Handbook of

Dissociation
Theoretical, Empirical, and
Clinical Perspectives
Handbook of
Dissociation
Theoretical, Empirical, and
Clinical Perspectives

Edited by

Larry K. Michelson and William}. Ray

The Pennsylvania State University
University Park, Pennsylvania

SPRINGER SCIENCE+BUSINESS MEDIA, LLC

 Library of Congress Cataloging-in-Publication Data
On file

ISBN 978-1-4899-0312-9 ISBN 978-1-4899-0310-5 (eBook)

DOI 10.1007/978-1-4899-0310-5

© 1996 Springer Science+Business Media New York

Originally published by Plenum Press, New York in 1996
Softcover reprint of the hardcover I st edition 1996

10987654321

All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any
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otherwise, without written permission from the Publisher
 To my wife Sandra, for her love, light, and laughter
-LKM

To my parents, my spouse, and my children,

who have shown me the varieties of loving relationships
-WJR
Contributors

Pamela C. Alexander, Department of Psychology, University of Maryland, College

Park, Maryland 20742

Catherine L Anderson, Northwest Center for Community Mental Health, Reston,

Virginia 22091
Peter M. Barach, Horizons Counseling Services, Inc., Cleveland, Ohio 44130
Alexandre Bennett, Department of Psychiatry, Yale University School of Medi-
cine, and National Center for PTSD, Department of Veterans Affairs Medical Center,
West Haven, Connecticut o6516
J. Douglas Bremner, Department of Psychiatry, Yale University School of Medi-
cine, and National Center for PTSD, Department of Veterans Affairs Medical Center,
West Haven, Connecticut o6516
Etzel Cardeiia, Department of Psychiatry, Uniformed Services University of the
Health Sciences, Bethesda, Maryland 20814
Dennis S. Charney, Department of Psychiatry, Yale University School of Medicine,
and National Center for PTSD, Department of Veterans Affairs Medical Center, West
Haven, Connecticut o6516
James A. Chu, Dissociative Disorders Program, McLean Hospital, Belmont, Massa-
chusetts 02178; and Department of Psychiatry, Harvard Medical School, Boston,
Massachusetts 02115
Catherine Classen, Department of Psychiatry and Behavioral Sciences, Stanford
University School of Medicine, Stanford, California 94305
Barry M. Cohen, P.O. Box 9853, Alexandria, Vu-ginia 22304
Pamela M. Cole, Department of Psychology, Pennsylvania State University, Univer-
sity Park, Pennsylvania 16802
Christine M. Comstock, Horizons Counseling Services, Inc., Cleveland, Ohio
44130 vii
viii Philip M. Coons, Department of Psychiatry, Indiana University School of Medi-
Contributors cine, Indianapolis, Indiana 46202
George H. Faust, 2515 Kemper Place, Shaker Heights, Ohio 44120
Catherine G. Fine, Dissociative Disorders Unit, Institute of Pennsylvania Hospital,
Philadelphia, Pennsylvania 19139
Edna B. Foa, Center for the Treatment and Study of Anxiety, Medical College of
Pennsylvania, Eastern Pennsylvania Psychiatric Institute, Philadelphia, Pennsylvania
19129
Jean M. Goodwin, Department of Psychiatry, University of Texas Medical Branch,
Galveston, Texas 77555.0428
George B. Greaves, 1175 LaVista Road, Apartment #205, Atlanta, Georgia 30324
Diana Hearst-Ikeda, National Center for Posttraumatic Stress Disorder, Women's
Health and Sciences Division, Boston Department of Veterans Mfairs Medical Cen-
ter, Boston, Massachusetts 02130
Nancy L Hornstein, Department of Psychiatry, Child Division, University of
Illinois at Chicago and Institute for Juvenile Research, Chicago, Illinois 61612
Richard P. Kluft, Dissociative Disorders Program, The Institute of Pennsylvania
Hospital, Philadelphia, Pennsylvania 19139
Cheryl Koopman, Department of Psychiatry and Behavioral Sciences, Stanford
University School of Medicine, Stanford, California 94305
John H. Krystal, Department of Psychiatry, Yale University School of Medicine,
and National Center for PTSD, Department of Veterans Affairs Medical Center, West
Haven, Connecticut 06516
Richard J. Loewenstein, Dissociative Disorders Service line, Sheppard Pratt
Health Systems, Baltimore, Maryland 21285; and Department of Psychiatry and
Behavioral Sciences, University of Maryland School of Medicine, Baltimore, Mary-
land 21201
Mary Main, Department of Psychology, University of California at Berkeley,
Berkeley, California 94720
Richard Moraga, Department of Psychology, Pennsylvania State University, Uni-
versity Park, Pennsylvania 16802
Hillary Morgan, Department of Psychology, University of California at Davis,
Davis, California 95616
Michael R. Nash, Department of Psychology, University of Tennessee at Knoxville,
Knoxville, Tennessee 37996
Judith A. Peterson, Phoenix Counseling, Consulting, and Forensic Services, 3 303
Chimney Brook Lane, Houston, Texas 77068
William}. Ray, Department of Psychology, Pennsylvania State University, Univer-
sity Park, Pennsylvania 16802
Colin A. Ross, Dissociative Disorders Unit, Charter Behavioral Health System of ix
Dallas, Plano, Texas 75024
Contributors
Roberta G. Sachs, Highland Park Psychological Resources, 660 LaSalle Place,
Highland Park, Illinois 60035
David K. Sakheim, 1610 Ellington Road, South Windsor, Connecticut 06o74
Steven M. Southwick, Department of Psychiatry, Yale University School of Medi-
cine, and National Center for PTSD, Department of Veterans Affairs Medical Center,
West Haven, Connecticut 06516
David Spiegel, Department of Psychiatry and Behavioral Sciences, Stanford Uni-
versity School of Medicine, Stanford, California 94305
Marlene Steinberg, Department of Psychiatry, Yale University School of Medicine,
New Haven, Connecticut 06510
Moshe S. Torem, Department of Psychiatry and Behavioral Sciences, Akron Gen-
eral Medical Center, Akron, Ohio 44307; and Department of Psychiatry, North-
eastern Ohio Universities College of Medicine, Akron, Ohio 44272
Onno Van der Hart, Department of Clinical and Health Psychology, Utrecht
University, and the Regional Institute for Ambulatory Mental Care, Amsterdam
South/New West, The Netherlands
Johan Vanderlinden, Department of Behavior Therapy, University Center St.
Jozef, B-3070 Kortenberg, Belgium
Katalin Varga, Department of Experimental Psychology, Eotvos Lorand University,
Budapest, Hungary
Helen H. Watkins, Department of Psychology, University of Montana, Missoula,
Montana 59801
John G. Watkins, Department of Psychology, University of Montana, Missoula,
Montana 59801
Jonathan E. Whalen, Department of Psychology, University of Tennessee at
Knoxville, Knoxville, Tennessee 37996
Linda J. Young, National Treatment Center for Traumatic and Dissociative Dis-
orders, Del Amo Hospital, Torrance, California 90505
Walter C. Young, National Treatment Center for Traumatic and Dissociative Disor-
ders, Del Amo Hospital, Torrance, California 90505
Theodore P. Zahn, Laboratory of Psychology and Psychopathology, National
Institute of Mental Health, Bethesda, Maryland 20892
Preface

Within the last decade there has been a tremendous explosion in the clinical,
theoretical, and empirical literature related to the study of dissociation. Not since
the work done at the tum of the century by Pierre Janet, Morton Prince, William
James, and others have the psychological and medical communities shown this
great an interest in describing and understanding dissociative phenomena. This
volume is the result of this significant expansion. Presently, interest in the scientific
and clinical progress in the field of dissociation is indicated by the following:
1. The explosion of conferences, workshops, and seminars devoted to disso-
ciative disorders treatment and research.
2. The emergence of NIMH-supported investigations that focus on dissociation.
3. The burgeoning literature on dissociation. According to a 1992 biblio-
graphic analysis of the field by Goettman et al. (1992), 72% of all writings
on the topic have appeared in the past decade, with about 1000 published
papers scattered across diverse disciplines and journals.
4. Current interest in dissociation as reflected in the appearance of major
articles and special issues in respected psychology and psychiatry journals.
5. The initiation of a journal entitled Dissociation (Richard Kluft, MD, Editor)
devoted to the area.
6. The development of scientific organizations such as the International
Society for the Study of Dissociation, as well as dissociation presentations
within such organizations as the Society for Experimental and Clinical
Hypnosis, the American Society of Clinical and Experimental Hypnosis,
and special interest groups within both the American Psychological Asso-
ciation and the American Psychiatric Association.
7. The growing awareness of the prevalence of childhood sexual abuse and
its sequelae in relation to dissociative phenomena.
8. The rapidly expanding database from psychology, psychiatry, medicine,
and epidemiology on the comorbidity of dissociation and affective, anxi-
ety, and posttraumatic stress disorders, in addition to eating, somatoform,
and personality disorders.
9. Growing international interest in dissociation as manifested by significant xi
xii increases in research, papers, and conferences from outside of North
Preface America.
10. Recent studies revealing the relatively high prevalence of dissociative
phenomena and disorders among inpatient, outpatient, and "normal"
populations, indicating it will likely remain a permanent and significant
area for conceptual, scientific, and clinical inquiry.
11. An increasing number of individuals presenting for treatment with disso-
ciative disorder.
12. The publication of three volumes, two on dissociative identity disorder
(multiple personality disorder) by Frank Putnam and Colin Ross and an
edited volume on theoretical and clinical perspectives of dissociation by
Steven Lynn and Judith Rhue.

However, from the outset it should be noted that with this renewed interest
also has come great controversy. Articles and letters have been written to scientific
journals suggesting that not only are dissociative disorders overestimated but that
certain disorders such as dissociative identity disorder may not exist at all. Since
early trauma and sexual abuse have been associated with the presence of dissocia-
tive disorders, there has been a growing concern as to valid methods for establish-
ing past trauma or sexual abuse. As part of this approach, authors have debated the
ability of a given individual to recover lost memories of trauma or sexual abuse.
Those of us who have tried to follow these debates quickly learn that the search for
objectivity and truth remains a complex process in the midst of highly rhetorical
presentations. Oearly, untrained therapists, in spite of their best motivations, seek
signs of abuse or dissociative disorders where they may not exist, and thus do not
act in the best interests of either their patients or the field of dissociation. However,
there are also individuals who move through the mental health system with unre-
cognized dissociative processes and remain untreated.
Presently there are few published volumes that provide a comprehensive,
state-of-the-art text that simultaneously addresses theoretical, conceptual, diagnos-
tic, assessment, treatment, ethical, and legal dimensions of the field of dissociation.
The luminary status of the volume's contributors, whose expertise spans the entire
spectrum of dissociative phenomena, has resulted in a stimulating, comprehensive,
and in-depth volume. The text's potential significance includes, but is certainly not
limited to, the following: (1) Highly respected theorists, scientists, clinical-
researchers, and psychotherapists share their expertise, resulting in an integrated
volume that reflects the cutting edge of the field; (2) the presence of a "critical
mass" of theory, research, and practice in the field of dissociation, which was
awaiting compilation into a substantive, cohesive, multidisciplinary volume; and
(3) likely audiences for the text include psychologists, psychiatrists, social workers,
and other mental health professionals, graduate students, interns, residents, univer-
sity libraries, and institutions of higher learning.
We believe the volume has much potential for stimulating dialogue in the
dissociation field, which is rapidly expanding and making fertile interconnections
with other disciplines and sciences. Further, we hope the text will serve as a
primary source for elucidation of both current and emerging theory, research, and
treatment of dissociative phenomena.
The volume is divided into seven parts. Part I, Foundations, entails historical,
epidemiological, phenomenological, etiological, normative, and cross-<:Ultural di- xill
mensions of dissociative phenomena, providing an empirical foundation for the Preface
remaining chapters. Part II, Developmental Perspectives, represents a newly emerg-
ing area that focuses on developmental aspects of dissociative processes, including
the potential role of incest and attachment in the development of dissociative
processes, as well as a description of dissociative disorders in childhood and
adolescence. Part m, Theoretical Models, encompasses contemporary conceptual
and research dimensions from a variety of perspectives. These contributions in-
clude psychobiological, information-processing models of dissociation, and the
relation of dissociation to hypnotic phenomena, moving beyond earlier theoretical
frameworks for elucidating the etiopathogenesis of dissociation. Part IY, entitled
Assessment, comprises three interrelated chapters devoted to the diagnosis, psy-
chological, and psychophysiological assessment of clients with dissociative dis-
orders.
Part V, Diagnostic Classifications, offers clinicians and researchers an overview
of current nosology, differential diagnoses, as well as conceptual and clinical impli-
cations of the varied dissociative disorders. In Part VI, Therapeutic Interventions,
eight chapters are presented that provide a wealth of information for clinicians
treating clients with dissociative disorders, posttraumatic stress disorders, and
survivors of sexual abuse and/or assault. These chapters reflect leading clinical
perspectives in the amelioration of dissociative disorders and related sequelae of
abuse. In Part VII, the final section, Special Topics, two chapters address ritual
abuse and ethical-legal issues in dissociative disorders that should be considered as
important readings for clinicians working with dissociative disorder clients.
In our clinical and research endeavors with clients with myriad dissociative
disorders, we have been sensitized to both the advances in theory, research, and
treatment, as well as, unfortunately, the many "black holes" of knowledge that await
further scientific study. We were struck by the need for a comprehensive volume on
dissociation that would be useful to the professional as well as for graduate-level
courses and seminars, providing a timely, balanced, and cogent review of the
controversial tributaries in the field. Hence, we endeavored to have the contribu-
tors address both fundamental domains as well as issues that have generated much
debate in scientific and clinical spheres.
We hope the reader finds the volume as intellectually and clinically rewarding
as we have in helping it come to fruition. We would like to extend our sincere
appreciation to the outstanding contributors who so generously offered their
cumulative wisdom and expertise. To the clients who so courageously shared their
experiences and whose quest for healing has enlightened us all, we want to express
our deepest gratitude and respect.
LARRY K. MICHElSON
WILLIAM J. RAY

REFERENCES

Gotteman, C., Greaves, G., & Coons, P. (1992). Multtple personality and dtssoctatton, 1791-1990: A
complete bibliography. Atlanta: Greaves.
Contents

I. FOUNDATIONS

1. History, Phenomenology, and Epidemiology of Dissociation 3

Colin A. Ross

2. European Studies of Dissociation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Johan Vanderlinden, Onno Van der Hart, and Katalin Varga

3. Dissociation in Normal Populations.......................... 51

William J. Ray

U. DEVEWPMENTAL PERSPECTIVES

4. Dissociation in Typical and Atypical Development: Examples

from Father-Daughter Incest Survivors . . . . . . . . . . . . . . . . . . . . . . 69
Pamela M. Cole, Pamela C. Alexander, and Catherine L. Anderson

5. Child Abuse in the Etiology of Dissociative Disorders . . . . . . . . . 91

Jean M. Goodwin and Roberta G. Sachs

6. Disorganization and Disorientation in Infant Strange Situation

Behavior: Phenotypic Resemblance to Dissociative States . . . . . . 107
Mary Main and Hillary Morgan

XV
xvi 7. Dissociative Disorders in Chlldren and Adolescents........... 139
Contents Nancy L. Hornstein

m. TIIEORETICAL MODELS

8. Recent Developments in the Neurobiology of Dissociation:

Implications for Posttraumatic Stress Disorder . . . . . . . . . . . . . . . 163
John H. Krystal, Alexandre Bennett, ]. Douglas Bremner,
Steven M. Southwick, and Dennis S. Charney

9. Hypnosis and Dissociation: Theoretical, Empirical, and

<linical~pecttves . . .. . . . .. .. .. . . . . . . . . . . . . . .. . . . . .. . . ... . 191
Jonathan E. Whalen and Michael R. Nash

10. Emotional Dissociation in Response to Trauma:

An Information-Processing Approach . . . . . . . . . . . . . . . . . . . . . . . . 207
Edna B. Foa and Diana Hearst-Ikeda

IV. ASSESSMENT

11. Diagnostic Issues, Criteria, and Comorbidity of Dissociative

Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Etzel Cardeiia and David Spiegel

12. The Psychological Assessment of Dissociation . . . . . . . . . . . . . . . . 251

Marlene Steinberg

13. Psychophysiological Assessment of Dissociattve Disorders 269

Theodore P. Zahn, Richard Moraga, and William J. Ray

V. DIAGNOSTIC CLASSIFICATIONS

14. Depersonalization and Derehlization . . . . . . . . . . . . . . . . . . . . . . . . . 291

Philip M. Coons

15. Dissociattve Amnesia and Dissociattve Fugue . . . . . . . . . . . . . . . . . 307

Richard J. Loewenstein
16. Dissociative Identity Disorder 337 xvii
Richard P. Kluft Contents

17. Dissociative Symptoms in the Diagnosis of Acute Stress

Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
David Spiegel, Cheryl Koopman, Etzel Cardefta,
and Catherine Classen

18. Posttraumatic Responses to Chlldhood Abuse and Implications

for Treat:Dlent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
James A. Chu

VI. THERAPEUTIC INTERVENTIONS

19. A Cognitively Based Treatment Model for DSM-IV Dissociative

Identity Disorder ........................................... 401
Catherine G. Fine

20. Psychodynamic Psychotherapy of Dissociative Identity

Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Peter M. Barach and Christine M. Comstock

21. Overt-Covert Dissociation and Hypnotic Ego State Therapy . . . 431

John G. Watkins and Helen H. Watkins

22. Hypnotherapeutic Techniques to Facilitate Psychotherapy

with PI'SD and Dissociative Clients .. . .. . . . . . . . . .. . . .. . .. . . . . 449
Judith A. Peterson

23. Memory Processing and the Healing Experience.............. 475

Roberta G. Sachs and Judith A. Peterson

24. Inpatient Treatment of Dissociative Disorders . . . . . . . . . . . . . . . . 499

Walter C. Young and Linda J. Young

25. Art and the Dissociative Paracosm: Uncommon Realities . . . . . . 525

Barry M. Cohen

26. Psychopharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545

Moshe S. Torem
xviii vn. SPECIAL TOPICS
Contents
27. CUnical Aspects of Sadistic Ritual Abuse . . . . . . . . . . . . . . . . . . . . . . 569
David K. Sakheirn

28. Legal and Ethical Issues in the Treatment of Dissociative

Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
George B. Greaves and George H. Faust

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
I
FOUNDATIONS

This section begins with the unique history of dissociation and the dissociative
disorders within the fields of psychology and psychiatry. In Chapter 1, Ross suggests
that dissociative processes have been recorded since the earliest times and treated
throughout history by shamans and priests in a tradition that continues throughout
the world up to the present time. Scientifically, dissociation represents an impor-
tant topic area that had its initial flowering in the 1800s and brought forth explana-
tions and descriptions by some of the great creative thinkers of the time, including
William James, Pierre Janet, Carl Jung, and Morton Price. During the twentieth
century, this tradition was largely ignored and forgotten until about 10 years ago. A
number of factors are described in the chapters of this section related to the
disappearance of scientific and clinical discussions of dissociative processes. These
include the rise of behaviorism in academic circles, the strength of psychoanalysis
with its emphasis on repression rather than dissociation, as well as the term
"schizophrenia" initially being used to describe dissociative symptoms.
An important theme found in the three chapters of this section is consistency
of the phenomenology of dissociative processes across a variety of cultures and
levels of pathology. The overall picture is that samples from the United States,
Canada, the Netherlands, Central Europe, and Japan show similarities even in the
more psychopathological forms of dissociation (e.g., dissociative identity disorder).
In fact, it is pointed out in this section that no clinical report from anywhere in
the world shows marked deviancy in its description of dissociative identity disor-
der.
Another important theme addressed in this section is the epidemiology of
dissociative processes. This is a new area but results are appearing that help to
detertnine the relative occurrence of each dissociative disorder, which Ross dis-
cusses in Chapter 1. Throughout the three chapters of this section, dissociative
experiences in the general population are discussed. Interestingly enough, both
Ross, using an adult nonclinical population in Wtnnipeg, Canada, and Ray (Chapter
3), using a college student population at a Big Ten university, found similar factor
structures using the best-studied dissociation scale. Ray further detertnined the
relationships between scores on this dissociation scale and other measures such as
absorption, absentmindedness, and hypnotic susceptibility, as well as health, stress,
and abuse. One intriguing finding from these data is that an orthogonal relationship 1
2 exists between dissociative tendencies and hypnotic susceptibility. This lack of
Foundations relationship has been seen consistently in a number of samples collected involving
over 2000 college students.
In Chapter 2, Johan Vanderlinden and his colleagues describe the progress in
studying dissociative processes in Western and Central Europe. They first describe
the modification and development of dissociation questionnaires targeted at the
European population. These researchers further compare the report of dissociative
experiences in the Netherlands and Belgium with those reported in Hungary as it
moved from a communist to a more democratic form of government.
1
History, Phenomenology, and
Epidemiology of Dissociation
Colin A. Ross

The dissociative disorders have a unique history within psychology and psychiatry.
Our understanding of this history, particularly the contributions of Pierre Janet in
the nineteenth century (Ellenberger, 1970; Nemiah, 1989; Putnam, 1989; Ross,
1989; van der Hart & Friedman, 1989), has shifted radically since 1980. Intertwined
with this development, a detailed, replicated description of the phenomenology of
dissociation has been built up, based primarily on research in North America
(North, Ryall, Ricci, & Wetzel, 1993), with significant contributions from the
Netherlands and Belgium (Boon & Draijer, 1993; Vanderlinden, 1993). A consider-
able amount of work has been done on the epidemiology of dissociation within
clinical populations and a lesser amount among college students (Frischholtz. et al.,
1990; Ross, Ryan, Anderson, Ross, & Hardy, 1989e; Ross, Ryan, Voigt, & Eide, 1990c;
Sanders, McRoberts, & Tollefson, 1989). One general population survey of dissocia-
tion has been completed in North America (Ross, 1991; Ross, Joshi, & Currie, 1990a,
1991b).
In this chapter, I will review the history, phenomenology, and epidemiology of
dissociation and the dissociative disorders, using the Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition (DSM-IV) nomenclature (American Psy-
chiatric Association, 1994). The five DSM-IV dissociative disorders are dissociative
amnesia disorder, dissociative fugue disorder, depersonalization disorder, dissocia-
tive identity disorder (multiple personality disorder), and dissociative disorder not
otherwise specified. For an exhaustive list of references on dissociation, the reader

Colin A. Ross • Dissociative Disorders Unit, Charter Behavioral Health System of Dallas, Plano,
Texas 75024.
Handbook of Dissociation: Tbearettca~ Empirlca~ and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 3
4 is referred to the bibliography by Goettman, Greaves, and Coons (1994), entitled
ColinA. Ross Multiple Personality and Dissociation, 1791-1990: A Complete Bibliography
(available from Dr. George Greaves at 529 Pharr Road, Smyrna, Georgia 30305).
Because the study of dissociative identity disorder (DID)/multiple personality
disorder (MPD) has been the major focus of the dissociative disorders field, it is not
possible to discuss dissociation without giving significant attention to DID. There-
fore, I will discuss the extreme form of dissociation, DID, and its complexity,
chronicity, and morbidity, to illustrate principles that apply to dissociation in
general and to the close relationship between trauma and dissociation.

IHSTORY

The history of dissociation begins in prehistory, with the ecstatic experiences

of the shamans (Eliade, 1964). Dissociation appears to be a fundamental and
universal component of human psychology. The psychological foundations of DID
and other complex dissociative disorders are illustrated by the trance and posses-
sion states found in most cultures throughout history. 1n Western civilization,
demonic possession is the historical precursor of DID (Crabtree, 1985; Oesterreich,
1974; Ross, 1989), and surprisingly a substantial number of contemporary MPD
patients have been treated unsuccessfully with exorcism (Bowman, 1993).
The structural components of MPD and other complex dissociative disorders
are switches of executive control from one identity to another and amnesia. 1n
somnambulistic possession, there is amnesia for the period during which the
possessing entity is in executive control, while in lucid possession there is no
amnesia, but the person does not experience himself as the agent of his body's
actions, and there is a direct, palpable experience of the presence of the possessing
entity. At the structural level, DID is based on universal human psychological
phenomena that have been harnessed to cope with overwhelming childhood
trauma. In our culture, the traumatized girl creates a tough secular adolescent male
protector personality, while in another culture the protector would be a deity, spirit
guide, or mythological figure. There is variation at the level of content, but the
structure is probably universal. 1n many cultures, extreme forms of dissociation are
normal and even prized and sought after through study, fasting, self-immolation,
peyote, solitude in the wilderness, or other techniques.

The Psychopathology of Dissociation in the Nineteenth Century

The dominant model of dissociation in nineteenth-century psychology and
psychiatry was a psychopathological one, in which dissociation occurred because
of a defect or deficit in ego strength (Janet, 1965/1907, 1977/1901). The relationship
between trauma and dissociation was well understood (Breuer & Freud, 1986/1895),
and there was a body of clinical, experimental, and theoretical literature on DID,
trauma, dissociation, hypnosis, and the paranormal. Some leading figures such as
Janet and Freud were not interested in the paranormal, while others like Myers
(1920) had no interest in trauma. Jung (1977/1902), in comparison, was interested
in all four components.
The late nineteenth-century dissociative models of psychopathology were not
narrowly focused on the disorders classified as dissociative in DSM-IY. They were 5
broad-based and included conversion disorder, somatization disorder, somnambul- History,
ism, some forms of obsessive-compulsive disorder, and everything encompassed Phenomenology,
under the term hysteria. Splitting of consciousness, and the sequestering of trau- and Epidemiology
matic memories and unacceptable impulses and ideas in dissociated packets of
psyche, was thought by scientists like Breuer, Myers, Janet, Prince, and Binet to
be the mechanism underlying paranormal phenomena, mediumship, possession
states, and a wide range of psychopathologies.
In their Studies on Hysteria, Breuer and Freud (1986/1891) presented cases
that meet DSM-IV criteria for DID and dissociative disorder not otherwise specified,
and childhood sexual trauma is reported in many of the case histories. Breuer and
Freud's treatments were based on a trauma-dissociation model of psychopathology,
and the sexual trauma was a key focus of treatment. Their thinking was consistent
with the clinical understanding of other psychologists and psychiatrists on both
sides of the Atlantic who both preceded and followed them, including Binet
(1977a/1896, 1977b/1890), James (1983/1890), Prince (1978/1905), and Janet
(1965/1907, 1977/1901). In the two decades from 1890 to 1910, trauma and dissocia-
tion were major, mainstream themes on the center stage of psychology and psychia-
try on both sides of the Atlantic.

The DecUne ln Interest ln Dissociation

ln the Early Twentieth Century
The curve of interest in dissociation from 1890 to 1994 is unique within
psychology and psychiatry. From a peak in the last two decades of the nineteenth
century, the curve drops off exponentially in the first two decades of the twentieth
century, to virtually zero (Goettman et al., 1991). This occurred so quickly and the
magnitude of the change was so great that the process cannot be explained by
passive forgetting, a gradual shift of interest to other priorities, or similar mecha-
nisms. There had to have been an active dissociation of dissociation from main-
stream psychiatry and psychology.
What were the factors that led to dissociation virtually disappearing from
mainstream academia early in the twentieth century? The first was Freud's repudia-
tion of the seduction theory, which was accompanied by his denigration of hyp-
nosis and his shift from a dissociation to a repression model of psychopathology. If
the women with dissociative disorders who were coming to Freud for treatment for
the long-term sequelae of childhood sexual trauma were never actually abused,
then how should they be understood and treated? By invalidating the childhood
sexual abuse, Freud disallowed the possibility of treatment of dissociative symp-
toms within a trauma model, and dissociative diagnoses became irrelevant to
mainstream clinical practice. The fundamental issue was not DID or dissociation
but the endemic nature of childhood sexual abuse and society's need to disavow the
reality of both the abuse itself and its long-term consequences.
The second factor was the creation of the term schizophrenia by Bleuler, who
wrote in 1924 that, "it is not alone in hysteria that one finds an arrangement of
different personalities one succeeding the other: through similar mechanisms
schizophrenia produces different personalities existing side by side" (quoted in
Boon & Draijer, 1993, p. 119). To the contemporary student of schizophrenia, it is
6 not obvious why Bleuler decided that dementia praecox should be called split
Colin A. Ross mind disorder, which is the meaning of the Greek term schizophrenia, since
splitting of mental functions is not a topic addressed in the contemporary schizo-
phrenia literature. The explanation for Bleuler's choosing the term schizophrenia is
that his clinical descriptions of schizophrenia are often descriptions of DSM-N
dissociative identity disorder.
Subsequent to the coining of the term schizophrenia, many DID patients were
transferred into a biomedical organic brain model, which is the model of schizo-
phrenia that dominates contemporary psychiatry. Patients who several decades
earlier would have received a dissociative diagnosis and treattnent focused on their
childhood sexual trauma were now triaged in one of two directions within the
mental health field: they were defined as hysterics and prescribed psychoanalysis
for their sexual fantasies, or they received a diagnosis of schizophrenia and were
assigned to a biomedical pathway.
The third factor was the rise of behaviorism. The intellectual gestalt of strict
behaviorism does not allow consideration of internal states of consciousness,
divided consciousness, or symptoms that evolve from causes 20 or 30 years in the
patient's past. As behaviorism acquired more academic territory, the time and
energy available for study of dissociation decreased (Hilgard, 1987).
Within a few decades, it was no longer possible to have a serious clinical,
theoretical, or phenomenological interest in the paranormal, dissociation, hyp-
nosis, or childhood sexual abuse, despite the fact that all four subjects had been on
center stage in the recent past. These interrelated topics were banished beyond the
fringes of psychology and psychiatry by active exclusion.
During the years 1920 to 1950, academic interest in DID dwindled to a handful
of publications per year in the entire world literature. If one searches the Index
Medicus even in the 1970s and 1980s, one will find hundreds of topics with more
citations than DID. No other disorder has been subject to this kind of exclusion
from mainstream psychological and medical study.

Resurgence of Interest in Dissociation in the 1970s and 1980s

During the 1980s, the curve of interest in dissociation turned upward and the
field began to undergo exponential growth. The number of annual publications on
DID and the number of cases reported increased by thousands of percents from
1979 to 1993. To use personal measures of the epidemiological shift, about 200
cases had been reported in the world literature in 1980, whereas my Dissociative
Disorders Unit admits more patients than this per year, and I have published or
presented independent series of 236 (Ross, Norton, & Wozney, 1989d), 102 (Ross,
et al., 1990b), and 107 cases ofMPD (C. A. Ross,]. Eliason, &D. Fuchs, unpublished
data).
The upturn in the curve has occurred against resistance from mainstream
psychology and psychiatry, which is the inverse of the process that occurred 80
years ago. What factors resulted in this exponential upward growth at this point in
history? The overwhelmingly important factor is childhood physical and sexual
abuse being brought out of the closet by the women's movement. In the three-
volume 1980 edition of the Comprehensive Textbook ofPsychiatry (Kaplan, Freed-
man, & Sadock, 1980), which is the main textbook of North American psychiatry, 7
there is a tiny section on incest that includes a reference to a 1955 study that found a History,
prevalence of incest of one family out of a million in North America. This estimate Phenomenology,
was out by a factor of at least 10,000, because incest actually occurs in more than and Epidemiology
one family out of 100 in our culture (Bagley & King, 1990).
When Chris Sizemore, who is Eve of The Three Faces of Eve (Thigpen &
Cleckley, 1957), was diagnosed, she was told that she was probably the only person
on the planet with DID. If less than 100 families in North America at any given time
have experienced incest, and if severe, chronic childhood trauma is the foundation
of dissociative psychopathology, then Eve being the only person alive with DID is a
reasonable estimate. If at least 5% of boys and 15% of girls experience unwanted,
sexually abusive treatment before age 18 in our culture, however, as Bagley and King
(1990) conclude from their review of the literature, then dissociative psychopathol-
ogy might be common and of mainstream clinical interest.
Although academic psychiatry and psychology can no longer maintain that
severe, chronic childhood trauma is rare, for the most part it is still considered
clinically peripheral. For instance, in the August 1993 special issue of the Canadian
journal ofPsychiatry on child and adolescent psychiatry, there are 12 articles and 2
editorials with a total of 467 references. Childhood sexual abuse is mentioned once
and referenced once in the entire issue, in an article entitled, "Public Health Nurse
Home Visitation for the Tertiary Prevention of Child Maltreatment: Results of a Pilot
Study" (MacMillan & Thomas, 1993). In this study, a history of sexual abuse was used
as an exclusion criterion for enrolling families, a fact that generated the single
reference on sexual abuse.
In the other 11 articles with a total of 428 references, there is not a single
reference to childhood physical or sexual abuse. In one article there are two
references to studies on child maltreatment, but they are discussed only in terms of
the psychometrics of the instruments used in the studies. The articles in the issue
deal with topics such as family factors in adolescent unipolar depression, psychi-
atric follow-up of adoptees, attachment and conduct disorder, disruptive behavior
problems, and child survivors of the Holocaust. These are all topics in which
childhood sexual trauma is of central interest.
It is not possible to understand the dissociative disorders or professional
resistance to them without a prior understanding of childhood sexual abuse. Any
attempt to debate the validity of DID is premature if there is no agreement that
chronic childhood trauma is a major etiologic theme in psychopathology.
The second factor helping to bring the dissociative disorders back into the
mainstream was the Vietnam War. For sociological reasons originating outside
psychology and psychiatry, the Vietnam War and the posttraumatic stress disorder
(PTSD) that arose from it were not forgotten when the veterans returned home, as
had been the case in the two world wars and the Korean War. The realization that
real, severe trauma could have serious long-term psychopathological consequences
was forced on society as a whole by Vietnam. Once this principle was accepted, it
was a short leap to the conclusion that severe childhood trauma might have serious
sequelae lasting into adulthood.
The third factor was publication of the books The Three Faces ofEve (Thigpen
& Cleckley, 1957) and Sybil (Schreiber, 1973), both of which were made into
8 successful Hollywood movies. These two cases brought dissociation into main-
CoHn A. Ross stream consciousness.
The fourth factor was the appearance of DSM-III in 1980 (American Psychiatric
Association, 1980). In DSM-III, the dissociative disorders were for the first time
given a separate section of their own, and operationalized diagnostic criteria for
multiple personality disorder were included for the first time. This development
in the DSM process provided a major impetus to the phenomenological research on
DID that was conducted in the 1980s.

Current Scientific State of the Art

In 1980, the dissociative disorders' field was in a prescientific state of develop-
ment. Since then, dissociation has become an established field of scientific study, a
fact that made this handbook possible. The transition to scientific status was
achieved remarkably quickly, given the small number of serious investigators in the
field and the small amount of grant money devoted to dissociation in the 1980s
compared to other aspects of psychopathology such as anxiety, depression, psy-
chosis, and substance abuse.
The majority of the clinical and research effort on dissociation since 1980 has
been devoted to DID for a number of reasons: it is the most interesting dissociative
disorder; it carries the most morbidity; undiagnosed DID patients often fare poorly
in the mental health system and receive numerous different diagnoses and ineffec-
tive treatments; specific psychotherapy can result in dramatic improvement in
function and reduction in symptoms (see Chapter 16, this volume); and the disorder
has the most to teach us of any dissociative disorder. Most of my brief review will
therefore focus on DID.
Several self-report measures of dissociation have been developed (Boon &
Draijer, 1993), of which the Dissociative Experiences Scale (DES) (Bernstein &
Putnam, 1986) is by far the most studied. The DES may become established as the
equivalent for dissociation of the Beck Depression Inventory (North et al., 1993).
The DES is a highly robust measure of dissociation with three factors that are stable
across a number of large series in the general population and in clinical populations
(Carlson et al., 1993; Frischholtz et al., 1990, 1991; Ross et al., 1991b). The factors are
absorption, amnesia, and depersonalization -derealization.
There are two structured interviews for diagnosing dissociative disorders: the
Dissociative Disorders Interview Schedule (DDIS) (Ross et al., 1989c), and the
Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D) (Boon
& Draijer, 1993; Bremner, Steinberg, Southwick, Johnson, & Charney, 1993; Stein-
berg, Rounsaville, & Cicchetti, 1990). Both the DDIS and the SCID-D require further
research on their validity and reliability, but both make a diagnosis of DID with an
interrater kappa of .95- .96, which is higher than the kappa for any diagnosis made
by the Structured Clinical Interview for DSM-III-R (Spitzer, Wtlliams, & Gibbon,
1987).
The sensitivity of the DDIS for DID in 396 subjects with that clinical diagnosis
was 95%, and in over 500 administrations of the structured interview to subjects
without clinical diagnoses of DID, the false-positive rate for the diagnosis of DID has
been 1% (C. A. Ross, unpublished data, 1993). Structured interviews for non-
dissociative diagnoses do not approach this level of diagnostic precision. Thus, 9
although further research is required, it appears that DID can be diagnosed with History,
higher reliability, greater sensitivity, and fewer false positives than any other dis- Phenomenology,
order in DSM-IY. and Epidemiology
The validity of DID in terms of treatment outcome is profound at the clinical
anecdote level and in preliminary financial cost-benefit analyses (Fraser & Raine,
1992; Ross & Dua, 1993). The treatment outcome data are nowhere near well-enough
developed to convince skeptics of the validity of the disorder, however. Anyone
who has treated a severely impaired individual with DID to stable integration
cannot help but have been deeply impressed by the power of the DID treatment
model, as outlined in this handbook and in texts by Putnam (1989) and Ross (1989).
The scientific study of dissociation in childhood is in very early stages, as are
transcultural studies. 1n the Netherlands, DID has the same clinical profile as in
North America (Boon & Draijer, 1993), and this is also true in Japan according to
studies done there with translated versions of the DES and DDIS (Berger et al.,
1992). It appears that DID can be readily diagnosed in Scotland (Macilwain, 1992),
Puerto Rico (Martinez-Taboas, 1989), and New Zealand (Altrocchi, 1992) by clini-
cians who inquire systematically for its features. DID personality systems I have
treated in native North Americans have the same features as those described in the
research literature. DID has also been reported sporadically from Switzerland
(Modestin, 1992) and a variety of other countries (Coons, Bowman, Kluft, &
Milstein, 1991).
The major foci for systematic research on DID in the 1990s will be further
demonstrating the reliability and validity of the disorder, exploring comorbidity,
tracking treatment outcome, and better defining childhood DID. For dissociation in
general, the focus of research will be on establishing its prevalence in various
clinical populations and the general population and demonstrating its correlations
with childhood trauma and other forms of psychopathology. An important book by
North et al. (1993) demonstrated that DID has begun to be taken seriously as a
subject of legitimate scientific study by investigators well grounded in research
methodology, who are not members of the small group of writers and researchers
that dealt with dissociative disorders in the 1980s.

A Paradigm Shyt in Progress in Psychiatry and Psychology

Classical paradigm shifts as defined by Thomas Kuhn (1962) do not occur very
frequently. Psychiatry, I believe, is currently in the process of a paradigm shift from
endogenous-reductionist models of psychopathology, which effectively ignore
environmental variables, to a trauma model of psychopathology, one driven by
research on DID and childhood trauma (Ross, 1992). Through most of the twentieth
century, DID has been an anomaly from the point of view of normal science
psychiatry and has been ignored as such. 1n the last 5 years it has becoming
increasingly evident that the DID is a paradigm-threatening anomaly.
Unlike the paradigm shift in physics from Newtonian to relativistic and
quantum-mechanical models, however, the shift to a trauma model in psychiatry
will to a large extent represent a return to a prior paradigm dominant from 1880 to
1900. I mention this paradigm shift briefly, without making any argument for its
10 validity, to alert those interested in the philosophy of science to an opportunity to
Colin A. Ross study a paradigm shift in progress. The content of this handbook provides the
substance of the argument.

PHENOMENOLOGY

The phenomenology of dissociation in clinical populations, college students,

and the general population has been studied in the last half decade, as mentioned
above. Dissociation consists of three factors: absorption-imaginative involvement,
amnesia, and depersonalization- derealization. Absorption is by far the most com-
mon subcomponent of dissociation in all populations studied, while the other two
factors tend to be clearly psychopathological in nature when elevated item scores
occur.
As Frankel (1990) warned, assessment of the severity of dissociative symptoms
has a lower interrater reliability when milder degrees of dissociation are being
assessed and high reliability when severe symptoms in DID patients are being
assessed (Boon & Draijer, 1993). The significance of statistically significant but
numerically small differences in DES scores within the general population is un-
known, but unlikely to be of any marked clinical significance.
In this section I will describe the dissociative continuum, the relationship
between borderline personality disorder and this continuum, and the phenomenol-
ogy of dissociative identity disorder, because it illustrates dissociation in the ex-
treme. I will briefly describe the other dissociative diso.•Jers by presenting the DSM-
N criteria.

The DSM-W Dissociative Disorders

The following are the DSM-N criteria for the five dissociative disorders (Ameri-
can Psychiatric Association, 1993):
300.12 Dissociative Amnesia
A. The predominant disturbance is one or more episodes of inability to recall
important personal information, usually of a traumatic or stressful nature,
that is too extensive to be explained by ordinary forgetfulness.
B. The disturbance does not occur exclusively during the course of Dissocia-
tive Identity Disorder and is not due to the direct effects of a substance
(e.g., drugs of abuse, medication) or a general medical condition (e.g.,
Amnestic Disorder due to head trauma).
300.13 Dissociative Fugue
A. The predominant disturbance is sudden, unexpected travel away from
home or one's customary place of work, with inability to recall one's past.
B. Confusion about personal identity or assumption of a new identity (partial
or complete).
C. The disturbance does not occur exclusively during the course of Dissocia-
tive Identity Disorder and is not due to the direct effects of a substance
(e.g., drugs of abuse, medication) or a general medical condition (e.g.,
temporal lobe epilepsy).
300.14 Dissociative Identity Disorder (Multiple Personality Disorder) 11
A. The presence of two or more distinct identities or personality states (each History,
with its own relatively enduring pattern of perceiving, relating to, and Phenomenology,
thinking about the environment and self). and Epidemiology
B. At least two of these identities or personality states recurrently take control
of the person's behavior.
C. Inability to recall important personal information that is too extensive to
be explained by ordinary forgetfulness.
D. Not due to the direct effects of a substance (e.g., blackouts or chaotic
behavior during Alcohol Intoxication) or a general medical condition (e.g.,
complex partial seizures). Note: In children, the symptoms are not attribu-
table to imaginary playmates or other fantasy play.
300.6 Depersonalization Disorder
A. Persistent or recurrent experiences of feeling detached from, and as if one
is an outside observer of, one's mental processes or body (e.g., feeling like
one is in a dream).
B. During the depersonalization experience, reality testing remains intact.
C. The depersonalization causes clinically significant distress or impairment in
social, occupational, or other important areas of function.
D. The depersonalization experience is not better accounted for by another
disorder, such as Schizophrenia, Dissociative Identity Disorder, or Panic
Disorder, and is not due to the direct effects of a substance (e.g., drugs of
abuse, medication) or a general medical condition (e.g., temporal lobe
epilepsy).
300.15 Dissociative Disorder Not Otherwise Specified
This category is reserved for disorders in which the predominant feature is a
dissociative symptom (i.e., a disturbance or alteration in the normal integrative
functions of identity, memory, or consciousness) but the criteria are not met
for any specific Dissociative Disorder. Examples include:
1. Clinical presentations similar to Dissociative Identity Disorder that fail to
meet full criteria for this disorder. Examples include presentations in which:
(a) there are not two or more distinct personality states, or (b) amnesia for
important personal information does not occur.
2. Derealization unaccompanied by depersonalization in adults.
3. States of dissociation that occur in individuals who have been subjected to
periods of prolonged and intensive coercive persuasion (e.g., brainwashing,
thought reform, or indoctrination while the captive of terrorists or cultists).
4. Dissociative trance disorder: single or episodic alterations in the state of
consciousness that are indigenous to particular locations and cultures.
Dissociative trance involves narrowing of awareness of immediate sur-
roundings or stereotyped behaviors or movements that are experienced as
being beyond one's control. Possession trance involves replacement of the
customary sense of personal identity by a new identity, attributed to the
influence of a spirit, power, deity, or other person, and associated with
stereotyped "involuntary" movements or amnesia. Examples include amok
(Indonesia), bebainan (Indonesia), latah (Malaysia),pibloktoq (Artic),phil
bob (Thailand), vimbuza (Nigeria), ataque de nervios (Latin America), and
12 possession (India). The dissociative or trance disorder is not a normal part
Colin A. Ross of a broadly accepted collective cultural or religious practice.
5. Loss of consciousness, stupor, or coma not attributable to a general medical
condition.
6. Ganser's syndrome: the giving of "approximate answers" to questions,
commonly associated with dissociative amnesia or fugue. •

The Dissociative Continuum

The idea that the dissociative disorders lie on a continuum of increasing
complexity, chronicity, and severity related to more extreme trauma was initially
proposed by Ross (1985) and Braun (1986); but this conceptualization is general to
the field and was likely arrived at independently by a large number of clinicians
working with the dissociative disorders. At the left-hand of the continuum is normal
dissociation, as represented by daydreaming, trancing out for a few blocks while
driving a car, absorption in a book or movie, and normal childhood imaginative play.
Next come more pathological forms of dissociative and trance-state phenomena
such as highway hypnosis, which are not freestanding psychiatric disorders. Fur-
ther to the right are simple dissociative disorders such as dissociative amnesia
disorder. These are followed by more complex and chronic forms of dissociative
disorder not otherwise specified (DDNOS), with DID at the far right-hand end of
the continuum.
It is widely accepted clinically in the dissociative disorders field, and in DSM-IY,
that many individuals with DDNOS have partial, not fully crystallized forms of DID,
and require a similar treatment involving memory retrieval and processing, integra-
tion of dissociated ego states, and resolution of conflicts between the ego states. But
what empirical evidence is there to support the concept of a dissociative spectrum?
So far, only three published studies address this issue (Boon & Draijer, 1993;
Coons, 1992; Ross et al., 1992b), and all support the continuum hypothesis. Boon
and Draijer's study is the most comprehensive and is based on Dutch versions of the
DES and Structured Clinical Interview for DSM-111-R Dissociative Disorders (SCID-
D). The DES, SCID-D, and DDIS can differentiate clinically diagnosed DID from
DDNOS at high levels of statistical significance on many different symptom clusters.
The continuum concept is widely accepted among clinicians in the dissociative
disorders field, and the only studies investigating it have supported the model;
therefore, it appears that future research is likely to confirm this conceptualization.
We can anticipate the appearance of more complex versions of the model as our
data base increases.

BorderUne PersonaUty Disorder and the Dissociative Disorders

The relationship between borderline personality disorder and the dissociative
disorders has been complicated rather than clarified in DSM-IY, because a ninth
criterion for borderline personality disorder has been added: "transient, stress-
related paranoid ideation or severe dissociative symptoms" (American Psychiatric

'Reprinted by pennission from Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition.
Copyright 1994 American Psychiatric Association.
Association, 1993). One now has to meet five of nine rather than five of eight 13
criteria, as was the case in DSM-III and DSM-III-R, in order to receive a borderline ltistory,
diagnosis. Phenomenology,
There are no exclusion criteria in the borderline diagnostic set, so there are no and Epidemiology
specific rules for determining when severe dissociative symptoms should result in
an Axis I dissociative diagnosis and when there should be no Axis I diagnosis but a
positive dissociative criterion on Axis II. Nor is it specified whether one can have a
positive dissociative borderline criterion on Axis II and a concurrent Axis I dissocia-
tive disorder.
While there is no systematic data set concerning dissociative symptoms and
disorders in a sample of borderlines, the inverse is not true. Beginning with a study
of Horevitz and Braun (1984), there have been several replications of the finding
that 38 to 700.4 of patients with DID meet criteria for borderline personality disorder
(Boon & Draijer, 1993; Fink & Golinkoff, 1990; Ross, Ellason, & Fuchs, 1992c; Ross,
Heber, Norton, &Anderson, 1989a; Ross et al., 1990b).ln a sample of102 clinically
diagnosed DID subjects, the average subject was positive for 5.2 (SD 2.3) borderline
criteria on the DDIS. The number of positive borderline criteria differentiates DID
from panic disorder, eating disorders, and schizophrenia (Ross et al., 1989a), and
from temporal lobe epilepsy (Ross et al., 1989b).
It is well-established that borderline personality disorder patients have high
rates of childhood trauma (Gunderson & Sabo, 1993), although Axis I dissociative
comorbidity was not examined in any of the supporting studies. To my way of
thinking, borderline personality disorder is a simple form of DID in which the
personality states are less crystallized, less personified, fewer in number, and not
separated by the same degree of amnesia. Inversely, DID is a complex variant of
borderline personality disorder.
Data to support this conceptualization come from Boon and Draijer (1993),
who showed that borderline personality disorder exists on a continuum of in-
creasing severity, with DDNOS having a greater degree of complexity than pure
borderline personality and DID the greatest degree of elaboration and crystalliza-
tion. They demonstrated this with SCID-D data and compelling clinical observation.
The relationship between trauma, dissociation, and DSM-IV borderline criteria
is a rich topic for future research. Large numbers of subjects should be compared on
the DES, SCID-D, and DDIS, as well as other measures, in future studies, and the
subject groups should include pure borderline personality disorder without an Axis
I dissociative disorder and DDNOS and DID groups with and without concurrent
borderline personality. Correlational analyses will likely demonstrate powerful rela-
tionships between the degree of childhood trauma, the complexity of dissociation,
and the number of positive borderline criteria.
At the present time, the existing data unequivocally refute the commonly
advanced proposition that DID patients are "really just borderlines." Fink (1991) has
provided the most comprehensive clinical discussion of the interaction between
DID and Axis II psychopathology.

The Phenomenology of Dissociative Identity Disorder

The phenomenology of DID is consistent in samples from Canada, the United
States, the Netherlands, and Japan studied with the DES, SCID-D, and DDIS, as
14 stated above. There are no clinical reports from anywhere in the world of a
Colin A. Ross markedly different form of DID, and there are no studies that have not confirmed
the symptom profile. DID can be diagnosed by the DDIS or SCID-D with an
interrater reliability unsurpassed by any other DSM-IV diagnosis. The kappa value
for the interrater reliability of DID on structured interview is .95-.96, compared
with an overall average for Axis I of .68 using the Structured Clinical Interview for
DSM-III-R, which does not make dissociative diagnoses (Spitzer et al., 1987).
The core phenomenology of the disorder is the existence of distinct person-
ality states that take turns being in executive control of the body and are separated
by varying degrees of amnesia. This phenomenon does not occur in any other
disorder, and is described in detail in texts by Putnam (1989) and Ross (1989). From
the core phenomenology, one can predict most of the secondary features of the
disorder: the frequency of the secondary features in a sample of 102 DID cases is
readily available (Ross et al., 1990b).
The secondary features include such items as blank spells or periods of missing
time; coming out of blank spells in unfamiliar surroundings, unsure of how one got
there; being told of disremembered events; finding objects present or missing in the
environment that cannot be accounted for; distinct changes of handwriting; refer-
ring to onself as "we" or "us"; and auditory hallucinations, which may include
voices commenting, voices conversing with one another, command hallucinations,
and other variations of internal voices and conversations.
The secondary features each exist on a spectrum from normal to severe forms
increasingly specific for DID. For instance, internal dialogues and monologues are
part of common experience, but to have a fully ego-alien voice shouting commands
for suicide inside one's head intermittently for decades is outside the range of
normal experience.
The subtle phenomenology of DID is mostly due to intrusions, influences, and
interactions of alter personalities not involving full switches of executive control.
For instance, laceration of the wrist may occur in a depersonalized state during
which the person experiences herself as not being the agent of the cutting. In full
DID, there will, in addition, often be command hallucinations to cut and episodes of
cutting for which the host personality is amnesic. In DID, a specific alter personality
that does the cutting can be contacted directly and engaged in conversation; this
degree of elaboration does not occur in DDNOS or pure borderline personality,
although depersonalized self-mutilation can occur at any point on the spectrum.
The general differential diagnostic principle is that patients with full DID exhibit all
the phenomenology of DDNOS, but in addition have crystallized symptoms due to
fully personified and differentiated personality states that do not occur in DDNOS.
DID patients have an extreme degree of Axis I and II comorbidity. In a sample
of 107 DID patients treated at Charter Behavioral Health System of Dallas, we found,
using the SCID-I and SCID-11, that the average patient met DSM-III-R criteria for 3.6
different personality disorders and 7.3 different Axis I disorders, in addition to the
DID, which is not diagnosed by the SCID (C. A. Ross et al., unpublished data). The
most common comorbid diagnoses include depression, panic disorder, PTSD, sub-
stance abuse, and eating disorders.
On Axis II, borderline, paranoid, avoidant, and self-defeating personality dis-
orders each occurred in 43.7- 56.3% of the 107 cases. The most common Axis II
diagnoses are in Cluster C, and a pure Cluster B profile (histrionic, narcissistic, 15
borderline, or antisocial) occurs in only 4.9% of cases. Histrionic personality dis- History,
order is one of the least common Axis II diagnoses with a frequency of 8. 7% in the Phenomenology,
sample of 107 patients. and Epidemiology
Why so much comorbidity? This can be understood by considering the case of
a 24-year-old, highly hypnotizable woman with no preexisting psychopathology
who is raped by a stranger. She copes with the assault by blocking out all memory
of it, and therefore has dissociative amnesia. This Axis I disorder might not require
treatment if it were not for the comorbidity that develops as part of the normal
human reaction to extreme psychological trauma. The rape victim develops either
subthreshold or a diagnostic level of many different DSM-IV disorders.
She begins to phobically avoid the area of the rape and experiences intense
anxiety if she does not do so (panic disorder with agoraphobia). She feels dirty and
showers four times a day (obsessive-compulsive disorder). Her relationship with
her lover becomes strained, and she develops inhibited sexual arousal and anorgas-
mia, although she was previously normally adjusted sexually. Her relationship with
her somewhat chauvinistic boss at work becomes stormy, stressful, and conflicted;
if this pattern had been present since adolescence, we would call it a personality
disorder.
Because of postraumatic numbing, intrusions, hypervigilance, nightmares, and
avoidance, she meets full criteria for PTSD and has trouble sleeping because of
nightmares. The feelings of dirtiness, self-blame for poor performance as a sexual
partner, and fatigue and interpersonal difficulties at work are demoralizing and may
result in her reaching threshold for a clinical depression. To sleep better, she begins
to drink excessively before bedtime. Within 6 weeks, this young woman, who was
well until raped, now meets or nearly meets criteria for mood, anxiety, dissociative,
sleep, psychosexual, and substance abuse disorders and has more than one diag-
nosis in some categories.
If the onset of the trauma had been in childhood, if the perpetrators had been
close relatives, and if the duration had been a decade or more, it is not difficult
to see why there would be the kind of comorbidity that is the norm in DID. The
comorbidity results in the average DID patient in two large series spending 6.8 years
in the mental health system prior to diagnosis of the dissociative disorder (Putnam,
1989; Ross, 1989), receiving numerous other diagnoses, and undergoing trials of
many different treatments.
Undiagnosed DID patients received incorrect diagnoses of schizophrenia in
25% and 40% of cases in two large series (Putnam, 1989; Ross, 1989), while in one
series 12% and in the other 16% had received electroconvulsive therapy. Over half of
102 DID patients in a third large series had been treated with neuroleptics (Ross et
al., 1990b). All available data unequivocally support the contention that undiag-
nosed DID patients are perceived as suffering from severe mental illnesses by
treating clinicians.
DID can usually be diagnosed in a single standard psychiatric assessment
once a decision tree for the diagnosis is incorporated into the interview. The mental
status assessment of DID has been described by Loewenstein (1991). The major
screening items for DID are a history of childhood physical and/or sexual abuse,
recurrent blank spells, auditory hallucinations, presence of positive borderline
16 criteria, and absence of a thought disorder. Subjects with this constellation are
Colin A. Ross highly likely to have either DDNOS or DID. When the blank spells are sharply de-
marcated, recurrent, and chronic, and the voices fully ego-alien, out loud, and internal,
DID is the most likely diagnosis, even in the absence of any further clinical informa-
tion. Although direct observation of switching of personality states is desirable for
final confirmation of the diagnosis, DSM-IV rules do not state that this is necessary
and direct observation of the active phase of the disorder is not required for any
other Axis I disorder; therefore, to require it for DID would be uniquely stringent.
Clinicians in the dissociative disorder field, by consensus, regard DID as the
paradigmatic example of the psychological response to severe, chronic childhood
trauma, and therefore view it as exhibiting the relationship between trauma and all
types of symptomatology through its primary and secondary features and comor-
bidity. DID patients are the extreme cases illustrating general principles of the
trauma response.

The Other Dissociative Disorders

The other dissociative disorders have not been studied as thoroughly as DID.
The best recent reviews are by Putnam (1993), Kluft (1993), Loewenstein (1993),
Steinberg (1993), Nemiah (1993), and Spiegel (1993). These chapters were origi-
nally published in the American Psychiatric Press' annual Review of Psychiatry
(Vol. 10). As described above, partial forms of DID currently classified as DDNOS
clearly fall into the dissociative spectrum and are related to substantial but less
severe histories of childhood trauma than those in DID.
Boon and Draijer (1993) found that 19 of 20 subjects in their study with an
initial diagnosis of DDNOS proved to have full DID on 1-year followup. The func-
tion of the DDNOS category is in part to provide a preliminary dissociative diag-
nosis for patients in whom DID is possible or suspected, but cannot be confirmed.
Dissociative amnesia commonly occurs in survivors of severe childhood
trauma who do not have a more complex dissociative disorder. It takes a number of
different forms. There can be complete amnesia for all life events from age 12 or 14
back, with a sudden onset of normal memory at a specific age. At other times, there
can be complete amnesia for a period of several years, with intact memory before
and afterward. Differentiating traumatic amnesia for childhood from normal forget-
ting can be difficult in marginal cases. One clinical clue is the ability of younger
siblings to recall details of vacations and other nontraumatic events that the index
sibling has dissociated.
Some survivors block out only the traumatic memories, leaving intact their
memories of the rest of childhood, while others block out everything. Although
definitive epidemiological studies have not been done, amnesia for childhood
trauma is probably the most common form of dissociative amnesia disorder. Amne-
sias for part or all of single-episode, adult-onset trauma has been recognized in
combat and other conditions for many years, however (Loewenstein, 1993).
There is no consensus in the field yet as to how often depersonalization
disorder exists as an independent disorder (Steinberg, 1993). Depersonalization
commonly occurs as a predominant symptom in mood, substance abuse, organic,
and psychotic disorders. In sexual abuse survivors, reports of floating up to the 17
ceiling or into the wall, or escaping into internal fantasy during abuse are the most History,
common form of depersonalization. Depersonalization can be pervasive and non- Phenomenology,
specific or can involve a detailed, time-limited, out-of-body experience. An interest- and Epidemiology
ing largely unexamined question is whether the body image distortions occurring
in anorexia nervosa and body dysmorphic disorder are often dissociative in nature.
Most clinicians in the dissociative disorders field have seen only a few cases
of pure dissociative fugue, although fugue episodes are common in DID. A diagnosis
of fugue should always prompt the clinician to carefully rule out DID by longitudi-
nal assessment.
A common pattern is for a patient to meet criteria for both dissociative amnesia
and depersonalization disorder by DSM-IV rules. Although we lack any research
data on the problem, clinical experience tells me that most of these patients have
either full or partial forms of DID, and therefore should be classified as DDNOS. The
problem is that DDNOS can be diagnosed only in the absence of any other dissocia-
tive disorder. This common problem in differential diagnosis within the dissociative
disorders will require attention in DSM-V and DSM-Vl. I favor the creation of a
category for partial forms of DID, the presence of which would be an exclusion
criterion for diagnosis of dissociative amnesia or depersonalization disorder.
The phenomenology of the dissociative disorders is rich, complex, and de-
scribed in detail in the referenced literature, as well as elsewhere in this volume.

EPIDEMIOWGY

At the time of publication of the texts by Putnam (1989) and Ross (1989), there
was no information on the epidemiology of dissociation in the general population
and very little in clinical populations. Since then, an increasing body of research
has begun to fill this gap in the literature. However, we still lack an adequate data
base of multicenter replicated findings. Therefore, everything said about epidemiol-
ogy is necessarily tentative.

Epidemiology of Dissociation in the General Population

Studies of the prevalence of dissociative experiences were not possible before
the development of reliable measures, of which the first was the DES (Bernstein &
Putnam, 1986). General population surveys have been completed in Canada using
the DES (Ross, 1991) and in the Netherlands and Belgium using the Dissociation
Questionnaire (Dis-Q) (Vanderlinden, 1993), in addition to surveys of college stu-
dent populations. All studies have yielded the same finding of a highly left-skewed
distribution of scores, with the mean DES score in Canada being 10.8 (SD 10.1) and
the median score 7.0. In the Netherlands, the mean DIS-Q score is 1.61 (SD 0.40).
DES and DIS-Q scores correlate with each other at very high levels in both the
Netherlands (Vanderlinden, 1993) and the United States (Sainton, Eliason, Mayran,
& Ross, 1993).
The DES yields three factors in the general population (N = 1055) (Ross et al.,
18 1991b): absorption-imaginative involvement; activities of dissociated states (an
Colin A. Ross amnesia factor); and depersonalization-derealization. The DIS-Q has four subscales
similar to those of the SCID-D, called identity confusion, loss of control, amnesia,
and absorption. It is evident that dissociation is not a unitary phenomenon and that
there are at least three aspects to the overall phenomenology.
In all surveys completed to date, the items in the absorption-imaginative
involvement factor are by far the most frequently endorsed. For instance, in the
sample of 1055 respondents in Winnipeg, Canada who completed the DES (Ross
et al., 1990a), the mean score for DES Item 2 from the absorption factor was 24.3
(SD 22.1); 83% of subjects endorsed the item and 28.9% of subjects reported that
they had this experience more than 30% of the time. In comparison, DES Item 4
from the amnesia factor had a mean score of 1.9 (SD 8.5), was endorsed by only
13.6% of subjects, and was experienced more than 30% of the time by only 1.5% of
subjects.
The frequency distributions of scores for these two items are shown in Table 1.
The DES is scored such that individual items can have scores only at intervals of 5:
the 28 items are summed and divided by 28 to yield an overall score ranging from
0 to 100, with overall scores usually expressed to one decimal point.
It is likely that high scores on the amnesia factor of the DES predict the
presence of a dissociative disorder, but no studies testing this prediction have been
reported to date. Dissociation in normal populations is discussed in greater detail in
Chapter 3, this volume.
The distribution of DES scores in Canada led Ross, Joshi, and Currie (1991b) to
predict that the lifetime prevalence of dissociative disorders in the general popula-
tion might be in the range of 5 to 10%, while DIS-Q scores in the Netherlands and
Belgium led Vanderlinden (1993) to predict a prevalence of 1-3% in those coun-
tries. Epidemiological studies with the DDIS and/or SCID-D will be required to
determine the prevalence of DSM-IV dissociative disorders in different countries.

Table 1- Frequency Distribution of Two DES

Items in the General Population
Number of Number of
subjects" subjects"
Score Item 2 Item 4 Score Item 2 Item 4

0 179 912 55 26 0
5 95 81 6o 15 2
10 119 27 65 18 2
15 102 9 70 19 0
20 99 3 75 18 1
25 90 6 80 9 2
30 65 2 85 9
35 54 2 90 6 0
40 42 0 95 4 2
45 42 3 100 0
50 43 1
•N= 1055.
Epidemiology of Dissociative Disorders 19
in the General Population History,
Phenomenology,
Only one study of the prevalence of dissociative disorders in the general and Epldemiology
population has been conducted (Ross, 1991). This survey, a stratified cluster sample
(N = 454), was conducted in Wmnipeg, Canada: the 454 subjects completing the
DDIS were a subset of 1055 subjects who completed the DES in the same project
(Ross et al., 1990a).
The study has a number of limitations. A much larger, multicenter sample is
required, the validity of the DDIS in the general population has not been estab-
lished, and validating interviews by "blind" clinicians were not undertaken. The
results of this survey must be considered a first approximation only. Until further
research is conducted, however, the results are consistent with DES data from the
larger sample and with the large number of undiagnosed cases detected in screen-
ing studies in clinical populations.
Subsequent to publication of the sample of 454 subjects, further interviews
were completed for a final sample of 502 subjects completing the DDIS. The
lifetime prevalence of the dissociative disorders in Wmnipeg, Canada from this
expanded sample of 502 subjects is shown in Table 2. According to the DSM-III-R
diagnostic criteria for multiple personality disorder embedded in the DDIS, 3.00Ai of
subjects were positive for the disorder. However, inspection of the DDIS profiles
revealed that only six of these subjects reported trauma histories and endorsed the
symptom profile for multiple personality disorder; therefore, the corrected esti-
mate for the prevalence of DID in the general population is 1%. Whether the other
nine subjects had another dissociative disorder or not is unknown; therefore, the
corrected estimate for the lifetime prevalence of dissociative disorders is in the
range of 10 to 12%. 1f this is accurate, dissociation is a major form of psychopathol-
ogy comparable in prevalence to anxiety, depression, and substance abuse.

Epidemiology of Dissociation in CUnical Populations

Studies in clinical populations using the DES, DDIS, SCID-D, and DIS-Q have
consistently found high rates of dissociative symptoms (Boon & Draijer, 1993; Chu
& Dill, 1990; Demitrack, Putnam, Brewerton, Brandt, & Gold, 1990; Kolodner &
Frances, 1993; North et al., 1993; Quimby & Putnam 1991; Ross, Anderson, Fleisher,

Table 2. Prevalence of DSM-m-R Dissociative Disorders

in the General Populationa

Diagnosis Percentage of respondents positive

Psychogenic amnesia 6.0

Psychogenic fugue 0.2
Depersonalization disorder 2.8
Multiple personality disorder 3.0
Dissociative disorder not otherwise specified 0.2
A dissociative disorder of some kind 12.2
•N= 502.
20 & Norton, 1991a; Ross et al., 1992d; Vanderlinden, 1993). Dissociation is much more
CoHn A. Ross common in clinical populations than in the general population across a wide
spectrum of settings and diagnostic categories, just as anxiety and mood symptoms
are encountered at elevated levels throughout the mental health field.
Future research into the treatment implications of dissociative comorbidity
will likely yield powerful predictors of differential treatment responses by highly
dissociative subjects (Ross, 1989, 1992). Tills may be the case in eating disorders
(Demitrack et al., 1990; Vanderlinden, 1993), substance abuse (Kolodner & Frances,
1993; Ross et al., 1992d), and a wide range of different diagnostic categories.
The factor structure of the DES in clinical populations appears to be similar to
that in the general population, with the item scores and overall scores being
elevated and the distribution of scores therefore shifted right compared with
nonclinical samples.

Epidemiology of Dissociative Disorders in Qinical Populations

In two studies published to date surveying general adult psychiatric inpatients
with the DES and DDIS, previously undiagnosed DID was found in 5% of subjects
in Wmnipeg (Ross et al., 1991a) and 4% of subjects in Boston (Saxe et al., 1993). The
frequency of the dissociative disorders overall in the two studies was 20.7% in
Winnipeg and 15% in Boston.
In a sample of 100 chemical dependency subjects in Winnipeg, 43 reported a
history of childhood physical and/or sexual abuse, while 39 met DDIS criteria for a
dissociative disorder, including 14 with DID (Ross et al., 1992d). Kolodner and
Frances (1993) found 13 cases of DID and 13 cases of DDNOS in a chemical
dependency population in the Washington, DC area. Other studies reporting clini-
cal detection of DID and other dissociative disorders have not used standardized
measures (Bliss & Jeppsen, 1985; Putnam, Loewenstein, Silberman, & Post, 1984)
Based on screening studies to date, it appears that the minimum rate of
undiagnosed DID in severely disturbed clinical populations such as general psychi-
atric inpatients is 5% (Ross et al., 1991a; Saxe et al., 1993). Given the likelihood that
other subjects with DDNOS or other dissociative disorders are likely to have
undiagnosed DID as well (Boon & Draijer, 1993), the actual rate may be in the range
of 15 to 20% in chemical dependency inpatients, general adult psychiatric in-
patients, and similar groups. The prevalence of all of the dissociative disorders
combined in these populations appears to be at least 20%.
If these findings are replicated and accepted, the differential diagnosis and
management of dissociative disorders will become part of daily mainstream clinical
practice.

CONCLUSIONS

The history of the dissociative disorders, with a peak of interest in the late
nineteenth century, then almost complete suppression of serious study for most of
the twentieth century prior to an exponential upsurge in interest in the 1980s, is
unique in the mental health field. The field shifted from a prescientific to a scientific
state in the second half of the 1980s, and it should be a mainstream component of 21
psychiatry and psychology by the end of the century. The resurgence in interest History,
occurred against political and ideological resistance. Phenomenology,
Studies in North America, Japan, and Europe with a variety of standardized and Epidemiology
measures and structured interviews have confirmed a stable, core set of symptoms
for the most complex dissociative disorder: DID. The ability of structured inter-
views to differentiate DID from DDNOS and borderline personality disorder has
been demonstrated, and preliminary evidence of the prevalence of dissociative
symptoms and disorders in clinical populations and the general population is
available.
The dissociative disorders as a group appear to have a lifetime prevalence of
about 10% in the general population in North America, including a prevalence of
about 1% for DID. These figures are expected to vary from country to country based
on differential rates of chronic childhood trauma and cultural factors. Dissociative
comorbidity may prove to be a powerful predictor of differential treatment re-
sponse in a variety of clinical populations.

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2
European Studies of
Dissociation
Johan Vanderlinden, Onno Van der Hart,
and Katalin Varga

INTRODUCfiON

Apart from the Netherlands and Belgium, clinical interest and research in Europe in
the field of dissociation and the dissociative disorders are lagging far behind North
American developments. In most European countries, strong professional igno-
rance and skepticism still exist. After a brief description of the clinical field in
Europe, in particular in the Netherlands and Belgium, the main focus of this chap-
ter is on European studies on dissociation and dissociative disorders. Special atten-
tion is given to studies on the development of a scale for the assessment of dis-
sociative experiences and symptoms and on the prevalence of these phenomena in
both general populations and psychiatric patient samples.

DISSOCIATIVE DISORDERS IN EUROPE

While rapid developments are taking place in the field of the dissociative
disorders in the Netherlands and Belgium, most other European countries are

Johan Vanderlinden • Department of Behavior Therapy, University Center St. }ozef, B-3070 Korten·
berg, Belgium. Onno Van der Hart • Department of Clinical and Health Psychology, Utrecht
University, and the Regional institute for Ambulatory Mental Care, Amsterdam South/New West, The
Netherlands. Katalln Varga • Department of Experimental Psychology, Eiitvos I.orand University,
Budapest, Hungary.
Handbook of Dissociation: Theoretical, Emplrlca~ and Clinical Perspectives, edited by lMry K.
Michelson and Wtlliarn J. Ray. Plenum Press, New York, 1996. 25
26 lagging far behind (cf. Vander Hart, 1993). Most clinicians are still ignorant of the
Johan Vanderlinden phenomenology and treatment of dissociative disorders, and research is nonexis-
et a1. tent. While in Britain official psychiatry exhibits a negative attitude, as is shown in
some publications in the British journal of Psychiatry (e.g., Fahy, 1988), there is
nevertheless a growing number of therapists who are treating adult or child patients
with dissociative identity disorder (DID) (e.g., Karle, 1992; Macilwain, 1992) and
who are organizing themselves into an informal network. At the University of
Warwick, Coventry, Dr. John S. Davis is carrying out a prevalence study using the
Dissociative Experiences Scale (DES) and the Dissociative Disorders Interview
Schedule (DDIS) on reported dissociative disorders. At the University College in
London, Waller and colleagues are studying the prevalence of dissociative symp-
toms in eating disordered patients compared to non-eating disordered women (see
Everill, Waller, & Macdonald, 1995). In Germany, until recently, DID was an almost
completely unknown diagnostic category, although the general public was in-
formed by the publication of a few translated biographies of DID patients. Since
then, a few workshops on diagnosis and treatment of DID, given by Dutch clini-
cians, have had a snowball effect. A number of serious publications in women's
magazines have attracted the attention of both the general public and psychothera-
pists. In 1995, Huber published the first German handbook on the treatment of DID
(Huber, 1995). In Scandinavian countries, there are a few clinicians treating disso-
ciative disorder patients, but professional ignorance is still strong. An important
exception is the Rogaland Psychiatric Hospital in Stavanger, Norway, which is very
active in the diagnosis and treatment of dissociative disorders. Currently, a preva-
lence study using the DES and the SCID-D is being carried out in this hospital.
In Switzerland, a study has been carried out about how frequently DID is
diagnosed. Modestin (1992) sent all qualified Swiss psychiatrists a questionnaire on
DID along with the Diagnostic and Statistical Manual of Mental Disorders, 3rd
edition (DSM-lll) description of MPD and three classical nineteenth-century case
examples. Thirty-nine percent of the 770 respondents reported they had not
known the concept of DID before the present study. Three percent reported that
they were treating or examining one or more patients meeting DSM-111 criteria for
DID. Ten percent indicated that they had seen DID at least once during their
professional career. Modestin concluded that MPD is relatively rare. However, with
more refined and updated information on DID phenomenology, he would probably
have found a higher prevalence. His study falls very short of the serious prevalence
studies in North America, Belgium, the Netherlands, and Norway; where validated
diagnostic instruments such as the Structured Clinical Interview for DSM-111-R
Dissociative Disorders (SCID-D) and the DDIS are used.
In Italy, Daile Grave and colleagues are doing promising work studying the
prevalence of dissociative symptoms using the Dissociation Questionnaire (DIS-Q)
in a large sample of eating-disordered people and college students (Daile Grave,
Rigamonti, & Todisco, in press) at the hospital Casajdi Cura in Garda. Meanwhile, at
the University of Padua Institute of Clinical Psychiatry, Favaro and Santonastaso are
studying the prevalence of dissociative symptoms in a student population sample
(Favaro & Santonastaso, 1995). At the University of Madrid in Spain, Iconan and
Orengo-Garcia are planning a validation study of the DES.
In most other European countries, much less can be reported. However, there
is an increase of information exchange between clinicians and researchers in
different countries, resulting, at least in Hungary, in a prevalence study on dissocia- 27
tive experiences having been carried out. European Studies of
Dissociation

TilE NETIIERLANDS

In the Netherlands, interest in the dissociative disorders developed in the early

1980s and was fostered and furthered by workshops on diagnosis and treatment
presented by North American specialists in the field, notably Drs. Bennett G. Braun,
Richard P. Kluft, and Roberta Sachs. Vander Hart (1991) reported on 60 DID patients
being treated in the Netherlands. Since then, Boon and Draijer (1993a,b) have been
able to get collaboration for their study of 71 Dutch DID patients treated by 60
clinicians. Van der Hart (1993) subsequently estimated that roughly 400 DID pa-
tients were treated by 250 clinicians in the Netherlands.
The prominence of the Netherlands in the dissociative disorders field in
Europe was exemplified by the fact that the Internat:nnal Conference on Multiple
Personality Disorder and Dissociative States, with 465 participants, was held in
Amsterdam, May 21-23, 1992 and again May 11-13, 1995, with more than 500
participants. Currently, there is a lot of media interest in DID. An increasing number
of mental health institutions are providing treatment for DID patients. A few
outpatient institutions have their own dissociative disorders teams, and the first
inpatient DID unit has recently been opened.

CUnical Studies

In the Netherlands and the Flemish part of Belgium, a number of clinical

studies on diagnosis and treatment have been published (e.g., Boon & Van der Hart,
1988a,b), 1989; Nijenhuis, 1994, 1995; Van der Hart, 1991). In 1991, Van der Hart
edited a book on trauma, dissociation, and hypnosis, which was widely read by a
professional audience and, due to his success, reprinted in 1995. Noteworthy in
these works is the return of the eminent French philosopher and psychiatrist Pierre
Janet (1859 -1947) to the pioneering clinical and theoretical studies on trauma and
dissociation (cf. Vander Hart, 1986, 1988; Vander Hart & Horst, 1989). Around the
turn of the century, Janet (1889, 1898, 1907, 1919) was probably the first author to
systematically study the relationship between traumatic experiences and dissocia-
tion in the etiology of a wide range of psychiatric problems, including the DSM-111-R
dissociative disorders and eating disorders. Janet's old definition of hysteria (i.e., the
dissociative disorders) seems to be as important today as it was a century ago:
A form of mental depression characterized by the retraction of the field of
personal consciousness and a tendency to the dissociation and emancipation of
the systems of ideas and functions that constitute personality. Qanet, 1907,
p. 332)
Janet's descriptions and analyses of traumatic experiences, traumatic memories,
and the transformation of traumatic memories into narrative memories serve as
important guidelines for modern treatment approaches of severely traumatized
patients. International cooperation has produced a number of English-language
publications showing the importance of Janet's pioneering observations and no-
28 tions to an international professional audience (cf. Vander Hart & Friedman, 1989;
Joban Vanderllnden Vander Hart, Brown, & VanderKolk, 1989; Vander Hart, Brown, &Turco, 1990; Van
etal. der Hart & Horst, 1989; Van der Hart, Steele, Boon, & Brown, 1993a; Van der Hart,
Witztum, & Friedman, 1993b; Van der Kolk & Van der Hart, 1989, 1991).

Empirical Studies
In a survey of sexual abuse of girls by relatives, Draijer (1988, 1990) found in a
representative sample of 1054 women that 15.6% reported childhood sexual abuse
by relatives. She concluded that such abuse is much more common than is usually
believed. Draijer found indications that those women who were probably most
severely abused were the least able to provide information about it. These women
presented symptoms indicating the existence of a dissociative disorder.
Ensink and Van Otterloo (1989) validated a Dutch version of the DES (Bernstein
& Putnam, 1986). In a study of 100 women having been sexually abused in child-
hood, Ensink (1992), using among other scales the DES (Bernstein & Putnam, 1986),
found that more than one third (36%) gained scores as high as patients with DID. A
cutoff score on the DES of 30 was used (F. W. Putnam, personal communication,
1990). Ensink found that a high level of dissociation (> 30 on the DES) tended to be
reported by: (1) women having a childhood history of sexual abuse during which
they feared they would be killed; (2) women who as children were subjected to
group rapes in which unknown perpetrators were involved; (3) women who were
sexually abused as children at the hands of multiple perpetrators; ( 4) women who
were physically assaulted as children by the perpetrator before the sexual abuse
started; (5) women who as children experienced physical aggression associated
with sexual abuse for a considerable amount of time; and (6) women whose
mothers were involved in the sexual abuse. A multiple regression analysis showed
four characteristics significantly contributing to the level of dissociation: (1) cumu-
lation of childhood trauma; (2) age at onset of sexual abuse; (3) physical aggression
preceding sexual abuse; and (4) being forced to have sexual contact with unknown
perpetrators.
In a prevalence study on 160 psychiatric inpatients, Draijer and Langeland
(1993) found that at least 5% of this group suffered from DID, a finding that is
remarkably similar to North American findings (Ross, Anderson, Fleisher, & Norton,
1991b; Saxe et al., 1993). These and other findings indicate that, contrary to some
opinions voiced in Europe (e.g., Aldridge-Morris, 1989), DID is not a North Ameri-
can culture-bound phenomenon, but probably occurs as often in Europe as in
North America. Findings of Boon and Draijer (1993b) on the characteristics of DID
patients in the Netherlands indicate also that the phenomenology of European and
North American DID patients is similar. In harmony with North American findings
on DID patients (Ross, 1989), Cohen, Wallage, and Vander Hart (1992) found in 80
successive referrals to a Regional Institute for Ambulatory Mental Health Care that
their DES scores correlated highly with reports on somatic complaints for which no.
physical cause could be found, which the authors regarded as mainly dissociative in
nature. This result seems to support the fact that in the IC~JO Classification of
Mental and Behavioural Disorders (World Health Organization, 1992) conversion
disorders are classified as dissociative disorders of movement and sensation.
In 1993, Boon and Draijer published their findings on a large study of the
reliability and validity of the SCID-D (Steinberg, Rounsaville, & Cichetti, 1990), a 29
diagnostic instrument for the assessment of dissociative disorders (Boon & Draijer, European Studies of
1993a,b). Several parts of this study were published before (Boon & Draijer, 1991). Dissociation
Besides the SCID-D, two other instruments were employed: the DES (Bernstein &
Putnam, 1986) and the Structured Trauma Interview (STI) (Draijer, 1990). First, a
pilot study carried out in 44 patients showed an interrater reliability of 97.7% for
the SCID-D. Ninety patients ( 45 with a dissociative disorder and 45 with another
psychiatric diagnosis) participated in the main study designed to validate the
SCID-D. All diagnoses of dissociative disorders by clinicians were confirmed by the
SCID-D. In the control condition, the diagnosis of a dissociative disorder was
excluded in 43 cases. In two cases (both diagnosed as borderline personality
disorder only), the diagnosis of a dissociative disorder was detected with the
SCID-D. The validity of the SCID-D was assessed for total score and severity of
specific dissociative symptoms. Overall ANOVA results showed a significant differ-
ence among the two groups (p < .0001) at all levels of assessment. Patients with a
dissociative disorder reported a cluster of severe and chronic dissociative symp-
toms, while patients without a dissociative disorder reported only minor dissocia-
tive symptoms, mainly associated with episodes of stress or depression, psychosis
or mania. These findings caused Boon and Draijer (1993b) to remark that it is no
longer acceptable to conceptualize dissociation on a continuum: dissociative symp-
toms in patients with dissociative disorders are qualitatively different and much
more severe compared to dissociative symptoms in patients without a dissociative
disorder.
Besides the SCID-D scores, Boon and Draijer (1993b) also compared the DES
scores between the two groups. Patients with a dissociative disorder gained a
significantly higher score on the DES: their mean DES score was 47.6 (SD = 16.3;
range, 11.6-81.3). Patients without a dissociative disorder had a mean DES score
of 12.0 (SD = 11.4; range, 0.0-38.6). A high Pearson correlation of .78 was found
between the DES and total SCID-D score, a finding further supporting the congru-
ent validity of the SCID-D. Boon and Draijer (1993b) also studied the utility of the
Dutch version of the DES as a screening instrument to discriminate between
patients with and without dissociative disorder. They found that a cutoff score of
25 yielded a good-to-excellent sensitivity and specificity. In spite of these optimistic
results, Boon and Draijer (1993b) remarked that a clinical assessment or the use of a
standardized interview such as the SCID-D is required in order to diagnose the
presence or absence of a dissociative disorder.
Their study of the clinical phenomenomogy of the DID patients showed that
94.4% of these patients reported a history of childhood physical and/or sexual
abuse, and 80% met criteria for posttraumatic stress disorder. Investigating the
relationship between traumatic experiences and dissociative symptoms and dis-
orders, Boon and Draijer (1993b) found that the childhood traumatic experiences
were significantly more prevalent and severe in dissociative disorder patients than
in patients without a dissociative disorder. These findings confirmed research data
from other researchers in the Netherlands (Ensink, 1992): The severity of the
dissociative symptoms was closely related to the severity of childhood trauma,
especially sexual abuse, together with the age at which the trauma started. The
younger the age of the patient at which the abuse started, the more severe the
dissociative symptoms.
30 Boon and Draijer (1993b) concluded that the SCID-D is a reliable and valid
Johan Vanderlinden diagnostic instrument to make an assessment of dissociative symptoms and disso-
et aL ciative disorders. They remarked:
Although the clinical awareness of MPD is growing rapidly in the Netherlands,
this diagnostic category deserves more systematic attention to prevent MPD
patients from spending years in the mental health system, without appropriate
treatment. Screening for dissociative pathology should become an integral part
of routine diagnostic assessment. (Boon & Draijer, 1993b, pp. 269-270)
Recently; Nijenhuis, Spinhoven, Van Dyck, Van der Hart and Vanderlinden
(1995), starting from clinically observed (dissociative) state-dependent somatoform
phenomena, have developed the 20-item Somatoform Dissociation Questionnaire
(SDQ-20). Statistical analyses revealed that the items were strongly scalable on a
unidimensional scale and that the reliability was high. Further analyses derived five
items (SDQ-5) that yielded optimal sensitivity (94%; capacity of a test to select true
positive~; here dissociative disorder cases) and specificity (96%; capacity to select
true negatives; here cases with other DSM-IV diagnoses). Trying to explain some of
these somatoform dissociative phenomena and the widely divergent psycho-
physiological reactions that are displayed in various dissociative states, Nijenhuis
and Vanderlinden (1996) drew an analogy between animal defensive states and
human dissociative states. Animal defense is of radical different topography, de-
pending on the stage of imminence. For example, while in the postencounter (with
a predator) stage tone, freezing behavior is functional; in the circa-strike stage
development of analgesia and the recuperative post-strike stage return of pain
perception are adaptive responses. Interestingly, the SDQ-items for a substantial
part relate to inability to move, analgesia, anesthesia, and pain. According to
Nijenhuis (1994, 1995), exposure to severe threat constitutes a classical condition-
ing procedure, in which various stages of imminence (unconditioned stimuli)
automatically evoke particular evolutionary prepared defensive states (uncondi-
tioned responses), which will be associated with salient stimuli that signal or refer
to threat. These conditioned stimuli ("triggers") will posttraumatically re-elicit
representations of the traumatic event and, by consequence, the defensive states of
relevance. Nijenhuis (1994, 1995) further argues that posttraumatic confrontations
between states that are "loaded" with trauma and states that are not, also constitute
classical conditioning procedures. These internal exposures to threat are aversive,
and may cause a phobia for traumatic memories, and a phobia for dissociative
states that encompass these representations and associated defensive reactions.
Both phobias maintain dissociative responding; functional defenses thus may turn
into pathology.

TilE DISSOCIATION QUESTIONNAIRE STUDIES IN BELGIUM

Development of the Dlssocation Questionnaire

Encouraged by the interesting pioneering work of Bernstein and Putnam
(1986) and because a European dissociation questionnaire was lacking (socio-
cultural factors may play an important role in the experience of dissociative phe-
nomena), Vanderlinden and colleagues decided to construct their own dissociation 31
questionnaire (Dis-Q) (Vanderlinden, Van Dyck, Vertommen, & Vandereycken, European Studies of
1992b; Vanderlinden, VanDyck, Vandereycken, Vertommen, & Yerkes, 1993a) (see Dlssoclation
Appendix).

Method
The item pool has been based (1) on statements by patients with dissociative
disorders and (2) on a selection of items of the three existing dissociation question-
naires [DES, Perceptual Alteration Scale (PAS), and Questionnaire of Experiences of
Dissociation (QED)]. After translation into Dutch, the latter items were reformu-
lated and modified to make them more suitable to the sociocultural situation in
Belgium and the Netherlands. In this way a pool of 95 items was composed. These
items were submitted to five clinicians (both psychologists and psychiatrists) who
had experience in dealing with dissociative disorder, with the request to evaluate to
which extent each item reflected something about a dissociative experience. Based
on their responses, 26 items were eliminated and 69 items were retained.
Five different answer categories were chosen: the subjects had to circle one of
the five numbers, indicating to what extent that item or statement is applicable to
that particular subject (1 =not at all; 2 =a little bit; 3 =moderately; 4 =quite a bit;
5 = extremely). While using the DES questionnaire, it was learned that some
patients found it difficult to answer the items of the DES by making a slash on a
10Q-mm line to indicate the percentage of time they experienced this particular
experience. Therefore, it was decided to use another way of answering the items in
the DIS-Q. All DIS-Q scores are average scores and can vary between 1 and 5. The
DIS-Q also gathers data on the age, sex, educational level, and demographic status of
the subject involved and contains a small trauma list. Subjects are asked "if they
remember having experienced severely damaging or life-threatening experiences."
When this question is positively answered, subjects are asked to describe the kind
of trauma of which several possibilities are given: severe bodily injury, state of war,
sexual abuse by family and nonfamily members, serious emotional maltreatment by
parents, and so forth.

Factor Analysis of the DIS-Q

The DIS-Q was first administered to a representative sample of the population
(n = 374) (Vanderlinden, VanDyck, Vandereycken & Vertommen, 1991). A factor
analysis was performed on the scores of the total sample and four subscales were
detected, which together accounted for 77% of the common variance: (1) identity
confusion-fragmentation (referring to experiences of derealization and deper-
sonalization); (2) loss ofcontrol over behavior, thoughts, and emotions (referring to
experiences of losing control over behavior, thoughts, and emotions); (3) amnesia
(referring to experiences of memory lacunas); and (4) absorption (referring to
experiences of enhanced concentration, which are supposed to play an important
role in hypnosis). Since then, several other factor analytic studies have been carried
out on different subject samples: on a second representative subject sample from
the Dutch population (N = 378) and on a group of psychiatric patients with mixed
32 diagnoses (N = 261) (Vanderlinden, 1993; Vanderlinden et al., 1993a). After rotation,
Johan Vanderlinden again the four-factor solution turned out to most adequately represent the underly-
et a1. ing latent structure in the DIS-Q data of both samples. An iterative Gulliksen item
analysis was performed on the items with a Pearson r of more than .30, and not a
single item has been eliminated.

ReliabiUty and Validity Studies of the DIS-Q

The Cronbach's alpha coefficients showed that the DIS-Q has a good internal
consistency: .96 for the total scale and .94, .93, .88, and .67 for the four subscales.
Test-retest reliability was measured by giving the DIS-Q to a group of 50 subjects
randomly selected from the general population (25 adolescents and 25 adults) on
two occasions with an interval of 3 to 4 weeks. The DIS.Q total score test-retest
reliability coefficient is .94 (JJ < .0001) and, respectively, .92, .92, .93, and .75 for
the four subscales. These results show that the DIS-Q scores are stable over time.
Next, the DIS-Q was administered to different psychiatric patient samples (diag-
nosed following DSM-m-R criteria): dissociative disorders [DID (n = 30) and disso-
ciative disorder not otherwise specified (DDNOS) (n = 23)]; posttraumatic stress
disorder (n = 13); schizophrenics (n = 31); eating disorders (n = 98); obsessive-
compulsive disorders (n = 29); and borderline personality disorder (n = 17) (see
Table 1).
A one-way analysis of variance (ANOVA) on the scores of the different groups
showed highly significant differences between the groups for the total DIS-Q scores
(DF =7, 618; F =133,50;p < .0001) and subscale scores (JJ < .0001). To compare the
DIS-Q scores of the different psychiatric categories, the Bonferroni procedure for
multiple comparisons was done (alpha was set at p < .05): the results showed that
the DID subgroup gained a significantly higher score than all other psychiatric
categories. Pearson r correlations have been assessed between the DES and DIS-Q in
a sample of 100 psychiatric patients and the results strongly supported the con-

Table 1. Mean and SD of DIS-Q Scores among Normal Subjects and Several
Patient Groups
015-Q total 015-Q1• 015-Q2 015-Q3 OIS-Q4
N Mean SD Mean SD Mean SD Mean SD Mean SD

Normals 378 1.5 0.4 1.4 0.4 1.7 0.5 1.4 0.4 1.9 0.6
Obsessive- 29 2.0 0.5 2.0 0.8 2.1 0.5 1.5 0.4 2.4 0.7
compulsive
Schizophrenics 31 2.0 0.6 2.0 0.7 2.1 0.6 1.9 0.6 2.5 0.8
Eating disorders 98 2.2 0.5 2.4 0.6 2.4 0.6 1.6 0.5 2.7 0.7
PfSJ)b 13 2.7 0.6 2.8 0.9 3.0 0.7 2.3 0.4 2.4 0.4
BPD 32 2.8 0.6 2.8 0.8 3.1 0.6 2.3 0.7 2.8 0.6
DDNOS 23 2.9 0.6 3.0 0.8 3.1 0.7 2.5 0.8 2.7 0.9
DID 30 3.5 0.4 3.8 0.5 3.2 0.5 3.3 0.6 3.1 0.5
•DJS.Ql, identity confusion; DJS.Q2, loss of control; DJS.Q3, amnesia; Dls.Q4, absorption.
"PTSD, posttraumatic stress disorder; DDNOS, dissociative disorder not otherwise specified; BPD, borderline person-
ality disorder; DID, Dissociative Identity Disorder.
struct validity of both the DES and DIS-Q (r =.85 between the total DES and DIS-Q 33
scores). European Studies of
Recently the reliability and validity of the DIS-Q have also been studied in a Dlssoclation
North American setting (Sainton, Eliason, Mayran, and Ross, 1993). The DIS-Q and
DES were administered to subjects with a clinical diagnosis of DID (n = 87),
inpatients with a primary chemical dependency diagnosis (n = 26), and under-
graduate students (n = 83). Cronbach's alpha of the DIS-Q was above .90 in all three
subject groups. The Pearson correlation between DES and DIS-Q was .87 (p <
.0001). Even more important was the fact that the average DIS-Q scores of American
undergraduate students and DID patients closely resembled the average scores of
European students and DID patients: respectively, 1.79 (SD =0.58) versus 1.70 (SD =
0.50) for the students and 3.63 (SD =0.58) versus 3.5 (SD =0.4) for the DID patients
(see also Table 1). Sainton et al. (1993) concluded that no other area of psychiatry
has produced self-report measures with greater reliability and validity than the DES
and the DIS-Q.
The present findings show that the DIS-Q has (1) a clear factorial structure; (2)
a good-to-excellent internal consistency and test-retest reliablity; (3) differentiates
clearly between patients with dissociative disorder and other subjects; and ( 4) has
good construct validity. Moreover, recent data (Sainton et al., 1993) show that the
DIS-Q can be assumed to be a valid measure of dissociation also in North America.

Dissociative Experiences in the General Population

First Study in Belgium and the Netherlands
Subjects. In a first study, the DIS-Q was sent to 500 subjects in the Nether-
lands and to 300 Flemish subjects in Belgium (see also Vanderlinden et al., 1991). In
all, 374 questionnaires were collected (235 Dutch and 139 Flemish subjects),
showing an almost perfect male-female ratio: 119 (50.6%) men versus 116 (49.6%)
women in the Dutch sample and 69 (49.6%) men versus 70 (50.4%) women in the
Flemish sample. The sample was representative in terms of sex and educational
level, but not fully representative for the variables of marital status and age distri-
bution.
Results. First, the specific effect of several variables on the DIS-Q scores,
such as age, sex, demographic status, marital status, and nationality, was studied by
means of ANOVA. Whenever the ANOVA was significant, two-tailed t-tests of
Scheffe's were done. The average item result (mean± SD) for the total scale was 1.61
± 0.40. With regard to the total DIS-Q score, it was found that age is the only variable
having a significant effect on the scores (DF =1, F= 30.89,p < .0001). These results
confirmed Ross' findings (Ross & Ryan 1989; Ross, Joshi, & Currie, 1990, 1991a),
indicating that dissociative experiences decline with age. Significant differences
(p < .05) were found between subjects aged 10-20 years and subjects aged 40-50
and > 60 years. With regard to the DIS-Q subscale scores, it was found that only the
subscale loss of control significantly (p < .05) declined with age. The decline of
dissociative experiences with age in the general population seemed to be mainly
related to the scores on the subscale loss of control.
No differences were found between men and women for the total DIS-Q score
(1.66 ± 0.45 for men versus 1.60 ± 0.37 for women). Educational level, nationality,
and marital status had no significant effect on the DIS-Q scores.
34 Prevalence of Dissociative Symptoms. To study the prevalence of disso-
Joban vanderllnden ciative experiences in the general population, first a cutoff score for the total DIS-Q
et al. score was assessed: The scores of the normal sample (N =37 4) were compared with
the scores of a patient group with dissociative disorders (N = 53). When a cutoff
score of 2.5 was used, an excellent sensitivity (the ability to correctly identify true
positive cases or subjects with dissociative disorder) and specificity (ability to
correctly identify true negative cases or subjects without dissociative disorder) was
detected: sensitivity was 91% and specificity 97%. These data indicated that 11
subjects or 2.94% of the total sample reported serious dissociative experiences. In
this group, four subjects (l.o6% of the total sample) had DIS-Q scores as high as the
scores of patients with DID, suggesting that they, too, had a severe dissociative
disorder. Next, several characteristics of this group with scores above 2.5 on the
DIS-Q were analyzed (N = 11). With regard to the sex of these subjects, a surprising
finding was that the majority were men a men vs. 4 women) in both groups
(Flemish and Dutch sample). This finding is in contrast with some earlier data from
the literature on the prevalence of DID, indicating a male-female ratio of 1:9 (cf.
Ross, Norton, & Wozney, 1989). Six subjects were Flemish, five Dutch, seven
subjects were married, three single, and one divorced; the mean age was 34. The
subjects had very different educational levels.

Second Study in the Netherlands

Method. Within the framework of further standardization and validation, the
DIS-Q was sent to a second representative sample (N =1000) of the Dutch popula·
tion (Vanderlinden, VanDyck, Vandereycken & Vertommen, 1993c). Besides study·
ing the prevalence of dissociative experiences, this study was also aimed at explor·
ing the relationship between self-reported trauma experiences (reported on the
small trauma list of the DIS-Q) and dissociative symptoms of the subjects involved. It
was assumed that subjects reporting a history of sexual abuse [such as rape or
unwanted sexual experiences by nonfamily members and/or by relatives (incest)],
would indicate a higher prevalence of dissociative symptoms, as compared with all
other subjects. Hence, it was decided to compare three groups: subjects reporting
no history of abuse (nontrauma group), subjects reporting sexual abuse (major
trauma group), and all other trauma categories (minor trauma group).
Data analysis consisted of deriving descriptive statistics and mean plus stan-
dard deviation values for the several subscale scores of the DIS-Q. First, an ANOVA
was done to study the effect of the different variables on the DIS-Q scores. Next
t-tests were performed to compare the trauma versus the nontrauma group. To
evaluate the effects of the traumatic experience (minor vs. major trauma) on the
different variables of the four questionnaires, a general linear model (GLM) proce-
dure was carried out. When the GLM procedure turned out to be significant, the
Bonferroni procedure for multiple comparisons was done (alpha was set at
p < .05).
Subjects. This second group (N =1000), obtained through random sampling
from the central register of population of a Dutch city, was representative of the
Dutch population in terms of age, sex, demographic status, and educational level.
Three hundred seventy-eight subjects returned the questionnaire fully completed.
The proportion of men to women was 141 (37.3%) versus 237 (62.7%). The data
showed that this sample was representative of the Dutch population in terms of age 35
distribution and educational level. However, with regard to sex and demographic European Studies of
status, both women and married subjects were overpresented. Dissociation
Average Scores and Frequency Distribution of the DIS-Q. The average
item result for the total group was 1.50 ± 0.35 (range, 1 to 3.6); this result does not
differ significantly from the average result of the previous Dutch sample (1.55 ±
0.40; range, 1-3.73). The average subscale results and standard deviations were as
follows: (1) identity confusion-fragmentation: 1.35 ± 0.38 (range, 1-4.04); (2) loss
of control: 1.69 ± 0.47 (range, 1-3.83); (3) amnesia: 1.36 ± 0.31 (range, 1- 2.92); and
(4) absorption: 1.85 ± 0.62 (range, 1-4.33). These results confirmed the findings
from the first study: Dissociative experiences are relatively common experiences in
the general population. The subscales loss of control and absorption had the
highest variation (standard deviation) in the population, while the subscales iden-
tity disorder and amnesia had the lowest frequency, suggesting that these scales
probably measure the most pathological dissociative experiences. When studying
the effects of the different variables on the DIS-Q scores, the results roughly
confirmed the findings from the first study. Again, the ANOVA indicated that age
significantly influences the total DIS-Q result (DF = 5, F = 2.43, p < .035). Younger
respondents (10-20 and 21-30 years) show much higher scores on loss of control
than the older age groups (51-60 and> 60 years). Men and women showed no
significantly different scores on the total DIS-Q. However, there was a clear differ-
ence for the subscale loss of control: Women showed significantly higher scores
than men (p < .GD8), but these differences are chiefly encountered in the age group
20-30 years. In harmony with the findings of the first study, training level had no
influence at all on the DIS-Q resu~ts. The demographic status, on the other hand,
appeared to exert a minor influence on the results.
Prevalence of Dissociative Experiences. In order to get an indication of
the possible prevalence of dissociative experiences in the general population, the
same cutoff score as used in the first study was employed. If a cutoff score of 2.5
(total result on the DIS-Q) was used, eight subjects (2.1%) gained a DIS-Q score
higher than 2.5. Two subjects (0.52%) gained scores comparable to the scores of a
patient group with DID. These percentages were lower than the findings from the
first study, where 11 subjects (2.94%) obtained a result above the cutoff score and 4
subjects (1.06%) a score comparable to the group of patients with DID. Unlike the
first study, the majority of the high scores were females (7 women vs. 1 man).
Reckoning with the number of men and women in this sample, there was a
proportion of 2.9% women versus 0.7% men (a proportion of 4 to 1) with a DIS-Q
result above the 2.5 cutoff. As for the other characteristics of this subgroup, four
respondents were married, two divorced and two single. The average age was 33.75
years (SD = 12.26, range, 19-56years). By means of the trauma list of the DIS-Q, six
subjects of this group reported having experienced serious trauma in their life: loss
of a child (n =1), loss of a father (n =1), incest (n =1), sexual abuse by a nonfamily
member (n = 1), divorce (n = 1), war and emotional maltreatment (n = 1). Two
subjects mentioned no trauma at all.
Self-Reported Trauma in the General Population. About 25% of the
subjects (n = 93) reported on the trauma list ofthe DIS-Q of having experienced at
least one of eight different traumatic situations: (1) physical or bodily injury;
36 (2) state of war; (3) sexual abuse; (4) serious emotional neglect by parents; (5) death
Johan Vanderllrulen of a family member; (6) specific strain on the family (such as alcohol abuse by a
et aL family member, serious fights between the parents, psychiatric problem of a family
member); (7) divorce or separation of the subject involved; and (8) psychiatric
problem of the subject involved. About 20% of the subjects reported more than one
traumatic situation. A remarkable finding was the fact that men reported mostly two
trauma categories: severe bodily injury (9.9%) and state of war (9.2%), while
women reported various traumatic experiences: loss of a family member (often the
loss of a child) (6. 7%), state of war ( 4.6%), incest and sexual abuse by nonfamily
members (together, 5%), strain on the family ( 4.6%), and severe bodily injury
( 4.6%). By using x2 tests, only one significant difference between men and women
for the trauma category sexual abuse was found (p < .004). The results of the total
group showed that state of war (7.1%), severe bodily injury (6.6%), and loss of a
family member (5.6%) were most frequently reported. Remarkably enough, not one
subject of the sample reported physical abuse.
The Relationship between Trauma and Dissociative Experiences. By
using x2 tests, no significant differences were found between the trauma group (n =
93) and the nontrauma group (n = 285) with regard to the following characteristics:
sex, demographic status, and educational level. An ANOVA showed no difference
for age between the two groups. A comparison was made between the subscale
scores of the trauma group compared with the nontrauma group. Next, the three
groups (major trauma, minor trauma, and no trauma) were compared, using a GLM
procedure. The results clearly indicated that the trauma group gained significantly
higher DIS-Q scores for both total result (p < .0001) and the four subscales,
especially identity confusion (p < .0001) and absorption (p < .0002). Hence,
subjects who mentioned a trauma reported significantly more dissociative symp-
toms than subjects who mentioned no trauma.
When comparing the sexually abused group (n = 11) with the two other groups
[no trauma (n = 279) and minor trauma (n = 84)], the results strongly suggested that
sexual abuse provoked significantly more dissociative experiences than all other
trauma categories (see Table 2). Another remarkable finding was that the sexually

Table 2. Comparison of Subscale Scores of Nontrauma versus

Minor/Major Trauma
Nontrauma Minor trauma Major trauma
(N= 279) (N= 84) (N= 11)
F
variable Mean SD Mean SD Mean SD (df =2) P"
Dls.Q1" 1.30 .32 1.48 .48 1.83 .51 17.12 .ooot•
Dls.Q2 1.64 .44 1.77 .50 2.31 .57 12.73 .ooot•
Dls.Q3 1.34 .28 1.39 .35 1.73 .39 9.16 .ooot•
Dls.Q4 1.77 .58 2.08 .72 2.04 .66 8.84 .0001
Dls.Q total 1.45 .31 l.6o .43 1.96 .39 16.66 .0001•
"1>15-QI, identity confusion-fragmentation; Dls.Q2, loss of control; Dls.Q3, amnesia; Dls.Q4,
absorption.
.. , Significant aftet application of Bonferronl correction for multiple comparisons (JJ < .05).
abused subjects reported significantly (p < .0001) more amnesia experiences (DIS. 37
Q3) as compared to all other groups. European Studies of
Dissociation
Dissociative Experiences in Eating Disorders. After Janet's pioneering
studies of dissociation and eating disorders, interest in this subject disappeared for
more than half a century but has reemerged in recent decades (Torem, 1986;
Vanderlinden & Vandereycken, 1988, 1990). The presence of minor dissociative
"hysterical" mechanisms in bulimic patients was already reported by Russell in
1979. Demitrack, Pumam, Brewerton, Brandt, and Gold (1990) studied dissociative
experiences in 30 female eating-disorder patients, compared with 30 age-matched
normal female subjects, and found that the patients demonstrated significantly
higher levels of dissociative psychopathology than the control subjects.
The goal of the following studies was to explore the presence of trauma and
dissociative experiences in eating disorders. A first pilot study in a sample of 50
eating-disorder patients (Vanderlinden, Vandereycken, Van Dyck, & Delacroix,
1992a) showed a self-reported trauma rate of 16%, much lower than the rates
reported in the literature. Compared with a group of normal control subjects
(n =378), the eating-disorder patients had significantly higher scores on the Dl8-Q.
In an analysis of several subgroups of eating-disorder patients, those with bulimic
and atypical eating disorders appeared to report significantly higher scores on the
D18-Q and these higher scores were partly related to the presence of traumatic
experiences.
These interesting findings stimulated a more refined study of the relationship
between trauma and dissociation in a larger sample of eating-disorder patients. In
this second study (Vanderlinden, Vandereycken, VanDyck, & Vertommen, 1993b),
the different subgroups of eating disorders were better matched for age, sex,
duration of illness, demographic status, and educational level. The relationship
between specific traumatic experiences and particular dissociative phenomena
were studied in detail.
Method. To assess the presence of dissociative experiences, the D18-Q was
administered. Past traumatic experiences (incest, sexual and/or physical abuse,
serious parental rejection) were explored by means of a self-reporting question-
naire about past sexual experiences (Lange, 1990) and a clinical interview.
Subjects. The sample consisted of 98 patients (2 males, % females) who
were consecutively admitted to the inpatient Eating Disorders Unit of the University
Center in Kortenberg. In case of DSM-111-R anorexia nervosa, a distinction was made
between the restricting type, i.e., pure tasters or abstainers (n = 34; 34.7%), and the
mixed type, i.e., combined with bingeing and/or purging (n =24; 24.5%). Normal-
weight bulimia nervosa was diagnosed in 28.6% (n = 28), while 12.2% (n = 12)
showed an atypical eating disorder (lacking one or more criteria of the previous
diagnoses). The mean age of this patient sample was 24.3 (SD = 6.68; range, 14-42
years). The duration of illness averaged 6.38 (SD =5.25; range, 0.5-11 years) with an
average age at onset of17.7 (SD = 4.3; range, 11-33 years). The four eating disorder
subgroups did not differ, except for the typical eating pathology.
Dissociative Experiences in Eating Disorders Compared to Normals.
An ANOVA and Scheffe's t-test were used to compare the D18-Q scores of eating-
disorder patients and age-matched female controls (n =66). The results of this study
38 confirmed the findings of a former study (Vanderlinden et al., 1992a) that showed
Johan vanderUnden that eating-disorder patients (especially bulimics and atypical eating disorders)
et aL report significantly higher levels of dissociative experiences than normal control
subjects. About 12% of the patient sample reported DIS-Q scores as high as the
scores of patients with dissociative disorders. The results supported the assumed
relationship between overwhelming trauma and a dissociative reaction, i.e., the
more serious the trauma, the higher the DIS-Q scores. Most interesting are the high
scores on the amnesia subscale in the case of incest and sexual abuse (see Table 3).
This finding seems to endorse Janet's conceptualization of dissociation, which
postulates that amnesia (the escape from conscious awareness of the idee fixe
relating to the trauma) is the most specific clinical characteristic in trauma-induced
dissociation (see also Chu & Dill, 1990; Van der K.olk & Van der Hart, 1991).
An important subgroup of the eating-disorder patients, about 12%, reported
pathological dissociative experiences. The great majority of these patients had
experienced a serious trauma during their life. Thus it may be concluded that in a
considerable subgroup of eating disorders (especially bulimia nervosa and atypical
eating disorder), trauma-induced dissociative experiences may play an important
role in the development of the eating disorder. Hence, those patients with both a
history of trauma and high scores on the DIS.Q should also be screened for the
diagnosis of dissociative disorder.
A Follow-up Study on Dissociative Symptoms in Eating Disorders.
Recently, a follow-up study has been carried out, studying the presence of dissocia-
tive symptoms in 62 eating disordered patients upon admission to a specialized
unit, six months after admission, and one year after admission (Vanderlinden,
Vandereyken, and Probst, 1995). Scores in the DIS-Q decreased in restricting an-
orectics and bulimics, but remained virtually unchanged for binging and purging
anorectics. Patients with a history of abuse had a worse outcome (compared to the
non-abused group), suggesting that abuse definitely must be considered as a risk
factor for the outcome in eating disorders.

Table 3- DIS-Q Scores According to Different Forms of Trauma in

Eating Disorders
Total DIS-Q1• DIS-Q2 DIS-Q3 DIS-Q4
N Mean SD Mean SD Mean SD Mean SD Mean SD

Nontrauma 71 2.2 0.5 2.3 0.7 2.3 0.6 1.5 0.4 2.6 0.7
Total trauma 27 2.4* 0.6 2.5 0.7 2.6 0.6 1.9** 0.6 2.8 0.8
group
Incest 8 2.5* 0.6 2.6 0.8 2.7 0.5 2.t••• 0.9 2.9 0.9
Sexual abuse• 12 2.5* 0.6 2.7 0.8 2.7* 0.6 1.9** 0.5 2.8 0.8
Physical abuse 3 2.1 0.3 2.0 0.4 2.5 0.4 1.7 0.3 2.2 0.5
Neglect 8 2.1 0.5 2.2 0.7 2.3 0.6 1.8 0.5 2.4 0.6
Loss of family 5 2.3 0.4 2.3 0.6 2.5 0.2 1.9* 0.6 2.4 0.6
member
•DJS.Ql, identity confusion; Dls-Q2, loss of control; DJS.Q3, amnesia; Dls-Q4, absorption. • p < .05; "p < .005;
••• p < .002.
bJiy other than family members.
STUDIES IN HUNGARY 39
European Studies of
Recently, the DIS-Q has been translated into the Hungarian language by Katalin Dissociation
Varga and Eva Banyai, two psychologists and researchers at the Eotvos Lorand
University in Budapest. (This research was made possible due to the financial
support of the grant OTKA [no. 284 0313, Eva Banyai and Katalin Varga]). The goal
was to replicate the DIS-Q studies carried out in the general population of Belgium
and the Netherlands in a Hungarian population sample. The results could give more
insight into possible sociocultural factors that might influence the DIS-Q scores.
Hungary is a former Communist country, currently struggling with a major eco-
nomic crisis and searching for a new identity. The end of the Communist regime
first resulted in a euphoric atmosphere ("finally we are free"), but very soon
changed to general frustration, confusion, and an important identity crisis for the
population. Taking into account these considerations, it was assumed that higher
DIS-Q scores would be obtained in the Hungarian population, compared to Belgium
and the Netherlands.

Method

The DI5-Q was administered to 311 subjects of the general population in

Hungary. Psychology students were asked to get data of the DIS-Q of about 300
subjects from the general population, according to the Hungarian age and sex
distribution. The students could give the DIS-Q questionnaire to anyone who
wanted to participate in the study. The only restriction was that the subject "was
not under hospital care currently or in the past 5 years." Hence, most subjects came
from the psychology students' families and friends. No money or other reward was
given to the subjects. Some preliminary data of this study are reported below.

ResuUs
Subjects. In all, 456 DIS-Q questionnaires were collected. Since the distribu-
tion of age of this sample was not fully representative for the Hungarian population,
a representative sample was chosen. This way, 311 subjects were selected: The
sample was representative for the Hungarian population for the variables of age, sex
(166 females and 145 males), and education.

Mean Scores and Frequency Distribution. Compared to the DI5-Q scores

of the second study in the Netherlands, the Hungarian sample gained significantly
higher DIS-Q scores on the DIS-Q total score (jJ < .0001) and all subscales (see Table
4). Several findings of the Dutch and Belgium DI5-Q studies were confirmed: The
subscales loss of control and absorption had the highest variation (standard devia-
tion) in the Hungarian population, while the subscales identity confusion and
amnesia had the lowest frequency.
Although the differences may not seem to be impressive (1.5 vs. 1.7 for the total
DIS-Q score), they become much more important with regard to the frequency
distribution of the DIS-Q scores. In Flemish and Dutch studies, 3% and 2% of the
subjects, respectively, gained DIS-Q scores above the 2.5 cutoff score. In Hungary,
40 Table 4. Mean and SD DIS·Q Scores of Netherlands versus Hungary
Johan VanderUnden DIS-Q" total Dls-Ql Dls-Q2 Dls-Q3 Dls-Q4
etal.
N Mean SD Mean SD Mean SD Mean SD Mean SD

Netherlands 378 1.5' 0.5 1.5" 0.5 1.7' 0.5 1.4' 0.4 1.9' 0.6
Hungary 311 1.7 0.5 1.6 0.5 1.9 0.7 1.6 0.5 2.3 0.8
"Dls.Ql, identity confusion; DIS-Q2, loss of control; Dls.Q3, amnesia; Dls.Q, absorption. • p < .0001; • p < .004.

the frequency distribution shows that 10.6% of this sample scores above the cutoff
score and reports severe dissociative symptoms; 2.6% scored as high as DID pa-
tients. This result is much higher compared to the previous studies, where 1% and
0.5%, respectively, gained scores as high as DID patients. These data support the
assumption of higher levels of dissociative symptoms in the Hungarian population.

Effect of the Different Variables on the DIS-Q Scores. By means of

ANOVA, the effects of the variables of sex and age on the DIS-Q scores were studied.
Whenever the ANOVA was significant, the Bonferroni procedure for multiple com-
parisons was done (alpha was set at p < .05). Again, the results showed that age
was the only variable significantly influencing the DIS-Q total score (DF = 5, 310; F =
26.22; p < .0001). Younger respondents (age 10-20 years) scored significantly
higher on the DIS-Q total scores (mean = 2.1; p < .05) and on subscales identity
confusion (mean= 2.0;p < .05) and loss of control (mean= 2.5;p < .05) compared
to all the other age categories. These findings correspond with the data of all
previous population studies on the prevalence of dissociative experiences: These
experiences are more frequently present in adolescents and young adults, and they
decline with age (Ross, 1991).
When comparing the scores of the male and female subjects, no significant
differences were found. These results confirm the data from our previous studies
(Vanderlinden et at., 1991, 1993c).

CONCLUDING REMARKS

The state of the art in Europe with regard to diagnosis, treatment, and study
of the dissociative disorders still leaves much to be desired. Important develop-
ments are nevertheless taking place, in particular, in the Netherlands and Belgium.
There also are signs that in countries such as Germany, the United Kingdom,
Norway, Italy, Hungary, and Spain, promising developments in the clinical field are
underway. There is an increasing number of studies on the prevalence of dissocia-
tive experiences being done, both in the general population and in psychiatric
patient samples using the DES or the DIS-Q. Apart from the Dutch validation study
of the SCID-D, there are currently studies being carried out on the prevalence of
dissociative disorders in different populations using the SCID-D and the DDIS. A
number of related studies are planned, such as the research being done by Nijenhuis
and collegues in the Netherlands and Belgium on the development of a new self-
reporting questionnaire to assess somatic and somatoform aspects of dissociation:
the Somatoform Dissociation Questionnaire. As exemplified by the DIS-Q study in 41
Hungary, there is a growing tendency for researchers from different European European Studies of
countries to collaborate on common projects. Perhaps the time has come for North Dissociation
American and European researchers to join ranks in conducting intercontinental
studies on dissociation and the dissociative disorders.

Appendix 1: DISSOCIATION QUESTIONNAIRE (DIS-Q)

This questionnaire consists of two parts. The first part contains a few general
questions about your background. In the second part you are asked to indicate to
what extent the following experiences apply to you. The experiences mentioned in
the questionnaire may occur when people are under the influence of alcohol, drugs
or medicines. It is intended to answer this questionnaire regarding your condition
without the use of any such means. You are asked to react to the statements by
circling the figure that applies to you. Any answer is good, so long as it reflects your
own view. Please react to all (of the) statements.

Example: To what extent does the following statement apply to you?

I find it hard to make up my mind. 1 2 3 4 5

By circling one of the figures, you can indicate whether that statement is more or
less applicable to you. If the statement "Moderately;' as in the above-mentioned
example, is applicable to you, you will circle number 3. Against each statement, you
will put a figure that is most applicable to you.

1 = This is not at all applicable.

2 = This a little bit applicable.
3 = This is moderately applicable.
4 = This is quite a bit applicable.
5 = This is extremely applicable.
Part 1
Name: _________________________

Date: -----------------------

Will you please fill in and cross where appropriate?

Your age: years

Your sex: o Male
D Female

Your marital status: D Single

D Married
D Living together
42 o Divorced
Johan Vanderlinden o Widower/Widow
etal.
Your training: o Elementary education
o First-grade secondary: o General educational
o Technical
o Vocational
o Second-grade secondary: o General educational
o Technical
o Vocational
D Higher nonuniversity
o University training

Please cross the training that corresponds most to your own training.

Do you remember having experienced severely damaging, life-threatening or trau-

matic events?
DNo
o Yes, i.e. (several answers being possible):
o Severe bodily injury
D Physical abuse
o State of war
o Sexual abuse by family members
o Sexual abuse by others (non-family members)
o Emotional maltreatment
o Otherwise: namely:

Part2
1 =Not at all 2 = A little bit 3 = Moderately 4 = Quite a bit 5 = Extremely

1. At times I have the feeling that I am dreaming. 1 2 3 4 5

2. I regularly have the feeling that everything is unreal. 1 2 3 4 5
3. At times it appears that I have lost contact with my 2 3 4 5
body.
4. I gorge myself with food without thinking about it. 1 2 3 4 5
5. While driving and/or bicycling, I suddenly realize that I 1 2 3 4 5
cannot remember what happened on the way.
6. I can, without reason, without wanting to, burst out 2 3 4 5
laughing or crying.
7. It happens that I have the feeling that I am, somebody 2 3 4 5
else.
 8. It happens that I am listening to someone and suddenly 2 3 4 5 43
realize that I have not heard part or the whole of the European Studies of
story. Dissociation
9. When I am tired, it seems as if a strange power from 2 3 4 5
outside takes possession of me and decides for me
what to do.
10. I get into situations in which I do not want to be. 2 3 4 5
11. At times I feel a great distance between myself and the 1 2 3 4 5
things I think and do.
12. At times I wonder who I am exactly. 1 2 3 4 5
13. It happens that I find new articles among my things 2 3 4 5
without being able to remember having ever purchased
these.
14. I regularly feel an urge to eat something, even when I 1 2 3 4 5
am not hungry.
15. It happens that I get angry without wanting to be at all. 2 3 4 5
16. It happens that I am determined to do something, but 2 3 4 5
my body acts quite differently against my own will.
17. It happens that I feel confused. 2 3 4 5
18. At moments I cannot remember where I was the day 2 3 4 5
(or days) before.
19. It happens that I am told that I act as if friends or fam- 2 3 4 5
ily members were strangers to me.
20. In particular situations I experience myself as a split 1 2 3 4 5
personality.
21. It happens that I cannot remember anything about cer- 2 3 4 5
tain important events in my life, such as my final exam-
inations or wedding day.
22. It happens that I am about to say something, but then 2 3 4 5
something quite different crosses my lips.
23. There can be a sudden, complete change in my mood. 2 3 4 5
24. It happens that I do something without thinking 1 2 3 4 5
about it.
25. I immediately forget what other people tell me. 2 3 4 5
26. It happens that I am doing something and that I am 2 3 4 5
suddenly struck by a blackout.
27. It occurs that I look at myself in the mirror without 2 3 4 5
recognizing myself.
28. It happens that I get the feeling that my body under- 2 3 4 5
goes an alteration.
29. It happens that I have the feeling that other people, 2 3 4 5
other things and the world surrounding me, are not
real.
30. I have the feeling that my body is not (really) mine. 2 3 4 5
31. When I watch television, I do not notice anything 2 3 4 5
about what goes on around me.
44 32. It happens that entire blocks of time drop out and that 1 2 3 4 5
Johan Vanderlinden I cannot remember what I did then.
et al. 33. I can remember so vividly something that happened 1 2 3 4 5
formerly, that I have the feeling that I am reliving it.
34. It happens that it seems as if someone else inside me 2 3 4 5
decides what I do.
35. Some ·imes I discover that I have done something with- 2 3 4 5
out remembering anything about it.
36. I wonder how I can prevent myself from doing certain 1 2 3 4 5
things.
37. Sometimes I suddenly notice that I find myself in a 2 3 4 5
place that is unknown to me, without knowing how I
got there.
38. It happens that I am not sure whether certain memo- 2 3 4 5
ries have really taken place, or if I merely dreamed
about them.
39. Sometimes I find myself in a well-known place that ap- 2 3 4 5
pears strange and unknown to me.
40. I have the feeling that I do certain things without 2 3 4 5
knowing why.
41. Sometimes I think or do something against my liking in 1 2 3 4 5
a way that does not suit me at all.
42. I notice that I watch myself closely in everything I do. 1 2 3 4 5
43. I can enclose myself in fantasies or daydreaming so 2 3 4 5
much that it seems to be really happening.
44. It happens that I am staring aimlessly, without thinking 2 3 4 5
about anything.
45. I often think about nothing. 1 2 3 4 5
46. I find it very hard to resist bad habits. 1 2 3 4 5
47. I sometimes forget where I have put something. 2 3 4 5
48. When eating, I do so without thinking about it. 2 3 4 5
49. It happens that I catch myself day-dreaming. 2 3 4 5
50. I wish I had more control of myself. 2 3 4 5
51. When I walk, I am aware of each step I make. 2 3 4 5
52. In particular situations, I notice that I am able to do 1 2 3 4 5
certain things with the greatest ease, that I find very
hard to do in others (e.g. sports, work, social
contacts).
53. When eating, I am aware of every bite I take. 2 3 4 5
54. I lose every notion of time. 1 2 3 4 5
55. It happens that I cannot remember whether I have re- 2 3 4 5
ally done something or if I merely planned it.
56. It happens that I want to do two things at the same 2 3 4 5
time and that I notice that I am arguing with myself the
pros. and cons.
57. It happens that I have the feeling that my mind is 2 3 4 5
split up.
58. It happens that I find notes, drawings or annotations of 1 2 3 4 5 45
my own, without remembering having ever made these. European Studies of
59. I have the feeling that I am made up of two (or more) 1 2 3 4 5 Dissociation
persons.
60. I often do something without thinking about it. 1 2 3 4 5
61. It happens that I hear voices in my head telling me 1 2 3 4 5
what I am to do or making comment on what I am do-
ing.
62. I see myself differently from the way other people see 1 2 3 4 5
me.
63. It happens that I feel I am looking at the world through 1 2 3 4 5
a haze, so that the people and things surrounding me
appear remote or vague.

Appendix D: DIS-Q Scoring Form

Name=---------------------------------------------------
Born: ____________________________________________________

DMe:----------------------------------------------------

DIS-Ql DIS-Q2 DIS-Q3 DIS-Q4

Identity -confusion
fragmentation Loss of control Amnesia Absorption
Nr Score Nr Score Nr Score Nr Score
2 1 13 33
3 4 18 42
7 5 19 51
9 6 21 52
10 8 25 53
11 14 26 56
12 15 31
16 17 32
20 23 35
22 24 37
27 38 45
28 43 47
29 44 55
30 46 58
34 48
36 49
39 54
40 60

(continued)
46 Appendix ll: DIS-Q Scoring Form (Continued)
Johan Vanderlinden
et al. DIS-Ql DIS-Q2 DIS-Q3 DIS-Q4
Identity- confusion
fragmentation Loss of control Amnesia Absorption
Nr Score Nr Score Nr Score Nr Score
41
50
57
59
61
62
63
Sum= Sum= Sum= Sum=
Sum: 25 = Sum: 18 = Sum: 14 = Sum: 6 =
TOTAL DIS-Q score =
TOTAL SUM: 63 =

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3
Dissociation in
Normal Populations
William ]. Ray

INTRODUCTION

Historically, dissociation was an important clinical and theoretical topic at the

beginning of the 1900s. The term psychological dissociation (desagn!gations psy-
chologiques) was developed by Pierre Janet (Janet, 1889), and his work has been
discussed by a number of sources (see Ellenberger, 1970; Haule, 1986; Quen, 1986;
Sjovall, 1967, for historical overviews). Dissociation for Janet was the resultant of
stress, with some individuals being seen as more susceptible to dissociation than
others. Janet and other nineteenth-century investigators studied unusual cases of
psychogenic memory disorder, dramatic changes in personality, discontinuities in
consciousness and awareness, and sensorimotor disturbances that were attributed
to the basic mechanism of dissociation (Nemiah, 1985, 1991). However, interest
increasingly waned throughout subsequent decades. Historically, this decline can
be attributed to both a rise of behaviorism in academic circles and the strength of
psychoanalysis in clinical practice. Theoretically, the works of Janet, Jung, and
others concerning dissociation were largely ignored in favor of Freud's rival hypoth-
esis of repression (Ellenberger, 1970; Frey-Rohn, 1974; Nemiah, 1985, 1991). How-
ever, we have recently seen a shift in perspective. With renewed interest in multiple
personality disorder (MPD) (Putnam, 1989; Ross, 1989) and posttraumatic stress
disorder (PTSD) in the 1980s, dissociation again has become an important theoreti-
cal and clinical consideration.

William]. Ray • Department of Psychology, Pennsylvania State University, University Park, Pennsyl-
vania 16802.
Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and WiUiam]. Ray. Plenum Press, New York, 1996. 51
52 likewise, the scientific study of dissociation is also regaining a place of impor-
Willlam J. Ray tance, both for the role played by dissociation processes in psychopathology, as
well as its potential value in understanding normal states of cognitive-emotional-
motoric processing and the relationship with underlying brain states. In terms of
recent conceptualizations of the construct itself, dissociation has been seen clini-
cally and theoretically to involve alternations in consciousness that appear to
involve a variety of individual memory processes (cf. Kihlstrom et al., 1994). These
processes or the lack thereof in tum manifest themselves in a variety of ways. Some
of these include: (1) depersonalization and derealization in the sense of not experi-
encing aspects of one's self or environment as real; (2) amnesia of either a short- or
long-term nature; (3) absorption such as the ability to be lost in the task at hand
whether watching a movie, reading a book, or driving down the highway; ( 4) the
existence of subpersonalities that may be experienced as separate; and (5) various
forms of both trance experiences and nonnormal processing and experience
within everyday life. Many of these states can occur in everyone's daily life as
manifested by forgetfulness, absentmindedness, or absorption into books or films.
Other dissociative processes may be more rare and found only in psychopathologi-
cal states. Such extreme dissociative processes as seen in fugue states, extreme
depersonalization, or dissociative identity disorders clearly represent an important
area of study as illustrated by the majority of chapters within this volume. However,
a number of theoretical questions remain to be answered in terms of the relation-
ship between normal and pathological states of dissociation as well as the manner in
which each is developed (see Chapter 4 for a discussion of dissociation considered
within normal developmental processes and Chapter 6 for a discussion of children
who develop disorganized modes of relating).

INDIVIDUAL DIFFERENCES

Conceptually, individual differences in dissociation have been discussed as

lying on a continuum, although this idea has not been thoroughly tested. Bernstein
and Putnam (1986) discuss the concept of such a continuum which they date to at
least the turn ofthe century with the work ofJanet, Prince, and James. The standard
continuum is conceptualized as ranging from the normal dissociative processes of
everyday life to the inclusion of major psychopathological processes (e.g., multiple
personality disorder and fugue states). From this perspective, one would assume
that dissociative tendencies (e.g., absentmindedness, "spacing out," etc.) seen in
the normal population lie at the basis of the more pathological forms seen in patient
populations. However, until recently there was little empirical research to help us
understand dissociative experiences as seen in normal populations.
An important research aspect of the study of dissociation has been the develop-
ment of objective instruments for the identification of dissociative processes. Four
self-report scales have been developed independently to identify the prevalence of
dissociative processes. These are the Dissociative Experiences Scale (DES), the
Perceptual Alteration Scale (PAS), the Questionnaire of Experiences of Dissociation
(QED), and the Dissociation Questionnaire (DIS-Q) (Bernstein & Putnam, 1986;
Sanders, 1986; Riley, 1988; Vanderlinden, Van Dyke, Vandereycken, & Vertommen,
1991, respectively). The DIS-Q was developed originally for use in Europe and is 53
discussed in Chapter 2. The DES, with 28 items, has been most extensively devel- Dissociation in
oped with abnormal populations (Bernstein & Putnam, 1986; Ross, Heber, Norton, Normal Populations
& Anderson, 1989). The PAS, with 60 items, was developed as a scale of altered
perceptual experiences, especially as related to dissociation and binge eating
(Sanders, 1986). The QED, with 26 items, was developed based on the responses of
over 1700 subjects (mainly undergraduates) with a true-false response format
(Riley, 1988). In terms of brief assessment devices with psychometric properties
based on large-scale samples, the DES and QED offer the best available scales of
dissociation at this time. These two scales describe experiences ranging from
normal dissociation (e.g., absorption while watching a movie or loss of awareness
while driving) to those of a more psychopathological nature (e.g., amnesia for
significant aspects of one's life).
Although a number of theoretical factors have been assumed to be compre-
hended within the domain of dissociation, there have been limited attempts to
describe these empirically. For example, the BASK model of dissociation (Braun,
1988) posits discontinuity of behavior, affect, sensation, and knowledge, one or
more of which may be temporally disconnected from the main stream of conscious-
ness, whereas the American Psychiatric Association (1987, 1994) identifies identity,
memory, and consciousness as the domains of disunity. The inclusion by Sanders
(1986) of somatic and behavioral control aspects of dissociative process is more
consistent with the theory and clinical observations of the early 1900s than with
current diagnostic distinctions. Our current taxonomy may or may not reflect
natural structural divisions of dissociated experience. If little is understood about
the structure of pathological dissociation, less is known about the structure of
normal dissociative processes and the extent to which structural elements covary in
different populations. It is unknown whether dissociative processes differ in struc-
ture, extent, or both, between the disordered and the normal population and
whether both are reflected on an identical association-dissociation continuum
(Spiegel, 1963). It is the purpose of the present chapter to focus on dissociative
processes as found within normal populations from a variety of perspectives.

BROAD-BASED NORMAL SAMPLES

One of the first studies of dissociative experiences within the general popula-
tion was conducted by Ross, Joshi, and Currie (1990) in the city of Winnipeg,
Canada. From an initial population of 650,000 people, these authors used a three-
part stratified random sampling technique to select 1055 individuals over the age of
18. The final sample included 41.7% males and 58.3% females with a mean age of
early 40s for both males and females. During the interview demographic informa-
tion was collected and the DES was administered. The DES requests the person to
rate on a 0% ("this never happens to me") to 100% ("this always happens to me")
scale the amount of time that a particular experience has occurred. Traditional
scoring requires that the items be summed and divided by 28. Thus, a score of 30
would suggest that a particular person acknowledges that the average of these 28
experiences happens to them 30% of the time. Previous research has suggested
54 scores in the 20 to 30 range as a cutoff for psychopathological responding (Ross
William]. Ray et al., 1989, 1990; Carlson & Putnam, 1993). Using the DES, Ross and co-workers
found a mean score of 10.8 (±10.2) for the Wrnnipeg sample. Further analysis
showed 5% of the Winnipeg sample scored above 30, 8.4% above 25, and 12.8%
above 20 on the DES, suggesting that dissociative experiences are very common
with at least 25% of this population. Overall, Ross and co-workers concluded that
dissociative experiences are: (1) common in the general population; (2) do not
differ in terms of gender of respondent; and (3) are reported less by older respon-
dents.
Whether the dissociative experiences reported by the Winnipeg sample are
indicative of psychopathology is of course a very different question; but these
results do suggest future directions for research. For example, in the Winnipeg
study a negative correlation ( -0.23) was found between DES score and age. Other
research by Ryan and Ross reported that responding to dissociation items declines
between early adolescence and college (Ryan, 1988; Ryan & Ross, 1988; described
in Ross, 1989), which brings forth the possibility that dissociative experiences are in
some manner a life span developmental process in that their occurrence in normal
populations decreases with age. However, there exists little research examining the
aging process in more psychopathological populations. A related area of future
research involves the potential differential pattern of responding between normal
and psychopathological groups. That is to say, even with similar scores, psycho-
pathological groups may respond to very different items on the DES than the
normal population. For example, 29% of the Winnipeg subjects reported that they
"... find that sometimes they are listening to someone talk and they suddenly realize
that they did not hear part or all of what was said," whereas less than 2% of the
subjects reported that they " ... have the experience of looking in a mirror and not
recognizing themselves." We begin such exploration in Table 1, which we will
discuss in more detail later in the chapter. One approach is to examine the factor
structure of the DES which we now turn to for the Winnipeg population.
Ross, Joshi, and Currie (1991a), using principal components analysis, identified
three dimensions based on the data from the Winnipeg study. The first factor was an
absorption-imaginative involvement factor that accounted for 47.1% of the vari-
ance. This factor included such items as "missing part of a conservation" and
"absorption in television." The second factor reflected activities of dissociated states
such as "finding oneself in a place but unaware how one got there" or "finding
oneself dressed in clothes one can't remember putting on." The third factor was a
depersonalization-derealization factor that included items such as "other people
and objects do not seem real" and "feeling as though one's body is not one's own."
In two studies limited to college-age populations Ray and his colleagues (Ray,
June, Turaj, & Lundy, 1992; Ray & Faith, 1995) examined the frequency of dissocia-
tive experiences using both the DES and QED. In the initial study with 264 subjects,
a seven-factor solution was produced for the DES and a six-factor solution for the
QED. The follow-up study with 1090 subjects produced a four-factor solution for the
DES that basically matched the first original four factors in the earlier study. The first
five factors on the QED were the same in both samples with slight variations
involving individual items. Overall, the DES produced four factors that, in order of
variance explained, were: (1) absorption-derealization; (2) depersonalization;
(3) segment amnesia; and ( 4) in situ amnesia. The QED produced five factors that 55
were: (1) depersonalization; (2) process amnesia; (3) fantasy-daydream; (4) dissoci- Dissociation in
ated body behavior; and (5) trance. The factor structure of the two scales are shown Normal Populations
in Tables 1 and 2.
Sanders and Green (1994) gave the DES to 566 female and 294 male college
students. These authors found three basic factors that they referred to as: (1) imagin-
ative involvement; (2) depersonalization-derealization; and (3) amnesia. These
factors are similar to both those found on the DES by both Ross's and Ray's
laboratories and not unlike those found in psychiatric populations (cited in Sanders
& Green, 1994; compare Carlson & Putnam, 1993).
With factor analytic techniques it is possible to specify the number of factors.
Since Ross and co-workers had reported a three-factor solution, the Ray and Faith
data were reanalyzed to fit such a solution. Table 3 shows the factor solutions for
the DES found in this reanalysis and compares them with those of Ross et al.

Table 1. DES Factors Based on Data from Ray and

Faith (1995)

Item number Item

Factor I Absorption- derealization

17 Absorbed in TV/movie
23 Amazing ease in certain situations
20 Stare into space
18 Absorbed in fantasy
14 Remember events as if real
15 Not remember if something really happened
22 Act differently as if two different people
19 Able to ignore pain
21 Talk out loud when alone
24 Not know if actually did event
16 Familiar place seems strange
Factor 2 Depersonalization
12 Other people not real
13 One's body does not bdong
II Not recognize self in mirror
28 Look at world through fog
7 Standing next to themself
27 Hear voices in head
Factor 3 Segment amnesia
5 Finding things did not buy
26 Find writing/drawing did not do
6 Approached by people do not know
10 Accused of lying
25 Do things do not remember doing
8 Do not recognize friends
9 No memory for important events
Factor 4 In situ amnesia
I Space out driving
3 Find self in place don't remember
4 Dressed in clothes don't remember
2 Space out while listening
56 Table 2. QED Factors Based on Data from Ray
William J. Ray
and Faith (1995)
Item numbers Item

Factor 1 Depersonalization
2 Feel like someone else
4 Wonder who I really am
1 Things are not real
5 Stranger in mirror
6 Removed from thoughts and actions
7 Confused and in a daze
Factor 2 Process amnesia
18 Mind goes blank
8 Couldn't remember where I had been
3 Mind blocks and goes empty
9 Words don't come out right
17 Forget where I put things
Factor 3 Fantasy- daydream
21 I daydream
15 Daydreamed in school as child
19 Rich fantasy life
11 Off in world of my own
20 Stare off into space
Factor 4 Dissociated body behavior
13 Someone inside directing actions
12 Body undergoing transformation
14 Umbs move on their own
10 Come to without knowing how I got there
16 Problems understanding speech
Factor 5 Trance
25 Gone into trance
23 Able to hypnotize myself
22 Soul leaves my body
24 Had imaginary companions
26 Periods of deja vu

(1991a). An examination of this table portrays a number of interesting relationships

in the two samples. First, the initial absorption -derealization factor matches almost
item for item for the DES in both samples. likewise, a similar depersonalization
factor is found in both samples. Whereas Ross and co-workers found a single
amnesia factor, Ray and Faith reported that these items differentiated into two
factors in this college-age population. The first amnesia factor (Factor liD reflects
particular past events (e.g., buying particular items) for which the person is not
aware that the events have occurred, whereas the second amnesia factor (Factor IV)
reflects a coming to awareness that the person has not been conscious of the
current situation (e.g., realizing that one has been spaced out while driving). As
expected, when a three-factor solution is required, a single amnesia factor comes
forth that includes all of the items found by Ross and co-workers to compose this
factor. Thus, the factors found in both the Winnipeg and the college-age study on
the DES show a high degree of similarity. It should also be noted that there were
Table 3. Means of Each DES Item and Percent of Subjects Scoring above Either 57
3 (Ray data) or 30 (Ross data)" Dlssodation in
Ray 0-9 > 3 Ross 0-100 >30 Normal Populations
Item
numbers Item Mean Percent Mean Percent

Factor 1 Absorption -derealization

17 Absorbed in TV/movie 4.37 59.4 20.2 24.2 1
23 Amazing ease in. certain situations 3.99 56.6 22.8 22.4 1
20 Stare into space 4.12 65.8 15.3 25.7 1
18 Absorbed in fantasy 3.49 44.8 10.0 10.91
14 Remember events as if real 3.65 49.3 17.4 19.2 1
15 Not remember if something really happened 4.14 56.1 12.6 12.5 1
22 Act differently as if two different people 3.17 40.5 11.5 11.81
19 Able to ignore pain 3.48 46.4 25.6 33.41
21 'Th1k out loud when alone 3.54 45.2 15.2 17.7 1
24 Not know if actually did event 3.67 49.2 21.2 24.7 1
16 Familiar place seems strange 2.52 30.2 (8.6 8.2)0
2 Space out while listening 5.08 77.4 24.9 29.0 1
Factor 2 Amnesia
5 Finding things did not buy 1.03 8.3 4.5 4.1 2
26 Find writing/drawing did not do 1.59 17.0 (6.7 6.3)0
25 Do things do not remember doing 2.37 27.2 (13.5 14.3)1
4 Dressed in clothes don't remember 0.53 1.5 1.9 1.42
3 Find self in place don't remember 1.18 10.8 2.8 2.02
6 Approached by people do not know 2.03 23.4 (12.4 4.1)0
8 Do not recognize friends 0.66 4.3 5.1 4.62
10 Accused of lying 2.12 23.9 (7.3 6.0)0
9 No memory for important events 1.03 9.6 (8.8 9.5)0
Factor 3 Depersonalization
12 Other people not real 1.7 19.3 4.9 4.P
13 One's body does not belong 1.2 10.9 3.9 3.63
11 Not recognize self in mirror 0.72 5.8 1.8 1.2~
28 Look at world through fog 1.2 11.6 4.7 4.0~
7 Standing next to themself 1.27 14.0 (5.3 4.3)0
27 Hear voices in head 1.59 17.9 5.3 7.3~

II'J'hree factors DES solution based on Ray data. Note similarity with Ross factor analytic solution. Ross factors shown as
superscripts. See text for more detail.

differences in frequency of dissociative experiences between the results found in

the Wmnipeg and college-age population. Consistent with developmental theory as
well as other findings, college-age subjects report a higher incidence of absorption
and depersonalization experiences than the older populations of Ross et al. Overall,
these data suggest that as one matures, one experiences a decrease in both experi-
ences of depersonalization and of absorption-derealization. On the other hand,
there exist a few items such as finding oneself W:essed in clothes one doesn't
remember putting on or an inability to recognize friends that are experiences with
equal and low frequencies across the lifespan.
What the relationship is between high scores on such sound psychometric
measures as the DES and day-t<Hiay experiences of individuals who achieve these
scores is an important question. That is to say, are there unique descriptive proper-
58 ties of a given individual's experience not adequately reflected in the DES and
William J. Ray would these experiences in a normal population be consistent with psycho-
pathological diagnoses? To help answer this question, both Ross, Ryan, Voigt, &
Eide (1991b) and Ray and Lukens (1995) interviewed college students who scored
high on the DES.
From an original sample of 345, Ross et al. (1991b) interviewed 22 college
students who scored above 22.6 and 20 who scored below 5 on the DES. These
subjects were asked to complete a widely used measure of general psychopathol-
ogy, the Symptom Checklist (SCL-90), and a personality measure [Millon Multiaxial
Clinical Inventory (MMCI)] as well as being interviewed with the Dissociative
Disorders Interview Schedule (DDIS) (Ross, 1989; Ross et al., 1989). Although the
high- and low-DES subjects did not differ in terms of demographics, the high-DES
subjects did show higher overall and subscales on the SCL-90 and a higher score on
the borderline subscale of the MMCI than the low-DES subjects. In terms of the
diagnostic interview, 70% (14) of the high-DES subjects met criteria for one or more
dissociative disorders. As expected, none in the low-DES group met any of the
criteria.
Another measure of psychopathological dissociation is the Structured Clinical
Interview for the DSM-IV Dissociative Disorders (SCID-D) (Steinberg, 1993). Al-
though the DSM-IV categories of dissociative disorders and this instrument are
discussed in greater detail in Chapter 12, it can be noted that this is a semistructured
interview that assesses five dissociative symptom clusters. These clusters are amne-
sia, depersonalization, derealization, identity confusion, and dissociative identity
disorder (the DSM-IV designation of MPD). Ray and Lukens (1995) used the SCID-D
with a sample of 17 college students who had scored high on the DES. All of the
high-DES subjects scored above the equivalent 20-30 score range that has been
seen as suggestive of psychopathology. However, in terms of the SCID-D, only 3 of
the 17 high-DES subjects met all criteria for a dissociative disorder. An additional 3
subjects met all criteria except the requirement for distress. DSM-IV states this
requirement as follows: "The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning." The
requirement for distress is an interesting one since all of the high-DES subjects we
interviewed denied ever seeking services for dissociative symptoms as well as not
being currently in therapy. Thus, although dissociative experiences are reported in
this normal population, these experiences do not seem to be an extremely disrup-
tive aspect of these subjects' life. Without considering distress as a requirement,
approximately one third of the high-DES subjects described dissociative experi-
ences consistent with a DSM-IV dissociative disorder. The other two thirds of high-
DES subjects also reported dissociative experiences, but these did not meet criteria
for a DSM-IV dissociative disorder.
One aspect the Ray and Lukens study sought to understand was the undiag-
nosed presence of dissociative experiences. The dissociative experiences reported
in the interview ranged from mild symptoms to severe difficulties. For example, in
response to the questions concerning amnesia, subjects reported gaps in memory
lasting from a few hours to an entire day. One person reported an amnesia experi-
ence as recently as one day before the interview was conducted. Another person
reported that she would walk through town and the next moment she would "wake
up" standing in line at a store's cash register with unfamiliar store items in her 59
hands. She also reported feeling embarrassed at having no explanation for her Dissociation in
actions. With regard to the depersonalization items, one individual reported, Normal Populations
"While I was sitting in my room, I zoned out and then as a third person or camera,
I watched myself, my body, leave the room to visit a friend. I then returned to my
room whereupon I snapped out of it. An hour had passed." She continued to say that
the experience was very different from that of dreaming or daydreaming. In fact, it
made such an impact on her that she felt the need to call her friend to see if she had
actually visited, which she had not. Another subject described in some details her
experiences of derealization, part of which is described: "I have episodes where I
see everything differently, everything starts blending ... things look more fluid. I
snap out of it on purpose because it is a disturbing experience. I can't tell what is
real and what is not." Other subjects report derealization experiences in which
"things were moving in slow motion," "voices echoed," and the surroundings
became "cartoonlike." Finally, some subjects described situations in which they
rose above or to the side of their body. From this perspective, they would watch
their own actions. These results seem consistent with more anecdotal reports in
that the experience of being outside of one's body are not uncommon experiences
for individuals with dissociative tendencies.
Overall, the studies from the Ross and Ray laboratories suggest that dissociative
experiences are common within the normal population. Further, these experiences
or tendencies do not seem to carry with them high levels of distress, which raises
questions in terms of referring to these dissociative experiences in a psycho-
pathological manner.

RElATIONSHIP TO OTHER INDIVIDUAL DIFFERENCE FACTORS

In order to understand how dissociative tendencies are related to and separate

from other individual difference factors, we have examined the relationship be-
tween two major dissociative scales and a variety of individual difference measures.
At this point, we have collected data from more than 2000 college students over a
5-year period, although not all subjects received every individual difference mea-
sure. In the following section we will discuss some of these measures.

Absentmindedness
One important question asks if dissociative tendencies share a common root
with other types of lapses of awareness such as absentmindedness or other types of
simple forgetfulness. Absentmindedness and other types of lapses of awareness
have been topics of great interest in the human factors literature (cf. Reason, 1984).
In this literature, distinctions have been make between "slips" and "mistakes:' Slips
would be considered actions not in accord with the overall goal in the case where
one had a good plan but it was poorly execution. Mistakes, on the other hand,
would be considered planning failures and the resultant of errors of judgement,
inference, and so forth. With a mistake one accurately follows the plan, but the plan
60 is faulty. Thus, in this section, to use the terminology of human factors, we are
William J. Ray interested in slips, lapses, and accidents but not mistakes.
We all know that accidents happen to people and that they are unpredictable
and random, as opposed to something someone plans to do. However, we can ask if
people who make one type of slip or error (e.g., attention) also make other types of
errors (e.g., memory). To help answer this question, at least two questionnaires
have been developed to assess error proneness. The first was developed by Broad-
bent and referred to as the Cognitive Failures Questionnaire (Broadbent, Cooper,
FitzGerald, & Parks, 1982). The second was developed by Reason and Mycielska
(1982) and referred to as the absentmindedness questionnaire. In our own work we
have found that these two questionnaires correlate highly with each other (r =.68).
Other research in the human factors area has reported that: (1) there exists a general
factor found in all questionnaires of absentmindedness or cognitive failures; (2) it is
difficult in general to find cognitive laboratory measures that discriminate between
high and low scorers on these questionnaires; (3) distributed attention tasks appear
to differentiate high and low scores especially when more than one task is at-
tempted simultaneously; and (4) subjects scoring high in absentminded or cogni-
tive failure cope by using more mental effort to deal with or suppress emotions,
whereas low subjects use more action-oriented techniques such as seeking support
from others. Such data have led Reason to suggest that high-scoring subjects have a
less adaptive coping style. Other research suggests that although stress may increase
the likelihood of cognitive failure, it is not a necessary condition for its occurrence.
However, Broadbent et al. (1982) suggest high cognitive failures scores are related
to increased vulnerability to externally imposed stress. In terms of data collected
with our college student population, we found that Broadbent's Cognitive Failures
Questionnaire correlates .47 (n = 541) with the DES and Reason's Absent-
Mindedness Questionnaire correlates .56 (n = 249). Given these correlations, it is
possible to speculate that there may exist similar processes that underlie both
normal absent-mindedness and more severe dissociative tendencies.

Absorption
Tellegen and Atkinson (1974) developed the Tellegen Absorption Scale (fAS),
which is a scale of openness to absorption. In a number of studies the TAS has been
shown to have low positive correlation with hypnotic susceptibility (.21 and .11 in
our samples of 243 and 278 subjects, respectively). Tellegen (1992) has described
absorption as a "marked restructuring of the phenomenal self and world." In terms
of dissociative tendencies, Tellegen suggests that "these more or less transient states
may have a dissociated or an integrative and peak-experience-like quality." The
finding in our samples of a moderately high correlation (.55 and .59 in samples of
243 and 278 subjects, respectively) supports this speculation.

Hypnotic Susceptibility
The phenomena of dissociation and hypnosis have been closely associated in
both the scientific and popular literature since at least the 1880s. The investigation
of clinical dissociative phenomena and the use of hypnosis in their study and
treatment was practiced by Janet and many of his contemporaries, including Char- 61
cot and Freud (Ellenberger, 1970). Since many of these dissociative phenomena Dissociation in
could be produced under hypnosis and were studied and treated within the context Normal Populations
of hypnosis, there was a natural association of the two phenomena. Historically, the
association between hypnosis and dissociation is based on empirical, theoretical,
and clinical grounds such as the similarity of hypnotic and dissociative states
(Hilgard, 1965; Spiegel & Cardeii.a, 1991) and the reported high hypnotizability of
dissociative clinical groups (Bliss, 1986; Frischholz, Upman, Braun, & Sachs, 1992;
Putnam, 1989). In terms of the dimensions of hypnotizability and dissociative
experiences in normal populations, little research exists that is available to answer
the question of whether the same individuals who are hypnotically susceptible are
also individuals who report experiencing dissociative processes. This was the
question we sought to answer (Faith and Ray, 1994). To study the relationship
between hypnotizability and dissociation in a nonclinical population, we report the
results of a large-scale correlational study, conducted over 3 years, using two
separate measures of dissociation (the DES and QED) and a highly regarded scale of
hypnotizability, that of the Harvard Grove Scale of Hypnotic Susceptibility
(HGSHS).
Across four administrations (866 subjects), correlation coefficients were com-
puted between the two dissociation scales and the hypnotizability scale. Correla-
tions between the DES and the QED for the entire sample was .81, which is
consistent with the findings of other studies (Angiulo & Kihlstrom, 1991; Ray et al.,
1992; Ray & Faith, 1995; Riley, 1988). For all subjects combined, correlations
between the dissociation scales (DES and QED) and the hypnotic susceptibility
scale (HGSHS:A) were .09 and .10, respectively. Therefore, for the sample as a
whole, the variance in hypnotizability scores explained by dissociation scales is
approximately 1%. It can also be noted that similar correlations between the
dissociation scales and the hypnotic susceptibility scales were found with each
administration.
Although there was little correlation between dissociation and hypnotizability,
there still existed a possibility of a nonlinear relationship. That is, the relationship
could exist only for selected aspects of the distribution such as high hypnotizability
subjects. This possibility was investigated using scatterplots of the data. QED and
DES scores were plotted independently against the HGSHS:A scores. Figure 1 shows
these results for the DES. The QED showed similar results, which are not repro-
duced in this chapter. Inspection of the plot does not support a nonlinear relation-
ship. Dissociation scores were scattered uniformly across the range of hypno-
tizability scores.
Another possibility is that separate factors on the HGSHS:A would correlate
differentially with dissociative experiences. Several distinct content dimensions
have repeatedly emerged in factor analytic studies of hypnotic susceptibility (Hil-
gard, 1965). In summary of Hilgard's presentation, these factors are: (1) a general
hypnotizability or direct suggestion factor; (2) a motor inhibition factor; (3) a
cognitive and sensory inhibition factor; and ( 4) a positive hallucination factor. The
cognitive-sensory inhibition factor includes amnesia and negative hallucinations.
However, some of the factors represent more difficult items than others.
To investigate whether difficulty level of hypnotic challenges, as reflected in
62 IIY1'1108I8 VD8U8 DB8

William J. Ray
·•··•·•····•·••••····•····•····•····•····•····•····•••··•···••·
1 1
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7.

'·
IIY1'1108I8
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Figure 1. Plots of dissociation scale scores with hypnotizability scores.

factorial structure, was related to dissociative experiences, we performed a factor

analysis (BMDP 4M with varimax rotation) on the HGSHS:A items with the present
subject sample. The factors that were found quite closely approximated those
reported in the literature (Hilgard, 1965; Peters, Dhanens, Lundy, & Landy, 1974).
Factor scores on the hypnotic susceptibility scale were computed for 858 sub-
jects and then correlated with DES and QED scores. All correlations ranged from
-.06 to .12 and were nonsignificant. The data suggest no relationship between
response difficulty and dissociation score, since the factors with items of greater
difficulty (posthypnotic suggestion, posthypnotic amnesia) were not associated
with a report of more dissociative experiences (DES or QED scores).
 Further, psychophysiological data suggest a differential of responding in indi- 63
viduals selected as high in hypnotic susceptibility and dissociative tendencies. That Dissociation in
is, although previous EEG baseline data demonstrate a differentiation of EEG activ- Normal Populations
ity, especially in the theta band, in hypnotically susceptible subjects (Graffin, Ray, &
Lundy, 1995), no differentiation of baseline Ef:G characteristics was found in
college-age subjects scoring high on the DES (Ray & Faith, 1993). Thus, in terms of
both psychometric and psychophysiological studies, an orthogonal relationship
between hypnotizability and dissociation exists, at least in normal populations.

Health, Stress, and Abuse

It is widely accepted that psychopathological forms of dissociation have at
their basis previous experiences of trauma, especially in childhood. In 100 MPD
cases surveyed by the National Institutes of Mental Health, 97% reported significant
childhood trauma, incest being the most commonly reported (Putnam, Guroff,
Silberman, Barban, & Post, 1986). Similar incidence rates of trauma in MPD are
reported by other researchers (Braun & Sachs, 1985; Coons & Milstein, 1984; Ross,
1989). Individuals with dissociative disorders other than MPD also frequently report
early abuse histories (Coons, Bowman, & Pellows, 1989). Likewise, among individ-
uals with nondissociative disorders, reported childhood abuse predicts dissociative
symptoms (Spiegel & Cardefia, 1991). However, there is as yet little empirical
substantiation of the relationship between dissociative tendencies and abuse in
nonclinical populations. Thus, our first task was to examine the relationship be-
tween self-reported abuse and dissociative tendencies. In a sample of 73 7 college
students, we found an overall positive relationship (r = .38) between all forms of
childhood abuse (sexual abuse, punishment, and neglect) and dissociative tenden-
cies. Looking at specific types of abuse, the strongest relationship was found
between experiences of neglect and dissociative tendencies (r = .34). That is,
subjects who reported being neglected, as in the case of inaccessible parents (e.g.,
alcoholic or frequently fighting parents), reported higher experiences of dissocia-
tive tendencies than those who reported sexual abuse (r = .19) or physical punish-
ment (r = .28).
In terms of the relationship between reporting dissociative experiences and
health and stress, a moderate relationship was found. There was a positive correla-
tion (r = .25, n = 492) between reporting dissociative experiences on the DES and
the amount oftime an individual felt to be under stress or felt to be upset/angry/sad
(r = .26, n =739). Likewise, scores on the DES correlated with both scores on the
Beck Depression Inventory (r = .30, n =415) and the State Trait Anxiety Inventory
(r = .31, n = 414). In terms of specific health symptoms, there was a positive
correlation between scores on the DES and the follow specific complaints: joint
pains/sore muscles (r =.41, n =739); sweaty palms or underarms/nervous stomach/
flushed (r =.30, n =739); bowel problems/indigestion (r =.25, n =739); aware of
heart rate/short of breath/feeling dizzy (r = .36, n =739); headaches (r = .26, n =
739); colds/flu/being sick (r = .34, n = 739); and using alcohoVdrugs (r = .33,
n = 739).
Given the previous correlations relating abuse, stress, health, and dissociative
64 experiences, the time is ripe to return to the original questions of Janet as to
William}. Ray constitutional predispositions of certain individuals to stress and dissociative ten-
dencies. It is also time to examine the developmental time line or order of events
that function as mediating or moderating factors in term of dissociatve processes
and their function in psychopathology. Empirical and theoretical implications of
such developmental processes are discussed in other chapters.

DEVEWPMENT OF DISSOCIATION IN NORMAL POPUlATIONS

Given that the research reported in this chapter with normal subjects reported
few subjects that did not endorse some type of dissociative experience, it is difficult
to view dissociation as other than a normal cognitive process. Our current way of
viewing dissociation is to suggest that all individuals come into this world in a
dissociative state. Tilis may result from either an immature nervous system that is
yet to form or even from a break of a physiological entrainment process between
the mother and her infant in the womb. That is to suggest that previous to birth the
physiological organizing principle of the developing nervous system is that of the
mother. With birth, this entrainment process is broken and the various aspects of
the child's nervous systems function in a less than totally integrative manner. If
indeed the development of physiological, emotional, cognitive, and motoric inte-
gration continues throughout a child's development until a unifying principle,
generally referred to as "self," develops, then dissociation can be seen as the
resultant of an interruption of that normal process. As has been pointed out by
others, such disorders as multiple personality disorder are not actually a number of
personalities but the lack of any strong personality or coherent system. At this point
trauma of various forms appears to be the more likely candidate for producing an
interruption in normal development that would lead to such psychopathological
dissociative states. However, Janet's original suggestion of constitutional weakness
must also be considered.
Although few physiological data exist at this point, it is important to consider
recent work in relation to the functioning of perceptual binding mechanisms,
although this mechanism takes place on a more micro level. Recent research
suggests that an approximately 40. to 70-Hz EEG signal appears in a variety of areas
across the brain when responding to a similar stimulus and that this serves to
combine our awareness into a coherent whole (cf. Gray & Singer, 1989). Crick and
Koch (1990) go further to suggest that such synchronous firing is not only a means
of combining perceptions but also of establishing consciousness. Although a con-
ceptual leap, it could be possible that with certain dissociative disorders (e.g.,
dissociative identity disorder), different binding mechanisms could be connected
with different "personalities." Of more interest to cognitive scientists is the further
suggestion that this binding process is the mechanism for placing cognitions into
working memory. If this same or a similar mechanism is not only involved in
bringing the various aspects of stimulus perception into a coherent whole exter-
nally but is also involved with internal experiences, then it would lie at the heart of
such dissociative experiences as amnesia and depersonalization-derealization.
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136, 374-378.
Steinberg, M. (1993). Structrlred Clinical Interview for DSM-W Dissociative Disorders (SCI[).D).
Washington, DC: American Psychiatric Press.
Tellegen, A. (1992). Note of structure and naming of tbe MPQ Absorption Scale. Unpublished manu-
script, University of Minnesota, Minneapolis.
Tellegen, A., & Atkinson, G. (1974). Complexity and measurement of hypnotic susceptibility: A com-
ment on Coe and Sarbin 's alternative interpretation. journal ofPersonality and Social Psychology,
33, 142-148.
Vanderlinden,}., VanDyck, R., Vandereycken, W., & Vertommen, H. (1991). Dissociative experiences in
the general population in the Netherlands and Belgium: A study with the Dissociative Questionnaire
(DIS-Q). Dissociative, 4, 180-184.
II
DEVELOPMENTAL
PERSPECTIVES

This section begins with the important relationship between dissociative disorders
and childhood trauma. Although there is ample evidence to suggest an association
between dissociative disorders and previous trauma, there has been little theory
and research to understand these processes within a developmental perspective.
Part II begins to approach this important theme and to place dissociative processes
within a developmental perspective. In Chapter 4, Pamela Cole and her colleagues
ask how dissociation can be understood from the standpoint of normative develop-
ment and emotional regulation. These researchers begin with the assumption that
early childhood trauma affects developing patterns of emotional regulation and
they examine the conditions under which trauma might promote dissociative
disorders. For example, they suggest that ages 3 to 5 represent a critical period in
which sexual abuse can lead to more severe dissociative disorders such as dissocia-
tive identity disorder. However, the story may not be quite so simple as these
authors demonstrate. They point out the importance of not only understanding a
trauma situation but also examining the developmental characteristics of the victim
prior to the trauma, during the trauma, and after the trauma is over. To help clarify
this relationship, the focus of Chapter 4 is on father-daughter incest. The important
question to ask is what are the co-occurring developmental processes that are
present with the onset of incest in particular and any trauma in general.
In Chapter 5, Goodwin and Sachs begin by describing stories of abuse from the
popular press and continue with survey data from professionals treating dissocia-
tive disorders. From their review, they suggest a strong relationship between
dissociative disorders and previous trauma. Throughout their discussion they raise
a number of intriguing questions as to the etiology of dissociative processes. First,
these authors note the similarity between patients with severe dissociative dis-
orders and shell-shocked combat veterans. Second, they ask if there exists a sim-
ilarity in mechanism between those processes, found in both animals and humans,
that place the organism in a deep trance during conditions of stress and those
underlying dissociative processing. Third, the question is raised as to why not all
individuals who experience severe child abuse develop dissociative disorders. And 67
68 fourth, the question of abuse and dissociation running in families is raised. Overall,
Developmental this chapter helps us to understand some of the questions that need to be asked in
Perspectives future research as well as the difficulty of finding simple answers.
All children proceed through certain developmental stages that include shifts
in perceptual, motor, and emotional development. Bowlby emphasized the emo-
tional attachment seen in infants with their caregivers, generally their mothers.
Developmental researchers have been interested in early attachment relationships
and later social competence. As will be described in great detail in the chapters, the
nature of these attachments can be classified into distinct patterns. In Chapter
6, Main and Morgan ask if one of the these distinct patterns-the disorganized-
disoriented pattern-has a phenotypic resemblance to dissociative states. Not
unlike the trance states of animals described by Goodwin and Sachs, Main and
Morgan describe certain infants as "freezing all movement." Interestingly enough,
there also appears to be a characteristic response of the parents of such infants,
again raising the question of intergenerational transition of traumatic behaviors
and responses. Main and Morgan describe one possible mechanism for such trans-
mission in a case report in which an infant learns to respond in a psychopathologi-
cal manner to the parents' responses to their own traumatic memories. The chap-
ters in this section also raise the important question as to why some individuals who
experience severe trauma never manifest dissociative experiences. Perhaps a better
understanding of attachment events and development sequences will hold the key
to this important question.
The final chapter in the section, by Hornstein, focuses on formal descriptions
of dissociative disorders in children and adolescents. As can be seen from the
chapter, dissociative experiences of children do not exist in isolation, but co-occur
with a variety of affective, attentional, and behavioral problems, making exact
differentiation difficult. As with adults, children who are diagnosed with dissocia-
tive disorders also have received a variety of previous psychiatric diagnoses, the
most common of which are depression, depressive psychosis, posttraumatic stress
disorder, oppositional defiant disorder, conduct disorder, and attention deficit
hyperactivity disorder.
4
Dissociation in Typical
and Atypical Development
Examples from Father-Daughter Incest Survivors

Pamela M. Cole, Pamela C. Alexander,

and Catherine L. Anderson

Dissociation has been characterized as the lack of normal integration of thoughts,

feelings, and experiences into the stream of consciousness and memory (Nemiah,
1981; Putnam, 1984). The term is used to describe clinical conditions in which
individuals lose awareness or memory of events and their attendant internal states.
In addition, the term is sometimes used to describe normative regulatory processes
by which an individual modulates internal state (e.g., intense emotion) and external
input (e.g., aversive stimulation). For example, denial and dissociation have been
described as primary defense mechanisms for children prior to school age (Cramer,
1991). Dissociation also appears to be a universal response to trauma at all ages
(Putnam, 1985). The disconnection of affective content from conscious awareness
at the time of trauma helps the individual both to mobilize for action without being
flooded by emotion and to tolerate trauma until it is ended and physical and
psychological help is available. Therefore, it may be that dissociation can be under-
stood from the standpoint of normative development and emotion regulation.
It is not known whether more common dissociative processes should be
regarded as being on a continuum of functionality with dissociative disorders, or

Pamela M. Cole • Department of Psychology, Pennsylvania State University, University Park, Pennsyl-
vania 16802. Pamela C. Alexander • Department of Psychology, University of Maryland, College
Park, Maryland 20742. Catherine L. Anderson • Northwest Center for Community Mental
Health, Reston, Virginia 22091.
Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William). Ray. Plenum Press, New York, 1996. 69
70 whether dissociative disorders represent a discrete and distinct set of processes.
Pamela M. Cole One possibility is that a normative regulatory process, under conditions of severe
etal. and/or sustained stress, may develop a dysfunctional quality. For example, if an
individual experiences intense emotional distress in childhood, she may become
primarily reliant on dissociative coping throughout development. Such an outcome
would interfere with her ability to function in an attuned and flexible manner in
adult relationships and to conduct the responsibilities of adult life. The prevailing
wisdom is that severe dissociation, including conditions like multiple personality
disorder (MPD), is particularly likely to occur in conjunction with early childhood
trauma. Retrospective research indicates that the development of a condition like
MPD is associated with sexual abuse that begins between the ages of 3 to 5 when
dissociation may be a primary normative emotion regulatory strategy (see Cole &
Putnam, 1992, for a developmental discussion).
Emotion regulation, a term that conveys that emotions are subject to regulation
and that they are regulatory of other functions (e.g., attention), can be used to
provide an integrative perspective on typical and atypical development related to
dissociation. Although emotion regulation is a moment-to-moment process, several
theorists contend that stable patterns of emotion regulation form a core of person-
ality (e.g., Izard, 1979; Malatesta, 1990; Rothbart & Ahadi, 1994; Watson & Clark,
1984). From this perspective, a habitual reliance on a particular method of regulat-
ing emotion can come to characterize an individual's style of coping. If that style is
dissociative, the likelihood is that there will be serious impairment in the individ-
ual's ability to act responsively and responsibly in life. Potential for serious impair-
ment exists as experiences, particularly emotion-laden experiences, become tem-
porally disconnected and episodes of time are thus lost from consciousness and
memory. In the most extreme forms of dissociative disorder, this style of emotional
functioning interferes with the integration of personality and promotes the devel-
opment of the experience of multiplicity of separate selves.
This chapter on developmental perspectives on dissociation is organized
around the assumption that early childhood trauma affects developing patterns of
emotion regulation and that under certain conditions that trauma can promote
dissociative disorders. The basis of our clinical perspective is our experience with
clients and research participants with a history of childhood sexual abuse. Dissocia-
tive disorder has been noted to occur among many, but by no means all, survivors of
childhood sexual abuse (Gelinas, 1983). Dissociation serves as both an initial protec-
tive response to emotional trauma and, for some, as a subsequent style of function-
ing and a form of psychopathology (Sexton, Harralson, Hulsey, & Nash, 1988). As a
result of exposure to repeated, severe, inescapable, and unpredictable sexual vic-
timization by a previously trusted individual, a child's ability to regulate distress is
quickly overtaxed (Braun, 1989; Putnam, 1989; Sanders, McRoberts, & Tollefson,
1989; Spiegel, 1986). In the case of incest, abuse may occur without adequately
soothing, restorative relationships that help the victim regulate emotional distress
(Kluft, 1984). As a result, many abused children appear to spontaneously enter
trance states in their self-regulatory attempts to find relief and to maintain emo-
tional equilibrium in the presence of continuing, inescapable, and unpredictable
trauma (Bliss, 1988).
In this chapter, we offer a developmental perspective on dissociation in both
its typical and atypical presentations. Unfortunately, the empirical evidence is
sparse and more questions are raised than answered. By using a developmental 71
psychopathology perspective, we hope to suggest that dissociation can be ex- Dissociation in
plored as a normative phenomenon and that particular conditions may promote the Typical and Atypical
development of atypical dissociative patterns. Such a perspective requires a de- Development
scription of dissociation in relation to normal child, adult, and family development
(Rutter & Garmezy, 1983; Sroufe & Rutter, 1984). To focus our discussion, we rely on
our clinical and research experiences with girls and women who have been victims
of father-daughter incest. Psychological vulnerabilities in reaction to a disturbed
parent-child relationship are conceptualized in terms of developmental factors
that influence the child's capacity to regulate the emotional trauma, specific devel-
opmental tasks that are compromised by the trauma, and familial conditions that
promote and sustain dissociative functioning as a primary means of regulating
emotion. We depict how incest can arise in families that cope through denial and
dissociation, how dissociation helps the child victim survive the incest, and how
the incest experience in its familial context can promote the consolidation of a
dissociative disorder.

THE RElATIONSHIP BETWEEN INCEST AND DISSOCIATION

Dissociation often occurs as a response to trauma, such as incest. Unlike many

other forms of trauma, however, incestuous behavior by a father is rarely a discrete
event. More typically, the incest is a disturbance in an existing primary relationship
that has as its focal point numerous episodes of unwanted sexual contact. In our
view, incest involves an extreme form of trauma in which psychological and often
physical injury occur regularly and chronically to the child. Although unwanted
sexual contacts provide a defining core of this particular form of abuse, incest may
be most debilitating in terms of the emotional injury to the relationship between
the child and her family. Therefore, the level of the child's emotional distress may
be determined more by the meaning of the sexual incidents and disturbed relation-
ship than by the incidents themselves. Her psychological interpretation of the
events determines the quality of her posttraumatic adaptation at any given point
(van der Kolk, 1987).
Most incest victims must cope with multiple aspects of the experience: (1) physi-
cal and psychological trauma in the form of the actual sexual experiences, including
violation of one's body; (2) extended periods of apprehension, guilt, and fear
between sexual contacts; and (3) the damage to and potential loss of a relationship
with one or more emotionally significant family members. The intense and sus-
tained nature of incest places excessive demands on the child's developing ability to
regulate emotional states and compromises her ability to acquire alternative coping
strategies as she matures. The incest violates whatever basic sense of trust she has
formed, deprives her of reliance on family members for comfort and problem-
solving, and interferes with her ability to seek and form emotionally satisfying and
soothing relationships with others. Therefore, the incest victim experiences sus-
tained, pervasive trauma that she cannot diminish or control in reality. As a result,
it is thought that dissociation affords the young victim the most reasonable recourse
in the face of an abusive parental relationship.
Emotion regulation is often discussed in terms of the intrapsychic processes
72 involved in managing emotion. It is equally important to emphasize that incest
Pamela M. Cole emerges within a context of broader family dysfunction. Incestuous families are not
etal. a homogeneous group, and a specific preexisting familial dysfunction has not been
isolated. Nonetheless, incest does not emerge at random. Instead, it reflects inter-
generational vulnerabilities that lead two adults to form a marriage and a family in
which a father perpetrates sexual abuse on his daughter. The incestuous family
environment promotes the child's dissociative processes by serving as (1) a predis-
posing climate in which dissociative processes are the primary means of the
family's emotional functioning, (2) a precipitating factor by virtue of the trauma of
the abuse, and (3) a perpetuating force in the maintenance of dissociation as a
means for the family to tolerate the trauma (Braun, 1984). For these reasons, we
focus not on the specific nature of the abuse but rather on the development of the
family and the incest victim at three different stages-before the incest begins,
during the incest, and after the sexual acts have ended.

THE DEVEWPMENTAL PERSPECI1VE

Child Development and Family Functioning in

the Preincestuous Period
In describing child development and family functioning in the incestuous
family, we assume that (1) family relationships are one of the most important units of
analysis, (2) family relationships have continuity and coherence over time such that
they are predictable across individuals and generations, (3) individuals internalize
family relationships, and ( 4) these internalized relationships are carried forward
into the next generation (Sroufe & Fleeson, 1988). We begin our review by discuss-
ing the nature of emotional development in the first years of childhood and the
nature of the family context out of which father-daughter incest eventually
emerges.

