JAMWA Article.hopenwasser

7/31/2019 JAMWA Article.hopenwasser

1/24

DissociativeDisordersinWomen:Long-TermConsequencesofViolenceAgainstChildren

KARENHOPENWASSER,MD

Dissociativedisorders,diagnosedasmuchasninetimesmorefrequentlyinwomenthanmen,arepoorlyunderstood.Themosaicsymptomatologyoftenleadstomisdiagnosisorincompleteassessment.Despitesubstantialresearchindicatingtheprobableetiologyasseverechildhoodabuse,manycliniciansdonotrecognizetherelationshipbetweenviolenceanddissociation.Anemergingbodyofresearchindicatesthatpost-traumaticmemorycanbedistinguishedneurobiologicallyfromotherformsofmemory.Whileclinicalresearchhasgivenustoolsforevaluatingdissociativesymptoms,neurobiologicalresearchisclarifyingtherelationshipbetweenbraindevelopment

inchildrenandadultdissociativesymptoms.Oncethediagnosisismade,manypatientsreportfeelingunderstoodforthefirsttimeintheirlives.Thisallowsforstrongertherapeuticalliancesandtheuseofcomplextreatmenttechniquestomanagepainandincreaseasenseofsafety.

Everydayphysiciansexaminewomenwhohaveexperiencedviolenceasanordinaryoccurrence.Theawarenessthattheyhavebeenphysicallybeatenand/or

sexuallyabusedissilencedinsomewomenbyunbearableshame,whileforothers,thecontextofviolencewithinthefamilycamouflagestheirawarenessaltogether.Aschildrenthesewomenusedmethodsofcopingthatallowedthemtomanagethepain,maintainemotionalconnections,andsurviveintoadulthood,albeitwithmultiplephysicalandpsychologicalproblems.Fewphysicianshavebeentrainedtorecognizethelong-termconsequencesofearlychildhoodabuseand

Dr.HopenwasserisaclinicalassistantprofessorofpsychiatryatCornellUniversityMedicalCollegeandisinpracticeinNewYorkCity.

dissociativedisorders,inparticular.Whilethedissociativedisordersareweightedwithgreatcontroversy,thiscontroversyhaspropelledmuch-neededresearchandscientificinterest.


2/24

Theconceptofdissociationputforthwithinthemedicalcommunitydatesbacktothelate19thcenturywiththeworkofJean-MartinCharcotandPierreJanet.1TheseSalptrirephysicianshadamajorinfluenceonSigmundFreud,whomorefullydevelopedtheconceptofhysteria.2Aspsychoanalyticthinkingmovedfromatraumatheoryofdissociationtoaseductiontheoryofhysteria,interestindissociationfaded.Althoughcliniciansrecognizedthephenomenonofbattlefatigue3insoldiersduringbothWorldWars,arenewedinterestindissociationdidnotemergeuntilthelate20thcentury.Currently,dissociationisrecognizedasaneurophysiologicalphenomenonthatdevelopsinresponsetoenvironmentalinfluencesandmanifestsitselfindistinctphysicalandpsychologicalsymptoms.Recentresearchontheneurobiologyofpost-traumaticstressdisorder(PTSD)anddissociation4-8hassupportedthedistinctcategorizationof

dissociativedisordersandchronicposttraumaticstates.Wearebecomingincreasinglyawarethatextremestress,particularlyintheformofinterpersonalmistreatment,hasaprofoundpsychophysiologicalimpactonthedevelopingchild.Asweunderstandmoreabouttheseconsequences,weneedtoreevaluatesomefundamentaltheoriesaboutthestructureofthemind,thephenomenologyofpsychiatricdiagnosis,andtheimpactofenvironmentonbraindevelopmentafterbirth.

