Dissociation

J R Maldonado
Stanford University, Stanford, CA, USA


Introduction
The word dissociation is defined as the act of dissociating or the state of being dissociated. It can also stand for the splitting off of a group of mental processes from the main body of consciousness. In psychiatry, the term is used to describe the reversible separation of elements of ''identity, memory or consciousness'' (APA, 2000) from the mainstream of consciousness or of behavior, as in dissociative amnesia, fugue, depersonalization, or dissociative identity disorder. The word comes from the Latin verb dissociate, meaning to separate, to disunite; dis, meaning asunder; and sociare, meaning to unite.
Thus, dissociation can be understood as themechanisms by which we are able to separate mental processes and contents. Ordinarily, these are processed together. Normally, the (nonpathological) mechanism of dissociation allows us to carry on more than one complex task or action simultaneously by keeping out of consciousness routine experiences or tasks. For example, it allows a person to watch a television program while knitting or cooking. Similarly, it allows individuals to successfully drive their car while listening and learning from a book on tape.
Unconsciously, the mechanism of dissociation can also be elicited as an attempt to preserve some sense of control, safety, and identity in the face of overwhelming stress. Dissociation is usually elicited as a response to trauma that threatens personal physical integrity or the safety of a loved one, or as a response to extreme isolation and abandonment. Unfortunately, dissociative defenses give victims a false sense of control while immediately provides temporary relief from the full impact of the traumatic experience. Because the use of dissociation allows people to separate themselves from the awareness of danger, some trauma victims act as if the event is not happening. Yet others act as if it had never happened.
Pathological dissociation is usually the result of trauma. The form of trauma may vary widely, ranging from abandonment to overt physical trauma. Trauma may involve natural disasters (e.g., earthquakes, tornadoes, floods), man-made accidental disasters (e.g., war, nuclear plant explosions), largescale man-made intentional disasters (e.g., the World Trade Center attack of 9/11 in New York City, the Oklahoma City bombing, school shootings, terrorism), or more personal traumas, such as rape, car accidents, or even a traumatic medical procedure. Probably among the most publicized of all forms of trauma are the victims of childhood physical and sexual abuse.
The traumatic experience invariably objectifies its victim. The sense of helplessness engendered by such situations creates sudden challenges to normal ways of processing perception, cognition, affect, and relationships. Trauma in the form of both natural disaster and human assault causes disruption to normal cognitive and affective processes and forces its victims to reorganize mental, psychological, and physiological processes in an attempt to prevent the immediate impact of the trauma. This reorganization may take the form of various forms of dissociative processes, fostering separation from painful surroundings and realities (derealization), or from the victim's own body (depersonalization). Even though such defenses may initially be adaptive, directed at maintaining control at times of overwhelming stress, some trauma victims develop persistent dissociative, amnestic, and anxiety-like symptoms. The ultimate sequelae of trauma for a substantial minority of its victims may be the development of traumatic stress disorders or dissociative disorders. Dissociative disorders have been described in many cultures and settings, with women making up the majority of cases. Nearly 90% or more of cases reported in the literature are women. The most common dissociative disorder diagnosis is the not otherwise specified category, both in the United States and in non-Western countries, where dissociative trance and possession trance are the most common dissociative disorder diagnoses.
Dissociation as a pathological (i.e., psychiatric) phenomena was initially described by the French philosopher and psychologist Pierre Janet. Janet used the French term désagrégation, which carries with it a different and more accurate nuance than its English translation, dissociation. désagrégation implies a separation of mental contents despite their general tendency to aggregate or be processed together. According to Janet, the problem experienced by patients suffering from dissociative phenomena is a difficulty in integration of psychic processes, rather than a proliferation of components of consciousness, memory, identity, or perception. Janet (1989) viewed désagrégation as a purely pathological process, ''a malady of the personal synthesis.'' Janet was also the first to study psychological trauma as a principal cause of dissociative phenomena. Unfortunately, during the twentieth century Janet's work and theories of dissociation as a pathological process were eclipsed by the emerging psychoanalytic theories proposed by Sigmund Freud.
Freud's teachings and methods emphasized the mechanism of repression, rather than dissociation, as the driving force of his patients' problems. Nevertheless, early writings by Freud and his colleague Josef Breuer explored unconscious phenomena through an examination of seemingly similar dissociative phenomena. Infact, expanding on the theories on hysteria of their mentor, the French neurologist Jean Marie Charcot, Breuer and Freud suggested that the dissociative symptoms exhibited by their patients could be attributed to the patients' capacity to enter spontaneous and uncontrolled hypnoid states.
Based on observations of combat soldiers and former concentration camp inmates, Hilgard developed a neodissociation theory that revived interest in Janetian psychology and psychopathology. Hilgard's neodissociation model conceived of a mental structure with divisions that were horizontal rather than vertical, different from Freud's topographic model, which was composed of deeper and deeper layers of unconscious mental processing. Unlike Freud's system, Hilgard's model allowed for immediate access to consciousness of any of a variety of warded-off memories. In his model, amnesia was the crucial mediating mechanism that provided the barriers that divided one set of mental contents from another. Thus, he proposed the flexible and reversible use of amnesia as a key defensive tool.
Carl Jung had a unique insight in recognizing that the dissociability of the psyche is a fundamental process that extends along the continuum from normal mental functioning to abnormal states. Thus, Jung viewed the process of dissociation as a universal and necessary psychic activity for the development of personality through the differentiation of functions. On the other hand, he postulated that when the cohesion of consciousness was shattered by extreme traumatic experiences (e.g., childhood physical or sexual abuse), the natural process of differentiation of function was intensified, creating extreme dissociative splits between autonomous forces in the psyche, as observed in the cases of several psychiatric disorders, e.g., borderline personality disorder (BPD) or dissociative identity disorder (DID).