Child Development. The ability to regulate one's own emotional state

begins in infancy and appears to be influenced by biologically governed disposi-
tional factors (temperament, certain cognitive capabilities) and socially governed
experiences (parent-child relationships, exposure to stress). For example, infants
use gaze aversion to reduce and seek stimulation from external sources and self-
sucking to reduce the level of internal autonomic activity (Rothbart, Ziaie, &
O'Boyle, 1992; Stifter & Moyer, 1991). These early behaviors indicate that the human
is equipped at the earliest stage to begin to regulate emotional experience by
refocusing attention (Wolff, 1987). It has been suggested that the capacity of infants
and toddlers to enter rapidly into deep trance states is indicative of a capacity to
dissociate from external events (Gardner & Olness, 1981).
Infants must rely, however, primarily on adult caregivers to regulate their
emotional states through responsive parenting. Parental regulatory behavior may
contribute to the rudiments of a normative dissociative capacity in young children
by stimulating state shifts through stroking, rocking, and singing (Gardner & 01-
ness, 1981). Furthermore, young children appear to adopt these strategies to sooth
themselves. For example, the young son of a colleague became terrified at a 73
fireworks display. His mother took him to the car and caressed him until he fell Dissociation in
asleep. He did not recall having been upset when they discussed it the next day. The Typical and Atypical
next time the family went to a fireworks display, the boy began stroking his hair and Development
spontaneously fell asleep.
Prior to age 8-10 months, infants do not appear to appreciate the continuity of
objects in space and time. For example, it is only during the end of the first year that
they begin to search for hidden objects (see Harris, 1983). Therefore, an accom-
plishment of infancy is the discovery that things exist beyond one's immediate,
concrete experience of them. This accomplishment, often called object perma-
nence or constancy, includes the capacity to temporarily hold onto the sense of
maternal emotional comfort during mother's absence and to delay distress until she
has returned (Ainsworth, Blehar, Waters, & Wall, 1978).
Developmental psychologists use the construct of attachment (Bowlby, 1969)
to conceptualize the manner in which emotion regulatory interactions take place in
the larger context of the infant-caregiver relationship. The quality of the attach-
ment relationship has been shown to predict later social competence (Waters,
Wippman, & Sroufe, 1979), formation of self-identity and self-understanding (Cic-
chetti & Beeghly, 1990), and even the quality of adult relationships with partners
and children (Main & Goldwyn, 1984).
Infants' attachment-related behaviors have been used to characterize the at-
tachment as secure or insecure (Ainsworth et al., 1978). Secure attachment involves
the infant's ability to tolerate negative affect for short periods of time with the
confidence that the parent will be available presently and to experience solace from
the caregiver as needed. Insecure attachment involves deviations from this pattern.
The two most commonly described forms of insecure attachment are avoidant
attachment in which the infant blunts negative emotions and remains detached
from the parent, and resistant attachment in which the infant actively attempts to
engage the parent but often without solace.
A third and more rare form of insecure attachment has been noted to occur
among children with a history of abuse. Disorganized attachment is defined by
simultaneous approach-avoidance, freezing, apprehension, and dazed expressions
when the child is reunited with the parent (Carlson, Cicchetti, Barnett, & Braun-
wald, 1989; Main & Solomon, 1986, 1990). For example, a child might rock on hands
and knees after unsuccessfully approaching the parent, may move away from the
parent while simultaneously displaying fearfulness about approaching anyone else,
or may freeze in posture for several seconds en route to approaching the parent. It is
thought that these stultifying behaviors reflect a confusion about approach and
avoidance that results in their mutual inhibition (Main & Hesse, 1990; Main &
Solomon, 1986). The apparent similarity of these behaviors to dissociation is note-
worthy.
This approach-avoidance tends to occur specifically in the presence of a
parent who exhibits what Main and Hesse (1990) refer to as "frightened and/or
frightening" behavior and who frequently has a history of traumatic loss or sexual
abuse. The parent, for example, may suddenly invade the infant's personal space,
such as looming into the infant's face or sliding his or her hands across the infant's
throat (Main & Hesse, 1990, 1992). Alternatively, the parent may appear to be
74 frightened as the infant reaches toward the parent's face. Thus, the parent appears
Pamela M. Cole to flee from the child (through expressions of fear, dissociation, or actually leaving,
et al. precisely at as time when the child is most in need of reassurance and nurturance
from the parent (Liotti, 1992). Liotti (1992) speculates that the parent's own unre-
solved attachment history, memories of which may be triggered or amplified by the
presence of the child, appear to cause the parent to unconsciously look to the child
for soothing and comfort. This role reversal has been observed in the relationship
between parents and disorganized children (Main & Cassidy, 1988). When the child
fails to adequately nurture the parent, the parent is likely to become angry and
aggressive (i.e., frightening) toward the child (Bowlby, 1985). Thus the child finds
herself in the untenable position of relating to a parent who is simultaneously the
source of the solution and the source of the problem (Main & Solomon, 1986). The
breakdown of the child's strategies for experiencing the security of the attachment
during times of stress are thwarted and this situation is thought to result in dissoci-
ated states.
Much of emotional development during toddlerhood is characterized by the
child's learning about her own and others' emotions and instrumental behaviors for
dealing with distress (Dunn, 1988; Kagan, 1981; Kopp, 1982; Stipek, Gralinski, &
Kopp, 1990; Zahn-Waxler, Radke-Yarrow, & King, 1979). These newly acquired
skills are limited, and toddlers are easily overwhelmed by life's emotional chal-
lenges. Parents attempt to support the child's developing emotional autonomy,
often using techniques such as distraction to manage toddler distress rather than the
physical caregiving that they provided in infancy. For example, when toddlers are
upset by minor problems, adults often redirect children's attention to interesting
toys or activities. This attentional shift separates the first event (the distress) from
the subsequent event (the toy). This normative use of distraction may promote or
extend the child's capacity to dissociate.
During these same years, language is rapidly developing and children are
learning labels for their internal states, e.g., emotions (Bretherton, Fritz, Zahn-
Waxler, & Ridgeway, 1986). Young children gain experience communicating about
emotion with their parents and siblings, and emotion words develop at approx-
imately the same time as self-referent terms like me and I (Bloom, 1991). Fischer
(1980) has theorized that development is characterized by the acquisition of indi-
vidual, specific skills and subsequent organization of sets of skills into units. For
example, toddlers acquire words for naming emotions, but they cannot use those
emotion terms in all the ways that an adult can. Also, a child may use and understand
positively and negatively valenced affective terms (e.g., nice and mean) but be
unable to integrate these two separate understandings. The acquisition of compo-
nent skills prior to their reorganization into more sophisticated skill units is the
basis for affective splitting, the inability to coordinate or integrate negative valences
about events that leads to them being treated as separate, unrelated events (see also
Harter, 1983).
The preschool years (ages 2 through 5 or 6) mark the transition from infancy to
childhood. During this period, children face the task of integrating their experience
of being an agentic self with the restrictions and sanctions of the social world. Their
developing cognitive skills and broadening social experience are associated with a
rapidly expanding ability to control their own actions and emotions (Kopp, 1982;
Dunn, 1988). Cognitive advances also allow the child to imagine possibilities be-
yond the concrete realities of her experience. The preschool child can engage in 75
symbolic play to explore the nature of experience (Garvey, 1977). Through interac- Dissociation in
tions and through play, preschoolers learn the limits of and differences between Typical and Atypical
what is real and what is not real and can experiment with imaginary characters and Development
scenarios for problem resolution (Wolf, 1990). That is, through the cognitive and
social activities of early childhood, children have experiences that help them
explore imagination and reality and promote the development of reality-based
coping with emotional distress.
In situations where preschoolers lack cognitively articulated scripts for cop-
ing, denial (behaving as if a problematic situation did not happen or is not true)
appears to be a common coping mechanism (Cramer, 1991; Fraiberg, 1959; Freud,
1966; Trad, 1989). Anna Freud argued that denial and dissociation are normative in
young children in part because they are promoted by techniques parents use to
help young children cope (e.g., when preparing a child for an inununization
injection, saying "Now, this won't hurt"). Empirical research has supported this
description of preschoolers' coping (Cramer, 1991; Dunn, 1988; Schibuk, Bond, &
Bouffard, 1989).
It is during the preschool years that children first appear to be able to integrate
positive and negative qualities of a person or an event. For example, with play
objects, older preschoolers can represent a single doll as a character who is nice and
then mean. But she is likely to be unable to conceptually represent the possibility
that two people interacting can be simultaneously nice and mean (see Fischer &
Pipp, 1984, for an extended discussion). Analyses of young children's play and
conversations indicate that they develop the capacity during the preschool years to
play out events by assigning roles to characters. They are able to assume roles and to
switch them fluidly during pretend play, to generate imaginary friends, and to blame
their own misdeeds on someone else or use a "pretend identity" (Dunn, 1988; Wolf,
1990).
Dissociative capacity is reported to increase during the preschool years. In
addition, denial, visual hallucinations, spontaneous trance states, amnesias, rapid
shifts in demeanor, imaginary playmates, and sleepwalking may be more common
in the preschool years (Cramer, 1991; Gardner & Olness, 1981; Putnam, 1991).
Although these behaviors may cause concern if seen in older children, they may
allow younger children to isolate and tolerate confusing and complex aspects of
their emotional worlds. Until they are able to coordinate and integrate multiple,
diverging aspects of experience intellectually, young children simply ignore one
part of an experience in order to dwell on the other. This dissociative pattern has
been called "fractionation" (Fischer & Pipp, 1984).
In sum, the data suggest that there is a period between infancy and elementary
school age during which young children may be capable of and tend to engage in
mental strategies that allow them to disconnect events in time, to play with
manipulating reality, and to organize experiences into different characters and
roles. At the same time, they are having many experiences that promote and assist
them with coping in a reality-based way (e.g., parents use of reviewing events and
reasoning about them).
In a family where there is clearly something wrong, and the parents continually
reassure the child that everything is all right and fail to provide opportunities for
labeling the distress, it seems logical that a child could develop a reliance on
76 dissociative coping-failing to cognize about distressful states and events, resorting
Pamela M. Cole to manipulations of reality in fantasy, and subjugating the experience of distress to
etaL the parental "worldview" that everything is well. Recent data indicate that mal-
treated toddlers are less likely to use internal state language than nonmaltreated
toddlers and that these differences are not attributable to differences in expressive
language skill (Beeghly & Cicchetti, 1994). In addition, Fischer and Ayoub (1994)
have shown in case studies and research samples of young children the powerful
influences of maltreatment on the development of the abilities to isolate and
integrate affective and cognitive information. Therefore, it is clear that family
violence and maltreatment interfere with the development of important skills that
allow the child to understand and integrate multiple aspects of their worlds.
The relation between the normative fluidity of young children's thinking and
feeling and instances of pathological dissociation is not understood, and the ques-
tion of whether pathological dissociation can take place in preschool age children is
unresolved. There are reports in the psychiatric literature of cases of child multiple
personality disorder (Kluft, 1985; Peterson, 1991), but the developmental status of
young children makes it particularly challenging to discriminate normative from
atypical patterns. Examination of the child's history may show evidence of extreme
or unremitting dissociative qualities that exceed that noted in typical development.
For example, a 4-year-old boy who had been an incest victim for most of his life
was seen for evaluation to determine whether he was "psychotic." The presenting
problem was that he was completely unresponsive when he was being scolded for
his misdeeds. Some of his wrongdoing was very serious, including trapping the pet
cat in the oven and turning on the oven, breaking all the mirrors in the house,
putting objects in an infant sibling's anus, and setting sheets on fire. When scolded,
he would enter a trancelike state during which he would not flinch if a loud sound
was made behind him. He appeared to have no recollection of the misdeeds or
reprimands. This phenomenon of dissociating himself this completely from what
these types of events is not typical of children this age. The casework history
revealed that he had been subjected to sexual abuse by his mother since infancy.
Studies designed from a developmental psychopathology framework are
needed to assess the various capacities of nonrisk young children and at-risk
children and to follow children's progress over time. Additionally, individual devel-
opment must be considered in the context of the family. We now tum to a
developmental discussion of the formation of incestuous families.

Family Functioning. Abusive family relationships are so imbedded in gen-

erations of family dysfunction that it is hard to define a beginning point. We begin
with the formation of the family in which incest is first identified. As stated
previously, even in the typical and adaptively functioning family, parents engage in
processes that promote the dissociative capacity of the young child. In the context
of a supportive, responsive family system that allows the flexibility to cope in
diverse ways, parents' and children's dissociation are but one of a variety of emotion
regulatory devices, including those that provide a context for the child to advance
to more sophisticated strategies. However, other families appear to function pre-
dominantly in terms of denial of interpersonal distress and via dissociation in the
recognition and interpretation of emotionally significant events.
 We believe that one way that this pattern emerges is when dissociative style 77
characterizes the psychological functioning of one, and usually both, parents. In Dissociation in
fact, we would argue that there is a tendency for young adults with dissociative Typical and Atypical
styles to select each other as marital partners due to a shared history of child abuse. Development
We argue that these parents become active participants in the intergenerational
transmission of psychological patterns that promote the continuation of abuse
across generations.
Attachment theory, which hypothesizes four distinct patterns of attachment,
provides a useful model for understanding the intergeneration:il transmission of
patterns of emotional functioning. In particular, Main and Goldwyn (1984) suggest
that adult attachment provides a means of conceptualizing how functional or
dysfunctional relationships in one's family of origin are internalized and replicated
in the family of procreation. Secure attachment in adulthood is reflected in the
ability to recall emotionally positive and negative childhood experiences with ease
and integration. Insecure attachment in adults is associated with difficulty and
inconsistency in memories of childhood. Adults with a dismissing pattern of attach-
ment idealize childhood. They fail to access negative memories and devalue the
importance of their attachment relationships; this pattern exists even when they
provide evidence of events that would suggest that childhood was far from ideal and
highly aversive. Adults with a preoccupied pattern of attachment are characterized
by heightened affect, excessive dependency on intimate relationships, and an
inability to move beyond the relationships with the caregivers.
A final category-unresolved-fearful adult attachment-may be particularly
important in the understanding of the development of incestuous relationships and
of dissociative disorders as a consequence of those relationships. Main and Hesse
(1990) used this category to describe the behavior of parents whose children were
classified as disorganized in their attachment. These parents appeared frightened
and/or frightening to their children and frequently had a history of their own
traumatic loss or sexual abuse. This same pattern of adult attachment has been
found to be prevalent among incest survivors (Alexander et al., 1995) and to be
significantly correlated with the degree of dissociation and borderline personality
disorder in incest survivors (Alexander et al., 1995; Anderson & Alexander, 1995).
That is, the unresolved, conflictual attachment history of the parent is likely to co-
occur with dissociative symptoms and negatively impinge on the child's ability to
use the parent as a secure base.
Secure attachment provides an individual with the ability to be effective in his
or her own emotional regulation and to be attuned to the emotional needs of
others. These qualities protect against the emergence of incest by guiding the
secure adult both in selecting a well-adjusted marital partner and in organizing the
parent's emotional responses to the challenges presented by children. Therefore,
secure attachment is less likely to be seen in abusive parents and their partners.
Preexisting insecure attachment, on the other hand, can set the stage for
abusive behavior (Alexander, 1992). In this regard, the unresolved-fearful pattern
may be the most predictive of incestuous abuse. Because of the lack of resolution
about their own trauma or loss in childhood, adults characterized by an unre-
solved-fearful attachment are inextricably connected to their families of origin by
the competing fears of intimacy and abandonment. They are enmeshed with their
78 own parents in patterns that are similar to those described by Main and Cassidy
Pamela M. Cole (1988) for the disorganized child. That is, their relations with their own parents are
etal. conflictual and reflect the approach-avoidance conflict that paralyzes the young
child. For example, Alexander and Schwartz (1995) found that dissociation is
significantly correlated with both fusion and triangulation with one's family of
origin. This intense emotional involvement with the parents and an inability to
resolve these ambivalent relationships interfere with the adult's ability to form
loyalties and intimacy with a marital partner and increases the likelihood that he or
she will act out the same approach- avoidance conflicts with the partner.
Research evidence indicates that the marital relationship of an adult who is
unresolved is compromised both by her difficulty in separating from her family of
origin as well as her social discomfort with and avoidance of intimacy (Alexander
et al., 1995). Many such adults never marry but for those who do, the result is
frequently a couple which, as a consequence of their own difficulties in emotion
regulation, is susceptible to patterns of rapid escalation of negative emotion during
conflicts (Kobak & Hazan, 1991). The threatening quality of the emotional escala-
tion activates the attachment system and the pattern of vacillation between intense
enmeshment and emotional distancing between the partners. They cannot satisfac-
torily resolve conflict or derive support and nurturance from one another. Fear of
abandonment, however, may preclude the dissolution of this unhappy, ultimately
destructive marriage.
When a child is born into this dysfunctional family system, the stage is set for
the stabilization of the family pattern and for the intergenerational repetition of the
incestuous pattern. Adults who have failed to resolve the fear and dependency of
their early attachment relationships and who have been abused at an early age are
likely to abuse younger children. In fact, perpetrators who abuse preschool-age
children have been distinguished from those who abuse older children; the former
appear to be motivated by unresolved conflicts related to nurturance, abandon-
ment, and separation, whereas those who abuse older children are more motivated
by power and dominance (Waterman, 1986).
The psychological functioning of adults who are unresolved with regard to
attachment, and who may exhibit the related dissociative and borderline person-
ality disorders, is characterized by splitting and projective identification (Alexander
et al., 1995; Everett, Halperin, Volgy, & Wissler, 1989). These defenses permeate all
relationships in the dissociative family (Sachs, Frischolz, & Wood, 1988) and inter-
fere with the parent's ability to distinguish the child's needs from the adult's needs
and to help the child integrate experience (Everett et al., 1989; Kluft, Braun, &
Sachs, 1984). Finally, the emotional demands that the child places on the parent
challenge the parent's sense of adequacy (Cole, Woolger, Power, & Smith, 1992),
which further activates dissociative functioning (Main, Kaplan, & Cassidy, 1985).
The young child enters this system with presumably normal emotional re-
sponses that organize her affiliative behavior. However, if the child's very presence
triggers a dissociative response from the parent or if the parent appears inexplica-
bly frightened or dissociates when interacting with the child, the impact on the
child is distressing. In such distress, the child is likely to feel an increased need to
access her attachment figure (the parent). This may in turn increase the parent's
withdrawal, fear, and dissociation. This emotional cycle is thought to lead to the
dissociative-disorganized attachment pattern observed in children (type D). The 79
child's resulting multiple and incompatible experiences of self may include the self Dissociation in
as vulnerable, as threatening, as rescuer of the frightened, vulnerable parent, and as Typical and Atypical
abandoned and unlovable (Liotti, 1992). Thus, the child is susceptible to the Development
development of a dissociative disorder even before the experience of abuse has
occurred.
We have taken considerable time to discuss the role of dissociation in early
childhood and parental risk factors that jeopardize family functioning and child
development prior to the onset of incest. It is important to recognize that the
trauma of incest may not cause dissociative disorder directly, but may be a product
of a larger intergenerational phenomenon in which a dissociative style creates a
climate in which sexual abuse can occur and be tolerated. In such a predisposing
atmosphere, it becomes difficult for the child to advance beyond a reliance on
dissociation as a primary means of emotion regulation. In this case, the onset of
sexual abuse in early childhood may create risk for the development of a severe
dissociative disorder. We now turn to the qualities of the child and family during the
incestuous period that could serve to support and sustain a reliance on dissociative
processes.

Child Development and Family Functioning during the Incest

The Chlld. In the years that precede the onset of puberty, there is a reported
decrease in the reliance on denial and dissociation as a method of emotion regula-
tion (Cramer, 1991). The socioemotional tasks of the childhood years include the
development of an increasing sense of one's own cognitive and social competence
and sense of control (Connell, 1990; Harter, 1983), and coming to understand
oneself in terms of intangible, psychological characteristics (thoughts, feelings,
motivations) and in relation to others (Harter, 1983; Ruble, Boggiano, Feldman, &
Loebl, 1980; Selman, 1980). Around age 8 or 9, conscious self-criticism and aware-
ness of feelings like shame and pride are more evident (Ferguson, Stegge, &
Damhuis, 1991; Harter, 1982; Selman, 1980).
The child is faced with understanding her social and private selves as having
both positive and negative qualities. A major developmental task of this period is
the integration of multiple aspects of self, including the integration of positive and
negative qualities; in younger children, "opposite" qualities (good and bad, happy
and sad, mean and nice) are cognitively incomprehensible, and they deny one or
the other quality (Fischer, Shaver, & Carnochan, 1990; Harter, 1983). The integration
of these multiple aspects is facilitated by the development of operational thought
and metacognitive processes that permit reflection upon the self as an object of
thought.
School-age children are also embarking on forming and maintaining relation-
ships of choice (Damon, 1983), which further aid them in their developing under-
standing and evaluation of themselves and others. They understand that friends
share enjoyable activities and are cooperative with one another, are sensitive to
peer evaluation, and begin to incorporate others' perspectives into their interper-
sonal transactions (Selman, 1980). As they approach adolescence, they achieve
more cognitively sophisticated experiences of loyalty and trust in their friendships
80 (Berndt, 1981; Selman, 1980). They also come to inhibit impulsive or selfish acts for
Pamela M. Cole the sake of social relations, to reconceptualize wrongdoing and experience guilt in
et aL terms of how they view themselves rather than on the concrete consequences of
wrongful actions (e.g., punishment), and to internalize a sense of how others see
them. Inference, reflection, and reasoning provide more latitude in problem-
solving. The cognitive and social advances of the childhood years may promote the
use of blaming (actual) others and rationalizing wrongdoing and a decrease in
denying or forgetting misdeeds (Cramer, 1991; Douglas, 1965; Freud, 1966; Sclllbuk
et al., 1989).
The timing of the onset of incest in most cases co-occurs with the timing of
these developmental tasks. The average age at which the first sexualized contact
between father and child occurs is between 7 and 9 years (Kendall-Tackett & Simon,
1988). Abuse prior to or at this time compromises the child's successful acquisition
of all of the developmental tasks of childhood. Unable to relate realistically to
emotionally intense experiences and lacking adequate models for flexible self-
control, the child's behavior may vacillate between diminished and rigid control.
Intense guilt, shame, and confusion diminish the likelihood of feeling secure
enough to build friendships and to receive social support outside the home. Data
show that physically abused school-age children are less liked by their peers
(Dodge, Pettit, & Bates, 1994) and that they develop an internal sense of themselves
as unlovable and others as unloving (McCrone, Egeland, Kalkoske, & Carlson, 1994).
However, it is not simply a case of the development of a negative view of the self and
the world; instead, dissociative processes interfere with an integrated view. More-
over, many perpetrators actively confuse the victim about the meaning and content
of events through the use of both denial and confusion techniques. For example,
one of our clients said that her father would ask her what had happened between
them after each sexual incident and then shout at her that she was wrong and crazy
and that he would kill her if she ever said such untruths. Thus, while denial and
dissociation typically decrease during this period, they appear to remain elevated in
sexually abused children (Adams-Thcker, 1985; Trickett, MacBride-Chang, & Put·
nam, 1994). These family dynamics interfere with the integration of positive and
negative aspects of self and realistic self-appraisal.

The Adolescent. Father-daughter incest is believed to have the longest

duration of all forms of childhood sexual abuse (Wyatt & Newcomb, 1990). There-
fore, the experience of incest usually compromises the child's resolution of the
tasks of adolescent development. The most salient of these tasks is adjustment to
the onset of puberty and emerging sexuality. In typical development, adolescence is
marked by cognitive advances that permit the adolescent to conceptualize psycho-
logical intimacy and to experience the intimacy of self-revelation and intense
closeness in friendships. This is also the period during which the developing
articulated sense of self begins to consolidate as a stable, whole experience (Damon
& Hart, 1982) and as a self-contained secure base for exploring the world that no
longer requires extensive regulation by parents. During this stage of development
toward a consolidated sense of self, youths also experience normative multiplicity
of self as they try on personae and attempt to discover and define who they "really"
are (Harter & Monsour, 1992). Transient experiences of depersonalization and
derealization are not atypical (Putnam, 1985).
 At a point when the typical adolescent girl has the developmental base from 81
which to absorb her changing sexual identity and to incorporate this into her peer Dlssocladon In
relationships, the incest victim has had precocious exposure to sexuality, experi- Typical and Atypical
ences herself as different from any and all of her peers, and has a distorted sense of Development
her self as a partner in relationships. Moreover, the continuing developmental task
of integrating the multiple and changing aspects of self into a coalesced, coherent
whole is probably significantly jeopardized. The nature of the adult outcomes
uniquely linked to incest suggest that this integration is profoundly compromised
by early-onset incest (Cole & Putnam, 1992). If it is the case that the emotional
demands of being an incest victim promote a reliance on dissociation of experi-
ence, then the alternatives of reflecting upon, reasoning about and planning in
relation to problems may be preempted. In fact, many adolescent victims act
impulsively or recklessly, engage in substance abuse, sexual acting out, and running
away, and self-destructive behavior.

Family Functioning. Several characteristics of the incestuous family, and

particularly the dissociation-generating incestuous family, serve to maintain the
abusive relationship and subsequent dissociation. The first characteristic of the
incestuous family that maintains the child's dissociative processes for coping with
the abuse is the dynamic of secrecy and isolation (Braun, 1984). While any form of
childhood sexual abuse is associated with a victim's shame and a strong motivation
for secrecy, children who have grown up in adaptively functioning families can
often overcome these feelings and utilize someone in their support system in the
interest of terminating the abuse. Families with parents characterized by unre-
solved attachment are more likely to depend solely on each other and to avoid social
contacts that might provide opportunities for disclosure (Alexander et al., 1995). In
any primary relationships, their fear of abandonment will preclude their revelation
of the incest. The abuse is therefore less likely to be detected and more likely to
continue into adolescence. Consequently, the child victims are isolated from more
mature adults who might provide a context for social support and affirmation of
reality. The fear of abandonment that permeates such a family further reinforces
avoidance of conflict in coping with the incest and the fear that disclosure will
dissolve the family.
The second characteristic of the family that generates and maintains dissocia-
tion is intense dysregulated affect. A cluster analysis of data from incestuous
families showed that individuals with clinical levels of dissociative symptoms de-
scribed their families as significantly more conflictual than individuals with lower
levels of dissociation (Alexander & Schaeffer, 1994). Both the fathers and the
mothers from these families were significantly more physically abusive to their
children and to each other than were the parents of incest survivors with lesser
dissociative tendencies. These conflicts, characterized by intense emotion and poor
impulse control, convey a very real sense of danger to the child and fosters the
dissociation of her own aggressive feelings as a necessary defense against the
overwhelming conflict she feels between fear of and dependence on the parents.
Finally, the nature ofthe abuse can help to maintain both the abusive relation-
ship and the dissociative response as a primary means of tolerating it. As stated
previously, incest associated with an outcome of dissociative disorder typically has
an onset at an early age. This early onset interferes with the fundamental aspects of
82 the development of self (Cole & Putnam, 1992), unlike the temporal dissociation
Pamela M. Cole more common among victims who are older at the age of onset (Speigel, 1986). In
etal. addition, the perpetrating father is often a primary attachment figure for the child;
he alternates the abuse with active expressions of nurturance and affection (Braun
& Sachs, 1987). In the course of experiencing some form of emotional sustenance
from the father, the victim may perceive and be told by others that she was
unwilling or unable to resist her perpetrator, framing her dependence on him as
active collusion in the abuse. These discontinuities between abusive and loving
behavior and between the victim's own fear and dependence are so confusing and
overwhelming to the young child that dissociation is perhaps the only recourse for
functioning. ·.Jung children, who are not able to integrate opposite qualities into
their understandings (Harter, 1983), must select one side of the paradox. This
aspect of the child's development then supports the unspoken parental dictum that
the paradox not be addressed or acknowledged, contributes to the family's se·
cretiveness, and can be translated into a lack of co-consciousness as in the case of
MPD (Spiegel, 1986).
Dissociation as a primary means of coping with incest is also promoted by
severe and bizarre abusive behaviors. Sometimes highly unusual and disturbing
behaviors are perpetrated by fathers who are otherwise perceived as successful,
prominent, admirable members of the community (Kluft et al., 1984). For example,
one of our clients was forced to drink her father's urine after he sexually abused her;
in his public life, he was a CEO and highly respected member of the church and
community. This discrepancy increases the child's sense of dissonance and unre-
ality and diminishes the likelihood that her disclosure would be believed and the
abuse would be ended. Moreover, the dramatic and sudden shifts between the
perpetrator's public persona and his abusive behavior actually model for the child
discontinuity in mental states (Kluft et al., 1984).
The final characteristic of the incestuous fumily that sustains dissociative proc·
esses is the absence ofa restorative, nurturant relationship that disrupts the abuse
and helps the child deal with the trauma. Many incest victims, despite the abusive
behavior of their fathers, also experienced some convincing love and affection from
him. The resulting ambivalence was heightened by the contrasting perception of
their mothers as emotionally unavailable and punitive. Victims who later develop
MPD often describe their relationships with their abusive fathers as preferable to
the abusive and/or neglectful relationships with their mothers (Anderson & Alex-
ander, 1995). Thus, the victim may feel motivated to sustain the one supportive
relationship she perceives, resulting in the omission of many facts and perceptions
from her consciousness and memory.
Although not all incestuous families are alike, we believe that these are· a
number of dimensions that serve to promote and support coping through the
reliance on dissociative processes. Unfortunately, many of these qualities persist
even if the sexual activity ceases. We now turn to a discussion of developmental
issues in the period after the sexual activity has ended.

Adult Development and Family Functioning after the Incest

The Adult Child. The family processes that support and sustain the dissocia-
tive process continue into adulthood unless intervening events, such as treatment,
reshape them. We therefore focus this section solely on the victim's adult develop- 83
ment. Adulthood from a developmental perspective is marked by a set of events and Dlssoclation in
transitions that are more self-directed than are the transitions of childhood (Cowan, Typic:al and Atypic:al
1991). These include marriage, birth of the first and last child, and an "expansion" Development
phase that follows the birth of the last child and marks a period of relative stability
(Elder, 1991). Although the order of these events may be variable, most American
adults have identified themselves in terms of one or more of these developmental
tasks by their late 20s and early 30s. The changes are reflected in self and social
development as one becomes identified in terms of a number of roles-worker,
wife, mother-and integrates one's own identity with those of others (Fischer,
1980). The individual has responsibilities to other individuals that must be fulfilled
and that require yet another level of ability to regulate self in such a way as to
accomplish these things maturely. Child-rearing, for example, demands that the
adult regulate his or her own time, activity, and affective state as well as the state of
young children, a particularly emotionally demanding experience (Dix, 1991).
By the mid-30s, typical adults have established an adult lifestyle and enter the
expansion phase characterized by the accumulation of experiences over time that
affords an opportunity for reflection upon these life circumstances and choices. In
terms of self-development, the youthful question, "What will I be when I grow up?"
has been transformed to the reflective question, "Who have I become?" The years
between 28 to 38 seem to be characterized by the awareness of the limitations and
imperfections of one's chosen paths and a sense of the narrowing of one's horizons
(Back & Gergen, 1968; Levenson, 1978).
By the time the incest survivor reaches adulthood, the cumulative impairments
to her self and social functioning may preclude a normal transition into adulthood
and the roles of adult women (Cole & Putnam, 1992; Downs, 1993). These impair-
ments may be reflected in the timing and sequence of major adult decisions, such as
when to marry or bear children. We have had clients who never had a sexual
relationship, who married in adolescence in order to escape the household, and
who have become pregnant in order to try to form a loving relationship with
someone. Moreover, adult sexual relationships are negatively affected in a variety of
ways. The ability to communicate with the sexual partner, to feel secure in express-
ing the limits of one's sexual comfort, and even to experience sexual arousal may be
interfered with due to a lack of mutuality in the survivor's first sexual experiences.
One client, a woman who was an executive secretary in a Fortune 500 firm,
reported that she was compelled to control men through her sexuality; each time
she met a wealthy man through her work, she would seduce and than abandon him,
taking pleasure in her domiltion over men.
Tendencies toward impulsiveness, lack of insight, and lack of self-respect can
easily promote revictimization. The formation of close, intimate relationships is
difficult because healthy adult relationships rely on trust, a secure sense of self in
relation to another, the ability to regulate oneself in emotional conflicts, and
sufficient knowledge of one's partner. Marriage and parenthood, in particular, test
the self-boundaries an individual has established and likely create more stress than
satisfaction for many incest victims.
On the other hand, adulthood does afford the opportunity to leave the home,
to form new relationships, and eventually to reflect upon and resolve the conflictual
patterns of one's life. Physical distance can promote psychological distance and
84 pave the path for the ability to reflect upon and to reason about the childhood
Pamela M. Cole sexual experience. Moreover, having one's own children and parenting those
etal. children, particularly during the ages when one's own abuse occurred, may serve as
a stimulus for reawakening forgotten or unresolved aspects of the abuse. In our
experience, the average age of the adult incest survivor in retrospective studies
other than college samples, approximately 32-38 years, suggests that incest victims
too enter a period of adulthood self-reflection. Interestingly, many incest survivors
enter therapy with presenting problems other than a history of child sexual abuse,
and a sizable number do not recall the abuse until later in the therapy relationship.
Thus, the therapy process, including the availability of a secure relationship with an
adult, may stimulate the recollection process and lead to resolution of the trauma
(Herman & Schztzow, 1987).

CONCLUSION

Our developmental analysis has contrasted typical emotional development

with the atypicalities of incestuous families that promote dissociative disorder.
There is a growing belief that such disorders emerge as a result of early childhood
trauma such as father-daughter incest. We offer a transactional model by which
normative dissociative phenomena in early childhood may be converted into disor-
ders as a function of (1) predisposing qualities of the parent-child relationship
that may increase the chance of incest occurring, (2) the developmental status of
the child during the time the trauma is occurring, and (3) the capabilities and
coping styles of the family once the incest has stopped. Many of our ideas have had
to rely more on clinical experience than empirical evidence, but we are encouraged
that a developmental framework provides a means of conceptualizing typical and
atypical dissociative phenomena.
There is an acute need for comparative research on the relation between
typical and atypical dissociation. This research requires attention to developmental
theory in order to assess the degree to which atypicalities are qualitatively different
from typical dissociativelike phenomena. The fluidity with which young children
switch roles, their propensities for experiencing imaginary friends and internal
voices, the ease with which they shift states and appear to forget distress, and their
suggestibility or even hypnotizability are all characteristics that can be examined in
typical preschoolers and contrasted with same-age children who have experienced
intense trauma such as incest.
It is necessary and possible to understand how challenges to normative pro-
cesses and deviations at a given point in time relate to the development of a clinical
condition. Developmental psychology offers theoretical perspectives on the course
of children's psychological growth that allow the use of age as a marker for cogni-
tive or socioemotional capacities and that permit cross-sectional comparisons of
nonrisk and high-risk children within specific age groups using measures that are
developmentally sensitive. However, questions addressing individual differences in
early childhood patterns of regulating emotion and the etiology of a dissociative
disorder require longitudinal research. Such work is expensive, time-consuming,
and difficult, and therefore requires careful conceptualization. Ideally, longitudinal
work using high- and low-risk samples would address the nature of the child's 85
coping prior to trauma, at the time of trauma or its disclosure, and periodic Dlssodation ln
assessment of functioning over time. Developmental psychology offers a frame- Typical and Atypical
work for identifying which elements of early childhood and family functioning Development
predict later outcome.
Developmental psychology also offers many procedures for studying social
and emotional functioning in children. In clinical research, there tends to be an
exclusive reliance on symptom checklists and diagnostic interviews. Although
these are valuable toward certain ends, it is also important to recognize that self-
report and parental report data are limited by factors such as a child's age or a family
member's clinical condition. The problems associated with dissociative disorder,
for example, are likely to interfere with the ability to make accurate observations
regarding one's own or other's behavior in emotionally challenging situations. As
can be gleaned from our chapter, developmental research offers a wide variety of
observational methods for studying children and families. Although most have been
used to study normative patterns or individual differences within unselected popu-
lations, many are sensitive to clinically relevant aspects of functioning and can be
used to compare risk and nonrisk groups. One fruitful approach is to assess
functioning under emotionally challenging conditions. For example, the research
on attachment in early childhood suggests that there are distinct ways of coping
with separation from a parent that may be directly comparable to coping with other
distressing situations.
Dissociation is such a fascinating intrapsychic phenomenon that it is easy to
lose sight of the familial context in which dissociative disorders develop. Qualities
of parents in dysfunctional families may promote and sustain abnormal dissociative
styles that not only accompany but may actually precede the onset of extreme
trauma to offspring as in the case of incest. Unfortunately, there is a dearth of
research on the families of individuals with a dissociative style or disorder. Again,
such research needs to include observational techniques including those that pre-
sent emotional challenges that access dissociation-related phenomena rather than
relying solely on self-report. A developmental perspective can guide research on
understanding "dissociation-generating" families, which could provide a subse-
quent basis for the prevention and treatment of dissociative disorder in the at-risk
child.

AcKNOWLEDGMENT. We wish to thank Frank Putnam for his constructive critique of

an earlier draft of this chapter.

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5
Child Abuse in the Etiology
of Dissociative Disorders
Jean M. Goodwin and Roberta G. Sachs

A growing body of literature, both case reports and surveys, links dissociative
symptoms and disorders to childhood experiences of severe abuse. Several surveys
(Bliss, 1980, 1984; Braun & Sachs, 1985; Kluft, 1984a; Putnam, Gurof, Silberman,
Barbar, & Post, 1986) report that 97% of patients with multiple personality disorder
(MPD; also known as dissociative identity disorder, or DID, since the publication of
the Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition [DSM-
IV; American Psychiatric Association, 1994]) report some history of abuse during
childhood. Since the early 1980s, the hypothesis that this high frequency of prior
abuse is somehow intrinsically related to the development of dissociative symp-
toms has become central to theory and research in the field. The present chapter
analyzes in detail this proposed etiologic association between childhood abuse and
MPD. We review case histories and case surveys in which adults and children
describe sadistically assaultive and soul-murdering childhood environments and the
depersonalization phenomena and fantasy absorption that took place during mo-
ments when this environment became overwhelming. We examine the problem of
corroborating histories of child abuse, which remains a major objection to the
hypothesis. We also review similarities between dissociative disorder patients and
other child abuse survivors. Similarities in family characteristics, victim symptoms,
and community response indicate that dissociative disorder patients may represent
some of the more severely abused and severely symptomatic of a continuum of
survivors of child abuse (Braun, 1990). Both abuse and dissociation were denied by

Jean M. Goodwin • Department of Psychiatry, University of Texas Medical Branch, Galveston, Texas
77555-M28. Roberta G. Sachs • Highland Park Psychological Resources, 660 LaSalle Place, High-
land Park, lllinois 60035.
Handbook of Dissociation: Tbeoretica~ Empiri~ and Clinical Perspectives, edited by lMry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 91
92 professionals in the first half of the twentieth century, probably as part of the same
Jean M. Goodwin historical process (Goodwin, 1985b). Comprehensive biopsychosocial understand-
and Roberta G. ing of these disorders requires integration of the child abuse hypothesis with data
Sachs about genetics, physiology, psychology, comorbidity, and natural history, including
treatment responses in patients who dissociate.

PRIOR CIHID ABUSE IN CASE IDSTORIES AND SURVEYS OF

PATIENTS WTI1I DISSOCIATIVE DISORDERS

Books detailing the case histories of patients with MPD have a predictable
rhythm leading to the recovery of the memory of childhood trauma. In Sybil
(Schrieber, 1983) we read about how the patient's mother hanged her upside down
by the feet and then inserted an enema tube into the child's urethra. The Minds of
Billy Milligan (Keyes, 1981) describes a similarly chilling scene: Billy is sodomized
by his stepfather and later buried in the barn for telling his mother; a breathing tube
is left in his mouth, but his father urinates into it. The details are excruciating and
seemingly endless.
Rosenbaum and Weaver (1980) reviewed all cases of multiple personality
published between 1934 and 1978 and found that the majority report incest or other
brutal sexual abuse in childhood, often by a psychotic adult. Saltman and Solomon
(1982) added six more such cases and suggested that much of the symptomatology
of multiplicity can be understood as a particular defensive reaction to sadistic
sexual trauma in childhood.
Bliss (1980), too, saw MPD as a sequel to childhood abuse in individuals
capable of responding to trauma with deep levels of self-hypnosis that can lead to
dreamlike confusion about reality and about the self. Nine of his 14 patients
reported childhood rapes; three others responded to the item with question mark.
Putnam and co-workers (1986) surveyed therapists treating 100 patients diag-
nosed as having MPD. He found that 97% of these patients described traumatic
childhoods; 83% described childhood sexual abuse; 75% reported physical abuse;
61% reported extreme neglect or abandonment; and 41% had witnessed extreme
violence. The number of types of childhood trauma undergone was significantly
correlated with the number of alternate personalities. Coons and Milstein (1984)
found a prior history of sexual or physical abuse in 85% of patients with MPD. Four
other large surveys find prior child abuse in 95 to 98% of such patients (Braun,
1990). These 80 to 100% frequencies of self-report of prior child abuse by MPDs
seem significantly different from the percentage of 42% found in unselected psychi-
atric inpatients (Carmen, Rieker, & Mills, 1984).
In addition, there seemed to be qualitative differences in the nature of the prior
abuse described by MPDs. Cornelia Wilbur (1984a) has detailed the planned,
bizarre, sadistic, multifaceted assaults on the child's self-esteem, of which physical
damage may be the least destructive element. These are not families who abuse out
of lack of impulse control in moments of crisis. In these families the child may be
partially buried in a backyard grave as the standard mode of discipline. Family rituals
may include several adults genitally instrumentating a preschool child, using bottles
or icepicks, the locking of children in closets for days (then punishing them for
having inevitably soiled themselves), and family participation in ritual tortures, 93
which may involve actual or threatened mutilations of animal or human victims Etiology of
(Putnam, 1989). Children are physiologically assaulted with forced fasts, forced Dissociative
feeding, forced enemas and cathartics, and forced alcohol intoxication. They are Disorders
denied medical attention. Within any category of abuse, the abuse experienced by
the future dissociative disorder patient is extreme. For example, in the sexual abuse
cases, these patients seem more likely to have experienced incest pregnancies,
instrumentation with physical damage to genitalia, involvement of multiple sexual
abusers, involvement of siblings and other children as covictims, threats of death or
threats with weapons, and beating or bondage associated with the sexual contact
(Goodwin, 1993a).
In the realm of emotional abuse, the dissociative patients are likely to have
been openly ridiculed and humiliated by multiple family members and insulted
when most hurt and vulnerable, such as being called a whore while the father is
attempting anal intercourse. Humiliating emotional abuse often takes place around
presents and holidays. In one family, the father always bought and wrapped pres-
ents for all the children and left them under the tree, but on Christmas morning he
burned all the presents. Another dissociative patient, as a young boy of 8, had a
group of boys arrive for his birthday party. His alcoholic mother opened the door to
greet them stark naked. Subsequently, he was ostracized by neighbors in his upper-
class suburb. Braun (1984a,b) has discussed the mixed messages that are given to
the child. For example, the child may be burned and then hugged. The child can be
told, "I love you," and a few seconds later is psychologically devalued, being told by
the same parent, "You're no good" or "I hate you." When the abuser is sadistic, there
is emphasis on acquiring total control over the child through terrorized obedience
and the induction of the child into violence as a coperpetrator (Goodwin, 1993a).
Again and again one hears these patients describe a chronic family pattern of
emotional neglect and abuse with chronic unresolved conflict, resentment, and
blaming of the children, confusion with miscommunication and misinformation,
and an inability to mobilize care or protection in crisis. This chronic state is then
punctuated by traumatic episodes-severe emotional abuse, a traumatic abandon-
ment such as being locked in a closet, a physical beating, or, most often, a rape
(Braun, 1984b).

DISSOCIATION AS A DEFENSE AGAINST CHilDHOOD TRAUMA

The kinds of trauma described by patients with severe dissociative disorders

share characteristics with the kinds of trauma described by shell-shocked combat
veterans (Goodwin, 1985a). In the traumatic situation the abused child (1) feared for
his/her own life, (2) feared for the life of a loved person, (3) was in a state of blurred
consciousness due to fatigue, pain, illness, or substance ingestion, ( 4) experienced
some sort of moral confusion, at times related to secrecy or actual "brainwashing,"
and (5) had no available support (Kluft, 1984a). The 5-year-old raped during sleep
and told that she and her mother will be killed if she tells experiences the same five
traumatogenic factors as does the adult in heavy combat who is wounded, whose
buddy is killed, and whose family does not want to talk about the war (van der Kolk,
94 1984). Moral confusion and dilemmas characterize both situations, as the subject is
Jean M. Goodwin
ordered to obey commands to disobey the usual prohibitions against overt violence
and Roberta G. or sexualiry.
Sachs There is a body of data linking a variery of dissociative symptoms to the
experience of stress-derealization, depersonalization, fugue, and amnesia. All of
these can occur in combat situations, panic attacks, and posttraumatic disorders
(APA, 1987, 1994; Spiegel, 1984). Bliss (1980, 1984) would link these symptoms to
the occurrence in extreme stress of spontaneous deep trance states, which are, he
hypothesizes, an emergency defense system in humans and other animals. When
the attacked animal lapses into deep trance, the attacker may believe the prey is
dead and abandon the attack. The animal is protected by trance from overwhelming
anxiery and its somatic consequences, which can result in death. The trance-
induced permeabiliry between psychological and somatic states may be lifesaving
by producing anesthesia or feats of extraordinary endurance and strength (Ross,
1989). 1f the animal subsequently survives, posttrance amnesias and distortions
protect against crippling residual phobias (Volgyesi, 1963). The absorption and
suggestibiliry of the trance state allow intense concentration on the problem of
survival and automatic obedience, which is often adaptive in the presence of the
attacker. (Later, however, this lack of critical capaciry may transform the attacker's
emotional abuse into unquestioned tenets of the victim's poor self-esteem.) The
"hidden observer" phenomenon allows the traumatized individual objectiviry and
emotional distance despite the panic-producing death threat.
Folklore and literature support the concept that dissociation protects against
death threat. In Jewish tradition there is a custom that when a child is very ill, on the
brink of death, one changes the child's name in the hope that the Angel of Death
will go away empry-handed if the child it has come to collect does not answer to the
old name (Arlow, 1966).
Many clinicians view the severe dissociative disorders as a maladaptive use of
dissociation in the face of the chronic stress of physical, emotional, or sexual abuse
(Putnam, 1985; Spiegel, 1984; Stem, 1984). A child who is continuously beaten by
his/her parents may defend against an attack by dissociating. Where abuse is
continuous, dissociation occurs repeatedly. Gradually, these dissociated states may
begin to take on a life history of their own, and if the process progresses, different
"personalities" or different "realities" may begin to develop as split-off experiential
worlds.
One source of supporting data for this hypothesis comes from studies of
general population samples reporting significant correlations between severiry of
remembered child abuse and elevations of measures of dissociation (DiTomasso and
Routh, 1993). Not all victims, however, even of the most severe child abuse, develop
dissociative disorders. The most plausible explanation seems to be that there are
wide constitutional differences in the abiliry to dissociate. Clinical observation and
research conducted over the last 25 years have clearly documented a range of
individual differences in response to a hypnotic induction (Frischholz, 1985;
Hilgard, 1970; Spiegel & Spiegel, 1978). Those hypnotic phenomena that are most
similar to dissociative symptoms, such as posthypnotic amnesia and the "hidden
observer," are significantly correlated with high hypnotizabiliry. In other words,
only the most hypnotizable subjects evidence dissociative phenomena (Hilgard,
1977). Abused children with limited capacities to dissociate may handle their terror 95
in other ways-through impulsive action, psychosomatic symptoms, obsessions or Etiology of
compulsions, creative sublimation, or other mechanisms. Dissociative
There may also be individual differences in the ability or tendency to create Disorders
fantasy figures who can substitute for the dissociated self during abuse incidents, or
who can remain untouched by the abuse in a fantasy world. The extraordinary
imaginative capacity of some dissociative patients has been noted (Wilbur, 1984b).
There may be another population of abuse survivors who are able to dissociate, but
do not elaborate alternative imaginative realities. Such individuals may be ham-
pered by depersonalization, uncontrolled trance phenomena, and dense childhood
amnesia, but may not develop fantasy identities.

CORROBORATIVE EVIDENCE FOR PATIENTS' ACCOUNTS OF

CHilDHOOD ABUSE

How valid is the patient's self-report? Since many consider patients with
dissociative disorders to be overly histrionic, they also question whether some of
their reported incidents of child abuse are elaborated by the patient in order to self-
dramatize. Freud came to view his patients' accounts of prior seductions as ver-
balized fantasies; events that the patient wished or imagined had happened but
never did (Goodwin, 1985b, 1993b). Some therapists are extremely cautious about
accepting the bizarre and grotesque accounts of family life recounted by patients
with multiple personality disorder with the same degree of certitude with which
they accept a patient's accounts of allergies or prior hospitalization.
Some of this caution is based on resistance to confronting a world in which
such horrors are commonplace. Some caution, however, is justified. The basic
therapeutic stance in reconstructing childhood memories requires an openness to
possible additions, to shifts of emphasis, to new emotional coloring, to restructur-
ing. In reconstructing an episode from a dissociative patient's past, therapist and
patient must face: (1) sometimes total forgetting and amnesia; (2) splitting of the
event into multiple memories or memory fragments held by different parts of the
self that were present or nearby at times of overwhelming stress; (3) distorted or
partial memories deliberately introduced by an alter who is trying to conceal
something worse than this "cover memory"; (4) memory that exists only as over-
whelming emotion, reenactment, somatic sensations, or dream material; and
(5) memories of dreams or fantasies derived from traumatic nightmares in child-
hood, or from daydreams during trance states self-induced to protect the patient
from his/her overwhelming fear during abusive episodes. However, when corrobo-
rative data have been available, time and again the therapeutic conclusion has been
that the end result of these distortions had led to minimization, rather than exag-
geration, of the extent of the childhood abuse (Putnam, 1989).
The search for corroborative and documentary evidence about the patient's
often totally forgotten childhood is an important part of treatment. School and
pediatric records can be helpful, and the patient may be ready for this kind of
documentation before family contact. Protective service or psychiatric records may
be available for the patient, for a sibling, or for a parent. Death or suicide of a sibling
96 is not infrequent in these disturbed families, and death certificates and autopsy
Jean M. Goodwin records are helpful here. Criminal and civil court records may also contain perti-
and Roberta G. nent data.
Sachs Parents, parent figures, and siblings can sometimes be interviewed or reached
by telephone or letter. In interviewing family members it helps to know that most
abusive parents deny abuse and that most require intensive individual and group
therapy before they can profit from family therapy. Siblings are often more open.
like the parents, they may deny abuse; but if asked specifically about violent
behaviors, they may describe witnessing violence or experiencing or perpetrating
abuse.
The task in interviews is the simple, almost journalistic one of rediscovering
details about life history that have been lost in the patient's dissociative amnesia and
confusion. Where did the family live and when? What were the major family events?
Illnesses? Deaths? Job changes? Did the patient have extrafamilial caretakers? Re-
viewing a parent's childhood history may be useful for both the parent and the
patient, in illuminating the nature of the parent's own emotional impoverishment.
Collateral interviews with family members should be done gently and with in-
formed consent, as paranoid or depressive breaks or suicidal attempts are possible.
With the dissociative patient, as with the abused child in foster or group home care,
it may be helpful to make a "life book" where documents, photographs, memories,
and information from collateral sources (including dissociated self-states) can be
integrated.
A current physical examination of the dissociative patient can also provide data
about fragmentary childhood memories. There may be radiological evidence of
fractures or genital mutilation or other scarring. It should be noted that the absence
of physical evidence does not disprove childhood abuse (Goodwin, 1982). In some
cases the patient will decide to involve a trained investigator, by informing protec-
tive service or law enforcement authorities about memories of crimes a parent may
have committed, or by hiring counsel to bring suit for damages against a parent or
parent figure.
Experienced therapists report that when corroboration was attempted, this
could be achieved in more than two thirds of patients (Braun, 1984b; Kluft, 1984b;
Kluft, Braun, & Sachs, 1984). For example, in one case the patient claimed that
when she was a little girl she had suffered a ruptured appendix and had been forced
by her mother to walk to the hospital. Hospital records confirmed her account. In
another case, a male dissociative patient claimed that his mother had inserted pearls
into his penis and pushed them up the urethra with a thermometer. When kidney
stones later prompted urologic consultation, considerable scar tissue was noted in
the patient's urethra and the passage was so dilated that a large stone passed with
little difficulty. Other kinds of convincing corroborative data include eyewitnessing
of abusive events by siblings, parents, adult or child acquaintances, or the identifica-
tion of other victims of physical or sexual violence either among family members or
neighbors or acquaintances who name the same abuser.
Neurophysiological evidence for prior child abuse can be clinically observed
during the course of therapy in some patients as they describe child abuse. For
example, one patient reported being repeatedly burned with a cigarette by her
mother. When she described this, the therapist noted red spots like burn marks
appearing on the patient's skin. In another case, as the patient was describing how 97
she had been choked by her mother, her voice changed abruptly to become hoarse EdoJogyof
and raspy. When a patient shows extreme physical pain or panic during a recon- Dissoclat1ve
struction, it may be helpful to obtain a pulse rate. When physiological changes are Disorders
present, the patient's narrative may have to be interrupted to avoid retraumati-
zation.
Other types of neurophysiological evidence can be seen in the patient's cur-
rent response to touch or other contact. One patient reported that whenever
anyone started to hug her she would hold her breath. When asked why, the patient
said, "Because that's the way I begin to go away." She described rapes by her father
when she was a child. She habitually dissociated from these attacks by holding her
breath and trying to disappear into the wall.
Such phenomena are instances of the "truth of abreaction" experienced by
many therapists. When a 3-year-old ego state describes a sexual assault by her father
in the language of a chronological3-year-old and using similar kinds of drawing, one
is hard put to disbelieve her account in the midst of an abreactive storm that may
include the destruction of the father doll and long episodes of sobbing. The
reenactments of traumata that occur in these patient's lives can also be emotionally
convincing: for example, the mother who does not recall her own rape at age 4 until
her daughter is raped at that exact age or the patient raped in adulthood by a
policeman as a prelude to recalling an identical childhood rape by a similar author-
ity figure.
More research is needed about the collection and assessment of accounts of
childhood trauma. Available data indicate that automatic dismissal of such accounts
as fantasy is not warranted, even (or perhaps especially) when the account includes
amnestic gaps. Herman and Schatzow (1987) found in a sample of 53 female
patients who gave sexual abuse histories that two thirds experienced dissociative or
amnestic gaps in their narratives, and three quarters were able to obtain corrobora-
tive data about their sexual abuse. Williams (1993) interviewed 100 adult women
whose child sexual abuse had been substantiated by medical records 17 years
before. Thirty eight percent denied any memory of sexual abuse.
These phenomena are consistent with laboratory research. Memory for events
ebbs and flows with time. Memory for traumatic events and memories from child-
hood are particularly fragile (Loftus, 1993). Procedural memory can persist, produc-
ing physiological and emotional effects when narrative memory has faded (Erdelyi,
1989). Because highly hypnotizable subjects are capable of experiencing both
negative and positive hallucinations and can misfile these as memory, either with or
without specific external suggestions, these phenomena, too, must be factored into
the reconstructive process.

DATA FROM CHilDREN WI11I DISSOCIATIVE DISORDERS

Since children and adolescents with dissociative disorders are closer in time to
childhood trauma, reconstruction with eyewitness or other evidentiary corrobora-
tion is sometimes easier. Kluft (1984a) found that four of five children with MPD
had been physically abused and that abusive incidents had precipitated new person-
98 ality splits. He also reported the case of a mother-child pair, both of whom had
Jean M. Goodwin dissociative disorders with the elaboration of alter personalities. Both host person-
and Roberta G. alities denied that physical abuse was a problem, even when this occurred in the
Sachs psychiatrist's office. It became apparent that both mother and child switched to
other personalities during abusive incidents. Fagan and McMahon (1984) also
reported four cases of childhood MPD, all of which involved severe child abuse.
Braun (1985) has reported that dissociative disorders may be transgenerational.
In a study of 17 MPD cases where family history data were available, several patients
with MPD were found to have mothers who suffered from this disorder. The
dissociative mothers were also abusive to their children. Braun estimates that 10%
of the children of patients with MPD are abused, often by violent alters. Such
children may carry a genetic vulnerability to high hypnotizability as well as being
exposed to a parent who displays sudden and extreme shifts in behavior and
emotion, as well as coping with incidents of traumatic abuse. These factors may
contribute to the transgenerational transmission of dissociative disorders in some
families (Kluft et al., 1984).
When dissociation develops in childhood, the defensive function against the
situational stress may be quite clear (Goodwin, 1985a), as illustrated by the follow-
ing case:
A 13-year-old girl complained to her mother of sexual abuse by her brother.
When mother ignored these complaints, the girl began to hear a named voice
inside her head telling her to criticize and rebel against her mother.
The case is reminiscent of Despine's 1836 description of 11-year-old Estelle, whose
alter personality could not tolerate her mother, although the host personality was a
devoted daughter (Ellenberger, 1980). Despine was unable to identify the reality
factors associated with his child patient's hatred of the mother.

PATfERNS IN CHILD ABUSE EPIDEMIOWGY WHICH SUGGEST

UNKS WITH THE DISSOCIATIVE DISORDERS

like MPD (DID) child abuse tends to run in families with as many as 80% of
abusers having been emotionally, physically, or sexually abused in childhood (Good-
win, 1982; Helfer, McKinney, & Kempe, 1976; Oliver, 1993). As noted in the pre-
vious section, some child victims of abuse present with dissociative symptoms.
Some abusive parents also are observed to dissociate (Brown, 1983). When a child
abuse victim describes the abusive parent as "two different" people, this may
represent accurate reality testing rather than the emergence of primitive splitting
(Lesnik-Oberstein, 1983). The following case illustrates the kind of problems pro-
tective service workers face in treating perpetrators who dissociate:
Six-year-old Jennifer was referred to protective services because of severe tan-
trums at school during which she threw off her clothes and shouted obscenities.
Physical examination showed a slack vagina, a broken hymen, and many bruises.
She said "Daddy squashes me when he lies on top of me and hurts my wee-wee."
She played repetitive games in therapy in which she was pursued and tortured
 by a monster. Her father, Victor, met confrontation with a blank denial, although 99
he said he had had a precognition that his child might be sexually abused. He
Etiology of
suggested a seance to identify the abuser. He had two prior convictions for Dissociative
pedophilia. He was usually soft-spoken and articulate, but exhibited sudden Disorders
violent behavior changes: on one occasion he strangled the family dog, on
another, he attempted to run over the social worker. He described his mother as
evil and his father as a tyrant. His twin brother had been psychiatrically hospi-
talized after trying to knife the mother. The only treatment Victor would accept
was sex change surgery so that he could become the named female alter who
had cross-dressed since childhood.

Parental dissociative disorder should be considered in those child abuse cases

where (1) the abuse is bizarre or severe, (2) the abuser denies all memory of the
abusive incident, (3) the abuser has multiple names or ways of presenting himself,
and ( 4) the violence in the abuser's family was extreme.
A review of the child abuse literature provides convincing evidence that se-
verely disturbed families of the type described by patients with dissociative dis-
orders exist, and that they account for a substantial minority of cases-15 to 50%,
depending on the type of abuse substantiated. Even with mandated reporting and
treatment of child abuse, it is estimated that at least 30% of abused children will be
reabused (Gabinet, 1983). As many as 15% of battered babies die and 50% suffer
serious damage (Smith, 1978). Faller (1991) estimates that 16% of incest cases
involve "polyincestuous" families in which the average number of perpetrators is
three and the average number of victims about the same. In most of these poly-
incestuous cases, extrafamilial perpetrators and group sexual activity are also pres-
ent. Recent data indicate that concepts from the 1970s and earlier describing the
"gentle" incest offenders were naive (Goodwin, 1993a). Such perpetrators may
have multiple sexual victims outside as well as inside the home, multiple other
sexual paraphilias, and other criminal offenses including property crimes and
physical assaults (Weinrott & Saylor, 1991). The work of Dorothy Lewis and her
collaborators (1979) indicates that antisocial syndromes may be frequent not only
among the perpetrators but also among the victims of child abuse.
Data about abusive parents broaden our questions about constitutional factors.
Antisocial personality, alcoholism and addictions, paraphilia, and mood disorders
(bipolar and unipolar) can all lead to severe parenting failures. For many of these
conditions there is also evidence of genetic transmission. There may be several
different kinds of familial pathways associated with intergenerational severe abuse.
Data from general population surveys confirm the existence of severe sexual
abuse. About 7% of women in the general population have experienced sexual
abuse by a father or stepfather. Sexual abuse by brothers is often extremely violent
(Finkelhor, 1979; Goodwin, 1982; Russell, 1983). Three percent of parents admit to
having kicked, punched, or bitten a child in the previous year (Gelles, 1979). Three
percent of college men admit to having molested a child (Fromuth, Burkhart, &
Jones, 1991). We know from physical examinations and autopsies of child victims
and from interviews with abusive parents that beatings, burning, knifing, tying
down, biting, and genital mutilation may accompany the sexual abuse of children.
Indeed, it has been suggested that Freud's seduction theory was based in part on his
100 having witnessed the autopsies of raped and murdered children while studying in
Jean M. Goodwin Paris (Masson, 1984).
and Roberta G.
Sachs
SIMILARITY OF SYMPfOM PATIERNS IN ABUSED CHILDREN AND
PATIENTS WITH DISSOCIATIVE DISORDERS

In MPD, the child personalities who still carry the affectively charged memo-
ries of abuse display many symptoms that are similar to those seen in abused
children and particularly similar to those seen in victims of intrafamilial sex abuse or
incest (Gelinas, 1983; Goodwin, 1982). In latency-age incest victims, one sees
headaches, stomachaches, and, more rarely, elective mutism, or globus hystericus
(difficulty swallowing) or hysterical blindness. School failure or erratic school
performance may become a problem and the school may complain that the child is
lying, sexually acting out, or fighting. In adolescence, the most symptomatic victims
present with runaways, promiscuity, suicide attempts, and pseudoseizures. Partial
amnesia for the sexual abuse may be reinforced by drug use or other compulsive
behavior such as eating disorders or sexual addictions. There may be deep confu-
sion about sexual identity, sexual orientation, and pleasure.
The dissociative identity disorder patient seems to represent a layered compo-
site of all these symptom complexes. Indeed, in treating some of the most severely
affected multiple personalities, one seems to be dealing with a human encyclopedia
of all possible sequelae of sexual abuse in childhood. One can see in the various
alters (1) the adaptation of denying the abuse and maintaining a childlike asexual
innocence, (2) the adaptation of rebelling against an authority perceived as corrupt
by rule-breaking and open, sometimes violent, defiance, (3) the adaptation of
becoming a sexual expert and using one's sexual experience to advantage in
promiscuity or prostitution, ( 4) the adaptation of exonerating the perpetrator by
taking all guilt upon oneself and abandoning oneself to suicidal regret and self-
blame, and (5) the adaptation of feeling chosen and special and above society's
rules. Each of these positions can be seen in members of an incest victim' group as
well as in the internal group of some dissociative patients (Goodwin, 1989).

SIMILAlUTIES IN lllSTORICAL RESPONSES TO CHllD ABUSE AND

DISSOCIATIVE DISORDERS

Both child abuse and MPD (DID) (the most complex dissociative syndrome)
are ancient syndromes well-described in folklore and mythology. For example, an
ancient Egyptian legend describes Helen of Troy as having two selves, one of which
stayed in Egypt throughout the years of the Trojan War (Green, 1967). According to
this tale, it was her "Ka," or double, that went with Paris to Troy to be raped and to
endure the siege. The myth alleges that it was the true, unwearied, unsullied Helen
that Menelalus reclaimed in Egypt after the years of war. Our patients, too, tell us
about the longing to send someone else to endure the pain and the desire to
preserve the potential of the self as it was before it was traumatized. One patient
described the death of her only supportive family member at age 4; she recalls
thinking, "I'll stop right here and I'll wait ... and part of me stopped ... part of me 101
decided to wait for him" (Confer & Ables, 1983, p.66). Etiology of
However, neither child abuse nor MPD achieved a place in the scientific Dissociative
literature until the late nineteenth century when Janet and Freud, respectively, laid Disorders
the framework for the modem understanding of multiple personality and of the
traumatic effects of child abuse. The use of dissociation as a heuristic mechanism
for understanding clinical symptomatology is usually credited to Janet (1889), who
believed that consciousness consisted of several streams that did not necessarily
flow together. His theory explained why material that entered consciousness via
one stream might not necessarily be accessible to another stream. This is exem-
plified in MPD (DID) in situations where one or more ancillary personalities carry
affectively charged memories of child abuse about which the host personality may
be totally amnestic.
Although Freud is not remembered primarily as an investigator of child abuse
and its effects, in the 1880s he was developing his seduction theory, which postu-
lated that all neurotic symptoms represented either unconscious repetition of
childhood sexual abuse, as in conversion seizures (Goodwin, Bergman, & Simms,
1979), or remnants of tactics used by the child to protect against the traumatic
impact of abuse, such as obsessional thought (Masson, 1984). Had Freud's and
Janet's observations been brought together at that time, the present chapter might
have been written in 1890. However, both multiple personality and child abuse
were destined virtually to vanish from the psychiatric literature from the turn of the
century to 1970.
Rosenbaum (1980) has noted that the diagnosis of MPD fell into disrepute
around 1910. He hypothesized that one reason for this decline was the introduction
of the term schizophrenia by Bleuler. Rosenbaum goes on to argue that many true
MPD patients were instead given a diagnosis of schizophrenia. This explanation
may account for the sharp decline in reports of MPD listed in the Index Medicus
from 1903 to 1978. Freud's disenchantment with hypnosis as a technique and his
quarrels with Janet may have reinforced the decline into obscurity of Janet's (1889)
ideas.
Another aspect of the rapid decline of interest in MPD is that many psychia-
trists started to believe that it was an artifact of hypnotic suggestion and hence not a
real diagnostic entity (Braun, 1984c; Kluft, 1982). These practitioners incorrectly
asserted that investigators from Despine to Prince had been unknowingly shaping
the very behavior they were observing (Laramore, Ludwig, & Cain, 1977). Research
that has focused on using hypnosis to "create" multiple personalities (Kampman,
1976) is a fallacious extension of this kind of logic. The current diagnostic criteria
for DID stress the importance of differential diagnosis, including schizophrenia and
other possibilities and balancing concerns about underdiagnosis due to lack of
professional awareness with concerns about overdiagnosis due to the suggestibility
of highly hypnotizable dissociative patients.
During this same era, Freud's rejection of the seduction theory on grounds that
patients were recounting sexual fantasies rather than real events created a scientific
mythology that for generations resisted all assaults by the realities brought to
therapists by the numerous victims of incest and their families. Not until 20 years
after the pediatrician, Henry Kempe, advocated the concept that babies with
102 broken bones might have been battered by their parents (Goodwin, 1985b) were
Jean M. Goodwin psychiatrists able to entertain the idea that children who recounted sexual contacts
and Roberta G. with parents might have been sexually abused.
Sacbs Many professionals and the public at large continue to resist both the idea that
dissociation exists and that abused children develop symptoms, perhaps because
both multiple personality patients and incest victims require us to believe things
about parents that we would prefer not to know (Miller, 1984). Humanistic, post-
Christian Western society finds bizarre and sadistic torture incomprehensible. We
have difficulty assimilating data that tell us that among certain schoolmasters,
certain elite secret police, certain religious cults, or sex rings, physical abuse and
torture are encouraged and condoned (Benthall, 1991; Goodwin, 1993a). It often
has been easier to blame or diagnose the victim rather than to try to confront or
empathize with the adult who has abused. Also, therapists are often all too willing
to focus on present-day somatic complaints or impending psychosis rather than
working to fill in the traumatic realities behind a patient's childhood amnesia.
Fortunately, since 1975, understanding, case identification, and treatment efficacy
have progressed in both the field of child abuse and dissociation.

CONCLUSIONS

This chapter has reviewed evidence that MPD (DID) is etiologically related to
dissociative responses to severe childhood abuse. Therapeutic reconstruction of
the life histories of patients like "Sybil" and Billy Milligan has revealed multimodal
childhood torture as a central reality of the patient's life. When larger series of cases
have been studied, childhood abuse has been found to be a factor in 80 to 100% of
cases. The abusive environment usually includes several types of abuse: physical,
sexual, emotional, abandonment, witnessed violence, and severe neglect, often
related to parental alcoholism or other illness. There is also often a special quality of
deliberate, cruel persecution of the child, with parental attempts to maximize the
child's physical and mental pain alternating with periods of normal parenting.
Contrary to some clinician's expectations, when corroborative evidence for prior
abuse is diligently sought, it can almost alwayS be obtained. The physiological and
emotional changes exhibited by the client during trauma narration are convincing
to clinicians but require further study. The many distortions of memory and com-
munication in DID appear designed to minimize and conceal prior abuse, not to
exaggerate it. When children with DID are evaluated, they are. almost always
undergoing abuse, and the splitting off of alters can readily be traced to recent
abusive incidents. The study of children with the syndrome has also provided
evidence that some of the parents sadistically abusing these children also have DID.
A review of the child abuse literature indicates that protective service workers are
also seeing bizarre and sadistic child abuse, which is a demographic fact of our
society, not an invention of patients with DID. The transgenerational transmission
of child abuse parallels patterns of transgenerational transmission seen in dissocia-
tive disorders. Patients with DID seem to demonstrate a composite of the symptoms
seen in incest and child abuse victims generally.
The centrality of child abuse in the etiology of dissociative disorders does not
imply unimodal causation, but rather opens the field to genetic studies of hypno- 103
tizability, antisocial behavior, mood disorders, and addictions and to biological data Etiology of
about the developmental physiology of trauma, learned helplessness, traumatic Dissociative
memory, traumatic anxiety, state change, and "kindling" effects (Erdelyi, 1989; van Disorders
der Kolk, 1987; Post, Weiss, & Post, 1988).

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6
Disorganization and
Disorientation in Infant
Strange Situation Behavior
Phenotypic Resemblance to Dissociative States

Mary Main and Hillary Morgan

The Ainsworth Strange Situation is a brief, structured observational procedure in

which one-year-old infants are exposed to two brief separations from the parent
in an unfamiliar laboratory environment (Ainsworth & Wittig, 1969). The infant's
response to this moderately stressful experience appears to reflect the history of
the caregiving it has experienced, and three traditional patterns of infant-mother
"attachment organization" have been identified, each related to a particular pattern
of maternal1 care (Ainsworth, Blehar, Waters & Wall, 1978). Infants who explore the
room and the toys in the parent's presence, show signs of missing the parent on
separation, seek proximity and contact on reunion, and then return to play are
termed secure. The mothers of these infants have repeatedly been observed to be

'Ainsworth's Baltimore study involved infant-mother dyads only. While many investigators have now
observed father-infant dyads within the Strange Situation, mothers and infants remain the principle
focus in attachment research. While we refer to observations of infant -mother interaction and use the
feniinine form in references to the attachment figure, the reader sbould be aware that infants are usually
attached to the father as well as to the mother, and that investigations of the influence of the early
attachment to the father have been undertaken by several laboratories (as see Suess, Grossmann, &
Sroufe, 1992).

Mary Main • Department of Psychology, University of California at Berkeley, Berkeley, California

94720. Hillary Morpn • Department of Psychology, University of California at Davis, Davis,
California 95616.
Handbook of Dissociation: Tbeorettcal, Empirical, and Cltntcal PerspecUves, edited by Larry K.
Michelson and William J. Ray. Plenum Press, New York, 1996. 107
108 relatively "sensitive and responsive" to their signals and communications across the
Mary Main and first year of life. Infants who focus almost exclusively on the toys, actively avoiding
Hillary Morgan and ignoritfg the parent on reunion, are termed insecure-avoidant, a response
linked to the mother's consistent rejection of infant attachment behavior. Finally,
infants who seem distressed, angry, and preoccupied with the mother throughout
the procedure, and fail to settle by the end of the final reunion episode are termed
insecure-resistant/ambivalent (hereafter, insecure-resistant). lbis behavior pat-
tern has been found linked to inconsistent and unpredictable maternal responsive-
ness. Each of these three traditional patterns of attachment are considered to
represent organized strategies for dealing with the stress of separation from the
parent in a strange environment (Main, 1990), although attachment to the mother
has repeatedly been found to predict less favorable outcomes than does secure
attachment in later childhood (see Cassidy & Berlin, 1994, and Main, 1995, for an
overview of the foregoing studies).
In the last decade, a fourth, insecure-disorganized/disoriented attachment
category has been identified (Main & Solomon, 1986, 1990). This category was
developed following the observation that some infants suffer one or several disrup-
tions in behavioral integration during the Strange Situation, as shown in markedly
disorganized and/or disoriented behavior exhibited in the parent's presence. While
home observations of disorganized infants and their parents have yet to be c.1m-
pleted, Main and Hesse (1990, 1992) have proposed that disorganized and disori-
ented behavior may result from frightened and/or frightening behavior on the part
of the parent. In general, these infants are currently expected to be at greater risk
for psychopathology than those falling in the "organized" insecure attachment
categories (Zeanah & Emde, 1993), and liotti (1992) has proposed that disorganized-
disoriented infants may be more vulnerable than other infants to developing disso-
ciative disorders in later life.
The overall aim of the present chapter is to examine liotti's hypothesis in the
light of what is presently known regarding behavioral and representational pro-
cesses in disorganized-disoriented children and their parents. While not all
disorganized-disoriented behaviors have a clear relation to dissociative phenom-
ena, some infants have been observed, for example, in postures which bear a strong
resemblance to dissociative trance. 2 Thus, a number of one-year-olds have been
observed freezing all movement for as long as 45 seconds, sometimes with hands in
air. During this period the infant appears unresponsive to changes in the environ-
ment, with eyes unmoving and half-closed. Additionally, the Strange Situation
behavior of a subset of disorganized -disoriented (hereafter, disorganized) infants is
suggestive of the intrusion of dissociated actions (and/or of brief changes in execu-
tive control) as described by Hilgard (1977/1986). For example, one 12-month-old
responded to the first seconds of reunion with her father as follows:
Creeping rapidly forward to father as though to greet him in the doorway, the
infant suddenly stops and turns her head 90 degrees to the side. Gazing blankly

"The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM·IV)
identifies "dissociative trance" as a •narrowing of awareness of Immediate surroundings or stereotyped
behaviors or movements that are experienced as being beyond one's control" (American Psychiatric
Association, 1994, p. 490).
 at the wall with face expressionless and eyes half-closed, she slaps her hand on 109
the floor three times. These gestures appear aggressive, yet they have a ritualis-
Disorganization and
tic quality. The baby then looks forward again, smiles, and resumes her ap- Disorientation
proach to father, seeking to be picked up.

Main and Hesse (1990, 1992) have proposed that disorganized-disoriented

infant attachment status may result from frightened and/or frightening behavior
on the part of the parent. Specifically, they suggest that because the attachment
figure is the primate infant's haven of safety in times of alarm, the infant frightened
by the attachment figure should experience simultaneous tendencies to approach
and to take flight. Conditions of this kind present an attached infant with a paradox
which cannot be resolved in behavioral terms, and a collapse of behavioral and
attentional strategy is therefore expectable.
Since maltreated infants will frequently have been directly threatened by the
attachment figure, this theory accords well with the fact that the great majority
(about 80%) of parentally maltreated infants in high-risk samples have been found
disorganized (Carlson, Cicchetti, Barnett, & Braunwald, 1989; Lyons-Ruth, Re-
pacholi, McLeod, & Silva, 1991). Disorganized behavior also appears, however, in
about 20% of infants in low-risk samples, where it has repeatedly been found
associated with parental lapses in the monitoring of reasoning or discourse during
discussions of traumatic experiences-most often the death of a significant person.
These lapses have been observed during the Adult Attachment Interview (George,
Kaplan, & Main, 1985/1995) where, when asked to describe a significant loss
experience the parent of a disorganized infant may fall silent; may exhibit contradic-
tions and confusions regarding the time at which the loss occurred; or may subtly
indicate that the dead person is in some way considered still alive in the physical
sense (Main & Hesse, 1990). Lapses of this kind suggest momentary disorganization
and disorientation in reasoning and language processes and may, like infant disorga-
nized attachment status, also fit to a dissociative modt'l (Main & Hesse, 1992). Main
and Hesse have proposed that parents suffering such lapses within the interview
context may also sporadically exhibit frightened, dissociated behavior in the pres-
ence of their infants, and hence at times be frightening. Under these conditions,
the parent's experience of trauma is presumed to be reflected in frightened-
dissociated behavior which, while sufficiently frightening to yield behavioral dis-
organization in infancy, is not directly threatening. In such cases, the infant's dis-
organized attachment status may be seen as a second-generation effect of the
parent's own directly traumatic experiences (Main & Hesse, 1990).
A relation between disorganized attachment status as observed with the pri-
mary caregiver in infancy and increased vulnerability to dissociative disorder was
first proposed by Liotti (1992). Because frightened-frightening parental behavior
arouses contradictory tendencies in the attached infant, Liotti suggested that dis-
organized behaviors may represent a semihypnotic response to the "paradoxical
behavioral injunction" presented by the frightened-frightening parent. Liotti's
(1993) hypothesis has been elaborated in a case study involving a dissociative adult
patient, who focused obsessively on anomalous fears regarding the fate of her infant
and was later found likely to have been disorganized with her mother during
infancy. Additionally, utilizing a relatively large clinic population, Liotti has found
110 evidence that a high proportion of patients suffering specifically from dissociative
Mary Main and
(as compared to other) disorders may have been disorganized with mother during
Hillary Morgan infancy (Iiotti, 1992, in press). Further support for liotti's hypothesis comes from a
recently completed prospective longitudinal study of adolescents originally ob-
served in the Strange Situation in infancy. In this study, dissociative behavior
observed by teachers in the high school setting was found predictable from disorga-
nized attachment status with the mother (Carlson, submitted manuscript).
If the essential feature of the dissociative disorders is "a disruption in the
usually integrated functions of consciousness, memory, identity or perception of
the environment" (American Psychiatric Association, 1994), disorganized and dis-
oriented behavior as it appears in the 12-month-old infant can at present only
provide intriguing parallels to dissociative experiences described by adults and by
older children. Moreover, although some lapses in reasoning and discourse ob-
served in the parents of disorganized infants seem compatible with a dissociative
model, these individuals have yet to be systematically queried regarding any accom-
panying sense of disruption in consciousness, memory, identity, or perception.
In this chapter, we refer therefore to a phenotypic resemblance between
disorganized behavior observed in infants, lapses in the monitoring of reasoning or
discourse observed in adults during the discussion of traumatic experience, and
dissociative states. The term phenotypic is selected for the purpose of reminding
the reader that we are dealing with appearances only. We do not know whether the
causes and antecedents of these phenomena are similar (homologous), and we have
as yet no satisfactory assessments of the subjective experiences of individuals
exhibiting the behaviors described. Indeed, whether early disorganized attachment
status in fact increases vulnerability to dissociative states, experiences, and dis-
orders is an empirical question which is only now beginning to be addressed in
prospective longitudinal studies.
In the conclusion to this chapter, we suggest that disorganized attachment
status in infancy is likely to increase vulnerability to a number of unfavorable
outcomes, including not only dissociative disorders, but also phobias, anxiety, and
heightened aggressiveness. In keeping with Lyons-Ruth's (in press) recent analysis
of the relations between hostile-aggressive behavior in the school setting and
infant disorganized attachment in a poverty sample, we speculate that there may be
an asymmetry of relation between disorganized attachment and dissociative dis-
order dependent on whether we are looking forwards from infancy (few disorga-
nized infants in Lyons-Ruth's sample showed clinical levels of hostile-aggressive
behavior) or looking backward (the great majority of those exhibiting above normal
levels of hostile-aggressive behavior had been disorganized as infants). Looking
forward, then, we may find that only a small proportion of previously disorganized
individuals suffer from dissociative disorder in later life. Looking backward from
those already suffering from such disorders, we may find that a substantial majority
had been disorganized with the primary caregiver during infancy. We examine
some of the reasons why this asymmetry of relations may be expected; we suggest
that there may be a general heightening of suggestibility and hypnotizability in
some previously disorganized infants; and we offer some suggestions for future
studies.
A'ITACHMENT, FEAR, AND THE MAINTENANCE OF BEHAVIORAL 111
ORGANIZATION WITIIIN THE STRANGE SITUATION: Disorganization and
BOWLBY'S THEORY AND AINSWORffi'S mREE TRADmONAL Disorientation
A'ITACHMENT CATEGORIES
In order to understand the import of both organized and disorganized re-
sponses to the mother's leavetaking in an unfamiliar environment, it is necessary
to turn to the theory of attachment as developed by Bowlby (1969, 1973, 1980).
Drawing on evolutionary theory, anthropology, and observations of ground-living
primates, Bowlby called attention to the functioning of an attachment behavioral
system which, having evolved in man's original environment of evolutionary adapt-
edness, still acts to lead the infant to continually monitor the physical and psycho-
logical accessibility of parental figures, termed attachment figures (Bowlby, 1958,
1969, 1982). Behaviors having the predictable outcome of increasing proximity
between infant and attachment figure (such as crying, calling, pursuing, and cling-
ing) are termed attachment behaviors, and are ascribed to the activity of this
complex, instinctively guided but environmentally inlluenced control system. For
ground-living primates attachment behavior, i.e., behavior assisting the infant in
maintaining proximity to a protective, older individUal represents the primary
behavioral mechanism regulating infant safety and survival. Although at present the
survival of human infants is usually assured even during substantial separations from
attachment figures, the infant's behavioral and emotional repertoire-i.e., its re-
sponse to threat of separation, to separation itself, and to reunion-is still consid-
ered to be inlluenced by its evolutionary heritage (Bowlby, 1973, 1980). Although
less readily activated at older ages, the system is presumed to function throughout
the lifetime, and variations in the physical and psychological accessibility of attach-
ment figures occurring during adulthood are still considered to account for central
aspects of an individual's mental state.
The selection of the first attachment figure (usually, but not necessarily, the
infant's biological parent) normally takes place between about 6 and 9 months of
age, and virtually all infants become attached. Attachments are presumed to be
formed on the basis of contingent social interactions (Ainsworth, 1969), but there is
no evidence that these interactions need be positive and infants unquestionably
take insensitive and maltreating parents as attachment figures. Once an attachment
figure has been selected, the infant closely monitors his or her whereabouts,
preserving proximity even under non-stressful conditions. If threatening conditions
arise, the system becomes highly activated, and the infant is led immediately to seek
close proximity and contact. In quiescent conditions where the attachment figure is
readily accessible, the infant's exploratory system is often activated, and the infant
then engages in play.
The import of the attachment figure to primate infants may be better under-
stood by considering the fact that while for some species a den or other dwelling is
sought in times of danger, for the ground-living, nomadic primates the attachment
figure is the single location which the infant must seek in times of alarm (Bowlby,
1969). For purposes of the present chapter, it is critical to note that the attachment
behavioral system is intimately related to fear, intensively focused upon the location
112 and accessibility of specific individuals, and heightened by frightening conditions
Mary Main and of any kind.
Hillary Morgan
The Strange Situation and the Three Traditional Patterns of
Irifant-Parent Attachment: Organized Responses Observed when
the Parent (Sensitive or Insensitive) Is Not Directly Frightening
The Strange Situation was designed to illustrate the functioning of the attach-
ment behavioral system in 1-year-old human infants by exposing them to two
"natural clues" to the increased likelihood of danger (Bowlby, 1973), namely, (1) an
unfamiliar environment, in which (2) the parent briefly departs (Ainsworth et al.,
1978). The 15- to 20-minute procedure is conducted in a comfortable laboratory
room filled with toys. Each episode is designed to last for 3 minutes, while separa-
tion episodes are terminated within 30 seconds or less if the infant is distressed. 1n
the first episode, the infant and mother are alone for three minutes, during which
time most infants explore the room and the toys. A stranger enters at the opening of
the second episode, and gradually attempts to engage the infant in play. In the next
episode, the mother departs and the infant is left with the stranger, after which the
mother returns. Three minutes later, the parent departs again, and the infant is left
entirely alone. The stranger then returns, attempting to comfort the infant if
necessary, and the mother returns again for the second and final reunion episode. At
the onset of each reunion the parent calls the child's name from outside the door,
and then pauses in the door to greet the infant. The procedure is videotaped in
order to permit extensive study of the infant's behavior.
The Strange Situation procedure was originally used in conjunction with an
intensive short-term longitudinal study of infant-mother dyads observed in the
home throughout the first year of life (Ainsworth & Wittig, 1969). At the outset of
this Baltimore study, Ainsworth expected almost all infants to use mother as a
"secure base" for exploration and play when she was present during the Strange
Situation; to show increasing signs of missing her during her absences (crying,
calling, searching); to greet her actively on reunion, usually demanding proximity
and/or contact; and to return to play once her continuing presence was assured. As
the reader can infer, this is the secure response pattern, and it is the behavioral
sequence to be expected on the basis of Bowlby's description of the normal
functioning of the attachment behavioral system.
Ainsworth discovered, however, that only two-thirds (13/23) of the infants in
her study exhibited this secure response pattern. This pattern was later found
associated with maternal sensitivity and responsiveness to the infant's signals and
communications, with mothers of secure infants being found more accepting,
cooperative, and accessible than the mothers of insecure infants. Succeeding
Strange Situation studies, now conducted worldwide, have continued to show that
about 55% to 65% of infants in low-risk samples are secure with their mothers as
determined by these behavioral criteria (see Van I]zendoorn & Kroonenberg, 1988).
Ainsworth selected letter-names for each "pattern" or "organization" of attachment
to a particular parent as represented in Strange Situation behavior, with the secure
behavioral response being designated as pattern B (Ainsworth et al., 1978).
Because the parent of the secure infant is relatively prompt and dependable in
responding to its signals, for secure infants the primary problem posed by the 113
Strange Situation is one of changes in caregiver location and additional anxieties Disorganization and
arising regarding the caregiver's likely· responsiveness are unlikely to be present. Disorientation
Sroufe, Egeland and others have demonstrated that children showing this response
pattern to the mother during infancy later exhibit more positive affect, greater
concentration, greater social competence and greater ego-resilience than insecure
infants at 6, 10, and even 15 years of age (see especially Grossmann & Grossmann,
1991; Main, 1995; Urban, Carlson, Egeland, & Sroufe, 1991). Moreover, outcomes
appear to be most favorable when a child has been judged secure with father as well
as mother (Suess, Grossmann & Sroufe, 1992).
The reader will recall, however, that in Ainsworth's original study (N = 23),
only two-thirds of infants showed the secure response pattern. Unexpectedly, six
infants showed little or no distress during separation from the mother, focused on
exploring the toys during her absence and, failing to exhibit attachment behavior,
actively avoided and ignored the mother on reunion. As noted earlier, Ainsworth's
home records indicated that the mothers of these insecure- avoidant ("pattern A")
infants were rejecting of attachment behavior in the home, turning the infant away
in response to bids for access (see Main, 1995; and Main & Stadtman, 1981, for
overview). In continuing studies of low-risk samples, this pattern of Strange Situa-
tion response has been exhibited by about 20% to 30% of infants.
Main has argued that infants whose caregivers have been persistently rejecting
may be facing a more complex problem in the Strange Situation than are secure
infants (Main, 1990). More specifically, the response of avoidant infants may be
influenced by the caregiver's consistent rejection of expressions of distress and
efforts to gain proximity, leading these infants to minimize the display of attach-
ment behavior relative to the probable high state of activation of the attachment
behavioral system. The high heart-rate of these infants during the separation epi-
sodes of the Strange Situation suggests experiences of distress comparable to or
even greater than that of secure infants, providing some support for the hypothesis
that, despite the absence of overt display of attachment behavior, the attachment
behavioral system remains activated (Sroufe and Waters, 1977; Spangler & Gross-
mann, 1993). The persistent attention to toys appearing under these conditions has
been seen as enabling the infant to maintain an "organized shift of attention" away
from the potentially stressful elements of the procedure}
Four infants in Ainsworth's Baltimore sample were highly distressed by the
Strange Situation, with some showing heightened apprehension even prior to the
first separation. These insecure-resistant infants became markedly upset upon
separation from the mother, yet appeared unable to obtain comfort from her
when she returned. Reunions were marked by continued displays of distress,
intermittent displays of anger, and an apparent inability to return to exploration and
play. Home observations of these infants showed that, while not notably rejecting,
their mothers were discouraging of autonomy, insensitive, and unpredictable

3Several hypotheses regarding the function of avoidance have been advanced, including the possibility
tbat avoidance not only assists in the maintenance of behavioral organization, but also facilitates tbe
infant in refraining from the display of attachment behavior toward a caregiver who has persistently
rebuffed both approach and expressions of distress (Main, 1981; Main & Weston, 1982).
114 (Ainsworth et al., 1978; Cassidy & Berlin, 1994). In succeeding studies of low-risk
Mary Main and samples, this "C" pattern of infant behavior has been displayed by about 5% to
Hillary Morgan 15% of infants.
Elsewhere, Main has suggested that infants of parents who are unpredictable,
and therefore potentially undependable in an emergency, may need to exaggerate
displays of attachment behavior in circumstances indicating even minimal cues to
danger (Main, 1990). In light of a history of unpredictability on the part of the
caregiver, then, resistant infants may respond to the stress of the Strange Situation
by maximizing the display of attachment behavior relative to the likely state of the
behavioral system and the environment. This latter pattern is displayed by about
5% to 15% of infants.
Issues of the stability of attachment organization, contributions from the
constitutional characteristics of the child, and cultural relativism have been pursued
at length elsewhere (see Main, 1995, for a recent overview), but may be summarized
as follows. First, in low-risk samples, reunion behavior following a one-hour separa-
tion from mother at age six has been found predictable from ABC attachment status
at one year of age (Main & Cassidy, 1988; Wartner, Grossmann, Fremmer-Bombik &
Suess, 1994). Overall distributions of ABC attachment patterning show some varia-
tion between countries, but the secure response pattern is shown by the majority of
infants worldwide, and there are greater differences in ABC distributions within
than between countries (Van IJzendoorn & Kroonenberg, 1988). Maternal charac-
teristics appear to influence Strange Situation behavior to a greater extent than do
child characteristics (Van I]zendoorn, Goldberg, Kroonenberg & Frenkel, 1992),
but the role of child characteristics remains intriguing. To date there are no pub-
lished studies of behavior genetics as related to infant Strange Situation behavior,
although several such studies are currently under way.

DISORGANIZED-DISORIENTED INFANT ATTACHMENT BEHAVIOR:

A COLlAPSE OF BEHAVIORAL AND ATIENTIONAL STRATEGIES
RESULTING FROM THE PARADOX PRESENTED BY FRIGHTENED/
FRIGHTENING PARENTAL BEHAVIOR?

The disorganized infant attachment category was developed following the

increasingly widespread recognition that responses to the Strange Situation proce-
dure in a number of infants observed in both low-risk (Main & Weston, 1981) and
high-risk-maltreatment samples were "unclassifiable" within the traditional ABC
system. In high-risk-maltreatment samples, a peculiar and unclassifiable mix of
avoidant (A) and resistant (C) behaviors had been frequently observed, leading to
the use of an "A-C" attachment category identified somewhat differently across
investigations (e.g., Crittenden, 1985; Radke-Yarrow, Cummings, Kuczinski & Chap-
man, 1985; see Main & Solomon, 1990, for review).
With the aim of better understanding "unclassifiable" attachment status in
infants 12 to 18 months of age, Main and Solomon examined videotapes of the
Strange Situation behavior of 55 infants judged difficult to classify (Main & Solomon,
1986). The consistency in patterning of Strange Situation behavior called for by
Ainsworth's original directions had been absent in about 13% of infants in Main's
Bay Area sample (Main & Weston, 1981), and during the initial review of these
videotapes, the possibility that further coherent organizations or patternings of 115
response would be identified was held open. Despite this approach, however, no Dlsorganjzation and
new patterns of organization comparable in coherence to Ainsworth's secure, Disorientation
avoidant and resistant patterns emerged.
What unclassifiable infants were instead found to share in common was the
display of a diverse array of inexplicable, odd, disorganized, disoriented or overtly
conflicted behaviors in the parent's presence. Many of these behaviors were sugges-
tive of an underlying experience of distress or even fright without solution, and
many could be most readily interpreted if it was presumed that the infant was
experiencing distress, apprehension or fright while having nowhere to turn.
One unclassifiable infant, for example, responded with apprehension to the
stranger's entrance but, moving away from rather than to the parent, leaned her
forehead on the wall, sobbing. Another rose to greet the parent on reunion, then fell
prone to the floor, with head hidden in arms. In other examples, unclassifiable
infants began crying shortly following reunion, then backed away from the parent,
turning in circles in the comer of the room; approached the parent with head
averted; rocked on hands and knees following an abortive approach; screamed for
the parent by the door on separation, then moved silently away as the parent
entered; raised hand to mouth in an apprehensive gesture immediately on the
parent's entrance; and slowly struck the parent's face with a trancelike expression,
while apparently in a good mood. Many of these behaviors appeared to be of a type
ethologists term conflict behaviors, that is, behaviors that result from the simul-
taneous activation of incompatible behavioral systems (see, e.g., Hinde, 1970).
The most striking theme running through the list of behaviors observed in
unclassifiable infants was that of disorganization, or an observed contradiction in
movement pattern, corresponding to an inferred contradiction in intention or plan.
Some infants, for example, approached the parent in anomalous ways that con-
tained signs of inhibition (as creeping sideways toward the parent with head
averted). The term disorientation was also used to describe behavior which, while
not overtly disorganized, nonetheless indicated a lack of orientation to the present
environment, such as immobilized behavior accompanied by a dazed expression.
Following their initial review of videotapes taken from the Bay Area sample,
Main and Solomon expanded their data base to include 200 difficult-to-classify
Strange Situation videotapes collected in their own and other laboratories, half
taken from low-risk, and half from high-risk and/or maltreatment samples (Main &
Solomon, 1990). The directions for identifying disorganized behavior were then
formalized, and interjudge agreement was obtained with several laboratories. While
by definition no exhaustive list of disorganized behaviors could be created, seven
thematic headings were identified. Infants are now judged to fit the disorganized
(D) category when, in the presence of the caregiver, they display behaviors fitting
to one or more of the following headings:
1. Sequential display of contradictory behavior patterns, e.g., calling loudly for
parent at door followed by avoidance at parent entrance;
2. Simultaneous display of contradictory behavior patterns, e.g., clinging to
the parent while arching the body away;
3. Undirected, misdirected, incomplete and interrupted movements and ex-
pressions, e.g., turning around and greeting the stranger brightly, arms
raised, as parent enters the room;
116 4. Stereotypies, asymmetrical movements, mistimed movements and anoma-
Mary Main and lous postures, e.g., rocking vigorously on hands and knees, or assuming an
Hillary Morgan awkward, uninterpretable posture;
5. Freezing, stilling and slowed movements and expressions, e.g., suddenly
stopping movement and freezing, hands in air, for 25 seconds or more; or
moving toward parent in extremely slow motion, as though resisting for-
ward movement;
6. Direct indices of apprehension regarding the parent, e.g., fear-smile or
hand-to-mouth gesture at parent entrance; and
7. Direct indices of disorganization and disorientation, e.g., raising hand to
mouth upon return of the parent, accompanied by a confused expression.
Bouts of disorganized-disoriented behavior sufficient for assignment to the
category are often brief, not infrequently consisting of just one episode lasting 10
to 30 seconds. The disorganized category is always assigned together with a best-
fitting, alternate avoidant, secure, resistant, or cannot classify (previously "unclassi-
fiable" or sometimes "A-C") category. An infant whose behavior is, for example,
otherwise well-fitting to the secure attachment category can be designated
disorganized-alternate secure (D-B) on the basis ofless than a minute of "freezing"
with a trancelike expression in the mother's presence.
The nature of many disorganized behaviors is such that it is natural to look for
neurological or other forms of impairment. Some disorganized behavior patterns
(such as stereotypies) are found in impaired infants (for example, those suffering
from autism or Downs' syndrome) but there is little evidence to date that disor-
ganized attachment status is substantially influenced by constitutional factors in
low-risk samples. 1f constitutional deficiencies were a substantial influence on the
development of disorganized behavior, then the behavior would normally be ex-
pected to appear with both the parents. 4,5 In a Bay Area sample containing 34
infants classified as disorganized with one parent, however, only three infants were
also judged "disorganized" with a second parent (Main & Solomon, 1990). Similarly,
Krentz found no relationship between unclassifiable (disorganized) attachment
status with mother and with daycare caregiver (Krentz, 1982) and in a recent study

'The only way of determining the role of heritable genetic lilctors in vulnerability to developing
disorganized-disoriented behavior patterns is through the methodologies established by behavior
genetics. Newborn behavior patterns are occasionally used as estimates of temperament, however, and
by combining two independent, low-risk samples of infants and mother in Germany, Spangler and his
colleagues (Spangler, Fremmer-Bombik, & Grossmann, 1995) have uncovered a modest but significant
(p < .05) association between disorganized attacbrnent status at one year and behavioral dysregulation
during the newborn period as assessed by the Brazelton examination. AB Spangler and his colleagues
point out, this finding could implicate intrauterine experiences, interactions in the earliest days of life,
heritable characteristics, or some combination of these factors. A recent study of a large (> 130)
poverty sample conducted in Minnesota found no relation between disorganized attachment and
newborn responses to the Brazelton, maternal medical problems, maternal history of drug or alcohol
use, medical complications during pregnancy or delivery, infant anomalies at birth, or Carey tempera·
ment ratings at 3 months (Carlson, submitted manuscript). It is not clear, however, whether these
investigators undertook an analysis of the Brazelton specific to indications of "dysregu!ation" as
identified in the German samples.
5'fhis reasoning holds unless the pattern is heritable through mother only, a possibility which cannot be
completely ruled out given recent findings in genetics.
of 90 families conducted in London, no infant was judged disorganized with both 117
mother and father (Steele, Steele, & Fonagy, in press). Disorganization and
Finally, infant disorganized attachment status does not appear sui generis, but Disorientation
rather is well predicted from (1) parental maltreatment and (2) lapses in reasoning
and discourse observed when the parent attempts to discuss traumatic experiences
during the Adult Attachment Interview. Moreover, where infants are observed
independently in separate Strange Situation procedures with each parent, disorga-
nization appears specifically and exclusively with the parent who has exhibited
these reasoning-discourse lapses. None of these results exclude the possibility of a
modest role played by heritable genetic factors, of course, and a study of pre-adopt
parents in which the parent is administered the Adult Attachment Interview prior
to the birth of the first child would be of considerable interest.

Characteristics of the Parents of Disorganized-Disoriented

Itifants
Studies of parent-infant interaction in disorganized dyads are now in progress,
but published reports are not yet available. As noted, however, two correlates of
infant disorganized attachment status are at present known. First, two studies have
compared the Strange Situation behavior of infants with maltreating parents with
that of well-matched controls. About 80% of the infab.ts in maltreating families in
each study were judged disorganized, as compared to between 20% and 40% of the
controls (Carlson et al., 1989; Lyons-Ruth et al., 1991). This finding is in keeping with
the Main-Hesse hypothesis (discussed below), since the maltreated infant is directly
exposed to threatening and inherently frightening behavior on the part of the
primary attachment figure. The finding is also in keeping with the hypothesized link
between disorganized infant attachment status and dissociative phenomena, since
dissociation is frequently believed to result from abuse in childhood (Malinosky-
Rummell & Hoier, 1991; Sanders & Giolas, 1991; Sandberg & Lynn, 1992), and indeed
to follow on a wide variety of directly traumatic experiences (Putnam, 1985;
Spiegel, 1990). Retrospective studies of adults with dissociative . disorders find
dissociative symptoms originating in childhood, and Kluft (1985), who concep-
tualized these disorders as a defense against severe child abuse, found patients
reported becoming multiple at a median age of 3. If dissociative disorders are
related to early abuse experiences, and disorganized attachment is linked to these
disorders, it is in keeping with Uotti's hypothesis that a very high proportion of
abused infants should be found disorganized.

Infant Disorganized Attachment Status as Predicted from Parental

Lapses in Monitoring during the Discussion of POtentially Traumatic Expe-
riences. The association between indices of disorganized mental states with
respect to major loss experiences and infant disorganized attachment status was
first uncovered in conjunction with a sixth-year follow-up study of Main's Bay Area
sample (Main, Kaplan & Cassidy, 1985). In this study, transcripts of a parent's
discussion of his or her attachment history during the Adult Attachment Interview
(George et al., 1985) were compared with the child's Strange Situation behavior
towards that parent five years earlier. This hour-long interview focuses initially
118 upon the description and evaluation of the adult's relationship to each parent
Mary Main and during childhood. Adults are later asked whether they had experienced the death of
Hillary Morgan a parent or parental figure, any close family member, or other person who was
especially important to them; how they reacted to the loss at the time; how they
thought the loss had affected their adult personalities; and how it may have affected
their responses to their child. The interview is transcribed verbatim, and following
the application of several detailed scoring systems, each subject is assigned a single
overall classification for his or her "state of mind with respect to attachment" (Main
& Goldwyn, 1985-1995). The classification system focuses upon discourse usage
during the description and evaluation of relationship history, rather than upon
relationship history in itself.
In keeping with the Ainsworth tripartite system,· transcripts obtained from the
parents in the Bay Area study were first placed in one of three categories equivalent
to the infant classifications: secure (corresponding to secure infant attachment
status), preoccupied with past attachment experiences (corresponding with resis-
tant attachment status), and dismissing of attachment (corresponding with avoidant
attachment status). A substantial match was found between a parent's attachment
status, as identified within the Adult Attachment Interview, and infant attachment
status, as assessed within the Strange Situation. Thus, secure parents were observed
to have had secure infants; preoccupied parents to have had resistant infants; and
dismissing parents to have had avoidant infants. This association between adult
security, as assessed utilizing the Adult Attachment Interview, and infant security, as
assessed in the Strange Situation, has been replicated in 16 succeeding samples (Van
I]zendoom, 1995).
The systematic nature of the relation between the three "organized" infant and
adult attachment categories suggested additionally that the Adult Attachment Inter-
view might be analyzed in ways which could serve to predict the infant's disorga-
nized classification. Somewhat astonishingly, during the discussion of loss experi-
ences, language and reasoning processes appearing in the parents of disorganized
infants were found to reflect the Strange Situation behavior exhibited by their
infants, in being suggestive of momentary disorganization and disorientation (Main
et al., 1985). Thus, in this Bay Area study a strong association was found between
infant disorganized attachment status and lapses in the monitoring of reasoning or
discourse during the parent's discussion of potentially traumatic events (in this
sample, the death of significant persons). A replication study undertaken by
Ainsworth and Eichberg demonstrated that parents who had suffered a significant
loss, but did not show lapses in reasoning or discourse during the discussion of this
occurrence did not have disorganized infants (Ainsworth & Eichberg, 1991). Shortly
thereafter, infant disorganized attachment status was shown to be linked as well
with discourse/reasoning lapses occurring during the discussion of abuse (Carlson,
1990; Ward & Carlson, 1995).
A system was then developed for scoring indices of disorganized mental
processes surrounding the discussion of potentially traumatic experiences in ver-
batim Adult Attachment Interview transcripts (Main & Goldwyn, 1985 -1995; Main
& Hesse, 1990). Where discourse or reasoning lapses were marked, the speaker was
classified as unresolved-disorganized/disoriented (hereafter, unresolved-disor-
ganized) with respect to the experience being described. As was the case with
disorganized behavior in infants, no exhaustive list of indicators of disorganization 119
in language and reasoning processes could be compiled. Thematic headings were, Disorganization and
however, identified and an Adult Attachment Interview transcript is now classified Disorientation
as unresolved-disorganized if speech surrounding the discussion of a potentially
traumatic event appears consonant with examples such as the following:
1. Lapses in the monitoring of reasoning during discussion of the experience.
These include indications of incompatible beliefs, often suggesting that the lost
person is considered simultaneously dead and alive in a physical, rather than a
religious-metaphysical sense, e.g., "It was actually better when he was dead,
because then he could get on with being dead and I could get on with my
schoolwork;" or "My father thinks I should go to law school." Indications of a belief
in having been causal in the death where no material cause was present are also
understood to be lapses in the monitoring of reasoning, e.g., "He died that night
because I forgot to pray for him." Similar principles are extended to identifying
unresolved-disorganized responses to the discussion of abuse experiences.
2. Lapses in the monitoring of discourse during discussion of the experience.
These are identified through, e.g., alterations in the form (register) of discourse
during the discussion of a potentially traumatic experience, suggesting that the
individual has entered into a special state of mind. These alterations include several
different kinds of disoriented changes in speech, such as sudden attention to
extreme details surrounding a death, an abrupt shift into a eulogistic style of speech
("She was young, she was lovely, and she was tom from us by that most dreaded of
diseases, tuberculosis, and I remember, even now, the funeral, the weeping of her
mother and sisters, the smell of the flowers ... "), or suddenly raising the discussion
of a traumatic experience in a completely unrelated context ("We used to play
dodge ball during recess. My mother died when I was 20").6 Again, similar princi-
ples are extended to the discussion of abuse experiences.
Just as infant disorganized attachment status can be assigned from only a few
seconds of behavior, adult unresolved attachment status is often assigned on the
basis of only a few sentences. This given, it is especially striking that the association
between parental discourse lapses and infant disorganized attachment uncovered in
the Bay Area sample (Main & Hesse, 1990) has been replicated in six succeeding
samples, including two poverty samples and four samples in which the Adult
Attachment Interview had been administered prior to the birth of the child
(Ainsworth & Eichberg, 1991; Benoit & Parker, 1994; Carlson, 1990; Radojevic, 1992;

6Main and Goldywn (1985 -1995) also required judges to place an Adult Attaclnnent Interview transcript
in the unresolved attachment category on the basis of reports of extreme behavioral reactions in
response to the trauma. These include reports of displacement of grief reactions, such as extreme
reactions to the death of public figures following absence of reaction to the death of a parent, and
reports of suicide attempts. If the speaker convincingly intlicates that her mental organization is now
entirely different than at the time of the reaction, such reports would not be included as indicative of
unresolved-disorganized status. Both our own experience and those of other investigators informally
queried have intlicated that assignment to the unresolved- tlisorganized adult attaclnnent category on
the basis of reports of extreme behavioral reactions is very rare, perhaps comprising under 5% of cases
of unresolved- tlisorganized category assigmnent.
120 Steele, Steele & Fonagy, in press; Ward & Carlson, 1995).7 In a recent meta-analysis
Mary Main and the effect size representing the overall relation between the unresolved-disor-
Hillary Morgan ganized adult attachment category and the disorganized infant attachment category
was found to be d = .65 (Van IJzendoom, 1995).
The reader should note that certain indications of affective states which might
appear clinically suggestive of incomplete resolution of a traumatic experience are
not considered unresolved in this context. These include reports of lingering grief,
crying during the discussion of the experience, expressions of continuing regret for
experiences missed with the lost person or (in the case of abuse) expressions of
continuing hatred for the perpetrators. Instead, assignment to the unresolved-
disorganized category is based solely on the above-described lapses in discourse
and reasoning.

The Paradox Presented by a Frightening/Frightened Attachment Fig-

ure: Disorganized-Disoriented Behavior as Indicative of a Collapse of
Behavioral/Attentional Strategies. Above, we discussed the ways in which
infants of parents who are rejecting or unpredictable, but not frightening, maintain
behavioral and attentional organization in stressful circumstances. Since the attach-
ment figure provides the infant with its only solution to conditions of danger,
however, both behavioral and attentional organization are likely to break down if
something about the attachment figure herself is frightening. A parent who is
frightening is, paradoxically, at once a haven of safety and a source of alarm,
compclling the infant to simultaneously approach and to take flight (Main, 1981).
Because conditions of this kind are, of course, not resolvable in behavioral terms,
they should lead to the collapse of behavioral strategy observed in disorganized
behavior. A collapse of attentional strategy as observed in disorientation may also be
expected, since the infant will be too frightened to manage the "organized" shift of
attention associated with avoidance, while also being unable to focus its attention
upon the frightening parent (Main & Hesse, 1992).
This approach to the understanding of infant disorganized- disoriented behav-
ior is well illustrated in the study of battered infants, discussed above. It was also
noted, however, that disorganized infant attachment occurs in a substantial propor-
tion of infants in low-risk samples, where it has been linked to discourse- reasoning
lapses on the part of the parent. While maltreatment of course occurs in low-risk
samples, it seems reasonable to consider other patterns of behavior which may be
associated with parental unresolved-disorganized attachment status.

7As of the present writing,we are aware of only two failures of replication. Steele et al. (in press) did not
find an association between unresolvm/disoriented adult attachment status and disorganized in1imt
attachment status in a London prebirth sample of 90 fathers and in1imts. In contrast to Radojevic's
0992) recent study, in which a high proportion of in1imts were judged disorganized with father and a
marked relation to the unresolved category was found, in the London sample only four in1imts had been
judged disorganized with father. Kolar and her colleagues (Kolar, Vondra, Friday, & Valley, 1993) found
no association between unresolved adult attachment status and in1imt disorganized attachment status in
a very low socioeconomic status sample of mothers and in1imts. Their suggested explanation of the
overall failure of match between Adult Attachment Interview classification and in1imt Strange Situation
classification in this sample was a lack of comprehension of the interview questions in some of the
mothers.
 Elsewhere, Main and Hesse have made the preliminary interpretation that 121
discourse/reasoning lapses occurring during the Adult Attachment Interview may Disorganization and
result from the intrusion of frightening ideation which is normally at least partially Disorientation
dissociated (Main & Hesse, 1992). From this point of view, parents suffering from
unresolved experiences of trauma may be expected on occasion to exhibit fright
(alarm) in the presence of the infant, in response to traumatic memories, or to
aspects of the environment somehow associated with those memories (when, for
example, the memories themselves are not fully accessible to consciousness).
Under these conditions, the parent's frightened-alarmed behavior will not have an
external referent (as when the infant reaches for a dangerous object or when a
potentially dangerous object is observed), but rather will be untraceable as to
experimental source (Hesse & Main, submitted). Because of its potentially alarming
nature, parental behavior of this kind may place the infant in a conflict situation not
unlike the one created by a parent whose behavior is directly frightening.
In keeping with a more general hypothesis examined earlier, then, Main and
Hesse have proposed that frightened (alarmed) as well as frightening (maltreating)
behavior may be a mechanism linking the parent's traumatized state of mind to the
infant's disorganized/disoriented behavior in stressful situations. Children as young
as 2!-2 months can in fact discriminate and respond to adult emotional expressions
(fronick, 1989), and by 9 months of age infants are able to identify objects that elicit
adults' emotional responses (see Bretherton, 1992, for review). We may therefore
speculate that by nine months infants could well become confused and frightened if
unable to identify the source of the parents' distress.

UOTI1'S HYPOTIIESIS: LINKING INFANT DISORGANIZED

AITACHMENT STATIJS TO INCREASED VULNERABDJTY TO
DISSOCIATIVE STATES

Ilotti has suggested that some disorganized infants may enter hypnotic states as
a defense against the kinds of frightened-frightening behavior described by Main
and Hesse, and that repeated experiences of this kind may make a child vulnerable
to developing dissociative disorders in response to succeeding trauma (Ilotti, 1992,
in press). This line of reasoning is based on the link between dissociation and
hypnotic (trancelike) states, and on the fact that paradoxical behavioral injunctions
are known to constitute one technique for inducing hypnotic states. Paradoxical
injunctions are seen in the "confusion techniques" of hypnotic induction, in which
the hypnotist may, for example, rapidly urge the subject to engage in contradictory
movements which cannot be carried out at the same time (Erickson, 1964). Ilotti
links these paradoxical confusion techniques to the experience of the infant who,
interacting with a frightening and/or frightened attachment figure, is repeatedly
exposed to the simultaneous and contradictory impulses of approach and flight.
While there is as yet only limited evidence that individuals suffering from
dissociative disorder were disorganized as infants (see Carlson, submitted manu-
script, discussed below), there is some preliminary support for a link between this
specific disorder and mothers' experience ofloss around the time of the offspring's
birth. Among 46 patients seen in a Rome clinic, 62% reported that their mothers
122 had experienced the loss of a significant relative within two years before to two
Mary Main and
years after their birth. In contrast, only 13% of the 119 patients with other psychi-
Hillary Morgan atric disorders reported that their mothers had experienced a loss during this
period of time (Liotti, 1992). Although these data are anamnestic, the potentially
traumatic impact of major loss occurring at this time could imply an increased
likelihood that the mothers of many of the dissociative patients were frightened/
frightening in the patient's earliest years, and hence that these patients may have
been disorganized in infancy.

Dissociative Responses to a Parent's Traumatic Memories:

The Case of Lisa
Above, we suggested that, like overtly threatening behavior, frightened behav-
ior untraceable as to a direct experiential source may be frightening to the infant,
and could therefore be the mechanism linking the parent's traumatic experiences
to the infant's disorganized behavior (Main & Hesse, 1990, 1992). Specifically, when
a parent reacts with fright to traumatic memories, or to otherwise benign aspects of
the immediate environment which are idiosyncratically associated with those mem-
ories, the infant may find the parent's behavior alarming, become frightened by the
parent, and hence, be placed in the behavioral/attentional paradox described
above. liotti (1993) further suggested that such behavior may also inadvertently
lead to the intergenerational transmission of dissociated fears and memories, since
experiences occurring while the child is in a trancelike state may enter memory in
altered form, and later be especially difficult to retrieve (cf. the description of Anna
O.'s "hypnoid states" as described by Breuer & Freud, 1893).
1n support of this hypothesis, liotti has described a 44-year-old patient, lisa,
who presented with a history of failed psychotherapies and complex disturbances
(Uotti, 1993). lisa's difficulties included frequent thoughts of committing suicide,
flickering attention, perceptual distortions and bizarre trancelike states (blank
spells during which she seemed to lose the ability to think and feel). These diffi-
culties were accompanied by a peculiar obsessive-compulsive disturbance, trig-
gered whenever glass was broken in the home. At such times, she became obsessed
with the idea that tiny fragments of glass could escape her attention, be inhaled or
ingested by her daughter, and cause her death.
This obsessive-compulsive pattern had its onset about one year after the birth
of her daughter, who was hospitalized for pneumonia at that time. Thereafter, Lisa
became panicked when she observed her daughter's difficulty breathing. This
panic was followed by an emerging concern that fragments of glass might be a
source of danger to her daughter, and at this time her blank spells, paralysis and
obsessive-compulsive behavior began. lisa now engaged in meticulous cleaning,
spending hours searching every corner of the house for minute, barely visible
pieces of glass. The search was executed under the pressure of mounting anxiety,
which often ended in frenzied paralysis of gaze and movement. As liotti de-
scribes it, under these conditions the surface of a table, glinting beneath a ray of
light, could become a trap, forcing lisa to remain motionless for an hour or more,
staring at the table in a desperate effort to make certain that no fragment of glass
was present.
 During one of her blank spells, Usa's therapist asked whether Usa's mother had 123
ever appeared frightened or frightening. Asking "How could you know?", Usa Disorganization and
replied with what she termed "a terrible story." When Usa was about 18 months Disorientation
old, her sister was born, and her mother had taken the newborn infant to the beach.
Her mother had then suffered a fit of dizziness, whereupon the baby fell from her
arms, and lay with her face in the sand. The next day the infant developed a high
fever and died within the week. In Usa's earliest years, her mother would frequently
recount this story, looking guilty and frightened and speaking in a highly incoher-
ent, fragmented and disorganized fashion. Usa described herself as suffering from
an uncanny feeling of impending disaster while she listened to her mother's re-
hearsal of her sister's illness and death.
Usa's therapist reviewed the details of this story in the following sessions, and
asked whether she saw any similarity between grains of sand and fragments of glass.
Usa acknowledged that grains of sand and fragments of glass were both tiny,
shining, barely visible things. Moreover, as Uotti recounts, she then noted that her
mental representation of both glass and sand was related to the danger of death if a
baby inhaled or ingested them. Usa had never previously made this connection
between the death of her newborn sister (lying face down in the sand, to which her
mother had attributed the infant's fatal illness) and the imagined death of her own
child (if she did not succeed in clearing away all broken glass). Once her therapist
had assisted her in finding the parallels between her mother's experiences and her
fears, Usa's blank spells disappeared for several months. After two years both her
blank spells and her obsessive fears appeared to be gone completely.
As noted above, Usa recalled feeling "uncanny" when her mother would tell
the story of her newborn sister's death. Uotti suggested that this feeling might
indicate that Usa had entered trancelike states during the many retellings of this
story, and that Usa may have failed to make the connection between her mother's
story and her own fears because she had encoded the story while in an altered state
of consciousness.

Disorganized Attachment Status in lrifancy, Childhood, and

Adulthood: Reconsidered in the Light of Liottl's Hypothesis
Following Uotti's analysis, Main and Hesse reconsidered the phenomena of
disorganized attachment noting (1) that some behaviors leading to disorganized
category placement bear a phenotypic resemblance to behaviors that would be
expectable had the infant entered a dissociative state, and (2) that some lapses in
the monitoring of reasoning or discourse observed during the attempted discussion
of traumatic experiences are compatible with behavior which is expectable when
an individual either enters into or reveals the existence of a dissociative state (Main
& Hesse, 1992). Uke Main (1991), Uotti has suggested that children disorganized
with mother in infancy may be more vulnerable than other children to creating
multiple, conflicting and rapidly shifting representations of self, other and relation-
ships (Uotti, 1992, 1993, in press), and we provide support for this contention.

Reconsideration of Infant Disorganized-Disoriented Attachment Sta-

tus. As noted, Main and Solomon had used the term disorientation to describe
124 behavior which, while not overtly disorganized, nonetheless indicated a lack of
Mary Main and
orientation to the present environment, such as immobilized behavior accom-
Hillary Morgan panied by a dazed expression (Main & Solomon, 1990, p. 133). This description of
disorientation is in itself indicative of an alteration of consciousness, and Main and
Solomon present numerous examples suggestive of such alterations, as, freezing all
movement with a trancelike expression, arms held out waist-high as though in ar-
rested motion. Judges are also instructed to consider assigning disorganized attach-
ment status when noting disorganized wandering accompanied by a disoriented
expression (observed in one infant whose mother was unresolved-disorganized),
and when noting any markedly disoriented facial expression, as seen in a sudden
"blind" look where the infant has previously used her eyes normally (observed in
one infant whose parent was later suspected of abuse).
1f trancelike states can indeed be compared to early self-hypnotic experiences,
and if early self-hypnotic experiences are in fact causally linked to later dissociation
(which is contested by some investigators, see Ross, 1989), then an ability to
dissociate may indeed develop in some individuals disorganized with the primary
caregiver during infancy. According to Putnam (Putnam, 1993), "the single best
predictor of a dissociative disorder [in children] is frequent trancelike behavior ...
The child is usually amnesic for these episodes and on termination of the trance
state may resume an interrupted task as if nothing had happened" (p. 42). One of
the primary signs of infant disorganized attachment status is behavior resembling
the dissociative trance, and Putnam's description can be compared with the follow-
ing observations of disorganized infants in the Strange Situation:
An infant sitting on the floor appears to be playing happily with her mother
during their second reunion. She suddenly slumps forward, her upper body
collapsed between her legs, and her torso falling flat on the floor. After three
seconds of stillness, she rises back to a sitting position and resumes playing.
Upon reunion, a mother picks up her very active son and sits down with him on
her lap. He sits still and closes his eyes. His mother calls his name but he does not
stir. Still calling his name, she bounces him on her knee and gently shakes him,
but he remains limp and still. After several seconds he opens his eyes, slides off
her lap, and darts across the room to retrieve a toy.

Main and Solomon defined disorganization as an observed contradiction in

movement pattern suggesting an inferred contradiction in intention or plan. Such
contradictions in movement do not inevitably imply dissociative processes, and
dissociative processes need not be inferred when, for example, an abused infant
shows signs of fear in smiling at the parent, or makes awkward, repeated stop-start
approach movements toward her. These movements and expressions indicate
conflict between approach and flight and, like indications of uncertainty or inde-
siveness in general, need not involve an accompanying lapse in consciousness (Main
& Hesse, 1992).
As the reader is no doubt aware, however, the phenomena of hypnosis (and
dissociation) include complex and purposeful actions undertaken outside of the
awareness of the actor. In Hilgard's "neodissociation" theory, it is not considered
unreasonable to attribute these actions to dissociated systems, operating either
alongside or outside of the principal system usually associated with consciousness.
From this point of view, each system may produce relatively coherent patterns of
behavior with sufficient complexity to represent some degree of internal organiza- 125
tion (Hilgard, 1977/1986; see also Bowlby, 1980). We may term the manifestations of Disorganization and
these secondary systems dissociated actions, and some disorganized infant behav- Disorientation
ior does appear in this form (Main & Hesse, 1992). One candidate for dissociated
action consists in an episode of distress or angry behavior which appears without
explanation or warning in the middle of a long period of contented play, and then
ceases as abruptly as it began. In addition, some infants have been observed raising
arms to the stranger (with whom they have already spent several minutes) with a
bright greeting ("Hi!") as the parent enters the room. They have also been observed
following the parent to the door crying, then smiling at the door as though in
greeting as it closes. The disorientation implied in each of these latter behavior
patterns is marked enough to imply a lapse in awareness of the immediate surround.
One example of a seemingly dissociated action was given at the onset of this
presentation, where an infant was observed interrupting a bright approach to the
parent with aggressive slapping of the floor. A number of other infants in an
apparently good mood have been observed assuming a dazed or trancelike expres-
sion, reaching slowly to strike at the parent's face or eyes, and then resuming
affectionate behavior or play behavior. The intrusion of aggressive actions while in
apparent good mood provides a striking parallel to behavior to be expected as a
result of temporary changes in executive control.
In sum, not all disorganized behavior patterns fit readily to the phenomena of
dissociation. Trancelike states and seemingly dissociated actions observed in a
subset of disorganized infants would, however, seem highly compatible with a
dissociative model (Main & Hesse, 1992).

A Reexamination of Lapses in Monitoring Observed in the Parents of

Disorganized-Disoriented Infants: Fit to a Dissociative Model? In response
to liotti's theorizing, Main and Hesse reconsidered the instructions for identifying
lapses in the monitoring of reasoning or discourse during the Adult Attachment
Interview (Main & Hesse, 1992). Dissociation has been traditionally considered
associated with traumatic experiences (Spiegel, 1990), and is identified through
alterations in consciousness and behavior. This given, it is especially intriguing that
the directions for identifying unresolved-disorganized attachment status require
focus upon alterations in the patterning of discourse occurring specifically during
the attempted discussion of traumatic experiences. Many of the unresolved parents
of disorganized infants are otherwise good speakers, and lapses in reasoning and
discourse occur only in these specific passages.
Lapses in the monitoring of discourse have been described as indicating that
the speaker has entered a state of mind in which she or he is no longer appropriately
conscious of the interview situation, and has in fact "lost awareness of the discourse
context ... [suggesting) an encapsulation or segregation of the event from normal
consciousness" (Main & Goldwyn, 1985-1995/1991 edition). Strikingly, some adult
discourse lapses directly parallel disoriented infant behavior. Just as infants may
halt all behavior and freeze for several seconds, only to resume movement, some
adults fall silent in the middle of a sentence discussing loss or trauma, and then
complete the sentence, 20 seconds or more later, as if no time had passed. Others
may never complete the sentence, as, "He died, and his face [52 second pause]. I
guess I was just finishing high school."
126 Other examples of lapses compatable with a dissociative model include sud-
Mary Main and
den shifts into differing registers of speech (discussed above); sudden, inappropri-
Hillary Morgan ate intrusions into the interview of information regarding a loss or other traumatic
experience; and changes into childlike speech forms while discussing early trau-
matic experiences (e.g., "If I didn't tell my mom about my report card then she'd
be really mad, 'cause I'd bided itfrom, you know, I hid it from her, and urn ... that's
when the punishment came, you know ... "). Although grammatically corrected ("I
hided ... I hid"), this lapse suggests that in retelling the story of an abusive episode,
the speaker had become sufficiently absorbed that her usage of the past tense
became that of a very young child.
The Main and Goldwyn (1985-1995) directions for identifying lapses in the
monitoring of reasoning also appear compatible with directions which might be used
to identify (1) efforts to dissociate memories from awareness, (2) current interference
from partially dissociated memories, and (3) co-existing but incompatible and disso-
ciated memories. For example, some unresolved speakers describe themselves as
putting bad memories in special places in their minds, or making their minds "just
go away" during an abuse experience. Others seem to suffer an intrusion of visual-
sensory images which interfere with correct speech, such as, "Yes, well what he did
was hit me, stick, stick, hurts ... brown stick." Finally, as noted earlier, some lapses
have suggested the simultaneous existence of incompatible systems of memory and
consciousness, indicating that a lost person is simultaneously believed dead and alive.
If lapses in monitoring such as those outlined above are indicative of at least
microdissociative states, then individuals exhibiting such lapses in the interview
context may enter altered states in other contexts as well. In keeping with this
expectation, several parents of disorganized infants have informally been observed
in what appear to be dissociative states during the Ainsworth Strange Situation
(Main & Hesse, 1990). Several mothers of disorganized infants have exhibited
abrupt changes in vocal quality, especially when greeting their infants after separa-
tion. In two cases, the mother's voice dropped to the male range as she called to her
infant; in other cases, the mother's "Hi" took on a "haunted" quality ("Hiiiiiii")
through simultaneous voicing and devoicing. One mother made a similar "eerie" or
"haunted" sound as she reached for her infant's hand, although this time the
underlying sound ("Huuuuunh") was not part of a greeting. Another mother, who
had suffered chronic sexual abuse by her father throughout her childhood, bent
over her seated infant and lapsed into low, haunted, frightening and incomprehen-
sible non-language sounds in a deep register. Some mothers of disorganized infants
have been observed sitting immobilized with eyes half closed or blankly staring into
space. In two of these cases, the infant immediately exhibited disoriented behavior.

Diffi.culties Contingent on Multiple Models of Self, Other, and Relation-

ships: A Spedal Vulnerability for Former Disorganized Infants? If disorga-
ruzed attachment is rooted in frightened- frightening parental behavior, disorganized
children may not only develop more frightening and rapidly shifting representa-
tions of self, other, and relationships than other children, but may at times have
difficulty in accessing any representation at all (as may be the case when the child
suffers a "blank spell," or is lost in a trancelike state). Liotti (1993, in press) suggests
that some children disorganized as infants may feel that the self is all powerful
(frightening to the parent) yet also completely vulnerable (helpless to the parent's
aggression). Similarly, the parent may be represented as both good (for the infant to 127
survive the caretaker must at least be minimally attentive) and frightening (fright- Disorganization and
ened by traumatic memories, or possibly even abusive to the infant). These incom- Disorientation
patible models may contribute to dissociative experiences in children who have
been disorganized as infants. Thus:

If the structures of propositional self-knowledge are fragmented rather than

coherent, competing rather than harmoniously orchestrated, and mutually in-
compatible rather than reciprocally integrated, the serial organization of infor-
mation may be hindered. Simultaneous or rapidly alternating incompatible,
dissociated actions may then be observed, while altered states of consciousness
will be subjectively experienced. (liotti, 1992, p. 200)

Our sixth-year follow-up studies of a Bay Area sample of infants seen in the
Strange Situation with both parents (Main et al., 1985), as well as succeeding studies
by other investigators (e.g., Solomon & George, 1995) provide some support for
liotti's contention (see also Main, 1991). First, children judged disorganized with a
particular parent in infancy often show controlling (role-reversing) responses to
reunion with that parent at age six, being either punitive toward the parent or
inappropriately solicitous and caregiving (Main & Cassidy, 1988; replicated in a
South German sample by Wartner et al., 1994; see also Jacobsen et al., 1992). While
this suggests that the previously disorganized infant tends in part to "solve" the
paradox presented by the frightened-frightening attachment figure by stepping
into the role of the parent, and out of the role of attached child (Main & Cassidy,
1988), a 6-year-old cannot in fact avoid also remaining in the "role" of the child. We
must therefore presume that at least two, or possibly even three contradictory roles
(child, punitive parent, solicitous-caregiving parent) may be developing with re-
spect to this primary relationship.
Representational as well as behavioral processes were investigated in the
6-year-olds involved in the Bay Area study, and disorganized attachment status with
mother in infancy predicted drawings, responses to a family photograph, and
Separation Anxiety Test responses suggestive of fear, disorientation, contradiction,
and absorption. The family drawings made by previously disorganized children
frequently had bizarre, distressing elements, and have been discussed at length
elsewhere (see Main, 1995, for overview). Responses to presentation of a family
photograph were also anomalous, suggesting that visual presentation of the family
had an overwhelming and/or absorbing quality, which drew attention away from
the immediate situation (Main et al., 1985). One child, for example, stared into the
photograph for several seconds, then murmured "where are you, mama?", while
another handled the photograph tenderly, then set it on the table and patted it.
Several appeared depressed when presented with the photograph, and some
seemed "lost" when gazing at it.
Kaplan (1987) administered Hansburg's Separation Anxiety Test (Hansburg,
1972; adapted for younger children by Klagsbrun & Bowlby, 1976) to the children in
the Bay Area follow-up study. In this procedure, each six-year-old was presented
with a series of six photographs of parent-child separations, and then asked what
the pictured child might feel, and what the pictured child might do. Kaplan
described the responses of previously disorganized-disoriented infants as fearful-
disorganized/disoriented, since the children appeared inexplicably afraid and yet
128 unable to do anything about it. Some children remained silent throughout the task,
Mary Main and whispering their answers, shrugging excessively, or falling silent for long periods.
Hillary Morgan Kaplan compared these responses to the stilling and freezing responses observed in
disorganized infants in the Strange Situation.
Other children seen in Kaplan's study engaged in catastrophic fantasies, sug-
gesting that the attachment figure would be seriously hurt or killed. One described
the pictured girl as feeling afraid, because "her dad might die and then she would be
all by herself," since her mother had died. Another suggested that the child would
lock himself up in a closet, and kill himself. Additionally, some previously disorga-
nized children implied that actions occurred without an agent, that is, that things
occurred or were done to them without knowing who the actor was. For example,
asked what would happen after the parents left the child alone in the house the
child might answer, "the light might go out." Such statements had an eerie quality,
suggesting the presence of unknown, invisible actors (Kaplan, 1987).
Note that statements of the latter kind are consonant with a history of inter-
actions with a traumatized parent repeatedly experiencing fright untraceable as to
source. Moreover, in many of these narratives the child imagines a situation which
Main and her colleagues had described as the essential experience of the disorga-
nized infant-an experience of fright, without solution (Main & Hesse, 1990; Main
& Solomon, 1990). Kaplan's findings were replicated in a Berlin study conducted by
Teresa Jacobsen (Jacobsen, Ziegenhain, Muller, Rottmann, Hofmann, & Edelstein,
1992). Later, Jacobsen discovered that Icelandic children exhibiting Kaplan's
fearful/disorganized response to separation stories at seven experienced marked
difficulties with verbally presented tests of formal reasoning in adolescence (Jac-
obsen, Edelstein & Hofmann, 1994). 8
Solomon and her colleagues used controlling reunion behavior toward the
mother to identify 6-year-olds likely to have been disorganized with mother in
infancy (Main & Cassidy, 1988), studying the responses of these children to parent-
child separations as presented in doll play (Solomon, George & DeJong, 1995). In
this study, a judge blind to the 6-year-old's reunion behavior found that the majority
of the controlling children depicted the self and caregivers as both frightening and
unpredictable, or frightened and helpless, a result consistent with a previous study
in which the mothers of controlling children had described themselves as helpless
or unable adequately to protect the child (George & Solomon, in press). All eight of
the controlling children (and only 1 of the remaining 36 children) were judged
frightened, either entering into fearfuVviolent and catastrophic "nightmare" fanta-
sies, 9 or else, like Kaplan's "silent" children, being constricted, inhibited, and silent.
In a catastrophic fantasy, for example, the house might catch fire while the parents
are gone. The child runs to a hill for safety, only to see the parents die below him on
the road in a car accident. Finally, the child himself might die, thrown from the hill
in an earthquake (cf. Solomon & George, 1991). Following repeated prompts from

"The fearful-disorganized children in Jacobsen's study were also described as exceptionally low in
observed self-confidence, a finding which accords well with Cassidy's report of an association between
tbe controlling category and negative self-concept (Cassidy, 1988).
9Jn a London study of first-born children in 100 middle-class families, themes of hurt and violence also
appeared in the doll-play of five-year-olds disorganized with mother in infancy (Steele et al., 1995). In
this sample, the Adult Attachment Interview had been administered prior to birth, and mother's
unresolved/disorganized attachment status predicted these themes as well.
the examiner, some of the silent (constricted-inhibited) controlling children also 129
offered catastrophic fantasies. Disorganization and
Among the controlling children, fantastic disasters frequently arose without Disorientation
warning, and some of the children quickly gave post-hoc explanations as though
they themselves were surprised or disturbed by the direction the story had taken.
Solomon and her colleagues suggest that disorganization at the representational
level is consistent with models of segregated or unintegrated systems of representa-
tion (Bowlby, 1980; Spiegel, 1990), and that the abrupt shift from constricted to
chaotic doll-play shown by some of the children in the study implied that a "system
which is parallel and segregated from consciousness" (Bowlby, 1980, p. 59) had
suddenly become disinhibited (Solomon et al., 1995).

CONCLUSIONS AND SUGGESTIONS FOR FUTURE STUDmS

We began this chapter with a description of the close tie between fear and
attachment, emphasizing the way in which the attachment figure normally provides
an infant with the solution to situations which are frightening. We suggested that
the "organized" (avoidant and resistant) patterns of insecure attachment represent
strategies for responding to frightening situations available to infants whose parents
are insensitive but not directly frightening, and that the behavioral manifestations of
these strategies may follow on alterations in the patterning of attention (Main, 1990).
Infant behavioral organization should, however, be expected to break down if
something about the attachment figure becomes directly frightening. This is a
condition that is too alarming and confusing for behavioral. organization to be
maintained through an "organized shift in attention" away from the caregiver (the
avoidant response pattern). At the same time, since the attachment figure is in this
case the source of the alarm, organization cannot be maintained by increasing
proximity to the caregiver (the secure and resistant response patterns), nor indeed
can the attached infant safely take flight. Under these conditions the collapse of
attentional and behavioral strategies observed in disorganized/disoriented behavior
will be expectable. 1bis outcome can be expected in response either to direct
maltreatment or to frightened parental behavior related to the parent's own history
of trauma (Main & Hesse, 1990, 1992).
liotti pointed to the phenotypic resemblance between hypnotic states and
some kinds of disorganized/disoriented behavior observed in infancy, and sug-
gested that frightened/frightening behavior on the part of an attachment figure may
constitute a paradoxical behavioral injunction of the kind yielding hypnotic states
(liotti, 1992). On this basis, he argued that individuals disorganized/disoriented
with mother in infancy may be more vulnerable than others to dissociative dis-
orders (liotti, 1992). liotti's hypothesis was supported by a case study, and by an
anamnestic study of dissociative versus other clinic patients. We provided further
partial support for this proposal with a description of trancelike expressions and
dissociated actions considered indicative of disorganized attachment. An analysis of
some lapses observed in the narratives of the parents of disorganized infants during
discussions of traumatic events also appeared to fit to a dissociative model.
In keeping with the developmental pathways analysis proposed by Bowlby
(Bowlby, 1988), and recently elaborated by Carlson and Sroufe (Carlson & Sroufe,
130 1995), liotti has suggested that dissociative disorder would be most likely to
Mary Main and
develop in disorganized infants later exposed to intervening trauma (Liotti, 1992,
Hillary Morgan 1993). We would point to the possibility that this intervening trauma could be quite
specific, as the case of lisa illustrates. lisa's first year with her infant had been
uneventful, and she described herself as having enjoyed caring for the baby. Her
trancelike states and her fears for her infant did not appear until her infant had
developed severe pneumonia. At that time, observation of the infant's breathing
difficulties led to the onset of panic. This "stressor" is specific to lisa's history
(i.e., to lisa's mother's story), and other more general intervening life-stressors (as,
loss of a significant person) might not have led to the onset of this disorder.
As this chapter goes to press, the first prospective longitudinal study focusing
on disorganized attachment status as related to dissociative behavior and overall
psychopathology in adolescence has been completed by Elizabeth Carlson (submitted
manuscript), utilizing Sroufe and Egeland's large Minnesota poverty sample. Disorga-
nized attachment in infancy significantly predicted dissociative behavior in both the
elementary and highschool setting, as indicated by a dissociative sub-scale for the
Achenbach devised by Carlson (Achenbach & Edelbrock, 1986). Additionally, the
K-SADS (Kiddie Schedule for Affective Disorders and Schizophrenia) was adminis-
tered to more than 130 of these subjects at 17~ years, and the adolescent's overall
history of psychopathology was rated on a 7-point likert-type scale. Disorganized
attachment status with mother in infancy was significantly related to overall psycho-
pathology as determined from this interview schedule. Additionally, the only adoles-
cents diagnosed as having experienced dissociative episodes according to K-SADS
criteria (n = 3) had been classified as disorganized with mother during infancy.
Increased vulnerability to the dissociative disorders is not the only unfavorable
sequelae which has been considered in relation to early disorganized attachment
status. Hesse and Main have proposed that children disorganized as infants may
develop anxiety, and may be more vulnerable than other individuals to phobias
(Hesse & Main, submitted manuscript). This suggestion is compatible with a recent
report in which a strong majority of mothers with anxiety disorders were found
unresolved-disorganized within the Adult Attachment Interview (Manassis et al.,
1994). Additionally, Lyons-Ruth (in press) has suggested that elevated levels of
aggressive/disruptive behavior such as are observed in antisocial conduct disorder
may be expected in some formerly disorganized/disoriented infants. Lyons-Ruth's
hypothesis is supported by the finding that 83% of seven-year-olds in a high-risk,
poverty sample exhibiting levels of hostility outside of normal range had been
judged disorganized in infancy. Elevated levels of aggressive behavior in the school
setting were also found significantly and specifically associated with the controlling
sixth-year attachment category in a recent study of 44 middle-class mother-child
dyadsto (Solomon et al., in press).

10Despite present theorizing regarding vulnerabilities to be uncovered in previously disorganized

infants, many can be expected to function competently in later life. Using a Charlottesville sample,
Cohn (1990) found that the overall social competence of controlling 6-year-olds was indistinguishable
from that of secure 6-year-olds, while in a German sample including several 6-year-olds who had been
disorganized with mother in infancy some were considered socially competent (most were socially
incompetent, see Wartner et al., 1994). As Wartner suggests, the successful outcomes for some of these
children may stem from the fact that in her middle·dass sample, the majority of children judged
disorganized as infants had alternatively fit to a secure Strange Situation response pattern.
 Among disorganized infants whose development follows an unfavorable 131
course a variety of outcomes are, then, expected. With respect specifically to the Disorganization and
dissociative disorders, it would seem reasonable to presume that looking backward Disorientation
from an existing dissociative disorder in childhood or adulthood, we may find the
expected relation to infant disorganized attachment status with mother or another
primary caregiver. Forward-looking prediction will necessarily be limited, since
those unfavorable life events later contributing to development of the disorder
cannot be known in advance, and since a substantial proportion of infants are
disorganized, while only a small percentage of individuals are dissociative. Forward-
looking prediction could conceivably be somewhat enhanced, however, through an
examination of sub-types of disorganization and disorientation. Among the likeliest
candidates to be predictive of the dissociative disorders are trancelike stilling and
freezing, dissociated actions, and simultaneous or rapidly alternating exhibition of
avoidance and resistance (see Main & Hesse, 1992, for an extensive discussion of
"A-C" attachment status in relation to dissociative identity disorder). Additionally,
forward-looking prediction may be enhanced where attachment to both parents is
known, and disorganized attachment status with both parents in infancy may
increase vulnerability to disorder by exacerbating the child's experience of "fright
without solution."
To date, we are not aware of any finalized reports other than Carlson's regard-
ing dissociation in individuals disorganized with one or both parents in infancy.
Many developmental investigators, however, now have longitudinal samples avail-
able which include videotaped observations of infant-mother (and not infrequently,
infant-father) Strange Situations. The children in these samples presently range to
19 years of age, and further assessments of dissociative capacities and any existing
evidence for dissociative disorders can now be undertaken. The most straightfor-
ward test of liotti's hypothesis would be to utilize an extensive Dissociative Disor-
ders Interview Schedule with a selected subsample of adolescents, comparing
those who had been, for example, disorganized with both parents in infancy with
those who had been disorganized with neither. In such studies, cooperation be-
tween clinical investigators and developmental investigators is advisable, with
investigators undertaking the Strange Situation assessments being highly skilled and
reliable 11 in use of the Main and Solomon coding system (Main & Solomon, 1990).
Putnam (1988, 1989) has suggested that personality switches in dissociative
identity disorder may be based on the highly discrete, rapidly changing behavioral
states observed in newborns (Wolff, 1987). While switching, adults often appear to
enter trancelike states with blank, unseeing eyes, facial twitching, upward rolls of
the eyes, and sudden shifts in affect. Main and Hesse (1992) have pointed out that
these adult behaviors are similar to infant disorganized behaviors, and may reflect a
temporary lapse in the serial processing of information contingent on exposure to

llJt should be noted that the coding system for identifying disorganized/disoriented behavior in tbe
Strange Situation is complex, and that in a meta-analysis of the overaU relation between parental
unresolved/disorganized and infant disorganized attachment status, Van I]zendoom found a strong
relation between tbe extent of training coders had had in the infant system and the strength of relation
between unresolved/disorganized parental and disorganized infant attachment status reported for a
given sample (Van I]zendoorn, 1995). A list of individuals trained in tbe infant coding system should be
available by winter 1996. Similarly, training is necessary to identifying controUing behavior at age six,
and to identifying unresolved-disorganized adult attachment status.
132 an attentional/behavioral paradox. In order to determine the overall similarity
Mary Main and between the behaviors described by Putnam and those observed in infancy, an
Blllary Morgan examination of adults undergoing changes in identity states could be undertaken by
investigators skilled in application of the system for identifying disorganized behav-
ior during infancy. In addition, a modification of the infant system could be applied
to videotapes of the Adult Attachment Interview as individuals respond to queries
regarding loss or abuse experiences. If lapses in the monitoring of reasoning or
discourse are indicative of partially dissociative experiences and/or of state shifts,
then behavioral indices of disorganization and disorientation during the discussion
of traumatic events may occur primarily in these individuals.
If disorganized infant attachment is in fact associated with dissociative states, it
may correlate with other variables known to be related to dissociative capacity.
Cooper and London found that children's hypnotic ability increased with longer
resting EEG alpha durations (Cooper & London 1976), and a study of attachment in
relation to brain-wave activity is presently in progress. Dissociative capacity has
been found associated with family enmeshment (Mann, 1992), and there is prelimi-
nary evidence that adults whose overall description and evaluation of family history
is placed in the preoccupied-enmeshed adult attachment category are more likely
than others to be judged unresolved/disorganized on the basis of their discussions
of trauma (Adam, Sheldon-Kellar & West, in press). Finally, dissociative capacity
has been found associated with being fantasy-prone (Lynn & Rhue, 1988), and
with belief in the paranormal (Nadon & Kihlstrom, 1987). Similarly, unresolved-
disorganized attachment status during adolescence has been found associated with
paranormal beliefs, including spiritualism, astrology, and ideas of possession (Main,
1993), and a modest relation to absorption has recently been uncovered (Hesse &
VaniJzendoom, unpublished data).
Hypothalamic-pituatary-adrenal axis dysregulation has recently been found
in sexually abused girls (see DeBellis et al., 1994), who as a population are not
infrequently reported to suffer from dissociative episodes. In this context, it is
especially intriguing to note a report regarding significantly elevated adrenocortisol
activity following the Strange Situation in disorganized (as opposed to secure and
avoidant) infants observed in a low-risk sample in Germany (Spangler and Gross-
mann, 1993). In this study, ABCD infants did not differ significantly in cortisol
output prior to the onset of the Strange Situation, but cortisol output was found to
be increasing 15 minutes and even 30 minutes following the procedure specifically
in disorganized infants 12 (cortisol output for secure infants was falling). These
results were recently replicated by Gunnar and her colleagues in a high-risk sample
studied at Minnesota, where cortisol was again significantly and specifically found
elevated in disorganized infants following the Strange Situation (Hertsgaard et al.,
1995). A similar rise in cortisol specific to disorganized infants has been observ~d

12Tite results of this German study are especially striking given that the great majority of the disorganized
inlimts were alternatively assigned to the secure attachment category. This means that only a few
seconds of (disorganized-disoriented) behavior dlstingulshed inlimts showing the greatest rise in post-
Strange Situation cortisol activity from those whose cortisol (foUowing expectable diurnal rhythms)
was falling.
in a third sample (Spangler & Schieche, 1994). In this sample, immunogobulin was 133
observed to decrease as well. Dlsorganlzation and
Perhaps the broadest-ranging outcome expectable for children and adults Disorientation
disorganized with the primary caregiver in infancy is elevated hypnotic ability and
overall dissociative capacity, including increased vulnerability to suggestion. Both
controlling children, and adults or adolescents disorganized with one or both
parents in infancy could be directly tested for hypnotizability, and these variables
could also be explored in unresolved adolescents and adults. Conceivably, the
catastrophic fantasies observed in many disorganized children may be reflective (if
not directly representative) of the parent's traumatic experiences, and disorganized
children may not only be more suggestible than other children, but may also
experience a heightened vulnerability to false memory (Main, 1993, in press).

SUMMARY AND IMPLICATIONS FOR RECENT CONTROVERSmS

Trancelike states and seemingly dissociated actions appear in moderately

stressful laboratory separation and reunion procedures as early as 12 months of age.
They are considered indicative of disorganized/disoriented attachment status with
respect to the parent with whom the infant is observed. At this age period,
dissociative responses are unlikely to be due to the effects of suggestion, and the
very high proportion of maltreated infants found disorganized/disoriented may
bear upon current controversies concerning relations (usually only retrospectively
reported) between dissociation and abuse. In several low-risk samples, disor-
ganized infant attachment has been found predictable from seemingly micro-
dissociative lapses in discourse or reasoning occurring as the parent attempts to
respond to close querying regarding potentially traumatic experiences (such as
abuse by attachment figures and/or the death of significant persons). Main and
Hesse have theorized that the link between parental discourse/reasoning lapses and
infant disorganization may lie in episodes of frightened/frightening parental behav-
ior in which the parent responds to partially dissociated memories for traumatic
experiences during interactions with the infant. Parental behavior of this kind
presents the attached infant with a paradox in which the collapse of behavioral and
attentional strategies seen in disorganized/dissociative behavior is expectable. Ad-
ditionally, the traumatic memories occasioning frightened/frightening behavior in
parents may for some children later become confused with personal (albeit "false")
memory for similar catastrophes (Main, in press), since the child's consciousness
while observing frightened/frightening parental behavior may be altered.

AcKNOWLEDGMENTS. This chapter was completed while Dr. Main was sponsored as
a Visiting Professor by the Center for Child and Family Studies and by the Institute
for the Study of Education and Human Development at Leiden University, the
Netherlands. Dr. Morgan's preparation of this chapter was supported in part by a
grant from the National Institute of Mental Health, T32MH18931, to the Postdoc-
toral Training Program in Emotion Research (Paul Ekman, Director). The authors
are grateful to Erik Hesse for his assistance in the final preparation of this manu-
script.
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7
Dissociative Disorders in
Children and Adolescents
Nancy L. Hornstein

INTRODUCTION

The clinical evolution of the recognition and treatment of dissociative disorders

occurring during childhood and adolescence owes a debt of gratitude to several
bodies of research and clinical literature that have accumulated over the last two
decades, including posttraumatic stress, the psychological sequelae of trauma and
child abuse, child development, and the study of dissociative disorders in adults.
The complexities of symptomatic presentation and underlying deficits that accom-
pany overt "dissociation" are perhaps nowhere as remarkable as they are during the
process of ongoing development in children. The evolution of knowledge in these
overlapping areas of investigation has created a framework for the conceptualiza-
tion and recognition of childhood dissociative disorders among those suffering
from the psychological sequelae of trauma.
Among the complexities facing diagnosticians and treating clinicians alike are
the variety of symptomatic disturbances that are part and parcel of the phenome-
nology of dissociative disorders in both children and adults, such as disturban-
ces in identity (splitting, fragmentation), affect regulation (depression, mood
swings, feelings isolated-dissociated from experience), autohypnotic phenome-
non (trances, misperceptions, time distortions, psychogenic numbing), memory
disturbances (psychogenic amnesia, fugue), revivification of traumatic experiences
(flashbacks, hallucinations), behavioral disturbances (inattention, poor impulse

Nancy L Hornstein • Department of Psychiatry, Child Division, University of Illinois at Chicago and
Institute for Juvenile Research, Chicago, Illinois 61612.
Handbook of Dissociation: Tbeoretica~ Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 139
140 control), and self-injury and suicidality (Albini & Pease, 1989; Barach, 1991; Bliss,
Nancy L Hornstein 1984; Bowman, 1990; Bowman, Blix, & Coons, 1985; Braun & Sachs, 1985; Braun,
1985; Brierre & Runtz, 1988; Chu & Dill, 1990; Conte & Schuerman, 1988; Coons,
Bowman, & Milstein, 1988; Coons, Cole, Pellow, & Milstein, 1990; Dell &
Eisenhower, 1990; Ensink, 1992; Fagan & McMahon, 1984; Famularo, Kinscherff, &
Fenton, 1992; Fink & Golinkoff, 1990; Fink, 1988; Fraiberg, 1982; Goodwin, 1990;
Greaves, 1980; Horevitz & Braun, 1984; Hornstein & Tyson, 1991; Hornstein &
Putnam, 1992, 1994; Kluft, 1984, 1985a,b, 1986, 1987a,b, 1991; Kramer, 1990;
Loewenstein, 1990; Ludwig, 1983; Malenbaum & Russel, 1987, McLeer, Deblinger,
Henry, & Orvaschel, 1992; Peterson, 1990; Putnam, Guroff, Silberman, Barban, &
Post, 1986; Putnam, 1985, 1989, 1990, 1991, 1993; Ross, Miller, Bjornson, Reagor,
Fraser, & Anderson, 1991; Ross, Miller, Bjorson, Reagor, Fraser, & Anderson, 1990;
Ross, Norton, & Wozney, 1989; Russel, Bott, & Sammons, 1989; Schetky, 1990;
Schulz, Braun, & Kluft, 1989; Shengold, 1989; Sherkow, 1990; Stein, Goldring,
Siegel, Burman, & Sorenson, 1988; Steinberg, Rounsaville, & Cicchetti, 1990; van
der Kolk & Kadish, 1987; Venn, 1984; Vincent & Pickering, 1988; Weiss, Sutton, &
Utecht, 1985).
The theoretical model behind the diagnosis of dissociative identity disturbance
has contributed further to our clinical understanding of the patient's symptomatic
presentation and his/her subjective experience. It is also helpful for developing
effective therapeutic approaches toward both adults (Barach, 1991; Braun & Sachs,
1985; Chu & Dill, 1990; Coons et al., 1988, 1990; Ensink, 1992; Fink & Golinkoff,
1990; Greaves, 1980; Horevitz & Braun, 1984; Kluft, 1987a,b, 1991; Loewenstein,
1990; Lovinger, 1983; Putnam, 1985, 1989, 1990; Putnam et al., 1986; Ross et al.,
1989, 1990; Schulz et al., 1989; Shengold, 1989; Sherkow, 1990; Spiegel, 1990, 1991;
van der Kolk & Kadish, 1987) and children (Bowman 1990; Bowman et al., 1985;
Brierre & Runtz, 1988; Dell & Eisenhower, 1990; Donovan & Mcintyre, 1990; Fagan
& McMahon, 1984; Famularo eta!., 1992; Fine, 1988; Fink, 1988; Fraiberg, 1982;
Goodwin, 1990; Hornstein & Tyson, 1991; Hornstein & Putnam, 1992; Kluft 1984,
1985a,b, 1986, 1987a,b, 1991; Malenbaum & Russel, 1987; Peterson, 1990; Putnam,
1990, 1991, 1993; Sherkow, 1990; Terr, 1990; Vmcent & Pickering, 1988; Weiss eta!.,
1985).
Although child and adolescent dissociative disorders were described in nine-
teenth- and early twentieth-century clinical reports (Bowman, 1990; Fine, 1988),
they later disappeared from clinical focus (along with their adult counterparts) for
much of the twentieth century. The sudden increase in reports of patients with
dissociative disorders caused initial controversy in modern psychiatry, with ques-
tions about the validity of the observers' perceptions in light of a century passing
with few reports of these phenomenon. Reasons for this historical dearth of clinical
interest and reports on these disorders have been postulated (Putnam, 1985, 1989).
Among the limiting factors described were theoretical adherence to a model em-
phasizing repression rather than dissociation as a means of excluding information
from conscious awareness.
Today, social scientists and historians have eloquently ruptured the myth of
"pure scientific truth," showing how we are vulnerable to fashions and trends and
how "what we see" is profoundly influenced by our theoretical constructs. My own
impression is that the advent of powerful antipsychotic medications led researchers
to focus eagerly on the biogenetics of psychiatric illness, temporarily stalling investi- 141
gations into the role environmental influences play in the development of psychi- Dlssoclative
atric disorders (not to mention their impact on "bioendocrinologic" and immune Disorders In
functioning), of which trauma and child abuse are but examples. Interest in psychi- ChiJdren and
Adolescents
atric sequelae related to stress and trauma is enjoying a resurgence as other areas of
psychiatric investigation reach limitations in their explanatory power.
Efforts to understand dissociative disorders are best served by a recognition
that we do not need to choose between our "theoretical truths," which seem to
compete with and contradict each other; rather, we can recognize that each of
them attempts to capture and cognitively organize some element of observable
reality, facilitating our understanding, investigation, and clinical work. The chal-
lenge then becomes searching for ways to integrate conflictual observations and
theoretical understandings that threaten our current understanding and signal us to
defensively reject, repress, or even dissociate them.
This chapter will present current research on dissociative disorders in children
and adolescents, highlighting the relationship between dissociative disorders and
childhood experiences of trauma/abuse, and will include clinical illustrations of the
role dissociation plays in the complex symptomatic presentation of these young
patients and the consequent differential diagnostic dilemma presented to the clini-
cian. An important but too often underemphasized point that will enhance under-
standing of the material to follow is that dissociation is a defense that is integral (by
definition) to the symptomatic presentations in the dissociative disorders, yet it is
only one aspect of these patients' complex developmental adjustment to their
experiences. The real utility of identifying dissociative symptoms lies in the recogni-
tion that the variety of disturbances in identity, affect modulation, behavioral
control, and attention that are present in these children are integrally related to
their past traumatic experiences. Thus, correct identification of dissociative symp-
toms has a tremendous impact on later diagnostic and treatment formulations in
these cases and has implications for psychosocial intervention to prevent further
trauma as well.

DISSOCIATION AND DISSOCIATIVE DISORDER

In order to meaningfully discuss a topic, in this case dissociation, one should

have a clear definition or description of the phenomenon. In the Diagnostic and
Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychi-
atric Association, 1994), a dissociative disturbance is defined as "a disturbance or
alteration in the normal integrative functions of identity, memory or consciousness"
(Armstrong, Putnam, & Carlson, 1994). These include dissociative identity distur-
bance (DID), psychogenic fugue, psychogenic amnesia, depersonalization disorder,
and dissociative disorder not otherwise specified (DDNOS). Dissociative identity
disturbance (formerly multiple personality disorder) involves alterations in all three
areas: identity, memory, and consciousness. One immediately runs into problems
defining such constructs as "identity" and "consciousness" and in differentiating the
alterations in memory that represent dissociation versus those present in repres-
sion. A truly cogent discussion of this topic would require at the very least it's own
142 chapter, if not an entire book, so interested readers are referred to two excellent
Nancy L Hornstein discussions of this topic by Ensink (1992) and by Putnam (1989).
An abbreviated discussion should clarify the nature of the phenomenon being
described. One conceptualization of dissociation, evolved from work with adult
patients, emphasizes a "disturbance in consciousness." In this conceptualization,
persons vary in the frequency and intensity of disturbances in the continuity of
conscious awareness. There is a continuum from minor dissociations of everyday
life, such as driving past your exit on the freeway, to the major forms of psycho-
pathology involving dissociation, such as multiple personality disorder (Putnam
et al., 1986; Putnam, 1989). All patients with a dissociative disorder suffer from a
variety of dissociative experiences such as amnesia, daze states, depersonalization,
derealization, and fugue states (Putnam, 1989). Putnam et al. (1986) found that
experiences of amnesia or time loss (time gaps) were the single most commonly
reported symptom in patients receiving the diagnosis of multiple personality disor-
der. Ensink (1992, p. 52) provides useful criteria for differentiating dissociative
"time-gaps" from other disturbances in consciousness. She writes:
[R]eports can be considered time-gaps only if they meet these criteria:

1. The person reports to have had no consciousness of the environment or her/his

behavior.
2. The person can not describe any focus of attention. This differentiates experience
[sic] of time-gaps from daydreanting, being absorbed in thoughts, or events excluded
from awareness because the focus of attention was on another event.
3. The person has no conscious or voluntary control of behavior (like speaking, read-
ing, writing), normally guided by consciousness. This criterion differentiates exten-
sive time-gaps from passive behavior such as staring or sitting down and from
complex but skilled acts normally not selectively attended such as driving a car.
4. Other people tend not to notice any difference in functioning of the person: This
criterion differentiates extensive time-gaps from immediate [sic] evident distur-
bances in consciousness, such as coma, fainting, pseudo-epileptical attacks or more
subtle changes in consciousness, such as staring, daydreanting, sleepwalking, etc.

This "operational description" of the dissociative symptom of time gaps is included

because it helps distinguish the kind of dissociative experiences that clearly differ-
entiate patients with dissociative disorders from those with other disturbances.
The child clinician or researcher has a difficult job in trying to use adult
descriptions of dissociative experiences when attempting to interview children
about similar phenomena. The clinician immediately encounters developmental
limitations in elucidating dissociative experiences in children. These limitations
include children's immature cognitive systems, which necessitates concretizing
questions about their "dissociative experiences"; immature speech and language,
which make dissociative identity disturbance impossible to diagnose before a child
has achieved certain milestones in their acquisition of language skills; the gradual
evolution of the child's internally held and integrated identity construct or subjec-
tive sense of identity over the primary school years; and the developmentally driven
changes in the capacity for and the frequency of the child's use of dissociative
defenses. Again, an adequate treatment of these considerations would require a
chapter in itself, although aspects of these issues are touched on in other chapters
in this volume.
 In light of the difficulties in evaluating children for dissociative disorders, a 143
clinical rule of thumb is to look for subjective experiences in children that are Dissociative
corollaries to those of their adult counterparts, but with a level of organization, Disorders In
"form of expression," and limitations in the child's capacity to report them that is Chl1dren and
Adolescents
influenced greatly by the child's age and acquisition of developmental milestones.
As children with dissociative disorders approach adolescence, the overt manifesta-
tions of their diagnosis are increasingly similar to those of adults. In children
younger than school age, dissociation can be recognized; but the diagnosis of
dissociative identity disturbance is very difficult and should include consultation
with experts experienced with this age group. Frequently, a diagnosis of DDNOS
must suffice in combination with clinical descriptions that elaborate on the areas of
disturbance present relative to norms for children of that age and developmental
level.
Dr. Gary Peterson has proposed a diagnostic category of "Dissociative Disorder
of Childhood" in recognition of these limitations (Peterson, 1990). In his working
copy for consideration by the Dissociative Disorders Study Group of the Task Force
on DSM-IY, he describes the "essential features of this disorder" as: "(1) the experi-
ence by the child of having amnestic periods and/or trancelike states and (2) the
child showing marked changes in behavior and functioning. In addition, the child
must exhibit an array of behaviors and/or emotional states which would usually be
considered to be symptoms of other disorders." His articles and the text of the
remainder of the DM8-IV proposal are additional sources for discussion of the
diagnostic issues referred to above.

IDENTIFYING DISSOCIATIVE SYMPI'OMS IN CHilDREN

There are several diagnostic screening tools available for use with children that
aim to detect the presence of dissociative symptoms. The most well-developed and
tested is the Childhood Dissociation Checklist (CDC) (Putnam, 1993), which can be
used in school-age children. For adolescents, the Adolescent Dissociative Experi-
ences Scale (Annstrong et al., 1994) and, for older adolescents, the Structured
Clinical Interview for the DSM-III-R Dissociative Disorders (SCID-D) Steinberg,
Rounsaville, & Cicchetti, 1990) can be used.
Ultimately, there is no available diagnostic substitute for the clinical interview
and evaluation. In order to better illustrate the clinical manifestations of dissociative
disorders in childhood, I'll turn to examples from some contemporary research. (A
portion of the following is a reworking of information from earlier publications
[Hornstein & Putnam, 1992, 1994].) The children who will be described were part
of a previously published study delineating the clinical profile of dissociative disor-
ders in childhood and adolescence (Hornstein & Tyson, 1991). In that study, behav-
ioral and symptomatic presentations of two independently collected case series of
children with dissociative disorders (64 cases), 44 with multiple personality disor-
der (MPD; now dissociative identity disturbance) in DSM-IY, and 20 with DDNOS
were compared with each other to test the construct validity of these diagnoses in
children and adolescents.
The first series, collected by Nancy Hornstein (NH), was largely composed of
children seen for evaluation and treatment in an inpatient unit at the University of
144 California at Los Angeles. The second series, collected by Frank Putnam was largely
Nancy L Hornstein composed of outpatients seen either as part of a longitudinal research project on
the psychobiological effects of sexual abuse conducted by the Laboratory of Devel-
opmental Psychology, National Institute of Mental Health, or in consultation either
with other NIH research projects or at Children's Hospital National Medical Center,
Washington, DC. The diagnoses of MPD or DDNOS were made using DSM-lli-R
(American Psychiatric Association, 1987) criteria augmented by NIMH criteria
based on clinical interviews of the children and their guardians, protective service
caseworkers, teachers, and therapists, and in the case of inpatients included ex-
tended observation on the ward. Standard psychological testing was obtained on
the majority of children. Parents or guardians also completed the CDC (Putnam,
1993). The mean ages in these two series (NH) followed by (FP) were 9.55 ± 3.36
years and 10.84 ± 3.63 years, respectively; there were 14 females and 16 males (NH)
and 28 females and 6 males (FP). The number diagnosed as having MPD versus
DDNOS were 22 versus 8 (NH) and 22 versus 12 (FP).
These children reported and/or were observed to have a variety of dissociative
symptoms, such as trance or daze states, depersonalization, involuntary move-
ments, passive influence experiences, and so forth and identity problems such as
alter personalities, spontaneous age regression, rapid changes in personality, and so
forth. Additionally, all children with MPD had demonstrable time gaps that would
have met the operational criteria described previously, as did many of the children
who received diagnoses of DDNOS.
As previously alluded to, gathering interview data on amnestic experiences or
time gaps in children is more difficult than gathering similar data from adult
patients. The reasons for this include that children's development of adult time
perception does not occur until late childhood, and a child's report of "not remem-
bering" behavior often represents "motivated forgetting" of their behavior to es-
cape consequences or uncomfortable feelings. Identifying time gaps often requires
interviewing strategies that take into account the child's developmental level sup-
plemented with observational data obtained in a variety of settings that suggest
discontinuities in the child's conscious experience.
Anchoring inquiry in the events of the child's daily life is the best approach for
obtaining information about dissociative experiences in preadolescent youngsters.
The interviewer may ask about gaps in the child's memory for common everyday
experiences, such as times he's been told that he already ate lunch when he thought
it was still morning, or times she is confused in class because she last remembered
the teacher going over math problems on the board and now the other kids are all
working on social studies. The child is asked to recount in his or her own words
experiences they have had that are similar to this. The interviewer may also ask
about experiences when the child requests to do an activity only to be told, "but,
you already did that."
To differentiate between dissociative experiences and lying, or motivated
forgetting, it is useful to inquire whether the child ever got thanked for doing a
chore he or she doesn't recall doing. An 11-year-old girl brightened when asked this
question, replying, "Oh yes, all the time. Just last night my Mom said 'thanks for
doing the dishes.' I thought she was teasing me because I didn't do them, but when I
looked in the kitchen they were all done and my Mom was happy. I know she didn't
do them either, so I can't guess who did because we were the only people at home:' 145
This child was previously assumed to be a chronic liar because of her disavowals Dissociative
of negative behaviors that had been observed by others. Disorders in
Observing the child for incongruous or unusual behaviors during the inter- Children and
Adolescents
view and inquiring about these, as well as inquiring "what just happened?" when a
child stares blankly, seems to change the subject, or seems suddenly confused about
a question the interviewer asked can reveal dissociative time gaps that occur during
the interview itself. The child is asked to describe his observed behaviors to
ascertain possible gaps in recall.
Emotionally laden experiences are often occasions in which time gaps occur
for dissociative children. Inquiry into experiences such as explosive outbursts,
schoolyard fights, or intense family sessions can lead to discovery of dissociative
processes. When a child seems to remember superficially, pressing him for whether
he actually remembers the occurrence or remembers only what he was later told
happened and has "blank periods" during the experience can help him describe his
subjective experience. Children who do not dissociate revel in this chance to give
detailed descriptions of what they feel and experience. Children who dissociate
may describe control-influence phenomenon or other aspects of their subjective
awareness of dissociative experiences. An 8-year-old boy responded to requests for
the details of his actual experiences during the frequent fights he was having by
saying, "You know, the bad me just takes over. (How?) It kind of comes out my nose,
and mouth and ears. (And then what happens?) Well, that bad me, it's got a hold on
my arm, and it's running my legs too. I'm saying inside 'no! stop!' but my legs just
keep going, and then my arm is striking the other boy and I can't stop it. I also get a
voice in my mind telling me to 'mind my own business'."
In adopting an approach that asks for details of a p~tient's subjective experi-
ences, numerous misleading assumptions are avoided, as well as the danger of
supplying information about symptoms which the child assents to for the sake of
simplicity, giving the interviewer a false sense of knowing what is going on with the
patient. Initially, there is no shortcut for experience in gaining access to this
information from children, along with a sense of developmentally typical versus
unusual responses deserving of more detailed follow-up. With children who have
been abused, gaining this access can be difficult and time consuming, since often a
level of trust must be built with them before they will talk openly. In some ways,
dogged attempts to understand their unique experiences, rather than to impose
preconceived notions on them, enhances the trust-building process.
Observational or historical data that lead the experienced clinician to consider
a dissociative disorder in a child's differential diagnosis include behavioral mani-
festations of dissociative time gaps. These include disavowal of witnessed behavior,
amnesia, fluctuations in apparent attentional ability, concentration, knowledge, or
performance, entrance into spontaneous "trancelike" states in which the child is
oblivious to external stimuli (often leading to evaluation for seizure activity), and
learning or reading difficulties.
In children with DID, there are "switches" between different states of con-
sciousness or subjective senses of self that are not integrated into conscious aware-
ness; these can be referred to as alternate personalities (alters). As in their adult
counterparts, these alters in children with DID manifest relatively stable patterns of
146 behavior, affect, gestures, speech patterns (tone, pitch, complexity of language
Nancy L Hornstein etc.), manner of relating, and aspects of identity (gender and role identifications,
name, age, etc.) that differ from each other.
The first clue that a child inpatient had DID came when an ordinarily ultra-
feminine girl, calling herselfJoanne, suddenly became rough and tomboyish, exhib-
iting differences in mannerism and voice tone during a baseball game. She insisted
upon being called "Jo" in this setting. By the time she returned to the unit, she again
was feminine, calling herself Joanne. When asked about the boyish "uniform" she
still wore and why she asked to be called ''Jo" earlier, she initially stared blankly,
then she said, "Oh, I'm never really there when I have to do that boy stuff." When
asked what she meant, she shrugged, later elaborating "Oh, I think that some boy Jo
that talks to me takes my place." She was asked how this works. Her reply, "I don't
know really, I don't remember it wen;• preceded her entry into a state in which she
appeared dazed, then had an abrupt change in manner, saying "I don't want to talk
about this s ... t, Doc. Joanne don't bother anybody. This ain't really none of your
concern." Needless to say, this was the first dissociative "change in personality" that
was witnessed in her.
In children, these "switches" between alternate personality states are fre-
quently observable as rapid age regression, sudden shifts in demeanor or person-
ality characteristics, or marked variations in ability and skill level. The younger the
child, the less elaborated these alters are relative to the often extensive elaboration
of separate "personality characteristics" seen in the alters of adult MPD patients.
Kluft (1984, 1985a,b, 1986) has pointed out that children have relatively fewer
resources through which alters can express separateness. In fact, children may be
very subtle and resourceful in the ways their "alters" attempt to assert their separate
identities, requiring close attention to detail on the part of the clinician.
A 9-year-old boy reported having three separate selves: a good, a bad, and a
regular Larry. In the process of trying to understand whether or not these "selves"
represented dissociative phenomenon, he was asked if it would be possible for
others to identify which self he was at a given moment. He smiled slyly and said,
"Yes, but they'd have to know how to:' (What would they have to know?) "Well, the
good Larry is all in white and is a good Larry fairy, and the bad Larry is in red like a
devil. The regular Larry is just plain skin." (Well, which Larry is speaking now?) A
broad smile: "Well, I'm the bad Larry, since you're asking about all the problems. I'm
wearing a red shirt and you're wearing red too." Further interviewing made clear
that this boy had MPD.
Children's alters similarly have less investment in the "separateness" of their
identities, and there tend to be less rigid amnestic barriers between the different
personality states. Despite these differences, all of the children who received a
diagnosis of multiple personality disorder did meet full DSM-III-R criteria for the
diagnosis.
None of the children in the inpatient series came with open revelations about
"having different personalities." At most they complained of "hearing voices" or
behaving in ways they "couldn't explain" or "couldn't remember." They were
unanimous in their secretiveness and fear that talking about their subjective experi-
ences of dissociative phenomenon made them "weirdos." They were fearful of what
other children and adults would think of them if they knew about this, and in all
cases one basis of the treatment alliance was their expectation that their therapist 147
would help them have more control so that these phenomenon could be even more Dissociative
"private" than they were initially. There was relatively no observable secondary gain Disorders in
through "dramatics" or attention seeking for the disorder. In several of the children, Children and
Adolescents
observations of dissociative symptomatology were present for some time before a
diagnosis of DID could be made. For two of the children, the diagnosis became
apparent only on subsequent hospitalizations. This is in contrast to some cases seen
in consultation in the private sector where aspects of the treatment the children
were receiving seemed to "reinforce" dramatic displays of symptomatology. In
these cases, diagnosis was complicated by a style of "treatment" that included an
inordinate amount of suggestion and gratification for displays of "dissociative alter's
behavior." In those cases it was only after a washout period of appropriate treatment
that the child could be adequately evaluated.
There are ongoing questions about the role of development in the elaboration
and organization of dissociative experience into alternate personalities during
childhood. In the cases above where there was a time gap antedating the emer-
gence of the DID diagnosis, retrospective accounts of the children argued in favor
of the increasing trust in the therapeutic relationship, rather than developmental
variables, playing a role in their eventual diagnosis. It is important to maintain a high
index of suspicion in children with extensive abuse histories and the presence of
some dissociative symptoms before DID is ruled out, especially when symptoms
suggestive of other disorders do not respond to the usual treatment approaches.
Some instances of DDNOS seem clinically to represent a traumatic dissociative
disorganization that is so severe that no real sense of self has been able to emerge.
These cases may initially present as reactive attachment disorders, atypical psy-
chosis, or even autism. In several of these, the provision of a stable nurturing
environment and treatment led the children to gradually organize a poorly inte-
grated identity diagnosable then as DID prior to forming an integrated sense of self.
Further research is needed on this group of children and on identifying subtypes of
DDNOS.

CUNICAL PRESENTATION OF CHILDHOOD

DISSOCIATIVE DISORDERS

All of the children with dissociative disorders in our sample, whether MPD or
DDNOS, had a plethora of affective, anxiety, attention-concentration problems,
and behavioral and learning difficulties that were suggestive of other diagnoses and
frequently played a role in their presentation for psychiatric treatment (Hornstein &
Putnam, 1992). Suicidal ideation was also frequently present in both groups, as were
auditory hallucinations. The average child had received close to three psychiatric
diagnoses prior to the diagnosis of a dissociative disorder. The most common prior
diagnoses were major depression or depressive psychosis (45.3%), posttraumatic
stress disorder (29.6%), oppositional defiant disorder (17%), conduct disorder
(14%), and attention deficit hyperactivity disorder (12.5%).
The presenting symptoms of depression, suicidality, auditory hallucinations,
148 and behavioral problems parallel symptom presentations reported for adult disso-
Nan.cy L Hornstein ciative disorder patients (Bliss, 1984; Chu & Dill, 1990; Coons et al., 1988; Fink &
Golinkoff, 1990; Greaves, 1980; Horevitz & Braun, 1984; Kluft, 1987a,b, 1991;
Loewenstein, 1990; Putnam et al., 1986; Putnam, 1989; Ross et al., 1989, 1990, 1991;
Schulz et al., 1989; Steinberg, 1991; Steinberg et al., 1990) and for previously
reported individual child cases and small clinical series (Bowman et al., 1985; Dell &
Eisenhower, 1990; Fagan & McMahon, 1984; Hornstein & Tyson, 1991; Hornstein &
Putnam, 1992; Kluft, 1984, 1985a,b, 1986; Malenbaum & Russel, 1987; Peterson,
1990; Putnam, 1993; Riley & Mead, 1988; Vmcent & Pickering, 1988; Weiss et al.,
1985), supporting a common syndromal pattern of symptoms present in child,
adolescent, and adult MPD cases. The children's dissociative symptoms were re-
viewed earlier in this chapter, so the manifestations of the most frequent symptoms
other than dissociation will be discussed.

Affect
A majority of the children had symptoms such as irritability, affect lability,
depression, hopeless feelings, low self-esteem, self-blame, and so on. Many had
suicidal ideation and some had attempted suicide. The children with MPD differed
in having made more serious suicide attempts. In observing these children over
time, some had chronic dysphoria, which was typically unresponsive to antidepres-
sant medication, but most had a very reactive mood. They were up when things
were going well, but had an exquisite sensitivity to slights, frustrations, alterations
in the mood-attentiveness of caregivers, and extreme rejection sensitivity. Follow-
ing a perceived injury to their self-esteem, their mood would plummet, suicidal
ideation tnight emerge, and they tnight remain dysphoric for days.
In some of the children, there were identifiable alternate personalities who
were sad, hopeless, and full of self-blame for the abuse they had experienced.
Environmental "triggers" that in some way reminded the children of their abuse
frequently precipitated a "switch" into one of these alternate personalities. It was
typical of these children that they held themselves responsible for abusive, neglect-
ful behavior of others toward them and for other difficulties they experienced in
relationships. Their feelings of hopelessness and worthlessness, while transitory,
could nevertheless lead to quite serious suicide attempts such as running out in
front of cars, or in the case of one young girl an attempt at self-electrocution via a
knife in a light socket.

Anxiety-Posttraumatic Symptoms
All of these children could be described as "sick with worry"; often this related
to realistic or at worst understandable concerns about the stability of their relation-
ships, the endurance of the regard in which others held them, the well-being of
their caregivers, and their own adequacy. Most had all the classic posttraumatic
stress disorder symptoms of hypervigilance, hyperstartle, fears, flashbacks, avoid-
ant behaviors, intrusive thoughts related to traumatic experiences, and traumatic
nightmares.
The hours before bedtime were associated for many of the children with the
emergence of intrusive thoughts about abuse that frequently occurred at home 149
during these hours and were often a period in which dissociative symptoms such as Dissodative
spontaneous age regressions, amnesias, "switches" in personality, and so forth Disorders In
occurred. For other children, use of the bathroom facilities brought on sudden Children and
Adolescents
reactions of terror, flashbacks, or dissociative phenomenon as well. An 11-year-old
boy with MPD first showed signs of dissociation when he was discovered huddled
in a comer of the bathroom, disoriented to location and the identity of a familiar
caregiver. Later, it was discovered that this child had been repeatedly and violently
sodomized, continued to experience pain with bowel movements related to his
injuries, and had severe flashbacks whenever he attempted to use the toilet.

Conduct-Behavioral Problems
Many of these children had explosive temper outbursts, oppositional or disrup-
tive behavior, and problems with aggression and fighting. Although often accused
of lying, they frequently had at least partial amnesia for their explosive, aggressive,
and disruptive behaviors. These behaviors were often sudden, unpredicted, and out
of keeping with the child's usual demeanor. Absent from these cases was the triad of
enuresis, cruelty to animals, and fire-setting.
The child's frequent misperceptions of interactions, perceived threats, as well
as rejection hypersensitivity played a role in producing these problems. Often these
abrupt behavior changes were preceded by a switch in personality in those children
with MPD. The children with DDNOS had similar alterations in perception and
cognition during their explosions, although they retained conscious recall and
some ability to integrate these behaviors.
These kinds of behavior problems were frequently the reason for referral to
inpatient treatment. Usually, when the dissociative aspect of the child's explosions
was recognized, the child could be assisted to gain better control of these behav-
iors. Caregivers who were made aware of the kinds of perceptual and cognitive
distortions that occurred when these children entered a state of defensive upset
were also more effective at providing appropriate reassurance to these children,
preventing the familiar eruption into aggressive behavior.
The conflicts around autonomy, identity, separation, and individuation that are
focal during adolescence make work with adolescent patients with dissociative
disorders particularly challenging in terms of managing acting-out behavior, even
though their presentation was otherwise similar to that of adult patients.

Sexualized Play, Inappropriate Sexual Behavior

Compulsive masturbation and promiscuity are frequent and 15% of the chil-
dren, including some very young children, had perpetrated sexual assaults or abuse
on other children. Most of the children were troubled by a variety of issues related
to sexuality and their sexual identity. For some, sexual acting out was a way of
compulsively reenacting their own experiences, and for others it served as a
reassurance that "they were normal," allaying fears of homosexuality in boys who
were molested by male perpetrators, or attempting to affirm their attractiveness
and control over relationships. For a few, there was sexual excitement in the
150 victimization of others, and many were vulnerable to revictimization by adults or
Nancy L Hornstein other children.

Attention-Concentration, Learning Problems

These children's high level of anxiety, posttraumatic symptoms, and their
dissociative trance states, amnesias, and so forth frequently manifested themselves
through difficulty attending to lessons and concentrating on school work. In some
children there were significant auditory processing difficulties, learning problems,
or difficulty with reading. Again, those children who have been followed through
their course of treattnent have had remarkable amelioration of these difficulties as
their internal disruption has decreased. This is all the more surprising given the past
history of intrauterine exposure to alcohol and/or drugs and past head trauma to
which some of these children were exposed. Comorbid diagnoses are, of course,
possible, but even when assumed present and treated as such, the better part of
clinical wisdom is served through reevaluation as treattnent progresses.
Dissociative episodes in childhood may be evident at times as perplexing
variations in the child's knowledge, skill level, and performance. Different alters
may have differing abilities and knowledge, or may have no conscious recall of
having learned something when another alter is present. Marked variations on
psychological tests assessing similar abilities may be seen, or there can be enormous
variations on the same test on different days as the child experiences switches in
personality.
The most striking example of this was a young girl who had evidence of nerve
deafness on two subsequent but different examinations, but in different ears.
Neurologically, her hearing was perfectly intact in both ears, but when she dissoci-
ated she had two different alters, each experiencing deafness in opposite ears; the
deafness was a conversion symptom related to two separate traumatic incidents.

Hallucinations-Thought Process Disturbances

Auditory hallucinations were present in most of the dissociative children. In
the majority of cases the child heard a voice or voices experienced as arising
internally and having distinctive characteristics such as age, gender, and personal
attributes, e.g., the voice of my father telling me I'm no good. These are similar to
descriptions by adults with MPD of their auditory hallucinations. Other types of
hallucinations were also experienced, such as seeing "ghosts," having visual hallu-
cinations of alters, and less commonly a variety of somatic and tactile hallucinations,
often representing hallucinated reexperiences of a somatic or sensory element of
dissociated traumas.
Frequent dissociation can cause a child to appear confused or disorganized at
times and tends to occur in stressful or emotion-laden situations. Apparent tangen-
tiality can be the efforts of the patient experiencing time gaps to cover up his or her
symptoms. Many of the children routinely confabulated to cover up memory gaps,
both to others and themselves. None of the children had a persistent thought
disorder, as frequent dissociation responded to safety, structure, and treattnent.
Dissociative experiences of having thoughts removed or put into the mind were
present in some children with MPD, representing a statistically nonsignificant
trend. These experiences are commonly reported by adult MPD patients, in addi- 151
tion to those with schizophrenic and bipolar illnesses (Fink & Golinkoff, 1990; Dissociative
Kluft, 1987a; Ross et al., 1990). Passive influence experiences, e.g., made thoughts Disorders in
and feelings, complex bodily movements not felt to be voluntarily initiated, auto- Children and
Adolescents
matic writing, and so forth are also commonly reported in adult MPD patients (Fink
& Golinkoff, 1990; Kluft, 1987a; Ross et al., 1990). In child MPD cases, the experi-
ence of involuntarily initiated body movements distinguished them from children
with DDNOS. An example of a child's description of this type of dissociative
phenomenon is present in the section on identifying dissociative symptoms in
children.
A number of clinical variables assist the clinician to differentiate between
childhood dissociation and childhood schizophrenia; of note, however, much lower
rates of control and influence experiences are reported in schizophrenic children
compared to those with MPD, along with much higher rates of delusional phenome-
non (Russel et al., 1989).

OveraU Clinical Picture

Children with dissociative disorders have a complicated symptomatic picture
related to the interaction between their use of dissociative defenses, the symptoms
from past traumatic experiences, and the problems they experience in regulating
their affect and behavior, as well as establishing a coherent experience of self and
others.

DIFFERENTIAL DIAGNOSIS

The complex symptomatic picture phenomenologically associated with disso-

ciative disorders in children often suggests or mimics more commonly diagnosed
childhood psychiatric disorders. Table 1 briefly describes symptoms frequently
found in dissociating children that may superficially appear to represent other
diagnoses (Hornstein & Tyson, 1991).
The presence of a dissociative disorder is no protection against seizures,
developmental learning disorders, or other diagnoses. The most important initial
diagnostic step is often, nevertheless, the recognition of dissociative symptoms. A
trial of treatment for dissociative disorder frequently leads to reduction or resolu-
tion of "seizures" in the presence of a normal electroencelphologram, affective,
attentional, thought-disordered, and learning disability symptoms.

