- traumata.gists, but lower than the 66% observed by Modes- In concert with the ﬁndings of Dunn et al.  andtin  among 1,273 Swiss psychiatrists, the 61.2% Mai , the diagnosis was made more frequently byMai  noted among 294 Canadian psychiatrists or younger psychiatrists. The relation between diagnosisthe 82% reported by Pope et al. . The M:F ratio of frequency and clinical experience is not unequivocal. Inour respondents coincides with Modestin’s  ﬁnd- Modestin’s  study, the diagnosis was made signiﬁ-ings. The mean clinical experience (15.3 years) is lower cantly more frequently by the more experienced psy-than in Modestin’s  (17.5 years) or in the studies of chiatrists. This ﬁnding is consonant with the hypoth-Putnam and Loewenstein studies  (23.4 years). esis that the total number of patients a psychiatrist has Due to the anonymity of the questionnaire, it was seen in his or her career, which is assumed to be roughlyimpossible to describe the non-responders. The M:F proportional to the years of clinical experience, willratio, the mean age, and the topographic distribution of affect the number of DID patients that the psychiatristour respondents however, coincides with the data Hut- had the opportunity to see. Dunn et al.  howeverschemaekers et al.  gathered on all Dutch psychia- noted more of a tendency on the part of hospitaltrists in 1992. In 1997, the M:F ratio of the members of psychiatrists with fewer years of experience to believe inthe Dutch psychiatric association was 69.3%:30.7% the validity of the DID diagnosis. In our study, the(personal communication 1998). Despite the disap- diagnosis was made signiﬁcantly more frequently by thepointing response rate, our cohort of respondents less experienced psychiatrists. The ﬁndings concerningwould seem to be representative for the Dutch psychi- age and clinical experience suggest a link with theatric community. timing of speciality training. Psychiatrists who were The conjecture that in the Netherlands a DID diag- confronted with the diagnosis before or during theirnosis is mainly made by a small number of psychiatrists training tended to make the diagnosis more frequentlyin and near Amsterdam  has not been conﬁrmed. In than those who did not learn of it until afterwards. One
Dissociative identity disorder in the Netherlands 275explanation might be the inﬂuence of he DSM classiﬁ- percentages of psychiatrists who reported using psycho-cation system on the psychiatrists’ diagnostic practices. therapy (95%) and hypnotherapy (70%) in the studySimultaneous with the introduction of the MPD diag- by Putnam and Loewenstein  was probably associ-nosis in 1980, the concept of hysteria – which the DID ated with a dissimilarity in the study populations. Indiagnosis was hitherto classiﬁed as a symptom of – was addition to psychiatrists, the respondents in their studyeliminated from the DSM-III. It is not inconceivable included psychologists, social workers, and psycho-that the psychiatrists who were certiﬁed before 1980 therapists who were members of the international soci-prefer the hysteria diagnosis to dissociative identity ety for the study of multiple personality and dissocia-disorder. tion. Of the 298 patients, 239 were treated by the respon- As was found in previous studies [3, 24, 28, 30], ourdents. This cohort of patients is somewhat smaller than study shows that most of the patients were mainlythe cohort of 305 patients in the study by Putnam and treated as outpatients. This ﬁnding is consistent withLoewenstein . The predominance of women is in the notion that treatment should be given on an outpa-agreement with the ratios noted in the literature, which tient basis, and that the indications for hospitalizationrange from 3:1 to 9:1 . The M:F ratio and mean age are similar to those for non-dissociative conditions [15,of the patients concur with the ﬁndings of Putnam and 16, 19, 20, 25]. In 49.5% of the cases, the treatmentLoewenstein . frequency was once a week. The mean treatment fre- The ‘bulge’ in the 20–30 age distribution category quency was thus lower than the twice a week advised bycoincides with previous observations that MPD usually Coons  and the mean frequency of 1.94 sessions amanifests itself in early adulthood and before the age of week reported by Putnam and Loewenstein .40 [1, 19]. The ﬁndings on mean age, educational level, A majority of the patients were treated with adjunc-and work situation of the patients also concur with the tive medications. Since no medication has yet demon-data of other authors [3, 28]. The percentage of people strated a speciﬁc impact on dissociative psychopathol-who live alone is somewhat higher than in the 100 ogy, the pharmacotherapy is evidently symptom-patients described by Putnam et al. . The age dis- oriented or palliative [19, 28, 34]. Several of thetribution of the patients