Models of Dissociation
Several models have been proposed to explain the process of dissociation. One such model, the neurological model, suggests that some underlying neurological process, such as hemispheric disconnection or epilepsy, causes the manifested clinical symptoms of dissociation. Several forms of epilepsy, particularly temporal lobe seizures, can manifest with rather complex behaviors (e.g., automatism), of which the subjects have little or no recollection. In other forms of epilepsy (e.g., petit mal seizures) subjects may experience depersonalization-like phenomena, reminiscence of dissociative phenomena.
The second proposed model is the role enactment model, also known as the social role demand theory. This model suggests that the symptoms associated with dissociative disorders represent an artificial social construct rather than a true psychiatric disorder. The proponents of this model suggest that dissociation is a clinical artifact created out of conscious or unconscious needs on the part of patients to capture the attention of their doctors. Some have even proposed a direct iatrogenic etiology in which therapists suggest the existence of symptoms (e.g., personality states). Finally, the autohypnotic model recognizes the connection between trauma, dissociation, and hypnotizability.
The third proposed model is the autohypnotic model. This theory recognizes and reconciles the connection between traumatic events, dissociative experiences, and hypnotizability. Thus, the autohypnotic model suggests that trauma victims dissociate or forget traumatic memories, using self-hypnotic mechanisms in order to keep them out of consciousness because reality is too painful to be faced. Memories may be stored at conscious and/or unconscious levels. The degree of amnesia varies, with some patients who have always remembered. Some remember only parts of the trauma. Yet in certain cases, some memories are transformed and others are interspersed with fantasy (e.g., cases of ritual abuse or alien abduction). Later on, some memories slowly leak into the conscious mind. Because full memories are not available it is difficult for patients to make sense of them. Some victims experience leaked memories in the form of flashbacks or dreams. Other trauma victims isolate themselves due to the shame they feel in relation to the suspected trauma.
Even though dissociated memories may be temporarily unavailable to consciousness, they may continue to influence conscious (or unconscious) experiences and behavior. Clinical experience suggests that dissociated information continues to affect patients' moods, behavior, and cognitive processes. It is common for patients suffering from dissociative disorders to feel that something is wrong but to be unable to identify what. Many patients will experience a sense of discomfort, or sometimes even panic, when in specific situations. In fact, many of the symptoms experienced by trauma victims (e.g., flashbacks, psychosomatic symptoms) can be explained by the influence exerted by dissociated (forgotten or inaccessible) memories. Nevertheless, it is important to remember that not everyone exposed to trauma will develop dissociative symptoms. In fact, studies conducted with war veterans reported that less than 25% of soldiers exposed to trauma during combat go on to develop severe dissociation or posttraumatic syndrome. This suggests that other factors may be involved in the production of dissociative and anxiety symptoms. A leading factor may involve the developmental stage during which the trauma occurs. Available data suggest that, as a rule, the earlier in life the trauma occurs, the greater the psychological sequelae caused. This is probably due, in part, to the defense mechanisms and coping styles that the victim has had an opportunity to develop prior to the occurrence of the trauma, which in turn will modulate the way in which the victim perceives the experience and adapts to its impact and consequences.
Putnam proposed the discrete behavioral states model of dissociative identity disorder. Forrest described a possible biological mechanism to support Putnam's theory by proposing the involvement of the orbital frontal cortex in the development of DID and suggesting a potential neurodevelopmental mechanism responsible for the development of multiple representations of the self. The proposed orbital frontal model integrates and elaborates on theory and research from four domains: the neurobiology of the orbital frontal cortex and its protective inhibitory role in the temporal organization of behavior, the development of emotion regulation, the development of the self, and experience-dependent reorganizing of neocortical processes. The hypothesis proposed by Forrest establishes that the experience-dependent maturation of the orbital frontal cortex in early abusive environments, characterized by discontinuity in dyadic socio-affective interactions between the infant and the caregiver, may be responsible for a pattern of lateral inhibition (i.e., dissociation or inhibition of conflicting subsets of self-representations that are normally integrated into a unified self). His basic idea is that discontinuity in the early caretaking environment is manifested in the discontinuity in the organization of the developing child's self. Brenner has suggested that dissociation may be seen as a complex defense. Furthermore, he believes that DID may be thought of as a lower level dissociative character, and that there is a unique psychic structure, which he calls the dissociative self, whose function is to create alter personalities out of disowned affects, memories, fantasies, and drives. As many other experts on dissociation have suggested, Brenner believes that this dissociative self must be dissolved during the therapeutic process in order for integration of alter personalities to occur.
In fact, recent scientific literature has focused on the characterological features of DID, thus extending the state versus trait debate to the realm of the dissociative disorders. This has lead to the development of theories suggesting that DID may be a variant of, on a continuum with, or comorbid with the diagnoses of narcissistic and BPDs. Brenner suggested that DID would be best considered as a distinct characterological entity. He presented two theories, which described DID as a personality disorder whose predominant defense is dissociation. The more developed model, which possibly has more explanatory value, is the dissociative character. In this schema, DID would be considered a lower-level dissociative character, utilizing primitive forms of dissociation in which splitting is enhanced by an autohypnotic defensive altered state of consciousness. These patients experience altered states, which originate in response to the overstimulation stemming from external trauma, but which are reactivated in response to here-and-now intrapsychic conflicts.


