Tuesday, June 4, 2013

A Life With Others…In Your Head?

By Stepheni Uh
Undergraduate Neuroscience and Behavioral Biology Major
Emory University
This post was written as part of the Contemporary Issues in Neuroethics Course

Although decades have passed since the world first heard of Billy Milligan, his predicament and story still cause confusion and wonder. As the field of neuroscience is expanding, more light has been shed upon his condition: an extreme case of dissociative identity disorder (DID), formerly known as multiple personality disorder. Advancements in neuroscience (i.e. in research techniques) has led to the investigation of possible neurobiological correlations to the symptoms of DID – yet, due to the rare cases of this disorder, the possible neurobiological basis for DID has not been established. Despite the lack of raw data, per se, neuroscience has fueled new perspectives regarding the nature of DID such as those involving the ideas of culpability, personhood, and individuality.


Billy Milligan
Billy Milligan, whose birth name is William Stanley Milligan, had approximately 24 different personalities that fought to take over his body – Arthur the intelligent Englishman; Philip the Brooklyn criminal; David the eight-year-old “keeper of pain”; Adalana the lesbian and everyone else, including the Teacher who could fuse all of the personalities and help them develop [1,4]. Milligan was involved in robberies and other crimes before he was prosecuted for kidnapping and raping three women from the Ohio State University campus in October 1977 [4]. According to his psychiatric report, Adalana had taken over Milligan and consequently raped the women due to her desire for affection. The other personalities, however, had no recollection of the incident [4]. Billy Milligan was eventually acquitted of his crimes by reason of insanity and sent to the Athens Mental Health Center to “recover.” Experts attempted to treat him by fusing all the personalities into one, which was already established by the Teacher; so they attempted to make the Teacher take over his “consciousness,” which had never happened before. Milligan was finally released in 1988 and then became free from supervision in 1991 [4]. As of today, no one knows what has happened to Billy Milligan and many questions remain unanswered.
According to the DSM-IV, DID is a “dissociative disorder” in which individuals with DID present two or more distinct personalities that repeatedly affect the individual’s behavior [3]. Dissociative disorders are ones that involve significant “…disturbances in memory, identity, consciousness, and/or perception of the external environment” [3]. In the case of a DID patient, his or her personalities may show evident differences in handwriting, voice, and even physical characteristics [3]. Another interesting aspect of this disorder is that many times dissociative amnesia is present for these individuals. Dissociative amnesia refers to the process of separating events or memories from one’s “stream of consciousness” due to the overwhelming stress that the event caused [5]. Often times for DID individuals, the behavior of one personality or alter are not recalled by the other alters [5]. In Billy Milligan’s case, therefore, it could be that when he became Adalana, the other personalities did not recall her actions due to the extremity of the crimes.

The causes of DID are controversial and still not agreed upon. Some psychotherapists, psychologists, and researchers believe that the core features of DID are a result from various social conventions such as therapists (who may cause the release or creation of more personalities by questioning the individual whether other personalities exist), media influences, as well as stigmatization of the disorder itself [3]. Others, meanwhile, advocate the idea that severe and traumatic experiences such as physical and sexual abuses during early childhood result in the dissociating of personalities as a means to cope with their pain, which then causes DID [3, 4]. The neurobiological basis of DID is also unclear, but one study found that DID individuals had smaller hippocampal and amygdalar volumes than healthy individuals [6]. Information and research on DID are lacking because of the small number of reported cases of DID, which could be due to either the rarity of the disorder or the difficulty of diagnosing the disorder itself. Thus, many dilemmas are present – particularly in the legal setting – when dealing with people who claim to have multiple personalities.

Several challenging and controversial ethical issues arise from the existence and characterizations of this disorder: determining the level of responsibility DID individuals hold over their actions; if criminals with DID are competent to stand trial and whether multiple personalities should be treated as multiple people. Due to the lack of knowledge concerning the basis and origins of DID, it is difficult to come up with any conclusions to the aforementioned issues. The first issue revolves around the extent of control DID individuals have over their actions as well as their intents. In particular, the ways in which alters take turns (not necessarily equally) to take over an individual’s body are ambiguous. Second, the difficulty of determining the level of competency for DID individuals to stand trial is underscored by amnesia of behaviors committed by specific alters. The inability to recall the actions of one alter by all other alters is unclear in terms of why and how this occurs. If they cannot remember what one of their alters did, how can they defend themselves [5]? It is possible, as mentioned before, that the criminal actions of one alter were so extreme that the individual dissociated the memory from all other alters. This postulation, however, then brings up the point of whether or not the individual is aware of right versus wrong as well as the ties to his/her consciousness. Another challenge is detecting if they are lying about their amnesia, which could potentially be investigated through brain-imaging techniques such as fMRI. The validity of brain imaging as a lie detector, however, is still debated and further investigated by many researchers[1].



