During the formative years of contemporary psychiatry much attention was paid to the continuing role of past traumatic experiences on the current lives of people. Charcot, Janet, and Freud all noted that fragmented memories of traumatic events dominated the mental life of many of their patient and built their theories about the nature and treatment of psychopathology on this recognition. Janet75 thought that traumatic memories of traumatic events persist as unassimilated fixed ideas that act as foci for the development of alternate states of consciousness, including dissociative phenomena, such as fugue states, amnesias, and chronic states of helplessness and depression. Unbidden memories of the trauma may return as physical sensations, horrific images or nightmares, behavioral reenactments, or a combination of these. Janet showed how traumatized individuals become fixated on the trauma: difficulties in assimilating subsequent experiences as well. It is “as if their personality development has stopped at a certain point and cannot expand anymore by the addition or assimilation of new elements.”76 Freud independently came to similar conclusions.43,45 Initially, he thought all hysterical symptoms were caused by childhood sexual “seduction” of which unconscious memories were activated, when during adolescence, a person was exposed to situations reminiscent of the original trauma. The trauma permanently disturbed the capacity to deal with other challenges, and the victim who did not integrate the trauma was doomed to “repeat the repressed material as a contemporary experience in instead or . . . remembering it as something belonging to the past.”44 In this article, I will show how the trauma is repeated on behavioral, emotional, physiologic, and neuroendocrinologic levels, whose confluence explains the diversity of repetition phenomena.
Many traumatized people
expose themselves, seemingly compulsively, to situations reminiscent
of the original trauma. These behavioral reenactments are rarely consciously
understood to be related to earlier life experiences. This “repetition
compulsion” has received surprisingly little systematic exploration
during the 70 years since its discovery, though it is regularly described
in the clinical literature.12,17,21,29,61,64,
Children seem more vulnerable
than adults to compulsive behavioral repetition and loss of conscious
memory of the trauma.70,136. However, responses to projective
tests show that adults, too, are liable to experience a large range
of stimuli vaguely reminiscent of the trauma as a return of the trauma
itself, and to react accordingly.39,42
BEHAVIORAL RE-ENACTMENT
In behavioral re-enactment of the trauma, the self may play the role of either victim or victimizer.
Harm to Others
Re-enactment of victimization is a major cause of violence. Criminals have often been physically or sexually abused as children.55,121 In a recent prospective study of 34 sexually abused boys, Burgess et al.20 found a link with drug abuse, juvenile delinquency, and criminal behavior only a few year later. Lewis89,91 has extensively studied the association between childhood abuse and subsequent victimization of others. Recently, she showed that of 14 juveniles condemned to death for murder in the United States in 1987, 12 had been brutally physically abused, and five had been sodomized by relatives.90 In a study of self-mutilating male criminals, Brach-y-Rita7 concluded that “the constellation of withdrawal, depressive reaction, hyperreactivity, stimulus-seeking behavior, impaired pain perception, and violent aggressive behavior directed at self or others may be the consequence of having been reared under conditions of maternal social deprivation. This constellation of symptoms is a common phenomenon among a member of environmentally deprived animals.”
Self-destructiveness
Self-destructive acts are common in abused children. Green53,54 found that 41 per cent of his sample of abused children engaged in headbanging, biting, burning, and cutting. In a controlled, double-blind study on traumatic antecedents of borderline personality disorder, we found a highly significant relationship between childhood sexual abuse and various kinds of self-harm later in life, particularly cutting and self-starving.143a Clinical reports also consistently show that self-mutilators have childhood histories of physical or sexual abuse, or repeated surgery.52,106,118,126 Simpson and Porter126 found a significant association between self-mutilation and other forms of self-deprecation or self-destruction such as alcohol and drug abuse and eating disorders. They sum up the conclusions of many students of this problem in stating that “self-destructive activities were not primarily related to conflict, guilt and superego pressure, but to more primitive behavior patterns originating in painful encounters wih hostile caretakers during the first years of life.”
Revictimization
Revictimization is a
consistent finding.35,47,61 Victims of rape are more likely
to be raped and women who were physically or sexually abused as children
are more likely to be abused as adults. Victims of child sexual abuse
are at high risk of becoming prostitutes.38,72,125 Russell,120 in a very careful study of the effects
of incest on the life of women, found that few women made a conscious
connection between their childhood victimization and their drug abuse,
prostitution, and suicide attempts. Whereas 38 per cent of a random
sample of women reported incidents of rape or attempted rape after age
14, 68 per cent of those with a childhood history of incest did. Twice
as many women with a history of physical violence in their marriages
(27 per cent), and more than twice as many (53 per cent) reported unwanted
sexual advances by an unrelated authority figure such as a teacher,
clergyman, or therapist. Victims of father-daughter incest were four
times more likely than nonincest victims to be asked to pose for pornography.
RE-EXPERIENCING AFTER ADULT TRAUMA
There are sporadic clinical
reports,12,59 but systematic studies on re-enactment
and revictimization in traumatized adults are even scarcer than in children.
In one study of adults who who had recently been in accidents,68 57 per cent showed behavioral re-enactments,
and 51 per cent had recurrent intrusive images. In this study, the frequency
with which recurrent memories were experienced on a somatic level, as
panic and anxiety attacks, was not examined. Studies of burned children131 and adult survivors of natural and
manmade disasters67,124 show that, over time, rucurrent
symbolic or visual recollections and behavioral re-enactments abate,
but there is often persistent chronic anxiety that can be interpreted
as partial somatosensory reliving, dissociated from visual or linguistic
representations of the trauma.141 There are scattered clinical reports64,65,109 of people re-enacting the trauma
on its anniversary. For example, we treated a Vietnam veteran who had
lit a cigarette at night and caused the death of a friend by a VietCong
sniper's bullet in 1968. From 1969 to 1986, on the exact anniversary
of the death, to the hour and minute, he yearly committed “armed
robbery” by putting a finger in his pocket and staging a “holdup,”
in order to provoke gunfire from the police. The compulsive re-enactment
ceased when he came to understand its meaning.
SOCIAL ATTACHMENT AND THE TRAUMA RESPONSE
Human beings are strongly dependent on social support for a sense of safety, meaning, power, and control.14,15,93 Even our biologic maturation is strongly influenced by the nature of early attachment bonds.137 Traumatization occurs when both internal and external resources are inadequate to cope with external threat. Physical and emotional maturation, as well as innate variations in physiologic reactivity to perceived danger, play important roles in the capacity to deal with external threat.77 The presence of familiar caregivers also plays an important role in helping children modulate their physiologic arousal.146 In the absence of a caregiver, chidren experience extremes of under-and over arousal that are physiologically aversive and disorganizing.38 The availability of a caregiver who can be blindly trusted when their own resources are inadequate is very important in coping with threats. If the caregiver is rejecting and abusive, children are likely to become hyperaroused. When the persons who are supposed to be the sources of safety and nurturance become simultaneously the sources of danger against which protection is needed, children maneuver to re-establish some sense of safety. Instead of turning on their caregivers and thereby losing hope for protection, they blame themselves. They become fearfully and hungrily attached and anxiously obedient.24 Bowlby16 calls this “a pattern of behavior in which avoidance of them competes with his desire for proximity and care and in which angry behavior is apt to become prominent.”
Studies by Bowlby and
Ainsworth1 in humans, and by Harlow and his
heirs58,114 in other primates, demonstrate the
crucial role that a “safe base” plays for normal social and
biologic development. As children mature, they continually acquire new
cognitive schemata in which to frame current life experiences. These
ever-expanding cognitive schemes decrease their reliance on the environment
for soothing and increase their own capacity to modulate physiologic
arousal in the face of threat. Thus, the cognitive preparedness (development)
of an individual interacts with the degree of physiologic disorganization
to determine the capacity for mental processing of potentially traumatizing
experiences.137,141
SEX DIFFERENCES
The frequency with which abused children repeat aggressive interactions has suggested to Green53 a link between the compulsion to repeat and identification with the aggressor, which replaces fear and helplessness with a sense of omnipotence. There are significant sex differences in the way trauma victims incorporate the abuse experience. Studies by Carmen et al.22,71 and others indicate that abused men and boys tend to identify with the aggressor and later victimize others wheras abused women are prone to become attached to abusive men who allow themselves and their offspring to be victimized further.
Reiker and colleagues113 have pointed out that “confrontations
wih violence challenges one's most basic assumptions about the self
as invulnerable and intrinsically worthy and about the world as orderly
and just. After abuse, the victim's view of self and world can never
be the same again: it must be reconstructed.to incorporate the abuse
experience.” Assuming responsibility for the abuse allows feelings
of helplessness to be replaced with an illusion of control. Ironically,
victims of rape who blame themselves have a better prognosis than those
who do not assume this false responsibility: it allows the locus of
control to remain internal and prevent helplessness. Children are even
more likely to blame themselves: “The child needs to hold on to
an image of the parent as good in order to deal with the intensity of
fear and rage which is the effect of the tormenting experiences.”113 Anger directed against the self
or others is always a central problem in the life of people who have
been violated. Reikers concludes that “this 'acting out' is seldom
understood by either victims or clinicians as being a repetitive re-enactment
of real events from the past.”
THE SEPARATION REPONSE
Primates have evolved
highly complex ways to maintain attachment bonds; they are intensely
dependent on their caregivers at the start. In lower primates, his dependency
is principally expressed in physical contact, in humans this is supplemented
by verbal communication. McLean93 suggests that language is an evolutionary
development from the mammalian separation cry that induces caregivers
to provide safety, nurturance, and social stimulation. Primates react
to separation from attachment figures as if they were directly threatened.
Thus, small children, unable to anticipate the future, experience separation
anxiety as soon as they lose sight of their mothers. Bowlby has described
the protest and dispair phases of this response in great detail.14,15 As people mature, hey develop an
ever-enlarging repertoire of coping responses, but adults are still
intensely dependent upon social support to prevent and overcome traumatization,
and under threat they still may cry out for their mothers.57 Sudden, uncontrollable loss of attachment
bonds is an essential element in the development of post-traumatic stress
syndromes.45,88,92,138 On exposure to extreme terror, even
mature people have protest and dispair responses (anger and grief, intrusion
and numbing) that make them turn toward the nearest available source
of comfort to return to a state of both psychological and physiologic
calm. Thus, severe external threat may result in renewed clinging and
neophobia in both children and adults.8,41,111 Because the attachment system is
so important, mobilization of social supports is an important element
in the treatment of post-traumatic stress disorder (PTSD).
