Guest Editor / éditorialiste invité: Dr George A Fraser, MD, FRCPC, Head, Trauma Disorders Study Team, Royal Ottawa Hospital; Assistant Professor, University of Ottawa, Ottawa, Ontario.
Introduction: Unmasking the Psychological Effects of Trauma—A Challenge for the 21st Century
The area of psychological trauma and its effects on people is on the threshold of becoming one of the most exciting and rewarding areas in clinical and research psychiatry. It is relatively understudied and offers great opportunities to those who are ready to accept a new challenge. It is with great pleasure that I have agreed to coordinate a section on trauma for the Bulletin.
I was fortunate to have 3 very qualified psychiatrists agree to write about 3 topics that are quite important as we learn about the effects of psychogenic trauma. As our abilities to study the brain increase through such instruments as measurement of neurotransmitters and brain imaging, avenues have opened up that will allow us to study trauma effects in ways which would have been difficult even a decade ago.
The areas chosen for this section include posttraumatic stress disorder (PTSD), dissociative disorders, and the much neglected adjunctive therapeutic strategy that we know as hypnosis. The participating authors are Dr David Spiegel, Dr Richard Kluft, and Dr John Curtis.
Dr David Spiegel is Professor of Psychiatry and Behavioral Medicine at the Stanford University School of Medicine. He will address the issue of hypnosis in the management of trauma.
Dr Richard Kluft of Philadelphia has written about current issues in the area of dissociation. He is Clinical Professor of Psychiatry at the Temple University School of Medicine in Philadelphia, Pennsylvania.
Dr John Curtis of Halifax discusses the role of PTSD in trauma disorders. He is in private psychiatric practice in Bedford, Nova Scotia.
Each author has extensive clinical and teaching experience in the area he addresses. Each highlights current knowledge that I believe will act as a preview of the interesting findings and research possibilities which await those who are ready to embrace the study of this relatively new area of psychiatry, a field in which the majority of “pioneers” are actively advancing conceptual and therapeutic models.
Recently, researchers and young clinicians have not particularly been falling over each other to embrace this area of study because of its controversial issues, which are sometimes referred to in the media as “false memory syndrome” and “repressed memory therapy.” The root of these problems is based on some therapists’ lack of knowledge concerning thevicissitudes of memory and whether recollection in therapy arose through free association, flashbacks, dreams, or hypnosis. The problem escalated when patients began laying abuse charges in the courts based solely on uncorroborated recollections they had while in therapy. A common misperception held by the courts and some therapists that recovered memories were most likely factual led to unsubstantiated convictions of alleged abusers. Some convictions were wrongful. Yet even at that time, literature was available cautioning us that hypnotically refreshed memories could as likely be false as true (1). This literature was ignored or not known by some. Unfortunately, the interplay of these factors led to a low period in the history of psychiatry in the 20th century. Now that it is more widely understood that recovered “memories” do not guarantee truth, it is most unlikely that convictions based on uncorroborated recall will be a problem in the future.
With these distractions in the process of being resolved, the psychological effects of trauma can now become an exciting area to treat, teach, and research. One area yet to be resolved is how best to manage those patients with difficulties related to intrusive trauma-related recollections. Some would offer the opinion that any discussion in therapy would constitute malpractice. This may not be the appropriate answer for every case. I believe that our profession must study this question on a large scale and avoid making premature decisions without balanced discussions, studies, and researched conclusions.
One of the major problems in the clinical management of the adult sequelae of repetitive childhood trauma has been a unilinear “cause–effect” approach to therapy. Many of us were taught in medical school, for example, that one virus results in one clinical condition. With repetitive psychological trauma during the developmental years, however, a combination (or complex) of Axis I and Axis II disorders frequently results.
Unless a therapist conceptualizes such a potential multidisorder complex, it becomes all too easy to focus on only one disorder and ignore or forget to consider other equally debilitating disorders that may coexist (2). I have found this approach useful and have adapted the concept and represented it diagrammatically as a “Repetitive Psychological Trauma Model” (Figure 1). The 8 areas that frequently result from this type of trauma are depression, panic disorder, substance abuse, eating disorders, somatoform disorders, dissociative disorders, PTSD, and Axis II disorders (frequently, borderline personality disorder).
Figure 1
This list is not all-inclusive, nor is each category necessarily present in each case. Viewing this diagram with patients frequently helps them to understand better their symptom complex. It can also be used to remind therapists of the possible disorders that such traumatized patients may experience.
These possible disorders are arranged in a clockwise manner beginning with depression. This approxi- mates, in many cases, a treatment-priority hierarchy. For example, it would be inappropriate to focus on what may be the more dramatic features of a dissociative disorder while ignoring the more pressing issue of the presence of a major depression with suicidal ideation. Conversely, it would equally be an error to focus on a depression and totally ignore dissociative or PTSD management if such conditions coexist.
Finally, I never cease to be astonished to hear of colleagues who pronounce that it is impossible to have traumatic amnesia. This flies in the face of the history of amnesia in psychiatry as well as the listing of amnesia in the dissociation, acute stress, and PTSD categories of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). What seem to be misunderstood are the lessons learned through the study of hypnosis, which explain that while most persons indeed do not forget traumatic events, there is, nonetheless, a small percentage who have quite a significant trance capacity and can develop peritraumatic amnesia.
Hypnosis is an area that I believe should be taught in all psychiatric residency programs, whether or not the doctors choose to use it. There are 2 well-known professional journals devoted to hypnosis: The International Journal of Clinical and Experimental Hypnosis and The American Journal of Clinical Hypnosis. Each represents its own society, which sponsors teaching seminars and a major annual conference. Most Canadian provinces also have hypnosis societies.
I invite you now to enjoy the contributions of Dr Spiegel, Dr Kluft, and Dr Curtis.
—GA Fraser
References
1. American Medical Association Council on Scientific Affairs. Council report: scientific status of refreshing recollection by the use of hypnosis. JAMA 1985;253:1918–23.