CHilDHOOD TRAUMA AND DISSOCIATION

Other chapters in this volume will no doubt adumbrate the relationship be-
tween childhood trauma and dissociative disorders in the adult dissociative disorder
and trauma literatures. In our series (Hornstein & Putnam, 1992), an overwhelming
majority of the children had experienced some identifiable trauma. In those with
MPD, over 80% had documented histories of sexual abuse and in 60% of the cases
this was combined with physical abuse as well. Documentation of neglect was
152 Table L Dissociative Symptoms Mistakenly Attributed to Other Diagnoses
Nancy L Hornstein Dissociative symptom Behavioral appearance Misdiagnosis
---------------------------------------------------
Brief amnestic periods "Trancelike," odd behavior, explosive Absence/psychomotor
outbursts seizures
Poor attention, concentration, hyper- Attention deficit with
arousal hyperactivity
Disavowal of witnessed behavior Conduct disorder
Switching between alter- Aggressive alters, running away, Conduct disorder
nate personalities truancy
Alters differ in task performance, aca- Developmental learning
demic achievement, other skills disorder
Affect disturbances Different alters may have different Affective disorder
moods, depressed- suicidal and ex-
cited alters not uncommon. Symp-
toms of posttraumatic stress dis-
order, including problems sleeping
related to hyperarousal/nlghttnares
common
Thought process distur- Alters experienced as hallucinated Psychotic illness
bances voices; visual hallucinations of past
trauma; alters, partial control by
alter similar to passive influence.
Rapid switching causes discon-
tinuity in stream of thought.
Somatoform symptoms Headaches commonly accompany Somatoform disorders
switching. Tic disorders
Parasthesias, somatic hallucinations,
conversion symptoms, odd move-
ments, etc.
Anxiety A high level of anxiety or accompany- Primary anxiety disorder
Posttraumatic stress ing posttraumatic stress disorder is
disorder common in dissociating children.

available in 80% of the cases. The percentages were only slightly lower in those
cases with DDNOS. Additionally, over 70% of the children witnessed family vio-
lence.
The high percentage of documented abuse, neglect, witnessed violence, and
other trauma in this large clinical series of children with dissociative disorders
provides validation for the already-existing literature linking traumatic, and partic-
ularly abusive, experiences in early childhood with the development of dissociative
disorders (Bowman et al., 1985; Braun & Sachs, 1985; Braun, 1990; Chu & Dill, 1990;
Coons et al., 1988; Ensink, 1992; Fraiberg, 1982; Greaves, 1980; Hornstein & Tyson,
1991; Hornstein & Putnam, 1992, 1994; Kluft, 1984, 1985a,b, 1986, 1987a,b, 1991;
Kramer, 1990; Loewenstein, 1990; Lovinger, 1983; Ludwig, 1983; Putnam et al.,
1986; Putnam, 1985, 1989, 1990; Rao, DiClemente, & Ponton, 1992; Rao, Hornstein,
& Stuber, 1994; Ross et al., 1991; Schetky, 1990; Shengold, 1989; Sherkow, 1990;
Spiegel, 1990, 1991; Stein et al., 1988; Stem, 1984; van der K.olk & Kadish, 1987;
Venn, 1984). It also weighs the "fact versus fantasy" debate regarding the validity of
adult recollections of childhood abusive experiences in patients with dissociative
disorders toward acceptance of there being some basis in reality for their reports, 153
however the passage of time may have altered, coalesced, or elaborated on the Dissociative
representation of "vertical truth" in contemporary memory of past subjective Disorders in
experiences. Children and
Adolescents

TREATMENT CONSIDERATIONS

What statistics and phenomenological descriptions cannot capture is the big

picture of how early in life many of these children (especially those with DID)
experienced neglect and abuse, the extent, severity, and chronicity of their trauma,
the chaotic and/or sadomasochistic nature of the relationships with caregivers that
was a reality for them, and the psychological impact of this past on their ongoing
experience of self and self with other. These children's clinical presentation be-
comes clearer when grasped in light of the children's efforts to adapt to, survive in,
and relate to a world populated by unpredictable significant others and replete with
traumatic experiences. These children could never rely on having basic needs for
nurture and protection met, and many experienced overt abandonment in addition
to combinations of physical, sexual, and emotional abuse, domestic violence,
exploitation, and sadism. The extent of the abuse, it's age of onset, the degree of
neglect, and the presence or absence of some stable adult relationship figure
prominently in the degree of psychological disturbance each individual child has,
as do the child's strengths, intellect, creativity, and disposition.
The child may have initially used dissociation to manage an overwhelming
trauma. With repeated trauma and neglect in the early years, it is not only the
specific traumas that are psychologically overwhelming. Many aspects of relation-
ships become highly conflictual, dependency needs are in and of themselves
overwhelming in this milieu, and affects become sources of danger and conflict.
The child's internalization of these highly conflictual experiences produces within
the child conflicts with aspects of their own identity. To integrate these conflicting
identifications, with their associated affects and traumatic memories, would cause
overwhelming anxiety. As a result, the child dissociates.
An aspect of the usual DID child's adaptation is the organization of the dissoci-
ated selves or alters around the extremes of response that must be readily available
to allow continued development in the face of repeated traumas. Fantasy assists the
child in coping with overwhelming realities. Often each alter has a different fanta-
sied representation of the child and the characteristics of the caregiver. With an
environment that demands constant vigilance and self-protective responses, there
is little time to focus on the development of internal regulation of affect and
behavior. An excellent adaptation to a world of repeated trauma becomes a hand-
icap when called upon to develop trusting, intimate relationships, focus on learning
in school, or behave in a predictable, consistent manner. The longing to trust in the
caring response of another, to develop true intimacy, is at odds with the terror that
past trauma may be repeated.
The role of the therapist is to assist these children's development of increasing
capacities for trust and intimacy, build internal capabilities for managing affect and
behavior, develop defenses that aid in resolution of internal conflicts and past
154 traumatic experiences without being overwhelmed, and finally to integrate the
Nancy L. Hornstein dissociated aspects of his or her personality. The treatment of childhood dissocia-
tive disorders can be conceptualized as involving six tasks. These tasks are not
discrete, but to some extent they assume relative temporal predominance. They are
(1) the establishment of a safe, nurturing environment; (2) the formation of a
therapeutic alliance; (3) the improvement of overall ego functioning and contain-
ment of disruptive-destructive behaviors; (4) a systematic uncovering of dissoci-
ated aspects of identity, broadening the scope of tolerable affect, increasing the
range of coping strategies, decreasing dissociative barriers, abreaction and working
through of traumatic memories and conflict laden issues; (5) integration of alters;
and (6) Postintegration therapy and follow-up at regular intervals through adoles-
cence.
Prognosis depends on the establishment, first and foremost, of a nontraumatic
environment for the child, and the ability of the child and therapist to develop a
working therapeutic relationship. Ensuring a safe, nontraumatic, nurturing environ-
ment can be daunting in an age of decreasing social and mental health services.
Without this, however, treatment can only be palliative; an attempt to remove the
child's dissociative defenses is destructive and likely to fail. A number of refractory
treatments, on closer inspection, failed to address this issue adequately (Hornstein
& Tyson, 1991). What about the child who has a loving and stable foster family who
lives in the heart of gang warfare in the inner city? What about the child whose
needs for food, clothing, and shelter are met in an institution that provides little
nurture? The therapist of the MPD child must be willing to roll up his sleeves and
attempt to address these issues realistically. Creative partial solutions can be bene·
ficial.
The degree of overall psychiatric disturbance in the child, his or her age, past
experiences, strengths, and support systems become factors that influence the
child's ability to develop a worldng therapeutic alliance and how quickly the
therapy proceeds. Reports of individual and small case series have been optimistic
about the rapidity to which childhood MPD can respond to treatment (Kluft,
1985a,b, 1986, 1987a; Riley & Mead, 1988; Vincent & Pickering, 1988; Weiss et al.,
1985). Making the correct diagnosis is helpful for designing interventions that bring
about improvements in the child's functioning. The child experiences unintegrated
aspects of themself as separate, alien, difficult to understand, or completely abhor-
rent. This is true even when the dissociation is incomplete and the child retains
some awareness of these feelings and behaviors. Accepting the child's subjective
experience enhances the therapeutic alliance. It is important to treat dissociative
experiences in an empathic and matter-of-fact fashion, getting to know the child's
subjective and/or dissociated experiences of themselves, us, and their "world." If
the child has ways of subjectively identifying dissociated aspects of self as separate,
it is helpful to know these and respond to preferences of the child's regarding
communication with these alters. Understanding the child's inner experience and
the importance it holds alleviates much of the anxiety that previously undiagnosed
children with DID have. They seem to feel, "If you can understand and accept this,
then perhaps so can 1," and their ability to grasp that alternate personalities are
actually parts of themselves rather than "someone else" is thus enhanced. One must
assume that an aspect of a child's need to dissociate is a conviction that some
feelings and/or behaviors are unacceptable and will lead to rejection or abuse. 155
Seemingly paradoxically, willingness to accept these alters in a matter-of-fact fash- Dlssodative
ion actually decreases the child's pressure to use dissociative defenses in the Disorders In
presence of a focus on establishing age-appropriate behavioral functioning. It is Children and
Adolescents
important that the therapist, family, and others in contact with the child avoid the
voyeuristic fascination that can accompany an introduction to DID. Being overly
enthusiastic about meeting all the alters, "getting them to switch," and so forth can
be exploitative and also can provide a secondary reinforcement of the illness where
the child feels his/her value depends on their interest to the psychiatric community.
Effective therapeutic intervention often includes the development of individu-
alized, psychodynamically informed, behavioral interventions that the family and
school use to assist the child maintain function when threatened. Therapeutic
interventions, which may or may not include dynamic interpretations, should be
judged by their ability to produce lasting effects on the child's behavior and ability
to have relationships. If an intervention is unsuccessful, assume the problem is with
the intervention, not the child: Reexamine the understanding and design of the
intervention. The goal of early interventions is to help the child to effectively meet
conflicting needs in relationships while maintaining age-appropriate functioning
and remaining as free as possible of dissociative episodes. For the child with DID,
this requires creating an awareness and understanding in the child of the presence
of dissociative experiences and working to alleviate undermining conflicts.
The child is often taught new coping strategies and ways of gaining attention
and other forms of positive reinforcement for more functional behaviors. A focus on
positive reinforcement that seeks to avoid punitive consequences for problematic
behaviors is most effective behaviorally with traumatized children. Limits should be
set on destructive behaviors through redirection or brief time-outs. The use of
seclusion or physical restraint should be limited to situations where this is abso-
lutely necessary to contain behaviors that would be physically damaging to the
child or others. Care should be taken so that the use of these measures is neither
punitive nor inadvertently reinforcing. Specific interventions that are particularly
useful for children with DID include continual reassurance of physical safety. Often
dissociative episodes are triggered by fear, resulting in the emergence of aggressive
alters. Reassurance of safety decreases the frequency of this kind of switching.
Misinterpretation of their physical and social environment is also common in these
children. They often require verbal assistance in order to clarify misconceptions
and decrease dissociative episodes.
Children can be taught to explore feelings and thoughts in the safety of the
therapy session, where a variety of relaxation techniques and careful pacing may be
used to provide "containment" of anxiety and affect during, at the close of, and
between sessions. The child is helped to achieve a sense of mastery over his/her
dissociation and switching by identifying the thoughts and feelings that occur at
those times. Dissociative barriers are decreased by encouraging the child to tolerate
and explore feelings and thoughts that are present in dissociated parts of himself.
Additionally, children are encouraged and reinforced for learning to call on previ-
ously dissociated aspects of self to help them in difficult situations. For example, the
child is encouraged to see if there is "someone inside" who can help to soothe when
she or he is upset or aggressive. Integration of this soothing capacity into the child's
156 developing self-definition follows over time. When indicated, it helps to speak to all
Nancy L Hornstein the alters collectively. Particularly when there is a need to deescalate aggressive or
nonverbal alters. Acknowledgment of the alters as a collective encourages coopera-
tion, decreases dissociative barriers, and helps set the stage for ultimate integration.
In the event of assaultive or destructive behaviors, especially at home or in
school, a consequence (time-out, etc.) should be required regardless of whether the
alter that "acted like that" is still present. After the consequence the child may be
told, "You are all responsible for what happens. Maybe there are some ways that you
can all help each other with feelings so that none of you have to take a time-out."
When emergent feelings and/or traumatic memories have created difficulties in the
child's ability to function, intervention is focused on restoring functional behavior
so the child can resume age-appropriate activity as soon as possible.
All of the child's alters must be validated and their individual and collective
strengths identified and discussed with the child. They should be viewed as equally
desirable and important and allowed to exist without criticism. This helps the child
to achieve greater acceptance of the alters as valuable aspects of himself, which are
to be integrated rather than disavowed. These interventions help the child attain an
improved ability to function in all settings, increased self-acceptance, and an aware-
ness of his/her use of dissociative defenses. The child's growing capacity to tolerate
a variety of feelings, memories, and experiences results in a diminution of the need
to dissociate, as well as increased mastery over his/her behavior.
In cases where there is a favorable, nurturing environment, resources for
intensive treatment, and a child with considerable resiliency and capacity for
developing intimacy despite having a severe dissociative disorder, treatment can
indeed be rapid and successful. Integration generally is the natural outcome of a
decreased need for dissociative defenses as treatment resolves traumatically in-
duced conflicts and improves ego functioning. Often, there is some anxiety about
"losing the ability to dissociate" that emerges as integration begins. Active discus-
sion of the changes taking place, reinforcement of emerging strengths, and encour-
agement to proceed help at this time, as does an openness to creative understand-
ings the child develops in order to cognitively master these occurrences and
provide self-reassurance.
Many cases do not fit this hopeful picture, however. In them, there has been
some success, but measured in small increments over greater lengths of time
(Hornstein & Putnam,l994). In all children who have had a dissociative disorder,
follow-up at intervals after integration is essential, even after postintegration ther-
apy has ensured stabilization. We do not know the impact of developmental
challenges and future traumas on these children, and inevitably they encounter
some conflict that threatens their new integration when their continuing develop-
ment brings about the need to achieve new levels of mastery in areas of previous
conflict-such as the emergence of sexuality, separation-individuation, indepen-
dence, and intimacy in love-relationships through adolescence into young adult-
hood.
There is a need for further research on treatment outcomes, prognostic indica-
tors, which approaches work best with which children, and so forth. An effective
therapeutic approach relies on the bedrock of dynamically oriented therapy, sup-
plemented with an understanding of dissociative processes that allows for limited
hypnotic interventions that help the child contain overwhelming affects and memo-
ries, occasional cognitive and behavioral interventions, family work, and interven- 157
tion with the school when necessary. A more extensive review of treatment ap- Dissociative
proaches would require it's own chapter, but the skills of most experienced child Disorders in
therapists do nicely with some added supervision by someone familiar with child- Cbildren and
Adolescents
hood dissociative disorders. There is also a need for longitudinal follow-up of
childhood dissociative cases to ascertain course and outcome, the stability of
integration as the child enters adolescence and adulthood, and their vulnerability to
new traumas.

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lll
THEORETICAL MODELS

Although there exist a plethora of models and metaphors that have been applied to
dissociative phenomena, our understanding of the theoretical processes involved is
still at an initial stage. In this section, three important perspectives are presented to
help clarify the construct of dissociation. First, dissociation is examined from a
neurobiological perspective; second, dissociation is discussed in terms of hypnosis;
and third, dissociation is discussed in terms of an information-processing per-
spective.
In examining dissociation from a neurobiological perspective, Krystal and his
colleagues make an important contribution, since this area has not received exten-
sive development. The researchers initially review pharmacological methods of
inducing dissociative-like conditions in both patients and healthy individuals and
then move on to cortical areas such as the frontal cortex and limbic structures
involved in various aspects of dissociative processes. Chapter 8 concludes with an
examination of therapeutic implications. Although not directly, this chapters offers
some insights as to the classification of PTSD, which is currently described by DSM-
IV as an anxiety disorder, and its relationship to dissociative disorders.
Given that historically dissociation and hypnosis have been described in simi-
lar ways, the chapter by Whalen and Nash helps to delineate the relationship
between the two constructs. First, it is clear that under hypnosis, individuals can
display dissociative-like processes such as alternations in perception, sensation,
emotion, and cognition. Second, hypnosis has been used successfully to treat
dissociative disorders. Third, subjective experiences described within the hypnotic
state such as "feeling unreal" or "things happening automatically" appear similar to
descriptions of dissociative experiences. And fourth, in the clinical literature there
has been an implicit connection between sexual trauma, dissociation, and hypnosis
since the nineteenth century. In fact, Janet saw dissociation as underlying both
psychopathology and real hypnotic processes. However, the research reviewed in
this chapter leads one to the conclusion that as an individual trait, there is little if
any overlap between hypnotic susceptibility and dissociative experiences. Further,
although there is evidence to suggest that early trauma leads to dissociative experi-
ences, the empirical evidence does not lead one to the same conclusion with
trauma and hypnotic susceptibility. An open research question remains as to 161
162 whether hypnosis, as useful as it is, carries a special relationship for the treatment of
Theoretical Models dissociative disorders over and above other forms of therapy.
Based on their work with trauma victims, Foa and Hearst-Ikeda examine the
construct of dissociation from an information processing perspective. Chapter 10
begins by differentiating the construct of dissociation into various aspects and
examines its relationship to stress and trauma. For example, based on the animal
literature, it is suggested that avoidance and numbing involve different mechanisms.
These differentiations are then considered in terms of abuse, assault, and trauma
victims and implications for treatment. If dissociation prevents the activation of a
traumatic memory, then successful treatment would require techniques such as
exposure therapy, which would repeatedly access the traumatic memory.
8
Recent Developments in the
Neurobiology of Dissociation
Implications for Posttraumatic Stress Disorder

John H. Krystal, Alexandre Bennett, ]. Douglas Bremner,

Steven M. Southwick, and Dennis S. Charney

There is a growing recognition by researchers and clinicians that dissociative states

are an integral component of traumatic stress response. The term dissociation has
been employed to describe a spectrum of subjective experiences in which percep-
tual, affective, memory, and identity functions are altered. Particular symptoms or
syndromes associated with dissociative states include distorted sensory percep-
tions, altered time perception, amnesia, derealization, depersonalization, conver-
sion symptoms, fugue states, and multiple personality (Freud & Breuer, 1953;
Mayer-Gross, 1935; Hilgard, 1977; Spiegel & Cardeiia 1991; Bremner et al., 1992).
Despite the broad array of symptoms associated with dissociative states in post-
traumatic stress disorder (PTSD), some recent data suggest that these symptoms
may be expressed across individuals as a single symptom cluster, rather than as
independent clusters of symptoms (Bremner et al., in review).
There is now ample documentation that dissociation occurs at the time of
traumatization, particularly in those individuals who progress to develop PTSD
(Janet, 1889; Fischer, 1945; Krystal, 1968, 1988; Spiegel & Cardeiia 1991; Carlson &
Rosser-Hogan 1991; Bremner et al., 1992, 1993). Dissociative states and increased

John H. Krystal, Alexandre Bennett, J. Douglas Bremner, Steven M. Southwick, and Dennis S.
Charney • Department of Psychiatry, Yale University School of Medicine, and National Center for
PTSD, Department of Veterans Mfairs Medical Center, West Haven, Connecticut 06516.
Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 163
164 hypnotizability also develop as ongoing sequelae of traumatization (Spiegel, Hunt,
John H. Krystal & Dondershine, 1988; Bernstein & Putnam, 1986; Loewenstein & Putnam, 1988;
etal. Bremner et al., 1992, 1993). While dissociated, acutely traumatized individuals may
appear confused, emotionally dulled, or even catatonic, giving rise to descriptive
phrases such as "shell shock" (Kardiner, 1941; Grinker & Spiegel, 1945; Krystal,
1968). Decades following traumatization, while recalling their traumatic experi-
ences, individuals may experience time as being slowed, have altered sensory
perceptions, and have feelings of unreality (Bremner et al., in review). Less fre-
quently, adult traumatization may produce fugue states, conversion reactions, or
multple personality as ongoing symptoms of PTSD (Grinker & Spiegel, 1945;
McDougle & Southwick, 1990).
Childhood psychological traumatization is also associated with dissociative
symptoms. In one study, approximately 60% of 450 adults traumatized as children
had periods in their lives when they had no memory of their abuse (Briere & Conte,
1993). Dissociative symptoms arising from childhood traumatization continue in
adulthood (Putnam, Guroff, Silberman, Barban, & Post, 1986; Hermann, Perry, &
van der Kolk, 1989). For example, psychiatric inpatients with histories of childhood
trauma have higher levels of dissociative symptoms than nontraumatized inpatients
(Chu & Dill, 1992).
Flashbacks, perhaps the most distinctive PTSD symptom, appear to represent
the convergence of dissociative states, intrusive traumatic memories, and hyper-
arousal. During flashbacks, patients vividly reexperience aspects of the traumatic
response while feeling detached from their surrounding environment. Ongoing
sensory processing may be altered or disrupted and patients may report that they
are in a fog or that they blacked out (Bremner eta!., 1993). Flashbacks involving the
recollection of traumatic experiences are frequently associated with intense emo-
tional responses and paniclike states (Mellman & Davis, 1985). Most flashbacks are
brief, lasting only a few minutes. However, some flashbacks may last several hours
or several days. Some flashbacks are accurate depictions of a traumatic situation and
others have unreal or distorted qualities, similar to dreams.
Despite progress in identifying, characterizing, and quantitatively assessing
dissociative states, there has been surprisingly little study of their neurobiology in
adults and no published studies, to our knowledge, of the developmental neurobiol-
ogy of dissociation. Associated with the failure to elucidate a unique neurobiology
for dissociative states, there have been few placebo-controlled pharmacotherapy
trials for dissociative disorders and no specific antidissociative drugs developed.
The absence of antidissociative pharmacotherapies contrasts with the development
of anxiolytics, antiobsessionals, antipsychotics, mood-stabilizing agents, and anti-
depressants. In light of the paucity of research in this area, the commonly held view-
that the core features of dissociative disorders are unresponsive to
pharmacotherapy-is not surprising (Kluft, 1987).
This chapter will review recent progress made in studying the neurobiology of
dissociative states in PTSD patients. In particular, it will focus on studies that have
produced dissociative states in healthy individuals and patients with PTSD or other
neurological disorders. In doing so, this chapter will attempt to highlight bridges
between the neurobiology and treatment of PTSD.
BARBITURATES AND GUIDED RECOU.ECTION: 165
''NARCOSYNTHESIS'' Neurobiology of
Dissociation
The medical facilitation of traumatic memory recall and flashbacks in trau-
matized individuals began in World War II as part of a therapeutic approach called
narcosynthesis or, more recently, the amytal interview. 1bis approach combined
barbiturates and guided recollection of traumatic memories (Sargent & Slater, 1940;
Bartemeier, Kubie, Menninger, Romano, & Whitehorn, 1946; Grinker & Spiegel,
1945). The use of barbiturates to facilitate traumatic memory recall was illustrated
by a case reported by Grinker (1944, pp. 142-143):
That afternoon I gave him 0.25 gm of pentothal sodium intravenously. He was
then told that he was up in the air on a strafing mission and that the man on his
wing was aflame .... Immediately he [shouted] to his friend ... pull up and bail
out. Why doesn't he pull up and bail out? ... he went over and over the traumatic
situation, crying and sobbing. As this reaction subsided he was allowed to close
his eyes and sleep ... [upon awakening] He stated I must have been asleep. I had
a dream about [my friend] ...

The facilitation of traumatic memories by barbiturates and benzodiazepines

creates the appearanace of a paradox: drugs with prominent amnestic effects
improving memory function. These drugs impair attention, learning, and memory
in humans (Kirk, Roache, & Griffiths, 1990; Krystal et al., in review). However, their
amnestic effects arise primarily through interfering with memory encoding rather
than memory storage or retrieval (Ghoneim & Mewaldt, 1990). Mechanisms
through which barbiturates facilitate the recollection of traumatic memories and
flashbacks are poorly understood. Barbiturates enhance the actions of gamma-
aminobutyric acid (GABA) at the GABAA receptor (Olsen, 1981) and they block the
actions of glutamate at non-N-methyl-l>'aspartic acid (NMDA) receptors (Collins &
Anson, 1987; Morgan, Bermudez, & Chang, 1991). However, barbiturates are not
specific in their capacity to facilitate recollection of traumatic memories in that
ether, ethanol, nitrous oxide, and scopolamine-morphine combinations also ap-
pear to facilitate the recall of inaccessible memories (Erickson, 1945; Rosen &
Meyers, 1947).
The prodissociative effects of these drugs are indirect. Benzodiazepines, for
example, do not increase scores on scales measuring dissociation in healthy individ-
uals (Krystal et al., in review). Clinical observations suggest that the sedating and
anxiolytic medications employed in narcosynthesis reduce anxiety and thus may
lessen the resistance to recalling anxiety-associated memories (Grinker & Spiegel,
1945). This view is consistent with a patient who experienced flashbacks during
relaxation training (Fitzgerald & Gonzalez, 1994). Alternatively, these medications,
viewed as "truth sera" by the popular press, may suppress involuntary mechanisms
responsible for reducing voluntary access to traumatic memories (Kardiner &
Spiegel, 1947). Related to this hypothesis, recent physiological research has pro-
vided additional evidence of a neural basis for directed forgetting and other pro-
cesses associated with reduced voluntary access to established memories (Geisel-
man, Bjork, & Fishmann, 1983; Paller, 1990).
166 PHARMACOLOGICAL CHAllENGE STIJDIES IN PfSD PATIENTS
John H. Krystal
etal
Flashbacks have been precipitated in Vietnam veterans with chronic PTSD
following the intravenous administration of sodium lactate (Rainey et al., 1987),
yohimbine (Southwick et al., 1993), and m-chl.orophenylpiperazine (MCPP) (South-
wick et al., 1991). Administration of each of these substances produces panic
attacks in a significant proportion of patients with either panic disorder (Pitts &
McClure, 1967; Charney, Heninger, & Breier, 1984; Charney, Woods, Goodman, &
Heninger, 1987) or PTSD (Rainey et al., 1987; Southwick et al., 1991, 1993), but not
other patients groups. However, PTSD patients are the first group studied to
experience flashbacks following administration of these substances.
Rainey and his associates (1987) compared the response to intravenous sodium
lactate, isoproterenol, and a dextrose placebo in seven Vietnam combat veterans,
six of whom also met criteria for panic disorder. All seven patients experienced
flashbacks following lactate, two patients also experienced flashbacks after iso-
proterenol infusion, and one patient experienced a flashback during placebo infu-
sion. The authors described these flashbacks as similar to those occurring naturally
as part of PTSD. Dissociative experiences that accompanied flashbacks included
depersonalization, derealization, and auditory and visual sensory perceptions. Six
of the seven lactate-induced flashbacks, both isoproterenol flashbacks, and the
dextrose flashback were followed by paniclike states. However, the absence of
reported anxiety ratings makes it impossible to determine whether subpanic in-
creases in anxiety preceded the flashbacks. The overlap of panic disorder and PTSD
in the patients in this study was another limitation of this study, because it raised
concerns that lactate-induced flashbacks were a property of panic disorder and not
independently associated with PTSD. little is known about the mechanisms
through which lactate produced panic attacks and flashbacks in PTSD patients.
The precipitation of flashbacks and panic attacks in PTSD patients by yohim-
bine linked noradrenergic systems, implicated in fear and arousal regulation, to the
symptoms of PTSD (Southwick et al., 1993). Yohimbine activates central nor-
adrenergic neurons through blockade of a-2 receptors located on noradrenergic
neurons. These a-2 receptors mediate, in part, feedback inhibition of noradrenergic
neurons (Starke, Borowski, & Endo, 1975). Following yohimbine, 40% (8/20) of
patients experienced flashbacks and 70% (14/20) of patients experienced panic
attacks. No panic attacks and only one flashback emerged following placebo admin-
istration. Although 45% of the patients in this study also met Diagnostic and
Statistical Manual ofMental Disorders, 3rd edition, revised (DSM-III-R) (American
Psychiatric Association, 1987) criteria for panic disorder, 43% of the yohimbine-
induced panic attacks occurred in individuals without panic disorder. The risk of a
yohimbine-induced panic attack was increased in patients with panic disorder
relative to those without comorbid panic disorder (89 vs. 43%). However, history of
panic disorder did not appear to influence the likelihood of experiencing a
yohimbine-induced flashback. The following vignette illustrates features of a
yohimbine-induced flashback:
10:00 AM: [Initiation of yohimbine infusion]
10:05 AM: Subject reports hot and cold flashes, goose bumps, palpitations.
 10:10 AM: Subject reports clammy hands; he asked the nurse to move away 167
from him ... in case he felt like running. "I feel like I'm picking up
Neurobiology of
dead bodies; the centrifuge sounds like a helicopter ... A chopper is Dissociation
shooting at us; we're trying to shoot back at it! One of the guys' head
is shot off! Brains are coming at me! I smell burnt flesh ... I feel
scared, I can't hear what's going on ....
The operational definition for flashback employed in this study led to the
exclusion of many dissociative states produced by yohimbine in the PTSD patients.
The following criteria were employed to define a drug-induced flashback: (1) re-
experiencing of a past traumatic event during drug infusion, (2) the reexperiencing
must involve one or more sensory modalities, and (3) for patients with a history of
flashbacks, the drug-induced state must be similar to naturally occurring flashbacks.
Despite the expedient characterization of flashbacks as being present or absent,
yohimbine actually produced a continuum of dissociative phenomena. Patients
experienced varying degrees of derealization and depersonalization that were often
accompanied by other dissociative symptoms. Yohimbine also elicited a range of
altered perceptual experiences, some of which were fragmentary or vague. For
example, one patient perceived the shadow produced by a sink in the testing
facility to be the shadow made by a tank turret. In addition to stimulating flash-
backs, yohimbine significantly increased the recall of traumatic memories. Al-
though yohimbine produced symptoms of autonomic arousal in many patients,
these symptoms were not the sole predictor of flasbacks within a session. Yohim-
bine also significantly increased the recall of traumatic memories. In some cases,
symptoms of autonomic arousal followed or were coincident with the reported
retrieval of traumatic memories (Southwick, personal communication). Thus, it
appeared that noradrenergic systems might be involved in the elicitation of disso-
ciative symptoms as a direct consequence of its central pharmacological actions on
neural circuitry contributing to dissociation and memory retrieval. These data
contrasted with models in which noradrenergic contributions to PTSD symptoms
were entirely mediated by peripheral autonomic systems.
The yohimbine study suggested that activation of noradrenergic systems by
yohimbine produced panic attacks and flashbacks in a subset of PTSD patients. One
question raised by this study was whether the elicitation of flashbacks by yohimbine
reflected a specific response to o:-2 receptor blockade or whether all anxiogenic
drugs produce flashbacks in PTSD patients. In order to investigate this question,
yohimbine and MCPP effects were compared in this population (Southwick et al.,
1991). This study found that both MCPP and yohimbine produced flashbacks and
other dissociative states in veterans with combat-related PTSD. Preliminary analyses
indicated that patients tended to experience panic attacks following yohimbine or
MCPP, but not both medications. As with the initial study, drug-induced traumatic
memories, autonomic activation, and anxiety states could be associated with the
induction of flashbacks, although no single response preceded flashbacks in all
cases. These observations raised the possibility that yohimbine and MCPP caused
flashbacks by modulating a final common pathway that has yet to be identified or
that multiple mechanisms might lead to the induction of flashbacks.
In order to to continue the search for key neurotransmitter systems involved in
dissociation in PTSD patients, we studied the effects of the benzodiazepine antago-
168 nist, flumazenil, in PTSD patients. This drug failed to precipitate flashbacks or panic
John H. Krystal attacks in PTSD patients (Randall et al., in press). As with lactate, yohimbine, and
etal. MCPP, this agent has been reported to produce panic attacks in patients with panic
disorder (Woods, Charney, Silver, Krystal, & Heninger, 1991). The absence of
flumazenil-induced panic attacks and flashbacks indicates that PTSD is not associ-
ated with the overproduction of an endogenous benzodiazepine inverse agonist,
such as diazepam-binding inhibitor, that might contribute to anxiety symptoms in
other disorders (Costa & Guidotti, 1987). Future studies will be needed to deter-
mine whether benzodiazepine inverse agonists, such as FG-7142 or iomazenil,
which precipitate anxiety in healthy subjects (Dorow, Horowski, Paschelke, Amin,
& Braestrup, 1983; Randall, Bremner, Southwick, Krystal, & Charney, personal
communication), will produce flashbacks in PTSD patients.
Case reports suggest that alcohol and opiate withdrawal may increase PTSD
symptoms, including flashbacks (Kosten & Krystal, 1988; Salloway, Southwick, &
Sadowsky, 1990; Seibyl, personal communication). Central noradrenergic systems
are activated during alcohol and opiate withdrawal, suggesting a possible parallel
between yohimbine- and withdrawal-induced flashbacks (Kosten & Krystal, 1988).

INDUCfiON OF DISSOCIATIVE STATES IN HEALTHY INDIVIDUAlS

Pathophysiological models that hypothesize a "final common pathway" for the

neurobiology of dissociation presuppose that modulation of the activity of this
pathway might produce dissociative states in healthy individuals. To date, three
classes of drugs commonly produce dissociativelike states in healthy subjects:
(1) antagonists of the N-methyl-o-aspartate (NMDA) subtype of glutamate receptor,
(2) cannabinoids, and (3) serotonergic hallucinogens.
The noncompetitive NMDA receptor antagonist anesthetics, phencyclidine
and ketamine, produce a derealized and depersonalized state characterized by
marked perceptual alterations and psychosis at subanesthetic doses (Luby, Cohen,
Rosenbaum, Gottlieb, & Kelley, 1959; Domino, Chodoff, & Corsson, 1965;
Yamakura, Mori, Masaki, Shimoji, & Mishina, 1993; Javitt & Zukin, 1991). The
capacity of ketamine to produce dissociativelike states in healthy subjects has been
rigorously evaluated in a series of studies (Krystal et al., 1994a,b, in review). In these
studies, dissociative symptoms were rated using the Clinician-Administered Disso-
ciative States Scale (CADSS) (Bremner et al., in review). At low blood levels,
ketamine produced a light-headed feeling. At higher blood levels, subjects reported
the slowing of time and alterations in the vividness, form, and context of sensory
experiences. For example, subjects noted that objects appeared brighter or duller
than expected, larger or smaller than usual, distorted in shape, or with altered
proximity. Also, some subjects had difficulty hearing someone speaking close to
them, while reporting that a radio playing quietly in the next room sounded
unusually loud. Altered proprioceptive experiences were reported by subjects,
who felt that their limbs changed form or were floating in air.
Cognitive effects of ketamine were also prominent. Subjects reported constric-
tion of their field of attention, resulting in the sensation of tunnel vision or the
feeling that they were surrounded by fog. As ketamine blood levels rose, the
circumference of their field of attention was increasingly constricted. For example, 169
subjects attending to a computer keyboard lost track of events happening on the Neurobiology of
computer monitor. Ketamine also produced learning and memory impairments. Its Dissociation
effects increased proportionately to the dose administered and the duration of delay
between stimulus presentation and testing. Ketamine also interfered with executive
functions such as abstraction, assessed by proverb interpretation, and problem
solving, evaluated by the WISconsin Card Sorting Test. Although subjects felt that
they had lost control of their thought processes, with effort they could focus on
tasks, Ketamine also produced emotional and identity-related responses. At low
doses, it had mild anxiolytic properties, while larger doses generally produced
euphoria and anxiety. Anxiety stimulated by ketamine tended to follow perceptual
alterations and thought disorganization and to be related to their degree of comfort
with the drug-induced disturbances in thought and perception. Some subjects
found the perceptual alterations produced by ketamine quite pleasurable, analo-
gous to a ride in an amusement park, while others found ketamine effects fright-
ening.
Ketamine-induced insight impairments may have contributed to the elicitation
of anxiety. Following drug infusion, some subjects lost the perspective that their
mental status change was produced by ketamine and they became concerned that
they had contracted a mental illness. Transient identity alterations were also ob-
served with ketamine. For example, a subject who received ketamine (0.26 mg/kg
intravenous bolus followed by 0.65 mg/kg per hr) stated "at first it seemed that I
didn't exist, I couldn't process information; after a while, I was convinced that I was
an organism; then I realized I was a human being; then after a longer while I
remembered that I was a medical student." Ketamine did not lead to the emergence
of multiple personalities, flashbacks, or vivid intrusive memories in research sub-
jects. However, symptoms associated with psychosis, including delusions and
thought disorder, were observed during ketamine infusion.
Two ongoing studies have attempted to pharmacologically alter ketamine-
induced dissociative states by pretreating healthy subjects with lorazepam or halo-
peridol (Krystal et al., in review). Preliminary data from these studies suggested that
2 mg lorazepam administered orally 2 hours prior to ketamine administration
tended to reduce altered environmental perceptions, but had no effects on other
dissociative symptoms or psychotic states produced by ketamine. Haloperidol
failed to reduce dissociative symptoms, vigilance impairments, or amnestic effects
produced by ketamine, but reduced ketamine-induced distractibility, abstraction
impairments, and bizarreness of thought processes. These data suggested that, at
the doses tested, neither agent is a true ketamine antidote. They are also consistent
with the literature suggesting that neuroleptics have limited efficacy in treating
dissociative symptoms (Kluft, 1987).
Dissociative states have also been produced by psychoactive cannabinoids,
such as tetrahydrocannabinol the principal psychoactive component of marijuana
and hashish. Cannabinoids bind to a specific G-protein-coupled reeptor (Her-
kenham et al., 1990) through which they alter cellular functions including blockade
of N-type calcium channels, inhibition of cyclic AMP accumulation, and stimulation
of arachidonic acid and intracellular calcium release (Felder et al., 1993). Some
cannabinoid effects may be mediated by stimulation of glucocorticoid receptors
170 (Eldridge & Landfi.eld, 1990) and blockade of NMDA receptors (Feigenbaum et al.,
John H. Krystal 1989). At high doses, cannabinoid intoxication produces depersonalization, dereal-
etal ization, perceptual alterations, and insight impairments (Bromberg, 1939; Melges,
Tinklenberg, Hollister, & Gillespie, 1970; Dittrich, Bahi.g, & von Zeppelin, 1973).
Cannabis has been reported to produce flashbacks in the drug-free state that
resemble cannabis intoxication (Hollister, 1986). In one study (Stanton, Mintz, &
Franklin, 1976), 3% (1/31) of habitual marijuana users and 1% (3/348) of nonhabitual
users reported flashbacks when drug-free, suggesting that flashbacks were not a
frequent consequence of cannabis use. However, this study suggested that mari-
juana use also enhanced the likelihood of experiencing flashbacks following inges-
tion of the serotonergic hallucinogens.
Serotonergic hallucinogens, such as lysergic acid diethylamide (LSD), mes-
caline, and dimethyltryptamine (DMT), also produce dissociative symptoms. These
agents stimulate serotonin-2 (5-HT2) receptors (Rasmussen, Glennon, & Aghaja-
nian, 1986; Titeler, Lyon, & Glennon, 1988). These drugs produce pronounced
visual hallucinations, illusions, synesthesia, and expansive or portentious emotional
responses (Freedman, 1968). Following ingestion of these psychedelics, feelings of
derealization or depersonalization may also be prominent. Environmental stimuli
may be experienced in a fragmented manner, body image may be distorted, and
individuals may feel detached from their surroundings (Savage, 1955; Liebert,
Werner, & Wapner, 1958; Klee, 1963; Rodin & Luby, 1966; Freedman, 1968). Some
clinicians also have reported that LSD may facilitate the recall of repressed memo-
ries (Freedman, 1968), although this capacity has never been rigorously evaluated.
Relative to the phencyclidine or ketamine experience, psychedelic hallucinogens
tend to produce perceptual effects that predominate over dissociative effects and
impairments in higher cognitive functions.
Flashbacks have been reported in healthy individuals following serotonergic
hallucinogen use. Freedman (1968) and Horowitz (1969) suggested that LSD intox-
ication was traumatic for some users because it diminished control over awareness,
resulting in intense emotional states experienced as beyond their control. In such
cases, LSD flashbacks might have a traumatic etiology. However, some LSD-like
experiences, such as synesthesia, may be reexperienced long after drug ingestion
by individuals who find such experiences pleasant. These effects do not easily fit a
trauma model, suggesting that sensitization, conditioning, or state-dependent learn-
ing might also apply (Freedman, 1968, 1984; Horowitz, 1969; McGee, 1984). Subject
expectancy may also play a role in druglike flashbacks. One study found that
flashbacks may be produced in healthy subjects following placebo administration, if
subjects are coached to anticipate that a placebo will to produce flashbacks
(Heaton, 1975). Heaton suggested that the expectancy of flashbacks led subjects to
mislabel and selectively attend to aspects of normal experience that are consistent
with a flashbacklike experience.

LESSONS FROM BRAIN STIMUlATION STIJDIES

Flashbacks are common to PTSD and conditions associated with local activa-
tion of cortical and limbic structures. Hughlings Jackson first described the com-
plex polysensory reexperiencing of events that occurred in association with tempo- 171
ral lobe epilepsy as memory flashbacks (faylor, 1931). Patients wtih clinical and Neurobiology of
encephalographic evidence of temporal lobe epilepsy exhibited a range of dissocia- Dissociation
tive symptoms including depersonalization, derealization, auditory and visual hallu-
cinations, and multiple personalities (Mesulam, 1981). Sacks (1985) also described a
patient with seizure foci in her medial temporal structures that produced repetitive
reexperiencing of Irish folk melodies. Anticonvulsant treatment eliminated the
intrusive musical reexperiencing, but also eliminated her ability to recall the
melodies.
Penfield and his colleagues elicited dreamlike states, memories, and complex
experiential phenomena through direct electrical stimulation of structures in the
temporal lobe, temporoparietal association areas, hippocampus, and amygdala
(Penfield & Perot, 1963). Temporal lobe stimulation resulted in some individuals
reexperiencing frightening events in a polysensory fashion, such as a possible
thwarted kidnapping. However, neutral or pleasant experiences were also pro-
duced, such as hearing a choir sing White Christmas. The amygdala and hippo-
campus appear to be implicated in the experiential phenomena associated with
temporal lobe activation. Gloor, Olivier, Quesney, Andermann, and Horowitz (1982)
found that experiential phenomena were associated with direct stimulation of the
amygdala and the hippocampus. Moreover, memories, dreamlike states, or other
complex experiential phenomena were only produced when temporal cortical
stimulation was followed by after-discharges in the amygdala or hippocampus.
Results of this study were consistent with an earlier one that produced complex
experiential phenomena through electrical stimulation of the hippocampus and
amygdala (Halgren Walter, Cherlow, & Crandall, 1978).
The brain stimulation studies suggest that the hippocampus and amygdala
control the retrieval of memory in a highly specific manner, much as a program
might control access to information stored on a computer. However, this interpreta-
tion appears overly simple. Complex experiential phenomena are usually associ-
ated with high-intensity stimuli or after-discharges, suggesting that fairly large
cortical areas must be activated (Halgren et al., 1978). Also, stimulation of the same
location over several trials does not reliably reproduce experiential phenomena,
while stimulation of disparate cortical regions may produce identical experiences
(Halgren et al., 1978; Horowitz, Adams, & Rutkin, 1968). In addition, surgical
excision of an area that produces a memory when directly stimulated does not
eliminate the memory (Baldwin, 1960). A more circumspect interpretation of these
data is that memory is stored within distributed networks and that the amygdala and
hippocampus stimulations bias the retrieval of memories in a more general fashion,
such as facilitating access to an associative network.
One of the striking similarities of flashback associated with PTSD and the brain
stimulation studies are the inflexible nature of memory retrieval under these condi-
tions. Dreams and memories often replay traumatic scenes in their entirety rather
than being retrieved with the cognitive flexibility characteristic of declarative
memory. The neurobiology underlying the loss of retrieval flexibility and efficiency
associated with traumatic memory retrieval, limbic stimulation studies, and the
developmental disorders are currently unclear. However, reduced mnemonic flex-
ibility has been reported to characterize memory retrieval under conditions where
172 the hippocampus is activated independently of the frontal cortex (Moscovitch,
John H. Krystal 1992). Memory encoding by the hippocampus is modular and organizing links
etal between memories arise largely through cue association, as occurs during condi-
tioning (Moscovitch, 1992). Retrieval strategies involving the hippocampus are cue-
dependent and not strategic. In other words, the hippocampus cannot efficiently
scan stored memories to retrieve a particular memory, even though it is involved in
memory encoding. The organizing and strategizing component of memory retrieval
appears to be dependent on the frontal cortex (Moscovitch, 1989, 1992). Thus,
flashbacks may share the qualities of memory retrieval exhibited by individuals
during hippocampal stimulation because these conditions involve retrieval strate-
gies that bypass the frontal component of memory retrieval in the face of relative
preservation of the hippocampal component of memory retrieval.
Recollective processes that bypass frontal executive mechanisms controlling
the strategic recollection of information may also share the quality of being reex-
perienced rather than recalled. Flashbacks produced in seizure patients by electri-
cal stimulation (Penfield & Perot, 1963) and those occurring in PTSD (Bremner
et al., 1992; Southwick et al., 1991) were both described in this manner. Frontal
cortical networks have been implicated in executive functions related to the con-
trol of memory retrieval (Baddeley, 1986). Frontal lobe lesions, unlike hippocampal
lesions, impair retrieval of autobiographical information (Baddeley & Wilson, 1988).
The frontal cortex has also been implicated in the prioritization of responses, the
generation of mental representations within working memory, self-monitoring, and
editing of thought (Stuss, 1992; Goldman-Rakic, 1987; Baddeley, 1986). The frontal
cortex is nested within networks involving the amygdala, mediodorsal thalamic
nucleus, the hippocampus, and other regions that provide access to input regarding
the nature and meaning of memories that are formed (Goldman-Rakic, 1987).
Sedative-hypnotic agents produce impairments on tests sensitive to frontal cortical
impairment, as does ketamine (Krystal et al., 1994b, in review).

TIIALAMIC NE1WORKS AND DISSOCIATIVE STATES

Dissociative states occur normally in individuals without dissociative disorders

at extremely low or high levels of sensory processing. Reductions in the intensity or
variability of sensory stimulation, associated with hypnosis, sleep deprivation, and
sensory deprivation, may produce altered states of consciousness with dissociative
features (Freud & Breuer, 1953; Bexton, Heron, & Scott, 1954; Lilly, 1956; Cappon &
Banks, 1960; Krystal, 1988). As an extreme illustration of this point, sensory poly-
neuropathies may cause marked depersonalization and derealization associated
with feelings of being disembodied (Sacks, 1985). Heightened sensory stimulation
or arousal may also produce altered sensory processing. Significant levels of arousal
and anxiety heighten the salience and vividness of environmental stimuli. Under
stress, attention is narrowed to the most salient aspects of the environment, consis-
tent with the need to focus on the danger at hand. Thus, individuals fixate faster and
longer on unusual or highly informative objects, such as weapons (Brown & Kulik,
1977; Burke et al., 1992; Christianson & Loftus, 1991), while less critical but impor-
tant information about the context of the trauma may not receive much attention
(Kramer, Buckhout, & Eugenio, 1990). At extremely high levels of arousal, coherent 173
integration of sensory information breaks down and dissociative symptoms emerge, Neurobiology of
even in individuals without dissociative disorders (Cappon & Banks, 1961; Ludwig, Dissociation
1972; Krystal, Woods, Hill, & Charney, 1988, 1991).
The thalamus plays a critical role in modulating responsivity to environmental
stimuli associated with sleep and dreaming and may play a similar role in the genesis
of dissociative states. As illustrated in Figure 1, the thalamus serves as a sensory gate
or filter that directly and indirectly modulates the access of sensory information to
the cortex, amygdala, and hippocampus (Amaral & Cowen, 1980; McCormick,
1992; Steriade & Llinas, 1988; 1\irner & Herkenham, 1991). During slow wave sleep,
for example, thalamic nuclei exhibit slow spindle oscillations that disrupt the
transmission of sensory information to cortical and limbic structures (Steriade &
Deschenes, 1984). During wakefulness, thalamic neurons fire in a relay mode that
facilitates transmission of sensory information to cortical regions. Rapid eye move-

Frontal cortex: Clngulata: Amygdala:

Generates prior~ization Involved in Modulates the Hippocampus:
plan for attention and prioritizing or shifting generation of Encodes long-term
working memory attention emotional states declarative memory

Thalamus:
Modulates the fidelity o f - - - - - - - - - Parahippocampal
sensory processing cortex

/r~
Sensory 1nput Direct and indirect Input from systems
feedback from modulating arousal:
cortical and limbic Locus coeruleus
structures (norepinephrine);
raphe nucleus
(serontln); reticular
nuclei (acetylcholine)
Figure 1. This schematic illustrates the position of the thalamus within networks that may he involved
in the generation of dissociative states. Sensory information reaches the thalamus and is transmitted to
limbic and cortical regions responsible for modulating thought, attention, learning and memory, and
emotion. The thalamus receives input from limbic regions, such as the amygdala, and brainstem regions
involved in stress-related arousal. It also receives direct and indirect feedback from cortical regions
involved in prioritizing attention. When functioning in relay mode, the thalamus facilitates the accurate
transmittal of sensory information. However, when slow oscillatory firing patterns predominate, the
thalamus impedes the flow of sensory information to cortical and limbic regions associated with the
predominate focus on internally generated thought processes and sensory experiences associated with
dreaming, night terrors, and perhaps dissociation (from Krystal, Bennett, Bremner, Southwick, &
Charney, in press).
174 ment (REM) sleep, associated with dreaming, is characterized by phasic enhance-
John H. Krystal ment of the activity of glutamatergic thalamocortical cells (Steriade, Datta, Pare,
etal Oakson, & Curr6 Dossi, 1990; Steriade & McCarley, 1990). In this model, dreams and
other sleep-related internally generated experiences may arise as thalamocortical or
other direct cortical projections from the amygdala and hippocampus bypass the
oscillatory thalamic processes that disrupt the flow of sensory information to the
cortex (Swanson, 1981; Uinas & Pare, 1991). Thus, like dissociative states, sleep
states may neurobiologically preserve associative and mnemonic functions while
interrupting sensory processing. Sensory processing alterations associated with
dissociative states could indicate the intrusion of sleep-related disturbances in
sensory processing into the waking state. If so, then alterations in thalamic activity
tnight link a spectrum of altered states of consciousness such as hypnosis, dream-
ing, and other conditions in which there is a combination of the features of sleep
and waking states (Mahowald & Schenck, 1991; Uinas & Pare, 1991). Dissociative
states tnight also be related to night terrors in which features of waking behavior
intrude upon sleep (Fischer, Kahn, Edwards, & Davis, 1973; Kales et al., 1980;
Oswald & Evans, 1985). Evidence for a thalatnic role in maintaining the boundary of
sleeplike behavior and wakefulness is provided by patients with paramedian
thalamic infarctions. These patients exhibit a profound sense of detachment, re-
duced responsivity to sensory stimuli, and sleeplike posturing throughout the
circadian cycle without the electrophysiological correlates of non-REM sleep
(Guilleminault, Quera-Salva, & Goldberg, 1993).
A thalamic role in dissociation is suggested by its distinctive role in modulating
the onset of night terrors as opposed to nightmares. Posttraumatic nightmares
occur within REM sleep and are not generally associated with motor behaviors,
although they may repetitively review aspects of the trauma (Fisher, Byrne, Ed-
wards, & Kahn, 1970; Fisher et al., 1973; Greenberg, Pearlman, & Bampel, 1972). In
contrast, posttraumatic night terrors bear a closer resemblance to flashbacks occur-
ring in the waking state. Night terrors are associated with confusion upon awaken-
ing, reduced responsivity to environmental stimuli, displays of intense emotion,
significant autonotnic activation, increased sleep motility, complex motor activity,
and somnambulism (Lavie & Hertz, 1979; Hafez, Metz, & Lavie, 1987; van der Kolk,
Blitz, Burr, Sherry, & Hartmann, 1984; Fisher et al., 1970, 1973). Despite behavioral
evidence that traumatic incidents are being reexperienced during night terrors,
such as calls for help and appearing to act out physical struggles, individuals are
generally amnestic for the content of their experiences. As with flashbacks and
nightmares, night terrors may be precipitated in PTSD patients by reminders of the
trauma or environmental stress (Krystal, 1968; Fisher et al., 1970). Unlike night-
mares, night terrors occur during deep sleep, particularly stage 4, and generally
within the first hour after falling asleep (Fisher et al., 1973; Kales et al., 1980).
Nightmares and night terrors may be further distinguished by the effects of parame-
dian thalamic lesions. These lesions eliminate the stages of sleep that contain night
terrors, but do not alter REM sleep and dreaming (Guilleminault et al., 1993).
Sensory distortions associated with stress may develop, in part, as a conse-
quence of the thalamic role in modulating sensory processing. Thalamic nuclei
appear to work both in series and in parallel with brain regions involved in
traumatic stress response. One region that may be critical for fear learning and
traumatic stress response is the central nucleus of the amygdala (LeDoux, 1987; 175
Davis, 1992; Charney, Deutch, Krystal, Southwick, & Davis, 1993). Once activated Neurobiology of
by uncontrollable stressors, the central nucleus of the amygdala facilitates the Dissociation
thalamic relay of sensory information to cortical and limbic structures (Clugnet &
LeDoux, 1990; McDonald, 1982; Steriade et al., 1990).
Central noradrenergic systems are also activated by signfiicant uncontrollable
stressors and have been linked to traumatic stress response (van der Kolk, Green-
berg, Boyd, & Krystal, 1985; Krystal et al., 1989). Stress-induced noradrenergic
activation would be expected to facilitate thalamic transduction of sensory informa-
tion by stimulating thalamic a-1 adrenoceptors that increase thalamic activity asso-
ciated with wakefulness and to inhibit slow thalamic oscillations (Buzsili, Kennedy,
Solt, & Ziegler, 1990; McCormick & Wang, 1991). Postsynaptic a-2 receptors pro-
mote thalamic slow oscillations. Thus yohimbine, an a-2 antagonist, could incease
thalamic bursting by increasing norepinephrine release and blocking the stimula-
tion slow oscillations produced by postsynaptic a-2 receptors (Buzsili et al., 1990).
Serotonergic systems, linked to PTSD symptoms by the MCPP study described
above (Southwick et al., 1993), also heighten sensory processing via the 5-HT2
receptor (McCormick & Wang, 1991). Both MCPP and the serotonergic hallu-
cinogens stimulate subtypes of this receptor (Sheldon & Aghajanian, 1991). Percep-
tual alterations associated with extreme or uncontrollable stress suggest that the
massive activation of monoamine systems under these conditions may modulate
thalamic function in a fashion that results in interference rather than enhancement
of the fidelity of sensory transmission.
Alterations in thalamic glutamatergic function also could contribute to sensory
gating disturbances. Glutamate is the primary excitatory neurotransmitter within
the thalamus (McCormick, 1992) and the neurotransmitter involved with thalamic
afferents from the amygdala, cerebral cortex, and hippocampus (Aggleton & Mish-
kin, 1984; Aggleton, Desimone, & Mishkin, 1986; Giguere & Goldman-Rakic, 1988;
LeDoux & Farb, 1991; McCormick, 1992). Indirect cortical thalamic modulation also
occurs via a circuit involving the striatum, globus pallidus, subthalamic nucleus,
and thalamus (Carlsson & Carlsson, 1990). Both NMDA and non-NMDA glutamate
receptors are localized to the thalamus, where they have complementary functions
(McCormick, 1992). Previous reviews have suggested that alterations of the sensory
filter function of the thalamus via blockade of NMDA receptors could contribute to
the psychotomimetic effects of the NMDA antagonists (Carlsson & Carlsson, 1990).
Given the prominent role of non-NMDA glutamate receptors in corticostriato-
thalamic circuitry, subanesthetic doses of selective NMDA antagonists might be
predicted to produce distortions rather than complete blockade of thalamic sen-
sory gating functions. This prediction is consistent with clinical observations,
suggesting that ketamine produces a state of detachment or withdrawal rather than
sleep. Also, ketamine produces sensory distortions and illusions rather than block-
ade of sensory perceptions or pure hallucinatory experiences (Krystal et al., 1994a).
The capacity of sensory deprivation to reduce rather than augment the behavioral
effects of phencyclidine further suggests that NMDA antagonists alter, rather than
block, sensory processing (Cohen, Luby, Rosenbaum, & Gottlieb, 1960). Future
research is needed to clarify the extent of thalamic contributions to dissociative
states.
176 The thalamus is a heterogenous structure and component thalamic nuclei have
John H. Krystal distinctive cortical afferents and efferents and different patterns of synaptic organi·
etal zation (M. L. Schwartz, Dekker, & Goldman-Rakic, 1991). For example, the reticular
nuclei of the thalamus fucntion in some ways as an extension of brainstem and
midbrain reticular activating systems (Steriade & Lliruis, 1988). However, other
thalamic nuclei, such as the anteroventral and mediodorsal nuclei, appear to be
involved in associative processes, such as learning (Orona & Gabriel, 1983; Gabriel,
Sparenborg, & Stolar, 1987; Gabriel, Vogt, Kubota, Poremba, & Kang, 1991).
Sensory processing alterations and changes in attention may be linked in
dissociative states. Clinically, the bridge between sensory gating and attention
modulation is evident in the reduced responsivity to environmental stimuli exhib-
ited by dissociated individuals and their reported focus on peripheral sensory
stimuli or internal mental processes (Carlson & Putnam, 1989). This connection also
is suggested by the convergence of corticolimbic networks upon the anterior
cingulate gyrus, a brain region implicated in the capacity to shift and focus attention
(Pardo, Pardo, Janer, & Raichle, 1990; Bench et al., 1993). Anterior cingulate lesions
may produce symptoms reminiscent of thalamic, limbic, and cortical lesions includ-
ing confusion, vivid daydreaming, apathy, impairments in sustained attention, and
learning impairments (Whitty & Lewin, 1957; Laplane, Degos, Baulac, & Gray, 1981).
Direct projections to the anterior cingulate gyrus from midline and intralaminar
thalamic nuclei suggest that the cingulate gyrus is responsive to shifts in thalamic
sensory processing functions (Vogt, Rosene, & Pandya, 1979). As suggested by the
clinical case reports of patients wtih cingulate lesions, the cingulate gyrus may also
be involved in the attribution of salience and the acquisition and retrieval of learned
information (Gabriel et al., 1991; Gaffan, Murray, & Fabre-Thorpe, 1993). The
contributions of the cingulate gyrus to sensory processing, emotional regulation,
and learning are facilitated by its connectivity to other brain regions. For example,
hippocampal and anteroventral thalamic inputs converge upon the anterior cingu-
late gyrus via the posterior cingulate gyrus (Gabriel et al., 1987; Gabriel & Sparen-
borg, 1987). Similarly, the anterior cingulate gyrus is an important point of conver-
gence for a network involving the amygdala, prefrontal cortex, and mediodorsal
thalamic nucleus (Aggleton & Mishkin, 1984; Goldman-Rakic & Porrino, 1985;
Gaffan & Murry, 1990; Gaffan et al., 1993; Orona & Gabriel, 1983).

CORTICAL DISCONNECTIVTIY AND DISSOCIATION

Geschwind (1980, p. 191) wrote, "there is no evidence for the existence of any
all-purpose computer in the brain." Consistent with this view, cortical functions are
highly distributed across several cortical regions that require integration in order to
generate coherent conscious experience. For example, frontoparietal interactions
help to locate memories or mental representations in space, while frontohippocam-
pal interactions appear to contribute contextual information regarding these mem-
ories (Goldman-Rakic, 1987). Also, the frontal cortex itself contains many func-
tionally heterogeneous regions. Distinct frontal cortex loci mediate the generation
of iconic or working memories for the location and features of environmental
stimuli. Brain lesions of one region of the frontal cortex results in memory gaps for
spatial features, while lesions of the other region produce an inability to recall faces 177
(Goldman-Rakic, 1987; Wilson, Scalaidhe, & Goldman-Rakic, 1993). If corticocorti- Neurobiology of
cal interactions were disturbed or disrupted, experiences and cognitive functions Dissociation
dependent on integrated cortical activity might be distorted. For example, if frontal
cortical regions processing features of objects and their spatial attributes were
interacting dysfunctionally, one might generate mental representations for stimuli
in which features were not correctly matched to their spatial locations, i.e., objects
could be experienced out of context or in bizarre or incoherent ways. Disturbances
in function arising from abnormal integration of cortical function may be similar, by
analogy, to conduction aphasias. In conduction aphasias, both comprehension and
fluency are preserved, but speech is paraphasic because information cannot be
effectively transmitted from association to motor cortices (Geschwind, 1970).
Drugs that produce dissociative states disturb cortical integration at several
levels. The key output neurons of the cortex are pyramidal neurons that utilize
glutamate as their primary neurotransmitter. These neurons are regulated locally by
modulatory GABAergic neurons. Pyramidal neurons also receive distant input from
subcortical monoaminergic, glutamatergic, and peptidergic systems and glutama-
tergic input from pyramidal neurons in other cortical areas (Goldman-Rakic, 1987;
Lewis, Hayes, Lund, & Oeth, 1992). In the piriform cortex, serotonergic hallu-
cinogens inhibit pyramidal neuronal activity by stimulating GABAergic inter-
neurons via the 5-HT2AI2B receptors. However, these drugs also activate pyramidal
neurons through stimulating 5-HT2c receptors (Sheldon & Aghajanian, 1991). Elec-
trophysiological data suggest that ketamine distorts the functional connectivity
within the cortex by blocking the NMDA receptor-mediated component of glutama-
tergic corticocortical connectivity. One study, for example, suggested that blockade
of NMDA receptors allowed sensory information to reach the cortex, but interfered
with the coherent transmission of this information from receptive areas to associa-
tion cortices (Corssen & Domino, 1966). Barbiturates, which preferentially block
non-NMDA glutamate receptors (Collins & Anson, 1987; Morgan et al., 1991), might
also interfere with cortical integration, although the human psychopharmacology
of non-NMDA glutamate receptors has received little direct study.

SUMMARY: ALTERATION IN GLUTAMATERGIC FUNCTION,

A FINAL COMMON PATIIWAY FOR DISSOCIATION?

Clinical studies related to the neurobiology of dissociative states are summa-

rized in Table 1. Yohimbine and MCPP produce dissociative states only in PTSD
patients, who are prone to have these experiences. These drugs primarily produce
dissociative states while stimulating anxiety or traumatic recollections. Thus,
yohimbine and MCPP may not directly induce dissociation, but rather contribute to
the activation of networks resulting in a dissociative state in vulnerable individuals.
In the amygdala, hippocampus, thalamus, and cortex, noradrenergic and seroton-
ergic systems serve to modulate the activity of glutamatergic neurons (Goldman-
Rakic, 1987; Lewis et al., 1992). Given the central role of glutamate in cortico-
cortical, thalamocortical, amygdalocortical, and hippocampocortical connectivity,
glutamatergic systems in the brain may be considered the framework on which
178 Table 1. Summary of Pharmacologically Facilitated
John H. Krystal
Dissociative States
etal Substance Healthy subjects" PTSD patients•

Yohimbine +
MCPP +
lActate +
Sedative-hypnotics +•
Benzodiazepine antagonists
NMDA antagonists +
Cannabinoids +
Serotonergic hallucinogens +
11 +, Associated with dissociative state; -,not associated with dissociative state;
?, unclear association with dissociative state; not formally evaluated in patients
with PTSD.
•Facilitation of dissociation during goided recollection.

higher cognitive functions rest. Thus, it may not be surprising that a drug, such as
ketamine, that alters glutamatergic neurotransmission produces dissociative states
in healthy individuals. The possibility that glutamate systems might be fundamen-
tally involved in generating dissociative states is consistent with the observation
that dissociative states produced by ketamine in healthy people arise as a direct
consequence of drug administration and are not dependent on generating intense
emotional responses or memories. The direct evocation of dissociative states by an
NMDA antagonist raises the possibility that reductions in NMDA receptor function
contribute to dissociative states in humans. If so, then pharmacological agents that
enhance NMDA receptor function might have antidissociative properties (Jones,
Wesnes, & Kirby, 1991; Saletu, Griinberger, & linzmayer, 1986; Schwartz et al., 1991;
Nicholls, 1993).

IMPUCATIONS FOR THE TREATMENT OF PfSD

Dissociative phenomena, traumatic memories, and affective regulation are

highly interrelated in PTSD patients. As reviewed earlier, traumatic memories and
intense emotions may trigger dissociative phenomena in PTSD patients. Similarly,
dissociative states and particular emotional states make the recall of traumatic
memories more accessible. Completing the triangle, traumatic memories and disso-
ciative phenomena may precipitate strong emotional responses. Thus, reducing the
incidence of flashbacks and the intrusiveness and distress related to traumatic
memories must be understood in the context of treating each of the three inter-
active processes.
The first step in treating dissociative states in traumatized individuals is to
alleviate the marked depersonalization, derealization, and extreme emotional
arousal. Barbiturates and benzodiazepines may be useful for this purpose (Kluft,
1987). The long-term benefits of acute anxiolysis are currently unclear. However,
Kardiner (1941) emphasized the importance of the peritraumatic period in creating
a long-lasting appraisal of traumatic events. Acute anxiolysis may be helpful in 179
reducing negatively valenced cognitive distortions. Thus, in the context of suppor- Neurobiology of
tive therapy, benzodiazepine treatment may facilitate the development of a more Dissociation
adaptive appraisal of the traumatic stress. Acute anxiolysis might alter the pairing
of emotions and memories. Anxiolysis may also reduce or prevent the development
of dissociative states, thus facilitating reflective reevaluation of information related
to the trauma.
Once hyperarousal is controlled, a second challenge faced by clinicians is to
reduce amnesia for traumatic events. Almost every psychotherapeutic strategy for
treating acute psychological trauma has as a goal the integration of the traumatic
experience within the conscious life of patients (Freud & Breuer 1953; Horowitz,
1976; Krystal, 1988). This task is difficult if the patient is amnestic for the trauma.
Several guided recollection strategies have been employed to facilitate patients'
access to traumatic memories including relaxation training, free association, dream
interpretation, hypnosis, and narcosynthesis (Grinker & Spiegel, 1943; Bartemeier
et al., 1946; Krystal, 1988; Keane, Fairbank, Caddell, & Zimering, 1989). Each of
these processes takes advantage of an altered state of consciousness associated with
increased suggestibility in which there is a reduction in functions usually associated
with the frontal cortex, such as reflection, self-monitoring, and editing of thought
(Stuss, 1992).
A potential risk associated with conducting guided recollection in a compro-
mised state is that ideas introduced by the clinician may be more readily incorpo-
rated into the memories of the patient. For example, under hypnosis or during
cannabis intoxication, subjects may not be able to accurately monitor the source or
validity of recalled memories (Laurence & Perry, 1983; Pfefferbaum, Darley, Tinklen-
berg, Roth, & Kopell, 1977). This concern is particularly relevant to narcosynthesis
or other techniques in which the therapist recreates the roles of people within the
patient's traumatic memory in order to facilitate memory retrieval (Grinker &
Spiegel, 1943, 1945). Further, the use of pharmacological agents, such as amytal, in
narcosynthesis may produce amnesia for remembered information (Ghoneim,
Hinrichs, & Mewaldt, 1984). Because patients may not fully recall information
produced during narcosynthesis at later times (Grinker, 1944), narcosynthesis may
be best viewed as an information-gathering procedure.
Once an individual has access to memories of the trauma, what can the
patient- clinician dyad do with them to reduce the incidence of intrusive memories
or flashbacks? Most patients are tormented by the intrusion of traumatic memories,
and for these individuals, merely reviewing them an additional time is not neces-
sarily therapeutic. Freud and Breuer (1953) initially suggested two strategies for
reducing dissociative or conversion symptoms associated with hysteria: abreaction
and the formation of new associations to the traumatic memories. By abreaction,
Freud and Breuer meant the discharge, during therapy, of stored feelings that could
not be adequately expressed at the time of the trauma. This hydraulic view of
emotions has largely been abandoned (Krystal, 1978). Alternatively, modern cogni-
tive, behavioral, and insight-oriented therapies focus on altering cognitive, affec-
tive, and identity-related associations to the trauma (Krystal, 1988; Keane et al.,
1989; Foa, Steketee, Olasov, & Rothbaum, 1989). Psychotherapy may help to reduce
the intrusiveness and distress related to traumatic memories by altering associations
180 to the traumatic events, essentially changing the meaning of the trauma to the
John H. Krystal individual.
etal. Managing the recollection of traumatic memories, dissociative states, and
intense affects in patients is a tremendous clinical challenge facing the clinician
treating PfSD. Guided reexperiencing of the trauma could evoke dissociative states
that interfere with associative learning and interfere with generalizing therapeutic
gains beyond the clinical setting. Intense emotions evoked during such recollec-
tions could reinforce the association between traumatic memories and intolerable
intense emotions, sensitizing individuals to reminders, promoting a sense of help-
lessness or other negative appraisals of the trauma, and making the individual more
reluctant or unable to review traumatic material in subsequent therapy sessions
(Pitman et al., 1991). Further, by stimulating intense emotional responses and
negative association in some individuals, flooding may exacerbate depression or
provoke impulsive behavior, including substance abuse (Pitman et al., 1991). These
potential problems help to explain the need for extensive relaxation training prior
to the initiation of guided reexposure therapies, such as flooding (Keane et al.,
1989). This step is probably a useful adjunct to all psychotherapies for PfSD
patients (Hickling, Sison, & Vanderploeg, 1986). Further, one might predict that
care must be taken to titrate the level of arousal associated with guided recollection
of traumatic memories to the patient's capacity to process information. When, in
the course of a therapy session, patients provide clinical data consistent with the
induction of dissociative states, further efforts to encourage them to process trau-
matic material seem unlikely to be fruitful.
The concern that interference with higher cognitive functions limits the clini-
cal utility of altered states of consciousness applies equally to proposed pharmaco-
logical adjuvants to psychotherapy such as the serotonergic hallucinogens (cf.,
Freedman, 1968) and NMDA antagonists (cf., Krystal et al., 1994a). Particularly in
patients with chronic PTSD who have been in many years of treatment, there seems
to be little benefit in guiding them to reexperience the trauma at the expense of
repeated dissociative episodes. Carefully conducted flooding therapy, preceded by
relaxation training, may reduce intrusive symptoms of PfSD, but have no beneficial
impact on numbing or avoidance (Keane et al., 1989). These authors highlight
significant psychological and social deficits that impair treatment response in pa-
tients with chronic PfSD. Thus, treatments aimed at reevaluating traumatic memo-
ries may have important, but focused, roles in their therapy. Also, research is
needed to characterize optimal strategies for integrating pharmacotherapy ap-
proaches with these cognitive and behavioral psychotherapies.
If, analogous to relaxation training, pharmacological strategies were developed
that preserved cognitive functions in the face of strong affects and traumatic
memories, the formation of new associations to traumatic memories might proceed
more effectively and rapidly. Benzodiazepines, reportedly useful in some PfSD
symptoms in patients with dissociative disorders (Loewenstein, Hornstein, & Far-
ber, 1988) might help by reducing the affective distress, although their amnestic
properties might be counterproductive at high doses. Alternatively, one could
evaluate pharmacological approaches to enhancing the cognitive processing. In
this regard, drugs that facilitate NMDA receptor function via enhancement of the
glycine site, such as cycloserine or milacemide (B. L. Schwartz, Hashtroudi, Herting,
Handerson, & Deutsch, 1991; Saletu et al., 1986), should be evaluated for anti- 181
dissociative and other cognitive enhancing properties in PfSD patients. Neurobiology of
Antidepressants are the best-studied pharmacotherapy for PfSD, and research Dissociation
suggests that they provide a moderate degree of relief from flashbacks and intrusive
memories. Case reports suggest that tricyclic antidepressants may reduce flash-
backs; night terrors, and distress related to intrusive memories of the trauma
(Marshall, 1975; Burnstein, 1983). Similar findings have been reported in open label
trials of monoamine oxidase inhibitors (Hogben & Cornfield, 1981; Lerer et al.,
1987) and serotonin reuptake blockers (McDougle, Southwick, Charney, & St.
James, 1991; Davidson, Roth, & Newman, 1991; Nagy, Morgan, Southwick, & Char-
ney, 1993). Placebo-controlled trials of tricyclic antidepressants and monoamine
oxidase inhibitors have supported the findings from the open label trials, although
variability between studies and small effect sizes have limited the optimism regard-
ing the efficacy of these agents (Kosten, Frank, Dan, McDougle, & Giller, 1991;
Davidson et al., 1990; Reist et al., 1989; Lerer et al., 1987). The few studies that
reported reexperiencing symptoms individually indicated that antidepressants
were most effective in reducing the intrusion of traumatic memories and night-
mares and less effective in reducing dissociative phenomena such as flashbacks and
amnesia (Lerer et al., 1987; Nagy et al., 1993). The disparity between dissociative
and other intrusive symptoms may indicate that antidepressants reduce flashbacks
as a secondary consequence of the other effects of these drugs. One mechanism
possibly related to the efficacy of these agents is their capacity to prevent or reduce
the consequences of noradrenergic hyperreactivity in PfSD patients (Krystal et al.,
1989). This hypothesis is consistent with the capacity of fluoxetine treatment to
block yohimbine-induced panic attacks in patients with panic disorder (Goddard,
Charney, Heinger, & Woods, 1990). The limited efficacy of agents based on mono-
aminergic transmission suggests that a new direction is need in the development of
pharmacotherapies for dissociative disorders. This new direction may be based in
the pharmacology of excitatory amino acid neurotransmission implicated in the
genesis of dissociative states.
Carbamazepine has also shown utility in reducing hyperarousal, sleep distur-
bance, and flashbacks in some PTSD patients (Upper et al., 1986). Despite limited
investigation, carbamazepine has received particular attention due to its capacity
to suppress a form of neural sensitization, kindling, that may provide a cellular
model for the sensitization to repeated stressors (Post & Weiss, 1989). Further
studies with anticonvulsant agents appear warranted.
Cognitive-enhancing pharmacotherapies, such as arginine vasopressin, have
been suggested as treatments for memory deficits associated with PfSD (Pitman,
1988; Pitman et al., 1993). Cognitive-enhancing pharmacotherapeutic strategies
might be beneficial in reducing encoding deficits associated with short-term mem-
ory impairment in PfSD patients. Drugs that might be evaluated for this purpose
include ones that facilitate glutamate and acetylcholine function, such as the glycine
partial agonist, cycloserine Oones et al., 1991), and the cholinesterase inhibitor,
tacrine (Davis et al., 1992). Vasopressin has been used to facilitate memory retrieval
in patients with PfSD (Pitman, Orr, & Lasko, 1993), based on preclinical studies
suggesting that vasopressin may enhance memory consolidation and retrieval in
animals. However, the preclinical foundation of the vasopressin studies has been
182 questioned because subsequent studies have suggested that the promnestic effects
John H. Krystal of exogenous administration of this hormone are attributable to its enhancement of
etal. arousal (Dawson, Heyes, & Iverson, 1992).
Cognitive-enhancing agents do not appear to be the appropriate phar-
macotherapeutic approach for reducing amnesia for the trauma. As noted earlier,
posttraumatic amnesia appears to arise from the suppression of retrieval rather than
from an ongoing memory encoding deficit. There is no evidence to suggest that
tacrine or cycloserine reduce the integrity of memory repression. Agents that do
appear to facilitate the recollection of traumatic memories, such as lactate, yohim-
bine, vasopressin, and MCPP, appear to reduce posttraumatic amnesia via facilitat-
ing state-dependent retrieval. However, the sedative-hypnotic agents are the most
commonly employed agents for this purpose, when combined with some form of
guided recollection, such as the amytal interview.

IMPUCATIONS

Dissociative states have received relatively little attention from neurobiolo-

gists. However, the initial pharmacological challenge studies suggest that many
neurotransmitter systems play important modulatory roles in the pathological
development of dissociative states, as in PTSD. Glutamate systems are critically
involved in cortical and limbic circuitry involved in sensory processing, attention
regulation, and strategic memory retrieval. Recent studies, employing ketamine,
suggest that deficits in NMDA receptor function may produce dissociationlike states
in healthy individuals. Further characterization of the neurobiology of these func-
tions may facilitate the development of antidissociative pharmacotherapies.

AcKNOWLEDGMENTS. This work was supported by funds from the Department of

Veterans Affairs to the National Center for Posttraumatic Stress Disorder, the VA-Yale
Alcoholism Research Center, and the Merit Review Grant Program Q.H.K.).

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9
Hypnosis and Dissociation
Theoretica~ Empirica~ and Clinical Perspectives

Jonathan E. Whalen and Michael R. Nash

The term association is used to describe the binding or linking together of ideas.
For over a century now, it has been invoked to explain various aspects of learning,
attitude change, and motivation (Skinner, 1953; Watson, 1930). In the later part of
the nineteenth century; Janet described an opposing phenomenon of the separa-
tion of certain mental operations from the main body of consciousness with various
degrees of auton~my (West, 1967). He termed this symptomatology desagregatton
(translated from the French as disaggregation), later referred to as dissociation.
Since the inception of dynamic psychiatry and experimental psychopathology in
the late nineteenth century, spontaneously occurring dissociative symptomatology
has been linked to hypnosis, with theorists positing the two phenomena to have
similar (and sometimes even identical) psychic mechanisms.

ARGUMENTS FAVORING HYPNOSIS-DISSOCIATION LINKAGE

Before we can meaningfully explore how clinical theorists have struggled with
the relationship between hypnosis and dissociation, we must understand what
moved them to do so. The answer is straightforward. Four fundamental observa-
tions concerning hypnosis and dissociation have been noted by researchers and
clinicians from Puysegur, Braid, Charcot, and Bernheim to Freud, Pavlov, E. R.
Hilgard, and Fromm. Together, these four observations pose an intriguing possi-
bility, one that was not lost on the earliest investigators of abnormal psychology

Jonathan E. Whalen and Michael R. Nash • Department of Psychology, University of Tennessee at

Knoxville, Knoxville, Tennessee 37996.
Handbook of Dissociation: TbeoiY!tical, Empirlca~ and Clinical Perspectives, edited by Larry K.
Michelson and William J. Ray. Plenum Press, New York, 1996. 191
192 (e.g., Charcot, Janet, Prince, Freud, and Sidis)-that by understanding hypnosis we
Jonathan E. Whalen may better understand dissociative pathology.
and Michael R. Nash 1. Phenotypic simflarlties. During hypnotic trance, behavioral and experien-
tial phenomena characteristic of dissociation can be elicited in nonsymptomatic
subjects. When otherwise nonsymptomatic subjects are hypnotized, they can elicit
a host of behavioral and experiential phenomena characteristic of dissociative
pathology. Hypnotic alterations in perception and sensation (hallucinations, time
sense distortion, anesthesia, deafness, blindness, anosmia), cognition (amnesia,
depersonalization, derealization), emotion (rage, lability, depression, anxiety), and
behavior (compulsions, automatic writing, impulsivity) are quite common, even in
the relatively neutral context of the experimental laboratory. These functional
aberrations associated with a dissociative disorder and those associated with hyp-
nosis are indeed alike in that they generally do not conform to patterns of organic
illness that might otherwise explain the shift in function or experience (head injury,
damage to peripheral nervous system, intoxication states) (see Blum, Porter, &
Geiwitz, 1978; Grosz & Zimmerman, 1965; L<?omis, Harvey, & Hobart, 1936; Pattie,
1935; Theodor & Mandelcom, 1973). In addition, there is some reason to believe
that, at least in the case of generalized sensory-based symptoms, hypnotically
induced functional aberrations are behaviorally and cognitively similar to their
dissociative disorder counterparts, and dissimilar to organically based disease
(Malmo, Boag, & Raginsky, 1954; Sackheim, Nordlie, & Gur, 1979).
2. Hypnosis as an effective treatment. Another argument for a shared under-
lying process linking hypnosis and psychopathology has been the long and well-
documented record of hypnosis as an agent of cure for many types of mental
disorders over two centuries of clinical practice, especially dissociative disorders.
Claims have sometimes been exaggerated, but there remains a solid and respectable
research literature that supports the general clinical efficacy of hypnosis (Beutler,
1979; Deabler, Fidel, Dillenkoffer, & Elder, 1973; DePiano & Salzberg, 1979; Fried-
man & Taub, 1978; Scagnelli-Jobsis, 1982; Wadden & Anderton, 1982). It seems
reasonable that, if an intervention can alter or even cure debilitating symptoms, then
it probably affects whatever process underlies the symptoms. Though reasonable,
the logic of this argument is not without flaw. Even if it can be shown that hypnosis
is indeed an especially efficacious therapeutic modality in cases of dissociative
disorder, there are many ameliorative interventions in general medicine that may
have only obscure and very limited relevance to the essential features of the disease
process (e.g., aspirin for headaches). Still, the clinical efficacy of hypnosis in
treating dissociative disorders is highly touted among many practitioners who
contend that hypnosis itself is an essential underlying feature of the dissociative
disorder.
3. Subjective similarities. "Time stood still," "I felt dazed; "Everything hap-
pened automatically," "Sometimes I did not know where I was," "Things seemed
unreal," "Parts of my body moved without my conscious assistance," "I felt unin-
hibited": statements like these (taken form Field's Scale of Hypnotic Depth; Field,
1965) indicate a striking similarity between normal hypnotic subjective experi-
ences and dissociative subjective experiences. Many theorists have noted these
similarities and hypothesized that spontaneously occurring self-hypnosis episodes
are the root source of various pathological states such 3S anxiety, conversions, 193
and so forth (Breuer & Freud, 1893-1895/1955; Frankel, 1974; Janet, 1919/1925; Hypnosis and
Spiegel & Spiegel, 1978). Dissociation
4. Common traumagenic etiology for hypnotizability and dissociation. An
association between early sexual trauma and dissociative states has been posited
since the nineteenth century. Freud (1893/1959, 1900/1953), Janet (1889), and
Prince (1906) believed that dissociative states resulted from defensive processes
arrayed against the experiences of sexual trauma.
Modern researchers contend that early trauma engenders the repeated use of
dissociative techniques, resulting in dramatic alterations in experiences of self and
environment; experiences highly similar to hypnotic experiences (Frischholz,
1985a; Kluft, 1987; Putnam, 1985; Spiegel, Hunt, & Dondershine, 1988). Indeed,
Bliss (1984), Frischholz (1985b), and Spiegel (1986), among others, argue that
hypnotizability levels are sensitive indices of dissociation, and thus reliable markers
of pathology presumably rooted in trauma.

Early Theoretical Formulations of

the Hypnosis-Dissociation Link
Taken together, these four observations are as difficult to ignore now as they
were 100 years ago at La Salpetriere. The similarities between hypnosis and certain
forms of psychopathology, along with the clinical efficacy of hypnosis, seem to be
valid and highly suggestive of shared processes. Many explanations of these four
key observations have been offered by clinical theorists since Charcot began his
work on hysteria in the 1870s.
First, Janet (1919/1925) understood most psychopathology and all genuine
hypnosis to be manifestations of a common process-dissociation; under special
circumstances, certain ideas, motives, sensations, and memories operate outside of
conscious awareness. These fixed ideas can function quite automatically via amne-
sic barriers separating clusters of perceptual-cognitive activity from one another.
Janet's ideas lost currency for several reasons most thoroughly reviewed by Ellen-
berger (1970). Experiments failed to support the idea that dissociated tasks could be
so completely separated that they would not, and could not, interfere with one
another (White & Shevach, 1942). Furthermore, in the first quarter of the twentieth
century, the mushrooming of interest in psychoanalysis obscured Janet's important
work.
Second, Freud was acutely interested in hypnosis and its relationship to psy-
chopathology, especially hysteria. In an early work coauthored with his mentor,
Josef Breuer (Breuer & Freud, 1893-1895/1955), Freud theorized that symptoms of
hysteria were actually manifestations of self-induced "hypnoid states" brought
about by the threatened eruption of early traumatic memories into awareness and
the subsequent conversion (expression) of these memories in the somatic or
functional sphere. In this very early Freudian formulation, the underlying process
shared by hypnosis and hysteria was a "splitting off" of certain mental contents
from the mainstream of awareness. Therapy then was curative to the extent that the
therapist could exploit the ability of hypnosis to isolate and focus on the somatically
194 expressed yet profoundly repressed affect-laden memories. Hypnotherapy sessions
Jonathan E. Whalen with these patients were often very dramatic, with violent explosions of emotion
and Michael R. Nash when the original memories surfaced; these were then followed by symptom relief.
Later, Freud came to view both hypnosis and psychopathology from a more devel-
opmental perspective, with psychopathology and hypnosis representing a return to
earlier modes of psychological functioning and relating (Freud 1917/1957).

CONTEMPORARY FORMULATIONS

There are two contemporary theoretical traditions that attempt to explain a

link between hypnosis and dissociation: one evolving from the early clinical work
with dissociative disordered patients and one evolving from cognitive psychology.
Most contemporary clinical theorists studying multiple personality disorder (MPD),
and other dissociative disorders, focus on the etiologic role of early trauma. They
have adopted models similar to that of Breuer and Freud (Breuer & Freud, 1893-
1895/1955), contending that early childhood trauma leads to repeated overuse of
dissociation until it becomes the individual's primary psychological defense, mani-
festing itself in dramatic alterations in the experience of self and world (Frischholtz,
1985b; Kluft, 1987; Putnam, 1985; Spiegel eta!., 1988). Based on a wealth of clinical
observation, these models define a causal continuity between trauma in childhood
and subsequent adult symptoms. What is so appealing about these traumagenic
models of psychopathology is that they also chart a sure course for treatment,
involving a therapeutic regression to the developmental stage in question, re-
emergence oflong repressed (or dissociated) memories, and gradual resumption of
development from that point.
The second theoretical tradition positing an underlying shared process in
hypnosis and dissociation is the neodissociation theory of Ernest Hilgard's (1992).
By bringing the study of consciousness back into the mainstream of scientific
inquiry, Hilgard has revitalized the concept of dissociation and spawned vigorous
experimental and clinical interest in the related phenomena of absorption, imagina-
tive involvement, fantasy proneness, and dissociative disorders (Hilgard, 1979a;
Tellegen & Atkinson, 1974; Lynn & Rhue, 1986; Bliss, 1984). Hilgard notes that both
hypnotic and dissociative pathological states are characterized by intense absorp-
tion, amnesias, cognitive inconsistencies, and experience of involuntariness. He
postulates a hierarchical system of cognitive control such that the relationship
between the higher executive levels and actual behavior become transiently discon-
nected. Thus behaviors are experienced as involuntary by the hypnotic subject
(e.g., "My arm got quite heavy and began to move down by itself").
From this theoretical perspective, the logic of a hypnosis-dissociation link is as
follows: Dissociative psychopathology is characterized by intense absorption, am-
nesias, fantasy proneness, automatism, depersonalization, and cognitive inconsis-
tencies. Since these same phenomena figure so prominently in hypnosis, a propen-
sity for spontaneous self-hypnosis may underlie dissociative disorders. If true, then
patients suffering from these disorders should test as more hypnotizable than
control individuals.
TilE RESEARCH EVIDENCE 195
Hypnosis and
Clinical observation and theoretical formulations strongly suggest some kind of Dissociation
relationship between hypnosis and dissociation. We now examine the empirical
evidence for such a linl{. If hypnosis and dissociative disorders do indeed share
important underlying psychic mechanisms, three core findings should obtain across
clinical and nonclinical samples. First, if the trait of dissociativity captures some-
thing essential about the trait of hypnotizability, then these two abilities should be
positively correlated, with highly hypnotizables also being highly dissociative (over-
lapping traits). Second, if hypnosis and dissociativity share common developmental
pathways involving trauma, then a history of trauma should be associated with
increased hypnotizability and increased dissociativity (common etiology). Third, if
hypnosis captures some essential pathological feature of dissociative disorders, it
may be especially effective in the treatment of these disorders (clinical efficacy).
Below we examine the empirical evidence regarding each of these questions.

Hypnotizability and Dissociativity as Overlapping Traits

If measures of hypnotizability and dissociativity can be shown to positively
correlate, we have then demonstrated that the two traits share some important
feature(s). Other chapters in the present volume adequately describe the various
self-report scales used to index an individual's dissociativity. However, measure-
ment of hypnotic susceptibility involves a radically different procedure. Before we
examine the empirical findings on the question of covariation between hypno-
tizability and dissociativity, we first must describe how hypnosis is measured and
the nature of hypnotic susceptibility in general.
Observations that people differ in their general level of responsiveness to
hypnotic procedures date back to the eighteenth century. Attempts to measure
hypnotic susceptibility began in the early nineteenth century, with Braid and
Bernheim (Zangwill, 1987) leading the way. But it was not until the late 1950s that a
rigorously normed and standardized procedure for measuring hypnotizability
emerged from the programmatic research of Ernest Hilgard at Stanford University:
The Stanford Hypnotic Susceptibility Scales, Forms A, B, and C. While the Stanford
Scales (especially Form C) remain somewhat of a "gold standard" in hypnosis
research, many other standardized protocols have been developed in the ensuing
years. But all operate from the basic premise that hypnotic responsiveness is best
measured by hypnotizing a subject, administering a series of suggestions that are
either passed or failed, and adding the number of "passed" items to obtain a score.
For example, the Stanford Scales involve administration of an induction along with
12 suggestions, including ideomotor suggestions (e.g., an extended arm becomes
unbearably heavy and moves down by itselt), cognitive suggestions (e.g., amnesia),
and perceptual suggestions (e.g., positive visual or auditory hallucination). Specific
behavioral criteria are established for obtaining a "pass" score on each of these 12
items. The total number of suggestions is the subject's score. The range of possible
scores is thus 0 to 12, with individuals scoring on the lower end of the spectrum
being less hypnotizable and those at the upper end being more hypnotizable.
196 This methodological breakthrough enabled researchers and clinicians to more
Jonathan E. Whalen confidently examine the nature of hypnotizability, especially its relative stability.
and Michael R. Nash Four important discoveries emerged from this work. First, hypnotic susceptibility is
for the most part normally distributed across the population, with almost everyone
able to experience hypnosis to some extent. Second, a person's responsiveness to
hypnosis is relatively unaffected by the technique used, environmental surround-
ings, and the hypnotist. In other words, the person's ability to be hypnotized
accounts for his/her responsiveness, not the specific techniques used, not the
expertise of the hypnotist, not the situational variables surrounding the test admin-
istration. Third, hypnotic susceptibility is a personality trait that changes little, if
any, across time. Test-retest reliabilities for hypnotizability scales compare favora-
bly with those ofiQ tests. In fact, Piccione, Hilgard, and Zimbardo (1989) reported a
15-year follow-up study that revealed an impressive correlation of .82 between the
scores subjects obtained in 1970 and the ones these same subjects obtained in 1985.
Fourth, children as young as 4 years of age can be hypnotized. Hypnotizability
appears to increase with age into early adolescence, when it plateaus, perhaps
decreasing slightly among the elderly.
Thus the mode of measurement for dissociativity and hypnosis are quite
distinct, with dissociativity usually indexed via self-report scales and hypnotizability
indexed via behavioral responses. At first flush this might seem to bode ill for
obtaining statistically and clinically meaningful results. But in fact just the opposite
is true. Cook and Cambell (1979) recommend precisely this type of arrangement
where related constructs are indexed across modes of measurement, such as
behavioral, physiological, and self-report, so as to minimize what they term
"method variance" (which can lead to spurious correlations attributable to the
similarity in method of measurement rather than commonality in construct).
We have then an opportunity to rigorously assess the extent to which disso-
ciativity and hypnosis overlap. Table 1 summarizes the 11 studies to date that have

Table 1. Correlations between Measures of Hypnotizability

and Dissociation
Study Measures N Pearson r, p value
Clinical samples
Segal & Lynn (1992-93) HGSHS/DES 85 .17,p =NS
Green & Lynn (1990) HGSHS/DES 218 .09,p = NS
Nadon et al. (1991) HGSHS/DES 475 .08,p = NS
Frischholz et al. (1992) HGSHS/DES 309 .12,p < .05
Putnam et a!. (unpublished) SCHCS:C CDC 105 .ll,p = NS
Nash et al. (1992) SUSS :A/IDS 98 .16,p = NS
Nonclinical samples
Spanos et al. (1993) CURSS:O/DES 75 .ll,p = NS
DiTomasso & Routh (1993) HGSHS/DES 312 .16,p < .01
Silva & Kirch (1992) CURSS:O/DES 190 .15,p = NS
Johnson et al. (1992) SUSS :A/DES 148 .20,p < .05
Tanabe & Kasal (1993) HGSHS/DES 107 .15,p = NS
correlated measures of dissociativity with measures of hypnotizability. In general, 197
scores on standard hypnosis scales are not significantly corelated with scores of Hypnosls and
dissociativity across clinical and nonclinical samples (Faith & Ray, 1994; Green & Dlssodation
Lynn, 1990; Nash, Hulsey, Sexton, Harralson, & Lambert, 1993; Putnam, Helmers, &
Trickett, submitted; Segal & Lynn, 1992, 1993; Silva & Kirch, 1992; Spanos, Arango,
& de Groot, 1993; Tanabe & Kasai, 1993). In the few cases where correlations reach
statistical significance, the magnitude of correlation is small (.15 to .20), accounting
for only 2-4% of the variance (DiTomasso & Routh, 1993; Frischholtz, Lipman,
Braun, & Sachs, 1992; Johnson & Kirsch, 1990).
Some researchers have investigated the degree of correlation between fantasy
proneness, absorption, hypnotizability, and dissociativity (Barrett, 1992; Glisky,
Tataryn, Tobais, Kihlstrom, & McConkey, 1991; Lynn & Rhue, 1986). Absorption is
thought to be trait-like and is defined as the ability to absorb self-altering experi-
ences. Fantasy proneness is the tendency to live in a self-created world of imagina-
tion and fantasy. Fantasy proneness is thought to be a personality type.
Basically, these studies find moderate-to-strong correlations between absorp-
tion and fantasy proneness, absorption and hypnotizability, and absorption and
dissociation. Fantasy proneness is moderately correlated with both hypnotizability
and dissociativity. Overall, hypnotizability and dissociativity are correlated more
strongly to absorption and fantasy proneness than to each other.
In sum, there is no compelling evidence to support the proposition that
hypnotizability and dissociativity are overlapping traits. Even for samples including
trauma victims, correlations either failed to reach significance or were so weak that
they are conceptually unimportant. Sharing little variance, hypnotizability and
dissociativity, in fact, seem to exist fairly independently of one another. They are
probably not overlapping, and are certainly not synonymous, personality con-
structs.

Common Traumagenic Etiologies for Hypnotizability and

Dissociativity
If hypnosis and dissociativity share common developmental pathways involv-
ing trauma, then a history of trauma should be associated with increased hypno-
tizability and increased dissociativity. There are of course two components to this
issue: Is a history of trauma associated with high hypnotizabilty and is a history of
trauma associated with high dissociativity?

Hypnosis and Trauma. There was some early support for the contention
that hypnotizability may be very modestly related to extent of physical punishment
during childhood. The research of Hilgard and others (Hilgard, 1974; London, 1962;
Nowlis, 1969) suggests that childhood experiences of severe punishment and
discipline are positively correlated with hypnotizability (correlations of around
.30). Nash and his colleagues (Nash & Lynn, 1985; Nash, Lynn, & Givens, 1984)
found that subjects who reported physical and sexual abuse in childhood were
more hypnotizable than subjects not reporting such a history (the effect size was in
the range of .30). The authors of the latter two studies came to understand these
findings as artifactual, attributable to contextual features of the testing situation
198 (testing for hypnotizability immediately following the questioning about early
Jonathan E. Whalen trauma) (see Council, Kirsch, & Hafner, 1986). 1n fact, six subsequent studies
and Mk:bael R. Nash examining the relationship between sexual abuse and hypnotizability found no
significant relationship (see Table 2).
Two of these studies were large-scale and particularly instructive; one exam-
ined children, the other adults. Putnam et al. (submitted) compared abused and
nonabused girls (6-15 years of age) on the Stanford Hypnotic Scale for Children
and the Child Dissociative Checklist. Abused and nonabused children did not differ
significantly on measures of hypnotizability. Nash et al. (1993) compared clinical
abused and nonclinical abused adult women on measures of dissociation Ondiana
Dissociative Symptom Scale, Dissociation Content Scale) and hypnotizability (Stan-
ford Hypnotic Susceptibility Scale: A [SHSS:A]). No significant relationship between
hypnotic susceptibility and abuse was detected, nor was the severity of abuse or age
of onset of abuse significantly correlated with hypnotizability.
There is, however, a second body of research that seems to suggest a trauma-
genic path to high hypnotizability. First, 85-97% of clinical MPD patients report
early life trauma (Coons, Bowman, & Milstein, 1988; Kluft, 1984; Putnam, Guroff,
Silberman, Barban, & Post, 1986; Ross, Heber, Norton, & Anderson, 1989). Second,
MPD patients are reported to be highly hypnotizable as a group (Bliss, 1984; Frisch-
holz, 1985b; Frischholz, Spiegel, Spiegel, llpman, & Bark, 1988; Frischholz et al.,
1992). Taken together, these two sets of findings would seem to confirm some
etiologic link between hypnosis and dissociation.
However, there is now some reason to question the generalizability of these
findings. Ross et al. (1991) have studied dissociative phenomena, MPD, and self-
report histories of childhood trauma in clinical as well as nonclinical populations
using the Dissociative Experiences Scale (DES). They estimated that between 5 and
10% of the general population is affected by a dissociated disorder. Ross et al. (1991)
also found incidents of MPD in the general population at a rate of 3.1% based on
a 450-person sample administered the Dissociative Disorder Interview Schedule
(DDIS) (Ross, Heber, Norton & Anderson, 1989). Ross et al. (1991) state that the data
of individuals with MPD in the general population were radically different from the
clinical MPD patient data. 1n the clinical MPD population, 85-97% of patients
report a history of severe sexual and physical abuse (Coons & Milstein, 1986; Kluft,
1987; Putnam et al., 1986). 1n the Ross et al. (1991) study, MPD subjects in the

Table 2. Correlation Effect Sizes For Hypnotizability and Trauma

Study Measure N Effect size Comparison

Nonclinical samples
DiTomasso & Routh (1993) HGSHS 312 .005 Nonabused undergraduates
Putnam et al. (unpublished) SHSS:C 116 .23 Matched, nonabused girls
Johnson & Kirsch (1992) SHSS:A 148 .025 Nonabused undergraduates
Rhue et al. (1990) HGSHS 100 .610 Nonabused undergraduates
Clinical samples
Johnson & Kirsch (1992) SHSS:A 40 .025 Nonabused outpatients
Clinical and noncllnical samples
Nash et al. (1993) SHSS:A 105 .12 Nonabused adults
general population rarely reported histories of abuse and reported experiencing 199
little distress. This is an interesting report of a supposedly extremely pathological Hypnosis and
condition heretofore always associated with severe childhood abuse, but now Dissociation
found in the general population relatively unassociated with a history of abuse and
profound distress. Earlier studies claiming to find evidence of a trauma-hypno-
tizability link (Bliss, 1984; Coons & Milstein, 1986; Kluft, 1987; Putnam et al., 1986)
may need to be reexamined in light of the Ross et al. (1991) findings.
Finally, there is one study that unambiguously demonstrates a relationship
between trauma and hypnotizability among Vietnam combat veterans. Veterans
suffering posttraumatic stress disorder (PTSD) are found to be more hypnotizable
than are non-PTSD veterans (Spiegel et al., 1988). Spiegel (1986) contends that
measures of hypnotizability may be a useful diagnostic tool in suspected cases of
MPD/PTSD among this population. However, it must be noted that the concept of
the developmental genesis of hypnotizability is strained in this study in large part
because these traumas were not in childhood.
In sum, there is little evidence for a broadband relationship between early
trauma and hypnotizability. Researchers do not find differences in hypnotizability
between individuals who have been traumatized and those who have not. Among
individuals with MPD, there is reason to suspect that trauma may not be the certain
comorbid sign that it was once assumed to be. Thus, reports of high hypnotizability
among MPD patients may not be so easily linked with early trauma in these cases.
The Spiegel study does suggest that among certain narrowly selected clinical
populations systematic covariance between hypnotizability and trauma may obtain.
But this is far from establishing a broad association between trauma and hypno-
tizability.

Trauma and Dissociation. One can make a stronger case for a relationship
between dissociativity and trauma, though there are methodological and defini-
tional problems that plague the literature. First, of the 14 studies examining trauma
and dissociativity, all have found higher levels of dissociativity among individuals
who have been traumatized. Five of these studies were with nonclinical samples
(Briere & Runtz, 1988; DiTomasso & Routh, 1993; Johnson & Kirsch, 1990; Putnam
et al., submitted; Sanberg & Lynn, 1992), eight were with clinical samples (Bremner
et al., 1992; Briere & Runtz, 1989; Chu & Dill, 1990; Goff et al., 1991; Pribor &
Dinwiddie, 1992; Sanders & Giolas, 1991; Strick & Wilcoxon, 1991; Warshaw et al.,
1993); and one was with both clinical and nonclinical samples (Nash et al., 1993).
The magnitude of the relationship between trauma and dissociation appears to be
in the r = .20 to .45 range. Second, the severity of trauma was positively correlated
with dissociation scores in four studies (Branscomb, 1991; Cardeiia & Spiegel, 1993;
Carlson & Rosser-Hogan, 1991; Kirby, Chu, & Dill, 1992), but not in a fifth (Nash et
al., 1993). In sum, there does seem to be some empirical support for the contention
that trauma and dissociation are associated.
It is important to consider some methodological difficulties with this literature
in general. First, the problem of defining trauma plagues the literature. For instance,
many theorists have assumed that childhood sexual abuse is by definition traumatic.
Yet, a more recent review questions whether all cases of sexual abuse necessarily
involve overwhelming affect, fear for safety, and helplessness (Kendall-Tackett,
200 Williams, & Finkelhor, 1993). Second, there are also some problems in defining and
Jonathan E. Whalen operationalizing dissociation. The DES (Bernstein & Putnam, 1986) is widely em-
and Michael B.. Nash ployed in this area, and it does demonstrate satisfactory split-half and test-retest
reliability. But there is some evidence that a large component of an individual's DES
score may be attributable not to dissociative pathology specifically, but to gross
psychopathology in general. Nash et al. (1993), Norton, Ross, and Novotny (1990),
and Sanberg and Lynn (in press) detected a confound between general psychologi-
cal impairment and DES scores, with high DES scores being associated with greater
general psychopathology. In the Nash et al. (1993) study, the DES correlated .70
with the F-scale of the Minnesota Multiphasic Personality Inventory. Similar findings
were obtained for two other scales: the Dissociation Content Scale (Boswell,
Sanders, & Hernandez, 1985) and the Indiana Dissociative Symptom Scale (Levitt,
1989). Thus, when the DES scores of traumatized patients exceed those of non-
traumatized patients, it is possible that the difference has less to do with dissocia-
tion per se and more to do with gross pathology.
Third, and perhaps most importantly, all but one of the above cited studies
linking trauma and dissociation neglected to consider other pathogenic factors in
the child's environment that might explain subsequent pathology. Families in which
abuse occurs are more pathological than nonabusing families, with higher levels of
role or boundary confusion, more rigid behavioral control, and less cohesiveness
and adaptability (Alexander & Lupfer, 1987; Harter, Alexander, & Neimeyer, 1988;
Hoagwood & Stewart, 1988). Thus, differences between abused and nonabused
samples on measures of psychopathology in general (and dissociation in particular)
may be due, not to the effects of trauma necessarily, but to the nonspecific effect of
a pathogenic home environment. Indeed, recent empirical work seems to suggest
that some adult pathology associated with childhood sexual trauma may reflect the
effects of a broadly pathogenic family environment rather than the effects of sexual
abuse per se (Harter et al., 1988; Fromuth, 1986; Wyatt & Newcomb, 1990). In the
only dissociation study controlling for pathogenic factors other than trauma, Nash
et al. (1993) found that subjects who were sexually traumatized in childhood were
significantly more dissociative than nonabused subjects. However, when family
environment was used as a covariate, the effect for early trauma receded into
nonsignificance.
Evidence for the common etiology hypothesis-that early trauma exaggerates
an individual's hypnotizability and dissociativity-is scant. First, trauma does not
appear to be an important feature in the development of high hypnotizability. The
overwhelming preponderance of high hypnotizables have not been traumatized;
and those subjects who have been traumatized are no more hypnotizable than
nontraumatized controls. Though there may be some possibility for an association
between trauma and hypnotizability within narrow diagnostic categories, there is
no convincing evidence that a history of early trauma is associated with high
hypnotizability. Second, there is a fairly extensive research literature that finds an
association between trauma and dissociation. Though serious methodological and
definitional issues compromise our certainty, at this time it appears that trauma and
dissociation may be linked. At the same time, however, it seems probable that this
link is not a linear cause-effect relationship. Indeed, given the confounding of
dissociation measures with measures of gross pathology and the neglect of other
pathogenic factors, what dissociation researchers may be finding is simply that 201
people who have had horribly troubling and chaotic home environments are more Hypnosis and
grossly pathological than those who had reasonably stable childhood home environ- Dissociation
ments. But even if we accept the premise that dissociativity is directly associated
with trauma, hypnosis is not. Therefore, experiences of early trauma do not exagge-
rate both an individual's dissociativity and hypnotizability. In this sense, then,
hypnotizability and dissociativity are not "fellow travelers;' following parallel trajec-
tories in response to early trauma. Here again we find reason to reject the conclu-
sion that these phenomena involve shared psychic mechanisms.

Hypnosis as an Effective Treatment. As stated earlier, there has been an

interest in using hypnosis as treatment for mental disorders for over two centuries.
Charcot, Janet, and Freud all employed hypnotic techniques to treat hysterical
symptoms. Large-scale use of hypnosis in the treatment of trauma occurred during
and after World War I where hypnotherapy was used to treat debilitating trauma or,
as it was then called, shell shock. Typical treatment involved the modification of the
traumatic memory, such that the soldier in question might return to normal levels of
functioning.
Such examples illustrate how therapeutic hypnosis can provide controlled
access to painful memories. This modulated access allows patients to experience a
sense of mastery over previously overwhelming affect-laden memories. Once ac-
complished, the patient begins to reframe those memories such that he or she
understands the memories to be a part of, but not all of, themselves (Spiegel, 1987).
Of note are two studies that foUnd psychotherapy with hypnosis to be no more
effective than psychotherapy without hypnosis in the treatment of MPD patients
(Putnam eta!., 1986; Ross & Norton, 1989). These are the only extant outcome
studies examining whether hypnosis is particularly effective in the treatment of
dissociative disorders; they provide no evidence to support a link between hyp-
nosis and dissociation, however.

SUMMARY

If there is any relationship between the constructs of dissociation and hyp-

nosis, it is complex and indirect. The three propositions, rooted in the assumption
of a hypnosis-dissociation link, are not supported empirically. The overlapping
trait proposition has been thoroughly tested: hypnotizability and dissociativity do
not covary -positive correlations between these measures are rare and nonreplica-
ble. Neither has the common traumagenic etiology proposition been confirmed
empirically. No definitive developmental pathway conjoining trauma, dissociativity,
and hypnotizability has emerged from the data. The specific and seemingly more
secure link between trauma and dissociation is still uncertain, owing to numerous
methodological and definitional problems (pathological family confounds, etc.).
Finally, the question of a special role for hypnosis in the treatment of dissocia-
tive disorders has not really been addressed adequately by the research literature.
Empirically demonstrated unique effects for any psychological intervention are few
and far between in psychotherapy outcome literature. A definitive test of the
202 importance of hypnosis in the treatment of dissociative disorders has not been
Jonathan E. Whalen attempted and is sorely needed.
aru1 Mic:hael R. Nash Given this state of affairs, we make the following recommendations for future
investigations. First, the time for unrefined examination of correlations between
hypnotizability and dissociativity scales has passed. Perhaps within specific diag-
nostic categories there is some nonrandom covariation between hypnosis and
dissociation, but for normal populations the bulk of the evidence speaks against
correlations between the two phenomenon.
Second, research examining the proposed traumagenic etiology of hypno-
tizability and dissociativity needs to be far more sophisticated. For instance, investi-
gators must take care to disentangle the effects of sexual abuse from the effects of
other sources of pathology in which the abuse may be embedded. In addition, there
is a clear and pressing need for longitudinal studies with child victims of trauma.
Only longitudinal studies can provide definitive data on proposed causal pathways
linking trauma with dissociation and hypnosis. Likewise, following the lead of Ross
et al. (1991), research should be undertaken to examine dissociative pathology
among nontreatment populations. Specifically, why do dissociative and hypno-
tizability scores correlate for clinical MPD-PTSD populations but not for nonclini-
cal MPD-PfSD populations. A final methodological point is related to extent of
trauma. Specifically, among trauma victims, is the extent of trauma associated with
the extent of dissociativity?
Our third recommendation addresses the clear need for empirically driven
assessments of the clinical efficacy of hypnotic interventions with dissociative-
disordered patients. Anecdotal evidence supportive of the efficacy of hypnosis
abounds. Yet, there are too few adequately designed studies in this area to allow
confident and satisfactory assessment of hypnotherapy efficacy. Methodologically,
time series designs are well suited for this type of research, as are the more
traditional control group approaches.

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10
Emotional Dissociation in
Response to Trauma
An Information-Processing Approach

Edna B. Foa and Diana Hearst-Ikeda

Pathological reactions to trauma and extreme stress have been noted in the psycho-
logical literature for over a century. These reactions were codified in the psychiatric
literature as posttraumatic stress disorder (PTSD) (American Psychiatric Associa·
tion, 1980). The diagnosis of PTSD is made when posttrauma symptoms occur in
three domains: emotional, cognitive, and visual reexperiencing of the trauma;
avoidance of trauma-relevant stimuli; and general arousal. Since the inception of
PTSD as a diagnostic entity, experts have focused on the fear and anxiety compo-
nents of the disorder (Foa, Steketee, & Rothbaum, 1989; Keane, Zimering, &
Caddell, 1985). More recently, trauma researchers have become interested in the
phenomenon of affective and cognitive avoidance that is commonly observed
following a trauma and has been referred to as dissociation (e.g., Spiegel, Hunt, &
Dondershine, 1988), denial (Horowitz, 1986; van der Kolk, 1987), or numbing (e.g.,
Foa, Riggs, & Gershuny, 1995; Horowitz, Wilner, Kaltreider, & Alvarez, 1980; Litz,
1993; van der Kolk & Ducey, 1989). Common to these constructs is a diminished
awareness of one's emotions or thoughts, which is hypothesized to be motivated by
self-preservation.
In this chapter we will discuss the construct of emotional dissociation, de-

Edna B. Foa • Center for the Treaunent and Study of Anxiety, Medical College of Pennsylvania, Eastern
Pennsylvania Psychiatric Institute, Philadelphia, Pennsylvania 19129. Diana Hearst-Ikeda • National
Center for Posttraumatic Stress Disorder, Women's Health and Sciences Division, Boston Deparunent of
Veterans Affairs Medical Center, Boston, Massachusetts 02130.
Handbook of Dissociation: Theoretical, Empirlca~ and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 207
208 scribe the measures that have been used to evaluate it, and review the relevant
Edna B. Foa and literature. Finally we will discuss mechanisms that are hypothesized to underlie
Diana Hearst-Ikeda dissociation and will propose that the presence of dissociation is an indicator of
incomplete emotional processing of the trauma.

DISSOCIATION, DENIAL, AVOIDANCE, AND NUMBING:

CONCEPfUAL ISSUES

The phenomenon of emotional detachment has gained considerable attention

in the late nineteenth century and was conceptualized as a defense against over-
whelming emotions (e.g., Breuer & Freud, 1985; Janet 1907, 1989). But it was Janet
(1907) who coined the term dtssociaUon to describe the lack of connection
between aspects of memory or conscious awareness observed during and after
extreme stress.
Since these early writings, many experts have noted that dissociation occurs in
nonpathological as well as in pathological states (e.g., Bliss, 1984; Braun & Sachs,
1985; Hilgard, 1977; Spiegel, 1963). Nemiah (1981) has proposed two characteristics
of pathological dissociation. The first is an alteration in one's sense of identity, as
in multiple personality disorder, and the second is a disturbance in the memory of
the specific experiences during a dissociative period (usually traumatically in-
duced). The DiagnosUc and StaUsUcal Manual of Mental Disorders, Fourth Edi-
tion (DSM-IV) has endorsed this dual view, stating "The essential feature of the
dissociative disorders is a disruption in the usually integrated functions of con-
sciousness, memory, identity, or perception of the environment" (American Psychi-
atric Association, 1994, p. 477).
A third characteristic of dissociation that has been proposed by several experts
(e.g., Coons & Milstein, 1986; Putnam, 1989; Spiegel, 1986) is its association with
traumatic experience. Accordingly, Spiegel and Cardena (1990) proposed that
"posttraumatic phenomenology frequently involves alterations in the relationship
to the self (e.g., depersonalization and multiple personality disorder), to the world
(e.g., derealization and hallucinatory phenomena), and to memory processes (e.g.,
psychogenic amnesia, fugue, and multiple personality disorder)" (p. 368). Support
for the view that dissociation is etiologically connected to traumatic experiences
also comes from clinical observations of children who have suffered repeated
exposure to extreme stress such as sexual, physical, or psychological abuse (ferr,
1991). Terr reported that children often use dissociation and numbing to escape the
trauma-related memories and the arousal they trigger.
It seems that the construct of dissociation is largely defined by a set of symp-
toms that have been observed in persons who experienced trauma. These include
amnesia, emotional detachment, feelings of depersonalization, out-of-body experi-
ences, dreamlike recall of events, feelings of estrangement, flashbacks, and abreac-
tion. In a review of psychological reactions that ensue from a traumatic experience,
Cardena and Spiegel (1993) have suggested that posttrauma dissociative symptoms
can be classified into three types of responses: (1) detachment from others and the
physical environment, (2) alterations in perceptions, and (3) impairments in
memory.
 A second construct, denial, was proposed by Horowitz (1986), who noted that 209
a common reaction to trauma is "the massive ideational denial of the event" (p. 16). Emotional
An examination of the items contained in the scale that Horowitz and his colleagues Dissociation in
developed to measure denial (i.e., the Impact of Events Scale; Horowitz, Wilner, & Response to Trauma
Alvarez, 1979) indicates that denial denotes attempts at cognitive and emotional
avoidance (e.g., "I avoid letting myself get upset when I thought about it [the
trauma] or was reminded of it," and "I tried to remove it from memory") but not
alteration in perception and memory impairment.
A third term that had been introduced into the DSM-III (American Psychiatric
Association, 1980) is "emotional numbing." This term is sometimes used inter-
changeably with denial and avoidance to describe the lack of affective expression in
trauma victims (American Psychiatric Association, 1980; Horowitz, 1986). Seven
symptoms comprise the avoidance-numbing symptom cluster ofDSM-III-R (Ameri-
can Psychiatric Association, 1987) and DSM-IV (American Psychiatric Association,
1994). These include effortful cognitive and behavioral avoidance of trauma re-
minders, memory loss, and emotional numbing (e.g., loss of interest in activities,
detachment from others, restricted affect, sense of a foreshortened future). Thus,
the effortful avoidance symptoms are grouped together with those of emotional
numbing in the diagnostic nomenclature.
The grouping of avoidance and numbing symptoms into one cluster suggests
that the DSM-IV authors had conceptualized emotional numbing and effortful
avoidance as an equivalent concept. However, a review of literature on experimen-
tal paradigms that elicit PTSD-like symptoms in animals suggests that effortful
avoidance and numbing involve separate mechanisms (Foa, Zinbarg, & Rothbaum,
1992). Foa and Riggs (1993) suggested that effortful avoidance may be regulated by
strategic psychological processes, whereas numbing may be mediated by biological
mechanisms resembling those underlying the freezing behavior in frightened ani-
mals. They further proposed that on exposure to trauma-related information, vic-
tims first mobilize effortful strategies to avoid the arousal associated with the
traumatic memories. When such strategies fails, a "shutting-down" of the affective
system occurs; this process is expressed as numbing symptoms. Consistent with
the view that effortful avoidance and numbing reflect separate phenomena are
findings from a factor analytical study of PTSD symptoms in female assault victims.
The numbing symptoms loaded on one factor that also included symptoms of
irritability and concentration problems; the effortful avoidance symptoms loaded
on a separate factor that included intrusive thoughts, emotional reactivity, hyper-
vigilance, and excessive startle (Foa et al., 1995).

MEASURES OF DISSOCIATION, DENIAL, AVOIDANCE,

AND NUMBING

As we noted earlier, many experts agree that dissociation, denial, avoidance,

and numbing are common responses to extreme stress. The first accounts of
dissociation relied on clinical observations of trauma victims. More recently, infor-
mation about this phenomenon has been based on measures that have been con-
structed to serve as operational definitions of dissociation. It is therefore important
210 to describe measures of dissociation before discussing the empirical data that have
Edna B. Foa aru1 employed these measures.
Diana Hearst-Ikeda
1. Dissociative Events Scale (DES) (Bernstein & Putnam, 1986). This is a 28-
item scale to assess the frequency and intensity of a range of experiences commonly
conceptualized as dissociation and depersonalization in a psychiatric population in
general and in traumatized individuals in particular. The DES items pertain to
disturbances of memory, attention, identity, and perception. According to Bern-
stein and Putnam, the DES is a trait measure, although this has not been empirically
validated. There are no items about numbing or cognitive avoidance in this scale.
2. Stanford Acute Stress Reaction Questionnaire (SASRQ) (Cardena, Clas-
sen, & Spiegel, 1991). The long version of this scale has 73 items that tap dissocia-
tion and anxiety experiences during and immediately after a trauma. Thirty-three
items comprise the dissociation scale that assesses five features: psychic numbing,
depersonalization, derealization, amnesia, and stupor. Forty items comprise the
anxiety scale that also assesses five features: intrusive thinking, somatic anxiety,
hyperarousal, attention disturbance, and sleep disturbance.
3. Perceptual Alterations Scale (PAS) (Sanders, 1986). This is a 25-item scale
designed to measure normal and pathological dissociation. Like the DES, it concep-
tualizes dissociation as a trait rather than a state or a pathological feature of a
disorder. The scale items were selected from the Minnesota Multiphasic Personality
Inventory. A factor analysis yielded three factors: affect and depersonalization,
depersonalization and loss of body control, and memory impairment.
4. Peritraumatic Dissodation Experiences Questionnaire (PDEQ-RV) (Mar-
mar & Weiss, 1990). This scale is available in two versions: (1) interview (nine items)
and (2) self-report (eight items). Similar to the SASRQ, it is designed to obtain
information about dissociative reactions and experiences during and immediately
after a trauma. The content of the items involve memory loss specific to the trauma,
depersonalization, and derealization.
5. Impact ofEvents Scale (IES) (Horowitz et al., 1979). This is a 15-item scale
that assesses intrusive reexperiencing and cognitive and affective avoidance. The
eight avoidance items assess effortful attempts to avoid emotional reactions to
trauma-related stimuli and thoughts about the trauma, but not depersonalization,
derealization, and emotional numbness.
6. PTSD Symptom Scale (PSS) (Foa, Riggs, Dancu, & Rothbaum, 1993b). Both
interview (PSS-1) and self-administered (PSS-SR) versions of this 17-item scale have
been validated with female victims of sexual and nonsexual assault. The items
correspond to the PTSD symptoms listed in the DSM-IY. Paralleling the DSM-IY, the
items are divided into three clusters: reexperiencing (four items), avoidance-
numbing (seven items), and arousal (six items). A factor analysis of this scale yielded
a numbing factor that combined the following symptoms: detachment from others,
irritability, sense of foreshortened future, and emotional numbness (Foa et al.,
1995).
7. The Dissodative Disorders Interview Schedule (DDIS) (Ross, Heber, Nor-
ton, Anderson, Anderson, & Barchet, 1989). The DDIS is a 131-item structured
interview developed to make diagnoses of dissociation somatization, major depres-
sion, and borderline personality disorder. Ross and colleagues (1989) recommend
the use of this scale with the DES to provide a complete picture of the range and 211
type of dissociation experiences and severity of psychopathology. Emotional
Dissociation in
Examination of the measures here described suggests that the constructs of Response to Trauma
dissociation, numbing, and avoidance primarily involve three features. The first
pertains to derealization, depersonalization, and memory loss; the second denotes
the absence of affect in emotional contexts; and the third relates to effortful
cognitive avoidance. Most measures focus on one or two of these features, with the
exception of the SASRQ, which includes all three. With these distinctions in mind,
we will now proceed to review the empirical literature on dissociation, numbing,
and avoidance.

STIJDIES OF DISSOCIATION, NUMBING, AND AVOIDANCE

Researchers have documented the presence of dissociative features following a

variety of traumatic experiences. The results of these empirical investigations are
summarized below, according to the type of trauma.

War Exposure
Using the DES with Vietnam War veterans, several studies have demonstrated
that PTSD is associated with increased use of dissociative strategies (Bernstein &
Putnam, 1986; Branscombe, 1991; Bremner et al., 1992; Coons, Bowman, Pellow &
Schneider, 1989; Huska & Weathers, 1991; Orr et al., 1990). The degree of dissocia-
tion, as measured by the DES, was higher in male veterans with PTSD than in
alcoholics, agoraphobics, and normals (Bernstein & Putnam, 1986). DES scores
were also positively related to the severity of PTSD in combat veterans (Bremner
et al., 1992; Waid & Urbanczyk, 1989). However, DES scores were also highly
correlated with depression and anxiety, suggesting that the relationship of dissocia-
tion to PTSD is not specific but rather reflects the relationship between dissociation
and psychopathology.
Several factor analytical studies of posttrauma symptoms in war veterans have
identified dissociation as a core feature of PTSD. Silver and Iacono (1984) have
conducted a factor analysis on psychiatric symptoms reported by Vietnam combat
veterans and have identified four factors: depression, grief-guilt, reexperiencing,
and detachment-anger. The latter factor was characterized by emotional detach-
ment and difficulty experiencing emotions. Since PTSD diagnosis was not deter-
mined, the relationship of these symptoms to traumatic experiences was not
determined. Davidson, Smith, and Kudler (1989) also factor analyzed the DSM-III-R
symptoms of PTSD reported by 116 veterans of World War II, Korea, and Vietnam.
Three factors were identified: reexperiencing and arousal, avoidance and detach-
ment, and constricted affect and memory impairment. In a third study, Solomon,
Mikulincer, and Benbenishty (1989) interviewed soldiers 1 year after the combat
and submitted their reported symptoms to a factor analysis. A psychic numbing
factor emerged that accounted for 20% of the variance (Solomon et al., 1989). The
symptoms that loaded on this factor were: detachment from others and from one's
surroundings, numbing of responses, mental escape, and distraction. The second
212 factor, anxiety reactions, accounted for 11% of the variance. These results point to
Edna B. Foa and the prominent position of dissociation in posttrauma sequela.
Diana Hearst-Ikeda Several studies have demonstrated that the use of dissociative strategies during
combat were associated with chronic posttrauma reactions. Using the IES, Solomon
and Mikulincer (1992) evaluated symptoms of intrusion and avoidance in two
groups of soldiers: those who suffered combat stress response (CSR), or "battle
shock," and those who did not. Soldiers with CSR reported more intrusion and
avoidance symptoms 3 years after combat than those without CSR. However, in
both groups, intrusion and avoidance symptoms decreased as a function of the time
that had elapsed since combat exposure.
In a retrospective study, Bremner et al. (1992) compared the reported dissocia-
tion at the time of specific traumatic events in Vietnam veterans with and without
ro'SD. Dissociation during combat was evaluated using a modified version of the
DES. PfSD patients reported more dissociative symptoms during combat traumas
than did those without PTSD. A similar study was conducted by Marmar and co-
workers (1992). These researchers also examined retrospectively the emotional
experiences during combat of female and male Vietnam theatre veterans using the
DES and the PDEQ-interviewer version. Consistent with the findings of Solomon
et al. (1989) and Bremner et al. (1992), dissociative experiences reported during
combat were highly associated with chronic posttrauma reactions.
Taken together, the above studies seem to indicate a common tendency to
dissociate during a combat experience, and that such dissociation results in pro-
longed pathological reactions. However, it is important to note that all three studies
used retrospective methodology, and therefore the results should be interpreted
with caution. It is possible that individuals with more severe posttrauma pathology
are more likely to report the dissociative experiences during the traumatic event
than do individuals who have successfully recovered, irrespective of the degree of
dissociation they had actually experienced during the traumatic event itself. If the
reported dissociation during trauma accurately reflects the degree of dissociation
during the trauma, then the argument can be made that although dissociation may
provide short-term relief during a stressful event, the use of this coping style
hinders recovery later on.
Several laboratory studies have explored dissociative phenomena in combat
veterans. Spiegel et al. (1988) found that combat veterans with PTSD were more
hypnotizable than their non-PTSD cohorts. Conceptualizing hypnotizability as a
measure of dissociation, they concluded that individuals with PTSD dissociate more
than those without PTSD. To study emotional numbing, veterans with and without
PTSD were given an affective recognition task. As expected, veterans with PTSD
had more difficulty evaluating and identifying emotions than those without PTSD
(Zimering, Caddell, Fairbank, & Keane, 1993). A different method to examine
numbing was employed by Orr (1991). Veterans with and without PTSD were asked
to imagine a pleasant scene. No differences emerged between the PTSD and non-
PTSD subjects on psychophysiology, self-report of emotional reactions, and facial
expression of emotions. Influenced by results from animal experiments demon-
strating opiate-mediated analgesia following uncontrollable electrical shocks, Pit-
man, van der Kolk, Orr, and Greenberg (1990) hypothesized that numbing symp-
toms in PTSD sufferers is mediated by endogenous opiates. To test this hypothesis,
veterans with and without PTSD were exposed to combat movies. Pain tolerance 213
was used as a measure of numbing. Veterans with PTSD showed decreased pain Emotional
sensitivity in response to an ice-cold water test after watching the movies. No such Dissoclatlon in
decrease occurred when naloxone, an opiate antagonist, was administered, sug- Response to Trauma
gesting an opiate-mediated stress-induced analgesia in PTSD. The non-PTSD vet-
erans showed no decrease in pain following the movies.

Abuse in Childhood
Several studies have investigated the relationship between dissociation and
PTSD in individuals who were sexually abused in childhood. Using the DES, Coons
et al. (1989) evaluated dissociation in psychiatric patients with a variety of diag-
noses, including PTSD. A significantly higher incidence of childhood abuse was
found among female patients who were referred to a counseling center than among
female bulimics attending an eating disorders clinic. Further, the incidence of
dissociation and PTSD was significantly higher in the former group.
Using the DES, Sanders and Giolas (1991) examined dissociation and childhood
abuse in a group of emotionally disturbed adolescents. Modest correlations be-
tween history of childhood abuse and DES score were obtained in this sample,
replicating the findings that have been obtained in college students (Sanders,
McRoberts, & Tollefson, 1989). Chu and Dill (1990) also found that female psychi-
atric inpatients with childhood physical or sexual abuse scored significantly higher
on the DES than did women without such a history. However, unlike the results of
Coons et al. (1989), the severity of the DES scores was not related to diagnoses of
PTSD or to dissociative disorders.
Several authors have postulated a relationship between symptoms of bor-
derline personality and childhood abuse (Gelinas, 1983; Herman, Perry, & van der
K.olk, 1989). In a retrospective study, Herman et al. (1989) examined the relation-
ship between childhood trauma histories of patients with borderline personality
disorder, PTSD symptoms (measured by lES), and the DES. They found a significant
relationship between severity of trauma history, severity of PTSD symptoms, and
the presence of borderline personality disorder. Also, patients with this disorder
generally reported higher DES scores than those without this diagnosis, suggesting
a link between sexual abuse, borderline personality, dissociation, and PTSD.
Similar results were reported in a study evaluating the sexual and physical
abuse experiences in female and male adults diagnosed with borderline personality
disorder using the Diagnostic Interview for Borderline Patients (Dill) (Gunderson,
Kolb, & Austin, 1982). Although the Dill is not specifically designed to evaluate a
wide range of dissociative experiences, a few items about derealization and deper-
sonalization are included. The results of the study confirmed the hypothesized
relationship among childhood sexual abuse, borderline personality, and dissociative
symptoms (Ogata, Silk, Goodrich, Lohr, Westen, & Hill, 1990). Finally, Boon and
Draijer (1991) reported a high prevalence of child abuse among patients who met
criteria for dissociative and personality disorders using the Structured Clinical
Interview for DSM-ill-R Dissociative Disorders (SCID-D).
The studies described above converge to suggest a relationship among child-
hood abuse, psychopathology (including PTSD, dissociative disorders, and person-
214 ality disorders), and tendency to employ dissociative strategies. However, this
Edna B. Foa and tendency is associated with general psychopathology and is not specific to PTSD.
Diana Hearst-Ikeda
Adult Victims of Assault
Symptoms of anxiety and dissociation have also been observed in adult victims
of assault (Burgess & Holmstrom, 1976). Moderate dissociation (measured by the
DES) in female victims of sexual and nonsexual assault was observed immediately
after the assault, which declined over time, reaching a normal range 3 months later
(Dancu, Riggs, Hearst-Ikeda, Shoyer, & Foa, in press). As with victims of childhood
abuse, dissociation was related to posttrauma psychopathology (e.g., RIES, Beck
Depression Inventory, State Trait Anxiety Inventory) in both rape and nonsexual
assault victims. Dissociation was also related to PTSD diagnosis in nonsexual victims
but not in rape victims. Thus, these results support the view that dissociation is
related to general psychopathology rather than PTSD. Riggs, Dancu, Gershuny,
Greenberg, and Foa (1992) also found that victims with a history of childhood
sexual abuse reported more dissociation than victims without such a history. These
findings are consistent with those of Chu and Dill (1990), and together they suggest
that trauma in childhood may predispose victims to dissociate after a subsequent
trauma in adulthood.
In the factor analytical study mentioned earlier that used the DSM-111-R symp-
toms of PTSD in recent female assault victims, Foa et al. (1993a) identified three
factors: arousal-avoidance, numbing, and intrusion. The items that loaded on the
numbing factor were: numbing of feelings, detachment from others, loss of interest,
and a sense of foreshortened future. The numbing symptoms best distinguished
assault victims with PTSD from those without PTSD 3 months after the assault.
These findings concur with those of Solomon and colleagues using the DES with
Israeli war veterans (Solomon eta!., 1989; Solomon & Mikulincer, 1992). Although
the symptoms that comprised the numbing factor differ from those of the DES, both
studies reveal association between dissociation and the experience of trauma.

Abduction and Incarceration

In two studies, Kinzie and colleagues (Kinzie, Sack, Angell, Manson, & Rath,
1986; Kinzie, Sack, Angell, Clarke, & Rath, 1989) evaluated the posttrauma reactions
of Cambodian adolescents 4 years after being incarcerated in the Pol Pot concentra-
tion camps. The victims reported a variety of traumas including separation from
family members, starvation, being beaten, and witnessing the deaths of their com-
panions. Four years after incarceration, half of these youths met DSM-111-R criteria
for PTSD, 58% avoided memories of the camp, and 43% avoided discussing their
traumas. Seven years after incarceration, 48% of the participants had PTSD and 41%
exhibited moderate to severe depression. Thus, avoidance of trauma reminders was
most common in victims of incarceration years after their traumatic experiences.
While no other dissociation symptoms were reported in this study, the high preva-
lence of PTSD suggests that many victims experienced numbing symptoms. More
direct evidence for the presence of dissociative symptoms following incarceration
comes from a review of anecdotal accounts of prisoners of war about their emo-
tional experiences during the trauma (Siegel, 1984). Twenty-six percent of the
prisoners evidenced emotional numbing and depersonalization, and 13% experi- 215
enced out of body experiences. Emotional
Dissociat:lon in
Response to Trauma
Accidents
Two studies by Noyes and colleagues examined dissociation in survivors of life-
threatening situations (e.g., an automobile accident, a drowning, a fall, a serious
illness). The first study consisted of interviewing accident survivors and administer-
ing a questionnaire inquiring about dissociative experiences during the trauma. The
questionnaire revealed a wide range of dissociative symptoms including detach-
ment, depersonalization, absence of affect, perceptual distortions, and feelings of
unreality (Noyes & Kletti, 1977). In the second study, the dissociative symptoms of
hospitalized automobile accident survivors and psychiatric patients were examined
(Noyes, Hoenk, Kuperman, & Slymen, 1977). Accident victims were asked about
their dissociative experiences during the trauma, and psychiatric patients were
asked about dissociative experiences during the most recent episode of their
illness. A 56-item questionnaire administered in this study was submitted to factor
analysis. Three factors emerged for both populations: detachment, mental cloud-
ing, and alertness. Both victims and psychiatric patients reported experiences of
depersonalization and dissociation; "mental clouding" was prevalent in psychiatric
patients, whereas perceptual and time distortions were the predominant symptoms
in accident victims. High prevalence of avoidance and numbing symptoms (about
25 to 40%) was also found among adult survivors of severe flame, chemical,
electrical, or scald bums (Roca, Spence, & Munster, 1992) and among survivors of
the Hyatt Regency Hotel skywalk collapse (Wilkinson, 1983) 4 to 5 months after the
trauma.

Natural Disasters
Dissociation and avoidance symptoms have also been reported in victims of
natural disasters and appear to be associated with persistent posttrauma psycho-
pathology. Using an expanded version of the Hopkins Symptom Checklist to in-
clude PTSD items, Madakasira and O'Brien (1987) evaluated the posttrauma reac-
tions of disaster victims after a tornado in North Carolina. Five months after the
trauma, 82% of the victims were bothered by intrusive thoughts, 61% suffered
memory loss of the trauma, 57% experienced feelings of estrangement, and 31%
avoided trauma reminders.
Two studies used the SASRQ to examine dissociation after a natural disaster. In
the first study, two groups of earthquake survivors were compared. One group was
evaluated 1 week after the earthquake and the other 4 months later. As expected,
more symptoms of dissociation and anxiety were reported by the former than the
latter group (Cardena & Spiegel, 1993). In the second study, firestorm survivors
were evaluated on two occasions: within the first month after the fire and 7 to 9
months later. Dissociation and anxiety were highly correlated within the first
month posttrauma and both symptom clusters followed similar recovery courses.
Interestingly, dissociative symptoms were stronger predictors of chronic post-
trauma reactions than symptoms of anxiety (Koopman, Cardefia, Classen, &
Spiegel, Ch. 17, this volume). Similarly, McFarlane (1986) reported that DSM-Ill-R
216 symptoms of avoidance predicted persistent PTSD in survivors of the Ash Wednes-
Edna B. Foa and day brush fires. These findings, like those ofFoa et al. (1995a), point to the cardinal
Diana Hearst-Ikeda role of dissociation in PTSD.

Witnessing Trauma
Using a short version of the SASRQ, Freinkel, Koopman, and Spiegel (1994)
studied anxiety and dissociation symptoms of journalists during and immediately
after witnessing· an execution. Symptoms of emotional numbing, cognitive avoid-
ance, and derealization were more prevalent than anxiety symptoms. The fre-
quency of the dissociation symptoms reported by this sample was as high as that of
survivors of natural disasters (Koopman, Classen, & Spiegel, 1994) but did not
persist as long.
In summary, the studies reviewed above indicate that dissociative experiences
during and immediately after a trauma are frequent and are strongly associated with
persistent posttrauma reactions. Moreover, dissociative symptoms during or shortly
after a trauma may be a stronger predictor of PTSD than anxiety symptoms. It is
unclear, however, whether the tendency to dissociate has a causal relationship to
the development of chronic PTSD. It is possible that both the tendency to dissociate
and the vulnerability to develop chronic PTSD are mediated by other factors such as
childhood experiences. The strong relationship between childhood abuse and
dissociation strongly supports this proposition. Most studies also indicate that
dissociative symptoms are not unique to trauma victims; rather, they seem to reflect
general psychopathology. How can we explain the relationship between traumatic
experiences, dissociation, and psychopathology?

INFORMATION-PROCESSING PERSPECfiVE OF EMOTIONAL

DISSOCIATION IN RESPONSE TO TRAUMA

Many authors have noted that emotional experiences are often relived long
after the original emotional events have occurred (e.g., Freud, 1920; Lindemann,
1944; Rachman, 1980; Foa & Kozak, 1991). As is apparent from the studies reviewed
above, this phenomenon is clearly exemplified in individuals who have experi-
enced traumatic events. Usually, the frequency and intensity of this emotional re-
experiencing of the trauma gradually diminishes over time. Thus, shortly after the
attack, a rape victim may experience intense fear when reminded of the assault, and
with time this fear lessens, although perhaps it never completely disappears.
Rachman (1980) discussed the significance of the processes that underlie the
decline of emotional reexperiencing and suggested that when these processes are
impaired, psychopathology surfaces. He further proposed that the persistence of
neurotic symptoms such as intrusive thoughts, nightmares, excessive feats, and
sleep disturbances are signs of unsatisfactory "absorption" of the emotional experi-
ence. The overlap between these signs and the symptom criteria for PTSD is
striking, and it has lead Foa (1993) to propose that the presence of PTSD reflects
impairment in emotional processing of a traumatic experience. If this is true, Foa
(1993) suggested, the identification of factors that differentiate trauma victims with
chronic PTSD from victims without PTSD would shed light on the mechanisms that 217
facilitate or hinder emotional processing. Moreover, successful treatment of PTSD Emotional
can be viewed as assisting in emotional processing, and thus, factors that distin- Dissociation In
guish individuals who improved with treatment from those who failed to show Response to Trauma
improvement may further our knowledge of the pathology underlying PTSD.
To explain the mechanism by which cognitive-behavioral therapy reduced
pathological anxiety (i.e., signs of impaired processing), Foa and Kozak (1986)
extended Lang's (1977, 1979) bioinformation model of pathological fear. Using this
framework, we will provide an information-processing analysis of how dissociation
impairs the normal processing of a traumatic event, thereby contributing to the
development and maintenance of chronic PTSD. We will also provide an explana-
tion of how exposure treatment prevents or negates the deleterious effects of
dissociation.

The Cognitive Structure of Fear

Lang (1977, 1979) proposed that fear is represented in memory as a structure
that comprises information about: (1) feared stimuli, (2) physiological and motor
responses, and (3) interpretive information about their meaning. Lang further
suggested that a fear structure constitutes a "program" for escape from threat. 1f a
fear structure is a program for escaping danger, then it must involve information
that trauma-related stimuli and/or responses are dangerous. And it is this meaning
information, Foa and Kozak (1986) contended, that distinguishes a fear structure
from other cognitive structures.
Most people experience fear in some circumstances, which implies the "run-
ning" of a fear program. "Normal" fear occurs when an individual perceives actual
threat, and it subsides when the danger is removed. When does a fear become
pathological? Foa and Kozak (1986) noted that several characteristics distinguish
pathological fear. First, fear becomes pathological when it is extremely intense and
when it persists, despite information that it is unrealistic. In other words, a patho-
logical fear structure involves excessive response elements, such as representations
of avoidance and physiological activity, that are resistant to modification. Second, a
pathological fear structure includes unrealistic elements. This implies that stim-
ulus-stimulus associations do not accurately represent the world. For example, for
the rape victim who was raped at gunpoint by a tall, bearded man, the elements
"tall, bearded man" may become erroneously associated with the stimulus "gun."
Third, mistaken associations between nondangerous stimuli and escape or avoid-
ance responses are also characteristic of a pathological fear structure. Indeed,
running away from a "tall, bearded man" is not likely to enhance the safety of the
victim.
In addition to erroneous association among elements, victims with patholog-
ical fear make several evaluative mistakes. First, they commonly believe that anxi-
ety, once experienced, will persist unless they escape the feared situation. Second,
they overestimate the probability that the feared stimuli or responses will cause
physical or psychological harm. And third, their feared consequences have an
extremely high negative valence.
According to Foa and Kozak (1986), different anxiety disorders represent
218 different pathological fear structures. For example, there is evidence to suggest that
Edna B. Foa and erroneous interpretations of fear responses distinguish the structure of agora-
Diana Hearst-Ikeda phobia from that of simple phobia. Agoraphobics commonly interpret anxiety
responses, themselves, as threatening, since they expect these responses to result
in physical or psychological harm. For an agoraphobic, stimulus elements such as
"tunnels" are not perceived as inherently dangerous; rather, the danger is perceived
to exist in the anxiety that these elements engender. In contrast, for simple phobics,
the danger lies in the stimulus situation itself, such as "snakes," "airplanes;• or
"insects:•
Foa (1993) suggested that PTSD, like the other anxiety disorders, can be
construed as reflecting a pathological fear structure that contains faulty associations
and erroneous evaluations. She further proposed that a trauma memory can be
viewed as a fear structure. It includes information about stimuli and responses
related to the trauma, as well as information about their meaning. The trauma
structure of a woman who was raped at gunpoint at her home in the suburbs will
include the stimulus elements of "gun;• "man," his physical characteristics such as
"tall," and "beard," and environmental stimuli such as "home" and suburbs." The
response elements will include physiological responses such as "tachycardia" and
behavioral responses such as "struggling" and "screaming."
In a trauma memory of a non-PTSD victim, "rape" and "pointed gun" are
associated with a "danger" meaning but neutral stimuli such as "man," "home," and
"suburbs" are not. In a pathological trauma structure that underlies PTSD, stimuli
that are inherently neutral such as "tall, bearded man;• "home," and "suburbs" are
associated with the meaning "danger." Because many stimuli become associated
with danger meaning, the world as a whole is perceived as threatening by the victim
with PTSD. Foa and Riggs (1993) have suggested that a pathological trauma struc-
ture includes not only erroneous interpretations of stimulus elements but also
mistaken interpretations of response elements. In particular, they proposed that
responses during the trauma such as "struggling" and "screaming" become associ-
ated with the meaning "self-incompetence." A pathological trauma structure also
includes particularly intense response elements that are reflected in PTSD symp-
toms such as excessive avoidance and arousal. In summary, a pathological trauma
structure is distinguished by excessive response elements, as well as erroneous
interpretations of intrinsically neutral stimuli as dangerous and normal responses
to trauma as reflecting self-incompetence.

Modification of the Trauma Structure

Studies have revealed that 95% of female rape victims and 75% of female
nonsexual assault victims met symptom criteria for PTSD within the first 2 weeks
after the trauma (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). It follows that,
for most people, immediately after a traumatic experience the trauma memory
includes pathological elements such as excessive responses and faulty interpreta-
tions. Rothbaum et al. (1992) further noted that over time, only 50% of rape victims
and 25% of nonsexual assault victims met criteria for the disorder. This finding
suggests that, in the course of time, the trauma structure of many victims undergoes
modification.
 Foa and Kozak (1986) have suggested that the modification of a pathological 219
fear structure is the essence of emotional processing, and that successful therapy Emotional
promotes emotional processing. How does emotional processing occur in the Dissociation in
natural progression of recovery from a trauma? We argue that the understanding of Response to Trauma
how cognitive behavioral therapy reduces pathological fear will help us concep-
tualize natural recovery from a trauma.
Foa and Kozak (1986) proposed that two conditions are necessary for emo-
tional processing to occur. First, therapists must activate the fear structure by
providing information that matches the information represented in the structure.
For if the fear structure remains unaccused, it will not be available for correction.
Second, information provided during therapy must also be incompatible with the
pathological elements in the structure. Extending this model, we propose that in
order to acquire a spontaneous decline of posttrauma emotional disturbances, the
trauma memory, including its emotional elements, must be repeatedly activated by
contact with trauma-related stimuli. Further, this contact should include corrective
information about the world (e.g., "not all tall, bearded men carry guns and rape")
and about oneself (e.g., "screaming during the rape does not mean that I am
incompetent").

Dissociation Impedes Emotional Processing

The view that repeated engagement with the trauma memory is important for
a successful resolution of the traumatic experience has been shared by many
theorists (e.g., Freud, 1920; Horowitz, 1986). In fact, Horowitz (1986) invented the
term completion principle to denote the natural tendency to process new informa-
tion until it is "brought up to date" with inner schemas of the self and of the world.
A stressful life event, he suggested, includes by definition information that is
incompatible with a person's inner cognitive models, and thus requires more
processing activity than nonstressful experiences. But the completion principle
conflicts with the tendency to avoid trauma reminders in order to protect oneself
from emotional pain, the pain that is associated with the trauma. Dissociation or
numbing, like avoidance, is a strategy to avert trauma-related distressing emotions
(Davidson & Foa, 1991; Spiegel eta!., 1988). If recovery (i.e., emotional processing)
requires repeated engagement with the trauma memory, then dissociation is ex-
pected to impede this process.
Indirect evidence supporting the hypothesis that dissociation impairs emo-
tional processing and hence impedes recovery comes from the repeated finding
that dissociation during or immediately after the traumatic experience is associated
with later psychopathology. More direct evidence comes from a study examining
the facial fear expression of assault victims during therapy that involved reliving of
the trauma (Foa, Riggs, Massie, & Yarczower, in press). Assault victims who dis-
played more intense facial fear expressions and reported greater subjective distress
during the first reliving session benefited more from treatment than those who
displayed less intense fear. These findings converge with those of other studies that
measured fear activation via increase in heart rate. With simple phobics, Lang,
Melamed, and Hart (1970) found that clients who evidenced higher heart rate
response during the first imaginal exposure to feared stimuli manifested greater
220 improvement in their phobias. Similar results were reported with obsessive-
Edna B. Foa aod compulsives: a strong positive correlation was found between heart rate increase
Diana Hearst-Ikeda during the first in vivo exposure to the patients' most feared situations and change
in measures of obsessional fear (Kozak, Foa, Steketee, & Grayson, 1988). In all of
these studies, emotional engagement with the feared memory enhanced emotional
processing. Conversely, emotional disengagement (i.e., dissociation) hampered
emotional processing. Interestingly, in the Foa and co-workers' (in press) study
described above, victims who reported more anger prior to treatment displayed
less fear during reliving of the trauma and benefited less from treatment. These
results correspond with the finding that intense anger shortly after an assault
predicts PTSD severity 1 month later in female victims (Riggs et al., 1992). If, as we
suggested, PTSD reflects a failure to emotionally process the traumatic event, then
anger appears to impede the mechanisms underlying both the "natural" emotional
processing and emotional processing during treatment. The negative association
between anger and facial fear expression implies that anger impedes processing of
the trauma by inhibiting the activation of fear. It is possible that anger, like effortful
avoidance and dissociation, is a means by which victims with PTSD regulate their
arousal and emotional distress.

FURTHER CONSIDERATIONS

In this chapter we have adopted the view that dissociation or numbing may
represent a strategy for reducing or avoiding trauma-related emotional distress. We
have proposed that excessive use of dissociation prevents the activation of the
traumatic memory, and that repeated activation is a necessary condition for emo-
tional processing to occur. It follows that dissociation is one factor underlying the
persistence of posttrauma disturbances, and thus, it is implicated in the develop-
ment of chronic PTSD and related psychopathology.
The conceptualization of dissociation that we have offered here carries impli-
cations for the treatment of trauma-related psychopathology. If recovery from a
trauma requires emotional engagement with the traumatic memory, then treatment
of chronic PTSD should involve the promotion of such engagement. Indeed, suc-
cessful treatments for PTSD consist of the reliving of the trauma in imagination
(Boudewyns & Wilson, 1972; Boudewyns, 1975; Foa, Rothbaum, Riggs, & Murdock,
1991; Keane, Fairbank, Caddell, & Zimering, 1989; Keane & Kaloupek, 1985).
The use of exposure therapy to promote emotional processing assumes that
the tendency to dissociate will be conquered by therapeutic instructions to engage
in the emotional reliving of the trauma. The results of treatment studies that
employed exposure support this presumption.
For the most part, successful reduction of trauma-related distress via treatment
should eliminate the function of dissociation, and thus reduce dissociative re-
sponses. However, clinical observations reveal that some traumatized individuals
continue to dissociate during the reliving of the trauma, rendering exposure ther-
apy ineffective. For such individuals, therapeutic techniques directly aimed at
reducing dissociation must be implemented. Such interventions are reported in the
literature (for a summary of treatment for multiple personality disorder, see Put- 221
nam, 1989), but studies of their efficacy are awaiting controlled investigation. Emotional
Dissociation in
AcKNOWLEDGMENTS. This research was supported by NIMH grant #MH42178-07 to Response to Trauma
the first author.

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IV
ASSESSMENT

Janet suggested that dissociation lies at the basis of almost all psychopathology. This
idea has been supported in previous chapters with the many comments describing
the manner in which dissociative experiences co-occur with a variety of affect
psychopathologies. However, if dissociation is related to everything, then it be-
comes problematic to differentiate dissociative processes from other forms of
psychopathology. This section approaches this important question and begins to
ask how to assess dissociative processes. In Chapter 11, Cardefi.a and Spiegel begin
to address the broad questions related to diagnostic issues including comorbidity of
dissociative disorders. In Chapter 12, the focus becomes more specific in terms of
DSM-IV criteria and the development of the SCID-D by Steinberg. Finally, Chapter
13, by Zahn, Moraga, and Ray, focuses on concomitant psychophysiological pro-
cesses and hints at some physiological mechanisms involved in dissociative dis-
orders.
Historically, some authors have identified dissociative disorders with hysteria.
By doing so, they have included conversion reactions as well as somatizations along
with severe shifts in identity, memory, and consciousness within the rubric of
dissociation. To aid in our clarification of the boundaries of the term dissociation,
Cardeiia and Spiegel consider the speculations and formulations that informed
DSM-IV by examining the five DSM-IV dissociative disorders: dissociative amnesia,
dissociative fugue, dissociative identity disorder, depersonalization disorders, and
dissociative disorders not otherwise specified. The chapter also raises the question
of whether acute stress disorder, which is seen as an anxiety disorder in DSM-IY,
should be considered to be a dissociative disorder. This, of course, raises a larger
question as to the relationship of dissociation to other types of affective disorders
such as anxiety and depression. In Chapter 12, Steinberg describes a variety of
measures for diagnosing dissociative experiences and disorders. She also describes
the development of the SCID-D with its structured and semistructured formats and
its ability to assess the presence and severity of dissociative symptoms. In the final
chapter of this section, Zahn, Moraga, and Ray examine psychophysiological indi-
cants of dissociative processing. One intriguing finding within the folklore of
dissociative identity disorder is the possibility that each identity can be organized
differently in terms of physiology. This would mean that one identity, for example,
could be allergic to one substance and another not show any signs of allergy. The 225
226 initial part of this chapter examines the question as to whether different identities
Assessment show differential physiological patterns, especially in terms of autonomic nervous
system measures, and begins with the earliest psychophysiological study of DID,
which was published by Morton Prince in 1908. The second part of the chapter
focuses on central nervous system measures of dissociative processes. Since tempo-
ral lobe epilepsy patients may display dissociative symptoms, an important question
asks if epilepsy lies at the heart of dissociative disorders. This chapter suggests that
although epilepsy may produce dissociative symptoms, it is not logical to conclude
that dissociation implies epilepsy.
11
Diagnostic Issues, Criteria,
and Comorbidity of
Dissociative Disorders
Etzel Cardeiia and David Spiegel
The fear of being nothing but an empty body that
anybody-I or anyone else-could occupy, and the
wretchedness of watching yourself, alive, and the doubt
that it is-it is not-real.
XAVIER VIU.AURRUTIA, Nocturno Mledo (translated by
Eliot Weinberger)

INTRODUCTION

While the interest in and concern with the dissociative disorders have grown
exponentially in the last decade, with annual conventions, a journal exclusively
devoted to dissociation, monographs, and so forth, this state of affairs represents
more a rediscovery of concepts and phenomena than a brand new area of inquiry
(cf. Spiegel & Cardefia, 1991; van der Kolk & van der Hart, 1989). Hysteria, a concept
closely connected with the dissociative disorders, can be traced back at least to
Pharaonic Egypt (cf. Kihlstrom, 1994). Closer to our times, just about every one of
the forebears of modern psychopathology studied disorders involving a "disruption
in the usually integrated functions of consciousness, memory, identity, or percep-
tion of the environment" (American Psychiatric Association, 1994, p. 477). For

Etzel Cardeiia • Department of Psychiatry, Uniformed Services University of the Health Sciences,
Bethesda, Maryland 20814. David Spiegel • Department of Psychiatry and Behavioral Sciences,
Stanford University School of Medicine, Stanford, California 94305.
Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 227
228 example, Breuer and Freud, Pierre Janet, WtlliamJames, and Morton Prince, among
E1Zel Cardeila and a longer list of distinguished psychologists at the turn of the century, all described
David Spiegel fascinating cases of pronounced shifts in identity, memory, somatic reactivity, and
consciousness.
Still more recently, the drive to create a reliable psychiatric nosology gave rise
to the first edition of a project that is now in its fourth decade and edition, namely
the Diagnostic and Statistical Manual ofMental Disorders (DSM) of the American
Psychiatric Association. The first edition of the DSM (American Psychiatric Associa-
tion, 1952), under the subheading of psychoneurotic disorders, included "dissocia-
tive reaction" and "conversion reaction." The second edition of the DSM (DSM-ll,
American Psychiatric Association, 1968)) was a more elaborate taxonomy that, for
the purposes of this chapter, classified what are currently regarded as dissociative
disorders in the categories of "depersonalization neurosis" and "hysterical neu-
rosis;" the latter either of a "conversion type" or a "dissociative type" (the latter
including amnesia, fugue, and multiple personality). A shift toward a more descrip-
tive and less theoretically laden taxonomy (e.g., note the deletion of the term
"neurosis") is evident in the third edition of the DSM (DSM-Ill, American Psychiatric
Association, 1980), which included a specific category for the dissociative disorders
(i.e., psychogenic amnesia, psychogenic fugue, depersonalization disorder, mul-
tiple personality disorder, and atypical dissociative disorder) as a major diagnosis. A
new term, "somatoform disorders," was devised for what used to be called "conver-
sion type neurosis." Although there were some important changes in the criteria for
the various diagnoses, the revised 3rd edition of the DSM (DSM-Ill-R, American
Psychiatnc Association, 1987) maintained the same general categories for the disso-
ciative disorders. (For a more thorough review of the conceptual transformation of
the concept of "dissociative disorders," consult Kihlstrom, 1994).

FROM DSM-m-R TO DSM-IV

A great wealth of information and theory has accumulated since the DSM-Ill-R,
particularly with respect to the most severe form of the dissociative disorders,
"dissociative identity disorder [or DID, previously known as multiple personality
disorder (MPD)]. Nonetheless, some basic conceptual issues are controversial and
far from solved, among them the uncertainty of whether dissociation is a descrip-
tive or a theoretical term and what its boundaries are (cf. Cardeiia, 1994). Another
important issue is whether what are now called the somatization disorders (previ-
ously known as conversion) should be included under the rubric of the dissociative
disorders. There are at least four arguments that can be adduced for subsuming
somatization under the dissociative disorder: (1) historically, what used to be called
hysteria typically included somatization phenomena such as hysterical paralysis and
blindness, along with other dissociative phenomena; (2) even within the province
of the current ·Categorization of the dissociative disorder, somatization symptoms
are frequently found among individuals with dissociative disorders (see comorbid-
ity section); (3) most, if not all, of the somatization disorders can be conceptualized
as a dissociation between the patient's anatomical or functional status and his/her
conscious awareness of that status; and ( 4) The International Classification of
Diseases, lOth edition (ICD-10) includes a dissociative (conversion) disorder; a 229
parallel development in the DSM would thus increase the compatibility between Diagnostic Issues of
the two systems (cf. Garcia, 1990). While this is not the place to fully develop this Dissociative
argument, the interested reader can consult Nemiah (1991) and Kihlstrom (1994) Disorders
for cogent discussions of this issue.
The bulk of this chapter provides the data and rationale for the changes made
to the dissociative disorders in the DSM-IY. The appendix shows a comparison
between the diagnostic criteria of the DSM-IV and those of its predecessor, the
DSM-III-R along with the proposed criteria for a diagnosis that, by virtue of being
placed in the appendix of the DSM-IV is under consideration for the 5th edition of
the DSM, namely dissociative trance disorder. The criteria and rationale for a
diagnosis that was not accepted, secondary dissociative disorder due to a non-
psychiatric medical condition, will also be briefly reviewed.
The appendix also contains the criteria for a new diagnosis, acute stress
disorder, that includes dissociative symptoms. This diagnosis, while added to the
DSM-IV under the anxiety stress disorders, was initially proposed by the Working
Group on Dissociative Disorders of the Task Force on DSM-IV under the term "brief
reactive dissociative disorder" (Spiegel & Cardeiia, 1991).

Dissociative Amnesia
Amnesia can be considered to be a disorder in its own right, and a building
block for other disorders such as fugue and DID. Indeed, personal identity requires
the sense of temporal continuity that personal, or episodic memory, provides. In
contrast with many forms of organic amnesia in which typically there is anterograde
loss (i.e., impairment with learning new material), dissociative amnesia is typically
retrograde (i.e., loss of memory for events preceding the episode) and is organized
according to affective rather than temporal dimensions (e.g., Schacter, Wang,
Thlving, & Freedman, 1982). A patient with dissociative amnesia may not be able to
remember a specific episode or personal information dealing with a stressful event
(e.g., forgetting a marriage and a family in the midst of a divorce) while preserving
"islets" of other information. In a recent study of dissociative amnesia, Coons and
Milstein (1992) found that out of 25 patients (23 women), 76% had amnesia for
selective information, 8% had a more generalized amnesia, while the remaining
16% had both types of amnesia; most patients had chronic cases of amnesia not of
sudden onset.
Dissociative amnesia is typically associated with stressful situations such as
early abuse, war or financial disaster, depression, and suicide attempts (Kopelman,
1987; Loewenstein, 1991). Coons and Milstein (1992) found the following precipi-
tants for amnesic episodes: child abuse (60%), severe marital troubles (24%), dis-
avowed sexual or illegal behavior (16%), and suicide attempts (16%).
Differential diagnoses for amnesia include malingering (particularly for pa-
tients with legal problems) and various organic disorders. Among the latter are
transient global amnesia, which is a transient, single amnestic episode involving
confusion and probably caused by transient vascular insufficiency (Rollinson,
1978), drug toxicity, Korsakoff's psychosis, head injury, epilepsy, dementia, amne-
sic stroke, posttraumatic amnesia, postoperative amnesia, postinfectious amnesia,
230 alcoholic "blackout," and anoxic amnesia (Benson, 1978; Keller & Shaywitz, 1986;
Etzel Cardefta and Kopelman, 1987). Generally, dissociative amnesia seems to differ from organic
David Spiegel amnesia in the lack of temporal arrangement, the fast resolution, the prepon-
derance of personal memory loss, a stressful precipitant, and a discernible motiva-
tion. Specific cases, however, might differ from this profile.
The changes in the diagnostic criteria for DSM-IV are:
1. The name of the condition itself became dissociative amnesia, instead of
psychogenic amnesia, to achieve compatibility with the nomenclature of the Inter-
national Classification of Diseases and to further link other dissociative disorders
that have amnesia as a constituent component (dissociative fugue, dissociative
identity disorder).
2. Criterion A was modified in the following ways: The term "sudden" to
qualify the onset of the condition was removed because it is unduly restrictive. The
course of dissociative amnesia may be gradual and insidious rather than abrupt;
amnesia may present as a discrete episode or as a chronic series of episodes of
varying intensity and duration. Based on the literature reviewed above, phrasing
was added in the DSM-IV to indicate that trauma and stress are the typical precipi-
tants of amnesia, and that dissociative amnesia should be distinguished from the
common amnesia for early years.
3. The list for differential diagnoses is more specific than that for the DSM-ffi-R.

Dissociative Fugue

Fugue states have been documented at least since the late 1800s. The most
famous case may be that of the Reverend Ansel Bourne, who reported leaving his
home and adopting a new identity after he had become amnestic for his previous
life (James, 1890/1923). Since World War 11, when fugue states were frequently
observed, there have been very few systematic studies of pure dissociative fugue
other than DID-involving episodes of fugue. This may be because of the lack of the
widespread stressful effect of war in the United States, but also because of a
"nonclassic" presentation of fugue in which patients may not present with amnesia
and dissociative symptoms unless queried about it. This group includes individuals
who are unlikely to come under the care of clinicians, including adolescent runa-
ways from abusive homes, homeless individuals, and so forth (cf. Loewenstein,
1991).
A recent review of the literature concluded that the definition of dissociative
fugue as a condition in which there is an adoption of a new identity is unduly
restrictive. Cases of fugue may involve only the loss of a personal identity or other
alterations in consciousness of personal identity without the assumption of a new
identity (Riether & Stoudemire, 1988). A case study by Keller and Shaywitz (1986) of
a 16-year-old male found entangled in a shrubbery along a state highway, who had
amnesia for personal identity, is a good example of fugue without the adoption of a
new identity. As with amnesia, fugue is typically associated with traumatic or very
stressful circumstances.
Differential diagnosis for fugue includes complex partial seizure episodes
involving postictal episodes of aimless wandering, followed by retrograde amnesia
and disorientation, or "poriomania" (Gross, 1979; Mayeux, Alexander, Benson, 231
Brandt, & Rosen, 1979). The clinician should also take into consideration other Diagnostic Issues of
organic conditions that could give rise to "fuguelike" states, including organic, Dissociative
nonepileptic factors (e.g., migraine, brain tumors), schizophrenia, alcohol- and Disorders
drug-related fugues, and so on (Akhtar & Brenner, 1979).
Changes in criteria for the DSM-N include:
1. The change of name from "psychogenic" to "dissociative" fugue, for the
reasons explained above.
2. A change in criterion B from the requirement of the assumption of a new
identity to the more general "confusion about personal identity or assump-
tion of a new identity."
3. A more specific list of exclusion diagnoses.

Dissociative Identity Disorder

The central feature of this condition is the presence within the individual of
two or more distinct identities. Without question, DID has been the most controver-
sial and researched of the dissociative disorders. DID is the most extreme disorder
within a spectrum of dissociation and it typically involves dissociative amnesia,
fugue, and depersonalization, along with other symptoms (e.g., Braun, 1993; Put-
nam, 1989). For instance, DID patients have been found to have more elevated
Minnesota Multiphase Personality Inventory (MMPI) F and SC scales than amnestic
patients (Coons & Milstein, 1992) and a higher incidence of other diagnoses such as
borderline personality and somatization than patients with dissociative disorders
not otherwise specified (Ross eta!., 1992).
Opinions on DID range from considering it a fiction cocreated by patient and
clinician, to accepting its validity. Within the latter position, a cogent case can be
made that DID should be included on Axis II (personality disorders) rather than on
Axis I, considering that it is a chronic, pervasive condition that represents a failure
in development rather than a regression from a previously higher level of function-
ing. Nonetheless, the eminently dissociative nature of DID argues strongly for its
continued presence within the dissociative disorders category.
DID has also been considered a subtype or variant of borderline personality
disorder (cf. Buck, 1983; Clary, Burstin, & Carpenter, 1984). There is considerable
diagnostic overlap between both conditions. For instance, Ross and colleagues
(1992) reported that 61% of DID patients could also be diagnosed as borderline. The
general view, however, is that they are separate categories (cf. Horevitz & Braun,
1984; Kemp, Gilbertson, & Torem, 1988). The conclusion by Ross, Norton, and
Wozney (1989c) that "the reciprocal relationship between the two disorders is
complex, and awaits further elucidation" is worth heeding.
Of the preexisting dissociative entities, DID shows the most changes in the
new edition of the DSM. The first and most obvious change is its name from
multiple personality disorder to dissociative identity disorder. The original name
has a long and controversial history. This fact was reflected in the divided opinion
among members of the Working Group on Dissociative Disorders for the DSM-N on
whether to adopt the new name. The prevailing view advanced the idea that the
232 classical definition of "personality" denotes a stable individual pattern. The fact
Etzel Cardefta and that, in the case of DID patients, individual consistency is formed by abrupt changes
David Spiegel in mood and identity does not alter this concept.
The new name also emphasizes the fact that the fundamental problem is a
failure of integration of various aspects of identity, memory, and consciousness
rather than a proliferation of "personalities." In addition, it brings the name into line
with others in the category and "preempts" the disorder from some of its meta-
physical connotations. The name and description of the condition now refer to
changes in "identity" rather than "personality." In a similar vein, DSM-IV defines DID
as the "presence of two or more distinct identities" rather than "the existence ...
of two or more distinct personalities," to avoid the ontological suggestion that two
or more personalities may reside within the individual.
The most critical change in diagnostic criteria, however, is the readoption of
the criterion of amnesia, which could be considered essential to the construct of
DID itself. DSM-ID contained this criterion, which was deleted because of the risk
that DID patients may not be aware of this symptom, or even deny it, so that
keeping the amnesia criterion would give rise to false-negative diagnoses (Kluft,
Steinberg, & Spitzer, 1988). Conversely, an argument could be made that not
requiring amnesia for a DID diagnosis may give rise to false-positive diagnoses, such
as not distinguishing ego states from actual DID. While at the time of the DSM-m
revision there was little systematic research investigating the possibility of false
positive- versus false-negative diagnoses in DID, we now have a number of studies
directly relevant to this issue.
In a study with 236 DID cases from various sources, Ross et al. (1989c) found
that 95% reported some form of amnesia at least among some alter identities. In a
survey of 100 cases, Putnam, Guroff, Silberman, Barban, & Post, (1986) reported
that 98% of DID patients had amnesia, while Bliss's (1984) figure was 85% of his DID
sample.
While these figures are very high, use of structured instruments shows an even
higher incidence of amnesia among DIDs. In one study, all102 DID patients given
the Dissociative Disorders Interview Schedule (DDIS) endorsed at least one of six
amnesia criteria (Ross et al., 1990). Complete endorsement by other samples of DID
patients was also found with the use of the Dissociative Experiences Scale (DES)
(Putnam, 1989), and the Structured Clinical Interview for the Dissociative Disorders
(SCID-D) (Steinberg, Rounsaville, & Ciccheti, 1990; Steinberg, 1991; Boon & Draijer,
1991). The data unequivocally show that the risk of false-negative diagnoses is
negligible when a systematic form of inquiry is used.
Finally, the single word "full" in criterion B, which addresses the intermittent
control of the person's behavior by different identities or personality states was
deleted based on the clinical observation of members of the Work Force, whose
experience shows that control of the individual's behavior may be at times divided
among two or more identities, or one identity may have a subtle influence on the
presenting one.
The diagnosis of DID is particularly difficult, since the disorder typically
presents with multiple symptoms and may also coexist with other psychiatric
disorders. In his review of differential diagnoses, Coons (1984) pointed out that DID
may be difficult to differentiate from the other dissociative disorders, psychotic
states, some personality disorders, drug and alcohol abuse, epilepsy, nonpsychotic
dissociative states, malingering, conversion and somatization disorders, depression, 233
and psychosexual disorders. Diagnostic Issues of
Along these lines, Putnam et al. (1986) found in their review that 95% of DID Dlssoclative
patients had received one or more psychiatric and/or neurological diagnoses (a Disorders
mean of 3.6 diagnoses) before being recognized as DIDs. The most common
previous diagnoses included depression (in about 70% of cases), neurotic disorders
(about 55%), personality disorder (about 50%), and schizophrenia (about 50%).
There was an average length of 6.8 years between the first diagnosis and the
eventual diagnosis of MPD. Coons, Bowman, and Milstein (1988), in their study of
50 cases of DID, showed that there was a mean of 3.8 diagnoses per patient. Besides
DID, the diagnoses included personality disorders, alcohol abuse, conversion dis-
orders, drug abuse, and affective disorders. Finally, Ross et al. (1989c) found that the
236 patients they studied had received an average of 2.74 diagnoses, including
affective disorder, personality disorder, anxiety disorder, and schizophrenia.
Patients with DID or other dissociative disorders may be misdiagnosed as
schizophrenics on account of their auditory hallucinations, distrust, feelings of
depersonalization, and performance on the MMPI (Kluft, 1987; Spiegel & Fink,
1979; Steingard & Frankel, 1985). Coons (1984), however, concluded that the
resemblance between the two disorders is merely superficial, and suggested that
the best way to differentiate schizophrenia from DID is on the basis of Bleuler's
primary symptoms.
In summary, criteria changes for DID include:
1. Changing of the name of the condition multiple personality disorder to
dissociative identity disorder.
2. Introducing language that does not objectify the individual's experience
(e.g., "existence of ... distinct personalities" to "presence ... of distinct
identities").
3. The reintroduction of the criterion of amnesia.
4. A more specific differential diagnosis list than before.

Depersonalization Disorder
Depersonalization disorder has been mentioned in the literature for more than
a century, although there has been little systematic research on it. It is defined as an
alteration in the perception or experience of the self in which the usual sense of
one's own reality is temporarily lost or altered. The self may be experienced as
being unreal, "dead," not having any emotions, or the person may observe him- or
herself from an external perspective. Our review (Kubin, Pakianathan, Cardeiia &
Spiegel, 1989) of the symptomatology of depersonalization in 17 case reports on 41
patients indicated that the four most common features were: (1) an altered sense of
self (e.g., "no sense of self," "my body doesn't belong to me"); (2) a precipitating
event (e.g., an accident, marijuana use); (3) a sense of unreality or a dreamlike state
(e.g., "nothing seems real," "I'm not real"); and (4) sensory clterations (e.g., "colors
are less vibrant," "voices sound strange").
A distinction must be made between depersonalization symptoms and deper-
sonalization syndrome. The former are very prevalent among psychiatric condi-
tions, but also are not uncommon as transient and not necessarily distressing
234 symptoms among young adults, or in the context of traumatic events and risk of
Etzel Cardeiia and death, or even during some forms of meditation and hypnosis. In contrast, deper-
David Spiegel sonalization syndrome is chronic, severe, distressing, and impairing and not associ-
ated with diminished reality testing. Steinberg (1991) has also made a distinction
between depersonalization as a predominant disturbance (but which may co-occur
with other dissociative symptoms or other disorders such as depression, panic, or
anxiety) or as a transient or secondary event.
The differential diagnosis of depersonalization should include other dissocia-
tive disorders, anxiety disorders (frequently co-occurring with depersonalization),
depression, obsessions and hypochondriacal symptoms, schizophrenia, borderline
personality disorder, substance abuse disorders, seizure disorders, organic illness,
and medication side effects (Steinberg, 1991).
Changes in the criteria of depersonalization for the DSM-IV consisted of minor
wording changes:
1. Criterion A was rephrased for greater clarity.
2. On criterion C, phrasing was added to indicate that the diagnosis would
require distress or impairment in social or occupational functioning, to
further distinguish transient and benign depersonalization from deperson-
alization syndrome.
3. The differential diagnosis criterion was further clarified.

Acute Stress Disorder

Acute stress disorder (ASD) is defined by peritraumatic, short-term dissociative

and anxiety symptomatology that brings pronounced distress and/or maladjust-
ment. This new diagnosis is placed in the anxiety disorders section of the DSM-IY,
although in its earlier forms it was conceived of as a dissociative disorder since it
consists of prominent dissociative symptoms (cf. Spiegel & Cardefia, 1991). Al-
though posttraumatic stress disorder (PTSD) also involves a reaction to trauma, it
differs from this diagnosis in that it cannot be diagnosed for 1 month after the
traumatic event and its criteria do not contain as explicit a list of dissociative
symptoms as ASD. Because the rationale for the adoption of this new diagnosis is
included in this handbook (see Chapter 17) and has been developed elsewhere
(e.g., Cardefia et al., 1995), it will not be presented here. Suffice it to say that the
literature contains by now a number of studies that show that dissociative reactions
to disasters and traumatic events are not only common but, in their more extreme
form, bring distress and maladjustment and are significant predictors of long-term
PTSD (Cardefia, 1995).
Some of the issues that arose during the consideration of this diagnosis in-
cluded the following: (1) whether dissociative reactions following a disaster or
trauma are prevalent enough to warrant a new diagnosis; or (2) even if they are
present, whether a new diagnosis would not pathologize a normal reaction to an
abnormal situation. The reviews cited above show that dissociative and anxiety
symptomatology are indeed quite prevalent during or following disaster or trauma,
and that individuals showing extreme dissociative reactions may not only endanger
themselves but are prone to develop a long-standing PTSD syndrome. The new
diagnosis of ASD should foster investigation of the type of interventions that will
alleviate ongoing symptoms and prevent long-term negative sequelae. The criteria 235
for ASD are included in the appendix. Diagnostic Issues of
Dissociative
Disorders
Dissociative Disorders Not Otherwise Specified
As with other catchall diagnoses in DSM-IY, DDNOS refers to disorders that are
clearly dissociative in nature but do not fit any of the previously described catego-
ries. Coons (1992) listed the following as DDNOS variants: Ganser's syndrome (the
use of approximate answers usually accompanied by other dissociative phenom-
ena), ego state disorders (in which changes in personality do not have the amnesia
and profound identity disturbance of DIDs), trance states, simple derealization,
dissociative states following coercive persuasion, different personality states associ-
ated with gender identity disorder, secondary dissociative disorder due to a non-
psychiatric medical condition, dissociation associated with culture-bound syn-
dromes, and so on. One of the greatest challenges for editors of future editions of
the DSM will be to obtain greater taxonomical clarity, considering that the majority
of diagnosed dissociative disorders do not fit the established criteria.
In India, Saxena and Prasad (1989) found that 90% of clinic outpatients receiv-
ing a DSM-111 dissociative diagnosis were "atypical dissociative disorder," or DDNOS.
In a very extensive study (N = 11,292) in the U.S. with general psychiatric patients,
Mezzich, Fabrega, Coffman, and Haley (1989) reported that the majority (57%) of
dissociative diagnoses were "atypical." Finally, Saxe et a!. (1993) found that within
the subgroup of general psychiatric patients reporting clinical levels of dissociation,
60% warranted a diagnosis of DDNOS.
The DSM-111-R contained some examples ofDDNOS and the following changes
have been made, as shown in Appendix 1:
1. A previous example that described identity confusion following purposeful
behavior and amnesia was deleted since it is now covered by the definition
for "dissociative fugue."
2. A description of DID in which a second identity does not assume full
control was also deleted because of the change of criteria for DID.
3. The definition of derealization was expanded to exclude these episodes
among children, since fantasy life at that age may be very prevalent and
nonpathological.
4. A thorough description of various forms of dissociative or possession phe-
nomena was included to account for the fact that these may be the most
prevalent forms of dissociation in non-Western cultures.
5. An example of loss of consciousness, stupor, or coma not attributable to a
general medical condition was added.
6. Dissociative amnesia or fugue were made superordinate to Ganser's syn-
drome (giving approximate answers to questions).

Dissociative Trance Disorder

This proposed diagnosis would include distressing or impairing alterations in
consciousness (i.e., narrowing of consciousness and stereotyped movements) or
identity (experience of possession by an external agent). In our proposal we have
236 been careful to distinguish between alterations of consciousness or identity that are
Etzel Cardeiia and prevalent in other cultures and are part of a cultural or religious practice (cf.
David Spiegel Bourguignon, 1976) and those forms of trance or possession that are not culturally
accepted and are distressing or impairing to the individual. Subsuming culture-
bound syndromes within a Western form of psychiatric nosology is not bereft of
problems (cf. Lewis-Femandez, 1992). Conversely, the lack of a specific diagnosis
for one of the most common forms of dissociative disorder in other cultures (cf.
Saxena & Prasad, 1989) and ours (Cardeii.a, 1992) may prevent development in
treatment, research, and conceptualization. We describe the rationale for and
against this proposal elsewhere (Cardeii.a et al., 1995).
Discussions of earlier revisions of the DSM have also remarked on the need for
a diagnosis similar to the one we have proposed. We hope that the inclusion of this
proposal in the appendix of DSM-IV will foster research and cross-cultural collab-
oration so that a much larger data base may be considered in future revisions of
the DSM. Appendix 1 describes the criteria for this diagnosis.

Secondary Dissociative Disorder due to a Nonpsychiatric

Medical Condition
This proposal includes dissociative symptomatology associated with a medical
condition (typically a complex partial seizure), not whether DID patients show
abnormal electroencephalograms. This new category was introduced into the
ICD-10 based on a number of studies suggesting a high number of dissociative
symptoms or disorders among complex seizure patients (e.g., Devinsky, Putnam,
Grafman, Bromfield, & Theodore, 1989; Iitwin & Cardeii.a, 1993; Ross, Heber,
Norton, & Anderson, 1989a; Schenk & Bear, 1981). In a review of this literature, we
concluded that, whereas seizure patients do not have the extent of dissociation that
DID or PTSD have, they nonetheless show a higher incidence of amnesia and
depersonalization symptoms than the nonclinical population (Cardeii.a et al., 1995).
While this proposal was not accepted, the diagnostician should be aware of the
possibility of dissociative symptomatology in seizure patients. The differential
diagnosis between psychologically based and neurologically based conditions is an
important area currently being developed (cf. Sivec & Lynn, 1995). Good (1993) has
developed the concept of an organic dissociative syndrome produced by various
drugs and medical conditions. Appendix 1 includes the proposed criteria for this
diagnosis.

