by Joan A. Turkus, M.D.
As society has become increasingly aware of the prevalence of child abuse and its serious consequences, there has been an explosion of information on posttraumatic and dissociative disorders resulting from abuse in childhood. Since most clinicians learned little about childhood trauma and its aftereffects in their training, many are struggling to build their knowledge base and clinical skills to effectively treat survivors and their families.
Understanding dissociation and its relationship to trauma is basic to understanding the posttraumatic and dissociative disorders. Dissociation is the disconnection from full awareness of self, time, and/or external circumstances. It is a complex neuropsychological process. Dissociation exists along a continuum from normal everyday experiences to disorders that interfere with everyday functioning. Common examples of normal dissociation are highway hypnosis (a trance-like feeling that develops as the miles go by), "getting lost" in a book or a movie so that one loses a sense of passing time and surroundings, and daydreaming.
Researchers and clinicians believe that dissociation is a common, naturally occurring defense against childhood trauma. Children tend to dissociate more readily than adults. Faced with overwhelming abuse, it is not surprising that children would psychologically flee (dissociate) from full awareness of their experience. Dissociation may become a defensive pattern that persists into adulthood and can result in a full-fledged dissociative disorder.
The essential feature of dissociative disorders is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. If the disturbance occurs primarily in memory, Dissociative Amnesia or Fugue (APA, 1994) results; important personal events cannot be recalled. Dissociative Amnesia with acute loss of memory may result from wartime trauma, a severe accident, or rape. Dissociative Fugue is indicated by not only loss of memory, but also travel to a new location and the assumption of a new identity. Posttraumatic Stress Disorder (PTSD), although not officially a dissociative disorder (it is classified as an anxiety disorder), can be thought of as part of the dissociative spectrum. In PTSD, recall/re-experiencing of the trauma (flashbacks) alternates with numbing (detachment or dissociation), and avoidance. Atypical dissociative disorders are classified as Dissociative Disorders Not Otherwise Specified (DDNOS). If the disturbance occurs primarily in identity with parts of the self assuming separate identities, the resulting disorder is Dissociative Identity Disorder (DID), formerly called Multiple Personality Disorder.
The Dissociative Spectrum
The dissociative spectrum (Braun, 1988) extends from normal dissociation to poly-fragmented DID. All of the disorders are trauma-based, and symptoms result from the habitual dissociation of traumatic memories. For example, a rape victim with Dissociative Amnesia may have no conscious memory of the attack, yet experience depression, numbness, and distress resulting from environmental stimuli such as colors, odors, sounds, and images that recall the traumatic experience. The dissociated memory is alive and active--not forgotten, merely submerged (Tasman & Goldfinger, 1991). Major studies have confirmed the traumatic origin of DID (Putnam, 1989, and Ross, 1989), which arises before the age of 12 (and often before age 5) as a result of severe physical, sexual, and/or emotional abuse. Poly-fragmented DID (involving over 100 personality states) may be the result of sadistic abuse by multiple perpetrators over an extended period of time.
Although DID is a common disorder (perhaps as common as one in 100) (Ross, 1989), the combination of PTSD-DDNOS is the most frequent diagnosis in survivors of childhood abuse. These survivors experience the flashbacks and intrusion of trauma memories, sometimes not until years after the childhood abuse, with dissociative experiences of distancing, "trancing out", feeling unreal, the ability to ignore pain, and feeling as if they were looking at the world through a fog.
The symptom profile of adults who were abuse as children includes posttraumatic and dissociative disorders combined with depression, anxiety syndromes, and addictions. These symptoms include (1) recurrent depression; (2) anxiety, panic, and phobias; (3) anger and rage; (4) low self-esteem, and feeling damaged and/or worthless; (5) shame; (6) somatic pain syndromes (7) self-destructive thoughts and/or behavior; (8) substance abuse; (9) eating disorders: bulimia, anorexia, and compulsive overeating; (10) relationship and intimacy difficulties; (11) sexual dysfunction, including addictions and avoidance; (12) time loss, memory gaps, and a sense of unreality; (13) flashbacks, intrusive thoughts and images of trauma; (14) hypervigilance; (15) sleep disturbances: nightmares, insomnia, and sleepwalking; and (16) alternative states of consciousness or personalities.