INCREASED ATTACHMENT IN THE FACE OF DANGER
People in general, and children in particular, seek increased attachment in the face of external danger. Pain, fear, fatigue, and loss of loved ones and protectors all evoke efforts to attract increased care,8,41,111 and most cultures have rituals designed to provide it. When there is no access to ordinary sources of comfort, people may turn toward their tormentors.14,38,80,102 Adults as well as children may develop strong emotional ties with people who intermittently harass, beat, and threaten them. Hostages have put up bail for their captors, expressed a wish to marry them, or had sexual relations with them;31 abused children often cling to their parents and resist being removed from the home;31,80 inmates of Nazi prison camps sometimes imitated their captors by sewing together clothing to copy SS uniforms.11 When Harlow observed this in nonhuman primates, he stated that “the immediate consequences of maternal rejection is the accentuation of proximity seeking on the part of the infant.”114
Walker145 and Dutton and Painter31 have noted that the bond between batter and victim in abusive marriages resembles the bond between captor and hostage or cult leader and follower. Social workers, police, and legal personnel are constantly frustrated by the strength of this bond. The woman's longing for the batterer soon prevails over memories of the terror, and she starts to make excuses for his behavior. This pattern is so common that women engaged in these sorts of relationships become the recipients of intense anger for social service personnel. They are then called masochistic, and like other psychiatric terms, this can be employed pejoratively rather than conveying an understanding of the underlying causes and treatment of the problem. Walker145 first applied ethnology to the study of traumatic bonding in such couples. A central component is captivity, the lack of permeability, and the absence of outside support or influence.31,62,119,145 The victim organizes her life completely around pleasing her captor and his demands. As Dutton and Painter point out, “her compliance legitimates his demands, builds up a store of repressed anger and frustration on her part (which may surface in her goading him or fighting back during an actual argument, leading to escalating violence), and systematically eliminates opportunities for her to build up a supportive network which could eventually assist her in leaving the relationship.”
Walker145 has clarified the operation of intermittent
reinforcement paradigms in such relationships, applying the animal model
of punishment-indulgence patterns. In child abuse or spouse battering,
this mechanism is accentuated by the extreme contrast of terror followed
by submission and reconciliation. When such negative reinforcement occurs
intermittently, the reinforced response consolidates the attachment
between victim and victimizer. During the abuse, victims tend to dissociate
emotionally with a sense of disbelief that the incident is really happening.
This is followed by the typical post-traumatic response of numbing and
constriction, resulting in inactivity, depression, self-blame, and feelings
of helplessness. Walker145 describes the process as follows:
“tension gradually builds” (during phase one), an explosive
battering incident occurs (during phase two), and a “calm, loving
respite follows phase three). The violence allows intense emotional
engagement and dramatic scenes of forgiveness, reconciliation, and physical
contact that restores the fantasy of fusion and symbiosis.87,140 Hence, there are two powerful sources
of reinforcement: the “arousal-jag” or excitement before the
violence and the peace of surrender afterwards, Both of these responses,
placed at appropriate intervals, reinforce the traumatic bond between
victim and abuser.31,145 To varying degrees, the memory of
the battering incidents is state-dependent or dissociated, and thus
only comes back in full force during renewed situations of terror. This
interferes with good judgment about the relationship and allows longing
for love an reconciliation to overcome realistic fears.
VULNERABILITY
TO DEVELOP
TRAUMATIC BONDING
At least four studies of family violence40,48,63,132 have found a direct relationship between the severity of childhood physical abuse and later marital violence. Interestingly, nonhuman primates subjected to early abuse and deprivation also are more likely to engage in violent relationships with their peers as adults.134 as in humans, males tend to be hyperaggressive, and females fail to protect themselves and their offspring against danger. Neither sex develops the capacity for sustained peaceful social interactions.134
People who are exposed
early to violence or neglect come to expect it as a way of life. They
see the chronic helplessness of their mothers and fathers' alternating
outbursts of affection and violence; they learn that they themselves
have no control. As adults they hope to undo the past by love, competency,
and exemplary behavior.46,87,145 When they fail they are likely to
make sense out of this situation by blaming themselves. When they have
little experience with nonviolent resolution of differences, partners
in relationships alternate between an expectation of perfect behavior
leading to perfect harmony and a state of helplessness, in which all
verbal communication seems futile. A return to earlier coping mechanisms,
such as self-blame, numbing (by means of emotional withdrawal or drugs
or alcohol), and physical violence sets the stage for a repetition of
the childhood trauma and “return of the repressed.”1,42,46,137
BIOLOGIC RESPONSES TO TRAUMATIZATION
Chronic physiologic hyperarousal to stimuli reminiscent of the trauma is a cardinal feature of the trauma response, well documented in a large variety of traumatized individuals, including victims of child abuse, burns, rape, natural disasters, and war.2,78,84,107,133,142 Because of their decreased capacity to modulate physiologic arousal, which leads to reduced ability to utilize symbols and fantasy to cope with stress, they tend to experience later stresses as somatic states, rather than as specific events that require specific means of coping.142 Thus, victims of trauma respond to contemporary stimuli as if the trauma had returned, without conscious awareness that past injury rather than current stress is the basis of their physiologic emergency responses. The hyperarousal interferes with their ability to make calm and rational assessments and prevents resolution and integration of the trauma.142 They respond to threats as emergencies requiring action rather than thought.
Chronic hyperarousal in response to new challenges is also found in animals exposed to inescapable shock.5 In fact, this phenomenon drew our attention to the possibility of using this animal model for the study of human traumatization.142 Human beings and other mammals are very similar biologically in respect to such relatively uncomplicated behaviors as fight, flight, and freeze responses. Exposure to inescapable aversive events has widespread behavioral and physiologic effects on animals including (1) deficits in learning to escape novel adverse situations, (2) decreased motivation for learning new options, (3) chronic subjective distress,94 and (4) increased tumor genesis and immunosuppression.143 All this is the result not of the shock itself but of a helplessness syndrome that is a result of the lack of control that the animal has in terminating shock.
Several neurotransmitters
have been shown to be affected by inescapably fearful experiences in
animals; they have low resting cerebro-spinal fluid (CSF) norepinephrine,
but under stress they respond with much higher elevations than other
animals. Something has disturbed the organisms capacity to modulate
the extent of arousal.37,95,115,116,142 Dysregulation of the serotonin system
has been implicated in this.123,139 Serotonin is thought to be the neurotransmitter
most involved in modulating the actions of other neurotransmitters;19 it has also been implicated in the
fine tuning of emotional reactions, particularly arousal and aggression.18 Traumatization also causes dysregulation
of the endogenous opioid system in both animals and humans. We will
discuss this phenomenon and how this could explain the clinical phenomenon
of compulsive re-exposure to trauma.
STATE-DEPENDENT LEARNING
Both Janet74 and Freud observed that early memory traces can be activated by later events that cause partial reliving of earlier traumas in the form of affect states, anxiety, or re-enactments. Their patients generally had a poor memory for traumatic childhood events, until they were brought back, by means of hypnosis, to a state of mind similar to the one they were in at the time of the trauma. In the past few decades, these notions have gained scientific confirmation with the discovery of state-dependent learning; for example what is learned under the influence of a particular drug tends to become dissociated and seemingly lost until return of the state similar to the one in which the memory was stored. State dependency can be roughly related to arousal levels. For example, state-dependent learning in humans is produced by both psychostimulants and depressants: alcohol, marijuana, barbituates, and amphetamines as well as other psychoactive agents.32 Reactivation of past learning is relatively automatic: contextual stimuli directly evoke memories without conscious awareness of the transition. The more similar are the contextual stimuli are to conditions prevailing at the time of the original storage of memories, the more likely the probability of retrieval. Both internal states, such as particular affects, or external events reminiscent of earlier trauma thus can trigger a return to feeling as if victims are back in their original traumatizing situation. Thus, battered women who otherwise behave competently may experience themselves within the battering relationship like the terrified child they once were in a violent or alcoholic home.119 Similarly, war veterans may be asymptomatic until they become intimate with a partner and start reliving feelings of loss, grief, vulnerability, and revenge related to the death of a comrade on the battlefield but that are now incorrectly attributed to some element of the current relationship. Disinhibition resulting from drugs or alcohol strongly facilitates the occurrence of such reliving experiences, which then may take the form of acting out violent or sexual traumatic episodes.107
During states of massive
autonomic arousal, memories are laid down that powerfully influence
later actions and interpretations of events. Long-term activation of
memory tracts is observed in animals exposed to a highly stressful stimulus.51,81 This pheromenon has been attributed
to massive noradrenergic activity at the time of the stress.129 In traumatized people, visual and
motoric reliving experiences, nightmares, flashbacks, and re-enactments
are generally preceded by physiologic arousal.30 Activation of long-term augmented
memory tracts may explain why current stress is experienced as a return
of the trauma.
“RETURN
OF THE REPRESSED” OCCURS IN SITUATIONS
OF THREAT
Under ordinary conditions, most previously traumatized individuals can adjust psychologically and socially. Studies have shown this to be true of victims of rape,82 battered women,63 and victims of child abuse.53 Nonhuman primates subjected to extended periods of isolation may later become reasonably well integrated socially. However, they do not respond to stress in the same ways as their nontraumatized peers. Studies in the Wisconsin primate laboratory have shown that, even after an initial good social adjustment, heightened emotional or physical arousal causes social withdrawal or aggression.86 Even monkeys that recover in other respects tend to respond inappropriately to sexual arousal and misperceive social cues when threatened by a dominant animal.4,95,101 Animals with a history of trauma also have much more intense catecholamine responses to stress85 and a blunted cortisol response.25
Stress causes a return
to earlier behavior patterns throughout the animal kingdom. In experiments
in mice, Mitchell and colleagues98,99 found that arousal state determines
how an animal will react to stimuli. In a state of low arousal, animals
tend to be curious and seek novelty. During high arousal, they are frightened,
avoid novelty, and perseverate in familiar behavior regardless of the
outcome. Under ordinary circumstances, an animal will choose the most
pleasant of two alternatives. When hyperaroused, it will seek the familiar,
regardless of the intrinsic rewards.99 Thus shocked animals returned to
the box in which they were originally shocked, in preference to less
familiar locations not associated with punishment. Punished animals
actually increased their exposure to shock as the trials continued.98 Mitchell concluded that this perseveration
is nonassociative, that is, if uncoupled from the usual rewards systems,
animals seek optimal levels of arousal,10,122 and this mediates patterns of alternation
and perseveration. Because novel stimuli cause arousal, an animal in
a state of high arousal will avoid even mildly novel stimuli even if
it would reduce exposure to pain.