2. Loewenstein RJ. An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatr Clin North Am 1991;14:567–604.
Introduction sur les effets des traumatismes psychologiques — Démasquer les effets psychologiques des traumatismes : un défi pour le 21e siècle
George A Fraser, MD, FRCPC
Les traumatismes psychologiques et leurs effets sur les personnes qui en sont victimes sont en voie de devenir l’un des domaines les plus intéressants et les plus enrichissants de la psychiatrie sur le plan clinique et sur celui de la recherche. C’est un domaine qui a été relativement peu étudié et qui offre d’excellentes occasions à ceux qui accepteront de relever ce nouveau défi. C’est donc avec un immense plaisir que j’ai accepté de rédiger cette section du Bulletin portant sur les traumatismes.
J’ai eu la chance de pouvoir compter sur 3 psychiatres très compétents qui ont accepté d’écrire sur 3 sujets qui se sont révélés de plus en plus importants à mesure que nous avons accumulé des connaissances sur les effets des traumatismes psychogènes. Plus nos capacités d’étudier le cerveau augmentent, grâce à des outils tels que la mesure des neurotransmetteurs et la scintigraphie cérébrale, plus de nouvelles avenues s’ouvrent qui nous permettent d’étudier les effets des traumatismes sous des angles que nous n’aurions pu envisager, même il y a 10 ans.
Dans cette section, nous aborderons l’état de stress posttraumatique, les troubles dissociatifs et l’hypnose, une stratégie thérapeutique d’appoint souvent oubliée. Mes collaborateurs sont les Drs David Spiegel, Richard Kluft et John Curtis.
Le Dr David Spiegel est professeur de psychiatrie et de médecine du comportement à la faculté de médecine de l’Université Stanford. Il traitera du rôle de l’hypnose dans la prise en charge du traumatisme.
Le Dr Richard Kluft, de Philadelphie, abordera les questions d’actualité concernant les troubles dissociatifs. Il est professeur clinique de psychiatrie à la faculté de médecine de l’Université Temple, Philadelphie, Pennsylvanie.
Le Dr John Curtis, de Halifax, parlera du rôle de l’état de stress post-traumatique. Il travaille en pratique privée, à Bedford, en Nouvelle-Écosse.
Chaque auteur possède une expérience clinique et pédagogique considérable dans le domaine. Ils mettront chacun en évidence les connaissances actuelles qui, selon moi, nous donneront un aperçu des résultats intéressants et des nombreuses occasions de recherche qui attendent ceux qui sont prêts à étudier ce domaine relativement nouveau de la psychiatrie, où la majorité des « pionniers » travaillent activement sur des modèles conceptuels et thérapeutiques.
Rares sont actuellement les chercheurs et les jeunes cliniciens qui étudient ce domaine en raison des controverses soulevées par les notions que les médias ont appellent parfois le « syndrome de la mémoire fictive » et le « traitement de la mémoire refoulée ». C’est un profond manque de connaissances de certains thérapeutes sur les vicissitudes de la mémoire, que les souvenirs évoqués pendant la thérapie aient émergé au moyen de la libre association, de flashbacks, de rêves ou d’hypnose, qui est à l’origine du problème. Ce problème s’est aggravé lorsque des patients ont commencé à intenter des procès, sur la seule foi de souvenirs ayant surgi pendant la thérapie, mais qui ne pouvaient s’appuyer sur aucune preuve concrète. À cause de certains juges et thérapeutes qui pensaient à tort que les souvenirs refaisant surface étaient vraisemblablement réels, on a condamné sans aucun fondement des présumés coupables, et certaines condamnations étaient injustifiées. Or, même à cette époque, il existait des preuves scientifiques qui mettaient les gens en garde sur le fait que les souvenirs qui remontaient pendant l’hypnose pouvaient être aussi vrais que faux (1). Certains ont ignoré que ces preuves scientifiques existaient ou ont préféré ne pas en tenir compte. Tous ces facteurs ont malheureusement assombri l’histoire de la psychiatrie du 20e siècle. Maintenant qu’il est généralement reconnu que les « souvenirs » recouvrés ne sont pas une preuve de vérité, il est peu probable que des sentences se fondant sur les seuls souvenirs qu’aucun fait réel ne confirme, soient encore prononcées.
Ces écueils étant sur le point de disparaître, l’effet psychologique d’un traumatisme peut maintenant devenir un domaine intéressant de traitement, d’enseignement et de recherche. Il reste à découvrir comment traiter le mieux possible les patients aux prises avec des troubles liés aux souvenirs importuns. Certains avanceront que toute discussion durant le traitement constituerait une négligence professionnelle, ce qui n’est pas toujours vrai. Je crois que notre profession doit étudier cette question sur une grande échelle et éviter de prendre des décisions prématurées sans les avoir, au préalable, pesées, étudiées et bien documentées.
L’un des principaux problèmes de la prise en charge clinique des séquelles, chez les adultes, de traumatismes répétés durant l’enfance a été l’approche thérapeutique non linéaire de « cause à effet ». Par exemple, on nous a souvent enseigné à la faculté de médecine qu’un seul virus entraîne une seule maladie. Cependant, dans le cas de traumatismes psychologiques répétés survenant durant les années de développement, il en résulte souvent non pas un seul trouble psychiatrique, mais une combinaison (ou complexe) de troubles des axes I et II.
À moins qu’un thérapeute conceptualise ce complexe possible de troubles multiples, il est beaucoup plus facile de se concentrer sur un seul trouble et d’ignorer, ou d’oublier d’envisager, d’autres troubles tout aussi invalidants qui peuvent coexister (2). J’ai trouvé cette approche utile et j’ai adapté un tel concept, que j’ai représenté sous forme de diagramme (figure 1) intitulé « Complexe des traumatismes répétés ». Ce type de traumatismes entraîne fréquemment 8 troubles, soit la dépression, le trouble panique, l’alcoolisme ou la toxicomanie, les troubles de l’alimentation, les troubles somatoformes, les troubles dissociatifs, l’état de stress posttraumatique (ESPT) et les troubles de l’axe II (souvent, de la personnalité limite).
