Cover
Endorsement
Half Title
Title Page
Copyright Page
Dedication
Table of Contents
Contributors
Preface
Acknowledgments
Introduction
Part 1: Historical and Conceptual Issues
Part 2: Etiological and Developmental Considerations
Part 3: Theoretical Approaches
Part 4: The Dissociative Disorders
Part 5: Dissociation as a Transdiagnostic Process – Acute and Chronic
Part 6: Neurobiological and Cognitive Understandings of Dissociation
Part 7: Assessment and Measurement
Part 8: Treatment Considerations and Conceptualizations
Part 9: Treatment Challenges and Therapist Considerations
Part 10: The Future
Concluding Thoughts
References
Part 1 Historical and Conceptual Issues
1 History of the Concept of Dissociation
Origins of Dissociation in the Scientific Literature
Dissociation as Division/Multiplication of Personality/Consciousness/Psyche
Amand De Chastenet De Puységur
Jacques Moreau De Tours
Gros Jean
Hippolyte Taine
Division Or Doubling of Consciousness and Clinical Dissociation: Hysteria and Hysterical Symptoms
Pierre Janet
Alfred Binet
Society for Psychical Research in Britain
Nineteenth-century Conceptualizations of Dissociation
Dissociation in North America
William James
Boris Sidis
Morton Prince
Dissociation in British Psychiatry During and After World War I
Charles Myers
Thomas Mitchell and William McDougall
Italian Cases of Dissociative Identity Disorder From the Early Twentieth Century
Dissociation in the Psychoanalytic Literature
Josef Breuer and Sigmund Freud
Sándor Ferenczi
Ronald Fairbairn
Bridging Psychoanalysis and Hypnosis: Herbert Spiegel
The Renaissance of Dissociation: Non-Pathological and Pathological Manifestations
Charles Tart and Arnold Ludwig
Henri Ellenberger and the 1970s
Ernest Hilgard
1980 and Beyond
Changes in the Concept of Dissociation: Progress in Understanding Or Conceptual Drift?
Contemporary Understandings and Challenges
Conclusion
Acknowledgments
Notes
References
2 The Conceptual Unity of Dissociation: A Philosophical Argument
Assumptions
Capability Assumption
Non-uniqueness Assumption
Diversification Assumption
Ownership Assumption
Accessibility Assumption
Dissociation Relative to Other Named Phenomena
Repression
Suppression
Denial
What Dissociation Is
What Dissociation Is Not
Inclusivity Vs Exclusivity
Acknowledgments
Notes
References
3 The Traumatic Disintegration Dimension
Distinguishing Between Traumatic Disintegration and Dissociation
Traumatic Disintegration
Disintegration Without Dissociation
Dissociation of Two Kinds: Disinhibited Dissociation and Inhibitory Dissociation
Disinhibited Dissociation
Inhibitory Dissociation
The Hierarchy of Hughlings Jackson
Sherrington and the Discovery of Inhibition as a Coordinative Factor
“Normal Integration” and the Dynamic Network Organization of the Brain
Disintegration and Failed Inhibition
Traumatic Attachment and Disintegration
The Neurobiological Effect of Traumatic Stress On Mental Integration
Neurophysiology of Disintegration Psychopathology
Failures of the Inhibition Control System and Executive Functions
Altered Pattern Separation and Threat Overgeneralization
Relational and Social Functioning: Disintegration of Social Cognition and Metacognition
Traumatic Disintegration of Self-Related Processes
Lateralization of Disintegration and the Impairment of Right Hemisphere Language
Trait and State Disintegration and Their Circular Causality
The Traumatic Disintegrative Dimension and Diagnostic Categories
Conclusions
References
4 Dissociation Versus Alterations in Consciousness: Related But Different Concepts
Alterations in Consciousness
A Continuum of Dissociation?
A Continuum of Alterations in Consciousness
Hypoarousal and Dissociation
Hypnotizability and Dissociation
Peritraumatic Alterations in Consciousness
Depersonalization and Derealization
Trauma-related Structural Dissociation of the Personality
Action Systems as the Foundation For Trauma-Related Structural Dissociation of the Personality
Dissociative Parts of the Personality
Dissociative Symptoms In Structural Dissociation
Differences Between General Alterations in Consciousness and Structural Dissociation
Failures of Perception and Memory
Sense and Idea of Self: First-Person Perspective
Field and Level of Consciousness in Dissociative Parts of the Personality
Complexities of Distinguishing Between Structural Dissociation and Alterations in Consciousness
Measures of Dissociation
Alterations in Consciousness and Dissociative Symptoms: Research Findings
Diagnostic Confusion in the DSM and ICD
Discussion
Acknowledgment
Notes
References
5 The Case for the Study of “Normal” Dissociation Processes
What Do We Mean By Normal And Pathological Dissociation?
Current Operationalization Of Normal And Pathological Dissociation
Are Normal And Pathological Dissociation Distinct?
Are Definitions Of Dissociation Related to the Dissociative Subtype of PTSD Overly Restrictive?
Normal Uses For Dissociation Processes
Can An Extreme Elevation In “Normal Dissociation” Be Pathological?
Could Normal Dissociation Be a Diathesis To Pathological Dissociation?