“THE COSTS OF PLEASURE AND THE BENEFITS OF PAIN'
Solomon127 proposes an “opponent process theory of acquired motivation” to explain addictive behavior that originates in frightening or painful events. He points out that frequent exposure to stimuli, pleasant or unpleasant, may lead to habituation; the resulting withdrawal or abstinence state can take on a powerful life of its own and may become an effective source of motivation. In drug addiction, for example, the motivation changes from getting high (pleasure) to controlling a highly aversive withdrawal state.
In contrast with drug taking, which initially is pleasant, many initially aversive stimuli, such as sauna bathing, marathon running, and parachute jumping, may also be eventually perceived as highly rewarding by people who have repeatedly exposed themselves to these frightening or painful situations. Parachute jumpers, sauna bathers, and marathon runners all feel exhilaration and a sense of well-being from the intially aversive activities. These new sources of pleasure become independent of the fear that was necessary to produce them in the first place. Solomon concludes that certain behaviors can become highly pleasurable: “…if they are derived from aversive processes they can provide a relatively enduring source of positive hedonic tone following the removal of the aversive reenforcer. Fear thus has its positive conquences.”127
Solomon and colleagues have applied these observations to imprinting and social attachment. Their research showed that young animals responded with increasing distress to repeated separations.66 Habituation did not occur, and attachment in fact increased, provided that the imprinting object was presented at fairly regular intervals. Starr130 demonstrated that there is a critical decay duration, the time that it takes for the withdrawal response to the original stimulus to wear off. If the reinforcing stimulus of the imprinting or attachment object is presented at intervals greater than the critical decay duration, increased attachment does not occur. However, animals earlier exposed to repeated separations are more vulnerable to increased distress upon later separations: “repeated exposures to the imprinting object took less time and fewer exposures than did the original exposures.” The strength of the imprinting eventually decays by disuse, but some residues of past experiences remain and facilitate the reactivation of the temporarily dormant system. Readdiction to nicotine and opiates occurs much faster than the initial addiction. If Starr is correct, similar processes account for social attachment to aversive objects and thus “the law of social attachment may be identical to the law of drug addiction.”130
Solomon and coworkers
established experimentally that animal and people become habituated
to the original stimulus, whether it is morphine, parachute jumping
or marathon running, but the withdrawal syndromes that follow a large
number of arousing events retain their integrity over time, and recur
when the original stimuli are reintroduced.127 Thus, the positive reinforcer loses
some of its power, but the negative reinforcer gains power and lasts
longer: parachute jumpers continued to feel exhilarated after jumping,
even when they feel less year beforehand. Solomon hypothesized that
endorphins are secreted in response to certain environmental stresses
and play a role in the opponent process. We have recently found evidence
that supports this view.
ADDICTION TO TRAUMA
Some traumatized people remain preoccupied with the trauma at the expense of other life experiences137,141 and continue to re-create it in some form for themselves or for others. War veterans may enlist as mercenaries,128 victims of incest may become prostitutes,47,120,125 and victims of childhood physical abuse seemingly provoke subsequent abuse in foster families53 or become self-mutilators143a Still others identify with the aggressor and do to others what was done to them.21,39 Clinically, these people are observed to have a vague sense of apprehension, emptiness, boredom, and anxiety when not involved in activities reminiscent of the trauma. There is no evidence to support Freud's idea that repetition eventually leads to mastery and resolution. In fact, reliving the trauma repeatedly in psychotherapy may serve to re-enforce the preoccupation and fixation.
Many observers of traumatic
bonding have speculated that victims become addicted to their victimizers.
Erschak33 asks why the batterer does not stop
when injury and pain are apparent and why does the victim not leave?
He answers that “they are addicted to each other and to abuse.
The system, the interaction, the relation takes hold; the individuals
are as powerless as junkies.”
ENDOGENOUS OPIATES AND ATTACHMENT
Thus Starr,130 Solomon,127 Erschak and others may be right in postulating that people can become physiologically addicted to each other. There is now considerable evidence that human attachment is, in part, mediated by the endogenous opiate system. Research in non-human primates shows that social attachment is related to the development of core neurobiologic functions in the primate brain. Early disruption of the attachment bond causes longlasting psychobiologic changes that not only reduce the capacity to cope with subsequent social disruption but also disturb parenting processes and create similar vulnerability into the next generation. In recent years knowledge about the brain circuits involved in the maintenance of affliative behavior are precisely those most richly endowed with opioid receptors.83 Behavioral studies show that the endogenous opioid system plays an important role in the maintenance of social attachment. According to Panksepp and colleagues, the separation response in rats can be inhibited with doses of neuroactive agents to have yielded reliable behavioral effects. Minute injections of morphine abolish both the separation cry in rate infants and the maternal response to it.100,103-105 Morphine-treated mothers (1 mg per kg) disregard male intruders, often attempting no defense of their offspring at all. One mother permitted a male intruder to eat her pups.
Blocking of opioid receptors with naloxone causes increased huddling in nonhuman primates, where as activation of brain opioid systems can decrease gregariousness.34,104 Lack of caregiving during the first few weeks of life decreases the number of opioid receptors in the cingulate gyrus in mice.13 Panksepp and colleagues have shown that the loss of social support decreases brain opioid activity and produces withdrawal symptoms; emotive circuits mediating loneliness-panic states are apparently activated or disinhibited. Re-establishment of social contact may, among other neural changes, activate endogenous opioid systems, alleviating separation distress and strengthening social bonds.103 If brain opioid activity fulfills social needs, opioid blockade might be expected to influence such other forms of gratification as sex. Indeed, opioid systems interact with the brain systems that regulate sex-steroid secretion,56 and naloxone facilitates sexual behavior in some mammals.49,96
High levels of stress,3 including social stress,97 also activate opioid systems. Animals exposed to inescapable shock develop stress-induced analgesia (SIA) when re-exposed to stress shortly afterward. This analgesic response is mediated by endogenous opioids and is readily reversible by the opioid receptor blocker naloxone.79 In humans elevations of enkephalins and plasma beta endorphins have been reported following a large variety of stressors.26,28,73 In testing the generalizability of the phenomenon of SIA to people, we found that seven of eight Vietnam veterans with PTSD showed a 30 percent reduction in perception of pain when viewing a movie depicting combat in Vietnam. This analgesia can be reversed with naloxone.107,143b This amount of analgesia produced by watching 15 minutes of a combat movie was equivalent to that which follows the injection of 8 mg. of morphine. We concluded that Beecher9 was right when, after observing that wounded soldiers require less morphine, he speculated that “strong emotions can block pain” because of the release of endogenous opioids. Our experiments show that even in people traumatized as adults, re-exposure to situations reminiscent of the trauma evokes as endogenous opioid response analogous to that of animals exposed to mild shock subsequent to inescapable shock. Thus, re-exposure to stress may have the same effect as the temporary application of exogenous opioids, providing a similar relief from anxiety.50
Field113 has suggested that normal play and
exploratory activity in infants are dependent on the presence of a familiar
attachment figure who modulates physiologic arousal by providing a balance
between soothing and stimulation. She, Reite,115,116 and others have shown that in the
absence of the mother, an infant experiences by psychological disorganizing
extremes of under- and overarousal. This soothing and arousal may be
mediated by alternate stimulation of different neurotransmitter systems,
in which the endogenous opioid system is likely to play a role, especially
in subjective experience of safety and soothing. Endogenous opioids
decrease central noradrenergic activity,6 and their activation may thus inhibit
hyperarousal. Childhood abuse and neglect may cause a long-term vulnerability
to be hyperaroused, expressed on a social level as decreased ability
to modulate strong affect states. “On a continuum from low to high
physiologic arousal there is an optimal level for every organism. The
shape of an individual's optimal stimulation curve may depend on the
level of stimulation received during early experience.”37 As a result, people who were neglected
or abused as children may require much higher external stimulation of
the endogenous opioid system for soothing than those whose endogenous
opioids can be more easily activated by conditioned responses based
on good early caregiving experiences. These victimized people neutralize
their hyperarousal by a variety of addictive behaviors including compulsive
re-exposure to situations reminiscent of the trauma.
CHILDHOOD
TRAUMA, ENDOGENOUS OPIOIDS, AND
SELF HARM
If recent animal research is any guide, people, particularly children, who have been exposed to severe, prolonged environmental stress will experience extraordinary increases in both catecholamine and endogenous opioid responses to subsequent stress. The endogenous opioid response may produce both dependence and withdrawal phenomena resembling those of exogenous opiods. This could explain, in part, why childhood trauma is associated with subsequent self-destructive behavior. Depending on which stimuli have come to condition an opioid response, self-destructive behavior may include chronic involvement with abusive partners, sexual masochism, self-starvation, and violence against self or others. In a recent study, we found that patients' reports of early childhood physical and sexual abuse were highly correlated with self-mutilation and self-starvation in adulthood.143a This controlled study supports numerous other clinical reports about the relationship between childhood abuse and self-destructive behavior.52,106,118 In these people, self-mutilation is a common response to abandonment; it is accompanied by both analgesia and an altered state of consciousness, and it provides relief and return to normality. The pain, cutting, and burning are apparent attempts at “repairing the cohesiveness of the self in the face of overwhelming anxiety.”35 This pattern is reminiscent of spouse abuse described by Walker:145 “tension gradually builds, an explosive battering (self-mutilating) incident occurs, and a 'calm, loving respite' follows.”
Bach-y-Rita7 studied men who were in prison because they habitually took out their frustrations on others violently. He found that they started to self-mutilate in prison when no external object of violence was available. Thus acts of violence that the perpetrator regards as horrible may, in fact, produce somatic calm.
The evidence for involvement
of the endogenous opioid system in self-mutilation is fairly good. A
recent study found increased levels of metenkephalins in habitual self-mutilators
during the active stage of self-harm, but not 3 months later.27 Opioid receptor blockade has been
found to decrease self-mutilation.60,117 The specific biologic factors that
account for the relief felt by these traumatized people who habitually
harm themselves or others are still unknown.
