Also published as Spiegel D: (ed): Dissociative Disorders: A Clinical Review. The Sidran Press: Lutherville, MD, 1993.

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FOREWORD

Unity of consciousness is an achievement, not a given. From this point of view, dissociative phenomena are not an oddity but rather a central problem in the study of psychopathology. The issue is no longer why dissociative symptoms occur; it becomes rather why they do not occur more often. The continuity of experience, memory, and identity is an accomplishment. The complexity of mental processing requires that most of it occur out of consciousness, making it possible if not probable that certain perceptions and memories may seem dis-integrated.

The phenomena of dissociation have themselves been dissociated from the mainstream of psychiatry and psychiatric theory despite origins at the heart of early psychiatric and psychological thought. William James, Boris Sidis, Morton Prince, Joseph Breuer, Sigmund Freud, and Pierre Janet based their diverse but influential theories of psychological functioning in large measure on their observations of dissociation and its effects. Despite this history, the phenomenon has been viewed as something of an oddity in psychiatry, causing many to doubt the validity of the disorders.

Dissociation is here to stay. The chapters that follow indicate that there is a growing body of clinical observation and research documenting the prevalence, phenomenology, psychophysiology, and treatment of dissociation. Dr. Putnam reviews the phenomenology of dissociation, underscoring the fact that dissociation is a normal as well as a pathological phenomenon. Dr. Kluft skillfully reviews the rapidly growing literature on multiple personality disorder, distilling what is known about the etiology of this rare and intriguing disorder in summarizing the principles of treatment, with emphasis on using various techniques to access and integrate these dissociated mental states in the context of working through traumatic memories. Dr. Lowenstein systematically reviews the literature on psychogenic fugue and amnesia, examining the combination of memory loss for specific episodes with evidence of availability of such memories that is at the heart of the dissociative process. a dissociated memory is not simply forgotten or unavailable; it is not available to consciousness and yet makes itself manifest. Dr. Steinberg provides a review of new work in the systematic assessment of depersonalization. This disorder is somewhat atypical for the dissociative disorders in that it can occur in a large variety of settings and has comorbidity with most other major psychiatric disorders, such as anxiety and depression. Dr. Nemiah demonstrates the important role of dissociation in conversion symptoms. Patients with dissociative symptoms have unusual abilities to alter somatic process to reflect psychological state, a theme illustrated by Dr. Putnam and Dr. Kluft as well. Dr. Nemiah argues that the dichotomy in the recent nosology between the dissociative symptoms on the one hand and somatoform symptoms do not do justice to the fundamental dissociative nature underlying many conversion symptoms. Finally, I review the literature suggesting that most dissociative disorders are in fact posttraumatic stress disorders. Trauma seems to be a common thread in the etiology of most of the dissociative disorders. Indeed, what is new in the field in the last decade is the recognition that dissociation is a response to trauma, both as it is occurring and then in the subsequent posttraumatic symptomatology. Many of the symptoms of posttraumatic stress disorder, the sudden reliving of trauma as though it were recurring, the reminiscent of dissociative reliving of traumatic experiences and the related phenomenon of hypnotic age regression. All of the chapters in this section make heavy reference to the high prevalence of traumatic experience in the histories of patients with dissociative disorders, and to the importance of working through traumatic memories in treatment.

Work by these authors and others had led to recommendations for changes in the dissociative disorders section in DSM-IV. the following are the major proposed alterations.

Psychogenic amnesia can be diagnosed even in the absence of sudden onset, but its usual occurrence in the wake of trauma should be noted.

Psychogenic fugue may occur without the development of a new identity. the loss of usual identity should be the requirement, with the assumption of a new identity optional.

Multiple personality disorder can be diagnosed when more than one personality or personality state takes control of the person. the requirement for amnesia as part of the diagnosis should be reinstituted. It is often extremely helpful in making the diagnosis to obtain a history of "losing time" or being unaware of having done things others commented on. This would also tighten the diagnostic criteria for the disorder.

Brief reactive dissociative disorder is being proposed as a new diagnostic entity. It is an acute dissociative response occurring during or within one month of a traumatic episode. It may involve stupor, depersonalization, amnesia, derealization, or other disconnection from the trauma that leads to dysfunction, for example failure to obtain necessary medical or legal assistance. There is no place in the current psychiatric nosology to describe an extreme, acute reaction to physical trauma.

Dissociation is a fascinating phenomenon. It presents us with dramatic shifts in cognition and affect, unusual changes in the boundary between conscious and unconscious experience, and is an effective means of coping with extreme discontinuities in physical experience. This section will provide you with an opportunity to integrate dissociation with our understanding of the response to trauma, differential diagnosis, and the range of psychiatric treatments.

AFTERWORD

Recent research suggests that dissociation is more likely to happen during and in the aftermath of physical trauma. Depersonalization, derealization, and psychogenic amnesia are common symptoms during natural disasters, combat, and other forms of physical trauma. In turn, a history of trauma has been found to be an almost universal etiology of such extreme chronic dissociative disorders as multiple personality disorder. In these cases the failure of integration of memory and identity serves a defensive purpose -- against painful affect, recognition of physical helplessness, and physical pain. while such defenses can be quite adaptive, they carry with them a risk of failure to work through traumatic events, leading to chronic and severe posttraumatic dissociative symptoms in some instances.

In his review of dissociative phenomena, Dr. Putnam emphasized the continuity between normal and abnormal failures of integration and noted physiological differences reflecting the variety of dissociative states. Dr. Lowenstein provided a comprehensive review of psychogenic amnesia and fugue, noting the frequent association of these disorders with sudden trauma. Dr. Steinberg observed that depersonalization disorder is an unusual dissociative symptom in that it co-occurs with a wide variety of other disorders, including anxiety and somatoform disorders. Dr. Kluft provided a concise and clea4r overview of the diagnosis and treatment of multiple personality disorder, emphasizing the structure necessary for effective psychotherapy, including recognition of transference problems elicited by early life trauma and the use of hypnosis. Dr. Nemiah provided a cogent argument for a reconciliation between the estranged conversion and dissociative disorders. In my chapter I reviewed the evidence linking trauma and dissociation.

Dissociation is an intrinsically interesting phenomenon. It seems to occur during experiences of physical trauma and to persist afterward, allowing individuals to ward off memories of abuse or trauma and the associated painful affects, but at the price of a sense of fragmentation, an inability to integrate and control memories, and a sense of demoralization. It is a disorder in which the part becomes the whole. The extremity of self as viewed during trauma comes to seem to be the real truth about a person, making for sudden and dizzying shifts in self-appraisal and mood. There are a variety of techniques, ranging from hypnosis to other kinds of psychotherapy that are clearly effective in helping patients manage dissociative disorders. Indeed, this is one of the hopeful areas in the domain of psychotherapy. Specific treatments have been shown to be efficacious, often more so than biologic treatments, which are generally adjunctive at best. It is hoped that in the future we will learn more about specific and effective psychotherapeutic techniques, new approaches to younger patients with dissociative disorders, and the psychophysiology of dissociation. As such, dissociation presents an unusual opportunity for advances in psychiatric research and treatment.

© Copyright 1991 American Psychiatric Press, Inc. Reprinted with permission