Link to a list of papers on dissociative disorder.
Link to a list of papers on dissociative disorder.
Note: an edited version of this paper, originally written in 1999, appears in H.E. Adams & P.B. Sutker (Eds.) (2001), Comprehensive Handbook of Psychopathology, 3rd Ed. (pp. 259-276). New York: Plenum.
In current diagnostic nosology, the category of dissociative disorders includes a wide variety of syndromes whose common core is an alteration in consciousness affecting memory and identity (American Psychiatric Association, 1994). In dissociative amnesia (formerly, psychogenic amnesia), the patient suffers a loss of autobiographical memory for certain past experiences; in dissociative fugue (psychogenic fugue), the amnesia is much more extensive, covering the whole of the individual's past life; and it is coupled with a loss of personal identity and, often, physical movement to another location; in dissociative identity disorder (multiple personality disorder), a single individual appears to manifest two or more distinct identities, each personality alternating in control over conscious experience, thought, and action, and separated by some degree of amnesia from the other(s); in depersonalization disorder the person believes that he or she has changed in some way, or is somehow unreal (in derealization the same beliefs are held about one's surroundings).
While impairments of memory and consciousness are often observed in the organic brain syndromes, the dissociative disorders are functional in nature: they are attributable to instigating events or processes that do not result in insult, injury, or disease to the brain, and produce more impairment than would normally occur in the absence of this instigating event or process (Schacter & Kihlstrom, 1999). The dissociative disorders appear to be rather rare, but for more than 100 years these and related phenomena have been objects of fascination for clinicians and experimentalists alike (for other recent reviews, see Bremner & Marmar, 1998; Kihlstrom, Tataryn, & Hoyt, 1993; Klein & Doane, 1994; Lynn & Rhue, 1994; Michaelson & Ray, 1996; Ross, 1997; Spiegel, 1991, 1994).
Once considered exotic, in the 1990s the dissociative disorders seem to have become the syndromes of the moment. In March 1999, a search of the PsycINFO database revealed 40 entries on psychogenic or dissociative amnesia, 28 of which (70%) had appeared since the prior edition of this chapter had been completed in 1990; there was also a total of eight entries on psychogenic or dissociative fugue, five of which (63%) had appeared in that same time period. Multiple personality, or dissociative identity disorder, the crown jewel of the dissociative disorders, yielded 868 entries: more than half of these (485, or 56%) appeared since 1990, and 708 (82%) had appeared since the first edition of this handbook was published in 1984. Remarkably, however, little of this literature consists of quantitative clinical studies, much less experimental research. Thus, the enormous amount of clinical and popular interest in the dissociative disorders has not yet translated into a substantial body of research.
It should be noted that the term "dissociative disorder" is almost unique in the psychiatric nosology because the label also implies a specific mechanism, dissociation, to account for the disturbances observed. Other category labels, such as schizophrenia, anxiety disorders, and personality disorders carry no such surplus etiological baggage. The origins of the idea of dissociation lie in a body of medical and scientific literature that emerged from 1775 to 1900, and which represents what Ellenberger (1970) called the "First Dynamic Psychiatry". The first dynamic psychiatrists were interested in a wide spectrum of phenomena, including hypnosis and other forms of suggestion, spiritism (automatic writing, crystal-gazing), the "magnetic diseases" of catalepsy, lethargy, and somnambulism (so named because of their resemblance to certain phenomena of animal magnetism, a precursor of hypnosis), ambulatory automatisms (fugue), multiple personality, and hysterical anesthesias and paralyses. Each of these phenomena reflected the power of ideas to engender action, as well as a change in consciousness in which experience, thought, and action occurred outside of phenomenal awareness and voluntary control. The pathological forms, such as hysteria and multiple personality, were "dynamic illnesses", caused by a suggestion or idea whose origins lay in some psychological trauma whose nature was unknown to the victim. As a result of this trauma, certain experiences, thoughts, and actions become separated from the monitoring and controlling function of a central executive ego.
The dominant figure in the First Dynamic Psychiatry was Pierre Janet (1889, 1907), who identified the elementary structures of the mental system as "psychological automatisms". Each automatism represented a complex act, finely tuned to external (environmental) and internal (intrapsychic) circumstances, preceded by an idea, and accompanied by an emotion. According to Janet, the normal person's entire repertoire of elementary psychological automatisms were bound together into a single, united stream of consciousness, accessible to introspective phenomenal awareness and voluntary control. However, under certain circumstances one or more automatisms could be split off from the rest, thus functioning outside of awareness, independent of voluntary control, or both -- a condition which Janet labeled desaggregation, translated into English as dissociation. The dissociation view of the unconscious, as distinct from the repression view elaborated by Freud and his followers, was endorsed by William James (1890/1980; Taylor, 1983, 1996), and promoted in America by Morton Prince and Boris Sidis, among others.
The dissociative conceptualization of consciousness was briefly popular, but the claims of the dissociation theorists were often overly broad, and their clinical and experimental studies often methodologically flawed. In the clinic, the Second Dynamic Psychiatry of Freud and his followers, with its emphasis on sex and aggression, dreams and repression, soon triumphed over the First. In the laboratory, the behaviorist revolution banished all reference to mental states, conscious or not, from the vocabulary of scientific discourse. After World War II, however, interest in consciousness -- attention, primary memory, and imagery -- was revived in the course of the cognitive revolution. The concept of dissociation, and the dissociative disorders, played a role in this revival, as indicated by Hilgard's (1977; see also Kihlstrom, 1992, 1998) "neodissociation" theory of divided consciousness.
Neodissociation theory assumes that the mind is organized as a system of mental structures, which monitor and control experience, thought, and action in different domains. In principle, each of the structures can process inputs and outputs independently of the others, although under ordinary circumstances each structure is in communication with the others, and several different structures might compete for a single input or output channel. At the center of the system, yet another structure exercises executive functions of monitoring and control, and which provides the mental basis for the experience of phenomenal awareness and voluntary control. According to Hilgard, the operations of the central executive can be constrained, and the integration and organization of the individual control structures disrupted, producing a state of divided consciousness. For example, the lines of communication between two subordinate structures might be cut: the operations of each would be represented in phenomenal awareness and perceived as under voluntary control, but they would not be integrated with each other. Alternatively, the links between a subordinate structure and the executive might be cut: under these circumstances, the operations of the subordinate would be isolated from phenomenal awareness and the experience of intentionality -- a classic instance of dissociation.