TREATMENT IMPLICATIONS
Compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control. Gaining control over one's current life, rather than repeating trauma in action, mood, or somatic states, is the goal of treatment.
Although verbalizing the contextual elements of the trauma is the essence of treatment of acute post-traumatic stress, the essential elements of chronic post-traumatic reactions generally are retrieved with difficulty and often cannot be dealt with until reasonable control over current behavior can assure the safety of both the patient and those in the patient's immediate surroundings. Failure to approach trauma-related material very gradually leads to intensification of the affects and physiologic states related to the trauma, leading to increased repetitive phenomena. It is important to keep in mind that the only reason to uncover the trauma is to gain conscious control over the unbidden re-experience or re-enactments. Prior to unearthing the traumatic roots of current behavior, people need to gain reasonable control over the longstanding secondary defenses that were originally elaborated to defend against being overwhelmed by traumatic material such as alcohol and drug abuse and violence against self or others. The trauma can only be worked through after a secure bond is established with another person. The presence of an attachment figure provides people with the security necessary to explore their life experiences and to interrupt the inner or social isolation that keeps people stuck in repetitive patterns. Both the etiology and the cure of trauma-related psychological disturbance depend fundamentally on security of interpersonal attachments. Once the traumatic experiences have been located in time and place, a person can start making distinctions between current life stresses and past trauma and decrease the impact of the trauma on present experience.137
Self-help organizations for people with addictions or with backgrounds that include childhood traumas or parental addictions have elaborated a model of treatment that appears to address many of the core issues of repetitive traumatization. These groups provide people with both human attachments and a meaningful cognitive frame for dealing with the sense of helplessness that is central to these problems.. They focus on the development of “serenity,” which can be understood both as a state of automatic stability and of being at peace with one's surroundings. These groups teach that the way to gain this serenity is by learning to trust, by surrendering, and by making contact and developing interpersonal commitments. They provide a support network that attempts to avoid the barriers that people create to bolster their individual differences, and they thus endeavor to circumvent the shame of being helpless and vulnerable that perpetuates social isolation. Shame and social isolation are thought to promote regression to earlier states of anxious attachment and to addictive involvements. In these circles it is said that: “No pain is so devastating as the pain a person refuses to face and no suffering is so lasting as suffering left unacknowledged.”23 There is emphasis on living in the here and now, generally with the acknowledgement that in contrast to victimized children, adults can learn to protect themselves and make a conscious choice about not engaging in relationships or behaviors that are known to be harmful. The underlying assumption is that conclusions drawn from a child's perspective retain their power into adulthood until verbalized and examined. In a group context, victims can learn that as children they were not responsible for the chaos, violence and despair surrounding them, but that as adults there are choices and consequences.23,137
These groups also teach that in order to avoid repetition, one has to give up the behavior, drug, or person involved in the addiction. Acknowledging the addictive quality of the involvement is known as overcoming denial. Avoiding acknowledging the feelings promotes acting out. Traumatized people need to understand that acknowledging feelings related to the trauma does not bring back the trauma itself, and its accompanying violence and helplessness. There must be emphasis on finding replacement activities and experiences that are more rewarding, successful and powerful in the immediate present. These may include being of help to victims of similar traumas as one's own.
Psychotropic medicines may be of help to decrease autonomic hypearousal and decrease all or none responses. Lithium, beta blockers, and serotonin reuptake blockers such as flouxetine, may be particularly helpful. By decreasing hyperarousal, one decreases the likelihood that current stress will be experienced as a recurrence of past trauma. This facilitates finding solutions appropriate to the current stress rather than the past.139 The use of medications that affect the opioid system should be regarded as experimental and at this time needs to be avoided except in life-threatening cases.
In our last study on
patients with borderline personality disorder Judith Herman and I (unpublished
data, 1988) asked our self-mutilating subjects what had helped them
most in overcoming the impact of their childhood traumas, including
their self-mutilation. All subjects attributed their improvement to
having found a safe therapeutic relationship in which they had been
able to explore the realities of their childhood experiences and their
reactions to them. All subjects reported that they had been able to
markedly decrease a variety of repetitive behaviors, including habitual
self-harm, after they had established a relationship in which they felt
safe to acknowledge the realities of both their past and their current
lives.
SUMMARY
Trauma can be repeated on behavioral, emotional, physiologic, and neuroendocriniologic levels. Repetition on these different levels causes a large variety of individual and social suffering. Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past.
People need a “safe base” for normal social and biologic development. Traumatization occurs when both internal and external resources are inadequate to cope with external threat. Uncontrolable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people whe intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Assaults lead to hyperarousal states for which the memory can be state-dependent or dissociated, and this memory only returns fully during renewed terror. This interferes with good judgment about these relationships and allows longing for attachment to overcome realistic fears.
All primates subjected to early abuse and deprivation are vulnerable to engage in violent relationships with peers as adults. Males tend to be hyperagressive, and females fail to protect themselves and their offspring against danger. Chronic physiologic hyperarousal persists, particularly to stimuli reminiscent of the trauma. Later stresses tend to be experienced as somatic states, rather than as specific events that require specific means of coping. Thus victims of trauma may respond to contemporary stimuli as a return of the trauma, without conscious awareness that past injury rather than current stress is the basis of their physiologic emergency responses. Hyperarousal interferes with the ability to make rational assessments and prevents resolution and integration of the trauma. Disturbances in the catecholamine, serotonin, and endogenous opioid systems have been implicated in this persistenence of all-or-nothing responses.
People who have been exposed to highly stressful stimuli develop long-term potentiation of memory tracts that are reactivated at times of subsequent arousal. This activation explains how current stress is experienced as a return of the trauma; it causes a return to earlier behavior patterns. Ordinarily, people will choose the most pleasant of two alternatives. High arousal causes people to engage in familiar behavior, regardless of the rewards. As novel stimuli are anxiety provoking, under stress, previously traumatized people tend return to familiar patterns, even if they cause pain.
The “opponent process theory of acquired motivation” explains how fear may become a pleasurable sensation and that “the laws of social attachment may be identical to those of drug addiction.” Victims can become addicted to their victimizers; social contact may activate endogenous opioid systems, alleviating separation distress and strengthening social bonds. High levels of social stress activate opioid systems as well. Vietnam veterans with PTSD show opiod-mediated reduction in pain perception after re-exposure to a traumatic stimulus. Thus re-exposure to stress can have the same effect as taking exogenous opioids, providing a similar relief from stress.
Childhood abuse and
neglect enhance long-term hyperarousal and decreased modulation of strong
affect states. Abused children may require much higher external stimulation
to affect the endogenous opioid system for soothing than when the biologic
concomitants of comfort are easily activated by conditioned responses
based on good early caregiving experiences. Victimized people may neutralize
their hyperarousal by a variety of addictive behaviors, including compulsive
re-exposure to victimization of self and others. Gaining control over
one's current life, rather than repeating trauma in action, mood, or
somatic states, is the goal of treatment. The only reason to uncover
traumatic material is to gain conscious control over unbidden re-experiences
or re-enactments. The presence of strong attachments provides people
with the security necessary to explore their life experiences and to
interrupt the inner or social isolation that keeps them stuck in repetitive
patterns. In contrast with victimized children, adults can learn to
protect themselves and make conscious choices about not engaging in
relationships or behaviors that are harmful.
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Massachusetts Mental Health Center
Harvard Medical School
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*Director, Trauma Center, Massachusetts Mental Health Center, Harvard Medical School, Boston, Massachusetts
Citation:
Dissociative Disorders Glossary
abreaction The discharge of energy [emotion] involved in recalling an event that has been repressed because it was consciously intolerable. The experience may be one of reliving the trauma as if it were happening in the present, complete with physical as well as emotional manifestations (also called revivification). A therapeutic effect sometimes occurs through partial discharge of or desensitization to the painful emotions and increased insight. Abreaction can happen spontaneously or can be therapeutically induced through verbal suggestion or hypnosis. Adapted from American Psychiatric Glossary, p.1. See also flashbacks.
acting out Originally an analytic term referring to the expression of unconscious feelings about the analyst, the commonly used meaning is the expression of unconscious feelings or conflicts in actions rather than words. This can take many forms including dangerous behavior such as self-harm or suicidal gestures.
acute stress disorder A disorder first named in DSM-IV. It is similar to Post-Traumatic Stress Disorder (PTSD) in that it is evoked by the same types of stressors that precipitate PTSD. However, in this disorder, the symptoms occur during or immediately following the trauma. The primary criteria are the same as those for PTSD, except that the disturbance lasts for a minimum of two days and a maximum of four weeks and occurs within four weeks of the traumatic event. Adapted from DSM-IV, p. 432.
adjunctive therapies In addition to individual psychotherapy with a primary therapist, a client may receive other therapy such as art therapy, psychodrama, dance therapy, or assertiveness training. These are considered adjunctive therapies.
affect “A pattern of observable behaviors that is the expression of a subjectively experienced feeling state (emotion). Common examples of affect are sadness, elation, and anger. In contrast to mood, which refers to a more pervasive and sustained emotional `climate,' affect refers to more fluctuating changes in emotional `weather.'” DSM-IV, p. 763.
age regression See regression.
alexithymia The inability to recognize or describe what one feels. This is common in post-traumatic stress disorder, somatization, and conversion disorders.
alter Another term for personality, alternate personality or personality state; also called an identity or dissociated part. A distinct identity or personality state, with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self. Modified from DSM-IV, p. 770. “Alters are dissociated parts of the mind that the patient experiences as separate from each other.” ISSD Practice Guidelines Glossary, 1994.
amnesia “Pathologic loss of memory; a phenomenon in which an area of experience becomes inaccessible to `conscious' recall. The loss in memory may be organic, emotional, dissociative, or of mixed origin, and may be permanent or limited to a sharply circumscribed period of time.” American Psychiatric Glossary, p. 13. See also dissociative amnesia.
anniversary reaction The experience of reacting with feelings or behavior on the “anniversary” of a previous event. For example, an individual whose house burned down on September 22nd may for years after the event have intense feelings or reactions on or around September 22nd. In some cases the person may not even consciously recall why he or she is feeling differently on that date. A common anniversary reaction is temporary depression.
assertiveness training This is a cognitive/behavioral technique that teaches clients to express their feelings and needs rather than being passive and letting other people take advantage, overwhelm, or dominate them (a characteristic of people who were abused in childhood). After a client and therapist identify problem situations, the client practices appropriate confrontation. Assertiveness, a middle ground between being passive and aggressive/hostile, may be learned on a one-to-one basis or in a group.
attachment (bonding) The process of developing and maintaining a healthy relationship between people; healthy attachment between a parent and child, is characterized by a sense of security, emotional attunement and regulation of physiological functioning such that the developing child becomes able to self-regulate over time.
auto-hypnosis See self-hypnosis.
autonomic arousal A physical symptom of PTSD which occurs automatically when a person perceives a situation to be life-threatening. Also known as nervous system hyper-reactivity, this physical response bypasses the cognitive/thinking process and generally includes an elevated heart rate, dilation of pupils, perspiring, and other fear responses. Trauma survivors may re-experience autonomic arousal when remembering traumatic events. See also flight or fight response.
