Handbook of Dissociation Theoretical, Empirical, and Clinical Perspectives

Handbook of Dissociation Theoretical, Empirical, and Clinical Perspectives

Edited by

Larry K. Michelson and William}. Ray The Pennsylvania State University University Park, Pennsylvania

SPRINGER SCIENCE+BUSINESS MEDIA, LLC

Library of Congress Cataloging-in-Publication Data

On file

ISBN 978-1-4899-0312-9 ISBN 978-1-4899-0310-5 (eBook) DOI 10.1007/978-1-4899-0310-5

© 1996 Springer Science+Business Media New York Originally published by Plenum Press, New York in 1996

Softcover reprint of the hardcover I st edition 1996

10987654321

All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

To my wife Sandra, for her love, light, and laughter

-LKM

To my parents, my spouse, and my children, who have shown me the varieties of loving relationships

-WJR

Contributors

Pamela C. Alexander, Department of Psychology, University of Maryland, College Park, Maryland 20742

Catherine L Anderson, Northwest Center for Community Mental Health, Reston, Virginia 22091

Peter M. Barach, Horizons Counseling Services, Inc., Cleveland, Ohio 44130

Alexandre Bennett, Department of Psychiatry, Yale University School of Medi­cine, and National Center for PTSD, Department of Veterans Affairs Medical Center, West Haven, Connecticut o6516

J. Douglas Bremner, Department of Psychiatry, Yale University School of Medi­cine, and National Center for PTSD, Department of Veterans Affairs Medical Center, West Haven, Connecticut o6516

Etzel Cardeiia, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814

Dennis S. Charney, Department of Psychiatry, Yale University School of Medicine, and National Center for PTSD, Department of Veterans Affairs Medical Center, West Haven, Connecticut o6516

James A. Chu, Dissociative Disorders Program, McLean Hospital, Belmont, Massa­chusetts 02178; and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

Catherine Classen, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305

Barry M. Cohen, P.O. Box 9853, Alexandria, Vu-ginia 22304

Pamela M. Cole, Department of Psychology, Pennsylvania State University, Univer­sity Park, Pennsylvania 16802

Christine M. Comstock, Horizons Counseling Services, Inc., Cleveland, Ohio 44130 vii

viii Contributors

Philip M. Coons, Department of Psychiatry, Indiana University School of Medi­cine, Indianapolis, Indiana 46202

George H. Faust, 2515 Kemper Place, Shaker Heights, Ohio 44120

Catherine G. Fine, Dissociative Disorders Unit, Institute of Pennsylvania Hospital, Philadelphia, Pennsylvania 19139

Edna B. Foa, Center for the Treatment and Study of Anxiety, Medical College of Pennsylvania, Eastern Pennsylvania Psychiatric Institute, Philadelphia, Pennsylvania 19129

Jean M. Goodwin, Department of Psychiatry, University of Texas Medical Branch, Galveston, Texas 77555.0428

George B. Greaves, 1175 LaVista Road, Apartment #205, Atlanta, Georgia 30324

Diana Hearst-Ikeda, National Center for Posttraumatic Stress Disorder, Women's Health and Sciences Division, Boston Department of Veterans Mfairs Medical Cen­ter, Boston, Massachusetts 02130

Nancy L Hornstein, Department of Psychiatry, Child Division, University of Illinois at Chicago and Institute for Juvenile Research, Chicago, Illinois 61612

Richard P. Kluft, Dissociative Disorders Program, The Institute of Pennsylvania Hospital, Philadelphia, Pennsylvania 19139

Cheryl Koopman, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305

John H. Krystal, Department of Psychiatry, Yale University School of Medicine, and National Center for PTSD, Department of Veterans Affairs Medical Center, West Haven, Connecticut 06516

Richard J. Loewenstein, Dissociative Disorders Service line, Sheppard Pratt Health Systems, Baltimore, Maryland 21285; and Department of Psychiatry and Behavioral Sciences, University of Maryland School of Medicine, Baltimore, Mary­land 21201

Mary Main, Department of Psychology, University of California at Berkeley, Berkeley, California 94720

Richard Moraga, Department of Psychology, Pennsylvania State University, Uni­versity Park, Pennsylvania 16802

Hillary Morgan, Department of Psychology, University of California at Davis, Davis, California 95616

Michael R. Nash, Department of Psychology, University of Tennessee at Knoxville, Knoxville, Tennessee 37996

Judith A. Peterson, Phoenix Counseling, Consulting, and Forensic Services, 3 303 Chimney Brook Lane, Houston, Texas 77068