Universality of Dissociation as a Syndrome
Dissociative symptoms have been reported in virtually every major psychiatric disorder and, in less severe forms, even in nonpatient (normal) populations. In the United States general (nonclinical) population, 6.3% of adults have reported three to four dissociative symptoms. Studies have suggested that dissociative disorders might comprise 5 to 10% of the psychiatric populations. Similarly, dissociative disorders have been described in many cultures and settings. Studies demonstrating prevalence rates have been conducted in Turkey, the Netherlands, Switzerland, Australia, Ethiopia, and Germany.


The Dissociative Disorders
The Diagnostic and Statistical Manual, 4th edition (DSM-IV) recognizes five different dissociative disorders. These include depersonalization disorder, in which patients feel detached from their own mental processes or body and which patients describe as a robot-like or out-of-body experience. Dissociative amnesia is a disorder in which patients exhibit an inability to recall important personal information. The memory loss (amnesia) may apply to a part of the trauma (localized) or all (selective) of the traumatic experience. In extreme cases the amnesia may include personal information regarding the patient's entire life (generalized amnesia). Patients suffering from dissociative fugue suddenly go away, usually traveling far from home and developing a new identity while remaining amnestic to their past personal history. Patients suffering from DID exhibit two or more identities or personality states accompanied by frequent memory gaps (i.e., amnesia). Finally, there is a category called dissociative disorder not otherwise specified (NOS), by which patients exhibiting the core of dissociative symptoms but not fulfilling the diagnostic criteria of the previous four syndromes are classified. An example that may fit in this category is patients suffering from trance states.


Dissociative Amnesia (Psychogenic Amnesia)
The hallmark of this disorder is the inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. This is probably the most common of all dissociative disorders. In fact, amnesia is not only a psychiatric disorder by itself, but also a symptom, commonly found in a number of other dissociative and anxiety disorders. The highest incidence of dissociative amnesia has been described in the context of war and other natural and manmade disasters. Data suggest a direct relationship between the severity of the exposure to trauma and the incidence of amnesia.
Cases of dissociative amnesia usually share the following characteristics. First, the memory loss is episodic. That is, patients usually suffer the first-person recollection of certain personal events rather than knowledge of procedures (i.e., a person may not remember that he or she is a mechanic by trade or training, but is still able to intuitively and competently handle the tools). The memory loss involves a discrete period of time ranging from minutes to years. There seems to be a clear, dense amnesia, not a vagueness or inefficient retrieval of memories. There is usually no difficulty in learning new episodic information. The memory loss generally encompasses events of a traumatic or stressful nature. In cases of dissociative amnesia patients are usually aware of their memory loss. Cases of dissociative amnesia can also be distinguished from amnesia of neurological origin by patients' intact cognition and capacity to learn new information. The primary problem in amnesia patients is a difficulty in retrieval rather than encoding or storage; thus, memory deficits are usually reversible. In fact, once the amnesia has cleared, normal memory function is resumed.
The epidemiology of this disorder is unknown. Nevertheless, dissociative amnesia is considered to be the most common of all dissociative disorders. The etiology of amnestic disorders is presumed to be posttraumatic, since they generally occur within the context of severe psychosocial stress. The duration of the disorder varies from a few days to a few years. Even though it is possible to experience a single episode of amnesia, many patients have experienced several episodes during their lifetime. This is more common when the stresses that caused the initial episode are not resolved. The spontaneous resolution of the symptoms is rather common. In fact, many patients experience spontaneous recovery without more treatment than a protective environment. Sometimes more systematic treatment may be necessary.
The differential diagnosis of dissociative amnesia includes epilepsy, brain malignancy, head trauma, medication side effect (e.g., benzodiazepines use), chronic drug abuse and acute intoxication, cardiovascular and metabolic abnormalities, other dissociative disorders, an organic brain syndrome, a factitious disorder, and malingering.


