Am J Psychiatry 154:1703-1710, December 1997
American Psychiatric Association
Objective Documentation of Child Abuse and Dissociation
in 12 Murderers With Dissociative Identity Disorder
Otnow Lewis, M.D., Catherine A. Yeager, M.A., Yael Swica, B.A., Jonathan H. Pincus, M.D., and Melvin Lewis, M.B.B.S., F.R.C.Psych.,
OBJECTIVE: The skepticism regarding the
existence of dissociative identity disorder as well as the abuse that engenders it persists for lack
of objective documentation. This is doubly so for the disorder in murderers because of issues of suspected malingering.
This article presents objective verification of both dissociative symptoms and severe abuse during childhood
in a series of adult murderers with dissociative identity disorder. METHOD: This study consisted
of a review of the clinical records of 11 men and one woman with DSM-IV-defined dissociative identity disorder
who had committed murder. Data were gathered from medical, psychiatric, social service, school, military,
and prison records and from records of interviews with subjects' family members and others. Handwriting
samples were also examined. Data were analyzed qualitatively. RESULTS: Signs and symptoms of dissociative
identity disorder in childhood and adulthood were corroborated independently and from several sources
in all 12 cases; objective evidence of severe abuse was obtained in 11 cases. The subjects had amnesia for
most of the abuse and underreported it. Marked changes in writing style and/or signatures were documented in 10
cases. CONCLUSIONS: This study establishes, once and for all, the linkage between early severe
abuse and dissociative identity disorder. Further, the data demonstrate that the disorder can be distinguished
from malingering and from other disorders. The study shows that it is possible, with great effort, to obtain
objective evidence of both the symptoms of dissociative identity disorder and the abuse that engenders
it. (Am J Psychiatry 1997; 154:1703–1710)
The diagnosis of dissociative identity disorder (formerly called multiple
personality disorder) is usually not made until adulthood (1), long after the extreme maltreatment thought to engender the condition has
passed. Therefore, although there is a consensus that the most common cause of the disorder is early, ongoing,
extreme physical and/or sexual abuse (2–6), accounts of such abuse are usually provided retrospectively by the patient
and lack objective verification. As Putnam (1) said, "In most reports, including the NIMH survey, there is no outside
verification that any trauma actively occurred."
Coons (7) recently attempted to verify abuse histories in a group of 19 children and
adolescents through interviews with families and "collateral reports from numerous sources." The extent
to which abuse was documented in each case was unclear. Because neither the symptoms nor the abuse engendering
them have ever been documented objectively in a group of dissociative identity disorder patients of
any kind (children, adolescents, adults, or murderers), both the diagnosis and its etiology in childhood
maltreatment have met with criticism ranging from skepticism to scorn (8–15).
The diagnosis in felons is doubly suspect. The prospect of facing the
consequences of a serious offense invites malingering (16, 17). Dinwiddie and colleagues (18) asserted that the disorder, especially in forensic cases, could not be distinguished
from malingering. Orne and colleagues (19) suggested that the most objective means of making the diagnosis in forensic
cases was through interviews with family members and others who had observed the characteristic behavioral
changes in the individual before he or she had committed a particular offense. To date, however, there
have been no such systematic studies of groups of felons with dissociative identity disorder or, for that matter,
of any other series of adult patients with the disorder. Carlisle (20) described 13 murderers suffering from multiple personality disorder but provided few objective data to support
the diagnosis or its etiology. Coons (21) collected information on a group of 18 murderers alleged to have suffered from multiple personality disorder;
his data were gleaned in great measure from newspaper accounts and legal decisions. For lack of objective documentation
of symptoms or abuse, in most instances the diagnosis was disbelieved.
= Given the dearth of objective documentation of dissociative symptoms
and the antecedent abuse that engenders dissociative identity disorder, we welcomed the opportunity to present
objective data on dissociation and abuse in 12 murderers suffering from the disorder. As will be discussed,
we believe that our findings are also relevant to cases of the disorder in adults who have not committed
During a 13-year period in the 1980s and 1990s, the first author (D.O.L.)
had the opportunity to do psychiatric evaluations of approximately 150 murderers. Of these murderers, 29 were subjects
in a study of death row inmates. The majority of the rest were evaluated at the request of individual defense
attorneys. Several others were evaluated at the request of the court, of prosecutors, or of family members.
