Table 1B.
Studies of voice hearing in Dissociative Identity Disorder (DID) and Other Dissociative Disorders.
| Study | Size of Dx Sample | Female | Sample | Trauma history | Study Setting | Diagnostic Assessment |
Voice Hearing Measure | Operational Definition/Description of Voice Hearing | Voice Hearing Rate | |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Bliss (49) | N = 11 | 100% | Patients with multiple personalities (mean age 30 years) who were identified by relatives or friends | Little to no details on trauma history (one patient may have been raped) | 14 individuals with multiple personalities that the author—a physician in an academic psychiatry department in Salt Lake City, Utah, USA—encountered and studied in the previous year. | “All had personalities who revealed themselves and their missions under hypnosis.” No other criteria for diagnosis specified. |
713-item self-report questionnaire developed by the author (completed by only 11 of the 14 total patients) | Not specified | 64% “schizophrenia” voices |
| 2 | Bliss (50) | N = 70 | 68.6% | Adult patients with multiple personalities (mean age not specified) | Sexual and physical abuse “when young” (60% of female and 27% of male patients reported early sexual abuse; 40% of female and 32% of male patients reported early physical abuse). | Research setting unspecified; however, author with affiliation with an academic psychiatry department in Salt Lake City, Utah, USA. | DSM-III criteria for MPD (n=20 females, n=12 males), or determined under hypnosis to have “possible multiples” even if DSM-III criteria not fully met (n=28 females, 10 males). NB: As there were no significant clinical differences observed between the DSM-III and possible multiples patients, the two groups were combined for analysis. | 327-item self-report questionnaire developed by the author (consisting of items from the Research Diagnostic Criteria, the MMPI, the literature, and other sources) | Not specified | 51.4% AH (54% in females, 45% in males) |
| 3 | Putnam et al (51) | N = 100 | 92% | Outpatients (mean age 35.8 years) identified by their treating clinician to have a diagnosis of MPD | Childhood trauma: sexual abuse (83%), physical abuse (75%), extreme neglect (60%), witness to violent death (~42%), extreme poverty (20%), and “other abuses” (~37%). | Questionnaires distributed to ~400 clinicians across North America who previously indicated an interest in MPD. Each clinician was asked to report on a single patient, currently or recently in treatment with that clinician, who met DSM-III criteria for MPD. Return rate was 40%. 100 cases were selected based on the number of questions completed (submitted by 92 clinicians, including 49 psychiatrists, 37 PhD clinical psychologists, and 6 MSW psychiatric social workers). | DSM-III criteria for MPD (criteria were specified on the cover page of the questionnaire, but “the interpretation of these criteria was left to the reporting clinician, since no independent confirmation was possible.”) | 386-item questionnaire developed by the authors, including a 73-item checklist of signs and symptoms observed by the clinician or reported by the patient during clinician's initial contacts with the patient | Not specified | 30% AH |
| 4 | Coons and Milstein (52) | N = 20 | 85% | 20 patients with MPD (mean age 29 years) diagnosed by the first author, compared with 20 age and sex-matched inpatients with primarily affective and characterologic disturbances and without schizophrenia or dissociative disorders | Childhood sexual (75%) and physical abuse (55%). Childhood abuse and/or rape confirmed by at least one family member or emergency room report in 17 patients (85%) | Patients with MPD receiving treatment at an academically affiliated psychiatric hospital in Indianapolis, IN, USA (n = 10 outpatient, n = 9 inpatient, n = 1 from the consultation-liaison service) who were seen by the first author during an 11-year period. | DSM-III criteria for MPD | Psychiatric interview (unstructured) and MMPI | Not specified | 60% AH |
| 5 | Kluft (53) | N = 30 | 70% | Patients with MPD (mean age not specified) who were determined to have achieved and maintained (for 27 months or more) fusion of personalities. Of 241 MPD interviewed patients, 135 were excluded for not having achieved fusion of personalities, 54 for not maintaining fusion 27 months or more, 11 for “relapse phenomena,” 4 for requiring psychiatric medications, and 7 for other reasons, leaving 30 patients in the study group. | Not specified | Referrals to the author—a physician affiliated with a psychiatric hospital in Philadelphia, PA, USA—for consideration or confirmation of the diagnosis of MPD. | DSM-III criteria for MPD | Data from the author's first interview with each patient | Author conducted interviews using Mellor’s first rank symptom definitions(68) (including for audible thoughts) and “generally employ[ing]” interview questions from Carpenter et al(69), with modifications. NB: the author “evolved novel questions” for voices arguing and voices conversing (exact questions not specified) | 46.7% first-rank AH (33.3% voices arguing, 30% voices conversing) |