Figure 1
Cette liste n’est pas du tout exhaustive et chaque catégorie n’est pas nécessairement présente dans chaque cas. L’examen du diagramme avec les patients les aide souvent à comprendre leur constellation de symptômes. Il peut également être utilisé pour rappeler aux thérapeutes les troubles possibles présents chez les patients ayant subi un traumatisme.
Ces troubles possibles sont présentés dans le sens des aiguilles d’une montre, en commençant par la dépression. Il s’agit, dans de nombreux cas, d’une hiérarchie des priorités thérapeutiques. Par exemple, il serait inapproprié de se concentrer sur les caractéristiques plus marquées d’un trouble dissociatif si l’on ignore le problème le plus presssant de la dépression majeure s’accompagnant d’idées suicidaires. À l’inverse, ce serait également une erreur de se concentrer sur la dépression et d’ignorer totalement le traitement du trouble dissociatif ou de l’ESPT, le cas échéant.
Enfin, je ne cesse de m’étonner quand j’entends des confrères affirmer qu’il est impossible de souffrir d’amnésie posttraumatique. Cela contredit l’histoire de l’amnésie en psychiatrie ainsi que les catégories des troubles dissociatifs, du stress aigu et de l’état de stress posttraumatique du DSM-IV. On semble avoir mal compris les leçons tirées de l’étude de l’hypnose, qui expliquent que, même si la plupart des gens n‘oublient pas les événements traumatiques, un certain pourcentage de la population a une capacité de transe assez marquée et peut souffrir d’amnésie péritraumatique.
À mon avis, l’hypnose est un sujet qui devrait être enseigné dans le cadre de tous les programmes de résidence en psychiatrie, que les médecins choisissent de l’utiliser ou non. Il existe deux revues professionnelles bien connues se consacrant à l’hypnose : The International Journal of Clinical and Experimental Hypnosis et l’American Journal of Clinical Hypnosis. Chacune représente sa propre association qui commandite des séminaires d’enseignement et une conférence annuelle importante. La plupart des provinces canadiennes ont également des associations d’hypnose.
Je vous invite maintenant à lire les propos des Drs Spiegel, Kluft et Curtis.
– GA Fraser
Références
1. American Medical Association Council on Scientific Affairs. Council report: scientific status of refreshing recollection by the use of hypnosis. JAMA 1985;253:1918–23.
2. Loewenstein RJ. An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatr Clin North Am 1991;14:567–604.
Hypnosis in the Management of Trauma
David Spiegel, MD, Department of Psychiatry and Behavioural Sciences, Stanford University School of Medicine, Stanford, California.
There has been far too much heat and not enough light in recent discussions of hypnosis, trauma, dissociation, and memory. This does a disservice to our profession and our patients. Despite extreme claims by recovered memory proponents on one side and so-called “false memory syndrome” proponents on the other, there are some well-established clinical facts that we should be able to agree upon:
1. Dissociation of memory, identity, and consciousness has occurred across cultures for millennia and long before psychiatry existed as a discipline.
2. Memories for traumatic events can be forgotten and later recovered. Such memories are no more or less inherently reliable than any other memories.
3. No memory, however elicited, can be determined to be true or false without external corroborating evidence. There are no rules about veracity that apply to all cases. As with any clinical problem in medicine, the individual facts of each case must be examined to determine the accuracy and salience to treatment of traumatic memories.
4. All memories are subject to suggestive influence, but studies of such influences indicate that only a minority of subjects alter their reports in response to suggestion, and alterations are more likely to occur when the suggestion is in the same direction as the actual experience.
5. If in some instances it is possible to falsely suggest that a traumatic event did occur when it did not, logically, it must be possible to falsely suggest that a traumatic event did not occur when it did. If there is a “false memory syndrome,” then dissociative amnesia is part of it.
6. Techniques such as hypnosis alter confidence more than the content of memories.
7. The dangers of hypnosis as a therapeutic tool have been exaggerated. Partly because of decades of careful research on the phenomenon, we better understand the risks and benefits of hypnosis.
8. Hypnosis can facilitate the treatment of posttraumatic stress disorder (PTSD) and dissociative disorders.
Dissociation and Trauma
One of the important developments in the modern understanding of PTSD and dissociative disorders is the establishment of a clearer link between trauma and dissociation (1). The role of traumatic stress in eliciting dissociative symptoms has been observed as far back as Janet (2) and Freud (3). There is a growing literature suggesting a connection between a history of physical and sexual abuse in childhood or traumatic stress and the development of dissociative symptoms (4–8). Dissociative symptoms are more prevalent in patients with Axis II disorders such as borderline personality disorder when there has been a history of childhood abuse (9,10). Research on survivors of life-threatening events indicates that more than one-half have experienced feelings of unreality, automatic movements, lack of emotion, depersonalization, and a sense of detachment (11–14). Numbing, loss of interest, and an inability to feel deeply about anything were observed in one-third of the survivors of the Hyatt Regency skywalk collapse (15) and in a similar proportion of survivors of a North Sea oil rig disaster (16). One-quarter of a sample of normal students reported marked depersonalization during and immediately after the Loma Prieta earthquake (17). While these dissociative responses to traumatic stressors have been conceptualized as adaptive defences to overwhelming situations, the thrust of the recent literature indicates that the presence of dissociative symptoms within 10 days to 2 weeks after trauma is a strong predictor of the development of later PTSD (18–21). For example, victims of the Oakland and Berkeley firestorm who reported significant dissociative symptoms were more likely to have significant PTSD symptoms 7 months later (18). Similarly, 2 studies of Vietnam veterans have found that peritraumatic dissociation was a strong predictor of later PTSD symptomatology (22,20). Thus physical trauma seems to elicit dissociation, perhaps in individuals who are prone to the use of this defence, either by virtue of previous traumatic experience or a constitutional tendency to dissociate.