William}. Ray, Department of Psychology, Pennsylvania State University, Univer­sity Park, Pennsylvania 16802

Colin A. Ross, Dissociative Disorders Unit, Charter Behavioral Health System of Dallas, Plano, Texas 75024

Roberta G. Sachs, Highland Park Psychological Resources, 660 LaSalle Place, Highland Park, Illinois 60035

David K. Sakheim, 1610 Ellington Road, South Windsor, Connecticut 06o74

Steven M. Southwick, Department of Psychiatry, Yale University School of Medi­cine, and National Center for PTSD, Department of Veterans Affairs Medical Center, West Haven, Connecticut 06516

David Spiegel, Department of Psychiatry and Behavioral Sciences, Stanford Uni­versity School of Medicine, Stanford, California 94305

Marlene Steinberg, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06510

Moshe S. Torem, Department of Psychiatry and Behavioral Sciences, Akron Gen­eral Medical Center, Akron, Ohio 44307; and Department of Psychiatry, North­eastern Ohio Universities College of Medicine, Akron, Ohio 44272

Onno Van der Hart, Department of Clinical and Health Psychology, Utrecht University, and the Regional Institute for Ambulatory Mental Care, Amsterdam South/New West, The Netherlands

Johan Vanderlinden, Department of Behavior Therapy, University Center St. Jozef, B-3070 Kortenberg, Belgium

Katalin Varga, Department of Experimental Psychology, Eotvos Lorand University, Budapest, Hungary

Helen H. Watkins, Department of Psychology, University of Montana, Missoula, Montana 59801

John G. Watkins, Department of Psychology, University of Montana, Missoula, Montana 59801

Jonathan E. Whalen, Department of Psychology, University of Tennessee at Knoxville, Knoxville, Tennessee 37996

Linda J. Young, National Treatment Center for Traumatic and Dissociative Dis­orders, Del Amo Hospital, Torrance, California 90505

Walter C. Young, National Treatment Center for Traumatic and Dissociative Disor­ders, Del Amo Hospital, Torrance, California 90505

Theodore P. Zahn, Laboratory of Psychology and Psychopathology, National Institute of Mental Health, Bethesda, Maryland 20892

ix Contributors

Preface

Within the last decade there has been a tremendous explosion in the clinical, theoretical, and empirical literature related to the study of dissociation. Not since the work done at the tum of the century by Pierre Janet, Morton Prince, William James, and others have the psychological and medical communities shown this great an interest in describing and understanding dissociative phenomena. This volume is the result of this significant expansion. Presently, interest in the scientific and clinical progress in the field of dissociation is indicated by the following:

1. The explosion of conferences, workshops, and seminars devoted to disso­ciative disorders treatment and research.

2. The emergence of NIMH-supported investigations that focus on dissociation. 3. The burgeoning literature on dissociation. According to a 1992 biblio­

graphic analysis of the field by Goettman et al. (1992), 72% of all writings on the topic have appeared in the past decade, with about 1000 published papers scattered across diverse disciplines and journals.

4. Current interest in dissociation as reflected in the appearance of major articles and special issues in respected psychology and psychiatry journals.

5. The initiation of a journal entitled Dissociation (Richard Kluft, MD, Editor) devoted to the area.

6. The development of scientific organizations such as the International Society for the Study of Dissociation, as well as dissociation presentations within such organizations as the Society for Experimental and Clinical Hypnosis, the American Society of Clinical and Experimental Hypnosis, and special interest groups within both the American Psychological Asso­ciation and the American Psychiatric Association.

7. The growing awareness of the prevalence of childhood sexual abuse and its sequelae in relation to dissociative phenomena.

8. The rapidly expanding database from psychology, psychiatry, medicine, and epidemiology on the comorbidity of dissociation and affective, anxi­ety, and posttraumatic stress disorders, in addition to eating, somatoform, and personality disorders.

9. Growing international interest in dissociation as manifested by significant xi

xii Preface

increases in research, papers, and conferences from outside of North America.

10. Recent studies revealing the relatively high prevalence of dissociative phenomena and disorders among inpatient, outpatient, and "normal" populations, indicating it will likely remain a permanent and significant area for conceptual, scientific, and clinical inquiry.

11. An increasing number of individuals presenting for treatment with disso­ciative disorder.

12. The publication of three volumes, two on dissociative identity disorder (multiple personality disorder) by Frank Putnam and Colin Ross and an edited volume on theoretical and clinical perspectives of dissociation by Steven Lynn and Judith Rhue.