Whereas both the classical dissociation theory of Janet (1889) and the neodissociation theory of Hilgard (1977; Kihlstrom, 1992) assume that the normal unity of consciousness is disrupted by an amnesia-like process, Woody and Bowers (1994) have offered an alternative view that many mental and behavioral functions are performed unconsciously and automatically to begin with, by specialized cognitive modules. Thus, some degree of dissociation is the natural state. Rather than reflecting the imposition of an amnesic barrier, the phenomena of dissociation reflect the failure of these modules to be integrated at higher levels of the system (e.g., by executive control structures associated with the frontal lobes). Currently, the distinction between dissociated experience and dissociated control is debated chiefly in the literature on hypnosis (Kihlstrom, 1998; Kirsch & Lynn, 1998; Woody, 1998), but the two competing formulations of neodissociation theory are clearly relevant to the dissociative disorders as well. Return to index.
The dissociative disorders have a somewhat checkered history in the Diagnostic and Statistical Manual (DSM) periodically published by the American Psychiatric Association (Kihlstrom, 1994). In the first edition of DSM (DSM-I), published in 1952, the dissociative syndromes were classified as Psychoneurotic Disorders, in which anxiety is either "directly felt and expressed or... unconsciously and automatically controlled" by various defense mechanisms" (p. 32). Under this label, the dissociative syndromes included depersonalization, dissociated (multiple) personality, stupor, fugue, amnesia, dream states, and somnambulism. While precursors to DSM-I had grouped the dissociative and conversion disorders under the single rubric of "conversion hysteria", the two subclasses were now distinguished -- dissociation by personality disorganization, conversion by isolated symptoms of anesthesia, paralysis, and dyskinesia. (DSM-I also carried a special listing of somnambulism, but this apparently referred specifically to sleepwalking.) The DSM-I conceptualization of the dissociative disorders was heavily influenced by psychoanalytic theory, as evidenced by its reference to the discharge or deflection of repressed impulses.
In some respects, DSM-II, published in 1968, reverted to pre-DSM practices. Here, Hysterical Neurosis, Dissociative Type, defined as an alteration in consciousness and identity, was joined by Hysterical Neurosis, Conversion Type, defined as a disorder of the special senses or the voluntary nervous system. Hysterical neurosis itself was characterized in psychoanalytic terms of the unconscious and automatic control of anxiety. However, explicit references to repression and the psychoanalytic theory of neurosis were absent from the description.
DSM-III (1980) and its revision, DSM-III-R (1987), abandoned both neurosis and hysteria as technical terms. The class of Dissociative Disorders included Psychogenic Amnesia, Psychogenic Fugue, Multiple Personality Disorder (MPD), and Depersonalization Disorder -- as well as Atypical Dissociative Disorder. Conversion Disorder, by contrast, was grouped with Body Dismorphic Disorder, Hypochondriasis, Somatization Disorder, and Somatoform Pain Disorder, under the heading of Somatoform Disorders. DSM-III-R stated that the essential feature of the dissociative disorders was "a disturbance in the normally integrative functions of identity, memory, or consciousness..." in the absence of brain insult, injury, or disease. In the case of Psychogenic Amnesia, the essential feature is, of course, loss of memory. Psychogenic Fugue added the assumption of a new identity, as well as physical relocation away from customary home or workplace. Somewhat surprisingly, however, the DSM-IIIR criterion for Multiple Personality Disorder specified only the alternating control of behavior by at least two distinct personalities, permits the diagnosis to be made on the basis of personality fragments rather than complex, integrated structures, and makes no reference to interpersonality amnesia. Thus, the DSM-IIIR criterion was rather liberal, as it diagnosed patients who formerly might qualify only for Atypical Dissociative Disorder as instances of full-blown MPD. This liberal diagnostic criterion may account for some of the increased reporting of MPD in the 1980s and 1990s.
This situation was corrected, to some degree, in DSM-IV (American Psychological Association, 1994), which returned an explicit criterion of amnesia to the diagnostic criteria for Multiple Personality Disorder, which was also renamed Dissociative Identity Disorder (DID). Thus, it is not enough simply to find evidence of two or more "ego states" in the same person -- a likely factor in the recent proliferation of the diagnosis. Some evidence of amnesia is also required, although the criterion does not specify interpersonality amnesia. Cases resembling DID, but without amnesia, are removed to the new category of "Dissociative Disorder Not Otherwise Specified" (DDNOS) -- a category which also covers derealization in the absence of depersonalization and trance states such as amok and latah. DSM-IV also strengthens the emphasis, in diagnosing psychogenic fugue, on changes in personal identity, whether the loss of an old one or the assumption of a new one. Return to index.
Dissociative amnesia, also known as limited functional amnesia (Schacter & Kihlstrom, 1999), entails a loss of personal memory that cannot be accounted for by ordinary forgetting, or by brain insult, injury, or disease (for other reviews, see Arrigo & Pezdek, 1997; Kopelman, 1995, 1997; Loewenstein, 1996; Pratt, 1977; Schacter & Kihlstrom, 1999; Stengel, 1962). The amnesia is typically retrograde, in that it covers a period of time before the precipitating event, -- although Janet (1893) did describe an unusual case of anterograde psychogenic amnesia, in which memory before the trauma remained intact, but the patient showed an inability, reminiscent of that observed in the organic amnesic syndrome, to remember events that transpired since the traumatic event. Nemiah (1979) has distinguished three forms of psychogenic amnesia, depending on its extent: localized, covering hours or weeks; systematized, covering only specific events and related material; and generalized, involving a transitory loss of memory for one's entire life -- a condition which shades into psychogenic fugue.
Although dissociative amnesia, by definition, is not caused by brain insult, injury, or disease, the relation between the syndrome and brain injury is better characterized as one of independence. That is, brain injury can occur without amnesia appearing as one of its sequelae; and functional amnesia can occur in association with head injury (Treadway, Cohen, and McCloskey, 1988). Although psychogenic amnesia has been the frequent subject of popular treatments, there has been very little research on the nature of the memory loss, its eliciting conditions, and the circumstances that lead to recovery of the lost memories (Schacter & Kihlstrom, 1999). Even Janet (1907) barely made mention of psychogenic amnesia outside of the context of somnambulism, fugue, and multiple personality. One important question for future research, especially in a forensic context, concerns the symptoms that differentiate organic and functional amnesias (Kopelman, 1995). Such information, in turn, would permit conclusions about the extent to which functional, psychogenic amnesias are misdiagnosed as organic amnesias, simply because they occur in temporal association with head injury. Return to index.