Dissociative Fugue (Psychogenic Fugue)
Dissociative fugue is characterized by the sudden, unexpected travel away from home or one's customary place of daily activities, with inability to recall some or all of one's past. As in the previous disorder, amnesia is present, causing a sense of confusion about personal identity. On occasion, patients assume a new identity.
In contrast to dissociative amnesia cases, patients suffering from fugue states appear normal to the lay observer. Patients usually exhibit no signs of psychopathology or cognitive deficit. Fugue patients differ from those with dissociative amnesia in that the former are usually unaware of their amnesia. Only upon resumption of their former identities do they recall past memories, at which time they usually become amnestic for experiences during the fugue episode. Often, patients suffering from fugue states take on an entirely new (and often unrelated) identity and occupation. In contrast to patients suffering from DID, in fugue states the old and new identities do not alternate.
Not much is known regarding the etiology of this disorder. Nevertheless, the underlying motivating factor appears to be a desire to withdraw from emotionally painful experiences. Clinical data suggest that predisposing factors include extreme psychosocial stress such as war or natural and man-made disasters, personal and/or financial pressures or losses, heavy alcohol use, and intense and overwhelming stress such as assault or rape. The onset of some fugue episodes may occur during sleep or be associated with sleep deprivation.
As in cases of acute dissociative amnesia, the onset of the disorder is usually associated with a traumatic or overwhelming event accompanied by strong emotions such as depression, grief, suicidal or aggressive impulses, or shame. Dissociative fugue is the least understood dissociative disorder. This may be due to the fact that most of these patients do not present for treatment. Usually they do not come to the attention of medical personnel until they have recovered their identity and memory and return home. Typically, patients seek psychiatric attention once the fugue is over and they are seeking to recover their original identity or retrieve their memory for events that occurred during the fugue.


Dissociative Identity Disorder
(Multiple Personality Disorder)
DID is defined by the presence of two or more distinct identities or personality states that recurrently take control of behavior. This disorder represents the failure to integrate various aspects of identity, memory, and consciousness. Characteristics of this disorder are memory disturbances and amnesia. In contrast to other dissociative disorders, the degree of amnesia experienced in DID is usually asymmetrical. That is, it selectively involves different areas of autobiographical information, i.e., alters (personality states or identities) differ in the degree of amnesia for the experiences of other alters and the access to autobiographical information.
Usually there is a primary or host personality that carries the patient's given name. Often the host is not completely aware of the presence of alters. Because of the presence of amnestic barriers, different personalities may have varying levels of awareness of the existence of other personalities. On average there are 2 to 4 personalities present at the time of diagnosis, and usually up to 13 to 15 personalities are discovered during the course of treatment.
The symptoms that usually prompt patients or their families to seek treatment include memory deficits, moodiness, erratic and unpredictable behavior, depression, self-mutilation, suicidal ideation or attempts, and the overt manifestation of an alternate personality. Transition from one personality to another is usually sudden and is commonly triggered by environmental/ interpersonal factors.
Alter identities may have different names, sexes, ages, and personal characteristics and often reflect various attempts to cope with difficult issues and problems. Alters can have a name and well-formed personalities, e.g., Rose, an 8-year-old girl, or can be named after their function or description, e.g., the Angry One.
The factors that can lead to the development of DID are quite varied, but most authors seem to agree that physical and sexual abuse during childhood is the most commonly found etiological factor in these patients. In fact, a history of sexual and/or physical abuse has been reported in 70–97% of patients suffering from DID, with incest being the most common form of sexual trauma (68%). Other forms of childhood trauma that are associated with later development of DID include physical abuse other than sexual abuse (75%), neglect, confinement, severe intimidation with physical harm, witnessing physical or sexual abuse of a sibling, witnessing the violent death of a relative or close friend, traumatic physical illness on self, and near-death experiences.
The actual incidence and prevalence of this disorder are unclear. The estimated prevalence of DID in the general population has been reported to range from 0.01 to 1%. The average time from the appearance of symptoms to an accurate diagnosis is 6 years. The average age at diagnosis is 29 to 35 years. It has been described to be more common in women than in men by a ratio of 3–9:1. Female patients are also reported to present more personalities (average of 15) than men (average of 8).
There is a high incidence of comorbid psychiatric and medical syndromes. Of the psychiatric disorders, depression is the most common (85–88%), followed by posttraumatic stress disorder, BPDs, and substance abuse. There are a number of other psychiatric symptoms common to patients with DID, including insomnia, suicide attempts or gestures, self-destructive behaviors, phobias, anxiety, panic attacks, auditory and visual hallucinations, somatization, conversion reactions, and psychotic-like behavior.
As in cases of dissociative amnesia and fugue, the differential diagnosis of dissociative disorders includes an organic condition (e.g., temporal lobe epilepsy, brain malignancy, head trauma, medication side effect, drug abuse, and intoxication), other dissociative disorders, psychotic disorders (e.g., schizophrenia), factitious disorder, and malingering.