Dissociation,though,remainsanelusiveconcept.FrankPutnamdefinesitas:aprocessthatproducesadiscerniblealterationinapersonsthoughts,feelings,oractionssothatforaperiodof

timecertaininformationisnotassociated

orintegratedwithotherinformation

asitnormallyorlogicallywouldbe.9

BesselvanderKolk,etalsubdividedissociationintothreecategories:primary,secondary,andtertiary.10Primaryreferstosensoryandemotionalelementsduringatraumaticexperiencethatmaynotbeintegratedintomemory.Secondaryreferstotheseparationoftheexperiencingandobservingself,suchasthefeelingoffloatingaboveoneselfandobservingfromadistance.Tertiaryreferstothe


3/24


4/24

ciativeDisorders,14theDissociativeDisordersInterviewSchedule,12andtheDissociativeExperiencesScale15,16helpsclinicianstomakethediagnosismorequickly.

Withincreasedrecognitionofdissociativedisorders,cliniciansfindthatpatientsfeelbetterunderstood,sometimesforthefirsttimeintheirlives.Thisenhancesthesenseoftrustvitaltothetherapeuticrelationshipandincreasesthesenseofsafetyessentialforhealing.

Despitesomemethodologicallimitations,studiesonlong-termoutcomeindicatethatsymptomsandthecostoftreatmentarebothreducedwhenpatientsarecorrectlydiagnosedwithDID.17,18EllasonandRosslookedat54inpatientswithDIDovertwoyearsandfoundthatwithtreatment,bothDissociativeExperiencesScaleandDissociativeDisorders

InterviewScalescoresdecreasedsignificantly,andothersymptomsimproved.17Thepurposeofthisreviewistohelpcliniciansunderstandthedissociativedisordersinbothindividualandlargersocialcontexts.Therelationshipbetweendissociationasapsychologicaldefenseandasapsychiatricillnessaffordsusinsightintowhatcanbecalledapost-Cartesianneurophilosophyofmind/bodyunity.19,20Thisshiftfromdualism,theseparationofphysicalandmental,toanappreciationofthematerialcomponents

ofconsciousness,helpsustounderstanddissociativedisorders.Thenexusofsymptompresentationwillbegintomakesenseasweunderstandtheneurophysiologyofconsciousnessandthedevelopmentalintegrationofphysicalandpsychologicalself.

RelationshipBetweenDissociationandViolence

Thedissociativedisordersare:

apsychobiologicalresponsetoa

relativelyspecificsetofexperiences

occurringwithinacircumscribed

developmentalwindow...themost

compellingandclinicallyusefulmodel


5/24

[ofthegenesisofDID]isbasedon

evidencethatrepeatedchildhood

traumaenhancesnormativedissocia

tivecapacities,whichinturnprovide

thebasisforthecreationandelabora

tionofalterpersonalitystatesover

time.21

Repeatedchildhoodtraumacanoccurwithinthecontextofsuchlargescalesocialviolenceastheholocaustorwar,orwithintheindividualfamily.TheoverwhelmingmajorityofUSwomenwhosufferfromchronicdissociativedisorderswerevictimsofchildhoodphysical,emotional,and/orsexualabuse

startingbetweentheagesof2and12yearsold.22-25Thisabuseincludestherepetitiveexposuretoviolenceagainstaparentorsiblingaswellasthatexperienceddirectly.

ArecentepidemiologicalstudyinOntario,Canadaofnearly10,000residentsage15andolderfoundthat31.2%ofmenand21.1%ofwomenreportedahistoryofchildhoodphysicalabuse.Childhoodsexualabusewasreportedby12.8%ofwomenand4.3%ofmen.

Severephysicalabuse(basedontheChildMaltreatmentHistorySelf-Report)wasreportednearlyequallybymenandwomen(about10%),whilenearlythreetimesasmanywomenasmenreportedseveresexualabuse(11.1%versus3.9%).26Thesefindingssupportthenationalconsensusthatdomesticviolenceagainstchildreniscommon,andthatseveresexualabuseismorecommoningirlsthanboysandhasaprevalenceofmorethan10%.