Somewhat more is known about psychogenic fugue, also called functional retrograde amnesia (for reviews see Kopelman, 1997; Loewenstein, 1996; Pratt, 1977; Schacter & Kihlstrom, 1999; Stengel, 1966). Fugue adds to the loss of personal memory observed in psychogenic amnesia a loss of identity as well, and sometimes physical relocation (hence the name), to boot. Fugue is often associated with physical or mental trauma, depression, problems with the legal system, or some other personal difficulty (Kaszniak, Nussbaum, Berren, & Santiago, 1988; Eisen, 1989).
Fisher (1945; Fisher & Joseph, 1949) has distinguished three types of fugues. In the classic instance, there is amnesia for personal history, accompanied by a change in identity and relocation to another domicile. Fugue may also entail amnesia accompanied by the simple loss, but no change, in personal identity. Finally, there may occur a reversion to an earlier period in one's own life, with an amnesia for the interval between that earlier period and the present, but no change in identity. Clearly, the distinction between psychogenic fugue and psychogenic amnesia is difficult to make. While one might say that fugues are simply very generalized amnesias, the loss of identity that is pathogonomic of fugue may be a qualitative difference.
The process of recovery from fugue is not well understood. Patients typically come to clinical attention when they become spontaneously aware of the situation, or when they fail to respond appropriately to specific questions about their background when questioned by the police, potential employers, or others. Some patients experience a sudden awakening to their original identity; others experience a sudden awareness that they do not know who they are. Nevertheless, when the situation is resolved, the patient is typically left with an island of amnesia covering the period of the fugue state itself.
Although there exist many clinical reports of psychogenic fugue, apparently only a single case has been subjected to controlled, experimental analysis. Schacter, Wang, Tulving, and Friedman (1982) performed such an analysis on a case, P.N., whose condition was apparently precipitated by the death of his grandfather. The boundaries of the amnesia were explored by means of the "Crovitz-Robinson" technique (Crovitz & Shiffman, 1974; Robinson, 1976), in which common words are presented as cues for the retrieval of conceptually related autobiographical memories. When tested during the fugue state, 86% of the patient's memories were drawn from the period covered by the fugue -- a stronger recency bias than is normally observed in such situations. Two weeks later, after the amnesia had remitted, fully 92% of the memories predated the amnesia (the lack of recency bias thus reflecting an amnesia for the fugue itself). By contrast, when asked to identify pictures of famous people, the patient performed equally well during and after the amnesia. Such findings were interpreted by Schacter et al. (1982) as reflecting a selective impairment in episodic memory which spares semantic memory. However, it should be noted that semantic memory includes aspects of personal identity -- one's name, birthdate, physical and psychosocial characteristics, the names of family members, etc. as well as impersonal world knowledge (Kihlstrom & Klein, 1994, 1997). Fugue impairs semantic memory for personal information, as well as episodic memory for personal experiences. Return to index.
Dissociative identity disorder (DID) takes the disruption of memory and identity observed in dissociative fugue one step further, because there is an alternation of both memory and identity (for recent reviews see Bliss, 1986; Putnam, 1989; Ross, 1997). That is, when one ego state is in control of thought and action, and monitoring environmental events, memory is continuous within that ego state. However, when monitoring and control shift to another ego state, the new personality may have no access to memories for the activities and experiences of the other(s). However, some degree of cooperation is possible among ego states, when one has information or resources that the other one needs.
On the basis of their review of 76 named (mostly classic) cases, Taylor and Martin (1944) listed a number of features distinguishing the various ego states:
(1) the "general quality" of the personality, as a whole;
(2) propriety of behavior;
(3) gender identity or erotosexual orientation;
(4) age, handedness, or language differences; and
(5) anesthesia in one or more sensory modalities, or paralysis in one or more limbs.
About two thirds of the cases studied by Taylor and Martin were dual personalities, and about half of these showed a pattern of mutual or symmetrical amnesia. Of the remainder, most displayed only three personalities, and a more complex pattern of asymmetrical amnesia. Ellenberger (1970) classified DID into three major categories: (1) successive multiple personalities, the usual case, with either symmetrical or asymmetrical amnesias (Ellenberger thought that "mutually cognizant" alter egos were infrequent); (2) simultaneous multiple personalities, very rare; and (3) personality clusters,
However, it is by no means a straightforward matter to discern which ego state, if any, is "primary". Following the example of Eve (Thigpen & Cleckley, 1954), and perhaps influenced by the psychoanalytic concept of the repression of conflict-laden ideas, drives, affects, and impulses, there appears to be some tendency to identify the primary personality with the ego-state displaying the most conventional, socially desirable qualities. However, Taylor and Martin (1944) argued that there was no clear pattern of "normality" or "pathology" distinguishing the primary personality from the alter egos; sometimes, a normally subconscious personality is better adjusted than a normally conscious one. In most cases, it may be convenient to assign the label "primary" to the ego state that is most frequently encountered, or has the longest-running identity. In the case of I.C. (Schacter, Kihlstrom, Canter Kihlstrom, & Berren, 1989), the pattern of memory deficit observed strongly suggested that the "primary" personality, defined in terms of frequency of encounter and degree of familiarity to other people, was actually an alter ego who first appeared when the patient was about 10 years old.1 Return to index.
The formal history of DID reaches back more than 200 years, to the very beginnings of the modern medical literature (Carlson, 1981, 1989).2 What might be called a "classic period" for the study of DID extended from about 1880 to 1920, as reflected in the well-known reports of Azam, Janet, Prince, Sidis, and others. Of the 76 named cases covered by Taylor and Martin (1944) in their exhaustive review of the published literature, 51 (67%) were first reported during this period, and the vast majority of the rest shortly before or after it. Almost two decades later, Sutcliffe and Jones (1962) added only a single acceptable case, the "Three Faces of Eve" (Thigpen & Cleckley, 1954).
Case reports of DID fell off rapidly in the half-century following 1920, a trend that may be attributable in part to the triumph of Freud over Janet, and in part to increased diagnosis of schizophrenia. They then took a sharp upward turn beginning around 1970 -- a trend that may be attributable in large part to the publication in the popular press of Sybil (Schreiber, 1973).3 There followed a literal avalanche of case reports, appearing in both the popular and professional press (Boor, 1982; Greaves, 1980; Kihlstrom et al., 1993). For example, a mail survey of selected clinicians identified 100 cases currently or recently in treatment as of 1982 (Putnam, Guroff, Silberman, Barban, & Post, 1986).
