Hypnosis and Traumatic Dissociation: Therapeutic Opportunities

ABSTRACT

Hypnosis and the related phenomenon of dissociation have long been linked to trauma. Evidence is reviewed regarding the relationship between trauma and dissociation, the prevalence of these dissociative symptoms in the acute aftermath of trauma, and their salience in predicting the development of later PTSD symptoms. The evidence reviewed regarding the prevalence of dissociative and other symptoms in the immediate aftermath of trauma formed the basis for including Acute Stress Disorder (ASD) as a new diagnosis in the DSM-IV. Dissociative amnesia is described as the key commonality between formally induced hypnosis and dissociative symptomatology, and controversy regarding traumatic amnesia is discussed. Finally principles of psychotherapy involving hypnosis and related techniques for dissociative and other post-traumatic symptoms are reviewed.     

The Structure of Dissociative Fugue: A Case Report

ABSTRACT

Classically, when an episode of dissociative fugue resolves, there is enduring amnesia for the period of fugue, with normal pre- and post-fugue memory. The authors describe a case in which their treatment goal was to reverse the amnesia for the period of fugue. In the course of treatment, the authors learned that dissociative fugue has a complex internal structure, is often preceded by major depression, and can be difficult to differentiate from other dissociative disorders. There is often a history of childhood trauma. Rather than being a simple dissociative disorder, as the authors had believed, fugue is complex, structured, and often accompanied by depression.     

Dissociation and Compulsive Eating

ABSTRACT

Numerous investigators have noted a correlation between compulsive eating patterns and dissociative symptoms, but there is no systematic explanation for how these two phenomena interact. It is not uncommon for patients with compulsive eating patterns to experience previously dissociated memories of abuse and trauma, but there are no generally accepted interventions that address both the eating disorder and the traumatic experience. Furthermore, there are no commonly accepted guidelines for assessing trauma and dissociative symptoms in the many patients with intractable compulsive eating symptoms who may initially present with no traumatic history. This article presents theoretical formulations, a review of relevant research, and a model that suggests a causal relationship between dissociation and compulsive eating. Guidelines for assessment and intervention are proposed. The theoretical constructs in this paper are based on hunger-based symptom assessment and a feminist interpretation of object relations theory as it applies to compulsive eating and body shame.     

Memory Fragmentation in Dissociative Identity Disorder

ABSTRACT

This study examined the quality of self-reported memories of traumatic experiences in participants with dissociative identity disorder (DID) and compared them with their memories of non-traumatic, but emotionally significant life experiences. Systematic interview data were gathered from 30 DID patients in The Netherlands. All participants reported a history of severe childhood abuse; 93.3% reported some period of amnesia for the index traumatic event, and 33.3% reported periods of amnesia for significant non-traumatic childhood experiences. All participants who had been amnestic for their trauma reported that their memories were initially retrieved in the form of somatosensory flashbacks. This suggests that, like PTSD patients, DID patients at least initially recall their trauma not as a narrative, but as somatosensory re-experiencing. Surprisingly, however, DID participants also recalled emotionally charged non-traumatic life events with significant somatosensory components, a phenomenon that has not been previously reported. This finding raises important issues regarding basic memory processing abnormalities in DID patients.     

The Language of Dissociation

ABSTRACT

Three case studies of inner-city elementary school children illustrate the connection between speech-language disorders and dissociative disorders in children who have known or suspected trauma histories. The role of speech language pathologists in identifying and responding to dissociative symptoms in children is explored. Lack of adequate training concerning the impact of trauma and scarce literature on the communication profiles of dissociative children contributes and greatly impacts the diagnosis, referral, and treatment of these children. The case studies demonstrate how unusual speech and language symptoms and awareness of dissociative features may aid in identifying trauma-related problems and instituting effective treatment. Grounding techniques and specific language interventions can assist children in acquiring the vocabulary needed for communicating both their daily experiences and traumatic histories. The nature of the relationship between dissociation and communication disorders is explored, and the importance of future research, interdisciplinary collaboration, and trauma training in the speech-language curriculum is emphasized.     