Of these murderers, 14 met the DSM-IV criteria for dissociative identity disorder. We were able to obtain
objective documentation of both child abuse and long-standing dissociative signs and symptoms in 11 of these 14
individuals and of early dissociative signs and symptoms in a 12th. This report focuses on the 12 murderers
with dissociative identity disorder for whom objective, confirmatory data on child abuse and/or long-standing
dissociative symptoms could be verified. There were 11 men and one woman. Their ages at the time of their
offenses averaged 28 years (range=15–44). Eight were white and four were black.
The subjects' psychiatric, neurologic, medical, social service, welfare,
school, probation, police, prison, and military records were reviewed, and in eight cases social service, medical,
psychiatric, military, court, or police records pertaining to parents were also reviewed. Any evidence
of abuse, neglect, and/or dissociative signs and symptoms was noted and tabulated.
All 12 subjects had been evaluated psychiatrically by the first author
(D.O.L.), a board-certified psychiatrist. Nine had been examined neurologically by one of the authors (J.H.P.),
a board-certified neurologist; a 10th was examined by another board-certified neurologist. An 11th,
at age 2, had been evaluated by a neurologist, at which time an EEG was performed. The psychiatric and neurologic
reports of these evaluations were reviewed. The nature of the psychiatric and neurologic evaluations and
the criteria for specific signs and symptoms have been described elsewhere (22–25). During these psychiatric evaluations, dissociative phenomena
were explored in detail and included questions about trances, time loss, fugues, amnesias, imaginary companions,
rapid mood shifts, auditory/visual hallucinations, fluctuations in skills, being blamed for disavowed
acts, sounding/acting like a different person, and using different names/signatures/handwriting. Records of
these neuropsychiatric evaluations and of any previous evaluations were reviewed for the presence or absence of
the above-mentioned signs and symptoms. Handwriting samples (e.g., old journals, letters) were also
examined. These written materials were produced before the subjects' psychiatric evaluations and thus were not
influenced by the examiner. In all cases, affidavits, testimony, and/or reports of interviews with family
members, friends, neighbors, childhood acquaintances, teachers, probation officers, police, and clergy
were reviewed for mention of the signs and symptoms and for any indications of abuse and neglect.
At the time of publication of this article, clinical data regarding
symptoms and abuse histories were in the public domain (i.e., in trial transcripts, exhibits, appeals briefs,
newspaper articles, and books); hence, informed consent to tabulate data was not necessary. Nevertheless,
out of respect for the privacy of the subjects and their families, we have not identified the subjects by
Signs and Symptoms of Dissociative Identity Disorder
Table 1 presents the subjects' dissociative symptoms in childhood and adulthood
and the corroborative documentation. Among the most common symptoms and signs were trances, amnesias for circumscribed
periods of time and/or particular behaviors, changes in voice and demeanor, and auditory hallucinations.
As can be seen in table 1, the amounts of information available on the subjects' childhoods varied.
We were able to obtain objective evidence that during childhood, eight of the 12 subjects had trances
and amnesias, nine had experienced auditory hallucinations, and 10 had vivid and long-standing imaginary companions
who seemed to be precursors of their alternate personality states.
Ten subjects experienced trance-like states in adulthood that were
also observed by others. Two described their ability to remove themselves from situations as "astral projection."
Others described their trance-like states as blanking out, spacing out, or transporting themselves to
imaginary places in their heads. Seven reported being able to block out physical pain.
All 12 subjects, as adults, had impaired memory for both violent and
nonviolent behaviors. For example, subject 5 pulled out his own toenails at night and, in the morning, did not
know how this had happened. Subjects 4, 5, and 11, all of whom had female alternate personalities, found
women's clothing in their possession and did not know how it got there. Subject 4, at trial, insisted
that the bloodstained suit he had been wearing at the time of his arrest belonged to someone else because it
was too big to be his.
All 12 subjects were described by others as having voice changes and/or
marked changes of demeanor. For example, three people reported that subject 9, the only woman in the study group,
periodically sounded like an aggressive male, and male subjects 4 and 11 at times reportedly sounded like
women. Subjects 5 and 6 were noted to have alternate personality states with different visual acuities,
and the lawyers for subject 4 reported that he did not recognize his own voice on tape-recorded police interviews
and insisted it was the voice of someone else. All 12 subjects had used different names at different times,
not in the context of avoiding arrest or responsibility. Writing samples obtained from 10 subjects revealed
markedly different handwritings. Figures 1, 2, 3, and 4 are examples of the different signatures and handwritings of three of
these 10 subjects.