Conclusions
References
6 Dissociation and Resilience
Traumatic Exposure and Resilience
Dissociation and Resilience
Volitional Dissociation: Facilitative and Debilitative
Dissociative Resilience
References
7 Adaptive Dissociation: A Response to Interpersonal, Institutional, and Cultural Betrayal
Betrayal Trauma Theory: Theoretical Foundations
Betrayal Trauma Theory: Research Evidence
Memory
Beyond Memory: Betrayal Trauma, Shame, and Dissociation
Betrayal Trauma, Dissociation, and Revictimization
Betrayal Trauma, Dissociation, and Other Posttraumatic Outcomes
Institutional Betrayal
Cultural Betrayal Trauma Theory
Future Directions
Measuring Betrayal Blindness
Conclusion
Acknowledgments
References
8 Dissociative Multiplicity and Psychoanalysis
Dissociative Multiplicity
Psychoanalysis
Scientific Challenges
Methodology
Talking About Ourselves As If Talking About Something Else
Biology vs Analogies From Artefacts
Defining Psychoanalysis as a Psychology (i.e., an Account of the Psyche)
Freud’s Definition: Method, Treatment, Theory
Freedom and Determinism in the Method
Clean and Dirty Starts: Abandoning Hypnosis
Scientific Hypotheses Vs Hermeneutics
The Reification of Freud’s ‘Ich,’ and the Other
I as Subject; Subjectivity
The Other: The Psychoanalytic ‘Object’
Dissociative Multiplicity: How Many of What?
Body, Psyche, Mind
Multiplication and Division
When ‘The Ego’ Becomes ‘The Nos’ – the We
Self; Self-Representation
Personality
Full-blown Dissociative Multiplicity: What Needs to Be Accounted For
Inner, Internal and Third Worlds: The Inscape
Dissociation and Psychoanalysis: The Literature
Dissociation and Splitting
Kinds of Splitting
Good-bad Splitting of Representations
Kleinian Splitting Proper
Good-bad Structural Splitting
Splitting Leading to Fragmentation
Can Splitting Explain Dissociation?
Can Dissociation Explain Splitting?
Perverse-psychotic Splitting
Brenner: Reducing Dissociative Multiplicity to Perverse Splitting
Fostering Attitudinal Splitting in Therapy
Dissociation and Repression
The Shift From Splitting to Repression: Klein’s Positions, Bowlby’s Phases, Kübler-Ross’s Stages
Freud’s Primal Category Mistake: Rejecting Hypnoid Hysteria in Favor of Defense
Dissociation, Repression and Conversion
Within Psychoanalysis: Conversion and Repression
Conversion in Psychiatric Nosology
Conversion in Dissociative Disorders
Repression Reinterpreted: Zero Process
Repression Reinterpreted: Unformulated Experience
Dissociation and Assorted Triads
Dissociation and the Œdipal Triangle
Dissociation and the Topography: Cs, Pcs and Ucs
Dissociation and the Structural Theory: Id, Ego and Superego
Fairbairn’s Triad
Kohut’s Triad: Dissociation and Self Psychology
Triadic Conclusion
Dissociation and Schemata in General
Object Relations Theory
Attachment Theory
Dissociation and States of Mind
Back to Breuer’s Hypnoid Hysteria
Federn’s Ego States and the Watkins’ Ego-State Therapy
Putnam: Discrete Behavioral States
Interpersonal and Relational Psychoanalysis
Needed Research
A Summary View
Dédoublement
Weakness Vs Defense
Full Adult DID
Repression as a Defense
Polar Splitting of Self and Object Representations
Id, Ego, Superego, and Other Triads
Internal Object Relations, Attachment, IWMS, Templates, Schemas
States
Technique
Psychoanalysis and Multiplicity: Recent Developments
Notes
References
Part 2 Etiological and Developmental Considerations
9 A Developmental Pathways Model of Dissociation
A Developmental Psychopathology Perspective On Dissociation
The Etiology of Dissociation
A Developmental Pathways Model of Dissociation
Implications and Future Directions
References
10 The Relationship Between Attachment and Dissociation: Theory, Research, and Clinical Implications
Defensive Exclusion and Segregated Mental States
Infant Disorganized Attachment and Dissociation
Frightening/frightened Parental Behavior and Infant’s Attachment Disorganization
Dissociation in the Childhood Sequelae of Infant Disorganization
Dissociative Phenomena in the Study of Adult Attachment
From Parental Lack of Care to Adult Dissociation: A Developmental Pathway
Internal Working Models of Attachment and Dissociated Multiplicity
Implications for Treatment
References
11 Attachment Trauma and the Developing Right Brain: Origins of Pathological Dissociation and Some Implications for Psychotherapy
The Interpersonal Neurobiology of Secure Attachment
The Neurobiology of Relational Attachment Trauma
Developmental Psychology of Dissociation
Right Brain Processes and Dissociation
Dysregulation of Right-Lateralized Limbic-Autonomic Circuits and Dissociation
Further Proposals On the Biological Mechanisms Underlying Dissociation
Right Brain Cortical and Subcortical Emotional Structures and Dissociation
The Right Brain Emotional-Corporeal Self and Somatic Dissociation
Attachment Trauma and Dissociation: Some Implications for Psychopathogenesis and Psychotherapy
References
12 Adverse Childhood Experiences and Dissociative Disorders: A Causal Pathway Based On the Disruptive Impacts of Cumulative Childhood Adversity and Distress-Related Dissociation
Adverse Childhood Experiences and Distress-Related Dissociation
Childhood Physical Abuse
Childhood Sexual Abuse
Childhood Emotional Abuse
Physical and Emotional Neglect
Household Dysfunction
Adverse Childhood Experiences and Dissociation: Distress, Disruption, and Disconnection
Attachment Dynamics, Threat and Deprivation, and Performance Versus Skills Deficits
Attachment Dynamics: ACEs-Related Impacts and Vulnerability to Dissociation
Threat and Deprivation: Conditions for Distress, Disruption, and Disconnection
Performance and Skills Deficits
ACEs and Distress-Related Dissociation: A Pathway for Vulnerability to Developing Dissociative Symptoms and Disorders
Conclusion
References
13 Beyond Death: Enduring Incest: The Fusion of Father With Daughter
Historical Foundations
Current Perspectives
Systematic Research Efforts
General Characteristics Of Ongoing Incestuous Abuse Of Adults
Common Observations
Discussion: Implications of the Patterns Observed
Why Was Any Systematic Examination of the Phenomena Of Ongoing Incestuous Abuse In Adulthood So Long In Coming?