Depersonalization Disorder
Depersonalization is characterized by persistent or recurrent episodes of feelings of detachment or estrangement from one's self. Depersonalization disorder is primarily a disturbance in the integration of perceptual experience. Individuals commonly report feeling like a robot or as if they are living a dream or a movie. Patients suffering this condition describe their experience as if they were an outside observer of their own mental processes and actions. In contrast to delusional disorders and other psychotic processes, reality testing is intact. The phenomena associated with depersonalization are not uncommon. In fact, depersonalization is seen in a number of psychiatric and neurological disorders, including agoraphobia and panic disorder, acute and posttraumatic stress disorder, schizophrenia, other dissociative disorders, personality disorders, acute drug intoxication or withdrawal, psychotic mood disorders, epilepsy, Méniére's disease, sensory and sleep deprivation, hyperventilation, and migraine headaches. In fact, people with no psychiatric condition can transiently experience symptoms of depersonalization. Because of this it is important that the diagnosis is applied only when the presence of symptoms causes severe impairment in functioning or marked distress.
The incidence and prevalence of this condition are unknown. The symptom of depersonalization has been described as being the third most common psychiatric symptom, after depression and anxiety. It is believed that under severe stress, up to 50% of all adults have experienced at least one brief episode of depersonalization. On the other hand, up to 12–46% of normal college students, nearly 30% of individuals exposed to life-threatening danger, up to 40% of hospitalized psychiatric patients, and about 69% of patients with panic disorder have experienced transient episodes of depersonalization. Episodes of depersonalization may also occur as a symptom of alcohol and drug abuse, as a side effect of prescription medication, and during stress and sensory deprivation. The sex distribution is unknown.
Theories for the etiology of this disorder range from the completely physiological, such as anatomical defects similar to epilepsy, to the purely psychological, such as a defense against painful and conflictual affects or the split between observing and participating ego/self, to combinations of all of the above as the result of a preformed functional response of the brain as an adaptation to overwhelming trauma. In any event, exposure to traumatic experiences seems to be the common etiological factor in this disorder. The course of the illness is usually chronic, with episodes of exacerbation usually following exposure to real or perceived stress.


Treatment
To date there are no controlled studies addressing the treatment of any of the dissociative disorders. All the information available reflects the experience and case reports of clinicians and specialized treatment centers. No single treatment modality has been systematically studied in this patient population. Similarly, there are no established pharmacological treatments except for the use of benzodiazepines or barbiturates for drug-assisted interviews.


Dissociative Amnesia (Psychogenic Amnesia)
Before treatment is started it is necessary to establish that the amnesia or fugue state is of dissociative (psychogenic) origin, ruling out the possibility of a neurological disorder such as temporal lobe epilepsy. Usually the initial step in the treatment is to provide a safe environment. Simply removing the person from the threatening situation and providing security and protection has allowed for the spontaneous recovery of acute episodes. At times additional help may be needed to obtain the necessary biographical information or to facilitate the patient's recall. Among the adjuvants commonly used, hypnosis and barbiturateor benzodiazepine-facilitated recall are the most popular and better described.
No studies have addressed the efficacy of hypnosis in the treatment of dissociative amnesia. Nevertheless, most researchers in this area agree that hypnosis is a very useful tool for the recovery of repressed and dissociated memories. Once the amnesia has been reversed, treatment should be directed at restructuring the events and defining the factors that led to the development of the amnesia. This is followed by the establishment of appropriate defenses and mechanisms to prevent further need for dissociation. This is best done within the context of more extensive therapeutic work.


Dissociative Fugue (Psychogenic Fugue)
The treatment should involve provision of rest and assurances of safety, development of a trusting therapeutic relationship, recovery of personal identity, review of triggers or factors associated to the onset of the fugue, reprocessing of traumatic material, reintegration of traumatic memories into personal history, and returning the patient to his or her previous life.
Hypnosis and drug-facilitated interviews have commonly been used during the stages of recovery of personal identity and memories associated with the onset of the fugue. Except for the facilitation of memory retrieval (narcosynthesis) or diminution of anxiety related to the therapeutic process, no pharmacotherapeutic agents have been systematically studied in the treatment of this condition. The treatments for acute dissociative amnesia and fugue states have been generally similar. Traditionally, hypnosis and amytal narcosynthesis were the tools of choice for the recovery of dissociated material in subjects suffering from both amnesia and fugue states. In fugue cases, treatment should be undertaken as quickly as possible, while the repressed material is more readily accessible and before the memories have an opportunity to consolidate into a nucleus, as this may increase the possibility of future flight episodes. Patients may also experience spontaneous memory recovery upon removal from the stressful situation, when exposed to cues from their past, or when they feel psychologically safe. Psychodynamic psychotherapy may help to address the conflicts that precipitated the amnesia or fugue, thereby reducing subsequent dissociation under stress.