Axis II pathology Axis II is one component of the diagnostic system described in the DSM- IV. Axis II contains the personality disorders, such as borderline personality disorder, narcissistic personality disorder and avoidant personality disorder. Personality disorders are defined as personality traits that are inflexible, maladaptive, and cause functional impairment or subjective distress. When a person has both DID and an Axis II diagnosis the treatment may be more complicated and chaotic. A person may resolve the DID and still need to deal with the Axis II diagnosis. Adapted from DSM- IV, p. 630.
BASK The BASK model of dissociation developed by Bennett G. Braun, M.D., conceptualizes dissociation as dimensions of Behavior, Affect, Sensation, and Knowledge. For example, a client with DID (MPD) may experience the behavior of other personality states as separate, or may experience the intense feelings of a personality state as separate, or may have body sensations of pain with no memory of trauma, or one personality state may have “knowledge” of trauma but no feelings or physical sensations. The goal of treatment is the integration of the BASK components over time. Braun, “The BASK Model of Dissociation,” pp. 4-23.
behavioral memory A lay term for implicit (or habit) memory. This type of memory is encoded in terms of a pattern of behavior rather than explicit knowledge. This term often refers to actions or fears which may indicate unconfirmed memories. (Lenore Terr, M.D., personal correspondence, 31 August 1994).
blending A commonly used dissociative disorders term coined by Catherine Fine, M.D. which refers to the moment at which the personality states or fragments temporarily come together as a single entity, either spontaneously or with the help of a therapist.
body memory This popularly-used term is actually a misnomer. The body does not have neurons capable of remembering; only the brain does. The term refers to body sensations that symbolically or literally captures some aspect of the trauma. Sensory impulses are recorded in the parietal lobes of the brain, and these remembrances of bodily sensations can be felt when similar occurrences or cues restimulate the stored memories.(Lenore Terr, M.D., personal correspondence, 31 August 1994). For example, a person who was raped may later experience pelvic pain similar to that experienced at the time of the event. This type of bodily sensation may occur in any sensory mode: tactile, taste, smell, kinesthetic, or sight. Body memories may be diagnosed as somatoform disorder. See also somatic memory.
borderline personality disorder (BPD) Borderline personality disorder is best understood as an attachment disorder. “The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts,” as indicated by five (or more) of the following:
In Borderline Personality Disorder, like DID (MPD), there is a likelihood of a trauma history: “Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation are more common in the childhood histories of those with Borderline Personality Disorder.” Adapted from DSM-IV, pp. 650-654.
boundaries For the comfort and safety of the client, therapist, and other outsiders, behavioral boundaries often need to be established. These limits may affect a range of issues from details of personal and therapeutic interactions, such as length of therapy sessions; appropriate touching; number, and duration, of phone calls to prevention of assault and suicide. Setting boundaries is particularly important in the treatment of dissociative disorders since lack of boundaries is usually a part of the history of a person who has been abused.
brief reactive psychosis One of the trauma related disorders listed in the DSM-III-R. It consists of a sudden and brief psychosis (loss of reality contact) lasting from a few hours to no more than one month. It is preceded by a major stressor which would be extremely stressful to almost anyone in similar circumstances in that person's culture. This has been renamed Brief Psychotic Disorder in DSM-IV with a slight modification in the criteria. Adapted from DSM-III-R, p. 207.
brief psychotic disorder The DSM- IV criteria are:
For this condition there are three specifiers: with marked stressor(s), without marked stressor(s), and with postpartum onset. Adapted from DSM-IV, p. 304.
co-consciousness For a person with DID (MPD), this is the awareness of the thoughts, feelings, beliefs, needs, etc. of other personality states.
co-existing disorders Refers to cases in which an individual has more than one mental disorder as described in the DSM-IV. Also known as co- morbidity. See also dual diagnosis.
cognitive/behavioral treatment A treatment approach that focuses both on observable behavior and on the thinking or beliefs that accompany the behavior. In psychotherapy, dysfunctional or maladaptive behaviors, thoughts, and beliefs are replaced by more adaptive ones. This approach is increasingly being used in the treatment of DID (MPD) and BPD.
cognitive distortion An error in thinking or reasoning based on drawing incorrect conclusions about past experience. For example, a trauma survivor who was sexually abused by a man with a beard might overgeneralize from the trauma experience and conclude that all men with beards are dangerous.
cognitive therapy A form of therapy that focuses on what the client thinks or believes. In this model, faulty thinking is seen as the basis for negative emotions and maladaptive behavior. Therapeutic intervention helps clients explore erroneous thoughts and beliefs and replace them with a more realistic assessment of themselves and their situation.
complex PTSD (also complex, chronic PTSD) A term used to refer to dissociative disorders. See also Posttraumatic Stress Disorder.
confabulation This term originally referred to a neurological deficit in which a person who is unable to recall previous situations or events fabricates stories in response to questions about those situations or events. It is now used more broadly to refer to “false memories” that are supposedly created in response to questions asked by a therapist or interviewer.
containment The process of consciously postponing dealing with intrusive PTSD symptoms, being able to notice a symptom, communicate about it, set it aside (contain it), and revisit it later.
context dependent memory See state dependent memory.
contracts Verbal or written agreements made between therapist and client for the express purposes of setting safe and reasonable boundaries for the client, to nurture the client's sense of cause and effect, and to encourage the internal personality system to take responsibility for its behavior.
conversion disorder Often precipitated by psychosocial stress, people with trauma histories have a higher than average rate of conversion disorder. The DSM-IV criteria are:
Adapted from DSM-IV, p. 457.
co-presence This occurs when two or more personalities are simultaneously present with or without knowledge of each other's existence or current presence. They may or may not exert influence on each other.
countertransference A therapist's conscious or unconscious emotional reactions to a client. It is a therapist's job to monitor his or her reactions to a client and to minimize their impact on the therapeutic relationship and treatment.
DDIS See Dissociative Disorder Interview Schedule.
delayed memory This term is used to describe the experience of an individual who recalls a memory for which he or she was previously amnestic. The recollection may occur spontaneously or in the context of therapy. This is a controversial concept: some individuals believe that delayed memory is an understandable response to traumatic stressors and others believe that important events, especially traumatic ones, are not forgotten. The term “delayed memory” is often used interchangeably with repressed memory, or false memory, but there are different meanings for these terms.
depersonalization disorder One of the dissociative disorders described in DSM-IV. The criteria include:
Adapted from DSM-IV, p. 490.
derealization A feeling of estrangement or detachment from one's environment. A sense that the external world is strange or unreal. Often accompanied by depersonalization.
DES See Dissociative Experiences Scale.
Diagnostic and Statistical Manual of Mental Disorders The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM- IV) was published in 1994 by the American Psychiatric Association. It contains standard definitions of psychological disorders. DSM-III-R refers to the third edition, revised, of the same manual, published in 1987. The diagnostic categories referred to in the trauma literature published in the late 1980s and early 1990s are those from the DSM-III-R.
DID See dissociative identity disorder.
dissociation The separation of ideas, feelings, information, identity, or memories that would normally go together. Dissociation exists on a continuum: At one end are mild dissociative experiences common to most people (such as daydreaming or highway hypnosis) and at the other extreme is severe chronic dissociation, such as DID (MPD) and other dissociative disorders. Dissociation appears to be a normal process used to handle trauma that over time becomes reinforced and develops into maladaptive coping.
dissociative amnesia One of the dissociative disorders described in DSM-IV. The three criteria are:
Adapted from DSM-IV,
pp. 478-481.
For individuals with DID (MPD), amnesia may exist differentially between
various personality
states or personality fragments. In one-way amnesia Personality
A is unaware of Personality B; however, Personality B knows everything
about Personality A. In two-way amnesia neither Personality A or B is
aware of the existence of the other.
Dissociative Disorder Interview Schedule (DDIS) A structured interview developed for both clinical and research purposes to standardize the diagnosis of DID (MPD). It takes 30-45 minutes to complete. The DDIS has shown that DID(MPD) is a valid diagnosis with a consistent set of features and that both dissociative experiences and dissociative disorders are common. Developed by Ross, Heber, Norton and Anderson, the DDIS has been used in several research studies and has good clinical validity. Ross, Multiple Personality Disorder, p.135.
dissociative disorder not otherwise specified (DDNOS) In DSM-IV this is the diagnostic category for individuals who have dissociative symptoms but do not meet the minimum criteria for any of the specific dissociative disorders. A client who has some (but not all) DID symptoms, and who does not have amnesia for important personal information, would be an example of a person with DDNOS. DSM- IV, p. 590.
dissociative disorders A group of psychiatric conditions with the disruption in the integrated functions of consciousness, memory, identity, or perception of the environment. DID (MPD) is one disorder in this category. See also dissociative amnesia, dissociative fugue, dissociative identity disorder, dissociative disorders not otherwise specified. Adapted from DSM-IV, p. 477.
Dissociative Experiences Scale (DES) Developed by Frank W. Putnam M.D. and Eve B. Carlson, Ph.D., the DES is a 28-item self-report instrument that can be completed in about 10 minutes. It asks the respondent to indicate the frequency with which certain dissociative or depersonalization experiences occur. An example of a typical DES question is “Some people have the experience of feeling that their body does not seem to belong to them. Circle a number to show what percentage of the time this happens to you.”
dissociative fugue One of the dissociative disorders described in DSM-IV. The diagnostic criteria are:
dissociative identity disorder (DID) One of the dissociative disorders in DSM- IV. There are four diagnostic criteria:
DID is the current name
for multiple personality disorder (MPD), first used in DSM-IV.