What Has Allowed for the Emergence of a Societal Awareness About The Extent Of Ongoing Incest During Adulthood?
How Does Ongoing Incest During Adulthood Inform The Etiology of DID?
How Do Perpetrators Of Enduring Incest Establish Enduring Control?
How Do Perpetrators’ Exploit Attachment and Identity Dynamics?
Where Does Ongoing Incest During Adulthood Fit Into the Spectrum of Forms of Abuse for Which There Is Emerging Recognition?
Treatment Issues
Concluding Observations
Notes
References
14 Clarifying the Etiology of the Dissociative Disorders: It’s Not All About Trauma
Trauma and the Dissociative Disorders
High Hypnotizability: The Road Not Taken
The Road Taken: An Inability to Synthesize Trauma
The Autohypnotic Model of the Dissociative Disorders
Janet Did Not Propose an Etiological Theory of Dissociation
Trauma Models of the Dissociative Disorders
Janet’s Refusal to Theorize
So, What Is the Relationship Between Trauma and Dissociative Divisions of the Personality?
The Theory of Structural Dissociation Needs to Incorporate High Hypnotizability
Ability
Defense
After Trauma
Before Trauma
Inability to Integrate Particular Events and Experiences
Trauma
What Is Trauma?
Chronic Relational Trauma
Why Is the Dissociation of the Dissociative Disorders Different From All Other Dissociation?
Disruption of the Framework of Perceptual Organization
Hypnotizability-Enabled Dissociative Defenses
Crucial Remaining Issues About High Hypnotizability
The Hypnotizability of Dissociative Patients
The Question of Whether Trauma Causes High Hypnotizability
Impending Surgery
Pregnancy
Severe Injury
Temporary Increases of Hypnotizability
Humans Have a Natural, Biological Ability to Alter Experience
Summary and Conclusions
The Bottom Line
References
Part 3 Theoretical Approaches
15 The Theory of Trauma-Related Structural Dissociation of the Personality
The Conceptual Origins of Structural Dissociation of the Personality
Deficits in Integrative Capacity as a Foundation for Structural Dissociation of the Personality
Prototypes in Structural Dissociation of the Personality
The “Apparently Normal” Part of Personality
The “Emotional” Part of the Personality
Action Systems Mediate ANP and EP
Psychological Defense in ANP and EP
Developmental Pathways to Structural Dissociation
Maintenance of Structural Dissociation
Degrees of Structural Dissociation and Diagnosis
Primary Structural Dissociation
Secondary Structural Dissociation
Tertiary Structural Dissociation
Symptoms of Structural Dissociation
Negative Psychoform Dissociative Symptoms
Negative Somatoform Dissociative Symptoms
Positive Psychoform Dissociative Symptoms
Positive Somatoform Dissociative Symptoms
Treatment Implications of the Theory of Structural Dissociation
Conclusion
Acknowledgment
References
16 Discrete Behavioral States Theory
Discrete Behavioral States/States of Being
The Ubiquity of States of Being
Repeating State Cycles
State Switches and Shifts
Characteristics of Switching
Infant States Form the Core of All Human States
The Role of Early Caretaking
Attunement
Attachment
Self-Modulation
Personality, Identity, Self, Self-System
The Self-System
Discrete Behavioral States and Psychopathology
Trauma, Posttraumatic Responding, Dissociation
Acute and Posttraumatic Stress Disorders (ASD & PTSD)
Dissociation
Dissociative Disorders (DD)
Depersonalization/derealization Disorder (DDD)
Dissociative Amnesia (DA)
Dissociative Identity Disorder
Conclusion
Notes
References
17 The Perceptual Theory of Dissociation
The Explanatory Mechanisms of Dissociation: The Perceptual Theory
Dissociation and Its Domain
The Experiential Structure of a Dissociative Perceptual Reaction During Threat
A Percept “Of Determining Significance”
General Principles Involved in Dissociation
A Continuum of Dissociative Complexity
Research Supporting the Perceptual Theory
Frequency and Complexity of Dissociative Reactions
The Relationship of Dissociative Reactions to the Focus of Perception
Temperamental Traits and Blocking Out the Background
Dissociation in Significant Situations
Dissociation in Positive Situations
Perceptual Experiments
The Necker Cube (NC)
Summary
The Perceptual Theory of Dissociative Disorders
The Dissociative Disorders: The Self System as Mechanism
Depersonalization/derealization Disorder as a Conditioned Dissociative Reaction
Depersonalization/derealization Disorder and the Self System
Example
Amnestic Disorders and Abreactions
Dissociative Identity Disorder
Switching
Presentification: The Perceptual Theory Applied to Psychotherapy
Theoretical and Empirical Foundation
Presentification: Overview
Conclusions and Implications
References
18 Contextual Dissociation Theory: The Dual Impact of Trauma and Developmental Deprivation
The Nature and Causes of Dissociation
Dissociation Related to a History of Trauma
Dissociation Related to Insecure Attachment
Beyond Trauma and Attachment: Psychological Development
Dissociation as Disconnection: A Unitary Substrate for Divergent Manifestations
A Key Distinction Between “Simple” and Complex Dissociation
Revealing a Broader Terrain of Dissociative Manifestations Via a Developmental Perspective
Integration of the Sense of Self
Integration of Self as a Developmental Process
Human Development, Interpersonal Connection, and the Integration of Sense of Self
Clinical Implications
Performance Deficits Versus Skills Deficits
Concluding Thoughts
Acknowledgments
Notes
References
19 The Four-Dimensional (4-D) Model as a Framework for Understanding Trauma-Related Dissociation
Prior Theoretical Bases for the 4-D Model
The 4-D Model as a Phenomenological Framework for Understanding Dissociative Experiences as ASC
Normal Waking Vs. Altered States of Consciousness of Time
Normal Waking Vs. Altered States of Consciousness of Thought
Normal Waking Vs. Altered States of Consciousness of the Body
Normal Waking Vs. Altered States of Consciousness of Emotion
Section Summary
Empirical Tests of Four Hypotheses of the 4-D Model
Hypothesis 1: Frequency of Symptom Occurrences
Hypothesis 2: Frequency of Symptom Co-Occurrences
Hypothesis 3: Frequency of Symptom Occurrences With Other Measures of Dissociative Experiences
Hypothesis 4: Specificity of Symptom Occurrences in Persons With Childhood Trauma Histories
Section Summary
Neurophenomenology and the 4-D Model: A Focus On Neuroimaging Studies of the Consciousness of Self
The 4-D Model as a Compartmental-Structural Theory for Understanding Dissociative Experiences
The 4-D Model, Dissociative Disorders, and the Dissociative Subtype of PTSD
Treating Trauma-Related Altered States of Consciousness
Conclusion
References
20 Dissociation and Unformulated Experience: A Psychoanalytic Model of Mind
Assumptions Underlying the Repression Model
Unformulated Experience: A Dissociation-Based Psychoanalytic Model of Mind
What Is Understanding?
