vol. 1, num. 1, 2003

Dissociative Phenomena. Questions and Answers.

Editors: Mario Di Fiorino and Maria Luisa Figueira

An Introduction to Dissociation

An Introduction to Dissociation

“Dissociation” seemed for us a suitable topic for this initiative. In January 2002 in Lisbon and in March 2002 in Saint. Petersburg two conferences on the subject were held. Some of the speakers of the conferences were invited for the elaboration of the present volume.
Effectively dissociation is a controversial and challenging issue with many implications allowing either a classic clinical approach or a more research based debates. They concern etiopathogenic factors as the role of trauma, organic versus functional nature of the symptoms, nosological versus transnosologic interpretation, the functions of consciousness and memory.
Historically the psychopathological concept of dissociation has two different roots. The one of Pierre Janet regarding the dissociation of consciousness and the conceptualization of Eugen Bleuler that looks into dissociation related to schizophrenia.
Previously, in 1845 Jacques-Joseph Moreau de Tours in a paper about the altered state of consciousness “of inebriation provoked by hashish”, coins, for the first time, the expression “dissociation of ideas” [1].
Pierre Janet (1859-1947) searches a new word for indicating “exactly that mood, simple and complex, of indefiniteness, of uncertainty..It is a disaggregation, a true dissolution of that intellectual whole, which we name moral faculties, The result in the spiritual order and in the material one is the same: the separation, the isolation of the ideas and of the molecules whose union formed an harmonious and complete whole. [2]”
Janet stated that some individuals on account of constitutional factors or traumatic history hadn’t enough energy to integrate all experiences. He considered that dissociation and conversion shared the same mechanism of disaggregation. In 1890 William James uses the term dissociation to translate to english the Janet’s concept of disaggregation[3]. Since then, a large evolution of the knowledge has been achieved still remaining several controversial questions. Some of these issues are discussed by Salomon Resnik and Lara Severino.
Biological basis of Dissociation are far from being understood. Chapter from Nash Boutros points to the possibility that dissociative symptoms could reflect an epileptic cerebral activity similar to what happens in panic attack patients, with therapeutical implications.
The article of Krupitsky E.M et al. reports the results of an experimental induction of altered states of consciousness with Ketamine a “psychedelic” drug which is relevant in the study of altered consciousness.
Bremner discusses clinical, legal and biological issues related to delayed recall of childhood abuse, providing several psychological and biological models that provide possible mechanisms.
Clinical and therapeutic perspectives are the topic of the second part of this publication. A revision of the classic nosologic entities: Pseudo-dementia, factious disorder including Münchausem and Ganser syndrome are explored by Manuel Paes de Sousa. In another article Di Fiorino, with Gemignani and Garuglieri, explored.
A research, exploring the frequency of factitious patients in a psychiatric inpatients population, is presented by Di Fiorino et al. In a dimensional perspective the analysis of dissociative phenomena permit to hypothesize a relevant role in the pathogenesis of factitious disorders.
In the next six chapters a discussion of clinical and therapeutic aspects of Dissociative disorders is performed. Kluft makes a review on Dissociative Identity Disorder (DID) and the controversies around it epidemiology and etiology, allegation of abuse, assessing DID , dealing with alters and trauma history in treatment . The author also refers different approaches emphasizing the role of individual psychotherapy in the treatment.
In the following chapter Krüger questions the separation between conversion disorder and dissociative disorders in DSM-IV classification. Using a scale that was built for conversion and dissociative items - State Scale of Dissociation (SSD) - in a sample of clinical and non-clinical participants, the authors concluded that conversion symptoms clustered with dissociative symptoms being closed related clinically supporting ICD10 classification.
On conversion and dissociative disorders in children and adolescents Diler made a review of some issues -epidemiology, diagnosis and treatment . This chapter points out the need of more studies comparing childhood and adult psychiatry to provide a base for reformulating modified diagnostic criteria and the need of recognition of the impact of somatization disorders on medical care in order to achieve a more effective treatment.
Approaching treatment Vanderlinden and Vandereycken describe the phases in the treatment of patients with a history of trauma and with dissociative symptoms, illustrating these phases with clinical cases. Since in the beginning many patients show lost of control in their lives with impulsive and self-destructive behaviour, the first goal is to achieve sufficient “internal control”. The authors focuse on trust and safety as two basic aspects of therapeutic relationship.
In another chapter Vanderlinden and Vandereycken explore the possibilities and limitations of hypnotic techniques in the treatment of patients with history of trauma and severe dissociative symptoms, describing different hypnotherapeutic techniques. Hypnosis would be integrated in the therapeutic approach as an alternative coping behavior for impulse dyscontrol symptoms and to alter the negative images, messages and suggestions commonly present in these patients. The authors also take into account a possibly negative side of hypnotherapy regarding the problem of (over)suggestibility and the dangers of trauma exploration.
Finishing Maria Luisa Figueira overviews the different aspects of treatment of Dissociative Disorders namely in a pharmacotherapeutic approach.. The author also mentions psychotherapy exploring its rational-the trauma model. Focusing on pharmacological treatment Luisa Figueira reviews pharmacological trials with several drugs (mainly antidepressants) and points out the difficulties concerning the lack of a well-established psychobiological basis of dissociation and the high frequency of comorbid conditions. The author concludes that the treatment should include a individual structured cognitive psychotherapy or a psychodynamic long-term therapy with adjuvant pharmacotherapy. In the absence of single treatment guidelines, the treatment should take into account the best knowledge for each sub-type of dissociative disorder and individual characteristics of each patient with clinical caution.

1 Jacques-Joseph Moreau de Tours: Du Haschisch et de l’Aleliénation Mentale, 1845.
2 Janet Pierre: L’automatisme psychologique. Essay de psychologie expérimentale sur le formes inférieures de l’activité humaine. Paris, Alcan, 1889.
3 James William: The Principles of Psychology. London, McMillan, 1891.

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