In addition to the name change, the criteria was increased by two items,
items C and D.
The term DID is felt to reflect more accurately the condition of an
individual with two or more personality states. This change recognizes
that MPD represents the failure to form one core personality rather
than to simply create many personalities. Adapted from DSM-IV,
p. 487.
dual diagnosis This refers to the co-existence of a mental disorder and substance abuse disorder. The current term for this is co-existing disorders, also called co-morbidity. See also co-existing disorders.
eating disorders A category of mental disorders described in DSM-IV. Individuals with these disorders, such as anorexia nervosa and bulimia, show a marked disturbance in eating behavior. Some individuals with DID (MPD) and PTSD also have an eating disorder.
ego states An organized system of behavior and experience in which the elements (ego states) are bound together by some common principle. In this theory of dissociation, developed by Helen H. and John G Watkins, ego states occur naturally in people and are separated from each other by boundaries that are more or less permeable. A problem arises only when the boundaries between ego states become non-permeable or maladaptive. The goal of treatment in ego state therapy is not the fusion or integration of ego states, but the harmonius cooperation between ego states. Watkins & Watkins, “Ego- State Therapy in the Treatment of Dissociative Disorders,” in Kluft & Fine, Clinical Perspectives on Multiple Personality Disorder, pp. 277-299.
empathy The ability to put one's self into the psychological frame of reference or point of view of another, to feel what another feels.
executive control In the internal system of a person with a dissociative disorder, authority over the body and its behavior by a particular personality state, usually the host.
experiential therapies Therapeutic techniques that utilize metaphors and analogies to help clients understand and change their behaviors, traditionally in a group format. These techniques encourage the client to directly experience feelings and thoughts by participating in activities such as art, group sculpting, outdoor challenge courses, etc. See also expressive therapies.
explicit memory Consciously recalled facts or events (knowing that) which have verbal components. This is the form of memory used, for example, when a person recounts the events of his or her day at work or at school. Also referred to as narrative or declarative memory. See also implicit memory.
expressive therapies Specific therapeutic techniques that facilitate expression of feelings through language or movement. Examples include dance, art, and poetry therapy. Most often used as adjunctive therapy to gain access to feelings or memories, expressive therapies are increasingly used for primary treatment in trauma cases. Since traumatic memories may be stored on sensory motor or visual levels, the use of these therapies may access memories not usually available through talking therapy.
Eye Movement Desensitization and Reprocessing (EMDR) A procedure which produces rapid eye movements in a client while a traumatic memory is recalled and processed. This technique seems to lessen the amount of therapeutic time needed to process and resolve traumatic memories. Developed by Francine Shapiro, this technique requires training and following of specific protocols for appropriate use.
false memory A
term developed in the early 1990s by the False Memory Syndrome Foundation
to describe memories that are not based on actual events. This term
is popular in the media, although the concept of false memory is not
based on clinical research or accepted theoretical formulation.
The terms false memory, delayed
memory, and repressed memory are often used interchangeably in
the popular literature but they actually have distinct meanings.
False Memory Syndrome
(FMS) “False memory syndrome” is a term coined in the
early 1990s by the False Memory Syndrome Foundation (FMSF). The FMSF
defines the syndrome as “a condition in which the person's personality
and interpersonal relationships are oriented around a memory that is
objectively false but strongly believed in to the detriment of the welfare
of the person and others involved in the memory.” Goldstein,
Confabulations: Creating False Memories - Destroying Families, p.
iv
This organization was founded by parents of adult children who reported
delayed memories of child abuse usually uncovered in psychotherapy.
These parents deny the abuse and believe false memories have been implanted
by therapists in the minds of their adult children.
The term “false memory syndrome” is popular in the media but
is not based on clinical research or accepted theoretical formulations.
It is not listed as a diagnosis or symptom in the DSM-IV, nor
is there a known treatment or cure. See also delayed memory and repression.
flashbacks A type of spontaneous abreaction common to victims of acute trauma. Also known as “intrusive recall,” flashbacks have been categorized into four types:
Putnam, Diagnosis and Treatment of Multiple Personality Disorder, pp. 236-237.
flight or fight response An automatic response to an experience that is perceived to be a threat to survival. The part of the brain that regulates metabolic and autonomic function and prepares muscles to act -- to either flee or fight. This survival mechanism works well when the situation allows for an active response. In repeated traumatic situations, when there is no opportunity to fight or flee, this response may result in a chronic state of physiological arousal which is very stressful to the body. See also autonomic arousal.
flooding The process of becoming overwhelmed by intrusive emotions, sensory experiences, or intense re-living experiences; commonly associated with posttraumatic stress disorder.
FMS See False Memory Syndrome.
fragment Within the personality system of a person who has a dissociative disorder, a fragment is a dissociated part of that person which has limited function and is less distinct or developed than a personality state. Usually a fragment has a consistent emotional and behavioral response to specific situations. For example, a fragment may handle the expression of feelings through drawing. The term “special purpose fragment” refers to a part with an even more narrowly defined function.
fugue See dissociative fugue.
fusion The moment when personality states or fragments come together as a single entity. The breaking down of dissociative barriers may occur spontaneously or as part of a specific therapeutic process. Fusion is different from integration.
grounding Reality based awareness in the here and now, a sense of connectedness to yourself and your environment.
host In dissociative identity disorder, the personality state that most frequently has control of the body and its behavior. The host is often initially unaware of the other identities and typically loses time when they appear. The host is the identity that most often initiates treatment, usually after developing symptoms, the most common being depression. See also executive control.
hypermnesia This experience of heightened memory is a symptom of PTSD. It is the opposite of amnesia, which is the forgetting of events. Hypermnesia consists of abnormally sharp or vivid recall. For example, a trauma survivor may vividly remember a traumatic event with total recall of all details--sight, sound, feel, smell, and touch. Hypermnesia may be intrusive and may interfere with everyday functioning.
hypervigilance One of the symptoms of PTSD. In this state an individual is overly sensitive to sounds and sights in the environment, scans the environment expecting danger, and feels keyed up and on edge. In addition, a traumatized person may have an exaggerated startle response and problems with memory and concentration.
hypnosis An altered
state of consciousness which is subjectively experienced by an individual
as different from normal alertness. This may occur spontaneously, as
in spontaneous trance, or may be suggested by a therapist or hypnotist.
The individual who is hypnotized may experience altered perception or
memory.
Hypnosis is often used in the treatment of DID (MPD) to facilitate communication
between personality
states, to overcome
amnesiac barriers and to promote healing through managed abreaction. Before using hypnosis in treatment
it is recommended that the client be provided with enough information
to give his or her informed
consent and that
this be documented. Hypnosis is also referred to as being in a trance state. The process of dissociation itself may be a form of self-hypnosis.
iatrogenesis When medical treatment or psychotherapy causes an illness or aggravates an existing illness. In psychotherapy, this may occur as a result of the comments, questions, or attitudes of the therapist. There are those who feel that DID (MPD) is an iatrogenic illness produced by a client to meet the expectations of a therapist. There is also a concern that traditional DID (MPD) treatment approaches may encourage the development of additional personality states. However, there is no scientific research to support the idea that DID (MPD) is an iatrogenic illness.
ideomotor signaling A hypnotic technique wherein the client and therapist agree on prearranged body movements to answer questions non-verbally. The most common technique uses finger signals to stand for “yes,” “no,” and “stop.” This allows nonverbal communication of unconscious material during hypnosis. Often the client will experience the movement of the fingers as “outside conscious control.” The technique may be used to contact personality states without direct emergence of those personality states.
imagery Using your imagination to manage stress responses and feelings.
implicit memory Behavioral knowledge of an experience (knowing how) without conscious recall or verbal components; habit memory. Driving, riding a bicycle, or reading are examples of skills which people implicitly remember how to do without consciously remembering steps involved. This type of memory is almost always irretrievable in words. (Lenore Terr, M.D., personal correspondence, 31 August 1994.) Also called procedural or sensorimotor memory. See also, explicit memory.
impulse An action urge.
informed consent In psychotherapy, informed consent occurs when a client is informed of:
The information must be presented in a form the client can understand and consent must be given without coercion. Often this information is presented in written form which the client signs, thereby giving permission for treatment. While this has historically been common for medical procedures and psychological research, it is now also being done during psychotherapy, especially with specific techniques such as hypnosis and sodium amytal interviews.
inner self-helper (ISH) A personality state, often a helper or protector, that has knowledge of the system and works with the therapist to facilitate the treatment.
integration The
ongoing process of bringing together all dissociated aspects of self,
whether they are thoughts, feelings, behavior, or are organized as personality states or fragments. This process begins before the fusion of specific personality states and
continues throughout the psychotherapy.
There is lack of agreement about the end goal of DID (MPD) treatment.
Some therapists and clients consider integration the treatment goal
while others do not. This complex decision is best discussed together
by therapist and client.
internal system see system.
International Society
for the Study of Dissociation (ISSD) Formerly the International
Society for the Study of Multiple Personality and Dissociation (ISSMP&D).
The organization voted to change its name in the spring of 1994 after
the classification of MPD was changed to dissociative identity disorder
(DID) in the DSM-IV.
The International Society for the Study of Dissociation is a not-for-profit
professional association organized to promote research and training
in the identification and treatment of Dissociative Identity Disorder
and other dissociative states. ISSD provides professional and public
education about DID and other dissociative states and serves as a catalyst
for international communication and cooperation among clinicians and
investigators working in this field. ISSMP&D Membership Directory,
1994, p. 2.
International Society for the Study of Multiple Personality & Dissociation (ISSMP&D) The original name of the ISSD when it was founded in 1984. It was changed in 1994 after the term MPD was changed to dissociative identity disorder (DID). See also International Society for the Study of Dissociation.
International Society for Traumatic Stress Studies, Inc. (ISTSS) A non-profit organization to “promote the advancement of knowledge about the immediate and long-term human consequences of extraordinary events and to promote effective methods of preventing or ameliorating the unwanted consequences of them.” ISTSS Membership Directory, 1993, p. iii.
intrapsychic The complex processes that occur within the mind of an individual rather than the dynamics between individuals or between an individual and the environment.