However, from the outset it should be noted that with this renewed interest also has come great controversy. Articles and letters have been written to scientific journals suggesting that not only are dissociative disorders overestimated but that certain disorders such as dissociative identity disorder may not exist at all. Since early trauma and sexual abuse have been associated with the presence of dissocia­tive disorders, there has been a growing concern as to valid methods for establish­ing past trauma or sexual abuse. As part of this approach, authors have debated the ability of a given individual to recover lost memories of trauma or sexual abuse. Those of us who have tried to follow these debates quickly learn that the search for objectivity and truth remains a complex process in the midst of highly rhetorical presentations. Oearly, untrained therapists, in spite of their best motivations, seek signs of abuse or dissociative disorders where they may not exist, and thus do not act in the best interests of either their patients or the field of dissociation. However, there are also individuals who move through the mental health system with unre­cognized dissociative processes and remain untreated.

Presently there are few published volumes that provide a comprehensive, state-of-the-art text that simultaneously addresses theoretical, conceptual, diagnos­tic, assessment, treatment, ethical, and legal dimensions of the field of dissociation. The luminary status of the volume's contributors, whose expertise spans the entire spectrum of dissociative phenomena, has resulted in a stimulating, comprehensive, and in-depth volume. The text's potential significance includes, but is certainly not limited to, the following: (1) Highly respected theorists, scientists, clinical­researchers, and psychotherapists share their expertise, resulting in an integrated volume that reflects the cutting edge of the field; (2) the presence of a "critical mass" of theory, research, and practice in the field of dissociation, which was awaiting compilation into a substantive, cohesive, multidisciplinary volume; and (3) likely audiences for the text include psychologists, psychiatrists, social workers, and other mental health professionals, graduate students, interns, residents, univer­sity libraries, and institutions of higher learning.

We believe the volume has much potential for stimulating dialogue in the dissociation field, which is rapidly expanding and making fertile interconnections with other disciplines and sciences. Further, we hope the text will serve as a primary source for elucidation of both current and emerging theory, research, and treatment of dissociative phenomena.

The volume is divided into seven parts. Part I, Foundations, entails historical,

epidemiological, phenomenological, etiological, normative, and cross-<:Ultural di­mensions of dissociative phenomena, providing an empirical foundation for the remaining chapters. Part II, Developmental Perspectives, represents a newly emerg­ing area that focuses on developmental aspects of dissociative processes, including the potential role of incest and attachment in the development of dissociative processes, as well as a description of dissociative disorders in childhood and adolescence. Part m, Theoretical Models, encompasses contemporary conceptual and research dimensions from a variety of perspectives. These contributions in­clude psychobiological, information-processing models of dissociation, and the relation of dissociation to hypnotic phenomena, moving beyond earlier theoretical frameworks for elucidating the etiopathogenesis of dissociation. Part IY, entitled Assessment, comprises three interrelated chapters devoted to the diagnosis, psy­chological, and psychophysiological assessment of clients with dissociative dis­orders.

Part V, Diagnostic Classifications, offers clinicians and researchers an overview of current nosology, differential diagnoses, as well as conceptual and clinical impli­cations of the varied dissociative disorders. In Part VI, Therapeutic Interventions, eight chapters are presented that provide a wealth of information for clinicians treating clients with dissociative disorders, posttraumatic stress disorders, and survivors of sexual abuse and/or assault. These chapters reflect leading clinical perspectives in the amelioration of dissociative disorders and related sequelae of abuse. In Part VII, the final section, Special Topics, two chapters address ritual abuse and ethical-legal issues in dissociative disorders that should be considered as important readings for clinicians working with dissociative disorder clients.

In our clinical and research endeavors with clients with myriad dissociative disorders, we have been sensitized to both the advances in theory, research, and treatment, as well as, unfortunately, the many "black holes" of knowledge that await further scientific study. We were struck by the need for a comprehensive volume on dissociation that would be useful to the professional as well as for graduate-level courses and seminars, providing a timely, balanced, and cogent review of the controversial tributaries in the field. Hence, we endeavored to have the contribu­tors address both fundamental domains as well as issues that have generated much debate in scientific and clinical spheres.

We hope the reader finds the volume as intellectually and clinically rewarding as we have in helping it come to fruition. We would like to extend our sincere appreciation to the outstanding contributors who so generously offered their cumulative wisdom and expertise. To the clients who so courageously shared their experiences and whose quest for healing has enlightened us all, we want to express our deepest gratitude and respect.