COMORBIDITY

As a separate major category, the dissociative disorders can be traced back only
to the third edition of the DSM (American Psychiatric Association, 1980); reliable
and valid diagnostic instruments are even younger still. This may help explain why
few studies have evaluated the comorbidity of the dissociative disorders, partic-
ularly in conditions other than DID. Dissociative disorders are typically poly-
symptomatic, and major surveys of DID (e.g., Putnam et al., 1986; Ross et al., 1990)
have found that these patients usually receive a number of psychiatric and/or
neurological diagnoses before being classified as DID. Previous diagnoses fre-
quently included affective disorder, personality disorder, anxiety disorder, schizo- 237
phrenia, substance abuse, and others. We will concentrate on the conditions most Diagnostic Issues of
commonly associated with the dissociative disorders in general, namely depression, Dissociative
anxiety, somatization, and first-rank symptoms, with the assumption that superordi- Disorders
nate diagnoses such as DID include other dissociative symptoms (amnesia and not
uncommonly fugue, depersonalization, "going into trances," etc.). In the DID sec-
tion, we have already alluded to the conceptual and empirical overlap between
borderline personality disorder and DID, so we will not revisit the topic.

Depression and Affective Lability

Depression is the most common comorbid symptom of DID patients. Bliss
(1980) reported that 100% of his 14 DID cases reported depression, whereas in their
study with 50 DID patients, Coons et al. (1988) found that 88% were depressed,
similar to the percentage found by Putnam et a!. (1986) in their review of 100 cases
treated by different clinicians. In a study using a structured interview with 102 DID
patients in four centers, Ross et a!. (1990) reported that 91% had a concurrent
diagnosis of major depressive disorder; Martinez-Taboas (1991), in a sample of 15
Puerto Rican DID patients, found depressive symptomatology in 93%, the same
percentage that Saxe eta!. (1993) found among their highly dissociative psychiatric
inpatients. These studies explain why the most common previous diagnosis of a
DID patient is depression (about 70% for Putnam eta!., 1986) or affective disorder
(64% for Ross et al., 1989c; see also Bliss, 1984; Kluft, 1985). A cross-cultural com-
parison of DID showed a 36% concurrent diagnosis of depression and 87% inci-
dence of depressive symptomatology (Coons, Bowman, Kluft, & Milstein, 1991).
Other studies have compared the rate of depression of dissociative patients to
that of other clinical groups. While Ross et a!. (1989) did not find that a major
depressive episode differentiated a group of 20 DID patients from an equal number
of patients with schizophrenia, panic disorder, or eating: disorders, Saxe eta!. (1993)
reported that major depression was significantly more prevalent among 15 patients
with confirmed dissociative diagnoses than among a comparison group of 15 clinical
patients who reported few episodes of dissociation. In a study with 15 women
treated for incestuous abuse and 15 women treated for depression, Vohra (1991)
found that the abuse patients reported levels of depression similar to the depressive
patients, and that depression and dissociative experiences were highly correlated.
In their study with 25 amnestic patients, Coons and Milstein (1992) found that
28% had a secondary diagnosis of dysthymia and 21% of major depression. These
percentages are substantially lower than those for DID, which could be explained
by the greater prevalence of abuse among DID than among amnesia patients.
Substantially higher rates were found among patients with DDNOS: 88% with
depression in the study by Ross et al. (1992) and 84% in the study by Coons (1992),
suggesting that DDNOS is a more severe group of syndromes than dissociative
amnesia. A recent study (Coons, 1994) gathered independent corroboration for
reports of child abuse.
Labile moods, or mood swings, are also very prevalent among DID: 87%, 70%,
and 64% in the surveys conducted by Martinez-Taboas (1991), Putnam et al. (1986),
and Coons et al. (1988), respectively.
Suicidal ideation and actual suicidal attempts or self-injurious behaviors are
238 related to depressive episodes and are very prevalent among patients with dissocia-
E1Zel Cardeila and tive disorders (Ross & Norton, 1989). Suicidal ideation was found among 100% of 71
David Spiegel Dutch DID patients (Boon & Draijer, 1991) and 92% of the patients studied by Ross
et al. (1990). Dissociative patients frequently engage in self-destructive behavior
(e.g., overdoses, wrist slashing, cigarette burning) frequently associated with epi-
sodes of depersonalization or of self-injury by a sadistic alter identity. Self-mutilation
has ranged between 33 and 56% across various DID samples (Coons et al., 1988,
1991; Martinez-Taboas, 1991; Putnam et al., 1986). Among patients with DDNOS,
34% presented with self-mutilation (Coons, 1992). Actual suicide attempts were
reported by 80"...6, 72%, and 71% of the samples of Martinez-Taboas (1991), Ross and
Norton (1989), and Putnam et al. (1986), respectively.
Although depression may very well be the most common psychiatric com-
plaint, the almost universal presence of depression among the most severe dissocia-
tive disorders and the very high incidence of suicidal and parasuicidal behavior
suggest that these symptoms are sensitive markers of dissociative pathology. A likely
explanation of this pattern is the extraordinarily high incidence of various forms of
early abuse and familial chaos, particularly in the more severe syndromes, which
have effects not only on the prevalence of dissociation but on fundamental issues of
identity, trust, and self-worth (cf. Putnam et al., 1986; Ross & Norton, 1989; Saxe
et al., 1993).

Anxiety
Even though they are indexed as different categories, it is clear that some
anxiety disorders, particularly PTSD, include both anxiety and dissociative symp-
tomatology (cf. Hyer, Albrecht, Poudewyns, Woods, & Brandsma, 1993; Spiegel &
Cardeiia, 1990). We have briefly alluded to this conceptual and empirical relation-
ship when discussing the new diagnosis, acute stress disorder, whose criteria
include dissociative and anxiety reactions to traumatic events. A recent study with a
nonclinical population exposed to the 1989 San Francisco earthquake found that
somewhere between 36 and 57% of the sample shortly after the event experienced
some types of anxiety, whereas about 40% experienced some forms of derealization
or depersonalization (Cardefta & Spiegel, 1993). Another study with survivors of the
Oakland/Berkeley firestorm of 1991 shows that dissociative symptoms related to the
disaster were significantly correlated with measures related to PTSD symptomatol-
ogy, namely the Civilian Mississippi Scale and the Impact of Event Scale (r = .59
and .53, respectively) and significantly predicted PTSD at a 7-month follow-up
(Koopman, Classen, & Spiegel, 1994).
With respect to DID, Bliss (1980) found that 100"...6 of his sample had reported
anxiety symptoms, including acute anxiety attacks and palpitations. Forty-four
percent of the 236 DID patients in the study by Ross et al. (1989c) had a previous
diagnosis of anxiety disorder, whereas 81% of Boon and Draijer's (1991) sample
presented with PTSD symptomatology and 30% with anxiety disorder. Panic attacks
were present in about 55% of Putnam and colleagues' (1986) sample. These consis-
tent results show that anxiety is prevalent among the dissociative disorders, al-
though unfortunately few studies have provided specific data for the various forms
of anxiety symptomatology. Despite the current separation of the anxiety and
dissociative disorders, the fact is that traumatic and severely stressful events typ- 239
ically produce both short- and long-term anxiety and dissociative symptoms. The Diagnostic Issues of
phenomenology of the symptoms and the relationship between anxiety and disso- Dissociative
ciation require a more thorough investigation than has been the case so far. This Disorders
relationship is probably not a simple casual one. For instance, dissociation in the
sense of detaching from an event could be a way to reduce the distress produced
by a dangerous situation, as in the so-called near-death experiences. Alternately,
dissociation in the sense of the emergence of isolated distressing memory units
could be the trigger for distress and anxiety (cf. Cardefia, 1994).

Conversion
The relatively recent separation of conversion from the dissociative disorders
represents more a classification fashion than an absolute distinction between the
disorders. Both have similar underlying dissociative mechanisms and they fre-
quently co-occur. Patients with dissociative disorders frequently complain of head-
aches, unexplained pain, various forms of paresthesias and analgesias, sexual dys-
functions, and so forth (cf. Ross, Heber, Norton, & Anderson, 1989b). In fact, the
association between somatization disorder, dissociative symptoms, and history of
abuse which Janet, among others, had postulated, has been confirmed recently in a
study with 79 female psychiatric patients (Priber, Yutzi, Dean, & Wetzel, 1993).
The authors reviewed below do not always make a distinction between conver-
sion and somatization, making further clarification of this overlapping symp-
tomatology difficult. In a well-controlled study by Saxe and collaborators (1994),
64% of dissociative disorder patients also met criteria for somatization disorder as
compared with none from a matched group of psychiatric patients with few
reported dissociative symptoms.
Ross et al. (1990) found that 92% of their 102 DID patients had reported five or
more somatic symptoms. In a smaller sample of 20 DID patients compared with the
same number of eating disorder, panic disorder, and schizophrenia patients, Ross
et al. (1989b) found that the DID patients reported more somatic symptoms (some-
times significantly so) than the other patients. Somatization in DID ranged between
73 and 36% across other studies (Coons et al., 1988, 1991; Martinez-Taboas, 1991;
Putnam et al., 1986). Rates of diagnoses for somatization disorder, rather than
symptomatology, were 16, 21, and 61% in the studies of Boon and Draijer (1991),
Coons et al. (1991), and Ross et al. (1990), respectively. Coons et al. (1988) also
reported a 40% incidence of conversion in their sample. Headache is the most
common somatic symptom among DID, ranging from 55 to 100% across various
studies (Bliss, 1980; Coons et al., 1988, 1991; by Martinez-Taboas, 1991; Putnam et al,
1986; Ross et al., 1989c).
In the case of dissociative amnesia, conversion disorder was a secondary
diagnosis among 24% of patients (Coons & Milstein, 1992). Among DDNOS pa-
tients, Ross et al. (1992) reported 25% of somatization disorder, whereas Coons
(1992) found 26% of somatization, 14% of conversion symptoms, and 32% incidence
of headaches.
Sexual dysfunction is also common among dissociative patients, ranging from
50 to 84% across various samples (Coons et al., 1988; Martinez-Taboas, 1991; Putnam
240 et al., 1986; Ross et al., 1989). Coons et al. (1991) reported a secondary diagnosis of
Et:zel Cardeiia and sexual dysfunction in 50% and of symptomatology in 73% of their patients. For
David Spiegel DDNOS patients, Coons (1992) reported 48% of sexual dysfunction.
Bliss (1984) has suggested that the preponderance of somatic symptoms found
among dissociative patients may be the result of an abuse of self-hypnotic tech-
niques, since hypnotic techniques can produce a number of physiological changes
among highly hypnotizable individuals (Spiegel & Vermutten, 1994). In this context
it is of interest that DID patients, who as a group, are very hypnotizable, almost
universally complain of headaches and that the outcome of a few hypnosis induc-
tions is a headache (e.g., Hilgard, 1974). Indeed, the intensity of migraine symptoms
is positively correlated with measured hypnotizability (Andreychuk & Skriver,
1975). Clearly there is a strong link between dissociation and somatization that
requires far more attention than it has received so far.

First-Rank Symptoms
Even though Schneiderian first-rank symptoms are sometimes assumed to be
pathognomic of schizophrenia, that is clearly not the case since they are also found
in a number of other conditions (Kluft, 1987). The phenomenology of DID, involv-
ing the influence and presence of different identities, is similar to some first-rank
symptoms, and, of course, dissociative symptoms may underlie some acute psy-
chosis (Spiegel & Fink, 1979; Steingard & Frankel, 1985). However, unlike schizo-
phrenics, individuals with dissociative disorders are typically found to have an
adequate sense of reality outside of specific events such as a fugue, they typically
lack the "negative" symptoms of chronic schizophrenics, and do not respond to
neuroleptics but do respond to psychotherapy employing hypnosis (Hollender &
Hirsch, 1964; Mallet & Gold, 1964; Spiegel & Fink, 1979).
In the first systematic study of this topic, Kluft (1987) found that all 30 DID
patients presented at least one first-rank symptom (mean of 3.6 symptoms, but
excluding audible thoughts, thought diffusion or broadcasting, and delusional
perception), Boon and Draijer (1991) observed in their study that "most of the
subjects" had these symptoms, and Ross et al. (1990) reported that 90% of their
sample presented with Schneiderian symptoms. Some specific examples of first-
rank symptoms include the experience of "someone trying to influence the pa-
tient;' present in 73% of Bliss's sample (1980), and reports of "voices" ranging
from 30 to 72% across various studies (Coons et al., 1988; Martinez-Taboas, 1991;
Putnam et al., 1986; Ross et al., 1989c).
The lack of Jhis information for dissociative disorders other than DID may be
the result of a lack of inquiry into this area, or of the absence of these symptoms
among patients who have a more integrated identity than do DID patients. Nonethe-
less, more research is needed on failures of reality testing in the various dissociative
syndromes and on, conversely, the presence of dissociative symptomatology in
psychotic populations.

Substance Abuse and Eating Disorders

These disorders, although sometimes present, have been less frequently associ-
ated with dissociative pathology than other disorders reviewed here. For the DID
population, rates for drug and alcohol abuse range from 31 to 64% across various 241
samples (Boon & Draijer, 1991; Coons et al., 1988; Martinez-Taboas, 1991; Putnam Diagnostic Issues. of
et al., 1986; Ross et al., 1989c; Saxe et al., 1993). Coons et al. (1988) report a 42% Dissociative
incidence of alcohol abuse. In their cross-cultural study of DID, Coons et al. (1991) Disorders
found the same percentage (13%) for a secondary diagnosis of alcohol or substance
abuse (13%), and symptoms of alcohol abuse in 53% and of drug abuse in 27% of
their sample. Although substance abuse is present in many other conditions, the
specific function that it plays in the dissociative disorders has not been system-
atically studied.
Alcohol abuse/dependence was present in 24% and drug abuse in 20% of the
sample of 50 amnestic patients studied by Coons and Milstei,n (1992). For DDNOS
patients, substance abuse was present in 42% of Ross and co-workers' sample
(1992), and in 46% for alcohol and 16% for drug abuse in Coons' sample (1992).
Some. researchers have also pointed to previous or concurrent diagnoses of
eating disorders among dissociative disorder patients. Demitrack, Putnam, Brewer-
ton, Brandt, and Gold (1990) describe various links between dissociation and eating
disorders: reports of increased hypnotizability, particularly among bulimics (e.g.
Pettinati, Home, & Staats, 1985; Barabasz, 1990); the usefulness of hypnosis in the
treatment of these disorders; the frequent incidence of early abuse among eating-
disorder patients; the early historical association of "hysteria" and a number of
gastrointestinal and eating disturbances; the presence of dissociative states in eating
disorders patients; and, conversely, the incidence of eating disorders in dissociative
disorders patients. For instance, McCallum, Lock, Kulla, Rorty, and Wetzel (1992)
report that 29% of their patients with eating disorders also fulfilled criteria for
dissociative disorders (18% of depersonalization, 10% of DID), and that dissociation
was associated with hinging-purging or severe restrictions, sexual behavior, and
self-harm.
Reported percentages of eating disorders among DID patients include 27% of
anorexia and about 15% of bulimia in Putnam and co-workers' (1986) study and a
76% history of eating problems in the sample of Boon and Draijer (1991). Sixteen
percent of the patients in Ross and colleagues' (1989c) sample had received a
previous diagnosis of eating disorder (23% for Boon & Draijer). Finally, 20% of the
amnestic patients in Coons and Milstein's (1992) sample presented with bulimia.
Nonetheless, these relationships are probably more complex than originally
thought. For instance, Greenes, Fava, Cioffi, and Herzog (1993) found in a clinical
sample that the relationship between bulimia and dissociation is confounded by the
relationship between dissociation and depression. Also, in a recent review of the
literature, Pope, Mangweth, Negrao, Hudson, and Cordas (1994) found no consis-
tent evidence for a link between abuse and bulimia. Thus, reported correlations
between eating disorders and dissociation may be mediated by other factors.

CONCLUSION

The various changes in criteria for previous dissociative disorders and the
proposal for new diagnostic entities represent a developing view of dissociative
psychopathology. The rather recent history of these disorders as an independent
category and the various changes and reconceptualizations made so far show an
242 evolving and far from complete perspective on dissociation. Many basic questions
Etzel Cardeiia and remain, among them: What differentiates normal from dysfunctional dissociation?
David Spiegel Why do some traumatized individuals develop dissociative pathology while others
develop different or no pathology? Why do some pathologies co-occur with the
dissociative disorders while others are rarely encountered?
Some major tasks to be accomplished in the following years include develop-
ing a more precise phenomenology and neurophysiology of these disorders, elu-
cidating the cultural variants of normal and pathological dissociation, and establish-
ing a clear theoretical and empirical basis to study the relationship between
dissociative phenomena and other related disorders such as depression, anxiety,
conversion, substance abuse, and eating disorders.

APPENDIX

DSM-IV DSM-III-R

Dissociative amnesia Psychogenic amnesia

A. The predominant disturbance is one or A. The predominant disturbance is an epi-
more episodes of inability to recall im- sode of sudden inability to recall impor-
portant personal information, usually of tant personal information that is too
a traumatic or stressful nature, that is extensive to be explained by ordinary
too extensive to be explained by ordi- forgetfulness
nary forgetfulness. B. The disturbance is not due to Multiple
B. The disrurbance does not occur exclu- Personality Disorder or to an Organic
sively during the course of Dissociative Mental Disorder (e.g., blackouts during
Identity Disorder, Dissociative Fugue, Alcohol Intoxication).
Posttraumatic Stress Disorder, Acute
Stress Disorder, or Somatization Disor-
der and is not due to the direct physio-
logical effects of a substance (e.g., a
drug of abuse, medication) or a neuro-
logical or other general medical condi-
tion (e.g., Amnestic Disorder due to
Head Trauma).
C. The symptoms cause clincally signifi-
cant distress or impairment in social,
occupational, or other important areas
of functioning.

Dissociative fugue Psychogenic fugue

A. The predominant disturbance is sud- A. The predominant disturbance is sud-
den, unexpected travel away from den, unexpected travel away from
home or one's customary place of home or one's customary place of
work, with inability to recall one's past. work, with inability to recall one's past
B. Confusion about personal identity or B. Assumption of a new identity (partial
assumption of a new identity (partial or or complete).
complete).
C. The disturbance does not occur exclu- C. The disturbance is not due to Multiple 243
sively during the course of Dissociative Personality Disorder or to an Organic
Diagnostic Issues of
Identity Disorder, and is not due to the Mental Disorder (e.g., partial complex Dissociative
direct physiological effects of a sub- seizures in temporal lobe epilepsy). Disorders
stance (e.g., a drug of abuse, a medica-
tion) or a general medical condition
(e.g., temporal lobe epilepsy).
D. The symptoms cause clincally signifi-
cant distress or impairment in social,
occupational, or other important areas
of functioning.

Dissociative Identity disorder Multiple personality disorder

A. The presence of two or more distinct A. The existence within the person of two
identities or personality states (each or more distinct personalities or per-
with its own relatively enduring pattern sonality states (each with its own rela-
of perceiving, relating to, and thinking tively enduring pattern of perceiving,
about the environment and self). relating to, and thinking about the envi-
B. At least two of these identities or per- ronment and self).
sonality states recurrently take control B. At least two of these personalities or
of the person's behavior. personality states recurrently take full
C. Inability to recall important personal in- control of the person's behavior.
formation that is too extensive to be
explained by ordinary forgetfulness
D. The disturbance is not due to the di-
rect physiological effects of a substance
(e.g., blackouts or chaotic behavior dur-
ing Alcohol Intoxication) or a general
medical condition (e.g., complex par-
tial seizures). NOTE: In children, the
symptoms are not attributable to imag-
inary playmates or other fantasy play.

Depersonalization dtsorder Depersonalization disorder

A. Persistent or rcurrent experiences of A. Persistent or recurrent experiences of
feeling detached from, and as if one is depersonalization as indicated by either
an outside observer of, one's mental (1) or (2):
processes or body (e.g., feeling like one (1) an experience of feeling detached
is in a dream). from, and as if one is an outside
B. During the depersonalization experi- obsever of, one's mental processes
ence, reality testing remains intact. or body
C. The depersonalization causes significant (2) an experience of feeling like an au-
impairment in social, occupational, or tomaton or as if in a dream
other important areas of functioning. B. During the depersonalization experi-
D. The depersonalization experience does ence, reality testing remains intact.
not occur exclusively during the course C. The depersonalization is sufficiently se-
of another mental disorder, such as vere and persistent to cause marked
Schizophrenia, Panic Disorder, Acute distress.
Stress Disorder, or another Dissociative D. The depersonalization experience is
Disorder, and is not due to the direct the predominant disturbance and is not
244 physiological effects of a substance a symptom of another disorder, such as
(e.g., a drug of abuse, a medication) or Schizophrenia, Panic Disorder, or
Etzel Cardeiia and
David Spiegel a general medical condition (e.g., tem- Agoraphobia without History of Panic
poral lobe epilepsy). Disorder but with limited symptom at-
tacks of depersonalization, or temporal
lobe epilepsy.

Dissociative disorders not otherwise Dissociative disorders not otherwise

specified specified
This category is included for disorders in Disorders in which the predominant
which the predominant feature is a feature is a dissociative symptom (i.e., a
dissociative symptom (i.e., a disruption in disturbance or alteration in the normally
the usually integrated functions of integrative functions of identity, memory,
consciousness, memory, identity, or or consciousness) that does not meet the
perception of the environment) that does criteria for a specific Dissociative Disorder.
not meet the criteria for a specific Examples:
Dissociative Disorder. Examples include: (1) Ganser's syndrome: the giving of
(1) Clinical presentations similar to "approximate answers" to question,
Dissociative Identity Disorder that fail commonly associated with other
to meet full criteria for this disorder. symptoms such as amnesia,
Examples include presentations in disorientation, perceptual disturbance,
which: fugue, and conversion symptoms
(a) there are not two or more distinct (2) Cases in which there is more than one
personality states, or personality state capable of assuming
(b) amnesia for important personal executive control of the individual, but
infortnation does not occur. not more than one personality state is
(2) Derealization unaccompanied by sufficiently distinct to meet the full
depersonalization in adults. criteria for Multiple Personality
(3) States of dissociation that occur in Disorder, or cases in which a second
individuals who have been subjected personality never assumes complete
to periods of prolonged and intense executive control
coercive persuasion (e.g., (3) Trance states, i.e., altered states of
brainwashing, thought reform, or consciousness with markedly
indoctrination while captive). diminished or selectively focused
(4) Dissociative trance disorder: single or responsiveness to environmental
episodic disturbances in the state of stimuli. In children this may occur
consciousness, identity or memory following physical abuse or trauma
that are indigenous to particular ( 4) Derealization unaccompanied by
locations and cultures. Dissociative depersonalization
trance involves narrowing of (5) Dissociated states that may occur in
awareness of immediate surroundings people who have been subjected to
or stereotyped behaviors or periods of prolonged and intense coer-
movements that are experienced as cive persuasion (e.g., brainwashing,
being beyond one's control. Possession thought reform, or indoctrination while
trance involves replacement of the the captive of terrorists or cultists)
customary sense of personal identity (6) Cases in which sudden, unexpected
by a new identity, attributed to the travel and organized, purposeful be-
influence of a spirit, power, deity, or havior with inability to recall one's
other person, and associated with past are not accompanied by the as-
stereotyped "involuntary" movements sumption of a new identity, partial or
or amnesia. Examples include amok complete.
 (Indonesia), bebatnan (Indonesia), 245
latah (Malaysia), pibloktoq (Artie), ata-
Diagnostic Issues of
que de nervios (Latin America), and Dlssoclative
possession (India). The dissociative or Disorders
trance disorder is not a normal part of
a broadly accepted collective cultural
or religious practice.
(5) Loss of consciousness, stupor, or coma
not attributable to a general medical
condition.
(6) Ganser's syndrome: the giving of ap-
proximate answers to questions (e.g.,
"2 plus 2 equals 5") when not associ-
ated with Dissociative Amnesia or Dis-
sociative Fugue.

Dissociative Trance Disorder

Possession and trance states are common and normal components of religious
and other ceremonies in many cultures. However, Dissociative Trance Disorder
(leading to distress and dysfunction) is also the most common dissociative disorder
reported in non-Western culture. DSM-m mentioned trancelike states as an example
of Atypical Dissociative Disorder. DSM-m-R expanded the example and provided a
definition of trance. ICD-10 has included a new category, Dissociative Trance
Disorders, within the Dissociative Disorders.
A. Either (1) or (2):
(1) trance, i.e., temporary marked alteration in the state of consciousness
or loss of customary sense of personal identity, without replacement by
an alternate identity, associated with at least one of the following:
(a) narrowing of awareness of immediate surroundings, or unusually
narrow and selective focusing on environmental stimuli
(b) stereotyped behaviors or movements that are experienced as being
beyond one's control
(2) possession trance, i.e., a single or episodic alteration in the state of
consciousness, characterized by the replacement of (the) customary
sense of personal identity by a new identity. This is attributed to the
influence of a spirit, power, deity or other person, as evidenced by one
(or more) of the following:
(a) stereotyped and culturally determined behaviors or movements
that are experienced as being controlled by the possessing agent
(b) full or partial amnesia for the event
B. The trance or possession state is not a normal part of a clinically collective
cultural or religious practice.
C. The trance or possession state causes clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning.
D. The trance or possession state does not occur exclusively during the course
of a Psychotic Disorder (including Mood Disorder with Psychotic Features
and Brief Reactive Psychosis) or Dissociative Identity Disorder, and is not
246 due to the direct physiological effects of a substance or general medical
Etzel Cardena and condition.
David Spiegel

Secondary Dissociative Disorder due to a Nonpsychiatrlc

Medical Condition
This category has been proposed but not accepted for DSM-IV and is included
in ICD-10. It is supported by studies that suggest an elevated prevalence of dissocia-
tive symptoms in individuals with complex partial seizures and that dissociative
symptoms accompanying complex partial seizures are not associated with a history
of physical and sexual trauma.
A. Amnesia, fugue, depersonalization, derealization, or other dissociative
symptoms.
B. There is evidence from the history, physical examination, or laboratory
findings that a general medical condition (e.g., complex partial seizure or
drug toxicity) is etiologically related to the dissociative symptoms.
C. The dissociative symptoms cause significant impairment in social or occu-
pational functioning, or cause marked distress.
D. Does not meet criteria for a secondary Cognitive Impairment Disorder (i.e.,
due to a general medical condition).

Acute Stress Disorder

This is a proposed new diagnosis, parallel to one included in ICD-10 (as "Acute
Stress Reaction"), which may help to describe cases that do not meet the criteria for
Posttraumatic Stress Disorder (because of differences in onset, duration, and symp-
tom presentation) and are more specific and severe than Adjustment Disorder.
A. The person has been exposed to a traumatic event in which both of the
following have been present:
(1) the person has experienced, witnessed, or been confronted with an
event or events that involve actual or threatened death or serious injury,
or a threat to the physical integrity of oneself or others.
(2) the person's response involved intense fear, helplessness, or horror.
B. Either while experiencing, or immediately after experiencing, the distress-
ing event, the individual has at least three of the following dissociative
symptoms:
(1) subjective sense of numbing, detachment, or absence of emotional
responsiveness
(2) a reduction in awareness of one's surroundings (e.g., "being in a daze")
(3) derealization
(4) depersonalization
(5) dissociative amnesia, ie., inability to recall an important aspect of the
trauma
C. The traumatic event is persistently reexperienced in at least one of the
following ways: recurrent images, thoughts, dreams, illusions, flashback
 episodes, or a sense of reliving the experience; or distress upon exposure to 247
reminders of the traumatic event. Diagnostic Issues of
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., Dissociative
thoughts, feelings, conversations, activities, places or people) Disorders
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping,
irritability, poor concentration, hypervigilance, exaggerated startle re-
sponse, and motor restlessness.
F. The disturbance causes clinically significant distress or impairment in so-
cial, occupational, or other important areas of functioning, or the individual
is prevented from pursuing some necessary task, such as obtaining neces-
sary medical or legal assistance or mobilizing personal resources by telling
family members about the traumatic experience.
G. The symptoms last for a minimum of two days and a maximum of four
weeks and occur within four weeks of the traumatic event.
H. Not due to the direct effects of a substance (e.g., drugs of abuse, medica-
tion) or a general medical condition, and is not merely an exacerbation of a
preexisting Axis I or Axis II disorder.

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12
The Psychological Assessment
of Dissociation
Marlene Steinberg

INTRODUCTION

The five dissociative disorders included in the Diagnostic and Statistical Manual
ofMental Disorders, 4th Edition (DSM-IV) [dissociative amnesia, dissociative fugue,
depersonalization disorder, dissociative identity disorder (multiple personality dis-
order), and dissociative disorder not otherwise specified (DDNOS)] are charac-
terized by disturbances in the integrative functions of memory, consciousness, and/
or identity (American Psychiatric Association, 1994). In recent years, mental health
professionals and researchers have found that dissociative disorders occur fre-
quently in psychiatric patients, and comprise as much as 10% of inpatient psychi-
atric populations (Bliss & Jeppsen, 1985). Moderate-to-severe dissociative symp-
toms are also common in patients with other psychiatric disorders, particularly the
anxiety disorders (including posttraumatic stress disorder), mood disorders, eating
disorders, and borderline personality disorder (Coons, 1984; Fink, 1991; Horevitz &
Braun, 1984; Kluft, 1987c; Putnam, Guroff, Silberman, Barban, & Post, 1986;
Schultz, Braun, & Kluft, 1989; Torem, 1986; Steinberg, 1995).
Despite growing recognition of the prevalence of dissociative symptoms, they
are often overlooked because of their intrinsic complexity and multiform presenta-
tion. Severe dissociation is recognized as being a posttraumatic defense mechanism
(Chu & Dill, 1990; Coons, Cole, Pellow, & Milstein, 1990; Kluft, 1987a; Wtlbur,
1984); a patient may be unaware of his or her dissociative symptoms as well as of the

Marlene Steinberg • Department of Psychiatry, Yale University School of Medicine, New Haven,
Connecticut 06510.
Handbook of Dissociation: Tbeoretlcal, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 251
252 memories of the traumatic event(s) (Coons, 1984; Edwards & Angus, 1972; Kluft,
Marlene Steinberg 1984a, 1991; Steinberg, 1991, 1995). In addition, the occurrence of hallucinations
and affective lability in patients with undetected dissociative disorders has led to
misdiagnoses of schizophrenia, affective disorder, and borderline personality disor-
der (Bliss, 1986; Clary, Burstin, & Carpenter, 1984; Coons, 1984; Horevitz & Braun,
1984; Kluft, 1984a, 1987c; Marcum, Wright, & Bissell, 1985; Putnam et al., 1984;
Putnam et al., 1986; Rosenbaum, 1980). Patients with undetected dissociative symp-
toms often remain misdiagnosed and improperly treated (Coons, Bowman, &
Milstein, 1988; Kluft, 1984b, 1991). Conversely, such patients who are properly
diagnosed usually respond well to appropriate treatment (Coons, 1986; Kluft,
1984b, 1991). In fact, the dissociative disorders are one of the few categories
of psychiatric illness for which a record of success with appropriate therapy is
developing (Spiegel, 1993). The recent development of reliable diagnostic instru-
ments, such as the Structured Clinical Interview for DSM-IV Dissociative Disorders
(SCID-D) (Steinberg, 1993b), allows for effective early identification and proper
treatment of patients with dissociative disorders.
This chapter offers an overview of testing methods available for the assessment
and diagnosis of dissociative symptoms and disorders. It will summarize the results
of both screening and diagnostic measures of dissociation and discuss the charac-
teristic profiles of patients with dissociative disorders on standard psychological
measurements such as the Minnesota Multiphasic Personality Inventory (MMPI).
The use of standard measurement techniques allows for reliable diagnoses of
dissociative symptoms and disorders. Moreover, specialized interviews such as the
SCID-D (Steinberg, 1993b) can facilitate the training of clinicians in the accurate
assessment of dissociative symptomatology.

DIAGNOSTIC INSTRUMENTS AND SYSTEMATIC ASSESSMENT OF

GENERAL PSYCHOPATHOLOGY

The introduction of standardized criteria and structured assessment tools has

raised the level of diagnostic accuracy for major disorders, in both clinical and
research settings (Endicott & Spitzer, 1978; Endicott et al., 1976; Helzer et al., 1977;
Maier, Phillipp, & Buller, 1988; Robins, Helzer, Croughan, & Ratcliff, 1981; Spitzer,
Williams, Gibbon, & First, 1990). Both structured diagnostic instruments and symp-
tom screeners enhance the validity of diagnostic procedures by limiting variability
between interviews, focusing inquiry on diagnostically discriminating features, and
insuring the analysis of a broader range of psychiatric issues (MacKinnon &
Yudofsky, 1986; Spitzer, 1983).
A variety of instruments are currently used in general psychiatric assessment.
These tools are based on criteria derived from several sources, including DSM
(American Psychiatric Association, 1987; Spitzer et al., 1990), Research Diagnostic
Criteria (Spitzer, Endicott, & Robins, 1978; Endicott & Spitzer, 1978; Robins et al.,
1981), and the International Classification of Diseases (lCD) (Garcia, 1990; Spitzer,
Williams, Gibbon, & First, 1992). The Present State Examination (PSE) (Wing, Birley,
Cooper, Graham, & Isaacs, 1967), and the National Institutes of Mental Health
Diagnostic Interview Schedule (DIS) (Robins et al., 1981) are structured interviews
with rating scales that make computerized diagnoses. The DIS was the first instru- 253
ment to incorporate DSM-III's comprehensive nosology (American Psychiatric As- Psychological
sociation, 1980). It is highly structured, allowing for use by nonclinician inter- Assessment of
viewers. The Structured Clinical Interview for DSM-111-R Dissociative Disorders Dlssocladon
(SCID) (Spitzer et al., 1990) is an open-ended structured clinical interview based on
DSM-III-R criteria, requiring the interviewer to draw on clinical judgment through-
out. The SCID was designed to be administered by experienced clinicians trained to
ask appropriate probing questions (Spitzer et al., 1992).
Although these instruments have increased the reliability of general psychi-
atric diagnosis, none of them are specifically designed for the diagnosis of dissocia-
tive symptoms or disorders. As a result, patients with dissociative disorders may be
diagnosed as suffering from schizophrenia or mood disorder, particularly when
questions for the dissociative disorders are omitted and/or questions worded to
include dissociative symptoms are included in subscales that score for nondissocia-
tive disorders.

ASSESSMENT OF DISSOCIATIVE DISORDERS

Self-Administered Screening Tools for Dissociative Symptoms

Self-administered instruments are time-efficient screening tools; they are there-
fore useful in studies involving large patient samples or several questionnaires.
Patients suspected of having dissociative disorders may then be followed up with a
confirmatory diagnostic interview. The disadvantages of self-administered instru-
ments include their limited scope, their tendency to result in false negatives in
patients unaware of their symptoms or unmotivated/aversive to symptom dis-
closure (MacKinnon & Yudofsky, 1986), and their high susceptibility to malingering
of dissociative symptoms (Gilbertson et al., 1992).

DepersonaUzation Questionnaires. Prior to the last decade, a variety of

questionnaires were designed exclusively for the measurement of depersonaliza-
tion. These questionnaires provided the basis for descriptive papers on the inci-
dence of depersonalization in college populations (Dixon, 1963; Myers & Grant,
1972; Roberts, 1960), psychiatric patients (Brauer, Harrow, & Tucker, 1970), and
survivors of life-threatening trauma (Noyes & Kletti, 1977; Noyes et al., 1977). These
instruments are highly structured, have not been tested on different clinical popula-
tions, and have not been evaluated in terms of their psychometric properties.
Nonetheless these questionnaires have provided important descriptive information
regarding the symptom of depersonalization.

The Dissociative Experiences Scale. The Dissociative Experiences Scale

(DES) (Bernstein & Putnam, 1986) is a self-administered dissociative experience
screener, consisting of 28 items rated with a visual analogue scale. The subject
marks a point on a line between two extremes (0 and 100%), according to the
frequency of the experience, yielding a total DES score between 0 and 100, which
represents an average of the scores for all28 items. A second version of the DES asks
254 the subject to circle a frequency percentage from 0 to 100%, spaced at 10% intervals.
Marlene Steinberg Subjects are instructed to report only those experiences that occur without the use
of drugs or alcohol.
Factor analysis yielded five categories of dissociation: amnestic dissociation,
depersonalization, derealization, absorption (preoccupation with a particular activ-
ity), and imaginative involvement (Carlson et al., 1991). Good test-retest and
internal reliability have been shown for the DES (Bernstein & Putnam, 1986;
Frischholz, 1985; Frischholz et al., 1990; Strick & Wilcoxon, 1991). Good conver-
gent and discriminant validity with respect to other measures were also found in a
number of other. studies (Bernstein & Putnam, 1986; Branscomb, 1991; Frischholz
et al., 1991; Nadon, Hoyt, Register, & Kihlstrom, 1991). Steinberg, Rounsaville, and
Cicchetti (1991) recommend the use of a DES cutoff of 15 to 20 when screening for
individuals suspected of having a dissociative disorder. Subjects with scores of
greater than 15 should then be followed up with a confirmatory diagnostic tool such
as the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D)
(Steinberg 1994a).
A number of researchers have pinpointed several limitations of the DES. In a
study of 100 substance abusers (Ross et al., 1992), the DES failed to discriminate
between patients with comorbid dissociative disorders and patients without disso-
ciative disorders. A factor analytic study of 507 undergraduates given the DES and
Perceptual Alteration Scale (PAS) (Fischer & Elnitsky, 1990) found different princi-
pal factors for each scale (PAS: disturbance in affect control; DES: disturbance in
cognition control), indicating that neither tool assesses dissociation in its entirety.
Last, studies by Antens et al. (1991) and Gilbertson et al. (1992) indicate that the
DES, as well as the PAS and the Questionnaire of Experiences of Dissociation, is
susceptible to malingerers: "all of these scales are very transparent to individuals
taking the test and thus are easily faked in either direction• (North et al., 1993,
p. 104).

The Perceptual Alteration Scale. The Perceptual Alteration Scale (PAS)

(Sanders, 1986) assesses dissociative symptoms using items adapted from the MMPI
(Hathaway & McKinley, 1970), selected on the basis of Hilgard's (1984) conceptual-
ization of neo-dissociation. This self-administered, 60-item questionnaire contains
likert scale ratings ranging from 1 to 4. The PAS was used to discriminate between a
sample of binge eaters and control subjects (N = 114, t = 5.12), finding higher
severity and frequency of PAS items in binge eaters than in normal subjects. The PAS
has reported limited data on reliability and validity, and its clinical usefulness
requires further exploration.

The Questionnaire of Experiences of Dissociation. The Questionnaire

of Experiences of Dissociation (QED) (Riley, 1988) contains 26 true-false items
related to a variety of dissociative phenomena. The items on the QED are simply
worded for ease of understanding. With a sample of over 1200 subjects, the QED
reported a reliability of .77, and discriminated between control subjects and pa-
tients with sotnatization disorder (N = 21) and multiple personality disorder (MPD)
(N = 3). Eleven items indicate dissociative psychopathology when marked true, and
half indicate the presence of dissociation when marked false. The QED's simple
one-page format allows for rapid screening for dissociative symptoms. Further 255
research is recommended using the QED on a variety of patient populations. Psychological
Assessment of
Dlssoclation
OTHER TOOLS NOT SPECIFIC TO DISSOCIATIVE DISORDERS

The Dissociative Disorders Interview Schedule

The Dissociative Disorders Interview Schedule (DDIS) (Ross et al., 1989a) is a
highly structured interview developed to diagnose the presence of dissociative
disorders, as well as major depression, borderline personality, and somatization
disorder. Though some studies have suggested that the DDIS has shown good
interrater reliability and sensitivity (Ross, Heber, Norton, & Anderson, 1989b),
others indicate poorer results (Ross et al., 1989a). The limitations of the DDIS
include its highly structured format, which incorporates only one item for each
DSM criterion, resulting in diagnoses that hinge on a "yes" response to only a few
items. Furthermore, many items in the DDIS are not diagnostic of the dissociative
disorders (e.g., items related to somatization disorder, major depression, and bor-
derline personality), and can be reliably evaluated by existing tools such as the
Structured Clinical Interview for DSM-III-R (Spitzer et al., 1990). Clinicians and
researchers should also note the limited utility of the DDIS in identifying dissocia-
tive disorders in the chemically dependent population.

Nonspecific Tests Used in Psychological Assessment

(Not Diagnostic for Dissociative Disorders)
Administration of standard psychological tests to patients with dissociative and
nondissociative disorders has proved to be inadequate in detecting the presence of
MPD or other dissociative disorders (North et al., 1993). Such tests may be useful in
providing relevant information about the subject's personalities once the MPD
diagnosis has otherwise been made, and may be helpful to the clinician in determin-
ing the presence and nature of other forms of psychopathology that may coexist
with dissociative disorders (Armstrong, 1991). But dependence on standard psycho-
logical tests (i.e., MMPI, Rorschach) to diagnose dissociative disorders has often led
to tragic cases of misdiagnosis (Hall, 1989).
Patients with DID have been frequently misdiagnosed as schizophrenics on the
basis of their MMPI responses (Bliss, 1984; Coons & Sterne, 1986; Solomon, 1983).
These misdiagnoses occur because the MMPI includes dissociative symptoms such
as amnesia on the schizophrenia scale. North et al. (1993) likewise conclude that
administration of the MMPI may be useful to clinicians in evaluating the severity and
nature of the co-ordinate or subordinate diagnoses of patients with polysymp-
tomatic/polysyndromic disorders, but not in diagnosing the presence of DID as
such.
Conllicting results have also emerged from the use of the Rorschach on
patients with dissociative identity disorder. North et al. (1993) assert that "the
Rorschach is unlikely to be a good screening instrument for detecting currently
undiagnosed cases of MPD" (p. 1o6).
256 Finally, intelligence testing of patients with DID has yielded mixed results.
Marlene Steinberg While some researchers have reported similar IQs across personalities (Berman,
1973; Ludwig, Brandsma, Wllbur, Benfeldt, &Jameson, 1972), others have observed
differences in scores (Ohberg, 1984). North et al. (1993) report that nonstandard
intelligence examinations may be required in order to obtain the best estimate of a
dissociative patient's true abilities, but, "as a group, patients with DID do not
appear to have significant cognitive or neuropsychological deficits on the tests
described to this point" (p. 74).

Diagnostic Tools Specific to Dissociative Disorders:

The Stnlctured Clinical Interview for DSM-IV Dissociative
Disorders (SCID-D) Interview
In order to fill the gap left by general diagnostic instruments, the SCID-D
(Steinberg, 1993b, 1994b) was developed to assess dissociative symptoms and
disorders. This instrument has proven useful in studying the phenomenology, of
dissociative symptoms, and comorbidity with nondissociative symptoms and disor-
ders, and is widely recognized as a standard in the field of diagnosis and assessment
of dissociative symptoms and disorders. The use of the SCID-D, which has under-
gone rigorous field-testing for reliability and validity has improved diagnostic accu-
racy with regard to dissociative disturbances, and has allowed for clinical investiga-
tions of the phenomenology and prevalence of dissociative symptoms and
disorders. This semistructured clinical interview comprehensively assesses five
specific dissociative symptoms and makes diagnoses of the dissociative disorders
based on DSM-IV criteria. The SCID-D's structure is based on the format of the
Structured Clinical Interview for DSM-ffi-R (SCID; Spitzer et al., 1990); it uses open-
ended questions and embeds DSM-IV criteria throughout the interview. Guidelines
for the administration, scoring, and interpretation of the SCID-D are described in
the Interviewer's Guide to the SCID-D (Steinberg, 1993a, 1994a).
The SCID-D systematically evaluates the presence and severity of five core
dissociative symptoms (amnesia, depersonalization, derealization, identity confu-
sion, and identity alteration) (Steinberg, 1994b, 1994c); and allows the interviewer
to make DSM-IV diagnoses of dissociative amnesia, dissociative fugue, depersonali-
zation disorder, dissociative identity disorder (multiple personality disorder), and
dissociative disorder not otherwise specified (DDNOS). Disorders newly proposed
in DSM-IV consisting of predominantly dissociative symptoms, including acute
dissociative (stress) disorder and possession trance disorder (in the DSM-IV appen-
dix) can also be assessed with the SCID-D (see Spiegel & Cardeiia, 1991; Steinberg,
1994a).

Development and Field Trials of the SCID-D. Good-to-excellent re-

liability and discriminant validity were reported for the SCID-D with respect to the
five dissociative symptoms and the dissociative disorders, on the basis of over 400
administrations of the instrument (Steinberg, Rounsaville, & Cicchetti, 1990; Stein-
berg, Cicchetti, Buchanan, Hall, & Rounsaville, 1989-1992). These results were
replicated by researchers at Harvard (Goff, Olin, Jenike, Baer, & Buttolph, 1992) and
in the Netherlands (Boon & Draijer, 1991). Preliminary results regarding SCID-D
psychometrics led to the award of an National Institute of Mental Health grant to 257
field-test the instrument (Steinberg et al., 1989-1992). The SCID-D was field-tested Psychological
on 140 patients with a variety of psychiatric disorders, including the affective, Assessment of
psychotic, anxiety, substance abuse, and personality disorders. SCID-D interviews Dissociation
were rated by two of five interviewers blind to the referring clinician's diagnosis.
Each subject was given two interviews with 1-week interval, and 50 were given a
third interview at 6-month follow-up. Analysis of the results of this field testing has
indicated good-to-excellent reliability and validity for dissociative symptoms and
disorders (Steinberg et al., 1989 -1992). In addition, multicenter field trials of the
SCID-D have been completed with expert researchers at four sites: in Philadelphia
(Drs. Kluft, Fine, and Fink); Indianapolis (Drs. Coons and Bowman); Summit, New
Jersey (Dr. Pamela Hall); and New Haven (Drs. Steinberg, Rounsaville, and Cic-
chetti) (Steinberg et al., 1989-1993). SCID-D interviews were performed at each of
the four sites and then corated by experts at the other sites. Preliminary analysis
(based on results from three of the four sites) continues to indicate good-to-
excellent interrater reliability for each of the five dissociative symptoms as well as
the diagnosis of the dissociative disorders. In addition, the SCID-D interview was
able to distinguish between patients with dissociative disorders, patients with
substance abuse disorders, and those with substance abuse disorder and a coexist-
ing dissociative disorder.

Format of the SCID-D. The SCID-D's semistructured format and use of

diagnostically discriminating questions allows for a clinically rich interview in
which interviewers are encouraged to add unscripted follow-up questions that
clarify or elaborate the subject's response.
The SCID-D is divided into five major sections, one for each of the five
dissociative symptoms. In addition, the instrument includes questions related to
associated features of identity disturbance, follow-up sections on identity confusion
and alteration, and intrainterview dissociative cues. DSM-N criteria are embedded
throughout the interview. Each DSM-N criterion is assessed with a series of ques-
tions that follow a preliminary screening question. Exclusionary factors for these
disorders (for medical illness, alcohol and drug use) are assessed within each
dissociative symptom section.
Due to the complexity and subtlety of dissociative identity disturbances, they
are further assessed in follow-up sections on identity confusion and alteration.
Follow-up sections are administered at the interviewer's discretion to subjects who
have endorsed significant dissociative symptoms. One or two of these modules may
be administered. A series of questions assess the degree of volition and distinctness
of personality states, drawing on patients' own terminology for their altered state(s)
of identity. The completion of this section allows the rater to determine whether
the subject's symptoms meet DSM-N criteria for multiple personality disorder and
DDNOS. After the interview, the rater records the five symptom severities and
dissociative disorder diagnosis on the summary score sheet, which records this
summary information in a visually concise form.
Throughout the SCID-D interview, responses to each item are recorded with
the following codes: ? =unclear, 1 =absent, 3 =present, 4 =inconsistent informa-
tion. A rating of 4 is given when a subject provides contradictory responses to a
question, which may occur in patients with significant identity confusion. A rating
258 of "?" is often given when patients are amnestic for information that is being
Marlene Steinberg assessed (which frequently occurs in patients with dissociative disorders). Descrip-
tive responses to open-ended inquiries are recorded in the space provided.
Severity rating definitions are provided in the Interviewer's Guide (Steinberg,
1993a) and allow the interviewer to determine symptom severity based on the
subject's responses to each section of the SCID-D. The severity of each dissociative
symptom is assessed through questions concerning the frequency, duration, dis-
tress, and dysfunction associated with each dissociative experience. Severity rating
codes are 1 = none, 2 = mild, 4 = moderate, and 5 = severe. A subject receives a
score from 1 to 5 for each of the five dissociative symptoms and also receives a total
score for all the symptoms ranging from 5 to 20.
All scores are recorded on a summary score sheet, which is intended to be filed
with the patient's records. The score sheet (together with the patient's responses as
recorded by the examiner in the SCID-D booklet) can be admitted as courtroom
evidence in forensic contexts. These records, when accurately scored and inter-
preted, offer the clinician documentary protection against potential allegations of
iatrogenic symptom production. In addition, these symptom profiles can be repre-
sented iconically on a SCID-D symptom profile graph, as demonstrated by the
characteristic profiles of patients with dissociative and nondissociative disorders
(see Figures 12.1 and 12.2).

Features of the SCID-D's Semistructured Interview Format. Numerous

authors have remarked on the benefits of semistructured interviews in improving
the reliability, validity, and richness of a psychiatric assessment (Cicchetti & Tyler,
1988; Endicott & Spitzer, 1978; Endicott et al., 1976; Helzer et al., 1977; MacKinnon
& Yudofsky, 1986; Maier et al., 1988; Robins et al., 1981; Saghir, 1971; Spitzer, 1983;
Spitzer et al., 1990). Semistructured interviews "enhance both the reliability and
validity of a respondent's information about a given subject . . . [providing] more
accurate descriptions than might be possible with other modes of test administra-
tion" (Cicchetti & Tyler, 1988). This is accomplished by balancing unstructured
features, such as open-ended responses and rapport, with structured features, such
as operationalized rating scales and interview instructions. According to Anastasi
(1976), such a design can "provide a rich harvest of leads for further exploration ...
permit[ting] more flexibility of search and more effective utilization of cues than
would be possible with a test, questionnaire, or other standardized procedure" (pp.
464, 484). The advantages of structured or setnistructured interviews over highly
structured checklists have been described by a number of authors (Anastasi, 1976;
Maier et al., 1988; Robins et al., 1981; Saghir, 1971). Whereas highly structured
interviews require the clinician to take a yes-no response at face value, SCID-D
interviewers can evaluate the descriptions offered by patients for each endorsed
symptom. This flexibility also permits clinicians to consider the intent of a response
rather than merely its face value conformity to a question (Spitzer, 1983). The SCID-
D's format also allows for exploration of the complexities and interconnections of
dissociative symptomatology. For example, patients may volunteer material sugges-
tive of the presence of identity confusion or identity alteration during earlier
portions of the interview. The SCID-D allows the interviewer to follow up on
specific descriptions of symptoms in order to clarify the existence of identity
confusion or alteration.
 259
Psychological
Assessment of
-(3) Dissociation

Mld(2)

Nane(1)

-(4)

-(3)

Mild (2)

Nane(1)

Dlpe...olllllzatlan dl.....

Multiple pei8CIIIIIIIIy d*'"ler (IIPD) and d'-IIIM d*'"ler not

at11erw18e ..-c1f1ec1 (DDNOS)
-(4)

------~~~~~--------------- D~
----:-
-(3)

Mlld(2)

Nane(1)

Figure 1 SCID-D symptom profiles of the dissociative disorders. Interviewer's Guide to the Struetured
Cltntcal Interview for DSM-IV Dtssoctattve Disorders. Reprinted with permission from M. Steinberg
(SCII)-D, Revised). Copyright 1994 American Psychiatric Press.
260
Marlene Steinberg

Amnesia Deperaonallzation Derealization Identity confusion Identity al18ralion

I -+- Dluoclallve disorders ---- Nondlssoclallw disorders -+-No psychiatric illneas I

Figure 2 SCJD.D dissociative symptom profiles for patients with dissociative disorders, patients with
nondissociative disorders, and subjects without psychiatric illness. Interviewer's Guide to the Struc-
tured Clinical Interview for DSM-IV Dissociative Disorders. Reprinted with permission from M.
Steinberg (SCJD.D, Revised). Copyright 1994 American Psychiatric Press.

Moreover, semistructured interviews such as the SCID and SCID-D allow the
clinician to skip questions that are not pertinent to the subject. This pattern of
questioning resembles a seasoned clinician's diagnostic decision tree and focuses
the interview on diagnostically discrinlinating issues (Spit2er, 1983).
In addition, the open-ended responses elicited by a semistructured format
contribute to the interviewer's access to nonverbal, behavioral cues that would not
be available in a self-administered or highly structured format. Kluft (1987b) notes
the importance of intrainterview amnesia, as well as fluctuations in voice, speech,
and movement characteristics, which can be essential clues to the presence of a
dissociative disorder. He adds that extended interviews (lasting over 4 hours) may
elicit observable symptoms in a patient with a dissociative disturbance; however,
the clinician must be informed and attuned to the possibility of their manifestation.
The SCID-D interview booklet includes a section for the clinician's notation and
description of intrainterview cues.
Structured Features. The incorporation of structure in a clinical interview
offers several advantages. The primary advantage is the exclusion of uncontrolled
variables. Systematic interviews reduce variability in the symptom areas assessed,
interpretations made from test results, and the types of questions asked of each
patient (Spitzer, 1983). This uniformity allows for the comparison of clinical data
from different sources, particularly in research settings (Saghir, 1971). The unreli-
ability, skepticism, and omissions of dissociative disorder diagnoses were major
factors motivating the development of the SCID-D.
For example, structured rating scales developed for the SCID-D allow the
interviewer to quantify the severity of individual dissociative symptoms, rather than
merely record their presence or absence. The SCID-D operationalized definitions of 261
severity according to multiple factors, which include: frequency, duration, and Psychological
onset of symptoms; degree of distress; and dysfunction. These detailed and stan- Assessment of
dardized criteria allow researchers to compare SCID-D results reliably across differ- Dissodatlon
ent patient populations.
Finally, because dissociative symptoms are posttraumatic, they are often diffi-
cult to detect. In order to obtain indications of these more elusive symptoms,
clinicians must routinely ask questions that can directly or indirectly retrieve
information essential to a correct diagnosis. The SCID-D was designed to assess
signs of dissociation whose significance may not be apparent to the subjects
themselves. For example, blank spells or time loss are indications of amnesia, and
being told by others that the subject acted in an uncharacteristic way is a sign of
identity alteration. As Kluft writes, "The Structured Clinical Interview for the DSM-
III-R Dissociative Disorders (Steinberg et al., 1990) is extremely comprehensive and
sensitive and has shown the capacity to pick up previously unsuspected cases of
dissociative disorders" (Kluft, 1991, p. 173). Thus, use of the SCID-D should become
an integral part of the diagnostic evolution process.

Clinical Applications of the SCID-D. The SCID-D is a time- and cost-

effective instrument with a variety of clinical applications. Indeed, given the high
costs of misdiagnosis of dissociative symptoms, health insurers would be wise to
cover the minimal expense of the use of the SCID-D interview. Its uses include
diagnosis for treatment, identification of symptoms for treatment planning, estimat-
ing the prevalence and comorbidity of dissociative symptoms and disorders, and
investigation of symptom phenomenology. Because the SCID-D's format facilitates
long-term follow-up of patients' symptoms, a clinician can administer the instru-
ment at 6-month or yearly intervals in order to monitor changes in symptomatology
and reassess treatment strategy accordingly. This feature makes the instrument
particularly useful to practitioners of hypnosis, in that it can be administered to
patients prior to the induction of formal hypnotic trance, in order to establish the
patient's symptomatic baseline. Moreover, the SCID-D is a tool that can be used for
patient education (during a follow-up session with the subject) regarding the nature
and significance of the patient's dissociative symptoms. Many patients have re-
ported immediate therapeutic benefits from the opportunity to discuss their symp-
toms with the interviewer. Last, since the instrument is designed to be filled with
patients' charts, it secures easily accessible documentation of symptoms, for re-
cordkeeping and psychological reports. This feature is particularly beneficial to
clinicians involved as expert witnesses in forensic cases, in that SCID-D results can
be submitted as evidentiary material that is less controversial than amytal inter-
views, hypnosis, or the results of psychological tests such as the MMPI. As North
et al. (1993) have remarked with regard to the MMPI:
[MMPI] validity scale patterns present a clear problem in forensic settings.
Because many patients with MPD, borderline personality disorder, and/or Bri-
quet's syndrome present invalid test results, one cannot confidently attribute
the production of invalid profiles to malingering alone .... In forensics, one must
simply conclude that one's test data are equivocal to some extent and that the
scientific conclusions that can be drawn from them are quite limited. (p. 81)
262 For a comprehensive overview of the dissociative symptoms and disorders, as well
Marlene Steinberg as an explanatory guide to the clinical applications of the SCID-D, the reader is
referred to the Handbook for the Assessment of Dissociation: A Clinical Guide
(Steinberg, 1995).

A Sample SCID-D Evaluation Report. As an illustration of the SCID-D's

specific applications in symptom documentation, psychological reports, and treat-
ment planning, a sample patient report follows:
(For the sake of conciseness, the past psychiatric history of this patient is
abbreviated and this sample protocol will focus primarily on the SCID-D evaluation.)
Jane Smith is a 35-year-old single woman. She has experienced intermittent
panic attacks, depression, auditory hallucinations, "trances," "blackouts," and
self-mutilating behaviors, since she was 12 years old. Jane reports a family
history of emotional and physical abuse at the hands of both parents. She has
been treated in outpatient psychotherapy four times since age 14, for periods of
up to 2 years; past diagnoses include bipolar disorder, schizophrenia, atypical
psychosis, and depression. She was referred for a diagnostic consultation by her
present therapist.
Dates of Evaluation
On 5/24/94, I administered the Structured Clinical Interview for DSM-IV
Dissociative Disorders (Steinberg, 1993b). Scoring and interpretation of the
SCID-D were performed according to the guidelines described in the Inter-
viewer's Guide to the SCIIJ..D (Ste"inberg, 1993a). On 5/31!94, I met with Jane
Smith to review the findings of the SCID-D interview and discussed recommen·
dations for treatment.
SCIIJ..D Evalitation and Diagnostic Assessment
A review of the significant findings from the SCID-D interview is as follows:
Jane suffers from bimonthly episodes of severe amnesia since age 9, which are
the "blackouts" she describes. She also experiences recurrent episodes of deper-
sonalization, which include her "trances," during which she feels she leaves her
body and is sitting on her own shoulder. She reports that she occasionally cuts
herself with a razor in order to alleviate the feelings of depersonalization. She
endorses symptoms of recurrent derealization and identity confusion. in addi-
tion, Jane reports evidence of identity alteration: she receives mail addressed to
"Samantha" and "Freddie," from two other students at different undergraduate
institutions; she has also reported that people had greeted her on the street as
"Samantha." During administration of the follow-up sections, Jane endorsed
having recurrent feelings that different people existed inside her, including a
child of toddler age, a "Biker" in her late teens, a rageful person called "Son-of-
a-Bitch" of uncertain age, and a person named "Idiot." She reported that she
experiences these people as separate from her "normal self" and that they
assume control of her behavior. As examples, she mentioned that "Idiot" was
talking to me during part of the interview; and that her boyfriend broke up with
her because the "Biker" came out several times during their dates and displayed
inappropriate behavior. During the SCID-D interview, I observed changes in
Jane's affect, speech, and physical posture consistent with her child alter, such
as curling up in the chair and sucking her thumb.
Jane's SCID-D symptom profile and past history of traumatic experiences
are consistent with a primary diagnosis of a dissociative disorder. Based on the
 SCID-D evaluation, Jane's symptoms of amnesia, depersonalization, derealiza- 263
tion, identity confusion, and identity alteration are all present at a severe level.
Psychological
She has suffered from chronic dissociative symptoms that interfere with her Assessment of
schoolwork and relationships and that appear to be related to her self-cutting. Dissociation
She has also described the presence of other personalities within her that take
control of her behavior to the extent of forming alternate sets of relationships
and behaviors. The constellation ofJane's symptoms meets DSM-IV criteria for a
diagnosis of dissociative identity disorder. Her depression appears to be second-
ary to the disruptions in her life caused by the alter personalities.
Recommendation
I recommended weekly individual therapy focused on the reduction of
Jane's dissociative symptoms. Patient education regarding these symptoms and
their triggers is recommended during the initial treatment phase. A subsequent
goal should be increased cooperation among the alternate personalities in order
to reduce the severity of Jane's amnesia, identity confusion, and identity alter-
ation. Finally, the use of an antidepressant may relieve some of the immediate
symptoms of depression.

SCID-D Research and the Differential Diagnosis of Dissociation. The

SCID-D can be useful to clinicians in detecting and assessing the severity of dissocia-
tive symptomatology in patients diagnosed with a nondissociative disorder, as well
as in patients with a high index of suspicion for a dissociative disturbance. Clini-
cians should note that dissociative symptoms may manifest in any of the disorders
classified under Axes I and II and DSM-IY. Research indicates that the relationship
between dissociative symptoms and nondissociative disorders will fall into one of
two basic patterns: (1) the primary disorder is nondissociative, but coexists with
some dissociative symptoms; and (2) the nondissociative disorder has been masking
the presence of an underlying, previously undetected dissociative disorder. Since
accurate diagnosis is essential to the planning and implementation of appropriate
treatment, selective administration of the SCID-D is helpful in preventing misin-
terpretation of a patient's dissociative symptoms. Research findings indicate that
the SCID-D is effective in detecting previously undiagnosed dissociative disorders
and in distinguishing between patients with dissociative disorders and other psychi-
atric disorders (including the anxiety disorders, personality disorders, substance
abuse and eating disorders, and the psychotic disorders) (see Goff et al., 1992;
Steinberg, Cicchetti, Buchanan, Raakfeldt, & Rounsaville, 1994). In addition, the
SCID-D can be used to discriminate between dissociative disorders and seizure
disorders (E. Bowman, 1994, personal communication). The reader is referred to
the Handbook for the Assessment of Dissociation (Steinberg, 1995) for a more
detailed discussion of the use of the SCID-D in differential diagnosis of dissociative
symptomatology in nondissociative as well as in dissociative disorders.

CONCLUSION

In summary, the last decade has witnessed the development of diagnostic

instruments which are specific for the dissociative disorders. Clinicians and re-
searchers can now choose from a variety of self-administered screeners, in order to
264 screen patients for dissociative symptomatology rapidly, as well as effective and
Marlene Steinberg time-effident clinician-administered tools for the diagnosis of the dissociative disor-
ders. Among these clinician-administered instruments, the SCID-D offers the advan-
tage of assessing the severity as well as the presence of dissociative symptoms and
disorders. Although IQ tests and projective and psychological tests such as the
Rorschach and MMPI respectively are not diagnostic of the presence of dissociation
and should not be used for that purpose, they may provide evidence of coexisting
psychopathology in some subjects, necessitating follow-up with instruments spe-
cific for the dissociative disorders.

ACKNoWLEDGMENTS. This research was supported by NIMH Grant ROI-43352.

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13
Psychophysiological
Assessment of
Dissociative Disorders
Theodore P. Zahn, Richard Moraga, and William J. Ray

The study of dissociative disorders by experimental methods such as those used in

psychophysiological experiments presents special challenges not encountered in
most other forms of psychopathology. In most disorders, patients are considered
relatively stable for some period of time, lasting for days to years, and data gathered
at any time is assumed to be representative of data gathered at any other time. In the
typical study, a group of patients is tested (usually when symptomatic with the
disorder) and compared with groups of patients with other disorders and/or nor-
mal controls. In the few instances where repeated testing in different symptomatic
states is done at all, it is done for some extended period of time such as weeks or
months. In major psychoses, for example, the periods of interest would be essen-
tially when ill and in remission; or to take another example, manic, depressed, and
euthymic could be the periods of interest. Likewise, the effects of a specific type of
treatment such as behavior therapy or pharmacotherapy are investigated.
Most of the relatively few psychophysiological studies on dissociative disorders
have been done on dissociative identity disorder (DID) (previously referred to as
multiple personality disorder), and here the interest has been in the differences in
psychophysiology and behavior occurring in different states, which may change on
a time scale of minutes, hours, or days, rather than whether such patients are

Theodore P. Zabn • Laboratory of Psychology and Psychopathology, National Institute of Mental

Health, Bethesda, Maryland 20892. Richard Moraga and William J. Ray • Department of Psy-
chology, Pennsylvania State University, University Park, Pennsylvania 16802.
Handbook of Dissoctatton: Tbeorettcal, Empirlca4 and Cltntcal Perspectives, edited by Larry K.
Michelson and William J. Ray. Plenum Press, New York, 1996. 269
270 psychophysiologically different from normal controls or from patients with depres-
Theodore P. Zabn sion or anxiety disorders. Indeed, since the states (alternate identities) are so
etal. different from each other behaviorally, this question, as applied to the individual
patient, may be thought to be essentially meaningless. The other difficulty is that
the "states" appear to be idiosyncratic or specific for each individual patient.
Therefore, this area has lent itself to the case study method to an extent not seen in
other disorders, even when objective measures of behavior or psychophysiology
have been used. In this chapter, those psychophysiological measures that focus on
the autonomic nervous system (ANS) and musculoskeletal system will be discussed
first, and research using electrocortical measures-electroencephalography and
event-related potentials-will then be covered.
One of the major objectives of psychophysiological studies of DID has been
simply to see if these variables can distinguish between different identities. Some-
times this has been done with the motivation of providing objective evidence that
the different identity manifestations are "real" rather than some kind of pretense.
Whatever the motivation for the study, it would seem that exhibiting consistent
psychophysiological differences between alternate identities would be a valuable
and necessary first step in determining how these measures might help to under-
stand the phenomenology of this disorder.
That real physiological differences may exist between different alter identities
is suggested by clinical anecdotal evidence. A survey of a large series of cases
(Putnam, Guroff, Silberman, Barban, & Post, 1986) reported that one or more
alternates (but not all) had headaches in 7 4% of the cases. Differential responses to
drugs, alcohol, and food and the presence of allergies in different alters were
observed in substantial proportions of cases. Handedness was different among
alters in 37% of the cases. These observations are suggestive of differences in
biological functioning among alters in many cases, but do not allow us to make
predictions about psychophysiological activity.

AUTONOMIC NERVOUS SYSTEM STUDIES

The potential of ANS studies to contribute to an understanding of DID has

been only minimally explored. Before getting to the very sparse literature on this
topic, it may be worthwhile to present brief reviews of the non-DID literature on
ANS activity in relation to normal personality, psychopathology, and emotion to
give the reader a feel for the advantages and limitations of such measures for
studying this disorder.

Psychophysf.ology and Normal Personality

Anyone who has done psychophysiological recording from a large series of
normal subjects using a variety of ANS measures cannot help but be impressed by
the wide range of individual differences that one observes, not only for each
measure separately but particularly in the patterning of different measures. It is
compelling to believe that such individual differences must have some relationship
to the personality of the subjects. Research has shown that these variables are both
state- and trait-related. They can be altered predictably by life situations and by 271
laboratory procedures such as task- or threat-induced stressors or long vigilance Psychophysiological
procedures. There are marked individual differences in both the extent and the Assessment
patterning of such reactions. Under reasonably similar conditions, they appear to
have adequate stability over time. The test-retest reliability of electrodermal activ-
ity (EDA), probably the most widely studied of such measures, varies with the
parameter measured, the conditions of the study (resting vs. stressed), and the time
period, but satisfactory reliabilities (.65 to .9) for major parameters such as skin
conductance level (SCL), skin conductance response (SCR) amplitude, and the
frequency of spontaneous SCRs for periods of a few weeks to a year have been
reported (Boucsein, 1992).
Despite this, finding consistent correlations with personality traits has been
difficult. For example, although ANS indices of activation and arousal increase
reliably under conditions under which subjects rate themselves as more anxious,
subjects within the normal population who rate themselves high on trait-anxiety do
not necessarily show greater activation than low trait-anxious persons under either
resting or stressful conditions (Myrtek, 1984; Zahn, Nurnberger, Berrettini, & Rob-
inson, 1991). Even when rather consistent and statistically significant relationships
have been found between personality and psychophysiology, they typically account
for a fairly small (10-20%) proportion of the variance (Gale & Edwards, 1986;
Stelmack, 1990) and may be quite specific to a small set of conditions or variables.
Thus it is not clear from this literature how much variation in ANS activity one
might expect from different alternate personalities.

Psychophysiology and Psychopathology

DID is not a normal condition, so perhaps a more relevant data base is the
literature concerning ANS markers of psychopathology. This is particularly so
because DID patients frequently present in clinical settings as some other form of
serious psychopathology-various major psychoses, obsessive-compulsive disor-
der, panic disorder, and so on (Putnam, 1989). This is usually attributed to one of the
alternate identities who is "out" at the time of these diagnoses. In such cases, where
it is possible to elicit an alter with a diagnosable form of psychopathology, it might
be possible to test whether this personality resembles non-DID subjects with that
diagnosis. This literature (for reviews, see Thrpin, 1989; Zahn, 1986) shows, for
example, that subjects with major psychoses have been found generally to have
absent or attenuated psychophysiological reactions to environmental stimuli. In-
dices of arousal such as heart rate (HR), SCL, or spontaneous SCR rate may be either
higher or lower than normal but only infrequently are at moderate levels. Patients
with chronic schizophrenia and retarded depression tend to be unusually low on
EDA, while schizophrenics undergoing an acute episode and agitated or anxious
depressed subjects may be very high on these indices. Subjects with anxiety
disorders, on the other hand, as might be expected, generally show high baseline
arousal and frequently exaggerated reactions and slow habituation of ANS re-
sponses to innocuous stimuli. Obsessive-compulsive disorder patients tend to be
higher than controls on both arousal and reactivity, but not extremely so.
In the present context, it is relevant that some investigators have found ex-
272 tremely high arousal indices and slow habituation in patients with conversion
Theodore P. Zahn disorder. Lader and Sartorius (1968) reported that patients who had conversion
etal. symptoms had even higher indices of arousal than patients with anxiety states. This
was replicated by Meares and Horvath (1972) in a subgroup of conversion disorder
patients with long-standing difficulties and poor prognosis, but not in patients with
a good premorbid adjustment and short-lived conversion symptoms, who were at
normal levels. An interesting facet of the Lader and Sartorius (1968) study was that
the ANS data correlated with self-rated anxiety, but not with an observer's rating of
anxiety in the patient. Thus the patients may have been manifesting classical/a belle
indifference, thought to be characteristic of conversion disorder, behaviorally but
not subjectively or autonomically. This illustrates the general point that patients
may not always be subjectively and autonomically what they appear to be, which is
a good argument for the use of ANS measures in a disorder like DID where inten-
tional and/or unintentional disguising of feelings may be an issue. The data from
these studies suggest, contrary to the usual theory of this disorder, that conversion
symptoms do not necessarily protect against high anxiety-arousal.
Somewhat in contrast, Lader (1975) reported several instances in which deper-
sonalization and derealization spontaneously occurred in very anxious patients, and
this was accompanied by profound decreases in EDA and HR. Lader suggests that
the reduction in sensory input occurring in these conditions may be linked to an
emergency physiological mechanism that protects the individual from excessive
arousal by blocking sensory input.
An implication of this section for DID is that in cases where one or more
personalities appear to have a diagnosable disorder, ANS recording may be useful in
determining whether the outward appearance of psychopathology is consistent
with what is known about psychophysiological activity in similar types of psycho-
pathology occurring in non-DIDs. To the authors' knowledge, no study of DID has
used this approach.

Psychophysiology and Emotion

When one reads the literature on DID written by clinicians who have had
much experience with this disorder (e.g., Putnam, 1989), it is clear that most
patients have alter identities whose function is to express certain emotions that the
"main" or "host" identity finds impossible to feel or express. The specific emotions
characterized by alters may be fairly similar from one patient to another. Hostile and
aggressive alters are quite frequent, as are anxious and fearful ones. Frequently the
host, or one or more alters, is withdrawn and/or sad and depressed, while others
may be lively, extroverted, and seductive. Therefore, the literature on the psychol-
ogy of emotion may be highly relevant in deriving hypotheses about specific cases
of DID.
There has been considerable controversy about the specificity of psycho-
physiological patterns in relation to different emotions. From the standpoint of
studymg DID, it is probably sufficient that there is general agreement that many
emotional states can be differentiated from nonemotional states by an arousal
dimension. Therefore, in studying the psychophysiology of alter identities, any
theory would predict more arousal in those alters who are expressing an active
emotion. A relevant question here is whether such patterns can be faked. Ekman 273
and his colleagues (cf., Levenson, Ekman, & Friesen, 1990), who were able to teach Psychophysiological
subjects to produce facial expressions characteristic of different emotions, found Assessment
that this tended to produce the appropriate subjective judgments and also to lead to
distinctive psychophysiological patterns. Although the efficacy of biofeedback in
producing therapeutically meaningful changes in cardiovascular and other systems
is controversial, there is no doubt that measurable changes can be produced by
these methods (Ray, Raczynski, Rogers, & Kimball, 1979; Hatch, Fisher, & Rugh,
1987). Increases in arousal can also be produced by hypnosis in highly hypnotizable
subjects (Maslach, 1979; Zimbardo, La Berge, & Butler, 1993), and patients with DID
are thought to be generally easily hypnotized (Putnam, 1989). Although in the above
lines of research subjects are taught to change their ANS activity by others, some
voluntary control over ANS activity would seem to be possible through self-
teaching and self-hypnosis. '

ANS Studies of DID

The preceding sections suggest that there are good reasons for expecting at
least some alter identities to exhibit distinct psychophysiological patterns com-
pared to others. Most of the few studies that have been done in this area have been
single case studies. In an abstract, Bahnson and Smith (1975) reported that they
found "consistent differences" between four different identities in EDA, HR, and
respiration reactions recorded in a therapeutic setting. They also observed dramatic
pauses in respiration of up to 2 minutes with accompanying bradycardia and
decreases in skin potential during the switch from one personality to another.
Larmore, Ludwig, and Cain (1977) reported another single session on a single
case in which EDA, muscle activity, HR, blood pressure, EEG, and ERPs were
recorded from four different alter identities. Possible differences in EDA were
obscured by marked habituation effects. HR was very high (98 to 110 beats per
minute) for all identities. Rather marked muscle activity and blood pressure eleva-
tions were seen in an alter whose function was to "absorb all physical and emotional
pain." This identity was also a marked "reducer" on a stimulus-intensity ERP para-
digm. Otherwise, the differences were unremarkable. Definite conclusions cannot
be drawn without replication in the same subject, but there is an interesting parallel
to the case to be reported next.
Brende (1984) recorded bilateral electrodermal responses (EDRs) in three alter
identities of a patient in several therapy sessions over the course of more than a year.
A protective identity demonstrated reduced EDRs and a victim identity exhibited
increased EDRs in each of the four sessions in which they both "appeared," but only
in left hand recordings. This replicated finding is conceptually similar to the ele-
vated electromyogram and blood pressure in the victim personality reported by
Larmore et al. (1977). In the experience of the senior author of this chapter (T.P.Z.),
it is highly unusual to see the marked lateral differences in EDA reported by Brende
(1984), even in brain-injured subjects with unilateral damage or in a study of DID to
be described below (Putnam, Zahn, & Post, 1990). Unfortunately, Brende's (1984)
data were collected using techniques that did not permit evaluation of commonly
used EDA variables and seemingly did not permit control over sources of artifacts.
274 However, the unilateral nature of the changes find a parallel in a clinical report of
Theodore P. Zahn two cases of DID studied neurologically (lschlondsky, 1955) in which unilateral
etal. changes in sensory function, pupil size, salivation, palmar sweating, and abdominal
reflexes occurred in an aggressive hypomanic identity and the opposite laterality
was shown by a timid dependent personality. A second case also showed different
laterality patterns in two alters, but the relationships between active and passive
identity and the specific lateral patterns were opposite of those shown by the first
case. This is explained by differences in handedness in the two patients.
The only study of ANS activity on more than one patient (Putnam et al., 1990)
was designed to provide a rigorous test of the hypothesis of consistent ANS
differences between alternate identities. Nine DID patients and five controls had
bilateral EDA, HR, and respiration recorded during a short protocol consisting of a
rest period, a series of innocuous tones, and a reaction time task. For the DID
subjects, the same three identities were tested during each of four to five sessions,
each time in different order. Controls produced "alter" states by simulation and by
hypnosis or deep relaxation. Thus each subject constituted a separate experiment
for which the data for each individual variable were subjected to an identity x
sessions analysis of variance (ANOVA). The number of significant F ratios for
identity for each subject was the basic measure of psychophysiological consistency.
Eight of the nine DID subjects showed more significant results at the .01level
than would be expected by chance and all nine showed more results than chance at
the .05 level. This demonstrates that alter identities do show reliable differences in
ANS activity, interpreted by Putnam et al. (1990) to suggest that "the alter person·
alities of MPD subjects are highly organized, discrete states of consciousness" (p.
256). Some caution in interpreting the data is indicated by the fact that both
hypnotized controls and one of the three nonhypnotized controls showed more
psychophysiological differences than expected by chance. However, it was noted
that the deviant state for the hypnotized controls was very deep relaxation-low
arousal-during the hypnotic trance, whereas the deviant states of the DID subjects
were increases in arousal in one or more alters compared to the host personality. It
was not attempted to produce increases in arousal hypnotically, but this might be a
worthy control in future studies. A separate set of tests of the hypothesis that there
were consistent differences among personalities in the laterality of EDA showed
that none of the subjects had appreciably more of these than would be expected by
chance.
The reliable differences shown among identities in ANS activity do not prove
that subjects were not voluntarily producing these patterns, since as shown above
such processes can be brought under voluntary control. However, only one of three
controls who adopted an alternate identity and relaxed without the benefit of
hypnosis was able to produce reliable changes in psychophysiology. Therefore, the
results seem highly suggestive that the distinctive psychophysiological states relia-
bly accompanying different alter identities are natural accompaniments, or possibly
determinants, of the state of consciousness represented by that identity.
Despite the positive results, this study has inherent limitations in design that
might have attenuated the differences among identities. Chief among these is the
rather artificial nature of the timing; the alter identities were called up for 10- to 15-
minute periods for the same, rather boring, testing sequence, a procedure that
figures to dampen the emotional responsivity ofthe alters compared to the natural 275
life situation in which a given alter spontaneously appears to cope with a life event. Psychophysiological
The short periods during which each alter was out precludes measuring the Assessment
influences of changes in slow-acting endocrine processes. Some limitations might
be overcome by the use of longer periods of recording, possibly using telemetering
of psychophysiological data, although here the control over environmental factors
would be less than optimal. In addition, Putnam et al. (1990) did not attempt to
relate any of the ANS data to particular clinical data on the patients. From the data
on personality, psychopathology, and emotion on normal subjects, it should be
possible in many patients to make definite predictions about the psychophysiology
from clinical knowledge of the alters.

Within-Identity Differences on Other Measures

Visual functions by means of a battery of optical tests were studied in 9 DID
patients and 9 controls by Miller (1989) and in 20 patients and 20 controls by Miller,
Blackburn, Scholes, White, and Mamalis (1991). In each study, three alter identities
were tested in the DID group and three play-acted personalities were tested in the
controls on visual acuity, visual field, manifest refraction, and eye muscle balance,
and the groups were compared on the pooled within-subject variance. Both studies
found that the variability among the alter identities was larger than that for the
controls on visual acuity and visual field. Miller (1989), but not Miller et al. (1991),
also found a similar difference for eye muscle balance. Pupil size, which is under
autonomic control, was assessed only by qualitative ratings, and showed no group
difference in variability. The same critical comments could be applied to this study
as were applied above to Putnam et al. (1990). It would appear that visual acuity and
field could be even more under voluntary control and subject to differences in
attention and motivation than ANS activity.
In a case study, Mathew, Jack, and West (1985) measured regional cerebral
blood flow (CBF) with the mxe inhalation technique in one patient on four
occasions. The major finding was that a fearful 7-year-old identity showed a marked
elevation in right temporal lobe CBF compared to the host identity, to the inte-
grated identities after therapy, and to normal controls. In contrast, Saxe, Vasile, Hill,
Bloomingdale, and van der Kolk (1992), using the higher-resolution single-photon
emission method of measuring regional CBF, reported elevated CBF in the left
temporal area of all four alter identities of a DID patient relative to whole brain
activity and to a control site. Although these studies conflict greatly in their findings,
both show changes specific to the temporal lobe. This brings to mind the associa-
tion between temporal lobe epilepsy and dissociative symptoms, which have been
reported in some patients (Mesulam, 1981; Schenk & Bear, 1981) and will be
discussed later in this chapter.

Studies of the Amnestic Relationships between Alter Identities

Another use of psychophysiological methods has been to test the claim that
certain identities are unaware of the experiences of certain other identities, fre-
quently to convince skeptics of the reality of DID as presented by the patients. We
276 will first review the few studies on this topic and then critique the methodology
Theodore P. Zahn from the standpoint of what is known about ANS activity and consciousness, with a
etal. view to determining what can and cannot be learned from such studies.
The first psychophysiological study of DID was done by the eminent neu-
rologist-psychologist Morton Prince and a psychiatrist colleague (Prince & Peter-
son, 1908). The objective was not to study DID per se, but to determine if the
psychogalvanic reaction (SCR) could be useful to corroborate the existence of
coconscious (sometimes called subconscious) ideas. The DID patient was "made
use of" as particularly suitable for this purpose. The patient had a "normal" identity
and two alters, one of which claimed amnesia for both other identities. The
identities could all be hypnotized, and only one of these hypnotic states was
coconscious with the other hypnotic states as well as the unhypnotized identities. A
number of studies were performed on this patient using electrodermal reactions to
words that on the basis of bad dreams or past experiences had conscious emotional
significance to some identities (and/or hypnotic states) and not to others.
The data show unequivocally that SCRs occurred to emotionally significant
words even when the personality or state being tested claimed to be unaware of
the experience that produced the emotional valence for that word. The studies
seem adequately controlled; the target words were presented unpredictably in a
series of control words; the authors were aware of habituation effects and at-
tempted to take them into account when comparing the magnitudes of the re-
sponses. However, comparative magnitudes are not critical in interpreting the data;
most of the data simply show that obvious SCRs were obtained to significant words
whether consciously perceived as significant or not and not to neutral words. One
possible problem is that presumably the words were presented verbally by one of
the investigators who would be familiar with the details of the case, so that an
unintentional change in intonation for the target words could have occurred.
However, in another experiment each of the identities was given a "strong tactile
stimulus" when in a hypnotic state. In two of these three states the subject was
"absolutely anesthetic" (Prince & Peterson, 1908, p. 124) yet marked SCRs were
obtained during all three of these hypnotic states, confirming the word studies that
SCRs occurred to stimuli whose emotional significance was out of conscious
awareness.
Prince and Peterson (1908) interpret the data as supporting their theory of
psychical subconscious processes that preserve memories that cannot be recalled
consciously but can influence electrodermal activity. It is difficult to know how
general the conclusions can be from data obtained on a single case of DID. This
patient had one alter identity that, in both her normal and hypnotized state, claimed
coconsciousness of the experiences of all other identities when they were out. The
authors suggest that the memories from all identities and states were preserved in
this alter and that she reacted to them electrodermally even when an amnestic
identity or state was being tested. This suggests that different results might be
obtained in cases in which there was no completely aware identity to remember
everything. An alternative hypothesis, of course, is that this patient was confabulat-
ing about her amnesia and also her anesthesia. It is not mentioned how the latter
condition was confirmed objectively. It does not seem possible to verify the amne-
sia independently, so the confabulation hypothesis in this case seems untestable on
the basis of the data presented.
 There seem to have been no subsequent studies of this kind until the compre- 277
hensive case study reported by Ludwig, Brandsma, Wilber, Bendfeldt, and Jameson Psychophysiological
(1972). This subject had a primary identity who was unaware of the three alters. Assessment
Each of the alters had "intimate" knowledge of the primary but only "peripheral"
knowledge of each other. Like Prince and Peterson (1908), these investigators
recorded SCRs to words that had emotional significance to one of the four identities
tested but not to the others. Each of the identities, which were elicited by means of
hypnosis, was given the same word list consisting of his own emotional words,
those of the other identities, and neutral words. The results showed clearly that
each of the alters gave large SCRs to their own significant words and to those of the
primary personality but much smaller SCRs to each other's significant words. The
primary identity was only moderately responsive to his own emotional words,
despite being tested first, but much less responsive to the significant words of the
alters. Thus, unlike the case reported by Prince and Peterson (1908), the electroder-
mal responsivity to the emotionally significant words covaried with the reported
amnestic relationships among the personalities, even when amnesia was not abso-
lute. In this case none of the identities claimed coconsciousness with all of the
others. There does not seem to be a reasonable explanation of these results based
on a confabulation hypothesis.
In contrast to these neat results, equivocal results were obtained with an SCR
classical conditioning procedure. Here, a different conditioned stimulus (CAS) was
used for each identity, the unconditioned stimulus (UCS) being an electric shock.
Following the establishment of conditioning for one identity, each of the other
identities was called forth in turn via hypnosis and exposed to two CS-only (test)
trials. After all the other identities had been tested, the original (conditioned)
identity was brought back and given two CS-only trials to index extinction. Cross-
conditioning between identities was said to occur when the mean SCR magnitude
to the test stimuli was greater than that obtained for that identity on his own
extinction trials. The results showed that of the 12 possible instances of cross-
conditioning, 9 were positive, and these did not bear any systematic relationship to
the amnestic relationships between identities. This leads to a different conclusion
than the word study. Although order of testing is an uncontrolled variable here, it is
difficult to imagine how this could artifactually produce the results obtained.
Another interesting result of this study was that, unlike the case of Prince and
Peterson (1908), one of the alter identities, who was found to be hyperalgesic on a
neurological exam, was very difficult to condition and even then gave small condi-
tioned SCRs. This alter did not show generally attenuated EDA, since he was quite
responsive on the words procedure.
In another approach to testing carryover effects between different identities, a
cross-habituation paradigm was used by Putnam et al. (1990). In this study, it will be
recalled, in nine DID cases and five controls the same three identities or states were
tested on four or five separate days in a different order in a protocol that included a
series of ten tones. In the DID group, since most alter identities claimed to be
unaware of the experiences of the others and since novel stimuli elicit larger SCRs,
which habituate over trials, it was expected that the DID group would show less
carryover of habituation across segments within a session than controls. The re-
sults showed that, on the contrary, for both the number and amplitudes of SCRs
significant carryover of habituation was shown by the DID group, and this did not
278 differ significantly from the controls. This result leads to the same conclusion of
Theodore P. Zahn "communication" between identities, at some level, as the conditioning results of
et al. Ludwig et al. (1972) but not those of their word-stimulation procedure.

ANS Activity and Awareness

The emotional word, conditioning, and habituation protocols were used in the
above studies in part to provide objective tests of the purported amnesia of one
identity for another. The implicit assumption is that EDA reflects or is congruent
with the conscious experience of the eliciting stimulus or situation. Under this
assumption the evidence of cross-communication of EDA between identities who
profess to be unaware of each other would be grounds for seriously questioning this
claim. We thus need to ask what the evidence is for the assumption of congruence
between EDA and cognition.
A strict congruence was questioned in Ohman's (1979) influential model of the
orienting response in which the novelty of the stimulus, and thus its probability of
eliciting an orienting response, was determined by preattentive processing of the
stimulus. This question was addressed in the context of differential electrodermal
conditioning by Dawson and Furedy (1976), who concluded from a review of a
number of studies that awareness of the stimulus contingencies (i.e., which of two
potential CSs may be followed by an aversive UCS) is a necessary but not a sufficient
condition for obtaining conditioning. They hypothesized, without presenting data,
that awareness of the termination of the CS-UCS relationship is a necessary but not
a sufficient condition for extinction to occur. Evidence for this latter point was
provided by Bridger and Mandel's (1965) finding that instructions that shock would
no longer be delivered and removal of the shock electrodes was not sufficient to
eliminate conditioned SCRs. It has also been shown that conditioned SCRs can be
elicited by stimuli that are out of awareness by virtue of being presented in the
unattended ear while subjects are attending to the other ear continuously in order
to perform a task (Dawson & Schell, 1982). Although this seems to occur unam-
biguously when the unattended ear is the left ear but not when it is the right ear
(Dawson & Schell, 1982), it is a demonstration of a dissociation between awareness
and psychophysiological responding nevertheless. Similarly, Ohman and Soares
(1993) reported that phobic subjects who had been differentially conditioned using
fearful stimuli maintained the conditioning when a backward masking procedure
prevented conscious recognition of the stimuli. These lines of research all show that
conditioned responses may be "remembered" in a part of the nervous system that is
not available to conscious awareness.
Other evidence on this point may be cited. Tranel and Damasio (1985), making
use of a finding that pictures of faces of famous persons elicit larger SCRs than
pictures of unknown persons (Tranel, Fowles, & Damasio, 1985), found that this
was true also in prosopagnosic patients despite a complete lack of conscious
recognition of the faces. In a quite different type of study of unexplained arousal
(Maslach, 1979; Zimbardo et al., 1993), subjects are hypnotized and given a posthyp-
notic suggestion that they will feel aroused and that their EDA, HR, and respiration
rate will increase. They are further told that they will not be aware of the source of
their arousal. Large posthypnotic increases in the physiological variables and in
ratings of subjective arousal have been demonstrated under these conditions in 279
highly hypnotizable subjects who profess to be unaware of the source of their Psychophysiological
arousal. These increases were larger than those shown by low hypnotizable sub- Assessment
jects and even larger than those of both groups when they remained aware that the
source of their arousal was a hypnotic suggestion. These studies show that increases
in autonomic responsivity and base levels may occur without conscious awareness
of the conditions producing these phenomena.
An implication of these studies for the investigation of DID is that they suggest
that a test of the amnestic relationships between identities based on conditioning
one identity and testing others will not necessarily be definitive. One might say that
a transfer of conditioning from identity A to identity B is a necessary but not a suffi-
cient condition for disproving the reality of the amnesia of B for A. If A is condi-
tioned to respond to circles and not to squares, and B subsequently shows CRs to
circles and not to squares, then a definite conclusion as to whether B's purported
amnesia for A's experiences is valid cannot be made. However, if there is no transfer,
then the claim of amnesia is strengthened considerably.
In the case study of Ludwig et al. (1972), it will be recalled that whereas there
was transfer of conditioning between mutually amnestic identities, there was no
transfer of responsivity to stimuli that were uniquely emotional for the separate
identities, findings that at face value seem conflicting. The evidence presented
above, however, suggests that the amnesia implied by the emotional word results is
not necessatily refuted by the conditioning results since the latter are not definitive.
But this raises the further question of why the affective reactions to the emotional
stimuli were not transferred. The answer here might lie in the complexity of the
stimuli. In a review of information processing without awareness, Greenwald
(1992) concludes that "unconscious cognition [is] severely limited in its analytic
capability" and that it might be limited to the "analysis of pattial meanings of single
words" (p. 775), although this patticulat limitation may be dependent on the
method of investigation (Kihlstrom, Batnhatdt, & Tataryn, 1992). Therefore, it is
possible to hypothesize that there may be information transmitted between amnes-
tic identities that is similarly limited in complexity, and that tests using simple
sensory stimuli, such as the CSs used by Ludwig et al. (1972) and simple tones used
by Putnam et al. (1990) in their habituation paradigm will not be definitive, whereas
paradigms using more complex stimuli might actually provide a more conclusive
test of amnesia. It will be recalled, however, that Prince and Peterson's (1908)
patient did show transfer of electrodermal reactions to emotional word stimuli
between her identities, attributed to a coconscious identity who was always pres-
ent. The methods discussed here would not seem to be able to test this assertion.

CENTRAL NERVOUS SYSTEM MEASURES OF

DISSOCIATIVE DISORDERS

Psychophysiological assessment of dissociative disorders offers one way to

address the complex relationship between the brain, consciousness, and behavior.
However, the scope and limitations of explicit and implicit views on mind-brain
relationships have constrained progress in understanding dissociative disorders.
280 Early models of the brain suggesting telephone switchboardlike processing or even
Theodore P. Zahn Freud's somewhat linear models involving repression make a physiological under-
etal. standing of dissociation difficult. }ung with his parallel model of cortical processes
offered a more compatible model. More recently, speculation from the neuro-
sciences has emphasized modular processes within the cortex. Neuropsychology
has demonstrated such modular relationships for vision, pain, and speech, but these
relationships have yet to be articulated in relation to dissociative states and the
brain. To this end current models of the mind suggest a promising approach to
psychophysiological assessment of dissociation. Neural networks propose parallel
information processing by neural control systems (coordinating brain and behav-
ior) with processing distributed among localized and broad brain areas and overlap-
ping control systems. Such models can enhance CNS research on the relationship
between the brain and dissociative phenomena. As was true of the ANS studies
reported earlier, DID has also been the most widely studied dissociative disorder in
terms of the central nervous system.

DID Studies
Electroencephalography (EEG) and evoked potentials (ERP) have been the
most widely used CNS measures in the study of dissociation. To date, much of this
research has consisted of single-case studies with only a few controlled group
studies. Among the first studies to examine EEG differences in different identity
states were reports of differences between identities (Thigpen & Cleckley, 1954;
Ludwig et al., 1972; Larmore et al., 1977). Larmore et al. (1977) describe a DID
patient who presented with suicidal ideation, memory gaps, medical problems, and
conversion symptoms. The neurological examination and the EEG were normal. In
terms of history, there was possible sexual abuse. Vtsual evoked response recorded
from the vertex (C, to A,_) revealed significantly larger differences in latency and
amplitude of three components (PI' Nl' and P2) across identities. The average
evoked response types were so distinct for each identity that the authors likened
them to having been elicited from four different individuals. The possibility of
faking the alternate identities was deemed unlikely based on clinical interviews and
psychological testing.
However, Coons, Milstein, and Marley (1982) investigated EEG differences
among the alters of two DID patients and a control with less clear-cut findings. The
control was a subject's therapist who simulated the client's alters. Significant right
central-temporal (C4-T4) amplitude differences were found among the identities
of one subject in delta, theta, and beta frequencies. Significant right temporal (T4-
T6) differences were found in the second patient in theta and beta bands. The
control, however, exhibited the greatest differences, predominantly in the right
hemisphere. Although the assessment procedure differed for the subjects, the
authors concluded that subject and control EEG differences merely reflected emo-
tional changes not related to dissociation.
Despite these contradictory findings, recent researchers report that there are
indeed significant EEG differences among alter identities. Ongoing work reported
by Putnam (1991b) obtained significant spontaneous and evoked EEG differences
among identities of DID subjects not duplicated by the controls. Braun (1983)
hypothesizes that conflicting findings may be accounted for by some "common 281
denominator" responsible for the suppression or expression of the physiological Psychophysiological
response. He suggests that emotionally cued autohypnotic or state-dependent learn- Assessment
ing mechanisms may determine the physiological expression of dissociative states.
Of course there exists a number of possible factors that may influence EEG
studies. For example, in the study by Coons et al. (1982) the greatest differential
EEG responding among alters was by a patient familiar with the clinical laboratory
from prior studies. likewise, differential responding may also be due to relationship
variables between the patients and therapists who elicited the alters. Another
possibility is the type of EEG measure used, since it has been observed that visual
evoked potentials appear to best elicit differences (Putnam, 1991). Lowenstein
(1993) also reports that visual evoked potentials "show more significant differences
between bona fide DID alters than between simulator controls switching between
sham alters" (pp. 598-599). Given the current state of EEG research with dissocia-
tive disorders, it is not surprising that this work has been critically described as both
"varied and conflicting" (Putnam, 1991a, p. 155) and with "little systematic effort to
study the neurophysiologic basis of dissociation" (Spiegel, 1991, p. 442). Further,
few of the researchers explain what type of EEG differences should be found. For
example, it is unclear if one would expect to find continuous EEG differences
during baseline conditions, whereas differences might be possible in response to
specific stimuli, e.g., emotional situations, by the different identities of a DID
individual.

DID, Epilepsy, and Seizure Disorder

An important neurological question is the relationship between dissociative
processes and temporal lobe epilepsy. There are actually two questions being
asked. First, can individuals with temporal lobe epilepsy show dissociative symp-
toms. And second, does the presence of dissociative symptoms suggest temporal
lobe epilepsy. The answer to the first question appears to be yes. The appearance of
dissociative phenomena among individuals with temporal lobe epilepsy has been
well documented (Devinslcy, Putnam, Grafman, Bromfield, & Theodore, 1989; Mes-
ulam, 1981; Schenk & Bear, 1981). Schenk and Bear (1981) reported EEG and
neuropsychological data for three patients who developed DID "years after the
onset of complex partial seizures" (p. 1311). They also sununarized data for 40
patients with temporal lobe epilepsy. Repeated EEGs in one subject " ... revealed
theta slowing over the left temporal region and from the left nasopharyngeal lead"
in the first and " ... sharp activity from the left nasopharyngeal lead" in the second
(p. 1311). Neuropsychological testing indicated left temporal dysfunction in this
patient. EEG in two other patients revealed bilateral temporal lobe abnormalities,
prominent in the right. Recurrent dissociative episodes were reported for one third
of the 40 patients with complex partial seizures and EEG confirmed temporal lobe
epilepsy.
Schenk and Bear (1981) described these findings as "highly distinctive" and " ...
suggestive of a causal relationship between temporal lobe epilepsy and dissociative
experiences, including multiple personality disorder" (p. 1314). They hypothesized
that the effect of seizure activity on the limbic system resulted in heightened
282 affective associations between the limbic system and sensory association cortex.
Theodore P. Zahn Patients with temporal lobe epilepsy would be predisposed to dissociate as a
etal. response to this intensified affect.
Mesulam (1981) also proposed a similar mechanism for dissociative phenom-
ena in patients with a temporal lobe focus of complex partial seizures. Clearly
abnormal EEG with a temporal lobe focus was found in 10 of 12 cases consistent
with psychomotor epilepsy. Dissociative experiences consisted of DID-like symp-
toms in seven patients and the illusion of possession in the others. The dissociative
phenomena were hypothesized to be a manifestation of the abnormal temporal
lobe activity based on the rich interconnections between the association cortex,
temporal lobes, and limbic structures. Such manifestations due to excitation, or
kindling, could be interictal as well as ictal in nature.
An interesting ancillary finding was that asymmetrical EEG abnormalities were
predominant in the nondominant temporal lobe in five of seven cases. Mesulam
(1981) conjectured that dominant (language) hemispheric mental phenomena are
less likely to be dissociative, or ego alien, relative to the nondominant hemisphere.
Both the limbic system and right hemisphere are central to emotional processing
and memory and involved in mental activity outside conscious awareness Qoseph,
1990). The questions raised in these studies regarding the possible roles of the
limbic system and the temporal lobes in dissociative phenomena have generated
much research.
The answer to the second question-does the presence of dissociative symp-
toms suggest temporal lobe epilepsy -appears less certain. The idea of a neurologi-
cal model of DID has been coined the "temporal lobe/complex partial seizure/
kindling model" (Putnam, 1991b, p. 498). Kindling is a process studied in animals by
which repeated stimuli lead to behavioral sensitization and convulsive responses. A
kindling theory of dissociation would suggest that brain structures can be altered
with repeated electrical stimulation, which could result from severe stress and
trauma (van der Kolk & Greenberg, 1987; Shearer, Peters, Quaytman, & Ogden,
1990; Teicher, Glod, Surrey, & Swett, 1993). However, EEG studies using subjects
with diagnosed dissociative disorders have not supported this model in the etiology
of dissociative disorders (Putnam, 1991a,b; Spiegel, 1991). One such study reported
intensive video-EEG monitoring of patients diagnosed with DID and dissociative
screening of 71 patients with generalized seizures (Devinsky et a!., 1989). The
referring diagnosis of seizure disorder was not confirmed by the EEG for the DID
patients. The prevalence of nonepileptiform abnormal EEGs suggested that seizures
and neurophysiological abnormalities might contribute to dissociative states. How-
ever, the data did not support a seizure disorder model as a primary mechanism for
dissociation.
likewise, Coons, Bowman, and Milstein (1988) conducted an extensive assess-
ment, including EEG and the Dissociative Experiences Scale (DES) (Bernstein and
Putnam, 1986) of 50 patients diagnosed with DID. EEGs were collected for 30
patients of which 7 showed abnormalities. Psychogenic seizures were found in 6
patients and organic seizures in 5 subjects. The DES was administered to 13 patients
with a group mean score of 41. The authors concluded that the etiology of DID in
this sample was not due to temporal lobe or chronic limbic epilepsy. Overall, these
studies indicate that neurologically diagnosable epileptic or complex partial sei-
zures do not account for DID.
 Spiegel's (1991) assessment of this literature supports the idea of temporal lobe 283
activity in the production of dissociative symptoms, especially since this relation- Psychophysiological
ship is found during the interictal period. The work by Mesulam (1981) and Schenk Assessment
and Bear (1981) did not so much attribute DID per se to limbic and temporal lobe
seizure activity, but rather identified the contribution of these areas to the develop-
ment of dissociative phenomena in certain individuals. Devinsky et a!. (1989) found
that seizure-disordered patients' DES scores fell between those of normals and DID
and suggested the role of seizures in dissociative states for selected individuals
(p. 840). Mesulam (1981) also raised the possibility of differential susceptibility to
drastic changes in affective, perceptual, and cognitive balance leading to impaired
personality integration and dissociative states. Precisely what factors constitute
"selected" or "susceptible" is unclear, but trauma is clearly implicated as a factor in
dissociation (Chu & Dill, 1990; Loewenstein, 1993; Ludwig, 1983; Teicher et a!.,
1993; Putnam et al., 1986).
Psychogenic seizures, concomitant dissociative symptoms, and EEG abnor-
malities are suspected to be related to physical or psychological trauma. However,
research in this area is often complicated by the difficulty in distinguishing between
organic and psychogenic seizures. Briefly stated, psychogenic seizures are diag-
nosed when a patient presents clinical seizure disorder activity in the absence of
change in preictal, ictal, or postictal EEG (Rachmandi & Schindler, 1993). Chu
(1991) further suggests that dissociative symptoms in patients with temporal lobe
epilepsy are less severe and that DES scores of patients with organic seizure are
generally lower than those with psychogenic seizures.
Rachmandi and Schindler (1993) were able to distinguish two groups of pseu-
doseizure patients: those that mimic complex partial type seizures and those that
mimic grand mal type seizures. Dissociative symptoms were more prominent
among pseudoseizure patients with the pseudo-complex partial type. These pa-
tients also showed recognizable psychological conflict in their histories before the
onset of the symptoms. For example, one pseudoseizure patient reported dissocia-
tive experiences following the death of her homosexual son from AIDS, which she
was unable to explain to co-workers.
In terms of trauma, studies have reported a high incidence of dissociative
symptoms and/or pseudoseizures in individuals with histories of early abuse. In one
study, complex partial seizures were frequently found in women with a history of
childhood abuse (Shearer et al., 1990). Bowman (1993) assessed 27 diagnosed
pseudoseizure patients, 5 with concomitant epilepsy, using video- EEG monitoring.
Most of these patients received an unstructured DSM-III-R-based interview and the
DES. Trauma was reported by 88% of the subjects (sexual = 77%; physical = 70%).
The mean DES score (26.7) was below that typical of DID but comparable to
posttraumatic stress disorder subjects. Affective, dissociative, and posttraumatic
stress disorders were the most prevalent Axis I disorders. In this study, all abused
subjects had a dissociative disorder. Twenty-five percent of the subjects had abnor-
mal EEGs possibly related to physical abuse. Bowman (1993) states, "it appears that
abuse experiences operate to produce both dissociative disorders and pseu-
doseizures" (p. 339).
Overall, current attempts to identify neurophysiological factors in dissociative
disorders have not been successful. The convergence of developing psychological
models of dissociation, neurological models of trauma, and EEG technology may
284 help clarify this issue. Recently a developmental model proposed repetitive trauma,
Theodore P. Zahn especially in childhood, as an etiologic factor in dissociative disorders (Loewen-
etal stein, 1993). Teicher et al. (1993) developed a self-report measure of symptoms
related to temporal lobe epilepsy and limbic system dysfunction, the limbic System
Checldist-33 (LSCL). Based on self-report data of 253 psychiatric outpatients, strong
statistical relationships were found between the LSCL-33 and both the DES and self-
reports of childhood abuse via the Life Experiences Questionnaire. Although ex-
ploratory in nature, this study supported a relationship between EEG abnormalities
and trauma, in particular early childhood sexual and physical abuse.

FUTIJRE DIRECI10NS

In conclusion, this review of the DID literature and related literature in the field
of psychophysiology suggests that the phenomena reported in DID patients can, in
principle, be accounted for by what is known about the relationships between
psychophysiological variables and psychopathology and emotion and awareness of
eliciting conditions. However, techniques used for studying this unique disorder
have not generallybeen appropriate and the research has generally not progressed
beyond the laboratory curiosity stage. Some variant of the case study method to
investigate the relationships between different personalities and psychophysiologi-
cal patterns would still seem valuable because of the clinical complexity of individ-
ual cases, but this should involve repeated testing on individual cases in order to
assess the reliability of the differences obtained. Similarly, studies of more than
single cases will be necessary in order to determine if any consistencies exist
between frequently occurring types of alter personalities and psychophysiological
patterns.
Since there is still skepticism about the "reality" of this disorder, it is partic-
ularly critical to develop valid techniques to test the limits of communication across
identities in relation to their purported degree of awareness of one another. Like-
wise, the issue of what sorts of information are communicated across amnestic
states in DID is an important one, and psychophysiological methods may be very
useful tools in addressing the problem. It may be observed that the conditions for
the use of the emotional word paradigm-namely, that different personalities have
uniquely emotional words-might not be able to be met in every case. However,
this paradigm can be seen as a variant of what is known as the Guilty Knowledge
Test (Lykken, 1981) used in the detection of deception in criminal cases. In this
method, a suspect, while hooked up to a polygraph, is queried about details of the
crime that only the criminal could know (i.e., was the victim wearing a red dress?),
so that larger reactions to questions about these details compared to equally
plausible but untrue alternatives (was the victim wearing slacks?) indicate famil-
iarity and thus guilt. This technique, of course, does not detect lying per se, but
simply reflects the obvious and well-established finding that psychophysiological
reactions to more significant stimuli are larger than those to less significant ones.
This technique might be used to test the psychophysiological "recognition" ofthe
life experiences of one personality by an amnestic alternate personality. Laboratory
tests using this approach have been well developed (see Ben-Shakhar & Furedy,
1990) and could be adapted for use with DID patients. In both of these approaches, 285
and also if transfer of conditioning is the method of choice, it would seem important Psychophysiological
to study the level of complexity of the information whose transmission is to be Assessment
tested for. In this way one might learn something useful about a given patient, about
DID patients in general, and even be informed about unconscious cognition in
normal subjects. Much more work along these lines needs to be done before a
definitive two-way test of the validity of the existence of mutually amnestic identi-
ties on a case-by-<:ase basis can be devised. Similarly, there is much current interest
and development in the general problem of unconscious information processing,
and as this field develops, a deeper understanding of the processes involved in
dissociative disorders will be possible.

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v
DIAGNOSTIC
CLASSIFICATIONS

lbis section is the most formal part of the handbook. The first three chapters
describe the specified dissociative disorders of DSM-IY. These include depersonal-
ization and derealization, amnesia, fugue, and dissociative identity disorders.
DSM-III included depersonalization and derealization without depersonalization
as a separate disorder, whereas in DSM-IY, only depersonalization is listed as a
dissociative disorder.
In Chapter 14, Coons point out that although the term was coined in the 1890s,
little is known about the epidemiology of depersonalization. What we do know
suggests that depersonalization is experienced by 80 percent of the general popula-
tion at some time and in some form and is the third most common psychiatric
symptom after depression and anxiety.
In Chapter 15, a discussion of amnesia and fugue is presented by Loewenstein.
1bis chapter updates earlier reviews by Loewenstein, demonstrating the strong
connection between trauma and amnesia. In terms of this discussion, three other
issues are raised: (1) the historical relationship and differentiation between the
construct of repression and that of dissociation; (2) the nature of amnesia described
by each; and (3) the influence the legal system has had on the question of trauma,
amnesia, and one's ability to remember past events. Finally, the question of treat-
ment is considered.
Dissociative identity disorder is the focus of Chapter 16. In this chapter, Kluft
traces the history of the disorder, including the first modem description of it in
1787. Although until recently considered a North American disorder, Kluft reports
its existence throughout the world. As can be seen from this chapter, great debate
has been associated with the disorder even within the DSM-N committee itself. The
question of what exactly is an "identity" is one of the core issues of this chapter.
Phenotl)enologically, DID patients display approximately two to four identities at
the time of diagnosis, although more identities may become apparent within
treatment. An important discussion in this chapter describes the course of the
disorder as well as the models that have been presented to understand DID.
During the past few years there has been a proposal to consider a new DSM 289
290 diagnosis, that of acute stress disorder. Chapter 17, by Koopman and her colleagues,
Diagnostic raises this possibility and begins to forge the links between dissociative disorders
Classifications and stress and trauma situations such as PTSD. Using the 1991 Oakland/Berkeley
fire, these researchers present empirical support to suggest that a combination of
dissociative and anxiety symptoms is able to define a diagnosis of acute stress
disorder.
The final chapter of the section continues the discussion of posttraumatic
response and describes the final dissociative disorder-dissociative disorder, not
otherwise specified. How to treat dissociation and abuse is a question that has been
discussed throughout the book and will continue in great detail in the next section.
In this chapter, Chu revisits the complex question of how to treat abuse and
describes the early, middle, and later stages of treatment.
14
Depersonalization and
Derealization
Philip M. Coons
How did I know that someday-at college, in Europe, some-
where, anywhere-the bell jar, with its stifling distortions,
wouldn't descend again?
Sylvia Plath,
The Bell jar (1971)

INTRODUCI10N

Depersonalization and derealization consist of altered perceptions about the self

and the environment. Both of these phenomena may be symptoms of a wide variety
of psychiatric disorders with exceedingly diverse etiologies. Both depersonaliza-
tion and derealization without depersonalization are listed as dissociative disorders
in the Diagnostic and Statistical Manual ofMental Disorders, 4th Edition (DSM-
IV) (American Psychiatric Association, 1994).
The scientific literature on both depersonalization and derealization is sparse.
Only 150 references are listed for both in an extensive bibliography on the dissocia-
tive disorders (Goettman, Greaves, & Coons, 1990); of these, only eight refer to
derealization, and only two of these refer to derealization unaccompanied by
depersonalization.

Philip M. Coons • Department of Psychiatry, Indiana University School of Medicine, Indianapolis,

Indiana 46202.
Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 291
292 Very little is known about the epidemiology of either depersonalization dis-
Phillp M. Coons order or derealization without depersonalization. In fact, the existence of the
psychiatric syndrome of derealization without depersonalization has recently been
challenged (Coons, 1992). Until the recent introduction of selective serotonin
reuptake inhibitors, the treatment of depersonalization disorder was problematic.
The remainder of this chapter will outline what is known about depersonaliza-
tion and derealization. Sections include history, definition, diagnosis, differential
diagnosis, epidemiology, etiology, a typical case example, treatment, and future
directions in research.

IHSTORY

Dugas (1898) coined the term "depersonalization" to describe what Krishaber

had called "cerebro-cardiac neurosis" in 1872 (as quoted in Ackner, 1954a). Al-
though numerous nineteenth- and early twentieth-century luminaries in psychol-
ogy, such as Ribot, Oestrreich, Bleuler, Freud, Breuer, and Janet, briefly com,mented
on the phenomenon or listed it as a symptom in nLilllerous celebrated cases, scant
attention was paid to it in textbooks until depersonalization was officially listed as a
psychiatric diagnosis in the DSM-III (American Psychiatric Association, 1980).
There were about a dozen papers on depersonalization between 1930 and
1960. Mayer-Gross (1935) began the modern study of depersonalization with his
classical paper in which he described 26 patients. Eleven years later, Shorvon (1946)
described an additional66 patients, and 8 years after that, Ackner (1954a,b) pub-
lished a series with an additional 54 patients.
Since the 1960s, there has been a steady increase of papers on depersonaliza-
tion to about 30-40 per decade. In the early 1960s, interest in depersonalization
was ignited by Roth's (1959) description of the phobic anxiety-depersonalization
syndrome. Interest in depersonalization was kept alive by Sedman's writings in the
1960s (Sedman, 1966; Sedman & Kenna, 1963; Sedman & Reed, 1963), studies by
Noyes and his colleagues on trauma and depersonalization in the 1970s (Noyes,
Hoenk, Kupperman, & Slymen, 1977; Noyes & Kletti, 1977), and Torch's (1987)
writings on the psychotherapy of depersonalization in the 1980s. Most recently,
Hollander and his colleagues (1990) have discussed the psychopharmacological
treatment of depersonalization.

DEFINITIONS

DepersonaUzation
The DSM-IV (American Psychiatric Association, 1994, p. 488) defines the
symptom of depersonalization as "a feeling of detachment or estrangement from
one's self." Depersonalization can take many forms, but only two are listed in the
DSM-IV: "a feeling of detachment from one's self" combined with "a sensation of
being an outside observer of one's body" (i.e., an out-of-body experience) and
"feeling like an automaton or as if he or she is living in a dream" (p. 488). Other 293
examples of depersonalization include emotional numbing, feeling as if one were in Depersonalization
a fog or a trance, not recognizing one's self in the mirror, feeling that behavior or and Derealization
emotions are not under the individual's control, or feeling like body parts are
detached, absent, unreal, foreign, or changed in size (Simeon & Hollander, 1993;
Steinberg, 1993a).
Jacobs and Bovasso (1992) described five subtypes of depersonalization. The
first is inauthenticity, or the loss of genuineness in the experience of the self. The
second, derealization will be described below. The third is self-objectification,
wherein "the world is experienced as rapidly changing and basic distinctions
between the self and objects are blurred" (p. 353). The fourth, or self-negation,
"involves denial that one is performing certain actions or that one is witnessing
certain events occurring in the environment" (pp. 353-354). In the fifth type of
depersonalization, body detachment, there is the perception that the body is
distorted or detached.

Derealization
The DSM-III-R (American Psychiatric Association, 1987, p. 269) defines dereal-
ization as "an alteration in the perception of one's surroundings so that a sense of
the reality of the external world is lost." Examples of derealization include feeling
that people or surroundings are fading away or disappearing or are unreal or foreign
and the inability to recognize friends, relatives, or familiar surroundings (Steinberg,
1993a,b).
Derealization is distinct from depersonalization. It is not a subset of deperson-
alization as some investigators have asserted (American Psychiatric Association,
1984; Jacobs & Bovasso, 1992; Sedman, 1966). An easy way to make the distinction
between depersonalization and derealization is to remember that depersonalization
is a feeling of estrangement from or unreality about the self while derealization is a
feeling of estrangement from or unreality about the environment (i.e., anything
outside the self).

TRANSIENT DEPERSONALIZATION

Depersonalization may occur either as a transient symptom or a syndrome

called depersonalization disorder in which the depersonalization is severe, pro-
longed, and causes marked distress. As symptoms, depersonalization and dereal-
ization may occur in a variety of psychiatric and medical disorders (American Psy-
chiatric Association, 1987, 1994). These symptoms are usually transient, but
occasionally prolonged depersonalization is seen with marijuana abuse.
Depersonalization and derealization are common symptoms in dissociative
disorders (American Psychiatric Association, 1987, 1994; Steinberg, 1993a,b), in-
cluding multiple personality disorder (MPD) (Coons, Bowman, & Milstein, 1988;
Loewenstein, 1991; Putnam, Guroff, Silberman, Barban, & Post, 1986), psychogenic
amnesia (Coons & Milstein, 1992), and dissociative disorder not otherwise specified
294 (DDNOS) (Coons, 1992). They also occur in schizophrenia (Bezzubova, 1991;
Philip M. Coons Rosenfeld, 1947; Seelman & Kenna, 1963); severe affective disorders including major
depression with psychosis and bipolar disorder (Blank, 1954; Seelman & Reed, 1963;
Thcker, Harrow, & Quinlan, 1973); agoraphobia and panic disorder (Ambrosino,
1973; Cassano et al., 1989; Hollander, Fairbanks, Decaria, & Liebowitz, 1989; James,
1961; Roth, 1959; Shraberg, 1977); posttraumatic stress disorder; personality disor·
ders including schizotypal personality disorder, borderline personality disorder
(Hunter, 1966), and obsessive personality disorder (Seelman & Reed, 1963; Torch,
1978); substance abuse disorders involving marijuana (Mathew, Wilson, Hum-
phreys, Lowe, & Weithe, 1993; Melges, Tinklenberg, Hollister, & Gillespie, 1970;
Moran, 1986; Szymanski, 1981), and the hallucinogens LSD (Waltzer, 1972) and
mescaline (Guttmann & Maclay, 1936). A wide range of conditions associated with
medical or neurological illnesses (Pies, 1991) and the use of a wide variety of
different medications can also result in depersonalization and derealization.
Medical or neurological conditions associated with depersonalization include
hyperventilation, migraine headaches, temporal lobe epilepsy (Devinsky, Feld-
mann, Burrowes, & Bromfield, 1989; Harper & Roth, 1962; Kenna & Seelman, 1965),
temporal lobe tumors, fever, delirium, cerebral trauma (Grigsby, 1986), cere-
brovascular disease, encephalitis, Alzheimer's disease, Huntington's chorea, Men-
iere's disease (Grigsby & Johnson, 1989), hypopituitarism, and hypothyroidism.
Medications that cause depersonalization include fluoxetine (Black & Wojeieszek,
1991), fluphenazine (Musa & Wollcott, 1982) and other antipsychotics, anxiolytics,
and indomethacin (Schwartz & Moura, 1983). Withdrawal from nitrazepam has also
been implicated (ferao, Yoshimura, Terao, & Abe, 1992).
Other nonmedical causes of depersonalization include brainwashing, hypnosis
(Wineberg & Straker, 1973), sleep deprivation, sensory deprivation (Horowitz,
1964; Reed & Seelman, 1964), exposure to trauma (Noyes et al., 1977; Noyes &
Kletti, 1977; Rosen, 1955), and relaxation-meditation (Castillo, 1990; Edinger, 1985;
Fewtrell, 1984; Kennedy, 1976; Signer, 1988).

DEPERSONALIZATION DISORDER

Diagnostic Criteria
The diagnostic criteria of depersonalization disorder from DSM-IV include the
following:
A. Persistent or recurrent experiences of feeling detached from, and as if one is
an outside observer of, one's mental processes or body (i.e., feeling like one
is in a dream).
B. During the depersonalization experience reality testing remains intact.
C. The depersonalization causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The depersonalization experience does not occur exclusively during the
course of another mental disorder, such as Schizophrenia, Panic Disorder,
Acute Stress Disorder, or another Dissociative Disorder, and is not due to the
 physiological effects of a substance (e.g., a drug of abuse, a medication) or a 295
general medical condition (e.g., temporal lobe epilepsy) (American Psychi-
Depersonallzation
atric Association, 1994, p. 490). and Derealization

Epidemiology
Depersonalization disorder has been reported in adolescents (Meares & Grose,
1978; McKellar, 1978; Meyer, 1961; Munich, 1977; Shimizu & Sakamoto, 1986). Only
two cases have been reported in children, one, a 10-year-old boy who felt "as if
I were always dreaming, and I didn't realize whether I was there or not" (Shimizu &
Sakamoto, 1986, p. 605), and the other, an 8-year-old boy, who felt "... a ghost
feeling ... like a machine ... " (Fast & Chethik, 1976, p. 484). Interestingly, a number
of patients with depersonalization disorder retrospectively report the onset of their
symptoms in childhood anywhere from age 5 to 10 years (Fast & Chethik, 1976).
Transient depersonalization has been reported in both children (Elliott, Rosenberg,
& Wagner, 1984) and adolescents (Dixon, 1963). The rarity of depersonalization and
derealization in children may reflect the child's inability to abstract and adequately
describe these phenomena.
In Mayer-Gross's (1936) pioneering study of 26 patients, there were six patients
between the ages of 30-39 years, two under 20, and the rest in their 20s. Their
mean age was 26.6 years. Not all of his patients may have had genuine depersonal-
ization disorder since there were 12 with depression and 6 with schizophrenia. In
Shorvon's (1946) series, the ages of onset ranged from 10 to 38 years with a mean
age of onset of about 24 years. Chee and Wong (1990) found an age range of 25 to 47
years with a mean age of onset of 25 years.
Although depersonalization is an apparently uncommon psychiatric disorder
whose precise incidence in the general population is unknown, the symptom of
depersonalization is the third most common psychiatric symptom after depression
and anxiety (Cattel, 1966). Depersonalization is experienced by 80% of the general
population (Probst & Jansen, 1991), 12-56% of normal college students (Dixon,
1963; Myers & Grant, 1970; Trueman, 1984), and 40-80% of psychiatric inpatients
(Brauer, Harrow, & Tucker, 1970; Noyes et al., 1977). Differences in reporting
statistics on depersonalization probably are caused by the use of different phraseol-
ogy in asking about depersonalization.
The sex ratio of those experiencing depersonalization and depersonalization
disorder is unclear. Of supposedly genuine cases of depersonalization, Mayer-Gross
(1935) reported a 4:1 female:male ratio, and Shorvon (1946) reported a 2:1 ratio. Of
normal college students experiencing the symptom of depersonalization, Roberts
(1960) reported a 3:1 ratio in favor of females, Myers and Grant (1970) reported a
2:1 preponderance of men over women, and Dixon (1963), Sedman (1966), and
Chee and Wong (1990) found no sex differences. Of the available reports of de-
personalization in adolescents, there is an approximately equal sex incidence.
Unfortunately, no large studies of patients with depersonalization disorder have
occurred since the introduction of the DSM-m, so the precise sex ratio of patients
with genuine depersonalization disorder is unknown.
There is no known familial pattern of inheritance for those with depersonal-
ization disorder.
296 Qinical Features
Philip M. Coons
Depersonalization disorder is characterized by persistent or recurrent symp-
toms of depersonalization severe enough to cause marked distress. It may not be
diagnosed in the presence of schizophrenia, panic disorder, multiple personality
disorder, or temporal lobe epilepsy. Symptoms of depersonalization are ego-
dystonic and reality testing remains intact. Although the onset of depersonalization
disorder is described as usually rapid, Shorvon (1946) and Chee and Wong (1990)
found that onset was gradual in 3 and 33% of cases, respectively.
Derealization symptoms are frequently present with depersonalization dis-
order. Depression and obsessionality also frequently accompany depersonalization
disorder (Grinberg, 1966; Lower, 1972; Sedman & Reed, 1963; Torch, 1978). Suicide
attempts are frequent with depersonalization, and occasionally the feelings of
depersonalization may be so distressing that successful suicide results (Chee &
Wong, 1990). Somatization, dizziness, time distortion, and a fear of becoming insane
may also be present (American Psychiatric Association, 1987). The course of deper-
sonalization disorder is chronic. Remissions and exacerbations are common.
Individual case reports reveal that predisposing factors may include military
combat, severe auto accidents, or some other type oftrauma. However, most of the
older case reports do not list trauma as a precipitating factor.

Diagnostic Aids
Two recent diagnostic instruments, the Dissociative Experiences Scale (DES)
(Bernstein & Putnam, 1986) and the Structured Clinical Interview for Dissociative
Disorders (SCID-D) (Steinberg, 1993a,b), have been introduced for use in diagnos--
ing dissociative disorders.
The DES is a self-administered screening instrument for dissociative symptoms.
It consists of 28 questions about depersonalization, derealization, amnesia, fugue,
absorption phenomena, identity confusion, and identity alteration. It requires
about 10-15 minutes to complete. Scores range from 1-100. Scores above 20 are
thought to be significant. Normals score in the 0-10 range, with adolescents
somewhat higher. Scores are elevated for those with schizophrenia, borderline
personality disorder, dissociative disorders, and posttraumatic stress disorder.
The SCID-D is a structured clinical interview used for assessing dissociative
symptoms. There are sections on amnesia, depersonalization, derealization, iden-
tity confusion, and identity alteration as well as a number of follow-up sections if the
examiner desires more information. The interview takes anywhere from 30-90
minutes to administer depending on the degree of dissociative psychopathology
present. After the interview is complete, the examiner rates each of the five
dissociative areas on a 1- to 4-point scale. A decision is then made on a dissociative
disorder diagnosis based on DSM-IV criteria.

Differential Diagnosis
The differential diagnosis of depersonalization is vast. All of the transient
causes of depersonalization must be considered. A thorough review of psychiatric,
medical, family, and social histories is indicated in addition to a physical and 297
neurological examination and mental status examination. Screening blood chemis- Depersonalization
tries such as a complete blood count, thyroid function tests, chemical profiles, and and Derealization
drug screens may be indicated. Electroencephalogram (EEG), computerized tomog-
raphy, or magnetic resonance imaging of the head may be indicated as well.
The diagnosis of depersonalization disorder may not be made if the deperson-
alization is not persistent and does not cause marked distress. Since depersonaliza-
tion disorder is quite uncommon, perhaps even rare, the clinician will usually find
that depersonalization symptoms are due to some other more common disorder
such as schizophrenia, panic disorder, multiple personality disorder, dissociative
disorder not otherwise specified, borderline personality disorder, temporal lobe
epilepsy, or medication use.

Etiology
The etiology for depersonalization symptoms is as diverse as the differential
diagnosis. It is likely that depersonalization symptoms are produced by a bewilder-
ing variety of biological and psychological agents acting through one final common
pathway: the temporal lobe and its various cerebral connections. More specifically,
serotonergic dysfunction has recently been suggested as the mechanism whereby
depersonalization symptoms are produced (Hollander et al., 1989, 1990).
The psychological triggering of depersonalization is well known. Emotional
stress caused by a variety of situations, including natural or human-made traumas,
overwhelming anxiety, conflict over anger or sexuality, or painful depressive affect,
causes patients with severe dissociative disorders such as multiple personality
disorder and dissociative disorder not otherwise specified to depersonalize and
even to dissociate into another ego state. Such a switch has been postulated to serve
as a defensive function to protect the individual against overwhelming anxiety
regarding conflicted impulses or painful affects (Feigenbaum, 1937; Kluft, 1987).
Based on improvement of depersonalization in patients treated with clozapine and
benzodiazepines, Nuller (1982) has postulated that depersonalization occurs as a
result of anxiety.

Treatment
The treatment for dissociative symptoms caused by the various psychiatric and
medical conditions listed previously should follow the treatment of the underlying
psychiatric or medical condition. Fortunately, depersonalization symptoms due to
these other conditions are usually transient, so no specific treatment is necessary
other than education, support, and reassurance that the depersonalization will
resolve.
The treatment of depersonalization disorder is more problematic. A wide
variety of treatments have been attempted, including electroconvulsive ther-
apy, anxiolytics, antipsychotics, stimulants, antidepressants, behavior therapy, and
psychotherapy. Because depersonalization disorder is so rare and may sponta-
neously remit, no large controlled studies of therapeutic efficacy have been under-
taken.
298 Behavior Therapy. Blue (1979) described a 50-year-old woman with deper-
PbiUp M. Coons sonalization who successfully responded to a six-session behavioral approach con-
sisting of establishing a baseline on dissociative symptoms through record keeping,
then recording feelings and activities associated with the depersonalization, and
finally involving behavioral prescriptions including paradoxical intention. Previous
treatment with 16 different psychopharmacological agents had been unsuccessful.
Sookman and Solyom (1978) reported two cases. A 48-year-old woman experi-
enced marked reduction of depersonalization through 20 1-hour flooding treat-
ments using fantasy over a 10-week period. A 40-year-old man was treated with a
combination of flooding through fantasy and paradoxical intention. His depersonal-
iZation symptoms diminished enough for him to return to work, but did not entirely
disappear.

Psychopharmacotherapy. Traditional Anttpsycbotics, Electroconvulsive

Therapy, and Other Heroic Treatments. Electroconvulsive therapy, traditional anti-
psychotic medication, and other heroic treatments including continuous narcosis,
leucotomy, vasodilators, metrazol, and insulin therapy have all been tried for deper-
sonalization disorder. None have shown much benefit, except in rare single cases
(Shorvon, 1946).
Stimulants. Both Shorvon (1946) and Davison (1964) found that a one-time
intravenous administration of amphetamines could abort an episode of depersonal-
ization disorder. About half of the patients treated with amphetamines responded
to such treatment, and, of these, about half quickly relapsed.
Antidepressants. Tricyclic antidepressants are sometimes useful in the treat-
ment of depersonalization disorder (Walsh, 1975; Noyes, Kupperman, & Olson,
1987). More recently treatment with selective serotonin reuptake inhibitors has
shown surprising success. Hollander et al. (1990) treated eight patients (five women
and two men) with fluoxetine; six were very much improved and two were only
minimally improved on dosages of fluoxetine that ranged from 5 to 80 mg/day.
Anxiolyttcs and Novel Antipsychotic Medication. Nuller (1982) reported on
57 patients with depersonalization, some of whom had an accompanying depres-
sion and some who had previously experienced acute psychosis. Forty-two were
treated with phenazepam and 15 were treated with clozapine. Of those treated with
clozapine, nine improved and six did not. Of those treated with phenazepam, 13
experienced complete remission, 21 experienced moderate to considerable im-
provement, and 8 experienced no improvement.
Recently Stein and Uhde (1989) reported a single patient, a 28-year-old woman,
who responded in a single-blind study to the benzodiazepine anticonvulsant
clonazepam, but not to carbamazepine. Symptoms worsened upon challenge with
caffeine while on both study drugs but not while on placebo.

Psychotherapy. Torch (1987) is a strong advocate of the use of psycho-

dynamic psychotherapy. Torch believes that depersonalization develops as a result
oflow self-esteem and a compensatory hypervigilance in which the self serves as an
obsessional focus. The individual's low self-esteem is postulated to result from an
inability to satisfy excessive parental demands. Successful treatment occurs by
attending to self-esteem issues and transferring responsibility for feelings of worth- 299
lessness back to the parents. Depersonallzation
Schilder (1939) perhaps best summarizes the effects of dynamic psycho- and Dereallzation
therapy. He indicates that psychotherapy for depersonalization is difficult, time-
consuming, does not always work, and does not prevent relapses. However, the
positive results achieved in some patients make this a technique that should be
considered when supportive and psychopharmacological measures fail.

Treatment Precautions. Numerous clinicians have observed that deper-

sonalization disorder is frequently accompanied by depression and suicidal behav-
ior. Chee and Wong (1990) found that almost half of the nine patients in their series
had attempted suicide and one was eventually successful. Although the precise
suicide rate in depersonalization disorder is unknown, the clinician should be
aware that suicide attempts are extremely common and should take appropriate
precautions.
Because depersonalization disorder has frequently been associated with affec-
tive disorders, the clinician should be especially cautious when treating with
stimulants or antidepressants. Liebowitz, McGrath, and Bush (1980) described two
young women, a 21-year-old and a 17-year-old, who became floridly psychotic after
being treated with moderately large doses of dextroamphetamine (30 mg/day) and
amitriptyline (300 mg/day), respectively. Therefore, the clinician should be careful
to inquire about previous symptoms of mania and take a family history for recurrent
affective disorder prior to instituting treatment with stimulants or antidepressants.

Case Example
Mrs. Brown (not her real name) was a 32-year-old married woman with a lOth
grade education. She was born in the South of Catholic parentage. In her early 20s
she had a 3- or 4-month period of depersonalization that was not severe enough to
require treatment. She had been steadily employed as a factory worker since age
19. She married at age 20 a truck driver who was employed intermittently and
abused alcohol. They had two children. The marital relationship was distant, partly
due to Mrs. Brown's aloof, almost schizoid personality traits.
Her current psychiatric illness had no obvious precipitant and was charac-
terized by a 6-month period of pervasive and unremitting depersonalization. Associ-
ated symptoms included headaches and dizziness. She described her symptoms as
follows:
I don't feel anything. It's like I'm on a bad, bad trip and everything feels like a
shell with nothing inside. Only my mind is working. My face and arms feel
numb. It's like being in a fog. I feel empty.

Although she denied feeling depressed, she experienced fatigue, guilt, low self-
esteem, and had tried to kill herself in order to escape the extremely dysphoric
feelings of depersonalization. Family history revealed that both her father and
brother had suffered from depression and that her brother and both grandfathers
were alcoholic.
300 Prior to her referral to a tertiary-care, psychiatric research hospital, her psychi-
Philip M. Coons atrists had tried a wide array of therapeutic doses of antipsychotics, anxiolytics, and
antidepressants including haloperidol, thioridazine, nortriptyline, amitriptyline,
doxepin, maprotiline, trazodone, lithium carbonate, carbamazepine, bupropion,
diazepam, and lorazepam. A course of ten bilateral electroconvulsive treatments
had also been unsuccessful.
Her referring psychiatrists were not really sure of her diagnosis; by the time she
reached our hospital, she had been labeled with major depression, agoraphobia,
bipolar disorder, dysthymic disorder, schizotypal personality, borderline person-
ality, passive aggressive personality, and dependent personality. She had never
shown any psychotic symptoms nor symptoms of panic disorder.
Further history revealed that she had been sexually abused by an uncle for
about a year when she was 7 or 8. From age 16 to 18 she had abused alcohol and
marijuana. During a move 5 years previously she had experienced a 2-day period of
amnesia. However, she had never experienced fugues or symptoms characteristic
of multiple personality.
Her physical and neurological examinations were normal, as were an EEG and
computed tomography scan. Laboratory tests including a urinalysis, complete
blood count, a chemistry-24 panel, thyroid function tests, and VDRL were all
negative. Psychological testing revealed an IQ of 110, absence of a thought disorder
and signs of organicity, but evidence of a mixed personality disorder.
She was placed on desipramine, involved in ward activities and occupational
therapy, and treated with supportive psychotherapy. A brief try of marital therapy
was ineffective due to her husband's refusal to return after three sessions. Her
symptoms gradually remitted and she was discharged to return to her factory job.
No follow-up information is available.

Comment. This case represents a classic case of depersonalization disorder.

Her first episode began in her early 20s. Depersonalization symptoms were perva-
sive, unremitting, and caused marked distress and dysfunction. Associated symp-
toms included headaches, dizziness, and depression. Onset of her illness was rapid
with a gradual remission. No evidence was present for the diagnoses of schizo-
phrenia, panic disorder, multiple personality, epilepsy, or other forms of organic
brain dysfunction. It is not known whether her remission was simply spontaneous
or was brought about by treatment with desipramine.

DEREALIZATION UNACCOMPANIED BY DEPERSONAIJZATION

In the seven available case reports or studies on derealization (Fast & Chethik,
1976; Fleiss, Gurland, & Goldberg, 1975; Krizek, 1989; Rosen, 1955; Sarlin, 1962;
Selinsky, 1968; Trueman, 1984), six patients, three adults and three children, are
mentioned. Analysis of these case reports reveals that five experienced both dereal-
ization and depersonalization and one experienced depersonalization only.
Trueman's study (1984) was a nonclinical sample of 221 undergraduate stu-
dents: 30.1% reported depersonalization experiences, 28.3% reported derealization
experiences, and 25.7% reported both types of experiences. Trueman reported that
some students experienced derealization without depersonalization, but failed to 301
indicate the exact number or percentage. Depersonalization
Shorvon (1946) and Chee and Wong (1990) reported on 61 and 9 cases of and Derealization
depersonalization disorder, respectively. Although both found that derealization
could accompany depersonalization, neither found any cases of derealization unac-
companied by depersonalization. 1n the extensive review of the literature con-
tained in this chapter, no cases of the disorder of derealization unaccompanied by
depersonalization were found.
Neither the DSM-111-R nor the DSM-IV (American Psychiatric Association, 1987,
1994) contain a clinical description of derealization unaccompanied by depersonal-
ization, although both list this disorder under dissociative disorder not otherwise
specified. Because of the lack of a single case of derealization unaccompanied by
depersonalization, it would be best to list this as a possible syndrome in an appen-
dix (Coons, 1992).

FUTURE DIRECTIONS IN RESEARCH

Because of the rarity of depersonalization disorder, little is known about

etiology, prevalence, predisposing factors, associated features, familial patterns,
and treatment. No studies of depersonalization disorder have been published that
have used either the DES as a screening instrument or the SCID-D as a study
instrument. The question of whether derealization unaccompanied by depersonal-
ization exists remains unanswered. Regarding treatment, there is one open study
using serotonin reuptake blockers to treat depersonalization disorder in eight
patients (Hollander et al., 1990) and one single-blind study using clonazepam in a
single patient.
Because of the rarity of depersonalization disorder, the only conceivable way
to study it is with a multicenter approach whereby patients with depersonalization
are recruited from dissociative disorder programs throughout North America. Clear
inclusion and exclusion criteria should be established, especially for derealization.
Patients enrolled in such studies should have a thorough psychiatric evaluation
including psychiatric, medical, family, and social histories, mental status examina-
tion, physical and neurological examinations, blood chemistries, EEGs, neuropsy-
chological testing, administration of the DES, SCID-D, and other structured inter-
views such as the SCID. The treatment of these patients would then be followed
prospectively in a double-blind fashion.

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15
Dissociative Amnesia and
Dissociative Fugue
Richard ]. Loewenstein

INTRODUCTION

In 1991, I published a comprehensive review of dissociative (psychogenic) amnesia

(DA) and dissociative (psychogenic) fugue (DF), emphasizing the relationship of
these conditions to overwhelming psychological trauma (Loewenstein, 199lb).
Since the publication of that work, several additional studies have been published
that support the basic premises of that review. Also, I have recently published a
review of treatment of dissociative amnesia and dissociative fugue (Loewenstein,
1995). In addition, however, there has arisen an intense public and academic
controversy about the validity of delayed adult recollections of childhood traumatic
events, particularly those for which the individual reports prior amnesia (Loftus,
1993). Further, critics of the dissociation-trauma model have questioned whether
DA for traumatic events ever occurs (McHugh, 1992). This chapter will update the
prior review. In addition, however, I will discuss issues in the current controversy
over the delayed recollection of traumatic events.

DIAGNOSTIC CRITERIA

The diagnostic criteria for DA and DF are found in Table I (American Psychi-
atric Association, 1994). The Diagnostic and Statistical Manual of Mental Dis-

Richard). Loewenstein • Dissociative Disorders Service Line, Sheppard Pratt Health Systems, Bal-
timore, Maryland 21285; and Department of Psychiatry and Behavioral Sciences, Universiry of Maryland
School of Medicine, Baltimore, Maryland 21201.
Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 307
308 Table 1. DSM-IV Diagnostic Criteria for Dissociative Amnesia and Dissociative
Richardj. Fugue"
Loewenstein
Diagnostic criteria for dissociative amnesia
1. The predominant disturbance Is one or more episodes of inability to recall important personal
information, usually of a traumatic or stressful nature, tbat Is too extensive to be explained by
ordinary forgetfulness.
2. The disturbance does not occur exclusively during tbe course of dissociative identity disorder,
dissociative fugue, posttraumatic stress disorder, acute stress disorder, or somatization disorder and is
not due to tbe direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a
neurological or otber general medical condition (e.g., amnestic disorder due to head trauma).
3. The symptoms cause clinically significant distress or impairment In social, occupational, or otber
important areas of functioning.

Diagnostic criteria for dissociative fugue

1. The predominant disturbance is sudden, unexpected travel away from home or one's customary
place of work, witb inability to recall one's past.
2. Confusion about personal identity or assumption of a new identity (partial or complete).
3. The disturbance does not occur exclusively during tbe course of dissocjative identity disorder and is
not due to tbe direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a
general medical condition (e.g., temporal lobe epilepsy).
4. The symptoms cause clinically significant distress or impairment In social, occupational, or otber
important areas of functioning.
"Reprinted by permission from the Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition. Copyright
1994 American Psychiatric Association.

orders, 4th edition (DSM-IV) criteria for DA differ from DSM-m-R version in that the
relationship to traumatic events and the chronic, recurrent nature of this condition
are emphasized. The DSM-IV criteria for DF have changed in that they no longer
require the development of an alternate identity at the termination of a fugue. Both
of these changes were supported by recent systematic data or by expert consensus
(Coons & Millstein, 1992).

Types of Dissociative Amnesia

Following Janet (1901), the discussion of amnesia in DSM-IV describes several
types of disturbance in the process of recall in this disorder. These are listed in Table
2. In addition, there are a variety of disturbances in the content of memory that
characterize DA, most of which are forms of localized, selective, and systematized
amnesias (fable 3). Many patients meeting diagnostic criteria for DA or DF will
actually have a far more extensive history of amnesia, fugue states, and dissociation
if closely questioned in the clinical interview or followed up longitudinally. Thus,
they will ultimately meet diagnostic criteria for dissociative identity disorder (DID)
or dissociative disorder not otherwise specified (DDNOS) (Kluft, 1985). For a full
discussion of the clinical presentation of individuals with complex forms of disso-
ciative amnesia, see Loewenstein (1991a,b).
Table 2. Types of Dissociative Amnesia" 309
Localized amnesia: Inability to recall events related to a circumscribed period of time. Dissociative
Selective amnesia: Ability to remember some, but not all, of tbe events during a circumscribed period Amnesia and
of time. Dissociative Fugue
Generalized amnesia: Failure to recall tbe whole life of tbe patient.
Continuous amnesia: Failure to recall successive events as tbey occur.
Systematized amnesia: Amnesia for certain categories of memory such as all memories relating to one's
family or a particular person.
"From American Psychiatric Association (1994), janet (1901), Loewenstein (1991b).

EPIDEMIOLOGY

Using the Dissociative Experiences Scale (DES) (Bernstein & Putnam, 1986)
and the Dissociative Disorders Interview Schedule (DDIS) (Ross, Heber, Norton, &
Anderson, 1989), Ross (Ross, 1991; Ross, Joshi, & Currie, 1990) examined 1005
randomly selected people from the general population of Wmnipeg, Canada. In
this study, the lifetime prevalence of a dissociative disorder was 11.2%. When over
half the respondents were followed up with the DDIS, about 7.0% of the sample met
criteria for DA. Less than 1% met criteria for DE DA was the most prevalent
dissociative disorder in this sample. DF may be more common in settings where
war or other forms of extreme social dislocation and violence are common (Put-
nam, 1985).
These data need replication in studies using more rigorous methodology (e.g.,
clinical examination of respondents given the DDIS, etc.). However, the prevalence
figure for all dissociative disorders is comparable to those reported in population
studies of individuals with posttraumatic stress disorder (Breslau, Davis, Andreski,
& Peterson, 1991; Davidson & Fairbank, 1993). Similarly, these prevalence figures
are consistent with the known high rates of childhood abuse and trauma as well as
adult traumatic experiences found in the general population (Breslau et al., 1991;
Davidson & Fairbank, 1993; Russell, 1983; van der Kolk, 1993).

CONCEPfUAL ISSUES

Amnesia is a specific disorder and also a diagnostic criterion for other dis-
orders. In DSM-IV (American Psychiatric Association, 1994), amnesia is one of the
diagnostic criteria for DID (previously known as multiple personality disorder, or
MPD). It is also among the DSM-IV diagnostic criteria for somatization disorder
(SD), acute stress disorder (ASD), and posttraumatic stress disorder (PTSD). This
reflects the repeatedly described correlation of dissociative symptoms with trau-
matic or overwhelmingly stressful life events. Also, somatization and somatoform
disorders are common in individuals with a history of trauma and vice versa
(Bowman, 1993; Loewenstein, 1990; Saxe et al., 1994; Walker, Katon, Harrop-
Griffiths, Holm, & Russo, 1988; Walker, Katon, Neraas, }emelka, & Massoth, 1992;
310 Table 3. The Experience of I>Jssociative Amnesia"
Richard}. Blackouts or "time loss"
Loewenstein Reports of disremembered behavior
Appearance of unexplained possessions
Perplexing changes in relationships
Fragmentary recall of the life history
Evidence of unusual fluctuations in skills, habits, tastes, knowledge
Fuguelike episodes
Recurrent, unexplained mistaken identity experiences
Brief, trancelike amnesia episodes ("microamnesias")
"From Loewenstein (199la,b), Steinberg (1993, 1994).

Walker, Katon, Roy-Byrne, Jemelka, & Russo, 1993). In fact, the DSM-IV work group
for PTSD proposed a superordinate category of the Trauma Disorders to encompass
dissociative disorders, PTSD, ASD, and possibly conversion disorder and somatiza-
tion disorder, among others (Davidson & Foa, 1993). This recommendation was not
followed in DSM-Iv, however.
Finally, amnesia can be viewed not only from a descriptive and psycho-
pathological perspective, but from an adaptational, process-oriented, psycho-
dynamic one as well. Here amnesia can be understood as a concomittant of cogni-
tive and/or intrapsychic defensive processes (Schacter & Kihlstrom, 1989; Spiegel,
1986). Discussions of amnesia and fugue in the literature often blur the distinction
between these ways of understanding dissociative phenomena, leading to impreci-
sion in conceptualization.
As discussed in my earlier writing (Loewenstein, 199lb, p. 47),
[Dissociative] amnesia can be more.broadly defined as a reversible memory
impairment in which groups of memories for personal experience that would
ordinarily be available for recall to the conscious mind cannot be retrieved or
retained in a verbal form (or, if temporarily retrieved, cannot be wholly retained
in consciousness). In addition, this disturbance is not primarily due to destruc-
tion or dysfunction of neurobiological systems and structures that subserve
memory or language but rather to a potentially reversible form of psychological
inhibition.
The diagnosis of dissociative amnesia generally connotes four factors. First,
relatively large groups of memories and associated affects have become unavail·
able, not just single memories, feelings, or thoughts (Rapaport, 1942). Second,
the unavailable memories usually relate to day-to-day information that would
ordinarily be a more-Qr-less routine part of conscious awareness: who I am, what
I did, where I went, whom I spoke to, what was said, what I thought and felt at
the time, etc. (Hilgard, 1986). Third, the ability to remember new factual
information, general cognitive functioning, and language capacity are usually
intact (lishman, 1987). Finally, the dissociated memories frequently indirectly
reveal their presence in more-Qr-less disguised form such as intrusive visual
images, somatoform symptoms, nightmares, conversion symptoms, and behav-
ioral reenactments.
Dissociation and Repression 311
Dlssodative
There are different schools of thought within academic psychology that debate Amnesia and
the existence of "repression" (Singer, 1990). In general, representatives of these DJssodative Fugue
schools do not differentiate dissociation from repression in a systematic fashion
(e.g., Loftus, 1993). This leads to additional conceptual confusion in evaluating and
comparing various theoretical and experimental works in the debate about the
existence of amnesia for traumatic circumstances.
Several of the recent popular and academic critics of the notion of posttrau-
matic dissociative amnesia for traumatic experiences neglect almost entirely the
extensive literature on dissociation and trauma, particularly that on combat vet-
erans, and rely instead on their own caricature of the psychoanalytic notion of
repression to support their views (see, for example, Ofshe & Watters, 1994). This is
an odd circumstance indeed, since many trauma researchers, theorists, and clini-
cians have found most psychoanalytic writings problematic, if not frankly inhospita-
ble, to trauma-based notions of human psychopathology (van der Kolk & Herman,
1986). Also, as is well known, since Freud's famed renunciation of the "seduction
theory," with few exceptions (e.g., Niederland, 1968, and other writers on the Nazi
Holocaust), until very recently psychoanalytic thinkers have mostly neglected and/
or discounted the importance of extreme psychological trauma in the genesis of
human psychopathology, particularly urging doubt on the veracity of claims of
paternal incest during childhood (Freud, 1933; Herman, 1981).
Conversely, psychoanalytic writers have found it difficult to fit dissociative
disorders into their theoretical system (Kluft, 1992). For example, Fisher (1945),
writing about patients with dissociative fugues associated with wartime and civilian
violence, stated that: "It does not seem ... that fugues are explicable in terms of the
usual concepts of ego and superego; that ultimately other operational principles
will have to be utilized when we know more about fugues" (p. 466).
The distinction between repression and dissociation made in this chapter
follows Rapaport (1942). In repression, single or a few memories, perceptions,
affects, thoughts, and/or images are thought to become relatively unavailable to full
conscious awareness. These are usually thought to have important but conftictual
meaning for the person. Repression can relate to many aspects of human experi-
ence and does not require extreme psychological trauma for its occurrence. Also, in
repression, large blocks of ordinary experience do not become unavailable to
consciousness along with the psychologically conftictual information. Repressed
information does not manifest itself indirectly in nightmares, flashbacks, intrusive
images, somatoform symptoms, and so forth, although psychoanalytic formulations
note the importance of slips of the tongue, dreams, and somatoform symptoms in
understanding material that has been subject to repression (Freud, 1910).
Individuals with DA are often subjectively aware of distinct gaps or deletions in
their sense of continuous memory for life history and/or experience (Steinberg,
1994). This is unusual in individuals conceptualized as manifesting repression, since
the material that is unavailable is so limited in scope.
Finally, animal research on stress and studies of combat veterans and former
prisoners of war and childhood abuse survivors. suggest that DA due to trauma may
312 have a distinct psychobiology involving alterations in the neuronal structure of the
Richard]. hippocampus, possibly due to excess glucocorticoid production (Bremner, Davis,
Loewenstein Southwick, Krystal, & Charney, 1993a; Bremner et al., 1995; Stein et al., 1995).
Recent studies using the MRI have found decreased size of hippocampus in brains
of combat veterans with PTSD and survivors of childhood sexual abuse (Bremner
et al., 1995; Stein et al., 1995). In the Stein et al. study, these alterations were
significantly correlated with measures of dissociation and the numbing/avoidance
symptom cluster of the DSM-IV diagnostic criteria for PTSD. The latter include
dissociative amnesia as a criterion symptom (American Psychiatric Association,
1994). Since the hippocampus is a structure vital to encoding of memory, it has
been suggested that these findings support a biological basis for memory difficulties
in individuals who have experienced extreme psychological trauma (see, for exam-
ple, Bremner et al., 1993c). Alterations in the amygdala and other neuronal systems
such as the benzodiazepine-GABA system, the opiate system, the norepinephrine
system, and the corticotropin-releasing factor-hypothalamic-pituitary-adrenal
axis system due to extreme stress may all contribute to the manifold memory
disturbances caused by trauma (Bremner et al., 1993a). In addition to DA, these
include depersonalization and the various forms of posttraumatic hyperamnesia
including reexperiencing (flashback) episodes, intrusive posttraumatic imagery,
and eidetic engraving of the traumatic experience in memory (ferr, 1988, 1991; van
der Kolk, 1986).
In this chapter, dissociation is conceptualized as a basic part of the psychobiol-
ogy of the human trauma response: a protective activation of altered states of
consciousness in reaction to overwhelming psychological trauma (putnam, 1991).
Memories and affects relating to the trauma are encoded during these altered states.
When the person returns to the baseline state, there is relatively less access to the
dissociated information, leading, in many cases, to DA for at least some part of the
traumatic events. However, the dissociated memories and affects can manifest
themselves in nonverbal forms: posttraumatic nightmares, reenactments, intrusive
imagery, and somatoform symptoms. Not only is there amnesia for the trauma, but
the person frequently has dissociated that certain basic assumptions about the self,
relationships, other people, and the nature of the world have been altered by the
trauma (Classen, Koopman, & Spiegel, 1993; Spiegel, 1988a, 1991a; Terr, 1991).
This view of dissociation is supported by virtually every systematic study and
comprehensive review of dissociation and dissociative disorders in the literature:
overtly traumatic circumstances such as wartime trauma, concentration camp
experiences, subjection to torture or atrocities, natural disasters, family violence,
child abuse, and other forms of civilian violence are extraordinarily prevalent in the
histories of dissociating patients or in the immediate circumstances in which
dissociative symptoms are manifested (Cardena & Spiegel, 1993; Jaffe, 1968;
Loewenstein, 1991b; Niederland, 1968; Putnam, 1985; Spiegel, 1991a). The converse
is true as well. Studies of traumatized populations consistently document the
presence of amnesia and other dissociative symptoms in the clinical phenomenol-
ogy of these individuals (Cardena & Spiegel, 1993; Carlson & Rosser-Hogan, 1991;
Davidson & Fairbank, 1993; Grinker & Spiegel, 1945;Jaffe, 1968; Kardiner & Spiegel,
1947; Kuch & Cox, 1993; Niederland, 1968; Sargent & Slater, 1941; Spiegel, 1991). In
addition, cross-cultural studies of European and Asian samples support the univer-
sality of dissociative symptoms in response to psychological trauma (Boon & Drai- 313
jer, 1993b; Carlson & Rosser-Hogan, 1991; Ensink, 1992). Dissociative
Amnesia and
Dissociative Fugue
Dissociative Amnesia, Normal Memory,
and Ordinary Forgetfulness

The DSM-IV diagnostic criteria for DA specify that the amnesic disturbance
must be "too extensive to be explained by ordinary forgetfulness" (American
Psychiatric Association, 1994, p. 481). This definition raises the question of what is
meant by "ordinary forgetfulness" and how DA differs from it. In addition, non-
pathological forms of amnesia have been described such as infantile and childhood
amnesia, amnesia for sleep and dreaming, and posthypnotic amnesia (Schacter &
Kihlstrom, 1989). Little systematic research has been performed differentiating and
characterizing different forms of DA and their relation to "repression," non-
pathological forms of amnesia, ordinary forgetfulness, or to cognitive disturbances
found in dementia, delirium, and other "organic" amnestic and cognitive disorders.
Most forms of DA are thought to primarily involve difficulties with the func-
tioning of episodic-autobiographical memory not implicit-semantic memory
(Schacter & Kihlstrom, 1989). However, several studies have confirmed the clinical
observation that subjects with dissociative amnesia for their life history can demon-
strate "implicit" autobiographical memory while amnesic (Schacter & Kihlstrom,
1989). Similar phenomena have been described in posthypnotic amnesia with
implicit demonstration that the memories for which amnesia has been suggested
have been encoded and stored, but without their being accessible directly for
retrieval (Orne, 1966; Schacter & Kihlstrom, 1989).
Amnesic patients may also have intense reactions to stimuli that are emo-
tionally significant without knowing consciously the reason for the reaction or the
significance of the stimuli (Kaszniak et al., 1988; Pitman, 1993; Schacter & Kihl-
strom, 1989). Clinically, this is most vividly demonstrated when a patient with PTSD
has a behavioral reexperiencing episode triggered by an apparently benign every-
day stimulus that the patient does not consciously connect with a traumatic experi-
ence. There is experimental evidence that the cues for flashbacks and reexperienc-
ing episodes in patients with PTSD are very specific to the traumatic experiences
that generated the PTSD-amnesia syndrome and not to more generic stressful life
events (Pitman, 1993).
Infantile and childhood amnesia can be experimentally documented in experi-
mental paradigms for autobiographic memory (Rubin, 1986). Clinically and experi-
mentally, patients with DA have been found to have exaggerated or extended forms
of childhood amnesia (Schacter, Kihlstrom, & Kihlstrom, 1989; Schacter, Wang, &
1\Jlving, 1982). Recall of autobiographical information while amnesic seemed to be
related to life events with positive affects that were unconnected with the traumatic
events precipitating the amnesia. Implicit autobiographical memory phenomena
was documented as well in these studies (Schacter et al., 1982, 1989). Similar
findings have been reported for Vietnam combat veterans with PTSD who show
deficits in retrieval of specific autobiographical memories, particularly after view-
ing videotapes of combat (McNally, Litz, Prassas, Shin, & Weathers, 1994).
314 mSTORICAL REVIEW
Richard}.
Loewenstcln Dissociative amnesia has been described in the world literature at least since
classical European accounts of demonic possession and exorcism where the pos-
sessed person is frequently described as showing amnesia for the period of posses-
sion and the exorcism (Ellenberger, 1970; laurence & Perry, 1988). In Europe in the
late eighteenth and early nineteenth centuries, amnesia was recognized as a con-
comitant of "artificial somnambulism," considered to be the prototype of modern
hypnosis, developed by devotees of Mesmer's animal magnetism theories (Ellen-
berger, 1970; laurence & Perry, 1988). In various countries during the nineteenth
century, there were periods of great interest in artificial somnambulism and in
"magnetic diseases," i.e., spontaneously occurring disorders with symptoms similar
to those that appeared in artificial somnambulism.
By the late nineteenth century, there was an interweaving of the notions of the
somnambulistic magnetic disorders with the concept of hysteria. In their classic
descriptions of hysteria, both Briquet (1859) and Charcot (quoted in Janet, 1901)
underscored the frequent occurrence of amnesia, memory problems, and fugue in
hysterical patients. Outside of Europe during this time, there was interest in similar
phenomena as well. For example, in the United States, William James described one
of the paradigmatic cases of fugue with change of personal identity, that of Ansel
Bourne (see Hilgard, 1986).
The work of Janet has vast importance for the modem study of dissocia-
tion. His giant contributions to psychology and psychiatry have been largely
ignored until the rediscovery of the importance of the dissociation concept in
recent decades (Ellenberger, 1970; van der Kolk & van der Hart, 1989). Janet was
influenced by the work of the early "magnetizers," as well by Charcot (Ellenberger,
1970; van der Hart & Friedman, 1989). His discussion of the etiology and phe-
nomenology of amnesia, fugue, and other dissociative conditions remains one of
the most comprehensive in the literature and is quite similar to more modem
conceptualizations (van der Hart & Friedman, 1989; van der Kolk & van der Hart,
1989).
Janet viewed amnesia as a basic part of the dissociative process in which
complex subsystems of memories, feelings, thoughts, and ideas became autono-
mous through disconnection from the overall executive control of the total person-
ality with f.illure to recognize these as part of the patient's own consciousness
(Janet, 1901, 1907). He hypothesized that fugue was based on dissociation of more
complex groups of mental functions than occurred in amnesia and was usually
organized around a powerful emotion or feeling state that linked many trains of
associations accompanied by a wish to run away.
The description of complex dissociative amnesia symptoms also can be found
in the original case descriptions of hysterical patients by Breuer and Freud (Freud,
1893-1895). For example, patients such as Anna 0. and Emmy von N. were de-
scribed as having blackouts, episodes of disremembered behavior, extensive amne-
sic gaps for the life history, fluctuations in handwriting, handedness, and language,
and spontaneous age regression with amnesia (Loewenstein, 1993).
Since the beginning of the twentieth century, there have been a number of
systematic studies and case reports about patients with amnesia and fugue. They
 make up the bulk of the literature on amnesia and fugue cited in psychiatric 315
textbooks and they form the underpinnings of most of the received notions about Dissociative
these conditions in the literature (Abeles & Schilder, 1935; Akhtar & Brenner, 1979; Amnesia and
Berrington, Iiddell, & Foulds, 1956; Croft, Healthfield, & Swash, 1973; Fisher, 1943, Dissociative Fugue
1945; Fisher &Joseph, 1949; Geleerd, Hacker, & Rapaport, 1945; Gill & Rapaport,
1942; Kiersch, 1962; Kirshner, 1973; Leavitt, 1935; Luparello, 1970; Menninger, 1919;
Parfitt & Carlyle-Gall, 1944; Stengel, 1939, 1941, 1943; Wilson, Rupp, & Wilson,
1950).
These studies have a multitude of methodological weaknesses. For example,
some patients diagnosed with DA in these studies actually had clear-cut fuguelike
episodes and vice versa. Also, some of these cases more closely approximate
modern diagnostic criteria for DID or DONOS rather than amnesia or fugue. Other
cases seem to have had other disorders such as epilepsy, a primary mood disorder,
or a psychotic disorder that could account for the memory disturbances and/or
pathological wandering (Stengel, 1939, 1941, 1943).
Despite the heterogeneity of these studies, most supported the view of Abeles
and Schilder (1935) that the psychosocial environment out of which DA and OF
develop are massively stressful, with the patient experiencing intolerable emotions
of shame, guilt, despair, rage, desperation, frustration, and conflict experienced as
unresolvable without suicide or flight.
A group of psychoanalytic clinicians and rese:Kchers became interested in
dissociation in the early 1940s. For example, Fisher (1943, 1945), Fisher and Joseph
(1949), Geleerd et al. (1945), Gill and Brenman (1959), Gill and Rapaport (1942), and
Rapaport (1942) described a number of cases of patients with amnesia, fugue, and
other dissociative disturbances. Bornstein (1946) reported a case of recurrent
amnesia and fuguelike symptoms in an 8-year-old girl. Fisher (1943, 1945; Fisher &
Joseph, 1949) and other psychodynamically oriented clinicians also produced an
extensive literature on amnesia and related disturbances resulting from combat
during World War II (see, for example, Grinker & Spiegel, 1945; Kardiner & Spiegel,
1947).
Traumatic circumstances surrounded the amnesia-fugue episodes in most of
the civilian cases reported by these authors. These included past wartime combat,
incest, other forms of childhood sexual assault, adult rape, threats of death or
physical violence, and other similarly overwhelming events. In addition to external
dangers or traumas, the patients were often struggling with extreme emotions or
impulses such as overwhelming fear and/or intense incestuous, sexual, suicidal, or
violent urges. Thus, the patients were also described as suffering from massive
psychological conflict from which fight or flight was impossible or psychologically
unacceptable without dissociation.
A few other psychoanalytic case reports have stressed that amnesia, altered
states of consciousness, "hypnoid states," and other forms of dissociation can be
conceptualized as defensive reactions to childhood trauma including childhood
sexual abuse, physical abuse, witness to violence, and so forth (Bychowski, 1962;
Dickes, 1965; Fleiss, 1953; Paley, 1988; Silber, 1979). More recent psychoanalytic
writing has begun to address the issues of trauma and dissociation in a more
systematic fashion (Armstrong, 1995; Marmer, 1980, 1991; Ross & Loewenstein,
1992; Schwartz, 1994).
316 AMNESIA AND TRAUMA
BichardJ.
Loewenstein Greenberg and van der Kolk (1986) state that: "Pathologies of memory are
characteristic features of posttraumatic stress disorder" (p. 191). A variety of mem-
ory disturbances for trauma are codified in the DSM-IV diagnostic criteria for PTSD.
These include intrusive recollections and reexperiencing symptoms, depersonaliza-
tion and detachment, and amnesia.

Combat-Related and Other Wartime Trauma

Amnesia and fugue are frequent concomitants of acute stress disorder pro-
duced by wartime experiences and were frequently described in association with
"shell shock" and "traumatic war neuroses" in case reports of soldiers in World War
I and II, respectively (Brown, 1918, 1919, 1920-1921; Grinker & Spiegel, 1945;
Henderson & Moore, 1944; Kardiner, 1941; Kardiner & Spiegel, 1947; Kubie, 1943;
Myers, 1915, 1916; Rivers, 1918; Sargent & Slater, 1941; Southard, 1919; Thorn &
Fenton, 1920; Threen & Stein, 1949). For example, Brown (1919), in discussing his
experiences during World War I using hypnotherapy for soldiers with severe
posttraumatic disorders, stated: "All the severe cases of 'shell shock' of the hysteri-
cal type (that is, showing functional disturbance or loss, of sensory or motor
powers) which I saw near the firing line in France suffered from loss of memory"
(p. 735, italics added).
Grinker and Spiegel (1945) reported that the extent of amnesia experienced by
psychiatric battlefield casualties in World War II ranged from relatively brief periods
of time to complete generalized amnesia as well as fugue episodes. Sargent and
Slater (1941) reported a 14.4% prevalence of amnesia as a "prominent symptom" in a
consecutive series of 1000 combat soldiers admitted to the Neurological Unit of
Sutton Emergency Hospital during World War II. Thirty-five percent of the 87
soldiers subjected to the most severe combat stress had amnesia for war experi-
ences, compared with 13% with "moderate" stress, and 6% with "trifling" stress.
Only about 10% of the soldiers had had a severe head injury that was related to
development of symptoms. In other studies from World War II, prevalence rates for
amnesia during combat ranged from 5 to 8.6% (Fisher, 1945; Henderson & Moore,
1944).
Some of Sargent and Slater's (1941) other findings are also consistent with data
acquired about veterans of the Vietnam War with PTSD (Bremner, Southwick,
Yehuda, Johnson, & Charney, 1993b; Foy, Sipprelle, Rueger, & Carroll, 1984; Kulka
et al., 1990). In these studies, intensity of combat exposure was the critical factor in
the development of posttraumatic stress symptoms and DA. However, there was a
group of individuals with a childhood history of trauma or of a dissociative disorder
who appeared to have a lower threshold for the development of overt dissociative
or PTSD symptoms when retraumatized during combat. These individuals also may
have a more severe and chronic course with PTSD after return to civilian life
(Bremner et al., 1993b).
Several studies have documented memory problems and amnesia for trauma in
veterans with delayed-onset PTSD from World War II, the Korean conflict, and the
Vietnam War (Archibald & Thddenham, 1965; Bremner, Steinberg, Southwick,
Johnson, & Charney, 1993c; Futterman & Pumpian-Mindlin, 1951; Grinker & 317
Spiegel, 1945; Hendin et al., 1984; Kardiner, 1941; Kardiner & Spiegel, 1947; Laufer,
Dissociative
Brett, & Gallops, 1984) Amnesia and
In a recent systematic study using structured interviews and other standard- Dissociative Fugue
ized measures, Bremner et al. (1993c) compared 40 Vietnam combat veterans with
PTSD to 15 Vietnam combat veterans without this condition. Subjects were studied
with the Structured Clinical Interview for DSM-N Dissociative Disorders (SCID)
(American Psychiatric Association, 1994) and the SCID-D (for DSM-III-R dissociative
disorders) (Steinberg, 1993) to make diagnoses of PTSD and of dissociative disor-
ders, respectively. Veterans with PTSD scored significantly higher on all subscales of
the SCID-D. The amnesia score in the PTSD group was significantly higher than that
of controls at the p < .0001 level. An earlier study (Bremner et al., 1992) found
significantly higher scores on the DES in combat veterans with PTSD compared
with those without PTSD. PTSD patients reported more dissociative symptoms,
specifically dissociative amnesia, at the time of trauma.
In another study, Bremner and his colleagues (Bremner, Scott, Delaney, et al.,
1993) found significantly lower scores in individuals with combat-related PTSD as
compared with normal controls on a number of subscales of the Wechsler Memory
Scale, including total recall, immediate recall, long-term storage, long-term re-
trieval, and several other measures. IQ did not differ significantly between patients
and controls. Abnormal neuropsychological findings in PTSD patients were compa-
rable to those in other clinical populations with temporal lobe/hippocampal dam-
age, consistent with the findings of hippocampal damage in patients with PTSD
(Bremner et al., 1995).

Systematic Studies of Amnesia and Fugue in

Other Traumatized Populations
Kuch and Cox (1992) studied 124 Jewish survivors of the Nazi Holocaust who
were seeking compensation from the German government. All were documented
to have undergone traumatic experiences including labor-camp placement, con-
centration camp incarceration for one month or more, and a group who were
tattooed survivors of Auschwitz. Almost half of the total sample and over two-thirds
of the Auschwitz group met DSM-III-R criteria for PTSD. About 3 percent of the total
sample and 10 percent of the Auschwitz sample were found to have dissociative
amnesia for at least some aspect of their Holocaust experiences.
Carlson and Rosser-Hogan (1991) studied 50 randomly selected Cambodian
refugees to the United States who had escaped from the Cambodian holocaust.
Subjects had experienced a variety of severe traumas and atrocities, including
murder of relatives in front of them, rape, forced labor and repatriation, torture, and
so forth. Eighty-six percent of subjects met full DSM-III-R PTSD criteria, and most of
the remainder had posttraumatic stress symptoms (mean number of PTSD symp-
toms per subject = 8.6). Forty percent met all DSM-III-R PTSD criteria that include
amnesia. Ninety-six percent of Cambodian refugees had high scores on the DES
translated into Cambodian (mean= 37.1) compared to Western samples in which a
DES score of 30 or higher predicts a diagnosis of a severe, clinically significant
dissociative disorder such as dissociative identity disorder.
318 Terr (1988) described 20 children who had experienced documented trauma
Richard}. before the age of 5, including physical trauma, sexual abuse, ritualistic abuse,
Loewenstein kidnapping, child pornography, and so forth. Children's reports of trauma were
compared with the documentary evidence. Single brief traumas were better re-
membered verbally, although little verbal memory was available for traumas that
occurred before 28 months of age. Virtually all children, especially those trau-
matized repetitively, "remembered," often uncannily accurately, in behavioral reen-
actments of the trauma. Preverbal traumas also were reenacted in this way. The
author suggests that the data support the hypothesis that trauma may be preferen-
tially encoded visually. This leads to a greater likelihood of remembering in imagery,
dreams, and behavioral reenactments, not in verbal recall.
Coons and Millstein (1992) studied a consecutive series of 25 patients referred
to a dissociative disorders clinic who met DSM-III criteria for dissociative amnesia.
Most patients had more than one episode of amnesia. Seventy-two percent of
patients had a history of child abuse: 52% reported a history of sexual abuse and
40% described a history of physical abuse. Abuse was reported to be the main
precipitant of the amnesia in almost 60% of cases. However, distressing personal
circumstances and behaviors that were being disavowed such as financial or sexual
indiscretions were found to be precipitants in 30% of cases.
Herman and Schatzow (1987) reported on 53 women in a 12-week time-limited
group therapy for the sequelae of reported childhood sexual abuse. Sixty-four
percent reported some amnesia for the abuse. Twenty-eight percent were said to
have "severe" memory deficits such as dense amnesia for many years of childhood.
Earlier and more violent forms of reported abuse correlated with more severe
memory deficits. Patients with later abuse (e.g., during latency) described more
depersonalization and less amnesia. Almost three quarters of this sample of women
reported corroboration of their reports of abuse by perpetrator admission, physical
evidence such as diaries or letters, and so forth.
Briere and Conte (1993) described a sample of 450 male and female clinical
subjects with a reported history of childhood sexual abuse. Fifty-nine percent of
subjects described an inability to remember the abuse at some time during their
lives. Subjects with amnesia were more likely to have had more severe, early-onset,
repetitive, physically injurious abuse with multiple perpetrators and direct prohibi-
tions of harm for disclosure. The subjects with a history of amnesia were more
globally symptomatic as well. Loftus (1993) has criticized this study since the
subjects were all in therapy and thus could have been influenced by the theoretical
models of their therapists that "repression" of traumatic memory commonly oc-
curs. She also criticized the wording of the question asked subjects concerning
memory difficulties for abuse on the grounds that it is subject to multiple interpreta-
tions. She cites her own data that indicates that only 18% of 100 women in out-
patient treatment for drug abuse who also reported a history of childhood sexual
abuse claimed that they "forgot" the abuse for a period of time and then remem-
bered it again. The Briere and Conte study presented data to suggest that the
dissociation model is more robust in accounting for their data than the repression
model: i.e., one based on posttraumatic alterations in memory and consciousness as
opposed to a model based on intrapsychic conflict.
Ensink (1992) described 100 Dutch women who reported a history of child-
hood sexual abuse. They were given a large number of structured and semistruc- 319
tured interview and testing materials concerning life history, psychiatric symptoms, Dissociative
functional status, age of onset of reported trauma, number of reported perpetra- Amnesia and
tors, types of reported childhood abuse (e.g., sexual, physical, neglect, witness to Dissociative Fugue
violence, etc.), violence of trauma, and so forth. Thirty-two subjects reported "time
gaps" (i.e., amnesia), including experiences such as disremembered behavior, ap-
pearance of perplexing possessions, inexplicable changes in relationships, and
fugues. Other dissociative symptoms such as spontaneous trances and depersonal-
ization were also described. The extent of amnesia correlated most strongly with
the cumulative trauma score. Ensink concluded succinctly that: "The more fre-
quently and severely a woman as a child has been traumatized, the more frequently
she tends to experience time-gaps" (pp. 104-105).
Williams (1994) followed up 129 women who had detailed, documented histo-
ries of childhood sexual abuse 17 years earlier. They had all been seen in an urban
emergency room as children because of the abuse. The study compared the
womens' current recollections obtained with a semistructured interview adminis-
tered by "blind" interviewers with medical and other records that had been com-
pleted at the time of the initial report of the details of the abuse, including genital
injury and physical trauma. Thirty-eight percent of the sample did not report the
index abuse event documented in the 1970s. On the other hand, 68% of the women
who did not recall the index event did describe another episode of childhood
sexual abuse. These data supported the notion that these women suffered from
amnesia for the abuse, not a reluctance to discuss abuse in general. The anecdotal
data from the detailed individual case histories also tended to confirm this hy-
pothesis.
Lack of memory for the abuse or accurate recall of the abuse did not follow
expected age trends based on the notion of early childhood amnesia. Some individ-
uals accurately reported documented abuse events that occurred when they were
as young as 3 years old and others did not recall abuse that occurred when they
were in latency or early adolescence. Subjects were less likely to recall abuse if they
had had a closer relationship to the perpetrator, had more genital trauma by report
in the 1970s, or had a higher "credibility rating" given at the time of the index event.
Sixteen percent of those who did recall the index event retrospectively reported
amnesia at some time for this event. Those with "recovered" memories were no less
accurate than those who "always" remembered. There were no differences found
for history of prior mental health treatment in those who always remembered
compared to those with apparent amnesia. This was thought to counter the notion
that reported amnesia might relate to the influence of therapists' theories about
memory on the subjects. In any event, most of these women had not received much
psychotherapy. They had been treated primarily for drug and alcohol abuse and
severe psychiatric disorders. There were, however, higher rates of psychiatric
hospitalization in those who did not recall the index event as compared to the other
women.
Boon and Draijer (1993a) compared a sample of Dutch women with dissocia-
tive disorders to a sample with personality disorders, primarily borderline and his-
trionic personality disorders. Diagnoses were made using the SCID-D (Steinberg,
1993). A cumulative trauma score was also compiled for each subject, including
320 data on severity and age of onset of sexual, physical, and other types of abuse.
Richard}. Patients with personality disorders did not differ significantly from those with
Loewenstein dissociative disorders on a measure of depersonalization. However, dissociative
disorder patients scored significantly higher on all other SCID-D subscales, includ-
ing that for amnesia (p < .0001 for all other subscales). Trauma severity scores were
also lower and trauma was of later onset in the personality disorder group as
compared with the dissociative group. Table 4 summarizes findings from these
studies suggesting factors that are more likely to lead to dissociative amnesia in
response to traumatic circumstances.

FORENSIC ISSUES RElATED TO

DISSOCIATIVE AMNESIA AND FUGUE

The problem of dissociation and the dissociative disorders has become an

increasingly complex and contentious issue in civil and criminal law (Beahrs, 1994;
(Coons, 1991; Lewis & Bard, 1991; Rubinsky & Brandt, 1986). Legal issues include
competence to stand trial or to act as a witness in court; detection of malingered
amnesia or other dissociative symptoms; responsibility for criminal behavior; and
reliability of dissociated memory in the court of law in both civil and criminal
matters.
From a legal standpoint, amnesia alone is not considered a sufficient factor to
generate a finding of incompetence to stand trial or a verdict of not guilty by reason
of insanity (Rubinsky & Brandt, 1986). Dissociative amnesia has been claimed by
perpetrators in 30 to 40% of homicide cases and in a lesser percentage of other
violent crimes (Kopelman, 1987a,b). Although malingering is often suspected in
such cases, many of these individuals did little to avoid being charged with a crime
and some even called the authorities themselves. In general, the murder cases with
apparent true DA were characterized by an unpremeditated assault in a state of high
emotional arousal on a victim closely related to the perpetrator (Kopelman, 1987b).
Most experts agree, however, that there is no absolute way to differentiate true
DA from malingering (Schacter, 1986). Malingerers have been noted to continue
their deception even during hypnotically or barbiturate-facilitated interviews

Table 4. Factors Leading to Persistent Dissociative Amnesia

after Traumatic Experiences
The trauma is more likely to be caused by human assault, not natural disaster.
Repeated traumatization, not single traumatic events.
Longer duration of trauma.
Earlier age of onset of trauma.
Trauma caused by multiple perpetrators.
Fear of death or significant harm during trauma.
Threats of death or significant harm by perpetrators if victim discloses.
Violence of trauma/physical injury caused by the trauma.
Close relationship between perpetrator and victim.
(Kluft, 1988). On the other hand, in the clinical case reports, many malingerers 321
quickly confessed their deceptions either spontanously or when confronted by the Dissociative
examiner. In these nonforensic reports, the malingered amnesics were frequently Amnesia and
pathetic individuals whose deception was transparent. It was often unclear where Dissociative Fugue
the conscious deception began and the unconscious defenses ended (Kopelman,
1987b; Iishman, 1987; Parfitt & Carlyle-Gall, 1944).
In clinical matters, most experienced clinicians firmly hold dissociative pa-
tients responsible for their behavior despite claims of amnesia or a sense of lack of
control over behavior (Beahrs, 1994). This stance is generally associated with a far
better outcome clinically. Thus, it follows that a similar standard should be used in
criminal matters. Under most circumstances dissociative patients know right from
wrong and can modulate their conduct to conform to rules and laws (Beahrs, 1994).