In the 1970s alone, at least by a liberal count, more cases of DID were reported than in all the previous time since Mary Reynolds. Ross (1997) has written that between 1979 and 1991 he saw Aabout 80" (p. 256) cases of DID in his practice in Winnepeg, Manitoba, and that between 1991 and 1997 over 500 cases had been admitted to a single dissociative disorders treatment unit in Dallas, Texas. As if that were not enough, there has been a dramatic increase in the number of alter egos manifested in the individual case. The vast majority of cases listed by Taylor and Martin (1944) -- 48, or 63% -- presented dual personalities, and only one case presented as many as 12 alter egos. By contrast, the majority of new cases listed by Greaves (1980) and Boor (1982) had three or more personalities, and the cases registered by Putnam et al. (1986) presented 13.3. Ross (1997) reported an average of 15.7 alter egos in a series of 236 patients.
The degree to which some of these cases are iatrogenic, or simply misdiagnosed, remains to be seen (Fahy, 1988). It is worth remembering that even in the heyday of multiple personality, around the turn of the century, when clinicians were very alert to the possibility of new cases, very few were actually diagnosed: even Janet and Prince described only four cases each (Taylor & Martin, 1944). And despite hundreds of referrals, Thigpen and Cleckley (1984) only saw one other case after Eve. Return to index.
Especially in view of the virtual avalanche of cases reported in both the professional and popular press since 1973, it is surprising that so few cases have been subject to controlled experimental analysis employing laboratory procedures. During the classic period, Prince and Sidis reported a number of studies of perception, reasoning, free association, and psychophysiology (for a review, see Kihlstrom et al., 1993). Later, (Osgood & Luria; 1954; Osgood, Luria, Jeans, & Smith, 1976; see also Kroonenberg, 1985) reported on blind analyses of semantic differential protocols collected from various personalities. While the recent revival of interest in DID has yielded a number of psychometric studies employing both projective and objective instruments (for a review, see Kihlstrom et al., 1993), experimental studies have been somewhat rarer.
A salient exception to this rule is the case of Jonah, a man with three (perhaps four) alter egos, studied by Ludwig and his associates (Brandsma & Ludwig, 1974; Ludwig, Brandsma, Wilbur, Bendfeldt, & Jameson, 1972). Each of the four principal alter egos was administered a battery of personality and intelligence tests (including the MMPI and the Gough Adjective Check List, and the WAIS), a number of learning and memory tasks (including paired-associate learning and prose memory), conditioning, and psychophysiological recordings (including electrodermal responses, EEG, and event-related potentials. Another study employed experiential time-sampling to document state changes in a woman vulnerable to extremely rapid alterations of personality (Lowenstein, Hamilton, Alagna, Reid, & deVries, 1987). Schacter et al. (1989) used the "Crovitz-Robinson" technique to study I.C., a case of DID with an very extensive childhood amnesia, compared to a carefully matched control group. Unfortunately, these investigators were not able to study autobiographical memory in any of the alter egos, although such an experimental case study was recently reported by Bryant (1995).
Further experimental study of DID is warranted because while this syndrome is defined in DSM-IV as a disorder of identity and the integration of self, it is also fundamentally a disorder of memory. In every dissociative disorder, the patient is unable to recollect some or all of his or her past actions and experiences; and in DID, an interpersonality amnesia reflects the inability of one alter ego to consciously recall the activities and experiences of others. However, there is more to memory than what the individual can bring to awareness, and there is evidence that memory for these forgotten events may influence the patient's ongoing experience, thought, and action outside of conscious awareness. In fact, as indicated earlier, clinical observation of such influences were the reason for the notion of Adissociation@ in the first place.
In modern terminology, the dissociative disorders may involve a dissociation between two expressions of memory, explicit and implicit (Schacter, 1987). Explicit memory refers to the person's conscious, intentional recollection of some previous episode, most commonly reflected in recall and recognition. Implicit memory, or memory without awareness, is reflected in any change in the person's experience, thought, or action which is attributable to some prior episode of experience, but which cannot be accounted for by explicit memory for that event. Dissociations between explicit and implicit memory are a common feature of the Aorganic@ amnesias associated with brain insult, injury, or disease (Shimamura, 1989), and are found in the Afunctional@ amnesias associated with the dissociative disorders as well (Schacter & Kihlstrom, 1999).
Although hints of implicit memory are found in some of the earliest cases of DID, the first formal demonstration along these lines was reported in the case of Jonah (Ludwig et al., 1972), who was completely unaware of his three other alter egos. In order to document the pattern of interpersonality amnesia apparent on clinical examination and history, Ludwig et al. conducted various studies of verbal learning, classical conditioning, transfer of training, and learning-to-learn. For example, Jonah could not recall paired associates learned by the other personalities; and while the others could recall items learned by Jonah, they could not recall items learned by each other. However, when one alter ego was asked to learn (rather than remember) a list of paired associates initially mastered by another, each showed considerable savings. Thus, there was transfer of information between personalities on the paired-associate learning test, but not on the paired-associate recall test.
The dissociation between explicit and implicit memory observed by Ludwig et al. (1972) was further explored by Nissen, Ross, Willingham, Mackenzie, and Schacter (1988), who performed a careful comparison between explicit and implicit memory in a single DID patient with 22 different alter egos. On each test, items were presented to one alter ego, and memory for these items was tested in another; a total of eight personalities, each separated from the others by an amnesic boundary, were tested in the experiment. On two tests of explicit memory, cued recall and yes-no recognition, each ego state showed a dense amnesia for items presented to the others -- in other words, there was no interpersonality transfer of explicit memory. The corresponding tests of implicit memory, however, yielded complex results: while five tasks yielded some evidence of interpersonality transfer, four others gave no evidence that implicit memory transferred between alter egos. Moreover, on some tasks there was less implicit memory between alter egos than within a single personality, indicating that even implicit memory sometimes failed to cross the amnesic barrier.
Recently, Eich and his colleagues have reported a nomothetic comparison of explicit and implicit memory in nine DID patients (Eich, Macaulay, Loewenstein, & Dihle, 1996). As in Nissen et al.'s (1988) case study, free recall and cued recall tests of explicit memory yielded strong evidence of interpersonality amnesia, confirming the clinical picture. However, while a test of picture-fragment completion indicated that implicit memory was spared, a test of word-stem completion did not. On the latter task, implicit memory was displayed only within, not between, alter egos. Eich et al. concluded that while tests of implicit memory could reveal transfer of information from one alter ego to another, Ahow much leakage occurs across personality states depends on the extent to which encoding and retrieval processes are susceptible to personality-specific factors (p. 421). While it would be tempting to conclude that implicit memory transfers across ego-state boundaries in DID, while explicit memory does not, the actual pattern of results is somewhat more complex than this, and remains to be clarified by further research.