Diagnosis
The diagnosis of dissociative disorders starts with an awareness of the prevalence of childhood abuse and its relation to these clinical disorders with their complex symptomatology. A clinical interview, whether the client is male or female, should always include questions about significant childhood and adult trauma. The interview should include questions related to the above list of symptoms with a particular focus on dissociative experiences. Pertinent questions include those related to blackouts/time loss, disremembered behaviors, fugues, unexplained possessions, inexplicable changes in relationships, fluctuations in skills and knowledge, fragmentary recall of life history, spontaneous trances, enthrallment, spontaneous age regression, out-of-body experiences, and awareness of other parts of self (Loewenstein, 1991).
Structured diagnostic interviews such as the Dissociative Experiences Scale (DES) (Putnam, 1989), the Dissociative Disorders Interview Schedule (DDIS) (Ross, 1989), and the Structured Clinical Interview for Dissociative Disorders (SCID-D) (Steinberg, 1990) are now available for the assessment of dissociative disorders. This can result in more rapid and appropriate help for survivors. Dissociative disorders can also be diagnosed by the Diagnostic Drawing Series (DDS) (Mills & Cohen, 1993).
The diagnostic criteria for the diagnosis of DID are (1) the existence within the person of two or more distinct personalities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self, (2) at least two of these personality states recurrently take full control of the person's behavior, (3) the inability to recall important personal information that is to extensive to be explained by ordinary forgetfulness, and (4) the disturbance is not due to the direct physiological effects of a substance (blackouts due to alcohol intoxication) or a general medical condition (APA, 1994). The clinician must, therefore, "meet" and observe the "switch process" between at least two personalities. The dissociative personality system usually includes a number of personality states (alter personalities) of varying ages (many are child alters) and of both sexes.
In the past, individuals with dissociative disorders were often in the mental health system for years before receiving an accurate diagnosis and appropriate treatment. As clinicians become more skilled in the identification and treatment dissociative disorders, there should no longer be such delay.
Treatment
The heart of the treatment of dissociative disorders is long-term psychodynamic/cognitive psychotherapy facilitated by hypnotherapy. It is not uncommon for survivors to need three to five years of intensive therapy work. Setting the frame for the trauma work is the most important part of therapy. One cannot do trauma work without some destabilization, so the therapy starts with assessment and stabilization before any abreactive work (revisiting the trauma).
A careful assessment should cover the basic issues of history (what happened to you?), sense of self (how do you think/feel about yourself?), symptoms (e.g., depression, anxiety, hypervigilance, rage, flashbacks, intrusive memories, inner voices, amnesias, numbing, nightmares, recurrent dreams), safety (of self, to and from others), relationship difficulties, substance abuse, eating disorders, family history (family of origin and current), social support system, and medical status.
After gathering important information, the therapist and client should jointly develop a plan for stabilization (Turkus, 1991). Treatment modalities should be carefully considered. These include individual psychotherapy, group therapy, expressive therapies (art, poetry, movement, psychodrama, music), family therapy (current family), psychoeducation, and pharmacotherapy. Hospital treatment may be necessary in some cases for a comprehensive assessment and stabilization. The Empowerment Model (Turkus, Cohen, & Courtois, 1991) for the treatment of survivors of childhood abuse--which can be adapted to outpatient treatment--uses ego-enhancing, progressive treatment to encourage the highest level of function ("how to keep your life together while doing the work"). The use of sequenced treatment using the above modalities for safe expression and processing of painful material within the structure of a therapeutic community of connectedness with healthy boundaries is particularly effective. Group experiences are critical to all survivors if they are to overcome the secrecy, shame, and isolation of survivorship.
Stabilization may include contracts to ensure physical and emotional safety and discussion before any disclosure or confrontation related to the abuse, and to prevent any precipitous stop in therapy. Physician consultants should be selected for medical needs or psychopharmacologic treatment. Antidepressant and antianxiety medications can be helpful adjunctive treatment for survivors, but they should be viewed as adjunctive to the psychotherapy, not as an alternative to it.
Developing a cognitive framework is also an essential part of stabilization. This involves sorting out how an abused child thinks and feels, undoing damaging self-concepts, and learning about what is "normal". Stabilization is a time to learn how to ask for help and build support networks. The stabilization stage may take a year or longer--as much time as is necessary for the patient to move safely into the next phase of treatment.
If the dissociative disorder is DID, stabilization involves the survivor's acceptance of the diagnosis and commitment to treatment. Diagnosis is in itself a crisis, and much work must be done to reframe DID as a creative survival tool (which it is) rather than a disease or stigma. The treatment frame for DID includes developing acceptance and respect for each alter as a part of the internal system. Each alter must be treated equally, whether it presents as a delightful child or an angry persecutor. Mapping of the dissociative personality system is the next step, followed by the work of internal dialogue and cooperation between alters. This is the critical stage in DID therapy, one that must be in place before trauma work begins. Communication and cooperation among the alters facilitates the gathering of ego strength that stabilizes the internal system, hence the whole person.