The Role of Language
Two Varieties of Dissociation
From Dissociation to Imagination: the Question of Psychopathology
Concluding Remarks
Notes
References
Part 4 The Dissociative Disorders
21 Dissociation in the ICDs and DSMs
Official Nosologies: the ICD and DSM
The ICD
The DSM
ICD and DSM History – Overview
ICD History: From Bertillon to ICD-9
American Nosology Prior to DSM-I
DSM-I (1952)
DSM-II (1968) and ICD-7-8-9
DSM-III (1980)
DSM-III-R (1987)
ICD-10 (1992)
DSM-IV/IV-TR – 1994/2000
DSM-IV-TR (2000)
DSM-5 (2013)
ICD-11 (2018/2022)
Dissociation in General
Dissociation: Evolution of the Definition
Specific Kinds of Dissociation
1. Dissociative Multiplicity
Prevalence
DSM-III: 300.14 – Multiple Personality
DSM-III-R: 300.14 – Multiple Personality Disorder
DSM-III-R: 300.15 – DDNOS-2
ICD-10: F44.81 – Multiple Personality Disorder
DSM-IV: 300.14 – Dissociative Identity Disorder
DSM-IV/IV-TR: 300.15 – DDNOS-1
DSM-5: F44.81 – Dissociative Identity Disorder
DSM-5: F44.88 – OSDD-1: Chronic and Recurrent Syndromes of Mixed Dissociative Symptoms
ICD-11: 6B64 – Dissociative Identity Disorder
ICD-11: 6B65 – Partial Dissociative Identity Disorder
2. Dissociation of Memory
DSM-III/III-R: 300.12 – Psychogenic Amnesia and 300.13 – Psychogenic Fugue
ICD-10 (1992): F44.0 – Dissociative Amnesia and F44.1 – Dissociative Fugue
DSM-IV/IV-TR: 300.12 – Dissociative Amnesia and 300.13 – Dissociative Fugue
DSM-5: F44.0 – Dissociative Amnesia (F44.1 If With Dissociative Fugue)
ICD-11: 6B61 – Dissociative Amnesia (± Dissociative Fugue)
3. Depersonalization and Derealization
DSM-II/ICD-9: 300.6 – Depersonalization Neurosis
DSM-III/III-R: 300.60 – Depersonalization Disorder
ICD-10: F48.1 – Depersonalization-Derealization Syndrome
DSM-IV/IV-TR: 300.6 Depersonalization Disorder, and DDNOS-2
DSM-5: F48.1 – Depersonalization/Derealization Disorder (DP/DRD)
ICD-11: 6B66 – Depersonalization-Derealization Disorder
4. Sensorimotor Dissociation
Overview
DSM-I: Conversion Reaction
DSM-II/ICD-9: 300.1 Hysterical Neurosis, Conversion Type
DSM-III/III-R: 300.11 Conversion Disorder
ICD-10: F44 – Dissociative [Conversion] Disorders
DSM-IV/IV-TR: 300.11 – Conversion Disorder and DDNOS-5
DSM-5: F44.4-7 – Conversion Disorder (Functional Neurological Symptom Disorder)
ICD-11: 6B60 – Dissociative Neurological Symptom Disorder
Concluding Comment
Dissociative Trance Disorder
Ganser’s Syndrome
OSDD-2: Brainwashing, Thought Reform, and Indoctrination
OSDD-3: Acute Dissociative Reactions to Stressful Events
5. Remaining Kinds of Dissociation
Dissociation Beyond the Dissociative Disorders
Trauma- and Stressor-Related Disorders
Personality Disorders
Differential Diagnosis in DSM-5
‘Thumbnail’ Summary
Prior to the Nosologies
ICD-I-5 (1900–1938)
DSM-I (1952)
DSM-II / ICD-7-9 (1968)
DSM-III/III-R (1980; 1987)
ICD-10 (1992)
DSM-IV/IV-TR (1994; 2000)
DSM-5 (2013)
ICD-11 (2022)
Discussion
Notes
References
22 Dissociative Amnesia and Dissociative Fugue
Definitions of Dissociation, Dissociative Amnesia and Dissociative Fugue
Problems With the DSM-5 Rules for Dissociative Amnesia and Dissociative Fugue
Problems With the DSM-5 Rules for Other Specified Dissociative Disorder
Persons With Dissociative Amnesia Do Not Appear to Be in the Dissociative Taxon
Severity of Trauma in Dissociative Amnesia and Dissociative Fugue
Empirical Strengths and Weaknesses of Dissociative Fugue and Dissociative Amnesia
Needed Research
References
23 Depersonalization/Derealization Disorder
The Symptoms of Depersonalization-Derealization Disorder
The Occurrence of DP/DR Symptoms
History of Depersonalization-Derealization Disorder
The Diagnosis and Clinical Picture of DDD
Prevalence of DDD
Typical Clinical Presentation of DDD Patients
The Course of DDD
Differential Diagnosis
Measurement and Diagnostics
Risk Factors for Developing DDD
Psychological Models of DDD
Understanding DP/DR With the Triangles of Conflict and Persons
Conclusion
Acknowledgment
References
24 A Grounded Theory of Dissociative Identity Disorder: Placing DID in Mind, Brain, and Body
What Is DID?