A more recent development, reflecting the increased interest in biological processes in psychopathology generally, has been the use of brain-imaging techniques such as EEG frequency analysis and event-related potentials (for a review, see Kihlstrom et al., 1993). Putnam (1984) presented a preliminary report of a study of 11 DID patients and 10 simulating controls that successfully distinguished the two groups on the basis of event-related potentials: within subjects, genuine alter egos showed greater differences in amplitude and latency than simulated ones. Mathew, Jack, & West (1985) reported a shift in regional cerebral blood flow (toward the right temporal lobe) in one patient, but there have been no similar studies employing PET or fMRI technologies. Given the enormous amount of interest in dissociative identity disorder, it is remarkable that these intriguing findings have not been followed up by studies using more rigorous methodologies which might reveal the biological substrates of amnesia, fugue, and multiple personality. Return to index.
Some of the most difficult aspects of the current DID "epidemic" are the loosening of diagnostic criteria, the influence of popular culture (in the late 19th century, Stevenson's Dr. Jekyll and Mr. Hyde; in the late 20th century, the cases of Eve and Sybil themselves) on patient and therapist alike, the investment that some clinicians seem to have in the syndrome, and the recent proliferation of cases with extremely large numbers of alter egos. Another troublesome aspect is the apparently common practice of eliciting alter egos through hypnosis, instead of observing them emerge spontaneously. Because the hypnotic interaction itself is highly suggestive, hypnosis affords an especially good opportunity to create alter egos out of whole cloth, and for their nature to be shaped by the hypnotist's suggestions and other cues and demands contained in the hypnotic situation (Bowers & Farvolden, 1996; Frankel, 1994).
Drawing on his social-psychological analysis of hypnotic phenomena Spanos (1986, 1994, 1996; but see Gleaves, 1996), offered an interpretation of dissociative identity disorder (and, by extension, the other dissociative disorders as well; see Spanos & Gottlieb, 1979) as a strategic social enactment in which an individual disavows responsibility for certain actions by attributing them some "indwelling entity, "part", or "personality" other than the self (pp. 36). Just as people learn the hypnotic role and then enact it under appropriate conditions, so people can learn to enact the role of multiple personalities -- to create a social impression that is congruent with the diagnosis, and that fulfills certain interpersonal goals. Just as the hypnotist abets this process by giving suggestions as to how the subject should behave, so clinicians explicitly and implicitly shape the behavior of their patients by encouraging then to adopt the role in the first place, providing them information about how to do so convincingly (for example, by displaying interpersonality amnesia), and then validating the performance by conferring a psychiatric diagnosis, and offering a particular form of therapy. Thus, the multiple personality is not so much a discovery as a creation -- a creation on the part of both patient and therapist. Even so, the benefits for achieving the diagnosis -- relief from interpersonal distress, mitigation of criminal responsibility, control of others, permission for untoward behavior -- may be so powerful as to lead patients to "become convinced by their own enactments and come to believe that they possess multiple selves" (p. 47).
The influence of interpersonal, cultural, and historical factors on dissociative identity disorder hardly be denied, but it is also something of a puzzle. The fact that the diagnosis experienced a golden age, waned after 1920, and showed a resurgence in the 1970s makes one wonder about the social conditions in which dissociative behaviors are expressed, and corresponding diagnoses made. This point has been made most forcefully by Kenny (1986), who has provided an ethnographic analysis of dissociative identity disorder and related conditions. Analyzing the classic cases of Mary Reynolds, Ansel Bourne, Miss Beauchamp, B.C.A., Eve, and Sybil, Kenny (1986) argues that DID is a response to changing conditions in American culture. For example, Mary Reynolds' alter ego seems not so much an alternate to her normal state as a contradiction of it, a rebellion against her old self. Similarly, Ansel Bourne's fugue state may be interpreted as a symbolic representation of his self-perceived status as a "changed man" following his religious conversion. Miss Beauchamp rebelled against the limitations imposed on women in turn-of-the-century America and was used as a vehicle for Morton Prince's campaign against Freudian psychoanalysis. Kenney does not argue that most, or even many, cases of DID are fraudulent: He closes his book with an image of an intense and preoccupied Ansel Bourne, "trying -- and failing -- to remember something important@ (1986, p. 188). Rather, his purpose is to understand how the definition and experience of self is shaped by the surrounding culture. There is no contradiction between excepting certain cases of dissociative disorder as genuine, and understanding the sociocultural context in which they occur. Return to index.
In addition to the gross disruptions of autobiographical memory self-integration seen in psychogenic amnesia, fugue, and dissociative identity disorder, the dissociative disorders include the experiences of depersonalization and derealization (Coons, 1996; Reed, 1979, 1988). As originally defined, depersonalization and derealization were thought to co-occur: the person experiences both him- or herself as totally different, and the world as strange and new. Later, they were construed as independent entities. Nemiah (1989) has suggested that derealization is the more general case, and depersonalization a limited form in which only the experience of self is changed. Both depersonalization and derealization are frequently seen as symptoms of other syndromes, such as anxiety, depression, and obsession -- for example, the phobic anxiety-depersonalization syndrome (Roth & Argyle, 1988). Depersonalization and derealization are nonspecific symptoms independent of other diagnoses ( Brauer, Harrow, & Tucker, 1970; Fleiss, Gurland, & Goldberg, 1975), and are salient components in the "near-death experience" reported by those who have been rescued at the last moment from drownings, falls, and other kinds of accidents. However, depersonalization and derealization also constitute psychopathological syndromes in their own right.
As a primary diagnosis, the central feature of depersonalization disorder is a subjective awareness or feeling of change in oneself (depersonalization) or the world (derealization). This often occurs suddenly, after awakening from sleep or after a frightening incident. The feeling puzzles the experiencer: the changed condition is perceived as unreal, and as discontinuous with his or her previous ego-state. The object of the experience, self (in depersonalization) or world (in derealization), is commonly described as isolated, lifeless, strange, and unfamiliar; oneself and others are perceived as "automatons", behaving mechanically, without initiative or self-control. Although the feeling of depersonalization and derealization may be pleasant when self-induced by means of psychedelic drugs, in clinical cases it is unpleasant, even aversive: the victim often feels as if he or she were going insane, or dying. Throughout, however, the person retains insight into what is happening: he or she remains aware of the contradictions between subjective experience and objective reality -- it is only "as if" things were not real. Occasionally, the person will develop a delusional explanation about the experience (Kihlstrom & Hoyt 1988), in which case both the puzzlement and the "as if" quality will disappear. Finally, depersonalization and derealization usually involve diminished emotional responsivity -- a loss of interest in the outside world, of feelings for other people, and of anxiety or depression.