Finally, there is much controversy in whether or not the multiple alters present in DID individuals are fully developed and autonomous personalities. This issue ties into the dilemma of criminal responsibility. In Billy Milligan’s case, Adalana is the one who committed the rapes, so should she be tried independently with separate legal representation from all the other alters? There actually have been some incidents where trial judges have required all DID alters to be sworn in before providing testimony [3]. Future neuroscience studies may be able to investigate whether there are functional, or perhaps even structural, brain changes when a DID individual becomes another alter. The data from this type of research could contribute to the issue of determining whether these alters are autonomous and separate from one another. Yet, this also raises the dilemma of defining “personhood”: can the human brain be used as a marker for different persons? Determining the criteria for personhood is a complex and philosophical issue that has yet to reach a conclusion. There are many factors that have been tied to defining personhood such as self-awareness, autonomy, and rationality, but neuroscience has opened the possibility of defining a person by his or her brain. For a DID individual, however, it seems that these alters have arisen from the various experiences of the individual. Thus, the alters are still technically part of one “person,” but simply represent the individual’s mental and emotional capacities. As in the case of Billy Milligan, he still contains the Teacher, which somehow encompassed all of his alters. In this case, they do not seem to be completely separate and autonomous individuals – two key aspects that I believe are necessary to define a person or an individual. Whether or not the brain can be used as a factor for distinguishing persons is also an interesting area of study that remains quite controversial. If the brain is in fact identified as a criterion for personhood, it would imply that the entity of a person is correlated – or “reduced” – to the brain. This notion of course is controversial and possibly impossible to ever solve.

DID exemplifies one of the most complex and controversial psychiatric disorders. How and why DID arises remain unanswered and therefore create many problems in determining how to treat DID individuals. The meanings and levels of responsibility, personality, and individuality are all questioned by DID thus making one wonder if this is a disorder of the mind, the brain, or perhaps both. Neuroscience can help provide more answers in terms of the possible correlations between the brain and behavior of DID individuals. Studies on the neurobiological aspects of DID patients can shed light onto whether or not there are significant changes in the brain when transitioning from one alter to the next. Determining the amount of control these individuals have over their behaviors while they are in their certain alters, however, will be an immense challenge. Thus, determining legal culpability of these individuals will not be as black and white. As the field of neuroscience continues to expand and progress, nevertheless, we may be able to define the nature of personhood in individuals who display multiple personalities. Until then, establishing the criteria for criminal culpability for and understanding the disposition of people like Billy Milligan will remain challenges that neuroscience may eventually help resolve.



[1] Wolpe and colleagues (2005) discuss and analyze the discourse on fMRI as a valid lie detector and emphasize the need for the ethical considerations of cognitive privacy, threats to civil liberties by this type of research, and subjective interpretations of fMRI data. 



References

1.  Coles, R. (1981, November 15). Arthur, Ragen, Allen, et al. The New York Times. Retrieved from: http://www.nytimes.com/1981/11/15/books/arthur-ragen-allen-et-al.html

2.  Lewis, D. O., Yeager, C. A., Swica, Y., Pincus, J. H., & Lewis, M. (1997). Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder. The American Journal of Psychiatry 154(12):1703-1710. 

3.  Lilienfeld, S. O., & Lynn, S. J. (2003). Dissociative identity disorder: multiple personalities, multiple controversies. In Lilienfeld, Lyn, & Lohr (Eds.), Science and pseudoscience in clinicial psychology (pp. 109-142). New York: Guilford Press. 

4.  Maher, J. (2007, October 28). 30 years later, multiple-personality case still fascinates. The Columbus Dispatch. Retrieved from: http://www.dispatch.com/content/stories/local/2007/10/28/BILLY.ART_ART_10-28-07_A1_EV89AGB.html

5.  Porter, S., Birt, A. R., Yuille, J. C., & Herve, H. F. (2001). Memory for murder: a  psychological perspective on dissociative amnesia in legal contexts. International Journal of Law and Psychiatry 24(1):23-42. 

6.  Vermetten, E., Schmahl, C., Lindner, S., Loewenstein, R. J., & Bremner, J. D. (2011). Hippocampal and amygdalar volumes in dissociative identity disorder. Am J Psychiatry 163(4):630-636.

7.  Wolpe, P. R., Foster, K., & Langleben, D. D. (2005). Emerging neurotechnologies for lie-detection: promises and perils. American Journal of Bioethics 5(2):39-49.



Want to cite this post?
Uh, S. (2013). A Life With Others…In Your Head? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2013/04/a-life-with-othersin-your-head.html

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