indicates that juvenile patients methodological difficulties described by Putnam andcan be diagnosed with DID: patients below the age of Loewenstein  limit the interpretation of our ﬁnd-10 have been described. Riley and Mead  reported ings on the type and efficacy of the prescribed medica-the treatment of a 3 year old girl. The percentage below tions. At most, the results render a tentative outline ofthe age of 21 is somewhat smaller than the 11% the medication regimens of psychiatrists during theKluft  noted as being diagnosed with DID before psychotherapeutic treatment of DID patients.the age of 20. A substantial number of patients treated with medi- The mean (2.9 years) and the longest (16 years) cation were given anti-depressant or anxiolytic medica-duration of treatment correspond with the ﬁndings in tions. In a majority of these cases, the reported efficacyprevious studies. [8, 28, 29] Studies by Coons  and was moderate to good. Ancillary anti-depressant orby Putnam and Loewenstein  demonstrated that anxiolytic medications were indicated in the event ofapproximately 95% of the patients were treated with concomitant anxiety, somatoform, and depressivepsychotherapy, and 80 and 90% respectively with hyp- symptoms [19, 21, 30, 32, 34]. Contrary to the ﬁnd-notherapy techniques. However, in the Netherlands ings of Coons , in 66.7% of nine patients treated,hypnotherapy techniques were used by a minority neuroleptics were reported to have had no effect or an(11.7%) of the psychiatrists. The divergence is indis- inverse effect in 15.3% of the patients. This ﬁnding isputably based on a dissimilarity in the respondent striking, since neuroleptics are alleged to reinforce dis-populations; it probably also reveals an omission in the sociation, which is a reason not to prescribe them .psychiatric speciality training. Our observation that In agreement with Loewenstein’s view ,psychotherapy is the most frequently used (64.4%) Torem  stressed that neuroleptics should only betreatment approach and that it was viewed by a major- prescribed in cases of severe agitation or in cases whereity of the respondents as the most effective treatment anti-depressant or anxiolytic drugs were ineffective.method, is probably linked to the ﬁnding that the DID A small number of patients had been treated withdiagnosis was more frequently made by psychiatrists anticonvulsants. For most of them, the estimated effi-who treated patients with psychotherapy. The higher cacy was moderate to good. A similarly small number of
276 H.N. Sno, H.F.A. Schalkenpatients had been treated with lithium. For most of concept can serve as a legitimate explanatory and con-them, there was slight or no estimated efficacy. This ceptual framework for the treatment of complex psy-ﬁnding conﬁrms the opinions of Loewenstein  and chological phenomena and psychiatric symptoms.Ross  that lithium should not be prescribed to treat Ross  rightly notes that therapists can lose sight ofDID. The prescription of anticonvulsants and lithium reality during the therapy and forget that ‘altered per-is based on the assumed post-traumatic etiology and the sonalities are not people. They are not even personali-speculated inﬂuence on limbic system kindling and the ties. (.....) The patient is acting as if she is more than oneGABA system . The treatment with anticonvul- person, but she isn’t.’ Descriptions in the media or insants is also based upon an assumed association with novels similarly exhibit a tendency towards literal inter-epilepsy [2, 11]. pretations. This is in fact quite understandable if one None of the respondents prescribed clonidine or bears in mind the intricacy of translating psychologicalpropanolol. According to Braun , the combination phenomena into words. One of the difficulties here isof clonidine, which inhibits the central noradrenergic the inﬂuence of very subtle semantic differences. Theactivity of the locus coeruleus, and a high dose of semantic inﬂuence is, for example, illustrated by thepropanolol, which inﬂuences the peripheral sympa- difference between the English translation and the Ger-thetic system, is effective in treating hyperarousal, anxi- man and Dutch translation of Stendhal’s French ‘deuxety, impaired impulse control, disorganized thinking, têtes’ (i.e., two heads) in ‘le Rouge et le Noir’ : “Julienand rapid switching of identities. As few as three re- rit de bon cœur de cette saillie de son esprit. En vérité,spondents prescribed naltrexone with a slight to mod- l’homme a deux têtes en lui, pensa-t-il. Qui diableerate effect. The prescription of this opiate antagonist is songeait à cette réﬂexion maligne ?” The English ver-based upon the hypothesis that the endorphin system is sion refers to ‘two separate beings’, and the German andactivated in DID patients . 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