REFERENCES

LARRY K. MICHElSON

WILLIAM J. RAY

Gotteman, C., Greaves, G., & Coons, P. (1992). Multtple personality and dtssoctatton, 1791-1990: A complete bibliography. Atlanta: Greaves.

xill Preface

Contents

I. FOUNDATIONS

1. History, Phenomenology, and Epidemiology of Dissociation 3 Colin A. Ross

2. European Studies of Dissociation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Johan Vanderlinden, Onno Van der Hart, and Katalin Varga

3. Dissociation in Normal Populations.......................... 51 William J. Ray

U. DEVEWPMENTAL PERSPECTIVES

4. Dissociation in Typical and Atypical Development: Examples from Father-Daughter Incest Survivors . . . . . . . . . . . . . . . . . . . . . . 69 Pamela M. Cole, Pamela C. Alexander, and Catherine L. Anderson

5. Child Abuse in the Etiology of Dissociative Disorders . . . . . . . . . 91 Jean M. Goodwin and Roberta G. Sachs

6. Disorganization and Disorientation in Infant Strange Situation Behavior: Phenotypic Resemblance to Dissociative States . . . . . . 107 Mary Main and Hillary Morgan

XV

xvi Contents

7. Dissociative Disorders in Chlldren and Adolescents........... 139 Nancy L. Hornstein

m. TIIEORETICAL MODELS

8. Recent Developments in the Neurobiology of Dissociation: Implications for Posttraumatic Stress Disorder . . . . . . . . . . . . . . . 163 John H. Krystal, Alexandre Bennett, ]. Douglas Bremner, Steven M. Southwick, and Dennis S. Charney

9. Hypnosis and Dissociation: Theoretical, Empirical, and <linical~pecttves . . .. . . . .. .. .. . . . . . . . . . . . . . .. . . . . .. . . ... . 191 Jonathan E. Whalen and Michael R. Nash

10. Emotional Dissociation in Response to Trauma: An Information-Processing Approach . . . . . . . . . . . . . . . . . . . . . . . . 207 Edna B. Foa and Diana Hearst-Ikeda

IV. ASSESSMENT

11. Diagnostic Issues, Criteria, and Comorbidity of Dissociative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Etzel Cardeiia and David Spiegel

12. The Psychological Assessment of Dissociation . . . . . . . . . . . . . . . . 251 Marlene Steinberg

13. Psychophysiological Assessment of Dissociattve Disorders 269 Theodore P. Zahn, Richard Moraga, and William J. Ray

V. DIAGNOSTIC CLASSIFICATIONS

14. Depersonalization and Derehlization . . . . . . . . . . . . . . . . . . . . . . . . . 291 Philip M. Coons

15. Dissociattve Amnesia and Dissociattve Fugue . . . . . . . . . . . . . . . . . 307 Richard J. Loewenstein

16. Dissociative Identity Disorder Richard P. Kluft

17. Dissociative Symptoms in the Diagnosis of Acute Stress

337

Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 David Spiegel, Cheryl Koopman, Etzel Cardefta, and Catherine Classen

18. Posttraumatic Responses to Chlldhood Abuse and Implications for Treat:Dlent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 James A. Chu

VI. THERAPEUTIC INTERVENTIONS

19. A Cognitively Based Treatment Model for DSM-IV Dissociative Identity Disorder ........................................... 401 Catherine G. Fine

20. Psychodynamic Psychotherapy of Dissociative Identity Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413 Peter M. Barach and Christine M. Comstock

21. Overt-Covert Dissociation and Hypnotic Ego State Therapy . . . 431 John G. Watkins and Helen H. Watkins

22. Hypnotherapeutic Techniques to Facilitate Psychotherapy with PI'SD and Dissociative Clients .. . .. . . . . . . . . .. . . .. . .. . . . . 449 Judith A. Peterson

23. Memory Processing and the Healing Experience.............. 475 Roberta G. Sachs and Judith A. Peterson

24. Inpatient Treatment of Dissociative Disorders . . . . . . . . . . . . . . . . 499 Walter C. Young and Linda J. Young

25. Art and the Dissociative Paracosm: Uncommon Realities . . . . . . 525 Barry M. Cohen

26. Psychopharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545 Moshe S. Torem

xvii Contents

xviii Contents

vn. SPECIAL TOPICS

27. CUnical Aspects of Sadistic Ritual Abuse . . . . . . . . . . . . . . . . . . . . . . 569 David K. Sakheirn

28. Legal and Ethical Issues in the Treatment of Dissociative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 George B. Greaves and George H. Faust

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617