What Is a Self-State?
Other Dissociative Symptoms Experienced in DID
Observable Manifestations of Self-States
Grounding DID in Environmental Risk Factors
Overwhelming Childhood Experiences, Trauma, and Abuse
Disorganized Attachment
Grounding DID in Biological Patterns
Neurobiology of DID
Common Methodologies
Neural Correlates of Self-States
Self-states Have Different Activity
Switching Between Self-States
Self-state Integration
Summary
DID Versus Nonpsychiatric Controls and People Simulating DID
Nonpsychiatric Controls
Simulating Controls
Summary
Placing DID On a Continuum With PTSD Neurobiology – Evidence of a Posttraumatic Adaptation
Structural Findings
Summary
A Neurobiological Fingerprint of DID?
Peripheral Psychophysiology of DID
Psychophysiology of Self-States
Simulating Controls
Summary
Placing DID On a Continuum With PTSD Psychophysiology – Evidence of a Posttraumatic Adaptation
Summary
Digging Deeper: DID Research Moving Forward
Conclusions
Remaining Questions
Acknowledgments
Note
References
25 Psychotic Presentations of Dissociative Disorders
Fragmentation and Beyond
Psychosis as a Transdiagnostic Phenomenon
The Concept of Reactive Psychosis
Psychogenic Psychosis
Reality Testing
“Borderline” Conditions
Crisis and Process
Psychotic Symptoms in Dissociative Disorders
Hallucinations
Schneiderian Symptoms
Loss of Insight
Grossly Disorganized Behavior
Formal Thought Disorder
Acute Reactive Dissociative Psychosis
Symptomatology
Overlap Between DID and ARDP
Dissociation and Psychosis: Continuity Or Comorbidity
The Dissociative Subtype of Schizophrenic Disorder
An “Interaction” (Duality) Model
Explanatory Mechanisms
The Dissociative Quality
The Traumatic Background
Conclusion
References
26 The Other in the Self: Possession, Trance, and Related Phenomena
Possession/Trance Phenomena and Dissociation
What Distinguishes Non-Pathological From Pathological PTP?
Explanatory Frameworks of PTP
Psychological/Developmental Theories of PTP
Cultural and Sociopolitical Theories of PTP
Biological Theories and Correlates of PTP
Conclusions and Further Research
Note
References
27 Dissociative Disorders in Children and Adolescents
A Brief History of the Field of Childhood Dissociation
Dissociation and Its Relation to Trauma
Diagnostic Considerations in Children and Adolescents
Dissociative Symptomatology
Preschool Children
School-Age Children
Adolescents
Assessment of Dissociation
Theoretical Considerations
The Neurophysiology of Trauma and Dissociation
Treatment
Where Do We Go From Here?
References
Part 5 Dissociation as a Transdiagnostic Process: Acute and Chronic
28 Peritraumatic Dissociation and Chronic Posttraumatic Symptomatology: Thirty Years and Counting
Dissociation
Peritraumatic Dissociation
Measures of Peritraumatic Dissociation
Physiological Correlates
Heart Rate
Blood Pressure
Electroactivity of Skeletal Muscles and Associated Nerve Functions
Skin Conductance
Stress Hormones
Genetic Correlates
Acute Stress Disorder and Posttraumatic Stress Disorder in the DSM Taxonomy
More Than One Acute Stress Disorder, More Than One Posttraumatic Stress Disorder
Peritraumatic Dissociation as a Predictor of Posttraumatic Diagnoses
Prospective Studies
Retrospective Studies
Studies With Non-Western Samples
PD and Lingering/Persistent Dissociation
PD Studies With Teens and Children
Mediators and Moderators of the Effect of PD On Psychopathology
Conclusions
References
29 Dissociation and Trauma: Clinical and Research Intersections in PTSD
Historical and Cultural Influences On the Conceptualization of Trauma and Dissociation
What Is Dissociation in Trauma?
Development of Pathological Dissociation
Evolving Conceptualization of Dissociation in PTSD
Dissociative Subtype
Dissociation Debates in PTSD
Dissociation in PTSD: Case Examples
Treatment Implications of Dissociation in PTSD
Trauma Spectrum Disorders – Revisited
An RDoC Approach Linking PTSD and Dissociation
Is There a Renewed Interest in Traumatic Dissociation?
Visioning Next Steps
References
30 Complex PTSD and Emotion Dysregulation: The Role of Dissociation
Dissociation in Complex PTSD
Emotion Dysregulation, Dissociation, and Complex PTSD
An Alternative Approach to Inclusion of Dissociation: Developmental Trauma Disorder (DTD)
Another Alternative Approach to Including Dissociation: The Dissociative Sub-Type of PTSD
Structural Dissociation in Complex PTSD
Conclusion
References
31 Is Dissociation an Integral Aspect of Borderline Personality Disorder, Or Is It a Comorbid Disorder?
Dissociation and the Dissociative Disorders
Dissociation and Borderline Personality Disorder
Diagnostic Issues
Borderline Personality Disorder and the DES
BPD Patients With a Comorbid Dissociative Disorder
Five Disputed Issues About Dissociation and BPD
1. Is Dissociation an Aspect of BPD Pathology Or a Separate, Co-Occurring Disorder?
A. An Aspect of BPD Pathology?
B. Co-Occurring Separate Disorders?
C. Summary Question: Is Dissociation an Aspect of BPD Pathology Or Is It a Separate, Co-Occurring Disorder?
2. Do the Dissociative Symptoms of Borderline Personality Disorder Differ From the Dissociative Symptoms of the Dissociative Disorders?