Amnesia, Memory, and the Courts

A number of state legislatures have extended statutes of limitations in civil and
criminal matters involving childhood abuse to permit legal actions for extended
periods. Some of these statutes and legal rulings related to them have allowed
extension of the statute of limitations based on return of previously dissociated or
"repressed" memories of abuse (Horowitz & Bulkley, 1994). This has led to heated
debate both in the media and to some extent in scholarly articles about the validity
of these "recovered memories" as a basis for legal actions (see Loftus, 1993).
Unfortunately, there is a dearth of research that balances the known effects of
trauma on memory with the well-developed literature on the fallibility and mal-
leability of memory under a variety of conditions.
From a clinical perspective, there is no requirement that adults who recall
childhood abuse "confront" their alleged abusers or prosecute them in order to
"heal." Unkss carefully thought out clinically, these sorts of confrontations often
result in a poor outcome at best for both accuser and accused (Schatzow & Herman,
1989). The long-term clinical focus is usually more appropriately placed on the
patient's resolving his or her conflictual attachment to the accused abusive relative.
When this is resolved, the pressure for confrontation frequently diminishes substan-
tially, or if disclosure to family members occurs, it is handled in a way that is more
likely to lead to resolution not exacerbation of difficulties (Schatzow & Herman,
1989).
Involvement of adult dissociative patients in the courts in attempts to sue or
prosecute alleged abusers frequently results in clinical deterioration of the patient.
This is due to the negative impact of the adversarial system on the patient who may
have a highly idealized view of what will occur; an increased sense of loss of control
due to the continual delays inherent in the legal process; the opening up of the
patient's psychiatric history and clinical status in the courts; and the inherent
difficulties in proving allegations of abuse with little evidence other than the
(frequently "recovered") recollections of a patient with a history of DA and often
of a significant psychiatric disturbance as well (Horowitz & Bulkley, 1994).
Clinicians should carefully review with the patient the potential clinical risks
of proceeding with confrontations against alleged abusers both in and out of the
courtroom. Many patients have little idea of the real implications of what will
322 happen if they proceed in this way. Despite these cautions, some patients will
Richard]. proceed to confront accused abusers despite the urgings of their therapists to re-
Loewenstein lent or to wait until other issues in treatment are better resolved before deciding
on this course of action.
In their recent review, Horowitz and Bulkley (1994) suggest that, due to the
current controversy and lack of sufficient, balanced scientific data, additional civil
and criminal cases based on delayed memory should be handled on a case-by-case
basis, rather than by passing new legislation. Further, they suggest that civil cases
only be allowed with corroborative evidence of abuse, a higher standard of proof
to "clear and convincing" evidence, and/or a limit on the number of years that the
statute of limitations could be extended for civil cases involving claims of abuse.
Many states have no statute of limitations for criminal matters. However, Horowitz
and Bulkley (1994) argue that criminal cases involve a higher burden of proof and
greater constitutional safeguards than civil ones and thus may offer greater protec-
tion to the accused.

TREATMENT

The treatment of DA and DF can be best conceptualized using a framework

from the treatment of trauma disorders in general (Loewenstein, 1995). Most
reviews have identified this as a phasic process characterized by at least three major
epochs (Herman, 1992; van der Hart, Steele, Boon, & Brown, 1993). In the first
phase, the traumatized individual is assisted to achieve safety and stability in his or
her life. Once this is established, the individual may engage, if indicated, in a phase
in which the focus is the processing of traumatic material in greater depth. This may
involve attempts to overcome persistent amnesia symptoms as well as resolution of
material that is undissociated or less completely dissociated. Finally, there is a third
phase of "resolution" or "reintegration" in which the traumatized person is "recon-
nect[ed] to ordinary life" (Herman, 1992, p. 155). In this phase, the focus is less on
the trauma per se and more on the development of a renewed, reinvigorated life
apart from the symptoms of the trauma disorder and the domination of the person's
psychology by issues related to traumatization.
In virtually all dynamic conceptualizations of DA, the adaptive function of the
amnesia can be conceived of as a kind of "safety valve" or "circuit breaker" that
reflects the patient's ability to tolerate full conscious awareness of the dissociated
material. It is not only the content of the dissociated memories that is experienced
as painfully intolerable, however. For the most part, it is the overwhelming affects
and the personal meaning of the traumatic events that most powerfully reinforce
the persistence of the amnesia (Spiegel, 1988b; Terr, 1991). Highly intense and often
conflictual emotions of despair, grief, guilt, shame, rage, self-hatred, helplessness,
and terror are commonly embedded in memories for which the person is amnestic.
In addition, ¢-e traumatic events may cause profound shifts in the person's view of
him or herself, significant others, and the nature of the world and all human
relations (Briere, 1989). These posttraumatically determined aspects of the person's
cognitive and assumptive world are also masked by amnesia. Without systematic
clinical attention during treatment to resolution of the specific meanings of the
trauma for the person, the amnestic patient usually will remain permanently symp- 323
tomatic in some way (van der Hart & Brown, 1992; van der Hart et al., 1993)
Dissociative
Amnesia and
Establishing Safety for the Patient with Dissociative Amnesia- Dissociative Fugue

Dissociative Fugue
This aspect of treatment is the most important and frequently most neglected
in the treatment of trauma disorders. Patients' and clinicians' impulse to "get the
memories" by intrusive means are probably shaped by the treatment literatures on
the acute wartime amnesias and by the literature on "classical" acute DA-DF presen-
tations. Generally speaking, the more acute the amnesia and the closer the patient is
to the situation that generated it, the shorter the treatment time to resolution of the
symptoms. However, even here, it is important to carefully stabilize acutely amnes-
tic patients and to titrate the intensity of bringing the dissociated information into
more ordinary conscious awareness (Brown, 1919; Fisher, 1943; Kardiner & Spiegel,
1947; Myers, 1916). In particular, a number of authors warn that acute amnesia and
fugue states are frequently psychological alternatives to suicide (Gudjonsson &
Haward, 1982). Clinical case reports have described successful suicide in amnestic
patients who have not achieved adequate therapeutic stabilization before attempt-
ing to overcome amnesia or before returning to their usual life situation (Takahashi,
1988).
In cases of more long-standing or childhood-onset amnesias, attempts to rap-
idly uncover dissociated trauma material is usually particularly ill-advised. Attempts
to uncover memories of single traumatic episodes through intrusive means, with-
out careful prior stabilization and preparation, usually result in "retraumatization,"
with the patient frequently suffering from more intense intrusive PTSD symptoms
accompanied by flashbacks to multiple traumatic events in addition to those of the
index event (Steele & Colrain, 1990). Destabilization of the patient with acute
dissociative and PTSD symptoms are common results of too rapid attempts to
overcome amnesia in these cases.
In the case of the patient with acute stress disorders (American Psychiatric
Association, 1994) primarily characterized by or accompanied by dissociative am-
nesia, the establishment of the person's physical safety is the first concern. This
involves removal from the traumatizing environment such as acute combat, evalua-
tion and treatment of medical problems including possible head injury, and provi-
sion of shelter, food, and sleep. Sedative medications such as the benzodiazepines
may be indicated in some cases to assist with the latter.
The neuropsychiatric literature from World Wars I and II describe that, in many
cases of acute wartime amnesias, removal of the soldier from combat and provision
of food and sleep were sufficient to resolve amnesia symptoms completely. How-
ever, if these measures were insufficient to resolve symptoms, more definitive
treatment was undertaken, generally after transporting the soldier away from the
front (Brown, 1918; Kardiner & Spiegel, 1947; Kubie, 1943). Similar issues are
important in cases of acute DA or DF presenting to civilian emergency or acute care
facilities. 1n the series of Abeles and Schilder (1935), about 75% of their 63 cases
of amnesia for personal identity were said to have had rapid spontaneous remission
of amnesia once they were brought to the safety of clinical attention.
324 If immediate spontaneous remission does not occur in cases of acute amnesia,
Richard]. symptoms may abate later simply in the course of the clinician taking a psychiatric
Loewenstein history or merely by assuring the patient that he or she can remember when he or
she is ready and that the patient can remember at his or her own pace without the
need to remember all the details or information at one time. The entire literature on
DA underscores the importance of permissive suggestions for recall. Helping the
patient experience a sense of control over the pace of recollection for dissociated
information is very important during the treatment process.
Patients with long-standing, chrofli.c amnesia presentations generally should be
managed in the framework of a psychotherapy directed at resolution of the com-
plex psychological sequelae of the events producing the amnesia, usually severe
traumatization due to childhood abuse, combat, and/or other forms of adult victim-
ization (Brende, 1985; Briere, 1993; Spiegel, 1988b; van der Kolk, 1986). Here, too,
the first tasks of treatment are restoration of the patient's physical well-being and
safety and establishment of a working alliance. The clinician must be prepared to
intervene actively if the patient's difficulties involve suicide attempts, self-
mutilation, eating disorders, alcohol or substance abuse, involvement in abusive or
destructive relationships, episodes of rage or violence, abuse of the individual's
own children or family members, and lack of adequate food, clothing, or shelter
(furkus, 1991). Hospitalization may be necessary to stabilize such patients, as well
as referral to specialty resources such as treatment for substance abuse or eating
disorders.
1n individuals with severe intrusive PTSD symptoms alternating with amnesia,
containment and management of intrusive recollection rather than attempts at
detailed processing of trauma material is usually the goal in the stabilization phases
of treatment. This may be accomplished by using supportive hypnotic techniques,
pharmacotherapy, and/or cognitive therapy techniques (Colrain & Steele, 1991;
Fine, 1990; Friedman, 1990; Saporta & Case, 1993; Spiegel, 1989; Steele & Colrain,
1990). There is no pharmacological agent that specifically targets DA or DE How-
ever, treatment of the patient's PTSD, affective, dyscontrol, psychotic, obsessive-
compulsive, and/or anxiety symptoms with medications may permit more focused
therapeutic attention to the amnesia (Friedman, 1987, 1990; Loewenstein, 1991c;
Saporta & Case, 1993).
Contraindications to a primary focus on uncovering dissociated memory mate-
rial incJude:

(1) Early stages of therapy; (2) an unstable therapeutic alliance; (3) current or
ongoing abuse; (4) current acute external life crisis; (5) extreme age, severe
physical infirmity, and/or terminal illness (abreaction may be carefully titrated in
certain cases); (6) lack of ego strength, including severe borderline and psychotic
states or pathological regression; (7) [in DID] uncontrolled rapid switching;
(8) uncontrolled flashbacks; (9) [in DID] severe conftict and lack of cooperation
in the [alter identity] system; (10) severe primary alexithymia; (11) temporary
contraindications include the anticipated absence of the therapist and transi-
tional times during the [patient's] life (Colrain & Steele, 1991, pp. 6-7)

Some severely impaired patients with PTSD and amnesia will never achieve
sufficient stability to be candidates for more intensive attempts at processing
dissociated memory material. Their entire treatment will consist of attempts to 325
better assure their safety and stability. Containment and distancing of intrusive Dissociative
memory material and more general attempts to modulate these patients' chronic Amnesia and
posttraumatic life maladaptations will be the goal of treatment. Dissociative Fugue

Stabilization of the Patient with Dissociative Fugue

Patients with DF may present specific problems in clinical management. Most
fugues are relatively brief and do not take the person far from home. However, case
reports have described DF patients crossing multiple national borders during wan-
derings lasting for months (Fisher, 1945). DF patients may present with a range of
dissociative memory disturbances including complete generalized amnesia with
loss of memory for personal identity; amnesia for the entire fugue episode; a
localized amnesia in which the patient believes it is a chronologically earlier time in
his or her life; or, rarely, with a change in personal identity (Fisher, 1945; Fisher &
Joseph, 1949; Gill & Brenman, 1959).
Some of these patients may resist uncovering their actual identity even with
hypnosis or amytal narcosynthesis. Appeals through the local (or even regional)
media may not alert the patient's significant others if he or she has wandered a
substantial distance from home (Lyon, 1985). Also, family, sexual, occupational,
and/or legal problems that were part of the original matrix that generated the fugue
episode may be substantially exacerbated by the time the patient's original identity
and life situation are detected.
Rarely, in the most extreme cases, the fugue patient has established a new
identity, occupation, and social relationships in a different location (Hilgard, 1986).
When the original identity is discovered, often by accident, there may be a variety of
predicaments that ensue having to do with the real world complications of this
situation. In response to this, the patient may become acutely suicidal, over-
whelmed, and/or confused. Also, the patient may display more extreme or bizarre
dissociative symptoms or attempt to engage in another fugue to escape the
situation.

Hypnosis
Hypnosis has frequently played an important adjunctive role in the treatment
of individuals with DA and DE Hypnosis is not a treatment in itself; it is a set of
adjunctive techniques that facilitate certain psychotherapeutic goals. All post-
traumatic and dissociative disorders can and have been successfully treated without
use of formal heterohypnosis (see, for example, Futterman & Pumpian-Mindlin,
1951).
Hypnosis can be used in a number of different ways in the treatment of DA-DE
In particular, hypnotic interventions are used to contain, modulate, and titrate the
intensity of symptoms; hypnosis can be used to facilitate controlled recall of
dissociated memories; hypnosis can be used supportively to provide "ego-
strengthening" for the patient; and, finally, hypnosis can promote working through
and integration of dissociated material (Brown & Fromm, 1986).
326 The clinician should be aware that use of hypnosis or drug-facilitated inter-
Richard). views in no way assures the veracity or lack of veracity of the information produced
Loewenstein (Kolb, 1985; American Society of Clinical Hypnosis, 1994). In some clinical and
research studies, the use of hypnosis has been associated with the production of
inaccurate "memories" in whose accuracy the subject strongly believes, particularly
in highly hypnotizable subjects (Laurence & Perry, 1988; McConkey, 1992). How-
ever, critical reviews have noted the complexity of this research problem, the
variability in findings among studies, and the many variables related both to hyp-
nosis and nonhypnotic factors that appear to influence this and related phenomena
(McConkey, 1992). On the other hand, many studies have confirmed the essential
accuracy of reports of traumatic experiences that were subject to DA, primarily
involving wartime trauma, but other sorts of trauma such as childhood abuse as well
(Brown, 1918; Coons & Millstein, 1986; Grinker & Spiegel, 1945; Herman & Schat-
zow, 1987; Kardiner & Spiegel, 1947; Terr, 1988; Williams, 1994).
Some have argued implicitly or explicitly that intensive emotional release
("abreaction") is the key therapeutic agent in the treatment of amnesia (Brown,
1920-1921; Kolb, 1985). Others have maintained that it is the integration of dissoci-
ated affects, cognitions, and self-perceptions that is essential to the resolution of
symptoms in amnestic patients (van der Hart & Brown, 1992; van der Hart et al.,
1993). They note that a primary treatment focus on intensive attempts to bring into
awareness extreme dissociated affects frequently results in a chronic decompensa-
tion rather than in a resolution of the patient's amnesia and PTSD symptoms. It is
now generally accepted that intense emotional release per se is rarely associated
with positive therapeutic outcome in dissociative patients. Full therapeutic resolu-
tion of dissociated imagery, memories, affects, cognitions, and self-perceptions is a
complex process that usually occurs over a number of treatment sessions.
Clinicians since World War I have recognized the importance of the patient
repeatedly processing dissociated material in a number of different sessions, often
at different levels of affective intensity, in order to complete the process of integra-
tion of the material (van der Hart & Brown, 1992). It is usually wise to begin working
with dissociated material in a more cognitive, distanced fashion to gain an outline of
the patient's history for which amnesia is present. Subsequently, the dissociated
memories can be increasingly worked with and their full affective and cognitive
meanings for the patient explored.
In cases of acute generalized, selective, or localized dissociative amnesia, after
establishing the patient's safety and the therapeutic relationship, the next task of
therapy is to help the patient regain awareness of his or her identity and general
personal circumstances. Subsequent sessions then focus on the events that led to
the development of the acute amnesia. The material is then reworked in greater
detail in subsequent sessions. In most cases, there will be resolution of amnesia
within days to a few months. However, there are cases of persistent generalized or
severe localized amnesia that have required years of intensive psychotherapy to
overcome (Eisen, 1989).
In the author's experience it is useful to try to account systematically for
different dimensions of the dissociated, usually traumatic, experiences: sensory,
affective, cognitive, and behavioral in order to assure that all key components have
been identified and reconstructed (Braun, 1988; van der Hart et al., 1993). Also, it is
useful to attempt to account systematically for a variety of dysphoric affects that are 327
commonly experienced during traumatic experiences: despair, sorrow, grief, hor- Dissociative
ror, shame, helplessness, rage, guilt, confusion, anguish, and so forth. Inquiry about Amnesia and
these other affects may be quite helpful in resolving the amnesia. In particular, Dissociative Fugue
shame, horror, helplessness, and overwhelming confusion are emotions that pa-
tients may have the most trouble identifying without assistance from the therapist.
There is often a "core" aspect of the experience, either a specific part of the
event or its meaning to the person that is central to resolving a persistent amnesia.
This aspect of the recollection frequently remains dissociated despite the patient's
discussing other parts of the experience. Identification of this aspect of the material
and making it a focus of continued clinical attention is usually crucial to full
resolution of amnesia.

RESOLUTION

In the final phases of treatment for DA, the patient is able to experience the
previously dissociated material as normal autobiographical material. There should
no longer be involuntary intrusions of imagery, affect, and sensation. The patient
should no longer experience a conscious sense of distinct gaps in memory for life
experience. Memories of the past should be experienced as parts of prior historical
time, not as current "living" events. Memory experience should have a quality of
voluntariness: For the most part, the patient can recollect the material or put it
aside. Memories of traumatic experiences should not have a "special" quality
distinct from other memory material. The patient may have the uncanny experi-
ence of actually beginning to "forget" the experiences; they are rarely called to
mind as the person turns his or her attention to everyday life (Herman, 1992; van
der Hart et al., 1993).
At this point, patients often experience a sense of perspective and calm about
issues that seemed previously overwhelming and disruptive. The patient frequently
reports greater energy for other life tasks such as relationships with others, work, or
leisure activities. Some chronically traumatized individuals may experience never
having lived in a calm, quiet, nontraumatized way. They may express amazement at
this new "boring" way of life.

Group Psychotherapy for Amnesia

In addition to individual psychotherapy, Kardiner (1941) described the use of
group psychotherapy and hypnotherapy to promote recovery in traumatic war-
related amnesia. Highly supportive, structured, reassuring and "reeducative" ap-
proaches were often used by the therapist to attempt to accomplish the return of
the patient to a functional status and to prevent chronic disability (Grinker &
Spiegel, 1945; Kardiner, 1941; Kardiner & Spiegel, 1947).
Time-limited and longer-term group psychotherapy has been reported to be
helpful treatment for many combat veterans with PTSD as well as for survivors of
childhood abuse (Briere, 1989; Courtois, 1988; Goodwin & Talwar, 1989; Herman,
1992; Smith, 1985). During group sessions, some authors report that patients may
328 recall memories for which they have had amnesia. Supportive interventions by the
Richard}. group members ami/or group therapist may facilitate integration and mastery of the
Loewenstein dissociated material (Goodwin & Talwar, 1989). On the other hand, clinicians
working with patients at the more severe end of the dissociative spectrum have
suggested that group therapy optimally should focus on "here-and-now" issues.
They state that discussion of specific, detailed trauma-related material is often
highly disruptive to group function and to the individual members (Coons &
Bradley, 1986).
Some patients with reported histories of childhood sexual abuse have made
use of self-help or 12-step groups. These groups can be highly problematic if
members attempt to access or process dissociated material during sessions. Some
clinicians have raised the issue of "contamination" of trauma reports among mem-
bers in these groups. Although some patients report subjective benefit from such
groups, clinicians should weigh carefully with the patient the potential risks and
benefits for entering such a group. Indeed, some clinicians refuse to work with
patients who attend self-help groups because of their potential to disrupt the
patient and to confuse the therapy (R. P. Kluft, E. Frischholz, personal communica-
tions, Vancouver, Canada, May, 1994).

Somatic Therapies
There is no known pharmacotherapy for DA and DF other than drug-facilitated
interviews (Perry & Jacobs, 1982; Ruedrich, Chu, & Wadle, 1985). A variety of
agents have been used for this purpose including sodium amytal, pentothal, oral
benzodiazepines, and amphetamines (Ruedrich et al., 1985). At the present time,
there have been no adequately controlled studies to assess the efficacy of any of
these agents in comparison with one another, with other treatment methods, or
with placebo (Ruedrich et al., 1985).
Narcosynthesis is a term devised by Grinker and Spiegel (1945) to underscore
the need for material uncovered in a drug-facilitated interview to be processed by
the patient in his or her usual conscious state. Narcosynthesis continues to be used
primarily to work with acute amnesias and conversion reactions, among other
indications, in general hospital psychiatric services (Perry & Jacobs, 1982). There
also is occasional utility for this procedure in refractory cases of chronic DA (Kolb,
1985). Some patients will only be able to overcome persistent amnesia with a drug-
facilitated interview and not with other interventions.
On the other hand, these procedures must be performed where resuscitation
equipment is available in case of respiratory arrest, albeit a rare complication. The
interview usually must be audiotaped or videotaped to replay for the patient since
amnesia generally persists for the interview. In narcosynthesis, the clinician usually
can not titrate the intensity of the patient's response as in hypnotherapeutic
interventions. Finally, repeated procedures are generally impractical and even may
lead to a dependence on drug-facilitated interviews in the patient.
A recent case report describes amelioration of some symptoms of apparent DA
with successful electroconvulsive treatment in a patient with a severe, refractory
major depression (Daniel & Crovitz, 1986). Convulsive treatments with electric
shock, insulin, and metrazol were occasionally prescribed for refractory combat-
related disorders during World War II (Kubie, 1943), although modem military 329
psychiatrists see no indication for sucb procedures Qones & Hales, 1987). At the Dissociative
present time, there appears to be no indication for treatment of DA or acute or Amnesia and
cbronic posttraumatic disorders with electroconvulsive therapy. Dissociative Fugue

CONCLUSIONS

The relationship of DA and DF to traumatic circumstances has been reported

repeatedly for more than a century. Recent systematic studies of traumatized
individuals have documented and refined this clinical observation. Further, an
emerging psychobiology of trauma may permit a neurobiological understanding of
the manifold memory disturbances related to overwhelming traumatic experi-
ences. It is important that these clinical and research findings are understood by the
professional community and by the public. Cognitive psychology research on the
fallibility of memory needs to be informed by studies on trauma, dissociation, and
dissociative amnesia just as scholarly work on dissociation needs to incorporate
findings from cognitive and memory studies. Collaborative research in this area
would be welcome.
The treatment of posttraumatic DA has been well described in increasingly
sophisticated clinical reports that incorporate both the classical findings about
these conditions as well as the data from more modem studies of the comprehen-
sive treatment of PTSD and trauma disorders. Methodologically rigorous outcome
studies still need to be performed, however, using standardized diagnostic and
outcome measures.
It is unfortunate that these complex issues concerning trauma and memory are
being played out in media and in the courts. The results of this process will only
make more difficult the treatment of dissociative patients as. well as rigorous
research on the impact of traumatic experiences on memory.

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16
Dissociative Identity Disorder
Richard P. Kluft

Dissociative identity disorder (DID), formerly known as multiple personality dis-

order (MPD), is a complex, chronic, posttraumatic dissociative psychopathology
(Kluft, 1987a; Loewenstein, 1991) characterized by disturbances of memory and
identity (Nemiah, 1980). It is distinguished from other mental disorders by the
ongoing coexistence of relatively consistent but alternating subjectively separate
identities and either recurrent episodes of memory disruption, frank amnesia, or
both, and/or amnesia for a period of noncontemporary autobiographic memory. It
almost invariably emerges as the sequela of overwhelming childhood experiences
(Putnam, Guroff, Silberman, Barban, & Post, 1986; Spiegel, 1984, 1991). Its child-
hood form is often rather simple and its traumatic antecedents frequently can be
documented with facility (e.g., Fagan & McMahan, 1984; Kluft, 1984a, 1985a;
Hornstein & Putnam, 1992; Coons, 1994). However, it appears that in some adult
cases, secondary autonomy of the defense of alter formation and function, the
development of additional complexity, and a reworking of childhood experiences
occur during adolescence. By virtue of this metamorphosis, the adult form often
becomes rather intricate in its structure, and adult patients' given histories demon-
strate the interplay of historical events, fantasy, confabulation, postevent information,
and the impact of many nontraumatic exogenous influences (Kluft, 1995, in press a).

DID IN AN IUSTORICAL AND CROSS-CULTURAL PERSPECTIVE

The majority of studied societies and cultures have conditions in which an-
other entity is understood to have taken over the body of an afflicted individual, i.e.,
possession states. Their common core is that

Richard P. Kluft • Dissociative Disorders Program, The Institute of Pennsylvania Hospital, Phila·
delphia, Pennsylvania 19139.
Handbook of Dissociation: Theoretical, Empirical, and Cltntcal Perspectives, edited by Larry K.
Michelson and Wtlliam]. Ray. Plenum Press, New York, 1996. 337
338 An individual suddenly seems to lose his identity to become anothet person. His
Richard P. Kluft
physiognomy changes and shows a striking resemblance to the individual of
whom he is, supposedly, the incarnation. With an alteted voice, he pronounces
words corresponding to the personality of the new individual. (Ellenberget,
1970, p. 13)
Until the end of the eighteenth century, many individuals in Western society
demonstrated such phenomena. They were understood, within the explanatory
paradigms of their eras, to be afflicted with the various Judeo-Christian forms of
possession and were treated with culturally endorsed forms of exorcism. When
theological explanations of mental disease gave way to the first dynamic psychiatry,
a process chronicled by Ellenberger (1970), the psychological constructs that
underlay the possession states and the mental conflicts they expressed did not
abruptly cease to exist. Instead, what is now called DID (and allied conditions)
began to enter the literature. DID provides a secular expression of many of the same
mental structures found in possession syndromes. 1n those societies in which
indigenous possession states remain powerful and sanctioned idioms for expressing
subjective experiences and conflicts, the psychopathological "niche" that DID
occupies elsewhere is already filled, and DID will be quite uncommon (e.g., Adit-
yanhjee, Raju, & Khandelwal, 1989).
Although DID was declared extinct in 1943 by Stengel, it appears to be present
in most societies in which indigenous possession states have lost or are losing their
cultural currency. Combining the published literature and the author's correspon-
dence with clinical colleagues over the last quarter century, DID has been identified
and treated in native-born citizens of the United States, Canada, Mexico, many
Caribbean and Central American nations, over half-a-dozen South American coun-
tries, all major western European and most eastern European states, Israel, Thrkey,
many African countries, Australia, Japan, Korea, and several Asian nations as well
(see Coons, Kluft, Bowman, & Milstein, 1991; van der Hart, 1993). Although it is still
is common to hear DID referred to as a North American culture-bound syndrome
(e.g., Fahy, 1988), this is not accurate. It appears to be found relatively readily
whenever psychiatric patient populations are systematically studied with objective
screening and diagnostic instruments. Recently Goff and Simms (1993) have re-
peated Fine's (1988a) demonstration that the symptomatology of DID has remained
relatively constant over the centuries, notwithstanding fluctuations of the quantita-
tive aspects of certain features, such as the number of alters.

THE IHSTORY OF MULTIPLE PERSONAUIY DISORDER

Although Bliss (1986) attributes a case description to Paracelsus, Petetain

published the first modem descriptions of DID phenomena in 1787. The first
attempt to delineate a specific syndrome or disorder consisting of these phenom-
ena, umgetauscbte Personlicbkeit (exchanged personality), is that of Eberhardt
Gmelin, in 1791. Both are described in Ellenberger (1970). Benjamin Rush described
such patients early in the nineteenth century (Carlson, 1981). Thereafter numerous
authorities made. substantial contributions to the study of DID, most of whom are
nearly forgotten by history. For example, the three Despines together saw over 40
 cases; Antoine Despine, Sr., is credited with the first psychotherapeutic cure of 339
DID, in 1836 (see Fine, 1988a). Under Charcot and Janet, many such patients were Dissociative
identified and treated at the Salpetriere; Janet's contributions remain fresh and Identity Disorder
relevant. In the United States, Morton Prince (1905) drew attention to the disorder
and made observations of lasting importance.
The study of DID and dissociation flourished briefly and waned. Appropriate
doubt was cast on many of Charcot's demonstrations (Ellenberger, 1970; McHugh,
1993). Janet left few followers; his influence was further eroded by the rise of
Freudian influence. Although Freud began with a close affinity to the study of
dissociation and DID [Anna 0. suffered this condition (Jones, 1953)], he distanced
himself from them as he developed his own models of the mind and repudiated the
seduction theory. Bleuler included DID under the rubric of schizophrenia; as the
diagnosis of schizophrenia rose in acceptance, the use of the diagnosis of DID
dropped off precipitously (Rosenbaum, 1980). Dismissed as a subject of importance
by the rising tides of psychoanalysis, descriptive-organicist psychiatry, and behav-
iorism, the study of dissociation and DID declined to near oblivion within a gen-
eration.
The current rise of interest in DID reflects the convergence of many influences
(Kluft, 1987a). The Diagnostic and Statistical Manual of Mental Disorders, 3rd
edition (DSM-111) (American Psychiatric Association, 1980) recognized DID as a free-
standing condition and provided landmark clinical descriptions. Feminism made a
most powerful impact. It sensitized the mental health professions to the hitherto
unacknowledged high incidence of child abuse, incest, and the exploitation of
women. Increasingly clinicians are listening to their adult patients' accounts of
childhood abuse without discounting them in advance as fantasies. DID is primarily
a disorder of sexually abused women; in this atmosphere, its recognition soared.
Also, there has been an explosion of interest in posttraumatic stress disorder
(PTSD), which, like DID, occurs consequent to trauma and has many dissociative
features (Stutman & Bliss, 1985; Spiegel, Hunt, & Dondershine, 1988). Many have
noted the similarity of the two conditions, bringing credibility to DID, an apprecia-
tion of the dissociative aspects of PTSD, and an application of the treatment
approaches useful for PTSD to MPD and vice versa.
Advances in psychopharmacology have encouraged greater diagnostic preci-
sion and closer scrutiny of treatment failures, a group that includes many unrecog-
nized DID patients (Kluft, 1987a). A renaissance of interest in hypnosis is underway,
and with it increased interest in dissociation. Lay attention to celebrated cases of
DID and its fictional representation in the media have played a role. Schrieber's 1973
book Sybil, describing Cornelia B. Wilbur's work with an MPD patient, was partic-
ularly influential. Excitement was generated by studies on the psychophysiological
aspects of DID (Putnam, 1984a, 1991a,b). A final influence has been the dedicated
teaching efforts of many of the pioneers in field.
Before 1980-1984, clinicians' information about DID was more likely to have
come from lay than professional sources. Over those 4 years, a vigorous professional
literature became available and has continued to expand, bringing DID increasingly
into the mainstream; 1984 marked the beginning of annual international confer-
ences on dissociation and DID. The journal, Dissociation: Progress in the Dissocia-
tive Disorders, began publication in 1988; 1989 marked the publication of Putnam's
340 masterful Diagnosis and Treatment ofMultiple Personality Disorder, and 1993 the
Richard P. K1uft remarkable Multiple Personality Disorder in the Netherlands, by Boon and Draijer
(1993a), which demonstrated the reliability and validity of the diagnosis. As of this
writing, DID has become a mainstream concern of the mental health professions,
albeit a controversial one. For further information about the modem history of DID,
see Greaves (1993).

PHENOMENOLOGY

Diagnostic Criteria
As psychiatry moves to achieve accurate and reliable diagnostic criteria, DID
has been redefined three times within a quarter century. In 1980, DSM-m proposed
three criteria: (1) the existence within the individual of two or more personalities,
each of which is dominant at a particular time; (2) the personality that is dominant
at any particular time determines the individual's behavior; and (3) each individual
personality is complex and integrated with its own unique behavior patterns and
social relationships. These criteria were written as a number of new and important
findings were emerging. In retrospect, they reflect the phenomenology of several
classic cases that were intelligent, creative, and female, had relatively few person-
alities, and were not typical in all respects. They implicitly endorse a classic but
superseded model of dissociation (Frischholz, 1985); that is, they rely on an ali-or-
none model in which what is dissociated is, for the moment, no longer a factor. In
fact, the essence of dissociation is that that which is dissociated often continues to
influence matters from "behind the scenes" (American Psychiatric Association,
1994; Kluft, 1987a, 1991a; Franklin, 1988; Spiegel, 1991).
With regard to criterion 1, the term dominance is misleading, because it
implies that the relationship among the personalities is an incessant power struggle
that is won completely for the moment. In fact, personalities may determine
behavior from behind the scenes without emerging and may share or contend for
control. Emitted behavior often is the combined vector of numerous influences,
functioning as a system (Kluft, 1991a,b). Personalities commonly try to pass for one
another. The same concerns apply to criterion 2. Also, recent findings indicate that
contemporary cases average 13 to 15 alters (Kluft, 1984b; Putnam et al., 1986; Ross,
Norton, and Wozney, 1989b; Schultz, Braun, & Kluft, 1989). Kluft (1985b) found that
only about half a dozen or less of these personalities spend significant periods of
time in executive control; that alters demonstrate a wide range of distinctness and
complexity; and that their importance, dominance, and elaborateness may vary
over time. Therefore, criterion 3 required revision.
DSM-m-R criteria were more flexible, less reified, and reflected clinical findings
in the broader range of DID patients: (1) The existence within the person of two or
more distinct personalities or personality states (each with its own relatively endur-
ing pattern of perceiving, relating to, and thinking about the environment and self);
and (2) at least two of these personalities or personality states recurrently take full
control of the person's behavior. DSM-m-R attempted to offer a pragmatic clinical
definition of the term "personality," which was a step forward. DSM·ID-R depicts
DID not in reifying terms that suggest that there are many people in a single body, 341
but indicates instead that in DID the mind is structured as a system of organizations Dissociative
of the self. Unfortunately, it retained the false and misleading statement that alters in Idendty Disorder
control exercise complete power. Just as DSM-m drew criticism as skewed toward
false-negative diagnoses, DSM-m-R, despite its consistency with the natural history
of DID (Kluft, 1985b), was seen by some critics as making the diagnosis too easy to
achieve and encouraging false positives. This fear has been disproven (Ross, 1989).
A greater awareness of DID, rising rapidly at the time DSM-ID-R was published,
accounts for most of the accelerated reporting of such cases. Nonetheless, although
these criteria accurately reflect a condition that can have a wide spectrum of of
manifestations, they have distressed some who prefer a crisper delineation of the
margins of clinical disorders.
Unlike the prior DSM committees that studied the dissociative disorders in an
atmosphere of scholarly deliberation, the DSM-IV committee was polarized and
contentious; consequently, the DSM-IV criteria were drafted in an adversarial atmo-
sphere. Both the criteria and the text are a major departure from DSM-ID-R and
reflect a compromise between the pressures of increasing knowledge on the one
hand and the power of skeptical authorities insistent on promoting their opinions
in the face of that knowledge on the other. The name of the condition was changed
to dissociative identity disorder, ostensibly to put to rest the controversy that
surrounds MPD and to initiate a new, scientific and objective era in its study.
Another rationale for the change was for uniformity in nomenclature (e.g., dissocia-
tive amnesia, dissociative fugue, dissociative identity disorder). However, deperson-
alization disorder was not changed, suggesting that once the name of DID had been
changed, uniformity was no longer such a pressing imperative!
The DSM-IV criteria are perceived as reasonable for clinical and research usage
even by those who argued bitterly over the name change (American Psychiatric
Association, 1994, p. 487):
1. The presence of two or more distinct identities or personality states (each
with its own relatively enduring pattern of perceiving, relating to, and
thinking about the environment and seiO.
2. At least two of these identities or personality states recurrently take control
of the person's behavior.
3. Inability to recall important personal information that is too extensive to be
explained by ordinary forgetfulness.
4. Not due to the direct effects of a substance (e.g., blackouts or chaotic
behavior during Alcohol Intoxication) or a general medical condition (e.g.,
complex partial seizures). Note: 1n children, the symptoms are not attribu-
table to imaginary playmates or other fantasy play.
The decision to replace "personality" with "identity" while retaining the ambiguous
and intermediate term "personality state" acknowledges the difficulties surround-
ing the revision of the DID section. "Personality" is admittedly a problematic term,
long associated with controversy and reification, both of which the committee
attempted to avoid. "Personality state" is a term introduced into DSM-ID-R with the
goal of discouraging reification. It is questionable whether "identity" will be confus-
ing or clarifying. The author's reading of the literature on identity suggests that it
342 will not be a useful heuristic, and that "self" may have been a more useful construct
llichard P. Kluft to explore.
There has always been considerable pressure toward including an amnesia
criterion (Coons, 1984; Braun, 1986; Putnam, 1984b). However, occasional patients
are encountered who have classic personalities but are without classic amnesia;
DID patients frequently have periods during which their amnestic barrier becomes
more permeable than usual; and many dissociative distortions of memory do not
involve formal amnesia (Kluft, Steinberg, & Spitzer, 1988). Excluding patients
without amnesia from the DID diagnosis will eliminate only about 5% of previously
diagnosed DID patients, many of whom have progressed well enough in treatment
to have achieved co-consciousness. However, it may delay the making of the
diagnosis in as many as one third of them, because amnesia is not acknowledged at
first interview by this percentage of patients ultimately diagnosed with DID (Put-
nam et al., 1986; Ross, 1989; Ross et al., 1989b). The pragmatic impact of the
addition of this criterion remains to be assessed. DSM-IV wisely eliminated the word
"full" in criterion 2, more accurately reflecting the function of a system of alters
over time (Kluft, 1985b; Putnam, 1989).
In applying diagnostic criteria, there is some difference of opinion among
experts as to whether to make the diagnosis on the basis of history, without having
encountered alter personalities on one or more occasions (Coons, 1984). One does
not wish to be duped by a factitious disorder patient or some other form of
"wannabe." However, the overtness of DID fluctuates over time in 80% or more of
DID patients (Kluft, 1985b, 1991b), and it is rather precious to withhold the
diagnosis in an otherwise well-documented case with currently covert manifesta-
tions. There is much to be said for being flexible and using criteria more stringent
than DSM-IV only for specialized research purposes. Often one can gain an excel-
lent picture of the alters' presence and impact without encountering them [e.g., in
the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) (Stein-
berg, 1993)], and in some' circumstances (e.g., forensic situations) making an effort
to elicit an alter may diminish the credibility of the patient's condition [e.g., The
"Hillside Strangler" case (Orne, Dinges, & Orne, 1984; Watkins & Watkins, 1984)].
Most DID patients do not fulfill DSM-IV criteria at all times during their illness,
and there are a great many patients who suffer dissociative disorders with the
structure of DID but never appear to fulfill diagnostic criteria (Kluft, 1985b; Ross
et al., 1992a; Coons, 1992; Boon & Draijer, 1993a). For such patients, the diagnosis of
dissociative disorder not otherwise specified (DDNOS) is technically more accu-
rate, although for all practical therapeutic purposes they are virtually identical with
DID. Two series of DDNOS patients with DID structures followed over time proved
to have periods of overt DID in almost every case (Boon & Draijer, 1993b; Kluft,
1985b).

The Personalities or Identities

In the context of general psychiatry, personality is taken to mean, "the charac-
teristic way in which a person thinks, feels, and behaves; the ingrained pattern of
behavior that each person evolves, both consciously and unconsciously, as the
style or way of being in adapting to the environment" (Talbott, Hales, & Yudofsky,
1988, p. 1261). Identity is understood to be "a person's global role in life and the 343
perception of his sense of self'' (falbott et al., 1988, p. 1255). In DID, the entities in DJssoclative
question are "here defined as a relatively enduring pattern of perceiving, relating to, Identity Disorder
and thinking about the environment and one's self that is exhibited in a wide range
of social and personal contexts. Personality states differ only in that the pattern is
not exhibited in as wide a range of contexts" (American Psychiatric Association,
1987, p. 269). Alter personalities are psychological structures, not separate people.
Several approaches to the issue of personality are current. Coons (1984), Kluft
(1984c), and Putnam (1989) agree that the sum total of all the personalities and their
interactions constitute the DID patient's personality in the more general sense.
Braun (1986) has attempted to distinguish quantitatively between personalities, as
defined in the above quotation, and less elaborated entities, which he terms frag-
ments.
Putnam (1989) "conceptualize[s] the alters as highly discrete states of con-
sciousness organized around a prevailing affect, sense of self (including body
image) with a limited repertoire of behaviors and a set of state dependent memo-
ries" (p. 103). Kluft (1988, p. 51) observed:

A disaggregate self state (i.e., personality) is the mental address of a relatively

stable and enduring particular pattern of selective mobilization of mental con-
tents and functions, which may be behaviorally enacted with noteworthy role-
taking and role-playing dimensions and sensitive to intrapsychic, interpersonal,
and environmental stimuli.... It has a sense of its own identity and ideation, and
a capacity for initiating thought processes and actions.

Both are describing reconfigurations rather than reified divisions, emphasizing that
the personalities should be understood as ways the mind may be organized rather
than "pieces of a pie." From this flows an appreciation that the number of person-
alities can be quite large, because they constitute configurations, rather than por-
tions of a unity.
Many skeptical of the reality of DID have argued that "we are all multiple
personalities"; i.e., an individual manifests many states of mind and/or facets. Since
the unity of the self is more a subjective illusion than an actuality (Hilgard, 1986),
this stance has a kernel of truth. Nonetheless, clinical DID differs from such "normal
multiplicity" in a number of dimensions. First, the normal individual in a wide range
of situations and roles experiences no change of identity and retains a sense of
continuity as to who and what he or she is. Second, one's different moods and
circumstances involve no major change in self-representation. An angry normal
woman does not experience herself as a large and menacing male. Third, notwith-
standing the phenomena of state and mood-dependent memory (Bower, 1981),
there are few major barriers in self-referential autobiographic memory across differ-
ent moods, roles, and situations for the normal individual who experiences him or
herself somewhat differently in various moods, roles, or situations. Fourth, there is
no loss of the sense of ownership of what goes on or is done in different states of
mind for the non-DID individual. For better or for worse, one's behavior (experien-
tially) remains one's own. Therefore, the statement "we are all multiple person-
alities" is misleadingly reductionistic.
Although the often dramatic differences across personalities tend to arrest the
344 attention of the observer, it is important to appreciate that their purpose is to create
Richard P. Kluft alternative self-structures and psychological realities within which or by virtue of
which emotional survival is facilitated. A "multiple reality disorder" (Kluft, 199la,b,
1993) is created to allow one to cope with the intolerable and is embodied within
the alters to allow the enactment of alternative approaches to trying circumstances:
For example, a young girl experiencing incest may generate an alter to hold the
incest experience so that she can remain in her family without conscious aware-
ness of what has befallen her and without being consciously burdened by the
fact of her betrayal by someone on whom she remains emotionally dependent.
She might create a male alter along the fantasy/wish that such a plight could not
befall a boy, or that a boy could better take the pain of such encounters.
The emitted observable phenomena of multiple personality disorder are
epiphenomena and tools of the defensive purpose. In terms of the patient's
needs, the personalities need only be as distinct, public, and elaborate as
becomes necessary in the handling of stressful situations ... Anything further
results from hypertrophy or secondary autonomy of these processes, and from
whatever narcissistic investments and secondary gains become associated with
them. (Kluft, 1991b, p. 610)
The purest form of DID is virtually isomorphic, occurring when a traumatized child
creates another version of him or herself either to hold an intolerable experience or
to stand for the wish to be unaffected by it. When alters can subserve their
defensive purpose without emerging completely and demonstrating their separate-
ness, they often do so, and the condition remains very covert (Kluft, 1985b, 199lb).
In sum, the most important aspects of the alters are not related to their dramatic
differences, which are no more than fascinating epiphenomena, but to their facili-
tating adaptation by segregating certain aspects of experience, self, and knowledge
from one another in a relatively consistent rule-bound fashion (Kluft, 199lb; see also
Spiegel, 1986).

Phenomenology of the Personalities

Several recent studies (Bliss, 1980; Boon & Draijer, 1993a; Coons & Milstein,
1986; Coons, Bowman, & Milstein, 1988; Putnam et al., 1986; Ross et al., 1989b) are
largely consistent in terms of the general trends that they demonstrate. At the time
of diagnosis (prior to exploration) approximately two to four personalities are in
evidence. In the course oftreattnent an average of13 to 15 are encountered, but this
figure is deceptive. The mode in virtually all series is three, and median number of
alters is eight to ten. Complex cases, with 26 or more alters (described in Kluft,
1988), constitute 15-25% of such series and unduly inflate the mean. Series cur-
rently being studied in tertiary referral centers appear to be more complex still
(Kluft, Fink, Brenner, & Fine, unpublished data). This is subject to a number of
interpretations. It is likely that the complexity of the more difficult and demanding
cases treated in such settings may be one aspect of what makes them require such
specialized care. It is also possible that the staff of such centers is differentially
sensitive to the need to probe for previously undiscovered complexity in their
efforts to treat patients who have failed to improve elsewhere. However, it is also
possible that patients unduly interested in their disorders and who generate facti-
tious complexity enter such series differentially, or that some factor in these units or 345
in those who refer to them encourages such complexity or at least the subjective Dissoclative
report thereof. Identity Disorder
The personalities' overt differences and disparate self-concepts may be strik-
ing. They may experience and represent themselves as being different ages, gen-
ders, races, religions, and sexual orientations; they may experience themselves as
having different appearances and/or hold discrepant values and belief systems.
Their awareness of one another may range from complete to nil. Directionality of
knowledge is almost always found among some alters, such that alter A knows of the
doings of alter B, but B is unaware of the activities of A. It is not uncommon for some
alters to have symptoms that others do not suffer. Psychophysiological differences
(see Chapter 13, this volume) have been documented. Differences in handwriting
and handedness, voice and vocabulary, accents and speech patterns, and even
preferred languages are encountered. Their facial expressions and movement char-
acteristics, both when neutral and affectively engaged, may show impressive and
rather consistent differences (Kluft, Poteat, & Kluft, 1986). When the personalities
have acquired separate wardrobes, followed different interests, pursued different
forms of creative expression, their differences may be marked. When patients do
not bring imagination and creativity to their alter systems, the differences may be
muted and pallid in comparison.
Investigators have attempted to describe types of personalities (Coons et al.,
1988; Putnam et al., 1986; Ross et al., 1989b). Unfortunately, their classification
systems are not readily reconcilable. It appears that the picture of DID as the
ongoing clash of polarized personality types (e.g., good girl-bad girl, upright
citizen-sociopath) is hard to sustain, although such clashes, when they occur,
arrest attention and at times become a concern of the forensic psychiatrist. Most
patients have personalities that are named, but there may be those who are name-
less or whose appellations are not proper names (i.e., "the slut;' "rage," etc.). Child
personalities, those who retain long periods of continuous awareness, those who
claim to know about all of the others, and depressed personalities are the most
frequent types enumerated (Putnam et al., 1986).
The classic host personality, which usually (over 50% of the time) presents for
treatment, nearly always bears the legal name and is depressed, anxious, somewhat
neurasthenic, compulsively good, masochistic, conscience-stricken, constricted
hedonically, and suffers both psychophysiological symptoms and time loss and/or
time distortion. While no personality types are invariably present, many are encoun-
tered quite frequently: childlike personalities (fearful, recalling traumata, or love-
seeking), protectors, helpers-advisors, inner self-helpers (serene, rational, and
objective helpers and advisors first described by Allison in 1974), personalities with
distinct affective states, guardians of memories and secrets (and of family bound-
aries), memory traces (holding continuity of memory), inner persecutors (often
based on identification with the aggressor), anesthetic personalities (created to
block out pain), expressers of forbidden impulses (pleasurable and otherwise, such
as defiant, aggressive, or antisocial), avengers (which express anger over abuses
endured and may wish to redress their grievances), defenders or apologists for the
abusers, those based on lost love objects and other introjections and identifications,
specialized encapsulators of traumatic experiences and powerful affects, very
346 specialized personalities, and those (often youthful) that preserve the idealized
Richard P. Kluft potential for happiness, growth, and the healthy expression of feelings (distorted
by traumata) in others (Kluft, 1984b).
The often dramatic differences among the personalities are more an arresting
epiphenomenon than the core of the condition. Characterological factors, cultural
influences, imagination, intelligence, and creativity make powerful contributions to
the form taken by the personalities. Most DID patients are rather muted compared
to those cases incorrectly assumed to epitomize the condition (Kluft, 1985b). The
personalities enact adaptational patterns and strategies that developed in the ser-
vice of defense and survival. Once this pattern, which disposes of upsetting mate-
rial and pressures rapidly and efficiently, is established, it may be repeated again and
again to cope with both further overwhelming experiences and more mundane
developmental and adaptational issues. Once the DID that developed in order to
cope with intolerable childhood circumstances has achieved some degree of sec-
ondary autonomy, it becomes increasingly maladaptive.

The Personality System and the Inner World of the PersonaUties

Less compelling but far more crucial than their overt manifestations are their
inner belief systems, cognitive processes, and complex interrelationships. The
personalities may have considerable investment in their own separateness and may
express a pseudo-delusional degree of conviction about their being separate and
autonomous (Kluft, 1984b). While not formally psychotic, they may behave with
the conviction that the actions that they take against the body or the other person-
alities will not affect them. Because the various alters have different memories, the
information that they use to inform their behaviors is not uniform, nor are their
modes of thinking identical. Hence, the several alters live in discrepant assumptive
worlds, fail to function by uniform cognitive rules and processes, and manage
identical data quite differently (Fine, 1988b). This contributes to the multiple reality
disorder (Kluft, 1991a, 1993) referred to above.
The personalities may have quite a complex and subjectively compelling inner
world. The alters comprise a system of mind, and not infrequently experience their
interactions as if they were relationships among actual people. Unfortunately, these
constellations often recapitulate, by direct imitation, symbolic representation, or by
clear analogy, the relationships associated with the patient's alleged abuse experi-
ences. Consequently, the sadomasochism of the abuse that generated the DID
phenomenology is recapitulated in the profoundly dysfunctional relationships
among the members of the alter system (Kluft, Braun, & Sachs, 1984; Brenner,
1994). Many of the clinical crises that so commonly are encountered in the treat-
ment of DID are a direct consequence of the reenactments of traumatic scenarios
within the patients' inner worlds.
The alters may have complex inner relationships, alliances, and hostilities;
their experience of one another may resemble an inner family or society with its
own rules and mores. They often try to influence one another. In this manner the
alter ostensibly in control of the body may feel the impact of the others and battle or
accede to their requests or find itself the recipient of passive influence experiences
(Kluft, 1987b) that influence its actual behavior and feeling state. For example, most
of the first-rank symptoms of schizophrenia described by Schneider (1959) are 347
common indications of the impact of one alter upon another (Kluft, 1987b; Ross Dissoclative
et al., 1990b). Recurrent command hallucinations were experienced by 82% of 28 Identity Disorder
DID patients; in each case the voice of a hostile alter was being heard within the
head (Kluft, unpublished data). In the same series 100% experienced strong bursts
of affect that were associated with alters that were not ostensibly in control at at the
time, but which were reacting to inner or outer stimuli and flooding the alter that
was "out" with their subjective experiences.
In such a manner alters can make an impact without emerging. This is a
particularly common phenomenon with so-called inner persecutors, often based
on identification with aggressors (either prior abusers or culturally sanctioned
icons of malevolent intent; e.g., an abusive parent or the devil). Inner persecutors
by their very nature require victim alters whom they intimidate, attack, dominate,
and torment. This may take place in the inner world of the alters and never become
manifest, or it may involve seizing executive control and disrupting and/or endan-
gering the patient's life. Not infrequently the alter ostensibly in control will be
bombarded by insults and threats and by command hallucinations urging it toward
self-harm or suicide. Furthermore, motor control may be seized in "made" actions,
so that the patient will feel himself flinging himself down the stairs without having
willed such behavior or watch in terror as his or her hands steer an automobile
toward an embankment, unable to regain control of his or her own limbs:
The apparent behavior or subjective state of an MPD patient is often the vector
of many interacting forces that are not apparent upon superficial exploration, or
represent a series of small behaviors or subjective experiences that have oc-
curred in rapid succession and stem from many different sources. (Kiuft, 199lb,
p. 612)

Aspects of Overtness
Several factors determine the likelihood that the inner structure of DID will
become behaviorally manifest to the extent that it is easily detected. Resilience in
the host alter makes overt switching less likely to occur, while the presence of
contemporary stress and trauma makes it more likely. Greater frequency and length
of alters' emergences make the DID more easily observed, while few and/or brief
emergences keep it more covert. If the alters are cooperating, they may share
contemporary memory, pass for one another, and switch smoothly and seamlessly
in order to achieve shared goals. If they are in conflict without clear resolution, the
picture may be dominated with the imposition of passive influence experiences and
the patient may appear borderline or psychotic. Should the contention lead to more
extreme swings of control, more overt switches may be observed.
Likewise, the manner in which alters influence one another also contributes to
the likeliness of overtness. As noted above, inner dialogue, passive influence, and
command hallucination will not lead to overt DID phenomena. Amnestic barriers,
when strong, auger for the recognition of overtness, because if alters share memo-
ries, it is easy for their overt differences to be discounted because the patient will
appear to have a continuous and ongoing life. If a patient has many similar alters, it
is less likely that the switches and amnestic episodes will trigger a suspicion of DID.
348 Many alter systems are organized in such a way as to keep themselves secret and
Richard P. Kluft may become very skilled in covering over their DID phenomena. When alters
assume control for very long periods of time, there may be no switches to observe
for years on end.
A final series of determinants regards the alters' investment in their separate-
ness and the narcissism across the alter system. The more pronounced the patient's
creativity, the more likely the alters' differences will be pronounced and evident.
Secondary gain and characterological features may have pronounced influences as
well. (I'he above discussion is drawn largely from Kluft, 1991b.)

PSYCHOPHYSIOLOGICAL ASPECTS OF DID

It is intriguing indeed to encounter personalities with different handedness,

different allergic responses (Braun, 1983), different responses to the same medica-
tion (Kluft, 1984b), requiring different eyeglass prescriptions and differing on
objective ophthalmological measures (Miller, 1989), and demonstrating measurably
different patterns of response to a given stimulus (Putnam, 1984a). Coons (1988)
has reviewed the massive but primarily anecdotal literature in this area. Although
there have been those who see such differences as proof of the "reality of DID,"
many thoughtful students of the field, preeminently Putnam (1984a), caution
against such inferences. In sum, the phenomena that attract perhaps undue atten-
tion when they occur in the context of DID are actually expressions of more basic
structures of the mind and processes in the brain; their exploration has implications
far beyond the study of DID (see Spiegel, Bierre, & Rootenberg, 1989; Putnam,
1988).

THE NATURAL IDSTORY OF DID

Kluft's (1985b) longitudinal study of 210 DID patients has established much of
the natural history of DID and has shown that DID does not undergo spontaneous
remission and rarely resolves in a treatment that fails to address it directly (Kluft,
1985b, 1993). DID has been demonstrated in children as young as 3 (Riley & Meade,
1988), but many children demonstrate rather vague dissociative features that gradu-
ally coalesce into precursors of DID (Fagan & McMahon, 1984; Braun & Sachs, 1985;
Peterson, 1990, 1991) and progress into a fully structured DID condition (Kluft,
1984a, 1985a) that may become overt or remain clandestine. Although often there
appears to be a clear relationship between the form taken by the DID and the
developmental phases in which traumata occur (Putnam, 1991c), in others the
dissociative response to trauma seems to stand aside from such considerations
(Kluft, 1985a). Most children with DID or its precursors show many trancelike
behaviors; fluctuations in abilities, age appropriateness, and moods; intermittent
depression; amnesia; hallucinated voices; passive influence experiences; dis-
avowed polarized behaviors; disavowed witnessed behaviors; may appear to be
liars; show muted and attenuated signs of DID; have inconsistencies in school
behavior; and appear to have other possible diagnoses (Kluft, 1984a). In addition,
they may show suicidal or self-injurious behaviors, have imaginary companion 349
phenomena when over 5 years of age, and show fluctuating physical symptoms Dissociative
(Putnam, cited in Kluft, 1984a). Children with DID or its precursors infrequently are Identity Disorder
invested in remaining divided; many can be treated rather rapidly (Kluft, 1986).
Recently many investigators have expanded our appreciation of DID in childhood
(Putnam, 1991c; Hornstein & Putnam, 1992; Peterson, 1990, 1991; Tyson, 1992).
In adolescence, the structure of DID usually becomes more complex and
diverse and the personalities more invested in retaining their autonomy (Kluft,
1985b; Kluft & Schultz, 1993). Often the process of personality formation becomes
a general way of coping with nontraumatic material as well, and specialized alters
are formed in connection with new academic, social, and psychosexual challenges.
Several patterns were noted in Kluft's series (1985b). One group of adolescent fe-
males appeared quite chaotic. Promiscuity, drug use, somatoform complaints, and
self-injury were not uncommon. Three quarters of them switched alters quite
floridly, but denied this. They usually were diagnosed as impulsive, histrionic, ictal,
schizophrenic, borderline, or a combination. More recently, rapid-cycling bipolar
disorder has been included in this differential. Many of these adolescents owed their
confusing manifest appearance to the rapid switching of alters and to the constant
inner bombardment (passive influence) of the personality ostensibly in control by
the other alters. Another group of the female adolescents had a more withdrawn
presentation. They had either a residual childlike form of DID or were evolving
toward the classic adult presentation of a depressed and neurasthenic host with
amnesias, headaches, and disremembered out-<Jf-cllaracter behaviors. They usually
were diagnosed with affective disorders, somatoform complaints, and anxiety dis-
orders.
Adolescent males included subgroups whose confrontation with the law or
school authorities were due to the actions of aggressive alters, a depressed sub-
group not unlike the second subgroup of females, and a small number of individuals
whose homosexual concerns dominated their presentations. The aggressive sub-
group often received psychotic diagnoses on the basis of their disorganized behav-
iors and hallucinations, which often had a command quality.
Older adults with DID sometimes retain a rather classic presentation and
simply had never been diagnosed earlier in life. Others, however, demonstrate the
increased dominance of one alter over time, the others making their presence
known by passive influence intrusions. Also, in many patients, the amnestic barriers
begin to fray. Many have been thought to have involutional disorders, because as the
barriers across the alters became more porous with age, unpleasant memories,
dysphoric affects, and the overheard voices of other alters flooded the presenting
personality (Kluft, 1985b).
Although approximately 20% of DID patients manifest classic phenomena over
a sustained period of time, and 20% are so expert at dissimulation, so infrequent in
their switching, or so covert that they rarely show diagnosable signs of DID, the
remaining 60% have periods in which their psychopathology is intrusive or symp-
tomatic and periods (sometimes a year or more) in which it is quiescent, sup-
pressed, or readily disavowed. Hence, 80% of a series of patients known to have
DSM-III DID had only certain "windows of diagnosability" during which their
circumstances could be recognized with ease by an alert clinician (Kluft, 1985b,
350 1987c). At other times, it would have been necessary to suspect or infer their
Richard P. Kluft diagnosis from history or to pursue their diagnosis with systematic inquiries.
Only approximately 10% of DID patients (6% of adults and a small minority
of adolescents) are exhibitionistic about their condition; in the main DID is, in
Gutheil's words, "a pathology of hiddenness" (Kluft, 1985b). DID patients may
show a degree of impairment that ranges from minimal to profound. Their degree of
impairment may appear to fluctuate widely.

EPIDEMIOLOGY

In the mid-1980s, Coons (1984) and Worrall (unpublished data) both estimated
the prevalence of DID at 1:10,000 population by comparing known cases to the
population base from which they were drawn. Bliss and Jeppson (1985) screened
their practices (a skewed sample) and calculated that 10% or more of their patients
might suffer DID. From new cases discovered in sequential admissions to a general
hospital psychiatric unit, Kluft (unpublished data) estimated 0.5-2% suffered DID.
These crude efforts indicated that although its incidence and prevalence were
uncertain, DID was far from rare.
More recently, three systematic studies undertaken to assess the prevalence of
DID in clinical populations have demonstrated that previously undiagnosed DID
patients can be identified in large number and with relative ease among hospitalized
psychiatric inpatients. Ross, Anderson, Fleischer, and Norton (1991b) screened a
year's sequential admissions to a university hospital in Canada, using the Dissocia-
tive Experiences Scale (DES) (Bernstein & Putnam, 1986). They excluded known
DID cases and patients with organicity and followed up patients with suggestive
scores with the Dissociative Disorders Interview Schedule (DDIS) (Ross, 1989), a
structured diagnostic interview: 3.3% of the patients had previously unsuspected
DID. Saxe et al. (1993) used a similar methodology to screen all patients in a Harvard
teaching psychiatric hospital and found 4% of the patients suffered undiagnosed
DID. Boon and Draijer (1993a) describe the screening of psychiatric inpatients in a
Dutch teaching hospital using Dutch versions of the DES and the SCID-D (Steinberg,
1993) and found 5% of the patients suffered previously undiagnosed DID. Unpub-
lished research reports have found similar percentages in Norwegian, German, and
Turkish cohorts. Ross has done a number of studies in other clinical populations.
For example, Ross et al. (1992b) found 14% of 100 adults with chemical dependency
suffered DID. Studies of this nature suggest that large numbers of DID patients
remain undiagnosed within psychiatric patient populations.
1n nonclinical settings, Ross, Joshi, and Currie (1991c) found that 5 -lO"AI of the
general population of a Canadian city had screening scores suggestive of a dissocia-
tive disorder, and in follow-up interviews (Ross, 1991) discovered 11.2% had a
diagnosable dissociative disorder and 3.1% had DID. However, on follow-up Ross
found that only 1.3% had clinical DID; the remainder (1.8%) were false positives.
Using the Dissociative Questionnaire (DIS-Q), Vanderlinden, Van Dyck, Vander-
eycken, and Vertommen (1991) found that 3% of their Belgian and Dutch sample
scored in the range of dissociative disorder patients and 1% scored as high as DID
patients. However, no follow-up interviews were undertaken and the meaning of
these findings is uncertain.
 In studies completed to date, the majority of the identified patients are females: 351
Bliss (1980), 100%; Putnam et al. (1986), 92%; Coons et al. (1988), 92%; Schultz et al. Dissociative
(1989), 90%; and Ross et al. (1989b), 87. 7%. Their average age at diagnosis is over 30. Identity Disorder
There is widespread belief that many males with DID enter the legal rather than the
psychiatric system and go unrecognized. Kluft (1985b) found that the majority of
male adolescents with DID encounter difficulties with the authorities. Bliss (1986)
found a high incidence of dissociative disorders among convicted sex offenders.
Also, the majority of childhood DID cases reported to date are male. Taken as a
whole, these findings suggest that as males with DID mature, certain aspects of
their behavior may lead to their evading clinical detection, or that they may enter
health care delivery systems in which the diagnosis of DID is less likely to be
entertained. The nearly 9:1 female to male ratio noted above probably misrepre-
sents the true gender distribution of DID. Recent efforts to study males with DID are
demonstrating that their presentations are not that dissimilar to those of female
patients (Loewenstein & Putnam, 1990; Ross & Norton, 1989) and may raise the
index of suspicion for DID in those working with male populations.
Taken as a whole and placed in the context of many recent reports of the
discovery of DID in more and more nations, it is clear that these studies and reports
demonstrate that DID is a widespread and not uncommon condition. It appears to
be a common adaptation to overwhelming childhood events and circumstances.
The occurrence of DID in several generations of the same family and in sibships
has been reported (e.g., Braun, 1985; Coons, 1985; Kluft, 1984a, 1985a). In some
cases it has been possible to ascertain and document an abuse history across several
generations in these families. It appears that when a child has a parent modeling
DID behavior, it may require less than the usual amount of abuse in order for the
child to make a DID adaptation.

THE ETIOLOGY OF DID

The Role of Trauma in Inducing Dissociation

Dissociative disorders commonly are associated with substantial psychological
distress or traumatic experiences (Putnam, 1985; Spiegel, 1991; Spiegel & Cardena,
1991). As Spiegel (1991, p. 261) has observed:
Dissociative defenses, which allow individuals to compartmentalize percep-
tions an memories, seem to serve a dual function. They help victims separate
themselves from the full impact of physical trauma while it is occurring, and, by
the same token, they may delay the necessary working through and putting into
perspective of these traumatic experiences after they have occurred. They help
the trauma victim maintain a sense of control during an episode of physical
helplessness, but then become a mechanism by which the individual feels
psychologically helpless once he or she has regained physical control.

Empirical studies of dissociation following upon documented trauma in nonpatient

populations have bolstered the strength of such observations (e.g., Kooper,
Classen, & Spiegel, 1994).
Terr (1991) has described profiles of two types of childhood traumatizations
with regard to memory. Type I follows upon the child's having experienced a single
352 discrete traumatic event. Memory of the event is full, detailed, and "etched in." Type
Richard P. Kluft II occurs in the aftermath of long-standing exposure to repeated untoward events.
Amnesia, self-anesthesia, and distancing with autohypnotic defenses is common,
with frequent impairment of memory. Although these differentiations are not com-
plete in the author's experience, they speak to an important distinction.
Combining the Spiegel and Terr insights, it is possible to understand that
repetitive traumatizations will lead to the evoking of dissociative defenses in a
manner that affects memory. Furthermore, traumatization leads to lesions of iden-
tity (Putnam, 1990). Lesions of identity and memory are the main stigmata of DID
(Nemiah, 1980).

Trauma Histories Given by DID Patients

Both anecdotal reports and systematic surveys show that DID patients are
universally the victims of overwhelming childhood experiences. Putnam et a!.
(1986) found that 97 of 100 DID patients reported having been abused as children.
Interestingly, the 3% who did not were also the patients that had most recently
entered treatment (Putnam, personal communication, 1986). Eighty-three percent
reported sexual abuse and 68% reported incest. Repeated physical abuse was
reported by 75%, 68% reported both sexual and physical abuse, and 45% stated that
they had witnessed a violent death. Over 60% described severe neglect.
Ross eta!. (1989b) studied 236 DID patients, claiming evidence that 88.5% had
been either sexually or physically abused, with some uncertainty about whether the
remainder had been abused: 74.9% alleged physical abuse, and 11.1% were unsure
about this; 79.2% alleged sexual abuse, and 8.1% were uncertain as to whether this
had occurred. Coons eta!., (1988) found that 96% of 50 DID patients alleged abuse:
68% sexual abuse, 60% physical abuse, and 22% neglect. Schultz et a!. (1989)
surveyed the therapists of 355 DID patients: 86% of the patients reported sexual
abuse, 82% physical abuse, and 98% one or both. Ross et a!. (1990a) studied 102
structured interviews of DID patients and found that 90.2% reported sexual abuse,
82.4% physical abuse, and 95.1% one or the other.
Boon and Draijer's (1993a) studied 82 Dutch DID patients in depth and found
that 65.1% reported physical and 60.3% sexual abuse, with a high prevalence of
other overwhelming experiences. They believed that amnesia for childhood events
led to their lower figures, because unlike most of the other investigators, they were
studying a population that included many patients referred for diagnostic study
whose treatments had not begun.
Although these studies did not document the abuse allegations, it is significant
that Bliss (1984) documented some of the allegations of 12 of 13 DID patients. Coons
and Milstein (1986) could document some allegations in 85% of a series of 20 DID
patients. Dell and Eisenhower (1990) could get independent corroboration from
73% of their adolescents with DID. Coons (1994a) was able to find documentation
of the abuse of 95% of 21 children and adolescents with DID and allied forms of
DDNOS. Hornstein and Putnam (1992) described finding documentation of abuse
in 95.3% of 64 children and adolescents with DID and allied forms of DDNOS. Kluft
(1984a) documented the abuse allegations of seven of eight childhood DID patients,
and Fagan and McMahon (1984) did so for the majority of their cases.
 Currently it is fashionable to dispute the allegations of those who allege 353
childhood traumatization, especially those that involve incest; here, space limita- Dissociative
tions preclude a review of this massive and contentious field. Suffice it to say that Identity Disorder
there is excellent documentation of the abuse suffered by children and adolescents
with DID and excellent reason to believe that adults with DID have been trau-
matized. However, one should approach the precise details of the accounts of adult
patients with some caution. Kluft (1984c) pointed out that in the allegations of DID
patients one might encounter excellent memory, fantasy and dream material mis-
taken for reality, misrepresentation, contamination, and confabulation. More re-
cently, Kluft (1994) has spoken of the metamorphosis of the childhood DID condi-
tion into the adult form of the disorder and noted the reworking and elaboration of
the initial memories in that context. Consequently, it is reasonable to appreciate
that DID is a complex and chronic posttraumatic condition (Loewenstein, 1991),
but to bear in mind that the account that the DID patient gives of his or her
traumatization may include elements of inaccuracy and distortion (Kluft, 1994, in
press a,b).

Various Models of DID

A number of models have been proposed to explain and explore DID (Kluft, in
press b). These are: (1) supernatural/transpersonal, (2) psychological, (3) sociologi-
cal, ( 4) illegitimate (role-playing/malingering/iatrogenesis/social-psychological),
(5) trance state/autohypnotic, (6) split brain/hemispheric laterality, (7) temporal
lobe/partial complex seizure/kindling, (8) behavioral states of consciousness,
(9) neural network/information processing, (10) neodissociation/ego state, and
(11) basic affects (which has much in common with models 8 and 9). No one of
these models precludes the operations of the other and none explains rather than
illustrates a possible mechanism for the formation of DID. Space precludes any
more than a cursory commentary on each.
1. Supernatural/transpersonal models hold that the alters are demons, linger-
ing spirits, the souls of the departed, and so forth. They have a venerable history
because DID is the secular expression of the form and structure of a variety of
endemic possession syndromes, including the Judeo-Christian form (Ellenberger,
1970; Kluft, 1991a). Although discounted by mainstream professionals, these ideas
were valued by Allison (1974, 1978) and have been the subject of a recent book
(Freisen, 1991) valued by religiously oriented mental health professionals. The
reader should note that recent studies (Bowman, 1993; Fraser, 1993) demonstrate
that interventions of an exorcistic nature can have deleterious effects in DID
patients.
2. Psychological models have been plentiful, but none had proven consistent
with all known cases of DID (Kluft, 1984c, 1985b). It is impossible to summarize
them succinctly. Loewenstein and Ross (1992) recently reviewed alternative psy-
choanalytic contributions. Many authors have thought that separation and sepa-
ration-individuation concerns may form a substrate for later responses to trauma.
Marmer (1980, 1991) speculates that with the failure of maternal and transitional
objects, a traumatized child may take an aspect of self as self-object and initiate the
experience of taking and perceiving self as object. More recently, Barach (1991) and
354 Uotti (1992) have offered clinical and research-based arguments that many DID
Ricbarcl P. Kluft concerns are consistent with the theories of Bowlby. It seems likely that the various
psychological models that have been advanced will continue to explain why some
DID patients behave as they do, but that the condition as a whole will elude a simple
formulation.
Related to the psychological model are the many speculations that DID is a
subtype of borderline personality disorder. Although many DID patients manifest
borderline phenomenology, the two conditions can be distinguished, and bor-
derline phenomena and dynamics are not intrinsic to DID (Armstrong, 1991, 1994;
Boon & Drajier, 1993b; Horevitz & Braun, 1984; Kluft, 1991a).
3. Sociological models hold that dissociative phenomena may be an attempt
to live, at different times, by different systems of values or in a manner that
compensates for controls imposed on certain individuals or groups of individuals in
various societies. This certainly is an attractive model for certain culture-bound
syndromes in which the sufferer is allowed to manifest, in a dissociated state, forms
of behavior proscribed for them in a rigid culture. While politically attractive to the
advocates of disenfranchised persons, it cannot explain the majority of DID phe-
nomena.
4. The illegitimate (role-playing/malingering/iatrogenesis/social-psycho-
logical) model holds that DID is not a naturalistically occurring condition, but
emerges in the context of the patient's enacting a role he or she has come to
understand will have beneficial consequences and/or be pleasing to someone who
is encouraging such behaviors and beliefs. Hence the disorder is instigate(! and
maintained by external contingencies and/or private motivations. Advocates of this
perspective (Spanos, 1986; Spanos, Weekes, & Bertrand, 1985; Spanos, Weekes,
Menary, & Bertrand, 1986; Merskey, 1992; McHugh, 1993) have been emphatic in
their opinions, but have failed to prove their point. Although it is quite easy to
create many of the manifestations of DID on a transient basis, the creation of the full
clinical picture of DID over a sustained period of time has yet to be demonstrated.
Merskey (1992) and McHugh (1993) offer their opinions on the basis of their
opinions, which have been used to deny the legitimacy of DID phenomena in the
first place. Their arguments are completely circular and entitle them to define any
DID they encounter as iatrogenic or factitious a priori. Thereafter they allege
antecedent events must have created them. Since DID cannot be legitimate, it must
be artifactual, and then it is merely a matter of assigning blame for the initiation and
perpetuation of the clinical picture. In the absence of a single proven case of
iatrogenic DID, such allegations must be regarded with caution. However, factitious
DID is not unknown and must be considered (Coons, 1994b; Kluft, 1995a). Kluft
(1982, 1995b) has maintained that although iatrogenesis has not been demonstrated
to cause DID, it has shown the capacity to worsen it. Kluft (1995a) argues that
although the condition occurs naturalistically, in a given patient particular mani-
festations may be due to iatrogenesis, factitious factors, social-psychological pres-
sures, and information absorbed from society and the media. He observes that some
DID patients are not above exacting secondary gain from their illnesses, and that a
therapist's fascination or ineptitude may exacerbate the baseline condition. It is
helpful to bear in mind that although high hypnotizable control subjects feigning
DID can show psychophysiological differences across their enacted alters, these
changes differed from the changes across alters in naturalistic DID (Putnam, Zahn, 355
& Post, 1990). Dls!ioclative
5. Trance state/autohypnotic models are attractive because a body of re- Identity Disorder
search demonstrates the high hypnotizability of DID patients (Bliss, 1984; Frisch-
holz, 1985). Bliss (1986), following the venerable hypotheses of Freud's collaborator
Josef Breuer (Breuer & Freud, 1893-95), has described DID as a disorder created by
the unwitting abuse of autohypnosis. Although any comprehensive model must
account for the high hypnotizability of DID patients, this model does not account
for the full range of DID phenomenology. In that connection, recall the Putnam
et al. (1990) findings cited above.
6. Split brain/hemispheric laterality models are intellectually intriguing, but
few data support them. At this point, they are no more than a potential heuristic.
7. Temporal lobe/partial complex seizure/kindling models emerged in the
context of two thought-provoking articles (Schenk & Bear, 1981; Mesulam, 1981)
that proposed that DID dissociative phenomena were associated with temporal
lobe/partial complex seizure and their interictal manifestations. They briefly
achieved a notoriety disproportionate with the strength of the data adduced to
support them. Subsequent studies have failed to demonstrate a convincing correla-
tion and have not found either epilepsy among DID patients or DID phenomena in
partial complex or generalized seizure epileptics with a frequency that would
suggest a strong connection (Coons et al., 1988; Devinsky, Putnam, Grafman,
Bramfield, & Theodore, 1989; Loewenstein & Putnam, 1988).
8. Behavioral states of consciousness models are very powerful because they
are consistent with what is known about the development of states of mind and self-
structures, draw on well-studied behavioral state phenomena in infants, and are
congruent with the psychophysiological studies of DID to date. Putnam (1988) has
discussed this model in depth, and Braun (1984) has authored a related study.
Putnam (1991b) has made this model the basis of one of the major definitions of alter
personalities: "the alter personalities represent discrete behavioral states of con-
sciousness with personality state-specific encoding of certain types of memory,
behavior, and psychophysiology" (p. 499). This model is a useful heuristic and
hypotheses drawn from it often are researchable.
9. Neural network/information-processing models are relatively new con-
tenders (Andorfer, 1985; U & Spiegel, 1992; Yates & Nasby, 1993). They offer
paradigms by which the alters can be understood as related to the creation and
activation of nodes in a particular neural network. The DID patient's executive
consciousness at a given point in time would consist of those nodes activated above
threshold at that particular moment. Stimulation and inhibition phenomena can be
used to model aspects of DID structures and functions. Although in their infancy,
such models have demonstrated their potential to offer hypothetical explanations
for complex DID phenomena bypassed by other theory builders, and they deserve
the most careful consideration in future research and theory building.
10. Neodissociation/ego state models assume that the mind may have several
simultaneously ongoing and autonomous centers of cognitive activity and/or that
the mind is at best a plurality of selves that, when congruent, leaves humans with
the subjective illusion of unity, but when in conflict or lacking congruence and
synchrony, give rise to the experience of several alternative self-structures at work
356 with different characteristics and the ability to influence ongoing behavior. Multi-
Richard P. Kluft plicity, then, is a norm and pathological multiplicity occurs when the boundaries
across these states or processes are sufficient to impede normal "commerce;' so
that parts may achieve full or partial control rather than participating in a process
consistent with subjective and behavioral unity (Beahrs, 1982; Hilgard, 1986; Wat-
kins & Watkins, 1979). These models are consistent with many laboratory and
clinical findings and must be considered in any definitive conceptualization.
11. The basic affects model put forth by Nathanson (in press) applies the
affect theories of the late Sylvan Tomkins and Nathanson's (1992) exegesis of them
to DID. Nathanson speculates that some personalities may be organized around
different basic affects and/or affect scripts. His work on shame scripts demonstrates
that this model may be able to bridge the psychological and psychophysiological
dimensions of DID.
In summary, while most of the above models deserve further study, an all-
encompassing model will have to encompass models 5, 8, 9, 10, and possibly 11, and
address 2. In any individual case, models 2 and 4 will require detailed attention.

A Pragmatic Clinical Model and Theory of DID

The etiology of DID and models for its understanding have been studied
(Braun, 1984; Braun & Sachs, 1985; Kluft, 1984b; Putnam, 1989; Stern, 1984). The
four-factor theory (Kluft, 1984b) encompasses most of the observations in the
literature. It holds that the person who will develop DID will have (1) the capacity
to dissociate, which becomes mobilized for defensive purposes in the face of (2) life
experiences that traumatically overwhelm the nondissociative defenses and adapta-
tional capacities of the child's ego; furthermore, (3) shaping influences and avail-
able substrates will determine the form taken by the dissociative defenses in the
process of alter formation. Although the conjunction of these three factors is quite
common and many overwhelmed children have dissociative episodes or briefly
show dissociative signs, those who will develop DID also experience ( 4) the
inadequate provision of stimulus barriers, soothing, and restorative experiences by
significant others. The dissociative defenses continue to serve a purpose, and the
person must fall back on aspects of her or himself to provide necessary functions
and relationships.
Factor 1, dissociation potential, is the biological rather than the compliance-
suggestibility component of hypnotizability (Spiegel & Spiegel, 1987). DID patients,
when stable and cooperative enough for such testing, are highly hypnotizable on
standard instruments (Bliss, 1984; Frischholz, 1985). It has been reported that
abused populations score more highly than controls on measurements of hypno-
tizability and/or dissociation. High hypnotizability is present in 8-12% of the popu-
lation; hypnotizability in general is highest in late childhood (see discussion in
Kluft, 1986).
Overwhelming experiences, factor 2, have been discussed above. As noted by
Putnam et al. (1986), 97% of North American DID patients allege histories of child
abuse. The majority allege sexual abuse, usually incestuous. Child abuse is all too
common, and sexual abuse may affect over one third of American women. Other
common factors in dissociation were discussed by Kluft (1984c, 1986). Some who
will develop DID have experienced the death or loss of significant others in 357
childhood, witnessed deaths or the deliberate destruction of a significant other, or Dissociative
been exposed to dead bodies (especially being forced to touch or kiss them). Identity Disorder
Exposure to the deaths of others in the course of war, accidents, and various
disasters may prove overwhelming, as may severe threats to one's survival or bodily
integrity, such as in severe sustained pain, debilitating illness, or a near-death
experience. Cultural dislocation, brainwashing by embattled parents, being treated
as if one were a different gender, and excessive exposure to family chaos may prove
decisive. Some factors seem to lower the child's defenses and render subsequent
events more traumatic. These include illness and pain, unintentional physical
trauma, fatigue, separation-individuation complications, and having congenital
anomalies, with narcissistic hurts and body ego disturbances.
DID patients often give unsettling histories of severe and bizarre abuse experi-
ences. Data relevant to the reality of the experiences of DID patients and the
vicissitudes of memory have been discussed earlier. Although it often is possible to
document allegations, often there are no surviving records or cooperative wit-
nesses. Few abusers indict themselves by confession. Herman and Schatzow (1987)
found that 74% of their 53 non-DID subjects were able to get confirmation of their
memories of incest, 9% got suggestive but not definitive information, and most of
the remainder actually did not pursue the inquires. It is of note that those whose
abuse was most violent were most likely to have had amnesia for it prior to
treatment. At this point in time it appears likely that the DID patient who alleges
abuse was indeed abused, but that the precise details of the recollection are subject
to all of the difficulties associated with autobiographic memory (see Kluft, 1984c,
p. 14).
Factor 3, shaping influences, notes that there are many unique configurations
of intrapsychic structures and dynamics and environmental influences that may
converge to give rise to the phenomenological expression of DID. There are many
naturally occurring phenomena that may serve as the substrates for alter formation
and many environmental factors that play a role as well. These include inherent
mechanisms and potentials for dividedness that may be enlisted in the presence of
factors 1 and 2: dissociation per se, autohypnosis, the existence and operations of
multiple systems of cognition and memory (e.g., the hidden observer phenomenon
described by Hilgard, 1986), ego state phenomena (Watkins & Watkins, 1979), state-
and mood-dependent memory (Bower, 1981), the many developmental lines de-
scribed in the psychoanalytic literature, imaginary companionship, the processes
of introjection, internalization and identification, state phenomena, protoaffect
structures, and others.
Extrinsic influences play roles as well, especially those of one's culture. Those
developing DID today often have alters based on television characters, an event
unthinkable 50 years before. Factors of interest in childhood may be the encourage-
ment of role-playing and acting by parents, contradictory parental demands and
reinforcement systems, numerous caretakers, and identification with a DID parent
among others. Certainly representations in the media and the techniques of the
therapist may influence the patient's phenomenology somewhat.
The absence of soothing and restorative experiences, factor 4, relates to
observations that many children with DID (Kluft, 1984a, 1985a) or incipient disso-
358 ciative features (Fagan & McMahon, 1984) simply stop manifesting them when they
Richard P. Kluft are protected from further traumatization. If children are not subjected to condi·
tions under which their nascent DID remains adaptive, in a substantial minority of
cases there is a spontaneous remission, while in others there usually is a rapid
response to treatment (Kluft, 1986).
The four-factor theory is consistent with clinical experience, but is less than
satisfactory in addressing the issues raised by the psychophysiological differences
across the alters (see Putnam, 1989).

COMORBIDITY

Findings Based on Phenomena at Presentation:

Apparent Comorbidity
DID is usually a polysymptomatic and pleiomorphic condition, varying widely
over its clinical course even within a single patient. Putnam, Loewenstein, Silber·
man, and Post (1984) suggest that it is best understood as a superordinate diagnosis
under which a vast array of symptomatology suggestive of other diagnostic entities
may be subsumed. Several investigators have described the psychopathology con·
comitant with DID (Bliss, 1980, 1986; Coons et al., 1988; Horevitz & Braun, 1984;
Putnam et al., 1986; Ross et al., 1989b). Unfortunately, their classifications and
definitions were not uniform. Therefore, although it is possible to discuss the
association of certain symptoms with DID, it is far more difficult to make statements
regarding actual comorbidity.
Combining data from the above sources, DID patients demonstrate anxiety
symptoms (psychophysiological, 100%; phobic, 60%; panic attacks, 55%; obses-
sive-compulsive, 35%), affective symptoms (depressive, 90%; "highs;' 15-73%),
allied dissociative symptoms (arnnesias, 57 -100%; fugues, 48-60%; depersonaliza·
tion, 38%), somatoform symptoms (all, 90%; conversion, 60%), sexual dysfunctions
(60-84%), suicide attempts (60-68%), self-mutilation (34%), psychoactive sub-
stance abuse (40-45%), eating disorders (16-40%), sleep disturbance (65%), symp-
toms suggestive of schizophrenia (depending on symptoms, 35- 73%), symptoms of
PTSD (70-85%), and the stigmata of borderline personality disorder (70%).
Since the first publication of this compilation (Kluft, 199la), a number of
authorities have taken issue with the statistics, claiming that their experience
indicates that certain symptoms were highly underrepresented. This criticism is no
doubt correct, because certain authors reported on some symptoms and not others,
and because the sources cited rarely stated their criteria for reporting. The fre·
quency of self-mutilation is considered understated. The percentages for amnesia
reflect more initial presentations than the complete symptom picture. Likewise, the
low percentage for depersonalization is an artifact of the Jack of systematic explora·
tion for this symptom until quite recently.
Affective symptoms, especially depressive, are experienced by 90% or more of
DID patients. However, it remains uncertain whether they suffer affective disor-
ders, posttraumatic sequelae, the despair, despondency, and hopelessness of hu-
man misery, or combinations of the above. Many of their depressive symptoms
clearly are related to the experience of rejection and guilt over responsibility they 359
attribute to themselves. Research at the author's program is underway to explore Dissoclative
the relationship of affective disorders and dissociative disorders. Identity Disorder
Symptoms of PTSD often occur in DID. The conditions have similar etiologies;
it is arguable that DID is a PTSD variant (e.g., Braun, 1986). Many clinicians hold that
PTSD is present in 85-95% of DID patients; Loewenstein (1991) sees PTSD symp-
toms as a nearly universal in DID cohorts. It is not uncommon for the exploration of
PTSD phenomena to lead to the DID diagnosis. As traumatic material emerges in the
treatmel)t of DID, not infrequently a delayed PTSD picture is precipitated as the
patient must contend with long-dissociated traumata.
Many phenomena are shared by DID and schizophrenia, as noted above. In the
modem era the coexistence of DID and schizophrenia has not yet been reported,
although occasionally (in 1-2% of hospitalized cases) a coexistent schizoaffective
disorder is diagnosed (Kluft, Fink, Brenner, & Fine, unpublished data).
The phenomena of borderline personality disorder (BPD) commonly co-occur
with DID. DID has been considered a BPD variant, but many DID patients are
without signs of BPD. Horevitz and Braun (1984) and Schultz, Kluft, and Braun
(unpublished data) found that 70% of DID patients satisfied DSM-m criteria for BPD,
but Horevitz and Braun (1984) found that DID and BPD were separate conditions.
Those who satisfied criteria for both disorders had a far lower level of function and
were more distressed. More recently Armstrong and Loewenstein (1990) and Arm-
strong (1991) have demonstrated that DID and BPD can be differentiated with a
battery of psychological tests. Armstrong (unpublished data) found that of DID
patients who appeared to have BPD as well, only 1-2% were truly BPD as well. Fink
and Golinkoff (1990) also demonstrated distinguishing between DID and BPD. Boon
and Draijer (1993b) were able to make a clear distinction between the two condi-
tions by using very valid and reliable instruments.
The DID-BPD interface is quite complex. First, because BPD patients are a
highly abused population, many could have a posttraumatic condition like DID.
Second, Solomon and Solomon (1982) demonstrated that the core phenomena of
DID led to the appearance of BPD rather than to an identical condition; i.e., DID
generates a phenocopy of BPD rather than coexisting with true BPD in many
instances. Third, Schultz, Kluft, and Braun (unpublished data) found that coexistent
BPD features did not alter the frequency with which DID patients achieved and
sustained integration, which is counterexpectational if true BPD were present.
Fourth, Kluft (1991a, unpublished data) found that of treatment-adherent patients
who appear to have both DID and BPD, one third rapidly ceased to show BPD
features once they settled into treatment, one third lost their apparent BPD as their
DID resolved, and one third retained BPD features even after integration. He
concluded that DID generates a phenocopy of BPD, and that only a minority of DID
patients have true BPD.
With regard to BPD and DID, often one's philosophy of diagnosis will deter-
mine whether one will decide whether a DID patient is BPD. The pure phenome-
nologist will be likely to diagnose both if their phenomena are present, regardless of
how those phenomena came to be manifested. Conversely, the dynamicist may be
inclined to disregard the surface phenomena and grapple with whether the BPD is
an epiphenomenon of the DID, discarding the BPD if he or she determines that to
360 be the source of the BPD phenomena. The author's clinical rule of thumb is that if
Richard P. Kluft most or all of the alters demonstrate BPD phenomena themselves, he is inclined to
make both diagnoses. When the BPD phenomena emerge from the chaos of the
alters and their interactions, he is inclined to omit the BPD diagnosis.

Related Findings
Ross (1989) has explored findings in DID patients and reported that as a group
they are likely to believe in psychic experiences and phenomena such as extrasen-
sory perception. These types of experiences have not received serious study in the
mainstream of the mental health sciences. Kluft (1995b) has studied the suicidality
of DID patients, and concluded that as a group they are among the most suicidal of
all patient populations.

CONCLUSION

The study of DID has accelerated over the last 15 years. Many major discoveries
have been made. Numerous advances have been achieved in understanding its
phenomenology and etiology and in improving its diagnosis and treatment. At
present, DID is very much in the mainstream of the American mental health
professions and sciences, notwithstanding the ambivalence of its reception. De-
spite this progress, our present state of knowledge is only the prelude to further
exciting advances.

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17
Dissociative Symptoms
in the Diagnosis of Acute
Stress Disorder
David Spiegel, Cheryl Koopman, Etzel Cardeiia,
and Catherine Classen

INTRODUCTION

The proposal for a new diagnostic entity requires very careful consideration of
the benefits and risks that such a decision entails. On the one hand, if a condition
that is prevalent in a substantial percentage of the population goes undiagnosed or
misdiagnosed, the affected individuals will lack proper diagnosis and treatment of
their condition. In turn, the lack of recognition of the diagnostic entity might
prevent the proper research designed to understand the condition, its treatment,
and its clinical and social ramifications. On the other hand, carelessly introducing
new diagnostic entities brings the risk of pathologizing what may be innocuous or
even appropriate reactions to the misfortunes of life. Further, even if the symp-
tomatology of the diagnosis can be considered "pathological;' it is still incumbent
upon the advocates of the diagnosis to show that their proposal will not simply add
to the profusion of diagnoses, but rather that the disorder cannot be reasonably
accommodated by the existing nosology.

David Spiegel, Cheryl Koopman, and Catherine Classen • Department of Psychiatry and Behav-
ioral Sciences, Stanford University School of Medicine, Stanford, California 94305. Etzel Car-
deiia • Department of Psychiatry, Unifonned Services University of the Health Sciences, Bethesda,
Maryland 20814.
Handbook of Dissociation: Tbeoretica~ Emptrlca~ and Clinical Perspectives, edited by Larry K.
Michelson and William J. Ray. Plenum Ptess, New York, 1996. 367
368 Elsewhere (Koopman, Classen, Cardeiia, & Spiegel, 1995; Spiegel, Koopman, &
David Spiegel et al. Classen, 1994), we have provided arguments for including the diagnosis of acute
stress disorder (ASD) in the fourth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994). We will
refer to these arguments here as they pertain to the role of dissociative responses to
acute trauma. It is noteworthy that dissociative responses to trauma are required in
the diagnosis of ASD even though they have not been directly mentioned in the
diagnosis of posttraumatic stress disorder (PTSD). In the next pages we make the
case that the emphasis on requiring three dissociative symptoms in the new
diagnosis of Acute Stress Disorder in the DSM-IV is justified on empirical and
theoretical grounds and fills a current vacuum that inhibits appropriate treatment
and research. In particular, we examine evidence that the dissociative symptoms
that comprise the disorder are directly related to the intensity of exposure to trauma
and are strongly predictive of the development of later PTSD. Accurate diagnosis of
this peritraumatic disorder will enhance our ability to predict and intervene with
those likely to develop PTSD. Last, the adoption of this diagnosis would bring about
concordance between the DSM-IV and the diagnosis of "acute stress reaction" in the
International Classification of Diseases and Related Health Problems, lOth edition
(ICD-10) (World Health Organization, 1990).
After giving a brief description of ASD, where the essential component is the
presence of dissociative symptomatology during or shortly after traumatic events,
we will briefly review the following converging lines of evidence: (1) the concep-
tual and empirical association between PTSD and dissociation, (2) the evidence for
the presence of dissociative responses during or shortly after trauma in a substantial
percentage of the population, (3) the association between level of exposure to
trauma and dissociative response, and (4) the association between peritraumatic
dissociative responses and later full-fledged PTSD. Thus, we will make the case that
dissociative symptomatology is a frequent accompaniment of trauma that, if un-
treated, may lead to short- and long-term distress and malfunction.

REVIEW OF THE LITERATURE

Dissociation and PTSD: Conceptual Links

In a number of studies (e.g., Mellman, Randolph, Brawman-Mintzer, Flores, &
Milanes, 1992), PTSD has been found to be the most prevalent lifetime disorder of
war combatants and other individuals exposed to trauma. Although PTSD is cur-
rently included in the anxiety disorders section of DSM-ill-R, we have earlier
discussed the analogy between the concept of dissociation (i.e., the lack of integra-
tion of mental processes) and such PTSD phenomena as the numbing of emotional
and social responsiveness and the intrusion of unbidden thoughts and feelings
(Spiegel & Cardeii.a, 1990). This conceptual discussion has been recently supported
by a number of studies showing significant correlations between standardized
PTSD and dissociation inventories. In a study with 52 survivors of childhood sexual
victimization, Gold and Cardeii.a (1993) found that dissociative symptomatology
was significantly correlated with 85% of the subscales of the Mississippi Scale for
Combat-Related PTSD (Keane, Caddell, & Taylor, 1988), the Trauma Symptom
Checklist-40, and the Response to Childhood Incest Questionnaire, and conclude Acute Stress
that the boundary between PTSD and dissociation may be less evident than previ- Disorder
ously thought. Bremner and collaborators (1992) also found a significant correlation
between PTSD (as measured by the Mississippi Scale) and dissociative symptoms on
the Dissociative Experiences Scale (DES) (Bernstein & Putnam, 1986). These results
are supported by a study with 239 male Vietnam veterans conducted by Marmar
et al. (1992), who also found that dissociative (DES) and PTSD measures [Mississippi
Scale; Minnesota Multiphasic Personality Inventory (MMPI) PTSD Scale; Impact of
Event Scale] (Horowitz, Wilner, & Alvarez, 1979) were significantly correlated, and
that this association was specific and did not reflect general psychopathology.
Finally, Branscombe (1991), in a study with 35 PTSD Vietnam veterans, also found
moderate to strong correlations between PTSD (the Mississippi scale) and two
dissociation scales [the DES and the Perceptual Alteration Scale (PAS)]. The author
also found that the DES scores of her sample were higher than those of the clinical
populations of other studies with the exception of multiple personality disorder.
Thus, the evidence suggests that despite the inclusion of PTSD among the stress
disorders, dissociative symptomatology is commonly present among patients suf-
fering from PTSD.
Two earlier studies showed that the hypnotizability of Vietnam veterans with
PTSD was significantly higher than that of comparison psychiatric patient and
normal populations (Stutman & Bliss, 1985; Spiegel, Hunt & Dondershine, 1988).
Since hypnosis is a form of controlled dissociation, this line of investigation also
supports the link between dissociative and PTSD symptomatology.

Dissociative Response during and Shortly after Trauma

There is accumulating anecdotal and research evidence that dissociative symp-
tomatology occurs in a substantial proportion of the population exposed to natural
and human-made disasters (cf. Cardeiia, Lewis-Fernandez, Bear, Pakianathan, &
Spiegel, 1995; Spiegel & Cardeiia, 1991). 1n a programmatic series of studies, we
have systematically documented the extent of dissociation occurring in individuals
exposed to events such as the Lorna Prieta earthquake of 1989 (Cardeiia & Spiegel,
1993), the Oakland/Berkeley firestorm of 1991 (Koopman, Classen, & Spiegel, in
press; Koopman, Classen & Spiegel, 1994), and in media execution witnesses
(Freinkel, Koopman, & Spiegel, 1994). During and shortly after the earthquake, a
normal student sample reported a significantly greater number of dissociative
symptoms, compared to responses 4 months after the earthquake. These dissocia-
tive symptoms included derealization and depersonalization, time distortions, and
alterations in cognition, memory, and somatic sensations. To a lesser extent they
also reported significantly more anxiety and Schneiderian first-rank symptoms. We
found similar results in a survey of 15 of the 18 journalists witnessing the execution
of Robert Alton Harris (Freinkel et al., 1994). They endorsed on average 11.5 of 25
dissociative symptoms, with symptoms ranging from "my mind went blank" (en-
dorsed by 27%) to "I felt distant from my emotions" (endorsed by 80%). This
prevalence of reported dissociative symptoms is comparable to that seen among
survivors of the recent Oakland firestorm.
370 From these and other studies of reactions to trauma, five kinds of dissociative
David Spiegel et aL symptoms have been identified: emotional numbing, derealization, depersonaliza-
tion, lack of awareness of one's surroundings (stupor), and amnesia for important
aspects of the traumatic event (Classen, Koopman, & Spiegel, 1993). These five
kinds of symptoms may be viewed as manifestations of the lack of integration that
the dissociative state entails. For example, with symptoms of depersonalization, a
person lacks a sense of connection between the usual associations between his or
her identity, body, and personal attributes. Similarly, with symptoms of derealiza-
tion, a person does not associate the usual characteristics to the environment: it
appears to be altered in some respects, perhaps temporally, spatially, and/or in
other ways. One indication of derealization is when time is experienced as slowing
down, as was reported by 51% of the respondents in our study of the Lorna Prieta
earthquake (Cardefi.a & Spiegel, 1993). Stupor is similar to derealization in being
related to one's experience of one's environment lacking the usual associations;
however, stupor constitutes a lack of awareness rather than alterations of aspects of
the environment. For example, not perceiving events as they are occurring has
been reported among persons held hostage (Siegel, 1984), as well as in other kinds
of traumatic events. Amnesia for important aspects of the trauma shows a direct
disconnection between conscious memories and earlier experience. In a recent
study, 90% of Cambodian refugees who had survived the holocaust reported amne-
sia for past traumatic experiences (Carlson & Rosser-Hogan, 1994). Emotional
numbing is a lack of feeling in response to either pleasurable or painful stimuli,
revealing a disconnection of emotional responsiveness to the environment, and
characterized the initial response to the Buffalo Creek disaster (Rangell, 1976).
These five dissociative symptoms have been described in a number of studies of
psychological reactions to acute trauma (see Koopman et al., 1995; Spiegel et al.,
1994, for reviews).

Exposure to Trauma and Dissociative Response

In a study of the relation between trauma and dissociation among Cambodian
refugees who had suffered considerable physical mistreatment and exposure to the
elements, Carlson and Rosser-Hogan (1991) reported a significant correlation be-
tween the amount of reported trauma and scores on the DES. Similarly, Marmar and
colleagues (1994) reported that retrospective accounts of peritraumatic dissocia-
tive responses were strong predictors of current PTSD symptomatology.

Peritraumatic Dissociative Responses and Later PTSD

These recent findings are consistent with inferences in the classical literature
on PTSD. lindemann (1944) noted that individuals who showed little or no initial
emotional reaction to the Coconut Grove fire and did not experience acute grief
over the loss of loved ones and physical injuries had extremely poor long-term
prognoses. Solomon, Mikulincer, and Benbenisty's (1989) study of combat stress
response in the Israeli army demonstrated that "psychic numbing" accounted for
20% of the variance in subsequent PTSD symptoms. Similarly, McFarlane (1986)
observed that avoidance in the wake of the Ash Wednesday bushfires was a strong
predictor of later PTSD. Thus, this literature provides convergent evidence that 371
dissociation occurs frequently in the immediate aftermath of trauma and that in Acute Stress
more extreme forms it predicts the development of later PTSD. Disorder
Based on these previous studies, we decided to analyze the dissociative and
anxiety symptoms reported among respondents in the immediate aftermath of the
1991 Oakland/Berkeley firestorm. We had two purposes in conducting these anal-
yses: (1) to examine differences in specific symptoms in response to varying levels
of exposure to trauma (i.e., to the firestorm), and (2) to evaluate alternative
combinations of symptoms that could constitute algorithms for defining ASD.

METIIODS

Background
This study analyzed the symptoms reported by persons who were recruited in
the immediate aftermath of the 1991 Oakland/Berkeley firestorm, which lasted
two days (October 20-21) and resulted in at least 24 deaths and the destruction of
3135 homes and apartments (faylor & Wildermuth, 1991), and was estimated to cost
as much as $5 billion in damage (Marshall, 1991). After obtaining expedited ap-
proval of this study by our institutional human subjects review board, we distrib-
uted the survey October 24-31 to respondents in the Oakland/Berkeley area.
Nearly all of the surveys (94%) were completed within 3 weeks after the firestorm
began. Seven months after the firestorm, we mailed follow-up assessments to those
181 respondents who had provided us with contact information. Follow-up assess-
ments were completed by 154 respondents for a follow-up rate of 82% of the
original sample, 97% of whom completed these assessments by the ninth month
after the firestorm.

Sample
We obtained informed consent from 187 individuals exposed to the firestorm.
These were 21% of the larger number of potential respondents to whom we
distributed questionnaires. Respondents received no compensation for completing
the baseline assessment. Participants were recruited from sources expected to
provide variation in exposure to the firestorm. These participants included: (1) 94
persons recruited in front of the Federal Emergency Management Agency providing
assistance to firestorm survivors and through personal contacts with people living
in neighborhoods next to the firestorm; (2) 44 University of California at Berkeley
students recruited from four fraternities and sororities that were evacuated during
the firestorm; and (3) 49 graduate students recruited from a professional school of
psychology in Berkeley that was near the fire but was not evacuated (see Koopman
et al., 1994). All participants spoke English and were at least 18 years old. This study
is based on the responses of these 187 participants completing the initial assess-
ments and also on the subset of 154 participants who completed and returned the
follow-up survey sent 7 months after the firestorm, allowing a longitudinal analysis
for these participants.
372 Measurements
David Spiegel et al.
Immediate Aftermath of the Firestorm
Contact with the Fire. Twelve items were used to assess respondents' con·
tact with the fire. Each item asked respondents to indicate whether or not they had
experienced various effects of the fire (e.g., saw smoke, evacuated residence, lost
home). A hierarchical index of contact with the fire was based on these responses,
in which high contact was defined as losing one's residence or being injured in the
fire, medium contact was defined as being evacuated, having trouble breathing,
worrying about residence, feeling heat, or having a loss other than residence, and
low contact was defined as seeing flames, seeing smoke, inhaling smoke, knowing
someone who was a victim of the fire, assisting others, and/or fighting the fire.
Stariford Acute Stress Reaction Questionnaire (SASRQ) (Cardefla,
Classen, & Spiege4 1991). This self-report instrument provides a comprehen·
sive assessment of dissociative and anxiety symptoms experienced during and in
the weeks immediately following a traumatic event. An earlier version was devel·
oped for a study of the psychological aftermath of the 1989 Lorna Prieta earthquake
(Cardefta & Spiegel, 1993). The assessment that was administered immediately
following the firestorm included 33 items assessing five types of dissociative symp-
toms: psychic numbing (4 items), depersonalization (9 items), derealization (9
items), amnesia (6 items), and stupor (5 items). It also included 34 items assessing
five kinds of anxiety symptoms: intrusive thinking (11 items), somatic anxiety
symptoms (17 items), hyperarousal (2 items), attention disturbance (3 items), and
sleep disturbance (1 item). Each item asks about the frequency with which the
respondent has experienced a particular manifestation of one of the symptoms, if at
all, and provides a six-point Ukert scale on which to respond as follows: "not
experienced" (0); "very rarely experienced" (1); "rarely experienced" (2); "some·
times experienced" (3); "often experienced" (4); or "very often experienced" (5).
This measure has been found to have high internal consistency (total dissociative
symptoms, Cronbach's alpha= .90; anxiety symptoms, Cronbach's alpha= .91) and
concurrent validity (r = .52-.69, p < .001) of both scales with scores on the
avoidance and intrusion subscales of the Impact of Event Scale (Horowitz et al.,
1979; Koopman et al., 1994; Spiegel, Koopman, Cardefta, & Classen, 1993).
Background Characteristics. Demographic and other background char·
acteristics were assessed with self-report items. These items included sex, age,
education, and place of residence.

FoHow-up Assessments.
Civilian Version of the Mississippi Scale for Posttraumatic Stress
Disorder. This scale measures posttraumatic stress symptoms among persons
who have undergone a particular trauma and was origil)ally validated and found to
have high reliability with combat-related trauma (Keane, Wolfe, & Taylor, 1987;
Keane et al., 1988). The instrument includes 39 Ukert-style statements, to which
respondents indicate their extent of agreement-disagreement with each on a 1-5
point scale. In this civilian version, for every specific reference to the trauma that
respondents had undergone, we inserted the words "the firestorm." This measure is
scored by first reversing the values for ten reverse-scored items and then summing
the point value of all of the items. Norms have not yet been established to determine 373
the cut-off score for diagnosing PI'SD using the civilian version. Acute Stress
Impact of Event Scale (IES) (Horowitz et aL, 1979). This instrument Disorder
assesses the degree of subjective distress experienced over the past week in relation
to a particular traumatic event, and contains two subscales-intrusive and avoidant
experiences-two core dimensions of PI'SD (Horowitz, Field, & Classen, 1993).
Items assessing intrusive experience focus on having unbidden thoughts, feelings,
and images of the traumatic event. Those assessing avoidant experiences focus on
the extent to which respondents have tried to prevent themselves from having.
thoughts or reminders of the event and tried to dull their emotional response to
memories of the event. Previous research has supported this measure's validity
(Schwarzwald, Solomon, Weisenberg, & Mikulincer, 1987; Zilberg, Weiss, & Horo-
witz, 1982). Responses are scaled as follows: (0, not at all; 1, rarely; 3, sometimes; 5,
often), so possible scores range from 0 to 75.

Data Analysis
To assess whether respondents experienced a particular symptom according
to their responses on the SASRQ, their responses to items were recoded dichot-
omously as occurrence versus nonoccurrence by defining the presence of a symp-
tom for responses of "3" or greater (meaning the symptoms occurred at least
"sometimes" and not merely "rarely" indicted by a "2," or "very rarely" indicated by
a "1," or even "not at all" indicated by a "0"). This was done for conceptual clarity
and was found to produce similar results to that of using the continuous scale for
each item.
We conducted two kinds of data analysis for this evaluation of dissociative and
anxiety symptoms. First, we examined and compared the percentages of respon-
dents who experienced each of the three levels of contact with the fire who
reported each particular symptom. The purpose of these analyses was to determine
whether all the symptoms varied appropriately in response to the level of trauma,
with respondents in the high trauma group most frequently reporting each symp-
tom and those in the low trauma group least frequently reporting each symptom.
We conducted one-way analysis of variance to statistically test the significance of
the differences between the groups.
Second, we evaluated all possible combinations of the five dissociative and five
anxiety symptoms by their overall frequency in the sample (which was better if
lower) and by their sensitivity and specificity in predicting the criterion group high
in posttraumatic stress at the 7-month follow-up. This criterion group is comprised
of 18 persons who scored within the highest 5% on any of three PI'SD measures
(Mississippi Civilian Version, Avoidance Subscale of the IES, Intrusion Subscale of the
IES) and/or on the anxiety measure (Anxiety subscale of the SASRQ at follow-up).

RESULTS
Respondents' demographic characteristics have already been described else-
where and were found to have little or no relationship to follow-up assessment
374 scores on the Civilian Version of the Mississippi Scale and the IES; in contrast, their
David Spiegel et al. overall numbers of dissociative and anxiety symptoms appeared to be important
predictors (Koopman et al., 1994). Our first step in considering these symptoms for
inclusion in the diagnosis of ASD was therefore to analyze the relationship between
each dissociative and anxiety symptom to the degree of trauma (contact with the
fire). The results of this analysis are presented in Table 1, showing the percentages
of the respondents experiencing each of the three levels of contact with the fire
who reported each of the dissociative and anxiety symptoms.
The symptoms were found to vary according to degree of contact with the fire,
with the respondents in the high contact group generally showing the highest
percentage reporting each symptom, the respondents in the low contact group
showing the lowest percentage reporting each symptom, and the respondents in
the medium contact group reporting a level of symptoms inbetween the other two
groups. F-test values are presented to show the results of using one-way analysis of
variance to test the statistical significance of group differences. These differences
are significant for four of the five dissociative symptoms (depersonalization, amne-
sia, stupor, and psychic numbing) and for three of the five anxiety symptoms (sleep
disturbances, intrusive thinking, and somatic symptoms). The differences for de-
realization and attention problem symptoms show statistical trends (p < .06) in the
same directions as the other symptoms. The results for hypervigilant fear did not
approach significance; however, the overall pattern is similar to the results for the
other symptoms.
Our second step in defining the diagnosis was then to evaluate alternative
combinations of these symptoms with reference to predicting later PTSD and
anxiety symptoms. This allowed us to examine the results of applying each algo-
rithm for defining the category on frequency, sensitivity, and specificity (Kraemer,
1992). The results are shown in Table 2. 1n the first column are the percentages of

Table 1. Percentages of oakland/Berkeley Fire

Victims (N = 187) Who Experienced Symptoms
Analyzed by Contact with the Fire
Contact with the fire

Symptom combination Low Medium High F-test

Dissociation
Depersonalization 19% 33% 52% 5.24"
Amnesia 22% 23% 58% 11.29'..
Numbing 34% 44% 69% 5.93"
Stupor 41% 43% 75% 8.13'"
Derealization 53% 72% 77% 2.89
Anxiety
Sleep disturbances 16% 35% 63% 10.68"'
Hypervigilant fear 56% 71% 70% 0.78
Intrusive thoughts 56% 74% 83% 3.68'
Somatic symptoms 59% 78% 90% 5.23"
Attention problems 69% 76% 90% 2.86
•p < .05; ••p < .01; -p < .001.
Table 2. Comparing Combinations of Dissociative and Anxiety 375
Symptoms of oakland/Berkeley Respondentsa Acute Stress
Disorder
Overall% Sensitivity Specificity

No dissociative symptom required

With no anxiety symptoms required 91% 100% 0%
Plus one anxiety symptom 91% 100% 10%
Plus two anxiety symptoms 81% 100% 22%
Plus three anxiety symptoms 65% 94% 39%
Plus four anxiety symptoms 52% 89% 53%
Plus five anxiety symptoms 19% 39% 84%

Single dissociative symptom

With no anxiety symptoms required 78% 100% 25%
Plus one anxiety symptom 77% 100% 26%
Plus two anxiety symptoms 72% 100% 32%
Plus three anxiety symptoms 59% 94% 46%
Plus four anxiety symptoms 48% 89% 57%
Plus five anxiety symptoms 18% 39% 84%

Two dissociative symptoms

With no anxiety symptoms required 61% 100% 44%
Plus one anxiety symptom 61% 100% 45%
Plus two anxiety symptoms 58% 100% 48%
Plus three anxiety symptoms 49% 94% 57%
Plus four anxiety symptoms 39% 89% 67%
Plus five anxiety symptoms 16% 39% 87%

Three dissociative symptoms

With no anxiety symptoms required 46% 94% 61%
Plus one anxiety symptom 46% 94% 61%
Plus two anxiety symptoms 44% 94% 64%
Plus three anxiety symptoms 38% 89% 69%
Plus four anxiety symptoms 32% 83% 75%
Plus five anxiety symptoms 14% 39% 90%

Four dissociative symptoms

With no anxiety symptoms required 31% 94% 78%
Plus one anxiety symptom 31% 94% 78%
Plus two anxiety symptoms 31% 94% 78%
Plus three anxiety symptoms 27% 89% 81%
Plus four anxiety symptoms 26% 83% 82%
Plus five anxiety symptoms 11% 39% 93%

Five dissociative symptoms

With no anxiety symptoms required 18% 67% 89%
Plus one anxiety symptom 18% 67% 89%
Plus two anxiety symptoms 17% 67% 90%
Plus three anxiety symptoms 15% 61% 91%
Plus four anxiety symptoms 14% 56% 91%
Plus five anxiety symptoms 5% 22% 98%

"These results are based on scoring a symptom as "posltivie" if the respondent reported on any
item measuring it that they experienced it at least "somedmes" (three or more on the 0-5
point scale).
376 the total sample of 147 persons who in the immediate aftermath of the Oakland/
David Spiegel et aL Berkeley firestorm met the criteria defined by the particular combination of disso-
ciative and/or anxiety symptoms. In the second column of Table 2 are the sensitivity
results of each combination. These are the percentages of the persons in the
criterion group of 18 distressed persons in the follow-up that our algorithm with the
baseline data (immediately following the firestorm) would have correctly predicted
as reporting high posttraumatic stress and/or anxiety at follow-up. In the third
column are the specificity results, the percentages of persons who are true nega-
tives divided by [the number of true negatives plus the number of false positives
(Kraemer, 1992). This value shows how many of those people who are not highly
distressed at follow-up were accurately predicted by the algorithm to be not at risk
for later distress.
These data suggest that if the algorithm for determining the disorder for DSM-
IV should include at least three of the five possible dissociative symptoms plus at
least one anxiety symptom. 1f the algorithm required the inclusion of fewer than
three dissociative symptoms, it showed little impact on the criterion value of
sensitivity. Alternative algorithms requiring no, one, or two dissociative symptoms
accurately include everyone or nearly everyone who was in the criterion group of
those reporting the greatest distress in the 7-month follow-up assessment of PTSD
and anxiety symptoms, depending on the number of anxiety symptoms required.
However, specificity greatly declined when fewer than three dissociative symptoms
were required in the algorithm. For example, for an algorithm that included three
anxiety symptoms, in combination with three dissociative symptoms the algorithm
resulted in a specificity of 69%; in combination with two dissociative symptoms the
algorithm declined to a specificity of 57%; in combination with one dissociative
symptom the algorithm further declined to a specificity of 46%; and if no dissocia-
tive symptom was required in addition to three anxiety symptoms, the algorithm
declined even further, to 39%. Alternatively, if the algorithm requires the inclusion
of five dissociative symptoms, specificity went up, to 91%, but this coincided with a
decline in sensitivity when compared to an algorithm requiring three dissociative
symptoms in addition to three anxiety symptoms, to 61% from 89%.
So far we have discussed the results that demonstrate that requiring three
dissociative symptoms in the algorithm resulted in better sensitivity and specificity.
Using the data from the Oakland/Berkeley firestorm study respondents, we find that
an algorithm requiring four dissociative symptoms produced better specificity
without hurting sensitivity. In other words, for these data, requiring four symptoms
in the algorithm identified fewer persons incorrectly as being in the criterion group
at follow-up than did algorithms that required three symptoms, yet it was just as
accurate in identifying those who did appear in the criterion group at follow-up.
However, in recognition of the limitation of this data set being drawn from a study
of one particular traumatic event, it is better to require three rather than four
dissociative symptoms in the algorithm for making the diagnosis of ASD. Our
reasoning can be illustrated with the results in Table 2; in comparison to requiring
three or fewer dissociative symptoms, requiring five dissociative symptoms resulted
in a substantial loss in sensitivity. It is likely that in response to other traumatic
events, requiring a minimum of four dissociative symptoms in the diagnosis would
also result in losing sensitivity in predicting who is at risk for later distress. Also, the
presence of three of the dissociative symptoms in combination with anxiety and 377
reexperiencing and avoiding the trauma lasting at least 2 days in the aftermath of a Acute Stress
traumatic event seems adequately distressing and disruptive to justify this diagnosis, Disorder
even if sometimes these acute symptoms decrease over time and do not result in
PfSD symptoms.

DISCUSSION

The results of this analysis support the inclusion of both dissociative and
anxiety symptoms in defining acute stress disorder as a new diagnostic category in
the DSM-IY. We observed a systematic relationship between the percentages of
persons reporting such symptoms and the level of their contact with the Oakland/
Berkeley firestorm. This suggests that these symptoms are common responses to
trauma and vary according to the intensity of the trauma. Furthermore, the relation-
ships between all possible combinations of these symptoms with posttraumatic
stress symptoms 7 months or more later suggest that dissociative symptoms may be
especially sensitive predictors of PfSD, although including anxiety symptoms in
addition to dissociative symptoms in the diagnosis improves the specificity of the
diagnosis somewhat. It is indeed interesting that dissociative symptoms imme-
diately after the trauma are such powerful predictors of later symptoms of a
different but clearly related type. According to the results of this analysis, the best
algorithm for defining ASD is to require a minimum of three dissociative symptoms
and three anxiety symptoms, resulting in 89% sensitivity and 69"..-6 specificity in
predicting later PfSD symptoms. This high number of required symptoms restricts
the diagnosis to individuals who are substantially symptomatic (38% of this sample),
thereby eliminating from identification as mentally ill the majority of the population
who responded to the trauma with fewer symptoms and who are less at risk for later
psychopathology.
This study is limited in part by its focus on a particular traumatic event, the
1991 Oakland/Berkeley firestorm. However, its results are consistent with a number
of studies that similarly suggest that there are high levels of dissociative, anxiety, and
other symptoms in the immediate aftermath of a variety of traumatic events, and
that these symptoms are predictive of later PfSD symptoms. In particular, future
research is needed to replicate the superiority of the algorithm of requiring three
dissociative symptoms found in this study to predict later posttraumatic stress after
a different kind of traumatic event. Although the 21% questionnaire return rate for
the baseline assessments was low, more careful recruitment methodology would
have delayed field recruitment and therefore the proximity of the trauma. We were
careful to recruit a sample that represented substantial variation in exposure to the
trauma, allowing us to examine the trauma-related sensitivity of our measures. Also,
the low return rate most likely reflected the failure of the most distressed persons to
complete and return questionnaires, suggesting that the symptomatology may have
been even higher among the overall pool of potential respondents. Furthermore,
the results of this study in conjunction with the growing body of other studies of
immediate psychological reactions to trauma lend strong support to the inclusion of
this diagnosis in the DSM-IY. Traumatic events continue to happen in the world,
378 with recent years being some of the worst years for disasters in US history (e.g.,
David Spiegel et aL Staff, 1993), and with observers remarking that traumatic events seem to be on the
increase in this complex and problem-filled world (Wtlkinson, 1983).
In addition to replicating the results of this research with samples of persons
who have recently undergone other kinds of traumatic events, further research is
needed to evaluate alternative interventions targeting persons diagnosed with ASD.
The core role of dissociative symptoms in ASD suggests that interventions that will
be most helpful in the immediate aftermath of trauma will draw upon approaches
such as guided imagery and hypnosis exercises that draw upon the dissociative
states that many trauma survivors will experience in the days following the trau-
matic event. Being able to diagnose this disorder is only an important first step in
being able to effectively treat it.

ACKNOWLEDGMENTS. This research was supported by a contract with the Violence

and Traumatic Stress Research Branch of the National Institute of Mental Health
and by a grant from the John D. and Catherine T. MacArthur Foundation and the
American Psychiatric Association. Helena C. Kraemer served as a consultant on the
data analysis. We also wish to thank Janet Williams, Robert Matano, Terrence M.
Keane, Susan Diamond, Dennis Barton, Susan Reaburn, Bita Nouriani, Jim Spira,
Beverly Brock-Alexander, and the Oakland/Berkeley firestorm survivors who con-
tributed to this research.

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18
Posttraumatic Responses
to Childhood Abuse and
Implications for Treatment
James A. Chu

INTRODUCTION

In July 1993, the National Research Council (1993) published a comprehensive

volume entitled Understanding Child Abuse and Neglect. In this volume, statistics
from the US Department of Health and Human Services documented reports of
child maltreatment in 1990 involving more than 2.7 million children. Not sur-
prisingly, childhood trauma, usually in the form of childhood physical, sexual, or
emotional abuse, or profound neglect, is a common feature in psychiatric patients.
In recent years, clinical observations concerning childhood abuse and research
studies have found that childhood physical and/or sexual abuse is reported in the
histories of nearly two thirds of adult female psychiatric patients (Bryer, Nelson,
Miller, & Krol, 1987; Chu & Dill, 1990; Surrey, Swett, Michaels, & Levin, 1990).
Through clinical observations and recent research, the impact of both severe
childhood abuse and the dysfunctional environments in which abuse occurs have
increasingly become more clearly defined.
Childhood abuse has been correlated with a variety of nonspecific effects such
as depressed mood, anxiety, self-destructive behavior, and poor self-esteem
(Courtois, 1979; Finkelhor, 1984; Gelinas, 1983; Herman, 1981; Herman, Russell, &

James A. Chu • Dissociative Disorders Program, Mclean Hospital, Belmont, Massachusetts 02178; and
Department of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115.
Handbook of Dissociation: Tbeoretica~ Empirtca~ and Clinical Perspectives, edited by I.Mry K.
Michelson and William]. Ray. Plenum Press, New York, 1996.

Portions of this chapter are reprinted from Cbu (1992a) and Gunderson and Chu (1993). 381
382 Trocki, 1986; Pribor & Dinwiddie, 1992; Russell, 1986; Shapiro, 1987; Swanson &
JamesA.Chu Biaggio, 1985). New research and clinical studies have suggested that severe child-
hood trauma is a primary etiologic factor with at least three major areas of psycho-
logical disturbance: dissociative symptoms (including dissociative identity disorder
as the most severe form) (Braun, 1990; Chu & Dill, 1990; Saxe et al., 1993; Putnam,
1985), posttraumatic stress symptoms (Donaldson & Gardner, 1985; Kirby, Chu, &
Dill, 1993; Pribor & Dinwiddie, 1992; Saxe et al., 1993; illman & Brothers, 1988; van
der Kolk, 1987a), and disruption of personality development and maturation such as
is seen in borderline personality disorder (Goldman, D'Angelo, DeMaso, & Mez-
zacappa, 1992; Herman, Perry & van der Kolk, 1989; Herman & van der Kolk, 1987;
Ludolph et al., 1990; Ogata et al., 1990; Saxe et al., 1993).
The contention that this triad of areas of psychological disturbance should
result from severe childhood trauma has considerable face validity. Dissociation
appears to be an available psychological defense for children whose limited coping
capacities are overwhelmed by extremely traumatic events (Putnam, 1985). Disso-
ciation enables such events to be "forgotten," or at least emotionally distanced.
Posttraumatic symptoms also appear to be logical consequences of childhood
abuse. Freud's (1920) repetition compulsion appears to be highly applicable to
repressed childhood trauma, and adults with such backgrounds evidence many
different kinds of reexperiencing phenomena (Chu, 1991a; van der Kolk & Kadish,
1987) as well as avoidant symptoms and autonomic arousal (illman & Brothers,
1988; van der Kolk, 1987a). Finally, symptoms of borderline personality disorder-
including ongoing relational disturbances, difficulty tolerating intense affects, be-
havioral dyscontrol, and identity diffusion -seem to be logical consequences of the
failures of attachment and the inadequate care and protection that are common in
dysfunctional and abusive families.
This discussion briefly examines each of the above areas of symptomatology
related to early childhood abuse with a focus on dissociative syndromes that do not
fall into well-defined categories and outlines a treatment model that addresses the
need to prioritize and sequence treatment interventions in patients with complex
posttraumatic symptomatology.

DISSOCIATION IN RElATION TO CHILDHOOD ABUSE

In early studies of multiple personality disorder, the finding of childhood abuse

was nearly universal (Putnam, Guroff, Silberman, Barban, & Post, 1986), leading
investigators to propose a link between dissociative symptoms and early trauma
(Putnam, 1985). Other investigators, such as Terr (1991), who investigated the
effects of psychic trauma on children, proposed a model in which dissociation is
"learned" by children as a way of escaping overwhelming experiences. This mecha-
nism may begin as a conscious attempt at self-hypnosis, but eventually becomes an
automatic and uncontrollable response to trauma or stimulus associated with
trauma. The development of dissociative defenses appears to occur more readily in
childhood (Putnam, 1985), and there is increasing evidence to suggest that severe
dissociative disorders are frequently linked to early childhood trauma (Kirby, Chu &
Dill, 1993).
 Dissociative disorders may be much more common than previously believed. 383
Using the Dissociative Experiences Scale (DES) (Bernstein & Putnam, 1986), Chu Posttraumatic
and Dill (1990) found that 24% of consecutively admitted adult women inpatients Responses to
scored above the previously established median for posttraumatic stress disorder Childhood Abuse
(PTSD) and that 6% scored above the median for multiple personality disorder
(MPD). 1n another study of inpatients, utilizing the Dissociative Disorders Interview
Schedule (DDIS) (Ross, 1989), Ross, Anderson, Fleischer, & Norton (1991) found a
dissociative disorder in 21% and MPD in over 5% of their subjects. The implications
of these finding are at least threefold. First, dissociative disorders may be generally
underdiagnosed, perhaps due to clinicians failing to ask about dissociative symp-
tomatology. Second, MPD or dissociative identity disorder (DID) may be much
more common than previously thought. Third, the majority of diagnosable dissocia-
tive disorders are not DID. In fact, these studies suggest that there may be three or
four times as many dissociative disorders which are not DID as are DID. While some
of these patients fall into recognizable categories such as dissociative amnesia,
fugue, and depersonalization disorder, many others are not so easily characterized.
Based on clinical experience, a very large number of patients who have a dissocia-
tive disorder, but who do not have DID, fall into the category of dissociative
disorder, not otherwise specified.

Dissociative Disorder, Not Otherwise Specified

Dissociative disorder, not otherwise specified (DDNOS) is described in the

DSM-IV as "disorders in which the predominant feature is a dissociative symptom
(i.e., a disturbance of alteration in the normal integrative functions of identity,
memory, or consciousness, memory, identity, or perception of the environment)
that does not meet the criteria for any specific Dissociative Disorder" (American
Psychiatric Association, 1994, p. 490). Examples include Ganser's syndrome (the
giving of approximate answers to questions accompanied by dissociative and
conversion symptoms), trance states, derealization unaccompanied by depersonal-
ization, dissociation following intense coercive persuasion, and atypical fuguelike
states and amnesia. 1n clinical experience, however, one of the most common types
of patients with DDNOS are those who have extensive fragmentation of experience
and identity, which resembles DID, but the fragmentation does not reach the level
of severity of DID.
Braun (1986), Bernstein and Putnam (1986) and others have proposed the
concept of a dissociative continuum with dissociative experiences ranging from
normal to pathological. Patients who fall in the range of the dissociative continuum
short of DID may, in fact, have severe dissociative symptoms including a fragmented
sense of self. Such patients often describe feeling as though they are different
people at different times, or that they watch themselves doing things almost as
though they were outside their own bodies. However, these kinds of DDNOS
patients are able to acknowledge that these alterations in sense of identity are
various split-off aspects of themselves and not separate identities. Watkins and
Watkins (1979) described such patients as having various "ego-states" in which they
have clear changes in their sense of identity, but do not necessarily have the
384 extreme dissociative barriers of DID. The following case example illustrates some of
James A. Chu the features of this kind of DDNOS:
A 32-year-old woman sought a psychiatric evaluation for chronic difficulties
with relationships. It rapidly became clear that she had a history of childhood
neglect and abuse, and that many of the relational issues inherent in the abuse
had strongly affected her adult relationships. The patient also described very
clear shifts in mood, behavior, and identity which often occurred abruptly and
were out of her control. One example she gave was in the context of becoming
involved in relationships. Often, as a relationship became increasingly intimate,
she would experience an internal emotional shift in which she would become
suddenly hostile and cold. She reponed, "Sometimes I can't believe the words
that are coming out of my mouth. I know it's me speaking, but I'm appalled at
the kinds of things I am saying." Other instances included occasions when she
would suddenly find herself crying for unknown reasons, and other times when
she would feel despairing and panicky for periods lasting from a few minutes to
a few hours. The patient described a life-long ability to "space out"; she would
sit in one spot or lie on her bed, staring off into space, not thinking about much
of anything, and feeling very far away. She described these periods as a kind of
"mental vacation.• During times of high stress, she also reponed brief amnestic
periods, and sometimes heard critical voices in her head which she recognized
as her own thoughts. Although the differential diagnosis included panic disor-
der, affective disorder, and temporal lobe epilepsy, the initial impression that the
patient's difficulties were consistent with DDNOS.

Patients with DDNOS who have major shifts in affect, identity, and behavior
often have associated symptomatology including chronic depersonalization and
derealization and sometimes auditory hallucinations. It should be noted that these
auditory hallucinations, which are heard inside the head, are actually a kind of
dissociative hallucinosis representing the thoughts of split-off pans of the self and
not evidence of true psychosis (Kluft, 1987; Putman et al., 1986).
An additional problem in making accurate diagnostic assessments with pa-
tients with dissociative disorders is that the level of dissociative symptomatology is
somewhat variable for many patients. For example, some patients with severe
dissociative symptoms may manifest more florid symptoms under conditions of
stress, sometimes to the extent of demonstrating transient but clear multiple per-
sonalities. Braun (1986, p. 20) labels such patients as having atypical MPD, and
notes: "In atypical MPD, the patient initially does not appear to have multiple
personalities at all. . .. Under sufficient stress, the atypical MPS patient will decom-
pensate and present as a typical MPD patient." Such patients do not consistently
meet the criteria for MPD or DID, and probably should be considered as having
DDNOS as in the following example from Chu (1991b, p. 201):
A 25-year-old woman with a known history of childhood physical and sexual
abuse, as well as symptoms of post-traumatic stress disorder, was admitted to the
hospital after being mugged on the street in her neighborhood. While in the
hospital, she showed evidence of three separate personalities, including a
depleted host personality, a child personality, and an angry persecutor person-
ality. She worked actively on issues related to the mugging and on how to
maintain personal safety, and was discharged in about two weeks. On follow-up
one month later, she was asked about the various personalities. She answered,
 "Well, they're all a pat't of me now," and her outpatient therapist confirmed that 385
there was no continuing evidence of separateness.
Posttraumatic
Responses to
Childhood Abuse
POSTTRAUMATIC STRESS DISORDER

One of the essential features of PTSD is a process in which overwhelming

traumatic experiences are dissociated from current awareness and periodically
reexperienced in various forms, e.g., flashbacks. There are particular differences in
posttraumatic and dissociative symptomatology between persons who have been
first traumatized as adults and those who have been traumatized as children.
Because children have a greater innate dissociative capacity, as well as less mature
and developed capacity to tolerate stress, severely abused children develop more
dissociative symptoms including more dissociative amnesia. Several studies have
demonstrated that extensive childhood abuse prior to adolescence frequently re-
sults in either partial or complete amnesia for the abusive events (Briere & Conte,
1993; Herman & Schatzow, 1987; Kirby et al., 1993). Not remembering abuse does
not free persons from reexperiencing aspects of the abuse. Instead, many survivors
of childhood abuse are frequently tormented by intensely dysphoric feelings such
as helplessness, depression, anger, and isolation that are connected to the forgotten
abuse. Moreover, since such patients are unable to report the core reasons for their
distress, neither they nor clinicians are able to make sense of their painful lives.
Judging from clinical experience, the reexperiencing of intense affect, bodily
sensation, and behavior related to childhood abuse is extremely common, often
accompanied by no awareness or only fragmentary awareness of the actual abuse.
A somewhat more subtle difficulty for persons with early childhood abuse has
to do with communication. Prior to adolescence, and especially in early childhood,
the primary modality of experiencing the world is not verbal and linguistic as it
is in adults, but is largely sensorimotor (van der Kolk & van der Hart, 1989). Thus,
traumatic events that occur early in childhood are encoded in the psyche in a
modality that is primarily nonverbal. When these events are reexperienced, they
have a similar nonverbal quality. In the clinical arena, it is quite striking to encoun-
ter patients who are otherwise highly intelligent, verbal, and articulate, but who
literally seem to have no words to describe their childhood experiences.
Several additional concepts connected with the syndrome of PTSD are impor-
tant in the treatment of survivors of childhood abuse. The biphasic response to
trauma, first described by Lindemann (1944) and subsequently by Horowitz (1976)
and van der Kolk (1987a), suggests that psychological trauma results in alternating
phases of intrusion and numbing. Intrusive responses, as described in the DSM-IY,
include distressing recollections of the traumatic events, traumatic dreams, reexpe-
riencing of the events, and intense distress on exposure to reminders of the trauma.
These alternate with the numbing responses, which include efforts to avoid
thoughts, feelings, or activities associated with the traumatic events, inability to
recall details of the events, diminished interest in activities, social withdrawal,
emotional constriction, and a sense of foreshortened future (American Psychiatric
Association, 1994). Survivors of childhood abuse may show all these features. When
in the intrusive phase, they are overwhelmed and in crisis, desperate to regain a
386 sense of control. When they are in the numbing phase, they are depressed, empty,
James A. Chu and feel that life has no meaning. The cycle of intrusion and numbing may continue
over long periods of time, with patients going through phases of intolerable crisis
followed by crushing depression.
Another. feature of PTSD common to survivors of childhood abuse is gener-
alized autonomic hyperarousal manifested by chronic anxiety, panic attacks, startle
responses, and disturbed sleep. These symptoms are often very distressing and
respond poorly to psychological interventions such as psychotherapy. However,
some partial relief can be obtained through the judicious use of medications.
Benzodiazepines such as lorazepam (Ativan) or clonazepam (Klonapin) may be
helpful for anxiety and panic attacks. In some cases, when patients do not respond
to or become addicted to benzodiazepines, low-dose neuroleptics may also be used
for extreme anxiety. Sleep disturbance in patients with PTSD stemming from early
trauma is often characterized by fear of falling asleep and multiple anxious midsleep
awakenings (Chu, unpublished manuscript). Low doses of sedating antidepressants
such as trazodone (Desyrel), amitriptyline (Elavil and others), or doxepin (Sine-
quan) have sometimes been helpful with this kind of sleep disturbance.

BORDERLINE PERSONAIJTY DISORDER AND CHHDHOOD ABUSE

Classic psychoanalytic theories concerning borderline personality disorder

(BPD) have focused on intrapsychic phenomenology such as ego strength or weak-
ness, defenses, and developmental history. Kernberg (1967, 1968, 1970) hypothe-
sized that there was a failure of normal psychological development early in life,
particularly around the necessary integration of contlictual feelings about primary
caretakers. Mahler's (1971, 1972) and Masterson's (1972) contributions point specif-
ically to the rapprochement subphase of the separation-individuation process
around the age of 18 months as a time of difficulty. They hypothesized that disrup-
tions of attachment can occur in the mother-child relationship if a proper balance
of holding and letting go does not occur.
Recent studies have demonstrated very high rates of traumatic childhood
experiences in adolescent and adult patients with BPD, generally in the range of 60
to 75% (Goldman et al., 1992; Herman et al., 1989; Herman & van der Kolk, 1987;
Ludolph et al., 1990; Ogata et al., 1990; Saxe et al., 19~3). This growing body of
evidence suggests that childhood abuse is often a significant factor in the develop-
ment of borderline psychopathology, and that a shift should be made in the concep-
tual paradigm of BPD. Rather than only focusing on issues concerning intrapsychic
structure, one must also consider the reality of the impact of cataclysmic events in
molding such structures. This shift in conceptual paradigm has major implications
for the treatment of borderline patients with childhood abuse (Gunderson & Chu,
1993).
In clinical experience, many patients with BPD report extensive histories of
childhood emotional, physical, and sexual abuse, profound neglect, and the wit-
nessing of violence. However, it is our contention that it is not the trauma per se that
results in BPD; after all, a significant minority of patients seem to develop BPD
without evidence of childhood trauma. Rather, it is the gross disruptions of familial
attachments and the massive failure of adequate care and protection of the child 387
that result in distortions of normal characterological development. Experiences of Posttraumatic
intrafamilial abuse and neglect are extreme manifestations of the failure of normal Responses to
parental attachment and nurturance. In most cases, these disruptions of attachment Chlldhood Abuse
and nurturance have been neither subtle nor circumscribed, but have existed
throughout multiple phases of childhood development.
In light of evidence of a history of significant trauma in many borderline
patients, borderline symptomatology has become more understandable. The inten-
sity of the borderline patients' relationships and the wild oscillations between
idealization and devaluation may well be understood as recapitulations of early
abusive relationships. Their poor affect tolerance and behavioral dyscontrol, as well
as self-destructive patterns of tension reduction, can be understood as the result of
the failure of early care and protection and the lack of proper support of the child's
ability to tolerate both internal and external experiences. Their fear of abandon-
ment and intense anger may be understood as resulting from real abandonment and
deprivation. And their persistent sense of emptiness and debased self-identity can
be understood as resulting from the failure of adequate mirroring and validation and
from real neglect and abuse.
In a paradigm that takes into account the actual occurrence of major trauma in
the early background of borderline patients, one must move away from the prevail-
ing view of a subtle kind of degeneracy, i.e., that borderline patients inherently have
abnormal or excessive reactions to current untoward life events. Rather, one must
see many patients with BPD as having adapted to overwhelming life events by
developing certain patterns of relating and specific defenses and by viewing them-
selves and reacting to others on the basis of long-standing and unresolved traumatic
experiences. These patterns of adaptation can be seen as currently dysfunctional
but eminently understandable in view of past life experiences. This kind of attitudi-
nal shift may be crucial in ameliorating the pejorative associations common to the
borderline diagnosis (Vaillant, 1992) and in providing effective treatment.

A TREATMENT MODEL

Certainly not all adults with histories of significant childhood abuse experi-
ence dissociative, posttraumatic, and severe personality disorder symptoms. How-
ever, close clinical observation suggests that many individuals with psychiatric
difficulties, particularly those who are the most disabled and those who are fre-
quently hospitalized, show evidence of this triad of symptoms. These patients
commonly present with a bewildering range of psychiatric symptomatology and
represent diagnostic and treatment challenges. It is understandably difficult to
know how to approach patients who manifest such a complex array of symptoms.
Perhaps it is because of this complexity of symptoms that these patients are seen as
difficult to treat, and much time and effort on the part of both the patient and
therapist are often wasted in misdirected therapeutic efforts. It is a common
experience for therapists to feel as though they are riding some kind of therapeutic
roller coaster, with little sense of control or direction, and to have a constant feeling
of impending crisis and potential danger. This discussion will examine the concepts
388 behind the management of complex childhood abuse survivors and set out a
James A. Chu rational paradigm for treatment (Chu, 1992a).
Clear recognition of the profound effects of early abusive experiences and the
complexity of adult syndromes related to such experiences underscores the need
for a sophisticated understanding of the treatment process for childhood abuse
survivors. Because of the many and varied psychiatric symptoms that such individ-
uals commonly present, clinicians need to conceptualize a hierarchy of treatment
approaches designed to address specific symptomatology. Many survivors of severe
childhood abuse require a lengthy period of building a psychotherapeutic founda-
tion, so that later, more definitive abreactive work will be successful.
The therapeutic value of abreaction in adult war veterans has been described
in studies using techniques that precipitate the reexperiencing of the traumatic
event in a context of high social support so that the experience is tolerated,
attitudinally reframed, and integrated into conscious experience (Foa, Steketee, &
Rothbaum, 1989; Keane, Fairbank, Caddell, & Zimering, 1989). There are no similar
studies of the use of abreactive techniques in survivors of childhood trauma.
However, based on clinical experience, it is widely believed that the eventual
reexperiencing and working through of childhood trauma has a beneficial thera-
peutic effect. Persons who have been able to successfully abreact abusive child-
hood experiences often report dramatic changes in their lives. They report changes
such as a reduction in acute symptomatology, fewer and less troubling intrusions of
the abusive experiences, a new sense of identity as being psychologically healthy
and functionally competent, and a much improved ability to relate to others.
The clear value of abreaction of childhood trauma in some patients has led to
an erroneous belief system that seems remarkably ubiquitous among many patients
and their therapists. 1n this belief system, it is felt that in any clinical situation where
childhood abuse is discovered in the history, all efforts should be made to imme-
diately explore and abreact those abusive experiences. Moreover, many clinicians
appear to feel that if current difficulties seem related to past abuse, then the
treatment of choice is to abreact the etiologic abuse. Unfortunately, in the treatment
of many patients, such a belief system is conceptually flawed and inappropriate and
can have untoward effects such as increasing acute symptomatology and functional
difficulties. Patients who have not done the necessary preliminary work are once
again overwhelmed by these experiences, and the patient is actually retraumatized
and there is little or no working through or resolution.
1n order to be able to tolerate abreactive work, the patient must be able to
utilize a high level of social and interpersonal support. Unfortunately, the ability to
relate to and feel supported by others is a primary area of disability in many patients
with a history of severe childhood abuse. These individuals often have acute
relational difficulties that derive from their early abusive experiences. Instead of
being able to trust in others to support them, they fully expect abandonment and
betrayal. Characteristically, when faced with any major stressor (internal or exter-
nal), severely abused patients flee into isolation as the perceived safest alternative
and/or resort to ingrained solutions that are dysfunctional in their current life.
Because therapy may explore past traumatic experiences, the therapist and the
therapeutic process may be experienced as major stressors and may precipitate
negative therapeutic reactions.
 The following model divides the treatment course into early, middle, and late 389
stages. The early stage is comprised primarily of building basic relational and coping Posttraumatic
skills. The middle stage involves exploration and abreaction of traumatic experi- Responses to
ences. Finally, the late stage consists of stabilization of gains and increased personal Chlldhood Abuse
growth particularly in relation to the external world. This division of the course of
treatment is somewhat arbitrary, since patients generally move back and forth
between stages, rather than progressing in a neat linear fashion. However, this
delineation is useful in specifying the components and hierarchy of treatment.

Early-Stage Treatment: The "Safer" Model

Abreaction and resolution of early traumatic experiences are limited by the
ability of childhood abuse survivors to utilize supportive relationships, including
the therapeutic relationship. Abreactive work must be deferred pending the devel-
opment of basic skills in terms of relating and coping. In a treatment model
previously described (Chu, 1992a), five areas of focus can be identified as crucial in
the early stages of treatment. These are discussed here as part of the mnemonic
SAFER: self-care, acknowledgment, functioning, expression, and relationships.

Self-Care. Survivors of childhood abuse are prone to become involved in a

wide variety of self-destructive and dysfunctional behaviors (van der Kolk, Perry &
Herman, 1991). Self-mutilation of a nonlethal nature is extremely common (Shapiro,
1987; van der Kolk et al., 1991) and, paradoxically, is often used as a soothing and
coping mechanism. Patients with histories of extensive childhood abuse often
describe their nonlethal cutting or burning as tension-relieving rather than painful.
Abuse survivors often have other dysfunctional behaviors such as substance abuse
(National Victim Center, 1992; Pribor & Dinwiddie, 1992), eating disorders (Hall,
Tice, Beresford, Wooley, & Hall, 1989), and addiction to risk-taking behaviors (van
der Kolk, 1987b). Finally, revictimization is remarkably common (Chu, 1992b),
including repetitions of emotional, physical, and sexual abuse. Patients' propen-
sities toward inadequate self-care through both self-destructive behavior and vul-
nerability to revictimization must be controlled prior to the institution of any
exploratory therapy. Failure to do so increases the likelihood of serious self-harm
when traumatic material is broached. Analogous to the situation of abused children,
abuse survivors must create an environment of personal safety prior to any disman-
tling of protective (albeit now dysfunctional) defenses.
Abuse survivors tend to be ambivalent about self-care. Perhaps one of the most
damaging aspects of chronic childhood abuse is the compulsion to continue the
patterns of abuse long after the original perpetrators are no longer actively abusive.
In addition, a sense of inner worthlessness may make self-care seem internally
inconsistent or unimportant. And perhaps most significantly, alternative coping
mechanisms, which involve reliance on others, may seem extremely risky to the
abuse survivors who have backgrounds of abandonment and betrayal. Nonetheless,
therapists need to insist that the therapy of patients with extensive childhood abuse
focus on self-care. It should be noted in the early stage of therapy that many patients
will lack the strength to fully achieve self-care. In many situations, lapses will occur
and patients may retreat to self-destructive behavior. However, such lapses are only
390 acceptable when patients are able to demonstrate a commitment to the principles
James A. Chu of self-care over time.

Acknowledgment. Although intensive exploration of past traumatic expe-

riences may be inadvisable in the early stage of treatment, acknowledgment of the
central role of the early trauma is crucial. Childhood abuse is an important determi-
nant in the lives of trauma survivors not only in terms of posttraumatic symp-
tomatology, but also in terms of ability to cope with normal life experiences,
especially interpersonal relationships. To ignore the role of abusive experiences is
to tacitly collude in patients' erroneous beliefs of inherent personal defectiveness.
The simple acknowledgment of the possible role of early traumatic experiences
begins the process of helping survivors to understand many of their current diffi-
culties as being derived from extraordinarily overwhelming events.
Patients who are abuse survivors are often remarkably ambivalent about ac-
knowledging the role of trauma in their lives. It is striking that many trauma
survivors continue to minimize obviously abusive experiences and their effects,
and instead insist that they are simply "crazy" or "bad" for having difficulties in their
lives. In the face of backgrounds of truly abusive experiences, such denial appears
to be further evidence of the extent and unbearable nature of the abuse.

Functioning. In therapy, patients who suffered early abuse often become

acutely symptomatic when they are overwhelmed by the reexperiencing of their
trauma. Without persistent effort on the part of both patients and their therapists to
maintain some semblance of normal functioning, the reexperiences of trauma can
rapidly consume every aspect of patients' lives. The syndrome of constant flash-
backs, repeatedly occurring crises, desperate efforts to obtain comfort and reas-
surance, and dysphoric dependence on therapists is seen frequently in treatment
that is out of control.
Maintaining some appropriate level of functioning is often difficult but none-
theless essential. Even if such efforts to function seem to patients to be superficial or
just "going through the motions," they are important in terms of balancing the
internal pull toward becoming totally immersed in past events. Therapists must
emphasize the importance of maintaining both functioning and supportive relation-
ships during the therapeutic process. Without an emphasis on functioning outside
the therapy, problems such as regression and overly intense transferences are prone
to flourish.

Expression. The intense affects associated with posttraumatic symptoma-

tology must be expressed in a nondestructive and therapeutic manner. Although
full exploration of the traumatic events may not be advisable in the early stage of
treatment, patients do experience some of the overwhelming negative affects
associated with the events such as dysphoria, panic, and anger. The nonverbal
nature of these feelings and patients' ingrained but dysfunctional coping mecha-
nistns frequently lead patients to withdraw and isolate themselves and to engage
in a variety of tension-releasing and destructive activities.
Unspeakable feelings need to find expression in words. Particularly in the early
stages of therapy, however, this process may be facilitated through therapeutic
nonverbal expression. The expressive therapies may have a special role in permit- 391
ting and encouraging appropriate nonverbal expression. In the early stage of Posttraumatic
therapy, such efforts should be directed primarily at therapeutic expression rather Responses to
than exploration, and they can be powerful forces in helping patients to find words Chlldhood Abuse
for their previously unspeakable feelings.

Relationships. Perhaps the most important task of early-stage treatment is

beginning to establish patterns of interpersonal relatedness that are mutual and
collaborative. Survivors of childhood abuse bring the abusive style of relating from
their childhood environments into all their adult relationships, including the thera-
peutic relationship. Childhood abandonments, betrayals, and abuse often transform
the therapeutic relationship into an emotional battlefield in which the patient and
therapist alternately take the perceived role of abused and abuser. The recapitula-
tion and reenactment of early abusive relationships makes collaborative work on
resolving past traumatic experiences impossible until some semblance of mutuality
is established.
In the early stage of therapy, the patient and therapist must repeatedly renegoti-
ate the therapeutic alliance. As the patient is repeatedly unconsciously compelled
to precipitate abusive reenactments within the treatment relationship, the therapist
must interpret the process and help the patient in developing a sense of collabora-
tion and mutuality. This process of disconnection and reconnection must occur on
seemingly endless occasions with endless variations before a minimal sense of basic
trust is formed. It is the difficulties encountered in the interpersonal process that
makes the early stage of therapy long and arduous. However, the repeated discon-
nection and reconnection is the vehicle that provides for the patient a model of
mutuality in relationships and ways to resolve conflict and ultimately provides a
corrective emotional experience. Negotiation of the relationship is a necessary and
prerequisite step for the eventual exploration and resolution of the actual traumatic
events.

Middle-Stage Treatment
When abuse survivors have mastered the tasks of early therapy, they may then
proceed to the exploration and abreactive work of the middle stage of treatment.
Patients vary considerably in their ability to move beyond early-stage treatment.
Some abuse survivors enter therapy with excellent coping skills and may quickly
move. toward middle-stage treatment. However, many others require months or
even years of preliminary work. Several caveats in terms of abreaction of traumatic
experiences should be noted. It is premature, at this point in time, to estimate what
proportion of abuse survivors will be able to abreact and successfully work through
early traumatic experiences. Clinical evidence suggests that although many are able
to do so, others may be able to achieve resolution and integration of traumatic
backgrounds only to a minimal or partial extent. For such patients, stabilization and
symptom management remain the long-term goals of treatment.
Significant regression is commonly observed in the face of abreaction of
traumatic experiences. That is, under the stress of reexperiencing early abuse,
patients may return to former patterns of isolation and dysfunctional or self-
392 destructive behavior. If and when these patterns reemerge, clinical attention should
James A. Chu return to early-stage issues until these issues are once again mastered. Patients need
to establish powerful relational bonds and be prepared to withstand extremely
dysphoric affects without resorting to dysfunctional behavior in order to tolerate
abreactive work. Thus, abreactive should be undertaken from a position of strength
rather than vulnerability. Without adequate preparation and support, patients are
prone to reexperience traumatic events once again in isolation and once again to be
overwhelmed by them. Although abuse survivors may be able to vent affect and
release internal tension through uncontrolled abreactions, these experiences have
very little lasting therapeutic value.
For patients with complex syndromes of posttraumatic symptomatology and
severe characterological difficulties, abreactive work is likely to be a series of
processes rather than a single cathartic event. It is the frequent expectation of
patients that traumatic events can be abreacted and worked through in a brief and
dramatic fashion. However, clinical experience suggests that working through each
major issue or important event may entail a prolonged process lasting days, weeks,
or months. Although patterns of abreaction differ according to the individual
characteristics of patients, several phases are commonly seen. These are: (1) in-
creased symptomatology, particularly more intrusive reexperiencing, (2) intense
internal conflict, (3) acceptance and mourning, and ( 4) mobilization and em-
powerment.
An increase in the reexperiencing of traumatic events-with symptoms such
as nightmares and disturbed sleep, increased anxiety, dissociative experiences, and
generalized hyperactivity and autonomic hyperarousal-is a common early feature
of the abreactive process. These symptoms are often accompanied by the patient's
efforts to deny any link to traumatic events, but denial of this type begins to break
down as patients are flooded by reexperiencing.
As the abreactive process continues, patients begin to tolerate and accept the
reality of past events and begin to attempt to reframe these events. With the
assistance of the perspective of the therapist, the events that were originally
experienced (and are being reexperienced in the present) from the perspective of a
helpless abused child begin to be seen from a more adult viewpoint. This process
produces intense internal conflict. As an example, patients are often unable to let go
of long-held feelings of self-blame at the same time that they begin to understand
that they were not responsible for their abuse. Patients may retain a sense of
identification with the perpetrators of abuse even though they know that they were
victimized. Abuse survivors may also experience intense shame about having
"given in" to the abuse even though they understand that they had no choice.
The resolution of such conflicts involves the patient's "new," stronger, and
healthier aspects understanding and having compassion for the "old" and dysfunc-
tional aspects. That is, patients must understand and accept that they did what they
had to do in response to extreme events. Acceptance of past feelings and behaviors
as opposed to rejection and disavowal leads to the resolution of these internal
conflicts.
Persons with unresolved abusive experiences frequently underestimate and
minimize the extent of their own victimization as a way of protecting themselves
from the full impact of the abuse. Despite the intense dysphoria that often accom-
panies fragmentary memories of the abuse, survivors are often stunned by the full 393
realization of the extent of past abuse. As patients begin to accept their past Posttraumatic
realities, they are often overcome by the extent of their former helplessness and by Responses to
the abandonment and betrayal of important people in their lives. This part of the Childhood Abuse
abreactive process often leaves patients emotionally drained, analogous to survivors
of a natural disaster who are just beginning to take in the extent of the devastation
that surrounds them.
Full realization of the extent of their abuse and the subsequent toll it has taken
on their lives allows patients to begin to mourn the losses that have resulted from
the abuse. This slow and painful process may involve patients examining each
significant aspect of their pasts and reframing their understanding of the events and
their meaning. Patients begin to accept that they were truly not to blame for their
victimization and to understand how the early abusive experiences may have made
them vulnerable to later revictimization.
Supported by these insights, patients begin the process of surrendering the
role of "victim" and replacing it with a sense of self as a "survivor" of abuse. Over
time, the abreactive process enables abuse survivors to mobilize their strengths and
to gain a sense of control. Diffuse feelings become more focused. For example,
rather than feeling frightened of all men, sexual abuse survivors may be able to
recognize that there were specific men responsible for the abuse. They may then be
able to focus their fear, anger, and outrage on the perpetrators as opposed to
displacing these feelings in a generalized fashion.
Abreaction of past trauma frees abuse survivors from fear of their own re-
pressed memories. Their nightmarish childhood realities have lost the power to
overwhelm and control them. Moreover, their sense of identity is positively en-
hanced by an understanding that they have been able to tolerate and overcome the
reexperiencing of past abuse. An adult perspective on the childhood trauma allows
abuse survivors freedom from unreasonable fear, as well as enabling them to protect
themselves from future victimization.

Late-Stage Treatment
Abreaction and resolution of past abusive experiences enables trauma sur-
vivors to proceed with their lives relatively unencumbered by their pasts. Late-stage
treatment is familiar to experienced therapists as the processes of healthy introspec-
tion and engagement of the external world, which is usual in the psychotherapy of
nontraumatized patients. Resolution of the all-encompassing and overwhelming
past events reduces survivors' narcissistic preoccupation with their symptoms and
difficulties. Moreover, an empowered sense of self leads patients to have increased
confidence in their abilities to participate successfully in interpersonal relation-
ships and other interactions in ways that previously eluded them. In persons who
previously have had a fragmented sense of identity, a profound sense of a new,
integrated self arising from new psychic structures often emerges, which facilitates
persons' ability to engage with the external world.
It should be noted that it is common for patients in the late stage of therapy to
find areas of yet unresolved trauma or trauma-related issues as they proceed with
their lives and encounter new situations. This process should be construed only as a
394 need to complete further abreactive work and not as a failure of therapy. In fact,
James A. Chu previous successful experiences with abreactive therapy facilitate and often
shorten any additional similar treatment.

CONCLUSIONS

The therapy of severely traumatized patients is often extremely complex and

confusing. Sophisticated understanding of both the nature of the psychological
effects of trauma and of the therapeutic process of psychotherapy is necessary to
design and implement a useful treatment program. When treating abuse survivors,
even clinically sophisticated therapists are still prone to encounter certain common
clinical dilemmas (Chu, 1988, 1992a). There appear to be particular characteristics
of abuse survivors and their therapy that interfere with therapists exercising their
usual clinical skills. As a result, therapists often find themselves beleaguered, emo-
tionally drained, and uncertain of what they are doing (Chu, 1988; Kluft, 1989),
which enhances their sense of riding a therapeutic roller coaster and facing a
constant sense of impending peril. Clinical dilemmas are often inherently part of
the treatment and must be negotiated. Common dilemmas often concern such
issues as maintaining the treatment frame, sharing therapeutic responsibility,
achieving control of dissociative symptoms, and managing transference-counter-
transference reactions (Chu, 1992a).
The profound effects of early abuse on the development of personality in terms
of relatedness and coping abilities must not be overlooked in efforts to confront
posttraumatic and dissociative symptomatology. Therapists must help patients ad-
dress these basic characterological issues in order to lay the foundations for later
abreactive work and resolution of the etiologic abuse. There are no real shortcuts in
the often lengthy and arduous process of the psychotherapy of severely harmed
trauma survivors. Premature efforts at abreaction are potentially dangerous in terms
of the likelihood of patients' regression and increased morbidity and mortality.
Even though the treatment of severely traumatized patients requires sophisti-
cated understandings and interventions, therapists should remember that the basic
tenets of psychotherapy are applicable to these patients. In particular, the provision
of a safe and containing environment is of central importance (Herman, 1992).
Without a sense of safety in both the therapeutic relationship and the patient's
outside life, little can be accomplished. As patients are able to experience them-
selves in a safe environment, they are able to move forward and progress in their
treatment.
The nature of the etiologic abuse and the dysfunctional family environments in
which the abuse occurred can precipitate many treatment traps, dilemmas, and
potential impasses within the therapeutic arena. Even in the hands of experienced
therapists, these difficulties cannot always be avoided or circumvented. In fact, the
nature of successful treatment of abuse survivors demands that therapists become
involved and fully appreciate the dilemmas and psychological pain that patients
experience. However, an understanding of the treatment process allows therapists
to be better prepared, less anxious about the treatment, and more proficient in
resolving problems when they arise.' Therapists must maintain clearly defined
therapeutic stances in regard to such issues and must sometimes.even insist that 395
patients ally with such therapeutic stances as a condition of continuing the treat- Posttraumatic
ment. After all, therapists should not be placed in the position of continuing and Responses to
colluding in any process that is inherently antitherapeutic and that does not have Chlldhood Abuse
the potential for a positive therapeutic result.
The psychotherapeutic process is a powerful interpersonal tool, capable of en-
abling both positive therapeutic growth and psychological harm. Therapists must
take seriously the potential of the psychotherapeutic process to harm patients. For
example, therapists must avoid collusion with patients' ingrained debased sense of
self and should help patients limit unending repetitions of reenactments of abusive
relatedness. On the other hand, well-conceived psychotherapeutic efforts, used
with good clinical judgment by dedicated psychotherapists, can have dramatic and
positive effects. Such treatment offers abuse survivors new hope, and many
patients-even those who have suffered the most horrendous childhood abuse-
are able to move forward and substantially improve their lives.

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10-20.
Ulman, R. B., & Brothers, D. (1988). Tbe shattered self. Hillsdale, llij: Analytic Press.
Vaillant, G. E. (1992). The beginning of wisdom is never calling a patient borderline. journal of
Psychotherapy PracUce and Research, 1, 117-134.
van der Kolk, B. A. (1987a). The psychological consequences of overwhelming life experiences. 1n B. A.
van der Kolk (Ed.), Psychological trauma (pp. 1-30). Washington, DC: American Psychiatric Press.
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Psychological trauma (pp. 63-79). Washington, DC: American Psychiatric Press.
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van der Kolk, B. A., & van der Hart, 0. (1989). Pierre Janet and the breakdown of adaptation in
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Shori-term approaches to psychotherapy (pp. 176-220). New York: Human Sciences Press.
Zanarini, M. C., Gunderson, J. G., & Marino, M. E (1987). Childhood experiences of borderline patients.
Comprehensive Psychiatry, 30, 18-25.
VI
THERAPEUTIC
INTERVENTIONS

lbis section provides an overview of the important and emerging question of the
treatment of dissociative disorders. Using a variety of perspectives, the authors
examine the difficulty and complexity of treatment. One common theme found in
all of the therapies is the initial establishment of safety in the therapeutic relation-
ship. A second theme is the allowing of experiences and memories to come forth
on the part of the patient rather than a search for "forgotten" events. In Chapter 19,
Fine discusses a cognitive behavioral treatment for DID. The basic premise is that
how one thinks will affect how one feels. As with other types of cognitive therapy,
the utilization of the Socratic method lies at the basis of the work, with each identity
in search of relevant cognitive schema. However, questions of control and trust are
also emphasized along with the cognitive work. In Chapter 20, Barach and Com-
stock examine DID from a psychoanalytic perspective. One of the main foci is on
reducing the need for dissociative defenses. The overall goal is to help the patient
reestablish emotional connection between events in his or her life. As described in
the chapter, this may also require developmental reeducation to approach develop-
ment aspects of the patient's life that were not accomplished because of the
psychopathology. Overall, this requires a more active therapist who is sensitive to
both the type of interpretations required as well as the variety of transference
relationships seen in these situations.
The next two chapters describe techniques that utilize hypnosis as a means to
facilitate therapy. In Chapter 21, Watkins and Watkins develop their model of ego
state therapy based on traditional psychodynamic theory. In Chapter 22, Peterson
emphasizes the nature of hypnosis itself in the treatment of dissociative disorders.
She begins by dispelling the popular press notion that the fundamental role of
hypnosis is memory retrieval. Throughout the chapter, specific techniques are
described that illustrate the treatment.
Throughout this volume, the role of trauma as precursor to dissociation has
been discussed. However, in the therapy situation, the question arises as to how to
work with trauma memories as they come forth. In Chapter 23, Sachs and Peterson
offer insights and techniques for processing these memories. The first rule sug- 399
400 gested is to honor the patients' defenses and allow them to process traumatic
Therapeutic memories at their own pace. This information then needs to be worked through
Interventions with the goal of achieving resolution and integration of the memories. An important
point raised by Sachs and Peterson is the fact that working with these difficult cases
may take its toll on the therapists themselves and they in turn often can suffer a
PTSD-type reaction.
In the final three chapters of this section, the authors approach specific types
of treatments for dissociative disorders: inpatient treatments, art, and psychophar-
macology. Whereas all of the therapies discussed previously emphasize the need for
a safe psychological environment, there are situations in which treatment must
begin with a safe physical environment, in particular, an inpatient situation. In
Chapter 24, Young and Young describe some of the precursors that establish the
need for hospitalization for the treatment of dissociative disorders, especially DID,
and the types of inpatient treatments available. They further discuss the important
question of inpatient staffing and the use of adjunctive therapies. One of the
adjunctive therapies is the use of art, which is described by Cohen in Chapter 25.
Art has the advantage of being able to move beyond the verbal to allow for
expression in a different form. Cohen suggests that art offers a fundamental way of
representing one's inner world, especially important when this world contains
traumatic experiences. The chapter ends by asking the provocative question of why
people with severe dissociative disorders produce so much art. In the final chapter
of the section, Torem overviews the uses and benefits of various psychotropic
medications directed at dissociative disorders. Although there is no pharmacologi-
cal cure for a dissociative disorder, Torem suggests their importance in three areas:
(1) reducing debilitating symptoms; (2) improving the patient's mental state in
order to benefit from psychotherapy; and (3) treating a comorbid disorder. The
chapter not only overviews specific medications, but also offers some general
guidelines when considering their use.
19
A Cognitively Based
Treatment Model for DSM-IV
Dissociative Identity Disorder
Catherine G. Fine

Dissociative identity disorder (DID) is the most recent renaming by the American
Psychiatric Association (1994) of a psychiatric syndrome that has been recorded
from the time ofParacelsus (sixteenth century) (Bliss, 1986; Kluft, 1991). Its recogni-
tion has waxed and waned more as a function of the socioreligious Zeitgeist and the
psychological theory(ies) dominating the era than from actual variations or fluctua-
tions of the disorder itself. The curious archivist and medical historian (Ellenberger,
1970) could readily track the various literature pools and obscure sources to shed
some light on the epidemiology of dissociative disorders. More recently, clinicians
with an interest in history and psychoarcheology have collected, reexamined,
reviewed, and sometimes reinterpreted past misdiagnosed conditions to be disso-
ciative ones (Goodwin, 1993). Skeptics of the existence of dissociative disorders
remain: some on politicophilosophical grounds (Orne, 1984a; Orne, Dinges, &
Orne, 1984), others because they have never seen them in their practice (Chodoff,
1987), and many because they are repulsed by the possibility that child abuse,
which is part of the etiology of DID in 97% of the cases (Putnam, Guroff, Silberman,
Barban, & Post, 1986), could be so prevalent. However, an increasing number of
men and women are currently being appropriately diagnosed with DID.
DID is considered to be a chronic, complex dissociative psychopathology
accompanied by disturbances of identity and memory (Kluft, 1991; Nemiah, 1991).

Catherine G. Fine • Dissociative Disorders Unit, Institute of Pennsylvania Hospital, Philadelphia,

Pennsylvania 19139.
Handbook of DtssociaUon: TbeoreUcal, Empirical, and Cltntcal Perspectives, edited by larry K.
Michelson and William J. Ray. Plenum Press, New York, 1996. 401
402 DID patients can be helpfully conceptualized as struggling with multiple reality
Catherine G. Fine disorder (Kluft, 1991); this means that DID patients live and function with fluctuat-
ing and alternating levels of hypnotic involvement in external and internal realities.
They can be thought of as trying to maintain (hypnotic) duality with one foot (one
ego state-one personality) in a social consensual reality and the other(s) in an
alternate one(s). Therefore, the therapy for DID patients needs to be one that is
cautiously disequilibrating and frequently restabilizing. The task of the therapist is
to bring to the forefront what was hidden (i.e., the other realities, the other
personalities with their concurrent experiences) and to help the patient as a whole
recognize, metabolize, and reabsorb through abreaction and subsequent process-
ing the experiences contained in the alter personalities or alternate realities. A
cognitive-behavioral treatment module for DID has become a straightforward
comprehensive integrationist model for the work with DID (Fine, 1991, 1992, 1993).

THE TRADffiONAL COGNITIVE-BEHAVIORAL MODEL IN

THE TREATMENT OF DID

A cognitive-behavioral (CB) model for treating DID fosters a more structured,

less chaotic therapy where safety, predictability, and consistency are favored. The
cognitive therapy for DID values an experimental model to hypothesis test the
established beliefs of the various personalities and those of the patient as a whole.
This CB model is based on the cognitive model of emotional disorder (Beck,
1976), which states that how someone thinks is going to effect how that person
feels. In treating DID, helping a personality notice cognitive-perceptual- affective-
behavioral incongruities and appropriately label and modify dysfunctional cogni-
tions will impact on the personality's inner world by correcting the distorted
conceptualizations and dysfunctional schemata that are the underpinnings of DID
patients unchallenged affects.

Do the Same Principles of Cognitive Therapy Apply to the

Dissociating as weU as the Nondissociating Patient?
Even though cognitive therapy for nondissociators is typically thought of as a
time-limited, brief psychotherapy geared to symptom relief through cognitive
change, the cognitive therapy of a DID patient can be best conceptualized as a
series of time-limited CB therapies with repeated treatment across all personalities,
all themes, and all affects. The challenges to the cognitive distortions need to be
about reconnecting the various parts of the mind to the current pleasant or even
unpleasant reality, often to the overt objection of many personalities who prefer
their dissociatively created worlds.
In the CB therapy of the DID patient the importance of the therapeutic alliance
cannot be overemphasized. Because the DID patient's trust has been violated in
such a profound way in childhood, appropriate respect and concern for the issue of
trust and its transferential entanglements are essential. With DID patients, trust is
built one step at a time, and therefore it is understood that the credibility of the
therapist will be challenged repeatedly. A direct and honest therapist with firm 403
boundaries will help the DID patient better negotiate the initial stages of the Cognitive Treatment
therapy, which can be particularly fraught with acting out. Furthermore, the struc- Model for DID
ture of the CB therapy and the collaborative directedness of the therapist creates an
environment of consistency, predictability, and safety for the DID patient in which
the therapist engages each personality very directly and with no hidden agendas.
Additionally, CB therapy promotes the use of the Socratic method for problem
solving through the asking of judicious questions by the therapist to each person-
ality of the DID patient. The Socratic method is especially helpful when working
with alter personalities who are resistant to any comment the therapist will make;
this means that the Socratic method is particularly beneficial when working with
adolescent alter personalities and those persecutor personalities who continue to
identify with external abusers. Overall, DID patients struggle with control issues
and mistrust. These are patients who are understandably cautious about any sugges-
tion made by an authority figure and will often balk at the most obvious self-
protective measure presented by the therapist.
The problem-solving quality of CB therapy facilitates and strengthens the
therapeutic alliance, helps uncover representational schemata underlying each
personality's belief system, and reveals the original and present function of each
personality. Approaching the patient with a psychoeducational stance furthers
their sense of budding self-efficacy and self-mastery as the therapist teaches the
patient what tools to use and how to use them. In the CB therapy of the DID patient,
as in any traditional CB therapy, the therapist becomes initially a role model for
information seeking and information testing for the patient.

Goals of Treatment for the DID Patient

There are two nonmutually exclusive ways of explaining the goals of treatment
for DID patients: (1) achievement of congruence of purpose and motivation across
the different parts of the mind (Kluft, 1985); and (2) experiencing completeness of
events and continuity of history over time using Braun's model of dissociation as a
referent (Fine, 1990, 1991). The latter conceptualization will be explored here.
Braun's (1988) BASK (behavior, affect, sensation, knowledge) model of disso-
ciation is conceptually synchronous with the CB therapy approach. This model has
noteworthy descriptive and explanatory power. It states that people, which in a
nondissociated state, experience events almost simultaneously across four dimen-
sions: they have knowledge of events, they can associate behaviors to those events,
they have sensations spanning all sensory receptors during them, and they feel
affects as well. For people in a dissociated state, any or all of these interconnections
can be completely or partially severed and seemingly fancifully recombined. The
treatment goal for the DID patient becomes reconnecting the four dimensions of
the BASK model for each event and then organizing the BASK events, life experi-
ences, along a time line for the patient to make meaning of his or her life. Formulat-
ing the DID treatment goal in this manner helps patients renegotiate their multiple
realities and move from a life that is necessarily decontextualized to one that is
increasingly integrated.
404 Formatting Treatment for the DID Patient to Prevent Crises and
Catherine G. Fine Work toward Integration

The tactical integration model proposed by Fine (1991, 1992, 1993) takes into
account the affective, cognitive, and perceptual struggles of the DID patient. DID
patients traditionally struggle with feeling out of control and vulnerable. The
tactical integration perspective focuses on establishing an increasingly stable cogni-
tive foundation prior to the patient feeling feelings with any degree of complete-
ness. In short, the tactical integration model helps the DID patient build up affect
tolerance prior to doing abreactive work related to their experiences.

The Treatment Model. Fine's (1991, 1992, 1993) model proposes an initial
suppression of affect phase in the treatment of DID. The patient learns to notice
what thoughts, sensations, and incomplete affects arise in everyday life as well as in
the therapy sessions. Once therapist and patient have a beginning overview of the
dissociative landscape, once ego strengths are assessed and the therapeutic alliance
is in process, and once a number of the personalities are actively involved in the
therapy, the cognitive stabilization phase will be followed by the dilution of affect
stage. This phase focuses on bringing into the cognitive narrative (i.e., the patient's
reported experiences) other BASK dimensions; these dimensions will be driven
particularly by the affective and sensation realms. Only then can DID patients begin
to truly piece their experiences together and inquire as to how these experiences
can be understood.

What Is Meant by Experience? Recent debates about normal memory,

traumatic memory, clinically retrieved memories, and memories retrieved in an
experimental setting could leave patients and therapists immobilized until re-
searchers, clinical and otherwise, come to some agreed upon closure. Meanwhile,
these debates, though relevant at the academic and legal levels, do very little to help
the hurting individual resolve their experiences. Many DID patients quite com-
monly attempt to push therapists to validate memories; even though patients'
reports can be extremely compelling, often therapists have very little corroborative
or independent reporting available to them to even begin a constructive exchange
on this topic. Additionally, in those patients where family members agree with the
patient's allegations and support the patient in his or her recovery, the conllict
remains and these patients can continue to deny what may already be documented
in medical, court, or family records. Therefore, what is truly relevant for the patient
is not that the therapist validate memories, but rather that the therapist help the
patient tackle and resolve an experience that may or may not have happened, that
may or may not have happened as recalled, or that may be a screen for something
else or outright confabulated. Kluft (in press) effectively summarizes a neutral
stance when he says that he believes in his patients but does not necessarily believe
his patients. The patients' indignant and sometimes overtly hostile posture when a
therapist chooses to not validate or invalidate what they say is often an unconscious
flashback (Blank, 1985) rather than a truly examined and explored position. There-
fore, the most helpful stance for the patient is that the therapist work with the
material that the patient brings to treatment and work with his or her experiences 405
as the patient understands them. Cognitive Treatment
Model for DID
The Role of Cognitive Interventions. The work with the DID patient
involves reconnecting, uniting, and processing the patient's dissociated life experi-
ences. Established cognitive techniques can be adapted to DID patients to help
them remember and assimilate previously dissociated thoughts and feelings. Ad-
junctive behavioral techniques can support modulation of intense affects to permit
more rapid affective and behavioral change. These cognitive interventions are
advanced in an atmosphere of safety and predictability in which the cognitive
therapist explores with the DID patient the value of the experimental model to
hypothesis test the validity of the established beliefs (Fine, 198&, 1991).
Fine (1990, 1991, 1992) has described elsewhere how to do cognitive restruc-
turing with DID patients by paying attention to patients' thinking and speech
patterns. She has recommended addressing what they say and don't say through
noticing the cognitive distortions (Fine, 1988, 1992) that they favor and overuse.
Fine has discussed the importance of helping the DID patient look for alternative
explanations for their thoughts rather than letting them assume that thoughts
rooted in childhood trauma continue to be valid (unless of course they are
legitimate-which means that the DID patient remains in abusive circumstances
and may require supportive therapy to leave these conditions before getting to the
dissociative work). Alternative explanations for strongly held cognitions are sought
through considering with the DID patient how an outside observer would under-
stand the held opinion. If there is agreement between what an outside observer
would believe and the DID patient, the belief-cognition is more likely to be
maintained; on the other hand, if there is discrepancy between these views, the
thought or belief is apt to be revisited and appropriate reattribution sought.
As the therapist promotes appropriate substitution with corrected attribu-
tions, the patients' negative self-attributions and their disequilibrated worldviews
are redressed. These stepwise cognitive interventions are a precursor to the DID
patients' correct recontextualization of cause and effect. These interventions re-
quire careful planning as well as sensitivity when confronting the patient's false
assumptions.

THE COGNITIVE MODEL REVISITED:

SCHEMA-FOCUSED COGNITIVE THERAPY

Though focusing on the cognitions is understood as the beginning of helping

the patient learn to contain the affect as well as explore its underpinnings, the pure
CB model has a tendency to decontextualize aspects of treatment, to not provide a
better frame for "why look at this particular distorted thought rather than another,"
and to not provide a structure within which the DID patient could with greater ease
begin to regroup, reassemble, and make sense of categories of distorted cognitions.
The pure CB model requires that the therapist address the distortions and elicit the
underlying beliefs, but it does not necessarily contextualize the themes and there-
406 fore does not formally connect categories of distortions with categories of affective
Catherine G. Fine experiences.
Art evolving model of CB therapy may begin to address these concerns; this
model is called schema-focused cognitive therapy (SFCI) and has been proposed by
Jeff Young (1990) as a way of treating personality disorders. Established cognitive
therapists have come to realize what analysts have known for years: that addressing
surface complaints (i.e., depression), however compelling, does little to resolve
long-term issues rooted in childhood. SFCT rests on the premise that significant
experiences of early life influence the formation of schemas (Young, 1990). A
schema is a mental construct that represents organized knowledge and affect about
a given concept or about a type of stimulus.

What Are Scbemas?

Schemas underlie everyday object categories and our social categories as well
(Janoff-Bulman, 1985). Schemas help individuals elucidate their position and role
within established social consensual structures. But more importantly, they also
underlie people's self-definitions. Schemas represent extremely strong beliefs that a
person holds about themselves; the belief is so strong that the person simply
assumes that it is true. A schema established in childhood reflects the perceptions
and subsequent cognitions from childhood experiences. This schema may still be
active and stimulated in adulthood whether or not the adult life circumstances
validate it or not. The strength of the schema for Young (1990) seems connected at
least heuristically to the assumption that it is bound to strong feelings because it
was initially encoded with very strong affect.
This affect, like a magnet, will pull for interpretations of information that will
be consistent with the schema even in the face of contradictory information.
Therefore, according to SFCT, these cognitively based schemas are affectively
driven themes which will be uncovered through exploration of the cognitive
distortions. Fine (1988a) has discussed the parallels between the cognitive distor-
tions of the DID patient and the depressogenic thoughts of the dysthymic patient;
however resilient to elucidation depressogenic cognitive distortions appear to be,
those of the DID patient are more established still.
The distortions of the DID patient are the outcome of a dual attack on the
schemas of the child. The first frontal attack is on the actual formation of the
schemas and the second attack is on the schemas once established whether they are
distorted or not and how these schemas get broken down.

Attack on the Formation of Scbemas

The evolution of perceptual-cognitive structures has been described by Piaget
(1971) who addresses his heuristic of four developmentally interrelated and contig-
uous stages through which all children progress. He has called these stages the
sensorimotor stage, the preoperational stage, the concrete operational stage, and
the formal operations stage. The child masters and then progresses from each stage
to the next through adaptation and organization. Adaptation for the child means
having to negotiate accommodative and assimilative functions coordinated with
one another by the supraordinate concept of organization. The overwhelming 407
affect experienced by the abused child leads to the formation of "war-based" Cognitive Treatment
schemas that are traumatogenic in content and schemas that are themselves im- Model for DID
pacted by dissociation in their inception.
When a child develops in an abusive environment, dissociative processes are
mobilized to deal with the impact of overwhelming stress imposed by violations to
the self (Kluft, 1984; Spiegel, 1984). The age of onset of abuse, its intensity, and its
duration will differentially affect the child's accommodative and assimilative func-
tions. Fish-Murray et al. (1987) have reported that self-correction in abused children
is difficult because their accommodative functions are impaired. Their cognitive
functions are more fixed than variable and lack optimal flexibility. Abuse affects not
only accommodation, but it also interferes with assimilation. If assimilation does not
occur, some of the cognitive schemas may remain fixed at a previous level of
ontogenic development in part or in totality. If this occurs, the schemas may remain
meaningless and nonintegrated, or they may reflect a meaning acquired at a preced-
ing developmental level and thus be incomplete or immature. These difficulties in
the proper evolution of schemas will lead to the cognitive distortions discussed
previously.
Young (1990) has labeled this schema-based deeper level of cognitive process
early maladaptive schemas (EMS). They reflect an unconditional belief about the
self, are self-perpetuating, are dysfunctional in a significant and recurrent manner,
are activated by relevant events in the environment, are tied to higher levels of
affect than underlying assumptions, and seem to be tied to early interrelationships
with family members (Young, 1990). For the DID patient, EMS may be at the
foundation of their developing perceptual cognitive structures and reflect in part
the impact of dissociative intrusions on the child's evolving sense of self. However,
all schemas may not be impacted by abuse; the dissociative intrusions may strike
both differentially and/or opportunistically.

