Dissociative Identity Disorder in a Forensic Psychiatric Patient: a Case Report

Criminal acts can be performed in a dissociative state. Since a percentage of male and female patients with dissociative disorders act out aggression and display criminal behaviors, some of them may be found in the criminal justice system. This case report demonstrates that the long-term failure to diagnose dissociative identity disorder in a forensic psychiatric patient permitted the continued existence of highly aggressive dissociative identity states, and near-relapses into homicidal behavior. The author concludes that careful screening for dissociative disorders and the provision of treatment for dissociative disorders in forensic settings is necessary. The risks of both false negative and false positive diagnoses should both be recognized. Criminal acts may be performed in a dissociated state (Bliss & Larson, 1985; Hall, 1989; Bisson, 1993), and some offenders display dissociative amnesia for their crimes (Vivian & Gudjonsson, 1986; Coons & Milstein, 1992). Putnam (1989) remarked that patients with dissociative disorders may encompass dissociative identity states whose functions may include or lead to fighting, theft, or rape. Nineteen percent of the male and 7% of the female dissociative identity disorder (DID) patients studied by Loewenstein and Putnam (1990) , reported successful perpetration of a homicide, while 47% of the males and 35% of the females reported having been engaged in criminal activity. Accordingly, some cases of dissociative disorders may present in the criminal justice system rather than in the mental health system. However, the prevalence of dissociative disorders among offenders is presently unknown, and an estimation of the relevant false negative rates for males and females in forensic settings is not available. Scientific evidence shows that dissociative disorders are more common than was once thought (1-Ioren, Leichner & Lawson, 1995; Latz, Kramer, & Hughes, 1995; Ross, Anderson, Fleisher, & Norton, 1992; Saxe, Van der Kolk, Berkowitz, Chinman, Hall, Lieberg, & Schwartz, 1993) . Moreover, these disorders can be reliably and validly diagnosed (Boon & Draijer, 1991, 1193; Ross, Heber, & Anderson, 1990; Steinberg, 1993; Steinberg, Rounsaville, & Cichetti, 1990, 1991). However, in some circumstances efforts may be questioned. It has been suggested that the recent rise in detected cases is due to iatrogenitc influences, self-suggestion, or malingering (that is, motivated by wishes to escape social responsibility or legal responsibility with respect to criminal deeds) (Piper, 1994). Factitious or malingered DID has been described in forensic and clinical settings (Coons, 1978; Orne, Dingus, & Orne, 1984; Kluft, 1987a; Coons, 1988; Coons & Grier, 1990; Chu, 1991; Coons, 1991; Coons & Milstein, 1994). With growing public availability of knowledge pertaining to dissociative phenomenology, simulators may have become more sophisticated in their fabrication of dissociative disorders. Therefore, the differentiation of true and false cases may have grown more difficult. Diagnostic efforts demand more clinical skill and consume more time (Chu, 1991). In a recent paper, Coons and Milstein (1994) report that about 10% of the patients who were referred to a dissociative disorders clinic because they were suspected to suffer from a dissociative disorder actually were false positive diagnoses. Coons (1991) stated that a high index of suspicion is required by any clinician evaluating a homicide defendant alleging DID. While the risk of diagnosing false positives both in clinical and in forensic settings should thus be recognized, the risk of failing to diagnose true positives, especially in forensic settings, should no less be considered a serious error. Since chances of spontaneous recovery of dissociative disorders seem to be minimal (Kluft, 1985, 1993), forensic patients with dissociative disorders who are not properly diagnosed and specifically treated for their psychiatric condition, could run a considerable risk of relapsing into criminal behavior. As the present case report demonstrates, dissociative identity states may have an inclination to commit murder, and be capable of performing this act. If the patient is not treated for the dissociative condition, the patient's aggressive feelings, ideas, and impulses may remain encapsulated