Mayer-Gross (1935) noted that depersonalization and derealization may occur with a host of other symptoms, including deja vu (in which the sense of having been in a place before coexists with the knowledge that this is not the case) and jamais vu (in which a situation is experienced as unfamiliar, despite the person's knowledge that it has been experienced many times before). In its totality, then, the experience of depersonalization is one of strangeness in oneself, in others, and of one's relation to them. Viewed from the perspective of cognitive psychology, these syndromes represent failures of recognition -- an inability to match current experience with past memories, something like what happens when one enters a familiar room whose furniture or paint scheme has been changed (Reed, 1979, 1988). Especially important here is the disruption of self-reference, which seems so crucial to the experience of recognition (Kihlstrom, 1997). Return to index.
The actual incidence and prevalence of the dissociative disorders is hard to estimate. The dissociative disorders were excluded from the massive Epidemiological Catchment Area survey (Regier, Myers, Kramer, et al., 1984), presumably because appropriate diagnostic criteria were not provided by the standardized assessment instruments available at the time. This situation has now been corrected. Steinberg and her colleagues have produced a version of the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), which diagnoses these syndromes according to the rules of DSM-IV (Steinberg, 1996).
Several investigators have also developed questionnaire surveys of dissociative experiences that can be conveniently administered to large samples. The most popular of these is the Dissociative Experiences Scale (DES) of Bernstein and Putnam (1986; Carlson & Putnam, 1993), which holds promise as a diagnostic screening tool, locating high-scoring subjects who might be at risk for dissociative disorder (Carlson, Putnam, Ross, et al., 1993). For example, a doctoral dissertation by Angiulo (1994) found that college students who achieved extremely high scores on the DES were significantly more likely to qualify for a formal diagnosis of dissociative disorder (usually DDNOS) when subsequently administered the SCID-D. Of course, the DES and similar instruments can also be employed as an instrument for research on normal personality structure and processes. For example, although the DES assesses levels of dissociation on a traitlike continuum from low to high, Waller and his colleagues (Waller, Putnam, & Carlson, 1996; Waller & Ross, 1997) have employed taxometric techniques to argue that individuals scoring high on the DES constitute a fairly discrete personality type.
While instruments such as the SCID-D and the DES are intended to measure relatively stable trait-like dispositions toward dissociation, the Clinician-Administered Dissociative States Scale (CADSS; Bremner, Krystal, Putnam, Southwick, Marmar, Charney, & Mazure, 1998) has been developed to measure episodic dissociative states, and is suitable for measuring changes in symptoms. Examination of item content, however, indicates that the CADSS focuses on symptoms of depersonalization and derealization, and not the disruptions of memory and identity that lie at the heart of dissociative amnesia and fugue, and dissociative identity disorder. Return to index.
In addition to being a puzzle for clinicians and experimentalists, the dissociative disorders have created substantial difficulties for the legal system. A victim who cannot remember the circumstances of a crime cannot offer valuable testimony that might lead to a conviction, while amnesic defendants cannot assist in their own defense. Moreover, the presence of amnesia for a criminal act may suggest that the crime was committed in an altered state of consciousness in which normal processes of monitoring and control were inoperative -- thus potentially qualifying the defendant for the insanity defense. Unfortunately, the diagnosis of dissociative disorder is difficult to substantiate -- even the structured clinical interview are susceptible to faking -- and there is no way to tell for sure whether a particular suspect's claim of amnesia is genuine or simulated (Kopelman, 1995; Schacter, 1986a, 1986b).
The legal problems associated with DID are especially severe, as illustrated by the case of Kenneth Bianchi, the AHillside Strangler@ (State v. Bianchi, No. 79-10116, Washington Superior Court, October 19, 1979).4 Bianchi was charged, along with his cousin, in 10 rape-murders in Los Angeles, and alone in two similar cases in Bellingham, Washington (Allison, 1984; Orne, Dinges, & Orne, 1984; Watkins, 1984). According to his defense, the crimes were perpetrated by an alter ego, "Steve Walker", a claim that was supported by evidence of high hypnotizability (a characteristic commonly associated with DID). However, the claim was undercut by other evidence suggesting that Bianchi had simulated hypnosis, and especially by inconsistencies in the self-presentation of the alter egos, psychological test evidence, and the lack of independent corroboration of the alter egos by people who knew him before he was arrested. Bianchi also had a great deal of background psychological knowledge, and had practiced psychotherapy under a false name and faked credentials (at one point in the proceedings he claimed that this was the work of a third alter ego, named "Billy"). Bianchi was convicted of eight counts of murder in the Hillside Strangler cases. He subsequently offered to testify against his cousin, who was also convicted. Return to index.
Stress, whether acute or chronic, is an extremely prominent feature in the dissociative disorders -- so much so that they are sometimes considered forms of post-traumatic stress disorder (PTSD; e.g., Putnam, 1985; Spiegel, 1984). The occurrence of depersonalization in response to life-threatening danger, and of psychogenic amnesia and fugue in victims of crime and disaster, has already been noted, as has the apparent frequency with which amnesia and fugue are seen in cases of "war neurosis".5 In particular, many authorities have noted an apparently strong relationship between DID and a history of childhood physical and sexual abuse. For example, Putnam et al. (1986) noted that fully 86% of their 100 recent cases presented a self-reported history of sexual abuse, 75% reported repeated physical abuse (68% reported both kinds of abuse), and 45% reported witnessing a violent death during childhood; only 3% of these cases had no history of significant childhood trauma. Reflecting a broad consensus among clinicians and researchers, Horevitz and Loewenstein (1994) have characterized DID as Aa traumatically induced developmental disorder of childhood@ (p. 290).