Empirical Comparison Of Dissociative Experiences in DID and BPD
BPD With Low Dissociation
BPD With Moderate Dissociation
BPD With High Dissociation
3. Are the Risk Factors for Dissociation in BPD Patients Different From the Risk Factors in Dissociative Disorder Patients?
Risk Factors for the Dissociative Disorders
Risk Factors for BPD
Comparing Risk Factors for the DDs and BPD
Mosquera and Colleagues’ Subgroup Model Of Risk Factors
Summary and Conclusions
4. Does BPD Treatment Ameliorate Dissociative Symptoms?
Standard BPD Treatment
Dissociation-focused BPD Treatment
Summary
5. Research On Dissociation in BPD: Quo Vadis?
Conclusions
BPD With Normal Levels of Dissociative Experience
BPD With Moderate Levels of Dissociative Experience
BPD With High Levels of Dissociative Experience
References
32 The Nature of Psychotic Symptoms: Traumatic in Origin and Dissociative in Kind?
Introduction and Overview
A Developmental Perspective On Trauma and Psychotic Disorders
The Prevalence and Significance of Childhood Trauma in Psychotic Disorders
How Can the Relationship Between Childhood Trauma and Psychosis Be Explained? Potential Mediating Variables
Attachment
Dissociation
Summary
Dissociation in Psychotic Disorders and Psychotic Symptoms in Dissociative Disorders: Hiding in Plain Sight?
Dissociative Disorders of Identity and Their Presentations
The Role of Dissociation in Psychotic Symptoms
Hallucinations
Delusions
Summary of the Relation Between Dissociation, Delusions and Hallucinations
The Prevalence and Significance of Dissociative Symptoms in Schizophrenia and Other Psychotic Disorders
Discussion
Differential Diagnosis and Novel Or Hybrid Diagnoses
Clinical Implications
Research Implications
Conclusions
Note
References
33 Somatoform Dissociation, Agency, and Consciousness
What Are Dissociative Symptoms Symptoms Of?
The Somatoform Dissociation Questionnaire (SDQ-20)
Terminology and Classification
DSM
ICD
Somatoform Dissociation in Various Mental Disorders
Somatoform and Psychoform Dissociation
Somatoform Dissociation, Adversity and Other Stressors
Complex Dissociative Disorders
Somatoform Dissociative Disorders
Pain Disorders
Curvilinear Associations
Causality
Somatoform Dissociation and Mammalian Defensive Reactions
Socioeconomic and Cultural Stressors
Conclusion
Agency
Phenomenal Self, World, and Self-World Coupling
Dissociative Phenomenal Self, World, and Self-World Coupling
Conclusion
Notes
References
34 Maladaptive Daydreaming Is a Dissociative Disorder: Supporting Evidence and Theory
Dissociative Absorption and the Disintegration of Conscious Experience
MD and DD: Phenomenological Similarities
MD and DD: Empirical Evidence
Qualitative Findings
Quantitative Findings
A Proposed Continuum of Agency and Control
Related Issues and Future Directions for Research
Absorption, MD, and the Neo-Janetian Perspective
Memory, Flashbacks, Nocturnal Dreaming, and Daydreaming
Fantasy Proneness
OCD and Embodiment
Attention and Control
Conclusion
Acknowledgment
Notes
References
35 Opioid Misuse and Dissociation: Two Powerful Modes of Distress Regulation
Common Etiological Roots
Trauma and the Neurobiological Basis for OUD
Co-morbidity of Dissociative Disorders and OUD
Similar Phenomenology
(1) Chemical Amnesia
(2) Chemical Suppression of Posttraumatic Arousal Symptoms
(3) Chemical Numbing, Depersonalization, and Derealization
(4) Soothing, Gratifying Pleasure
Conclusion
Note
References
36 Dissociative Factors Contributing to Violence and Antisocial Orientations
The Relationship of Dissociation to Violent Behavior
Rage as Primary Vehicle for Violence
Criminality in Dissociative Disorders – Cultural Influences
Diagnostic Considerations Within Settings of Incarceration
Summary
Notes
References
Part 6 Neurobiological and Cognitive Understandings of Dissociation
37 The Defense Cascade, Traumatic Dissociation and the Self: A Neuroscientific Model
The Complexity of Dissociative Experiences
Emotions – Basic Affective Circuits
The Midbrain Structures
Integration of Information at the Subcortical (Including the Brainstem) Level
Higher Brain Stem Structures – Alexithymia and Feelings
Under Threat – Decreased Cortical Function
BASIC Affective Circuits – Defensive Emotions
Defense Responses Are Hierarchical
Last Resort – Collapse, Despair, Immobilization, Death
Dorsal and Ventral PAG – Active Vs Passive Defensive Responses
Lateral/Dorsolateral PAG (L/dlPAG) Activation
Ventrolateral PAG (VlPAG) Activation
Peritraumatic Dissociation, Structural Dissociation, Intracortical Dissociation
Attachment – Setting the Stage
Attachment and Endogenous Opiates
Attachment, Stress, and Opioidergic Activation
Opioid Effects – Sensory and Affective
Emotion Dysregulation in PTSD and Dissociative Disorders
Attachment – Seeking for Food
Child Rearing – Pain, Isolation, Social Defeat
Dissociative Disorders – Implications for Therapeutic Interventions
Summary
References
38 Towards an Ecology of Dissociation in the Context of Trauma: Implications for the Psychobiological Study of Dissociative Disorders
TSDP in Brief
Structural Brain Studies of Dissociation in Trauma
Gray Matter in PTSD, Partial DID and DID
General Hypotheses
Hippocampal Volume in PTSD, Partial DID, and DID
Findings
Findings
Findings
Findings
Exploring the Parahippocampal Gyrus in PTSD, Partial DID and DID
Exploring the Amygdalae in PTSD and DID
Whole Brain Analyses for PTSD
Whole Brain Analyses for DID and PTSD
Findings
Exploring Cortical Thickness and Cortical Surface in DID
Hippocampal and Parahippocampal Volume in Women Who Had Recovered From DID
Findings
White Matter
Findings
Assessment of DID Using Structural Neuroimaging
Findings
Summary Comments
Functional Brain Studies of ANP and Fragile EP in Women With DID
ANP and FEP in DID: Neural Patterns and Identity (Reinders Et Al., 2003)
Hypotheses 13-16
Findings
ANP and FEP in DID: Psychobiological Reactions to Neutral and Trauma Memory Scripts (Reinders Et Al., 2006)
Hypotheses 17–19
Findings
Authentic and Simulated ANP and Fragile EP (Reinders Et Al., 2012, 2016)
Hypothesis
Findings
Hypotheses
Findings
ANP and Fragile EP in DID: Psychobiological Reactions to Subliminally Presented Faces (Schlumpf Et Al., 2013)
Hypotheses
Findings
ANP and Fragile EP in DID: Psychobiological Reactions Following Instructions to Rest (Schlumpf Et Al., 2014)
Hypotheses
Finding
Summary Comments
What Do (Our) Psychobiological Findings Tell Us?