Dissociative Symptomatology
Dissociative disorders involve a failure of the customary integration of identity, memory, or consciousness (23). Since dissociation is 1 of the 3 main components of hypnosis, it makes sense that hypnosis might be useful in identifying and controlling dissociative symptoms. Dissociation of identity (dissociative identity disorder), memory (dissociative amnesia and fugue), or consciousness (depersonalization disorder, dissociative trance disorder) results in an array of symptoms that affect intrapsychic and interpersonal functioning. Loss of access of parts of experience to consciousness can intensify many preexisting problems. Indeed, there is evidence from experimental studies with hypnosis that lack of awareness of an instructed increase in arousal intensifies the physiological consequences of it (24). Hypnosis can be helpful in clarifying the diagnosis as well as in facilitating psychotherapy (25,26). For example, the induction of hypnosis may elicit dissociative phenomena. Patients with pseudoseizures or dissociative identity disorder may spontaneously produce the conversion symptom or switch identities during or after a hypnotic induction. This may come from state-dependent associations between the dissociative symptom and the hypnotic state (27). While this is often viewed as a worrisome side effect of hypnotic techniques, it actually provides an opportunity to explain to the patient the nature of the symptoms, and it also provides a means of accessing and controlling them.
Any clinical interview or psychotherapy involves eliciting memories that emerge with varying degrees of accuracy. Concerns about the veraciousness of memory are appropriate but cannot stop us from asking patients questions about the past.
Since the memory loss in dissociative disorders is often complex and chronic, its retrieval is likewise a more extended and integral part of the psychotherapeutic process (28). The therapy is designed to counter the fragmentation characteristic of the disorder, which often involves amnesia. It is now clear that a substantial minority of abuse victims cannot recall episodes of documented trauma (29,30). Conceptualizing dissociative identity disorder, for example a chronic posttraumatic stress disorder, provides a rationale for using hypnosis to gain access to memories in addition to controlling the dissociation. Controlled access to memories facilitates psychotherapy. It is appropriate to remind patients that retrieval with the help of hypnosis provides no guarantee of accuracy. This can only come with external corroboration.
Once recollections of earlier traumatic experience have been brought into consciousness, it is crucial to help the patient work through the painful affect, inappropriate self blame, and other reactions to these memories. Doing this work does not necessarily imply that the memories are completely accurate. Patients with dissociative disorders may be helped with a psychotherapeutic approach that facilitates conscious integration of dissociated memories and motivations for behaviour previously experienced as automatic and unwilled (31).
Outcome
While there are no controlled trials of the efficacy of hypnosis in treating dissociative disorders, the clinical literature indicates that it is a useful tool (25,32–34). A recent survey of 305 clinicians indicated that individual psychotherapy facilitated by hypnosis on a twice-weekly basis was the primary treatment modality for patients with dissociative identity disorder, while treatment with anxiolytics and antidepressants was a secondary adjunctive tool (35). There are numerous clinical reports of the effectiveness of hypnosis as an adjunct to treatment of PTSD (2,34,36–38). One controlled study of 112 subjects with PTSD demonstrated that psychotherapy with hypnosis was superior to a control condition, that it was equivalent to both psychodynamic therapy and systematic desensitization, and that it was especially effective in reducing intrusion symptoms (39).
Conclusion
While there is reason to be concerned about the suggestibility that accompanies hypnotic techniques, hypnotic-like phenomena occur spontaneously among individuals with dissociative disorders. They are better controlled by identifying, accessing, and teaching patients how to manage dissociative states. Hypnotic influences on memory involve confidence more than accuracy. Despite concern that hypnosis inevitably contaminates memory, the research literature on hypnosis and memory indicates that hypnosis affects belief more than content (4,5,40–42). Any memory retrieval technique that increases the production of memories may affect the willingness of a subject to report a thought as a memory (43). Thus the mere act of trying harder to remember something about an event can always convert thoughts, fantasies, or leading questions into memories (30,44). Any special effects of hypnosis may be more feared because they have been more thoroughly studied (personal communication). Despite these concerns, the use of hypnosis is salient, safe, and useful in the treatment of dissociative and posttraumatic syndromes.
References
1. Spiegel D, Cardeña E. Disintegrated experience: the dissociative disorders revisited. J Abnorm Psychol 1991;100:366–78.
2. van der Hart O, Brown P, Turco RN. Hypnotherapy for traumatic grief: janetian and modern approaches integrated. Am J Clin Hypn 1990;32:263–71.
3. Breuer J, Freud S. Studies in hysteria. In: Strachey J, editor. The standard edition of the complete psychological works of Sigmund Freud. Volume 2. London: Hogarth Press; 1893–95 (reprinted 1995).
4. Butler L, Spiegel D. Trauma and memory. In: Dickstein L, Riba M, Oldham J, editors. Review of psychiatry. Volume 16. American Psychiatric Press Review of Psychiatry. Washington (DC): American Psychiatric Press; 1997.
5. Butler LD, Duran REF, Jasiukaitis P, Koopman C, Spiegel D. Hypnotizability and traumatic experience: a diathesis-stress model of dissociative symptomatology. Am J Psychiatry 1996;153:41–63.
6. Spiegel D. Multiple personality as a post-traumatic stress disorder. Psychiatr Clin North Am 1984;7:101–10.
7. Kluft RP. Dissociation as a response to extreme trauma. In: Kluft RP, editor. Childhood antecedents of multiple personality. Washington (DC): American Psychiatric Press; 1985.
8. Coons PM, Milstein V. Psychosexual disturbances in multiple personality: part I. Characteristics, etiology, and treatment. J Clin Psychiatry 1986;47:106–10.
9. Chu JA, Dill DL. Dissociative symptoms in relation to childhood physical and sexual abuse [see comments]. Am J Psychiatry 1990;147:887–92.
10. Herman JL, Perry JC, van der Kolk BA. Childhood trauma in borderline personality disorder [see comments]. Am J Psychiatry 1989;146:490–5.