All 12 subjects had histories of experiencing
auditory hallucinations that, during psychiatric evaluation, were recognized by the examiner as being
voices of alternate personalities. Seven experienced severe headaches when they heard arguments in their heads
among alternate personalities. Subject 1 pulled out his own teeth in an unsuccessful effort to cure
his excruciating headaches.
In all cases, examiners were able to speak with at least one alternate
personality. The subjects averaged three to four personality states (the range was one to seven). These figures
may be underestimates because of the limited time available for evaluations. Nine subjects (including
our only female subject) had violent male alternate personalities, most of whom said they "took the pain."
Six male subjects had older female alternate personalities whose functions were caretaking, comforting, and
protecting. Of note, five subjects had alternate personalities who were embodiments of parents or relatives;
two had abusive father personalities, one had an abusive mother personality, one had a powerful aunt personality,
and one had a sister personality. The nature and function of these alternate personalities and their relevance
to the crimes committed will be described in a subsequent paper.
Table 1 lists the sources of information confirming evidence of dissociative
identity disorder in each subject. As can be seen, documentation regarding subjects' dramatic changes of voice
and/or demeanor came not just from family members but also from police records, notes of a legal assistant, observations
of a jail guard, observations of a prosecution psychiatrist, and subjects' co-workers, roommates, acquaintances,
and friends. As mentioned, objective documentation of personality changes in the form of different handwriting
and signatures could also be found in the journals, letters, and documents of 10 subjects.
The Nature of Maltreatment in Childhood
Because the histories of abuse of both patients with dissociative identity
disorder and murder suspects are often questioned, we call special attention to table 2, which presents objective documentation of the nature and extent of
physical and sexual abuse of 11 of our 12 subjects. The term "abuse" does not do justice to the quality
of maltreatment these individuals endured. A more accurate term would be "torture." For example, subject 4
was deliberately set on fire by his parents. Subject 6 was used in child pornography by stepfathers and was deeply
scarred from anus to mid-buttock from having been made to sit on a stove burner. At 3 years of age,
subject 2 had his penis scalded and "circumcised" by his father. Subject 5 was tied down by his stepmother,
given enemas allegedly containing blood, and, to stanch the blood, had tampons inserted into his rectum, thus
simulating menstruation. This subject was removed from one foster family because he had been caught molesting
other children and wearing girls' underwear and sanitary napkins.
We were surprised to find that in their usual personality states,
most subjects denied or minimized childhood maltreatment. Four of them, for whom documentation of extraordinary
abuse was discovered, totally denied any physical or sexual abuse. Seven others who had been severely
physically and/or sexually abused had but fragmentary memories of the abuse. None attempted to use histories
of abuse to enlist the sympathy of jurors or to excuse their violent acts. Since in their usual personality
states most of the subjects had no idea of the kinds of maltreatment they had sustained, they could
not use histories of abuse to manipulate clinicians or anyone else.
Histories of maltreatment were obtained primarily from old records,
accounts provided by first-degree relatives, and the reminiscences of childhood friends. For example, subject
3 had no recollection of his incestuous relationship with his mother; information regarding incest was
gleaned from the social service records of his brother. Similarly, subject 6 knew nothing of the sexual abuse
sustained at the hands of his grandparents. The affidavit of a cousin who lived with him during childhood—a
document discovered by one of the authors (D.O.L.) after the subject had been executed—revealed
that his grandmother had dressed him as a girl and given him to his grandfather to be used for sexual
Before evaluation none of the subjects was aware that he or she
suffered from dissociative identity disorder, and most remained ignorant of their condition after their psychiatric
evaluations. Even after some were told of their condition, they tended to disbelieve it. For example,
when subject 4 learned of his diagnosis at a court hearing, his response was, "I think you're full of shit."
Of note, in this case, because of his dramatically changing demeanor during incarceration, the subject's fellow
prisoners had made the diagnosis of multiple personality disorder years before the psychiatrist ever
Our ability to interview subjects' family members and friends, our
access to their past psychiatric, social, and educational records, and our access to their personal letters and
diaries enabled us to document evidence of long-standing dissociative symptoms in all 12 of our subjects
and to obtain objective evidence of extreme abuse of 11 of them. Rarely, if ever, do psychiatrists have
the opportunity to obtain this quantity and quality of confirmatory data about adults with dissociative identity
disorder. It was only because of the time-consuming investigations conducted in the course of the legal
representation of these murderers that we could amass these kinds of data.