Attack on the Established Schemas

In Braun's (1988) BASK model of dissociation, he proposes that an event can be
dissociated into its four components: behavior, affect, sensation, and knowledge. It
is heuristically plausible that not only does abuse sever knowledge from the three
other dimensions as described by Braun, but abuse may force the knowledge
dimension to shatter into smaller units of information, into fragments of knowl-
edge. Knowledge may not only be broken down into its schematic elements, but
the schematic elements themselves may get split off.
Dissociation consequent to abuse may affect the schemas in a number of ways.
The cognitive schemas may become completely segregated from one another,
leading to two separate schemas encapsulating two seemingly complete but differ-
ent information pools (i.e., two separate alter personalities in a patient: one who
knows, for instance, that the neighbor abused him/her, the other who just knows
that the neighbor was great fun). Second, the cognitive schemas may be partially
severed from one another, with both overlapping and disjunctive parts leading to a
common information pool and one or more divergent pools. Two personalities may
know that the neighbor abused them (common information); however, one be-
408 lieves it was just physical abuse, whereas the other knows about some of the sexual
Catherine G. Fine abuse (separate information). Third, the cognitive schemas may be entirely severed
in an imbalanced way, with one cognitive schema being replete with information
while the other schema holds only minimal residual information. For example, one
alter in a DID patient knows the whole family and is quiet in treatment, whereas
another alter who vehemently claims much knowledge of family genealogy may
truly know only one family member directly who so happens to be the family
historian. Finally, the cognitive schema may be entirely severed from one another
and forced into almost exact self-replication (cloning); this is relatively frequent in
DID patients who use event-based dissociation. Regardless of how the EMSs are
formed, they will have to be addressed systematically.

The Doing and Undoing of EMS

Young (1990) states that short-term cognitive therapy has been concerned
with three levels of cognitive phenomena: automatic thoughts, cognitive distor-
tions, and underlying assumptions. Fine (1991, 1992), in her adaptation of cognitive
therapy to the treatment of DID, has focused on organizing the work with the DID
patient to better correct the cognitive distortions through the uses of direct or
indirect interventions. Knowledge of the cognition delineates the likely/plausible
or at least tacit content of the schema on which both the therapist and the patient
will need to focus and intervene. For those interventions to be most effective,
understanding some of the processes that sustain and aid in the nonresolution of
EMS is helpful.
Three processes are thought to operate on these EMS to keep them well in
place: schema maintenance, schema avoidance, and schema compensation (Young,
1990).

Schema Maintenance. It is understood according to SFCT that EMSs are the

cornerstone of the DID patient's self-concept. Schema maintenance refers to proc-
esses by which the EMSs are reinforced. These processes are upheld cognitively and
behaviorally; they include the habitual utilization of both cognitive distortions and
self-defeating behaviors. Schema maintenance processes account for the rigidity so
commonly seen in DID patients' cognitive and affective realities. At the cognitive
level, schema maintenance is usually accomplished by "highlighting or exaggerat-
ing information that confirms the schema, and by negating, minimizing or denying
information that contradicts the schema" (Young, 1990, p. 17). The more obvious
cognitive interventions that I use with DID patients (with or without formal
hypnosiS), such as cognitive restructuring, cognitive refraining, or facilitating per-
ceptual shifting, focus on challenging DID patients' schema maintenance condition-
ing. The second process that keeps EMS active and dysfunction is schema avoid-
ance.

Schema Avoidance- Avoiding feelings, especially avoiding certain feelings,

is common in DID patients. SFCT therapists would say that when the particular EMS
is triggered, the DID patient experiences a high level of ego dystonic affect, such as
guilt, intense anger, profound shame, or fear. These emotions and their intensity is
so overwhelming to some DID patients or to some personalities within the patient 409
that either in or out of awareness, the DID patient avoids the triggering of the Cognitive Treatment
schema or the experience of affect connected to it. Model for DID
Some DID patients-personalities reorganize their inner and/or their outer
reality to avoid these feelings. The inner reality modification may be an inflexibility
in 'the adult patient to accept varying configurations of personalities. The therapist
can suspect active schema avoidance components when there is dysfunctional and/
or rapid switching of personalities. When the DID patient tries to control external
reality to avoid triggering EMSs, the patient is often obsessionally preoccupied with
controlling everyday objects, occurrences, and people; the DID patient in the midst
of this struggle appears paranoid, manipulative, and extremely controlling. Schema
avoidance processes can be likened to aversive conditioning (Young, 1990).
One schema avoidance process is cognitive avoidance. This process "refers to
automatic or volitional attempts to block thoughts, images that might trigger the
schema" (Young, 1990, p. 16). For example a common strategy used by some DID
patients to thought block is to disguise it in "amnesialike" talk where there may be
little to no true amnesia, but rather a decision to not attend to drifting or stray
thoughts. Two other expressions of this same phenomenon are the ongoing editing
of some DID patients as well as the intentional vagueness of their responses. An
example of suspicious amnesia could be:
THERAPIST: Josie, you have given me generous amounts of data, of detail about
your experiences in first grade, your teacher, your friends, your favorite games
at school. What was it like at home during that same year?
PATIENT: I don't know (rapidly).
Further exploration led to understanding that she did know some very stressful
details about life at home that she justly understood as only the tip of an iceberg.
Another schema avoidance process is affective avoidance. This process re-
flects "automatic or volitional attempts to block feelings that are triggered by
schemas" (Young, 1990, p. 16). In the face of distressing life events, some DID
patients are fully capable of reporting their cognitions, yet deny experiencing the
emotions that would normally accompany these thoughts (belle indifference). This
affective avoidance in DID patients and/or in some of their personalities makes
them appear either flat in affect or affect phobic. However, those DID patients who
report little affect and who do not talk about feelings are more likely to report
chronic, diffuse generalized anxiety or psychosomatic symptoms. A typical exam-
ple would be the "I feel fine" DID patient who comes into your office, sits down
on the couch, and either grabs a pillow that she folds and places on her abdomen
"nonchalantly" or who tries to disguise a raging dissociative headache by rearrang-
ing her bangs. The third and final process proposed by Young (1990) to keep EMSs
in place is schema compensation.

Schema Compensation. This refers to processes that overcompensate for

EMS. Many DID patients or personalities within them may adopt cognitive-
behavioral styles that are the opposite of what we would predict as the therapist
comes to understand or have knowledge of the patient's EMSs. Schema compensa-
tion is functional to a certain extent. Counterphobic impulses can be advantageous.
410 But schema compensation is truly best understood as only a partially successful
Catherine G. Fine attempt by DID patients to challenge the original schema and almost always in-
volves a failure to recognize the underlying vulnerability. For instance, one of my
DID patients would walk in with leather boots, leather jacket, and "walking tough."
When the time came to begin to explore childhood issues, she required increasing
amounts of benzodiazepines as she slowly learned to control her acting out im-
pulses. It took several years before she could tentatively acknowledge her helpless-
ness; as she disclosed more of her fear, her dressing habits changed as did her walk.
In summary, SFCf supports the elicitation and restructuring of EMSs in order
to reconfigure the dysfunctional belief system of the DID patient. It behooves the
DID therapist to attend to all means of maintenance of EMS in the DID patient in order
to disequilibrate the faulty thinking and favor integration of all parts of the mind.

TREATMENT IMPliCATIONS

The treatment of DID patients can be challenging and protracted. A traditional

cognitively based model of therapy has proven helpful from the tactical integration-
ist perspective of work with DID patients (Fine, 1991, 1992, 1993). A more complete
theoretical heuristic may allow for more thorough and rapid rectification of dis-
torted belief systems by increased specificity of intervention.
The validity of SFCf model in the work with DID patients would be supported
by recurrent and similar clinical findings across a number of personalities. Indeed,
the more fragmented the DID patient, the more each personality locks into an EMS.
There is no anecdotal evidence for the preferred use of one EMS over another as a
function of the number of personalities. However, there is some suggestion that
very fragmented DID patients demonstrate a smaller range of affect and an in-
creased commitment to alternate realities perhaps in response to a capitulation to
entrenched EMSs. If this premise is accurate, the CB interventions of choice would
be geared to rectification of EMS by taking each personality through the process of
exploring affect-laden schema in terms of their schema maintenance, schema
avoidance, and schema compensation aspects.
Speculatively, SFCT would allow a DID patient to experience and talk about
affect through a process mediated by the cognition in a schema-oriented supra-
structure. This supraordinate understanding would lend itself to a heightened
organizing of the therapy, increased structuring, and therefore stabilization of the
work and should facilitate the recontextualization of the patients' beliefs and
distorted cognitions. SFCT may allow the therapist, from treatment onset, to better
focus the DID patient on an affectively based consensual reality without the down-
falls of spontaneous and unwanted abreactions.

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Fine, C. G. (1989). Treatment errors and iatrogenesis across therapeutic modalities in MPD and allied
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20
Psychodynamic
Psychotherapy of
Dissociative Identity Disorder
Peter M. Barach and Christine M. Comstock

The tools of psychodynamic therapy serve the purpose of bringing disparate

elements of the psyche together. These tools originate from a model of the psyche
that highlights the symptomatic properties of unresolved and unconscious con-
flicts, and the tools help to bring these conflicts to awareness so that the patient may
confront them. The psychodynamic approach aims to "give [the patient's] ego back
its mastery over lost provinces of his mental life" (Freud, 1969, p. 30) and is well
suited for the treatment of dissociative identity disorder (DID).
Although most of the literature on treating DID recommends a primarily
psychodynamic approach (e.g., Kluft, 1991; Kluft & Wtlbur, 1989; Putnam, 1989;
Ross, 1989), writers have tended to highlight aspects of the treatment process that
are other than psychodynamic. They highlight specialized techniques for dealing
with alters, symptoms, and crises. They focus on the phenomenology of the
disorder (Thigpen & Cleckley, 1957), the use of hypnosis by patient (Bliss, 1980)
and therapist (Kluft, 1982, 1983), the healing effects of recalling the abreacting
traumatic memories in the context of a nurturant therapeutic relationship (Schrei-
ber, 1973), and the functions and interactions of the alternate personalities (Braun,
1986).
However, by focusing primarily on dissociative behaviors and specialized
techniques for managing them, the therapist turns away from the psychological

Peter M. Barach and Christine M. Comstock • Horizons Counseling Services, Inc., Cleveland, Ohio
44130.
Handbook of Dissociation: Tbeoretlca~ Empirical, and Cltntcal Perspectives, edited by Larry K.
Michelson and William J. Ray. Plenum Press, New York, 1996. 413
414 functioning of the patient as a whole. The therapist inadvertently adopts the
Peter M. Barach dissociative patient's worldview, perceiving related events as separate. In contrast,
and Christine M. an integrative psychodynamic treatment approach is more consistent with the goal
Comstock of producing an integrated patient.
An integrative psychodynamic approach focuses on helping the patient alter a
continued reliance on dissociative defenses. The dissociative patient maintains
emotional stability by ignoring connections between events (Braun, 1988). It is as if
she has been examining a halftone newspaper reproduction of a disturbing photo
by holding it so close to her face that she sees only the individual dots. Psycho-
dynamic psychotherapy enables the patient to reassociate aspects of psychological
functioning that are actively being held apart. By directing the patient's attention to
possible connections between emotional and behavioral events, the therapist helps
the patient to associate things that have previously seemed unrelated. In effect, the
therapist encourages the patient to move the photo away so that she can allow
herself to see the whole picture. He does this by using familiar psychodynamic
tools, such as interpretations, questions, empathic reflection, and confrontation.
Adding to the therapeutic value of specific psychodynamic interventions, the
treatment setting itself provides a predictability and stability that allows the patient
to encounter and eventually to integrate disavowed parts of the mind. The therapist
does this without exploiting, manipulating, or attempting to control verbal expres-
sion. The therapist may be the only person in the patient's life who has tried to
relate to all aspects of her personhood, allowing her the freedom to verbalize all
aspects of her mental life.

A SINGLE-SELF MODEL OF DID

Psychodynamic interventions are well suited for treating DID, in which the
"lost provinces" of the psyche are like walled city-states that are unaware of each
other. However, DID should not be seen as a disorder of multiple selves. Many
descriptions of DID seem to describe multiple selves operating as separate people.
A multiple-self model is probably being used when one uses implicit spatial meta-
phors to describe alters, such as characterizing them as "inside; "in front of; and
"layered." Multiple-self models reify the alters by depicting them as talking to,
comforting, or fighting with each other.
Although the transferences, resistances, and defensive styles of DID patients
have often been described as multiple (e.g., Wilbur, 1984), they can be more
parsimoniously understood as aspects or facets of a single self. We understand DID
as taking place within a single-self system that has access to several stable configura-
tions of memories, cognitive styles, and emotions (Barach, 1992; Watkins & Wat-
kins, 1993). The emotional demands of the patient's immediate situation govern
which configuration is active. The patient may know each configuration as an
alternate personality, experiencing mental conflicts as verbal or physical inter-
actions between alters. These experiences may be understood as autohypnotic
phenomena (Bliss, 1986) that have become elaborated over many years (Putnam,
1989). DID patients are highly hypnotizable (Frischholz, lipman, Braun, & Sachs,
1992), and they have concretized conflicting aspects of the psyche at the hallucina-
tory intensity accessible to hypnotizable people in trance states. However, from the
framework of a single-self model of DID, when alters are not influencing behavior, 415
they do not exist independently, except as potential ego states. As symptoms, alters Psychodynamic
are compromise formations (Fenichel, 1945) between complete repression of trau- Psychotherapy
matic material and emergence of that material into awareness. A single-self perspec- of DID
tive simplifies the therapeutic task of understanding and interpreting the inter-
actions of alters as reifications of psychic conflict.

GOAlS OF PSYCHODYNAMIC PSYCHOTIIERAPY FOR DID

Writers generally describe integration as an overall goal for the treatment of

DID. The term makes most sense conceptually when it refers to the development of
integrated psychological functioning in the patient and not to the disappearance
of dissociative phenomena: "It denotes an ongoing process in the tradition of
psychoanalytic perspectives on structural change" (Kluft, 1993, p. 109).
From our perspective, the establishment of truly integrated psychological
functioning in a DID patient involves the resolution of developmental deficits that
have resulted from repeated trauma. From a psychodynamic perspective, trauma is
defined by the internal experience of the child, not by the external circumstances;
it is "an influx of stimuli from within or without which wholly or partly breaks
through the ego's protective shield and floods the system with excitation" (Furman,
1986, p. 192). Resolving the resulting developmental deficits can reduce the pa-
tient's need for dissociative defenses or acting out and can alleviate the asocial (or
"negative") symptoms of dissociation. With treatment organized around these
goals, the dissociated aspects of the mind (alters) tend to integrate spontaneously
and gradually without the need for structured integration rituals.

Developmental Issues to Be Resolved

Treatment of DID best brings about integration by dealing with a number of
developmental tasks that must be resolved. Psychodynamic treatment of DID goes
beyond the goal of eliminating dissociative dividedness and treats the charac-
terological and object relations difficulties that abusive and neglectful childhood
experiences have created. Incest and other sexual abuse can affect many aspects of
self and social development (Cole & Putnam, 1992; Putnam, 1990), the ability to
protect oneself (Kluft, 1990; Wyatt, Guthrie, & Notgrass, 1992), sexual functioning
(Putnam, 1990), and the ability to be a nurturant parent (Kluft, 1987). The effects of
trauma on early personality development are so pervasive that DID patients never
reached a state of integrated psychological functioning in childhood. If the treat-
ment is organized around dissociative phenomena rather than psychological func-
tioning as a whole, developmental deficits resulting from abuse and neglect are
never addressed. An attempt to resolve five key developmental deficits furnishes
the therapist with a set of psychodynamic goals for treating DID. These develop-
mental issues are discussed below.

Establishment of an Internalized Secure Base of Attachment. Several

authors (Alexander, 1992; Barach, 1991; Uotti, 1992) have noted that sexual abuse
survivors and DID patients have difficulties in feeling a secure sense of connection
416 to important people in their lives. Their childhood experiences with emotionally
Peter M. Barach unavailable or abusive caretakers have led to dysfunctional working models of
and Christine M. what to expect from later attachment figures (Bowlby, 1973). Two explanations
Comstock have been proposed for the attachment difficulties that DID patients experience:
(1) They may have detached themselves (i.e., dissociated) from awareness of their
needs because often nobody responded to their attachment behaviors during early
childhood (Barach, 1991); or (2) they may have developed disorganized patterns of
attachment as the result of having caretakers who alternated between frightening
them and being frightened by their needs (Liotti, 1992).
DID patients tend to alternate between detachment and separation anxiety
(which they often manifest as dependence) in their relationships. The transference
will, of course, reflect these patterns. During the early stages of treatment, patients
often present many crises, requiring large amounts of time and attention from the
therapist. From the viewpoint of attachment theory, these crises may reflect the
reactivation of attachment behavior in the face of the therapist's steady responsive-
ness. Repressed and dissociated material has begun to come to the patient's aware-
ness, causing a wish for safety and security. Internal signals of danger tend to trigger
attachment behavior, and the patient urgently reaches out for help. However, as
mentioned earlier, experiences of abuse, abandonment, and neglect have taught
the patient to detach from awareness of attachment needs and caretaking figures.
Internal signals of danger will periodically lead the DID patient to revert to de-
tached states of emotional and physical numbness. The therapist will see this as a
fluctuation between alters who request caretaking and alters who push away from
the therapist's empathic response.
In time, the patient begins to internalize a secure sense of attachment. The
therapist's physical presence or voice seems less necessary during periods of stress
or emotional upset. The patient learns to retain a sense of internal connection with
the therapist, and emergency calls become less frequent. This comes about when
the therapist remains a steady and consistent presence to which the patient can
return and when the therapist interprets attachment issues so that the patient can
resolve them using the ego resources available to him as an adult. Working models
based on the therapeutic relationship gradually replace working models of attach-
ment figures based on abusive or neglectful caretakers.

Ability to Tolerate Affect. Infants who have been overwhelmingly trau-

matized tend to experience any affect as an unbearable reminder of their early
abuse (Krystal, 1988). Thus, as adults, DID patients try to avoid any experience of
affect through switching, numbing, or other dissociative sensory alterations such as
depersonalization, derealization, and a loss of time sense (ferr, 1990, 1991). The
inadequacy of soothing experiences during childhood (Kluft, 1984) has impaired
the patient's development of the ability to soothe herself.
In contrast to the patients' parents, the therapist is nondissociative, consistent,
and (generally) calm no matter what the patient expresses. like a healthy parent,
the therapist's steady and containing presence helps the patient tolerate his feel-
ings. The patient gradually sees that the therapist does not reject or hurt him when
he expresses his feelings and needs. He can then begin to allow strongly conflicting
feelings and needs to cohabitate in his awareness, instead of using dissociative
behaviors to keep them separate. By interna,lizing the containment aspects of the
therapeutic setting, he finds that he can tolerate and regulate his feelings without 417
dissociating. The patient allows himself to experience ambivalence, where earlier Psychodynamic
in treatment he would have experienced dissociation. Psychotherapy
of DID
Formation of a Cohesive Sense of Self. DID patients display inconsistent
and.disconnected senses of self, echoing the inconsistent parental responses that
they report. In DID, emergence of dissociated aspects of the self may bring a
perceived change in identity and often amnesia. The therapist then faces the task of
interpreting behavior that only one part of the patient remembers.
Dissociative patients do not experience their personality aspects as belonging
to them. Therefore, they have no appreciation of why different alters seem to take
control at particular times. The parade of alters and dissociative experiences seems
to them as random and unpredictable as the childhood environments in which they
grew up. When the therapist helps the patient to see that alters and the memories
associated with them come for a reason, then the patient begins to see his mental
process as a single experience, instead of as a collection of disconnected internal
events and separate "people:'
Once the therapist has begun to understand the functions served by each alter,
she can help the patient develop a cohesive sense of self by interpreting the feelings
and actions of one alter in relationship to the feelings of another. For example, the
therapist may "talk to the bleachers" (Loewenstein, personal communication),
inquiring about the reactions of alters who may be listening without assuming
executive control. Over time, as the patient's observing ego widens its field of view
to include the alters, such interventions promote self-acceptance and tolerance of
conflictual feelings; the patient's sense of self becomes integrated.

Development of Coherent Object and Self Representations. Important

people in the DID patient's childhood failed to provide an atmosphere in which
conflicting self and object representations could be integrated. A child with predict-
able parents comes to understand that people who care about him will still main-
tain their loving feelings though they may be angry with him. If the patient
experienced dissociated, confused, and often violent parenting, different aspects of
the mind might contain dissociated and contradictory perceptions (i.e., cognitive
schemata) (Fine, 1988) of what to expect from people. Abused children develop
bizarre yet functional expectations that they use to make sense out of the way
others have treated them.
From a psychodynamic perspective, the dysfunctional cognitions in the DID
patient are maintained by means of the defense mechanism known as splitting.
Whether or not DID is a subset of borderline personality disorder as some believe
(Lauer, Black, & Keen, 1993; cf. Armstrong, 1991; Kemp, Gilbertson, & Torem, 1988;
Marmer, 1991), descriptions of this defense in the literature on borderline person-
ality disorder bear much relevance to treating DID patients. Kernberg (1984) has
described how "aggressively determined" object and self representations are ac-
tively separated from equally intense "libidinally determined" self and object repre-
sentations: "Because of the implicit threat to the good object relations, bringing
together opposite Ooving and hateful) images of the self and of significant others
would trigger unbearable anxiety and guilt" (Kernberg, 1984, p. 112).
The "aggressively determined" nature of the object representations may be-
418 come comprehensible if one considers that child abuse may have brought them
Peter M. Barach about. Splitting enables an abused child to interact with the perpetrator(s) of the
and Christine M. abuse during the more benign interactions that occupy much of the child's daily
Comstock existence. In this way, splitting has an adaptive value: "Learning to split off bad self
images and others' images minimizes awareness of the ever-constant threat from
which the child cannot escape" (Perry & Herman, 1993, p. 134).
Consistent interpretation of defense mechanisms such as splitting and projec-
tive identification will eventually lead to more coherent object and self representa-
tions (Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989). The therapist's
consistently neutral and nonjudgmental stance, maintained in spite of powerful
negative transferences and projective identifications, helps the patient to blend
mixed or ambivalent feelings about another person that the patient has hitherto
kept from conjoint awareness. The therapist gently undermines dissociation and
splitting between contradictory object and self representations by looking for
relationships. He looks for the coherence behind the seemingly puzzling sequences
of personality switches and affective shifts, then points out to the patient in a
tentative way how each occurrence may be related to what has come before.
Of course, as in any psychodynamic therapy, the therapist needs to choose
which interpretations will be most useful to the patient at any given time, and must
not overload the patient with too much at once. The usual psychodynamic princi-
ple of interpreting defense before content (Greenson, 1967) applies to DID pa-
tients. The therapist should avoid using present-day feelings and events to enlighten
a patient about the content of dissociated material. Such misguided reconstructions
may lead the patient to clutch at the therapist's suggestions as historical fact,
thereby avoiding what was actually dissociated. Dissociative defenses are not al-
tered by such interventions.
However, interpretation of dissociative defenses (rather than dissociated con-
tent) will gradually reduce the patient's overreliance on dissociation. For example, a
child alter was about to describe an episode of sadistic abuse. Suddenly, an aggres-
sive alter appeared and attempted to hurt herself (i.e., hurt the child alter). It would
have been a technical error to tell the patient that perhaps an adult had told the
child she would be hurt if she told what happened. Instead, the therapist remarked
that perhaps the patient could not manage in childhood to be aware of her intense
mix of anger, guilt, and shame concerning the abuse; and that she had relegated
those feelings to another part of her that evolved into an aggressive alter.
This kind of defense interpretation is useful because it brings the split self-
representations into the patient's awareness at the same time. In time, the patient
begins to own dissociated aspects of the self, instead of seeing herself as a passive
victim of their apparently independent activities. A similarly beneficial effect on the
integration of split object representations will occur when the therapist can inter-
pret that the emergence of an alter may have the purpose of reducing the anxiety
engendered by holding contradictory images of another person in mind at the same
time.

The Ability to Differentiate Fact from Fantasy. In contrast to patients

with "good enough" parenting, DID patients do not learn to distinguish reliably
between internally generated reality and external reality. The confusion is partly the
result of the seeming reality of hypnotically developed internal experiences and of 419
the seeming unreality of dissociated historical experiences. Wishes, fears, memo- Psychodynamic
ries, fantasies, and dreams mingle together in such a way that the patient is unable Psychotherapy
to distinguish among them. The confusion often occurs in relation to present-day as of DID
well as to past experiences, and may at times reach psychotic proportions in some
patients.
Several aspects of the treatment help the patient learn to differentiate between
fact and fantasy. As patients become more able to tolerate intense affect without
resorting to dissociation, they enter autohypnotic states less frequently. Conse-
quently, they become more able to separate fact from fantasy in understanding their
present-day experiences. Also, cognitive distortions that support their misattribu-
tions of responsibility can be confronted during the processing of abreacted or
interpreted material.

Reduction of Acting Out

Acting out represents "a reenactment of a past memory. The action is a slightly
disguised repetition of the past ... The patient seems intent upon acting instead of
remembering; it is a defense against memory" (Greenson, 1967, pp. 259). As one
would expect, therapists find considerable acting out in DID patients, who have so
much they wish to forget.
Some patients will act out to destroy emerging awareness of the meanings of
their feelings (Bion, 1967; Langs, 1990). They attempt to "dump" feelings and
memories into the therapist by means of their behavior. No doubt DID patients
experienced this sort of dumping from their caretakers, and it has therefore be-
come a familiar mode of discharging tension.
Psychodynamic psychotherapy has a distinct advantage over more directive
therapies in treating patients who chronically act out. Psychodynamic psycho-
therapy implicitly and explicitly communicates to the adult patient that he is
responsible for all of his own present-day behavior. In contrast, more directive
therapies may replicate the authoritarian atmosphere of the patient's childhood,
leading the patient to expect the therapist to control her. This situation may not be
helpful to DID patients who, like others who act out, already tend to view them-
selves as not in control of their behavior. They see their self-destructive wishes as
powerful needs that demand action from themselves and others. Their actions
require the therapist to set forceful limits (such as not permitting overtly sexual,
violent, or self-injurious activities during therapy sessions; or arranging hospital-
ization).
However, acting out should be more than merely managed; it should be
interpreted. Interpretation helps the patient to use her adult resources and the
stability of the therapeutic setting to face experiences from which she dissociated
herself when her ego resources were overwhelmed.
Acting out may convey information about traumatic experiences not only in its
content, but in the feelings and actions that it elicits from other people. When
acting out is viewed as a form of communication between patient and therapist, the
interpersonal effects of acting out can illuminate the patient's past experiences
(Chu, 1991). Acting out often brings interactional pressure on the therapist to
420 respond in a particular way. For example, many patients will state that they must cut
Peter M. Barach themselves to relieve internal emotional pressure or else they will have to kill
and Christine M. themselves. The patient may ask the therapist to make a bargain in which a less
Comstock dangerous action is "allowed" in exchange for a no-suicide promise. In this scenario,
acceding to the patient's request puts the therapist in the role of the unprotecting
parent who allows the abuse to continue right under his nose. The request may also
induce a sense of helplessness, anger, frustration, and emotional conflict in the
therapist, echoing the unvoiced feelings of the patient. The therapist can use his
reactions to formulate tentative interpretations concerning the defensive function
served by the acting out.

Reduction of the "Negative Symptoms" of Dissociation

By analogy with the schizophrenia literature (e.g., Strauss, Carpenter, & Bartko,
1974), the symptoms of DID can be characterized as either positive (characterized
by their obvious presence) or negative (characterized by the absence of normal
personality function). The positive symptoms are the focus of most of the therapy,
especially in its early and middle stages. These symptoms include the presence of
alters, flashbacks, suicidal or other self-destructive behavior, dissociative head-
aches, and autohypnotic behavior. Positive symptoms represent adaptations to
experiences of intrusive abuse.
Negative symptoms may result from a combination of the psychological se-
quelae of childhood neglect and the biological sequelae of chronic trauma (Van der
Kolk and Greenberg, 1987). Present in DID patients in varying degrees, negative
symptoms include the absence of meaningful relationships, affective numbing,
denial of sexual feelings, and the overall avoidance of excitement and stimulation.
In the common emphasis on abreactive work to help DID patients deal with
intrusive trauma, the "quiet trauma" of neglect may be overlooked. For example,
patients may abreact rapes by parents, but they do not abreact directly the experi-
ence of having an emotionally absent father. Such experiences are, however, readily
brought to awareness through examination of the transference.
The trauma of neglect may indirectly be reenacted during abreactive work.
Focusing on the content of past trauma recalled during abreaction may cause the
therapist to overlook the feelings that follow. The endpoint of each abreaction is a
feeling of profound abandonment-by parents, God, the therapist, other people,
and oneself. Abreactions as a whole may be the psyche's regressive attempt to cope
with dissociated and repressed experiences of abandonment and neglect.
Negative symptoms respond to several aspects of psychodynamic treatment.
First, the consistent, emotionally involved presence of the therapist may have a
soothing effect that in time the patient can internalize, partially supplanting the
chaotic internalizations made during childhood. Second, the therapist's overall
interpretive stance directs the patient away from demands that the therapist take
care of him when he feels abandoned and instead helps him to mourn childhood
experiences of neglect. Third, interpretations may help the patient to challenge
dysfunctional cognitions that discourage him from drawing more stimulation from
the environment. Fourth, psychodynamic psychotherapy steers the therapist away
from a directive approach that may reinforce therapist-pleasing behavior and exces-
sive dependency. Although useful at times, a directive approach may allow patients 421
to maintain a mental map of the world in which satisfying the needs of others Psychodynamic
continues to be a central organizing principle. Directive techniques may promote Psychotherapy
reliance on the therapist, rather than on oneself. When the therapist is willing to of DID
take a primarily directive stance, the patient has little need to learn how to manage
his environment to satisfy his own needs.

TECHNICAL ASPECfS OF TilE TREATMENT

Once the goals of DID are considered in psychodynamic terms, the preferred
treatment framework becomes clear. Psychodynamic treatment involves a relatively
nondirective therapist who creates a setting in which the patient is encouraged to
put all of her needs and wishes into words. The structure of the treatment invites all
aspects of the psyche to be verbalized, which eventually helps the patient to
experience all aspects of the psyche in an increasingly integrated way.

Boundaries
Early in treatment, the therapist should establish clearly defined boundaries
that she expects she can maintain. For DID patients, clear boundaries bring predict-
ability, a quality that was rarely in evidence in their childhood experiences. The
therapist should spell out the length and starting time of sessions, fees and how they
will be paid, emergency availability, and guidelines about when it is appropriate for
the patient to call. We believe that it is generally not helpful for therapists to touch
DID patients, because the meaning of touch may be confusing to patients who have
experienced abuse. Because previous treatment settings and approaches have
sometimes included touch, and because some patients have been sexually exploited
by previous therapists (Kluft, 1990), it may be necessary to state specifically that the
therapist will not be touching the patient.
Although the structure of a therapy should fit the needs of the specific pa-
tient, psychodynamic therapists treating DID generally see DID patients face-to-face
between one and three times a week, with sessions lasting between 45 and 90
minutes. If the patient needs an extra session during a crisis, we clearly label it as
an exception to the regular schedule. When there are problems (as there usually
are) in the patient's significant relationships, we prefer to have someone other
than the patient's therapist meet with or treat the couple, the family, or the
children. The patient is asked to authorize the various therapists to stay in commu-
nication.

Therapeutic Neutrality
A relatively neutral therapeutic stance may permit the patient to move beyond
the production of material that complies with what she thinks the therapist wants
to hear. Although complete neutrality is impossible, a silent, critical, or detached
therapist may inadvertently replicate crucial traumatic aspects of the patient's
childhood environment (Giovacchini, 1989), resulting in a therapeutic impasse.
422 Furthermore, a high level of therapist activity is necessary during crises, particularly
Peter M. Barach early in treatment.
and Christine M.
Comstock
Management oftbe Transference
The presence of dissociative defenses results in some modifications in the
therapist's way of working with transference. Generally, psychodynamic psycho-
therapists identify and interpret transference by deducing its presence from the
patient's free associations, dreams, and resistances. Although these sources of
information are certainly available to the therapist treating DID, transference makes
itself known in some additional ways. By adopting a single-self model of DID, the
therapist can identify transferential implications in the presentation, tinting, and
sequencing of dissociative phenomena in the therapy session. For example, a
sudden switch from calm personality John to belligerent alter Rocky can signify the
activation of a transference reaction. Transference reactions occur not only to the
therapist's behavior, but also to the patient's feelings about the therapist's behavior.
Thus, Rocky might emerge not as a defense to a perceived attack by the therapist,
but to the patient's discomfort with his own loving feelings for the therapist.
The usual method of interpreting transference should be slightly modified for
DID patients to allow for the presence of dissociative amnesia. Interpretation
becomes difficult when the patient has amnesia for the associations the therapist is
trying to interpret. However, amnestic barriers are rarely as absolute as they appear.
In the preceding example, the therapist might suggest that Rocky has perhaps taken
control to protect the system of personalities from frightening feelings that arose
when John was "out." Once the dissociative defense has been interpreted in this
way, the therapist can evoke John when Rocky is in control of behavior, asking
Rocky to check "inside" and see what John might have been feeling. If Rocky
cooperates, he may then experience the anxiety that occurred when loving feelings
toward the therapist arose in John. The experience of sharing feelings across alters
is integrative in nature and effect, and also brings memories or associations that
underlie the transference to the conscious mind.
The transferences that come forward in DID patients are usually quite intense
and often unmodulated in their expression. Most patients develop an aggressive
transference, a caretaking transference, some form of erotized transference, and a
"victim" transference (in which the therapist is consciously or unconsciously per-
ceived as a perpetrator in the patient's abuse memories) (Loewenstein, 1993). Any
of these transferences may become so strongly expressed in action as to interfere
with treatment progress. For example, patients may act out sexually toward the
therapist, may threaten the therapist or break things in the office, or may cower in
the comer because they believe the therapist is about to hurt them. Within the
limits of the therapist's tolerance, the therapist can attempt to interpret such
behaviors; these responses occur in venues other than the therapist's office and
may in fact have brought the patient into treatment.
Acting out in the transference can be a resistance, enabling the patient to avoid
upsetting feelings and memories (Greenson, 1967), and it is profitable to explore
what the acting out means. However, if it is reasonably clear that the patient is
making no progress in exploring these issues or if the expression of transference is
beyond the limits of the therapist's tolerance, the patient may need to be referred to 423
another therapist or to a more structured treatment setting. Psychodynamic
Psychotherapy
of DID
Countertransference
Although DID patients may elicit stronger countertransference than many
other patients (Comstock, 1991; Wilbur, 1984), the management of counter-
transference feelings is no different from its management with other patients: The
therapist's feelings are to be handled by the therapist. The patient may be con-
fronted about behavior that results in negative responses from the therapist, but the
patient is not "blamed" for the therapist's feelings.
When the therapist is tempted to make a treatment deviation, the temptation
often arises from unresolved countertransference. As with all other feelings in a
psychodynamic treatment, countertransference feelings should be examined be-
fore being acted upon.

The Role of Hypnosis

Most therapists use hypnosis in treating DID (Putnam & Loewenstein, 1993).
As with any directive intervention, the therapist's use of hypnosis has transferential
significance. Hypnosis tends to intensify transference (Gill & Brenman, 1959),
including wishes for rescue. This effect may be especially true for dissociative
patients, who already spend much of their time in spontaneous or self-induced
trance (Bliss, 1986). lfthe therapist relies on hypnosis as an uncovering technique,
he temporarily circumvents the patient's resistances to remembering and feeling,
but does so at the risk of eliciting more extreme forms of dissociation and more
primitive defenses to manage the resulting anxiety. Even by overpowering the
patient's conscious resistance to remembering, the therapist is asserting his will
over the patient's will. For example, some patients unconsciously view the hyp-
notic penetration of amnestic barriers as a rape. They may also consciously experi-
ence the therapist as an abuser, especially during moments when they are abreact-
ing child abuse (Spiegel, 1993).
Therapists often use hypnosis to effect integration of alters (e.g., Kluft, 1993).
However, misuse or overreliance on hypnotically facilitated integration may vitiate
the special value of hypnosis in giving the patient a sense of control over the
emergence of distressing feelings and memories (Spiegel, 1989).
We have come to prefer a minimal use of therapist-induced hypnosis in outpa-
tient treatment. Knowledge of hypnosis is useful in understanding dissociative
phenomena and sometimes in explaining them to the patient. Also, hypnosis can
occasionally be useful in managing crises. However, we have found that psycho-
dynamic interventions produce the desired goals without the transferential compli-
cations that hypnosis introduces.

Abreactions
Abreactions occurring within a therapy context are multidetermined. Their
content may reflect past experiences of trauma. They are also stimulated by situa-
424 tions and feelings about the present that are represented metaphorically in the
Peter M. Barach content, affective tone, and timing of the abreaction. Because the therapist cannot
and Christine M. ascertain literal accuracy of the retrieved material, she must adopt a neutral thera-
Comstock peutic stance so that the patient can have the freedom to explore his own fears and
certainties as he works to create a cohesive sense of his own history.
Besides conveying information about dissociated trauma, abreactions can com-
bine elements of reenactment, resistance, and communication to the therapist
about the therapeutic relationship. Abreacted material does not emerge as a chro-
nological reconstruction of the patient's childhood, but piece by piece as it is
elicited by the patient's present-day situation. As the therapist interprets the paral-
lels between the abreacted material and the patient's present life situation, dissoci-
ated feelings concerning the present situation will come forward in tandem with
their metaphorical appearance in the content of the abreaction. As the patient
develops the ability to modulate affect and put her feelings into words, she begins
to have associations instead of abreactions. By then, she has less need to experience
feelings metaphorically by reliving them.
In contrast to some other approaches to treating DID, psychodynamic psych~
therapy is not organized around the goal of "getting out the memories." Abreactive
work occurs in DID patients because it is dissociative in nature. It emerges from
the dissociative strategies that DID patients adopted to survive their childhoods.
As the patient comes to rely less on dissociative defenses, abreactive work will
become less frequent, and the patient will recall historical material by means of free
association.

CASE STIJDY

We present two vignettes from the treatment of a DID patient that illustrate
discrete psychodynamic interventions. For reasons of confidentiality and brevity,
the vignettes combine elements of many patients' therapies, selected to illustrate
the process of treatment.
Diane, a 30-year-old white female, sought therapy for panic attacks and night
terrors that began soon after her daughter revealed abuse by a neighbor. When Dr.
Jones tried to take a history, he found that Diane had few memories before age 16.
She often experienced periods of missing time, found things in her possession she
did not remember buying, and sometimes found herself on the floor playing with
her daughter's toys. Diane scored 35 on the Dissociative Experiences Scale (DES)
(Bernstein & Putnam, 1986).
During a diagnostic interview, Diane displayed dissociative behaviors, includ-
ing spontaneous trance states, brief periods of confusion, and apparent difficulty
remembering what she had said earlier in the interview. When he asked her if she
had experienced physical or sexual abuse in childhood, she started to hyperventi·
late. She stared out of the window, talked in a calm child's voice, and said, "Diane is
in the comer over there in that white house. It's safe over there." "Safe from what?"
"Safe from the man." Diane closed her eyes for a moment. When she opened them,
she appeared dazed, and asked what had happened. Dr. Jones said, "You got
panicked when I asked if you had been abused." Diane recalled the panic, but did
not recall the emergence of a child ego state.
 Diane began to hear the voices of children within her mind, which frightened 425
her. She started to make frequent calls to Dr. }ones after office hours, and requested Psychodynamic
extra sessions. In session, Dr. Jones told her that he was available after hours only in Psychotherapy
the event of an emergency, which he defined as imminent suicidal or homicidal of DID
behavior. She then switched to an angry alter who said, "You don't give a damn
about her. She thought you were going to help her, but it was just a trick so you
could get her hooked and then dump her. Well, she won't be coming back again."
Dr. }ones asked her whether there was any way he could have been more direct
about his limits, and pointed out that even clear boundaries felt like a trick to her.
He gradually interpreted her belligerent posture as a defense against the feelings of
vulnerability displayed by the child alters that had been calling him. He pointed out
that she must have had some experiences that taught her to expect that she would
be let down if she needed someone. Eventually, the belligerent alter began to allow
herself to feel some of the vulnerability, and the vulnerable alter began to express
some of her anger about being let down.
Because Dr. }ones remained relatively steady and consistent in his response to
the patient, the patient found she could hold herself together in between sessions.
She began to experience periods of sadness. The sadness gradually coalesced into
childhood memories of having been hit by her mother when she asked for help and
then having been left alone in a closet for hours. The patient began to understand
why she abruptly shifted from clinging, regressive dependency to biting sarcasm in
dealing with her husband. She also began to express a sense of trust in Dr. }ones'
steady availability.
This highly condensed vignette shows a patient working on several of the goals
described earlier. First, Diane is working on establishing a secure base for attach-
ment. As Diane began to feel a sense of internal danger (i.e., signal anxiety) when
treatment began, she displayed separation anxiety by making frequent calls to Dr.
}ones. When Dr. Jones was unwilling to be available to her whenever she wanted
him, the transference probably reflected experiences of parental abandonment. Dr.
}ones interpreted her defense (the appearance of a belligerent alter who represents
a form of passive-into-active defense: "I'll be the one who leaves, not you"). Second,
Diane is developing a more coherent object representation of Dr. Jones: He gradu-
ally becomes someone who she sees as consistently caring, even though she is
disappointed that she cannot call him whenever she wants. Third, Diane began to
make more gradual transitions between ego states; the belligerent and vulnerable
experiences shifted from being experienced as separate people to being experi-
enced as mixed feelings.
Interpretation was the major therapeutic intervention. The dissociated memo-
ries of abuse and neglect arose spontaneously rather than through hypnotic inter-
vention, as the result of interpretation of the transference. As Diane became aware
of how she responded to her unconscious expectations of abandonment, she
engaged in the process of working through and applied her insight to her marriage.
Interpretation of the connections between alters gradually led to a blurring of their
differences and then to some preliminary integration.
Early in treatment, a seductive alter named Regina began to appear in sessions.
Her seductiveness was at first nonverbal, but later she began to talk about how
much she wanted to have sex with Dr. Jones. He told her that he would not have sex
with a patient at any time during or after treatment, that a sexual relationship with a
426 patient would be harmful as well as unethical. Regina protested that a sexual
Peter M. Barach relationship with a loving man like Dr. Jones would only be good for her. Going
and Christine M. beyond merely setting a limit, Dr. Jones also asked Regina how Little Diane (a
Comstock trusting and naive child alter) would feel if she found herself having sex with Dr.
Jones. Regina said, "She doesn't deal with any of that stuff." Regina went on to
describe sadistic sexual abuse by a trusted uncle. The host personality had not
recalled this material before this point. Regina noted how much she had enjoyed it
and how Little Diane had stayed "inside," crying and screaming during the abuse.
Dr. Jones then interpreted the behavior of the two alters in relationship to each
other. He said that perhaps abusive experiences like the memories concerning the
uncle were what Diane (the patient as a whole) expected from men; that Little
Diane had wished to trust Dr. Jones; and that perhaps Regina had come forward to
cope with what Diane expected would come next: sexual abuse from Dr. Jones.
Regina admitted that this was indeed what she had expected, but said that it
wouldn't have been abuse because she would have enjoyed it. Dr. Jones asked her to
think back to what she felt when her uncle had sex with her, and Regina noted that
actually she had felt quite numb. He then asked if she would be willing to check on
what Little Diane might have felt during the abuse. Regina reported that Little Diane
had felt frightened and hurt.
Regina then began to abreact the abuse spontaneously, partly blending with
Little Diane during the process. That is, Regina recalled numbing herself but also
felt some of the fear and pain that had been relegated to Little Diane. During the
abreaction, Dr. Jones let the patient know that this was not happening in the
present, that she was in his office, that she could open her eyes and look around to
orient herself. After the abreaction, Diane, Regina, and Little Diane all shared a
common understanding of the mixture of feelings concerning the memory of abuse
by her uncle.
In this session, Dr. Jones interpreted the patient's acting out in terms of the
interactions among alters in response to transference. The patient then recalled
dissociated material that she had unknowingly been acting out. This treatment
sequence helped the patient to integrate object and self representations that had
been split among several alters. As a result of many such sequences, Diane began to
see herself as having complex and contradictory feelings about significant people in
her lives. She began to use her associations to present-day events to understand her
own reactions, and was less prone to switching.

SUMMARY

The DID patient benefits from a therapeutic outlook in which all behavior and
feelings are presumed to reflect a single self. Psychodynamic psychotherapy, in
contrast to approaches that emphasize directive and specialized techniques, en-
gages the patient and therapist in the shared goal of understanding all of the
patient's actions and behavior. It communicates respect for the patient's autonomy,
but does not sanction the patient's unconscious attempts to get reparation for past
abuse by means of acting out. Dissociative symptoms may have helped the person
to survive years of neglect and abuse, but they cannot compensate for the inability
of the patient to complete important aspects of psychological development. If 427
treatment focuses on completion of important developmental tasks and avoids Psychodynamic
limiting itself to eliminating dissociative phenomena, many patients can develop a Psychotherapy
resilient integration. If treatment is integrative, the patient can integrate. of DID

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21
Overt-Covert Dissociation
and Hypnotic Ego State
Therapy
John G. Watkins and Helen H. Watkins

THE ORIGIN AND DEVELOPMENT OF EGO STATES

During the past decade, the psychological process of dissociation has received an
increasing amount of attention as witnessed by the contributions in this volume.
However, the focus has been largely on its severe ramifications evidenced in
amnesia and multiple personality disorder (MPD). Such a focus has resulted in an
emphasis on its pathological effects as found in severe mental illness to the neglect
of its more normal manifestations as an adaptive defense. This more normal aspect
of dissociation is demonstrated in many behavioral, adjustment problems and in
various neurotic and psychosomatic reactions.
The continuous nature of dissociation as a separating process has been noted
by various contributors, i.e., by Braun (1988) in his BASK model (see also Chapter
5). Still, the greatest interest to date has been in the understanding and treatment of
this condition as manifested in true MPD.
Ego state theory (see Spring 1993 issue of American journal of Clinical
Hypnosis) is an extension of the principles and findings that have been noted in
the sevue maladjustments of MPD-now renamed dissociative identity disorder
(DID), in the current revision of the American Psychiatric Association's (1994)
Diagnostic and Statistical Manual of Mental Disorders.

John G. Watkins and Helen H. Watkins • Department of Psychology, University of Montana,

Missoula, Montana 59801.
Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William). Ray. Plenum Press, New York, 1996. 431
432 Our ego state theory stems from writings by Paul Fedem (1952) and his
John G. Watkins associate, Edoardo Weiss (1960), whose concepts we have elaborated and devel·
and Helen H. oped further. We have summarized this theory in a number of publications (H.
Watkins Watkins, 1978, 1993; Watkins & Watkins, 1979, 1981, 1986, 1991).
Ego state therapy is a treatment methodology based on this theory and derived
from both our therapy with true MPD cases and from research with normal
volunteers (Watkins & Watkins, 1979-80, 1980). These studies involved replication
of aspects of the "hidden observer" experiments reported by Hilgard (1986) (see
also Watkins & Watkins, 1992).
Hypnosis-itself a form of controlled dissociation (Hilgard, 1986)-has been
the modality within which the treatment strategy has been most expeditiously
carried out-although one of us (HHW) has developed a nonhypnotic technique of
ego state therapy that can be used by practitioners not skilled in hypnotherapy. Our
hypnotic techniques have been described in detail (Watkins, 1987, 1992).
Other researchers and clinicians are currently showing interest in ego state
therapy, and a number of contributions have appeared that extend and further
apply its procedures (Edelstien, 1982; Frederick & McNeal, 1993; Frederick & Kim,
1993; Gainer & Torem, 1993; Malmo, 1991; Newey, 1986; Philips, 1993; Philips &
Frederick, 1995; Torem, 1987, 1993).
Our own interest in the development of ego state therapy has been motivated
by the great need for a psychodynamic therapy that could achieve significant
personality reorganization in less time than required by traditional psychanalysis
(Freud, 1953; Fenichel, 1945). At the present time, much of the remuneration to
psychotherapists is paid by insurance companies and other third-party reimbursers.
Psychoanalysts have had difficulty securing compensation since that approach
requires several sessions a week, often for many years. Even the more active
psychoanalytic therapies, such as those proposed by Alexander and French (1946),
have not been widely followed. Psychodynamically oriented practitioners have
been frustrated by their inability to receive reimbursement for the time required by
such treatments.
On the other hand, briefer forms of treatment, such as behavior therapy
(Wright, Thase, Beck, & Ludgate, 1993) and cognitive therapy (Spiegler & Guevre-
mont, 1993), while operating within a much shorter time frame, do not generally
achieve the more profound character reorganization that is often required for long-
lasting results, especially in the treatment of MPD. And it is here, where a therapist
seeks psychodynamic resolution of unconscious conflicts within a comparatively
lesser number of sessions, that ego state therapy holds substantial promise. It
was with this problem in mind that we have been motivated in our study of ego
states and their applicability to such conditions as weight reduction, smoking
cessation, improved study habits, behavior and adjustment disorders, psycho-
somatic symptotns, and neurotic disorders, as well as the treatment of true multiple
personalities.
We have attempted to share our experiences in this endeavor with colleagues
through a number of workshops that have been sponsored by universities, medical
schools, and scientific societies (Steckler, 1989). The essence of ego state theory
follows.
INTEGRATION AND DIFFERENTIATION 433
Dissociation and
Human personality develops through two basic processes: integration and Hypnotic Ego State
differentiation. Through integration, a child learns to put concepts together, like Therapy
dog and cat, and thus to build more complex units as in that called "animals." By
differentiation, the child separates general concepts into more specific meanings,
such as discriminating between "good doggies" and "bad doggies." Both processes
are normal and adaptive. It is normal differentiation that permits us to experience
one set of behaviors at a party Saturday night and another at the office during the
week. When this separating or differentiating process becomes excessive and
maladaptive, we call it "dissociation." The boundaries between two or more ego
states become rigid and impermeable, thus preventing communication. If this
dissociation is severe enough, the Individual may develop amnesias or multiple
personalities.
Paul Federn (1952), a close associate of Freud's, held that personality was not
simply a collection of perceptions, cognitions, and affects, but that these were
organized into clusters or patterns, which he called "ego states." An ego state may
be defined as an organized system of behavior and experience whose elements are
bound together by some common principle, and differentiated from another by
boundaries that are more or less permeable. Defined in this way, ego states subsume
what we call "multiple personalities." They may or may not reach consciousness
and directly affect behavior.
Ego states may be large and include all the various behaviors and experiences
activated in one's occupation. They may be small like the behaviors and feelings
elicited when attending a baseball game. They may represent current modes of
behavior and experience, or, as in the case of hypnotic regression, include many
memories, postures, feelings, and so forth, which were apparently learned at an
earlier age. They may be organized in different dimensions. For example, an ego
state may be built around being 6 years of age. Another one may represent patterns
of behavior toward father and authority figures. These two would overlap on
experiences with father at the age of 6. Obviously, different ego states may use the
same English language, but with some variations in the terms and expressions
spoken.