11. Noyes Jr R, Kletti R. Depersonalization in response to life-threatening danger. Compr Psychiatry 1977;18:375–84.
12. Madakasira S, O’Brien KF. Acute posttraumatic stress disorder in victims of a natural disaster. J Nerv Ment Dis 1987;175:286–90.
13. Sloan P. Post-traumatic stress in survivors of an airplane crash-landing: a clinical and exploratory research intervention. J Trauma Stress 1988;1:211–29.
14. Noyes Jr R, Hoenk PR, Kuperman S, Slymen DJ. Depersonalization in accident victims and psychiatric patients. J Nerv Ment Dis 1977;164:401–7.
15. Wilkinson CB. Aftermath of a disaster: the collapse of the Hyatt Regency Hotel skywalks. Am J Psychiatry 1983;140:1134–9.
16. Holen A. The North Sea oil rig disaster. New York: Plenum; 1993.
17. Cardeña E, Spiegel D. Dissociative reactions to the San Francisco Bay area earthquake of 1989. Am J Psychiatry 1993;150:474–8.
18. Koopman C, Classen C, Spiegel D. Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley, California, firestorm. Am J Psychiatry 1994;151:888–94.
19. Koopman C, Classen C, Spiegel D. Dissociative responses in the immediate aftermath of the Oakland/Berkeley Firestorm. J Trauma Stress 1996;9:521–40.
20. Marmar CR, Weiss DS, Schlenger WE, Fairbank JA, Jordan BK, Kulka RA, and others. Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans. Am J Psychiatry 1994;151:902–7.
21. MacFarlane AC. Post traumatic morbidity of a disaster. J Nerv Ment Dis 1986;174:4–14.
22. Bremner JD, Southwick S, Brett E, and others. Dissociation and posttraumatic stress disorder in Vietnam combat veterans. Am J Psychiatry 1992;149:328–32.
23. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington (DC): American Psychiatric Press; 1994.
24. Zimbardo PG, LaBerge S, Butler LD. Psychophysiological consequences of unexplained arousal: a posthypnotic suggestion paradigm. J Abnorm Psychol 1993;102:466–73.
25. Kluft RP. Varieties of hypnotic interventions in the treatment of multiple personality. Am J Clin Hypn 1982;24:230–40.
26. Spiegel H, Spiegel D. Trance and treatment: clinical uses of hypnosis. New York: Basic Books; 1987.
27. Bower GH. Mood and memory. Am Psychol 1981;36:129–48.
28. Loewenstein RJ. Psychogenic amnesia and psychogenic fugue: a comprehensive review. In: Tasman A, Goldfinger SM, editors. American Psychiatric Press Review of Psychiatry. Volume 10. Washington (DC): American Psychiatric Press; 1991.
29. Williams LM. Recovered memories of abuse in women with documented child victimization histories. J Trauma Stress 1995;8:649–73.
30. Loftus EF, Polonsky S, Fullilove MT. Memories of childhood sexual abuse: remembering and repressing. Psychology of Women Quarterly 1994;18:67–84.
31. Kluft R. Multiple personality disorder. Volume 10. Washington (DC): American Psychiatric Press; 1991.
32. Kluft RP. Treatment of multiple personality disorder. A study of 33 cases. Psychiatr Clin North Am 1984;7:9–29.
33. Putnam FW. Diagnosis and treatment of multiple personality disorder. New York: Guilford Press; 1989.
34. Putnam FW. Using hypnosis for therapeutic abreactions. Psychiatr Med 1992;10:51–65.
35. Putnam FW, Loewenstein RJ. Treatment of multiple personality disorder: a survey of current practices. Am J Psychiatry 1993;150:1048–52.
36. Spiegel D. Vietnam grief work using hypnosis. Am J Clin Hypn 1981;24:33–40.
37. van der Hart O, Spiegel D. Hypnotic assessment and treatment of trauma-induced psychoses. International Journal of Clinical and Experimental Hypnosis 1993;41:191–209.
38. Brende J, Benedict B. The Vietnam combat delayed stress response syndrome: hypnotherapy of “dissociative symptoms.” Am J Clin Hypn 1980;23:38–40.
39. Brom D, Kleber RJ, Defare PB. Brief psychotherapy for post-traumatic stress disorder. J Consult Clin Psychol 1989;57:607–12.
40. Dywan J, Bowers K. The use of hypnosis to enhance recall. Science 1983;222:184–5.
41. Sheehan P, Statham D, Jamieson G. Pseudomemory effects and their relationship to level of susceptibility to hypnosis and state instruction. J Pers Soc Psychol 1991;60:130–7.
42. McConkey KM, Sheehan PW. Hypnosis, memory, and behavior in criminal investigation. New York: Guilford Press; 1995.
43. Erdelyi MH, Kleinbard J. Has Ebbinghaus decayed with time? The growth of recall (hypermnesia) over days. Journal of Experimental Psychology. Human Learning and Memory 1978;4:275–89.
44. Loftus E. Leading questions and the eyewitness report. Cognitive Psychology 1975;7:560–72.
Dissociation
Richard Kluft, MD, Clinical Professor of Psychiatry, Temple University
School of Medicine, Philadelphia, Pennsylvania.
Dissociation encompasses a wide spectrum of normal and pathological phenomena in which there is a separation of mental contents and/or processes that would ordinarily be associated with one another or processed together. Within this spectrum are dissociative experiences that are involuntary (such as depersonalization or amnesia associated with trauma and the near-death experience), those that are deliberately sought out (such as mystic states, mediumship, and glossolalia), those that are quite disturbing (such as fugue and dissociative identity disorder), and those that may be desired and/or enjoyed (such as inspiration and transcendent experiences). Cardeña spoke of a domain of dissociation including 1) the absence of conscious awareness of impinging stimuli or ongoing behaviours; 2) the coexistence of separate mental systems or identities that should be integrated into one’s consciousness, memory, or identity; and 3) ongoing behaviours or perceptions that are inconsistent with a person’s introspective verbal report (1). Overall, dissociation is linked with the formation and dissolution of compartmentalization phenomena, so that things are either segregated from one another in a relatively rule-bound manner (such as in amnesia) or so that normal boundaries are breached (such as mystic or meditative states in which one may feel he or she has transcended personal identity).