Revisiting and reworking the trauma is the next stage. This may involve abreactions, which can release pain and allow dissociated trauma back into the normal memory track. An abreaction might be described as the vivid re-experiencing of a traumatic event accompanied by the release of related emotion and the recovery of repressed or dissociated aspects of that event (Steele & Colrain, 1990). The retrieval of traumatic memories should be staged with planned abreactions. Hypnosis, when facilitated by a trained professional, is extremely useful in abreactive work to safely contain the abreaction and release the painful emotions more quickly. Some survivors may only be able to do abreactive work on an inpatient basis in a safe and supportive environment. In any setting, the work must be paced and contained to prevent retraumatization and to give the client a feeling of mastery. This means that the speed of the work must be carefully monitored, and the release painful material must be thoughtfully managed and controlled, so as not to be overwhelming. An abreaction of a person diagnosed with DID may involve a number of different alters, who must all participate in the work. The reworking of the trauma involves sharing the abuse story, undoing unnecessary shame and guilt, doing some anger work, and grieving. Grief work pertains to both the abuse and abandonment and the damage to one's life. Throughout this mid-level work, there is integration of memories and, in DID, alternate personalities; the substitution of adult methods of coping for dissociation; and the learning of new life skills.
This leads into the final phase of the therapy work. There is continued processing of traumatic memories and cognitive distortions, and further letting go of shame. At the end of the grieving process, creative energy is released. The survivor can reclaim self-worth and personal power and rebuild life after so much focus on healing. There are often important life choices to be made about vocation and relationships at this time, as well as solidifying gains from treatment.
This is challenging and satisfying work for both survivors and therapists. The journey is painful, but the rewards are great. Successfully working through the healing journey can significantly impact a survivor's life and philosophy. Coming through this intense, self-reflective process might lead one to discover a desire to contribute to society in a variety of vital ways.
References
Braun, B. (1988). The BASK model of dissociation. DISSOCIATION, 1, 4-23. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Loewenstein, R.J. (1991). An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatric Clinics of North America, 14(3), 567-604.
Mills, A. & Cohen, B.M. (1993). Facilitating the identification of multiple personality disorder through art: The Diagnostic Drawing Series. In E. Kluft (Ed.), Expressive and functional therapies in the treatment of multiple personality disorder. Springfield: Charles C. Thomas.
Putnam, F.W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Press.
Ross, C.A. (1989). Multiple personality disorder: Diagnosis, clinical features, and treatment. New York: Wiley.
Steele, K., & Colrain, J. (1990). Abreactive work with sexual abuse survivors: Concepts and techniques. In Hunter, M. (Ed.), The sexually abused male, 2, 1-55. Lexington, MA: Lexington Books.
Steinberg, M., et al. (1990). The structured clinical interview for DSM III-R dissociative disorders: Preliminary report on a new diagnostic instrument. American Journal of Psychiatry, 147, 1.
Tasman, A., & Goldfinger, S. (1991). American psychiatric press review of psychiatry. Washington, DC: American Psychiatric Press.
Turkus, J.A. (1991). Psychotherapy and case management for multiple personality disorder: Synthesis for continuity of care. Psychiatric Clinics of North America, 14(3), 649-660.
Turkus, J.A., Cohen, B.M., & Courtois, C.A. (1991). The empowerment model for the treatment of post-abuse and dissociative disorders. In B. Braun (Ed.), Proceedings of the 8th International Conference on Multiple Personality/Dissociative States (p. 58). Skokie, IL: International Society for the Study of Multiple Personality Disorder.
Joan A. Turkus, M.D., has extensive clinical experience in the diagnosis and treatment of post-abuse syndromes and DID. She is the medical director of The Center: Post-Traumatic & Dissociative Disorders Program at The Psychiatric Institute of Washington. A general and forensic psychiatrist in private practice, Dr. Turkus frequently provides supervision, consultation, and teaching for therapists on a national basis. She is co-editor of the forthcoming book, Multiple Personality Disorder: Continuum of Care.
* This article was adapted by Barry M. Cohen, M.A., A.T.R.. It was originally published in the May/June, 1992, issue of Moving Forward, a semi-annual newsletter for survivors of childhood sexual abuse and those who care about them. For subscription information, write P.O. Box 4426, Arlington, VA, 22204, or call 703/271-4024.