Dissociative Identity Disorder
(Multiple Personality Disorder)
To date, there are no studies demonstrating the efficacy of pharmacological agents in the treatment of DID. As in the other dissociative disorders, pharmacological agents do not seem to address the disorder, but may serve as adjunct treatment of accessory symptoms (e.g., comorbid insomnia, anxiety and depressive symptoms).
Almost every psychotherapeutic and psychopharmacological treatment modality has been applied to patients suffering from DID, from group psychotherapy to family therapy, from antidepressants to antipsychotics to anticonvulsants to b-blockers, from hypnosis to eye movement desensitization and reprocessing (EMDR) to electroconvulsive therapy (ECT). All of them have been shown to have various degree of success.
In general terms, the treatment of DID involves (1) development of a therapeutic relationship based on safety and trust, (2) negotiation with the patient about cooperation with treatment, (3) development of a contract against harm to self or others, (4) history taking and understanding personality structure, (5) abreaction and working through of traumatic experiences and frequently repressed or dissociated material, (6) negotiating and modulating conflicts among aspects of identity and personality states, (7) development of mature and more appropriate, nondissociative defenses, and (8) working toward integration of alters.
Techniques such as hypnosis can facilitate control over dissociative episodes and integration of traumatic memories (see next section for details). Efforts at development of a social network and support system are helpful. Once integration has been achieved, further work is needed to deal with residual or renewed dissociative responses to external stress or internal conflicts and to further integration with society. The treatment of DID is usually arduous, painful, and prolonged. Even though the ultimate goal is the achievement of integration, in some cases a reasonable degree of conflict-free collaboration among the personalities is all that can be achieved. Among clinicians, the most common treatment modality used is individual psychotherapy facilitated by the use of hypnosis. The average DID patient is seen twice a week for a period of about 4 years before integration is achieved. Clinical experience seems to suggest that patients suffering from DID do not experience spontaneous remission of their illness if left untreated.


Depersonalization Disorder
Episodes of depersonalization are usually transient and thus remit without formal treatment. Recurrent or persistent depersonalization may require intervention. Treatment modalities include paradoxical intention, record keeping and positive reward, flooding, psychodynamic psychotherapy, psychoeducation, psychostimulants, antidepressants, antipsychotics, anticonvulsants, benzodiazepines, ECT, and hypnosis. In considering somatic treatments for depersonalization, it is important to determine whether the complaint represents the primary condition or whether it is secondary to another disorder. When an additional psychiatric diagnosis (e.g., anxiety or depression) is present and successfully treated, the symptoms of depersonalization usually improved or resolve. Thus, the most important aspect of the treatment of depersonalization disorder is careful assessment of possible psychiatric comorbidity and treatment of those conditions.
As a symptom, depersonalization responds to selfhypnosis training. Often, hypnotic induction will induce transient depersonalization symptoms in patients. This is a useful exercise because having a structure for inducing the symptoms provides patients with a context for understanding and controlling them. Individuals for whom this approach is effective can be taught to induce a pleasant sense of floating lightness or heaviness in place of the anxiety-related somatic detachment. Often, the use of an imaginary screen to picture problems in a way that detaches them from the typical somatic response is also helpful.