Contrary to Dinwiddie and colleagues (18), we have demonstrated that dissociative identity disorder can be differentiated
from malingering and other disorders. The evidence of strikingly different handwriting styles antedating
the murders in question, plus the documentation of amnesias and of changes in voice, demeanor, and appearance
observed by family members and others before our subjects' crimes, settles once and for all the issue
of malingering in these cases. To have malingered, our subjects would have to have planned their murders
long in advance and feigned their early symptoms in anticipation of some day committing a violent crime,
a highly unlikely scenario. In short, with adequate data, it is possible to distinguish dissociation from
malingering and from other disorders. For example, although dissociative identity disorder shares certain
symptoms with schizophrenia, bipolar disorder, and other syndromes, none of these other disorders is
characterized by the voice, demeanor, and handwriting changes and amnesias characteristic of dissociative
identity disorder, as documented in our study group.
The question remains: to what extent are our 12 murderers with dissociative
identity disorder representative of other adults with the disorder? After all, most patients with the disorder
do not commit murder. On the other hand, most patients with the disorder do have aggressive, protector personality
states (1, 5). However, relatively few commit violent crimes, reflecting, at least in part,
the fact that most recognized cases of dissociative identity disorder occur in women (1, 26, 27), and women as a group are far less violent than men (28). Whereas Loewenstein and Putnam (26) reported that similar percentages of men and women among their subjects
with multiple personality disorder had "homicidal alters" (35% versus 32%), 19% of the men and only
7% of the women reported actually having committed murder. In our own clinical experience, we found that among
the male outpatients seeking treatment for dissociative identity disorder at our clinic, a substantial
percentage (64%) had demonstrated rageful behaviors that came just short of homicide. In fact, one patient
reported spending time in a reformatory after committing murder, and two others had been arrested for attempted
murder. A much smaller percentage of the women in our clinic group (9%) were similarly aggressive. One
had attempted to shoot her adult son, and another had tried to push her father in front of a car.
The majority of the males with dissociative identity disorder that
we have seen have not been clinic outpatients but, rather, have been examined in prisons, where they were incarcerated
for violent crimes. On the basis of our clinical experience, we suspect that the diagnosis of dissociative
identity disorder is overlooked in males more often than it is in females because the violent behaviors
of the protector alternate personality states of men go unrecognized and their violence is regarded instead
as "sociopathy." As a result, males with the disorder are far more likely than their female counterparts to be
arrested and incarcerated.
The 12 murderers in our study were unaware of their psychiatric condition.
They also had partial or total amnesia for the abuse they had experienced as children. Such is the nature of dissociative
identity disorder. Contrary to the commonly held assumption that individuals facing the consequences of murder
charges will exaggerate their childhood misfortunes, these murderers could barely remember anything
about their childhoods. What is more, contrary to the popular belief that probing questions will either instill
false memories or encourage lying, especially in dissociative patients, of our 12 subjects, not one produced false
memories or lied after inquiries regarding maltreatment. On the contrary, our subjects either denied
or minimized their early abusive experiences. We had to rely for the most part on objective records and
on interviews with family and friends to discover that major abuse had occurred.
Even if the subjects had been able to provide memories of maltreatment
and even if they had been aware of their diagnosis, because we were dealing with two problematic issues—murder
and dissociative identity disorder—it was vital that we document from outside sources as much
objective evidence as possible of dissociative symptoms and childhood maltreatment. We did this. In
every case, three or more outside sources provided independent evidence of subjects' marked changes in voice, demeanor,
and behavior, and in 11 cases abuse was also verified objectively. Furthermore, in 10 cases handwriting samples
produced before the offenses in question documented changes in writing styles and signatures. Thus,
the diagnosis of dissociative identity disorder and the history of abuse did not rest exclusively or even
primarily on reports obtained from a subject.
The extent to which it was possible in these murder cases to review
old records, interview families, and obtain objective documentation of symptoms and early abuse was, of course,
unusual. In most cases of dissociative identity disorder, this degree of verification is not possible.
Nevertheless, our experience with these 12 murder cases illustrates that with sensitivity, diligence,
and appropriate resources, corroborative external evidence of prior dissociative symptoms and of early, extreme
abuse in adult patients with dissociative identity disorder is there to be found. We may not always be able
to obtain this extensive a body of documentation for all of our patients, but we must try.
Received April 5, 1996; revisions
received March 24 and July 7, 1997; accepted July 31, 1997. From the Department of Psychiatry, Division of Child and Adolescent Psychiatry, New York University School of Medicine. Address reprint requests to Dr.
Lewis, Department of Psychiatry, New York University School of Medicine, 550 First Avenue/New Bellevue 21 South 14, New York, NY 10016.
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