TilE DEVELOPMENT OF EGO STATES

Ego states apparently develop by one or more of the following three processes:
normal differentiation, introjection of significant others, and reactions to trauma.
First, through normal differentiation the child learns to discriminate foods that taste
good and those that do not. He or she not only makes such simple discriminations,
but also develops entire patterns of behavior that are appropriate for dealing with
parents, teachers, or playmates. They are adaptive for adjusting to school, the
playground, and so forth. These changes are considered quite normal, yet they do
represent patterns of behavior and experience that are clustered and organized
under some common principle. As such, they can be considered ego states.
434 The boundaries between these entities are very flexible and permeable. The
John G. Watkins child in school is quite aware (or easily capable of becoming aware) of himself in a
and Helen H. playground situation. Playground behaviors, however, are not as easily activated
Watkins when at the school desk. He or she is now in a different ego state, and there is
resistance at the boundaries. These less-clearly differentiated ego states are usually
adaptive and are economic in providing appropriate behavior patterns when
needed.
Second, through the introjection of significant others the child erects patterns
of behavior which if ego-cathected become roles that he himself experiences and if
object-cathected represent inner objects with whom he must relate and interact.
For example, if a boy introjects a punishing parent, hence developing an ego state
pattern around his perceptions of that parent, he may be constantly depressed as he
tries to cope inwardly and covertly with a continuation of the accusations and abuse
originally heaped on him by the real parent. However, if he ego-cathects this state
(e.g., infuses it with self-energy), he will not suffer, but he will abuse his own child.
We say he has identified with his bad parent. He not only introjects the abusing
parent, but he also introjects the drama of the original parent-child conflict;
whether he suffers from this ego state or identifies with it and inflicts suffering on
others will depend on whether it is primarily object or self. In a multiple personality
he may alternate between these two patterns of response. Finally, if he introjects
both his mother and father and if these two parents were constantly quarreling with
each other, then he will have internalized their war. This may be manifested by
constant headaches of whose origin he is unaware as the two parental ego states
battle with each other.
Third, when confronted with overwhelming trauma, rejection, or abuse, the
child may dissociate. A lonesome youngster often removes the ego cathexis (self
energy) from part of himself, reenergizes it with object cathexis (non-self energy),
and creates an imaginary playmate with whom he or she can interact. Most children
with imaginary playmates discard or repress these entities upon going to school.
But if such an ego state is merely repressed, later conflict and environmental
pressure may cause it to be reinvested with energy and to reemerge, perhaps in
malevolent form as it did in the case of Rhonda Johnson, who coauthored with me
Q.G.W) her life story and treatment in We, the Divided Self (Watkins & Johnson,
1982), or the murdering Steve personality of Ken Bianchi, the "Hillside Strangler"
(see Watkins, 1984).
Evidence has been accumulating from hypnotherapy cases involving hyper-
mnesia and regression that differentiation, and perhaps even severe dissociation,
may begin at a very early age, at least within the first few months of life and possibly
even before birth. This whole issue of the veridicality of early memories is contro-
versial today, with experimental research often in opposition to clinical findings
(see Loftus, 1993; Watkins, 1989, 1993). The child knows the meaning of pain before
it has developed a word for this. Later, when it has learned to attach a word to this
feeling, it is in a position to report on earlier pain experiences.
A paper by Helen Watkins (1986) on "Treating the Trauma of Abortion" pre-
sented specific cases where this splitting had apparently occurred. In that paper,
she also described how hypnoanalytic ego state therapy was employed in treating
these dissociations.
 As defense mechanisms are increasingly utilized to avoid guilt and anxiety, the 435
individual develops more unwillingness or inability to face reality and accept the Dissociation and
consequences of his own behavior. True dissociation involves strong avoidance of Hypnotic Ego State
responsibility for one's own behavior and unwillingness to face the consequences Therapy
of one's actions. Ego states become more sharply differentiated from one another as
the separating boundaries become increasingly less permeable.
The extreme of this continuum is reached when the boundaries are so rigid
and impermeable that there is little or no interaction between states. If the dissocia-
tion is quite complete, the individual, when ego state A is executive, is not con-
scious of the behaviors and experiences that occurred when B is "out." There is
then a broad amnesia for these events (especially if they are recent), and a true
multiple personality is manifested. The only way these other events can be accessed
is through a complete change of ego states, or as we term it, a switching of "alters."
We use the term "ego state" to cover all of those discrete patterns of behavior
and experience, which range from the simple organizational patterns in "normal"
adjustment, through the intermediate ones represented by neurotic defense and
true neuroses, to the severe dissociations of MPD. We reserve the term "alters," as
in current usage, for those ego states involved in true MPD.
In the differentiation-dissociation continuum, normal and neurotic ego states
lie between simple adaptive differentiation at the one extreme and the severe
dissociation of true multiple personality at the other (see Figure 1). The variable
here is the rigidity or permeability of the separating boundaries. Normal separa-
tions in everyday life are exemplified by the organization of patterns of behavior
and experience dividing the average person's function while at work as contrasted
with the activities and mental processes needed during periods of recreation,
relationships with family; and so forth.
As adaptation to everyday problems of life become more complex and stress-
ful, the separating boundaries between the various ego states become less perme-
able in order to minimize conflicts between incompatible states, which would
cause increased anxiety. In the lower intermediate area, characterized in Fig. I as
"defensive", one finds processes like rationalization, compensation, reaction forma-
tion, and other neurotic defense mechanisms. These involve a partial shielding of

~~~~~
~ \:lY \:lY \:t) \:t)
Normal Borderline Multiple
Neurotic
Well-adjusted multiple personality

Adaptive differentiation Defensive Pathological dissociation

Figure 1. Differentiation-clissociation continuum.

436 the individual from the conflictual consequences of direct contact with unaccept-
John G. Watkins able elements of mental life, such as the unwillingness to assume responsibility or
and Helen H. guilt for misbehavior. As is well known, these mechanisms are adaptive in the sense
Watkins that they keep apart incompatible elements of mental life, thus rendering the
individual more free of stress. However, he or she pays a price in that behavior
becomes more rigid, less geared to reality. These mechanisms are considered to be
more immature and can be a step in the direction of less-adaptive behaviors. Ego
states, therefore, can be normal, adaptive, defensive, or dissociative, depending on
the permeability of their separating boundaries, this permeability or rigidity having
been influenced by the severity of internal conflicts and the individual's perception
of his or her need to escape mental "pain."
A common characteristic of ego states is, even though they are capable of
growth and change, they may often be fixated at the time of their creation. Thus,
a 5-year-<>ld ego state, which was developed by a child at that age perhaps to deal
with a traumatic event, may talk and act with the concrete "paralogic" typical of a
5-year-<>ld. Understanding this point can be of great significance when a therapist is
dealing with it. To resonate well with this state, the clinician needs to be able to use
a child's terminology and logic, perhaps by drawing on a child ego state within him
or herself. The clinician may find this difficult, since the scientific training of
therapists (and even more so of researchers) emphasizes principles of Aristotelian
logic.

SUBJECT-OBJECT

A fundamental distinction ever present in treating cases of dissociation, covert

or overt, is recognition of just when a psychological process, act, or state is subject
and when it is object. Subject means "me," "myself," and sometimes is called "ego
syntonic." Object means "not me," hence, "he;' "she," or "it." The determining
criteria is how it is experienced by the individual.
When I move my hand up and down, the movement is by "my" hand and it is
experienced as being initiated by "me." I am both conscious of the movement and of
its origin within "my self." If I have been hypnotized, however, the hand is dissoci-
ated from me, followed by the suggestion that "it" will wag up and down, the
movement will be experienced as "object," and hence is ego-alien. I will not
perceive it as something "I" am doing, but rather as something happening to me and
as if "my self" is responding to an outside force. I may be quite surprised at the
experience.
Normally, a conscious thought is experienced as subject. I recognize it as my
thought. However, in cases of psychosis a thought may become conscious, but
actually be object. It reaches the threshold of awareness without being imbued with
the sensation of "self-ness" or "me-ness." It is experienced then like a perception,
and I may report that I am seeing my dead mother, not that I am thinking of her.
Others say that I am having a hallucination.
This distinction between subject experiences and object experiences within
the psychological life of an individual has profound significance for treatment. Too
often, clinicians have described aspects of the functioning of patients without
specifying and clearly describing whether the individual is experiencing the proc- 437
ess as subject ("me") or object ("not me"). This failure to so distinguish is found Dissociation and
frequently in clinical reports and scientific articles. Hypnotic Ego State
Moreover, if subject-object, like most other psychological phenomena, exists Therapy
on a continuum, rather than on an either-or, we may be dealing with variability as
to the extent to which a reported experience (or an observed behavior) is under the
control of "the self;' where the individual should be held responsible for it, or
whether it is determined by "object, not self" processes, and hence not under the
conscious "control" of the individual. This question gets us directly into the whole
field of legal responsibility for thoughts or actions.
If the person's thoughts are object, experienced as perceptions, then he may
be psychotic and not competent. However, where does the responsibility lie if an
action is partially determined by object experiences and partially by subject ones?
We have tried to address this problem in regards to certain criminal cases (see
Watkins, 1976, 1978b).

FEDERN'S 1WO-ENERGY THEORY

In addition to his conceptualization of ego states, Paul Federn made another

significant theoretical contribution to the understanding of subject and object.
Departing from Freud's term "libido" (as an erotic, object energy), he posited two
kinds of psychic energy: subject, or ego cathexis, and object cathexis. Cathexis
merely means a quantum of energy that activates a process. A motor is "cathected"
with electricity.
The distinction here is related to the qualitative nature of the energy. Ego
cathexis consists of "I" energy. Within it inheres the feeling of "self," or "me-ness:'
Any part of the body, any movement or any psychological process activated with
ego cathexis will be experienced as "my" body, "my" action, or "my" thought. If a
part of my body is invested with ego cathexis, like my normal hand and arm, I will
experience it as "my" hand, "my arm." If I move it up and down, and it is invested
with ego cathexis, I will experience it as "my" movement, "my" choice, and by "my"
free will. The presence of ego-type energy determines the "me-ness" or "self"
aspect.
A corollary to this might be that ego cathexis is not the energy of the the self; it
is the self. Self is simply an energy and derives its content to be experienced as "my"
memory, "my" experience, "my" motivation, body, behavior, and so on when that
element is invested with ego cathexis.
If, on the other hand, the arm is not invested with ego cathexis, I will be unable
to consciously move it or consciously feel it. To me, it will be as if it is anesthetized
and paralyzed. If it has been hypnotically invested with object energy, then its
movement will be experienced as dissociated, as ego-alien. I may be aware that "it"
is wagging up and down, but not that "I" am doing it. And if a thought has reached
consciousness, but is invested only with object cathexis, it will be experienced as a
perception of something coming from the outside. For example, if a child ego state
is activated that contains the image of being pursued by a monster, and if this state is
ego-cathected, then I will experience fear. It is "my" fear. If in the same dream state
438 the child ego state is object-cathected, then I will simply be observing the boy as
John G. Watkins "not-me." The fear is "his" fear, not mine, and I will not experience fear-except
and Helen H. what might naturally occur through "resonance" with another person (Watkins,
Watkins 1978a).

HYPNOSIS

Hypnosis is a process that involves the alteration and moving of energies, both
object cathexes and ego cathexes. We can hypnotically anesthetize and paralyze a
part of the body by removing its ego cathexis. It is then no longer experienced as
part of the self. By investing a hysterically paralyzed arm with ego cathexis, we
remove the paralysis and bring it once more within the body ego. In hypnotherapy
we utilize this ability to activate and deactivate various symptoms, experiences, and
behaviors. In normal differentiation and in pathological dissociation the individual
initiates these same energy dispositions by himself.
Since hypnosis is a modality that can change subject into object experiences,
and vice versa, then hypnosis becomes a modality for the manipulation of ego and
object cathexes. With this technique a therapist can (at least temporarily and in
some cases) remove hysterical paralyses, change hallucinatory experiences back
into self-thoughts, activate dissociated ego states, switch MPD alters, and so forth.
This appears to give the therapist great powers of manipulation. However, it is not
quite that simple. Established patterns of energy interchange are not that easily
altered. The many ways in which hypnosis can be employed to move cathexes have
been described in detail in our two-volume work (Watkins, 1987, 1992).
It should be noted here that ego and object cathexes are theoretical concepts.
They may or may not exist in reality. No experimental data are currently available to
prove or disprove their existence. However, a two-energy theory does offer a
rationale for many psychological phenomena such as dissociation, repression,
displacement, reaction formation, and so on, which cannot be nearly as well
understood through traditional "libido" theory. It also offers something tangible to
the psychotherapist on which to base strategic and tactical considerations.

CONSOOUSNESS IN EGO STATE TIIEORY

One other aspect of ego state theory is its suggestion for the understanding of
"consciousness." An item becomes "conscious" depending on the magnitude ofthe
impact of an object on "self," on an ego-cathected element or ego state. It is a
question of economics. An analogy to hearing might be appropriate. lf a loud noise
strikes my eardrum, I will hear it, assuming that my eardrum and related sensory
endings have normal sensitivity. If the noise is quite soft, I may not have the
sensitivity to record it. Recording is possible if the volume of the noise is increased
or if the sensitivity of the eardrum and related nerve endings are increased.
likewise, we become conscious of an external object if the stimuli from it
(auditory, visual, tactual, etc.) are strong enough to be recorded on impact with an
ego, hence, self-cathected ego state. Very sensitive (highly cathected) therapists,
who possess what Theodore Reik (1948) called "the third ear," can pick up nuances 439
of communication that would not register or would do so only unconsciously to less Dissociation and
highly energized practitioners. Since the boundary between the sleeping individual Hypnotic Ego State
and the external world is less energized than when that person is awake, sounds Therapy
and sight may impact without being felt, recorded, and perceived consciously.
Repeated light stimulation, such as a prolonged tickle, may become conscious as
the "self" awakens from sleep and is recathected. The treatment approach of ego
state therapy is based on the foregoing theory.

EGO STATE THERAPY

Ego states that are cognitively dissonant from one another or have contradic-
tory goals often develop conflicts with each other. If they are highly energized and
have rigid, impermeable boundaries, multiple personalities develop. However,
such conflicts appear between ego states that are only covert. These may be
manifested by anxiety, depression, or any number of neurotic symptoms and
maladaptive behaviors. For example, we have often found obesity to result from
pressures on the executive personality by a disgruntled, covert ego state. Such
conflicts require a kind of internal diplomacy not unlike what we do in treating true
multiple personalities. However, since the contending ego states do not sponta-
neously appear overtly, they must generally be activated through hypnosis. We call
this ego state therapy (H. Watkins, 1993).
Ego state therapy is the utilization of individual, family, and group therapy
techniques for the resolution of conflicts between the different ego states that
constitute a "family of self" within a single individual. It is a kind of internal
diplomacy that may employ any of the directive, behavioral, cognitive, analytic, or
humanistic techniques of treatment, usually under hypnosis.

TECHNIQUES OF EGO STATE THERAPY1

Building Trust
The first and most important task for the therapist, and a "must" before
undertaking serious therapeutic work, is the establishing of trust. Every behavior,
whether verbal or nonverbal, is scanned by the patient, especially by those who
experienced abuse as children. The basic question for them: "Are you to be
trusted?"
It is understandable that ego states might be angry at the therapist for disrupt-
ing a system that has been in operation for many years. Furthermore, they have
much at stake to maintain the status quo, even if the system is damaging to psyche
or soma.
When activating an ego state, it needs to be treated with courtesy, even if the

IThe techniques presented here represent a briefer outline of procedures that are described in Watkins
and Watkins (in press).
440 thinking seems naive or preposterous to the therapist. An ego state is not a thing or
John G. Watkins a process. It is a part-person, and as such it wants to be accorded the dignity of being
and Helen H. heard with respect.
Watkins In establishing good relationships with each state, be sure to include the
seemingly malevolent ones. Malevolent ones are often protective in origin. In their
origin they were adaptive, at least temporarily. In working with such a state, it
becomes essential to underscore its protective function. Perhaps then a change to
more benevolent behavior is possible (Watkins and Watkins, 1988).
There are many ways to contact ego states. The most direct way is to hypnotize
the patient and ask if there is a part that feels different from the main personality, or
that feels an emotion the therapist knows is counter to what the patient feels in the
waking state. In other words, the purpose is to find out if there is a part of the
personality that is in conflict with other parts, and which is available under hyp-
nosis. The therapist can add: "If there is such a separate part, then just say, 'I'm
here: " However, the first time this is done, it is important to add a disclaimer, as
follows: "But if there is no such separate part, that's just fine," or words to that
effect. The purpose is to avoid producing an artifact. It is possible for a very good
hypnotic subject to produce whatever he or she thinks the therapist may want.
However, an artifact will not usually last or produce meaningful results.
Another method of contacting an ego state, after the initial hypnotic induction,
is to suggest descending plush-covered stairs together with the therapist. At the
bottom of the stairs, it is worthwhile to suggest a room with a couch and a chair and
"other furniture." To continue the fantasy, say, "As we walk into this room, you sit on
the couch while I sit on the chair." In the concrete thinking of hypnosis such a
statement makes clear that there is no intention of bodily harm. The therapist
anticipates that several ego states might enter the scene. That anticipation will
depend on knowledge obtained from previous sessions. With the setting in the
hallucinated room established, it is time to evoke an ego state if one or more are
available at this point in therapy. Speaking to the patient, one can say as follows:
"Please watch the door and let me know what you see. Is there someone who
might come in who knows about - -?"
"Who wants to be heard?"
"Who is willing to --?"
"Who feels different from (name of patient)?"
"But if there is no such separate part, that's just fine." The purpose of the last
sentence is to obviate the possibility of artificial cooperation. If the patient reports
seeing nothing, a separate ego state may still exist. It may mean one is not suffi-
ciently formed to be a separate vocal or visual entity, because the segments of the
personality are very permeable. Or it could be that no one is willing to make an
appearance at this time. Separate out only those ego states pertinent to a· given
problem the patient wants to resolve.

Diagnostic Exploration
After the patient has indicated the presence of someone in the hallucinated
room, it is time to get acquainted. Ask for:
 1. Its age and origin: "How old was (name of patient) when you came to 441
be?" If a specific age is given then, "What was happening at that time?" The specific Dissociation and
age gives a clue to a possible trauma that might be abreacted at a future session. Hypnotic Ego State
2. Its name: "What name would you like me to call you?" If it resists a name, Therapy
then "Is it all right if I call you by the age you· gave me?" Since the ego state has
appeared, it stands to reason that it wants to be heard. If the therapist expresses
interest in the opinions of the ego state, then that state is most likely to agree to a
word that will bring it forth under hypnosis. Persons want to be heard, even part-
persons.
3. Its needs: "What needs do you have?" or more indirectly, "What do you
want (name of patient) to do?" The satisfaction of needs are vital in ego state
therapy. By satisfying needs, cooperation can be established. Needs are normal, but
the internal behavior to achieve those needs can be destructive. Ego states, like
whole persons, have achievement needs, play needs, dependency needs, protective
needs, destructive needs, safety needs, and so forth.
4. Its function or internal behavior: The problem arises internally when
an ego state has, for example, a strong achievement need and then nags and
criticizes other states to achieve a goal that is never good enough. The surface
symptom may then be in the form of depression or anxiety. An ego state is usually
willing to change its internal behavior if its underlying need is being met.
5. Its degree ofpermeability: Is the ego state aware of "anyone else" within
that inner world? That is to say, who knows whom, and what are the attitudes
toward each other.
6. Its gender: Ego states are not always the same gender as the patient. If a
female patient was abused by a male as a child, then at least one ego state is likely to
be male. The reason is not related to sexuality per se but to the concept of strength.
As one ego state said very clearly: "I have to be male; only males have strength."
7. Nonemotional part: Sometimes a nonemotional part of the personality
is available. It has wisdom; it is nonjudgmental; it has information as to the internal
landscape; and it can be a great resource for the therapist. Its inner function is to
observe.

The above categories may provide understanding for the therapist on how to
proceed toward the therapeutic goal. However, such information is best obtained
gradually and not by a shopping list of questions at the first meeting.
Upon first meeting with an ego state the therapist's attitude sets the tone for
future interaction. Since most ego states were created when the patient was a child,
the best way to communicate is to think like a child.
Assume that "everyone" is listening. The therapist is less likely to make an error
that will infuriate an ego state other than the one being addressed. It is a gross error
to express to the one being addressed that it is more cooperative, nicer, or better in
some way than other ego states. And it can be fatal to therapy to suggest that some
ego state should be eliminated entirely.
Ego states and the total personality must understand that the resolution of
emotional conflict lies within not outside the individual. For example, if an internal
child state feels lonely and rejected because of abandonment experiences in child-
442 hood, the solution lies in someone nurturing within the system, not by a nurturing
John G. Watkins adult in the outside world. H the therapist accedes to demands for nurturance
and Helen H. (whether explicitly or implicitly made), there is a liklihood of overdependency in
Watkins the patient. Effective therapy through constructive inner change stops.
A certain degree of dependency is desirable in a good therapeutic relationship.
The therapist must be willing to make a commitment to the patient and be willing
to accept and tolerate a degree of dependency. Hone insists on being too objective,
a resentful patient may reject the therapist and terminate treatment. There is a
possible dilemma here for the therapist. Both no dependency or overdependency in
the therapeutic relationship may well sabotage the process.]. Watkins (1978a) in his
treatise on The Therapeutic Self describes this conflict in considerable detail as a
balance between "objectivity" and "resonance." When we are objective, we view
the patient's problems like an outsider, unaffected by them emotionally. We do not
contaminate our perception and understanding of the patient by our own feelings,
experiences, or perhaps "transferences:· When we resonate, we use our whole self
through temporarily introjecting the patient and his situation, so that we can
coexperience what he or she is going through. When we resonate too deeply
without appropriate, objective safeguards, we encourage overdependency. The
secret is to balance the two.
Internal dialoguing is the best way to understand the relationship between
states. For example, if an ego state ap{iears to a patient in the hallucinated room,
then the therapist can suggest they speak to each other, silently or out loud. If the
conversation is silent, the therapist can always inquire what happened. In family
therapy, the therapist intervenes with one member only as long as necessary to
achieve a certain change. That principle is also true for ego states. Ego states, like
the less permeable alters in MPD, often contain information or feelings about past
experiences that are amnestic to the main personality (the person in the waking
state). In treatment we seek to make the primary person co-conscious of painful
experiences currently dissociated within underlying ego states. Co-consciousness
between states promotes the erosion of amnestic barriers. Such erosion opens the
door to differing states understanding each other.
For example, if a "table technique" is used, the therapist can ask for everyone
to enter the hypnotic room and sit at the table so that everyone can meet. Not
everyone involved in the problem may come, but the scene is an opportunity for
internal dialoguing, relating, and understanding. It may give evidence as to who did
not come-also informational. As each ego state enters, ask each where it would
like to sit and beside whom. Such a seemingly polite and social question also gives
information about relationships and possible future integration or resolution. (See
Fraser, 1991, for a variation of the table technique.)

Integration and Fusion

From our point of view, integration and fusion are not synonymous. Fusion
suggests an amalgamation of all states into a single unit. Since we believe that the
typical human being is not so fused, our goal is not fusion. Integration implies
cooperation in a mutually needs-meeting resolution of differences. Sometimes two
or more ego states find that their needs and the expression of those needs are so 443
similar that it is no longer necessary or advantageous to divide their energies and be Dissociation and
separate. They may simply decide to stay together. But that is their choice, not the Hypnotic Ego State
therapist's. Therapy
We have been asked whether activating ego states doesn't increase dissocia-
tion. Paradoxically, ego state therapy does not increase dissociation. It decreases it.
If an ego state is split off during trauma in childhood, that entity retains the feelings
of the experience and the thinking of that moment in time. It does not grow up with
the rest of the personality. It is as if that ego state were encased in a cocoon in which
time had frozen and stood still. Communication and interaction between ego states
increases boundary permeability and growth, resulting in reduced dissociation.

Dealing with Fear

Fearful states clearly need help. That can be accomplished by finding a con-
structive state to care for them, to play with them, or satisfy whatever need is
apparent. Such a needs-meeting process, in order to be effective, must be with the
consent of both parties. They need to work out the details of their "contract" with
each other through internal dialoguing.

The Safe Room Technique

Using a safe room technique (Watkins, 1992) is another way to make fearful
states more secure. The following is an example under hypnosis, using stairs for
deepening:
"Now that we are at the bottom of the stairs, we walk along this hallway. At
the end of the hallway is a door to a room of your own choosing, in which you will
feel safe and comfortable. As we come close to the door, look at it carefully and
describe the door for me, even the doorknob. Now I want to ask you a question.
Whatever your answer, it's fine with me. Do you want me to come in with you, or do
you want to go in alone?"
The answer is an index of the dependency on the therapist. If they indicate a
"yes," then the the!<!pist opens the door. If a "no;' then they enter while the
therapist waits outside.
"Look around this room of your own choosing in which you will feel safe and
comfortable. Find a place where you can sit or lie comfortably. (Pause) Now I'd like
you to search for something. What I'd like you to search for is your inner core of
strength. That inner core of strength will take symbolic form. It may be part of
the animal kingdom, the vegetable kingdom, or the mineral kingdom. If it is part of
the animal kingdom, then it could be an animal or human form; if part of the
vegetable kingdom, it could be a flower, or plant or tree; and if part of the mineral
kingdom it could be an object, or maybe even an energy. I don't know what
symbolic form it will take. All I know is that inner core of strength exists within you.
(Whatever the response, I continue) Touch that [symbol mentioned], feel it, smell
444 it, know it is part of you, and will help to strengthen you. This is a place to which
John G. Watkins you can return any time you wish by just closing your eyes, and walking into this
and Helen H. room. No one else is allowed to enter here unless you specifically invite them and
Watkins unless they say positive things to you." (Arousal.)
The safe room can be used for a specific ego state or for the total personality,
whatever seems appropriate to do. It is also a technique that can be practiced at
home. At one time a patient of mine was afraid at the door of the safe room because
the "bad one is here." I said, "Don't worry. I'll hold on to him, while you run into the
safe room and close the door." That maneuver worked fine.
Another technique might be providing a "cocoon" for safety:
"I'd like you to close your eyes and imagine a font of golden-white energy
springing from the top of your head, moving down your body, around each arm, and
around each leg, so that you are completely surrounded by this golden-white energy
that lets you move about freely, is invisible to anyone else, but is strong and protects
you. It protects you from hurt, from bad words someone might throw at you. If
someone throws nasty words at you, it will seem like arrows coming at you, but
those arrows hit the cocoon and fall off. Or maybe they stick a little, but they can't
get inside. You are in control of that cocoon. If you want to take it off at night, you
can. Let's try it out:'
In fact, both techniques can be used with the same patient; one does not
preclude the other. These methods are temporary devices. Eventually the fear needs
to be ameliorated by the inside system in order to have permanent resolution.

Dealing with Critical States

In coping with critical states, the approach of choice is more likely to be con-
frontive, logical, or practical. Often a demanding state can be motivated to change
if it really understands that a change of internal behavior is to its advantage. For
example, an ego state whose need is achievement might be willing to change its
nagging behavior if it can be convinced that speaking more positively, more suppor-
tively, more encouragingly to the one who is procrastinating will bring about more
achievement. Sometimes it is useful to suggest trying out this kind of tactic for only
a few days, allowing the critical one to determine how successful the change was.
Then it has the choice of continuing the new behavior or returning to old familiar
patterns. Under these circumstance it is wise for the therapist to also contact the
one who is procrastinating to gain its cooperation. Giving a critical state choice to
try something new has great appeal. The critical, ambitious ego state versus the in-
ternal procrastinator no doubt represents an original conflict from the patient's past.
For example, a parent long ago tnay have nagged the youngster to study. Unless
the student was happy to do the homework, resistance will develop within the
child, regardless of the actual behavior of the youngster at that time. With repeated
naggings the individual will introject this dratna and grow up feeling both the
"should" side of itself and the "I don't want to" facet of the personality when
challenged to achieve.
Resolving Internal Conflicts 445
Dissociation and
In order to undo original conflicts, it is sometimes necessary to return to those Hypnotic Ego State
experiences via hypnotic regression, perhaps to undertake an abreaction. I might Therapy
have one or more of the ego states touch each other. Touch at this level can evoke all
kinds of responses, including pleasure, aversion, temperature change, relief, and
so on.
One ego state can converse with another, silently or out loud, either by the
therapist's suggestion or spontaneously. In internal dialoguing, my most frequent
statement is as follows: "Say what you want to say to (other state)." However,
suggesting what one ego state should say to another is akin to directing a play. It
does not spring from internal sincerity and is likely to be ineffective. Allowing the
ego state to say what it wishes gives credence to what is communicated.

Communicating with Child States

Remember that states introjected in childhood and those resulting from child-
hood trauma think concretely like children. To think like a child becomes an asset
for the therapist.
For example, one patient told me that there were some states behind the door
of the hallucinated room who were afraid of me. I suggested that they could peek in
from the doorway, watch and hear me while I spoke to the hypnotized patient, and
then decide if I was to be feared. In that way they could gradually get used to me.
Isn't that what young children do naturally with strangers?
At another time a regressed patient was afraid of monsters coming into her
room. I told her I had a secret, that I knew how to get rid of monsters, and "Would
you like to know my secret?" That is an irresistable question to a small child. Of
course, she agreed. I continued, sitting close beside her: "Now you watch the door,
and as soon as you see a monster come in, say 'Go 'way!' real loud, and the monster
will go away." And, not surprisingly, she reported the monster was gone. If I had
spoken to her adult self, nothing would have happened, and it would not have been
helpful in allaying her fear.

Ego State 'Pain"

Under hypnosis, pain within an ego state can also be drained into an adult state
who agrees to accept it (Watkins & Watkins, 1990a). It is essential that both agree to
the arrangement. Although it may sound strange, some ego states are reluctant to let
go of the pain for fear they might disappear, die, have no power, or have no reason
to exist. As one said, "My pain is me!" On the other hand, if the adult state has
repressed the pain for many years, it also is reluctant to take it back. It needs to be
gently persuaded along the lines of its individual logic, its individual ways of
thinking, so that it will believe in the advantages of such a change. With one patient,
the two states finally agreed to this process while the adult held the child in safety
and love, and they were content to stay together. The result was integration.
446 The Use of Volunteer States
John G. Watkins
and Helen H.
A volunteer can also be used to help out a child state, such as in the following
Watkins verbalizations:
"Susie, would you look at the door of our room. I'm going to ask a volunteer to
come in to help you out. It will be someone who wants to do this. I don't know who
that might be. Let me know who comes in."
I never use this technique unless I am certain there is a nurturing aspect to the
patient. If she says, "Nobody's coming," then I say, "You must want someone to
come:' That works well.
After the frightened one sees someone, one can ask for a description. Then we
proceed with internal dialoguing and communication with me. The purpose is to
meet the child's needs with the agreement of the volunteer.
Another method of helping a child state might be for an adult state to snatch
the "child" away from an abuser. One can describe a room with a one-way vision
screen where they can view what is happenening on the other side. Then the
therapist may suggest a consciously recalled setting from childhood, such as when
the patient was a little girl in her bedroom. "I think someone is coming into the
room. Let me know what happens:'

Use of an Observer State

The availability of an observer state can be of tremendous help. It can be asked
to take the patient to a certain experience, or to an experience of the observer's
choice. It can be consulted for advice or for an appraisal of the internal scene. After
an abreaction, the observer might be able to tell the therapist how effective the
abreaction was and if it needs to be repeated. Much information is possible through
this entity. Finally, it must be recognized that all the transference-countertrans-
ference problems that involve interactions with a whole person can also exist
between therapists and ego states (Watkins & Watkins, 1990b).

SUMMARY

Ego state therapy is an extension of understandings and procedures developed

through the study of severe dissociation. It is based on the assumption that dissocia-
tion is an extreme and maladaptive splitting on a continuum, ranging from normal
and adaptive differentiation, through an intermediate zone of defensive personality
separation. It combines theoretical concepts originally proposed by Paul Federn
with techniques of hypnoanalysis to develop a therapeutic approach that promises
greater efficiency in the treatment of many normal, neurotic, and psychosomatic
conditions, as well as in true multiple personality disorders.

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Torem, M. S. (1987). Ego-state therapy for eating disorders. American journal of Clinical Hypnosis, 30,
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Torem, M. S. (1993). Therapeutic writing as a form of ego-state therapy. American journal of Clinical
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22
Hypnotherapeutic Techniques
to Facilitate Psychotherapy
with PTSD and Dissociative
Clients
Judith A. Peterson

INTRODUCTION

The inclusion of a chapter on hypnosis stems from the fact that this therapeutic
phenomena falls within the body of knowledge needed to treat trauma or dissocia-
tive clients. However, the discussion about the relationship between hypnosis and
dissociation is an ongoing one effectively treated in this and other books. The entire
history of hypnosis is a convoluted one, and in the end relies on its advocacy by
contemporary reputable therapists based on a wide variety of work that discusses
its clinical applications. For those seriously interested in learning about the use of
hypnosis within the therapeutic world, refer to the reference section.
Despite the fact that many therapists treating patients with dissociative disor-
ders use hypnotherapy in their practice (and some do not), the use is still con-
troversial, particularly because of its peculiar history. When Franz Mesmer, in the
eighteenth century, "invented" hypnosis, but called it "animal magnetism," its
effectiveness was discredited by the king of France (Hammond, 1992). When an
English physician carried the term hypnosis from the Greek words for sleep, he

Judith A. Peterson • Phoenix Counseling, Consulting, and Forensic Services, 3303 Chintoey Brook
Lane, Houston, Texas 77068.
Handbook of Dissociation: Tbeoretica~ Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 449
450 made a subtle error. The phenomena is not actually sleep (even though the phrase
Judith A. Peterson "deep sleep" remains in hypnotic induction vocabulary and amnesia can occur at
the very deepest levels of trance), but rather it is what Hammond (1992) refers to as
the ability of the individual to concentrate and focus his or her attention to self-
focus inward the power of the mind (self-hypnosis).
There are a variety of ways hypnosis is used in contemporary society and it has
been referred to as a "cultural creation" (Lynn and Rhue, 1991). It is some of these
uses that cloud its legitimate, therapeutic use within the confines of the psycho-
therapeutic alliance of the patient and therapist. In fact, Spanos and Chaves (1989)
claim that there is no empitical evidence to show that what occurs to hypnotic
subjects is any different than what can be accomplished with nonhypnotic control
subjects.
With acknowledgment of the controversy, here the subject of hypnotherapy is
discussed from the perspective of personal and shared clinical practice based on
years of training and use. The suggestions and conclusions found in this chapter
focus more on the "how-to" than the empirical-theoretical and are based on
personal practice and familiarity with the practice of many colleagues who use
similar techniques.
The purpose of this chapter is to describe some of the more helpful hypno-
therapeutic techniques to incorporate into psychotherapy as the clinician works
with dissociative clients. The degree of dissociation, the therapeutic task at hand,
and the comfort level between the therapist and the client will help determine the
hypnotic techniques most useful throughout therapy. Beyond describing tech-
niques, examples of how to use these skills with particular clients will be illustrated.
Specific words for hypnotic treatment are included.
This chapter does not attempt to discuss the relationship between memory,
suggestibility, and hypnosis. Instead, it is assumed that clinicians are familiar with
and follow the ethical guidelines and standards of care in our field, and have
received training in hypnosis followed by continual supervision and further con-
tinuing education in the areas of both hypnosis and psychotherapy with dissocia-
tive or trauma survivors. Furthermore, it is assumed that there are types, levels, and
continuums of awareness, consciousness, and memory that are determined by the
citcumstances the client has experienced. It is also assumed that therapists know
that the citcumstances experienced effect memory and that all memory is inaccu-
rate to one degree or another. These topics are covered both in other chapters in
this volume and in books by Hammond (1992) and Brown, Sheflin, and Hammond
(1996). Some memories are difficult to retrieve and there are those that are even
itretrievable (Farthing, 1992). To put it simply, we remember and we forget. We
recall some events, other events are more difficult to retrieve, and some never
return to consciousness. The inaccuracy of all memory has never been questioned.
Five people that witness an accident will all immediately have different perceptions
of what just occurred. What is essential is that cognitive restructuring is based on
the core existential crisis that the client feels. To the therapist, whether the details
are accurate is itrelevant compared to the daunting task of helping a client recover
from profoundly deep feelings of shame and low self-worth.
It is assumed that the clinician understands the difference between appropri-
ate suggestion for symptom reduction, such as shame reduction or self-esteem
enhancement, and inappropriate suggestions leading to conclusions that have no 451
basis in reality or reflect the biases of the therapist more than the client. Suggestions Hypnotherapeutic
that are made during altered states of consciousness are a fine art, used in mutual Techniques
agreement between therapist and client. As a general rule, examples of appropriate
suggestion during hypnosis might include some of the following: make suggestions
to help build self-esteem; restructure false and negative self-perceptions or negative
belief systems; suggest pain reduction images; suggest the lessening of anxiety or
panic; and develop useful images such as safe places, containment of feelings,
distance from frightening images, and other helpful images or metaphors.
Suggestions recommended during the processing of most memories should be
restricted to helping reduce discomfort, the shortening of time (time distortion)
through a difficult memory, and the suggestion of affect release if needed for
symptom reduction and resolution. It is strongly suggested that any questioning
during memory processing about content be restricted to simply asking "and what
happened next." After the entire memory is processed, suggestions about a new
way to feel about oneself and strong statements of positive affirmation would be
appropriate.
Dissociative patients usually enter therapy because they have become "uncom-
fortable" with posttraumatic stress disorder (PTSD) symptoms such as anxiety
attacks, intrusive dreams, flashbacks, severe depression, sleep disorder, night ter-
rors, and somatization or body memories. Often clients report spontaneous abreac-
tions, flashbacks, or some form of acting out, but the symptoms usually reflect the
intrusive memories emerging through dissociative barriers. The therapist has sev-
eral responsibilities. Immediate relief can begin by teaching regrounding tech-
niques to control the flashbacks and the flood of affect. The client can be trained to
use self-hypnosis to temper and control the spontaneous material. Then, later, the
memories can be processed in an organized fashion. The therapist can suggest the
client see a physician for medication review to assist in control of the physiological
discomforts both during spontaneous flashbacks and the feelings later in therapy.
The therapist trained in clinical hypnotic techniques will find many hypnotic
tools available to resolve trauma in clients who fall within any part of the continuum
of posttraumatic stress disorder or dissociative disorders. A dissociative experience,
of at least one aspect of the behavior, affect, sensation, knowledge (BASK) model
(Braun, 1988) occurs with almost every trauma for at least a short period of time. It
is hoped that the hypnotic techniques described in this chapter can help facilitate
both reassociation of the dissociated material caused by severe trauma and protec-
tion of clients during memory processing in a parallel way that dissociation or
altered states of consciousness were protective during the original trauma. With
process~g and reassociation of the memory, resolution may develop and healing
may occur. The traumatic memory moves from a trauma to a normal part of
narrative memory (van der Kolk, 1987).
Due to the severity of the experiences that trauma victims have frequently had,
not only beginning, but much more advanced hypnotic techniques are needed to
help facilitate psychotherapy. All hypnosis is a form of self-hypnosis. Self-hypnosis is
a survival skill that most of these clients have used to dissociate and escape into an
altered state of consciousness during the original trauma (Ludwig, 1983). Conse-
quently, appreciating and relearning (if needed) the hypnotic skills that the clients
452 already used (often without an awareness of their original skills) can help reassocia-
Judith A. Peterson tion, can protect the clients during each phase of therapy, and can help with
movement toward positive self-esteem, shame reduction, and healing.
There is a common misperception that hypnosis should or is only used for the
purposes of "memory retrieval" or to "age regress" the client. In reality, hypno-
therapy has many purposes in therapy. In addition, memory retrieval is normally a
client-originated phenomenon that may involve spontaneously emerging fragments
of memory of abuse over a lifetime, not just early childhood experiences of abuse.
Often trauma victims describe an entire life history of abuse, including current
abuse patterns that cause continual retraumatization. Fragments of memories are
usually accompanied by intolerable, intrusive symptoms. The clients bring these
fragments together to form a cohesive collection of fragments that become the
"memory" of the client. The core body feelings, profound terror, and the core
existential crisis need to be honored and processed. Clients need to be encouraged
to balance the understanding that they have formulated as their own histories of
the abuse and also encourage careful examination of the true-not true, tricks,
deception, use of drugs, and suggestions from other people. The client, over time,
becomes skilled at looking for the cause of current symptoms, retrieving and
processing the memory, and experiencing symptom reduction.
Memories are usually chosen by clients because the client feels intolerable,
intrusive symptoms. The client brings the memory to the therapist for assistance
with the resolution of the memory in psychotherapy. Therefore, it is the position of
this author that hypnotic techniques should not be used for simply exploring or for
finding "proof" that a client has been sexually abused. "Digging" often causes
symptom escalation. There are rare exceptions to this approach and the therapist is
urged to use caution and seek consultation about hypnotic exploration. Successful
work revolves around symptom alleviation. Clients need to be well grounded in
hypnotic techniques and learn how to pace themselves to better explore their
symptoms. Most clients in this population are far more involved in presenting too
much intrusive material that they journal or produce in art and need to be taught
how to pace their therapy. Therefore, hypnotic exploration is not often needed
except in the rare case where the client has presented with symptoms over time.
With no symptom alleviation, hypnotic exploration appears to be the most viable
solution and is often agreed to by both client and therapist.
The reader is referred to Brown et al. (1996), Hammond (1991), Kluft (1989),
and Sachs (1990), for both a history of the use of hypnosis with dissociative
populations and a list of specific techniques used with this population. Hypno-
therapy is helpful throughout the entire course of treattnent of traumatized or
dissociative clients from initial work to postintegrative session. The purpose of this
chapter is to describe specific techniques that have been helpful during the various
stages of therapy with dissociative clients.

DIAGNOSIS

As often as possible, diagnostic work is easier to interpret if hypnosis is not

used during the diagnostic phase. Hypnosis may occur either through spontaneous
trance experienced by the client or through a formal induction by the clinician. 453
During trance, various ego states may be noted. The distinction should be made Hypnotherapeutic
between ego states that are only available during formal hypnosis and parts that Techniques
spontaneously emerge. Consistent presentation of parts that consistently have their
own history and identity as separate from the part that originally presented usually
indicates that the client is distinctively dissociative. Distinctive amnestic barriers
are a hallmark of a classic dissociative identity disorder (DID). Hypnosis might be
considered when, for example, a client may be so anxious that deep relaxation or
light trance may be indicated for calming. If parts emerge during hypnosis, it is well
advised to observe the phenomena of how parts emerge over several sessions,
particularly sessions without the use of hypnosis, before making a definitive diag-
nosis.

UNDERSTANDING TRANCE IN THE CLIENT'S LIFE

Many therapists prefer to use the words "deep relaxation" or "guided imagery"
rather than hypnosis. Actually, many words or phrases describe various levels or
experiences of trance or hypnosis. While it is advisable to use a vocabulary that
both client and therapist find comfortable, the client should be aware that each
level of trance is a part of an experiential continuum from the absence of trance to
deep trance states. Since abused clients have already used altered states of con-
sciousness to help them tolerate the intolerable, these clients are often found to
have an exceptional ability to participate in deep relaxation or guided imagery.
Hypnosis can increase the capacity for building trust, building self-esteem, correct-
ing cognitive distortions, and changing deeply embedded negative messages.
If asked, clients often describe their mental "escape route" from previous
unmanageable trauma. Descriptions vary from simple to elaborate "paths" to safe
places (Hilgard, 1970). The clients' gift for self-hypnosis has helped their survival
in the past and can now be used to facilitate their therapeutic process in the
present. Asking detailed questions about how the client experienced the dissoci-
ated state can reveal how the altered state of awareness previously occurred.
Exploring further, clients can often describe how "going away" occurs and where
to retreat to within a dissociative state or within the organization or system inherent
in many multiples. While therapists attempt trance depth for their client's internal
safety, the client is often already adept at deep trance. When the client realizes he or
she possesses a beneficial tool, the client often feels empowered within the thera-
peutic setting. The client is able to use and reframe what was once a defense
mechanism caused by abuse as the gift it is when used to manage and maintain
mastery over various aspects of therapy.
Resistance to the use of hypnosis in therapy occurs when misunderstanding
and misinformation leads clients to believe that hypnosis is controlling and manipu-
lative. Clients need to understand how they have already mastered the use of
hypnosis in a positive way earlier in life. Hypnosis is a fully focused attention to a
selected part of the internal or external environment. Learning new hypnotic
techniques in therapy actually gives them more control of their feelings and behav-
ior. If hypnosis was used in a negative way by a perpetrator, the transference issues
454 need to be worked through as they arise. Therapists are often perceived as having
Judith A. Peterson characteristics of the perpetrator and are misinterpreted in regard to the motives
surrounding therapy. Hypnosis is not recommended with these clients while the
transference issues are negative. Interestingly, some complex dissociatives or Dills
appear nonhypnotizable to the therapist.
Some clients have strong religious beliefs that prevent the use of hypnosis;
thus, it is necessary to process that issue as a part of therapy and respect the wishes
and beliefs of the client. Hypnosis is usually a point of controversy in cases that end
up in court. Familiarity with the laws and court rulings of your state are recom-
mended (Kanovitz, 1992; Sheflin, 1991).

THERAPEUTIC TASKS FOR EACH PHASE OF TREATMENT OF

TRAUMA VICTIMS

Phase 1
• Build trust and establish a therapeutic relationship.
• Establish safety in present time (may start with safety in the psychotherapy
session).
• Establish hypotheses about the differential diagnoses, share with the client,
and take actions through appropriate interventions such as medication,
working through addictions, dealing with characterological issues.
• Establish and maintain appropriate boundaries.
• Suppress spontaneous abreactions or flashbacks.
• Establish psychoeducational approach to treatment.
• Teach about the phases of treatment.
• Establish and educate the client about the combination of developmental,
psychoeducational, psychodynamic and cognitive-behavioral approach to
therapy.
• Promote reading of instructional, educational (not anecdotal) material.
• Teach pacing of therapy.
• Educate about medication management.
• Manage transference and countertransference issues.
• Encourage journaling.
• Encourage art therapy and self-expressive modalities.
• Master beginning hypnotic skills: safe place, containment, affect modula-
tion, affect toleration, rapid induction, distancing, time distortion, establish-
ing ideomotor signals, positive age progression and regression, permissive
amnesia, deepening techniques, and ideomotor signals.
• Build self-esteem and overall functionality.
• Process and cognitively restructure.
• Contain memories retrieved by client outside of therapy to be processed
later in therapy.
• Teach how to plan and process retrieved memories later in therapy.
• Teach internal communication if client has parts.
• Use spiritual and healing approaches to your client.
Phase2 455
Hypnotherapeutic
• Learn to plan and pace the memory processing of memories retrieved by Techniques
clients.
Teach and help client practice advanced hypnotic techniques: advanced
ideomotor signals, advanced deepening techniques, mobilization of affect
and cognition, penetrating or creating barriers for safety and titration, more
advanced contracting for safety, combining memories, reversing the mem-
ory, dividing a memory across therapy sessions, and self-hypnosis and use of
hypnotic tapes with self-esteem-building messages.
Teach titration or fractionation of feelings or memories.
Use cognitive restructuring to help manage shame, guilt, self-image, etc.
Review and focus on all aspects of Phase 1 of treatment.
Blend and integrate parts when processing memories (if client has parts).
Use group therapy (if necessary and appropriate).
Group psychotherapy needs to focus on present day relationships and tasks.

Phase3
• Continue all aspects of Phases 1 and 2 as necessary.
• Begin developmental reconstructive psychotherapy.
• Use spiritual and creative therapy.
• Move into more complex memory processing if necessary.
• Continue blending and integration.
• Continue cognitive restructuring.
• Begin psychodynamic psychotherapy as a "single" personality.
Many of the hypotherapeutic techniques are described here, but this chapter
is not intended to be a complete list or description of all uses of hypnosis with
trauma survivors. Also, examples of PTSD and various degrees of dissociation are
mixed together to help demonstate the use of all these techniques, regardless of the
client's level of PTSD or dissociation.

Ideomotor Signals
The use of ideomotor signals (Cheek, 1994) provides a hypnotherapeutic
method for the exploration of the parts of the ego structure that are not readily
accessible at the conscious level. These signals are often finger levitations or the
lifting of a finger, but also include head nods and other body movements that
become nonverbal signals. Use of this as a device for communicating through
hypnosis is a means to "establish a set of prearranged signals" (putnam, 1989, p.
224) that allow a client to "tell" without speaking. Braun (1984) has described a
prevalent method to teach specific signaling. Kluft (1992) has described a method
for nurses and other staff in a hospital to establish and use ideomotor signals with
dissociatives. The most important issue is that communication can take place with
sub voce alters or parts that do not have to emerge in order to make their ideas
known.
456 Ideomotor signals may be reliable with some clients, but not with others. With
Judith A. Peterson those who can use them reliably, there is a standard hypnotic induction before their
use, although that is not found to be necessary with particularly highly dissociative
clients. Also, after using ideomotor signals in therapy for a period of time, they are
often used by the therapist and client in sessions for many reasons and no formal
induction is needed.
The following instructions might be used with clients to establish ideomotor
signals:
1. Tell the client that you do not expect or want a conscious, deliberate or
voluntary movement of the fingers, but instead ask the client to let the
unconscious mind establish a method of communication. In addition, let
the client know that lifting the finger may feel like it is being tugged by a
string attached to a helium balloon.
2. Ask the client if all parts of the ego structure are listening and signal when
they are all listening by lifting a finger.
3. Then, ask everyone inside, or all parts of the conscious and unconscious, to
let the therapist see which fingers signal "yes," "no," and "stop." Wait each
time to see that a different finger makes a movement, even if subtle.
4. Then, ask questions that have a "yes" or "no" answer in order to talk to all
parts of the ego structure, alters or parts about a therapeutic issue or until
you have worked out safety.
As the client learns each hypnotic technique, ideomotor signals are one of the ways
that the client and therapist can communicate about the progress they are together
making forward jointly established goals of therapy.

Safe Place
The therapist might ask the client if there was a safe place that was used to
escape from trauma (Hammond, 1990). Clients often describe safe places that they
have used for years. They can continue to use these safe places in therapy. With
highly dissociative clients, several safe places might have been used or will be
developed during therapy. Different parts may need different types of safety. Ac-
complishing safety on the inside, never before achieved, can provide the potential
for a positive healing place for specific parts of the ego structure. Spirituality is
often incorporated into these places by these clients as new ways of comfort and
healing are explored and experienced internally. This helps to establish a core sense
of healing that is needed when these clients have been so profoundly assaulted.

Affect Modulation and Toleration

Trauma survivors often experience their feelings as being on or off, similar to a
light switch. Since they either feel overwhelmed by their feelings (and might
experience panic) or totally numb, survivors are often afraid to feel anything at all.
As clients learn both affect modulation and affect toleration, these skills will help
them in their daily functioning, throughout therapy, and in processing memories.
To develop modulation, clients might practice experiencing a specific feeling
such as anxiety. A way to facilitate this skill is to suggest to clients to imagine a scale 457
from 0 to 10 with 0 representing calm (an absence of anxiety) and 10 being a Hypnotherapeutic
maximum feeling of anxiety. The therapist counts from 0 to 10 and back to 0 again. Techniques
Toleration is often built by stopping at whatever number the client has difficulty
with, such as 4, waiting an agreed upon time, such as 60 ·seconds, feeling that
feeling for that time period, and then counting back down to 0. Gradually, clients
can learn to build their tolerance of difficult feelings. They can learn to stop the
feeling and gain a sense of mastery and control over the feeling. A concrete example
to help a client begin might be to ask the client to relax the hands at the count of 0
and then progressively clench them until the count of 10. Then, slowly relax the
hand until it is completely relaxed as the therapist counts back from 10 to 0. Safe
emotions, such as joy, might be experimented with in this way first before attempt-
ing a more difficult emotion.

Containment Techniques
Clients find it helpful to develop containers and barriers needed to hold the
different types of feelings (affective, physical, motor) that can become overwhelm-
ing before, during, or after a therapy session. One suggestion for a nonthreatening
approach to the containment process is to suggest to the client that a good feeling
(such as joy) can be contained in a gift box. Holding on to that positive feeling and
using the pleasant and rewarding metaphor of a gift allows the client the oppor-
tunity to understand the concept of sheltering positive feelings. An added benefit to
this process is that these positive feelings may be opened as a gift and experienced
during difficult periods of time. Later, the client might want to use a steel vault to
contain shame, guilt, or rage. Transferring the skill that the client first used for a
positive feeling to the containment of a negative feeling is a practical aid in process-
ing difficult experiences and remaining fully functional between therapy sessions.
Examples of patients' creations of containment can include internal quiet rooms
where alters can scream, yell, and kick. Other internal structures can provide
peaceful areas to rest or sleep for alters who cannot remain in control. Even a place
for "internal restraints" is effective for alters who need containing between sessions
or who need to contain or restrain the body during memory processing (Young,
1986, 1991). Containers, domes, and expandable compartments are all examples of
ways to place feelings within surroundings to not allow them to slip out at the
wrong time. Sometimes feelings or parts of the ego structure need to be completely
closed off until the next therapy session. At other times, a small, slow leak of affect
is desirable to gradually allow the feeling to dissipate. Some patients build elaborate
mechanisms with controls, dials, and other sophisticated metaphors to control
their feelings or parts (Hammond, 1992).

Age Progression and Age Regression (Hypnotic Time Distortion)

Age progression is a form of time distortion that allows the client to move
forward in time far enough to imagine the future. For example, the client can
choose to look back on therapy with a sense of mastery and personal accomplish-
ment. Hypnotically moving through time allows suggestions for a successful family
458 life or a satisfying career, which builds self-esteem and creates a positive frame
Judith A. Peterson during present-day difficulties. Watkins's (1971) affect bridge can be used to move
forward or backward in time. The client can focus on a positive feeling of calm and
then follow that feeling of calm like a rainbow bridge to a future time and enjoy
peace. The client can also follow the calm feeling to a calm past event while the
therapist counts from 0 to 10 and back to 0 again.
The client can then practice experiencing a mildly positive or negative past
experience while the therapist counts (an experience already known to the client).
Later, when the client is prepared to work through a trauma, the practice facilitates
the ease at which the client is able to return to the trauma for a very limited amount
of time. The client can complete the needed work and then return to the present,
using whatever containment techniques are needed.
Clients need to understand that time can be distorted, that pleasant events can
be extended to feel as if they last for hours. They need to understand and experi-
ence how very difficult traumas can also be time-shortened in order to process a
lengthy trauma in just a few moments. Memory processing and other aspects of
therapy can become less difficult. When trauma victims were being hurt or tor-
tured, they often felt that time stopped and that the pain went on forever. The
knowledge and the experience that time is limited is crucial and comforting for
these severely abused clients.
An example of words to facilitate this process:
Age Progression
I am wondering now if you can take the new insights that you have and
begin to move forward in time .... past today and into the future .... and begin to
feel the feelings of this new understanding as it permeates and changes your
perceptions of the world around you and your relationships with people .... in
the future 5 years from now .... I am going to begin counting as you feel yourself
going forward in age .... perhaps imagining that you are sitting on a park bench
.... or sitting on a grassy hill .... overlooking a beautiful view .... or sitting by the
ocean on the sand .... watching a sunset, and further reminiscing .... as you
begin to progress ahead in time .... as I count, 1, moving forward in time, 2,
feeling yourself moving toward that wonderful relaxing image .... perhaps on a
vacation and looking back on your therapy, 3, moving even further forward, 4 to
5, being completely there and able to look back .... and have the insight and
understanding of what these new feelings and new understandings have meant
to you over the last 5 years .... and letting those float down into every cell .... as
you appreciate the changes .. .. see the differences in your life .. .. feel the
mastery over new things .... things you enjoy now .... hobbies, work, family,
looking out on that relaxing scene and feeling the peace come down over you
.... and feeling that white light .... that healing light .... that at first encircled a
few parts of you, and now encompasses all of you and acts as a protective shield
around all of you .... around your entire body .... a wonderful sense of feeling ....
a feeling of being whole .... and now it is time to go back to the present bringing
with you that understanding of the future .... as I count back .... 4, 3, 2, 1.
Time distortion can also be used for a different purpose by suggesting that just a few
moments of calm and healing and sleep can feel like a whole night of rest. Especially
when difficult material has been processed in a therapy session, a few minutes of
calm and healing peace that feels like unlimited rest can allow the client to leave the
session rested and relaxed, knowing that hard work was completed and feeling 459
mastery at the end of the session. Hypnotherapeutic
Techniques
Hypnotic Distancing Techniques
Trance offers dissociative clients varying degrees of hypnotic distance while
processing memories. Some parts need to be protected from knowing or process-
ing specific past traumas and they ask for or require amnesia. This can be aided by
hypnosis. Furthermore, parts who want to observe from a distance may do so while
being protected from direct feelings through the use of trance. They may be en-
couraged to feel only what they are ready to feei while remaining safe. In processing
sessions, distancing can help the client remain with the cognitive discussion while
allowing the emotions to remain distant.
The following is one of many examples of distancing techniques. The therapist
asks the client to imagine a large theater complete with stage and many rows of
seats. The client is invited to be as close to or as removed from the action on the
stage (the memory or the topic of discussion) as they wish to be. The therapist can
suggest additional changes to decrease the intensity of the experience by changing
the size of the figures on the stage or the color and backdrop of the stage. The scene
can be changed from color to black and white, or changed by creating a curtain hung
in front of the stage to alter the intensity of the scene. During the above process, the
therapist continually assesses the client's safety. Ideomotor signals can be used to
determine that all the distancing required has been successfully completed. Dis-
tancing metaphors can be changed at any time. For most clients, one can assume
there is more awareness of the sessions' content than is openly acknowledged.
These forms of suggestions simply offer the concept of distancing as a pacing
method to allow a gradual awareness that clients can tolerate (Hammond, 1992).

MORE ADVANCED HYPNOTIC TECHNIQUES

The purpose of the more advanced hypnotic techniques described in this

section is to facilitate the therapeutic process in several ways: (1) to help clients to
better tolerate and safely manage the profound shame and other intense feelings,
(2) to offer a safety net and helpful techniques to reduce affect overload and
decrease the need for hospitalization, and (3) to help clients combine as many
traumas together as possible to expedite their therapy. Advanced hypnotic tech-
niques can particularly facilitate repair in fragmented clients with repetitive, severe
abuse memories that can be processed in a single session. Clients with polyfragmen-
tation can experience fewer difficulties with repetitive abuse memories being
processed in a single session. This allows combinations of experiences to be
processed at one time. This has the potential to shorten the treattnent for these
profoundly abused patients. In order to work with these clients, it is helpful to rely
on a consistent, reliable therapeutic frame (as described earlier in this chapter) with
specific boundaries that the client can depend on to facilitate processing complex
work. A consistent framework for therapy is helpful in order for the client to feel
safe enough to process independently retrieved complex memories.
460 Advanced Ideomotor Signaling
Judith A. Peterson
More advanced ideomotor signaling techniques include the following:
1. Ideomotor signals can help determine if containment is at a safe level for the
patient to leave the office. Sometimes, with very dissociative clients, the
therapist and parts in the client need to hypnotically create amnestic
barriers between the host and other parts to facilitate safety. Also, barriers
are often needed between a functional alter that can help the system by
staying out while other parts of the system are behind protective barriers to
rest or amnestic barriers. Ideomotor signals are helpful in determining if
enough resolution of affect has taken place, or if enough affect has been
expressed by the alters to allow the memory to be resolved.
2. The glove anesthesia technique (Hammond, 1992) might be combined with
ideomotor signals at times. The therapist can ask if some of the alters or the
host need to be totally unaware of the finger signals. This may be due to
safety issues or due to information needed to plan therapy that the system is
unable to know or it will be unsafe. The fingers can first indicate that the
hand is separate from the body and then the fingers can be asked the
necessary questions without the answers disturbing the system as a whole.
3. The fingers can also be asked if the body needs to be at a deeper trance level
and can indicate when the body is at that deeper level. Then further
questions or further therapeutic work can be asked of the system.
4. In addition, the fingers can be asked if there are alters at deeper levels that
answer with the other hand or answer with the same hand only at deeper
layers or systems. Often, in complex patients, both hands answer for differ-
ent layers and each hand answers with different fingers to questions at
different layers. For example, there might be four layers represented on the
right hand and three more layers represented on the left hand.
5. Also, information about layers or alters that block can be discovered and
worked through to help facilitate therapy.

Fractionation
Almost any aspect of any experience that the client is processing in therapy
can be fractionated or divided up into tolerable pieces of information or feelings. A
client may be prepared to process 5% of the affect or 50% of the affect or 2% of the
cognition, and so on. Every aspect of the preparation for and the processing of the
BASK model can be divided or titrated. The memory itself can be divided into
manageable parts and worked on over several therapy sessions.
Teresa had remembered being raped by her brother, then he and his friends, and
then her father came home drunk and brutally raped her. Teresa chose to
manage the rape by her brother in one session. She completed a healing piece
about that part of the memory that included identification of the existential
crisis and working through the cognitive restructuring related to the crisis. The
next session was spent handling the gang rape of her brother's friends and the
existential crises about her brother letting his friends do that to her. More
healing images were used at the end of that session. The third session about this
 memory included the memory of what her father did when he came home. All 461
three parts of the memory were brought together with healing images. Blending
Hypnotherapeudc
and integration of those parts occurred. Techniques
Another advanced fractionation technique is to combine intense feelings or
memories about an event, but only from the count from 0 to 10 and back to 0. Then,
send the client to a calm, peaceful, safe place for the same amount of time with the
hypnotic suggestion that those moments of reset feel like hours of rest. That two-
part juxtaposition of intense difficult affect combined with peace and calm rest
can be completed in a cycle as often as needed to dissipate the affect.

Deepening of Trance
Readers are referred to various publications including (Hammond, 1992) for
various examples of both standard and rapid hypnotic inductions. Later, as work
progresses, trance depth becomes more important and acts as more of a cushion. It
allows an opportunity for the therapist to work with the imbedded experiences and
messages caused by abusers during the existential crisis. The client has an oppor-
tunity to hear new statements that can build positive self-esteem and negate the old
messages that have been so self-destructive. These new statements may positively
affect core belief systems. Examples of words that might help clients move through
various levels of trance depth:
.... as you begin to float down, as you now go deeper and deeper into trance ....
beginning to float like feathers that float out of a pillow .... like clouds that float
down and cover quietly like a fog .... like sand that filters through water, you
begin to find the natural place that allows for the protection and internal caring,
that allows you to very carefully explore the memory today .... and as you float
down now deeper and deeper.
(Ideomotor signals may be used to check what is happening internally.)
In regard to using memory processing with dissociatives, PTSD, and DID, the
depth of trance is extremely important and helpful. The following are suggestions
that would help depending upon the patient.
• For traumatized patient with and without definitive ego states:
Moving farther and farther down with more and more relaxation as you move
deeper and deeper, moving to the depth of trance that you need today. Feeling
the water as you slip over the side of the boat and begin to let yourself float
down into the depths ....
Another metaphor:
.... feeling yourself floating out into space as the earth gets smaller and smaller ....
Another metaphor:
.... feeling that parachute billow out and begin to float you down ever so slowly
.... moving even deeper to the level where all can hear and all parts can feel and
see and know at whatever level you are ready to know .... in whatever way you
are able to understand ....
Further suggestions:
.... moving even deeper through the layers of the unconscious ....
462 • For more defined dissociation- DID who are processing a very difficult
Judith A. Peterson memory:
Referring to their mapping in DIDs or layers of the unconscious:
.... moving down through the layers ....
or using whatever image that they have:
.... moving beyond the layer with the triangles and shapes (previously referred
to or mapped) .... moving beyond the alters that are so frightened of their
memories .... moving even further down .... seeing yourself floating down ....
counting down now . . . . down through all the layers whether I know about
them or not .... whether they have engaged in therapy or not .... just moving
past them without any memory of passing them ....
permissive amnesia again:
.... moving deeper and deeper, and then counting 1 through 10 .... with less and
less memory of what you are moving deeply through ....
using ideomotor signaling to say:
.... and when you have reached all the way to the depths .... then let a "yes"
finger float up ....
wait now while you watch for your patient's signal:
.... now move even deeper and deeper beyond that last layer, to a point where
you can look up at the entire system .... how helpful that might be .... so unique
to see yourself from an entirely different place .... like looking up from the
bottom of the ocean as you float further and further down .... and can barely see
the boat floating up on top of the water ....
Some abused victims need to be this deep in trance in order to do their work. This is
a very somnambulistic depth from patient reports. Typically, this is more likely to
occur when sufficient time has gone by and trust has developed between the
therapist and the patient.
Complex, polyfragmented, multilayered DIDs often seem to have had so much
experience with trance that they have their own "pathways" into trance. Explora-
tion of former trance experience can be actively explored. Then, as the client can
be encouraged to reexperience those experiences, this process can facilitate rapid
movement to a very familiar deep trance level. From that deeper level of trance,
even deeper levels can be achieved every time trance is facilitated through "piggy-
backing" on the previous experience and adding deepening images. Sometimes
trance deepening occurs by moving the patient to alters formed at deeper levels of
trance or by asking for certain parts to facilitate helping the system as a whole to
move to a deeper level of trance.

Mobilization of Affect and Cognition

Feelings from a particular memory that have been processed can be sent
throughout the system to parts that have not been in therapy yet. For example,
when one part of the system experiences a terrifying memory, the therapist can
help the parts transfer not only the feelings of terror, but the feelings of mastery and
new insight to the alters not in therapy yet. In some systems, for example, upper
alters who feel terror from being tortured may have an impact on deeper alters who 463
considered themselves "leaders." These leaders often do not have the feelings about Hypnotherapeutic
what has happened to the system as a whole and sometimes have been told they Techniques
will never feel the feelings the upper alters have felt. The purpose of this therapeu-
tic intervention is to help the entire system develop insight about what happened to
the whole ego structure and to ultimately stay safely away from more traumatic
situations through their new awareness.
Patient, Susan, had alters who worked through all the feelings of being gang
raped by perpetrators. These experiences were cognitively known by deeper
alters, but the feelings were not felt. At the end of the memory, the alters who
had the feelings from the gang rape decided to send feelings to the alters who
continued to place the body in promiscuous situations and who had not been
particularly concerned. They just thought that the job of the body was to
sexually service other people. The new terrifying insights had a significant
impact on these deeper alters. Behavioral changes occurred immediately with
new insights beginning to occur long before those deeper alters were involved
in their own memory work.

Ask the client if there are new awarenesses or ideas that the rest of the system
needs to know. Sending cognitive reality throughout a system prepares the way so
the therapist does not need to start over with basic concepts at every level. Often
the deeper alters do not realize that the abusers have threatened and lied to the
entire system.
Patient, Carol's, alters had been told they would be arrested for pornographic
experiences despite the fact that they were forced to participate. Cognitive
restructuring involved processing the knowledge that the perpetrators would
be implicated as criminals and their acts constituted the actual crime. This new
understanding was then sent through the entire system and was powerful in
freeing up the system to new truth.

With advanced hypnotic techniques, the therapist can successfully encourage

change within the system. Each therapeutic intervention potentially provides a
catalyst for healing beyond the specific therapy session or even beyond one particu-
lar part of the system.

Age Regression
Sometimes age regression is needed for specific reasons. The following are
found to be helpful words to use in regard to age regression and moving the client
directly to the beginning of the event that the client has chosen to process.
With patients that are not DID, there is more work to do with age regression.
With patients who are DID, you can usually just simply ask for that alter and ask
for that experience and ask for all those to be there that need to be there who
remember the memory. Often that alter needs to be age-regressed to the origin of
the trauma:
• Dissociatives and PTSD:
.... counting down using the elevator .... moving through the family scrapbook
and feeling younger and younger .... imaging different birthday parties .... going
464 down through the ages in regard to life experiences, such as high school and
junior high and elementary school, getting younger and younger .... and letting
Judith A. Peterson
your finger come up at the point where you are as young as you need to be ....

• For ego state and DID:

.... I atn wondering if all of those that are there who are ready to begin to work
on this memory can come together now with the one that remembers the
beginning of the memory, in fact, to move back in time to just before the
memory begins .... if that alter or that part could be there now ....

• In all patients: as you see that emerging, then enhance through the fol-
lowing:
.... I atn wondering if you can remember now and be there and feel what is
under your feet .... and feel what is around your body .... and smell the smells
.... and hear the sounds .... as you feel yourself as much there as you need to be
in order to work through this memory ....

The patient typically escalates when the reference to the different senses occurs:
. . . . can you begin to tell me now what happened at the beginning of your
memory .... and let me know through your fingers when another part needs to
be here, or there is a feeling that we need to manage the memory in a different
way .... so tell me where you are now?

Using ideomotor signals helps the patient remain at a deeper level of trance, since
verbalizations tend to interrupt deeper trance. ~plaining what is happening might
better happen later (unless necessary). Then you begin to ask:
.... and then what happened, etc? ....
. . . . and what happened next? ....

Do not lead the patient, but repeat the words and ask what happened next,
and move the patient through the memory, using time distortion as needed. Clients
are encouraged to state a cognitive pan first, but some patients first express
affective parts as they move through the memory. Going back to the BASK model, it
is important that the therapist understand that the ultimate goal is to combine all
dissociated parts. The more that can be pulled together, the more complete the
experience. Sometimes you might need images such as the following:
.... it may be that you need to view it on a movie screen .... the event that you all
shared in order to get through .... because of the difficulty of the memory ....
and I atn wondering if you would like to all see it .... and see the parts that are
difficult at a very rapid rate .... and be as close or as far away from the screen as
you need to be in order to view what happened ....

Ifyou get a "yes" signal from the ideomotor signals, then the therapist might want to
use the metaphor of a movie screen as a preliminary to working through the
memory (Hammond, 1991). Also, when going through the memory, it might be
helpful to ask:
.... are you able to handle the memory today? Does any part of you need special
precautions in handling the memory? Will any part of the memory lead to
feelings you will need special help with?
 Often the client knows at some level how the memory is going to be managed 465
and the therapist can use titration, containment, collapsing, or fractionation. As the Hypnotherapeutic
client moves through the memory, as the therapist asks what is happening, and it is Techniques
heard, for example, "they're on top of me, they're heavy, it's one after another."
The patient may report a rape scene of one perpetrator after another. It might be
helpful to again ask the fingers,
.... can we do all of this at once ....
and most often the answer is "yes."
. . .. I am going to count to 10 and I would like you to remember all the
perpetration that you need to remember that occurred, all the physical and
emotional feelings that you all need to feel by the time I count to 10 .... and I will
make sure I count back to 1 to make sure that the feelings are back at a place
where you can contain them and they have gone away ....
At that time, the therapist can count from 1 to 10. The patient will usually let
out a lot of affect at 10. Pause there in terms of the curve of memory processing to
allow for sufficient feeling to be expressed. It is important to pause, and then count
back down to 1. As the client moves through processing the memory, the therapist
can then continue to count from 1 to 10 whenever there is a spot where the
therapist finds affect present and needing to be expressed. Then, at the end of the
memory, the therapist might find it helpful to ask the patient if there is any more
feeling that is needed to be expressed. If the answer is "yes":
.... I am wondering if the body can express all the fear and all the terror that it
needs to feel in order not to feel those feelings anymore in any intrusive manner
.... and so I'm going to count from 1 to 10 and back down to 1 again.
. .. . I am wondering if part of you is feeling angry or rageful ....
the answer is almost always "yes." Then ask the same questions about other feelings:
.... Express as much feeling as you need to feel, and can contain safely with me
. . . . To dissipate the feelings
........ I'm going to begin to count down again now from 10 to 1 as every feeling
that is left over that you need to be rid of melts way .... 10 .... 5 .... 1.

Penetrating or Creating Barriers in DIDs

Amnestic barriers or strong resistance can be broken through within complex
systems by sending strong affect through the perceived barrier or through the
resistance. This strong affect often occurs during the processing of a memory and
can accelerate change in complex systems.
To work with parts who were amnestic to what had happened, the therapist
might say:
.... I am wondering if the conscious part (or host) is ready to remember what
has happened? ....
If you get a "yes;' it is suggested that you check about safety by asking:
466 .... is the conscious part or host ready for just the memory on the movie screen,
Judith A. Peterson
or is the host ready for the entire memory including the feelings .... if the host
does remember, Is the host going to be harmful to herself or to other people ....
are her feelings going to be very big .... or too big ....

Respond to all "yes" by modifying and containing affect until safety is established. It
is important to monitor for safety before a problem develops, not after. Once safety
is established and the associated part is willing to join with the dissociated part and
take on this memory, then the following might be said:
.... and now I would like all of you that are going to gather around the memory,
who have remembered this today, to now begin at the beginning again and send
all of the perceptions of the memory (or to those parts that did not remember
before) .... and allow as I count from 1 to 10 .... for that part to remember all of
what happened as it moves fast forward through her mind .... all of the feelings
(or as much as was agreed was safe) .... and as I count from 1 to 10 .... pause at
10 ....
Reviewing or penetrating the amnestic barrier can be extremely intense
.... and count back down to 0 ....

At this point, the patient often experiences the existential crisis of knowing or
feeling something that was unknowable or unacceptable before. It is extremely
important to allow that part to understand the crisis and also experiencing healing.
More ego strengthening surrounding the perception of the experience occurs after
you have joined together the parts that need to remember. Monitor for safety again!
Understanding the process of therapeutic healing can be enhanced with words
such as:
.... the new understanding about this memory and the feelings about it are
filtered throughout the mind . . . . some of these insights will begin to filter
through whatever layers there are all the way down to wherever they need to be
.... so that the new insights and understanding are available .... so you can begin
to learn about what it is like to work through memories and work through
feelings in an accepted and safe environment .... and achieve new understand-
ings.

Notice the absence of leading and the pertnission to use the statements as they
want. Sometimes to keep the client well paced (functional), there are only certain
aspects of the memory that the client, host, or primary part is ready to process.
Here is an example of a client who's memory tnight need protective barriers:
A part of the patient, Phyllis, remembered that not only was she abused by her
father, but had the perception that her mother allegedly stood by watching. The
intense anger from that new insight helped in therapy. But she indicated that she
could not handle any negative information about mother at that time. New
insights can be used as a motivator to facilitate change and speed up treatment.

Contracting for Safety

.... I would like you or everyone inside, or every part inside, to allow those
barriers to come down now to protect you .... or need to have your feelings
 titrated . . . . slowly leaking out the feelings only as you are ready . . . . letting 467
yourself be protected that were not protected before .... letting the caring and
Hypnotherapeutic
the loving and concern move throughout you .... throughout all of you .... as it Techniques
has never happened before ....
and then hopefully you'll get a "yes" response:
.... Is everyone where they need to be in order to remain protected? .... and in
order to be safe outside the therapy session? (contracting for safety)
Sometimes the host in the dissociative needs to be inside, or there needs to be
a part inside that is carefully cared for. The therapist might say:
.... The parts that have especially been hurt that need to be comforted and loved
.... I am wondering if those parts can stay safely within that healing light ....
or whatever healing image the patient has developed with you. Power comes from
using the patient's consistent images developed during the therapy.
Look for ideomotor signals now for safety:
.... can you stay within that healing light until yout next appointment .... can
the part of you that has always taken very good care of the body take very good
care of the body in between sessions ....
Stop each time you don't get a "yes." Work until you have a safety agreement. For
each patient it is an individual process. The therapist can begin to say:
.... you are now free of the effects of this .... you can let go of any of those
feelings from before, from long ago .... because you don't have to feel them
anymore .... and all the energy that was bound up inside is now ready for you to
use in a new way as you heal and develop new feelings .... you are free now of
that experience .... and it will no longer be hurting you .... and the hard work
you have done before to contain the feelings can now be used to help you in
yout therapy, until you understand what happened .... and you can feel very
good about the work that you have done.
This allows for the freedom to use the energy that was bound up in "secret
keeping" for other purposes. It is essential that the therapist carefully evaluate the
readiness of the client's system for this and other active roles within the system.
Clients can penetrate electroshock, pain, terror, and other physical or affect
memory barriers by moving the memory of that pain away to another part of the
system. This allows for the processing of new information without feeling the
difficult feelings until a different time.
A complex patient determined that a pain barrier existed within her system that
she described as having been caused by electroshock given to her body through
wires hooked up to a generator. She then worked with her therapist to decide
whether to go above or below the pain barrier and to place the physical feelings
from the barrier within an internal container until they could be processed at a
later time. Next, the patient chose the easiest route to move past the barrier. The
alters beyond that barrier were freed up to work in therapy and the physical
body memories from the electroshock were felt later.
In this way, different parts of the BASK model can be processed (such as
knowledge) and other parts of the BASK model can be saved until another time. Part
468 of the model (such as the electricity) can be saved from several memories and
Judith A. Peterson processed together in one memory-processing session. Hypnotic images that move
from the dark, which often represents amnesia or frightening memories, into the
light, which represents insight, knowledge, and mastery over fearful experiences,
are consistent images that add a new dimension to the internal perceptions of the
system. Ritualistic-sadomasochistic or mind control victims often report that the
dark represents the perpetrators perennial power. They describe being pulled into
the blackness or what they refer to as the "black hole." The power of the light as an
image, sweeping like a giant flashlight, allowing vision to permeate the entire
system and moving to every comer of memory, begins to erode that sense of inky
black criminal power or perhaps even unconsciousness, allowing alters to see the
light of day.
A ritualistic abuse victim, lisa, described many memories that took place in the
blackness-closets, holes in the ground, a coffin. During one memory after
another, the healing light that represented the normal world to her, the light of a
higher power, the light of knowledge and understanding, began to permeate the
blackness. Alters accelerated their process of healing by reaching out to the
light. Other alters became jealous of possession of the light and wanted to
complete their memory work in order to be out in the light.

COMPLEX HYPNOTIC TECHNIQUES

Processing the Memory in Reverse

Reverse memory processing allows a trauma survivor to start at the end of the
memory (f + 1) and to end at the beginning of the memory, right before (f - 1).
The traditional starting point and ending point of the memory are reversed. This
process is especially appropriate when the following circumstances are involved.
H a ritualized event has occurred over and over again for several years, it is better
for the client for the memory to end at the youngest or original point rather than
at the oldest or most devastating point in time. This process begins with the part
of the ego that holds the memories about an event and holds the memory of when
they were last abused. The information about the events is collected before the
session begins. This includes what occurred at each year moving from the oldest
or last memories to the earliest memories. Then, all of the alters at all ages are
asked to come forward and wait their tum as the processing of the memory is begun
with the oldest alters. The alters can experience the elements of the BASK model
and then blend into each other, as one alter blends into the next younger set of
alters.
As this process proceeds, the number of alters decreases with every year of
memory that is processed. Also, as the alters decrease in age, the memory of abuse
typically becomes less and less impactful or takes on a different significance. For
example, at 6 years of age, the alters only remember abuse at 6 and 3 (if 3 is the
youngest age of that particular abuse). At age 18, that abuse may be perceived to
have happened many more times. By the time the alters move to the 3-year-old
experience, the alter is only remembering the first time the abuse occurred.
Developmentally though, the impact of early rape may be more profound than later 469
similar experiences. Then, the ego structure moves back to just before T - 1, to just Hypnotberapeutic
before this abuse occurred. Next, this young part can begin to be comforted by the Techniques
adult, and slowly, as ready, blend into the alter of origin or the host or the core of
the client and can begin to grow up, through hypnotic suggestion, and blend. The
oldest alters in this type of memory processing may start with sudden, very intense
affect. Then, throughout the processing of the memory the affect slowly dissipates
as the alters that are experiencing this abuse are younger and younger and remem-
ber less trauma. Usually, once a patient has completed this process, the patient will
ask to complete work in this way as often as possible. One of the reasons is that the
feeling at the end is usually that of a part that is innocent, has not been abused, and
is at peace. That uninjured part can easily be blended into the host. Ego strengthen-
ing as well as cognitive restructuring techniques add to this dynamic approach to
repeated abuse. This process is effective with alterations at any part of the dissocia-
tive continuum.

Combining Memories
Combinations of similar memories that are held can be combined into one
memory-processing session. It is suggested that the therapist attend to the BASK
model as an oQtline for all types of combinations of experiences that can be
juxtapositioned. For example, all of the affect that is similar from some memories
can be combined. All of the physical sensation that is similar can be combined.
Kristin, a survivor with a young child, asked her system to have the alters that
specifically had any information about the abuse of her son to share that
knowledge. Then, that knowledge was processed and the cognitive distortions,
lies, were processed and the cognitive restructuring completed. Following the
knowledge of this, then the affect soon began to emerge and was managed
within several sessions as it was too overwhelming to handle within one
memory-processing session.

Another way to combine memories is through using the image of the reverse of
the "big bang" theory. This is based on the concept that fragmentation feels like it
happens at many levels of PTSD or dissociation through very profound, ego-
shattering experiences such as electroshock or being forced to do something
profoundly ego dystonic. Using the image of the big bang, the patient can process
the feeling that the experience sent parts or fragments flying in all directions. Then,
the hypnotic suggestion can be made that by starting at the point where those
fragments are furthest from their point of origin and moving back to T - 1, which is
the time just prior to the split, all of those fragments can come back together. An
image that helps with this concept is one of the stars in the universe and how they
might have resulted from an explosion and are still being propelled out into the
universe. Reversing that concept and allowing for them to see themselves like the
stars moving back into the original mass and then seeing the fragments moving back
into the whole alter or ego state or client is a powerful image. Much healing that
involves ego strengthening and cognitive reframing can then be used to facilitate
the strength of that whole part.
470 Working with "Decision Makers"
Judith A. Peterson
Another more advanced technique with DIDs is to achieve a working relation-
ship with the system leaders that are often deeply placed within the system.
Consequently, the more superficial alters that might have originally presented in
therapy are either near the bottom or are protected somewhere else in the system,
such as in a safe place. This allows for the deepest alters to map the entire system
from their knowledge and point of view, to plan therapeutic strategy with the
therapist, and to complete other important therapeutic tasks at a faster pace.

Alice, a complex, multisystemed multiple personality disorder, was finally able

to have her leaders come out to work in therapy. In understanding the process
by which they emerged, it became apparent that these deeper alters were used
to being "out" in abusive situations and found it to be a new experience to be
"out" under nonabusive and even therapeutic situations. Also, they had much
more choice now than during their perpetration. Many alters were afraid of
what these deeper alters would do if they were out and could just "run loose."
Their description of the knowledge they had of the system, and what they could
accomplish if out, led to problem solving about therapy at a new level. The
alters explained to the therapist that the system "flipped" during abusive situa-
tions anyway. The deeper parts handled the abuse and protected the surfilce
parts. The deeper alters began to learn how to function in the here and now and
alters on the surfilce had the opportunity to observe. Therefore, she was able to
move f.ISter in therapy, the system as a whole was able to understand the feeling
of being present without abuse. The sense of cognitive restructuring and heal-
ing images was not just unidirectional in source coming from the therapist, but
was felt throughout the systems.

In addition, the entire system was able to benefit from the ego strength that the
leaders had been using in a negative way (particularly blocking therapy). Dramatic
changes appear to take place in these patients. Often this is a process that is
completed time after time as each system with complex patients is ready to allow
their strongest parts to be out and direct the therapist to the important issues.

Dividing a Memory through Several Therapy Sessions

Another advanced technique is to take a single memory, organize it according

to which aspects of the BASK can be managed and in which order. The next step is
to divide the various aspects of the memory into individual outpatient psycho-
therapy sessions.

Susan had a difficult memory surrounding her perception of abuse by her

parents and her brother. She had a deep knowledge of the abuse and processed
the cognitive portion of the abuse. Then, she expressed her affect in the next
therapy session. The third session was spent with her ego states each taking
turns reading their words about their perpetrators while they imaged them in
chairs in the office. Following these three sessions, she decided to feel and know
completely what had happened because enough affect had been dissipated that
she felt that her suicidal feelings could now be managed.
 These examples of hypnotic techniques can shorten treatment, allow for the 471
containment of affect within a therapy session, and are only limited by the therapist Hypnotherapeutic
and client's personal creativity. These techniques also allow for as much of the ego Techniques
strength of the ego system to be used as is available. Rather than having less able
surface alters out, the potential is there for accessing leaders that represent strength
in the system and allows the patient and therapist together to use as much of their
resources as possible.

Examples of Hypnotic Techniques Found Helpful in Processing

the Existential Crises and Promoting Cognitive Restructuring
• Adult frame of reference:
.... I am wondering now, that at the same time, that the child is feeling what has
happened and is confused .... that an adult part of you can be very close by and
be observing what is happening from an adult's eyes ....
and look for a finger signal "yes:"
.... from that adult point of view I am wondering if you can begin to understand
and pass that understanding on to the child about whose fault it is and what
choices the child really had when this memory was occurring ....

wait again for a finger signal:

.... and I am wondering if the child then can understand what the adult is saying.
The adult might need to speak in very small words, to explain to this child that
very bad things happened .... that the child had no choice .... and that the child
is not bad ....

• Cognitive reframing:
.... I am wondering if you can begin to hear the things that you thought about
yourself because of this memory ....
This is where you may hear, "I am bad," "I am worthless," "if I remember this I have
to die," "I should have died," etc., and this is where the patient often has an
existential crisis. It is important at this point to reframe that:
.... as you hear the words now I am wondering if the adult inside can begin to
say other things to the child, and if someone can begin to say the new under-
standing outloud ....
and hope to get a "yes" signal. What you will hear are statements like, "I am not
bad," "bad things happened to me." If you don't begin to hear those you can begin to
include them:
. . . . I am wondering if you can hear my statements about my view of your
experience in the past ....

You can then add statements:

.... and let the feelings about what I am saying, or what the adult inside is saying,
filter down now so that you are able to be aware of what is happening, begin to
feel the impact of this new thinking ....
472 You are allowing the possibility of new insight at the moment in time when the
Judith A. Peterson memory is wide open. You are able to suggest a new thought, a new self-perception,
and build self-esteem.

Examples of Other Special Hypnotic Techniques Found Helpful

with Trauma Survivors during the Processing of a Memory
• Snapshots:
.... I would like the mind to take snapshots throughout the memory so that we
have pictures that are saved .... they can be put into a book and opened up in
therapy to be looked at later .... to understand exactly what happened from an
adult point of view.

• For additional control of intense feelings. Add the following into your nor-
mal induction:
.... the bigger your feelings, the more angry you feel (or whatever other feeling
you are concerned about) .... the heavier your limbs are going to be, and the
more that they are going to feel that they cannot leave the couch, the bed, the
chair (or wherever else the patient is located).

In fact, for patients where the affect is going to be fairly big:

.... it might even feel as if your hands and your wrists are tightly secured in a very
safe and loving and kind manner so that they do not leave an area of safety that
you find there as you feel the feeling of the couch.

• Spontaneous abreaction. It is extremely helpful to establish both a verbal

and a physical cue prior to having a spontaneous reaction occur in your
office, or have your patient call, or the patient's significant other call about a
flashback, for example:
.... when I say the words "deep sleep;' the part of you who is extremely helpful,
very cognitive and understands what is happening, will be here to talk to me and
explain to me what is happening inside ....

• With someone who is not a dissociative:

.... when you hear the words "deep sleep" you will move into a deep trance,
deep enough that you will be able to leave the scene that troubles you and be
able to move forward to the present and begin to feel where you are, and have a
heightened sense of what you are touching, and holding, and hearing, and
seeing, as you find yourself back in the present .... and even those words can be
heard inside, as a way of beginning to help you to move forward to the present,
to be in the here and now ....

• To add a physical cue:

.... when I touch your shoulder, or when I touch your hand, that will be the
reminder or the cue for you or the trigger for you to then come back to the
present now .... be here, clearly see me, hear me, be aware of where you are
sitting or lying .... be totally aware of your environment .... alert and present
and able to talk as much as you need to about what is happening inside ....
This requires practice so that you make sure you have it intact. Use it when you are 473
in a nonemergency situation so that you can then use it with confidence when a Hypnotherapeutic
patient is in crisis. Techniques

CONCLUSIONS

The inner world of the survivor ofPfSD or complex dissociation, as a dynamic .

entity, can be entered and explored and choices made by the client and the
therapist together as needed. Once inside that universe, for example, the therapist
can help the client make choices about modulation, which memories to process, or
depths to which trance might move to reduce symptoms. All of these experiences
make adjustments possible in this dynamic internal world that enables the client to
begin to see the world from a viewpoint beyond that of the victim. Initially, the
therapist observes the client from an outside point of view. At first, the client allows
only the tip of the iceberg to be known. Next, as trust develops and empathy is
established, the client allows the therapist to make the therapeutic and hypnotic
leap to learn about what is occurring inside. This opens the therapeutic process up
to entire new vistas for the successful processing of memories, resolution of
existential crises, reduction of shame, cognitive restructuring and the healing that
all survivors deserve. Knowledgeable hypnotherapy is an essential ingredient in
turning psychotherapy into the art that allows healing to occur and the opportunity
for the victim to be come a true survivor.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of wumial disorders (4th
ed.). Washington, DC: Author.
Braun, B. G. (1984). Hypnosis creates multiple personality: Myth or reality? International journal of
Clinical and Experlwumtal Hypnosis, 32. 191-197.
Braun, B. G. (Ed.). 0986). Treatment of multiple personality disorder. Washington, DC: American
Psychiatric Press.
Braun, B. G. (1988). The BASK (behavior, affect, sensation, knowledge) model of dissociation. Dissocia-
tion, 1(1), 4-23.
Brown, D.P., Sheflin, A., & Hammond, D. C., (1996). Memory, therapy and the taw. Hillsdale, NJ:
Erlbaum.
Brown, D.P., & Fromm, E. (1986). Hypnotherapy and hypnoanalysis. Hillsdale, N]: Lawrence Erlbaum.
Cheek, D. B., & I.e Cron, (1968). Clinical hypnotherapy. New York: Grune & Stratton.
Cheek, D. B. (1994). Hypnosis: The application of ideomotor techniques. Needham Heights, MA: Allyn
&Bacon.
Diamond, M. ]. (1986). Hypnotically augmented psychotherapy: The unique contributions of the
hypnotically trained clinician. American journal ofCltnical Hypnosis, 28(4), 238-247.
Farthing, G. W. (1992). The psychology of consciousness. Englewood Oiffs, N]: Prentice-Hall.
Hammond, D. C. (1988). The integrative hypnotherapy model. Unpublished paper. Salt Lake City, Utah.
Hammond, D. C. (1990). Handbook of hypnotic suggestions and metaphors. New York: Norton.
Hilgard, J. (1970). Personality and hypnosis: A study of imaginative tnvolvewumt. Chicago: University
of Chicago Press.
Kanovitz, J. (1992). Hypnotic memories and civil sexual abuse trials. Vanderbilt Law Review, 45(5),
1185-1262.
474 Kluft, R. P., 0983). Hypnotic crisis intervention in multiple personality. American journal of Clinical
Hypnosis, 26{2), 73-83.
Judith A. Peterson Kluft, R. P. (Ed.) 0985). Childhood antecedents of multiple personality. Washington, DC: American
Psychiatric Press.
Kluft, R. P. (1989). Playing for time: Temporizing techniques in the treatment of multiple personality
disorder. American journal of Clinical Hypnosis, 32(2), 90-98.
Kluft, R. P. 0992). Enhancing the hospital treatment of dissociative disorder patients by developing
nursing expertise in the application of hypnotic techniques without formal trance induction.
American journal of Hypnosis.
Kluft, R. P. and Fme, C. J. (Eds.) (1993), Clinical perspectives on multiple personality disorder,
Washington, DC, American Psychiatric Press.
Ludwig, A. M. 0983). The psychobiological function of dissociation. American journal of Clinical
Hypnosis, 26, 93-99.
Lynn, S. J. and Rhue, J. W., (1991). Theories of hypnosis: Current models and perspectives. New York:
Guilford.
Peterson, J. A. 0991). Advanced hypnotic techniques. Eighth International Conference on Multiple
Personality and Dissociative Disorders, Chicago, IL.
Putnam, E W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford.
Ross, C. A. (1989). Multiple personality disorder: Diagnosis, clinical features and treatment. New
York: John Wiley.
Sachs, R., and Peterson,]. A. 0994). Processing memories retrieved by trauma victims and survivors:
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Scheflin, A., Brown, D., & Hammond, D. C. 0994). Memory therapy, and tbe law. Des Plaines, IL:
American Society of Clinical Hypnosis Press.
Spanos, N. P. and Chaves,}. E (Eds.) 0989) Hypnosis: Tbe cognitive-behavioralperspective. Buffalo, NH:
Prometheus Books.
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Watkins, J. G., (1971) Tbe affect bridge: A bypnoanalytic techniques. International journal of Clinical
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Young, W. C., (1986). Restraints in the treatment of a patient with multiple personality. American
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Dissociation, 4(2), 74-76.
23
Memory Processing and
the Healing Experience
Roberta G. Sachs and Judith A. Peterson

INTRODUCI10N

The mental health field is in the midst of a paradigm shift. The position that Freud in
1898 was unable to sustain when he thought that the roots of mental illness were
related to sexual abuse is currently being advanced by a number of researchers (van
der Kolk, 1987; van der Kolk & van der Hart, 1991; van der Kolk-Perry, & Herman,
1991; Jacobsen, Koehler, & Jones-Brown, 1987; Herman, 1992; Boon & Draijer,
1993). They and others in our field are finding that this paradigm shift is occurring
as research appears to link many of the symptoms of mental illness with past or
present traumatic symptoms and with dysfunctional events in the lives of clients.
Originally Freud was not believed. Yet, when van der Kolk (1991) asked Kernberg
about the incidence of sexual abuse in the original population of clients labeled as
borderline, the percentage was very high. VanderKolk (1993) estimated that 15% of
the population of the United States suffers from symptoms of posttraumatic stress
disorder. Today, therapists are faced with many clients who present symptomotol-
ogy resulting from trauma in childhood or adulthood.
Moreover, the psychiatric field has just recently discovered that there is a
significant difference between the impact of everyday stressors and the impact of
profound present or past trauma. In studying the continuum of trauma, clinicians
have found that the effect of trauma is both a physiological and a psychological

Roberta G. Sachs • Highland Park Psychological Resources, 66o Walle Place, Highland Park, Illinois
60035. Judith A. Peterson • Phoenix Counseling, Consulting, and Forensic Services, Houston,
Texas 77090.
Handbook of Dissociation: Theoretical, Emptrlca~ and Cltntcal Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 475
476 phenomenon (van der Kolk, 1987b). To reduce symptoms permanently related to
Roberta G. Sachs profound trauma, origins of the trauma need to be processed and resolved. "Trau-
and Judith A. matology" is a newly coined term describing "the study of natural and man-made
Peterson trauma (from the "natural" trauma of the accidental and the geophysical, to the
horrors of human inadvertent or volitional cruelty ... )" (Donovan, 1991, p. 433).

TilE PURPOSE OF THIS CHAPI'ER

The purpose of this chapter is to offer therapists insight and specific therapeu-
tic tools for managing the complexity of processing experiences of past trauma. As
memory traces of trauma begin to emerge, both client and therapist may have
concerns about how to begin this process. Therapists who have used more tradi-
tional psychotherapy may find that additional skills are necessary to manage the
processing of traumatic experiences (Sachs & Peterson, 1992; Steele, 1989; Steele &
Colrain, 1991).
The reason that memory processing is a key to the treatment of trauma victims
is that reassociating the events that were originally dissociated during the trauma is
essential for the recovery of the client. Organizing memories as they emerge and
helping clients to plan memory processing sessions allows for a client's sense of
mastery and permits the therapist to maintain cohesive therapeutic goals.
This chapter describes methods to facilitate planned memory processing ses-
sions. It does not focus on methods to facilitate retrieving repressed memories of
past abuse. Rather, the authors take the position of honoring the layers of defenses
that the client has established to protect the ego structure, with a number of
exceptions such as when clients exhibit symptoms of severe somatization, sui-
cidality, homicidality, and protracted anxiety or depression.
Understanding the process for resolving traumatic experiences is sometimes
difficult for the client. Many clients experience spontaneous abreactions and flash-
backs that are painful and frightening but are common symptoms in posttraumatic
stress disorder. Spontaneous abreactions may cause retraumatization, whereas
planned memory processing sessions that facilitate cognitive restructuring can
have a healing effect.

DESCRIPI10N, PRESENTATION, AND COMPLEXITY OF

TRAUMA VICTIMS

The client, whether suffering from posttraumatic stress disorder, dissociative

disorder, or multiple personality disorder, seeks treatment because some aspect of
his or her life situation is dysfunctional or painful. In presenting this situation and
listing the symptoms, the client sometimes describes posttraumatic symptoms
without any apparent awareness of trauma. Often there is no present-day explana-
tion for symptoms, such as chronic depression, suicide attempts, self-mutilation,
amnesia, anxiety, repeated nightmares, panic attacks, obsessive and intrusive
thoughts, or bizarre and unexplainable behavior or flashbacks. It is widely accepted
that these symptoms sometimes result from deeply embedded messages tied to an
unknown earlier source. Finding the historical cause of dysfunctional symptomotol- 477
ogy offers the opportunity for reducing these symptoms. Memory Processing
Conversely, those symptoms may have been caused by the repression of and the Healing
appropriate emotional and behavioral responses even though the client has always Experience
had detailed cognitive knowledge of the past event. Discovering the link between
dysfunctional symptoms and possible trauma facilitates behavioral and affective
change and growth.
Research has shown that environmental triggers with no conscious connec-
tion to known narrative history may cause the sudden emergence of memory traces
of material (van der Kolk, 1987a). Basic environmental stimuli also trigger memory
traces that are either sensory or affective, including sights, sounds, smells, touch,
words, feelings, or pain. Basically, the authors find that when therapy focuses on
processing memories as they emerge, the client is better able to maintain stability
because his or her defenses remain in tact. Typical examples of possible trauma that
might emerge in an adult client are: a rape as an adult or memories from a war, an
accident, or a natural disaster. Sometimes memories emerge because of develop-
mental issues. The memories may be triggered by events such as giving birth to a
first child, a last child leaving home, or a child reaching a particular age when abuse
has happened to the client. The age at which a trauma occurs does not determine if
the memory to be processed is more or less complex to manage.
The authors refer the reader to other chapters of this book to understand the
Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition-Revised and
4th Edition (DSM-m-R and DSM-IV) categories for posttraumatic stress disorder and
dissociative disorders. However, dissociative or traumatized clients present with
"windows of diagnostic opportunity," since the defensive structure of the clients
was in place long before they entered therapy. In fact, what the clinician sees that is
diagnostic depends on what clients are able to or want to reveal at the time of the
interview. What clients choose to or are ready to disclose to the clinician varies
depending on many issues such as the level of trust, therapeutic alliance, presence
or absence of current abuse, and degree and chronicity of abuse throughout the
client's life.
A client may initially present in psychotherapy as a "whole person" and
maintain that presentation throughout therapy. The therapist might believe that the
client is the victim of a single traumatic episode that might have originated from
childhood or adulthood. Later, as trust develops, more dissociative symptoms
sometimes become apparent. However, a client may present so subtly that parts are
difficult to distinguish and remain that way throughout therapy as in dissociative
disorder not otherwise specified (DDNOS). On the other hand, some clients may be
found to have classic dissociative identity disorder or even polyfragmented dissocia-
tive identity disorder. Thus, as therapy progresses, the diagnosis may change.
The reason it is important to know the eclectic nature of trauma victims is that
the memory processing techniques needed will vary according to the (1) complex-
ity and nature of the internal defensive structure of the client, (2) the level of inter-
nal compartmentalization, and (3) the formation and structure of amnestic barriers.
Kluft (1992) has described complex dissociative clients in detail. In addition,
the authors of this chapter have found that complex dissociative victims have other
characteristics that affect memory processing. These include: (1) groups of parts
478 that are amnestic to other parts, (2) groups of parts with specific memories or jobs
Roberta G. Sachs in common, (3) layers of parts with amnestic barriers between them, (4) multiple
and Judith A. systems with varying degrees of amnesia, (5) mirrored or twinned systems, (6) syn-
Peterson thetic parts (purposefully externally created parts), (7) sadomasochistic parts, or
(8) system wide sociopathy.

USEFUL TERMS AND DEFINITIONS

Memory takes many forms. Some clients enter therapy reporting abuse memo-
ries they have never forgotten dating from early childhood. Others report different
forms of memories including flashbacks, recurrent dreams, somatic complaints
with no medical basis, and repetition-compulsions, to name a few.

Memory Retrieval
For the purposes of this chapter, the term memory retrieval will refer to the
process the client uses to become aware of information about past events that they
have not instinctively brought to therapy. These past events have been blocked by a
defense called dissociation because part or all of the event overwhelmed the
individual's adaptive capacity to process it. The authors do not recommend that
therapists intentionally uncover traumas except under unusual circumstances. The
following is a short list of times in treatment when it is appropriate to intentionally
uncover memories.
1. In the case of a medical emergency
2. In the event of extreme, self-destructive behavior such as self-mutilation
3. In the event of potentially life-threatening symptoms such as uncontrollable
choking
4. In a psychological emergency, such as the patient feeling obsessed with
suicidal and/or homicidal thoughts
These examples are not frequent occurrences in the therapy of trauma survivors.
Therapists are encouraged to uncover underlying psychodynamic issues, as these
will frequently precede or coincide with the natural emergence of memories. lf the
client has retrieved a memory that is impacting his or her here-and-now function-
ing, then careful attention should be given to the preparation and pacing of working
through this material. Rather, therapists are encouraged to pace the timing of the
"working through" of traumatic material revealed by clients. Generally the authors
allow the client's process to unfold gradually by honoring the dissociative defense.
Therapists are encouraged to caution their clients about the unreliability of memory
and to urge them to search for all possible interpretations of what they believe they
have uncovered.

Abreaction
The term abreaction (coined by Viennese physician Josef Breuer who worked
with clients diagnosed as suffering from "hysteria") refers to experiencing intense
feelings at moments when recalling a past disturbing event that is connected to a 479
present day neurotic symptom. During this recall, a client often momentarily Memory Processing
reaches what Breuer referred to as "catharsis" during which original feelings of and the Healing
intense emotion, previously barred from current memory, reoccur. Experience
There is a misunderstanding, however, concerning the term abreaction. Many
think that abreaction causes the patient to become regressed. Therapists deserve to
be criticized if therapy leads to ongoing regression. However, during memory
processing the client might experience an "abreactive spike" or an emotionally
"cathartic moment."
Momentary releases of affect from any trauma at any age is not regression. In
addition, misunderstanding occurs when professionals assume that processing of a
past experience is always a childhood memory. In many cases, the experience
processed involves a trauma from teenage years or adulthood. In the past the term
"abreaction" has been used within the field to describe all aspects of memory
processing. Further refinement of terminology clarifies that abreaction is just one
aspect of memory processing (Peterson, 1993; van der Hart et al., 1993).

Flashbacks or Spontaneous Abreactions

Many clients have flashbacks (another word for spontaneous abreactions).
Flashbacks are defined as uncontrolled physiological memory loops surfacing spon-
taneously from implicit and explicit levels of consciousness (Graf & Schacter, 1988).
These partial, traumatic memory traces can take the form of flashes of scenes,
sudden body memories, intense affect such as terror or rage, suspicious smells,
sounds, or tastes that become frightening, or a touch that becomes upsetting.
Clients often experience spontaneous memory traces in flashbacks without any
cognitive frame of reference that enables them to understand what is happening.
In 1989, Putnam listed Blank's (1955) typography (Kluft & Fine, 1993) that
describes four types of flashbacks: (1) vivid dreams and nightmares of the traumatic
events, (2) vivid dreams from which the dreamer awakens still under the influence
of the dream content and has difficulty making contact with reality, (3) conscious
flashbacks in which the subject experiences intrusive recall of traumatic events
accompanied by vivid multimodal hallucinations, and may or may not lose contact
with reality, and (4) unconscious flashbacks in which the individual has a sudden,
discrete experience that leads to an action that recreates or repeats a traumatic
event but the subject does not have any awareness at the time or later of the
connection between this action and the past trauma.
Since clients cannot predict or explain the occurrence of flashbacks, they
often feel overwhelmed and out of control. Their symptomotology may resemble
symptoms of other psychiatric disorders and may be misinterpreted as such. Clients
usually report relief when they can learn to control flashbacks and can safely ex-
plore the content of their traumas using a planned memory processing framework.

Memory Processing
Memory processing is defined as working through a past trauma from the
beginning to the end of the perceived trauma with the cognitive processing and
480 restructuring that facilitates symptom reduction and expression of whatever affect
Roberta G. Sachs is necessary to resolve the trauma. Thorough processing of the trauma enables the
and Judith A. client to move the experience from a traumatic remembrance to a place in narrative
Peterson memory wherein the client knows it occurred in the past and has good cognitive
understanding of the event. Even if the past event was unbearable, there is a
recognition that it will always be a part of that individual's past. In theory, there will
be a healing experience with a new understanding of that experience. When this
occurs, the client has the potential to know both an inner peace and external
positive change in current symptoms.

ResoluUon
Resolution refers to the abatement of symptoms after completion of memory
processing and cognitive restructuring. Resolution is that state of co-consciousness
where internal conflict and disagreement among internal parts cease. All known
parts are able to function together as a team and have a different perspective about
their previous roles and their relationships.

Blending
Blending is the process during which discrete internal parts or alters change
their barriers, become closer in awareness, and even begin to overlap or merge.

IntegraUon
Kluft (1993) defines integration as "an ongoing process of undoing all aspects
of dissociative dividedness . . . from long before reduction of numbers through
fusion to a deeper level." Further, integration is "an ongoing process that follows the
same processes as the tradition of psychoanalytic perspectives on structural
change."

TilE COMPONENTS OF MEMORY

The study of memory is complex, but Braun (1988) has created a pragmatic
model to facilitate the organization or memory within a clinical setting. He identi-
fied four components necessary to completely process memory of past trauma:
behavior, affect, sensation, and knowledge (BASK). His BASK model of dissociation
helps therapists to understand the necessity of integrating these components com-
pletely. It is only when the four components are congruent and confluent over time
that a person can be said to possibly experience a complete memory.
The question of what is true about any memory perplexes those in this difficult
field. It is assumed that the therapist will explain how confusing and unreliable
memory can be and that it may be several years before any clarity of memory takes
place, if at all. Therefore, focus is placed on starting with the client's belief of what
is true and asking the client to take the responsibility for his or her recollections.
The therapist is not an investigator but a facilitator of healing.
The Continuum of Complexity in Memory Processing 481
Memory Processing
Even though there are no well-defined stages in memory processing, the and the Healing
authors have found that there is a continuum in the complexity of memory process- Experience
ing experiences. At one end of the continuum are clients who have retrieved a
memory about one trauma and are able to master processing the memory in a single
therapy session. At the other end of the continuum are clients who have very
complex memories involving mastery of a profound existential crisis (such as a
near-death experience) and will require many sessions of therapy to complete their
memory processing.
The ease with which memories are managed depends on the most basic of
psychotherapeutic tasks. First, the client must attain a comfortable and assumed
level of trust in the therapist; second, the client must have achieved internal trust
among dissociated ego states, alters, or parts; third, the therapist should be aware
that memory processing is affected by the complexity and severity of the client's
previously processed trauma; fourth, therapist and client must learn and master
identified therapeutic tasks; finally, the therapist should consider teaching the client
hypnotic techniques that will facilitate memory processing.

Examples of the Continuum of Complexity of Memory

Case 1. A client in her 30s had always cognitively known of the inappro-
priate discipline she received from her foster parent who was a minister. He falsely
accused her of acting out in high school and punished her by paddling her across
his knees. The purpose of processing this memory was to reassociate the affec-
tive and sensory parts of these experiences with the knowledge that had always
existed. In addition, the client needed empathy with regard to her shame as well
as validation for her feelings, and finally cognitive restructuring to resolve this
trauma.
Case 2. A client in her 40s already diagnosed as DDNOS began to have
flashbacks about a date rape. She was taught containment techniques and asked
to have a part that could maintain control journal as many details of the experience
as could be recalled. In reading the journaling, the therapist realized that several
parts were involved in this life-threatening experience. After rereading the journal,
the client realized that a number of events of that night were unknown to her.
Subsequently, the therapist helped the client organize all of the parts who dissoci-
ated all of the aspects of this trauma to participate in a memory processing session.
Case 3. A highly dissociative client had spontaneous cramping and hemor-
rhaging on her 25th birthday. After seeking treatment at the local emergency room
and being told she was physically normal, she called her therapist. The client
presented with extreme agitation and no conscious awareness of the reason for her
symptoms. Parts emerged to tell the therapist about the birthday ritual that her
father and brothers had made her participate in during childhood and adolescence.
Several parts described prolonged use of intentional sadistic abuse. Many weeks
were spent as the parts and host prepared for the memory processing that was
needed. After the memory was processed, the physical symptoms never reoc-
curred.
482 A1; clients gain experience in memory processing, they tend to gain insight into
Roberta G. Sachs how they can contain feelings both before and after the memory processing
and Judith A. session. Also, they become better able to distinguish what core elements of the
Peterson memory are really essential to process in therapy. Complex dissociative or multiple
personality disorder clients often learn how to combine similar experiences in one
memory processing session.

PSYCHOTIIERAPEUTIC TASKS DURING TilE BEGINNING PHASE

OF TREATMENT

Prior to beginning planned memory processing sessions, mastery of key thera-

peutic tasks is helpful to establish the framework of therapy. The order of the
therapeutic tasks is flexible and depends on both the client's and therapist's style.
Premature and disorganized discussion or processing of traumatic experiences may
be a recapitulation of the abuse. The suppression of spontaneous flashbacks is
highly recommended to help avoid the reexperience of trauma. Containment
techniques and cognitive processing of the event are part of the overall preparation
for organized memory processing.

Mapping
Mapping is often a part of therapy for clients who have dissociative identity
disorder. It is a special procedure that allows clients an external way to concretize
their internal structural description (Braun & Sachs, 1986). This may be accom-
plished through art media, the sand tray (Sachs, 1992), occupational therapy, or
joumaling. Mapping involves a continuum of complexity: (1) a simple sociogram,
(2) a more complex, multilayered sociogram, (3) a map depicting systems rather
than distinct personalities, (4) a map depicting a combination of both individual
parts and systems, or (5) a systemically layered structure.
Mapping may be used by the client to uncover data, to describe origins and
alliances of parts, and to help focus and organize memory processing for therapy.
The very process of mapping seems to help organize and focus chaotic and frag-
mented clients. In complex dissociative identity disorder clients, it may be helpful
for clients to redo individual sections of their mapping in detail or expand on
sections as they prepare for more advanced memory work. With complex clients,
the more thorough the preparation, the greater the possibility of combining and
collapsing memories in one or two memory processing sessions. Combining similar
memories may also lead to a better cognitive understanding of the gestalt of the
client's experience, a greater understanding of the existential crises, resolution, and
eventual blending of internal parts.

PLANNED MEMORY-PROCESSING SESSIONS

The purpose of a first memory-processing experience is to practice the thera-

peutic tasks and to introduce a sense of mastery to clients. Therefore, the first
memory processed may not have significant long-term meaning but is chosen to 483
build skills and to ensure a mastery experience. If more difficult work is necessary Memory Processing
later in therapy, processing less traumatic material builds the foundation for more and the Healing
complex work. In dissociative or highly dissociative identity disorder clients, the Experience
internal parts or alters that the therapist may not have met are watching and
listening to determine whether a safe environment exists for their later therapeutic
work.

Expressing the BASK Model

The different parts of the BASK model (Braun, 1988) can be expressed in
memory processing by separating out the behavior, feelings, physical or body
sensations, and knowledge. Whenever possible, it is advisable to attempt to work
through the BASK model by beginning with the knowledge or cognitive part of the
memory. Even though the acronym implies one would start with the behavior
component, the recommendation is to start with knowledge. This insures that the
client will maintain self-control and not be overwhelmed.
The therapist may choose to work with any one of the aspects of the BASK
model during memory processing. He or she may choose to work solely on the grief
from a past trauma for several memory processing sessions; the therapist may
attempt to combine anger and somatic memories in one session; or the therapist
may choose to fractionate the knowledge clients bring to a memory processing
session to keep the total knowledge from being overwhelming. The task is to
eventually bring all aspects of the BASK together and achieve congruence, cognitive
restructuring, and resolution. Any initial division or fractionation of the memory is
to facilitate pacing and mastery in therapy.

Hypnotic Induction or Progressive Relaxation

A rule of thumb is that the more dissociative a client, the less formal a hypnotic
induction is needed or traditionally used by therapists. Therefore, a less dissociative
client appears to need a more formal hypnotic induction in regular therapy ses-
sions. But almost all dissociative clients appear to benefit strongly from a formal
hypnotic induction when beginning memory-processing sessions. The purpose of
hypnosis is to provide safety and facilitate processing during the session, not to
retrieve memories. It is assumed that the client already has retrieved most of the
content prior to this session. It is the authors' belief that if the client is suffering
from posttraumatic stress disorder or from discrete dissociative episodes, the thera-
pist needs even more formal training in hypnosis.

Memory Process with Complex Dissodatives: Helping Alters to

Safe Places and Restructuring InternaUy Prior to Memory
Processing
With highly hypnotizable clients, only a brief induction may be necessary
before suggesting that they retreat to their "safe places" (see Chapter 22, this
volume). With other clients, detailed hypnotic induction and deepening work may
484 be needed to establish a safe place prior to actual memory processing work. Parts
Roberta G. Sachs that are involved with the memory need to remain close to the surface. Parts that
and Judith A. want or need to be amnestic can be hypnotically blocked from the processing of the
Peterson memory. Furthermore, parts that want to watch from different distances still need
permission to observe and at the same time feel only what they are ready to feel
while they remain safe. Thus, the therapist continues to assess the client to make
sure that the memory work will be as complete as possible while simultaneously
ensuring the client's maintaining protection of his or her ego structure. In most
systems it is a safe assumption that all parts are aware to some degree of the memory
processing session.

Cognitive Narrative
The client relates the memory cognitively, that is, without sensory, somatic, or
affective components. Only the knowledge component of the BASK model is
utilized so that the client can practice relating the memory from beginning to end.
After the cognitive summary, the therapist ascertains that all parts involved in the
trauma are present and that other parts are observing at a comfortable distance. In
addition, those parts unable to tolerate reassociating this memory need to be
hypnotically helped to a safe place where they do not have to experience the
memory-processing session.
It is important that the therapist actively listen to the cognitive narrative
without adding or changing any part or detail of it. While listening to the story, the
therapist looks and listens for manifestations of the other BASK components-
affect, sensation and behavior. The client proceeds from T - 1 to T + 1 (Peterson,
1991), describing the beginning, middle, and end of the total memory. What the
therapist hears may differ from what the client has journaled or expressed in art or
the sand tray. Clients and their therapy are dynamic, not static. The therapist must
be certain that the memory being processed in the cognitive narrative is the
memory that the therapist and client planned to process. After the cognitive
narrative has been completed, the therapist validates, reinforces mastery, and
checks the safety and well-being of the client.

Identiflcatton of Existential Crisis Statements

Trauma creates existential crises that appear to affect forever how these clients
feel and think about themselves. The overall goals of memory processing are to
release the immense affect of the experience and to identify the existential crises
that have affected these clients all their lives. When this has been completed, the
therapist facilitates cognitive restructuring, mastery, and empowerment to help
create long-term change. Existential crises occur when basic beliefs or assumptions
about the world, reality, or sense of self are profoundly experienced as having been
shattered. They may be precipitated by dramatic events as profound as rape,
torture, murder, loss, or natural disaster. On the other hand, the catalyst may be as
subtle as losing faith in someone who had been implicitly trusted.
These traumatic events create a loss of basic security and a disconnection from
other human beings. Working through these moments of existential crisis comprise
the fundamental work needed for recovery. Therapist and client alike may find it 485
difficult to hear, to process, and to allow the expression of shame, humiliation, guilt, Memory Processing
denigration, or hopelessness. and the Healing
Experience
The basic assumptions with which we ground our own security crumble, and
we become confused and anxious. The credo shatters: I believe the world is
meaningful and comprehensive; I believe the world is safe and I am invulnera-
ble; I see myself in a positive light. I am free; I can choose. (Steele, 1989, p. 155)

The painful process of exposing and processing the cause of the overwhelming
feelings of hopelessness, panic, anxiety, and low self-esteem lead to feelings of
power, mastery, and hope as healing occurs. Simply exposing the feelings or
hearing existential crisis statements does not help. Cognitive restructuring is neces-
sary for the healing process to occur.

Cognitive Restructuring
Cognitive restructuring is defined as the process by which the deeply embed-
ded negative experiences are reframed in a positive way. New positive statements
about the client are then introduced to help build self-esteem, to foster a new
understanding of the context of the past trauma, and to help the development of
new ways of relating to others in the present.
Unless the existential crisis statements are identified and cognitive restructur-
ing begun as memories are processed, significant change over time does not appear
to occur. Mfect, pain, or momentary abreaction are only by-products of the trauma.
The expression of intense feelings may provide temporary relief to the client, but it
does not ensure that changes will occur. Acceptance and resolution of existential
crises provide the foundation for permanently changed self-perception.

Regrounding and Assessing the Client

If during a memory processing session the client appears overwhelmed, the
therapist may need to interrupt the affective process even if the client does not
signal "stop." When this happens, the therapist should reground the client in the
present so that he or she can "metabolize" what has been overwhelming. A cogni-
tive approach is most helpful at this time. If the client is able to easily review the
narrative structure of the memory, then the therapist knows the client is managing
satisfactorily. At the end of the memory-processing session it is wise for the thera-
pist to determine whether residual body memories exist that need to be alleviated,
whether the client needs to take prearranged medication, or whether the client is
able to return home safely.

HeaUng Images
One final step in memory processing should be to suggest positive metaphoric
images of increased self-esteem. A healing light is an example of a hypnotic image
that can be effectively used at the end of a session. The repetition of one familiar
image appears to facilitate the building of a positive sense of self from one session to
486 the next. Once a healing image has been established, the mere mention of it may
Roberta G. Sachs help the client return to an internal feeling of safety, peace, and a familiar place.
and Judith A. Finally, blending and integrating metaphors may be used to promote new ego
Peterson strength. Spontaneous integration is often the result of a successful memory proc-
essing session.

Safety Contracting
Safety contracting is the. last task in a memory processing session and is
essential for all clients regardless of their level of dissociation. When clients have
parts, the parts as well as the presenting personality need to guarantee safety. Even
when safety is continually reassessed throughout the session, some dissociated
parts who remained in their "safe places" may not have responded to your previous
inquiries about present and future safety. If ideomotor signals are used, verbal and
ideomotor contracts must be congruent to ensure the greatest possibility for ongo-
ing safety. If there is any discrepancy between verbal and nonverbal signals concern-
ing self-harm or harm to others, the session cannot be considered complete. More
processing and negotiating with parts who are reluctant to agree to a safety contract
must take place. If after a reasonable time of negotiation (a maximum of 20 minutes)
there still remain actively suicidal or homicidal parts unwilling to contract for safety,
hospitalization is an appropriate option and should be discussed. Therapists need
to be familiar with state laws about commitment procedures for clients who are
homicidal or suicidal.
The following criteria help detertnine if successful memory processing has
been completed:
1. Has the client experienced the reduction of dysfunctional symptoms, such
as those accompanying posttraumatic stress disorder, depression, anxiety,
and other psychiatric disorders?
2. Has the client become aware of the existential crises and cognitively re-
structured the experience to allow for new insights and a different inter-
pretation of the experience?
3. Does the client have mastery over the memory as a narrative part of his or
her personal history?
4. Is the client in the process of choosing to lead a life that demonstrates
reduction of retraumatizing experiences?
5. Does the client feel an increase in self-esteem and ego-strength?
6. Does the client realize the reality of positive "choices"?

ADVANCED CONCEPI'S IN MEMORY PROCESSING

Combining Memories
After the client has learned how to process several individual memories, it is
possible to teach him or her how to process similar abuses in one memory-
processing session. Preparation involves the client retrieving one memory as a base.
Ideomotor signals for dissociated parts may indicate if the patient has experienced
similar abuse at other times; journaling, art, or sand tray work are also helpful
indicators. The memories surrounding traumatic experiences may be assimilated 487
by combining them so that they are processed in one session. This approach allows Memory Processing
the opportunity for the client to learn new insights at multiple levels of conscious- and the HeaUng
ness. Experience

Techniques for Management of Severe Fragmentation

Some trauma victims have experienced such severe abuse that parts simply
shattered at the moment of assault. Clients describe the experience as an "explo-
sion" inside. It is helpful to suggest to clients that through memory processing they
can reverse the shattering so that parts and fragments come together as they were
before the abusive event. This may be accomplished by distorting or reversing time
and processing the memory backward. The client may decide to start at the end of
the abusive incident (f + 1) and move backward through time until just before the
abuse occurred (f - 1). At this point the client has reached the moment in time just
before the shattering and that past may be experienced as a whole. Even if polyfrag-
mentation has not occurred, this method may be helpful. An advantage to this
technique is that it enables parts to know that they survived the abuse and to return
to the point in time before they were abused. This technique often facilitates
healing, blending, and integration.

Fractionation of a Memory or Fractionation of

an Amnestic Barrier
Fractionation refers to the division of any part of the psychotherapeutic experi-
ence by the therapist into parts in order to make the process more manageable to
the client. Any of the feelings, thoughts, sensations, or knowledge of memories can
be separated or divided from each other to be processed individually. Other ways to
fractionate include distancing the client from an event, time distorting an event, or
dividing affect into portions.
With this therapeutic technique a client may be asked to imagine what 100% of
the rage feels like and then decide what portion of the feeling he or she can manage
to release with safety and mastery. If the client could only release 25%, then he or
she would take four sessions to complete a memory. On the other hand, 100% of the
feelings might be expressed in one extended session by using fractionation to pace
the session.

USING OTIIER TIIERAPEUTIC MODAUTIES TO

PROCESS MEMORIES

When working with dissociative disorders the expressive therapies (i.e., art,
movement, occupational, and sand tray) offer numerous applications to facilitate
diagnosis and treattnent. Basically, the expressive therapies allow access through an
indirect means to dissociated memories that are adversely affecting a client's ongo-
ing behavior. These techniques help the client to circumvent conscious knowledge
when the content is too threatening while allowing for other means of accessing
488 memory traces of traumatic material. Moreover, the expressive therapies provide an
Roberta G. Sachs opportunity for participating in multiple levels of communication.
and Judith A. One difference the authors note between dissociative disorder clients and
Peterson other psychiatric populations is the concreteness with which dissociative clients
use these modalities to represent their perception of the experienced trauma. The
expressive therapies have been acknowledged for their contribution in the diag·
nosis and treatment of complex dissociative disorders (Cohen & Cox, 1989; Sachs,
1992; Fuhrman et al., 1990). Therefore, the routine use of these therapies can yield
important diagnostic information; help the client become more consciously aware
of memories; process the intense feelings attached to the traumatic events; facilitate
the development of mastery and a unified sense of self; and provide the therapist
with a unique way to monitor the progress and process of treatment.

PERSONALITY TRAITS AND CHARACfEROLOGICAL MANAGEMENT

Personality traits are enduring patterns of perceiving, relating to and thinking

about the environment and oneself, and are exhibited in a wide range of
important social and personal contexts. It is only when personality traits are
inflexible and maladaptive and cause either significant functional impairment or
subjective distress that they constitute personality disorders. (American Psychi-
atric Association, 1987, p. 335)
Working with personality disorders means managing characterological issues.
This involves empathy (understanding the clients' definitions, criteria, and beliefs at
a cognitive and affective level), safety (establishing and maintaining psychological
and physical boundaries and limits), and negotiation (presenting options that both
the client and therapist can accept). Character pathology is a primary focus of
treatment because adults abused as children have no sense of boundaries and/or
healthy interpersonal relationships.
The authors believe that protection of the ego is the primary purpose of all
clients' defensive structures. Clients who have experienced decades of profound
abuse and double-bind experiences by those who should have been trustworthy
experience the intense need for protection at the slightest emotional or physical
threat. In addition, these victims frequently participate in unhealthy alliances, i.e.,
they veer from normal personality development by recreating their childhood
abuse with self-destructive acts or retraumatization.
Patients may present in therapy with any number of personality disturbances.
In clients with parts, one goal of therapy is to determine the difference between a
general personality dysfunction and one manifested by an alter or fragment. If
character pathology is not addressed, the issues surrounding this aspect of their
dysfunctionality will continue even after significant trauma resolution has taken
place.

Setting Limits t~nd Boundtlrles

The following case studies highlight some of the more common charac-
terological issues therapists have to manage:
 Case L At the end of a memory-processing session, an alter refuses to 489
guarantee safety of the body or commit to further therapy sessions. The therapist Memory Processing
aligns himself or herself with this alter to protect the client's safety without and the Healing
preempting her role within the system. The therapist actually asks for advice on Experience
how they can work together, as this fosters mutuality while empowering the client.
However, it is the therapist who makes sure the rules of therapy are in place.
Case 2. The client continually places emergency life-threatening calls to the
therapist in the middle of the night. The therapist quickly assesses the level of the
crisis to determine if the call is a manipulation. If so, the client is redirected to a
hotline or other supportive resource. If the call is a genuine crisis, the therapist may
attempt to resolve the issue or direct the client to the nearest emergency room.
Case 3. Within the last 5 minutes of the therapy session the patient regresses
into a spontaneous abreaction or raises a major therapeutic issue. If this is the first
occurrence, the therapist attempts to reground the client and cognitively process
this boundary violation both in this session and the next session. If this continues to
be a pattern, the therapist reminds the client that safety is always required at the end
of the session and can say, "If you cannot ground yourself in the present and leave
the office safely, then I will have my secretary hold your car keys while you sit in
another office until you decide how to manage going home safely." As a last resort
the therapist can offer to assist the client to a hospital setting by calling the
paramedics.

Se{f-MutilatiOtL' Chronic vs. CycUcal

In a severely traumatized population, self-mutilation, i.e., cutting and scoring
various parts of the body, is a common problem serving a variety of purposes for the
client: (1) to punish the self, (2) to silence alters, (3) to create physical pain to
distract the client from emotional pain, (4) to feel anything in order to feel "alive,"
(5) to fulfill an addiction to physical pain by triggering a euphoric feeling, (6) to
express automatic behavior, or (T) to express resistance (or distraction) from the
therapeutic issues. All of these can be manifested on a continuum ranging from
subtle to overtly dangerous behavior. Self-mutilation that is cyclical might have
more to do with anniversaries of particular life experiences such as birthdays,
seasons of the year, or holidays. An assessment needs to be made to determine if
there is an addictive quality to the mutilation, whether chronic or cyclical. For
mutilation that has an addictive quality, medication exists that has been highly effec-
tive in breaking the self-destructive cycle. Referral to a physician familiar with the
medical management of these symptoms can be very helpful (van der Kolk, 1987a,b).

Sabotaging of Memory Processing

Dissociative clients who have survived profound childhood trauma often are
equipped with survival skills derived from an interaction of discrete parts of the self
who assume a protective role. In order to survive, clients often become as aggres-
sive as those who harmed them. Since they have had to harm themselves or others
in order to survive, their behavior in the here and now is often a recapitulation of
the past.
490 During memory processing the hostile alters frequently act out by attempting
Roberta G. Sachs to harm self, persecute other alters, harm the therapist, or extend limits and
and Judith A. disregard boundaries. The client may also place the therapist in a double-bind
Peterson position by saying, for example, "If you elicit this memory, I will be self-destructive;
if you don't elicit and process this memory, I will continue to be self-destructive."
Catherine Fine (1988), in her paper on crisis prevention at the International Society
for the Study of Multiple Personality Disorder conference, stated: "The only win-
ning move is not to play."
Therapists must show respect for the alters' protective function while chal-
lenging the perception of self-sufficiency only through self-harm. Introducing new
choices about self-sufficiency, such as protecting the body, being brave enough to
facilitate recovery, and so on, helps to set the stage for creating positive choices.
The belief that there is only one way (usually a destructive one) for an alter to
maintain safety of the body needs to be effectively challenged because it represents
rigid and constrictive thinking. Careful, organized planning using hostile alters as
allies will help to avoid a situation where the client may harm the body. In addition,
understanding various reasons for blocking or threatening hostile behavior may
further insure a client's safety.

Pacing
The goal of any kind of therapy is to provide continued mastery over memory
experiences. Yet clients who have had profowi.d abuse very often want to work
through material as quickly as possible to rid themselves of the pain. When this
occurs, clients often are bombarded with knowledge and affect they are unable to
process, thus becoming overwhelmed and emotionally paralyzed. It is up to the
therapist to educate the client about pacing therapy so as to maintain a delicate
balance between client memory retrieval and processing the memories in therapy.

Blocking
When the processing of a memory is blocked for any reason, the client may be
indicating the need for solving therapeutic problems, whether internal or external.
Often the part of the system that emerges will directly explain what has been
forgotten or what will happen if therapy proceeds. Blocking memories or engaging
in resistance remains the ultimate defense mechanism for these clients. Finding the
cause of this resistance, interpreting the defenses, and processing the impasse
opens the door to subsequent memory retrieval. Blocking by the system is diagnos-
tic and should be carefully explored. It may take any of the following forms: (1) an
alter emerging to express hostility, (2) silence, (3) distracting statements, ( 4) emer-
gence of child parts, or (5) spontaneous abreactions.

Out-of-Control or Violent Behavior

Out-of-control alters are a potential threat to the self, others, and the therapist.
Understanding the client's presentation and teaching him or her to rechannel
destructive energy and hostility results in more productive sessions.
 When a therapist confronts a crisis, help from another therapist may be 491
required to ensure physical control and safety. Physically restraining an out-of- Memory Processing
control client is necessary if the client's or therapist's safety is at risk. Therefore, the and the Healing
therapist needs to learn appropriate and approved techniques for restraining cli- Experience
ents. Regardless of how many safe sessions therapist and client experience, there
are certain times in the therapeutic process when out-of-control behavior can be
expected such as: (1) when new levels or parts of the client's system emerge,
(2) when material is uncovered that triggers violent protective parts, (3) when the
client has been abused in the here and now, or ( 4) when the client appears to
exhibit compulsive or automatic behavior.
Safety limits are most often upheld and respected when the client and therapist
define them. The client's unpredictable history is a precursor to tlie potential for
unpredictable violent behavior in a therapy session. Early in therapy the client
needs to understand that unsafe behavior will not be allowed. Once the client's
behavior is safely under control, communication takes place with those who
provoked the incident. "Talking through" the presenting part to the violent acting-
out parts is the safest way to manage therapy after an explosive incident. A team
approach is helpful in outpatient work. Sometimes a session's content will trigger
an acting-out incident by an internal alter. Regardless of whether this is a normal
psychotherapy session or a planned memory-processing session, the therapist must
be aware of a client's unpredictability.

Confabulation
Confabulation is defined in Webster's dictionary as "filling in gaps in the
memory with detailed, but more or less unconscious accounts of fictitious events."
In dissociative patients confabulation serves a variety of purposes: (1) it helps
clients hide the fact that time for them is discontinuous; (2) it helps to normalize
both past and present experiences; (3) within the memory of an experience,
confabulation of a less intense event can be a defense against an intolerable aspect
of the event; ( 4) it may be used for secondary gain whether intentional or un-
intentional; (5) it may be used to idealize the image of a significant other; and (6) it
serves to maintain the client's secrecy.

Disclosure-Recanting Cycle
Clients move through stages of belief and disbelief as a normal part of therapy.
Most clients have an existential crisis surrounding the issue of never knowing with
certainty about the accuracy of the details of their past. They must process the
feeling of being robbed of a part of their lives through not having clear memory.
Eventually the client comes to his or her own reality about what has happened. At
all times therapists need to be cautious about not leading.
Often denial can tum into recanting. This is very common in many other
populations of clients including criminals, child molesters, abusers, and so forth.
Recanting appears to be related to several variables. Profound shame and guilt can
be so overwhelming that recanting is easier than working through the feelings.
Historically, sadomasochistic abusers have made victims feel that they voluntarily
492 enjoyed perpetration. It becomes far easier to recant and/or blame the therapist for
Roberta G. Sachs memories that are intolerable (when the system's dissociative barriers begin to
and Judith A. break down) than to take responsibility for one's past behavior.
Peterson Terror of the consequences of "having told" in therapy is another factor in
recanting. Clients fear retaliation both internally from parts that threaten to harm
the body and externally through fear of harm from those who told them never to
reveal the secrets. Additionally, the fear that they might be criminally charged is also
significant. Returning to the belief system that accompanied the dissociation is far
more psychologically comfortable than processing the tremendous pain that results
from the experience of being abused or having abused others. Recanting helps
clients feel more secure about their safety and quells their fears about being placed
in jail or prison. While that is unlikely, reassurances about confidentiality are truly
limited because knowledge of child abuse requires mandatory reporting by therapists.
Finally, the effects of the Stockholm syndrome (Ochberg, 1978) with these
clients must not be overlooked. Through terror and torture these victims initially
have much more alliance with their abusers (even if the abuser is dead) than with
their therapist.

CONTRAINDICATIONS FOR MEMORY PROCESSING

Some clients are not suited for any memory processing work. This can often
be ascertained through a full battery of psychological testing. The level of ego
strength, characterological considerations, and any indications of psychotic symp-
toms need to be carefully assessed and fully understood before attempting memory
processing even if the client is already experiencing spontaneous memory traces.

Traumatic-Psychotic Transference
Difficult negative transference issues have been described by Kluft (1984) and
Spiegel (1984) as "traumatic transference" (Kluft, 1984, Loewenstein, 1993; and
Spiegel, 1991). Very traumatized clients frequently view everything their therapist
does, no matter how helpful it appears to be, as abusive, narcissistic, and self-
fulfilling on the part of the therapist. Clients often have a very difficult time viewing
any relationship as nonabusive. Parts not engaged in therapy frequently are continu-
ing to "internally dialogue" about the supposed ulterior motives of the therapist. In
addition, Spiegel has also described "flashback transference" wherein the client
very literally (or with trance logic) views the therapist as a perpetrator. Further-
more, as the level of sadomasochism increases, there is a likelihood that either
sadistic or masochistic transference issues will increase. While the major therapy
issues are resolved by working through the negative transference, in some cases
clients are simply unwilling or unable to engage in processing the shame and guilt
surrounding their victim or perpetrator issues. When this occurs, therapy is stuck
in a traumatic transference where personal ownership of malevolence is bestowed
on the therapist. Unless a solid therapeutic alliance is available as a safety net while
difficult issues are processed, it is likely that many clients will leave therapy with the
perception that they were abused.
MaUgnant Narcissism 493
Memory Processing
Malignant narcissism refers to clients who are so invested in their dissociative and the Healing
disorder that they may obtain secondary gain from the diagnosis or have some other Experience
reason for a lack of commitment to the therapeutic process. Achieving notoriety
through media appearances, gaining special attention in the family system, being
relieved of adult responsibilities, or gaining wealth from publishing a life story are
examples of by-products of malignant narcissism.

Sadomasochism
Clients may be addicted to abuse or may be unwilling to break the pleasure-
pain bond that has been conditioned in their everyday life. When parents and
children are sadomasochistically addicted, children have no escape route. Conse-
quently, whether adults are caught in a current sadomasochistic relationship or a
child or adolescent is still living with sadomasochistic caregivers, once the therapist
becomes aware of this problem, memory work is not indicated until family circum-
stances change.

MaUgnant Suicide
Clients who are malignantly suicidal truly wish to kill themselves. These clients
actively manifest their death wish through severe self-mutilation, life-threatening
anorexia, and other various suicidal behavior. The authors have seen both ends of a
bimodal expression of this suicide phenomena. Clients who have difficulty disso-
ciating severe trauma appear often to choose suicide as their escape. On the other
end of the continuum, clients who believe they have no free will choose suicide as
well.
Further contraindications for memory processing not related to psychological
testing include; the client is in the early stages of the::apy; the client is physically
impaired, acutely ill, or terminally ill; the client is elderly and chooses not to resolve
past issues; the client is currently being abused or is dangerously self-abusive; the
client has no therapeutic alliance or is not capable of forming a therapeutic alliance;
the client has a psychotic overlay that cannot be managed with appropriate medica-
tions; the client does not have the financial resources for continued therapy; the
client's ego structure is too fragile to prevent decompensation; the client is continu-
ally being flooded with flashbacks or intense affect despite adequate attempts to
teach containment techniques; or the client has a serious present-day crisis to
manage (i.e., divorce, job loss). Given these difficulties, it is hoped that therapists
approach clients with the concept of memory processing very carefully. In the
above instances maintenance and supportive therapy is the only responsible and
appropriate choice.

POS'ITRAUMATIC STRESS DISORDER IN TIIERAPISTS

Therapists who treat dissociative disorders are often overwhelmed by the

nature of the abuse their clients report. This abuse seems to exceed the scope of
what is imaginable and is very difficult if not impossible for the therapist to defend
494 against. The thoughts and emotions felt by therapists range from total denial to
Roberta G. Sachs compelling rescue fantasies. Consequently, therapists frequently suffer from exis-
and Judith A. tential crises that parallel their clients' in intensity. Many therapists are experienc-
Peterson ing the syndrome of posttraumatic stress disorder without realizing the origin of
their symptomatology. Therapists need to know that these reactions are the norm
and not the exception.
In a recent study (Perry, 1993), over 1000 therapists were surveyed with regard
to their responses in working with this population. One half to three fourths
reported that it had a significant impact on both their work and general life
circumstances; relationships with both f.unily and friends were affected. Those
surveyed often withdrew from others, which led to their feeling a sense of isolation.
One third reported existential crises. In addition, therapists also reported symp-
toms of depression, exhaustion, alienation, obsession, and paranoia. Ethical di-
lemmas were reported, including deciding whether to report other professionals
for unprofessional behavior; reporting clients' previous criminal activity; or report-
ing incidents of child abuse. In addition, therapists reported emotional harassment
such as clients lying about sexual molestation or clients threatening malpractice in
order to discredit the therapist. Thirty-eight percent of the therapists reported
being threatened physically. Safety measures listed by therapists in the study in-
cluded having alarm systems, planning therapy sessions when other therapists are
in the office, and taking self-defense classes.
Despite these negative results, many therapists reported enhancement in their
lives from working with dissociative clients. Personal growth, increased spirituality,
and close personal ties to supportive people were found to be important. Thera-
pists reported helpful coping strategies, including a strong support system of f.unily
and colleagues; continued monitoring of their own mental health; keeping a focus
on the balance between f.unily and professional life; limiting the number of dissocia-
tives In their practice; and proper rest, recreation, diet, and Involvement In extra-
curricular activities.

CONCLUSION

Processing memories associated with past traumatic events is a highly complex

form of therapy requiring astute timing and skilled use of specific therapeutic
techniques. The concepts presented in this chapter are intended to provide thera-
pists with an introduction to memory processing and follow-up therapy. It is
important to recognize that what has been presented here is only one way of
approaching memory processing, based on years of experience and our own
clinical work. The order of memory processing presented here is not necessarily
the order in which it takes place; depending on the client, there needs to be
flexibility in managing the therapeutic process.
The authors do not believe in processing memories unless retrieved by the
client. The exceptions to that are noted in the text. Currently issues about false
memories, contamination, confabulation, recanting and iatrogenesis provide major
controversies in the field of trauma. Sadly, these controversies are influencing the
way in which both therapists and clients engage in the therapeutic process. Suppor-
tive therapy, although important, seems to be taking the place of appropriate 495
memory processing, thus limiting therapeutic progress for this population. Finally, Memory Processing
core existential issues remain unresolved because of clients tnternal fears of retri- and the Healing
bution and therapists and clients fears of external retribution. Experience

APPENDIX: TIIERAPEUTIC TASKS FOR EACH PHASE OF

TREATMENT OF TRAUMA VICTIMS

Phase I
• Build trust and establish a therapeutic relationship.
• Establish safety in present time (may scirt with safety in the psychotherapy
session).
• Establish hypotheses about the differential diagnoses.
• Establish and maintain appropriate boundaries.
• Suppress spontaneous abreactions or flashbacks.
• Establish psychoeducational approach to treatment.
• Teach about the phases of treatment.
• Promote reading of instructional, educational (not anecdotal) material.
• Teach pacing of therapy.
• Educate about medication management.
• Manage transference and countertransference issues.
• Teach journaling.
• Teach art therapy and other modalities.
• Mastery of beginning hypnotic skills: safe place, containment, affect modula-
tion, affect toleration, rapid induction, distancing, time distortion, establish
ideomotor signals, positive age progression and regression, permissive am-
nesia, and deepening techniques.
• Build self-esteem and overall functionality.
• Process and cognitively restructure.
• Contain memories retrieved by client outside of therapy to be processed
later in therapy.
• Teach the planning and processing of retrieved memories.
• Teach internal communication if client has parts.

Pbase2
• Learn to plan and pace the memory processing of retrieved memories.
• Teach and help client practice advanced hypnotic techniques.
• Teach titration or fractionation of feelings or memories.
• Use cognitive restructuring.
• Review and focus on all aspects of Phase 1 of treatment.
• Blend and integrate parts when processing memories (if client has parts).
• Use group therapy (if necessary and appropriate).
• Group psychotherapy needs to focus on present day relationshps and tasks.
496 Phase3
Roberta G. Sachs
and Judith A. • Continue all aspects of Phases 1 and 2 as necessary.
Peterson • Begin developmental reconstructive psychotherapy.
• Use spiritual and creative therapy.
• Move into more complex memory processing if necessary.
• Continue blending and integration.
• Continue cognitive restructuring.
• Begin psychodynamic psychotherapy as a "single" personality.

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24
Inpatient Treatment of
Dissociative Disorders
Walter C. Young and Linda]. Young

INTRODUCTION

The past two decades have seen an explosion in the diagnosis of severe dissociative
disorders, including dissociative identity disorder (DID), formerly multiple person-
ality disorder (MPD), and a variety of other related syndromes lacking the clinical
specificity of dissociative identity disorder (Barkin, Braun, & Kluft, 1986; Bliss, 1986;
Bliss & Jeppsen, 1985; Braun, 1986; Coons, Bowman, & Milstein, 1988; Kluft,
1984a,b, 1991a,b; Quimby, Andrei, & Putnam, 1993; Greaves, 1980, 1993; Putnam,
1986; Putnam, Guroff, Silberman, Barban, & Post, 1986; Ross, 1989, 1991; Ross,
Norton, & Wozney, 1989). Fortunately, the Diagnostic and Statistical Manual for
Mental Disorders, 4th edition (DSM-IV) (American Psychiatric Association, 1994)
has renamed multiple personality disorder to dissociative identity disorder (DID),
which will more accurately represent dissociative conditions as belonging to a
continuum of trauma-related syndromes that disrupt normal identity formation
using prominent dissociative defenses. This renaming will go a long way to end
confusion that MPD is a bizarre condition in which many persons exist in a single
mind and will shift clinical focus to a more traditional psychological framework
where the disorder of identity reflects a dissociative elaboration that owes its
complexity to early and prolonged child abuse (Coons et al., 1988; Putnam, 1985,
1989; Putnam et al., 1986; Kluft, 1984a, 1990, 1991a,b; Ross, 1989; Ross et al., 1989;
Spiegel, 1984).

Walter C. Young and UndaJ. Young • National Treatment Center for Traumatic and Dissociative
Disorders, Del Amo Hospital, Torrance, California 90505.
Handbook of DissoctaUon: TbeoreUca~ Empiric~ and Clinical PerspecUves, edited by Larry K.
Michelson and William J. Ray. Plenum Press, New York, 1996. 499
500 DID is an inherently unstable condition, often leading to crises requiring
Walter C. Young hospitalization (Braun, 1986, 1993; Kluft, 1991b; Putnam, 1989; Ross, 1989). The
and UndaJ. Young most accepted theory, though controversial, is that chronic abuse in some individ-
uals fosters the gradual evolution of dissociative states that remain separated by
amnesic barriers, resulting in the failure to assimilate information and a sense of self
into a unified, cohesive identity (Kluft, 1991a; Putnam, 1989; Young, 1988b). Infor-
mation storage occurs within a variety of dissociative states that alternate as the
individual reacts to various internal or external stimuli. Dissociated identity forma-
tion is one form of traumatic residue that leads to a diffused identity, with patients
experiencing impoverished memory about significant events in their lives.
Trauma itself is highly disorganizing, leading to _a variety of traumatic syn-
dromes (Herman, 1992; Horowitz, 1986; Kluft, 1990; Kroll, 1993; Terr, 1990; van der
Kolk, 1987). Important for the development and subsequent treatment of dissocia-
tive conditions is the propensity for traumatic memory to be processed patholog-
ically, so that information and meaning of the events related to the alleged trauma
remain largely unknown and thereby unmodified by new experience. Memory may
be represented in a chaotic form, with severe cognitive distortions and a lack of
coherent integration, which leads to a failure of the normal developmental pro-
cesses that provide emotional regulation that prepares one for later life (Fine, 1988,
1990; Kluft, 1990, 1991b). Rigid, pathological defenses predominate, binding mental
energy to inhibitory modes of functioning. Since the dissociative system of defenses
grows out of a matrix of extensive child abuse, there are a variety of identifications
reflecting persecutory, victim, counterphobic, fantasy material, and a variety of
other states that intrude or disrupt smooth mental functioning (Kluft, 1991a,b;
Putnam, 1989; van der Kolk, 1987; Young, 1988a). Dissociated material lacks a
means of verbal expression and therefore surfaces through reenactment behaviors,
flashbacks, and abreactions all accompanied by vivid emotions. Further, patients
are vulnerable to crises and emotional triggering when inner or outer stimuli
threaten the barriers to excessively painful material (Horowitz, 1986; Kluft, 1991b;
Kroll, 1993; van der Kolk, 1987). These factors all interact to provide a psychological
matrix that is unstable and disorganizing, making these patients especially vulner-
able and prone to the need for hospitalization (Braun, 1986; Kluft, 1991b; Putnam,
1985; Ross, 1989).
This chapter outlines basic issues in the hospital treatment of adults with
severe dissociative disorders.

INDICATIONS FOR HOSPITAI.JZATION

In general, the needs for hospitalization are similar to those for nondissociative
conditions. Suicidality, serious danger to others, inability to use partial hospital or
outpatient treatment, and grave disability are all indications for hospitalization.
Further, when local communities lack the expertise to diagnose or treat dissociative
conditions, referral to a center specializing in these conditions is warranted. A
number of authors have discussed the indications for hospitalization and inpatient
care (Braun, 1986, 1993; Kluft, 1991b; Putnam, 1986, 1989; Ross, 1989; Sakheim,
Hess & Chivas, 1986). Table 1 provides a list of indications for hospitalization.
 Table 1. Indications for Hospitalization 501
1. The applicant is actively suicidal or homicidal. Inpatient Treatment
2. The applicant is too disorganized to manage outside of the hospital. of Dissociative
3. The material emerging requires the safety or structure of a hospital to process. Disorders
4. Outpatient treatment has been ineffective or blocked and less restricted settings have failed.
5. Medical complications require inpatient assessment.
6. There is a need for inpatient medication adjustment.
7. Diagnostic issues require inpatient observation or a specialty center.
8. There is severe, uncontrollable, destructive acting out.
9. Fugue behaviors interrupt outpatient treatment and functioning.
10. The patient risks losing a family or job during an acute crisis.
11. There is a psychotic or acute decompensation.
12. Inpatient treatment is needed to help evaluate a treatment impasse.
13. The patient is unreliable with medication.
14. Substance abuse prevents stable outpatient treatment.

GOALS OF HOSPITALIZATION

Goals for hospitalization should be clearly spelled out to correct unrealistic

expectations by the patient (Braun, 1986; Kluft, 1991a,b; Putnam, 1989; Ross, 1989;
Sakheim et al., 1986). Further, hospital treatment is inherently regressive for some
patients so that short-term stays with a rapid assessment are preferred (Sakheim
et a!., 1986). Patients or therapists may have high and unachievable expectations
such as full integration or excessively vague ones such as "memory work" to
unearth suspected abuse memories. Overall satisfaction by both patients and thera-
pists will be enhanced when realistic goals are defined and achievable prior to
admission. Kluft (1991b) notes lengths of stay will vary and goals may need to be
reassessed after a period of evaluation. Lengths of stay for discreet issues may last
for 1- 2 weeks or extend for several months when ego strengths are lacking and
there is poor impulse control or if a personality disorder impedes effective thera-
peutic engagement.
When possible, the patient's principal therapist should be included in the
patient's care and discharge planning (Braun, 1993; Kluft, 1991b). In addition to
assessing the patient, it is critical to assess the outpatient treatment and the thera-
peutic relationship itself, so recommendations may be given to help referring
therapists and provide them help with transference and countertransference obsta-
cles that cause therapeutic impasses.
Despite the tendency of patients to present in states of crisis and go to press
for elaboration of dissociated material, time should be taken in the early phases of
treatment to ensure the patient has the capacity to manage the emotional states that
occur with "memory" work. Premature efforts at retrieving dissociated information
lead to further decompensation without an accompanying capacity to integrate the
material usefully. In these instances patients may abreact repetitively with little
improvement. Emotional homeostasis is severely disrupted when observing ego
functions cannot work through emerging material (Fine, 1991; Kluft, 199la,b). The
therapist must be cognizant that reports of traumatic memories recovered in
therapy are not necessarily historically accurate and may be distorted and elabo-
502 rated by a variety of external and internal mental processes, yet still be perceived as
Walter C. Young real by patients.
and LlndaJ. Young

D~ANGEMOTIONALCONT~STRATEGmS

Much of the initial focus of treatment, especially with patients needing hospi-
talization, has to be directed toward learning to contain suicidal and destructive
impulses and managing the high levels of emotional arousal that are typically
released when dissociated material emerges. The destructive identifications with
abusers, the masochistic behaviors arising from chronic victimization, the low self-
esteem, the poorly defined internal structures that manage the pressures from
internal destructive dissociative states, and the lack of impulse control during
dysphoric periods all combine to make self-destructive acting out a persistent
problem as psychotherapy proceeds. The learning of self-control techniques and
the careful pacing of treatment then become important considerations (Fine, 1991;
Kluft, 1982, 1983, 1989, 1991b; Putnam, 1989).
Hospital staff can help develop emotional containment strategies. The pa-
tient's external support systems and resources should be assessed. Family, friends,
using music, art work, exercise, and other supports can all be developed. Social
service, family, and staff members working with the patient can all help identify
concrete external stabilizing activities.
It is equally important to develop inner coping skills to use in times of crisis.
Patients need to learn that all crises are not equally threatening. Patients often react
to any trigger with an ali-or-none response and need to start thinking of crises as
occurring along a scale of intensity that allows modified responses. Learning that
states of crisis are not interminable but exist for a finite period is extremely valuable.
Using hypnotic techniques enhances the patient's capacity to channel dissocia-
tion in a healthy way (Braun, 1984; Kluft, 1982, 1983, 1991b; Putnam, 1989). Guided
imagery and trance inductions with suggestions of a safe place to retreat internally
can be invaluable. Alter personalities may be taught to help when the patient is
overwhelmed. Establishing "inner councils" of alters or developing inner dialogue
fosters greater control (Caul, 1984; Putnam, 1989). Further, hypnotic states of
relaxation may be utilized to control the pace of processing dissociated information
or to allow access to other internal states. Self-hypnosis can provide patients the
means of using dissociation themselves and demonstrates that dissociation can be
brought under their own control.
Ideomotor signals allow questioning of an entire internal dissociated system
with "yes" or "no" questions. They can also be used to assess self-destructive or
suicidal risks by inner states having destructive impulses of which the patient is
unaware. Milieu staff can learn to "ask inside" about the safety of a patient by
inquiring if there is any immediate danger or if an agreement to ask for help can be
made so the patient will come to staff ahead of time to get help if he or she feels out
of control. As soon as internal dialogue is established, it should replace ideomotor
signals to increase the expectation of patient accountability for his or her system
and to promote movement toward further integration and inner cooperation.
It should be noted that some patients cannot be trusted with ideomotor signals
and they should not be relied on in these instances. Ideomotor signals should 503
include signs for "stop" and "I don't know" to allow patients to stop proceeding if Inpatient Treatment
answering is not safe. "I don't know" helps preclude a demand response that may be of Dissociative
inaccurate or misleading. Disorders
When using hypnotic techniques, staff needs to be aware of the ease with
which erroneous material may be accepted by patients and elaborated on when
patients are in trance states (American Medical Association, 1985; Orne, 1979;
Pettinati, 1988). Direct and leading suggestions, especially when ideomotor signals
are utilized or "memory" work is being done, are likely to produce artifacts. Open-
ended questions are always preferable.
Within the hospital, however, developing inner containment strategies may
allow staff to approach patients in crisis and reduce tension rapidly before there is
a loss of control. For example, talking briefly with a patient in crisis, then having
them "close down;' go to a "safe place inside," or some other equivalent, lets
patients know that staff is aware of the crisis and can address it later when there is
time or refer it to a more appropriate person, such as a case manager or therapist.
Making a list of resources such as friends, trusted family members, support
groups, and relaxing activities such as music, art work, writing, exercise, hobbies,
and so on is very helpful during crises. Joumaling and drawing are valuable tools to
learn so that material may be disclosed in ways that are less threatening than telling
a therapist "forbidden" information. In addition, patients may switch into altered
states while using these media and thereby depict important information. }ournal-
ing is an important tool to use for developing internal communication between
states. Patient's alters can learn to write to each other and sign their entries. There
are a variety of expressive but also "closing down" and other supportive uses of a
journal that exceed merely detailing traumatic events (Adams, 1990, 1993).
These internal strategies and external resources can be assessed and developed
by a trained inpatient staff so that patients have specific skills that complement the
primary therapist's treatment focus and prepare the patient for reprocessing disso-
ciated traumatic material. It is helpful for patients to list their resources so they will
know what they can do when they encounter a crisis. A written list helps when
patients cannot think clearly and are disorganized so they can then refer to a
prepared list to move through the crisis. The development of these patient coping
skills becomes a key focus for a hospital team that in effect also reflects the
beginning of discharge planning. Maintaining emotional equilibrium after hospital-
ization also requires resources outside of the hospital. Assessing these resources is a
key ingredient in the hospitalized patient's treatment. Patients will be returned to
an environment that may already be insufficient to meet their needs, and for the
working person maintaining stability is crucial to job stability.

SPECIALTY UNITS

There are increasing numbers of hospitals offering inpatient treatment for

dissociative disorders. These vary from those integrating dissociative disorders into
a general milieu to those with specialty tracks to those with geographically sepa-
rated units.
5o4 Presently, the authors recommend separate units rather than mixing dissocia·
walter C. YOWlll tive patients with general inpatient populations. This works better for several
and UndaJ. YOWlll reasons. First, many patients have difficult experiences on general units. General
patients view switching, childlike behaviors, and abreactions with fear or by alienat-
ing dissociative patients. They may openly disbelieve the condition of multiplicity.
These reactions are experienced abusively by dissociative patients and may be
responded to by closing off further communication. Second, on general units
patients often complain that the needs of dissociative patients divert staff time away
from others. Third, dissociative patients are ill at ease and feel exposed and vulner-
able to the scrutiny of both staff and patients who do not understand their dy-
namics. Last, much of the highly traumatic material dissociative patients disclose in
groups disrupts or overwhelms a general population.
From a staff perspective, nursing staff may be highly skeptical and may chal-
lenge or react with negative countertransference reactions to the behaviors seen in
MPD. This is demoralizing for traumatized patients who already anticipate they will
be disbelieved and ridiculed (Kluft, 1991b). A staff not specifically trained may not
recognize or be equipped to deal with altered states or the variety of transference
paradigms and clinical pictures that present themselves. This leads to confusion,
inconsistency, punitive responses, avoidance, rejection, or inappropriate curiosity
and loss of boundaries.
Kluft (1991b) points out a number of advantages to special programs for
dissociative conditions. He notes that staff are accustomed to the behaviors and
traumatic material presented and that dissociative patients are not curiosities. A
unit milieu invested in by the patients begins to develop, which fosters a milieu that
overall is more therapeutic. Patients do not derive their principal sense of unique-
ness and esteem through the "specialness" of their disorder. Specialty units allow
the development of a closely knit team that recognizes dissociative problems,
responds empathetically and appropriately, and who want to work with dissocia-
tive patients. Patient management is more consistent and staff can support one
another when traumatic material or unit intensity threatens staff with burnout.

The Milieu
The ultimate function of a hospital milieu is to assess and address the dysfunc-
tional problems that bring the patient into the hospital. It uses the unit structure to
diagnose and confront behavior problems. The hospital structure provides a protec-
tive and stable environment where the patient's needs are more clearly defined and
where critical problem areas requiring inpatient care are resolved. The patient's
outpatient treatment is evaluated and revised so that patients can return to out-
patient treatment as quicldy as possible with as little regression and interference
with the patient's healthier functioning as possible (Kluft, 1991b; Kroll, 1993;
Putnam, 1989; Ross, 1989; Sakheim et al., 1986).
A milieu must also recognize the acuity presented by dissociative patients in a
special unit. Because of their inherent instability, these patients should be consid-
ered high risks; but the least restrictive interventions should be instituted, depend-
ing on clinical situations and knowledge of the patients. If instability is ongoing,
patients may require restricted privileges and have full unit privileges returned
slowly, even if they appear in control by switching back to normal from a risky 505
personality state. Despite the outward appearance of calm, patients can switch lnpadenttreaunent
rapidly or be triggered inadvertently in therapy or group sessions into states that are of Dlssodative
highly suicidal, self-destructive, self-mutilating, assaultive, belligerent, or elopement- Disorders
prone. There may be instances when a period of quiet, out-of-program time, unit or
room restriction, or, in severe situations, the use of a seclusion area is needed.
Unlike many hospital patients in intensive care settings, the acute states may
not be ongoing and obvious, as they are in patients with schizophrenia, impulse
disorders, or bipolar conditions. Interventions may be relatively brief if the patient
can switch out of these states and reestablish control. Staff needs to recognize that
patients still need to be closely monitored, especially if safety agreements to come
to staff are ineffective.

STAFF DEVEWPMENT

Nursing staffs will require special training when working with dissociative
patients (Kluft, 1991b). First, staff will need to understand the dynamics and func-
tion of dissociation and the variety of clinical pictures presented by these patients.
Second, they will need to be taught proper boundaries and limit-setting to avoid
overindulgence or excessive rigidity in their therapeutic interventions. Third, they
will need to implement a variety of treatment interventions that protect milieu
structure and maintain milieu stability. Last, they will need an awareness of the
potential for information distortion that occurs in a milieu of highly suggestible
patients who may be exposed to leading questions as well as the productions of
other patients. Staff needs a sound framework in which to consider the information
they hear.

Dynamics
Beginning with patient dynamics, staff must be selected that are willing to
work with victims of abuse. Staff must be taught that dissociative defenses serve
both a defensive and a protective function. Furthermore, staff need to learn that
patients do not necessarily announce their dissociative states, so that provocative
behaviors may not be recognized as coming from alter personality states. Patients
that switch are in distress and interventions should be geared to understanding
and supporting agitated patients rather than viewing them as borderline or unmoti-
vated. At times behavior is the only means patients have of communicating con-
flicts. Empathy should guide staff in knowing that patients communicate in the
best way they are able. Alternative behaviors may need to be taught. Staff will also
need to be supported if they are depreciated by patients as being uncaring or un-
helpful.
As victims of abuse, patients may present attitudes of entitlement and revictim-
ization. They may reenact trauma or display symptoms of profound withdrawal,
regression, hyperactivity, sleep disorder, helplessness, dependency, or counter-
phobic behaviors that characterize variations of trauma residue (Herman, 1992;
Kluft, 1990, 1991b; Kroll, 1993; van der Kolk, 1987).
506 Boundaries and Limits
Walter C. Young
and UndaJ. Young Patients with severe behavioral disturbances and abusive histories place inordi-
nate or inappropriate demands on staff. Staff can become confused when disruptive
behaviors in some altered states are denied when the patient returns to their normal
state. Often reenactment behaviors and expectations of entitlement present un-
recognized invitations for inconsistent staff reactions. Staff may become over-
involved or, on the other hand, react punitively. It is imperative that clear bound-
aries and limits be established that guide both patient and staff expectations.
Communication and training should define clear staff roles and responsibilities.
It is common for patients and staff to have differing agendas when treatment
commences. On the one hand, patients may be expecting gratification of their
needs or be accustomed to inappropriate indulgences by well-meaning therapists
who are trying to provide caring attitudes through inappropriate nurturing experi-
ences in a misguided effort to provide a corrective emotional environment instead
of promoting a change in lifestyle and realistic expectations of others (Kroll, 1993).
These agendas manifest themselves through unrecognized impulses to reenact
preexisting pathological behaviors in the program milieu (Kroll, 1993; van der Kolk,
1989).
The unit, on the other hand, expects to provide support, confrontation, and
interpretations to promote growth and change. While this is appropriate, it may not
yet be the agreed upon understanding of patients looking for need gratification but
also expecting to be reabused or to reenact abuse scenarios.
Policies that result in excessive regression and disruption of the milieu should
be avoided. In the authors' experience, such practices as allowing baby bottles,
holding or embracing patients, and physical soothing often feel gratifying to pa-
tients, but predictably become expectations for staff by increasing numbers of
patients. This may appear to be valued by patients but serves more often to avoid
confronting realistic discussion of patient needs or other difficult feelings. There are
many reasons that these techniques pose problems, but they preempt the verbal
expression of a patient's needs or feelings of worthlessness. Providing for physical
nurturing interventions can be misunderstood by patients and lead to potential
abuse by staff. They may also be requested at times when patient behaviors are
inappropriate or staff is struggling with negative countertransference feelings.
Maintaining good therapeutic boundaries regardless of diagnosis always remains
the best rule. When staff members spend long periods of one-to-one time with
patients or, on the other hand, remain aloof and distanced, an uneven distribution
of staff time among patients may occur. Clear expectations should be set that allow
patients to know the time available to them by staff. It is important for staff to avoid
premature processing of new material when patients are not ready. This often
produces emotional escalation or functional decompensation.

Milieu Structure
Thrning to milieu structure, it is important that a set of unit guidelines govern-
ing expectations and behaviors on the unit be available both to staff and patients.
It is advisable that these guidelines be explained simply, their rationale be clear, and
whenever possible given to patients prior to their admission. When expectations 507
are clear, the maintenance of milieu structure, safety, and consistency are enhanced. Inpatient Treatment
Standardized guidelines allow staff, especially pool staff, to orient to appropriate of Dissociative
interventions and set consistent limits. They provide a predictable program that is Disorders
reassuring to patients who often are still accustomed to external authority to gauge
what is appropriate and who depend on staff to react with a minimum of counter-
transference interference.
Patients may act out in a variety of ways and verbally challenge both staff
competence and empathy. They will also engage in control struggles of various
kinds to deviate from unit policy. This acting out should be viewed as reenactment
and behavioral communications reflecting a residual trauma effect. These behaviors
are a window to important information of how patients think, process, or avoid
painful material. Untrained staff may become easily engaged in power struggles and
feel that patients are merely "manipulative" or "borderline;' resulting in anger and
potentially punitive responses. Table 2 suggests a few guidelines, but every unit
will need to develop guidelines that work within their own system.

Contamination
Last, staff needs to be aware of the potential for inpatient units to generate
contagion effects. The exposure of material to suggestible patients often leads to
imitative behaviors or to the inadvertent absorbing of material heard on the unit,
resulting in patients repressing its source and then retrieving the absorbed informa-
tion and perceiving it as memories of their own. Patients may also respond when
suggestions or expectations are given and produce material to please staff. This is
especially true when hypnosis is used (Orne, 1979; Pettinati, 1988).

Table 2. Partial Ust of Suggested Patient GuideUnes

1. Patients can expect to be called by their given names in the milieu.
2. Patients will not abuse each other or staff.
3. Out-of-control, overt acts of self-destructive behavior or abuse toward others will result in a
modified program or may result in discharge.
4. Patients have an identified therapist avaialable to work with them upon discharge.
5. Patients felt to be a safety risk may be restricted to the unit.
6. Patient privileges will be determined by program participation and milieu behavior.
7. All medications will be kept by the nursing staff unless directed otherwise.
8. Patients should not bring valuables to prevent their inadvertent loss.
9. Patients will be held accountable for all of their behavior. If a patient is highly dissociative, the
system as a whole is accountable, and reasonable therapeutic responses to the patient will be made
by staff even if individual alters provoke the need for structure or control.
10. Contacts and involvement by referring therapists are encouraged.
11. Patients will participate in their treatment planning and be given informed consent if special
procedures or medications are used.
12. Patients are expected to clean their rooms, make their beds, and dress appropriately.
13. Room assignments will be decided by staff.
14. Patients are expected to participate in the program designed by their treatment team.
508 There is a variety of contaminants that can be introduced and erroneous
Walter C. Young conclusions drawn if memories are "validated" using only the information of a few
and llndaJ. Young personality states without integrating the information in others. Memories often
shift dramatically as more dissociated material is assimilated. It is important, then,
that staff not validate material from patients unless there is clear, independent
confirmation, despite patient wishes to the contrary. Premature validation can fix a
patient to a particular memory and prevent their openness to alternate explanations
as new information becomes available. One can, however, empathize with the
patient's suffering and recognize that a clearer picture of what may have occurred
can be more evident later.

PROGRAM COMPONENTS

Inpatient programs can offer a variety of therapeutic experiences. When

working with severely abused patients, it is important that crucial issues around
abuse and its impact on character development and cognition be well understood.
While many options are considered here, each facility needs to be guided by
available expertise and the logistics of the facility.

Informed Consent
Because of the nature of dissociative conditions, one cannot predict the con-
tent or course of treatment. One often finds a degree of regression and disorganiza-
tion inevitable when dissociated material is surfacing. Further, it is wise to inform
patients about the uncertain nature of memory itself, especially in patients with a
variety of internal states containing differing and incomplete information that lacks
integration and cohesion. Clinicians often have a relatively narrow understanding of
the complexity of retrieved memories and the many differing ways reality may be
perceived by patients. Patients may be more adequately informed as therapists learn
the literature on memory, trauma, and how to consider the bizarre reports, for
example, of sadistic ritual abuse (Sakheim & Devine, 1992; Young, 1992; Young,
Sachs, Braun, & Watkins, 1991a). There is much to be learned from the literature of
related fields, including anthropology, sociology, learning theory, hypnosis, and
memory research, that will help therapists and patients alike become better in-
formed about our evolving interpretation of dissociative disorders and dissociated
material (Colligan, Pennebaker, & Murphy, 1982; Ganaway, 1989; Markush, 1973;
Mulhern, 1991; Pettinati, 1988; Putnam, 1991; Sakheim & Devine, 1992; Watzlawick,
1984; Victor, 1993; Richardson, Best, & Bromley, 1991; Young et al., 1991a; Young,
1992).
Therefore, patients should be made aware of the potential sources for the
contamination of memory and therapists should not attempt to establish the histori-
cal accuracy of memories as a primary therapeutic goal. Patients often seek valida-
tion from staff, which can misdirect their work into a fact-finding investigation
instead of a treatment effort. Validation should be provided only when reliable
corroborating data are available. When litigation is possible, hypnosis should be
discussed carefully before being introduced in treatment, since in many states the
use of this procedure may interfere or limit subsequent court testimony (Orne, 509
1979). Inpatient Treatment
It is imperative that therapists working with dissociative disorders be aware of of Dissociative
the present debate surrounding the existence of dissociative disorders and recov- Disorders
ered memories of abuse. Much of this literature has polarized the field and taken
extreme viewpoints or generalized a single representation of theory within the field
as representative of what is actually a very rapidly evolving field with changing
viewpoints which cannot be held accountable as a static model agreed by all within
the field. Nonetheless there are important contributions from various disciplines
that need to be incorporated into dissociation models as our experience develops.
This chapter cannot deal with all of these areas in depth but the reader is
referred to a number of references for a more articulated discussion. Issues of
validation have been approached by Coons (1994a,b), Briere & Conte (1993),
Simpson (1995), Gelinas (1995), Kluft (1995), Terr (1994), and Williams (in press).
Problems surrounding the use of hypnosis have wide discussions by Pettinati
(1988), Mersky (1995), Lynn & Nash (1995), Yapko (1994) and American Psychiatric
Association's statement on memories of sexual abuse (1993).
Numerous articles have addressed the validity of recovered memories includ-
ing Loftus (1995), Koss et al. (1995), Brown (1995), Greaves (1992), Coons (1994),
Spence (1994), Kihlstrom (1994), Spanos et a!. (1994), and van der Kolk (1994).
A number of significant discussions are reported in related topics such as
rumor panic Mulhern (1991, 1994), Victor (1993), Richardson et al. (1991), epidemic
hysteria and fantasy by Wilson and Barber (1983), Collian et a!. (1982), Young
(1988), and Powers (1991). Several informative volumes are devoted to these discus-
sions including Frankel & Perry (1994, 1995), American Journal of Clinical Hypnosis
36 (1994) and Cohen et a!. (1995).
Appendixes 1 and 2 provide examples of informed consents used by the
authors that may be adapted for individual use when treating dissociative patients
or using hypnosis.

Staffing
Staffing patterns should be governed by acuity. A consistent staff should be
available for adequate continuity of care and for the development of specialized
skills. Four patients per staff member is a recommended when possible: preferred
by the authors. Evenings may need to be staffed more intensely since evenings are
likely to pose problems for individuals who were abused at night or who have sleep
disturbances, and patients are more likely to be in program activity or seeing
individual therapists during the day.
Social Services should be available, and a full-time person for every 10 to 12
patients is optimal. Social Services are essential to explore needed resources for
patients, to communicate with referring therapists, and to assess and work with
families. It is important that children be assessed or referred for evaluation when
indicated, since dissociative disorders occur more frequently in family members
when one member has a dissociative disorder (Braun, 1985). Further, children of
abused parents are generally at higher risk of being abused. Last, the family as a
whole may need support in dealing with the stress of living with a family member
510 having a dissociative disorder (Benjamin & Benjamin, 1992; Sachs, 1986; Sachs,
Walter C. Young Frischohz, & Wood, 1988).
andUndaJ. Young
Discharge Planning
This should be initiated even as hospitalization begins, with the goals for
hospitalization clearly in focus. Regular treatment planning and contacts with
community supports and the referring therapist are essential. A summary of treat-
ment recommendations given to the referring therapist provides needed continuity
in the transition to outpatient care.

Expressive Therapies
The use of art therapy (Cohen & Cox, 1989; Mills & Cohen, 1993), sand tray
work (Sachs, 1990), movement therapy, and occupational therapy add essential
dimensions to verbal work, and is discussed in more detail elsewhere in this volume
(see Chapter 25). Specialized treatments should be provided by trained or certified
therapists familiar with dissociation and trauma. Expressive modalities allow a
broader dimension for patient work. These modalities foster a reconnection for
patients with their self-expression, with their bodies, and the learning of healthy
body attitudes that were distorted when their bodies were sources of pain and the
objects of intrusive violations. Journaling, as previously mentioned, can be cre-
atively used to establish inner dialogue, problem-solving skills, or exploring private
information in new ways, in addition to merely maintaining a trauma diary or poems
of suffering. Adams (1990, 1993) has written extensively in this area. These modal-
ities allow a freer access to dissociated information held in other states or the
representing information that is too painful or feels too forbidden to express
verbally.
There are numerous clinical issues applicable to dissociative patients, and a
well-rounded program establishes groups or treatment plans that address a variety
of these. Table 3 gives a partial list of some problem areas that are frequently
encountered in these patients.
Groups should be run by skilled therapists, and it is advisable when possible to
have a cotherapist who can help maintain group focus and lend continuity if the
therapist is away. Patients who are disruptive or cannot work effectively may be
asked to stay out of groups until they can work effectively and stay in control.
Patients should be allowed to leave groups if they are overwhelmed. If this is a
regular occurrence, a reevaluation of their suitability for the troublesome groups is
in order. Groups should be selectively assigned at treatment planning conferences.
When group size exceeds 10 to 12 patients, it is advisable to duplicate groups.
The authors do not object if patients switch in groups as long as the patient is not a
disruption and is able to make use of the group activity.

Treatment Planning
Treatment planning should include the treating therapists as well as the various
clinical disciplines on the team. Weekly staffings keep everyone updated on the
 Table 3. Some Suggested Topics for 511
Program Content Inpatient Treatment
of Dissociative
1. Grief and loss
Disorders
2. Coping with dissociation
3. Sexuality, gender
4. Relationships, attachment, trust, and intimacy
5. Becoming empowered, taking initiatives
6. Daily living, social and work skills
7. Women's and men's issues
8. Correcting cognitive distortions and improving reality testing
9. Eating disorders
10. living with pain
11. Surviving incest and perpetration
12. Spirituality and existential crises
13. Crisis management
14. Marital and parenting skills
15. Substance abuse
16. Group processes and interactional skills
17. Suicidal, self-mutilating, and aggressive behaviors
18. Emotional control, impulse control, maintaining safety
19. Creativity, leisure, and fun
20. Self-esteem
21. Recognizing pathological or reenactment behaviors

patient's progress and allow a coordinated plan. Patients may attend if they assist
in the planning and are not disruptive. At a minimum, they should provide input to
the team and have their care plans explained to them.
When self-destructive, acting out, or abusive behaviors occur, staff needs to
respond definitively. Staff may decide to alter the treatment plan, remove the
patient from the general milieu, or keep them out of the regular program and
provide substitute tasks that focus on understanding and controlling the aberrant
behaviors. When this work is completed, the patient can reenter the program.

Aggressive Personality States

Frequently, patients harbor one or more aggressive personality states that
threaten or present a history of dangerous behavior. These states often press for
self-destructive, self-mutilating behaviors or suicide attempts that necessitate clini·
cal interventions.
Aggressive personality states usually reflect an identification with alleged early
perpetrators and should be understood as defensive functions that have, albeit
illogically, a survival value. Patients often perceive dissociated material to be forbid·
den, or as children they feared retribution if they revealed their abuse. A state that
induces self-destructive behavior when material surfaces assures safety by main-
taining silence and keeping the patient from revealing information that in the past
would have put them in danger.
In working with these states, caution should be exercised not to encourage
their presenting externally until the system can assure safety. Early communications
512 may be through writing, mediating through other alters, or by use of finger signals.
Walter C. Young An appreciation of their function should be conveyed and efforts should reflect an
and UndaJ. Young interest in their inclusion in the patient's whole dissociative system and not in their
elimination. The patient needs to acknowledge these states and the issues that led
to their particular function. These may initially be unknown by these states as well,
especially as these states developed disconnected attitudes through secondary
dissociations. As these states develop working alliances and work with their own
issues, the internal perpetration stops and the patient starts resolving the issues
underlying the development of these aggressive personality states. Aggressive per-
sonalities eventually see the dissociated issues as their own concerns, as well. It
should always be recognized that each personality state's issues are, in fact, the
issues of the single, whole patient being treated.

MEDICATION

There is no specific pharmacological therapy for dissociative disorders. In

general, inpatient medication usage should be guided by the symptoms dominating
the clinical picture (Loewenstein, 1991). Since most patients experience depres-
sion, anxiety, and posttraumatic stress symptoms, targeting these areas with estab-
lished regimens is the most appropriate. Medications should be used judiciously
and discontinued if not effective. Patients often end up with a potpourri of medica-
tions as one drug is added to another for persistent symptoms. It is not likely that all
symptoms will be controlled as completely as desired and overmedication is a
continuous hazard. Treatment is most effective if symptoms pervade most of the
patient's dissociative system. Caution is warranted in patients with a history of
substance abuse as they may be at risk for drug dependency. Last, the therapist
needs to be aware of patient compliance and whether patients are actively suicidal
and prone to overdosing.

Affective Disorders
Many patients can be expected to have a significant depressive overlay during
th~ course of treatment. It is important to assess the patient's system as a whole. If
most states show depressive features, antidepressant treatment is warranted. Ade-
quate trials should be undertaken, and when ineffective, medications should be
discontinued.
Both tricyclics and monoamine oxidase inhibitors have been effective, but one
can expect that significant affective disturbance may remain while painful material
continues to emerge and be processed. If they are carefully monitored, adjunctive
medications such as lithium, thyroid, or psychostimulants can augment antidepres-
sant medication. Van der Kolk (1987) has found tluoxetine useful for posttraumatic
stress disorders. If agitation is severe, using more sedative drugs such as amitrip-
tyline or trazodone may be useful and given at bedtime to enhance sleep. Newer
antidepressants such as paroxetine, bupropion, and sertraline may also find their
place.
 Bipolar disorders should be screened as they can easily be overlooked due to 513
the shifting clinical picture in MPD. Family history and careful monitoring may assist Inpatient Treatment
in diagnosis. of Dissociative
Dissociative patients need especially close monitoring and some personality Disorders
states may harbor suicidal impulses not acknowledged in general questioning.
Checking the whole "system" or some personality that knows the internal state may
permit a more accurate assessment of suicidal risk and the potential for overdosing.

Anxiety
Panic and anxiety are especially common symptoms and it is often necessary to
use anxiolytic medications. Patients should expect that their symptoms will not be
entirely alleviated. Use of medications is directed to reducing anxiety so that
patients can usefully process material as functionally as possible without overseda-
tion. Judicious use of benzodiazepines can be used. Longer-acting preparations
result in smoother blood levels. Several reports have shown that clonazepam is
effective (Loewenstein, 1991; Loewenstein, Hornstein, & Farber, 1988). Because it is
generally used in seizure disorders, informed consent should be given that it is
being used for symptoms for which it was not developed.
Antipsychotic medications have not usually been effective and often produce a
feeling of further depersonalization. It adds the additional risk of tardive dyskinesia.
In occasional instances, especially if there are psychotic features, neuroleptic medi-
cations have helped. Caution should be taken to discontinue them if there is no
clinical improvement.
Braun (1990) and Barkin et al. (1986) have described the use of propranolol in
large doses with careful monitoring of pulse and blood pressure. Improvement is
seen in patients that experience rapid switching. Informed consent is required for
non-FDA usage and one needs to watch for depressive side effects and medical
contraindications when using beta blockers.

Sleep Disturbances
Many patients report insomnia and nightmares. If this is a major problem that is
not controlled by other medications or hypnotic techniques, sedative medication
can be helpful. When possible, antianxiety or sedating antidepressant medications
can be used at bedtime to avoid adding additional medications. Otherwise, the use
of sedative hypnotics may be intermittently necessary and discontinued if their
effectiveness stops.

Pain Medication
Pain symptoms are a frequent and ticklish problem. Most patients suffer so-
matic pains related to the emergence of dissociated material. Dissociative patients
also have a high incidence of headaches. For this reason it is common for patients to
request pain medications. The decision to use pain medications must be carefully
measured against the potential for addiction. One general guideline used by the
514 authors is to resist addictive pain medication in cases of somatic symptoms without
Walter C. Young demonstrable physical cause. One needs to be aware, however, that patients may
and UndaJ. Young actually have physical ailments, including migraine headaches, where the judicious
use of pain medications is appropriate.
Excellent summaries of medications for posttraumatic stress disorder and
dissociative disorders have been published by Barkin et al. (1986), Braun (1990), van
der Kolk (1987), Loewenstein (1991), Loewenstein et al. (1988), Putnam (1989), and
Ross (1989) and elsewhere in this volume (see Chapter 26). The clinician is encour-
aged to consult these.

CONCLUSION

Inpatient treatment of dissociative disorders is an interim treatment warranted

to restore sufficient stability to allow continued outpatient care. Long stays should
be avoided unless adequate justification is present to prevent regression and disrup-
tion in the patient's outside life. Inpatient treatment provides a valuable treatment
resource when patients become overwhelmed or require a structured, safe setting
for evaluation and treatment during periods when outpatient care is not sufficient.
For most effective results, hospital staff need a good understanding of the
dynamics, clinical features, and problems these patients present so that they can
respond appropriately and with a minimum of countertransference interference.
Staff and patients should each be clear about reasonable hospital goals and the limits
and boundaries of the inpatient milieu and staff treatment interventions. Staff
guidelines are a major help in maintaining this consistency. A variety of evaluations
and treatment approaches can be developed to educate patients and resolve inner
conflicts when well-trained therapists are available.
In the current climate of shorter inpatient stays and financial cutbacks, mental
health hospitals will need to be increasingly aware of useful, focused interventions
that are efficient and still effective in returning patients to outpatient care. Even as
our present understandings are shaping our treatment strategies, new insights are
emerging that may offer even more effective interventions. Increasing communica-
tion between different treatment centers and outcome research studies are needed
to document the beneficial effects of hospital care and determine which patients
will benefit most from this intervention.

APPENDIX 1: INFORMED CONSENT REGARDING THE TREATMENT

OF TRAUMATIC AND DISSOCIATIVE DISORDERS

This information is offered to give you important information about your

treatment and provide you with an informed basis with which to understand the
benefits and potential pitfalls in the treatment of traumatic and dissociative disor-
ders. It is not meant to undermine your personal experience or make light of any
work you have done. Rather, it is felt that an informed person will be able to weigh
the risks and benefits of treatment and to be aware of problem areas that may have a
bearing on your recovery. This can help you make the most responsible decisions
about your own treatment and in the interpretation of traumatic material that may 515
emerge as you progress. Inpatient Treatment
There are many issues that you need to know about your treatment. Many of Dissociative
patients experience a variety of problems in the course of their treatment that Disorders
include flashbacks, flooding of emotions, overstimulation, nightmares, anxiety and
panic attacks, suicidality, self-destructive or angry impulses, depression, increased
dissociative behavior, and feelings of disorganization. There may be a need for
hospital care at times. Some people may have trouble maintaining employment or
have problems with their social and family relationships. It is possible to feel worse
before one feels better, and some people may not feel they get better but just feel
worse. Others may find they regularly feel better. Your therapy can feel demanding,
and it is important that you develop friends, helpful support, activities, and other
personal resources to turn to if you are in a crisis and your therapist is not available.
These problems can be anticipated and discussed with your therapist.
On the other hand, most people coming into treatment are already having
severe symptoms and feel they need to enter treatment because of the problems
that they are already facing. In most cases, therapy may be the only way to regain a
sense of balance and health. You must decide whether the risks of treatment, even
if it turns out not to be helpful, is acceptable if it offers a hope for a happier and
more integrated life.
The treatment of traumatic and dissociative disorders is still evolving, and it is
not possible to predict what your treatment experience will be. This will also
depend upon factors in you and your fit with your therapist.
Ordinarily your treatment will include a variety of components to help you
gain self-control and improve your personal relationships and your functioning in
the present. It will address erroneous patterns of thinking, the re-enactment of old
conflicts through your behavior, and help to resolve the residuals of trauma and
abuse. Treatment can take months or years for some and be much briefer for others.
There is no way to predict a length of therapy. Hospitalization should be as brief as
possible to prevent an interruption of your life.
There are other approaches that are available to you or that can be used
simultaneously. These include a variety of traditional psychotherapies, group thera-
pies, cognitive therapies, behavioral modification techniques, careful use of hyp-
nosis, eye movement desensitization and reprocessing (EMDR or accelerated infor-
mation processing AlP), and the use of a variety of medications. Some people feel
treatment makes them feel worse and prefer to stop. You need to discuss your plan
with your therapist. Consultations or a second opinion can always be requested if
you feel stuck.
The mental health field is presently divided in their beliefs and understanding
about dissociation and the validity of repressed memories retrieved in adulthood or
during treatment. On one end of the spectrum are therapists that accept all material
as accurate with no independent corroboration, and they may even suggest the
presence of abuse memories based on symptoms even when memories are absent.
On the other end of the spectrum are those who do not believe abuse memories are
repressed, that repressed memories for severe abuse do not occur but are im-
planted by poorly informed therapists into unwitting, naive, or suggestible patients.
Given this division, even among many credible professionals, an awareness of what
516 we believe is exceedingly important so that your treatment leads you to your own
Walter C. Young conclusions and you are aware of alternative approaches from which to choose. It is
and UndaJ. Young hoped that informed decisions and an open mind will give you the best chance to
heal.
Studies to date have clearly established the presence of child sexual, physical,
and emotional abuse. They have also shown that a variety of adult behaviors and
symptoms are correlated with a history of abuse. There are, however, instances
where abuse may not always lead to significant disturbance, and simultaneously
many symptomatic individuals may not have a history of severe abuse. Reports of
memories for abuse do not guarantee its authenticity. Nor, on the other hand, does a
failure to recall abuse mean that none was present.
Our best understanding at present is that memories of abuse may be accurate,
distorted, confabulated, dissociated, or repressed from conscious recall or contami-
nated by a variety of other factors.
Further, memories of traumatic events may change over time as new informa-
tion that is repressed or discovered becomes available. For this reason, it is wise to
suspend judgement on memories until sufficient time has elapsed to allow the
dissociated information to emerge and cognitive distortions to be corrected so a
fuller and more accurate assimilation of retrieved material can be completed and a
clearer perspective and meaning of these events can be integrated.
You should know that amnesia for traumatic events and child abuse is a
regularly documented finding. What is less well known, and often objected to on
the basis of its appearing to reinjure abuse survivors, is the recognition that people
can under a variety of circumstances appear to remember events that, in fact, never
happened. In other instances, events may have happened quite differently than
they are remembered. Even inaccurate recall, however, does not mean that some
kind of abuse did not occur.
Inaccurate recollections can, in some instances, be experienced as being so
real and vivid and be accompanied by such significant physical sensations or body
pain that they are accepted as real memories with absolute conviction.
This is not meant to discount what you know but to permit you the widest
possible latitude in reconstructing your life. Memory is a complicated business. Real
memory can also be recalled with intensity, vividness and physical sensations that
reflect a representation of the original trauma. This is especially true with repressed
memory and particularly in dissociative conditions. In dissociative conditions, the
manner in which traumatic material is stored makes this problem especially difficult
since both accurate, distorted and inaccurate information can be experienced
similarly and believed with the same conviction.
There is no way that professionals can tell with certainty the historical accu-
racy of any account, and therefore it is important to know that professionals cannot
validate the historical truth of any memory. The concern about being unable to
validate an individual's account of their personal history is presented to help you
know the limitations of therapy, and that validation would be something you would
have to establish for yourself with independent corroboration or allow your thera-
pist, if it were appropriate, to contact people in your life directly to attempt to
clarify what was true, despite knowing from the literature that there is a pattern
of denial in families where abuse has occurred. This would only be recommended
if it were therapeutically indicated and then only with your written consent.
 lbis information is not meant to discount the impact of your suffering, nor to 517
suggest that you not discuss the material that emerges in your treatment. Recollec- Inpatient Treatment
tions, even in people who may inadvertently have accepted inaccurate information of Dlssodative
as memories, will continue to have a significant impact on how people organize and Disorders
think about their lives. These recollections, despite the issue of accuracy, are still
what shape self-esteem, influence behavior, and provide meaning and perspective
for people's lives. It is still important, however, that you know that severe child
abuse is a known fact and that severe trauma can be forgotten and dissociated by
many people and in a variety of situations.
There are times when people recall memories of things that have not occurred
to them, and more problematic still are those who will purposefully present false
memory for their own reasons. A professional therapist has no way of knowing the
difference and must help those who may be unknowingly reporting erroneous
memory by periodically challenging or trying to understand material in new ways
to allow some people to arrive at different or more accurate formulations about
their recollections and the impact these recollections have had.
Unfortunately we cannot distinguish malingering based only on a person's
reports either. This does not take away from the seriousness of the problems faced
by real survivors. Professionals have encountered memories they have not believed
that subsequently turned out to be true, and similarly they have encountered
memories they believed to be true that have turned out not to be. 1bis requires that
therapists and patients alike work without a pre-established bias and tolerate the
ambiguity of what emerges in treatment. lbis will allow you to grow and resolve
what you decide is true for you. The National Treatment Center and your therapist
may write or use terms such as "recall," "memory," "repressed memory," "a history
of," and similar terms. In the absence of external corroboration, the only respon-
sible position for you, your treatment team, the National Treatment Center and,
your therapist is to know that these terms are used for convenience in communicat-
ing and not as a statement of validation of their historical truth.
lbis is true not only in the treatment of trauma survivors but in the treatment
of all patients where the therapist and patient work only with material that is
reported. The treatment remains focused on helping to resolve the patient's suffer-
ing and not on establishing historical accuracy.
Some other possibilities suggested for contamination of memory include per-
suasion by therapists, hypnotic suggestibility, the unwitting recalling of someone
else's experiences as one's own memories, the effects of hysterical contagion as in
the spread of rumors, mistaking fantasy for reality, deception, substituting a false
memory for a more painful reality, the confusion of memory that was encoded
during states of disorganization when a preverbal or immature child was not
capable of storing memory realistically, and a variety of other possibilities as well.
Even in dissociative disorders there are a variety of coexisting yet different "real-
ities" which are believed simultaneously.
There are a variety of explanations offered to explain false memory produc-
tion. While these explanations have been hypothesized, many have not been
studied. Further, there is a great deal of research information about memory that is
learned from nonclinical populations that may not apply to you. Professionals still
have a lot to learn about the problems of memory in nontraumatic situations and
more still about the problems of processing memory in survivors of abuse. One
518 cannot necessarily translate information about memory in nontraumatized people
Walter C. Young to those who were traumatized. It is hoped that the issue of false memories and the
and UndaJ. Young polarized viewpoints among professionals can be put aside so that you can receive
the best possible treatment for your condition.
You also need to know that many, many people have been successfully treated
and feel better after entering treatment for their traumatic and dissociative condi-
tions. While treatment approaChes may continue to change as professionals learn
more, we feel that treatment results do provide a significant hope and expectation
for improvement so that you can enter treatment with an understanding that many
people have markedly improved or recovered.
* * * •
I have read the above information about the treatment of my condition. I have
discussed questions I may have had and understand the complexities involved in my
treatment and with memory in general. I understand I can assist in my treatment
planning and I can discontinue treatment at any time. I agree to treatment based on
my own informed with to proceed and at my own risk as well as my potential
benefit.

Patient's Signature Date

Witness Date

APPENDIX 2: INFORMED CONSENT FOR USE OF

CIJNICAL HYPNOSIS

Before deciding to use clinical hypnosis, it is important that you understand

the use of clinical hypnosis in the treatment of dissociative and traumatic disorders.
Hypnosis is a valuable tool, but has been the subject of considerable controversy
amongst clinicians in the field. For this reason, it is important that you understand
some basic issues about hypnosis to be adequately informed.
Hypnosis is an altered state of consciousness which has a number of charac-
teristics. These include a capacity for deep absorption in the hypnotic state with a
reduction in the awareness of external events, an alteration in one's perception of
reality and a high level of suggestibility, and a suspension of critical judgement,
including the evaluation of information retrieved during the hypnotic state. These
characteristics are more prominent in people who have dissociative conditions and,
therefore, contaminations of memory and information retrieved in hypnotic states
are more prone to occur. All of these features combine to increase the possibility
of producing inaccurate, distorted or false memories. The hypnotic state can result
in the confusion between reality, one's fantasy life, suggestions or demands from a
therapist, and the influence of other stimuli occurring in hypnosis that may alter the
realistic interpretation of retrieved information.
 Research with hypnosis has demonstrated that hypnosis may enhance mem- 519
ory, but also distort or lead to the production of false information that is still Inpatient Treatment
perceived as memory. This is due to the nature of hypnosis, the demand quality of Dlssoclative
inherent in some hypnotic suggestions as well as the individual's expectations of Disorders
what a therapist may be wanting to discover. Further, information may be retrieved
in a hypnotic state that is accompanied by high levels of intensity, body sensations
and a conviction that the information is accurate, despite evidence that the informa-
tion was the product of contamination or hypnotic suggestion. On the other hand,
hypnosis Is capable of enhancing real memory and retrieving real information
which has been repressed or forgotten. Individuals in a hypnotic state may not be
able to distinguish the difference between information that is accurate and informa-
tion that is artifact.
Hypnotic studies, however, have not adequately studied the accuracy of hyp-
notic retrieval of dissociated memory for traumatic events. The uncertainty of
hypnotic memory retrieval means that information retrieved in hypnosis should be
accepted only with caution and a recognition that it may or may not be historically
correct. There is no way of knowing whether any information that is retrieved
through hypnosis is historically accurate. This can only be done by the independent
validation of information that is retrieved. This is true of all memories reported in
psychotherapy. These issues are particularly relevant for individuals with dissocia-
tive conditions since they are often highly suggestible and therefore, more prone to
the complications of hypnosis in which the suspension of critical judgement,
suggestibility, and the absorption in the experience may allow even greater degrees
of distortion.
People with dissociative disorders are still more prone to accepting sugges-
tions whether they are placed in formal hypnosis or not. Dissociative individuals
are often in states of autohypnosis or self-induced trance, especially during psycho-
therapy sessions or periods of stress.
There are other sources of contamination. Subjects retrieving memories in
hypnosis may recall information that they have heard from other sources or even of
their own fears or fantasies and experience them as though they were memories.
One forgets the original source of the information and subsequently feels as though
it originated in oneself, attributing the emerging material to memory. This phenom-
ena, known as source amnesia, is well known in hypnosis and can be very com-
pelling.
Beyond the issue of memory, it is exceedingly important to be aware that in
many legal jurisdictions and in different states, the use of hypnosis may have an
impact in litigation. The use of hypnotically refreshed memory, for example, or
simply the use of hypnosis may prevent or disqualify individuals from testifying in
legal proceedings. It is important that you be aware of this in the event that you
are involved in a legal action, or expect that you might utilize information that you
learn in your treatment in a future legal action. Hypnosis may impede or prevent
you from testifying. You may want to contact your attorney if the potential for
litigation is relevant.
There are other complications that may occur with the use of hypnosis. These
the include flooding of emotions, the development of flashbacks and traumatic
imagery, the sudden return of highly charged traumatic memories that can lead to
520 increased disorganization, suicidality, and self-destructive or aggressive behaviors.
Walter C. Young Hypnosis might result in premature emergence of information that you do not feel
and Undaj. Young ready to manage. These problems may occur and produce the same symptoms
without using clinical hypnosis.
Hypnosis, on the other hand, has many potential values. It may be used
effectively for reducing anxiety, developing internal states of relaxation, or inducing
guided imagery which can help during periods of crisis. Hypnosis may also help to
gain information which is unavailable because it is contained in dissociated states. It
may also be valuable in developing the capacity to have an internal dialogue
between, or an awareness of, other internal states.
Hypnosis is not required for your treatment and many people have successfully
completed treatment without it. You can utilize traditional forms of psychotherapy,
groups, cognitive and behavioral techniques, the use of medications, and emotional
containment strategies to develop a sense of safety in your treatment.
• • • •
I have been fully informed about the pitfalls as well as potential advantages of
hypnosis. I am also aware that other forms of treatment such as psychotherapy,
group therapies, cognitive therapies, and other forms of therapy are used very
successfully and may reduce some of the risks surrounding memory distortion. I
understand and give my consent to the utilization of hypnosis, knowing that I may
discontinue it at any time.

Signed Date

Witness Date

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25
Art and the
Dissociative Paracosm
Uncommon Realities

Barry M. Cohen
Art must venture into areas of experience that are not yet clearly understood and
perhaps never will be.
MIHALY CsiKSZENTMIHALYI (1978)

INTRODUCflON

During the last decade, increasing attention has been given to the long-term se-
quelae of incestuous and sadistic early childhood abuse and, more specifically, the
dissociative symptomatology that results (e.g., Courtois, 1988; Herman, 1992; Kluft,
1985, 1990; Loewenstein, 1991; McCann & Pearlman, 1990; Putnam, 1989; Ross,
1989). A body of research has grown to complement the observations of practi-
tioners and their eminent predecessors, such as Janet and Prince, regarding the
variform trauma in young children and the development of chronic posttraumatic
dissociation (Boon & Draijer, 1993; Herman, Perry, & van der Kolk, 1989; Loewen-
stein, 1993; Putnam, 1991).
Those who have chosen to study and treat this complex and demanding
population are aware that voluminous creative productions can be generated by
many of these clients (Coons, 1988). When such productions are brought into the
treatment context, their mere presence has galvanized some psychotherapists into
incorporating art into therapy without training themselves in the therapeutic use of
art. This is certainly tempting, and at first seems expeditious; the art is visually and

Barry M. Cohen • P.O. Box 9853, Alexandria, Virginia 22304.

Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 525
526 emotionally compelling and contains important information about its makers and
Barry M. Cohen their personal worlds. Further, therapists often feel deskilled at one point or
another during the course of treatment, and some have responded to this phenome-
non by consciously or unwittingly engaging in unconventional practices (profes-
sional and/or personal) that they would not consider with nondissociative clients
(Fine, 1990). It is the author's observation that therapists who make the choice to
treat this segment of the traumatized population are typically (or fancy themselves)
highly creative persons, and so may consider art to be their lingua franca. Recogniz-
ing the potential for therapeutic misadventures arising from this situation, Frye and
Gannon (1990) devised excellent guidelines for clinicians not trained as art thera-
pists.
In the past several years, however, a small body ofliterature has been published
concerning the informed use, based on formal training, of expressive arts modal-
ities with adults who have severe dissociative conditions. Most of it can be found or
referenced in a few books and certain professional journals (Cohen, Barnes, &
Rankin, 1995; Cohen & Cox, 1995; Kluft, 1993; Simonds, 1994); one comprehensive
review of the audio literature on this subject is also available (Mills, 1992a).
This chapter, unlike the aforementioned literature, is not concerned with
approaches to treatment or differential diagnosis of this population through art. Its
purpose is primarily theoretical: to explore the relationships among visual art,
traumatic experience, therapeutic art-making, and the internal worlds of people
suffering from complex posttraumatic dissociation. Using clients diagnosed with
dissociative identity disorder (DID) (formerly multiple personality disorder) as a
focus, the author hopes to reveal the extraordinary kinship between the dissocia-
tive reality and the art reality, and to clarify the rationale for the well-informed use
of art therapy in treating survivors of severe early trauma.

ESTABLISHING REAUTY

In vain do we ever say what we see; what we see never resides in what we say.
MICHEL FoUCAULT (1982)
Each of us has unique perceptions of the world, based largely on our personal,
psychological, sociocultural, and physiological experiences. For instance, two
adults from similar backgrounds, of the same gender, with identical demographics
can look at the same stimulus and each see different things, as any visit to an art
gallery will confirm. Nearly all psychology students have seen the simple black and
white design that shifts between the image of a chalice (in the center) and two
profiles facing each other (at the sides); M. C. Escher's graphic oeuvre, with its bird
and fish motifs, so familiar to millions, is rooted in this perceptual challenge.
Individuality dictates reality at even the most basic levels (I'yler, 1978). The German
expressionist artist, Max Beckmann, said, "It may sound paradoxical, but it is, in
fact, reality which forms the mystery of our existence" (cited in Rose, 1987, p. vi).
Traditionally, psychotherapy requires patients to rely on verbal language to
both express their feelings and communicate their thoughts and experiences-
their inner realities. In order to be able to participate effectively in psychotherapy,
clinicians must learn to apprehend the complexities of interpersonal expression by 527
attending to both verbal and nonverbal cues. It is not sufficient, for instance, to Art and the
merely comprehend the words that a client uses to recount her story. The way in Dissociative
which the words are spoken-volume, tone, enunciation, and emphasis, as well as Paracosm
facial expression, posture, and gesticulations of the speaker-must be noted.
Supportive-expressive treatment, for instance, a method of psychoanalytic
psychotherapy, has four phases: listening, understanding, responding, and return to
listening (Luborsky, 1984). The therapist is challenged to comprehend what the
patient says and actively comment on it in order to provide clarification. In the best
of circumstances, the individuality of both clinician and patient, as well as the
limitations of verbal communication, can hamper effective listening, accurate un-
derstanding, and skillful responding within the dyad. Furthermore, the name
"supportive-expressive" promises two experiences. It is certainly possible to pro-
vide verbal support in this format, but can psychotherapy be truly expressive when
language is its primary vehicle?
To take this questioning a bit further, is it possible to make sense of an
unfamiliar spoken language? Is it possible to communicate linguistically without the
benefit of a shared vocabulary and syntax? In such a circumstance, it seems doubtful
that one could deduce or assume meaning and expect it to be accurate. This
impasse in communication has profound implications for the treatment of survivors
of abuse. The severely traumatized client frequently communicates in a personal
language that often seems foreign, even to the seasoned mental health professional.
In order to engage a dissociative survivor of childhood abuse in psychotherapy,
one must use a language that the client finds effective; the interaction between
language and individuality already poses an obstacle to effective communication.
Because visual and sensorimotor functions are critical in the storage, coding, and
recall of traumatic events, one must be willing to learn about the impact of trauma
on imagery and how they manifest through art-making. Art therapy naturally facili-
tates the extemalization of most of the aspects and outcomes of traumatic experi-
ence and clinicians can benefit from familiarity with the theories of this discipline
(Cohen, 1993).

DISRUPTION AND DISCONTINUITY

What we cannot speak about we must pass over in silence.

LUDWIG WITrGENSTEIN

The relationship between art activity and the transformation of trauma can be
simply illustrated through the theoretical model that uses schemas as a metaphor
for the organization of various internalized constructs. Schemas are patterns of
experience that help us comprehend and organize our existence; they frame issues
such as safety; trust, independence, and power. Schemas are developed in response
to the process of living. McCann and Pearlman (1990), in their constructivist self-
development theory, describe schemas as "assumptions, beliefs, and expectations
about self and world" (p. 57).
As new experiences are tested against one's existing expectations, they may be
528 found to be congruent with each other, or not. It is theorized that those experi-
Barry M. Cohen ences that are found to be congruent with existing schemas can be internalized in
such a way that the related images can be easily translated into word representa-
tions and later coded to facilitate storage in memory (Horowitz, 1970). These coded
perceptions of experience are the basis of narrative memory. Narrative memory
allows us to tell our experiences to others -communicate socially with them -and
helps us to make sense of, accommodate, and work through experiences by
recounting them (van der Kolk & van der Hart, 1991).
When experiences are found to be overwhelming, unexpected, or undesir-
able, they cannot be adequately processed. Because they are incongruent with our
existing patterns and cannot be translated into language (Horowitz, 1970), these
disrupted schemas are stored in short-term memory, primarily on an iconic (visual)
and sensorimotor (body) level, and form the basis of traumatic memory. Wordless-
and sometimes meaningless-this type of memory cannot be easily communicated.
Its contents remain rigid and immutable despite the passage of time (van der Kolk &
van der Hart, 1991).
Although some experiences succeed in entering cognition through image
formation, others directly enter the lexical system. The presence of conflict, as in
traumatic situations, may serve to inhibit integration of these two components,
therefore preventing the development of a sense of meaning related to the experi-
ence. In the absence of meaningful connections, available images of these events
might be regarded by the traumatized individual as puzzling. Maintaining traumatic
images out of awareness, however, guards against the rekindling of intense emo-
tions through connection with other unpleasant or unresolved schemas (Horowitz,
1970).
Even when they cannot be adequately processed, traumatic memories con-
tinue to manifest themselves in several ways: somatic sensations (body memories),
which recur spontaneously or as a result of an environmental cue and typically
revive unpleasant physiological phenomena; behavioral reenactments (repetition
compulsion) in which the person participates unknowingly either as victim or
perpetrator in situations reminiscent of the original trauma; and nightmares and
flashbacks (intrusive revisualization) in which visual fragments or "trauma replays"
arise unbidden (Brett & Ostroff, 1985).
Repetition of traumatic material "is generally understood as an attempt to
come to terms with, or to integrate, the strong affects and somatic sensations
invoked by the trauma into the fabric of one's life experience" (Greenberg & van
der Kolk, 1987, p. 191). For the incestuously victimized child, however, demands for
secrecy, coupled with potent threats, increase the likelihood of amnesia regarding
these psychologically undigestible episodes.
Stored images that continue to press toward revisualization until translation is
complete are often reflected in artwork as themes (repeated over a lifetime) or as
perseveration in a single work of art. Magritte, the Belgian surrealist, created a series
of paintings in which the broken shards of a window pane lie on the floor (Cal-
vocoressi, 1979). Each piece of glass retains a part of the image of the scene which
can also be viewed through the window. Although the image through the window
is not traumatic per se, the window pane nonetheless continues to reflect the
moment of the trauma. These paintings illustrate the lasting effects of unprocessed
traumatic memory, which, carried in visual and somatic fragments, is more difficult 529
to resurrect than the more complete gestalts of verbally processed narrative Art and the
memory. Dissoclative
Spiegel (1991) defines trauma as a "sudden discontinuity in physical and psy- Parac:osm
chological experience" in which the discontinuity is both a defense by the victim
against the traumatic input (flight from harm), as well as a reflection of it (schema
shifts and dissociation). Thus, abusive behavior induces various types of discon-
tinuous experiences in its targets. The victim shifts states of consciousness in order
to avoid pain, separates any previous positive connection with the perpetrator from
awareness, and becomes a thing instead of a person -a creation of the abuser in the
form of the abuse. This moment of disparity and despair facilitates a hypnoid or
trance state in the victim that fosters the creation of arational, atemporal, and
nonlinear constructs (Horowitz, 1970). The response to this state of overwhelming
experience has been described as "speechless terror," since information can neither
be fully assimilated nor accommodated (van der Kolk & van der Hart, 1991).
1n this state of consciousness, incoming bits of information may be associated
into discrete ego centers or, in the case of DID, alter personalities. Trauma often
causes the inadvertent association of disparate stimuli; some forms of sexual abuse,
for example, pair pleasure with pain. 1n childhood incest, maintaining secrecy
obliges the victim to pair the actuality of the assault with the enforced facade of the
happy family; thus, she is required to maintain long-term cognitive dissonance.
Since the ability to retrieve information in a manner in which it can be translated
into words depends on compatibility with or similarity to current cues, modalities
that access material associated visually, kinesthetically, or through the senses offer
great rewards in the healing process (Crabtree, 1992; Simonds, 1994).
Van der Kolk and van der Hart (1991) suggest that the traumatized individual
lives in two different worlds: the realm of the trauma (past) and the realm of
"ordinary" life (present). The realm of the trauma is internal reality-a world that is
repetitive, solitary, and, very importantly, timeless. One needs to be more adaptable
to "ordinary" life, on the other hand, because it is more unpredictable and contex-
tual. Further, these are two "utterly incompatible worlds" (1991, p. 448). Disparity,
like disruption and discontinuity, becomes all too familiar in the lives of those who
have experienced chronic trauma. This explains in part why traumatized individ-
uals crave metaphor and imagery in treatment to make sense of their worlds (Rose,
1987). The art reality offers a relatively safe parallel realm in which these disrupted
schemas can be recalled, explored, and transformed.

THE ART REAllTY

Art does not render what is visible, it renders visible.

PAULKum

Nelson Goodman (1978) described art as a "fundamental way of knowing the

world" because of the potential it holds as a vehicle for and process of communica-
tion. Several key qualities contribute to the unique nature of what is herein referred
to as the art reality. Isomorphism is the central concept in the psychology of art and
530 the expressive arts therapies. It derives from Gestalt psychology and refers to the
Barry M. Cohen similarity in structure between a person's internal state and its external expression
(Arnheim, 1969). Body language, for instance, is a "pop" application of the isomor-
phism concept. It is isomorphism that allows us to feel the curving reverberations
of Munch's ubiquitous expressionist icon, "The Scream" (1895), which reflects the
artist's inner state of tension and, at the same time, induces a similar state in the
viewer. "Whoever paints a figure," wrote Dante, "unless he can be it, cannot set it
down."
In communicating their messages to viewers, artists use certain techniques
that pertain to the arrangement, clarity, manipulation, and interrelationship of
pictorial elements (Cohen & Cox, 1995; Dondis, 1973). Styles in the art are patterns
of picture-making behavior that are constructed from clusters of these techniques.
There are several styles in the modem history of art that are essential components
of the art reality. These styles help to highlight some of the inherent qualities of art
that allow for its characterization as an uncommon reality.
Cubism, the earliest of abstract styles, was a manipulation of form and space
that afforded a view of a subject from multiple vantage points; thus we see sides,
front, and back simultaneously. The surrealists were also interested in space, but,
unlike the cubists, focused on internal rather than external space. In keeping with
their fascination with the irrational, they sought to create accurate depictions of
imaginary or dream space. "Pure psychic automatism" in surrealism, according to
its founder, Andre' Breton (cited in Crofton, 1988, p. 181), was intended to express
the true process of thought, free from the exercise of reason. Surrealist composi-
tions feature the trance logic of the hypnoid state, including its distortions of time.
Surrealist artist Salvador Dali manipulated time and space in his paintings through
the use of complex juxtaposition, distorted scale, and mixed perspectives. His early
work is typified by the painting, "lliumined Pleasures" (1929), which is composi-
tionally devised in such a way that several scenarios are perceived by the viewer to
be occurring simultaneously; violent, sexual, and symbolic/oneiric themes are
freely mixed with the banal.
Aesthetic forebears of the surrealists, the dadaists bestowed upon them a love
for juxtaposing elements in novel and unexpected combinations. The dada work
that best illustrates the power of juxtaposition is the provocative mixed media
assemblage by Meret Oppenheim, "Object (Breakfast in Fur)" (1936), a fur-covered
teacup and spoon, which incites a veritable sensory riot by the joining of two
ordinary items from our everyday reality. Associating images that have no apparent
connection by bringing them together in a single work enables the artist to generate
new connections and meanings that reason alone is unlikely to anticipate (Rose,
1987). In the same way, disparate schemas that have been associated during trau-
matic experience can be effectively retrieved through an isomorphic process in art.
Expressionism externalizes affect through intense color, distorted form, and
gestural movement. Foreshadowed by the late works of Van Gogh, developed by the
Germans early in this century, and epitomized by the New York School of abstrac-
tionists such as DeK.ooning, Kline, and Pollock, the externalization of raw feeling in
expressionist art is frequently paralleled in the artwork of traumatized persons.
Futurism, a relatively little-known style, developed in Italy during the same
years cubism was evolving in France. Its proponents strove to engage the viewer in
active participation through the visual evocatipn of dynamic movement. Marcel 531
Duchamp, though primarily known as a dadaist, painted an example of futurism Art and the
known to all students of twentieth-century art. His "Nude Descending a Staircase" Di8soclative
(1912) attempts to record a figure moving through space, using abstract form to Paracosm
convey its narrative; the effect is of a strobelike pattern. It is difficult to avoid
physical empathy with such an image; in this way, art can elicit motor responses
through visual and kinesthetic cuing.
The attributes of the art reality enable the wordless image to work its way out
in "a continuous process of concretion" (Cassirer, 1953, p. 184) without the neces-
sity of language. There is no mandate for sequential thought in the nonverbal mind;
art carries information differently than language-in visual images rather than in
words. These images need not themselves be narrative because form in art is
content; it alone can communicate. "Form is ... most associated with conscious-
ness, judgement, control, and other ego attributes" (Storr, 1993, p. 224).
Gertrude Stein, a contemporary of the cubists, developed a literary style that
was essentially cubist in nature and did not rely on narrative. The following is an
excerpt from her word portrait of a Spanish dancer, written in 1913 (cited in Haas,
1976, p. 57):

Sweet sweet sweet sweet sweet tea.

Susie Asado
Sweet sweet sweet sweet sweet tea.
Susie Asado
Susie Asado whlch is a told tray sure.
A lean on the shoe this means slips slips hers.
When the ancient light grey is clean it is yellow, it is a silver seller.
This is a please this is a please there are the saids to jelly ...

When the narrative content is taken out of written communication, as in the Stein
poem, words are distilled into sounds and rhythm, and meaningful references are
lost. In visual art, however, form, color, movement, and composition remain to
express the artist's intent, even if the narrative has been obscured or removed. Take,
for example, Picasso's portraits in the analytical cubist style which shatter the
subject's image into many small planes of color and light. At first one might see only
the paint, or the complex design, but soon the image coalesces in the viewer's
mind's eye and the figure can be discerned.
"Language is simply unable to capture the quality of visual truth; it muddies as
much as it mediates" (Rose, 1987, p. 176). This is because words, the primary means
of conveying images in spoken and written communication, have been arbitrarily
assigned meaning for the things to which they refer; what does "chair" have to do
with the actual object on which one sits, for instance? How many referents are
ascribed to the sound "bow"? Where, exactly, is "over there"? When you hear or see
the word "pipe," do you think of smoking or plumbing? Why?
The Belgian surrealist Magritte created sophisticated paradoxes that force us to
confront the uneasy relationship between words, images, and consensual reality
(Handler-Spitz, 1987). "This is not a pipe," inscribed in French on a painting that
clearly depicts a pipe used for smoking, is a well-known example of his work.
Magritte uses the combination of writing and painting in this piece to create an
532 especially complex disparity. Of course this is not a pipe-it is a painting of a pipe
Barry M. Cohen (Foucault, 1982). 1 The semiotic dilemma here is not very different from the un-
trained nonspecialist introducing art into the trauma therapy context. "Seeing an
artwork without knowing it is an artwork, is like experiencing print before being
able to read" (Dissanayake, 1991, p. 183).
The capacity of visual language to convey feeling, meaning, psychological time
and space and to invoke sensation, movement, and cognitive connections com-
mends art reality as an important correlate in communicating with traumatized
people.

TilE DISSOCIATIVE REAUfY

When you own the shop and there are no customers, you can do anyihing you
want.
COUN MARTINDALE (1990)

The dissociative reality, which thrives on the disrupted schemas of the trau-
matic realm, extends the challenges regarding individuality and interpersonal com-
munication in psychotherapy to even more complex levels. People with DID
usually manifest the most complicated psychopathology that characterizes this
uncommon reality. A chronic complex form of posttraumatic stress, DID features
frequent periods of dissociative amnesia during which alternate personalities take
executive control of behavior.
For those who do not live it, it is nearly impossible to truly understand
dissociative reality or effectively describe it. What words can one use to adequately
communicate phenomena like switching, co-consciousness, a system of highly
particularized alters, or internal safe places? Both patients and therapists frequently
develop exquisitely refined (although somewhat rigid and unidimensional) verbal
metaphors to describe these aspects of the dissociative reality. The visual image is,
however, more immediate and more directly attuned to individual needs than is any
verbal metaphor because art allows us "to visualize, not merely to conceptualize"
(Cassirer, 1944, p. 216).
The discontinuity and disparity that are engendered by childhood abuse foster
the development of pathological levels of dissociation in the young victim striving
for survival. As a result, the severely abused child begins the self-hypnotic process of
establishing an internal reality that differs radically from consensual reality. Silvey
and MacKeith (1988) referred to elaborate invented realities of childhood as para-

1Itis interesting to note how thoroughly many of Magritte's images have been adopted into popular
culture. I believe the proliferation of surrealist imagery, which flourished after World War l-and
Magritte's imagery in particular-on album covers, window dressing, greeting cards, T-shirts, and the
like is a reflection of society's craving for disparity and discontinuity. The public needs these elements
concretized and externalized for them and the surrealists provided just such a service. The daily news
confirms that there is rampant trauma in all our lives. However, many people participate in a consensual
trance in which certain kinds of trauma do not really exist-witness surveys regarding doubt that the
Holocaust actually happened.
cosms. Paracosms are spontaneously created, systemized private worlds. Sustained 533
over an appreciable length of time, they are internally consistent and deeply Art and the
significant to the individual. The dissociative reality is essentially a posttraumatic Dlssoclative
paracosm in which discretely organized constructs and affects are elaborated into Paracosm
adaptive metaphorical and/or pathological realms. These internal worlds usually
reflect the magical thinking of early childhood and, unlike the delusional reality of
psychotics, are self-referential.
It has been suggested that alter personalities are constructs developed in an
attempt to master a variety of very intense affects (Nathanson, 1993). Ross (1989)
compared them to theatrical devices. The alter personalities that reside in dissocia-
tive paracosms may also be likened to styles in art, in that they represent distinct
patterns of behavior that are visually distinguishable by their characteristic commu-
nication techniques; some alters may also be identified by their function within the
personality system. Typically, this environment is inhabited by perpetrator intro-
jects with cognitively distorted agendas (Ross & Gahan, 1988). In addition, un-
processed remnants of the trauma itself tend to resurface spontaneously-pressing
for revisualization. For these reasons, not all posttraumatic paracosms are safe
places to be.
Paracosms should not be confused with system pictures, which depict the
organization of the alter personalities (Cohen & Cox, 1989), nor should they be
confused with system maps (Putnam, 1989), which are typically transitory rela-
tional diagrams of the internal cast of characters. Paracosms, on the other hand,
include the internal reality's environment, architecture, rules, culture, and constitu-
ents. It is in this realm, deep beneath the chaos shown outwardly to the world, that
the unity beneath the patient's multiplicity might be examined (Braude, 1992).
Because paracosms are so elaborate, one is more likely to glimpse different aspects
of a single example across a number of art productions by a given client than to see
one represented in a single art production.
In addition to these idiosyncratic imaginal realities, people with DID seem to
have their own linguistic system (Greaves, 1992). It includes the use of such phrases
as "the body," "the mother," and the omission of pronouns in order to avoid
committing to "I" or "we" statements or indicating ownership statements with the
words "my" or "mine." Kluft has informally referred to this idiosyncratic style of
thinking and communicating as "multiplese." listening to multiplese can be disori-
enting, but not nearly as difficult as having to make sense of the dissociative reality
(with its cubist-futurist-surrealist and time-space distortions) without the help of
art reality.
The dissociative reality derives from several negative constructs that are the
direct result of trauma. These constructs reflect discontinuity and disparity in
schemas related to identity, awareness, responsibility, and time. A patient's dissocia-
tive reality may be summed up by the following:

• not me-disavowal-dissociation of part selves

• not now-inability to remain in or experience the present
• not then-disavowal-dissociation of personal history
• not ever-lack of hope or future orientation
534 UNCOMMON REAIJTIES: A KINSIDP
Barry M. Cohen
... the urgent need in everyone to give form to his or her life.
Rou.o MAY

As strong kinship exists between the art reality and the dissociative reality;
inherent qualities of both realms parallel one another. The therapist's ability to
capitalize on this affinity makes communication and therefore treatment easier and
more effective than the use of language alone.
·Bisociation refers to the pairing of habitually incompatible elements during the
creative process (Koestler, 1964). As mentioned earlier, this occurs naturally in
the context of trauma, when incongruent ideas or experiences are powerfully
associated during an altered state. Dali's work perhaps best illustrates this quality
in art. His famous portrait of Mae West (1934), in which the subject is depicted as a
brothel parlor with her cascading hair as the drapery and her ruby lips as a sofa,
provides an elegant example of bisociation. Dali created a trancelike reality in his
painting through the trancelike process of art-making and invites the viewer to join
him in it.
Plasticity is the inherent quality of art that facilitates the malleability of form,
time, and space; it maximizes the effects of visual communication. 1n the dissocia-
tive patient's experience, the plasticity of trance logic allows for the simultaneous
or consecutive experiencing of past and present time within a spatially variable
posttraumatic paracosm. Plasticity is the phenomenon that enables the patient to
continually reperceive herself in her various dissociated identities. Dali unwittingly
illustrated plasticity as a function of both art reality and dissociative reality in a
single work of art; his emblematic surrealist painting of melting watches in a
timeless landscape is, ironically, titled "The Persistence of Memory" (1931).
Absorption is another key factor in the kinship between art reality and dissocia-
tive reality. It is the intensely focused state of consciousness accessible to both the
artist and the highly hypnotizable person. As Storr (1993), states, "creative people
are often astonished by what they have produced, and treat it ... as if someone else
has produced it" (p. 219). An example of absorption during the creative process,
this description is remarkably similar to the dissociative amnesia of DID patients
who create art in their various alter personality states. Properly structured, art-
making can engage dissociative clients in a pleasurable activity that channels their
propensity for absorption.
Multileveledness suggests that several distinct levels of meaning can be com-
prehended in a single work of art and further that there is no hierarchy of impor-
tance among these various levels (Kreitler & Kreitler, 1972). Cohen and Cox (1989)
have pointed out art's efficiency in allowing for the simultaneous revealing and
concealing of information regarding abuse, dissociation, or multiplicity, which is
derived from this phenomenon. Art's multileveled quality promotes repeated exam-
inations by the viewer of a single work. Similarly, the variety and stratification of
alters in a DID system invites ongoing reexamination by the therapist. This intrigu-
ing quality can sometimes offset the difficulties of working with such complex
persons and case material.
 535
Art and the
Dissociative
Paracosm

' ...
•

Figure 1. In this drawing by a woman with DID, the childhood experience associated with the
showerhead becomes graphically signified by the crying sunflower.

For the child fellating the adult in the shower on the left side of the drawing in
Figure 1, drawn by a woman with DID, the pouring shower head is equated with the
bright yellow image of a sunflower on the right. The child could only allow herself
to cry in the shower where her tears would be washed away undetected, hence the
crying sunflower. Once this association is concretized, future drawings that may
refer to knowledge of this incident or the dissociated affective and sensory re-
sponses related to it may be simply signified by the sunflower. The sunflower is a
schema-in this case, an art term meaning a basic pattern or configuration that is
used repeatedly to denote something (Lowenfeld & Brittain, 1975).
A flower schema is employed again in Figure 2, also drawn by a DID patient. In
this image, it suggests a system and an internal threat. If trauma creates disrupted
mental schemas that need to be externalized in order to effect healing, and art
activity is the most effective way to accomplish this externalization, then graphic
schemas are the royal road to enhancing the therapeutic outcome in the treatment
of severely traumatized clients.
According to Csikszentmihalyi (1978), "Art is an adaptive tool by which we
master forces in the environment in order to survive in it" (p. 125). Picture-making,
like hypnosis, provides a directable shift in consciousness to an image-based con-
struct (Kingsbury, 1988). In this way, art can offer an escape from the chaos of life to
another, more cotnfortable, realm. Martindale (1990) has pointed out that if you do
something useful, you yourself can become a tool. The all-too-usable victimized
536
Barry M. Cohen

Figure 2. A flower schema is used to represent the internal personality system, which is under attack.

child adopts art as an activity of survival because it is not at all useful to the abuser
and is, therefore, use-less. A child can express her internal or external reality
through art in ways "that could not be expressed, and therefore controUed, by other
means" (Csikszentmihalyi, 1978, p. 120).
like any aspect of human behavior, art can be analyzed or interpreted accord-
ing to any number of constructs. likewise, art therapy approaches correspond to
various schools of psychological theory. Differing outlooks on art therapy practice
can be sought elsewhere in the professional literature (e.g., Landgarten, 1987;
Lusebrink, 1990; McNiff, 1981; Moon, 1990; Naumburg, 1966; Rhyne 1973; Robbins
& Sibley, 1976; Rubin, 1984; Schaverien, 1992; Wadeson, Durkin, & Perach, 1989).
ART THERAPY IN THE TREATMENT OF DID 537
Art and the
I hey and I forget, I see and I remember, I do and I understand. Dissociative
Paracosm
PROVERB

Art therapy is frequently misunderstood by non- art therapists as a method of

creative-expressive exorcism. This misconception most likely stems from the
haphazard introduction of art activity by untrained practitioners into the context of
verbal psychotherapy, where cuing of undigested traumatic material has triggered
posttraumatic stress disorder symptoms and heightened affective responses in
clients. Performed skillfully, however, art therapy can provide a structured transfor-
mation of imagery and energy through the triadic relationship between therapist,
client, and the art product (Schaverien, 1992).
Art therapy as treatment for people with severe dissociative disorders engages
cognition, affect, sensation, and motor behavior. It helps to order and complete
fragmented and discontinuous gestalts. Art-making externalizes visually encoded
images and long-standing idiosyncratic inner realms. It gives the maker an oppor-
tunity to work through unresolved life issues in order to reach a new equilibrium.
Art therapy teaches coping skills that can be used to structure time and provide a
tangible reminder of the therapeutic work. It bridges two otherwise incompatible
realities: the posttraumatic-dissociative and the everyday-ordinary. These are sub-
stantial rewards in working with DID clients; the potential benefits of art therapy
are, however, even more extensive (Mills, 1992b).
One particularly important feature of art-making for individuals who have
severe dissociative disorders is that the artist is both the maker and the observer of
the image. Although art is about making messages from oneself to oneself, people
who experience substantial amnesia have even more to learn from within than
those who do not. Therapeutic art activity provides the client with evidence that
the healing is coming from within her (Schaverien, 1992).
One practical model for structuring the art therapy process that minimizes the
risk of regression with regard to the treatment of dissociative disorder clients has
been discussed by Cohen (1992). His framework for the thoughtful and disciplined
practice of art therapy with this population is based on the integration of the BASK
model (Braun, 1988a,b), which posits a theory of dissociation and a model for its
treatment, with the expressive therapies continuum (ETC) (Kagin & Lusebrink,
1978), which organizes theories of the creative process into a model for planning
interventions in the expressive arts therapies.
The BASK model suggests that when behavior, affect, sensation, and knowl-
edge (BASK) are congruent with each other and confluent over time, there is mental
health (Braun, 1988a). Any or all of the BASK levels can be separated or dissociated
from the others in the course of daily life. The same phenomenon holds true in art,
as is illustrated in the work of DID clients who frequently feature one of the four
BASK levels in their graphic expressions, to the exclusion of the others (Fuhrman,
1993).
The ETC assists the art therapist in the selection of media and tasks appropriate
to the client's needs, strengths, and treatment goals. The ETC delineates the facets
of the art-making process as: kinesthetic-sensory, perceptual-affective, cognitive-
538 symbolic, and creative. One can readily see the four BASK levels paralleled in this
Barry M. Cohen model. The ETC suggests that art media requiring physical energy to manipulate,
applied with tools that offer physical separation between the materials and the
proprioceptive system, structured by tasks that employ a number of steps to
complete, facilitate appropriate cognitive distance during the creative process to
enhance ego function and hinder regression (Lusebrink, 1990).
.Figures 3 through 6, drawn by women diagnosed with multiple personality
disorder, each illustrate one BASK level. Although any art-making activity engages
all levels of the ETC, those ETC levels that correspond to the BASK levels illustrated
by these figures are indicated in parentheses.
• Behaviors are often depicted in drawings, such as the one reproduced in
Figure 3, as self-destructive reenactments of trauma. If one perceives drawing
behavior as a sublimation of the impulse to act, then-in this case-art is highly
preferable to its alternative. (kinesthetic, creative).
• Art objectifies affect by giving it form. A pervasive and uneasy feeling is
expressed in Figure 4. Amorphous shape and a murky use of color poignantly
convey the essence of sexual shame in this watercolor painting. (perceptual,
affective)
• Sensation images, such as the one in Figure 5, trigger a visceral response in
the viewer, as conveyed by the maker. To avoid this isomorphic response, one
would have to dissociate. It is rather unusual that such a naturalistic, narrative
technique be employed to depict a sensory experience; painful sensations are more
typically portrayed expressionistically through heightened color and movement. In

