Discussion: Are Alter Personalities Fragments or Figments?

One of the finest academic traditions of medicine is the clinical case conference. Customarily a resident shares clinical material which is then sagely discussed by a visiting graybeard who attempts to provide insight into the pathological processes, offer treatment recommendations, share some thoughts about the prognosis, and venture some generalizations about the disorder. All parties hope he or she will also impart a larger perspective or theoretical position that serves to organize the case and generate a deeper understanding of the underlying dynamics. One of the strengths of such conferences is that the discussants are specifically asked to focus on precisely this last task, the imparting of a clinical perspective, theoretical position, or dynamic model that can be applied to other cases.

It is the challenge of demonstrating that one's model or position is applicable, relevant, and useful that each discussant faces today as we come to grips the clinical material presented here. Dr. Lyon has provided us with a richly detailed and evocative case, including her own responses and her attempts to understand and utilize them in the treatment of this very difficult patient. Her metaphor, the shattered mirror, conveys a powerful image of what appears to have gone wrong and evokes a bleak picture of the patient's ultimate prognosis. For how does one piece together a shattered