Whilenotallabusedchildrendevelopdissociativedisorders,studieshaveshownahighrateofdissociativedisordersinwomenwhoidentifythemselvesassurvivorsofsexualabuse.24,27-29Onestudyof98femalepsychiatricinpatientsfoundthat83%haddissociativesymptomscoresabovewhatwouldbeconsideredmedianfornormaladults,andthosewithahistoryofchildhoodsexualabuse


6/24

hadthehighestdissociativeexperiencescalescores.Inaddition,ahistoryofchildhoodsexualabuseseemedtodoubletheriskofconcurrentphysicalandsexualabuseinadultlife.24

SomeclinicianshavespeculatedthatmenwithDIDarefoundmoreofteninthecriminaljusticesystemthanthementalhealthsystem.21,30AnexamplecanbefoundintheworkofJamesGilligan,aforensicpsychiatrist,whonotedcaseaftercaseofsevereearlychildhoodmaltreatmentamongmalemurderersinprison.31Inareviewofrecordsof11menandonewomanwhohadcommittedmurder,

clinicalresearcherswereabletoestablishalinkbetweenearlysevereabuseandDID.Theywereabletoruleoutmalingering,whiletheevidenceofearlyabusewasbaseduponcorroboratinginformationfromfamilymembers,neighbors,courtandhospitalrecords.Mostofthe

subjectshadatleastpartialamnesiafortheabuse.32

NeurobiologyofDissociation

Whenabusedchildrengrowup,theyoftenhavefragmentedmemoriesoftheirchildhoodexperienceofviolence.Whilephysiciansareawarethatdomesticviolenceisanationwideseriouspublichealthproblem,33adultswithinconsistentrecallareoftengreetedwithskepticism.Anumberofstudiesofnormal

collegestudentsanduntraumatizedchildrenhavedemonstratedthatchildrenaresuggestible,andthatmemoryisunreliable.34,35Thesestudieshavebeenusedinamediacampaignthathascreatedexcessivedoubtinthemindsofbothcliniciansandpatients.

Theencodingofmemoriesoftraumaissubjecttostresshormoneinfluencesthataredifferentfromthoseofnontraumaticmemory.Neurobiologicalresearch,asopposedtolaboratorycognitivepsychological

research,hasdemonstratedthatintenseoverstimulationoftheamygdala(asaresultofaterrifyingstimulus)interfereswithhippocampalfunction.Asaresult,registrationofsensorimotorperceptionmayoccurwithoutsymbolicorsemanticcoding.36Theincreasedfiringofhypothlamic-corticalpathwaysunderstressmayleadtoincreasedfacilitationoflong-termmemory.Thiscouldaccount


7/24

fortheeidetic(photographic)natureofflashbacks.Overstimulationmayalsoleadtodecreasedsensitivityofreceptors,leadingtodecreasedregistration,consolidation,andintegrationofmemory.Thisaccountsforboththeblackholes37ofdissociationaswellaserrorsofrecall.

Inastudylookingatbrainactivityduringflashbacks,positronemissiontomographyshowedincreasedactivityinrightlimbic,paralimbicareasandvisualcortex,whileactivitywasremarkablydecreasedinleftinferiorfrontal(Brocasarea)andmedialtemporalcortex,thebrainareasnecessaryforonetofindwordstodescribetheseexperiences.38In

180JAMWAVol.53,No.4


8/24

addition,neuroendocrinologicalalterationsleadtoafailureinthedevelopmentofaconventionallinearsenseoftime.Insteadofsteadyforwardmovementtherearegapsincontinuity.39Failuretoexperiencetimeinalinearfashioncanleadtoablurringtogetherofmemories,notunlikewhatwouldhappenifseveraltransparencieswereprojectedontopofoneanother.40Wewouldnotbeabletodistinguishonefromtheother.Thus,thephenomenonofdelayedrecallwillnotbeunderstoodwithoutfurtherresearchintheneurobiologyoftraumaticstressanddissociativeadaptation.