At the same time, it must be underscored that this consensus is largely based on retrospective surveys of a sample of patients (and clinicians) whose representativeness of the population of DID is unknown. The definition of childhood trauma in these surveys is often very broad, including extreme neglect and poverty as well as sexual and physical abuse, and there is rarely any quantification of the number of traumatic episodes, their severity or their duration. The extent to which reports of childhood sexual abuse and other trauma may be biased by the patients' or clinicians' own intuitive theories of DID is unknown, but it is fairly certain that those who seek evidence of abuse and other trauma in childhood will be able to find it. Self-reported histories of childhood trauma, abuse, and neglect are rarely subject to independent verification, perhaps because since the earliest days of psychoanalysis the causal link between trauma and dissociation is so intuitively appealing.
Even with independent corroboration of abuse histories, most studies in this area are retrospective in nature, and necessarily overestimate the strength of the relationship, if indeed any relationship exists at all, between childhood trauma and adult dissociative disorder (Dawes, 1993; Kihlstrom, Eich, Sandbrand, & Tobias, 1997; Pope & Hudson, 1995). For this purpose, the gold standard is provided by prospective studies which condition subjects on the antecedent -- e.g., taking representative groups of abused and nonabused children and following them into adulthood to determine who among them develops dissociative disorder.
In fact, authoritative reviews of prospective research failed to find evidence of any specific impact of child sexual abuse on adult personality and psychopathology (Kendall-Tackett, Williams, & Finkelhor, 1993; Nash, Mulsey, Sexton, et al., 1993). This is not to say that child sexual abuse is benign -- it is only to say that there are currently no empirical grounds to accept the proposition that childhood sexual abuse causes, or even increases the risk for, later dissociative disorder. Prospective analyses of other kinds of trauma yield similar findings. For example, Holocaust survivors may show signs of PTSD, but dissociative amnesia is not a prominent feature of their profiles (Wagenaar & Groeneweg, 1990). At this point, the traumatic etiology for dissociative identity disorder and other dissociative disorders must be considered to be a hypothesis -- not an established empirical fact which can inform prevention and treatment. Return to index.
Other than dissociative identity disorder, little has been written about the treatment of the dissociative disorders (Reid, 1989). Apparently, most cases of psychogenic amnesia and fugue resolve themselves spontaneously. Sometimes, the patient recovers his or her memories and identity unaided. In other cases, this process is prompted by contact with family and friends, or by hints generated through free associations or dream reports. Many cases report that recovery was stimulated by the induction of hypnosis, or sedation by means of intravenous barbiturates such as thiopental. However, these reports should be viewed against a background of experimental literature indicating that hypnosis has no special efficacy for the recovery of forgotten, repressed, or dissociated memories (Kihlstrom & Barnhardt, 1992; Kihlstrom & Eich, 1994). Moreover, no clinical or experimental study of barbiturate hypnosis has attempted independent corroboration of the ostensibly recovered memories (Piper, 1993).
Depersonalization symptoms are typically intermittent, but because episodes are often associated with acute mood disorder, and drug treatment for anxiety and/or depression is often recommended. Presumably, benzodiazepines and other psychoactive drugs act on the anxiety and depression in which depersonalization and derealization occur, rather than on the feelings of unreality directly.
With respect to dissociative identity disorder, the traditional approach to the treatment of DID, initially popularized by Thigpen and Cleckley (1957), involves psychodynamic uncovering, abreaction, and working through of the trauma and other conflictual issues presumed to underlie the disorder, followed by an attempt at integrating the personalities into a single identity (Braun, 1986). The cooperation of each personality is required, entailing considerable effort directed toward developing therapeutic alliances. Hypnosis is often used, both for communicating with the personalities and for the integration, which is sometimes performed almost as a ceremony. Of course, psychotherapy does not necessarily stop with fusion: additional time may be required in order to work through the insights achieved earlier in therapy, support the new fusion among the alter egos, and cope with the changes produced by integration.
Even though the modal therapy for DID is insight-oriented, there have been occasional attempts at cognitive-behavioral treatments (e.g., Kirsch & Barton, 1988). Regardless of treatment approach, there appears to be general consensus that the syndrome presents a number of specific challenges to treatment (Reid, 1989), including secondary gain (for the patient, and for the therapist) countertransference reactions of anger, exasperation, and aggression (as well as sexual attraction), suggestibility (especially where the evidence for DID is elicited by hypnosis, without independent corroboration), and the integration of confabulations and other distortions into memory.
As with the other dissociative disorders, there is little in the literature by way of systematic outcome studies (Reid, 1989; Ross, 1997). One exception is report by Coons (1986) on 20 cases; another is the periodic updates by Kluft (e.g., 1988) on a large series of cases. Ross (1997) reported a two-year follow-up of 54 patients (from an original sample of 103): only 12 of these patients had achieved a therapeutic goal of stable integration, although the group as a whole reported diminished levels of dissociative experiences. Still, as Ross (1997) notes, Astrictly speaking, there are no treatment outcome data for dissociative identity disorder in the literature@ (p. 247). Given all the attention that DID, has received since 1980, and the fact that whole units, if not entire hospitals, have been developed for its treatment, with the ensuing claims for out-of-pocket and third-party payment, this situation is remarkable and deplorable.
Most current treatments of DID appear to be predicated on the notion that the syndrome is caused by childhood trauma such as sexual and physical abuse (Horevitz & Loewenstein, 1994; Ross, 1997). Thus, after the patient has been stabilized, Kluft (1993) recommends a focus on the uncovering and resolving trauma and the abandonment of dissociative defenses. This recommendation would make no sense if there were not memories of trauma to be uncovered and dissociative defenses against such memories to be eliminated. However, as noted earlier, it is not at all clear that the origins of dissociative identity disorder lie in sexual abuse or any other form of childhood trauma. In the absence of convincing prospective evidence that DID has its origins in childhood trauma, such a post-centered focus seems premature at best, and at worst raises the possibility that false memories of childhood sexual abuse may be constructed during the course of treatment. Return to index.
The dissociative disorders constitute only a portion of what was formerly described as "hysteria" (Kihlstrom, 1994). Janet in his pioneering classificatory work, was quite clear that the functional anesthesias, paralyses, and amnesias, including the amnesias of fugue and multiple personality, all belonged together in a single class, distinct from phobias, obsessions and compulsions, and other subtypes of neurosis. Early diagnostic usage, through DSM-II, essentially honored Janet's principles. However, DSM-III and its revision, DSM-IIIR, abandoned hysteria and separated the dissociative disorders from the conversion disorders. The conversion disorders, in turn, were removed to the category of "Somatoform Disorders" along with somatization disorder (Briquet's syndrome), hypochondriasis, somatoform (psychogenic) pain disorder, body dysmorphic disorder (formerly known as dysmorphophobia), and the like (for reviews of the somatoform disorders. This separation persists in DSM-IV.