Scholars have long debated whether all dissociative phenomena fall along a single continuum or whether there are both normal and abnormal forms of dissociation. Although the debate continues and the momentum has shifted toward the latter stance, it is clear that there is merit in understanding that dissociation becomes pathological when phenomena that are normal in small quantities are present in large quantities and when phenomena that are distinctly out of the realm of normal experiences are encountered. For example, “spacing out,” which is not very abnormal as a mild or infrequent phenomenon, becomes pathological when a person enters into prolonged trance states. Conversely, suddenly switching to another identity with a distinctly different name, way of speaking, autobiographic memory, and stance toward the world is distinctly abnormal.
Dissociative phenomena play an important role in many forms of psychopathology, such as the dissociative disorders, acute stress disorder, posttraumatic stress disorder (PTSD), borderline personality disorder, and somatoform disorder. They also appear to play a role in bulimic behaviours. The connection of dissociative symptomatology with trauma is particularly important; most disorders with prominent dissociative symptomatology are highly associated with antecedent traumatization. Dissociation occurs both peritraumatically, that is, at the time of a traumatic event, and posttraumatically, as a consequence of exposure to trauma. It appears to function as a defensive process to buffer the impact of trauma as it is occurring and as a means of restructuring the mind to preserve it from the impact of what has occurred. In both cases, it may exclude awareness of (amnesia) or complete connectedness to (depersonalization and/or derealization) the traumatic event(s). Such efforts create both an anodyne, a protection against the helplessness that is so integral to the experience of being traumatized, and an illusion of mastery (it did not happen, it was not a real event, it did not affect me). Spiegel and his colleagues have studied the dissociative sequelae of documented traumatic events, such as earthquakes, fires, shootings, and executions, and demonstrated the frequency with which dissociative symptoms occur in their aftermath (2,3). Peritraumatic dissociation is highly predictive of PTSD, and high hypnotizability and dissociative features are good predictors of chronicity in PTSD populations.
Therefore, dissociative symptoms and disorders, especially in traumatized populations, are extremely important targets for psychotherapy. The current preoccupation of the mental-health professions with the “false memory debate” has detracted attention from the need for mental-health professionals to become proficient in their treatment and resolution. Stage-oriented trauma treatment is understood to be a preferred approach. In this treatment, a phase in which the patient is made to feel safe and is strengthened is followed by a phase in which traumatic material is recalled and processed, and the consequences of the trauma are mourned. Finally, a reconnection is made as the mind is reintegrated (4). In order for the continuity of a traumatized individual’s identity to be restored, his or her traumatic experiences must be addressed, whether or not their historical accuracy can be verified. The turmoil that has surrounded the issue of the possible inaccuracy of memory in general and recovered memory in particular has bypassed the fact that the traumatized individual must deal with his or her mind’s representation of his or her autobiographical material (5).
Several major tasks await resolution by psychiatry in the 21st century. Psychiatry must move beyond the “memory wars” perspective that characterized the 1990s. The construct of “false memory” has been given credence without its ever having been validated. There are more than 30 studies demonstrating that traumatic material can be lost to conscious recall and become available once again (6). Studies document traumata described by patients with dissociative identity disorder, even in their recovered memories (7). Dalenberg recently demonstrated that always conscious and recovered memories of abuse were equally subject to corroboration (74%) (8). Nonetheless, it is clear that pseudomemories can be encountered in clinical settings, although the frequency with which they occur is unknown. The allegations of the widespread encouragement of false memories by therapists are supported more by opinion than by data. Psychiatry must avoid the temptation to leap to support one or the other of the polarized perspectives that have been voiced so vehemently and must slowly and circumspectly sort this issue out. In the process, it must resuscitate hypnosis, a valuable adjunct in the treatment of traumatized patients, which has been unduly and inaccurately denigrated in the course of the memory wars, and encourage its judicious use. It is one of the few reliable approaches to alleviating the dissociative sequelae of trauma, and efforts to promote its exclusion from therapeutic usage constitute a major misadventure.
We can look forward to major advances in the study of the psychobiology of trauma and in the psycho- biology of dissociation. The latter field of study is in its infancy, but already it is suggesting that glutamatergic function may be involved as a final common pathway for dissociative mechanisms (9). Should this field develop, it may be possible for the first time to mount a successful psychopharmacologic approach to dissociative psychopathologies. To date, all drug approaches have been, relatively speaking, shots in the dark.
We have much to learn about the natural history and the developmental psychobiology of dissociative responses to trauma in both adults and children. The work of Putnam and his colleagues is a welcome start. In view of the fact that traumatization is a wide-spread experience and its costs to society are enormous, such studies are long-overdue (10).
Finally, we very much need systematic study of the psychotherapy of dissociative traumatized populations. We need to study and compare alternative treatment approaches. Also, we have developed therapeutic approaches that are directed toward comprehensive treatment, but it is clear that many such patients are too overwhelmed or suffer too much comorbid psychopathology to permit those approaches to be applied safety. We need to develop a thoughtful and nonnihilistic approach to the supportive treatment of such populations.
The 20th-century study of dissociation has created a strong foundation for future research and clinical advances. If these advances are not lost in the aftermath of the “false memory debate,” the 21st century should be a time of great advances in the study of dissociation.
References
1. Cardeña E. The domain of dissociation. In: Lynn SJ, Rhue JW, editors. Dissociation: clinical and theoretical perspectives. New York: Guilford; 1994. p 15–31.