WhileresearchisclarifyingthemechanismsofPTSD,muchlessisunderstoodspecificallyabouttheneurophysiologyofdissociation.Thethalamusplaysacrucialroleindissociativestates,servingasasensorygatetomodulateinformationbetweenbrainstem,cortex,amygdala,

andhippocampus.41Onecurrenttheoryofthebiologicalbasisofconsciousawarenessisthatitisdependentonoscillatingconnectionsbetweenthethalamusandcortex.42Theorganizationofconsciousnessisdependentonintegratedcorticocorticalfunction.Certaindrugsthatproducedissociationinterferewithcorticalintegration.Muchlaboratoryresearchisnowfocusedonvariousneurotransmitters,includingtheexcitatorytransmitterglutamateandtheNMDA(N-methyl-D-aspartate)receptor.There

ishopethatthestudyofthesetransmittersandreceptorswillsomedaygiveusinsightintothepharmacologicmanagementofseveredissociativestates.41

ClinicalPictureofDissociativeDisorders

TheDSM-IVdividesdissociativedisordersintofivediagnosticcategories:dissociativeamnesia,dissociativefugue,dissociativeidentitydisorder,depersonalizationdisorder,anddissociativedisordernot

otherwisespecified(DDNOS).DDNOSincludesmanywomenwhowereseverelyabusedaschildrenbuthavenotdevelopeddistinctalteridentities.ThetransitionfromtheoldconceptofmultiplepersonalitydisordertoDIDrepresentsanattemptatconceptualadvancement.Alteridentitiesarenotpersonalitiesatall,butcouldbethoughtofasunintegratedorpartiallyintegratedpathwaysof


9/24

neuralnetworksregulatedbyneurotransmittersandneurohormones.40Aschronicallytraumatizedchildrenmature,theymayfailtointegrateaffectivelychargedmemorywithcognitivefunctioning,andasaresult,dissociatedalterstates(orwhatPutnamcallsdiscretebehavioralstates)39mayemerge.Thisaccountsfortheclassicsymptomoflosttimeormemorylapses.Inotherwords,DIDisadisorderofconsciousnessandidentityintegrationovertime.40Oneofthemajortasksofpsychotherapeutictreatmentisthedevelopmentofanintegrated,subjectivesenseofpastandpresentsoastodistinguishbetweenthenandnow.

Itismybeliefthatthisfailuretodistinguishbetweenpastandpresentisprobablyresponsibleforsomeoftherangeofpsychiatricsymptomsweseeindissociativepatients,suchaspanicattacks,phobias,cyclingmoodchanges,

suicidaldepression,paranoia,andevenattentiondeficittypesymptoms.Thephysicalmanifestationofthisfailureisseeninflashbackstatesandsomaticmemory.Bothsomaticmemoryandsomaticsymptomsbringthesepatientsintotheprimarycarephysiciansoffice.

Themultitudeofsymptomsassociatedwiththesedisordersoftenleadstoconfusionaboutdiagnosis.Manysymptomsplaytogethertocreateauniquepicture,whileindividualsymptomsoverlapwith

thoseofotherdiagnoses:panicdisorder,rapidcyclingmooddisorders,PTSD,andeatingdisorders.12Thereisalsoacertainamountofco-morbidity,particularlywithchemicaldependencyproblems,borderlinepersonalitydisorder,PTSD,andmooddisorders.28,43ConfusionbetweentheAxisIIdiagnosisborderlinepersonalitydisorderandAxisIdiagnosisdissociativedisorderisstriking.Thetwocancertainlycoexist,whileattimesoneismisdiagnosedfortheother.Researchonborderlinepersonalitydisorder

hasshownanimpressivecorrelationwithearlychildhoodabuse,44-46anddiagnosticcriteria(identitydisturbance,poorimpulsecontrol,self-mutilation)clearlyoverlap.Oneprospectivestudyfoundthat38.6%of44childrendiagnosedwithborderlinepersonalitydisorderhadabusehistories,comparedtoonly9%of100controlswitharangeofotherdiagnoses.45