Somatoform Dissociation

Abstract

In most of the recent scientific and clinical literature, dissociation has been equated with dissociative amnesia, depersonalization, derealization, and fragmentation of identity. However, according to Pierre Janet and several World War I psychiatrists, dissociation also pertains to a lack of integration of somatoform components of experience, reactions, and functions. Some clinical observations and contemporary studies have supported this view. Somatoform dissociation, which can be measured with the Somatoform Dissociation Questionnaire (SDQ-20), is highly characteristic of dissociative disorder patients, and a core feature in many patients with somatoform disorders and in a subgroup of patients with eating disorders. It is strongly associated with reported trauma among psychiatric patients and patients with chronic pelvic pain presenting in medical healthcare settings. Motor inhibitions and anesthesia/analgesia are somatoform dissociative symptoms that are similar to animal defensive reactions to major threat and injury. Among a wider range of somatoform dissociative symptoms, these particular symptoms are highly characteristic of patients with dissociative disorders. The empirical findings reviewed in this article should have implications for the contemporary conceptualization and definition of dissociation, as well as the categorization of somatoform disorders in a future version of the DSM.     

Somatoform Dissociation in Traumatized World War I Combat Soldiers

Abstract

The massive traumatization of World War I combat soldiers led to an unprecedented incidence of somatoform dissociative disorders and symptoms, usually diagnosed as hysterical disorders during the war years. Following a brief overview of the scope of the suffering during this Great War, attention is given to British army psychiatrist Charles S. Myers' (1940) observations of the alternation between a so-called “emotional” personality and an “apparently normal” personality in traumatized combat soldiers. Somatoform dissociation, further categorized into positive and negative symptoms, is related to this structural dissociation, and to fixation in the trauma and avoidance of the trauma, and may be part of a more encompassing symptomatology. Next, a short overview of diagnostic issues is given. We argue that the DSM-IV category of “conversion disorder” is incorrect. Rather, the findings revealed here support Janet's classic and Nijenhuis' more recent views on somatoform dissociation. Finally, treatment issues are briefly presented.     

The Science and Folklore of Traumatic Amnesia

Some clinical theorists believe that certain experiences are so overwhelmingly traumatic that many victims dissociate their memory for the experience (Cleaves, Smith, Butler, & Spiegel, this issue). Unfortunately, clinicians who endorse this hypothesis often exhibit confusion about the very studies they cite in support of it. For example, they often misinterpret everyday forget-fulness that develops after a trauma with an inability to remember the trauma itself; they confuse organic amnesia with traumatic amnesia; they confuse psychogenic amnesia (massive non-organic retrograde amnesia coupled with loss of personal identity) with (alleged) inability to remember a traumatic event; and they confuse not thinking about something (e.g., sexual abuse) for a long period of time with an inability to remember it (i.e., amnesia). The purpose of this commentary is to dispel some of this confusion.     

Comment on “Dissociation and Schizophrenia”

ABSTRCT

This paper suggests a tentative hypothesis to explain the apparent paucity of dissociative disorder patients between the 1920s and the 1970s: that the trance phenomenon that is now so characteristic in patients who struggle with childhood trauma may be a manner of handling emotional distress specific to certain periods in American history. The paper argues that trance is learnable; that there are specific periods in American history in which trance is encouraged in religious experience and that we are now in one such period; that in such periods, trance becomes incorporated into a complex behavioral practice in religious settings in which the boundary between the perceptually real and unreal may be blurred; and that the prevalence of this practice in religious settings may influence the symptom expression of those who struggle with the aftermath of trauma.     

Dissociative Amnesia in Dissociative Disorders and Borderline Personality Disorder: Self-Rating Assessment in a College Population

Dissociative amnesia (DA) among subjects with a dissociative disorder and/or borderline personality disorder (BPD) recruited from a nonclinical population was examined. The Steinberg Dissociative Amnesia Questionnaire (SDAQ), the Childhood Trauma Questionnaire, and the self-report screening tool of the BPD section of the Structured Clinical Interview for DSM–IV(SCID-BPD) were administered to 1,301 college students. A total of 80 participants who were diagnosed with BPD according to the clinician-administered SCID-BPD and 111 nonborderline controls were evaluated using the Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D) by a psychiatrist blind to diagnosis and scale scores. Internal consistency analyses and test–retest evaluations suggested that the SDAQ is a reliable instrument for the population studied. Of the participants, 20.6% reported an SDAQ score of 20 or above and impairment by DA. Those who had both dissociative disorder and BPD (n = 78) had the highest SDAQ scores. Both disorders had significant effects on the SCID-D total and amnesia scores in the variance analysis. On SDAQ scores, however, only BPD had this effect. There was a significant interaction between the 2 disorders for the SCID-D total but not for the SDAQ or SCID-D amnesia scores. BPD represented the severity of dissociation and childhood trauma in this study group. However, in contrast to the dissociative disorders, BPD was characterized by better awareness of DA in self-report. The discrepancies between self-report and clinical interview associated with BPD and dissociative disorders are discussed in the context of betrayal theory (J. J. Freyd, 1994) of BPD and perceptual theory (D. B. Beere, 2009) of dissociative disorders.     