2. Spiegel D. Dissociating damage. Am J Clin Hypn 1986;29:123–31.
3. Spiegel D, editor. Dissociation: culture, mind, and body. Washington (DC): American Psychiatric Press; 1994.
4. Herman JL. Trauma and recovery. New York: Basic Books; 1992.
5. Kluft RP. Treating the traumatic memories of patients with dissociative identity disorder. Am J Psychiatry 1996;153:103–10 (Festschrift Supplement).
6. Brown D, Scheflin AW, Hammond DC. Memory, trauma treatment, and the law. New York: Norton; 1997.
7. Kluft RP. The confirmation and disconfirmation of memories of abuse in DID patients: a naturalistic clinical study. Dissociation 1995;8:253–8.
8. Dahlenberg CJ. Accuracy, timing and circumstances of disclosure in therapy of recovered and continuous memories of abuse. The Journal of Psychiatry and Law 1996;24:229–76.
9. Krystal JH, Bremner JD, Southwick SM, Charney DS. The emerging neurobiology of dissociation: implications for the treatment of posttraumatic stress disorder. In: Bremner JD, Marmar CR, editors. Trauma, memory, and dissociation. Washington (DC): American Psychiatric Press; 1998. p 321–64.
10. Putnam FW. Dissociation in children and adolescents. New York: Guilford; 1997.
Whither PTSD: Disorder or Solution?
John Curtis, MD, FRCPC, Psychiatrist in Private Practice, Halifax, Nova Scotia.
As a diagnosis, posttraumatic stress disorder (PTSD) is almost respectable. Launched just 18 years ago in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and termed controversial for years, PTSD now seems to have entered mainstream psychiatry (1). This is reflected somewhat in MEDLINE, which had 171 papers on PTSD listed in 1987 and 477 listed for 1997.
In a surprisingly short period of time, we have come to know a lot about PTSD in terms of biochemistry and neuroanatomy. Southwick has made us aware of the state-dependent nature of PTSD, with an injection of yohimbine producing PTSD symptomatology in Vietnam veterans (70%) and not in normal controls (7%) (2). They now suggest that there may be 2 neurobiological subgroups of PTSD, one with a sensitized noradrenergic system and the other with a sensitized serotonergic system (3). Prior studies have found reduced hippocampal volume with combat veterans, and a 1997 Winnipeg report showed reduced (5% smaller) left-sided hippocampal volume in 21 women who reported sexual victimization in childhood, compared with 21 nonvictimized women (4). Positron emission tomography (PET) scans of patients with PTSD having flashbacks have shown right-sided lateralization, with the amygdala and visual cortex prominently infused, while Broca’s area was conspicuously silent (5).
It is fascinating to see what technology is teaching us about PTSD, which long ago was called “railroad spine.” Things are going so fast that it is difficult to know where we are, let alone where we are going.
John Briere, PhD, addresses the questions of where we are going by turning the concept of PTSD on its head (6). He uses a variant of the “exposure gradient” concept and talks of a grenade being tossed into a room. Were we to interview the 100 lucky survivors of the grenade explosion; we would find that those closest to the grenade do not all develop PTSD, yet others with “less exposure” may. Posttraumatic stress disorder is not simply dose-related. Oddly enough, studies seem to show that only 20 to 25 of the survivors would have the full-blown symptoms at 6 months. Years later, the numbers would be reduced to 4 to 6 survivors, and, probably, this cohort would remain chronic for the rest of their lives. What happened to the other 95%? Some would have had partial symptomatology over time, but many would eventually be well.
Who does not get well? The earliest hints about this came from studies of Vietnam veterans. Those with histories of childhood trauma were more likely to have developed chronic PTSD. More recently, we have begun to look at “neglect” as a factor, which is difficult because it is hard to study that which was not there.
Briere addresses these issues with humour and talks about whether the person came from the “good house” or the “bad house” (noting that he has it on good authority that there are only “6 good houses in North America” and, having the photos of all 6, no one in his audience had come from the “good house”).
In the “good house,” the parental figures teach 2 basic skills: affect tolerance and affect regulation. Affect tolerance is the ability to stay with a painful emotion, which is a necessary skill if one is then to manage the emotion.
In his excellent book, Emotional Intelligence, Daniel Goelman characterized the parent as an “emotional tutor,” stating that one’s emotional IQ is a better predictor of future success than the standard IQ test (7). The 4 emotional IQ questions are: 1) Do you know what to do with your anger? 2) Can you sooth yourself? 3) Can you read feelings? and 4) Can you delay gratification?
If the parental figures of the “bad house” have not been present, have not provided soothing during times of emotional and physical pain, and have not taught the child how to stay with the pain or how to problem solve around these issues, the child may not have the tools to deal with severe problems. (The “bad house” may not have been “all that bad.” It may, for instance, have bought the mythology that intellect is better and may not have valued or may have even discouraged the expression of emotion.)
But what if the “bad house” is really bad? What if there has been betrayal of the basic assumptions that every child holds about the world: that the world is safe, that they are of value, and that their life has meaning (8). Recently, Freyd has advanced a very testable theory that this betrayal of trust is the most central issue in trauma (9). Often this takes the form of physical and/or sexual abuse. The child, who is already disadvantaged in terms of being able to deal with negative affect, may now be overwhelmed. The only option may be to turn it off, because escape is not an option. This next-best tool, a step up so to speak, is called dissociation, for the smaller number of patients who can effectively do so.
Briere believes that PTSD is only a “disorder” for that 4% to 6% who do not get better. It has been a “solution” for those who recovered. He proposes that intrusive symptomatology such as flashbacks are actually a natural biophysiological process whereby the mind practices systematic desensitation, just as any good therapist would. In addition, the mind is so clever that it only does its work when we are safe, when the trauma has ceased. It also uses “triggers” or reminders of the trauma in our natural environment to nudge us into doing the work of healing.
He notes that a child does not remember the whole scene of a sexual abuse like a movie but as a flash of the wall paper, a hand, a musty smell, and so on. The mind is presenting small manageable components of data, chunks of “snakehood” if you will, seemingly with the intent that they will be mastered. Memory is being disengaged from stress.
