Norman Bates and Dr. Jekyll got us thinking about the actual phenomenon of fractured self. As a teenager, I (Meg) became fascinated with this topic, delving into nonfiction books like Sybil (1973) by Flora Rheta Schreiber, and The Three Faces of Eve (1950) by Corbett H. Thigpen and Hervey M. Cleckley. Both of these books were later turned into biopics, dramatically portraying the anguish of women who were an amalgam of numerous personalities. Fictionalized split personality has long been a popular trope in horror films, from Identity (2003), to Secret Window (2004), and Split (2016). While it has undoubtedly been perpetuated in forms of entertainment, the notion of split personalities, clinically known as dissociative identity disorder (DID), has been one wrought with controversy. Many in the medical community believe it to be a pseudo-condition, while others fight for it to be legitimized in both the medical and cultural spheres. This begs the scientific question, is dissociative identity disorder a proven condition? And what are the attitudes toward it in the psychiatric community? And if it is authentic, would this mean Norman Bates wouldn’t be responsible for his crimes? To find out more, we spoke with Mayo Clinic psychiatrist William Leasure, MD:
Meg: “Can you first tell us a little about your practice and the sort of work you do on a daily basis?”
Dr. Leasure: “I work in a practice called Integrated Behavioral Health. The name comes from our integration within the primary care practice, where we provide mental health services. The practice is an outpatient practice and we work hand-in-hand with primary care providers. The patients have a variety of mental health problems, with the most common being depression, anxiety, bipolar disorder, ADHD, schizophrenia, substance use disorders, and personality disorders. Patients are typically referred to me, a psychiatrist, for diagnostic questions and treatment with psychotropic medications. Most patients are seen by me on a short-term basis and then returned to their primary care provider for ongoing management.”
Kelly: “In the film Psycho, Norman Bates notoriously embodies his mother by wearing her clothes and speaking in her voice. He kills ‘as’ his mother and then is shown to not remember this act. Would this lead you down the road of considering a type of dissociative disorder?”
Dr. Leasure: “The behavior does in some ways suggest dissociation; however, its portrayal depicts a dramatized version of dissociative identity disorder, which is a controversial diagnosis that I am highly skeptical of. More common than embodiment of another’s personality are dissociative symptoms which may take the form of depersonalization (experiences of unreality or detachment from one’s mind, self, or body), derealization (experiences of unreality or detachment from one’s surroundings), or dissociative amnesia. These symptoms are not uncommon in individuals who have experienced trauma. They are typically short-lived and do not involve taking on another’s identity, dressing as them, talking, or acting as them.”
Meg: “As you mentioned, dissociative identity disorder (formerly multiple personality disorder) is a controversial diagnosis. Psychology Today calls DID “unstable, open to debate and hard to pin down.” Was it covered in your education? If so, how has it been treated in the psychiatric community?”
Dr. Leasure: “DID is indeed a controversial diagnosis. Most modern mental health providers, including psychiatrists, strongly question the validity of the diagnosis, or outright believe it is a bogus diagnosis that is better accounted for by other problems, which may include substance use, neurologic disorders, PTSD, personality disorders, or malingering. In my training we received essentially no training related to DID diagnosis, other than skepticism of its existence and acknowledgment that diagnostic criteria for the diagnosis exist in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is now in its 5th version. There is a common acceptance that a large number of individuals who are purported to have DID have a history of often severe physical or sexual trauma in childhood.”
Kelly: “Based on your knowledge and experience, where do you stand on the controversy of DID?”
Dr. Leasure: “I am highly skeptical of the diagnosis and close to the line of thinking it is completely bogus. I am hesitant to state outright that it doesn’t exist, but if it does, it is exceedingly rare to the point that most clinicians have no practical knowledge or experience with it.”
Meg: “Wow, fascinating! I knew it was rare, but that puts it into perspective. So, imagine Norman Bates is in your office seeking help. He describes an extreme fixation on his mother, as well as moments of amnesia, and let’s not forget how this dangerous fixation is now spreading to all the women in Norman’s midst (as it did with the character’s real-life inspiration, Ed Gein). What sort of modern medicine/therapy could you provide Norman?”
Dr. Leasure: “My first priority would be assessing safety. I would be interested in hearing if at any time he had thoughts of harming his mother or anyone else, or if they were otherwise at risk. I would be interested in the nature of his fixation with them to help in this determination. Assessing for any abnormalities in his thinking, such as delusional beliefs, would also be important. With the periods of amnesia, I would be interested in determining if he’d had any seizures, head injuries, or other medical problems or medication side effects that might have caused amnesia. I would also be interested in assessing his use of substances to determine if they might have contributed to the amnesia or changes in his thinking. Potential treatment is difficult to speculate about without knowing more about potential symptoms or diagnoses. Certainly, if there were safety concerns due to a mental disorder then psychiatric hospitalization might be warranted. As for medication, if he had psychosis, then I would consider an antipsychotic medication. However, without knowing more information, it’s not clear to me how a medication might be effective. Psychotherapy could be a consideration.”
Kelly: “Too bad Norman didn’t get help! How does modern medicine/therapy differ from what would have been offered to him in 1960?”
Dr. Leasure: “I don’t know which treatment might have been more likely for Norman Bates at the time. Treatment in 1960 might have gone down a couple of paths. One might have employed psychoanalysis to try to get at the root cause of the problem and remedy it. In Mr. Bates’s case there likely would have been a focus on his development, upbringing, early childhood experiences, trauma, relationships, etc. Given the fixation on his mother, his relationship with her would have been explored in detail. Another potential treatment avenue could have been institutionalization where he might have received heavily sedating medication. Medication options were limited and many of those used were heavily sedating. Until the sixties, long-term institutionalization was not uncommon. Electroconvulsive therapy (ECT) was also a treatment option, although I’m not sure if it would have been used in this situation. It fell out of favor in the 1960s before becoming more commonly used starting around the 1980s.”