The transgenerational transmission of holocaust trauma

Abstract

This paper outlines an attachment-theory based model of transgenerational trauma inspired by the successful psychoanalytic treatment of a severely disturbed adolescent with obsessive-compulsive disorder who was the first child of the first daughter of a holocaust survivor. It is proposed that the transmission of specific traumatic ideas across generations may be mediated by a vulnerability to dissociative states established in the infant by frightened or frightening caregiving, which, in its turn, is trauma-related. Disorganized attachment behaviour in infancy may indicate an absence of self-organization, or a dissociative core self. This leaves the child susceptible to the internalization of sets of trauma-related ideation from the attachment figure, which remain unintegrated in the self-structure and cannot be reflected on or thought about. The disturbing effect of these ideas may be relatively easily addressed by a psychotherapeutic treatment approach that emphasizes the importance of mentalization and the role of playful engagement with feelings and beliefs rather than a classical insight-oriented, interpretive approach.     

Trauma‐related dissociation: Psychological features and psychophysiological responses to script‐driven imagery in borderline personality disorder

Defense reactions to threatening situations are vital adaptations to stress that protect organisms from injury and ensure survival. We retrospectively investigated the role of peritraumatic dissociation (PD) in the occurrence of severe psychopathology and dissociative patterns of reactions in borderline personality disorder (BPD). We recruited 28 patients with a clinical diagnosis of BPD and 15 healthy controls. The BPD group was divided according to the level of PD (low vs. high): BPD and PD (n = 15) and BPD only (n = 13). We conducted an extensive investigation of history of trauma, clinical status, and measurements of emotional and physiologic responses to recall of personalized aversive experiences. Participants with BPD and high PD displayed highest degrees of trauma exposure and clinical symptoms. Their significant heart rate decline during the imagery of personal traumatic events was opposed to the heart rate increases exhibited by the other two groups and may indicate a dissociative reaction pattern. Skin conductance responses did not differentiate between groups. Several emotional responses to imagery also reinforced the idea that PD may play a role in memory processing of traumatic events and thus in the aggravation and maintenance of symptoms in particularly severe forms of BPD. Within a stepwise linear regression analysis, the best model for trauma‐evoked heart rate responses included PD and borderline symptoms, but no measures of state or trait dissociation. Our findings may provide initial evidence of an evolutionary model of peritraumatic reaction stages evolving from arousal to dissociation.     

Case report: Improvement in dissociative symptoms with mixed amphetamine salts

Symptoms of dissociation, including dissociative amnesia, depersonalization, and derealization, commonly develop in individuals subject to chronic and repeated trauma during development. This includes the trauma of environmental inability to facilitate development of adequate cognitive strategies for coping with strong negative emotions. Dissociation likely involves dysregulated balance of prefrontal inhibition of limbic structures and inadequate regulation of attentional bias by both prefrontal and limbic systems. There is currently no established psychopharmacologic treatment for dissociative symptoms. Here the case of a woman with severe dissociative symptoms that were markedly improved with the administration of mixed amphetamine salts is discussed. Potential neurobiologic mechanisms for dissociative symptom improvement with psychostimulants are discussed.     

The Detection of Dissociative Identity Disorder by Northern Irish Clinical Psychologists and Psychiatrists: A Clinical Vignettes Study

ABSTRACT

A sample of Northern Irish clinical psychologists (N = 27) and psychiatrists (N = 29) completed three clinical vignettes designed to assess the detection of dissociative identity disorder. Data suggested that psychiatrists and clinical psychologists were better able to detect dissociative identity disorder when discriminating and characteristic symptoms were present. However, the majority of clinicians still failed to diagnose dissociative identity disorder as the most likely condition in a clear-cut case.     

Participation in War-Zone Atrocities and Trait Dissociation Among Vietnam Veterans with Combat-Related Posttraumatic Stress Disorder

Abstract

Objective: This study tested the hypothesis that participation in war-zone atrocities would be significantly related to long-standing dissociative symptomatology among Vietnam veterans with combat-related PTSD.