Philosophical Materialism and Its Major Problems
Consciousness as Experience
Materialism Forgets Itself: Methodology
Materialism Forgets Itself: Need and Desire
Consciousness Is Absolute, Knowledge Relational
Matter ‘Says’ Something, Not Everything
Leaping From Gray and White Matter to the Mind
Causing
Correlation Does Not Imply Causing
The Brain Does Not Know What It Is Like
Epiphenomenalism
Measuring the Brain and the Mind in Tandem
The Nature of Matter
Steps Toward an Ecology of Dissociation in Trauma
What Whole Is Traumatized and Dissociated?
Substance
Properties, Truths, and Truthmakers
Neurophenomenology
Taking the Nature of Dissociative Disorders Seriously
Longing and Striving
Affordances and Meaning Making
Action and Passion, Joy and Sorrow
More Than a Brain
Life: An Ecological Affair
Methodology
Linking the Mind and the Brain
Group Comparison Designs and Multiple Case Studies
Researchers as Ecological Systems
Participants and Researchers in Dialogue
Retrieval of Encoding Context
Retrieval of Target-Related Details
Conclusions
Notes
References
39 The Neurobiology of Dissociation in Chronic PTSD
Alterations in Arousal in PTSD+DS
The Corticolimbic Model
Dissociative Responses and the Defense Cascade
Chronic Activation of Immobilizing Defenses
Sensory Integration and Self-Perception
Discussion
References
40 Subjective Amnesia in Dissociative Identity Disorder: A Dual Path Model Drawing On Metacognitive Beliefs Related to Self and Memory Functioning
Metacognition and Metamemory
Metamemory and Feeling of Knowing/Not Knowing
Feeling of Knowing and Its Accuracy
What Determines Feeling of Knowing?
Overview of Model Proposed in This Chapter
Path One: Cue Familiarity
Path Two: Accessibility of Related Details
Ownership of Memories
Directions for Research
Implications for Treatment
Conclusion
Acknowledgments
Notes
References
Part 7 Assessment and Measurement
41 Diagnosing the Dissociative Disorders: Conceptual, Theoretical, and Practical Considerations
Exploration of the Existing Diagnostic Instruments
Operationalizing the DSM Criteria
Mental Status Examination (MSE)
Description
Context and Origin
Conceptual and Theoretical Underpinning
Administration and Scoring
Knowledge and Training Required to Administer
Applicability and Accessibility
Dissociative Disorders Interview Schedule (DDIS)
Description
Context and Origin
Conceptual and Theoretical Underpinning
Administration and Scoring
Knowledge and Training Required to Administer
Applicability and Accessibility
Structured Clinical Interview for Dissociative Disorders (SCID-D)
Description
Context and Origin
Conceptual and Theoretical Underpinning
Administration and Scoring
Knowledge and Training Required to Administer
Applicability and Accessibility
Multidimensional Inventory of Dissociation (MID)
Description
Context and Origin
Conceptual and Theoretical Underpinning
Administration and Scoring
Knowledge and Training Required to Administer
Applicability and Accessibility
Summary
References
42 True Drama Or True Trauma?: Forensic Trauma Assessment and the Challenge of Detecting Malingering
Assessing Malingering in the Trauma Context: The Nature of the Challenge
Similarities Between Presentations of Trauma and Malingering
Psychological Testing and Trauma Response: Not in the Cookbook
So What’s an Evaluator to Do?
Validity and Post-Trauma Responding
Indicators of Anti-Social Stance
Does It Look Like a Duck? Trauma-Consistent Test Responses On Non-Trauma-Specific Tests
Trauma-specific Tests
Narrative Analysis
Cultural Competence in Assessment
Can We Be Sure?