ISH See inner self-helper.
journal writing The process of using structured exercises to write about thoughts, feelings, and stress responses in an effort to increase self-awareness and decrease symptomotology.
learned helplessness
A term developed by Martin Seligman, pioneering researcher in animal
psychology, to describe what occurs when animals or human beings learn
that their behavior has no effect on the environment. The impact of
this experience leaves an individual apathetic, depressed, and unwilling
to try previous or new behavior.
This concept is relevant to people with dissociative disorders who may
show some degree of learned helplessness due to repeated exposure to
traumatic events which they could not change or avoid by their behavior.
losing time Specific to the dissociative disorder field, having no recollection of one's activities during a given time period (hours, days, years). Unaccounted-for periods of time are generally confusing and frightening to an individual who has DID (MPD) and may allow for the person's re-victimization.
mapping A technique used in psychotherapy with DID (MPD) clients to gain knowledge about the internal personality system. The client is asked to draw a map or diagram of the personality states to explain the inner world of personalities. This provides useful information about the system, such as the connections or lack of connections between personality states. The map may need to be updated as therapy progresses and can be used for integration work to help ensure that all internal parts have been integrated. Also known as personality mapping; system mapping. Mapping can also be used to understand the relationships among feeling states as well.
medical model The view that abnormal behavior results from a physical/biological cause and should be treated medically. This emphasis on biological causes of mental disorder is in contrast with cognitive/behavioral approaches that see beliefs and socially reinforced behavior as a cause of mental disorder. As non-medical disciplines have become more involved in the treatment of mental disorders, the conflict between the medical model and social/behavioral models has become heightened.
memory “The
ability, process, or act of remembering or recalling; especially the
ability to reproduce what has been learned or explained.” American
Psychiatric Glossary, p. 126.
The question, “What is a memory?” has become increasingly
controversial in the last decade. As PTSD and dissociative disorder
clients report delayed and dissociated memories of childhood trauma,
the accuracy or validity of these memories has been questioned. At the
present time there is no reliable scientific method to assess the self-report
of traumatic events. While the presence of corroborating evidence (or
witnesses) may support a survivor's memories, it does not in itself
determine the validity of abuse reports. See also explicit memory, implicit
memory, body memory and false
memory.
mental status exam (MSE) The MSE, which is conducted by a mental health professional, is a formal evaluation of a client's current psychological, emotional, and behavioral functioning. Areas of assessment include: orientation to time, place, and person as well as thought content, cognition, mood, affect, insight, and general intelligence. This evaluation is usually summarized on the five axes of DSM-IV and in a narrative report.
MPD See multiple personality disorder.
multiple personality disorder (MPD) In DSM-III-R, MPD was classified as a dissociative disorder. The diagnostic criteria were:
In general, individuals with MPD have a background of child abuse or other forms of severe childhood trauma. Dissociative identity disorder (DID) is the current name for this disorder in DSM-IV. In addition to the name change two items have been added to the criteria. See also dissociative identity disorder for the current criteria. Adapted from DSM-III- R, p. 272.
numbing A symptom common to individuals with PTSD. It represents an individual's attempt to compensate for intrusive thoughts, memories, or feelings of the trauma by shutting down and becoming numb to internal or external stimuli. Also called psychic numbing.
original personality This term is no longer commonly used but is found frequently in the historical MPD literature. In earlier MPD theory, this refers to the personality state with which an individual is born and from which other personality states were “split off.” See also splitting.
passive influence Individuals with dissociative disorders often experience their actions or thoughts as being controlled by dissociated aspects of the self. Some may feel that a passive outside or inside force has control without an overt or visible expression of that influence. Automatic writing is an example of passive influence.
personality see personality states.
personality mapping see mapping.
personality states In the dissociative disorders field, this refers to an entity that has the following:
Also known as ego states, personalities, alters, parts, etc. Braun, Treatment of Multiple Personality Disorder, p. xii.
personality system see system
posttraumatic stress disorder (PTSD) An anxiety disorder based on how an individual responds to a traumatic event. According to DSM-IV, the following criteria must be met:
PTSD may be acute, chronic, or with delayed onset. Many individuals with DID (MPD) also have PTSD. The literature sometimes describes DID(MPD) as complex and/or chronic PTSD. Adapted from DSM-IV, p. 427-429.
presenting personality The personality state that first comes to therapy. It is often the host personality.
pseudo-memory A non- technical term to describe memory of events that did not occur. This term is often used interchangeably with false memory, another non-technical term coined by members of the False Memory Syndrome Foundation.
pseudoseizures
“Pseudoseizures are sudden changes in a person's behavior and/or
mental state that resemble epileptic seizures but which are not caused
by a physical disorder of the brain. They may look like any type of
epileptic seizure: staring unresponsively, generalized stiffening and
rhythmic jerking, movements of only a few body parts, or alterations
of awareness. During these spells, brain cells are firing normally and
the brain wave tracing does not show the changes which are characteristic
of epileptic seizures.
“Several research studies have found that many pseudoseizures are
really dissociative trance episodes, dissociative switching of ego states,
or dissociative states in which unconscious emotional distress is expressed.
Many studies have noted high rates of sexual and physical abuse among
pseudoseizure patients and pointed to abuse as one cause of pseudoseizures.
Pseudoseizures have been reported in dissociative identity disorder
patients and may be the symptom that leads to seeking treatment. There
are non-dissociative causes for pseudoseizures, so persons who suffer
from them should not be assumed to have a dissociative disorder.”
(Elizabeth S. Bowman, M.D., personal correspondence, 22 August 1994.)
psychic numbing see numbing
psychodrama A group psychotherapy technique. Under the direction of a therapist, individuals re-enact life situations or feelings in order to gain insight or learn new ways of coping. It is one of the adjunctive therapies used in treating trauma disorders.
psychodynamic A theoretical orientation that recognizes the role of the unconscious in determining behavior. It also considers the interplay of the unconscious with the current situation, cognitive ability, and life experience.
psychogenic amnesia A type of dissociative disorder described in DSM-III-R. The name was changed to dissociative amnesia in DSM-IV. See also dissociative amnesia.
psychogenic fugue A type of dissociative disorder described in DSM-III-R. The name was changed to dissociative fugue in DSM-IV. See also dissociative fugue.
PTSD See posttraumatic stress disorder.
Rational Emotive Therapy (RET) A cognitive psychotherapy approach developed by Albert Ellis which focuses on the client's thoughts and beliefs. The goals of therapy are to identify unrealistic and illogical thoughts (such as “I must always be happy”), question these thoughts or beliefs, and replace them with more reasonable and constructive views. In this school of thought, behavior is understood to be based on beliefs rather than external conditions. This form of therapy is used to help trauma survivors to identify mistaken beliefs brought on by the traumatic experiences.
reality check A technique that helps you to become aware of the true state of affairs in a particular experience.
regression The return to earlier or younger behavior and thinking. Trauma often overwhelms everyday defenses and brings about behavioral regression. Child personality states are an example of trauma-based regression. In “age regression,” a person experiences him or herself at a specific earlier age. The person does not always return to the age of a child, however; age regression may take a client back a few years earlier in adult life.
repetition compulsion Originally defined by Freud as the repetitive re-enactment of earlier emotional experiences, this type of behavior may be seen in the lives of trauma survivors. For example, a survivor of traumatic abuse may put herself in a situation where there is a risk of additional abuse in an attempt to psychologically master the previous traumatic experiences.
repression An unconscious defense mechanism which occurs when unacceptable ideas, images, or fantasies are kept out of awareness. This is done without an individual consciously knowing that it has taken place. Repression is one psychological mechanism that may account for amnesia of traumatic events.
re-traumatizing Re-enacting or reinforcing a traumatic experience or belief.
revictimization Describes the experience of a survivor being victimized or traumatized after the original trauma. Examples of revictimization include psychological abuse that may occur in a survivor's interactions with authorities such as the courts, law enforcement personnel, or therapists. This process is important to address in therapy. In some cases it seems that a survivor may unconsciously allow or encourage this subsequent trauma to occur.
revivification The vivid remembering of past experiences. When remembering traumatic events the client may see, hear, taste, smell, and feel as though the event is happening in the present. This is common during an abreaction or flashback of previous trauma.
ritual abuse This
term has been defined in a variety of ways by different authors and
researchers. One definition developed for a study of abuse in child
daycare defined ritual abuse as “abuse that occurs in a context
linked to some symbols or group activity that have a religious, magical,
or supernatural connotation and where the invocation of these symbols
or activities, repeated over time, is used to frighten and intimidate
the children.” Finkelhor, D., & Meyers, L. M., Nursery Crimes:
Sexual Abuse in Day Care, p. 59.
Another definition developed by the Los Angeles Commission for Women
(1989) refers to ritual abuse as, “A brutal form of abuse of children,
adolescents, and adults, consisting of physical, sexual, and psychological
abuse, and involving the use of rituals. Ritual does not necessarily
mean satanic. However, most survivors state that they were ritually
abused as part of satanic worship for the purpose of indoctrinating
them into satanic beliefs and practices. Ritual abuse rarely consists
of a single episode. It usually involves repeated abuse over an extended
period of time.” Report of the Ritual Abuse Task Force, Los Angeles
County Commission for Women, 1991, p. 1.