Those who have not mastered affect tolerance and regulation will not be able to perform this healing task. Those who employ dissociation will do even worse. Remembering powerful material automatically triggers avoidance. Avoidance undercuts the effectiveness of the reparative flashback process, however, because you cannot process that with which you are not connected. Dissociation can delay recovery. It makes you chronic.
Are there any scientific data to back this up? The best evidence is the emerging realization that “peritraumatic dissociation” may be the best predictor of who is going to develop PTSD. A variety of studies using the Peritraumatic Dissociative Experiences Questionnaire (PTDQ) (10) have shown that 9 questions concerning losing track or blanking out, acting on “automatic pilot,” the event seeming unreal, and so on, strongly predict PTSD (11). Going back to the aforementioned use of yohimbine to bring on PTSD symptoms, is it possible that the biological pump has previously been primed, so to speak?
Further evidence has been suggested by van der Kolk in a follow-up study of the previously mentioned PTSD patients who received a PET scan while having a flashback. He reports that upon recovering and when given a second PET scan, 6 of these individuals showed more infusion of the frontal lobes, which had previously been quiet (13). Could this be some of what we observe in therapy when the patient seems to start to view their trauma more distantly and manage their emotions?
What are the implications for our therapeutic management of PTSD and dissociation if the above is valid?
1. It may be wise to respect a person’s natural defence system and not “go after” memories. “You’ll remember when you are ready to.”
2. Therapies aimed at “abreaction” may be unwise.
3. When people are experiencing flashbacks, especially if they are debilitating, it may be wise to help them dampen this process down. Therapy, no matter which method one uses, is a process of titration. One is always balancing the amount of intrusion going on against the ability to process.
4. This other side of the equation is the building of a strong “self” that can process these data. Most therapists are doing this from the first moments of the first interview. It is part of the transference, the coping methods, the positive affirmations, the cognitive restructuring, and so on.
5. If dissociation, or “disconnection” as I often rephrase it, is the culprit, then reconnection may be the solution. A number of modalities have come on stream that hasten this process.
6. Anxiety seems to drive dissociation, and selective serotonin reuptake inhibitors (SSRIs) may be particularly helpful to dampen this. It has long been noted, however, that there is no one drug or modality that seems to work. The research concerning noradrenergic function mentioned above may give one cause to consider using drugs that address this group, such as clonidine hydrochloride or propranalol hydrochloride. A test infusion of yohimbine may become the method of sorting them out.
7. Fluoxetine seems to have 2 qualities that set it apart from other SSRIs. It does a better job in terms of connecting one with one’s emotions. It also helps to bring on line the “rational self” (left frontal cortex?) and “observing ego” (right frontal cortex?). Being able to read one’s affective states and to watch and manage them is, after all, what we are trying to promote. Some therapists avoid fluoxetine because the balance can be too much toward getting in touch with negative emotions or memories that the patient cannot manage. To address this the therapist needs further skills in the area of affect management, such as eye movement desensitization and reprocessing (EMDR) (12).
8. There are a number of “alternating movement” techniques, the best known of which is EMDR. It is a useful tool for symptom relief, especially in PTSD. Some have speculated that it may operate at the level of the corpus callosum, opening up neuronal tracts and permitting better information transfer between the hemispheres (13).
9. When we sit with our verbally challenged patients, we now must give some thought to Broca’s areas, which are not infused, and hippocampi with reduced volume. It is felt that the hippocampus is where the story is told. Maybe therapies that do not rely so heavily on “the story” and more on the visual and tactile will be more helpful.
Briere believes that the wise therapist is, strangely enough, in the business of giving their patient PTSD. He would state that chronic PTSD is probably very different from acute PTSD. Our therapies should be about making the reconnections so that our patients can have acute PTSD and get better. He is certainly wrong about one thing—most of our patients come from the “good house,” because the majority do get better.
References
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington (DC): American Psychiatric Press; 1980.
2. Southwick SM, Krystal JH, Morgan CA, Johnson D, Nagy LM, Niculaou A, and others. Abnormal noradrenergic function in post traumatic stress disorder. Arch Gen Psychiatry 1993;50:266–74.
3. Southwick SM, Krystal JH, Bremmer JD, Morgan CA, Nicolaou AL, Nagy LM, and others. Noradrenergic and seratonergic function in post traumatic stress disorder. Arch Gen Psychiatry 1997;54:749–58.
4. Stein MB, Koverola C, Hanna D, Torchia MG, McClarity B. Hippocampal volume in women victimized by childhood abuse. Psychol Med 1997;27:951–9.
5. Rauch SL, van der Kolk BA, Fisler RE, Alpert MN, Orr SP, Savage CR, and others. A symptom provocation study of post traumatic stress disorder using positron emission tomography and script driven imagery. Arch Gen Psychiatry 1996:53:380–7.
6. Briere J. Plenary session: self issues and emotional processing in the treatment of trauma. Delivered at the 13th Annual Fall Conference of The Society for the Study of Dissociation, Nov. 8, 1996, San Francisco, CA.
7. Goleman D. Emotional intelligence. New York: Bantam Books; 1995.
8. Janoff-Bulman R. Shattered assumptions: towards a new psychology of trauma. New York: The Free Press; 1992.
9. Freyd J. Betrayal trauma: the logic of forgetting child abuse. Cambridge: Harvard University Press; 1996.
10. Marmar CR, Weiss DS, Metzler TJ. The peritraumatic dissociative experiences questionnaire. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD: a practitioners handbook. New York: Guilford Press; 1997.
11. van der Kolk BA, van der Hart O, Marmar CR. Dissociation and information processing in post traumatic stress disorder. In: van der Kolk BA, McFarlane AC, Weisaeth L, editors. Traumatic stress. New York: Guilford Press; 1996.
12. Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols, and procedures. New York: Guilford Press; 1995.
13. van der Kolk BA. Workshop on PTSD and trauma. Presented at the Royal Ottawa Hospital, Ottawa, Ontario. Feb 6–7, 1997.