10/24

Failuretorecognizeorappreciateahistoryofsevereearlytraumacanhinderunderstandingofsuchextremebehaviorsasself-mutilation,whichisoftenapainmanagementtechniqueusedintheserviceofemotionalsurvivalratherthanofself-destruction.47Whendoneinastateofpost-traumaticnumbnessitcanbeparticularlyalienatingforthehelpingprofessionaltowatch.Bothclinicianandpatientarecaughtintheeddyofforgettingthefunctionofthisbehavior.

DissociativeDisordersinMedicalPractice

Womenwithdissociativedisordersfrequentlyreportsomaticcomplaints;12,48-50thelistislengthy,withheadache,bodypain,gastrointestinalandgynecologicalcomplaintsparticularlycommon.Millerfoundsignificantvariabilityinvisualfunctioning,withmeasurablechangesin

refractionbetweenalterstatesintwostudiescomparingDIDpatientswithsimulatedcontrols.51,52Electromyographicstudiesindicatetheremaybemarkedchangesinmuscletensionasswitchesamongconsciousstatesaremade.53Onerecentexampleencounteredpersonallywasawomanwhodevelopedblistersonherfeetwearingshoesthatwerealreadybrokeninandpreviouslyquitecomfortable.Aswitchintoanotherconsciousstate(sometimescalledapart)ledtoashiftinpostureandmannerofwalking.

Fluctuationsinsensitivitytomedicationsanddifferentialexpressionofallergicreactions,whichcanbeproblematicforthephysicianprescribingmedication,havebeenfound.Cliniciansshouldnotassumethepatientismisleadingifshegivesahistoryoferraticreactionstomedicationorisconfusedaboutwhethershehashadallergicreactions.Inthepresenceofahistoryofearlytrauma,thismaybeindicativeofdissociativestatechanges.

Bothelectroencephalographicandthyroidstudiescanbeinconsistent.54Inaprospective,longitudinalstudyofgirlsage8to15years,14sexuallyabusedgirlswerecomparedwith13controlsubjects.Thesexuallyabusedgirlshadtwicethefrequencyofpositiveplasmaantinuclearantibodytiterswhencomparedwithmatchedcontrols,suggestingthepossibility


11/24

ofalterationinimmunefunction.55

Summer1998181


12/24


13/24

foradultswhowerevictimsofrepeatedviolenceinchildhood.ThesearenotyetDSM-IVdiagnoses,althoughthecriteriawereusedduringsomeofthePTSDclinicalfieldtrials.Theseproposeddiagnosestakeintoconsiderationthatprolonged,repeatedtraumainchildhood(whatLenoreTerrhascalledTypeIItrauma)64disruptssubsequentmaturationalprocessesandleadstoaplethoraofsymptomsinadultlife,65includingfailuretoself-regulateaffect,inabilitytocomfortoneself,impairedattachment(bothclingingandfearofintimacy),impairedinterpersonalfunctioning,andmistrustfulattitudetowardtheworld.

Useofadiagnosislikedisordersofextremestresswouldallowustoidentifyagroupofpatientswhoareotherwisemisdiagnosedand,consequently,sometimestreatedinappropriately.Itwouldfacilitateaviewofthepatientasawhole

personwithadisorderofadaptation,ratherthanfragmenteddiagnosestomatchthefragmentedsenseofself.