At the present time there is tremendous controversy about the objective
reality of ritual abuse. While some clinicians, researchers, and police
believe that ritual abuse occurs, others do not. They believe that reports
of ritual abuse are part of a mass hysteria fed by media accounts and
talk show programs. There is no consensus about the reality and/or extent
of ritual abuse.
sadistic abuse Describes “extreme adverse experiences which include sadistic sexual and physical abuse, acts of torture, over-control, and terrorization, induction into violence, ritual involvements, and malevolent emotional abuse. Sadism was defined by Freud's mentor, Krafft-Ebing (1894-1965), in the nineteenth century, as follows: 'The experience of sexual or pleasurable sensations... produced by acts of cruelty, as bodily punishment inflicted on one's own body or witnessed in others, be they animals or human beings. It may also consist of innate desire to humiliate, hurt, wound, or even destroy others. . . .'” See also ritual abuse. Goodwin, “Sadistic Abuse: Definition, Recognition, and Treatment,” Dissociation, 6:3, pp. 181-182.
sand tray therapy A therapeutic technique, similar to play therapy, in which a tray of sand with figures and toys is provided for a client to create a scene or story to be discussed with a therapist. The “world” that a client creates may directly or symbolically represent previous life experiences, conflicts, feelings, or fears. This technique, when used to process traumatic events, allows a client emotional distance and the opportunity to process the feelings, thoughts, and beliefs that may accompany a traumatic experience.
satanic abuse Abuse that evokes the name, image, or concept of satan as part of the abuse. Even though this term is used interchangeably with ritual and sadistic abuse they each have specific meanings. Abuse could be ritual and sadistic but not satanic if the concept of satan is not used as a part of the abuse. See also ritual abuse for a more detailed explanation of that term.
screen memory A partially true memory that an individual subconsciously creates because the actual memory is intolerable. For example, a client may report abuse by a distant uncle when actually the abuser was the father. This disguised presentation allows the client time to adjust to aspects of the abuse before accepting the total reality of the situation.
script memory A type of memory that is created during ritual or cult abuse when a person is given a scripted identity and memories. For example, a victim may given a historical identity and the information and memories related to that identity. Mungadze, “Scripts and screen memories in victims of ritual abuse: etiological and treatment implications,” November 1992 Conference, ISSMP&D.
secondary PTSD See vicarious traumatization.
self-harm The action of harming oneself without the intent to commit suicide. The many forms of self-harm include cutting, burning, eating disorders, etc. For trauma survivors, self-harm can function as tension reduction, punishment, trauma re-enactment, or rage expression. Also called self-inflicted violence or self-injury. See also self-mutilation.
self-inflicted violence See self-harm.
self-injury See self-harm.
self-hypnosis “Spontaneous or purposeful hypnotic trance states produced within his or her own psyche. These states may include any or all of the full range of hypnotic phenomena such as sensory alterations, anesthesia, time distortion, relaxation, age regression, and alterations in physiological functioning.” ISSD Practice Guidelines, Glossary, 1994.
self-mutilation A form of self-harm motivated specifically by the desire to scar or disfigure one's body; “Defined by Walsh and Rosen (1988) as `deliberate, non- life-threatening, self-effected bodily harm or disfigurement of a socially unacceptable nature' (p.10), self-mutilation most typically involves repetitious cutting or carving of the body or limbs, burning of the skin . . . .” Briere, Child Abuse Trauma: Theory and Treatment of the Lasting Effects, p. 66. See also self-harm.
self-regulation The process of consciously managing different internal states by 1. experiencing them as they come up, 2. expressing what you are experiencing, 3. consciously postponing dealing with traumatic material or overwhelming aspects of feelings, and 4. retrieving part of what you have contained when you are better able to manage it.
sleep disorders A category in DSM-IV which includes various disorders of sleep: primary sleep disorders such as insomnia and secondary sleep disorders due to medical conditions. Sleep disturbances are common in people with PTSD.
sodium amytal
A hypnotic sedative drug occasionally used in psychotherapy with trauma
clients to access repressed or unconscious material including feelings
and memories. This procedure, an IV drip infused with sodium amytal,
is usually done on an inpatient basis due to the slight risk of medical
complications. Even though sodium amytal has been referred to as a “truth
serum” it does not guarantee truth any more than any other interview
technique.
It is suggested that informed
consent be obtained
before using this technique in the treatment of dissociative disorder
or PTSD clients.
somatic memory “A physical sensation or change in physical functioning without the presence of organic illness, that represents a dissociated aspect of a traumatic or abusive experience.” ISSD Practice Guidelines, Glossary, 1994. See also body memory.
somatoform disorder According to DSM-IV, the common feature of somatoform disorders is the presence of physical symptoms that suggest a general medical condition but are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder. These conditions may represent the unconscious conversion of psychological conflicts to medical problems or medical concerns. Examples of somatoform disorders include: somatization disorder, conversion disorder, and hypochondriasis. Adapted from DSM-IV, p. 445.
split screen phenomenon A hypnotic therapeutic technique which enables a client to see the past trauma on a mental screen in which one half is the historical event and the other half is the current therapeutic situation. This allows the client to deal with a traumatic memory without being emotionally overwhelmed. The technique may be helpful for abreactive and intense memory work.
splitting In general
psychiatric literature splitting is “a mental mechanism in which
the self or others are reviewed as all good or all bad, with failure
to integrate the positive and negative qualities of self and others
into cohesive images. Often the person alternately idealizes and devalues
the same person.” American Psychiatric Glossary, p.199.
Splitting is a symptom of borderline
personality disorder.
In the dissociative disorder field “splitting” is an outdated
term, although it is still used. Historically, the formation of an alter personality state was conceptualized
as a split from the original
personality or
birth personality, suggesting there is a finite number of personalities
that can occur during the splitting process. Current thinking by leaders
in the field (Putnam, Kluft, and others) indicates that pretending to
be other people, or trying out different roles, is a normal dissociative
phenomenon in young children, which is intensified when trauma occurs,
resulting in the creation of alter personality states. Thus, the terms
“splitting” and “split personality” are no longer
relevant when referring to the formation of personality
states.
spontaneous trance See self- hypnosis.
startle reaction This symptom of both PTSD and generalized anxiety disorder occurs when an individual reacts strongly to new and unexpected stimuli in the environment. An example of a startle reaction would be jumping out of a chair when a door is slammed. Also called startle response.
state dependent memory A similar concept to state dependent learning. Based on research and clinical experience, it appears that information and events may be best remembered in the same emotional or physiological state in which it was learned. For trauma survivors an event that produced extreme fear may not be recalled during normal everyday conditions, including psychotherapy. Recall of this past event may only be available to consciousness at another time of extreme fear. This is one reason why a current traumatic event, with all the feelings and high arousal state, may trigger memory of forgotten earlier trauma. Also referred to as context dependent memory.
Structured Clinical Interview for DSM-IV Dissociative Disorder (SCID-D) This is the first diagnostic instrument for the comprehensive evaluation of dissociative symptoms and disorders. It was developed by Marlene Steinberg, M.D., to enable a clinically trained interviewer to assess the nature and severity of dissociative symptoms in a variety of clinical disorders (including Posttraumatic Stress Disorder, eating disorders, etc.) and to make diagnoses of disociative disorders, based on DSM-IV criteria.
switching The process of changing from one already existing personality state or fragment to another personality state or fragment. Switching may be set off by outside stimuli such as an environmental trigger, or by internal stimuli, such as feelings or memories. Switching may be observable, such as changes in posture or facial expression, as well as changes in voice tone or speech patterns. Switching may also be observed by changes in mood, regressed behavior, and variable cognitive functioning.
system A descriptive term for all the aspects or parts of the mind in an individual with DID (MPD). This includes personality states, memories, feelings, ego states, entities, and any other way of describing dissociated aspects of an individual. Understanding the parts as a system rather than as separate personality states provides an important frame of reference for treatment. Also called internal system or personality system.
talking through The therapeutic technique of talking to the personality system as a whole or talking to one or more personality states that are not in executive control. For example, a therapist may say “I want everyone inside to listen,” or “I want to talk to Mean Bill inside who made that angry phone call last week.” Talking this way encourages the system to work together and to dissolve the dissociative barriers.
trance Used interchangeably with hypnosis. A person in a trance or in an altered state of focused attention is in a hypnotic state.
trance logic The ability of a hypnotized person to tolerate the existence of inconsistent perceptions or ideas. “The inconsistent perceptions are not kept isolated but appear in juxtaposition . . . The essence of this phenomenon seems to be the suspension of critical thinking.” Udolf, Handbook of Hypnosis for Professionals, pp.108-108.
transference “The unconscious assignment to others of feelings and attitudes that were originally associated with important figures in one's early life.” The psychodynamically oriented clinician uses this to help the client understand the origins of emotional problems. The transference phenomena is complicated in MPD because each alter may have its own transference relationship with the therapist. American Psychiatric Glossary, p. 211. See also traumatic transference.
trauma A medical
term for any sudden injury or damage to an organism. Psychological trauma
is an event that is outside the range of usual human experience and
which is so seriously distressing as to overwhelm the mind's defenses
and cause lasting emotional harm.
Psychological traumata include natural disasters, accidents, or human
actions, such as child abuse, rape, torture, etc., which cause the victim
to be terrified, helpless, and under extreme physical stress. Most individuals
with DID (MPD) have been victims of repeated trauma and generally also
exhibit symptoms of post traumatic stress disorder. See also Type I and Type
II Trauma.
traumatic transference The unconscious assignment to a therapist of feelings and attitudes associated with an abuser during earlier traumatic events. For example, recalling being beaten in childhood, a client may ask the therapist not to hit or hurt her, as if she were talking to the abuser. Working through the traumatic transference may be an important aspect for understanding early childhood trauma.
trigger An event, object, person, etc. that sets a series of thoughts in motion or reminds a person of some aspect of his or her traumatic past. The person may be unaware of what is “triggering” the memory (i.e., loud noises, a particular color, piece of music, odor, etc.). Learning not to overreact to triggers is a therapeutic task in the treatment of dissociative disorders.
Type I and Type II Trauma Terms developed by Lenore Terr to describe different types of trauma. A single traumatic event such as a fire or single rape episode is considered to be Type I Trauma. Repeated, prolonged trauma, such as extensive child abuse, is considered to be Type II Trauma. According to Terr's formulation of this concept, these two types of trauma result in different coping styles. Individuals with Type I Trauma receive support from family and friends and usually remember the trauma event. Individuals with Type II Trauma are more likely to have severe PTSD symptoms, such as psychic numbing, and dissociation. Type II Trauma is often kept a secret and support from family and friends may be absent. Terr, Unchained Memories, p. 11, 30.
unification “An overall, general term that encompasses both fusion and integration.” Kluft, “Clinical Approaches to the Integration of Personalities,” in Clinical Perspectives on Multiple Personality Disorder, p.109.
V-codes These are categories of problems that may need therapeutic intervention but are not considered psychological disorders or mental illness. Conflict between parents and teenagers would be an example of this. Adapted from DSM-IV, p. 681.
vicarious traumatization Describes the experiences of mental health providers who become overly empathic after listening to accounts of abuse or violence by trauma survivors. Symptoms of vicarious traumatization are similar to those experienced by individuals with PTSD, and include psychic numbing, hypervigilance, difficulty sleeping, and intrusive thoughts of the trauma, which were reported by the client. Also called secondary PTSD or compassion fatigue. Kluft and Fine, Clinical Perspectives, p.164.