Figure 3. Impulsivity can be communicated and behavior sublimated through art-making.

 539
Art and the
Dissociative
Paracosm

Figure 4 . Color and form effectively externalize affect and convey it to the viewer.

this image, distortion and exaggeration give the grimacing face its visual impact.
(sensory)
• Collage requires the maker to engage in a kind of spatial organization that
serves to structure cognition; this process helps clients work with the knowledge
component of experience. Since the images used in collage have been appropriated
from an external source (such as a magazine), adequate emotional distance can be
maintained; thus, this technique fosters containment and control within the client.
The collage shown in Figure 6 is titled, "Tools of the Trade." The making of this piece
helped the client to organize the chaos of a physically abusive childhood into a
manageable space; once accomplished, she could begin to redefine her relationship
with the everyday items represented in the collage which were previously known
to her as weapons for punishment. (cognitive, symbolic)
540
Barry M. Cohen

Figure S. The impact of intense sensation is conveyed by distortion and exaggeration in this image.

Figure 6. CoUage, a populat art-making technique, can enhance knowledge by encouraging the maker
to organize and define pictorial elements.
 Art therapy's function in the treatment of dissociative disorders can be 541
summed up by the following effects, each of which is associated with one or more Art and the
of the BASK levels essential for the transformation of nonverbally encoded or Dissociative
dissociated material: Paracosm

• The restorative effect of art therapy refers to the attainment of mastery over
the past. It recovers visually stored, unprocessed representations and restores them
to consciousness. Anxiety-provoking material is externalized and concretized in a
tolerable or pleasurable way. (affect and sensation)
• The orientative effect of art therapy communicates new information about
the person and her world and suggests ways for the integration of disparity within
each. It deals with revealing a previously discontinuous narrative in the present.
Once an issue is externalized and concretized, an appropriate resolution may be
attempted. (knowledge)
• The preparative effect of art therapy provides for rehearsal of upcoming
events and reinforcement of control in the present. It is about practicing for the
future and facing challenges in a planned, methodical way. (behavior)

CONCLUSION

We talk too much; we should talk less and draw more.

GoETHE

Relying solely on verbal communication in the psychotherapy of people with

severe dissociative disorders limits the possibilities for discovery; understanding,
and growth. This is true, in part, because verbal psychotherapy is not an iso-
morphically advantageous vehicle for accessing the trauma-based constructs that
constitute dissociative paracosms. Therapy with persons who have survived severe
trauma must focus on the externalization of those traumatic experiences in order to
adjust the anomalous constructs formed in trauma's wake. According to Herman
(1992), "Creating pictures may represent the most effective initial approach to these
'indelible images' "(p. 177). Before attempting to introduce art into psychotherapy
with those who were severely abused in childhood, however, it is essential that
therapists be fully aware of the training necessary to effectively negotiate the
complexities of graphic communication and be mindful of the option to refer or
consult with a specialist for this aspect of the treatment.
Art reality and the dissociative reality have a variety of attributes in common
that favor the spontaneous making of art and facilitate the use of art therapy in
addressing the cognitive, emotional, behavioral, biological, and interper.sonal con-
sequences of trauma. These qualities can readily be observed in the characteristics
of art movements that have spanned the last 100 years; the very same century since
the development of Janet's landmark theory of dissociation.
For patients who consider themselves to be literally invisible, not worth taking
up any space, or utterly powerless, engaging in art therapy can be an assertion that
they are not simply a physiological entity, but rather a physical and psychological
force in the universe. The artist's ability to make her mark on the world, simply by
542 poking the clay or making a mark on paper, can be existentially fulfilling
Barry M. Cohen (Csikszentmihalyi, 1978).
Why do people with severe dissociative disorders produce so much art? In
order to communicate. Through art, the patient is saying to the viewer, "Please
listen. This happened to me. No one would believe me. I cannot remember, yet I
cannot forget."
Why do people with severe dissociative disorders produce so much art? In
order to exist. Through art, the patient is saying to the viewer, "I learned quickly not
to feel, not to be. I went away; now I am back, taking control ... yet stuck between
two realities."

AcKNOWLEDGMENTS. Portions of this chapter were previously presented at the Fifth

Annual Eastern Regional Conference on Abuse and Multiple Personality, Alexandria,
Vrrginia, June 5, 1993. The author wishes to express his thanks to Anne Mills, M.A.,
A.T.R., for her invaluable assistance during all phases in the preparation of this
chapter.

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can Psychiatric Press.
Koestler, A. (1964). Tbe act of creatton. New York: Dell Publishing.
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Loewenstein, R. J. (Ed.). (1991). The psychiatric clinics of North America: Multiple personality disor-
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G. Braun & E. B. Carlson (Eds.), Proceedings of the lOth International conference on multiple
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Alexandria, VA: Audio Transcripts.
544 Moon, B. L. (1990). Existential art tberapy: Tbe canvas mirror. Springfield, lL: Charles C Thomas.
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Sons.
26
Psychopharmacology
Moshe S. Torem

INTRODUCI10N

This chapter provides a review of the various psychotropic medications and bene-
fits of their use in the treatment of patients with dissociative identity disorder
(DID). Psychopharmacology in the broad perspective includes the study of the
effects of psychoactive drugs on the human mind, including the patient's thoughts,
feelings, physical sensations, fantasies, activities and behavior applied in day-to-day
living. In general, it is important to state that currently there is no one specific
medication or combination of medications that cure patients with a dissociative
disorder. However, the use of psychotropic medications can be quite helpful by
providing the following benefits:
1. Reduce the intensity of debilitating symptoms such as anxiety, depression,
poor concentration, insomnia, restlessness, nightmares, panic states, exag-
gerated startle response, and phobias.
2. Improve the patient's mental state and attention focus to be more amenable
and ready to benefit from psychotherapeutic interventions.
3. Provide the benefit of psychopharmalogical interventions in patients who
have the comorbidity of a dissociative disorder with another psychiatric dis-
order such as major depression, bipolar disorder, panic disorder, obsessive-
compulsive disorder, and so forth.
The primary treatment for patients with dissociative disorders is psycho-
therapy using a psychodynamic approach with adjunctive use of hypnosis when

Moshe S. Torero • Department of Psychiatry and Behavioral Sciences, Akron General Medical Center,
Akron, Ohio 44307; and Department of Psychiatry, Northeastetn Ohio Universities College of Medicine,
Akron, Ohio 44272.
Handbook of Dissociation: Tbeoretica~ Empirical, and Cltntcal Perspectives, edited by larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 545
546 indicated (Kluft, 1984, 1985, 1989; Braun, 1986; Coons, 1986; Putnam, 1986, 1989;
Moshe S. Torem Ross, 1989). However, I believe that a comprehensive integrative approach is more
effective and commonly used by many practicing psychotherapists. Such a psycho-
therapeutic approach integrates psychodynamic, behavioral, existential, and cogni-
tive modalities. The relationship between the patient and the therapist is of para-
mount importance in creating a partnership whereby the patient is empowered to
make choices, report on the use or misuse of medications, and participate in the
evaluation of a desired outcome, whether it is the alleviation of symptoms, the
improvement in functioning with the activities of daily living, or both.

MEDICATIONS AND PSYCHOTHERAPY:

GENERAL CONSIDERATION

Physicians are traditionally exposed in their training to the idea that medica-
tions are an important part of any general clinical practice. Nonmedical therapists
need to educate themselves on the special meaning and use of psychotropic
medications and their place in the psychotherapy of patients with dissociative
disorders.
The outcome effects in using psychotropic medications are highly influenced
by the nature of the relationship between the patient and the treating clinician,
especially the one who prescribes the medications. This has been scientifically
recognized and has been termed the placebo effect to include expectations of
outcome as perceived by the patient as well as the therapist and not just the direct
influence of the active chemical ingredient in the prescribed drug. This is so
important that it has become a standard in the efficacy evaluation of new medica-
tions to include double-blind studies so that neither the patient nor the prescribing
physician know which drug is the placebo and which is the one with the tested
active chemical ingredient. The placebo effect is a phenomenon that occurs regu-
larly when the patient uses medications. The placebo effect may enhance the direct
therapeutic effect of the chemical ingredient in the medication, which is termed
the positive placebo effect. On the other hand, the negative placebo effect refers to
a phenomenon that diminishes the therapeutic efficacy of the chemical ingredient
in the prescribed medication. At times, the negative placebo effect can be so
powerful that it not only eliminates any potential therapeutic effect of the chemical
ingredient, but may also produce undesirable and noxious side effects (Plotkin,
1985; Evans, 1985; Shapiro, 1960, 1968; Shapiro & Morris, 1978).
The purpose of the prescribing clinician is to do everything possible to en-
hance the possible placebo effect to maximize the therapeutic efficacy of the
prescribed medication. Enhancing the positive placebo effect involves the utiliza-
tion of the patient's positive transference relationship to the doctor and the pa-
tient's belief that the prescribed medication is going to have the desired therapeutic
effect, as well as believing in the curative powers of the physician. On the physi-
cian's side, it involves the belief in his or her skills and knowledge in treating the
patient's condition, the belief that the prescribed medication is in fact going to
work in a positive therapeutic manner, and the belief that the patient receiving the
prescribed medication is in fact someone who can be trusted to benefit from the 547
medication and has hope for healing and recovery. Psychopharma-
It's important to remember that any time the patient swallows the prescribed cology
medication, he or she will symbolically incorporate and internalize their image of
the doctor, including what took place in the previous session. This internalization
when the medication is swallowed is extremely important to remember since the
very relationship with the prescribing doctor is an essential part of practicing
rational psychopharmacotherapy. Well-trained and skillful doctors know this, and
therefore spend at least 20 to 30 minutes and at times up to an hour with a patient
even though the primary therapist of the patient is at times another clinician who
sees the patient weekly and whose focus is on psychotherapy. It is also important to
emphasize that the nonmedical therapist can enhance the efficacy of the prescribed
medications by positively endorsing the prescribing physician and his or her
therapeutic knowledge, experience, and skill in the field of dissociative disorders
and previous successes with other patients.
In hospitalized patients, additional members of the team that influence this
process should not be ignored. They are the nurse and the nursing assistant, as well
as occupational therapist, art therapist, social workers, and pharmacist who may
endorse the efficacy and positive therapeutic expectations of the prescribed medi-
cation and the positive reputation of the prescribing physician or they may criticize
and question the wisdom of using the prescribed medication, and thus diminish its
therapeutic efficacy.
All of the above-mentioned factors may explain the high degree of variability of
results in using psychotropic or other medications in patients with dissociative
disorders.

MEDICATIONS AND PSYCHOTIIERAPY: SPECIFIC CONSIDERATION

FOR DISSOCIATIVE DISORDERS

Patients with dissociative disorders deserve specific considerations in using

psychopharmacotherapy. The following points are important to remember:
1. Patients with dissociative disorders usually have a history of past trauma and
may have a tendency to express their unresolved trauma by repeating and reenact-
ing the traumatic event in the relationship with the doctor. This in itself may involve
an expectation that the doctor looks and behaves in a nice way but in fact may end
up hurting the patient just as it happened in the past. Spiegel (1986) called this
phenomenon the traumatic transference. This phenomenon originates from the
double binds and dysfunctional families common in these patients' childhood
memory. Spiegel cautioned that the doctor must be aware of it and its potential to
sabotage and undermine any therapeutic intervention, including pharmacotherapy.
2. Patients with dissociative disorders frequently dissociate during the session
and may have amnesia for certain parts or the whole session. This may interfere
with the patient's compliance and understanding in the proper use of the pre-
scribed medications.
548 3. In patients with dissociative identity disorder (DID), it is vitally important to
Moshe S. Torem recognize that alter personality states, even though hidden, obscure, and not
directly involved in the dialogue that takes place between the doctor and patient,
may still sabotage and undermine the desirable therapeutic outcome of prescribed
medications. This may take place in a variety of ways, such as hiding the medica-
tions while in an altered ego state and later having amnesia to it, enhancing
undesirable side effects, taking higher than prescribed doses, and so forth.
4. Patients with dissociative disorders at times may be highly suggestible and
could use what Orne (1959) termed "trance logic." In this type oflogic, the patient's
thinking is rather concrete and devoid of the ability for abstraction.
5. In patients with DID, the prescribing doctor may face the phenomenon of
one personality state being depressed, anxious, or even psychotic and requiring
pharmacotherapy with a specific medication. On the other hand, other personality
states may be in a quiet, relaxed, and neutral state of mind, not needing any
medications. The dilemma for the doctor is to choose the most appropriate and
efficacious therapeutic intervention. Should the medications be prescribed for the
patient as a whole only when the specific symptoms are shared by all the person-
alities, or is it legitimate to prescribe medications when the dominant personality
states suffer from certain dysfunctional symptoms?
6. The issue of comorbidity is also very important since patients with dissocia-
tive disorders may also suffer from other psychiatric disorders such as major
affective disorders, anxiety disorders, attention deficit hyperactivity disorder, alco-
holism, obsessive-compulsive disorder, as well as a variety of different personality
disorders, such as borderline personality disorder, narcissistic personality disorder,
histrionic personality disorder, dependent personality disorder, avoidant person-
ality disorder, and so forth. It is certainly legitimate to use pharmacotherapy for a
dissociative patient who has comorbidity with another psychiatric disorder.
7. The phenomenon of dissociation in itself is many times associated with a
variety of physical signs and symptoms such as changes in heart rate, perspiration,
breathing, blood pressure, blurred vision, numbness, intestinal hyperperistalsis,
urinary frequency, urinary urgency, dry mouth, and so forth. All these may be
difficult to differentiate from potential side effects of a given medication or the
coexistence of a medical illness.
8. A variety of medications can act as triggers for dissociative episodes. These
are medications used in the general practice of medicine, such as the decongestant
Sudafed; the antihypertensive nifedipine; anti-inflammatory agents, such as ibupro-
fen; cortical steroids, such as dexamethasone; antibiotics, such as norfloxacin and
ofloxacin; and antiparkinsonian agents, such as benztropine.

REVIEW OF THE LITERA11JRE

Loewenstein (1991) provides good basic guidelines for the use of rational
psychopharmacology in the treatment of patients with DID. He mentioned several
ground rules. The first is that the use of medications for multiple personality
disorder (MPD) patients must be understood in the context of the total treatment of
MPD, pointing out that it is important to establish clear reasoning for the expected
benefits of the medications and to have clinical criteria for assessment as to whether 549
the medication is beneficial. The second rule states that most problems in the Psychopharma-
treatment of MPD patients are not solvable with medications and have to be cology
addressed in a broader context of psychotherapy done in a trustful therapist-
patient relationship. Loewenstein's third guideline has two parts to it: (1) The
doctor must attempt to treat symptoms in MPD that are valid psychopharmacologi-
cal targets; and (2) The doctor must target symptoms that are present across the
whole person and not those localized in separate alter personalities, i.e., are the
result of dissociative switching.
Kluft (1985) pointed out that the presence of valid medication-responsive
symptoms are very important before the decision to use medication is enacted.
Nonpharmacological interventions have to be utilized for the same symptoms in
order to enhance the potential positive response from the psychotropic medica-
tions. The physician prescribing the medications should have a trustful relationship
with the patient and understand the patient as a whole, including the history of
previous experiences with psychotropic medications. Some clinical trials reported
partial success in individual cases with dissociative disorders using a variety of
medications such as antidepressants, benzodiazepines, beta-blockers, clonidine, or
low-dose neuroleptics (Barkin, Brown, Kluft, 1986; Braun, 1990; Fichtner, Kuhlman,
& Gruenfeld, 1990; Loewenstein, Hornstein, & Farber, 1988; Ross, 1989).
Loewenstein et al. (1988) reported on a systematic study of pharmacotherapy
for patients with MPD. Loewenstein and his colleagues reported moderate improve-
ment with the use of clonazepam in some posttraumatic stress disorder (PTSD)
symptoms and in five MPD patients in an open-label, nonblind clinical trial. The
patients showed sustained improvement over 6 to 12 months in the continuity of
sleep and lessening severity of nightmares and flashbacks. The patients maintained
a stable clonazepam dose.
Braun (1990) reported on the use of clonidine and high doses of propranolol
for the treatment of hyperarousal, anxiety, poor impulse control, disorganized
thinking, and rapid switching in patients with dissociative disorders.
Many patients with DID suffer from the typical posttraumatic stress symptoms
such as heightened sympathetic arousal, exaggerated startle response, disrupted
sleep, and disrupted dreaming. These symptoms have been studied extensively in
the Veterans Administration with posttraumatic stress disorder. Friedman (1988,
1991, 1993, 1994) noted that there is a serious shortage of double blind drug trials in
the pharmacotherapy of patients with posttraumatic stress disorder, as is true for
patients with dissociative identity disorder. However, from the available research it
is clear so far that neuroleptics are not a first-line choice for PfSD symptoms.
Neuroleptic drugs should be used only briefly to control severe agitation. If other
drugs, such as anxiolytics and antidepressants have not worked, neuroleptic may be
added for a more extended use.

Anttkindling Agents
Kindling is a neurobiological phenomenon that occurs following exposure to
traumatic stress. Kindling involves a hypersensitivity of certain parts in the limbic
system of the brain. Chronic high intensity of sympathetic arousal is mediated by
550 the locus coeruleus frequently releasing norepinephrine thus kindling the limbic
Moshe S. Torem system nuclei. This produces a stable persistence neurobiological abnormality. Van
der Kolk (1987) and Friedman (1988) have independently suggested that the
chronic central nervous system sympathetic arousal associated with PTSD pro-
duced an endogenous state that optimized conditions for limbic system kindling.
The increased arousal is characterized by symptoms of insomnia, nightmares,
flashbacks, impulsivity, affective storms, aggressivity, and acting out a compulsion
to repeat the trauma. For these symptoms, antikindling drugs have been found
somewhat effective. The antikindling agents most studied are: carbamazepine (feg-
retol) and valproate (Depakote). Carbamazepine has been studied by Lipper et al
(1986), who observed a reduction in the intensity and frequency of nightmares,
flashbacks, and intrusive recollections. Valproate was studied by Fesler (1991) who
showed that this drug can produce an alleviation of hyperarousal, as well as an
alleviation in the avoidant numbing symptoms in patients with PTSD.

PHARMACOTIIERAPY FOR SPECIFIC SYMPI'OMS

Anxiety
Anxiety is a very common symptom in patients with dissociative disorders. It
may be expressed with a sense of subjectiveness, restlessness, the feeling that some
·disastrous event may take place, loss of control, agitation, and a variety symptoms
such as shortness of breath, blurred vision, urinary frequency; urinary urgency,
diarrhea, tension headaches, poor concentration, dispepsia, and parastesias (pe-
ripheral numbness). The following groups of medications can be used for the
control of anxiety: benzodiazepines, sedative antihistamines, buspirones, beta-
blockers, as well as small doses of certain neuroleptics.

Benzodiazepines. Benzodiazepines are relatively safe anxiolytic medica-

tions. They can be classified into three major subgroups: short-acting, intermediate,
and long-acting (as shown in Table 1). The two drugs in the short-acting group, i.e.,
midazolam and triazolam, are not recommended for use with dissociative disorders.
From the intermediate group, the most often used have been lorazepam and
alprazolam. And from the long-acting subgroup, the most commonly used have
been clonazepam, diazepam, chlordiazepoxide, and clorazepate. Generally speak-

Table L Benzodiazepines: Comparative Action Time

Short-acting Midazolam (Versed) Long-acting Chlordiazepoxide (librium)
Triazolam (Halcion) Clonazepam (Klonopin)
Intermediate-acting Alprazolam (Xanax) aorazepate (I'ranxene)
Halazepam (Paxipam) Diazepam (Valium)
Lorazepam (Ativan) Estazolam (ProSom)
Oxazepam (Serax) Flurazepam (Dalmane)
Temazepam (Restoril) Prazepam (Centrax)
Quazepam (Doral)
ing, all benzodiazepines are well absorbed from the intestines after all administra- 551
tion. There is no significant correlation between plasma concentration and clinical Psychopbarma-
effects, so plasma level monitoring has no clinical benefit. The duration of action is cology
determined mainly by the distribution and not by the rate of elimination. The major
metabolism of these medications is done in the liver through microsomal oxidation
and demethylation. Patients with liver disease may have trouble metabolizing these
medications.
Potential Side Effects. Relatively, these medications are very well tolerated
with few side effects, which disappear with dose adjustment. The most common
side effects are oversedation, fatigue, drowsiness, nystagmus, anterograde amnesia
(most likely with high potency agents), and confusion and disorientation (mostly in
elderly patients). In some patients, paradoxical agitation may take place in the form
of insomnia, hallucinations, nightmares, and rage reactions. All of these are likely to
occur in patients with a previous history of aggressive behavior.
WithdrawaL Abrupt discontinuation of a benzodiazapine may produce the
following symptoms:
1. Withdrawal: This occurs within 1 to 2 days in the short-acting group, 3 to 4
days in the intermediate-acting group, and 5 to 10 days in the long-acting
group. Common symptoms include insomnia, agitation, anxiety, changes in
perception, dysphoria, gastrointestinal distress, and even severe reactions
such as hallucinations, seizures, and coma.
2. Rebound: Rebound occurs hours to days after medication withdrawal.
Symptoms of anxiety may be similar or more intense than those originally
reported by the patient.
3. Relapse: Symptoms may occur weeks to months after the medication was
discontinued, and the symptoms are similar to the original anxiety present
prior to the use of the medication.
Withdrawal ProtocoL To withdraw patients from benzodiazepine, use an
equivalent dose of diazepam as a substitute (for equivalent doses, see Table 2). The
withdrawal should be done according to the following protocol:
1. Reduce diazepam by 10 mg daily until a total daily dose of 20 mg is reached.
2. Then continue to reduce by 5 mg daily to an end point of total abstinence.
3. Consider propranolol to aid in the withdrawal process.
4. Alprazolam requires a special protocol that includes the following steps:
• Reduce alprazolam by 0.5 mg/week; quicker withdraw may result in
delirium and seizures.

Table 2. Benzodiazepines:
Comparative Equivalent Doses
Alprazolam (Xanax) 0.5 mg
Chlordiazepoxide (Librlum) 25.0mg
aonazepam (Klonopin) 0.25 mg
Diazepam (Valium) 5.0mg
Lorazepam (Ativan) 1.0 mg
552 • Carbamazapine in therapeutic doses may aid in the withdrawal process.
Moshe S. Torem • An alternative to the above method is to substitute alprazolam with an
equal dose of clonazepam in divided doses and then decrease the
clonazepam by 1 mg/day.
Special Precautions for AU Benzodiazepines
• Do not use on patients with sleep apnea disorders.
• Administer with extreme caution to patients who perform hazardous
tasks that require mental alertness and physical coordination.
• Benzodiazepines lower tolerance to alcohol and high doses may produce
mental confusion similar to alcohol intoxication.
• Physical and psychological dependence, tolerance, and withdrawal
symptoms may be produced by all benzodiazepines. These are correlated
with the dose and the duration of use.
• Abrupt withdrawal following prolonged use may produce seizures.
Toxicity. Overdose with these medications is rarely fatal if taken alone.
However, it may be lethal when the overdose is taken in combination with other
drugs, such as alcohol and barbiturates. Symptoms of overdose may include hypo-
tension, depressed breathing, and coma. Pregnant women must be cautioned that
benzodiazepines freely cross the placenta and may accumulate in the fetus. Data
regarding the issue of teratogenicity are inconclusive.
Special Instructions to Patients
• -consumption of caffeinated beverages may counteract the therapeutic
effects of the prescribed medication.
• The dose should be maintained as prescribed. Do not increase the dose
without consulting your physician.
• Driving a car or operating other machinery should be avoided until a
response to the drug is determined.
• Avoid the use of alcohol since it may enhance the effects of these
medications, as well as alcohol side effects.
• Avoid abrupt stopping of these medications.
Drug Interactions
• Caffeine may counteract sedation and increase insomnia.
• Cimetidine may decrease the metabolism of benzodiazepines.
• Antihistamines may increase central nervous system depression, as well
as coma and respiratory depression in high doses.
• Barbiturates may cause the same drug interactions as antihistamines.
• Alcohol may cause the same drug interactions as antihistamines.
• Estrogens (including oral contraceptives) may decrease the metabolism
of benzodiazepines, and thus increase its plasma levels as well as its
duration in the body.
• Propoxyphene (Darvon) may decrease the metabolism of benzodiazepines.
Comparing Various Benzodiazepines (See Table 3)
1. Alprazolam (Xanax)
• Reaches a peak plasma level within 1-2 hours of administration.
• Half-life elimination is reached between 9 and 20 hours.
Table 3. Benzodiazepine Trade Names and Dosage Ranges 553
Usual adult dosage range Adult single dose range Psychopharma-
Generic name Trade name (mg/day) (mg) cology

Alprazolam Xanax 0.5-6 0.25-1

Chlordiazepoxide" Ubrium 15-100 5-25
Clonazepam Klonopin 1.5-10 0.5-2
Clorazepate Tranxene 7.5-60 3.25-22.5
Diazepam• Valium 2-60 2-10
Flurazepam• Dalmane 15-30 15-30
Halazepam Paxipam 60-160 20-40
Lorazepam Ativan 2-6 0.5-2
Oxazepam Serax 30-120 10-30
Prazepam Centrax 20-60 10-20
Quazepam• Dora! 7.5-30 7.5-30
Temazepam• Restoril 15-30 15-30
Triazoiam• Halcion 0.125-0.5 0.125-0.5
aAlso available for parenteral administration. Diazepam is available for IV administration in 5 mg/ml
syringes. Lorazepam is available for IM administration in 2 and 4 mglml syringes.
bFDA approved for use as a hypnotic.

• It is rapidly and completely absorbed by most patients. Increasing the

speed of absorption can be achieved by using it sublingually.
• It is effective in patients with panic attacks and as an adjunct in the
treatment of depression.
• Dosing: Starting dose 0.25 mg three times a day; usual daily dose 1-5 mg/
day; maximum daily dose 10 mg/day.
• Please note special precautions on withdrawal.
• Effects on sleep: Decreases stages I, N, and REM sleep; increases stage II
sleep.
2. Chlordiazepoxide (Librium)
• 25 mg of chlordiazepoxide is equivalent to 0.5 mg of alprazolam.
• Peak plasma level is reached through oral administration in 1-4 hours.
• Elimination half·life is 4-29 hours of the parent drug and 28-100 hours of
the active metabolites.
• Oxazepam (Serax) is one of chlordiazepoxide's active metabolites.
• Avoid use by intramuscular injections since the absorption is erratic and
unpredictable.
• Most commonly used in patients with alcohol withdrawal to preventing
delirium tremens.
• Antacids decrease the absorption rate from the gastrointestinal tract.
• Dosing: Starting dose 5 mg three times a day; usual daily dose 15-100 mg/
day; maximum daily dose is 300 mg/day.
3. Clonazepam (Kionopin)
• 0.25 mg of clonazepam is equivalent to 0.5 mg of alprazolam or 25 mg of
chlordiazepoxide.
• Clonazepam is quickly and completely absorbed through the intestine
and reaches a peak plasma level within 1-4 hours. However, it has a slow
onset of activity.
554 •Elimination half-life is 19-60 hours.
Moshe s. Torem •It has no active metabolites.
•It has strong anticonvulsant effects.
•It is commonly used for the treatment and prevention of panic attack and
is also effective in patients in a manic episode.
o It is effective in controlling aggressive behavior

• It is also effective in controlling symptoms of akathisia

4. Diazepam (Valium)
• Equivalent dose: 5 mg of diazepam are equivalent to 0.5 mg of alprazo-
lam, 0.25 mg of clonazepam, or 25 mg of chlordiazepoxide.
• It has a rapid onset of action and reaches the peak plasma level within 1- 2
hours of oral administration.
• Elimination half-life is 14-70 hours for the parent drug and 30-200 hours
for its metabolites.
• It is metabolized in the liver and has active metabolites such as oxazepam
and temazepam.
• Males have a shorter half-life and higher clearance rate than females.
• Chronic use causes accumulation in fat tissue.
• Heavy smoking is associated with higher clearance.
• Especially effective as an anticonvulsant, in alcohol withdrawal and
akathisia, and as muscle relaxant.
• Effects on sleep: Decreases stages I, IY, and REM sleep.
5. Lorazepam (Ativan)
• Equivalent dose: 1 mg oflorazepam is equivalent to 0.25 mg of clonazepam,
0.5 mg of alprazolam, 5 mg of diazepam, or 25 mg of chlordiazepoxide.
• It is well absorbed with oral administration, including sublingually.
• Peak plasma level is reached within 2 hours by oral administration, within
45-75 minutes by intramuscular injection, within 5-10 minutes by intra-
venous injection, and within 60 minutes with sublingual administration.
o Elimination half-life is 8-24 hours.

• It has no active metabolites.

o It has a slow onset of action.
o Dosing: Starting dose 0.5 mg twice a day; usual daily dose 2-6 mg/day;

maximum daily dose 10-20 mg/day.

o It is a good muscle relaxant.

o It is effective for akathisia and acute dystonia.

• It has significant anterograde amnesia which does not correlate directly

with the sedative potency.
• Withdrawal symptoms appear sooner than with long-acting drugs.
o Effects on sleep: Decreases stage I and REM sleep; increases stage II of

sleep.

Alprazolam and clonazepam are relatively more potent for panic and some-
what less potent with generalized anxiety.

Sedative Antihistamines. In this group, I mention two examples: hydroxy-

zine (Vistaril, Atarax) and diphenhydramine (Benadryl). These medications do have
some antianxiety effects. They have no muscle-relaxing features. There is no poten- 555
tial abuse or habituation. They have some antiemetic features. Psychopharma-
Hydroxyzine has few side effects. Its sedation when used for longer periods of cology
time loses its effect because patients develop tolerance. Starting dose is 10 mg three
times a day; usual dose 25 mg three times a day; maximum dose is 400 mg/day.
Diphenhydramine is available over the counter in the United States in a variety
of cough syrups, as well as decongestant agents. It depresses the REM sleep in
doses of 50 mg and higher. Starting dose is 25 mg twice daily; usual daily dose is
25 mg four times a day or every 4-6 hours as needed; maximum dose is 500 mg
per day.
Side Effects and Toxicity. These include drowsiness and dry mouth, and
they may cause urinary retention in high doses. Antihistamines should be avoided in
patients with asthma, glaucoma, emphysema, chronic pulmonary disease, or short-
ness of breath. Alcohol should be avoided since it will increase the drowsiness.

Buspirone. Buspirone (BuSpar) is a relatively new selective anxiolytic medi-

cation which is not a benzodiazepine. It has no anticonvulsant features nor is it a
muscle relaxant. On the other hand, this medication does not develop any tolerance
or habituation. It is believed that it works on the central nervous system by
decreasing the noradrenergic and dopaminergic activity. Long-term administration
of buspirone may cause a down-regulation of the serotonin type II receptors. This
medication is specifically effective where sedation is desired without causing any
psychomotor impairment in functioning. Patients with a history of alcohol and
substance abuse benefit from buspirone rather than benzodiazepines. It has also
been used for the augmentation of antidepressant medications, and some claim
(Jacobsen, 1991) that buspirone also has its own antidepressant effect when given in
doses of 40-80 mg/day. may also potentiate antiobsessional effects of tluoxetine,
sertraline, or paroxetine.
Dosage. Starting dose is 5 mg two times a day; usual daily dose is 10 mg three
times a day; and the maximum dose is 60-80 mg/day. Clinical efficacy begins within
1-2 weeks of administering the usual dose of 30 mg per day. This medication is not
useful on an as-needed basis. The maximum effect is usually seen in 3-4 weeks from
the onset of administration. Food may reduce the rate of absorption. Peak plasma
takes place between 0. 7 and 1.5 hours. Elimination half-life is 1-11 hours. The drug
has one active metabolite.
Potential Side Effects and Toxicity. The following side effects have been
reported with buspirone: headaches, dizziness, light-headedness, fatigue, numb-
ness, and upset stomach. Withdrawal effects have not been reported. There is no
cross-tolerance with benzodiazepines, barbiturates, or alcohol.
It is a relatively safe medication and no deaths have been reported in people
who overdose on buspirone. Toxic effects in cases of overdose include dizziness,
nausea, and vomiting. Use during pregnancy in terms of safety has not been
determined. However, both buspirone and its metabolites are excreted in the
mother's milk.
Drug Interactions. Haloperidol may be inhibited in its metabolism when
given in combination with buspirone, and thus plasma levels may stay higher for a
longer time. Fluoxetine and monoamine oxydase inhibitors, when used in combina-
556 tion with buspirone, may cause high blood pressure and also potentiate antiobses-
Moshe S. Torem sional effects. Buspirone may cause an increase in the serum level of diazepam.
Wise Tip. The antianxiety effects of buspirone are gradual, and signs of
improvement may begin within 7-10 days after starting the medication, reaching a
peak of improvement in 2-4 weeks.

Beta-Blockers. These agents, such as propranolol (lnderal), are most effec·

tive in the treatment of the autonomic symptoms of anxiety. This medication blocks
the beta-adrenergic receptor sites, and thus prevents the natural neurotransmitters
of norepinephrine and epinephrine from taking effect. Since the 1960s, they have
been used for the treatment of anticipatory anxiety, such as performance during
tests, public speeches, the theater, interviews, and so forth. The starting dose of
propranol is 10 mg three times a day; usual daily dose is 20 mg three times a day; and
the maximum dose is 240 mg/day. Braun (1990) reported on the experimental use
of higher doses of propranolol in patients with MPD in order to reduce rapid
switching. However, the control of anxiety is not a primary indication and does not
appear in the Physicians Desk Reference nor is it specifically approved by the Food
and Drug Administration for this specific purpose.
Side litfects. These include bradycardia, hypotension, light-headedness, diz·
ziness, and occasionally fainting. It may also cause mental depression.

Neuroleptics. Some patients with severe anxiety to the point of agitation,

impulsivity, and aggressivity may respond better to small doses of sedative neurolep-
tics, such as perphenazine (frilafon), 2 mg three times a day up to 4 mg four times a
day; thioridazine (Mellaril), 10 mg three times a day up to 25 mg four times day; and
chlorprothixene (faractan), 10 mg three times a day up to 50 mg four times a day.
Some patients with very severe agitation respond better to an intramuscular injec-
tion of droperidol (lnapsine), 2.5-5.0 mg, which produces sedation and sleep
lasting between 1 to 3 hours, following which the patient wakes up relaxed with no
agitation (see Table 4).
Side IU:fects. Neuroleptic drugs have a variety of side effects ranging from
drowsiness to extrapyramidal-parkinsonian reactions such as akinesia, rigidity and
tremor, akathisia, acute dystonia, acute dyskinesia, and the late-appearing tardive
dyskinesia. Many patients develop autonomic nervous system symptoms such as
dry mouth, tachycardia, blurred vision, nasal congestion, and orthostatic hypoten-
sion. Some patients may develop agranulocytosis, dermatitis, jaundice, purpura,
and even a malignant neuroleptic syndrome.

Depression
Depression associated with feelings of helplessness, hopelessness, futureless-
ness, and anhedonia is a common symptom in patients with dissociative disorder.
Some patients may have the comorbidity of a major depression, a dysthymic dis-
order, or bipolar disorder. These should be treated accordingly as indicated in the
standards of practice for mood disorders.
Antidepressant medications are currently available in the following groups:
tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reup- 557
take inhibitors, and miscellaneous antidepressants. In selecting the use of an anti- Psychopharma-
depressant medication, I use the following guidelines: cology

1. Safety. It is of paramount importance to emphasize the fact that some

depressed patients may be very impulsive and can act out on an instant urge in a self-
destructive way. Prescribing the patient with an antidepressant medication that
potentially can be overdosed by the patient must be considered in terms of the
medication's safety profile. The wider the gap between the therapeutic dose and
the toxic lethal dose, the safer the medication. In that sense, the tricyclic anti-
depressants and the monoamine oxidase inhibitors are the least safe, while the new
generation of antidepressants such as the selective serotonin reuptake inhibitors are
the safest; such medications as trazodone and bupropion are significantly safer than
the tricyclics but not as safe as the selective serotonin reuptake inhibitors.
2. Symptom Profile. Some patients who have depression may slow down
and withdraw emotionally and physically, have increased sleep (hypersomnia),
increased eating (hyperphagia), generalized fatigue, and low energy level. This
subgroup of patients responds well to antidepressant medications that not only
alleviate the patient's mood but also have an energizing effect by suppressing the
appetite and decreasing the patient's need to sleep. Medications that belong to this
group include fluoxetine (Prozac), paroxetine (Paxil), bupropion (Wellbutrin),
protriptyline (Vivactil), and, to a lesser extent, desipramine (Norpramin) and tranyl-
cypromine (Parnate). On the other hand, there is another subgroup of patients who
experience depression associated with psychomotor agitation and restlessness.
Such patients also experience insomnia, anxiety, poor appetite at times associated
with weight loss, and a feeling of aimless energy. These patients respond better to
antidepressants that have a sedating effect, which improves their sleep and reduces
the patient's level of anxiety and agitation. The following medications belong to this
group: trazodone (Desyrel), amitriptyline (Elavil), doxepin (Sinequan), trimipra-
mine (Surmontil), and maprotiline (Ludiomil).
3. Side Effect Profile
• Anticholinergic. Some patients are particularly sensitive to anticholin-
ergic side effects such as dry mouth, blurred vision, constipation, and delayed
micturition (urinary retention). Antidepressants that are highly potent in their
anticholinergic side effects are the following: amitriptyline, clomipramine, dox-
epin, maprotiline, and amoxapine. On the other hand, the following antidepres-
sants have the least anticholinergic side effects: desipramine, nortriptyline, trazo-
done, fluoxetine, sertraline, and paroxetine.
• Cardiovascular Side Effects. Cardiovascular side effects such as ortho-
static hypotension, dizziness, tachycardia, and cardiac arrhythmias are not uncom-
mon with antidepressant medications. The following antidepressants have the least
cardiovascular side effects: fluoxetine, sertraline, paroxetine, and nortriptyline.
The antidepressants with a higher frequency for cardiovascular side effects include
amitriptyline, clomipramine, and imipramine.
• Extrapyramidal Side Effects. Amoxapine is the antidepressant most com-
monly related to these specific side effects due to a metabolite resembling the
neuroleptic drugs.
558 • Epileptic Seizures. These have been reported in maprotiline in doses
Moshe S. Torem above 225 mg/day and in bupropion in doses of 450 mg/day and higher.
Weight Gain. The issue of weight gain is extremely sensitive in our cul-
ture. Many patients will not cooperate in taking certain medications if it is associ-
ated with weight gain. The following antidepressants are associated with a weight
gain of 10 pounds or more: amitriptyline, doxepin, and maprotiline. Those associ·
ated with the least weight gain are fluoxetine, sertraline, paroxetine, bupropion,
protriptyline, and tranylcypromine.
4. Concomitant Medical Conditions. Some patients suffer from narrow·
angle glaucoma, which is relatively well managed with eye drops. Such patients
should not be given antidepressants that have anticholinergic effects since it may
exacerbate a state of acute glaucoma requiring emergency intervention. Other
patients may have benign hypertrophy of the prostate gland, which makes them
more sensitive to developing urinary retention with medications that have anti-
cholinergic effects.
5. Previous Experience with a Certain Antidepressant. Patients who had a
positive previous experience with a certain antidepressant prefer to use it again if
faced with the choice of taking one. Prescribing clinicians should be sensitive to
this issue and inquire as to the patient's previous experience with certain anti-
depressants. A simple guideline is, "What worked before has a good chance of
working again." The opposite of that is also true. The patient's negative experience
with a certain antidepressant will diminish the chances of its efficacy even if
everything else is compatible.
6. Previous Familiarity with a Certain Antidepressant. Some patients are
familiar with certain antidepressants based on their positive efficacy with a family
member, friend, or from their own reading about it. Such information should be
elicited from the patient since it potentiates the positive placebo effect and im-
proves the chances of a positive therapeutic outcome providing the rest is compa·
tible and there is no contraindication.
7. Timing. Many antidepressants can be given in one dose and this will be
sufficient for 24 hours. Most patients with insomnia will benefit from a once a day
dose given at bedtime, thus promoting the patient's sleep, in addition to the anti-
depressant effects. This will also increase the patient's compliance in using the
medication.
8. Patient Choice. Some patients with dissociative disorders detest being
controlled and dictated to by the medical profession or any other authority figures.
It is extremely important to incorporate the patient's need for empowerment and
mastery into the prescribing skills of the doctor. I ask the patient to choose their
own time when they wish to take their medication, whether it is before meals or
after meals, in a once-a-day dose or in divided doses, providing everything else is
equal. This increases the patient's sense of partnership in the decision process and
improves the chances for cooperation in taking the prescribed medication.
9. Age. Elderly patients are more sensitive to hypotensive side effects of any
medications, including antidepressants. Therefore, they should be given anti-
depressants with the least hypotensive side effects and should be educated as to
measures to prevent orthostatic hypotension.
10. Cost. High cost of an antidepressant that is beyond the patient's eco-
nomic affordability will reduce the chances of the patient's cooperation in taking
the prescribed medication. Physicians should be sensitive to the issue of cost and 559
educate themselves as to the financial impact that a specific medication may have Psychopharma-
on the patient's weekly and monthly budget. This issue should be included in the cology
discussion with the patient prior to choosing a specific antidepressant.
For specific daily doses of antidepressant medications, look for details in Table 4.

Flashbacks and Poor Impulse Control

These symptoms are quite common in patients with dissociative disorders.
The following medications have been found to provide some relief of the intensity
of these symptoms: perphenazine, chlorprothixene, haloperidol, and droperidol. It
is important to note that such medications should be used with great caution and in
low doses. Once the symptom has been significantly reduced, every attempt should
be made to decrease and discontinue the specific neuroleptic medication used.
Droperidol is available only by injection for intramuscular or intravenous use. In
dissociative patients, it should be used only as an intramuscular injection in extreme
states of high agitation with flashbacks, confusion, and destructive acting out.
Droperidol has been found to be very helpful in doses of 2.5 to 5 mg every 4 to 6
hours. The therapeutic response takes place within 15-30 minutes. Many patients
fall asleep and wake up in a different state of mind, more relaxed, mature, and
appropriate. For specific daily doses of these medications, see Table 5.

Rapid Switching
This symptom is not easy to control. Braun (1990) reported on the use of
propranolol and clonazepam with limited success in reducing rapid switching. My
experience involved the use of Inderal in doses of 60-240 mg a day, as well as
donazepam in doses of 6-16 mg a day. The success rate improves with the utiliza-
tion of hypnotherapeutic centering techniques (forem & Gainer, 1993, 1995).

Table 4. Daily Dosages of Antidepressant Medications

Starting dose Usual dose Maximum
Generic name Trade name (mg/day) (mg/day) dose (mg/day)

Nonriptyline Pamelor 10-25 75-100 150

Amitriptyline Elavil 10-75 100-150 300
Imipramine Tofranil 10-50 100-150 300
Protrlptyline Vivactil 5-10 30-45 60
Trimipramine Surmontil 25-50 100-150 300
Doxepin Sinequan 25-50 100-150 300
Amoxapine Asendin 50-100 100-200 600
Maprotiline Ludiomil 25-50 75-125 225
Fluoxetine Prozac 10-20 20-40 80
Sertraline Zoloft 25-50 100-150 200
Paroxetine Paxil 10-20 20-40 50
Trazodone Desyrel 25-75 100-250 600
Bupropion Wellbutrln 75-100 150-300 450
Tranylcypromine Paroate 10-20 20-40 60
560 Table s. Daily Dosages of Neuroleptics
Moshe S. Torem Commonly Maximum dose
Generic name Brand name Starting dose used dose (mgtday)

Perphenazine Trilafon 2 mg TID" 4 mg/QID 24-30

Chlorprothlxene Taractan 10 mgTID 50 mgQID 300
Thioridazine MeUaril 10mgTID 25 mgQID 100
Droperidol lnapsine 1.25 mg TID 2.5 mg TID 10
"TTD, three times a day; QID, four times a day.

In two patients, there was a moderate response to the use of the antiepileptic
and mood stabilizer carbamazepine in doses of 100 mg, three times a day, up to 200
mg, four times a day. Therapeutic serum levels for carbamazepine should be in the
range of 4-12 f!.g/ml.

New Released Medications

The following medications have recently been released by the Food and Drug
Administration for the use with a variety of psychiatric conditions and may also be
helpful in patients with DID: fluvoxomine, naltrexone, nefazodone, risperidone,
and venlafaxine.
Table 6 provides basic information regarding the drugs' primary indications,
postulated mechanisms of action, and the various appropriate doses.

Fluvoxomine. Fluvoxomine is a selective seratonin reuptake inhibitor

(SSRI). In that sense, it is quite similar to others in the SSRI group, such as
fluoxetine, sertraline, and paroxetine. Even though the medication is particularly
indicated in the treatment of patients with obsessive-compulsive disorder, it has
also been known to have antidepressant features similar to the other SSRis. So far, I
have only limited experience in the use of this medication, and I have found it
helpful in DID patients who have roominating thoughts, various obsessions, and
compulsions, as well as in cases of DID patients who have a concurrent diagnosis of
obsessive-compulsive disorder. For further information on this newly released
medicine, please refer to the articles by John Griest et al. (1995). However it may be
important to note here that fluvoxemine inhibits the activity of cytochrome P450
isozymes 1A2, 2C9 and 3A4, thereby slowing down the metabolism of other medica-
tions that are taken concurrently by the patient. It delays the clearance and increases
serum concentration of the following drugs: alprazolam, propranolol, terfenadine,
astemizole, and some of the tricyclic antidepressants. Dissociative identity disorder
patients who concurrently suffer from drug addiction and are receiving methadone
treatment may have increase plasma concentrations of methadone if they concur-
rently take fluvoxamine. In addition, fluvoxamine and MAO inhibitors should not be
taken within two to three weeks of each other.

Naltrexone. This medication has been found helpful in DID patients who
suffer from a concurrent diagnosis of alcohol dependence and opiate addiction.
Table 6. Newly Released Drug Names and Dosage Ranges 561
Average adult Adult single Psychopharma-
dose range dose range cology
Generic name Brand name Indication (mg/day) (mg/day)

Fluvoxontine Luvox OCD 100-200 50-300

Naltrexone ReVta Alcoholism/narcotic dependence 50-100 25-150
Neiilzodone Serzone Antidepressant 200-300 200-600
Risperidone Risperdal Antipsychotic 2-4 2-8
Venlafaxlne Effexor Antidepressant 100-125 75-225

Naltrexone is an opiate antagonist, and animal studies have shown that opiate
antagonists will decrease the animal's drinking of alcohol and craving for opiate-
type drugs. In 1990, Braun reported some success in the use of naltrexone in the
treatment of DID patients. Dr. Braun believes that some of the DID patient's
symptoms can be understood in terms of the brain's addiction to its own internal
opiates, i.e., the beta endorphins. Beta endorphins may be stimulated for increase in
higher amounts at the time of repeated abreactions and repeated self-injurious
behavior, which, according to Braun, are analogous to a drug addict's dependence
on opiates. Dr. Braun reported on a trial of naltrexone for the control of such self-
injurious behaviors as self-mutilation, hinging and purging, compulsive sexuality,
and compulsive exercising. However, this was a non-blind trial. So far, I have not had
any experience in my practice with the use of this medication. Its place and efficacy
in the treatment of DID patients remains to be seen in further research.

Nefazodone. lbis drug is chemically related to trazodone. It is an anti-

depressant and works by blocking the re-uptake of norepinepherine, serotonin, and
dopamine. One of the effects of nefazodone is somnolence, which makes it best to
be used at bedtime and perhaps an effective drug in the treatment of insomnia since
it does not interfere with the patient's REM sleep. My experience in using this new
drug with DID patients is rather limited, however, it may have a special place in the
treatment of DID patients who suffer from depression associated with severe
insomnia, since this drug does not reduce the patient's REM sleep and, in fact,
according to a recent study by Sharpley et al. (1992), may increase REM sleep.

Risperidone. Risperidone is a newly-released neuroleptic classified as an

atypical antipsychotic medication which is claimed not to have any extrapyramidal
side effects and no tardive dyskinesia side effects. Apparently its mechanism of
action may be mediated by blocking the receptors for dopamine type 2 (D2) and
serotonin type 2 receptors. It also blocks alpha 1 and alpha 2 adrenergic receptors,
as well as histaminergic receptors. My clinical experience with risperidone in DID
patients has been limited to several severe cases dominated by symptoms of rapid
switching, severe flashbacks, and other PTSD-intrusive symptoms such as severe
anxiety, panic, and agitation. A dose of 0.5-3.0 mg, twice a day, was found to be
highly effective in diminishing flashbacks, nightmares, agitation, and rapid switch-
ing. I have heard similar reports on the success in using this medication for DID
562 patients with the above symptoms from other clinicians, such as Dr. James Chu,
Mosbe S. Torem from McLean Hospital in Boston, Massachusetts (1995) and Dr. Richard Wolin from
Buffalo, New York (1994).
Further research and clinical trials need to be done to have a better assessment
on the efficacy and usefulness of this medication with DID patients.

V("Oiafaxine. Venlafaxine is a newly released antidepressant whose mecha-

nism of action is believed to be the inhibition of reuptake of serotonin and nor-
epinephrine. It is also a weak inhibitor of dopamine reuptake. Chemically, it is
unrelated to tricyclics or other known antidepressant agents. The drug is reported
to have no anticholinergic side effects. It should not be used in conjunction with MAO
inhibitors. Venlafaxine is metabolized in the liver by the Cytochrome P450IID6
system. So any drugs that inhibit the effectiveness of this system will increase the
plasma level of venlafaxine. The major side effects of this medication are nausea
(37%), headaches (25%), and somnalence (23%). The usual dosing begins with 25
mg, three times a day, gradually increasing up to a maximum dose of 225 mg/day. My
experience with the use of this medication in DID patients is rather limited, and I
have reserved its use for those DID patients who suffer from depression as a major
dysfunctional symptom and have not responded to other well-known antidepres-
sants. For further information on venlafaxine, see Montgomery (1993).

Moclobemide. Moclobemide is a reversible monoamine oxidose inhibitor

type-A. It is focused on affecting the central nervous system rather than the periph-
ery. Amrein et al. (1989) pointed out that this drug has more potency in vivo than in
vitro, suggesting that it is most likely metabolized to a different chemical form with
higher affinity for the MAO-A than the parent compound. Moclobemide has also
been shown not to have the increased inhibition of monoamine oxidaze by re-
peated administration of the drug, which does occur with the irreversible MAO
inhibitors. The half-life of moclobemide is about 12 hours. This drug has been found
effective in patients with all types of depression, including psychotic and bipolar
depression. It is expected that this drug will be effective in the treatment of patients
with bulimia, panic disorder, and posttraumatic stress disorder, as well as patients
with dissociative disorders. Some of these effects have been shown by Versiana
et al. (1992), Larsen et al. (1991), and Rossel and Moll (1990). The dose required is
in the range of 300 to 600 mg/day. The drug interaction profile is very favorable. No
interaction has been found in combining moclobemide with lithium, tricyclics,
serotonin reuptake inhibitors, or neuroleptics (Amrein et al., 1992). Moreover, this
drug does not require any dieting restrictions regarding tyramine-containing foods.
The above feature of the drug increases the possibility of making moclobemide and
other reversible MAOIs first-line choices. The drug is expected to be approved by
the Food and Drug Adminsitration in 1996.

SLEEP APNEA AND NOCTURNAL MYOCLONUS

In the past two years, I have had the experience of treating more than a dozen
cases of patients with DID who have been in long-term psychotherapy and have
worked through many of their unresolved issues. However, in the face of various 563
medications, these patients have continued to suffer from insomnia, as well as Psychopharma-
daytime symptoms of dissociation, amnesia, confusion, flashbacks, repetitive head- cology
aches, and depression. A thorough history included information from the patients'
spouses and other relatives, revealing nighttime snoring as well as leg-jerking. This
resulted in a special referral to the sleep lab for a nighttime polysomnogram, which
revealed the diagnosis of obstructive sleep apnea, at times in combination with
nocturnal myoclonus. The obstructive sleep apnea is apparently not uncommon in
DID and PfSD patients. It interferes with the completion of healthy sleep cycles,
including REM sleep, and it reduces oxygen saturation, causing the brain to suffer
from brief periods of hypoxia. This results in chronic sleep deprivation, as well as
daytime symptoms such as sleepiness and poor concentration. Effective therapy for
these cases involved treatment with a continuous pressurized air perfusion ma-
chine or bilevel pressurized air perfusion machine. In addition, the patients who
were diagnosed with nocturnal myoclonus were successfully treated with small
amounts of clonazepam (up to 3 mg at bedtime) or small amounts of sinemet in
doses ranging from one tablet of 25/100 mg to 50/200 mg at bedtime. The improve-
ment in the patient's quality of sleep at night resulted in a dramatic improvement in
the patient's daytime symptoms, including many of the dissociative symptoms
mentioned above, as well as in the patient's level of daytime functioning. Dr.
Michael Gainer and myself reported on these findings in the November meeting of
the International Society for the Study of Dissociation in Chicago, Illinois, as well as
in a recent report in the ISSD Newsletter (Gainer & Torem, 1994). Dr. Richard Kluft,
who was at our presentation in Chicago, reported that he too has had several cases
of DID patients who concommentantly suffered from sleep apnea and whose
daytime symptoms were significantly improved following appropriate treatment
with the continuous pressurized air perfusion machine. This information suggests
that dissociative symptoms in patients with DID, as well as other aggravating
symptoms, may be of multiple origins and may require a multimodel approach for
successful treatment. It also points out that many DID patients may have comorbid-
ity with other psychiatric disorders, as well as medical disorders.

CONCLUSION

It is important to remember the following points when prescribing medica-

tions with patients who suffer from DID:
1. Treat the person, not the illness. I believe that effective therapy of a DID
patient involves the whole person and not just DID or any other disease. It
is the person as a whole who should be treated, not just a disease or
symptom.
2. There is no one specific medication or medication combination that cures
the core symptoms of patients with dissociative disorders.
3. Medications are used as an aid in reducing the intensity of some symp-
toms, alleviating other symptoms, and helping the patient to better utilize
psychotherapy.
564 4. In cases where the psychotherapy and the pharmacotherapy are provided
Moshe S. Torem by two different clinicians, it is vital for these clinicians to work together as
a cooperative team to improve the therapeutic response to prescribed
medications.
5. Patients with dissociatve disorders are not immune to other psychiatric
diagnoses such as bipolar or unipolar mood disorders, panic disorder,
obsessive-compulsive disorder, nocturnal myoclonus, or other conditions
which do respond quite well to pharmacotherapy. In cases where comor-
bidity does exist, pharmacotherapy should be considered and used.
6. Safety should always be of the highest priority. In suicidal patients with
histories of overdoses, the administration of new medications should be
done cautiously and preferably in an inpatient setting.
7. Taking medication from a caring and empathic physician and making it an
experience of mastery for the patient increases the chances for a positive
therapeutic outcome.
8. More research is needed in this area of psychopharmacotherapy to deter-
mine which combinations of medication adminsitration are the ones that
have the best therapeutic outcome in specific patients.
9. Sleep Apnea: In a recent report by Michael Gainer and myself (Gainer &
Torem, 1994), we found that in a subgroup of patients who were diag-
nosed with DID, they also had a comorbidity of sleep apnea. The proper
treatment of the sleep apnea significantlyreduces the dissociative switch-
ing and amnesia during the day.
10. Do not be too aggressive with pharmacotherapy. Sometimes the side
effects can be worse than the original presenting symptoms. Use a rational
benefit risk assessment. When the potential benefits outweigh the poten-
tial risks, there is value in prescribing pharmacotherapy or any other
therapeutic intervention.

REFERENCES

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(1989). Pharmacology of reversible MAO!. British journal of Psychiatry, 144, 66-71.
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VII
SPECIAL TOPICS

In this final section of the volume, two areas that have generated heated debate are
considered-ritual abuse and forensic interpretation of dissociative disorders. Rit-
ual abuse is discussed by Sakheim in Chapter 27. In this chapter, he begins by
defining ritual abuse and discussing modifiers such as "satanism" that have been
applied to its description. Calling for more research, he begins by describing
reports from a variety of sources related to ritual abuse. He then moves to a
metacognition level and examines four of the ways in which people have related to
these reports. By utilizing four approaches previously suggested by Greaves, gen-
eral reactions can be characterized as coming from (l) Nihilists, (2) Apologists,
(3) Heuristics, and ( 4) Methodologists. Unfortunately, Sakheim points out, there are
no Methodologists since there are so few hard data at this time. However, the mere
description of ritual abuse brings forth many complex and difficult questions for
treating such abuse victims. Tilis chapter emphasizes that these occur on both the
level of the patient, whose information one must process in therapy, and on the
level of the therapist, who must consider his or her own personal reactions to
hearing stories of ritual abuse.
Dissociative identity disorder has placed the courts in the strange position of
having to consider in what ways a dominant identity is responsible for crimes
committed by one of the alters. In Chapter 28, Greaves and Faust give their personal
reactions to legal, ethical, and historical development in the field of dissociative
disorders. Using a narrative style, they consider, from the perspective of their own
experience, the relationship between psychology and the law. Tilis discussion is
amplified by presentation of one of the most famous "multiple personality cases"-
that of "Billy Milligan." The famous Billy Milligan case is one in which the courts
found Mr. Milligan not guilty by reason of insanity after he had committed rapes
under the control of one of the alters. For many people, these types of outcomes
bring forth the consideration of malingering and further questioning related to the
diagnosis of dissociative disorder as well as therapeutic techniques such as hyp-
nosis. In contrast to the current legal interest in dissociative disorders, these
authors actually suggest that dissociative disorders will play less of a role in future
court cases.

567
27
Clinical Aspects of
Sadistic Ritual Abuse
David K. Sakheim

In recent years, therapists have been confronted with thousands of cases in which
both children and adults are alleging horrendous abuse at the hands of satanic cults.
These patients have been labeled as "ritually abused" and/or "satanic cult sur-
vivors:' 1 How to make sense of the memories of atrocities described by such
individuals has resulted in tremendous controversy within the field. Unfortunately,
both clinicians and researchers tend to take strong emotionally based positions,
despite the absence of sufficient empirical data to do so in an educated fashion. This
chapter is an attempt to discuss and clarify some of the issues that arise in this area
and to give an overview of what is currently known in the field.

TERMINOLOGY

"Ritual abuse" is a new term, yet it has already gone through a number of
permutations in meaning. It was originally proposed by Lawrence Pazder and
Michelle Smith to describe her cult abuse experiences (Smith & Pazder, 1980). The
term was designed to reflect a type of abuse that occurred because of the religious
beliefs of the perpetrators. As others began disclosing similar stories, most of

1This term will be used to refer to individuals who present for psychotherapy and describe atrocities that

were inflicted upon them by secret organized groups of people as part of religious rituals. Female
pronouns will be used throughout this chapter when referring to ritual abuse survivors since, at
present, the vast majority of survivors in therapy are women.

David K. Sakheim • 1610 Ellington Road, South Windsor, Connecticut o6o74.

Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William J. Ray. Plenum Press, New York, 1996. 569
570 which involved groups practicing satanism, the phrase "satanic ritual abuse" began
David K. Sakheim to be applied in the literature. However, it was immediately noted that virtually any
group can as systematically abuse a child as can someone practicing satanism
(Lanning, 1989). Kenneth Lanning (1992) also pointed out that it does not make
sense to label a crime with the religion of the perpetrator. For example, in speaking
about child abuse in the recent Waco Texas cult of David Koresh, people did not
describe such abuse as a "Christian crime," and it would not have been useful to do
so. Thus, the "satanic" was dropped in most uses.
In a task force summary report, the Los Angeles County Commission for
Women defined ritual abuse as follows:
A brutal form of abuse of children, adolescents, and adults, consisting of physi-
cal, sexual, and psychological abuse, and involving the use of rituals. Ritual does
not necessarily mean satanic. However, most survivors state that they were
ritually abused as part of satanic worship for the purpose of indoctrinating them
into satanic beliefs and practices. Ritual abuse rarely consists of a single episode.
It usually involves repeated abuse over an extended period of time. (Ritual
Abuse Task Force, 1989, p. 1)
Current usage of the term "ritual abuse" has broadened somewhat from the
original meaning and usually refers to the extremes of human cruelty in which an
individual has experienced the combination of repeated physical, sexual, psycho-
logical, and spiritual abuses, usually within a religious context. Jean Goodwin
(1993) recently recommended using the term "sadistic ritual abuse" to better
capture that the phrase almost always applies to the effects of deliberate and
repeated sadism.
Most children who are severely and repetitively abused experience this abuse
in nonsatanic situations. In fact, it would appear that most child abuse occurs
within the context of the family. Although child abuse in satanic cults is an impor-
tant area, it would be a major error for the field only to focus on cults and miss the
far greater problem of everyday child abuse.

SATANISM

Despite the broadened definition, most ritual abuse survivors who seek psy-
chotherapy describe an involvement with satanism among their tormentors. This
has made for some confusion about just who are these groups of perpetrators. As
one attends to the details of abuses and the specifics of described practices, it
becomes clear that these groups are not the same as any of the currently known
satanic worshipers. A definition of "satanism" is not simple because the individuals
and groups that get so labeled are actually very heterogeneous. "Satanism" as a
religion does not necessitate any illegal or abusive activities. Thus, it is very impor-
tant to be cautious and specific with how one uses the term (see Table 1).
As can be seen in Table 1, satanism can be a label applied by one group to
another or a self-applied designation. It can refer to both known and controversial
groups and can imply both legal and illegal practices. Throughout history, when
one group was called satanic by another, the label usually was being given to justify
Table 1. Satanism 571
I. Groups known to exist Sadistic
A. Labeled by others Ritual Abuse
l. Individuals persecuted due to their beliefs or practices
2. Groups labeled satanic to justify oppression (typically due to different religious beliefs)
3. Whole nations labeled satanic to justify their "enemy" status

B. Self-labeled
1. Organized legal and open satanic churches
2. Individual dabblers (often with preexisting psychological problems)
3. Small, disconnected groups/gangs that dabble in satanic practices
4. Organized crime groups who practice satanic rituals, often with the belief that this will
add to their power

ll. Groups that are controversial

A. Small groups of families or daycare personnel alleged to practice highly illegal and violent
rituals

B. lntergenerational satanic cults alleged to be an interconnected global network and to prac-

tice secret murderous/abusive rituals

warfare or oppression. It has usually been a way of saying that the individual or
group in question is immoral and evil. For example, Ayatollah Khoemeni recently
labeled the United States as "The Great Satan" and informed his followers that their
moral duty was to fight this evil enemy.
On the other hand, satanism has been used as a self-definition (see Table 1).
There are legal, constitutionally protected religions that practice satanism (e.g., the
Church of Satan· and the Temple of Set) which do not espouse any illegal activities. It
is important to note that these legal and open religious groups are almost never
named by ritual abuse survivors as being involved in their abuse.
Individuals and groups that break the law in their practice of "satanism" are
heterogeneous as well. There are individuals who become fascinated with satanism
or the occult and who may dabble in some homespun version (such as an alienated
high school student who dabbles in black magic and drugs). There are groups (such
as youth gangs) who get involved in satanism, often as part of their rebellion against
authority. There are even organized crime groups that get involved in such practices
(such as Adolfo Constanzo's murderous drug ring in Matamoros, Mexico).
It is very important to note that none of the above individuals or groups are the
people that satanic cult survivors typically describe in their therapies. What is
described is actually quite different from any of the known or documented individ-
uals or groups listed above. Public discussions of satanism typically confuse these
various groups. What is controversial is the description provided by ritual abuse
survivors in therapy of highly organized intergenerational satanic cults and the
extreme atrocities that these groups are alleged to commit. However, the media, for
example, in presenting coverage about this controversy, frequently uses examples
ofthe above groups (e.g., the groups in Section I.B of Table 1) to support survivors'
reports in therapy or to provide evidence that well-organized intergenerational
satanic cults exist. Unfortunately, this only serves to further confuse the issue. There
572 is no question that satanism exists. The only controversial groups in Table 1 are
David K. Sakheim those listed in Section II.

INCUDENCE-PREVALENCE

There have been no well-controlled studies on the incidence or prevalence of

satanic ritual abuse reports. However, it is clear that more and more cases are
appearing in the mental health system each year. Leon Jaroff (1993) noted that a
recent survey found that roughly one third of a national sample of psychologists
responded that they had treated at least one case of ritual abuse. He also noted that
one referral agency in California alone claimed to receive over 5000 calls each year
from survivors. This explosion of cases is not just limited to the United States, but is
clearly a worldwide phenomena (Braun, 1989a). The lack of clear research data has
not stopped speculation about actual incidence and prevalence figures. However,
estimates vary tremendously, with some assuming that this phenomena is non-
existent or extremely rare and others suggesting that this is a common occurrence.
Dr. Bennett Braun, a noted researcher in the dissociative disorders field, has stated
that, based on his experience and research, he would estimate this phenomena to
be as frequent as 28% of all patients with multiple personality disorder (Braun &
Gray, 1987), or even as high as 50% of all inpatients with multiple personality
disorder (Braun, 1989b). Clearly, there is a need for more empirical research to
address even such basic questions as how common are these reports in clinical
settings.

AllEGATIONS OF RITUAL ABUSE SURVIVORS

There are primarily two ways in which these extreme types of reports come to
light. The first are reports coming from adult women in psychotherapy to deal with
child abuse, and the second come from daycare abuse investigations with children.
It is important to be clear that survivors are discussing an entirely different type
oftotalist group experience than any of the known forms of satanism in our culture.
It is these descriptions of secret, violent, yet well-organized intergenerational sa-
tanic cults that many people find hard to accept and about which there is very little
information or evidence.
What is typically described by these groups has nothing to do with those in
Section I of Table 1. Instead, there is usually a description of a family or group of
families that secretly have been practicing satanism for generations. The reports
consistently describe extremely violent paramilitary organizations that indoctrinate
their children from birth onward to become part of their belief system. The
allegations almost always include the torture and murder of children and adults;
sexual, physical, and emotional abuse of children; creation of child and adult
pornography; forced impregnations and subsequent abortions of teenagers and
adults; drug use and sales; forced participation in deviant sexual activities; forced
consumption of bodily wastes; cannibalism; and other extreme forms of deviance
and violence. These cults are alleged to be very well organized, to commit extreme 573
abuse and violence, and to go to great lengths to cover up their activities. Sadistic
The primary factor that has led some clinicians to believe the stories of their Ritual Abuse
patients is that the allegations made by these survivors are quite detailed and
consistent and often match those of other survivors who have never met, even in
differing parts of the world (Braun, 1989a). The similarities in reports from sur-
vivors around the world can be uncanny, even down to the wording of specific
prayers, the details and sequences of practices for specific holidays, or the secret
coding systems and symbols alleged to be used by these groups. Until recently, such
information was not widely available, convincing many clinicians that these itldivid-
uals had been exposed to the kinds of experiences they claimed.

Reported Beliefs and Practices

Survivors typically describe a similar set of beliefs and practices among their
tormentors. Although the reality is often disputed, it is interesting to note the
commonalties in specific acts, beliefs, teachings, and motivations.
Katchen and Sakheim (1992) have summarized and catalogued these beliefs
and practices. They point out that the belief systems described usually stem from a
Gnostic viewpoint, in which the world is believed to be under the influence and
control of hostile spirits. Thus, in order to survive in such a world, one must learn to
control these spirits by becoming more powerful than they are. Learning "black
magick" is believed to be the path to this end. This belief system often includes the
notion that a person also can become more powerful by being possessed by one of
these powerful evil spirits. "Possession" is seen as a way to obtain the power of such
a being. For example, many survivors describe being forced to hold a hot object
without reacting. A psychological explanation of such an event would be that the
individual had to dissociate from the pain involved and hypnotically shut off his or
her feelings. It would also be assumed that the pain was being registered out of
conscious awareness. The cult view, on the other hand, is that the person was
possessed by a strong demon or spirit who was able to handle such things without
reaction. In other words, the psychological view would see this event as traumatic
and likely to create later problems, while the cult view would see this as a strength-
ening experience for the person involved, since it connects him or her with such a
powerful spirit. By later reconnecting with this spirit, that individual would be
capable of superhuman abilities (e.g., of not feeling pain). Many of the events
described by survivors appear designed to create such a "possession" experience,
believed to increase the person's power in the world. It is also reported that these
experiences are of value to the group because when the evil spirit leaves (the
person returns to a normal state), memory of cult activities is usually gone as well
(dissociated). This then adds an element of protection for the secret rituals that is
also valued by the group.

Rituals
In general, the rituals described by survivors appear to have one of three
primary purposes. These are indoctrinating someone into the group, helping some-
574 one in the group to attain increased power through possession or other magic, or
David K. Sakheim intimidating a member never to disclose cult-related activities (Hudson, 1990;
Katchen & Sakheim, 1992; Young, Sachs, Braun, & Watkins, 1991).

Indoctrination Rituals. There are rituals described at certain ages to con-

vince a child that she is "evil" and therefore a part of the group. For example, most
survivors describe death and rebirth rituals in which the child is first tortured and
is then placed in a box or coffin, usually along with bugs and dead animals. The
child is told that she is being killed and buried. Aftet being left for an extended
period of time, she is then dug up (sometimes put inside and then pulled out of an
animal carcass) and is told that she is "being reborn unto Satan:'
As noted above, there are many other types of tortures described by survivors,
usually with the goal of getting the person into an altered state of consciousness so
that dissociation (what they regard as possession) can occur. These include such
abuses as being raped and/or physically injured, being partially hung, drowned,
starved, dehydrated, locked in boxes or closets, given electric shocks and/or drugs,
and so on. When the person does dissociate, this is encouraged and the split-off
parts of the self are sometimes even given new cult names. The idea is that they can
then be called on when a certain strength or ability is needed in the future.
Another way that the cults are reported to attack a survivor's sense of identity
is to force her to commit atrocities toward others. This confuses any sense of
being a good person, and is reinforced by messages to the contrary, such as telling
the person that she is evil and therefore a part of the group.
The descriptions of such rituals make it clear that in order to survive, the
person must either become an exquisite liar or must learn to dissociate (or both).
For example, patients have described being tortured until they would agree to
participate in a ceremony. However, when they finally agree, they are told that
this is not good enough because they are only doing so to avoid further pain and not
because they "really want" to participate. The torture then continues until the
person either convinces the group that she really wants this or until she can split off
a part of herself that is able to identify with the group's agenda. This is what the
group is hoping to accomplish. If the person can dissociate and create a willing
group member, the cult views this as possession by a cooperative spirit and there-
fore as success.
Many survivors describe elaborate "magic tricks" that are used to convince
members of the group's power. For example, a number of patients have described
having what is supposed to be holy water (but is actually acid) thrown on them. The
high priest secretly makes the switch, and then, when the "holy water" bums the
person's flesh, both she and the other group members are convinced that she truly
must be evil and therefore have become part of the group. This kind of trick can be
especially powerful when members of the group are using hallucinogenic drugs at
the same time. Such drug use is a commonly reported part of most ceremonies.
Such tricks also add to the later confusion about what is real and what was ima-
gined. For example, child survivors from some of the daycare cases have described
impossible events such as seeing other children taken apart and then put back
together. Other survivors have reported being able to figure out some of these
tricks, but most describe a profound sense of disbelief in their own perceptions that
results from such confusing and bizarre experiences.
 Acquisition of Power. Many of the descriptions of rituals involve reversals 575
of traditional Christian practices and symbols. Survivors typically report that satanic Sadistic
groups see such desecrations as additional ways to attain the power to do magic. Ritual Abuse
Thus, backward prayers, backward writing (e.g., "nema" instead of "amen"), dese-
cration of church property, inverted symbols (e.g., upside-down crosses), and
reversals of most Christian holidays and practices are deliberately embraced. This
includes reversals of Christian rites of passage such as baptism. In the cult version,
the goal is opposite to the Christian one, and becomes a rite to make the person
"impure."
Most survivors also speak about having been forced to participate in rituals
involving animal and/or human sacrifices. They claim that the groups view sacrifice
as a way of obtaining the life force (power) of the organism being killed. In an
tt:tempt to explain ~he usefulness of sacrifices, Aleister Crowley (1924/1976) wrote:
It would be unwise to condemn as irrational the practice of those savages who
tear the heart and liver from an adversary and devour them while yet warm. In
any case it was the theory of the ancient Magicians, that any living being is a
storehouse of energy varying in quantity according to the size and health of the
animal, and in quality according to its mental and moral character. At the death
of the animal this energy is liberated suddenly. (pp. 94-95)

In other words, the younger or more "innocent" and "pure" the victim, the
more power is believed to reside there. It is also believed that the more physiologi-
cal arousal present, the more energy there is to obtain. Thus, survivor descriptions
often include not only killing, but the deliberate induction of maximal fear and/or
sexual arousal in the victim just prior to its death. Some of the cult practices
described in therapy suggest that some groups are far more involved with the
elaborate details of these practices, believing that numbers, colors, shapes, sym-
bols, and specific practices all contain important magical significance. Other groups
appear far less engrossed in such detail and seem much more involved in the sadism,
power, and/or monetary aspects of the various activities.

Prevention of Disclosure. These groups are routinely described as going

to great lengths to terrorize the members into complete obedience and silence.
Everything from tricks and illusions to blackmail and direct threats are used.
Children often report being threatened that any disclosure will result in harm to
pets, family members, or to themselves.
Many survivors also describe sophisticated uses of hypnosis ("programming")
to insure loyalty to the group. A common report of such programming concerns
"magical surgery." This process has been widely described by survivors in therapy
(Hudson, 1990; Katchen & Sakheim, 1992; Young et al., 1991). For example, a child
is drugged and upon awakening is informed that a bomb was surgically placed
inside her that is programmed to explode if she ever tells anyone about the group.
She is told that this will kill her as well as the person she tells. This kind of
suggestion is very clever since it capitalizes on the person's physiology to enhance
its effects. 1f the child even thinks of telling someone, her nervous increase in heart
rate may be misconstrued as the bomb's ticking.
Some clinicians have reported incredibly sophisticated and intricate "program-
ming" involving elaborate attempts at mind control that begin early in a child's life
576 and are reinforced on a regular basis. What makes most of these reports even more
David K. Sakheim controversial is that they often include references to the involvement of CIA and
other government intelligence agencies. It is alleged that these groups have been
interested in studying mind control in an attempt to develop the perfect assassin,
soldier, or messenger, by using deliberately created dissociation. Although US and
other intelligence agencies have revealed that they have carried out secret mind
control experiments on unsuspecting civilians and have even involved organized
crime figures in their research (Marks, 1979; Shefflin, 1993), the present allegations
suggest a 1ilr more elaborate and organized effort involving long-term experimenta-
tion, using a variety of tortures, on hundreds of nonvolunteers, mostly children. If
confirmed, it undoubtedly would be the biggest scandal in US history. Clearly, many
of these reports sound filrfetched. But, once again, what has been convincing to
some therapists is that numerous clinicians have validated running into simila'r
detailed descriptions of these mind control strategies and the agencies involved,
even down to the same unusual code words and techniques being mentioned and
the same individuals being named (Hammond, 1993).
Various types of conspiracy theories abound when it comes to this area, and
some writers believe that blaming satanism has become a way to have simple
answers for the complex and overwhelming violence and turmoil in our current
world as well as disillusionment with current political answers (Hicks, 1991). These
authors point to the massive conspiracy theories as examples. For instance, in his
book, The mttmate Evil, Maury Terry 0987) postulates interconnections between
organized satanic cults, the Process Church, the Manson murders, and the Son of
Sam killings.

The Black Mass. The most controversial allegations made by survivors

involve reports of forced abortions, infanticide, and cannibalism. These usually
have to do with descriptions of a Black Mass. Such depictions are not new, and have
emerged in very similar forms throughout recorded history. However, historians are
as divided as current researchers as to the significance of such reports (Hill &
Goodwin, 1989; Noll, 1989; Raschke, 1990). Some historians believe that these
stories are the evidence for an ongoing satanic conspiracy that has been unmasked
from time to time. Others see them as fictional accounts designed to titillate (such
as the stories from the Marquis de Sade). There are still others who believe that
these are primarily the text of tortured confessions produced by inquisitions and
are therefore completely unreliable. Finally, there are historians who believe that
these reports are genuine criminal acts, but are the actions of isolated groups of
mentally unbalanced individuals who happened to hit on similar bizarre behaviors
in acting out their perversions. They explain the similarities of reports as being due
to the fact that there are a limited number of options available for such extreme
sadism and debauchery. Thus, the similarities in reports do not suggest interconnec-
tions between groups, but merely similarities among the pathologies of the per-
petrators.
Specific descriptions of the Black Mass usually include the reciting of backward
prayers, the murder of an infant or the use of an aborted fetus in the ceremony
(many survivors report being raped in previous ceremonies so that they will be
pregnant and can be aborted in this ritual), the consumption of blood and flesh,
the use of alcohol and drugs throughout, and finally, a sexual orgy where children 577
and adults are all involved. The Black Mass allegedly is designed to combine the Sadistic
various rituals that the group believes can enhance theit power to do magic. Ritual Abuse

Summary
Whatever the rationales, it is clear that vittually all of the allegations from
survivors are of terrible abuses and tortures by the very people who were supposed
to protect them. In fact, vittually every survivor also describes sadistic abuses at
home in addition to the traumas that occurred at rituals and cult ceremonies.
Whether or not the specific descriptions have all occurred, a picture almost always
emerges of a family that is almost exclusively focused on power and control in every
sphere of life. The experience that survivors present dramatically portrays having
felt completely helpless and alone in a sadistic, controlled, and power-oriented
envitonment. For most clinicians, it is difficult to believe that that experience was
not in some way real, even if aspects of the survivor's presentation turn out to be
something else.

CREDmiiJTY ISSUES

The most common area for discussion about satanic cults in current papers,
conferences, and the media is to debate the reality of theit existence. The opinions
expressed vary from the extreme position assuming 100% accuracy of survivors'
recall to the equally extreme alternative position that none of the descriptions of
atrocities are real. Clearly, until more investigative work is completed, there can be
no definitive answers to this debate. However, it seems likely that there will never
be one single answer. Patients will probably range from those who are malingering
for secondary gain to those who are delusional or who were tricked and confused.
There are likely to be others for whom descriptions of satanism are screen memo-
ries, incorporated ideas from readings or support groups, metaphoric communica-
tions, or even exaggerated memories. There are likely to be some distortions due to
trance phenomena for patients who are highly dissociative, and finally, there are
likely to be some individuals who have truly experienced extreme and ritualized
forms of abuse.
The situation becomes even more complex when one sees that not only is it
probable that patients will differ in these ways, but that even for one individual,
different memories may have different meanings. A patient who was actually
abused in a cult may have some memories that are distorted due to tricks, confu-
sion, or drug use at the time and other memories that are more clear and unmistak-
able. Some memories may be more elaborated due to secondary gain, while others
may even be able to be corroborated. In other words, each individual will likely
experience a variety of influences to memory so that each description has its own
complex meanings.
At present, the field is not yet acknowledging this complexity, but is more
involved in a debate about whether or not the phenomena are real. Unfortunately
our field has a tendency to become polarized in such situations, with some clini-
578 cians claiming that every patient's story is true and that the rest of the field is
David K. Sakheim heartless (e.g., "believe the children"), while others claim that every patient's story
is delusional, that there is no such thing as dissociation or repression, and that the
rest of the field is merely too gullible (e.g., the proponents of a ""false memory
syndrome"). This argument primarily comes down to how to make sense of two
conflicting aspects of these claims. The first is that survivors from all over the world
are coming forward with very similar descriptions and reports of abusive practices
by satanic cults (Edwards, 1990). The second is that there has not been sufficient
forensic evidence found to date that would validate these allegations, especially the
more extreme charges of infanticide and adult murders (Hicks, 1991). In an excel-
lent discussion of this dilemma, George Greaves (1992) points out that in the
presence of conflicting information and the absence of clear data, therapists,
sociologists, historians, anthropologists, police, and other researchers in this area
tend to take one of four positions. He calls these the Nihilists, the Apologists, the
Heuristics, and the Methodologists.

Ritual Abuse as False Memory

Greaves (1992) refers to the first viewpoint about this area as being "Nihilist."
The commonality for this group is that they believe that reports by survivors cannot
be true. Some members of this group naively cannot conceive the possibility that
human beings could be so violent and cruel to each other. However, the majority of
this group's membership are clear-thinking individuals. Some are clinicians who do
not work in the trauma field (and are therefore less moved by similarities between
these and other trauma survivors), others are police who have become skeptical of
survivor reports after failed investigations, and most of the rest are researchers (e.g.,
historians and anthropologists) who are hypothesizing that false ritual abuse re-
ports are a phenomena that occurs under certain problematic social conditions.
The police in this group point out that in addition to the lack of sufficient
physical evidence, ritual abuse reports are usually different from what is currently
understood about other types of crime (Van Benschoten, 1990). Ken Lanning of
the FBI notes that there are aspects of these crimes that make them hard to accept.
For instance, the reports typically describe as many female as male perpetrators,
something unseen in the forensic world. The reports also involve multiple-victim,
multiple-perpetrator conspiracy crimes in which very dysfunctional individuals are
alleged to go for long periods of time maintaining tightly controlled secrets and
group loyalties. Lanning points out that these individuals are described as being
completely out of control and impulsive at times, yet able to commit massive
conspiracy crimes while maintaining total group loyalty and cohesion, as well as
being able to cover up all forensic evidence of their crimes. He suggests that this is
difficult to accept, especially on such a large scale (Lanning, 1992).
Interestingly, there is a small group made up of therapists and client advocates
who take the Nihilist position as well. These individuals are fearful that the more
extreme reports of ritual abuse survivors will not be verified in the long run and that
this will harm the hard-won credibility of other abuse survivors and of the trauma
recovery movement itself.
 The Nihilists point out the lack of convincing forensic evidence to date. For 579
example, Hicks (1991) provides an excellent critique of much of the evidence that Sadistic
has been used to support ritual abuse allegations. However, this group has largely Ritual Abuse
been unable to come up with satisfying arguments to explain the allegations
themselves of why survivors from around the world are saying such similar things.
Some of the explanations generated by this group are shown in Table 2.
George Ganaway (1989) compared the phenomena of patients reporting ritual
abuse to those reporting UFO abductions, suggesting that the same psychological
mechanisms (the creation of dissociative fantasies and distortions) may be at work
for both populations. Of the various writers in this group, he offers the most
plausible psychological explanations of why some survivor reports may not be
accurate.
The sociologists and anthropologists in the Nihilist group also point out ways
that communities can become involved in believing inaccurate reports about sa-
taoism. Examples include "urban legends;' where interesting but untrue stories get
rapidly spread through a population, or rumor panics that effect small rural areas
(Victor, 1990). The Nihilists believe that this type of social contagion is not only
occurring in the larger society, but is specifically taking shape in the psycho-
therapeutic community. As satanism is more widely reported, therapists believe
they are seeing it and/or patients believe that this must have been their experience
(Brunvand, 1986; Hicks, 1991; Mulhern, 1990, 1991; Richardson, Best, & Bromley,
1991; Victor, 1989).
Although it is certainly the case that each of the above hypotheses can account
for some cases, therapists working in the field usually do not see them as satisfactory
explanations for what they are witnessing clinically. If the Nihilists are correct that
this phenomena is completely unreal, there will need to be better psychological
explanations for how this can occur. The field simply does not yet have an adequate
theory to account for thousands of people making up and believing detailed and
consistent stories of horrendous abuse.

Table 2. Nihilist Explanations for Ritual

Abuse Allegations
Individual reports
1. Screen memories
2. Incorporation from reading, lectures, or other patients
3. Delusions/hallucinations
4. Therapist influence/suggestion
5. Reinforcement by therapist for severe abuse allegations
6. Errors in hypnotically recovered memories
7. Material from the collective unconscious

Community hysteria about cults

1. Social contagion
2. Urban legends
3. Rumor-panics
580 Memory as Accurate Reconstruction
David K. Sakhebn
George Greaves (1992) calls the second viewpoint about ritual abuse the
"Apologists." This group is primarily made up of the clinicians who work with ritual
abuse survivors and who insist that patient reports of massive atrocities must be
true. These therapists tend to work with incest victims and other trauma survivors,
and many have been politically active in pushing the field to understand the
psychological impacts of such trauma; they therefore tend to approach abuse
reports from an advocacy stance. There is a strong belief that an injustice has been
done to trauma survivors in the past because of the field's disbelief in reports of
incest and other family abuses (Masson, 1984), and many in this group caution that
we not make the same mistakes again. In order to maintain this position, the
Apologists must then account for why so few validating data have been available.
Some Apologists argue that in fact there has been forensic evidence to support
survivor claims, that numerous cases have even been won in court, but that these
data are often unavailable because there is currently no organized police mecha-
nism for collecting such case information (Boyd, 1991; Raschke, 1990; Tamarkin,
1993). However, more typically, in order to explain the paucity of available forensic
evidence to support the numerous claims by survivors, Apologists tend to trace the
flow of the investigative process, pointing out the problems that occur for ritual
abuse survivors at every step of the way.
The Apologists point out that most ritual abuse survivors are too intimidated
and afraid to go to the police in the first place, and even if they do go, they often are
not taken seriously because of the bizarre nature of the allegations or because the
accusations are being made by a child or an adult with a psychiatric history. Even if
the police believe the reports, it is noted that they tend to be very hesitant to devote
the resources needed to investigate such claims because of limited manpower or
because the statute of limitations for prosecution has frequently run out.
When investigations do occur, the Apologists claim that it is not surprising that
more information has not been found since the cults use very sophisticated mecha-
nisms to destroy evidence (such as portable crematoriums) and because the police
are not trained to investigate these types of groups (just as special units had to be
formed to successfully investigate organized crime). The Apologists go on to sug-
gest that when evidence has been found and cases have been pursued, they
frequently have been so mismanaged by investigators that they become impossible
to pursue to a trial. Most people in the field agree that the cases that have gone to
court have been terribly mishandled (such as the McMartin case), making it almost
impossible to sort out what really happened. Errors have included leading inter-
views, contamination between witnesses, premature notification of potential per-
petrators, lost evidence, poorly trained therapists and police, to name but a few.
Thus, rather than saying that no confirming evidence has yet been found,
Apologists argue that it would be more fair to say that there have not yet been any
adequate investigations. Some Apologists even go so far as to suggest that in many of
these cases the above problems have been compounded because police or other
investigative agencies were infiltrated by cult members who sabotaged attempts to
explore cult-related charges.
 Many Apologists accurately point out that the cases that reach the court system 581
are frequently "sanitized" so that claims of satanic cult activities are dropped or Sadistic
restated in more traditional legal language. This is done by prosecutors who are Ritual Abuse
afraid that juries will become incredulous at the more extreme charges, so they
leave out the controversial aspects of the case and prosecute for "child abuse;'
"murder," "cruelty to animals;' "child pornography," and so on. The result is that if
they then obtain convictions, these do not appear to be convictions of "satanic cult
cases."
The above explanations account for some cases being inadequately pursued,
examined, or followed up. However, these arguments are not sufficiently satisfying
to police and others who are trying to understand how it is possible that thousands
of survivors (each alleging massive conspiracy crimes that involve multiple mur-
ders, abortions, stabbings, kidnappings, etc.) have not resulted in more substantive
forensic evidence to date. This criticism becomes more and more problematic as
time goes by, especially since some police forces and district attorneys are now
willing to pursue these allegations, are providing training to their officers, and are
devoting manpower and resources to investigate this area.

Accuracy of Memory as Irrelevant

George Greaves (1992) describes another group of clinicians who claim that it
does not matter if this phenomena is real or not. He calls this group the "Heuristics."
They point out that these patients seem to get better if they are treated like other
trauma survivors and their stories are accepted as truth. In other words, if a clinician
acts as if the reports are real and helps the patient to work through her feelings,
the patient can recover. It is argued that the clinician is not an investigator and
that the veracity of the material is not relevant. Clearly, however, this is not a viable
social position because it does matter if the reports are real or not. A major problem
with this position has come about as more and more of these cases end up in court.
One might argue that the truth of such claims can sort itself out in the haven of the
consulting office; however, once people's lives and reputations are on the line in
court, a different standard becomes essential. In addition, the truth of allegations
about children and adults being being raped, killed, cannibalized, or used to make
pornography certainly does matter in terms of society's obligation toward protec-
tion and prevention.

Positions Based on Research and Data

The last group described by Dr. Greaves (1992) are the "Methodologists." This
group is made up of people who base their views on the data. Unfortunately, at
the present time this group clearly has no members! There does not yet appear to
be sufficient data to come to any solid conclusions about this area. Until there is a
more centralized way of disseminating information about investigations of these
cases and until such investigations are able to be assessed from beginning to end, it
is simply not possible to fairly assess whether adequate efforts have yet been
pursued.
582 RITUAL ABUSE SURVIVORS AS A HETEROGENEOUS POPUlATION
David K. Sakheim
In the absence of such clear research data, much of the writing to date is based
on clinical experiences, speculations, and preexisting assumptions. However, a
careful study of clinical cases would actually suggest that the outcome of this debate
may be to endorse a more complex view than any of those described by Dr. Greaves
(1992). It may well be that patients presenting as ritual abuse survivors are actually
quite a heterogeneous group. Memory is a very complicated, and as yet, little
understood process. Some of the known factors affecting recovered memories are
shown in Table 3.
There is no question that some patients are lying about having had cult
experiences. For example, various kinds of false sexual abuse allegations can occur
in some custody battles in order to obtain increased leverage. The truth in such
complex legal cases is often impossible to sort out. There are also some patients
who appear to be malingering in order to obtain attention, availability of staff, and
monetary support or increased psychotherapy time. It is unfortunate but true that
current practices in the mental health field sometimes differentially reinforce cer-
tain types of problems so that patients can be pushed toward defining themselves in
more extreme ways. For example, it is not uncommon for more interest and
resources to be expended for a "satanic ritual abuse survivor" than for someone
who is "merely" disclosing a history of family violence.
It is also clear that some patients present with delusional disorders, demon-
strating primary process thinking. Psychotic patients frequently can include satan-
ism as part of their delusional system. Such a presentation, however, is usually quite
different from the degree of specificity, knowledge, and detail described earlier.
Some clinicians have reported seeing instances of incorporation where a
patient comes to believe that he or she has experienced ritual abuse (or other
trauma) after being exposed to it verbally or after reading about someone else's
experiences. The reported instances of this "sponging" of material from another
patient usually have been described as occurring for patients who are struggling to
make sense of their own vague feelings and symptoms. After reading or hearing a

Table 3. "Memory" as a Complex Process within

and across Individuals
1. Conscious lying
2. Malingering for secondary gain
3. Delusional material
4. Screen memories
5. Incorporated memories from others
6. Metaphoric communications
7. Exaggerated memories
8. Misperception based on confusion or trickery
9. Torture or drug-induced distonions
10. Trance phenomena in the creation or retrieval of memories
11. Other, as yet unknown types of distonions (e.g., pseudo-PTSD)
12. Actual experiences
description of another person's experiences, they confuse identification with the 583
feelings with the belief that the same things must have happened to them. It would Sadistic
seem likely, therefore, that even if the descriptive material is not accurate in these Ritual Abuse
instances, it is still important to attend to the feelings behind the descriptions. Thus,
it would be a mistake to discount such incorporation as being out of whole cloth.
The person is likely struggling to convey something for which they may not have
words, but which is about feelings that seemed accurately conveyed when some-
one else described their experiences. It is certainly possible that some UFO abduc-
tion reports and/or past lives descriptions are similar in being attempts to find
images to convey something only currently available on a feeling level.
A ritual abuse memory could also turn out to be a screen for more usual family
incest experiences. However, this is mostly inadequate as an explanation of these
recovered memories because most ritual abuse survivors typically also describe
memories of severe abuses within their families. Thus, the idea of a "screen" to
protect them from such overwhelming betrayal would not apply (Greaves, 1992).
Some survivors appear to be speaking in the language of metaphor. These
individuals do not usually describe details of holidays, coding systems, or the
content of prayers. However, their descriptions of rape and other abuses by Satan
worshipers may speak to how their nonsatanic childhood abuse experiences actu-
ally felt to them. Just like those who incorporate someone else's story, these
individuals may be using images and metaphors in an attempt to communicate
about experiences and feelings for which they do not currently have the words.
Some trauma survivors defend themselves by minimizing the significance of
the abuses they actually experienced. Thus, to convey the horrors of what they felt
(and often feel while remembering), there may be some need to exaggerate their
story. In other words, the patient is communicating about feelings. For example,
they may feel that in order to convey to the listener the degree of horror and taboo
experienced as a sexually abused child, they must describe something as extreme
as cannibalism or infanticide.
There is also no question that some trauma memories become confused or
distorted. People are generally terrible as witnesses, even under ideal circum-
stances (Orne, 1979). If one is hearing the retrieval of a dissociated memory, 20
years after the fact, that was created under the influence of trickery, fear, torture,
pain, terror, and sometimes a variety of drugs, it would be inconceivable to imagine
that some distortions do not occur. Thus, it is quite likely that most trauma memo-
ries have at least some element of idiosyncratic distortions. This confusion of
perception is often one of the most painful aspects for any torture survivor in his
or her struggle to sort out what is real.
Hypnosis has been shown to influence memory in a variety of ways. The most
significant is that the subject is often able to fill in memory gaps. These can be
accurate or inaccurate reconstructions, but the person involved usually increases
his or her belief in the material in either case (Bliss, 1986; Orne, 1979). It would
make sense that this could occur whether or not the hypnosis was part of a formal
induction procedure or happened in the patient's own recovery of a dissociated
memory (e.g., in a flashback, dream, body memory, etc.). Many survivors also
describe deliberate hypnotic procedures as part of their abuse in which all sorts of
distortions of experience were suggested to them. Thus, although this is not well
584 understood, it would appear that some survivor memories may have been influ-
David K. Sakhelm enced by hypnotic distortions or hypnotic artifacts that have occurred from the
traumas experienced and other distortions from the memory recovery process
itself.
It is clear that some patients describe traumas that external investigations
suggest were never experienced. Clinicians have reported examples of this such as
a Vietnam veteran who presents with combat-related posttraumatic stress disorder
(PTSD), but who, upon external investigation, turns out to never have been in the
military, or patients who describe aspects of near-death visions, abuse in a past life,
abduction and abuse by space aliens, and so on. It is certainly conceivable that some
ritual abuse survivors fall into a similar category. It clearly would provide the field
with very useful information to follow such patients in order to see if their symp-
toms reflect some other type of trauma or are instead more similar to some form of
delusional disorder. Following the therapy course for patients with "pseudo-PTSD"
would help us understand more about the various categories in Table 3. It would
also help us to understand what is helpful in psychotherapy in such cases. For
instance, is it necessary for the patient to eventually come to understand their
distortions or can therapy be helpful if it never challenges these? Does the psycho-
therapy for such patients follow a similar or a different course than the therapy for
more typical PTSD cases? Some clinicians have reported success in dealing with
such material as if it were real; for example, Morse and Perry (1990) and Ring (1984)
describe the clinical usefulness of exploring near-death visions, and Feldman (1993)
and Ryder (1992) both describe the help to their clients of abreacting "past life"
memories as real events. It seems difficult to imagine that treatment could truly be
successful without ultimately dealing with whatever is behind such material and the
need to disguise it with these metaphors; but this is clearly an empirical question
that has not yet been addressed.
last, for anyone working with this group of patients, it is very convincing that
at least some have had the experiences they describe. Many present a clinical
picture fitting the profile of a torture survivor, and the course of treatment often
supports this view. It seems unlikely that the vast numbers of patients presenting as
ritual abuse survivors have all been through such extreme abuses; however, it
certainly seems possible that some have. A few patients have even been able to
present external evidence to support their claims, with a small minority being able
to find some forensic data to support them.

Complexity of Memory
It is very important to appreciate the complexity of this area and it seems likely
that even for any particular patient, different memories that surface may fit into
different categories in Table 3. 1n fact, it is probably fair to say that most patients will
present with a combination of these factors. The field is only just beginning to
acknowledge the complexity of memory (e.g., the American Psychological Associa-
tion just commissioned a task force to investigate and summarize the data about
repressed-recovered memory). Thus, it is very important to recognize that mem-
ory has many functions and many forms. 1f clinicians can keep an open mind about a
patient's descriptions, the patient will be far better served than if the clinician
comes to his or her work with a preconceived notion about the veracity of recov- 585
ered information. Sadistic
A recent example from my practice may help to exemplify this complexity. A Ritual Abuse
woman in her late 20s, who had been in therapy for a few years, had made major
positive changes in her life, primarily by working through numerous childhood
abuse memories. She and I had been able to validate the accuracy of many of these
in discussions with siblings, grandparents, and parents, through medical examina-
tions that documented her internal and external injuries, as well as through obtain-
ing a variety of documents (e.g., school and medical records) and even recovering
some of the objects used in the abuse. After a few years in therapy she began to have
a memory of being present at the murder of a little boy. This memory was very
confusing for her as her perspective was not at all clear. In order to help to clarify
her confusion about it, she drew the scene that was in her mind (see Figure 1).
Unlike other memories, instead of becoming more and more clear as she worked
on it, this one became more and more confused. At times it seemed as though she
had been the woman in the drawing, at other times she thought that she had been
the little boy, and sometimes she even thought that she had been the priest doing
the killing.
The mystery was finally solved when she discovered an almost identical pic-
ture in her mother's attic. Upon finding this picture, she remembered that on one of
the many times that she was being abused, she had dissociated, left her body, and
gone into the nearest picture on the wall (a defense she had used many times

Figure 1. Client's drawing of her "memory."

586 before). Unfortunately, instead of finding it to be a pleasant scene in which to
David K. Sakheim escape, she found the picture shown in Figure 2. Thus, not only did this leave a
dissociated memory of the real abuse, but also left her with the confusing sense
that she had experienced what was in this picture.
The above example is not given to suggest that all ritual abuse memories are
created in this way. It is given to show the incredible complexity of memory. Even
for someone with externally well-validated memories, it is possible to find one that
turns out to be something other than directly factual. It is noteworthy that this
memory felt different to her, motivating her to continue to pursue its meaning even
after she had "recovered" it. However, her case points out the potential danger if a
clinician assumes that there is perfect accuracy in recall (especially if the "memory"
leads to charges being made against other individuals), as well as the danger of
dismissing all recovered memory as fantasy (since many of her other memories had
been able to be validated).
The fact that trauma survivors can give very accurate accounts, can speak in
metaphor, can lie, can be confused, and so forth should really not be all that
surprising to clinicians. Unfortunately, the field's need to see survivors as either
being perfectly accurate or as having "false memories" misses this complexity. This
can create problems clinically, but especially creates them when survivors enter the
legal system. There is no reason to think that the testimony of an abused person
cannot have the same kinds of distortions and contaminations as other people's
testimony. In addition, it appears that severe abuse can create confusion and a need
for distance, which can result in additional distortions. It would be tragic to
disallow such testimony, but it would be equally mistaken to assume perfect
veracity. Just as we might expect that a crime victim could make errors in identifica-
tion due to his or her state of emotional arousal at the time of the crime, we must
assume that this is possible for severe child abuse survivors. However, we do not

Figure 2. Picture on the attic wall in parents' home.

disallow the testimony of all crime victims just because we know that they can 587
make errors. What is done instead is to insist that there be corroboration via a Sadistic
combination of evidence (including witness testimony) that helps to rule out Ritual Abuse
reasonable doubts about what is being alleged.
It is worrisome that some court systems are beginning to disallow hypnotically
refreshed testimony rather than educating themselves about the potential costs and
benefits of such a process. The reason this is problematic is that many abuse
survivors use their own hypnotic abilities to defend themselves against the abuse.
They also use hypnotic processes to recover the memories later on (whether or not
this is pursued in conjunction with a therapist). If this defense is then regarded as
something that makes them less than credible, we would be denying many victims
of violence the possibility of using the courts. Just as fear can create inaccurate
recollections for any crime victim, dissociation (use of one's hypnotic abilities to
distance from an overwhelming situation) can lead to inaccuracies later on. The
answer is not to disallow all testimony contaminated by hypnotic processes any
more than it would be to disallow all testimony contaminated by fear. The same
principles should apply when it comes to the reports of sadistic abuse survivors as
for any other population. Juries should be educated about the kinds of errors and
accuracies that can occur with such memories and should then be allowed to assess
the whole of the evidence presented.

TREATMENT ISSUES

A discussion of the treatment of ritual abuse survivors is obviously complicated

by the fact that, as noted above, ritual abuse survivors are a heterogeneous and
complex group of patients. However, it is possible to discuss certain important
issues that are likely to emerge in this work. As in any good therapy, the first phase
of treatment is assessment. The initial assessment of these patients is not so differ-
ent from any other evaluations and primarily utilizes a therapist's standard assess-
ment skills and knowledge of posttrauma syndromes. It is important to make a
comprehensive evaluation of the patient's presenting problems, as well as to begin
to hypothesize about where in Table 3 this patient seems to fit (or which combina-
tion of areas apply). Since virtually all of these patients appear to have some kind of
trauma history, it is important to examine the areas of functioning known to be
affected by such experiences. In reviewing the research and clinical literature on
the effects of trauma, Sakheim and Devine (1995) suggest that in addition to the
standard psychiatric assessment that would occur for any patient, a comprehensive
assessment for trauma survivors should include evaluation of the following areas
found in the research and clinical literature to be impacted by trauma and violence:
relational disturbances, general distancing defenses, hypnotic distancing defenses,
returning memory fragments, physical and physiological consequences, cognitive
consequences, aggressive-sociopathic responses, spiritual consequences, aspects
of the trauma itself, past and present support, the internal strengths of the patient,
and the patient's current external situation.
Unfortunately, many standard psychological assessment techniques are not
validated for the impact of severe trauma and can result in a misdiagnosis (Mangen,
588 1992). However, Mangen (1992) points out ways that psychological testing can be
David K. Sakheim effectively utilized, as well as noting some of the newer, more specific assessment
devices that are being developed.
Most clinicians working with severe trauma survivors suggest that in addition
to assessment, the early phase of psychotherapy is primarily aimed at establishing a
trusting relationship and an environment of safety both inside and outside of the
therapy setting (Herman, 1992). This often takes a very long time for people who
have been severely abused and betrayed by those who were supposed to protect
them.
The stages of therapy with ritual abuse survivors are very similar to those for
other trauma survivors with PTSD. Judith Herman's (1992) model of psychotherapy
will not be reiterated here, but is a simple and elegant outline for the psychotherapy
process that should be must reading for any clinician working in this area. Since
virtually all of these patients have experienced severe kinds of abuse, most have
utilized dissociative defenses. Thus, in working with this population, it is also
important to be familiar with what has been learned in recent years about the
dissociative disorders and appropriate treatment interventions (Kluft, 1989; Put-
nam, 1989; Ross, 1989). In general, the approaches needed with ritual abuse sur-
vivors vary only in that these patients often appear to be at the far end of the abuse-
torture continuum and therefore require more attention to safety and grounding
issues as well as concern about maintaining functioning and stability.

SPECIFIC TREATMENT ISSUES

Much of the treatment of ritual abuse survivors involves an attempt to under-

stand the original adaptive significance of many of the current problematic behav-
iors of the patient. This search usually reveals that in their original context, these
same behaviors were very helpful to the person's survival. Thus, the patient comes
to see that she is not "crazy," but rather, has been continuing a defensive strategy
that was once adaptive but is no longer necessary or helpful now that she is out of
the abusive, controlled context. In such an examination of symptoms, instead of
seeing herself as pathological, the patient comes to see herself as having survived a
very difficult and threatening time, using creative defenses.

Self-Abuse
One of the symptoms that almost always emerges for such severe abuse
survivors is that of self-abuse. This is an area that has been widely misunderstood,
but recently has been best discussed by John Briere (1993), who explains such
behaviors as "tension reduction" strategies. Briere points out the defensive value of
self-abuse in its management of otherwise intolerable affects.
In trying to help someone stop hurting themselves, it is essential to explore
what purpose such behavior is serving. Only through an understanding of the costs
and benefits of that particular kind of self-abuse, at that particular time, is it possible
to really begin to explore realistic alternatives. There are countless reasons why
people injure themselves, and Table 4 shows some of the more common patient
descriptions of how it can be helpful as a defense.
Table 4. Reasons for Self-Abuse 589
1. Distraction from painful affect Sadistic
Ritual Abuse
2. To show others the pain inside, "to make the outside look like the inside feels"

3. To go into a trance
a. To push away a painful memory/feeling
b. To bring forward a personality who handled pain by being anesthetized, thereby eliminating
current pain
c. To use a trance state to come back from a flashback
d. To switch alters to achieve a more tolerable feeling state
e. To speed up a flashback by jumping to the end via replicating the physically painful part
f. To self-sooth by leaving the body or otherwise going to an internal safe place

4. To see blood/feel pain

a. To feel real (instead of some kind of dissociated unreality)
b. To recreate part of an abuse memory
c. To ground oneself by becoming aware of one's body and the present instead of being lost in a
memory

5. Internal communication
a. For one alter to punish another
b. For one alter to try to communicate about a memory (such as by carving a symbol on the body),
especially if they are not being heard any other way

6. To express anger
a. A generalized expression of anger by an alter that doesn't feel pain
b. If one alter blames another or themselves
c. To pretend the self-abuse is being done to a perpetrator

7. Physiological
a. To trick the body into releasing endorphins
b. To create a feeling tbat is incompatible with a frightening one (such as creating pain so as not to
feel sexual feelings)

8. Confusion of feeling states due to early abuse experiences

a. Confusion of pain/closeness
b. Confusion of pain/sexuality

9. Other personal meanings

In order to help someone to find alternatives to self-abuse, one must first

understand its idiosyncratic meanings. For example, one woman cut herself va-
ginally every night before being able to go to sleep. If she did not do this, she was
unable to sleep. In exploring this symptom, she remembered that most nights when
she was a child, her brother would hide in her room, jump out after she was in bed,
and violently rape her. She recalled being unable to fall asleep, knowing this was
likely to occur; however, once it was over, she could go to sleep, knowing that she
was now "safe" for the rest of the night. Thus, as an adult, she would lie in bed, in a
state of hypervigilance, unable to sleep. However, once she cut herself, she could
replicate the feelings that she had had that made her feel that the danger was past
and that she could let down her guard and sleep. Once this was understood, she was
able to find an alternative to the self-abuse. She could remind herself of the safety
of her current room and that her brother was no longer in her life. She got a burglar
alann so that she could decrease her need for internal vigilance. She learned and
590 practiced other self-soothing strategies at bedtime, with a special focus on helping
David K. Sakheim the parts of her that had experienced the abuse to be in an internal safe place.
The above example points out the importance of understanding the meaning
of any symptom to the person, of learning its original adaptive value, and then of
seeing if it is still serving any important functions. One can then work on finding
alternatives that achieve similar benefits without the same costs. Alternatives are
often relatively easy to find once the symptom is truly understood. For example, if
someone is using self-abuse to go into a trance, one can teach them much easier and
less harmful way to accomplish this. There are many types of trance induction that
are not self-damaging. Slow drawing on the arm with a magic marker may work just
as well as slow cutting. In general, self-hypnosis or other relaxation strategies are
often just as effective trance induction methods. If the person is trying to show how
horrible things are internally, drawing and/or writing may be a good alternative. If
an alter is trying to communicate something, encouraging the person to find safe
ways to listen to that part of themselves may negate the need for such extreme
action. If an alter is expressing anger by cutting, learning that other parts of the
person do feel this as well as learning other ways to express such feelings might be
helpful. If an alter is blaming themselves or another personality for the abuse,
exploration of the incident may help to reframe this misperception. Even if the
person is trying to trick the body into releasing endorphins by creating a minor
injury [an automatic reaction the body has after any injury (Van der Kolk and
Greenberg, 1987)], this same effect can often be accomplished using hypnosis and
sometimes by using medications or other self-soothing approaches. If the person is
confusing feeling states because of early experiences in which these always oc-
curred together (e.g., pain with sexual feelings), this can be explored in therapy,
and ultimately the patient can be encouraged to experiment with experiencing one
without the other.
In other words, the solution cannot be prescribed ahead of time, and one
person's solutions may not work for someone else. It is critical to explore the
personal meanings of the behavior, its original adaptive significance, its current
functions, and to explore what might work as a substitute in accomplishing the
same goals without the same costs.

Programming
Many patients who describe ritual abuse histories include detailed descrip-
tions of perpetrators using deliberate hypnotic suggestions designed to control
their later behaviors. Programming, as described earlier, is an area about which
many clinicians disagree. At present, for those clinicians who believe that it does
occur, there are primarily three approaches that get suggested to deal with it in
treatment. These are attempting to dismantle the program, countering the original
programmers with alternative suggestions, and last, treating the program like any
other abuse symptom.
The first approach assumes that people are like machines that can be pro-
grammed. It is believed that the therapist must understand sophisticated mind
control techniques in order to safely deprogram the patient. This approach is
similar to defusing a time bomb. It is believed that a wrong move can result in dire
consequences. This approach primarily comes from the work of Corrydon Ham- 591
mond (1993), who describes some patients as having been programmed by the Sadistic
intelligence community, utilizing incredibly sophisticated layers of programs, spe- Ritual Abuse
cialized codes, and protective systems. The second approach views programming
as merely hypnotic suggestions that were given to the patient as part of their abuse.
Thus, the solution is simply to give countersuggestions. The last approach views
programming as hypnotic suggestion, but also sees it as part of an abuse incident
that must be abreacted and reframed in order to truly undo its effects. It is viewed
here as just another type of abuse.
In the absence of any clinical trials of these approaches, they can only be
addressed in terms of personal clinical experiences. Some would argue that the first
approach is unnecessary since many clinicians are successfully dealing with this
area without being experts on mind control. However, others argue that these
clinicians are missing important programs and controls that will cause later symp-
toms for their patients. The second approach, of trying to outsmart the original
programmers, appears to work in many instances, but many clinicians report that
this is usually only a short-term solution, and that the patient's belief in the original
program will eventually resurface again. In general, most clinicians seem to agree
that a long-term solution requires that the patient remember the abuse incident in
which such a suggestion was made in order to experience how it was really a trick,
and to fully understand how the suggestion affected them. At that point, counter-
suggestions may not even be needed.

Danger
The issue frequently arises of how much danger exists for both patients and
therapists involved in this work. Many clinicians in the field believe that there is
great danger from currently active cults. Interestingly, a recent study suggests that
there is little direct evidence of harm coming to either patients or therapists who
are working on ritual abuse issues (Stanek, 1993). Despite these data, there is often a
tremendous degree of fear that is generated in such work, with many patients
becoming convinced that they will be killed for disclosing information and many
therapists becoming convinced that their own or their family's lives are in danger. It
is certainly conceivable that working with this population could pose risks; how-
ever, the data noted above would suggest that this has not occurred with any
frequency to date. It may well be that both patients and therapists are primarily
responding to the intensely projected affects from childhood memories of extreme
powerlessness, danger, and fear. This is clearly an important area to investigate
further because if the danger is no longer in the present, it would clearly be a
disservice to the patient for clinicians to validate such feelings, instead of helping
the patient understand them as part of their past experiences.

SUMMARY

Psychotherapy with ritual abuse survivors is very complex and very difficult
work. The extremes of human cruelty that are described are bound to affect the
592 therapist in profound ways. Although the work can reaffirm the therapist's faith in
David K. Sakheim human beings and in the ability of love to survive even the most unimaginable
horrors (Sakheim, 1993), it can also bring into question many of the therapist's
previous beliefs about people and about life in general (McCann & Pearlman, 1990).
It is an easy area in which to lose objectivity and to develop countertransference
difficulties. The therapist must not be seduced by his or her own needs or by the com-
pelling material and the intensely projected affects to give up a therapeutic role.
The degree to which intergenerational satanic cults exist, conspire, and are
organized is not yet clear. However, there is not disagreement about the fact that
many of the patients in question have experienced severe forms of abuse and that as
therapists we will need to find ways to help them to heal. Clearly, there is a need to
investigate the claims of these patients further in order to help ascertain the reality
behind the allegations. However, even if we discover that there is no global satanic
conspiracy, or that some of the descriptions are metaphors for other types of abuse,
we will still need to develop ways to provide treatment for these clients and to
investigate and prosecute the criminal acts that have occurred. Too strong a focus
on Satan or on any of the other more mystical and sensational aspects of this area
can take us away from the sad reality of the extreme sadism and violence that are
truly behind the problems that these and many other patients experience.

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28
Legal and Ethical Issues
in the Treatment of
Dissociative Disorders
George B. Greaves and George H. Faust

The whole of the legal matter as regards the status of dissociation and pathological
dissociation is that it is more than nine parts lore and less than one part law.
There is abundantly more collective (and contradictory) lore than statutory or
judicial law in regard to all aspects of the alleged "special status" that dissociative
phenomena-ordinary or pathological in character-purportedly deserve.
As one famous psychiatrist in the field of multiple personality disorder (MPD,
now called dissociative identity order, or DID) put it: "We all feel that we need to
treat MPD patients in a "special" way, but no one can say exactly why."
Beginning with the publication of Sybil (Schreiber, 1973) and continuing with
The Minds ofBilly Milligan (Keyes, 1981), a mystique seemed to grow among many
psychiatrists, psychologists, a few judges, some prosecuting attorneys, and a
plethora of defense attorneys that individuals undisputedly suffering from dissocia-
tive identity and other dissociative disorders deserved special consideration under
both the canons of psychiatric standards of care and the civil and criminal and
administrative law.
"Special;' under this way of looking at things, variously meant differential,
preferential, exceptional, and even deferential consideration as to criminal sentenc-
ing, or exemplary-punitive rewards as plaintiffs in civil tort actions, or as complai-
nants against therapists in administrative actions against therapists' licenses. It

George B. Greaves • 1175 LaVIsta Road, Apartment #205, Atlanta, Georgia 30324. George H.
Faust • 2515 Kemper Place, Shaker Heights, Ohio 44120.
Handbook of Dissodation: Theoretical, Empirical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 595
596 became the "uniquely crippled" defense cry in criminal cases and the "uniquely
George B. Gf'eaves crippled" plaintiff's cry in civil cases.
and George H. Faust By about 1985, virtually anybody who proclaimed himself or herself to be an
"expert" in dissociative identity disorder could do so, even those who had never
published on the subject in a major professional journal, and those who boasted
that they had never read the collective scientific literature on the matter, "because it
was too dreadfully awful to digest." Whether the "dreadfully awful part" was
because of the lurid content of DID patients and their clinical reporters, or because
the whole field was regarded as simply bad or trilling science, differed from
instance to instance, and continues so to this day. Whatever the case, a pros-
ecutorial mind grew up against the whole notion of dissociative identity as a clinical
entity beginning in the mid-seventies and is now, however, grudgingly, relenting to
the main clinical facts of MPD/DID (Goettman, Greaves, & Coons, 1994; Greaves,
1993).
The bottom line during the 1970s and 1980s concerning the more severe disso-
ciative disorders was child abuse-not ordinary spanking, but severe child abuse
and neglect. We in the forensic area knew the truth. Children locked in closets or
bedrooms or chained inside houses for days or years at a time; skeletons of children
concealed within walls. There is no reason to be lurid about it. We've been in many
trials attempting to defend the child abuser, with no success. The evidence has been
overwhelming against our clients. It is recently that criminal physical and negli-
gence charges against children has been strenuously pressed in the courts, and the
whole evidentiary matter is usually quick, straightforward, unambiguous, unargu-
able, and final.
The matter of alleged child sexual abuse is a significantly different matter. We
absolutely know, from a forensic standpoint, that actual child sexual abuse of most
heinous and unbelievable varieties-even to very young children -actually occurs,
though it is beyond the ken of any normal man or woman either to even conceive of
it and least of all to carry it out. We know it from the physical evidence, the directly
correlated evidence of those confessing to particular details, and from direct and
corroborated eyewitness reports other than the child victims themselves.
We also know that children lie outright about many things, distort actual
events, confuse dreams and memories and wishes and fantasies, can be rather easily
coerced to believe and elaborate on events which never happened, can act as
stooges, and can confabulate quite freely about partial events. We utterly refute the
ersatz notion that no child, willingly or by default of memory, would lie on the
witness stand. We also know that some young children behave in highly sexually
explicit ways. To complete the circle, we also know that children of no apparent
sexual interests are sexually abused by other children and adults, that even young
children may have quite explicit sexual fantasies and desires, and arising out of
sexual guilt, may project that guilt onto adults. Tbe Children's Hour and Tbe Sailor
who Fellfrom Grace with the Sea are exemplary portrayals of the latter phenome-
non. Every hypothesis and observation about child sexual abuse is partially true:

1. It actually happens.
2. It is overreported.
3. It is underreported.
4. It is exaggerated in importance.
 5. It is diminished in importance. 597
6. It is lied about. Legal and
7. It is covered up. Ethical Issues
8. It is denied altogether as ever happening.

What is lacking in the process of the law is the someones who can system-
atically contrast (1) from G), and who can convincingly compare and contrast the
gradients within the list in matrix fashion.
We get a little closer to the legal tests of truth with child physical abuse because
there are forensic indicators in physical as well as psychiatric forms. For all that, the
medical and psychiatric politics from about 1960 to 1980, many physicians seemed
to eschew the notion of "actual" child abuse. Neglect, maybe, yes, even probably, in
some cases. The consensus seemed to be that such reports were vastly overinter-
preted and overemphasized by other specialists, including pediatricians, psychia-
trists, emergency room physicians, psychologists, clinical social workers, coroners,
and others to the extent that it has become an "obsession" -meaning a neurosis-a
shared "hysteria" among them. That was to miss the point entirely. It wasn't the
reports of abuse that so startled the latter community, it was the direct medical and
scientific evidence they were quite involuntarily collecting, publishing about and
testifying to (Goodwin, 1985; Greaves, 1989).
Part of the denial of the actually existing, forensically documented cases of
child abuse seems to be that psychiatrists and psychologists seem either not to like
or not to appreciate scientific, legal, and psychiatric forensics; don't know about it;
don't care to know about it; don't want to know anything about it; or don't want
to be bothered by knowing anything about it.
But you can bet your last piece of toast on a miserably cold, child-starved day
in medieval England, they're all crack experts on the subject once on the witness
stand.
Against this backdrop came the American Psychiatric Association's long (both
as to time and to size) struggles with producing the third edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Asso-
ciation, 1980), followed very quickly by a revised edition (DSM-III-R; APA, 1987).
While many psychiatrists and clinical psychologists welcomed the new diagnostic
work, a large number of well-established practitioners and psychiatry professors
loathed it. They felt it was far too radical a departure from the second edition
(DSM-II; APA, 1972), which had been the mainstay of psychiatric diagnosis for many
years and whose nosology and nomenclature were the natural outcome of psychi-
atric evolution since the 19th century. They found DSM-III nosologically fraction-
ated and some of its nomenclature and concepts if not actually spurious, certainly
debatable. For purposes of this chapter, the grouping of the dissociative disorders
was especially ill-received-and the notion of multiple personality disorder being
singled out as ein Ding an sich as a diagnostic entity rankled many. Many simply
dismissed it as an error of the APA nomenclature committees. When subordinate
clinicians began to use the diagnosis, their diagnoses were changed. In some
instances, the patients were removed from the care of the subordinates and the
subordinates were chastised.
The American Psychological Association had, in turn, ventured out on its own
grand vision which consumed some ten years of committee work. The purpose was
598 to write the sine qua non of psychological ethics as concerned the practice of
George B. Greaves psychotherapy and related procedures. The new ethical principles and guidelines
and George H. Faust first appeared in December, 1991, and, like the reception of DSM-m, was anything
but universally endorsed by the APA membership. Some vexing ambiguities in past
codifications had been gratefully clarified. On the other hand, certain issues which
formerly had been relatively clear now became frankly perplexing, especially in the
area of dual relationships.
The boy who mows the neighbors' lawns, including the psychologist's, con-
fides in the psychologist that his father is quite depressed after losing his job. If
the father were willing, would the psychologist see him? The father follows through
and the psychologist accepts him into treatment. Does the psychologist now have
to terminate the boy's services in order to avoid a dual relationship with the father?
A majority of psychologists in an advanced ethics training seminar soberly an-
swered yes.
Dr. Thatcher is a lifelong Lutheran and attends St. Timothy's in Wmslow. She
belongs to the pastor's Sunday School class. A new patient moves to Winslow, who
is also a Lutheran and also winds up at St. Timothy's and in the pastor's Sunday
School class. What are Dr. Thatcher's ethical obligations regarding dual relation-
ships in this situation? More than half the participants stated that Thatcher and her
patient should not be in the same Sunday School class, as Dr. Thatcher's expressed
religious view in the course of the dialectic of the class may well contaminate
therapy. They also felt that they should sit at opposite ends of the church so that
Dr. Thatcher's emotional responses to sermons and the liturgy would not show.
The "dual role" matters above are the analogue of an old psychoanalytic
problem-quite honestly and seriously debated for years. An analyst sees his last
patient of the day and leaves his office. There is a downpour outside as the analyst
enters the parking lot. He sees his patient shuddering in the wind. The analyst has a
hefty umbrella; the patient has none. Would it be too intimate a thing for the analyst
to escort his or her patient to his or her (the patient's) car under the protection of
his or her umbrella? Might this be misread as a sexual gesture? Or a gesture to the
patient to be overdependent on the analyst? Shouldn't a good analyst just let the
patient soak in the downpour, letting him or her know that he or she should take
responsibility for him- or herself in the most rudimentary of situations, and to
emphasize that the analyst has no real power over anything?
These examples are like straining at a gnat and swallowing the camel to a
lawyer's mind. The Council of Nicea actually did a better job of canonizing the
many ancient texts known to them which now comprise the Bible.
We have taken on the task and risk of writing this chapter as lawyers, histo-
rians, and serious scientific psychologists would look at it: very, very skeptically.
The laws of Caesar change slowly.

TilE FIRST MAJOR ETIUCAL PROBLEM IN MPD:

CORNEUA WILBUR AND SYBIL

The most important case recorded in the clinical archives of literature on

multiple personality disorder is undoubtedly that of a woman whom Connie Wtlbur
called Sybil (Greaves, 1993). Frank Putnam, M.D., the National Institute of Mental 599
Health's resident expert on dissociative disorders for many years, calls this case Legal and
"essential reading" in the field of dissociative disorders (Putnam, 1989). Ethical Issues
Flora Rheta Schreiber, the author of Sybil, was a professor of English on the
faculty of a major school of law in Manhattan. She lived in Gramercy Park until her
death some recent years ago. She met Comella Wtlbur at a women's business group
in New York City and the two struck up a spirited friendship, based on a mutual
admiration of each other's expertise in their fields.
Wilbur, whose parents were both highly trained scientists, obtained advanced
degrees in chemistry, medicine, and psychiatry. She had moved to Manhattan to
obtain even more advanced training in psychoanalysis, training which in the 1950s
and 1960s, and even today, is available in only a few major cities in the world.
She began to speak to Professor Schreiber of an unusual patient she had been
working with for a number of years in Omaha, Nebraska, whom she described as
having multiple personalities. Wilbur went on to say that there was no evidence
that anyone had ever successfully treated such a condition, but that she felt she
could, especially with her new, advanced training and her advanced skills in the
knowledge and clinical use of hypnosis.
Wilbur went on to state that the patient had followed her to New York in order
to continue treatment.
As Schreiber stated to Greaves in an extensive conversation (personal commu-
nication, Schreiber, 1983, paraphrased):
I was fascinated by her [Dr. Wilbur's] description of Sybil. But when she asked
me if I would like to write a book on the subject I replied: "How could I possibly
write a book without an ending? She's [Sybil] still in treatment:• It was when she
persuaded me to meet Sybil that everything changed.

Everything did, indeed, change-in Sybil's life, in Schreiber's life, and in Wil-
bur's life.
Schreiber was enchanted with Sybil, who came to live with her over quite
some course of time. Sybil eventually became well under Wtlbur's care, after
suffering many years of severe mental illness, and eventually relocated to New
England to become art instructor in a small college. Wilbur and Schreiber became
enormously famous. Sybil preferred to remain anonymous.
Largely as a result of her work with Sybil, Wtlbur was promoted from her
advanced New York training and psychoanalytic practice to become Chair of the
Department of Psychiatry at the University of Kentucky Medical School in Lex-
ington. She ultimately retired and died there, faithfully admired by a nationwide
host of colleagues, most of whom eventually became members of the International
Society for the Study of Multiple Personality and Dissociation, an organization
founded by Greaves, one of her many followers (Greaves, 1993).
This would seem to add up to a happy ending. Such was not to be the case
at all.
The treatment of Sybil occurred over a span of sixteen years. Wtlbur went to
heroic efforts to treat her. In believing the essential theme of the origins of Sybil's
baffling illness-extremely cruel childhood sexual abuse-and her objective
checking out of Sybil's accounts, Wilbur gained not only the reputation as a pioneer
600 in the treatment of multiple personality disorder, but a pioneer in the discovery and
George B. Greaves confirmation of severe child sexual abuse as well.
and George H. Faust But Wilbur could not obtain publication of her work with Sybil in mainstream
psychiatric journals. Her offerings were repeatedly turned down by editors and
reviewers. It was during this period of frustration that she turned to Flora Schreiber
for help.
Thus began a series of ironies that persists to this day and continues well into
the foreseeable future.
In the book Sybil, one reads the most important book about a psychiatrist and
patient ever written, a book instructive to tens of thousands of multiple personality
patients, their psychotherapists, and the public.
Schreiber's book hit the ground running, selling by now into the millions of
copies range, considering its various paperback releases, and was turned into the
award-winning four-hour television movie of the same name, starring Sally Field as
Sybil and Joanne Woodward as Dr. Wilbur.
Such a book could only have been written by a third party to the proceedings,
observing many of the proceedings, and from the unique vantage point of a
journalist.
Certain members of the American Psychiatric Association viewed the publica-
tion of Sybil not with a joyful welcoming of a new day in psychiatry in which a
rare and pernicious mental illness known for 150 years had finally been treated
successfully by one of their own, but with outrage.
Whether or not Sybil had been cured or not was thrown to the winds. The
main issues raised at the time were that:

1. Wilbur should never have allowed to be exposed in the popular press what
had not previously been approved and published in scientific journals.
2. Wilbur was seriously "overly involved" with Sybil.
A huge outcry arose within the American Psychiatric Association for the
expulsion of Dr. Wilbur from its ranks. Fortunately for science, Dr. Wilbur, and
the crucial rediscovery of multiple personality, with all its attending implications in
the 1970s and 1980s, the attempted expulsion of Dr. Wilbur was a fiasco.
When put to the vote, the psychiatrists involved in the matter could not agree
among themselves what, exactly, "overinvolvement" with a patient would be, or
where, exactly, the ethical rule was that one had to publish in a scientific journal
before one could release results into the "public" press.
For all the folderol, hype, gossip, rumors, novels, movies, and judicious and
injudicious decisions-at all levels of fantasy and the law and professional ethics
and personal and journalistic speculation about dissociative disorders-they all
owe their contemporary history to the two cases mentioned above: Sybil and
Milligan. All else is footnotes to these guiding cases.
We exclude from our discussion The Three Faces of Eve case (Thigpen &
Cleckley, 1957), because litigation issues surrounding it arose only much later and
were primarily focused on copyright issues (Sizemore & Pittillo, 1977).
Judging Wilbur for ethics violations under present-day APA guidelines:

1. Making living arrangements with Flora Schreiber,

2. Seeing patient outside of office,
 3. Traveling with patient to verify abuse, 601
4. Inadequate training to treat patient, Legal and
5. Failure to discharge patient when she was not getting better (16 years is a Ethical Issues
long treatment),
6. Dual relationships with patient (treating patient while a book was being
written about her; becoming a traveling companion with the patient),
7. Numerous "boundary violations," and
8. Probable violations of confidentiality.
But these were the years 1956 to 1972.
Giving an organization a new code of ethics is like giving a child a new BB gun.
The very first thing a father teaches a child about a new BB gun, beyond fundamen-
tal safety issues, is never to shoot a bird. Shoot a bird and the gun is gone.
Yet the "hallway hangings" of Connie Wilbur we have listened to at profes-
sional meetings over many years have been lifted totally out of context, and fraught
with a most peculiar vindictiveness. There seems to be a perverse penchant for
aiming the sights of the new weapon into the past-like a time traveler.
In these conversations, no distinction was drawn between the present and the
past. In the past, Freud loaned or gave money to his patients. In the past Sandor
Ferenczi, one of Freud's favorite disciples, either allowed or encouraged patients to
sit on his lap and even kissed them, though Freud was disturbed upon learning
about this. In the 1960s, hugging patients or students or strangers in "encounter
groups" was highly recommended as a therapeutic means of contact, recognition,
appreciation, confirmation, and grounding. Earlier in the century, analysts taking
the month of August off for vacation were frequently followed or accompanied by
an entourage of patients.
That these kinds of relationships with patients sometimes led to immediate or
long-term misadventures between therapists and patients gave rise to a constant
review of the interpersonal process between them. These systematic observations,
in turn, gave rise over the course of many years' evolution to ethical guidelines
based on trial and error: what works and doesn't work.
The essence of contemporary ethical guidelines in psychiatry, generically
speaking, is that practitioners in a treating or advisory capacity have allegedly been
schooled and trained in such a way that they have such vastly superior knowledge,
skills, authority, and power, and that they could readily disadvantage a client were
they to choose to do so out of malice or cunning, or they could innocently injure
their clients out of neglect of the knowledge of the powers or applications of their
learning. Ethical principles are therefore proscriptive and restrictive in nature: that
is, they do not so much inform a professional practitioner about what to do, but
about what not to do as regards a client.
That is as helpful as the beginning of the Hippocratic Oath: prima non docere.
Very helpful. But no one ever asks how Hippocrates learned that.

TilE FIRST MAJOR LEGAL PROBLEM IN MPD: BILLY MllllGAN

Connie Wilbur ethically malpracticed in her treatment of Sybil? The lore and
law of the time said no.
602 Billy Milligan was a criminal serial rapist? The lore of the time said no. Serial
George B. Greaves rapist? Undoubtedly yes. Criminal rapist? No.
and George H. Faust The Milligan case is the most important and least studied of multiple person-
ality cases in the modem lexicon of law. The so-called "Milligan defense" has, in our
experience, been tried-both in concept and in court-more often than virtually
all other versions of the "amnesia for criminal actions" defense.
First of all, the Milligan felony kidnapping-rape-armed robbery case never went
to trial; therefore, it never generated either a jury-verdict opinion or appellate
decision.
Second, virtually all courts, appellate courts, and juries trying similar cases
have subsequently rejected Milligan-type defenses outright.
For all the d:rarilatic reality of the Billy Milligan case, a popular myth persists in
many attorneys' and mental health professionals' minds that Billy Milligan was
acquitted for his three major multifelony crimes by a jury of his peers based on "not
guilty by reason of insanity;' commonly know as the NGBRI (NEEG-bree) plea, in the
jargon.
None of these believers in the Milligan form of the NGBRI defense (meaning
basically that one person cannot be held criminally liable for the independent and
unsanctioned criminal actions of others-in the absence of a criminal collusion
between the defendant and others-even when the «others" happen to inhabit
one's own body), can precis the case correctly.
The history and background of the Milligan case is essentially thus:
During the early autumn of 1977, three young women were abducted from the
Ohio State University campus at gunpoint, driven to nearby Delaware County in
their own cars, raped, and subsequently robbed. One was an optometry student,
the second was a nurse in the huge medical school complex, the third was a twenty-
year-old student who has never been identified in the quasi-official public literature
on the case beyond the pseudonym of Polly Newton.
Milligan's crime spree, ultimately resulting in numerous felony assaults, lasted
perhaps thirteen days, ending with his arrest on or about October, 27, after mid-
night.
To understand what happened next, one has to understand the culture of
Columbus, Ohio. Ohio is a very conservative state and one thing which Columbus,
its capital, will not put up with is violence.
It not only had to put up with the Kent state rioting in which four completely
unarmed students were needlessly and pathetically killed in May of 1970 by the
Ohio National Guard (which was an army, after all, not a police force), but the pride
of its enormous public university system-Ohio State-was forced to close during
the student rioting following the Kent State tragedy.
It was the apex of civil protest against the Vietnam war, in the capital of the
very state which, with Virginia, had produced significantly more than half the
elected Presidents of the United States during more than half the nation's formative
history. Ohio's version of the tally was: Ohio-8, Virginia-7.
To put the context of the matter somewhat more remotely, historians of the
American Civil War would be hard put to find two nobler and greater adversaries
than the State of Ohio and the Commonwealth of Virginia. General Lee of Vrrginia
surrendered to General Grant of Ohio after General Sherman of Ohio "broke the
back of the Confederacy" in his largely unopposed "march to the sea" from Atlanta
to Savannah. Legal and
Ohioans never believed that they won the Civil War by themselves or that the Ethical Issues
Virginians lost it by themselves. But Ohioans believed that they were the phalanx of
Union bravery just as Virginia lay at the heart of Confederate bravery.
This would be a gratuitous regression into history except for two things. Ohio
came out of the Civil War rich, but sober, and contributed an amazing number of
generals, statesmen, presidents, and the first human being to set foot on the moon.
Ohio was high-tech to the Nth degree in agriculture, engineering, education and
manufacturing before the Civil War and continued to grow in civil law, social
services development and administration, highway development, police science,
aviation, communications science, medicine, research, publishing, high tech-
nology-you name it-well into the late twentieth century.
But the Kent State massacre virtually undid the state-a festered black eye for
all the world to see-chilling Ohio's pride to its core. It had to make up for it in
fairness. And Billy Milligan was one of the benefactors of its new moral awareness
and campus safety.
By 1977, no one sidled onto the campus of Ohio State University -in whatever
imaginable disguise and with whatever alibi-kidnapped young women from the
campus between 7 a.m. and 8 a.m., and got very far for very long. The Ohio State
University Police force is many times larger than most small town jurisdictions
across the country, owing to the population density in the three or four square miles
the campus itself encompasses, as well as the adjacent areas. For all that, there were
no checkpoints, passports, or passes needed to obtain entry to any part of the cam-
pus, except, of course, course registration cards to enter certain training class-
rooms. It was all high-surveillance.
Given its virtually instant high technology, it took barely two weeks to catch
Billy Milligan. Within the first week of his crimes he was labeled as "the campus
rapist" around the world. Police artists drew ambiguous sketches of Milligan which
appeared on the front pages and magazines everywhere. The closest we can come
to in the present time is the vast lore and mystery of the "Unabomber," who has
apparently committed his crimes over a period of 17 years.
Once Milligan was firmly established worldwide as the notorious "campus
rapist" at Ohio State, all eyes were focused on Columbus to see what would happen
next. What did happen was as far from the Kent State debacle as could be imagined,
and was born of the strangest conceivable set of ironies.
George Greaves had arrived at the Ohio State campus in the summer of 1970,
while the whole of the east side of North High Street across from the main campus
was still a shambles-glass and the detritus of mob destruction everywhere, former
businesses boarded up. After doing a year of post-doctoral training at the College of
Medicine's department of psychiatry, he headed on to gather still more advanced
training at the Kitchener-Waterloo Hospital in Ontario, Canada, where he accepted
the directorship of the 24-hour psychiatric crisis clinic.
It was there, in January of 1972, that Greaves and his staff encountered their
first unmistakable case of multiple personality, an individual they studied and cared
for most attentively for a number of months.
In the meantime, Greaves's services were needed back in Columbus. At the
604 invitation of Jim Gibson, executive director of the new Southwest Mental Health
George B. Greaves Center, Greaves agreed to assume the role of developer and director of the center's
and George H. Faust several outpatient programs. Included among these was the Southwest Forensic
Center, which was contracted with Franklin County in Columbus to provide foren·
sic evaluations for indigent prisoners suspected of suffering from mental disorders.
With Greaves's concurrence, Gibson hired Dorothy Thmer and Stella Karolin as the
first two clinicians in the new program in early 1973.
Once the outpatient programs were up and operational, Greaves received an
invitation from the University of California Medical Center in San Francisco as a
research psychologist. UCSF was the virtual world's research headquarters for
studies in the neurotransmitters, which Greaves saw as the psychiatric wave of the
future. Here was yet another opportunity to sharply upgrade his psychiatric knowl-
edge.
Yet half a year later, Ohio called him back: this time to develop and head his
own tri-county mental health center, replete with hundreds of thousands of dollars
of new facilities construction.
Greaves, who headed the new Gallia-Jackson-Meigs Mental Health Center,
quickly made the acquaintance of David Caul, who headed the adjacent Athens-
Vinton- Hocking Mental Health Center. They quickly discovered their mutual inter-
est in MPD which, along with a sense of great mutual respect, formed the basis of an
abiding friendship which lasted until Caul died in March, 1988, and led them
through many adventures and heartaches. Caul was also a protege of Connie Wilbur,
who had recently moved into the area, and began drawing Greaves into Wilbur's
training seminars in 1975.
To begin to pull some of these peripatetics together as regards the Milligan
case, we may begin with the irony that it was the Southwest Forensic Program that
first recognized Billy Milligan as having multiple personality disorder, possibly the
result of Greaves' sojourn in Canada and subsequent oral accounts of the condition.
The next remarkable event that happened in the Milligan case was that Judge
Jay C. Flowers, the Common Pleas Court assigned to the case, sought his own
special expert for advice on the case, once it appeared that Billy Milligan was likely a
multiple. It was both the most conservative and wisest decision possible for a judge
in terms of what was quickly shaping up as a unique legal case.
His selection for an advisor was neither a crony, nor pro forma. Instead he
enlisted the consultation of a physician who was undisputedly the most respected
psychiatrist in the state: George Harding, Jr. Harding came from a transgenerational
family of psychiatrists, much like the Menningers in Kansas, and, as director of the
Harding Hospital on Columbus' north side, he was in a position to be philanthropic
in the service of justice. He undertook the diagnosis and treatment of Milligan,
creating a special treatment team, and sought consultation with Drs. Caul and
Wilbur.
Dr. Harding wrote an eloquent report detailing the reality of Milligan's clinical
condition. This was backed up by depositional testimony by Drs. Wilbur, Caul, and
Kaolin and by Ms. Thmer. Mr. Yavitz, the Franklin County prosecutor, declined any
attempt at prosecution in the face of such evidence. Judge Flowers ruled Mr.
Milligan not guilty by reason of insanity (under M'Naghten) and the inability to
refrain from his acts (under Durham).
The only thing now that remained was the disposition of the detainee.
 David Caul was willing to treat Billy Milligan as an inpatient at the Athens 605
Mental Health Center, with the concurrence of his state superiors.
Legal and
Milligan prospered under the care of Drs. Harding and Caul and soon became Ethical Issues
so well that he was moved into what was called "transitional care." He was moved
out of the hospital to live on his own recognizance nearby, with daily check-ins at
the hospital. He rented a nearby farm with the extraordinary money he had been
making from his extraordinary oil paintings. He contacted Daniel Keyes to write his
side of the story of what had gone wrong, but Keyes would have nothing to do with
anything of the sort. He was not a "ghost writer" or a "subwriter." Keyes was an
honest-to-goodness "real writer:' As such, he called the shots. And Milligan, who
would otherwise have composed a completely self-serving work, was all the better
for Keyes' objectively written work.
Then, suddenly, the bottom fell out.
David Caul was removed from the Milligan case abruptly, almost as soon as he
had brought about an amelioration of Milligan's MPD disorder, though he was
following Ohio State and Joint Commission for Accreditation of Hospitals treatment
policy. The crucial policy was that as patients improved in their conditions, they
should be transferred to the least restrictive environment consistent with their care.
Milligan is not what one would call your average good mental patient. He went
AWOL on occasions. It is claimed that he was found drunk in a neighboring town
and was in a fight past curfew hours and had no reason to be there anyway.
Months later, as Caul put the whole incident and many others to Greaves,
described his whole treatment of Milligan, and pointed out on the Athens Mectal
Health Center campus exactly when and whe ·e Milligan got drunk on a pass or tled
up this hill or that as a prank, he became gravely despondent. His eyes were red and
he sniffed in the cold hilly air. He never quite bounced back from the Milligan case.
His heart was not so much sorrowed by Billy Milligan's ongoing teenage,
sociopathic betrayals-Caul knew very well Milligan was a sociopath and was far
too wise to commingle his heartstrings with those of his capricious patient-- but by
what he felt were the betrayals by his own kind. Psychiatrists and psycholc:r.ists up
to this time had been standing shoulder to shoulder with Caul, along with many
defense attorneys and state attorneys and judges.
Now, given Milligan's deliberately annoying escapades, Caul began to be
second-guessed. He was treating Billy too "special." He was overindulging him. He
was "allowing him" to act out. Caul was perfectly willing and able to pull the reins in
on Billy (and Milligan freely agrees with this), but he was never given the chance.
Milligan was a political hot potato. He came to be regarded as a treatment failure
under Caul and was removed from the Athens Mental Health Center altogether to
the Dayton Forensic Center. From there he was transferred to the Lima State
Hospital for the Criminally Insane. Finally, he was transferred to the new Timothy B.
Moritz Correctional Center, a barbed wire compound on the grounds of Central
State Hospital in Columbus.

The Cases Come In

While Milligan was being shifted from pillar to post, appellate decisions of the
Milligan-type began to appear.
606 In State v. Darnell (1980, Oregon), in a flagrant case of male multiple person-
George B. Greaves ality, the jury found Darnell "responsible and guilty" of the murder of his father.
and George H. Faust Kirkland v. State (1983, Georgia) became the classic case which still prevails.
It was uncontested that the bank robber was psychiatrically ill from MPD. But under
M'Naghten, whatever part of the consciousness of the person who committed the
crime knew that he or she was committing a crime by way of objective evidence
(e.g., elaborate plans for escape and evasion of capture).
In State v. Rodrigues (1984, Hawaii), the lower court judge ruled for acquittal
in an MPD case. The state appealed and the higher court reversed the judge, stating
"a defense of multiple personality syndrome (MPS) does not per se require a finding
of acquittal."
In State v. Brooks (1986, Ohio), Ohio itself had a second look at the Milligan-
type defense. The defendant was convicted on three counts of aggravated murder,
but defense appealed on the basis that he suffered from amnesia. Despite that, and
given that the defendant was mentally ill at the time, descriptions of his behavior at
the times of the crimes made it perfectly clear to everyone that the murders were
conscionably premeditated. State v. Dillard concurred (1986, Idaho) with Rod-
rigues the same year.
During 1988, United States v. Davis, 11 Cir., a federal appellate court cited
Greaves in its findings that he would never attribute second-hand facts to his
decisions about whether or not an individual person might or might not be suffer-
ing from multiple personality; and if that was even his clinical diagnosis, upon
direct examination-that a certain person suffered from MPD-that did not, in
itself, preclude a person from knowing what he or she was doing was criminally
wrong (under M'Naghten).
Numerous other appellate cases have evolved regarding MPD/DID and the
other dissociative disorders. The best annotated list is found in Multiple Personality
and Dissociation, 1791-1992: A Complete Bibliography (Goettman, Greaves,
Coons, 1994). Virtually all the criminal topics can be subsumed under two rubrics:
1) whatever personality or personalities commit a crime shall be subject to examina-
tion and adjudication, in full, on the M'Naghten rule; and 2) the existence of mul-
tiple personality disorder in an individual may be used as a mitigating diminished-
capacity defense to avoid a sentence of death.

What Ever Happened to BiUy MiUigan?

In December of 1977, the director of the Franklin County Mental Health and
Mental Retardation Board in Columbus called George Greaves at his office in
Atlanta.
"We have certain problems with the Billy Milligan case;' the director began
forthright. "You come widely recommended as a person to serve as a consultant on
this case and to conduct an evaluation of Mr. Milligan."
He went on to explain that they had had Milligan in the system for a decade
now, but were not sure he belonged there or how to get him out. Ironically, Billy had
served more time in mental health incarceration than he likely would have served
doing straight time (a Ia One Flew Over the Cuckoo's Nest) and, well, there was
another problem. Billy had become the prison "attorney." Making use of the prison
library, he was filing lawsuits, motions, and briefs which were resulting in increas-
ing mayhem in the Franklin County State and Common Pleas Courts. Legal and
After negotiating fees, parameters, expectations, and the like, Greaves agreed Ethical Issues
to evaluate Milligan during the first part of February, 1988, and to furnish a report.
In addition to his familiarity with Milligan through press reports, Keyes' book,
and David Caul, Greaves spent four hours at the Moritz center poring through a
large stack of hospital reports, the so-called official records. For the next four hours,
he took Milligan through a far-ranging interview, specially designed to uncover
remnants of dissociated personality elements. There were none. Milligan himself
was a bright, engaging, likeable sort, with a keen sense of humor. Obviously, he was
on his best behavior-but even good-natured people can grow testy after four
hours of questions, some quite personal, out of the blue. But Milligan didn't flinch.
The only time he became bitter was when he related how the state had seized the
$350,000, which was his half of the profits from The Minds of Bflly Milligan, to
apply to his "treatment costs." It had taken a special act of the Ohio Legislature to do
this. "One should not be able to capitalize from a crime" was the principle. Greaves
knew that what he was telling him was true, because he had followed the whole
matter through the national news. As he sat with Milligan, he couldn't help but
wonder about the Watergate bunch.
Greaves phoned the director once he had returned to Atlanta and told him
what he had found.
"Mr. Milligan does not have MPD which is the disorder which sparked his legal
troubles, and I take it that he has not had it for some time. The records and my
interview do not reflect that he has any present mental disorder, nor is he being
treated for any; yet you have him incarcerated in a high-security mental facility.
In my opinion he is being held unlawfully."
"You'll send me that in writing with a discharge plan, a transitional care plan,
and a treatment/follow up plan?"
"Before the week is out."
"It's done then. Thank you. Send me your bill."
Within the month Milligan was a free man, with a new identity and a new job.

IT WAS NEVER ABOUT MULTIPLE PERSONAUTY ANYWAY

When Faust and Greaves began their collaboration in 1984, both were fully
aware that multiple personality was a faux appellation.
What concerned them from a forensic standpoint was they were by no means
sure that psychiatrists, psychologists, social workers, and attorneys generally under-
stood this. In fact, they heard dozens of persons speaking both in the parlors and
from the podium as if different persons actually shared the same body. "Bad facts
make bad law," we both said over and over, and for years we lived in rue of the day
that some civil court would accept this impossible premise as a given and some
appellate court would uphold it. Fortunately this never happened and now likely
never will, thanks to DSM-IV nomenclature. But there was a run of some twenty
years when some metaphysically handicapped practitioners were willing to put
God's forswearance to the point.
608 Greaves was thoroughly trained in British analytic philosophy, as well as
George B. Greaves . personality theory, and was fully aware of the absurdity of the notion of multiple
and George H. Faust personality. It was one of those unfortunately inherited psychiatric terms from the
past, as misleading as hysterical conditions said to arise out of the involuntary
wanderings of the uterus within a woman's pelvis, giving her the most frightening
jitters and phantasms. No one really believed this nowadays-quite-though the
fact remained that hysteria was still overwhelmingly a female family of psychiatric
illnesses.
Of the score or so of civil and criminal MPD cases Greaves took on in the 1980s
and early 1990s, as expert consultant, he was cautious with attorneys in helping
them to understand that they were not dealing with different people in these
clients, but with different aspects of a single person. For all that, he found attorneys
separately deposing different "personalities," becoming frustrated when one or
another personality refused to cooperate, or feeling at their wit's end when a
particular personality refused to sign a release for legal documents.
Given the needless perplexities the terms "multiple personality" and "multiple
personality disorder" were generating in all sorts of arenas, Greaves set out in 1990
to reconceive of and attempt to rename the related clinical disorders. He completed
this project by 1993 and published his revisions in an American Psychiatric Press
text, edited by Richard Kluft and Catherine Fine.
Greaves proffered two novel modifications to the clinical concept of MPD.
First, instead of conceiving of MPD as a neurosis, as was the historical lore, Greaves
conceived of MPD as an organized series of "recurrent episode psychoses." Sec-
ondly, he held that the hallmark of MPD was not that of multiple personality, but
that of multiple identity process. He suggested the disorder be renamed multiple
identity disorder.
A year later, when DSM-IV appeared, MPD had been changed to dissociative
identity disorder. Whether this happenstance was a matter of parallel evolution,
synchronicity, or the fact that Greaves's editor was a member of the Dissociative
Disorders Committee for DSM-IV is of minor importance. The major importance is
that for the first time in nearly 200 years a major, elusive mental illness was finely
given a name descriptive of it.
It was actually Richard Kluft who said it best, quoting an unnamed colleague at
Harvard:
The problem with MPD is not that the person has too many personalities, but
that they don't even have one functional one.

THE PARTICULAR HAZARDS IN TREATING DID PATIENTS

Numerous clinical authors have written about and catalogued the hazards of
working with certain DID patients. On the one hand, the issue of physical violence
has been stressed (e.g., Watkins & Watkins, 1984, 1988; Young, 1986). On the other
hand the emotional viciousness of the DID patient toward the therapist has been
stressed. The classical paper in this genre is that of Chris Comstock and Diane
Vickery (1992), entitled "Therapist as Victim."
 The active hatred of some patients toward their putatively neutral or nurturing 609
therapist is by no means a new topic in psychotherapy. Freud was familiar with the Legal and
transference phenomenon in which the therapist was projected to be the bad object. Ethicallllsues
But in the early days of treating multiple personality, as far back as Eve (Thig-
pen & Cleckley, 1967) and through most of the early 1980s, little was reported
about the physically and emotionally violent proclivities of MPD patients. If any-
thing, they were regarded as rather exemplary patients to work with from a rela-
tional standpoint.
Then Richard Horevitz and Bennett Braun (1984) began taking notice of the
borderline personality features of many MPD patients, followed by George Gana-
way (1989). Even Frank Putnam, in his 1989 classic, talks about frank sexual attacks
by MPD patients (p. 192) and the proclivities for some patients to "bad mouth" their
present and former therapists (p. 194). Putnam's counsel is to take all such reports
with a grain of salt.
But by 1994, based both on survey and personal experience, the cat was out of
the bag. We let them speak for themselves:

Direct attacks, apart from verbal and physical assaultiveness to the therapist,
have included unusual behavior such as leaving dead animals on the therapist's
porch, poisoning and/or releasing of therapist's dogs, attacks on the therapist's
possessions and/or person, and shooting guns in the therapist's office or home.
More usual types of attacks have taken the form of filing frivolous or malicious
lawsuits and reports to supervisors or Ethics Boards, harassing telephone calls,
violating the therapist's space by refusing to leave, refusing to pay, and bringing
guns or knives to the therapist's office.

We could supplement with our own direct knowledge a list of aggressions and
transgressions: death threats to the therapist and family; threatened kidnapping of
children; broken windows; slashed tires; egging and scratching of cars' surfaces;
breaking, entering, and theft; telling other patients wildly-fabricated stories about
therapy sessions; phoning therapists' parents with sordid details of sexual abomi-
nations in the therapist's office; actual stabbings and other unanticipated sudden
injuries of therapists; numerous false and concocted late night crises (e.g., massive
drug overdoses which never occurred); wholesale blackmail (e.g., "If you ever let
on to a soul what I did last night, I'll march right down to the police station and
holler rape at the top of my voice.").
How each and every of these types of crises is worked through therapeutically
is of the gravest importance, and there is not the slightest doubt that to fail to
recognize these gambits for what they are and to fully resolve each example can
lead not only to an escalation of such crises, but to the most painful misadventures
possible on everyone's part (Chu, 1988; Greaves, 1988).
But there is a glitch in all this, a glitch we will elaborate on at length below.
When a DID patient makes a de nouveau attack upon a therapist, there arises a
general suspicion among fellow practitioners that the therapist has somehow made
a therapeutic mistake or invited or provoked the attack. And the worse the attack,
of course, the more grievous must have been the therapeutic error that caused it.
Now, while it is all quite true that the failure to come to a complete understanding
and resolution of the attack is a therapeutic error, it does not follow that the attack
610 itself was provoked by therapeutic error. When a therapist is seeing a number of
George B. Greaves DID patients, a number of de nouveau attacks are possible, inflamed by contagion
and George 1L Faust effects. Where there is smoke there must be fire. Now there is a therapist out of
control.
The answer to this small riddle is quite simple. Therapists schooled in the
nature and psychotherapeutic treatment of the neuroses simply do not believe in
vicious, de nouveau, aggression. Neurotics simply do not behave that way unless
some gross therapeutic error or series of errors has occurred, in which case such
outbursts would be reactive in nature and not de nouveau at all.
Almost no one but psychoanalysts and a few psychiatrists are thoroughly
schooled in the psychodynamics of pre-oedipal psychopathology, including its
object inconstancy, splitting phenomena, narcissistic omnipotence, and ego-
syntonic rage. Greaves had drawn these conclusions about MPD character structure
as early as his 1980 "Mary Reynolds" paper, but it had either not been understood
for what it implied or had not been taken seriously.
The point to be made is that in dealing with pre-oedipal character pathology,
unprovoked rage is the norm in the therapy situation, not the exception. Un-
suspecting therapists working with DID patients were completely taken aback by
this- and sometimes emotionally quite injured-while their equally unsuspecting
colleagues began to suspect they were working with Job.
It is considered to be the therapist's responsibility to set and maintain the
therapeutic boundaries in therapy. Yet as has correctly been observed, the internal
boundary chaos of DID patients, due to their nearly boundaryless upbringing, have
poor external boundary control because of their impoverished internal boundaries.
Boundary establishment on the part of the therapist is thus felt to be an important
corrective element of the treatment in and of itself.
But some DID patients, i.e., those with severe underlying pre-oedipal character
disorders, will agree to any boundary, and adhere to none. When such acting out
against boundaries is limited to noncompliance with therapy, termination of ther-
apy may well be warranted, though some therapists, wisely or unwisely, are willing
to tolerate quite wide degrees, or "exceptions," to noncompliance. But when the
acting out takes the form of criminal behavior, there may be no remedy short of
arrest and criminal action. One therapist we have followed was so severely put
upon by his patient in such an obsessive and aggressive way, that he was able to
obtain a permanent Superior Court injunction barring the patient from any further
contact by any means whatever, direct or indirect.
Except for examples as extreme as the last, it is not commonly said that the
patient trashed boundaries, or refused to honor boundaries, or violated boundaries,
or repeatedly crossed boundaries, or the many other permutations of the concept.
What is most commonly said is that the therapist did not hold or enforce bound-
aries. By way of example, one of Greaves' patients eloped from her day care pro-
gram by driving her car to another state and by remaining secluded in the moun-
tains at a motel for several days.
The question put to Greaves was not why this errant event had taken place, but
why he had let her do it.
A therapist's purely conceptional and fictional omnipotence in maintaining the
therapeutic framework is no :match whatever for a patient's real rageful, infantile
omnipotence. People tend to forget that outpatients, in particular, are free to 611
exercise the full range of their civil rights. Legal and
Ethical Issues
The Worst Nightmare of AU
In this last section on the law and ethics as pertaining to the dissociative
disorders, we are going to take the reader through some totally unfamiliar
territory-through a chamber of horrors as it were. Yet it exists. We've followed
these cases firsthand from our vantage point as members of the Legal and Ethics
Committee for the International Society for the Study of Dissociation for several
years (Faust was cochair), until the Committee was disbanded. In the meantime we
verified Comstock and Vickery's suspicions quite thoroughly. During one sixteen-
month period we became aware of 86 lawsuits, licensing board actions, and other
administrative actions lodged against those treating DID patients.
Paul Dell was not the first to notice, but was the first to systematically study the
other side of the equation: not the patients' hostilities toward their therapists, but
colleagues' hostilities toward MPD therapists (Dell, 1988, 1988a). The papers were
both riveting and sad commentaries on the sociological aspects of scientific discov-
ery toward the end of the century.
As in the cases of Sybil and Milligan, however, a couple of paradigm cases and
a couple of spinoff cases are wholly adequate to make our point.
Over the years, quite out of idle curiosity, we have asked a wide variety of
people upon what, historically, the American legal system is based. Nearly always
we receive the answer: the English Common Law.
This is quite a remarkable notion given that until very recently virtually every
county and state court house, and every state capitol, and most all civic buildings
and post offices were built in Romanesque architecture. Virtually all technical legal
terms are in Latin. The American legal heritage, like the English legal heritage is
Roman thtough and through. It is based on statutory and judicial law, much of it
unchanged for more than 2,000 years.
Physicians, psychiatrists, psychologists, social workers, and others seem to
quake at the day they may be called to court to answer a lawsuit.
In point of fact, to be sued in Caesar's court is the finest place on earth to be
sued. The reason is quite simple. First of all, if one is a practitioner, one has insur-
ance to cover lawyers' fees for the litigation. Secondly, there are strict rules of
procedure which assure that the adversarial game is played fairly, with all the cards
on the table. The orderly process of the discovery of relevant evidence, and its
sharing with both sides, mitigates against ambush. Rules of evidence mitigate
against gossip, hearsay, innuendo, and past reputation being considered in the
present dispute. Since the entire case is laid out in advance of the trial, there
normally is no trial. The judge and attorneys can read the matrix which is often
quite clear on one side or the other. Agreements are made, and assuming the judge
concurs, the matter is settled and put permanently to rest.
Try this matter by contrast:
Dr. Jones is visited, by appointment, by the State Board of licensing Examiners
whereupon it is revealed that a complaint against him has been lodged on behalf of
Ms. J. Smith. He is informed that the identity of the complainant or group of
612 complainants is confidential. He is also told that he will not be permitted to read any
George B. Greaves portion of the complaint, nor any paraphrasing of the complaint, nor will he be
and George H. Faust furnished with any bill of particulars until the time of any hearing which may come
about. He is asked a few perfunctory questions and told that he may proffer an
affidavit in the matter. This he does, on advice of counsel, though the affidavit is, by
necessity, general in nature.
Six months later, the same thing happens. This time it is in regard to a Ms.
Thomas. Another six months goes by with no word or action. Friends call the board
to see if Jones is under investigation. One friend calls the President of the Board,
and is told that Jones has not been and is not being investigated.
Nearly a year later, Jones is summoned to meet with the Board to answer
charges of sexual misconduct and "such other concerns as the Board may wish to
address."
Attorneys are employed. They are told that they have 10 days in which to
conduct discovery, though the board has been conducting discovery in secret for
two years. A prosecution list of 21 witnesses is presented, about a third without
any identifying information, addresses, or phone numbers. Only one witness has
waived her confidentiality privilege, but she refuses to testify at the hearing ifJones
is present. The hearing officer allows full television presence throughout the
hearings, subject to several provisions: (1) the witnesses would have their faces
blocked out; (2) their hands would not be photographed; (3) they would all be
given aliases; (4) Jones could be photographed in full at any time; and (5) the
television station would be given full editorial discretion over whatever it chose to
broadcast. The defense team puts forth 21 motions pertaining to due process in the
hearings, and all were denied. The prosecution's chief expert witness states that the
keystone case should not be included in the hearings for ex postfacto reasons. The
witness who has declined to face Jones on the witness stand has her current
therapist testify in her behalf-a complete hearsay testimony over the strenuous
objections of the defense. A second expert witness for the state admits that while
Jones has done nothing technically wrong regarding the main charge, that he
nevertheless feels that Jones has behaved unethically, because the Ethical Code
is too liberal in that regard. When confronted by the defense that his views are in a
small minority and do not reflect the will or tenor of the American Psychological
Association, he freely recognizes that fact, but still feels he is right and the majority
is wrong.
Jones was being vilified by both these "make up the rules as you go" proce-
dures and by the local 1V channel in "investigative" news the week before the
hearings. Jones and his attorneys had no choice but to pull the plug, as the stress
was beginning to take a toll on Jones' physical health as well. Jones' professional
liability insurance had no provision for attorneys' fees in administrative actions, and
with procedures varying so extremely from normal civil procedures, his legal fees
were mounting rapidly. False, collusory charges; no viable defense.
Jones and his attorneys entered into a consent agreement to revoke his license
with no finding of guilt or innocence. Jones lost his means of livelihood, his home,
his solvency, and his retirement, and was forced into bankruptcy.
There is a interesting aftermath to the story, however. Every subsequent law-
suit arising from this fiasco fizzled in Caesar's court. And it did not cost Dr. Jones a
dime to be tried in a civil court. One very short story more and we will have proved 613
our point. Legal and
Dr. Jane did not trust Ms. Betsy's father because of his reputation as a tyrant. Ethical Issues
She decided that it would be safest if she tape-recorded every therapy session
between them to which Ms. Betsy agreed. About a year later, Ms. Betsy's father got
it in his head that Dr. Jane and his daughter were conspiring against him and that he
was going to teach Dr. Jane a lesson. Given the vagaries of the situation, he knew
that the law could not help him, but he was advised that the State Board of
Psychology could get to the bottom of things and it wouldn't cost him a dime.
Dr. Jane hired Greaves as a consultant. The Board had ordered her to turn over
all her therapy records in written form. Her taping had thus backfired, as it cost her
nearly $5,000 to have the transcripts made within the time frame allowed her by the
Board.
Greaves was able to obtain, in this case, a copy of the letter of complaint, as in
that state jurisdiction, complainees were furnished with those details.
Quite innocently, believing the Board to be the psychologist's friend, Dr. Jane
had been corresponding freely with the Board with no idea of the implications of
doing so. It cost another $5,000 in attorney's fees just to get negotiations on track.
She had no clue that Ms. Betsy's father was out to k.ill her license and career.
Then came the matter of Greaves's piecing together a multi-page rambling
complaint against several hundred pages of transcript. As it turned out, Greaves was
able find copious examples within the transcripts which were diametrically oppo-
site to the father's contentions, but it required dozens of tedious hours and thou-
sands of more dollars by the time Greaves finished his lengthy report to the State
Board. The point is not in the least subtle, though it is grim. Hundreds of people
with both honorable and evil intentions are learning to use the free services of the
State Boards of Licensure for both corrective and nefarious purposes.

RECOMMENDATIONS

We have come full circle in this chapter, from how law and ethics affect DD
patients to how they affect DD practitioners.
The past ten years make no bones of the fact that concentrating in the
treatment of DID patients is a high-risk enterprise, no matter how earnest, able,
trained, or honest a practitioner may be.
It is in the nature of kangaroo courts that by their very nature they are meant
to be expeditious, not fair. They are meant to make a quick end to some real or
perceived trouble forthwith and are based on power plays, not equanimity. Yet this
is precisely where practitioners are at highest risk. Lose a lawsuit, you lose money,
perhaps some degree of reputation. Lose your license and it is catastrophic to all of a
purely material nature one has built, as well as having to shelve years of finely honed
sk.ills.
1. The first change we would make in the status quo is to include in profes-
sional liability policies provisions for legal coverage for administrative hearings, at
minimum State Licensing Board proceedings. Given the antipsychotherapy and
614 hate groups we have seen organized within the past decade, it is no longer possible
George B. Greaves to believe that licensed professionals and professional boards are not being system·
and George H. Faust atically abused.
2. Secondly, we would add an entire new section to the APA Code of Ethics
having to do with psychologists serving in adjudicative roles. Among issues ad-
dressed should be the following:
a. No psychologist will serve in an adjudicative capacity in any forum in which
a colleague is denied right of counsel.
b. No psychologist will serve in an adjudicative capacity in which there is
unequal due process in terms of evidentiary discovery and sharing.
c. No psychologist will serve in an adjudicative capacity in which a full bill of
particulars is not amply served upon a colleague.
d. No psychologist will serve in an adjudicative capacity in areas esoteric to his
or her field of training in the absence of an acknowledged expert defense witness.
e. No psychologist will serve in an adjudicative capacity who holds "nullifica-
tion views" towards relevant portions of the Code of Ethics under which his col·
league is being tried.
f. Every psychologist serving in an adjudicatory role will remain cognizant at
all times of time frames of alleged unethical behavior, and will in no case apply
superseding standards in an ex post facto manner.
3. Thirdly, we maintain that all actions against professional licenses be man-
dated to conform to the rules of the uniform civil code for the state; preferably that
actions against professional licenses be handled as matters of personal chattel and
assigned to the jurisdiction of Superior or Common Pleas Courts.

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American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th
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Chu,J. A. (1988). Ten traps for therapists in the treatment of trauma survivors. Dissociation, 1, 24-32.
Comstock, C., & Vickery, D. (1992). The therapist as victim: A preliminary discussion. Dissociation, 5,
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Dell, P. E (1988a). Professional skepticism about multiple personality. journal of Nervous and Mental
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Dell, P. E (1988b). Not reasonable skepticism, but extreme skepticism: A reply. journal ofNervous and
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Greaves, G. (1989). Observations on the claim of iatrogenesis in the promulgation of MPD: A discussion.
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Index

Abandonment Accident victims, dissociation in, 215

abreaction as response to, 420 Acting out
borderline personality disorder patients' fear definition, 419
of, 387 by dissociative identity disorder patients,
Abduction victims 422-423
emotional numbing in, 214-215 in inpatient treatment settings, 511
ofUFOs, 579, 583 sexual, 149
Abreaction by incest victims, 81
as abandonment response, 420 therapeutic reduction of, 415, 419-420
in childhood abuse survivors Acute stress disorder, 289-290, 367-380
in early-stage treatment, 390-391 amnesia associated with, 309
in late-stage treatment, 393-394 anxiety associated with, 373-374, 376-377
in middle-stage treatment, 391-393 dissociation associated with, 373-374, 375,
as retraumatization cause, 388 376-377
in combat veterans, 388 DSM-IV proposed diagnostic criteria for,
definition, 479 234-235,246-247,367-368
dissociation-related, 208 in Oakland/Berkeley firestorm survivors,
in dissociative amnesia therapy, 326 371-377
in psychotherapeutic context, 179, 326, patients' physical safety in, 323
420,423-424 as posttraumatic stress disorder predictor,
in early-stage treatment, 390-391 368-369,370-371,374,376-377
in late-stage treatment, 393-394 Adolescent Dissociative Experiences Scale, 143
in middle-stage treatment, 391-393 Adolescents
as retraumatization cause, 388 as concentration camp survivors, 214-215
spontaneous dissociative disorders in, 149
posttraumatic stress disorder-related, 476 depersonalization disorder, 295
See also Flashbacks dissociative identity disorder, 349, 351,
"truth" of, 97 403
Absentmindedness, 52, 59-60 relationship to disorganized attachment
Absentmindedness Questionnaire, 60 status, 110
Absorption, 10, 52, 133 as incest victims, 80-81
correlation with hypnotizability, 197 sexually-abused, symptoms of, 100
in general populations, 54, 55, 57 a-1-Adrenoceptors, thalamic, 175
measurement scale for, 60 Affect
Abstractionism, 530 artistic objectification of, 538
Abusive behavior, in inpatient treatment set- mobilization of, with hypnotherapy, 462-
tings, 511 463

617
618 Affect (cont.) Amnesia, nonpathological, 229-230, 309,
Index modulation of, with hypnotherapy, 456 313
toleration of, 416-417, 419 transient global, 229
with hypnotherapy, 456 Amnesia, dissociative, 52,141,208,307-336,
Affective disorders 370,433.435,478,532
derealization and depersonalization associ· childhood trauma-related, 16, 229, 385
ated with, 294 in children, 75, 149, 150, 313
dissociative disorder misdiagnosed as, 252 retraumatization in, 323
pharmacotherapy for, 512-513 combat experience-related, 316-317
Affective splitting, 74 comorbidity
Affect lability, comorbidity with dissociative conversion disorder, 239
identity disorder, 23 7 substance abuse, 241
Affect model, of dissociative identity disorder, conceptual issues regarding, 309-313
356 as criminal defense, 602, 606
Age progression, 457-458 derealization and depersonalization associ-
Age regression, 463-465 ated with, 293
in children, 146, 149 diagnostic criteria, 307-308
spontaneous, 314 DSM-III·R, 242
Aggression DSM-IV, 3-4, 10, 230, 242
attachment as risk factor for, 131 differential diagnosis of, 229-230
by patients towards therapists, 608-611 as dissociative disorder not otherwise speci-
Aggressive personality states, 511-512 fied,383
Agitation, pharmacotherapy for, 561 dissociative identity disorder-related, 14,
Agoraphobia, 218 142,232,337,358
depersonalization and derealization associ· epidemiology, 309
ated with, 294 factitious, 409
Ainsworth Strange Situation; see Infant forensic issues regarding, 320-322
Strange Situation behavior in general populations, 19, 55, 56, 57, 58
Alcohol abuse/alcoholism historical review of, 314-316
comorbidity with dissociative identity disor- illegal behavior-related, 229
der, 241 implications for psychopharmacotherapy,
naltrexone therapy for, 560, 561 547
parental, 99 incest and, 38
Alcohol withdrawal, effect on posttraumatic marital discord-related, 229
stress disorder symptoms, 168 ordinary forgetfulness and, 313
Alienation, in therapists, 494 pharmacotherapy for, 181, 182
Allergies, of alter identities, 270 phobias and, 94
Alprazolam, 550 posttraumatic, 311-312
dosage ranges, 552 repression and, 311-313
interaction with benzodiazepines, 553 severity rating of, 259
withdrawal protocol for, 551, 553 in sexual abuse survivors, 36-37, 38
Alter identities/personalities: see Dissociative sexual behavior-related, 229
identity disorder, alter identities/per- suicidal behavior-related, 229
sonalities in trauma and, 316-320
Alzheimer's disease, depersonalization and treatment, 179,322-329
derealization associated with, 294 resolution stage of, 322, 327-329
American Psychiatric Association (APA), ethi- types, 308-309
cal principles and guidelines of, 600- Amnestic barriers, 500
601, 614 in dissociative identity disorder, in older
American Psychological Association, ethical adults, 349
principles and guidelines of, 597-598 hypnotherapy-assisted penetration of, 423,
y-Aminobutyric acid, barbiturates-related en- 453,465-466
hancement of, 165 memory processing and, 453
Amitriptyline, 512 in transference management, 422
adverse effects, 557-558 Amnestic relations, among alter identities,
as sleep disturbance therapy, 386 275-278,284-285
Amok, 12 Anxiety/anxiety disorders (cont.) 619
Amphetamines, as depersonalization therapy, as depersonalization cause, 297 Index
298 dissociative identity disorder-related, 358
Amtriptyline, as depression therapy, 557 in natural disaster survivors, 215
Amygdala pathological fear structure in, 217-218
central nucleus, in traumatic stress re- pharmacotherapy, 513, 550-556
sponse, 174-175 Anxiety-depersonalization syndrome, phobic,
glutaminergic neuronal activity modulation 292
activity of, 177 Anxiolytic agents, 164, 513, 555-556
memory retrieval function of, 171 as depersonalization therapy, 298
Amytal interview, 165, 179, 182 as dissociative disorder therapy, 178-179
Anger, childhood abuse-related, 385 See also Antidepressants
Animal defensive states, analogy to dissocia- Aphasia, conduction, 177
tion, 30 Arginine vasopressin, as posttraumatic stress
Animal magnetism, 314, 449 disorder therapy, 181-182
Animals Arousal
mutilation of, 92-93 in alter identities, 272-273
sacrifice of, by satanic cults, 575 dissociative symptoms and, 172-173
Anna 0., 122, 314, 339 hypnosis-related, 273, 274, 278-279
Anorexia, depression-related, 557 in obsessive-compulsive disorder, 271
Anorexia nervosa, 38 pharmacotherapy for, 178
body image distortions associated with, 17 Arrhythmias, antidepressants-related, 557
comorbidity with dissociative identity disor- Art, definition of, 529
der, 241 Art styles, 530-531
Antidepressants, 512-513, 556-558 Art therapy, 525-544
adverse effects. 557-558 art reality and, 529-532
daily dosages, 558, 559 BASK model in, 537-541
as depersonalization therapy, 298, 299 expressive therapies continuum of, 537-
as dissociative disorder therapy, 549 541
as posttraumatic stress disorder therapy, 181 for dis5ociative identity disorder patients,
as sleep disturbance therapy, 386 532-542
Antihistamines, sedative, 554-555 in inpatient treattnent, 502, 503, 510
Antikindling agents, 549-550 isomorphism of, 529-530, 538
Antipsychotic drugs, 164 in memory processing, 486-487
as depersonalization and derealization paracosms and, 532-533
cause, 294 schema model of, 527-529, 535, 536
as depersonalization therapy, 298 Ash Wednesday bush fire survivors, 215-216,
implications for psychiatric illness research, 370-371
140-141 Assault victims
See also Psychopharmacotherapy dissociation in, 214
Antisocial conduct disorder, 131 facial fear expression by, 219
Antisocial personality, parental, 99 posttraumatic stress disorder in, 220
Anxiety/anxiety disorders Association, def"mition of, 191
abreaction-related, 392 Ataque de nervtos, 12
acute stress disorder-related, 373-374, 377 Athens-Vinton-Hocking Mental Healh Center,
in assault victims, 214 604,605
attachment-related, 131 Attachment, 73
in childhood abuse survivors, 386 Bowlby'stheoryof, 111-112
in children with dissociative disorder, 148- disorganized/disoriented, 68, 73-74, 114-
149, 150 133
cognitive-behavioral therapy for, 217 as aggression risk factor, 131
in combat veterans, 211 as anxiety risk factor, 131
comorbidity as borderline personality disorder risk fac-
with dissociative disorders, 251 tor, 386-387
with dissociative identity disorder, 238- case history, 122-123, 130
239 conflict behavior in, 115
620 Attachment (cont.) BASK (behavior, affect, sensation, and knowl-
Index disorganized/disoriented (cont.) edge) model, of dissociation, 53, 431
criteria, 115-116 in art therapy, 537-541
as dissociation risk factor, I2I- I3 3 in cognitive-behavioral therapy, 403, 404,
genetic factors in, 116 407
hypnotic ability and, 13 3 in hypnosis, 451, 454, 460, 464, 467, 469,
parental attachment status and, II7 -I20, 470
I22 in memory processing, 480, 483, 484
parental characteristics and, II 7 Battle shock, 212
parental dissociation states and, I25- Bebainan, 12
I27 Beckmann, Max, 526
parental frightened-alarmed behavior and, Behaviorism, 6, 51
I20-I2I, I22, I27-I28, I30 Behavior problems, of pediatric dissociative
as phobia risk factor, I3I disorder patients, 147-148,149, I55
separation-anxiety and, I28-I29 Behavior therapy, for depersonalization, 298
trance behavior and, I24, 125, 127, 130, Belgium
I3I-I32 dissociation prevalence in, 17, 18
insecure-avoidant, 108 dissociation research in, 30-34
insecure-disorganized/disoriented, I08; see BeUe indifference, Ia, 272, 409
also Attachment, disorganized/disori· Benadryl: see Diphenhydramine
ented Benzodiazepines
insecure-resistant/ambivalent, I 08 adverse effects, 551-553
secure, 77, I07-I08 as anxiety therapy, 386, 550-554
unresolved-fearful, 77-78 as depersonalization therapy, 297
Attachment behavior as dissociative disorder therapy, 165, 178,
of dissociative identity disorder patients, 549
4I5-4I6 dosage range, 552
fear-related, 111-112 equivalent doses, 550, 553, 554
Attention deficit hyperactivity disorder, I47 as panic attack therapy, 386
Auschwitz concentration camp survivors, post· as posttraumatic stress disorder therapy, 180
traumatic stress disorder in, 317 withdrawal from, 551
Autohypnosis phenomenon, dissociative disor· Benztropine, as dissociative episode trigger,
der-related, 139; see also See also 548
Numbing, emotional; Time distortion; Beta blockers
Trance states adverse effects, 513
Automatism, pure psychic, 530 anxiolytic activity, 555-556
Automobile accidents, as depersonalization dis· as dissociative disorder therapy, clinical tri·
order risk factor, 296 als of, 549
Avoidance behavior, 162 Bianchi, Ken ("Hillside Strangler"), 342, 434
by accident survivors, 2I5 Big bang image technique, for combining
affective, 409 memories, 469
of children, 148 Binet, A., 5
cognitive, 409 Bipolar disorder, 294, 349, 513
emotional numbing and, 209 Bissociation, 534
mechanisms, 209 Blackmail, of therapists, 609
of natural disaster survivors, 215-216 Black Mass, 576-577
of witnesses to trauma, 216 Blackouts, alcoholic, 229-230
Avoidance-numbing cluster, 209 Blending, definition of, 480
Bleuer, Eugen, 5-6, 101, 292
Baptism, of satanic cult members, 575 Body dysmorphic disorder, 17
Barbiturates Body language, 530
as dissociation treattnent, 178, 179 Borderline personality disorder
interaction with benzodiazepines, 552 childhood abuse-related, 213-214, 382, 386-
use in narcosynthesis, 165 387
non-N-methyl·D·asparate receptor blocking depersonalization and derealization associ-
activity of, 177 ated with, 294, 297
Borderline personality disorder (cont.) Caul, David, 604, 605, 607 621
developmental factors in, 386 Central Intelligence Agency, mind control ex- Index
DSM·IV diagnostic criteria for, 12-13 periments by, 576
dissociative disorder misdiagnosed as, 252 Central nervous system measures, of dissocia-
dissociative disorders relationship of, 12-13, tion,279-284
251,354,358,359-360,417 Cerebral blood flow studies, of alter identities,
unresolved attachment in, 78 275
Boundary setting Cerebrovascular disease, depersonalization
as characterological issue, 488-489 and derealization associated with, 294
dissociative identity disorder patients' viola- Characterological management, of personality
tions of, 610 disorders, 488-492
in inpatient treatment settings, 506 Charcot, Jean M.
in psychodynamic psychotherapy, 421 dissociative identity disorder therapy by, 339
Bourne, Ansel, 230 hypnosis use by, 60-61, 191-192
Brain stimulation studies, of posttraumatic hysteria research by, 193
stress disorder, 170-171 as influence onJanet, 314
Brainwashing, 93, 294 Charter Behavioral Health System, Dallas,
Braun, Bennett G., 27 Texas, 14
Breton, Andre, 530 Child abuse
Breuer, Josef, research and theories of criminal cases regarding, 596-597
abreaction, 479 denial of, 597
amnesia, 314 children's development and, 75-76
depersonalization, 292 in general populations, 63-64, 99
dissociation, 5 incestuous: see Incest
dissociative disorders, 227-228 incidence, 381
hypnoid states, 193 intergenerational transmission, 77
hysteria, 193, 479 by satanic cults: see Ritual abuse
Brief psychotherapy, ego state therapy as, 432 schema development and, 406-408
Brtttsh journal of Psychiatry, 26 See also Childhood abuse survivors; Incest;
Brothers, sexual abuse by, 99 Incest victims; Physical abuse, child-
Brush fire survivors, 215-216 hood; Sexual abuse, childhood
Buffalo Creek disaster survivors, 3 70 Child abusers, 28
Bulimia, 37, 38, 241 as childhood abuse victims, 98
Bupropion, 512 dissociation in, 98-99
overdose risk, 556-557 psychological motivations of, 78
Bum victims, 215 Child custody cases, false sexual abuse allega-
Bush, Benjamin, 338 tions in, 582
Buspirone, 555 Child Dissociative Checklist, 198
Child development, in incestuous families, 78-
Cambodian refugees, 317, 370 85
Canada during incest period, 79-81
dissociation prevalence in, 17, 53-54 during pre-incest period, 72-76
dissociative identity disorder in Childhood abuse survivors
phenomenology of, 14 abreaction in
prevalence of, 350 in early-stage treatment, 390-391
Canadian journal of Psychiatry, 7 in late-stage treattnent, 393-394
Cannabinoids, dissociative state·inducing ef- in middle-stage treatment, 391-393
fect of, 168, 169-170, 178 as retraumatization cause, 388
Cannibalism, by satanic cult members, 572, borderline personality disorder in, 386-387
576-577 dissociation in, 164
Carbamazepine as defense mechanism, 382
as posttraumatic stress disorder therapy, relationship to hypnotizability, 197-201
181 dissociative disorders in, 63-64
as rapid switching therapy, 559 dissociative identity disorder in, 356, 401
Catharsis, 479 dissociative reality development by, 532-
Cathexis, 437-438 533
622 Childhood abuse survivors (cont.) Children (cont.)
multiple personality disorder in, 9I-I05 multiple personality disorder in, 97-98
Index
case histories, 92-93 satanic cult abuse of: see Ritual abuse
corroboration, 9I as witnesses to violence, 92, 152, 155, 156,
historical background, I 00- I 02 386
prevalence, 9I Children's Hour, The, 596
non-dissociative psychological sequelae in, Chlordiazepoxide, 550
38I-382 dosage ranges, 552
posttraumatic stress disorder in, 385-386 equivalent doses, 550
psychiatric patients as, 38I interaction with benzodiazepines, 553
traumatic memories of m-Chlorophenylpiperazine
nonverbal encoding of, 385 dissociation-inducing effect of, 177, 178
as verbal memories, 38I flashback-inducing effect of, 166, 167
traumatic memory recovery by, 385 effect on serotonergic receptors, 178
corroboration and validity of, 95-97, I 52- use in traumatic memory retrieval, 182
I 53 Chlorprothixene, 556
legal implications of, 32I-322 as flashbacks and impulsivity therapy, 558-
treatment model for, 387-395 559
early-stage, 389-39I Christian rituals, use by satanic cults, 575
late-stage, 393-394 Cingulate gyrus, 176
middle-stage, 391-393 Civil War, 602-603
Childhood Dissociation Checklist, 143 Clinician-Administered Dissociative States
Child neglect, 597 Scale, 168
as borderline personality disorder risk fac- Clonazepam
tor, 386-387 as anxiety therapy, 513
as dissociative disorder risk factor, 151-152, as dissociative identity disorder therapy, 549
153,352,353 dosage ranges, 552
Children informed consent for use of, 513
of abused parents, 509 interaction with benzodiazepines, 553
denial as defense mechanism of, 69, 75, 79, as nocturnal myoclonus therapy, 563
80 as panic attack therapy, 386
depersonalization disorder in, 295 as posttraumatic stress disorder therapy,
developmental stages of, 406-407 549
dissociation in as rapid switching therapy, 559
misdiagnosis of, 152 withdrawal protocol for, 551
normal versus pathological, 76 Clonazepine, as depersonalization therapy,
obstacles to evaluation of, 142-143 297,298
dissociative capacity of, 74-75 Clonidine, as dissociative disorder therapy,
dissociative disorder not otherwise speci· clinical trials, 549
fiedin, 139-150 Clorazepate, as anxiety therapy, 550, 552
dissociative disorders in, 139-159 Clozapine, as depersonalization therapy, 298
clinical presentation, 147-151 Cognition, mobilization of, with hypnother-
differential diagnosis, 151 apy,462-463
dissociative symptom identification in, Cognitive avoidance, 409
143-147 Cognitive-behavioral therapy
hallucinations associated with, 75, 147- for dissociative identity disorder, 402-410
148, 150 BASK model and, 403, 404, 407
historical background of, 140 schema-focused, 405-410
treatment, 153-157 Socratic method use in, 403
dissociative identity disorder in, 14 5- 147, tactical integration model of, 404
348-349,351 therapeutic alliance in, 402-403
alter identities/personalities in, 145-147, for pathological anxiety, 217
148, 149, 153, 154, 155-156 Cognitive deficits, ketamine·related, 168-169
ego state development in, 433-434 Cognitive Failures Questionnaire, 60
as legal witnesses, in child abuse cases, 596- Cognitive narratives, 484
597 Cognitive reframing, 471
Cognitive restructuring, 405
with hypnotherapy, 470-471
Coping skills training, in inpatient treattnent, 623
502,503 Index
with memory processing, 485 Corpses, children's exposure to, 356-357
with reverse memory processing, 469 Cortisol levels, relationship to infants' attach·
Collage, as art therapy, 539, 540 ment statns, 133
College students, dissociation in, 3, 54-59 Countertransference
Columbus, Ohio, as site of Milligan case, 602- in ego state therapy, 446
603 negative, by nursing staff, 504
Combat stress response, 212 in psychodynamic psychotherapy, 423
Combat veterans Criminal defense
amnesia in, 316-317 amnesia as, 602
anxiety in, 211 dissociative identity disorder as, 595-596
emotional numbing in, 211-213 case example, 601-607
posttraumatic stress disorder in, 368 Cubism, 530, 531
dissociation associated with, 211-213 Cycloserine, as posttraumatic stress disorder
group therapy for, 327-328 therap~ 180-181, 182
hippocampal size and, 312
measurement scale for, 368-369 Dadaism, 530, 531
trauma experienced by, 93-94 Dali, Salvador, 530, 534
prevalence in Netherlands, 36 Danger to others, as hospitalization indication,
See also Israeli soldiers; Korean War veter· 500
ans; Vietnam War veterans; World Dante Alighieri, 530
War I soldiers; World War I veterans; Davis, JohnS., 26
World War II soldiers; World War II Daycare, satanic cult ritual abuse in, 574
veterans Daydreaming, 56
Communication, patient-therapist, 526-527 Dead bodies, children's exposure to, 356-357
Completion principle, of information process- Death
ing, 219 of significant others, 356-357
Comprehensive Textbook of Psychiatry violent
(Kaplan, Freedman, and Sadock), 6- children as witnesess to, 356-357
7 dissociative identity disorder patients as
Computerized tomography, use in depersonal· witnesses to, 352
ization disorder diagnosis, 297 Defense mechanisms, in dissociation, 435-436
Concentration camp survivors, posttraumatic denial as, 69, 75, 79, 80
stress disorder in, 214-215, 317 projective identification as, 418
Concentration deficits, in children with disso- splitting as, 417, 418
ciative disorders, 150 DeKooning, Willem, 530
Conditioning Delirium, depersonalization and derealization
in phobias, 278 associated with, 294
in threat exposure response, 30 Delusions, ketamine-related, 169
Conduct disorder, 147 Dementia praecox, 6
Confabulation, 491 Denial
Consciousness, ego state theory of, 438-439 as children's defense mechanism, 69, 75,
Conspiracy theories, about satanic cults, 576 79,80
Constanzo,Ado~o,571 dissociation-related, 208-209
Containment strategies posttraumatic, 207
in hypnotherapy, 456-457 as recanting, 491-492
in inpatient treattnent, 502-503 Dependence
Conversion disorder/reaction, 5, 164 of dissociative identity disorder patients,
arousal in, 271-272 416
comorbidity with dissociative identity disor- in therapeutic relationship, 442
der, 239-240, 358 Depersonalization, 141, 294-300, 370
Diagnostic and Statistical Manual diagnos- in accident victims, 215
tic criteria for, 228 in adolescents, 80
International Classification of Disease classi- assessment questionnaires for, 253
fication of, 28 autonomic nervous system activity in, 272
624 Depersonalization (cont.) Derealization (cont.)
dissociative identity disorder-related, 416
cannabinoids-related, 180
Index
in children, 144 distinguished from depersonalization, 293
clinical features, 233, 296 in general populations, 54, 55, 56, 57, 58
definition, 292-293 in natural disaster survivors, 369
diagnostic aids for, 296 pharmacotherapy for, 178
diagnostic criteria of, 294-295 sensory po)yneuropathy-related, 172
DSM-III-R, 243-244 as stress response, 94
DSM-IV, 3-4, 11, 234, 243-244 unaccompanied by depersonalization, 300-
differential diagnosis of, 296-297 301
as dissociation component, 10, 52, 208 in witnesses to trauma, 216
dissociative identity disorder-related, 358, Desagregation, 191
416 Desipramine, adverse effects, 557
distinguished from derealization, 293 Despine family, 98, 338-339
epidemiology, 295 Development, dissociation and
etiology, 297 in incestuous families, 75-84
in general populations, 19, 54, 55, 56, 57, during incest period, 79-81
58,289,295 during pre-incest period, 72-76
in natural disaster survivors, 369 in typical development, 72-75
pharmacotherapy for, 178 Developmental factors, in borderline personal-
sensory polyneuropathy-related, 172 ity disorder, 386
as stress response, 94 Developmental issues, in dissociative identity
symptoms of, depersonalization syndrome disorder psychotherapy, 415-419
versus, 233-234 Developmental stages, Piagetian, 406-407
transient, 293-294 Dexamethasone, as dissociative episode trig-
treatment, 292, 297-299 ger, 548
case example, 299-300 Dextroamphetamine, adverse effects, 299
Depersonalization syndrome, 233-234 Dextrose, flashback-inducing effect, 166
Depression Diagnostic and Statistical Manual of Mental
antidepressant therapy for, 512-513, 556- Disorders, First Edition (DSM-1), 228
558, 559 Diagnostic and Statistical Manual of Mental
childhood abuse-related, 385 Disorders, Third Edition (DSM-111), 597
in combat veterans, 211 depersonalization diagnostic criteria, 292
dissociative identity disorder misdiagnosed dissociative disorder not otherwise speci-
as, 233 fied diagnostic criteria, 339
dissociative disorders associated with, 23 7- dissociative disorders diagnostic criteria,
238 228
in children, 147-148 dissociative identity disorder diagnostic crite-
depersonalization and derealization, 294, ria, 232, 340
296,299 Diagnostic and Statistical Manual of Mental
dissociative identity disorder, 14-15, 358- Disorders, Third Edition, Revised
359 (DSM-III-R), 597
insomnia associated with, 557, 561 assessment instrument criteria, 252
pharmacotherapy for, 562 avoidance-numbing cluster, 209
in inpatient settings, 512-513 derealization definition, 293
in therapists, 494 derealization unaccompanied by depersonal-
Deprogamming, of ritual abuse survivors, 590- ization diagnostic criteria, 301
591 dissociative amnesia diagnostic criteria, 307-
Derealization, 291-292, 370 308
in adolescents, 80 dissociative identity diagnostic criteria, 340-
autonomic nervous system activity in, 272 342
cannabinoids-related, 170 posttraumatic stress disorder diagnostic cri-
definition, 293 teria, 477
as dissociation component, 10, 52 Diagnostic and Statistical Manual of Mental
as dissociative disorder not otherwise speci- Disorders, Fourth Edition (DSM-IV)
fied,235,383 avoidance-numbing cluster, 209
Diagnostic and Statistical Manual ofMental
Disorders, Fourth Edition (DSM-IV)
Discharge planning, 501, 510 625
Dissociation, 3-24 Index
(cont.) age factors in, 54
borderline personality disorder diagnostic as childhood trauma defense mechanism,
criteria, 12-13 69,93-95,382
depersonalization definition, 292-293 components of, 10, 52, 53
depersonalization disorder diagnostic crite- consciousness disturbances in, 142
ria, 11, 234, 289, 294-295 continuum of, 12, 383
derealization diagnostic criteria, 291 cultural factors in, 4
derealization unaccompanied by depersonal- definition,69, 163,433
ization diagnostic criteria, 301 epidemiology, 17-20
dissociative amnesia diagnostic criteria, 10, in folklore, 94
230,307-308,309,313 in general populations, 3, 17-18, 19-20
dissociative disorder not otherwise speci- undiagnosed, 58-59
fied diagnostic criteria, 11-12, 235 history of, 1, 4-10
dissociative disorders definition, 141 in early twentieth century, 5-6
dissociative disorders diagnostic criteria, 3- in 1970s-1980s, 6-8
4,10-12,208,251,309 in nineteenth century, 4-5
dissociative fugue diagnostic criteria, 10-11, hypnotizability associated with, 195-197
231,308 increased interest in, 52
dissociative identity disorder diagnostic crite- measurement instruments for, 8, 209-211;
ria, 11, 16, 231-233, 342-343, 608 see also names of specific measure-
relationship to multiple personality disor- ment instruments
der, 499, 607, 608 in normal populations, 51-66, 69, 208
dissociative trance definition, 108n. in broad-based samples, 53-59
posttraumatic stress disorder diagnostic cri- in children, 72-73
teria, 316, 477 development of, 64
proposed diagnostic classifications individual differences in, 52-53
acute stress disorder, 234-235, 246-247, pharmacological induction of, 168-170
367-368 relationship to other individual difference
dissociative disorder of childhood, 143 factors, 59-64
dissociative trance disorder, 235-236, thalamic networks and, 172
245-246 origin of term, 191, 208
secondary dissociative disorder due to a pharmacologically-induced, 168-170, 177-
nonpsychiatric medical condition, 178
236,246 phenomenology of, 3. 10-17
DSM-IV work group, Trauma Disorders su- international, 1
perordinate category proposal, 310 in nineteenth century, 51
Dtagnostic and Treatment ofMultiple Person- potential for, 356
ality Dtsorder (Boon and Draijer), psychological, 51
339-340 self-report measures of, 8
Diagnostic Interview of Borderline Personality, signs and symptoms of, 208-209, 370, 382,
213 548
Diagnostic Interview Schedule, 252-253 in Belgian populations, 34
Diazepam,553-554 in Dutch populations, 34-36
dosage ranges, 552 misdiagnosis of, 152
equivalent doses, 550 undiagnosed, 58-59
withdrawal protocol, 551 Dissociation: Progress In the Dtssoclative Dis-
Differentiation orders, 339-340
in ego state development, 433-434 Dissociation Questionnaire, 30-38, 41-46, 52,
as personality developmental process, 433 53
Differentiation-dissociation continuum, 435- use with eating disorder patients, 26, 3 7-
436 38
Dimethyltryptamine, 170 use with general populations, 33-37, 39-
Diphenhydramine, sedative effects, 554-555 40
Disability, as hospitalization indication, 500 reliability and validity of, 32-33
626 Dissociative Content Scale, correlation with Dissociative disorders (cont.)
Minnesota Multiphasic Personality In- prevalence, 198
Index
ventory, 200 in clinical populations, 20, 251, 383
Dissociative Disorder Interview Scale, 198 in general population, 19, 21
Dissociative disorder not otherwise specified, symptoms, 139-140
12,141,477 types of, 141
amnesia and fugue associated with, 308 undiagnosed, 251-252
childhood abuse and, 352 See also specific dissociative disorders
in children, 142, 147, 151 Dissociative Disorders Interview Schedule
comorbidity (DDIS), 210-211, 255
depersonalization, 297 anmesia criteria, 232, 233, 309
depression, 237 for dissociative identity disorder/dissociative
sexual dysfunction, 240 disorder not otherwise specified dif-
substance abuse, 241 ferentiation, 12
DSM-III-R diagnostic criteria, 235, 244-245 use with general populations, 19, 58
DSM-IV diagnostic criteria, 3-4, 11-12, 235, interrater reliability in, 14
244-245,383 use with psychiatric inpatients, 383
differentiated from dissociative identity dis- sensitivity, 8-9
order, 14 Dissociative Events Scale, 21 0
Dissociation Questionnaire scores in, 32 use with childhood sexual abuse victims,
dissociative identity disorder associated 213-214
with, 12, 17, 342 use with combat veterans, 211, 212, 214
dissociative identity disorder classified as, Dissociative Experiences Scale, 8, 52, 53, 198,
16 200,253-254,296,301
prevalence amnesia criteria, 232
in clinical populations, 235 use with clinical populations, 20
in general populations, 19 for dissociative amnesia evaluation, 309
Structured Clinical Interview for DSM-IV for dissociative disoders/dissociative identity
Dissociative Disorders use in, 256, 257 disorder not otherwise specified dif-
Dissociative disorder of childhood, 143 ferentiation, 12
Dissociative disorders Dissociation Questionnaire correlation, 32-
borderline personality disorder relationship, 33
12-13,231 use with European populations
in children and adolescents, 139-159 in Netherlands, 28
childhood trauma and, 151-153 in Norway, 26
clinical presentation, 147-151 in United Kingdom, 26
comorbidity, 147 use with female psychiatric patients, 383
development of, 94 use with general populations, 10, 17-18
differential diagnosis, 151 in Canada, 53-54
dissociative symptom identification in, college students, 55-58
143-147 correlation with health symptoms, 63
historical background, 140 hypnotizability scales correlation, 61, 62
treatment, 153-157 interrater reliability, 14
comorbidity, 236-241, 251 limitations, 254
in children and adolescents, 147 posttraumatic stress disorder measures corre-
complex lation, 369
mapping in, 482 use with seizure disorder patients, 282, 283,
nonhypnotizability in, 454 284
continuum of, 12 use with sexual abuse victims, 28
definition, 141, 232 Structured Clinical Interview for DSM-IV
DSM-IV diagnostic criteria, 228-247 Dissociative Disorders correlation,
differential diagnosis, 232-233 29
historical background of, 227-228 Dissociative identity disorder, 337-366, 477
Minnesota Multiphasic Personality Inventory in adolescents, 349, 351
scores in, 231 alter personalities/identities in, 141, 232,
misdiagnosis, 252 342-348
Dissociative identity disorder (cont.)
alter personalities/identities in (cont.)
Dissociative identity disorder (cont.) 627
comorbidiry, 14-15, 236-241, 358-360 Inde¥
amnestic relationships among, 275-278, implications for pharmacotherapy, 548,
284, 285 563-564
arousal levels in, 272-273 sleep apnea, 562-563, 564
as autohypnotic phenomena, 414 consciousness alteration in, 141-142
autonomic nervous system studies of, cross-cultural perspective, 337-338
270-279 definition, 232, 337
based on television characters, 357 diagnosis, 15-16
central nervous system measures in, 280- difficulry of, 349-350
281 reliabiliry of, 9, 14
characteriological factors, 346, 348 DSM-III-R diagnostic criteria, 340-341
child personalities, I 00 DSM-IV diagnostic criteria, 3-4, 11, 231-
in children, 144, 145-147, 148, 149, 153, 232,233,243,341-342
154, 155-156 differential diagnosis, 232-233
common types, 345-346 differentiated from dissociative disorder not
conditioning and, 277, 278-279 otherwise specified, 14
dissociative paracosms and, 533 epidemiology, 350-351
dominance of, 340, 341 international, 289, 338
emotional expression and, 272-273 etiology, 351-358
formation of, 500 factitious, 354-355
host personality, 272, 345-346 first modem description of, 289
as "inner persecutors," 347 historical perspective on, 100, 289, 337-
inner world of, 346-347 338,401
number of, 289, 340 hypnotizability associated with, 355,356,414
overtness of, 340, 341, 347-348 intergenerational, 351
as potential ego states, 414-415 linguistic system in, 53 3
psychopharmacology and, 548 Minnesota Multiphasic Personality Inventory
psychophysiology of, 150, 270-279, 280- scores in, 231
281,345,348,354-355,533 misdiagnosis, 15, 233
relationships among, 346-347 models, 353-358
sexual abuse-induced adaptations in, affect, 356
100 behavioral states of consciousness, 355
switching between, 132, 347-348, 559, illegitimate, 354-355
561 neodissociation/ego state, 355-356
system maps of, 533 neural network/information processing, 355
system pictures of, 53 3 pragmantic clinical, 356-358
See also Ego states psychological, 353-354
amnesia and fugue associated with, 232, sociological, 354
233,308 split brain/hemispheric lateraliry, 355
art therapy for, 532-542 supernatural/transpersonal, 353
as borderline personality disorder variant, temporal lobe/partial complex seizure/kin-
321 dling,355
childhood sexual abuse-related, 29 trance state/autohypnotic, 355
in children, 9, 151, 341, 348-349, 351, 356, natural history, 348-3 50
357-358 negative symptoms, 420-421
alter identities/personalities, 145-147, parental factors in, 357
148, 149, 153, 154, 155-156 phenomenology, 14-16, 340-348
treatment, 153-157 polyfragmented, 477
cognitive-behavioral therapy, 402-410 positive symptoms, 420
BASKmodeland,403,404,407 prevalence
schema-focused, 405-410 in clinical populations, 350
Socratic method use in, 403 gender differences in, 350-351
tactical integration model, 404 in general populations, 350
therapeutic alliance in, 402-403 in Netherlands, 28
treatment goal in, 403 in Switzerland, 26
628 Dissociative identity disorder (cont.) Doxepin
Index psychodynamic psychotherapy for, 413- as depression therapy, 55 7
428 as sleep disturbance therapy, 386
abreactionin,420,423-424 Dreams
as acting out therapy, 415, 419-420 intepretation of, for traumatic memory recall,
boundary setting in, 421 179
case study, 424-426 thalamic activity in, 174
countertransference management in, 423 Droperidol, as flashbacks and impulsivity ther-
developmental issues in, 415-419 apy, 558-559
goals, 415-421 Drug abuse
hypnosis use in, 423 in adolescent sexual abuse victims, 100
negative symptoms reduction in, 420- comorbidity with dissociative identity disor-
421 der, 241
purpose, 413 Dual relationships, 598, 601
single-self model, 414-415 Duchamp, Marcel, 531
technical aspects, 421-424 Durham case, 604
therapeutic neutrality in, 421-422
transference management in, 422-423 Earthquake survivors, dissociation in, 215,
psychopharmacotherapy for, 545-566 369
for anxiety, 550-5 56 Eating disorders
for depression, 556-558 in adolescent sexual abuse victims, 100
for flashbacks, 558-559 in childhood abuse survivors, 389
general considerations in, 546-547 comorbidity with dissociative disorders, 14-
guidelines, 548-549, 563-564 15,26,240-241,251,358
literature review, 548-550 Dissociation Questionnaire scores in, 26,
newly released medications, 559-562 32
for nocturnal myoclonus, 562-653 Ego cathexis, 43 7, 438
overdose risk in, 564 Ego state disorders, 235
for poor impulse control, 558-559 Ego states
for rapid switching, 559, 561 adaptive, 436
for sleep apnea, 562-563 conflict resolution among, 12
specific considerations in, 547-548 defensive, 436
for specific symptoms, 550-562 definition, 433
research in, 9 development of, 431-436
trauma and, 351-353 dissociative, 436
treatment dissociative disorder not otherwise specified-
in Germany, 26 related, 383-384
hazards experienced by therapist in, 608- integration of, 12
613 normal, 436
outcome, 9 potential, 414-415
undiagnosed, 8 subject-object experiences in, 436-437
See also Multiple personality disorder during trance, 4 53
Dissociative identity disorder patients two-energy theory of, 437-438
hostility and aggression towards therapists Ego state theory, 431-432
by, 608-611 of consciousness, 438-439
psychic beliefs of, 360 two-energy theory, 43 7-438
Dissociative Indiana Dissociative Symptom Ego state therapy, 432
Scale, 200 techniques, 434, 439-446
Dissociative processes, epidemiology, 1-2 Ego strength deficits, as dissociation cause, 4
Distancing techniques, hypnotic, 458 Ego strengthening techniques, with reverse
Dizziness, antidepressants-related, 557 memory processing, 469
Domestic violence Elderly patients, antidepressant use by, 558
children as witnesses to, 152 Electroconvulsive therapy
See also Child abuse; Childhood abuse survi- as depersonalization therapy, 298
vors; Physical abuse, childhood; Vio- as dissociative amnesia and fugue therapy,
lence 328-329
Electroencephalographic (EEG) activity
in depersonalization disorder, 297
Existential crises, 484-485 629
amnestic barriers in, 465-466
Index
in dissociative identity disorder, 280-284 hypnotherapy-assisted processing of, 470-
in hypnotically-susceptible subjects, 63 471
Emmyvon N., 314 of therapists, 494
Emotional abuse, of children, 93 Exorcism
Emotional detachment, dissociation-related, dissociative amnesia and, 314, 318
208 as multiple personality disorder therapy, 4
Emotional dissociation, 207-224 Expert witnesses, on child abuse, 597
in accident survivors, 215 Expressionism, 530
information-processing in, 216-220 Expressive therapies
Emotional processing use with childhood abuse survivors, 390-
effect of dissociation on, 219-221 391
pathological fear structure processing in, continuum of, 537-541
218-219 use in inpatient treatment settings, 510
Emotion regulation, 67, 70, 71-72 use in memory processing, 487-488
by infants, 72
Encephalitis, depersonalization and derealiza- Family
tion associated with, 294 of dissociative disorder patients, 509-510
Encounter groups, 601 of incest victims, dysfunctionality of, 76-
Endorphins. 561, 590 79,81-82
Enmeshed families, 133 Family environment, relationship to childhood
Environmental stimuli abuse-related dissociation, 200
in stress, 172 Fantasy
thalamus-modulated responsivity to, 173 dissociative identity disorder patients' per-
as traumatic memory "triggers," 477 ception of, 418-419
Epidemic hysteria, 509 epidemic, 509
Escher, M.C., 526 Fantasy-proneness, 133, 197
Estelle, 98 Fear
Estrangement, dissociation-related, 208 attachment behavior and, 111-112
Estrogen, interaction with benzodiazepines, cognitive structure of, 217-218
553 normal, 217
Ethanol, use in traumatic memory recall, 165 posttraumatic stress disorder-related, 218-
Ether, use in traumatic memory recall, 165 220
Ethical issues, in dissociative disorders treat- trauma-related, 216
ment, 7-8,92,339,494,598-601 Federn, Paul, 437
Milligan case, 92, 595, 601-607 Feminism, 339
patients' aggression towards therapist, 608- Ferenczi, Sandor, 601
611 Fetus, dissociation in, 64, 434
Sybil case, 598-601 Fever, depersonalization and derealization asso-
European studies, of dissociation, 25-49 ciated with, 294
in Belgium, 25-26 FG-7142, 168
Dissociation Questionnaire studies, 30-34 Field, Sally, 600
in Germany, 26 Fine, Catherine, 608
in Hungary, 39-40 First-rank symptoms, 240-241
in Italy, 26 Flashbacks, 208
in Netherlands, 25-26 in children, 148, 149
clinical studies, 27-28 content of, 164
Dissociation Questionnaire studies, 33-37 definition, 479
eating disorder studies, 37-38 dissociative identity disorder-related, 420
empirical studies, 28-30 duration, 164
in Scandinavia, 26 LSD-related, 170
in Spain, 26 memory retrieval strategies for, 172
in Switzerland, 26 pharmacologically-induced, 166, 170
in United Kingdom, 26 pharmacotherapy for, 181, 558-559, 561
Evoked potentials, in dissociation, 280, 281 placebo-induced, 170
630 Flashbacks (cont.)
posttraumatic stress disorder-related, 164,
Fugue, dissociative, 17, 141, 164
definition, 230
Index
476 diagnostic criteria, 308
neurobiology of, 165, 166-168, 171-172 DSM·III·R, 242-243
pharmacotherapy for, 181 DSM·IV, 10-11, 3-4, 141, 231, 242-243
types, 479 differential diagnosis, 230-231
withdrawal-related, 168 as dissociative disorder not otherwise speci-
Flooding therapy, 180 fied,383
Flowers, Jay C., 604 dissociative identity disorder-related, 17,
Flumazenil, panic attack-inducing effect, 167- 358
168 early research in, 314-315
Fluoxetine epidemiology, 309
adverse effects, 557 in general populations, 19
buspirone-induced potentiation of, 555 hysteria-related, 314
as depersonalization and derealization legal issues, 320
cause, 294 severity rating, 259
as depression therapy, 557 as stress response, 94
as posttraumatic stress disorder therapy, 512 treatment, 322-329
as yohimbine-induced panic attack blocker, Fugue, nondissociative, 230-231
181 Fusion, in ego state therapy, 442-443
Fluphenazine, as depersonalization and dereali· Futurism, 530-531
zation cause, 294
Flurazepam, dosage ranges, 552 Gallia-Jackson-Meig Health Center, 604
Fluvoxomine, 559, 560 Gamma-aminobutyric acid, barbiturates-re·
Folklore, dissociative disorders in, 94, 100 lated enhancement of, 165
Forgetfulness, 52 Ganser's syndrome, 235, 244, 245, 383
Fractionation Gaze aversion, 72
in children, 75 Germany, dissociation research in, 26
definition, 487 Gibson, Jim, 603-604
use in hypnotherapy, 460 Glaucoma, narrow-angle, anticholinergic anti·
in memory processing, 483, 487 depressant use in, 557-558
Fragmentation Glove anesthesia technique, 459
dissociative disorder not otherwise specified· Glutamate, as thalamic neurotransmitter, 175
related, 383 Glutaminergic neurons, in dissociation, 177-
hypnotherapy for, 452 178
management of, 487 Gmelin, Eberhardt, 338
Free association, use in traumatic memory re· Grant, Ulyses S., 602-603
call, 179 Greaves,George,603-604,605,606-608,610
Freud, Anna, 75 Group therapy, 510
Freud, Sigmund, research and theories of, 601 for amnesia, 327-328
amnesia, 314 Guided imagery, 453
brain models, 280 Guilty Knowledge Test, 284
depersonalization, 292
dissociative disorders, 4, 5, 227-228 Halazepam, dosage ranges, 552
hypnosis, 60-61, 191-192, 193-194 Hallucinations
seduction theory, 101 auditory
origin of, 99-100 in children, 147-148, 150
repudiation of, 5, 95, 101, 339,475 dissociative disorder not otherwise speci·
Friendships, children's development of, 79- fled-related, 384
80 benzodiazepines-related, 551
Fromm, Erich, 191 dissociative identity disorder-related, 14,
Frontal cortex 347,349
disconnectivity in, 176-177 flashbacks-related, 479
glutaminergic neuronal activity modulation as memories, 97
activity in, 177 serotonergic, 178
in memory retrieval, 172 visual, in children, 75, 150
Hallucinogen abuse, depersonalization and Hyperphagia, depression-related, 557 631
derealization associated with, 294 Hypersomnia, depression-related, 557 Index
Hallucinogens, serotonergic, 168, 170, 175, Hyperventilation, depersonalization and dere·
180 alization associated with, 294
Haloperidol Hypnoid states, as defensive reactions, 315
as flashbacks and impulsivity therapy, 558- Hypnosis, 161-162, 179, 191-206, 449, 463,
559 474,483-484
interaction with buspirone, 555 appropriate suggestions in, 450-451
as ketamine antidote, 169 arousal and, 273, 274, 278-279
Handbook for the Assessment of Dissocia- clients' resistance to, 453-454
tion: A Clinical Guide (Steinberg), as combat-related trauma disorder therapy,
261 316
Handedness, of alter identities, 270 definition, 449-450
Harding, George Jr., 604, 605 as depersonalization and derealization
Harvard Grove Scale of Hypnotic Susceptibil- cause, 294
ity, 61, 62 dissociation relationship of, 60-63, 94-95,
Headaches, 513 161, 195-197
in alter identities/personalities, 270 in combat veterans, 212-213
comorbidity with dissociative identity disor· common traumagenic etiology, 193
der, 239, 240, 420 contemporary theories of, 194
relationship to hypnotizability, 240 early theories of, 193-194
Health, relationship to dissociative experi- hypnotizabilityjdissociativity overlap, 195-
ences, 63-64 197
Helen of Troy, 100 phenotypic similarities, 192
Helplessness, childhood abuse-related, 385 research findings, 195-201, 202
"Hidden observer" phenomenon, 94 subjective similarities, 192-193
Hilgard, Ernest R., 191, 194, 195 as dissociative amnesia and fugue therapy,
Hillside Strangler, 342, 434 325-327
Hippocampus in ego state therapy, 432, 438
electrical stimulation of, 171-172 Freud's use of, 191-192, 193-194
glutaminergic neuronal activity modulation headaches and, 240
activity in, 177 highway, 12
memory encoding function of, 171-172 inappropriate suggestions in, 450-451
memory retrieval function of, 171 increased interest in, 339
size, in combat veterans, 312 informed consent for, 508-509, 518-520
Hippocratic Oath, 601 in inpatient treatment, 502-503, 507
Histrionic personality disorder, 15 legal aspects, 454
Holocaust survivors, amnesia in, 317 multiple personality disorder as artifact of,
Homicidal ideation, memory retrieval and, 479 101
Homicide cases, dissociative amnesia defense as psychodynamic psychotherapy adjunct,
in, 320-321 423, 545-546
Hopkins Symptom Checklist, 215 of ritual abuse survivors, 575-576, 583-584
Hospitalization: see Inpatient treatment as self-abuse therapy, 590
Hostages, stupor in, 370 as sleep disturbance therapy, 513
Human sacrifice, by satanic cults, 575 techniques, 454-472
Hungary, dissociation research in, 39-40 advanced, 459-468
Huntington's chorea, depersonalization and advanced ideomotor signaling, 459-460,
derealization associated with, 294 464,466-467
Hyatt Regency Hotel skywalk collapse survi- affect modulation and tolerance, 456
vors, 215 age progression, 457-458
Hydroxyzine, sedative effects, 554 age regression, 463-465
Hyperarousal BASK model, 451, 454, 460, 464, 467,
abreaction-related, 392 469,470
posttraumatic stress disorder-related for cognitive restructuring, 470-471
in childhood abuse survivors, 386 combining memories, 469
limbic system kindling in, 550 complex, 468-472
632 Hypnosis (cont.) Incest, 71-72,357, 525
Index techniques (cont.) adult development after, 82-84
containment, 456-457 brother·sister, 99
contracting for safety, 466-468 child development effects of
distancing, 458 during incest, 79-81
for existential crises processing, 470-471 during pre·incest period, 72-76
fractionation, 460 family dysfunctionality context of, 72
hypnotic frame, 454-455 during incest, 81-82
ideomotor signals, 454, 455, 458, 502- during pre·incest period, 72-76
503 father·daughter, child development effects
memory division, 470 of, 72-81
mobilization of affect and cognition, 462- as multiple personality disorder cause, 63
463 number of perpetrators in, 99
penetrating or creating barriers, 465-466 onset age, 80
reverse memory processing, 468-469 as "polyincest," 99
safe place, 455-456, 502, 503 prevalence, 6-7, 28
time distortion, 457-458 Incest victims
trance deepening, 460-462 adult development of, 82-84
working with "decision makers," 469-470 attachment patterns of, 77
transference issues associated with, 453- dissociative disorders in, 28
454 dissociative identity disorders in, 352, 353
Hypopituitarism, depersonalization and dereali· eating disorders of, 38
zation associated with, 294 latency·age, 100
Hypotension, orthostatic, antidepressants·re· physical symptoms of, 100
lated, 557 trance states in, 70
Hypothalamic·pituitary·adrenal axis dysregula· Index Medicus, 6
tion, in sexually·abused girls, 133 India, dissociative disorder not otherwise
Hypothyroidism, depersonalization and dereali· specified prevalence in, 235
zation associated with, 294 Indoctrination rituals, of satanic cults, 574
Hysteria, 5, 193, 479 Indomethacin, as depersonalization and dere·
amnesia and fugue asociated with, 314 alization cause, 294
definition, 27 Infanticide, by satanic cult members, 576-
epidemic, 509 577,578
Freud's theory of, 193-194 Infants
historical background, 227 attachment behavior of, 73, 111-112
somatization phenomenon associated with, battered, morbidity and mortality rates in, 99
228 gaze aversion by, 72
object permanence in, 73
Ibuprofen, as dissociative episode trigger, self·sucking behavior of, 72
548 Infant Strange Situation behavior, 107-138
Identity disorganized/disoriented attachment behav·
definition, 343 ior, 68,73-74, 114-133
fugue·related changes in, 325 as aggression risk factor, 131
See also Dissociative identity disorder, alter as anxiety risk factor, 131
identities/personalities in case history, 122-123. 130
Ideomotor signals, in hypnotherapy, 454, 455, conflict behavior in, 115
458,459-460,464,466-467 criteria, 115- 116
"Illumined Pleasures" (Dali), 530 as dissociation risk factor, 121-123
Images, traumatic, 528 genetic factors in, 116
Imaginary companions, 75, 348-349, 434 hypnotic ability and, 133
Impact of Events Scale, 210, 373-374 parental attachment status and, 117-120,
use with combat veterans, 212 122
Impulsivity, pharmacotherapy for, 558-559 parental characteristics and, 114, 11 7
Inauthenticity, depersonalization·related, 293 parental dissociation states and, 125-127
Incarceration victims, posttraumatic stress dis· parental frightened·alarmed behavior and,
order in, 214-215 120-121, 122, 127-128, 130
Infant Strange Simation behavior (cont.) International Conference of Multiple Personal- 633
disorganized/disoriented attachment behav- ity Disorder and Dissociative States, Index
ior (cont.) 27
as phobia risk factor, 131 International Society for the Study of Disso-
separation-anxiety and, 128-129 ciation, Legal and Ethics Committee,
trance behavior and, 124, 125, 127, 130, 611
131-132 International Society for the Smdy of Multiple
insecure-avoidant behavior, 113 Personality and Dissociation, 599
insecure-resistant behavior, 113-114 Intimacy, in therapist-patient relationship, 601
secure attachment, 112- 113, 114 Intrusive thoughts/memories, 216
Information processing, in emotional dissocia- of childhood abuse survivors, 385-386
tion, 216-220 in children, 148-149
Informed consent psychopharmacotherapy for, 181
for antianxiety medication use, 513 therapeutic reduction of, 179-180, 181
for clonazepam use, 513 Iomazenil, 168
for hypnosis use, 508-509, 518-520 Isolation
for inpatient treatment, 508-509, 514-520 childhood abuse-related, 385
for propranolol use, 513 of incestuous families, 81
for traumatic and dissociative disorders treat- Isomorphism
ment, 514-518 in art therapy, 529-530, 538
Inpatient treatment, of dissociative disorders of dissociative identity disorder personality
patients, 499-524 states, 344
discharge planning in, 501, 510 Isoproterenol, flashback-inducing effect, 166
dissociative amnesia and fugue therapy in, Israeli soldiers, posttraumatic stress disorder
324 in, 214, 370
emotional containment strategies in, 502- Italy, dissociation disorder research in, 26
503
expressive therapies in, 510 James, William, 227-228
indications for, 500-501 ]anet, Pierre, research and theories of
informed consent for, 508-509, 514-520 amnesia, 314
milieu structure of, 504-505, 506-507 consciousness, 101
program components of, 508-512 depersonalization, 208, 292
psychopharmacotherapy in, 512-514, 547 dissociation, 101
in specialty units, 503-505 dissociative disorders, 3, 4, 51, 227-228
staff development for, 505-508 dissociative identity disorder, 339
staffing requirements for, 509-510 hypnosis, 60-61, 191-192
Insomnia hysteria, 27
antidepressant therapy for, 557, 558 traumatic memory work, 27-28
depression-related, 557 Japan, dissociative identity disorder in, 9, 14
nefazodone therapy for, 561 Johnson,Rhonda,434
Integration Journaling,486-487
definition, 480 use in inpatient treatment settings, 503, 510
as development technique, 79, 81 ]ung, Carl, 4, 280
as dissociative identity disorder treatment
goal, 415 Karolin, Stella, 604
of ego states, 12, 442-443, 445 Kempe, Henry, 101-102
as personality developmental process, 433 Kent State University riots, 602, 603
Intelligence agencies, mind control experi- Ketamine
ments by, 576, 591 cortical connectivity effect of, 177
Intelligence testing, 256, 263 dissociative and cognitive effects of, 168-
Intense dysregulated effect, 81 169, 178
International Classification of Diseases (lCD), frontal cortex function effects, 172
252 sensory distortion effects of, 175
amnesia classification, 230 Keyes, Daniel, 605, 607
conversion disorder classification, 28 Kiddie Schedule for Affective Disorders and
dissociative disorders classification, 228-229 Schizophrenia, 130-131
634 Kindling, 549-550 Magritte,Rene,528-529, 531-532
Malingering
Index carbamazepine-related suppression of, 181
Kindling model, of dissociation, 282-283, dissociative amnesia differentiated from,
355 320-321
Kirkland v. State, 606 dissociative identity disorder as, 354
Kitchener-Waterloo Hospital, Ontario, 603 factitious amnesia in, 229
Kluft, Richard P., 27, 608 implications for psychological testing, 254
Korean War veterans, amnesia in, 316 Manson, Charles, 576
Koresh, David, 570 Mapping, 482
Maprotiline, 557
Marijuana use
La belle indifference, 272, 409 depersonalization and derealization associ-
Lactate
ated with, 294
dissociation-inducing activity of, 178
flashbacks associated with, 170
use in traumatic memory retrieval, 182
Marital relationship, effect of parental attach·
Language, visual truth and, 531
ment patterns on, 77-78
Language development, 74
Masturbation, compulsive, by children, 149
Latah, 12
McMartin case, 580
Learning deficits, in children with dissociative
Meditation, as depersonalization and derealiza-
disorder, 150
tion cause, 294
Lee, Robert E., 602-603
Memories, traumatic, 208, 528
Legal issues
artistic expression of, 528-529
in child abuse, 596-597
behavioral reenactment of, 5 28
in dissociative amnesia and fugue, 320-
combinations of, 469
322
"contamination" of, in inpatient settings,
in dissociative disorders therapy, 595-615
507-508, 517
in hypnosis, 454, 508-509
corroboration of, 95-97, 515
lawsuits against therapists, 611
effect of dissociation on, 218, 220
licensing board actions, 611-613
environmental stimul-related triggering of,
Milligan case, 92, 595, 601-607
477
Librium: see Chlordiazepoxide
as false memory, 95
Life Experiences Questionnaire, 284
informed consent and, 516-518
Limbic System Checklist-33, 284
in satanic cult victims, 578-579
Limbic system dysfunction, in dissociation, as fear structure, 218
282-283,284
inaccuracy of, 450
Limit settings
irretrievable, 450
as characterological issue, 488-489
intrusive, 216
in inpatient settings, 506
in children, 148-149
Lithium, 512
pharmacotherapy for, 181
Logic, trance, 548
therapeutic reduction of, 179-180, 181
Lorna Prieta earthquake survivors, dissociation
nonverbal encoding of, 385
in, 369
pathological processing of, 500
Lorazepam, 554
as somatic sensation, 528
dosage ranges, 552
unprocessed, 528-529
equivalent doses, 550
as verbal memory, 381
as ketamine antidote, 169
visual form of, 528
as panic attack therapy, 386
Memory
Lying, differentiated from dissociative experi-
components, 480-482
ences, 144-14 5
narrative, 528
Lysergic acid diethylamide (LSD), 170
Memory impairment, as dissociative disorder
symptom, 208
"Magical surgery," 575 See also Amnesia; Depersonalization; Intru-
Magnetic diseases, 314 sive thoughts/memories
Magnetic resonance imaging (MRI), use in Memory processing, 475-498
depersonalization disorder diagno- advanced concepts of, 486-487
sis, 297 with art therapy: see Art therapy
Memory processing (cont.) N-Methyl-D-aspartate receptor antagonists 635
BASK model of, 480, 483, 484 dissociation-inducing effects, 168-169, 170 Index
blocking in, 490 as psychotherapy adjuvant, 180
characteriological management in, 488- thalamic blockade effects, 175
492 N-Methyl-D-aspartate receptors, blockade of,
clients' sabotaging of, 489-490 165, 177
cognitive narrative in, 484 M'Naghten, 604, 606
cognitive restructuring in, 485 Migraine headaches, depersonalization and
continuum of complexity in, 481-482 derealization associated with, 294
contraindications to, 324-325, 492-493 Milacemide, as posttraumatic stress disorder
definition, 480 therapy, 180-181
disclosure-recanting cycle in, 491-492 Military combat
in dissociative amnesia and fugue patients, as depersonalization disorder risk factor, 296
326,327-328 See also Combat veterans
contraindications to, 324-325 Milligan, Billy, 92, 595, 601-607
existential crises statements identification Million Multiaxial Clinical Inventory, 58
in, 484-485 Mind-brain relationship, 279-280
fractionation in, 483, 487 Mind control experiments, by intelligence
fragmentation management, 487 agencies, 576, 591
healing images in, 485-486 Minds of Btlly Milltgan, 92, 595, 607
hypnotherapyin,483-484 Minnesota Multiphasic Personality Inventory
hypnotic suggestions during, 451 (MMPI), 252, 263
trance depth, 461-462 correlation with Dissociation Content Scale,
informed consent for, 514-518 200
in initial treatment phase, 482 correlation with Dissociative Experiences
irretrievable memories in, 450 Scale, 200
pacing of, 490 correlation with Indiana Dissociative Symp·
pathological, 500 tom Scale, 200
planned sessions in, 482-486 dissociative identity disorder misdiagnosis
progressive relaxation in, 483 and, 255
reverse, 468-469 use in forensic settings, 261
safety contracting in, 486 Mississippi Scale for Combat-Related Posttrau-
terminology of, 478-482 matic Stress Disorder, 368-369
therapeutic relationship in, 481 Civilian Version, 372-3 73
time distortion and, 457 Mistakes, 59-60
with violent clients, 490-491 Moclobemide, 562
Memory retrieval, 179, 385, 452 Monoamine oxidase inhibitors, 512
amygdala control of, 171 overdose risk, 556-557
effect of brain electrical stimulation on, 171- as posttraumatic stress disorder therapy, 181
172 Mood disorders
corroboration and validity of, 95-97, 152- comorbidity with dissociative disorders, 251
153, 509 parental, 99
definition, 478 Mother-child relationship, attachment disrup-
with ethanol, 165 tion in
with ether, 165 as borderline personality disorder cause,
hippocampal control of, 171 386-387
indicators for, 478 See also Infant Strange Situation behavior
informed consent for, 514-518 Mothers, sexual abuse by, 28
legal implications of, 321-322 Movement, involuntary, in children, 144, 151
with narcosynthesis, 165, 179, 328 Movement therapy, in inpatient treatment set-
with nitrous oxide, 165 tings, 510
in posttraumatic stress disorder, 180 Multiple personalities
Meniere's disease, depersonalization and dere- definition, 433
alization associated with, 294 development, 435
Mescaline, 170 See also Dissociative identity disorder, alter
Mesmer, Franz, 314, 449 identities/personalities in
636 Multiple Personoltty and Dissociation,
1791-1992: A Complete Bibliog-
Narcosynthesis, 165, 179, 328
Narrative memory, 528
Index
raphy (Goettman, Greaves, Coons), National Institutes of Mental Health Diagnostic
3-4,606 Interview Schedule, 252-253
Multiple personality disorder, 164 Native Americans, dissociative identity disor-
amnestic barriers associated with, 453 ders in, 9
as artifact of hypnosis, 101 Natural disaster survivors, dissociation in, 369
atypical, 384-385 associated with· posttraumatic stress disor-
childhood abuse-related, 70, 91-105, 198- der, 215-216
199 Near-death visions, 584
case histories, 92-93 Nefazodone. as dissociative identity disorder
corroboration of, 91 therapy, 559, 560, 561
historical background, 101-102 Neodissociationjego state model, of dissocia-
prevalence, 91 tive identity disorder, 355-356
in children, 76, 97-98 Neodissociation theory, 125, 194, 355-356
depersonalization and derealization associ- Netherlands
ated with, 293, 296, 297 dissociative identity disorder in
DSM-III-R diagnostic criteria, 243 clinical profile, 9
DSM-IV reclassification of, 499,607,608 phenomenology, 14
ego states in, 435 prevalence,350
exorcism as treatment for, 4 dissociation prevalence in, 17, 18
forensic implications of, 607-608 dissociation research in, 25-26
history of, 338-340 clinical studies, 27-28
hypnotherapy for, 463 Dissociation Questionnaire studies, 33-38
legal issues in, 595-608 eating disorder studies, 3 7-38
Milligan case, 92, 595, 601-607 empirical studies, 28-30
Sybil case, 598-601 Neural network/information processing
memory processing therapy, 482 model, of dissociative identity disor-
prevalence, 198 der, 355
in clinical populations, 383 Neurobiology, of dissociation, 163-190
in general populations, 19 brain stimulation studies, 170-172
propranolol therapy, 556 cortical disconnectivity, 176-177
reclassification as dissociative identity disor- glutaminergic function alteration, 177-178
der, 499, 607, 6os limbic system kindling, 549-550
sense of identity alteration in, 208 pharmacological challenge studies, 166-168
transgenerational, 98, 99 of pharmacologically-facilitated dissociative
Multiple personality disorder patients states, 178
children of, 98 treatment implications, 178-182
nonhypnotizability of, 454 Neuroleptics
satanic ritual abuse allegations by, 572 as anxiety therapy, 386, 513, 556
Multiple reality disorder, 344 daily dosages, 560
Multiplese, 533 as dissociative disorders therapy
Murder clinical trials, 549
by satanic cult members, 572, 576-577, inefficacy, 169
578 as dissociative identity disorder therapy, 15
See also Homicidal ideation; Homidicide Neurophysiological evidence, of child abuse,
cases 96-97
Mutilation Neurosis
during ritual abuse, 92-93 cerebro-cardiac, 292
See also Self-mutilation traumatic war, 316
Myers, F.W.H., 4, 5 Neurotic disorders, dissociative identity disor-
Myoclonus, nocturnal, 562-563 der misdiagnosed as, 233
New Zealand, dissociative identity disorder
Naltrexone, as dissociative identity disorder clinical profile in, 9
therapy, 559, 560, 561 Nifedipine, as dissociative episode trigger,
Narcissism, malignant, 493 548
Nightmares, 216 Occupational therapy, in inpatient treatment 637
abreaction-related, 392 settings, 510 Index
benzodiazepines-related, 551 Ofloxacin, as dissociative episode trigger,
in children, 148 548
as flashbacks, 479 Ohio State University, 602, 603
posttraumatic stress disorder-related, 181 Opiate addiction, naltrexone therapy for, 560-
psychopharmacotherapy for, 181, 561 561
during REM sleep, 174 Opiate withdrawal, effect on posttraumatic
as traumatic memory manifestation, 528 stress disorder symptoms, 168
Night terrors, thalamic modulation of, 174 Oppenheim, Meret, 530
Nitrous oxide, use in traumatic memory recall, Oppositional deficit disorder, 147, 149
165 Organic brain model, of dissociative identity
Nocturnal myoclonus, 562-563 disorder, 6
Noradrenergic system Out-of-body experiences
in posttraumatic stress disorder, 166, 167, 168 depersonalization-related, 292-293
in traumatic stress response, 175 dissociation-related, 208
Norfloxacin, as dissociative episode trigger, 548 Overdose, by dissociative identity disorder
Nortripyline, adverse effects, 557 patients, 556-557, 564
Norway, dissociative disorder diagnosis and risk assessment, 513
treatment in, 26 Oxazepam, dosage ranges, 552
Not guilty by reason of insanity (NGBRI) plea,
602 Pacing, in therapy, 452
case examples, 605-606 Pain medication, 513-514
Milligan case, 601-607 Panic attacks
"Nude Descending a Staircase" (Duchamp), 531 in childhood abuse survivors, 386
Numbing dissociative identity disorder-related, 358
emotional, 207, 208, 370 pharmacologically-induced, 166. 167-168
in assault victims, 214 Panic disorder
in childhood abuse survivors, 385, 386 depersonalization and derealization associ-
in combat veterans, 211-213 ated with, 294, 296, 297
in concentration camp victims, 214-215 dissociative identity disorder-related, 14-
definition, 209 15
depersonalization-related, 293 Paracelsus, 338, 401
in dissociative identity disorder patients, 416 Paracosms, 533
mechanisms, 209 Paranoia, in therapists, 494
in witnesses to trauma, 216 Paranormal, belief in, as dissociation risk fac-
peripheral, anxiety-related, 550 tor, 133
Nurses, interactions with dissociative disorder Paraphilia, 99
patients, 504, 505 Paroxetine, 512
adverse effects, 557
Oakland/Berkeley firestorm survivors, dissocia- buspirone-induced potentiation of, 555
tive and anxiety symptoms in, 369, as depression therapy, 557
371-377 Passive influence experiences, in children,
"Object (Breakfast in Fur)" (Oppenheim), 530 144, 151
Object cathexis, 43 7-438 Past lives descriptions, 583
Object experiences, 436-437 Pavlov, Ivan, 191
Object permanence, 73 Perceptual alterations
Object representations, 417-418 in accident survivors, 215
Obsession, in therapists, 494 as dissociative disorders symptom, 208
Obsessive-compulsive disorder, 358 Perceptual Alterations Scale, 52, 210, 369
arousal and reactivity levels in, 271 Perceptual Attention Scale, 254
depersonalization and derealization associ- Perceptual binding mechanisms, 64
ated with, 294 Peritraumatic Dissociation Experiences Ques-
Dissociation Questionnaire scores in, 32 tionnaire, 210, 212
as dissociative disorder, 5 Perphenazine, 556, 558-559
obsessional fear treatment in, 220 "Persistence of Memory, The" (Dali), 534
638 Personal identity, fugue-related changes in, 325
Personality
Postraumatic stress disorder
acute stress disorder as predictor of, 370-
Index
definition, 342-343 371,374,376-377
development, 433 amnesia associated with, 309
childhood trauma-related disruption of, antikindling agent therapy, 549-550
382 childhood abuse-related, 382, 385-385
Personality disorders in children, 147, 148, 150
characterological management in, 488-492 clonazepam therapy, 549
dissociative identity disorder misdiagnosed in combat veterans
as, 233 dissociation associated with, 211-213
Personality states, in dissociative identity disor- hippocampal size in, 312
der, 343 hypnotizability and, 199
Personality traits, definition, 488 measurement scale for, 3683-69
Pharmacological challenge tests, 166-168 in concentration camp survivors, 214-215,
Phenazepam, as depersonalization therapy, 317
298 depersonalization and derealization associ-
Phencyclidine, 175 ated with, 294
Phil bob, 12 diagnosis, 207
Phobias, 218 differentiated from acute stress disorder,
amnesia as defense against, 94 234
attachment as risk factor for, 131 dissociation as predictor of, 216, 339, 370-
conditioning in, 278 371
dissociative identity disorder-related, 358 dissociation associated with, 163
for dissociative states, 30 relationship to childhood sexual abuse,
heart rate in, 219-220 213-214
for traumatic memories, 30 relationship to hypnotizability, 199, 202,
Physical abuse, childhood 212-213
corroboration of, 95-97 Dissociation Questionnaire scores in, 32
of dissociative disorder not otherwise speci- dissociative identity disorder-related, 14-15,
fied patients, 152 358, 359
of dissociative identity disorder patients, dissociative identity disorder similarity,
352 339
of multiple personality disorder patients, 92, dissociative symptomatology of, 368-369
151 emotional processing impairment associated
of psychiatric patients, 381 with, 216-217
relationship to hypnotizability, 197-198 hyperarousal associated with, 386
Physical examination, of dissociative patients, hypnotherapy, 461, 463
96 incidence, 475
Pibloktoq, 12 in natural disaster survivors, 215-216
Picasso, Pablo, 531 neurobiology of, 163-190
Placebo effect, 546 brain stimulation studies, 170-172
Plasticity, 534 cortical disconnectivity, 176-177
Play, sexualized, 149-150 glutaminergic function alterations, 177-
Pleasure-pain, 529 178
Pollock, Jackson, 530 limbic system kindling, 549-550
Pol Pot concentration camp survivors, 214- pharmacological challenge studies, 166-
215 168
Polysomnography, 562 of pharmacologically-facilitated dissocia-
Poriomania, 230-231 tive states, 178
Possession treatment implications, 178-182
demonic, 4, 314, 573 neuroleptic therapy, 549
dissociative identity disorder as, 337-338, pathological fear structure of, 218-220
353 prevalence
lucid, 4 in clinical populations, 383
somnambulistic, 4 in general population, 309
Possession trance, 11-12, 244-246 psychopharmacotherapy for, 180-182
Postraumatic stress disorder (cont.) Psychological testing 639
reexperiencing episodes in, 313 of dissociative disorders patients, 251-267 Index
serontonergic systems in, 175 general psychiatric assessment tests, 252-
in therapists, 494 253
treatment instruments not specific to dissociative dis·
retraumatization associated with, 323 orders, 255-256
traumatic memories in, 220 instruments specific to dissociative disor·
Posttraumatic Stress Disorder Symptom Scale, ders, 256-263
210 screening tests, 252
Prazepam, dosage ranges, 552 screening tests, self·administered, 253-255
Present State Examination, 252-253 structured, 252
Prince, Morton, 5, 191-192, 227-228, 339 of trauma survivors, 587-588
Process Church, 576 Psychology, paradigm shifts in, 9-10
Programming, of satanic cult members, 575- Psychopharmacotherapy, 545-566
576 for anxiety, 550-556
deprogramming following, 590-591 benefits of, 545
Progressive relaxation, 483 definition, 545
Projective identification, 418 for depersonalization, 297, 298
unresolved attachment·related, 78 for depression, 512-513, 556-562, 559
Promiscuity for dissociative amnesia and fugue, 328
in adolescent sexual·abuse victims, 100 for dissociative identity disorders, 545-566
in children, 149 guidelines, 563-564
Propranolol general considerations in, 546-547
as anxiety therapy, 513, 555, 556 inefficacy of, 164
as dissociative disorder therapy, 549 inpatient, 512-514
as rapid switching therapy, 559 placebo effect, 546
withdrawal protocol for, 551 See also names of specific drugs
Prostate gland, benign hypertrophy of, an· Psychophysiology, of dissociative identity disor·
ticholinergic antidepressant use in, de~ 150, 269-290, 345, 348, 354-
558 355, 533
Protriptyline, as depression therapy, 557 autonomic nervous system measures, 270-
Prozac: see Fluoxetine 279
Psychiatry, paradigm shifts in, 9-10 central nervous system measures, 279-284
Psychic energy, 437-438 Psychoses
Psychoanalysis conscious thoughts in, 436
health insurance reimbursement for, 432 psychophysioogical reactions in, 271
influence on dissociation research, 51 Psychostimulants, 512
Psychodynamic psychotherapy, for dissocia· Psychotherapy
tive disorders, 545-546 for depersonalization, 298-299
for dissociative identity disorder, 413-428 with ritual abuse survivors, 588, 591-592
abreaction in, 420, 423-424 therapeutic relationship in, 588
as acting·out therapy, 415, 419-420 verbal and nonverbal cues in, 526-527
boundary setting in, 421 See also Psychodynamic psychotherapy;
case study, 424-426 Therapists
countertransference management in, Puerto Rico, dissociative identity disorder clini·
423 cal profile in, 9
developmental issues in, 415-419 Pyramidal neurons, 177
goals, 415-421
hypnosis use in, 423 QED: see Questionnaire of Experiences of Dis·
negative symptoms reduction with, 420- sociation
421 Quazepam, dosage ranges, 552
purpose, 413 Questionnaire of Experiences of Dissociation,
single·self model of, 414-415 52, 254-255
technical aspects of, 421-424 correlation with hypnotizability scores, 61, 62
therapeutic neutrality in, 421-422 use with general populations, 54-55, 56
transference management in, 422-423 malingering and, 254
640 Rapid switching, pharmacotherapy for, 559, Ritual abuse, sadistic (cont.)
credibility issues regarding, 577-582
Index 561
Rape as dissociative amnesia cause, 318
gang,28 as false memory, 578-579
by satanic cults, 574, 576-577 hypnosisin,575-576,583-584
Rape victims incidence and prevalence of, 572
dissociation in, 214 as multiple personality cause, 92-93
posttraumatic stress disorder in, 218 survivors as heterogenous population, 582-
Reality 587
dissociative identity disorder patients' per- terminology of, 569-570
ception of, 418-419 treatment issues regarding, 587-592
internal, 529 Ritual abuse survivors, hypnotic images experi-
Recanting, denial as, 491-492 enced by, 467-468
Regression, as abreaction response, 391-392, Rorschach test, 255, 263
394,479 Rumor panic, 509
Regrounding techniques, 451
Relaxation training Sachs, Roberta, 27
deep,453 Sadomasochism
as depersonalization and derealization as memory processing contraindication,
cause,294 492,493
use in memory processing, 483 See also Ritual abuse, sadistic
of pediatric dissociative disorder patients, 155 SAFER model, of abreaction, 389-391
prior to guided reexperience therapy, 180 Safe room technique, 443-444, 455-456
progressive, 483 Safety procedures, for client violence manage-
for traumatic memory recall, 179 ment, 494
REM sleep Satlor Who FeU From Grace with the Sea,
posttraumatic nightmares in, 174 The,596
thalamic activity in, 173-174 Salpetriere, La, 193, 339
Repetition compulsion, 528 Sand tray work
Repression use in inpatient treatment settings, 510
of childhood sexual abuse memories, 318 use in memory processing therapy, 486-
relationship to dissociation, 311-313 487
Research Diagnostic Criteria, 252 Satanic cults, ritual abuse by: see Ritual abuse,
Resolution, definition, 48o sadistic
Response to Childhood Incest Questionnaire, Satanism, 570-572
369 legality of, 571
Restraint Scale of Hypnotic Depth, 192
of pediatric dissociative disorder patients, Scandinavian countries, dissociation disorder
155, 155 research in, 26
of violent patients, 491 Schema,defiitition,406
Retraumatlzation Schema-focused cognitive therapy, 405-410
of childhood amnesia patients, 323 Schema model, of art therapy, 527-529
physiological predictors of, 97 Schizophrenia
spontaneous abreaction-related, 476 alter identities/personalities and, 346-347
Revictimization, of childhood abuse survivors, Bleuler's contribution to, 5-6. 339
389,393 depersonalization and derealization associ-
Review of Psychiatry, 16 ated with, 294, 296, 297
Risk-taking behavior, by childhood abuse sur- Dissociation Questionnaire scores in, 32
vivors, 389 dissociative disorders misdiagnosed as, 15,
Risperidone, as dissociative identity disorder 101,233,252,255.339
therapy, 559, 560, 561 symptoms
Ritual, Christian, use by satanic cult members, dissociative identity disorder-related, 358,
575 359
Ritual abuse, sadistic, 569-594 first-rank, 240-241
allegations of survivors, 572-577 Schizophrenic symptoms, dissociative identity
beliefs and practices in, 573-577 disorder-related, 358, 359
Schizotypal personality disorder, depersonal- Sensory deprivation, as depersonalization and 641
ization and derealization associated derealization cause, 294 Index
with, 294 Sensory perceptual distortion, trauma-related,
Schneiderian symptoms, 240-241 164, 174-175
School failure, by adolescent sexual abuse vic- Sensory stimuli, as traumatic memory "trig-
tims, 100 gers," 477
Schreiber, Flora Rheta, 7-8, 92, 339, 595, 599, Separation anxiety, in dissociative identity dis-
600 order patients, 416
Scopolamine-morphine, use in traumatic mem- Separation Anxiety Test, 128
ory recall, 165 Separation-individuation
Scotland, dissociative identity disorder clinical by adolescents with dissociative disorder,
profile in, 9 149
"Scream, The" (Munch), 530 rapprochment subphase of, 386
Secrecy, in incestuous families, 81 Serotonergic systems, in posttraumatic stress
Sedative antihistamines, 554-555 disorder, 175
Sedative-hypnotics, 512, 513 Serotonin-2 receptors, serotonergic hallucino-
dissociation-inducing effect of, 178 gen-related stimulation, 170
frontal cortex function effect of, 172 Serotonin reuptake inhibitors
traumatic memory retrieval effect of, 182 as depersonalization therapy, 298
Seizures overdose risk, 556-557
antidepressants-related, 557 as posttraumatic stress disorder therapy, 181
relationship to dissociative experiences, Sertraline, 512
281-284 adverse effects, 557
Self-abuse: see Self-mutilation buspirone-induced potentiation of, 555
Self-care, by childhood abuse survivors, 389- Sex offenders, dissociative disorders in, 351
390 Sexual abuse, prevalence of, 99
Self-destructive behavior: see Self-injurious be- in women, 356
havior Sexual abuse, childhood
Self-esteem, low, in children, 148 by children, 596
Self-hypnosis criminal cases regarding, 596
by abuse survivors, 587 as dissociative amnesia cause, 318-319
definition, 450 as dissociative disorder not otherwise speci-
by dissociative disorders patients. 194 fled cause, 152
as somatic symptoms cause, 240 as dissociative disorders cause, 6-7, 67, 368-
by dissociative identity disorder patients, 92 369
effect on reality perception, 418-419 in Netherlands, 34, 36-37
as positive symptom, 420 as dissociative identity disorder cause, 339,
hypnosis as, 451-452 352-353
Self-injurious behavior duration, 80
by childhood abuse survivors, 389, 391-392 experienced by psychiatric patients, 381
dissociative identity disorder-related, 23 7- false allegations of, in custody cases, 582
238,348-349,420 Freud's observations of, 99-100
by incest victims, 81 mothers' involvement in, 28
in inpatient settings, 511 as multiple personality cause, 151
Self-mutilation case histories, 92-93
by childhood abuse survivors, 389 patients' self-reports of
chronic versus cyclical, 489 corroboration of, 97
dissociative identity disorder-related, 358 credibility of, 353, 357
memory retrieval and, 478 as recovered memories, 509
motivations for, 489, 589 as sexual fantasies, 101-102
treatment, 588-590 prevalence of, 7
Self-negation, depersonalization-related, 293 relationship to hypnotizability, 197- 198
Self-objectification, depersonalization-related, relationship to later-life sexual trauma re-
293 sponses, 214
Self-sucking behavior, 72 relationship to posttraumatic stress disorder,
Sense of self, cohesiveness of, 417 213-214
642 Sexual abuse, childhood (cont.) Split brain/hemispheric laterality model, of dis-
Index by satanic cults, 572, 576-577 sociative identity disorder, 355
twelve-step programs and, 328 Split mind disorder, 6
types of abuse, 93 Splitting,95,417,418
See also Childhood abuse survivors affective, 74
Sexual abuse survivors unresolved attachment-related, 78
abandonment of "victim" role by, 393 Stanford Acute Stress Reaction Questionnaire,
lack ofattachment to others, 415-416 210,372,373
See also Childhood abuse survivors Stanford Hypnotic Scale for Children, 198
Sexual assaults, by children on children, 149- Stanford Hypnotic Susceptibility Scale, 195-
150 196
Sexual dysfunction, dissociative identity disor- Startle response, in childhood abuse survi-
der-related, 239-240, 358 vors, 386
Shamans,4 State Ucenslng Boards, administrative actions
Shame, of childhood abuse survivors, 392 of, 611-614
Shell shock, 164, 316 State v. Brookes, 606
Sizemore, Chris, 7 State v. Darnell, 606
Sleep Stein, Gertrude, 531
REM Stimulants, as depersonalization therapy, 298,
posttrauamtic nightmares in, 174 299
thalamic activity in, 173-174 Stockholm syndrome, 492
sensory processing alterations in, 173-174 Stress
Sleep apnea, 562-563, 564 as depersonalization cause, 297
Sleep deprivation, as depersonalization and as dissociation cause, 51, 94
derealization cause, 294 correlation with health status, 63-64
Sleep disturbances as dissociative amnesia and· fugue cause,
abreaction-related, 392 315
in childhood abuse survivors, 386 effect on dissociative disorder symptomatol-
dissociative identity disorder-related, 358 ogy,384
psychopharmacotherapy for, 386, 512, 513 Janet's theory of, 51
trauma-related, 216 as sensory distortion cause, 174-175
Slips, 59,60 Structured Clinical Interview for DMS-III-R Dis-
Snapshots technique, 471 sociative Disorders, 12
Social services, for dissociative disorder pa- Structured Clinical Interview for DSM-IV Dis-
tients and their families, 509-501 sociative Disorders, 8, 252, 253, 256-
Socratic method, use in cognitive-behavioral 263,296,301,342
therapy, 403 use with adolescents, 143
Sodium lactate, flashback-inducing effect, 166 amnesia criterion, 14, 232, 319-320
Somatic symptoms, 5, 228-229 clinical applications, 261
amnesia associated with, 390 use with college srudents, 58
correlation with Dissociative Experiences use with combat veterans, 317
Scale scores, 28 correlation with Dissociative Experiences
dissociative identity disorder associated Scale,29,254
with,239,240,358 use for dissociative amnesia evaluation, 319-
traumatic memory manifestation as, 528 320
Somatic therapies, for dissociative amnesia field tests of, 256-257
and fugue, 328-329 format, 257-261
Somatoform Dissociation Questionnaire, 30, use in Netherlands, 29, 30
40-41 use in Norway, 26
Somnambulism, 5 reliability and validity of, 14, 29, 30, 256-
artificial, 314 257
Son of Sam, 576 sample evaluation report for, 261-263
Southwest Mental Health Center, Columbus, Studtes on Hysteria (Breuer and Freud), 5
Ohio, 603-604 Srupor, 12, 370
Spain, dissociation disorder research in, 26 Subject experiences, 436-437
"Speechless terror," 529 Subject representations, 417
Substance abuse Temporal lobe/partial complex seizure/kin- 643
by childhood abuse survivors, 389 dling model, of dissociative identity Index
depersonalization and derealization associ- disorder, 3 55
ated with, 294 Temporal lobe tumors, depersonalization and
dissociative identity disorder-related, 14-15, derealization associated with, 294
240-241,358 Testimony, hypnotically refreshed, 587
Sudafed, as dissociative episode trigger, 548 Tetrahydrocannabinol, dissociative state-induc-
Suicidality ing effect, 169
of adolescent sexual abuse victims, 100 Thalamic networks, in dissociative states, 172-
assessment, 513 176
of children, 147-148 Thalamus, glutaminergic neuronal activity
depersonalization as risk factor for, 296, 299 modulation activity of, 177
of dissociative amnesia and fugue patients, Therapeutic alliance
324 with childhood abuse survivors, 391, 394-
of dissociative identity disorder patients, 395
237-238,348-349,358,360,420 in cognitive-behavioral therapy, 402-403
emotional containment strategies for, 502 See also Therapeutic relationship
as hospitalization indication, 500 Therapeutic neutrality, 421-422
ideomotor signals and, 502 Therapeutic relationship
as memory retrieval indication, 478 communication in, 526-527
as overdose risk, 564 dependencyin,442
Suicide intimacy in, 601
by dissociative amnesia and fugue patients, oftrauma survivors, 588
323 Therapeutic Self, The (Watkins), 442
malignant, as memory processing containdi- Therapists
cation, 493 alienation in, 494
Supernatural/transpersonal model, of dissocia- depression in, 494
tive identity disorder, 3 53 dissociative identity disorder patients' aggres-
Supportive-expressive treatment, 527 sion towards, 608-611
Surrealism, 530 dual relationships of, 598, 601
Switzerland existential crises of, 494
dissociative disorders research in, 26 health insurance reimbursement of, 432
dissociative identity disorder clinical profile obsession in, 494
in, 9 paranoia in, 494
Sybil,598-601 posttraumatic stress disorder in, 494
Sybil (Schreiber), 7-8, 92, 339, 595, 599, 600 "third-ear" ability of, 438-439
Synesthesia, 170 Thioridazine, 556
System maps, 533 Thought insertion, 150-151
System pictures, 533 Thoughts, psychotic, 436
Threat exposure, conditioned response, 30
Tacrine, 181, 182 Three Faces of Eve, The (Thigpen and Cleck-
Tactical integration model, of cognitive-behav- ley), 7-8, 600
ioral therapy, 404 Thyroid medication, 512
Tardive dyskinesia, 513 Time distortion
Television characters, alter identities/ person- in accident victims, 215
alities based on, 357 in dissociative identity disorder patients, 416
Tellegen Absorption Scale, 60 hypnotic management of, 451, 457-458
Temazepam, dosage ranges, 552 Time gaps, 142, 144, 145
Temporal lobe, electrical stimulation of, 171 Time out, for destructive behavior control,
Temporal lobe epilepsy 155, 156
depersonalization and derealization associ- Time regression, in children, 144
ated with, 294, 296, 297 Tornado survivors, dissociation in, 215
as dissociative identity disorder cause, 355 Torture, ritual, 92-93, 572, 574, 577
memory flashbacks and, 170-171 Trance logic, 548
relationship to dissociative experiences, Trance state/autohypnosis model, of dissocia-
171, 281-284 tive identity disorder, 355
644 Trance/trance states, 4, 11-12, 235-236, 245- Trimipramine, 557
"Truth sera," 165
246,453-454
in children and adolescents, 72, 75, 144, Turner, Dorothy, 604
145,150,348 Twelve-step groups, childhood sexual abuse
as defense mechanism, 67, 94 survivors' participation in, 328
definition, 108n. Two-energy theory, 437-438
depth, 460-462
as dissociation component, 52 UFO abductions, 579, 583
as dissociative disorder not otherwise speci- Ultimate Evi~ The (ferry), 576
fied,235,383 Umgetauschte Personlichkeit, 338
disorganized/disoriented attachment and, Unabomber, 603
124, 125, 127, 130, 131-132 Understanding Childhood Abuse and Neglect
ego states during, 453 (National Research Council), 381
in general populations, 56 United Kingdom, dissociation research in, 26
of incest victims, 70 United States v. Davis, 606
in infants, 108-109 Urban legends, satanic ritual abuse as. 579
possession, 11-12, 244-246
in self-abuse. 590 Valium: see Diazepam
Transference Van Gogh, Vincent, 530
with dissociative identity disorder patients, Vasopressin, effect on traumatic memory re-
416,422-423 trieval, 182
in ego state therapy, 442, 446 Venlafaxine, as dissociative identity disorder
flashback, 492 therapy, 559, 560, 561-562
in hypnosis, 453-454 Vietnam War veterans
as memory processing contraindication, amnesia in, 316-317
492-493 posttraumatic stress disorder in
in psychodynamic psychotherapy, 422-423 autobiographical memory retrieval defi-
traumatic, 547 cits, 313
Trauma dissociation associated with, 211-212
amnesia and, 315, 316-320 hypnotizability associated with, 199,
biphasic response to, 385-386 369
definition, 415, 529 pharmacologically-induced flashbacks in,
as depersonalization disorder cause, 296 166
as dissociation cause, 163-164, 370-371 societal acceptance of, 7
as dissociative identity disorder cause, 351- Vimbuza, 12
353 Violence
in general populations, 35-36 as hospitalization indication, 500
as hypnotizability cause, 163-164 by pediatric dissociative disorder patients,
See also Childhood abuse survivors; Physi- 155, 156
cal abuse, childhood; Sexual abuse, towards therapists, 494
childhood by dissociative identity disorder patients,
Trauma survivors, complexity of, 476-478 608-611
Trauma Symptom Checklist-40, 369 during memory processing, 490-491
Traumatization, in childhood, 351-352; see witnessed by children, 92, 152, 155, 156,
also Childhood abuse survivors; Physi- 386
cal abuse, childhood: Sexual abuse, Visual acuity, of alter identities, 275
childhood Visual form, of traumatic memories, 528
Traumatology, 476
Trazodone,512 Waco, Texas, 570
adverse effects, 557 We, the Dtvtded Self (Watkins and Johnson),
overdose risk, 556-557 434
as sleep disturbance therapy, 386 Wechsler Memory Scale, use with combat vet-
Triazolam, dosage ranges, 552 erans, 317
Tricyclic antidepressants, 512 Weight gain, antidepressants-related, 557
overdose risk, 556-557 West, Mae, 534
as posttraumatic stress disorder therapy, 181 Wilbur, Cornelia B., 339, 598-601,604
Withdrawal, as flashback cause, 168
Witnesses
World War II soldiers, amnesia in 323
World War II veterans, amnesia in, 315, 328-
645
Index
to trauma. dissociation in, 216 328
to violence, children as, 92. 152, 155, 156
Women's movement, 6 Xanax: see Alprazolam
Woodward, joanne, 600
Words, arbitrary meanings of, 531 Yohimbine
World War I soldiers, amnesia in, 323 dissociation-inducing effect, 177, 178
World War I veterans, amnesia in, 316 flashback-inducing effect, 166-167
World War II, amnestic fugue occurrence dur- thalamic bursting effect, 175
ing, 230 use in traumatic memory retrieval, 182