TreatmentConsiderations

NocontrolledstudieshaveaddressedthetreatmentofDID.PerhapsthegreatestbenefitofthecontroversyaroundDIDhasbeenthedevelopmentoftreatmentguidelines.TheInternationalSocietyfortheStudyofDissociationreleased

GuidelinesforTreatingDissociativeIdentityDisorderinAdultsinMay1994.Revisedin1997basedontheavailableclinicalandresearchliterature,theguidelinescoverdiagnosticprocedures,treatmentplanning,andanoutlineforpsychotherapy.66Whilethereareavarietyoftreatmentapproaches,themanyclinicianswithextensiveexperienceseemtoagreethatanemphasisonpainmanagementandcreationofasenseofsafetyarenecessaryregardlessofapproach.67,68Buildingthetrustessentialforasenseof

safetystartswithclearlydefinedboundarieswithinthetherapeuticrelationship.69

Becausesymptomsarebroadandmultisystem,aninformaltreatmentteampsychotherapistorpsychiatrist,primarycarephysicianand/orgynecologist,andadjunctivesocialsupportsismostproductive.Someonewhoischemicallydependentcannotlearntomanageintense


14/24

affectandintegratethiswithcognitivefunction,sotheuseof12-stepprograms

isessentialtomaintainsobriety.Whilenumerousinpatientprogramsaroundthecountrytreatadultswiththedualdiagnosisofchemicaldependencyanddissociativeproblems,themajorityoftreatmentoccursinanoutpatientsetting.Evenseveresymptomscanbemanagedonanoutpatientbasiswithpharmacologicalagents,withinthecontextofpsychotherapeuticsupport.Antidepressantsrelievesomedepressivesymptoms,thoughalterswitchingmaycreatetheimpressionthatmedicationhasstoppedworking.70Flashbackscanoftenbemanagedwiththelong-actingbenzodiazapineclonazapam.Anecdotalreportsindicatethatthealphaadrenergicagonistsclonidineandguanfacinediminishflashbacks,whilecasereportshaveshowntheefficacyofpropanolol.39Becausepropanololcanhavesubstantialsideeffectsanddrug-

druginteractions,Ihavetriedthebetablockerpindolol,alsousefulintreatingresistantdepression,withsomesuccess.Carbamazepine,valproicacid,andlow-dosenewgenerationneurolepticshavealsobeenhelpful.Asmentionedabove,neurobiologicalresearchondissociationsuggestsatheoreticalroleforanti-glutamatedrugs,yettobedeveloped.

Psychotherapeutictreatmentrequiresflexibilityandversatility.Cognitiverestructuring,themodificationoflong-

heldbeliefs,71mustbedonewithinacarefulexploratorycontext.Thisisusuallyfacilitatedthroughtheuseofsuchadjunctivetherapeutictoolsasjournalwriting,artwork,poetry,yoga,meditation,andsometimesbodywork.Inadditiontotraditionalindividualandgrouppsychotherapy,manyadultvictimsofchildhoodabusebenefitfromnonverbaltreatmentapproaches,suchasartandmovementtherapy.72

Howmuchonehastorememberin

ordertohealisamatterofdebate,butitappearsthatonemustrememberenoughtovalidateonesexperienceandtomournwhatwaslostbyorstolenfromthetraumatizedchild.67,68Speakingtheunspeakableandhavingothersbearwitnesstoithasallowedmanywomentomoveonintheirlives.Theprocessisexquisitelypainful,andwehavefewtoolstoamelioratethatpain.Iapproachdissociative


15/24

symptomsasaformofmemory.Treatmentneedstosupporttheintegrationof

182JAMWAVol.53,No.4


16/24

thesememoriesaslongastheypersist,especiallysincedissociationseemstoincreasetheriskofrevictimization,describedbyKluftasasittingducksyndrome.73Whendissociationdiminishesandnolongerinterfereswithfunctioning,thenrememberingisdeterminedbyindividualstrengthsandothersubjectivetraits.Manywomenfindthatspiritualconnectionistheonlywaytoholdandtoleratetheirmemoriesofutterhelplessnessanddespair.