Hypnosis as a Treatment Tool in the
Psychotherapy of Dissociative Disorders
Traumatic memories may be elicited or spontaneously emerge during the course of psychotherapy without the utilization of any technique for memory enhancement. Nevertheless, there may be instances when the judicious use of hypnosis as adjuvant to psychotherapy is recommended. For instance, hypnosis may facilitate access to repressed memories that have not emerged using other methods. Clinical experience suggests that many trauma victims respond to the traumatic event by using dissociative-like defenses during or after the trauma. In cases of repeated trauma, some victims learn how to trigger these dissociative responses (self-hypnosis-like defenses) in order to avoid further suffering. The structured use of a therapeutic hypnotic induction may elicit dissociative phenomena, as seen during the administration of the hypnotic induction profile. If needed, hypnosis can be helpful in facilitating controlled access to dissociated personalities and can be used tosimply call up different identities or personality states as needed during the therapeutic process. More importantly, teaching patients to use self-hypnotic techniques to access alter states helps patients understand that they can have control over traumatic memories and experiences, leading to a way to control the episodes of spontaneous dissociation (e.g., flashbacks, personality states).
Studies show that patients suffering from dissociative disorders are highly hypnotizable. Thus, if hypnotic-like states are elicited during traumatic experiences and some patients unknowingly used them in order to dissociate from their surroundings, it makes sense that the very entry into this same state could lead to the retrieval of memories and effects associated with the original trauma, as would be predicted by the theory of state-dependent memory. Hypnosis then can be useful both as a diagnostic tool and as a powerful therapeutic technique. Properly done, hypnotic techniques can effectively facilitate symbolic restructuring of the traumatic experience. The condensed hypnotic approach using hypnosis as a facilitator has two major treatment goals: to make conscious previously repressed traumatic memories and to develop a sense of congruence between memories associated with the traumatic experience and patients' current realities and self-images. These goals can be achieved by the use of six consecutive and interdependent steps or stages. Each of themis designed to help patients work through previously repressed memories, while enhancing control over their dissociative mental processes. The six stages are confrontation, condensation, confession, consolation, concentration, and control.
During the first stage, confrontation of the trauma, patients come to terms with the factors and events associated to the trauma. The therapist's role at this time is that of a supportive, nonjudgmental listener, who avoids suggesting or implanting facts. During the second stage, hypnosis is used to facilitate a condensation of the traumatic memories. There is little need to force patients to recount all the details of every traumatic episode. Thus, therapists can use hypnosis to define segments or episodes that summarize the traumatic experience without allowing patients to compulsively relive the entire trauma. This is followed by the stage of confession of feelings and experiences that patients are profoundly ashamed of and may have never told anyone before. During this stage the therapist should convey a sense of being present for the patient, while remaining neutral.
The recovery and confession of traumatic memories is often accompanied by an immense sense of shame and sorrow. Thus, during the next stage, consolation, the therapist is more active and emotionally available to patients. It is appropriate to make empathic comments about the impact the experience must have had on them. Because of the frequent incidence of boundary violations during the episodes of abuse, therapists are warned to be extra careful regarding the ways in which care and empathy are expressed. Therapists are reminded of the possibility of the development of traumatic transference relationship at this point. That is, patients may interpret the therapist's interest in their past as a pretext for making them suffer again. Because of the mobilization of painful emotions, therapists are experiencing as hurting rather than helping them.
The intense concentration characteristic of hypnosis facilitates therapeutic work on selective traumatic memories. The structure of the hypnotic trance allows patients to turn on memories in the secure environment of the therapy session, while allowing them to shut them off once the intended work has been completed at the end of the session. Hypnosis also provides the flexibility to work on one aspect of the memory without requiring patients to recall the entire trauma. Therefore, the hypnotic process promotes concentration on the desired goal while helping patients remain in control. Using the structured experience of the therapeutic trance, patients learn how to think about the trauma in a constructive fashion.
Finally, patients should be helped to achieve an enhanced level of control, while restoring a sense of mastery and order in their lives. In order to achieve that goal, therapists guide the therapeutic interaction in such a way that patients' sense of control over their memories is enhanced. Patients are allowed to remember as much as can safely be remembered now, rather than pushed to remember the entire event at the therapist's will or in a compulsive fashion. The therapeutic use of self-hypnosis teaches patients that they are in charge of the experience, thus they can regain control of their memories. It allows patients to learn to trust their own feelings, perceptions, and judgments. An important aspect in enhancing patients' sense of mastery is for them to learn not only how to control memories and symptoms, but also, equally important, when to ask for help.


Legal Ramifications of Memory Work
Every treatment involving potential repressed memories or childhood abuse must be preceded by a thorough explanation of the therapeutic and legal ramifications and a complete informed consent. Because of these potential problems some courts have restricted the admissibility of the testimony of hypnotized witnesses. Patients need to be warned about the fallibility surrounding hypnotically (or indeed any, even nonhypnotically) recovered memories, including the possibilities of confabulation, concreting, and the difficulty of differentiating between fantasized or remembered memories. It is difficult to avoid potential contamination using any memory enhancement (e.g., imagery work, hypnosis, EMDR, and conventional psychotherapy); thus, the therapist must use a neutral tone throughout the entire treatment. If hypnosis is to be used, therapists may guide patients through the experience, but at all times must avoid using leading or suggestive questions. The goal is to avoid contamination by introducing or suggesting information during the course of treatment. Indeed, hypnosis and any other nonhypnotic method of memory enhancement, including police interrogation, can distort memory by any of three ways: confabulation (the creation of pseudomemories, which are then reported as real); concreting (an unwarranted increased sense of confidence with which hypnotized individuals report their memories, whether these are true or false), or as the result of an additional recall trial.
More recently, there has been concern about the creation of false memories. Nevertheless, we must remember that the mind is not an accurate tape recorder that registers every experience we have. Because of the way people register, encode, and recover filed memories, false memories are by no means rare. In fact, most people probably are in doubt about certain aspects of their past. At times it may be difficult to differentiate things that we have seen, said, or done from those we have dreamed or just imagined. It is very likely that the most frequent source of false memory is the accounts we give to others of our experiences. Usually, such accounts are almost always made both more simple and more interesting than the truth. In fact, memory can be understood as a capacity for the organization and reconstruction of past experiences and impressions in the service of present needs, fears, and interests. Thus, therapists must be aware that not every memory recovered with the use of hypnosis (or any other method of memory enhancement) is necessarily true. Hypnosis can facilitate improved recall of both true as well as confabulated material.
If memories of abuse are recovered, we do not encourage our patients to take legal action. There is no scientific evidence indicating that confrontation with alleged perpetrators of childhood abuse provides any therapeutic benefit to patients. The same is true for the pursuit of legal action or retribution toward perpetrators. It is impossible for therapists or the courts to be certain of the veracity of the memories recovered by either conventional therapy or hypnosis. Without objective external confirmation, therapists cannot distinguish among memories that are real, those that are the result of confabulation, and those that result from a combination of both. Furthermore, clinical experience in abuse cases suggests that not only would it be difficult to substantiate many of the allegations, but also little can be done in order to protect patients from the embarrassment, humiliation, and further trauma that would be imposed on them by virtue of the legal proceedings.
Several professional organizations have established clear guidelines regarding the use of hypnosis in instances where hypnosis is used as a method of memory enhancement. The guidelines suggest that when hypnosis or any other memory enhancement method is being used for forensic purposes or in the context of working out traumatic memories, especially those related to childhood physical and/or sexual abuse, multiple steps should be applied to minimize the possibility of memory contamination and maximizing the integrity of original memory.