References
Part 8 Treatment Considerations and Conceptualizations
43 Encountering the Singularities of Multiplicity: Meeting and Treating the Unique Person
Presentation and Initial Evaluation
Evaluation Continues as Preliminary Interventions Begin
Preliminary Interventions
History Gathering and Mapping
Metabolism of Trauma
The Rest of the Story
References
44 Controversies in the Treatment of Traumatic Dissociation: The Phased Model, ‘Exposure,’ and the Challenges of Therapy for Complex Trauma
Revisiting Phased Treatment for Complex Trauma
Phased Treatment Rationale
Challenge to the Phased Treatment Approach: ‘First Line’, ‘Trauma Focused’ and the Imprimatur of ‘Evidence-Based’
Exposure Therapy/ies: Questions Which Arise
The Treatment of Patients With Dissociative Disorders (TOP DD) Study
Emerging Therapies and `Multiple Resource’ Models: Alternative Critiques of Phased Treatment
The Comprehensive Resource Model (CRM)
Other Critiques Yet Continued Reference to Phases
The Role of Attachment
An Attachment-Informed Approach to Treating Trauma and Dissociation
The Ideal Parent Figure Imagery Method
Assessing Optimal Treatment For Complex Trauma
Conclusion
Notes
References
45 The Unconscionable in the Unconscious: The Evolution of Relationality in the Conceptualization of the Treatment of Trauma and Dissociation
Psychodynamic Theory and the Unconscious
Trauma and Dissociation
Hysteria, Trauma, and the Splitting of Consciousness
Psychodynamically Speaking: From Seduction to Oedipus
The Matter of Meaning in the Unconscious
Dissociation and the Unconscionable as Subjects of Inquiry
Ferenczi
Object Relations Theories
Fairbairn
Winnicott
Contemporary Models of Mind and Major Developers
Interpersonal
Feminism and Relationality
Relationality
Subjectivity and Intersubjectivity
Attachment Theory
Implicit Relational Knowing
Enactment
Attachment, Trauma, and the Developing Brain
Trauma Treatment
Phase-oriented Treatment
Developing Application
The Unconscionable in the Unconscious
Entitlement
Conclusion
References
Part 9 Treatment Challenges and Therapist Considerations
46 Memory, Trauma and the Therapeutic Encounter
Memory and Trauma
Aspects of Forgetting
Aspects of Recovered Memories
Veracity of Memories of Trauma
Types of Memory
Short-term Memory
Procedural Memory
Perceptual Memory
Semantic Memory
Episodic Memory
A Model of Memory
Memory Formation
Encoding and Consolidation
Retrieval
Enhancement
Memory Development in Childhood
The (Re)constructive Nature of Memory
Memory and the Self
Memory and Dissociation
Compartmentalization
Detachment
Dissociative Memory Fragmentation
Single Incident Traumatic Events
Childhood Trauma
Case Study
Case Discussion
Implications for Therapy
Conclusion
Acknowledgment
References
47 Conceptual Foundations for Long-Term Psychotherapy of Dissociative Identity Disorder
DID: A Diagnostic and Therapeutic Paradox
So, What Should You Know?
Discrete Behavioral States Theory (DBST) and DID
Discrete Behavioral States Theory, Self, Identity, Self-System, and Personality States
DID: A Posttraumatic, Developmental State-Change Disorder
DID and Self-States
Psychodynamic Concepts
The “Older” DID Treatment Literature
Hypnosis
Abstractions, Metaphors, Reification, the Mind, and DID
Reification and DID
Conceptualizing Self-States and Self-State Systems
Self-States
Self-State Systems
“Executive Control”
“The Whole Human Being”
Reification: Losing Sight of the Whole
Self-States/Systems: Important Principles
Helpers, Protectors, and Problem-Solvers
“Host” Self-States
“Malevolent,” “Persecutory” “Introject” Self-States
Suicidal Self-States as Paradoxical Protectors
Pragmatics of Attachment and Betrayal Trauma Theory
Shame and DID Psychotherapy
Shame and Attachment
Coercive Control
Power Dynamics
Social, Economic, Gender, and Cross-Cultural Issues
The Psychological Profile of DID From Psychological Assessment Studies
DID Personality Profile and Cognitive Processing Style
The Rorschach Traumatic Content Score
Splitting Versus Polarization
Complexity, Dissociative Distancing, and Auto-Hypnotic Defenses
DID Psychological Profile and the Process of DID Psychotherapy
Capacity for Insight
Traumatic Transference
Mind Control Transference
Attachment, Humiliation, and the Traumatic Transference
Implications
Negative Therapeutic Reaction
The Phobia of Feeling Good
Trauma-Dissociation Logic: There Is Always a “Method in the Madness”
Metacognition and Mentalization
Conclusion
Notes
References
Part 10 The Future
48 A Research Agenda for the Dissociative Disorders Field
The Broader Field
Definition
Recommended Research
Recommended Research
Recommended Research
Assessment
Epidemiology
Etiology and Psychopathogenesis
Developmental Trauma
Recommended Research
Recommended Research
Recommended Research
Insecure Attachment
Neurobiology and Genetics
Family, Culture, and Society
Overview
Recommended Research
Diagnostic Domains
Dissociative Identity Disorder and Its Partial Presentations
Dissociative Amnesia (With Or Without Fugue)
Depersonalization-Derealization Disorder
Functional (Dissociative) Neurological Symptoms (FNS)
Acute Dissociative Reaction to a Stressful Event
Recommended Research
Acute Reactive Dissociative Psychosis
Recommended Research
Identity Disturbance Due to Coercion
Recommended Research
Dissociative Trance Disorder (DTD)
Recommended Research
Dissociative Children and Adolescents
Recommended Research
Dissociative Disorder as Comorbidity
Recommended Research
Dissociation and Other Psychiatric Disorders
Schizophrenia
Recommended Research
Mood Disorders
Recommended Research
Borderline Personality Disorder (BPD)
Recommended Research
Posttraumatic Stress Disorder (PTSD)
Recommended Research
Obsessive-Compulsive Disorder
Recommended Research
Eating Disorders
Recommended Research
Possession
Recommended Research
Suicide and Self-Destructive Behavior
Recommended Research
Violence
Recommended Research
State Dissociation
Recommended Research
Recommended Research
Associated Phenomena
Treatment Outcome
Conclusions
References
49 Integrating Dissociation
Trauma and Dissociation
Diagnostic Nosology: DSM III, IV and 5
The Future of Dissociation
Neurobiology of Dissociation
Conclusion
References
Index