Method: Self-report data concerning childhood sexual/physical abuse, combat exposure, participation in war-zone atrocities, and trait dissociation were examined.

Conclusion: Vietnam veterans who participated in war-zone atrocities are more likely to report long-standing dissociative symptoms.

Results: Exposure to childhood abuse, as well as exposure to general combat events, was not correlated with trait dissociation. However, participation in war-zone atrocities was correlated with trait dissociation.     

Three controversies about dissociative identity disorder

Three controversies about Dissociative Identity Disorder are discussed. First, is DID an artefact due to iatrogenic influences? The empirical evidence does not support such a conclusion, although iatrogenic influences may play a considerable part in the presentation of this disorder. Second, how adequate are the present diagnostic criteria? It is argued that the DSM-IV may elicit overdiagnosis and that the use of structured clinical interviews is mandatory. The third controversy concerns memory processes of DID patients. Does psychogenic amnesia for sexual abuse exist, or are the so-called repressed memories of sexual abuse false memories (unintentionally) induced by overzealous therapists? Clinical data and experimental laboratory findings do not converge in this. The massive amnesia for traumatic events that is clinically reported in dissociative disorders, has not been replicated in laboratory studies, whereas memory research has shown that some false memories can be created in the laboratory. © 1998 John Wiley & Sons, Ltd.     

Drug-Induced Dissociative States of a Sleep Terror Patient

ABSTRACT

Frightening negative hallucinations as a side effect of fencamfamine (a central nervous system stimulant), aggressive behavior and amnesia due to interactions between metoprolol (a beta adrenergic blocking agent) and alcohol, chronic and severe sleep terrors and conversion disorder are described in a middle-aged man with high social status and no personality disorder. Rare mental side effects should draw attention to the possibility of a latent dissociative disorder. The relationship between beta-blocker induced disturbing dreams, dissociative disorders and sleep terrors is discussed.     

Evaluation of the Swedish Version of Dissociation Questionnaire (DIS-Q), Dis-Q-Sweden,Among Adolescents

ABSTRACT

The aim of this study was to investigate the psychometric properties of the Swedish version of the Dissociation Questionnaire in a normative adolescent population and also to investigate dissociative symptoms associated with trauma including sexual and physical abuse. A normative sample of 449 adolescents between the ages of 12 and 19 and a clinical group of 74 adolescents with known experiences of trauma, sexual and/or physical abuse was given Dis-Q-Sweden. A mixed group of 22 abused and non-abused adolescents who answered Dis-Q-Sweden was also interviewed by using the Structural Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). A test-retest procedure was conducted with 90 subjects from the normative group. The results showed good reliability concerning both internal consistency and test-retest stability. Validity was tested in several ways (criterion, predictive, construct and concurrent) and found to be satisfactory. Significant differences for the total sum scores of Dis-Q-Sweden were found between the normative group and the clinical group with known sexual abuse (p < 0.001). The prevalence of dissociative symptoms (cut-off score > 2.5) was 2.3% in the normative group and 50% in the clinical group. Dis-Q-Sweden has proven to be a screening instrument with good psychometric properties and has proven to be able to capture dissociative symptoms in adolescents with self-reported trauma and known trauma (sexual abuse).     

Pathological Dissociative Taxon Membership,Absorption, and Reported Childhood Trauma in Women with Trauma-Related Disorders

Abstract

Employing a community sample, Irwin (1999) used the Childhood Trauma Questionnaire (CTQ; Bernstein et al, 1994) and Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986) to show that trauma predicts pathological dissociation as measured by Waller, Putnam, and Carlson's (1996) DES-T (dissociative “taxon”) scale but does not predict ostensibly non-pathological DES absorption. Yet Irwin merely studied DES-T scores as a continuous variable rather than classifying participants with respect to taxon membership, as the DES-T items were designed to do. The present study hypothesized that, in a traumatized clinical sample, trauma would be associated both with dissociative taxon membership and with absorption. An inpatient sample of 235 women were administered the CTQ and DES. Even in this relatively homogeneous trauma sample, taxon membership showed good discriminant validity with respect to clinical diagnosis and reported childhood abuse. Furthermore, whereas the effect of reported childhood sexual abuse on absorption was accounted for by taxon membership, reported childhood emotional abuse related to absorption independent of taxon membership. The authors discuss the diagnostic utility of computing taxon membership as well as the clinical significance of highly elevated absorption scores in a trauma population.