| 6 | Coons et al (54) | N = 50 | 92% | The first 50 patients with MPD (mean age 29 years) who were consecutively evaluated by the first author as part of a longitudinal 10-year follow-up study of patients with dissociative disorders | Childhood—sexual abuse (68%), physical abuse (60%), neglect (22%), abandonment (20%), emotional abuse (10%), witness to accidental death (4%). Adult trauma also occurred after diagnosis of MPD: rape (24%), domestic violence (10%). | Longitudinal study of MPD based in an academically affiliated psychiatric hospital in Indianapolis, IN, USA (n = 40 inpatients; n = 10 outpatients). | DSM-III criteria for MPD, and MMPI. (RDC used to diagnose 20 patients early in the study) |
Modified 406-item version of the Putnam etal (51) questionnaire(51), BPRS, and DES at study intake | Which measure was used to estimate VH prevalence not specified | 72% AH |
| 7 | Ross et al (55) | N = 236 | 87.7% | Patients with MPD (mean age 30.1 years) reported on by clinicians throughout North America via a mail-in questionnaire | Childhood sexual abuse (79.2%), childhood physical abuse (74.9%). 53.6% of the male and 67.1% of the female patients had experienced both childhood sexual and physical abuse. 63.9% of the male and 66.6% of the female patients had been raped. | Questionnaire about MPD mailed to 1,729 members of the Canadian Psychiatric Association and to 515 members of the International Society for the Study of Multiple Personality and Dissociation. Each respondent was asked to complete the questionnaire on a recent case of MPD the respondent had seen, or to indicate that the respondent had not made a diagnosis of MPD. The 236 MPD cases were reported by 203 clinicians throughout North America (including psychiatrists, non-psychiatric MD’s, psychologists, social workers, nurses, occupational therapists, and “other”) | 36-item questionnaire on MPD, which inquired how well the patients met DSM-III-R and NIMH† diagnostic criteria for MPD | 36-item questionnaire on MPD, which inquired about the number of Schneiderian first rank symptoms of schizophrenia experienced by the patient, among other questions | Schneiderian first rank VH (actual item(s) not specified or provided) | 71.7% voices arguing, 66.1% voices commenting |
| 8 | Ross et al (56) | N = 102 | 90.2% | Patients with clinical diagnoses of MPD (mean age 31.8 years) | Childhood sexual (90.2%) and physical abuse (82.4%). Altogether, 95.1% of patients had experienced one or both forms of childhood trauma. | Four medical centers in North America: Winnipeg (n = 50; patients presenting for initial assessment), Utah (n = 20; patients participating as subjects for a PhD thesis), California (n = 17; patients presenting for initial assessment), and Ottawa (n = 15; patients drawn from an existing caseload, primarily therapy outpatients). No differences between centers on demographics or mean number of Schneiderian symptoms endorsed. | Clinical interview and DDIS (131-item structured interview that takes 30–45min to administer; sensitivity 90% and specificity 100% for MPD diagnosis(70, 71) | DDIS section on secondary features of MPD Note: in a complementary paper by Ross et al (1990) (72), the DDIS section on positive symptoms of schizophrenia (Schneiderian first rank symptoms) is used to estimate VH in the same sample of 102 MPD patients |
DDIS Q96: “Do you hear voices talking to you sometimes or talking inside your head?” DDIS Q64: “Have you ever experienced the following: a) voices arguing in your head, b) voices commenting on your actions…” (DDIS also asks if Schneiderian symptoms have occurred only under the influence of drugs or alcohol, or only during a major depressive episode.) |
87.3% voices talking (Q96) 78.4% voices arguing, 81.4% voices commenting(Q64)(72) |
| 9 | Loewenstein and Putnam (34) | N = 21 | 0% | 21 male patients with MPD (mean age 38.6 years) were compared with data on 92 female patients previously collected for a different study on MPD (which used questionnaires mailed to outpatient clinicians across North America)(51). | Childhood—sexual abuse (85%), physical abuse (~95%), neglect (~66%), extreme poverty (~34% male), witness to violence (~40% male), other trauma (93% male, 85% female), i.e. confinement, emotional abuse, etc. | Referrals for dissociative disorder consultation to the two authors. Most patients came from the clinical services of a Veterans Affairs Medical Center in West Los Angeles, CA (patients of RJL), or from a federally operated psychiatric hospital in Washington, DC (patients of FWP), USA, although it is noted that several patients also came from other private and public settings. | DSM-III/DSM-III-R and NIMH† research criteria for MPD | 386-item NIMH questionnaire (clinician-rated) describing characteristics of the patients(51) | Not specified | 75% AH (vs. 30% in females) |