See Also the Following Entrys
Hypnosis; Memory Impairment; Posttraumatic Stress Disorder: Clinical Posttraumatic Stress Disorder; Delayed Posttraumatic Stress Disorder; Neurobiology of Posttraumatic Stress Disorder; Posttraumatic Therapy; Trauma and Memory.


Further Reading
Anderson, G., Yasenik, L. and Ross, C. A. (1993). Dissociative experiences and disorders among women who identify themselves as sexual abuse survivors. Child Abuse and Neglect 17, 677–686.
Brenner, I. (1999). Deconstructing DID. American Journal of Psychotherapy 53, 344–360.
Brown, G. R. and Anderson, B. (1991). Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse. American Journal of Psychiatry 148, 55–61.
Cattell, J. P. and Cattell, J. S. (1974). Depersonalization: psychological and social perspectives. In: Arieti, S. (ed.) American Handbook of Psychiatry, pp. 767–799. New York: Basic Books.
Chu, J. A., Frey, L. M., Ganzel, B. L., et al. (1999). Memories of childhood abuse: dissociation, amnesia, and corroboration. American Journal of Psychiatry 156, 749–755.
Foote, B., Smolin, Y., Kaplan, M., Legatt, M. E. and Lipschitz, D. (2006). Prevalence of dissociative disorders in psychiatric outpatients. American Journal of Psychiatry 163, 623–629.
Hammond, D. C., Garver, R. B., Mutter, C. B., et al. (1995). Clinical hypnosis and memory: Guidelines for clinicians and for forensic hypnosis. Bloomingdale, IL: American Society of Clinical Hypnosis Press.
Horevitz, R. P. and Braun, B. G. (1984). Are multiple personalities borderline? An analysis of 33 cases. Psychiatr Clin North Am 7, 69–87.
Kluft, R. P. (1991). Multiple personality disorder. In: Tasman, A. & Goldfinger, S. M. (eds.) American Psychiatric Press Review of Psychiatry (vol. 10), pp. 161–188. Washington, D.C.: American Psychiatric Press.
Li, D. and Spiegel, D. (1992). A neural network model of dissociative disorders. Psychiatr Ann 22, 144–147.
Maldonado, J. R. and Spiegel, D. (1998). Trauma, dissociation and hypnotizability. In: Marmar, C. R. & Bremmer, J. D. (eds.) Trauma, memory and dissociation, pp. 57–106. Washington, D.C.: American Psychiatric Press.
Maldonado, J. R., Butler, L. D. and Spiegel, D. (2000). Treatment of dissociative disorders. In: Nathan, P. & Gorman, J. M. (eds.) Treatments that work, pp. 463–493. New York: Oxford University Press.
Maldonado, J. R. and Spiegel, D. (2007). Dissociative disorders. In: Talbot, J. & Yudosky, S. (eds.) Textbook of Psychiatry (Fifth Edition). Washington, DC: American Psychiatric Press (in press; last edition, 4th info: pp. 709–742, published 2002).
Orne, M. T., Axelrad, A. D., Diamond, B. L., et al. (1985). Scientific status of refreshing recollection by the use of hypnosis. Journal of the American Medical Association 253, 1918–1923.
Spiegel, D. (1990). Hypnosis, dissociation and trauma: hidden and overt observers. In: Singer, J. L. (ed.) Repression and dissociation, pp. 121–142. Chicago, IL: University of Chicago.


Glossary
Absorption The process of absorbing or being absorbed; great interest; entire occupation of the mind.


Dissociation The act of dissociating or state of being dissociated; separation. In psychology, term used to describe the separation of whole segments of the personality (as in multiple personality) or of discrete mental processes (as in the schizophrenias) from the mainstream of consciousness or of behavior.


Hypnosis The state of being hypnotized; abnormal sleep. There is no formal definition in the dictionary for hypnotizability or hypnotic capacity. This could properly be defined as a subject's ability to use a natural state of mind known as hypnosis.


Suggestibility The ability to influence by suggestion.


Trauma Bodily injury caused by violence; emotional shock (psychic trauma) with a lasting effect; a disordered psychic or behavioral state resulting from mental or emotional stress or physical injury.