December 18, 1998

Dorothy Lewis, M.D., a psychiatrist in New York and an expert on causes of violence, thought dissociative identity disorder was a figment of someone's overactive imagination until she witnessed Marie Moore, accused of murdering an adolescent in New Jersey, switch to her male alternate personality Billy while interviewing her in 1984.

Lewis, who spoke at the American Academy of Child and Adolescent Psychiatry meeting in October in Anaheim, said "I knew dissociative identity disorder (DID) was an extremely rare phenomenon, so I did not expect to see it. Furthermore, my clinical training at Yale University led me to believe that the disorder did not exist." Her numerous psychiatric evaluations of murderers between 1984 and the present eventually convinced her otherwise.

Lewis is a professor of psychiatry at New York University School of Medicine and clinical professor at Yale Child Study Center in New Haven.

She found that 12 of the approximately 150 cases met the DSM-IV criteria for DID. She obtained objective documentation of child abuse and or longstanding dissociative signs and symptoms in these individuals, who included three who were juveniles when they committed their crimes. Her study was published in the December 1997 American Journal of Psychiatry.

The common experience that led to the disorder was being subjected to extraordinary and repeated sexual and physical abuse in early childhood, said Lewis.

"To survive unspeakable abuse, children unconsciously develop voices or imaginary characters in their minds to block out the pain," she explained.

"If a child continues to be subjected to extraordinary pain and abuse, he or she will often take on the identity of one of the imaginary characters, which becomes an alternative personality state," added Lewis.

One personality state is usually a protector, who talks to and comforts the child in his or her pain and takes the pain. "Dissociation is a coping mechanism that allows the child to interact with the abuser who usually is a caretaker," said Lewis.

"However, it is the protector personality that often acts violently and lashes out at potential aggressors, whether real or imagined."

A case in point was Johnny Frank Garrett who murdered a 76-year-old nun in Texas in 1981 and was executed in 1992. "After an altercation with his mother, and possibly an exchange with his abusive grandmother, Garrett crept into a convent, climbed into a window, brutally and repeatedly stabbed the elderly nun, and then slit her throat, killing her," said Lewis.

She first interviewed Garrett in 1986 when he was 22 and diagnosed him with schizophrenia because his symptoms included auditory hallucinations, paranoia, and vivid imaginary companions.

Years later, however, two colleagues of Lewis observed Garrett switch to an alternate personality state during an interview on the television show "48 Hours." They informed Lewis that she had misdiagnosed him. Lewis returned to Huntsville, Texas, and reinterviewed him in 1991.

During the interview, she witnessed him switch into his protector personality Aaron Shockman, who said he knew Johnny since age 12. Shockman said he took the pain when Johnny was sexually abused by various stepfathers and men who engaged in child pornography. He was also physically abused by his grandmother who among other things sat him on a hot oven burner when he was a young child.

Lewis describes evidence of Garrett's physical abuse in her new book Guilty by Reason of Insanity published this year by Fawcett Columbine. "A deep scar about three inches long and a half inch wide, extended diagonally outward, starting from his anus and ending in the middle of his left buttock-a shiny canyon where seared muscle and flesh must have slowly knitted together."

Lewis stressed the importance of obtaining objective documentation of DID, especially in murder cases, due to skepticism about the illness and malingering. "You need to show that this person has a longstanding history of a severe disorder that antedates your meeting."

For example, Garrett had signs and symptoms of DID as a child, which included vivid imaginary companions, trances, fugues, and epilepsy. Those symptoms continued into his adulthood when he also began experiencing voice and demeanor changes, and amnesia. There were also striking differences in names, signatures, handwriting, drawing styles, and visual acuities, reflecting different personality states, Lewis noted.

Garrett's symptoms were corroborated by his cousin, schoolteacher, prison psychiatrist, and handwritten documents and letters.

Lewis said she misdiagnosed Garrett because DID mimics the signs and symptoms of schizophrenia. "Patients say they hear voices, are controlled by external forces, have command and auditory hallucinations, and vivid imaginary companions."

Dissociative identity disorder can also look like bipolar mood disorder because the patient experiences mood swings, episodic rages, suicidal behavior, long periods without sleep, and inappropriate sexual behaviors, noted Lewis.

"I have no doubt that I have misdiagnosed cases of psychomotor seizures that were in fact DID because of the similarity in symptoms including dreamlike states, blanking out, impaired memory, loss of time, and out-of-body experiences," added Lewis.

Arecent study she conducted showed that ADHD was diagnosed at one time or another in every severely abused child and adolescent who exhibited severe dissociative symptoms in a residential treatment center.

"One of the saddest misdiagnoses is that of conduct disorder or antisocial personality disorder. It is often confused with DID because these children fight with authority figures. Something gets triggered that reminds them of the individual who tortured or raped them. They flip into a different personality state often characterized by episodic violence, apparent lying, and apparent stealing," said Lewis.

She explained that she used the term "apparent" because the child does not remember lying or stealing in his or her alternate personality state and will deny any culpability, despite there being witnesses to the behavior.

It is also common to misdiagnose DID because therapists mistake children's imaginary companions for normal play, said Lewis. "In contrast to normal children who have one or two companions who fade away usually at age six, children with DID have several imaginary companions long after age six. These are not the typical cuddly companions but aggressive, forceful, and strong alternate personality states," said Lewis.

"However, the main reason for the misdiagnosis is that many psychiatrists don't believe it exists. That is why it is so important to get documentation."

Lewis recommended psychodynamic treatment for DID to reintegrate the different personalities and antipanic medication to diminish the intensity of the stressors that cause flashbacks and switching. "In my experience antipsychotic medications do not diminish auditory hallucinations in patients with DID."