| 10 | Dell and Eisenhower (57) | N = 11 | 64% | Adolescents with MPD (mean age 14.7 years) followed in therapy by the first author | Childhood – sexual abuse (73%), physical abuse (73%), emotional abuse (82%), medical/surgical trauma (9%), injury (9%). Mean number of different types of trauma (i.e. sexual, physical, and emotional abuse, injury, medical/surgical trauma) reported was 2.4 (range, 1 to 4). Trauma and abuse was confirmed in 73% of the cases. | Referrals for diagnostic evaluation and/or therapy to the first author, a clinical psychologist affiliated with an academic medical center in Norfolk, VA, USA, over a 4-year period | DSM-III-R criteria plus NIMH† research criteria for MPD | Clinical interviews involving patients and their families | Not specified | 81.8% “AH (voices heard within the head)” |
| 11 | Hornstein and Putnam (58) | N = 64 | 65.6% | Children and adolescents with dissociative disorders (n = 44 MPD, mean age 11.1 years; n = 20 DDNOS, mean age 8.4 years) | Childhood – sexual abuse (about 57% DDNOS, 80% MPD), physical abuse (about 64% DDNOS, 69% MPD), both sexual and physical abuse (about 50% DDNOS, 61% MPD), witnessed violence (about 80% DDNOS, 70% MPD), neglect (ab0ut 63% DDNOS, 80% MPD), abandonment (about 50% DDNOS, 46%MPD), witnessed parental death (about 12% DDNOS, 4% MPD). | First series, collected by the first author, consisted of patients (n = 22 MPD, n=8 DDNOS) seen for evaluation and treatment in an inpatient unit (except four outpatients) at UCLA in Los Angeles, CA, USA. Second series, collected by the second author, consisted of mostly outpatients (n = 22 MPD, n = 12 DDNOS) who participated in a longitudinal research project on the psychobiological effects of sexual abuse at the NIMH or who received consultation or treatment at a children's hospital in Washington, DC, USA. Data from the two series were pooled, as there were no statistically significant between-site differences for the MPD cases or the DDNOS cases (except higher rate of learning disabilities in DDNOS cases in the second series). | DSM-III-R criteria augmented by NIMH† criteria for MPD. The DSM-III-R DDNOS diagnosis lacks specific criteria; DDNOS diagnosis was given to cases in whom there were no clear-cut alter personalities but in whom there was observable dissociation manifested by amnesias, trance states, depersonalization, rapid age regression, dissociative hallucinations, and perplexing shifts in knowledge, skills, and abilities. All cases had persistence of 3+ symptoms. |
Database developed by the authors to standardize data collection between the two sites. The database consisted of more than 100 symptoms and behaviors grouped into 16 factors, one of which was hallucinations. | Not specified | AH in: -97% of MPD -75% of DDNOS Command hallucinations in: -60% of MPD -25% of DDNOS “Voices urge violence” in: -41% of MPD -5% of DDNOS |
| 12 | Boon and Draijer (59) | N = 71 | 95.8% | Patients with MPD (mean age 33.1 years) referred from across The Netherlands; 48 referred with diagnosis of MPD prior to the study, 23 referred for evaluation because a dissociative disorder suspected by the referring clinician. | Childhood and adult trauma. History of childhood sexual or physical abuse reported by 94.4% of patients. Specifically, 77.5% of patients experienced childhood sexual abuse and 80.3% experienced physical abuse. 42.3% of patients also reported sexual and physical abuse in adulthood (individual rates not specified) | Patients referred by 60 clinicians from across The Netherlands (76% outpatients, 14.1% inpatients, 9.9% psychiatric day hospital) | Dutch version of the SCID-D (for DSM-III-R MPD) | SCID-D for DSM-III-R MPD section on associated features, Dutch version | Not specified | 94.2% voices commenting, 90.1% voices talking or arguing. (Hearing voices outside one's head in only 2.8%) |
| 13 | Sar et al (8) | N = 35 | 88.6% | Turkish patients with clinical diagnoses of DID (mean age 22.8 years) | Childhood trauma: physical abuse (62.9%), sexual abuse (57.1%), neglect (62.9%), emotional abuse (57.1%). 77.1% of the patients experienced one or both physical and sexual abuse. 88.6% of patients experienced at least one type of childhood trauma listed above. | Medical center (including in- and outpatient psychiatric services) at the University of Istanbul, Turkey | DSM-IV criteria for DID, and n=29 (82.9%) met criteria for MPD on the Turkish version of the DDIS (sensitivity 95% and specificity 98.3%) | Turkish versions of DDIS and DES | DDIS Q96: “Do you hear voices talking to you sometimes or talking inside your head?” | 94.3% “voices talking” |