Put bluntly, this reclassification was, and remains, a mistake. It has long been known that conversion disorder, reflecting monosymptomatic disorders of the sensory-motor system, has nothing in common with Briquet's syndrome, hysterical personality, hypochondriasis, and the other somatoform disorders (Kihlstrom, 1992, 1994). They have much more in common with the dissociative disorders: in both cases events (in the current or past environment) have been registered, and influence the patient's experience, thought, and action, even though the patient is not consciously aware of them.
The proper classification of the conversion disorders, as essentially dissociative, is suggested by the pseudoneurological nature of their presenting symptoms, and further supported by closer psychological analysis of the paradoxes and contradictions in behavior observed in the classic cases described by Janet (1907). The functionally blind patient complains of being unable to see, but correctly guesses how many fingers the examiner holds up before his eyes. The functionally deaf patient claims to be unable to hear, but orients when her name is called from outside her field of vision. In both cases, the patient's problem is in gaining conscious access to something that has been processed and registered in the sensory-perceptual system. But in the absence of conscious access, the percepts in question nevertheless influence the patient's experience, thought, and action outside of phenomenal awareness. The parallel to functional amnesia, where the patient complains of being unable to recollect past episodes, but is nevertheless influenced by the unremembered events, is clear -- at least to us. Just as the functionally amnesic patient is not conscious of what he or she remembers, the functionally blind or deaf patient is not conscious of what he or she sees or hears. This disruption of conscious awareness is the essence of dissociation.
By analogy with implicit memory, the paradoxes and contradictions in the behavior of conversion disorder patients may be labeled as expressions of "implicit perception" (Kihlstrom, 1996; 1999; Kihlstrom, Barnhardt, and Tataryn, 1992): they show the influence of events in the current environment, in the absence of conscious perception of these events.
Fundamentally, then, both the dissociative and conversion disorders reflect a disruption of the normal functions of consciousness (Hilgard, 1977; Kihlstrom, 1984, 1992, 1994). These functions include: (1) monitoring ourselves and our environment, permitting us to be aware of current events and to recollect the past, such that the world is accurately represented in phenomenal awareness; and (2) controlling ourselves, so that we have the experience of voluntarily initiating and terminating mental activities, at will, in order to achieve our personal goals and meet environmental demands. Accordingly, their essential unity should be reflected in our diagnostic nosology (for a similar suggestion, see Nemiah, 1989). Therefore, we suggest that henceforth the term "conversion disorder" be dropped from the diagnostic nosology, as an inappropriate holdover from the days when psychoanalysis dominated our conception of the neuroses. Furthermore, the erstwhile conversion disorders should be removed from the somatoform category and regrouped with the other dissociative disorders, forming three subcategories: (1) dissociative anesthesia, including psychogenic blindness, deafness, analgesia, and other functional disorders of sensation and perception; (2) dissociative paralysis, including psychogenic aphonia and other functional disorders of motor function; and (3) dissociative amnesia, including dissociative amnesia and fugue, dissociative identity, depersonalization and dissociation, and other functional disorders of memory and awareness. Return to index.
Preparation of this chapter, and the research contributing to the point of view represented herein, was supported in part by Grant #MH-35856 from the National Institute of Mental Health. I thank Douglas J. Tataryn and Irene P. Tobis (nee Hoyt) for the contributions to the version of this chapter published in the 2nd edition of this book (Kihlstrom et al., 1993). While some material from that chapter has been retained in the present edition, a great deal of material had to be excluded for reasons of space. The interested reader is referred there for more comprehensive treatment of the literature prior to 1990.
1Although DID is usually considered to be a syndrome of adult psychopathology, the fact that alter egos may begin to appear in childhood suggests that it can be diagnosed and treated in children as well (Main & Morgan, 1996; Putnam, 1997). Return to text.
2The best known of the earliest cases is Mary Reynolds, reported by Mitchill (1816; see Carlson, 1984). Ellenberger (1970) cited this case on the basis of secondary reports by S.W. Mitchell (1888) and others. However, he was unable to locate the primary reference, attributed to the Medical Repository of 1815. A diligent search of the library shelves by Dr. Malcolm Macmillan, now of Deakin University, Australia, turned up the primary reference in the 1816 volume (Mitchill, 1816), as correspondence dated that year. The 1816 and 1817 volumes were bound together, which may explain why Taylor and Martin (1944) provided the correct volume and page number, but dated the article 1817. Ellenberger also misspells Samuel Latham Mitchill's last name, and incorrectly identifies him with John Kearsley Mitchell, father of Silas Weir Mitchell (1888), who knew the Reynolds family and brought the case to the attention of William James (1890, p. 359-363). I thank Dr. Macmillan for his kindness in sharing his detective work, and refer readers to his important historical work on the relationship between Freud and Janet (e.g., Macmillan, 1996). For a further history of the Mary Reynolds case, see also Carlson (1981, 1984, 1989). For a history of another famous case, Miss Beauchamp, see Rosenzweig (1987, 1988). Return to text.
3This claim has been made by Putnam (1989), Borch-Jacobson (1997), and Acocella (1998), among others. For a description of the impact of this case on a DID patient, see Atwood, 1978). Interestingly, Herbert Spiegel, a Columbia University psychiatrist and distinguished hypnosis researcher who examined Sybil and also occasionally served as her surrogate therapist, has expressed doubts that she was a genuine case of multiple personality (Borch-Jacobson, 1997). Return to text.
4The Bianchi case was extensively documented in a two-hour Frontline documentary, "The Mind of a Murderer", broadcast on PBS in 1984. Return to text.
5Even this evidence is ambiguous with respect to the traumatic etiology of dissociative disorder. For example, because depersonalization occurs in association with anxiety, the mere fact that disaster victims report increased levels of depersonalization (Cardena & Spiegel, 1993) cannot be taken as evidence that trauma causes any form of dissociative disorder. Similarly, biological factors such as concussive head injury and sleep deprivation cannot be ruled out in cases of war-related amnesia, while amnesia for crime may reflect intoxication (Piper, 1998; Pope, Hudson, Bodkin, & Oliva, 1998; Pope, Oliva, & Hudson, 1999). For a debate concerning the status of repressed or dissociated memories of trauma, see Scheflin and Brown (1996) and Piper (1997). For a critical analysis of the argument that traumatic memories are Aspecial@, see Shobe & Kihlstrom (1997). Return to text.
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