| 14 | Coons (60) | N = 25 | 84% | Children (n = 4 DDNOS) and adolescents (n = 11 MPD, n = 9 DDNOS, n = 1 psychogenic amnesia) with DSM-III-R dissociative disorders who were consecutively referred for diagnostic evaluation (mean age of the 4 children was 8.5 years, range 5–12 years; mean age of the 21 adolescents was 15.8 years, range 13–17 years) | Childhood sexual (76%) and physical abuse (68%). Child abuse confirmed in 8 of the 9 cases of MPD and in 12 cases of DDNOS. | Referrals (n = 10 outpatient, n = 11 inpatient) for diagnostic evaluation by a specialized dissociative disorders clinic at a psychiatric hospital in Indianapolis, IN, USA between 1984-1993 | DSM-III-R criteria for MPD. DDNOS was diagnosed in cases similar to MPD that failed to meet full diagnostic criteria for MPD. |
Adolescents: DES and MMPI (in inpatients) Children: CDC completed by parents |
Exactly how VH was defined or measured not specified | “Inner voices” reported by: -100% of adolescents with MPD -77% of adolescents with DDNOS -50% of children with DDNOS |
| 15 | Middleton and Butler (9) | N = 62 | 87% | Patients with DID (mean age 31.6 years) | Childhood/adolescent sexual abuse (87%), physical abuse (85%), emotional abuse (79%). Confirmation of significant past trauma was obtained for 29% of patients via actual admissions from principal abusers, other family members, photographic evidence, and medical or police records. | Patients seen over a 5-year period (1992–1997) by either of the two authors, who were affiliated with a university and a private psychiatric hospital in Queensland, Australia. Assessments were not part of a formal research project. The clinical settings were diverse (i.e., acute hospital admissions, inpatient or outpatient referrals, medical ward consultations, civil and criminal medicolegal evaluations, etc.). | DSM-IV criteria for DID, DDIS, and DES | DDIS, DES, and clinical interviews | Exactly how VH was defined or measured not specified | 98% “auditory hallucinations or pseudo-hallucinations.” Both internalized and externalized voices were experienced in the majority (at least 67%; unspecified 14%) |
| 16 | Dell (10) | N = 220 | 90% | Patients clinically diagnosed with DID (mean age 41 years) and undergoing active psychotherapy | Not specified | Outpatient settings (n = 161) throughout the USA and Canada; inpatient facilities (n = 57) in the USA (California, Texas, Massachusetts), Canada, and Australia; clinical setting of n = 2 unknown. | Clinically diagnosed by therapist to have DSM-IV DID. Diagnosis confirmed with SCID-D-R in a subset (n = 41). | 259-item precursor of the final version of the MID (with 218 items) | See Table 2 | 95% voices commenting, 89% voices arguing |
AH, auditory hallucinations; BPRS, Brief Psychiatric Rating Scale (73); CAPS, Clinician Administered PTSD Scale (74); CDC, Child Dissociation Checklist (75); DDIS, Dissociative Disorders Interview Schedule (70, 71); DDNOS, Dissociative disorder not otherwise specified; DES, Dissociative Experiences Scale (63); DES-II, Dissociative Experiences Scale, version II (67); DSM, Diagnostic and Statistical Manual of Mental Disorders [e.g., DSM-III (76), DSM-IV (77)]; K-SADS, Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children (62); MID, Multidimensional Inventory of Dissociation (78); MMPI, Minnesota Multiphasic Personality Inventory (79); MPD, Multiple Personality Disorder; M-PTSD, Mississippi Scale for Combat-Related Posttraumatic Stress Disorder (80); PANSS, Positive and Negative Syndrome Scale (64); PDS, Posttraumatic Stress Diagnostic Scale (81); PSS, Posttraumatic Stress Scale (82); PTSD-I, Posttraumatic Stress Disorder Inventory (83); RDC, Research Diagnostic Criteria (84); SAPS, Scale for the Assessment of Positive Symptoms (85); SADS-C, Schedule for Affective Disorders and Schizophrenia, Change Version (86); SCID, Structured Clinical Interview for DSM [SCID for DSM-III-R (87), SCID for DSM-IV (88)]; SCID-D, Structured Clinical interview for DSM-III-R Dissociative Disorders (89); SCID-D-R, Structured Clinical interview for DSM-IV Dissociative Disorders-Revised (90); SCL-90-R, Symptom Checklist 90, Revised (66); VH, voice hearing.
†The National Institute of Mental Health (NIMH) research criteria for MPD specified that, in addition to DSM-III or DSM-III-R criteria for MPD being satisfied, two or more alter personalities had to exhibit distinct alter personality-specific behavior on at least three separate occasions, and that psychogenic amnesia was reported or observed(34).