Oneverynewtherapeutictoolfordiminishingfear,enhancingsafety,anddecreasingpainiseyemovementdesensitizationandreprocessing(EMDR).74OriginallydevelopedtotreatPTSD,itcanbeincorporatedintotheoveralltreatmentofdissociativedisorders.75,76ClinicalevidenceindicatesthatEMDRallowsthepatienttodownregulatetheintensityofaffectandprocesstraumatic

memoriesinclusters,ratherthanindividually.Italsoallowsfortheprocessingofsomaticmemoryintheabsenceofvisualimages.EMDRisnotahypnotictechniqueanddoesnotinvolvesuggestion.InthecourseofanEMDRsession,thebrainisstimulatedthroughalternatingleftandrightperceptioneitherthrougheyemovement,auditoryortactilestimulation.Priortotheeyemovements,thepatientisencouragedtogenerateanauthentic,positivecognition,evenifitisdifficulttobelieveinthethought.The

alternatingstimulationseemstoallowfortherapidintegrationofcognitiveandemotionalinformation.WhileresearchhasnotyetexplainedthemechanismorefficacyofEMDR,theabsenceoftheoryoraconceptualfoundationisnotsufficienttodismisstotallythepreliminaryfindingsofthetechnique.77Inthehandsofaskilledandcompetenttherapist,EMDRcanbeanadditionalusefultool.Theuseofhypnosisintreatmentandtherisksofsuggestibilityhavegeneratedconsiderablecontroversy.

Inresponsetoconcernsaboutpseudo-memories,theAmericanSocietyofClinicalHypnosisreleaseda1995taskforcereportconcludingthatmemoriesmayberecoveredlaterinlife,thathypnosismayfacilitaterecoveryofmemories,andthatpseudo-memoriesmayoccurinandoutoftherapy,withorwithouthypnosis.78Dissociationisa


17/24


18/24

1.KrippnerS,PowersSM.BrokenImages,BrokenSelves.Washington,DC:Bruner/Mazel;1997.2.BreurJ,FreudS.Studiesonhysteria.In:StracheyJ,ed.TheStandardEditionoftheCompletePsychologicalWorksofSigmundFreud.Vol2.London:HogarthPress;1955:1-305.3.KardinerA.TheTraumaticNeurosesofWar.NewYork,NY:Hoeber;1941.4.vanderKolkBA.PsychologicalTrauma.Washington,DC:AmericanPsychiatricPress;1987.5.BrownP.Towardapsychobiologicalmodelofdissociationandpost-traumaticstressdisorder.In:LynnSJ,RhueJW,eds.Dissociation.NewYork,NY:Guilford;1994:95-122.6.FriedmanMJ,CharneyDS,DeutchAY,eds.NeurobiologicalandClinicalConsequencesofStress:FromNormalAdaptationtoPost-TraumaticStressDisorder.Philadelphia,Pa:Lippincott-

Raven;1995.

7.vanderKolkBA,McFarlandAC,WeisaethL,eds.TraumaticStress.NewYork,NY:Guilford;1995.8.YehudaR,McFarlaneAC.Psychobiologyofposttraumaticstressdisorder.AnnNYAcadSci.1997;821:.9.PutnamFW.Dissociativephenomena.In:TasmanA,GoldfingerS,eds.ReviewofPsychiatry.

Vol.10.Washington,DC:AmericanPsychiatricPress;1991:145-160.10.vanderKolkBA,vanderHartO,MarmarCR.Dissociationandinformationprocessinginposttraumaticstressdisorder.In:vanderKolkBA,McFarlaneAC,WeisaethL,eds.TraumaticStress.NewYork,NY:Guilford;1995:303-327.11.DiagnosticandStatisticalManualofMentalDisorders.4thed.Washington,DC:AmericanPsychiatricAssociation;1994.12.RossC.MultiplePersonalityDisorder:Diagnosis,ClinicalFeaturesandTreatment.NewYork,NY:Wiley;1989:316-334.

13.KluftR.Multiplepersonalitydisorder.In:TasmanA,GoldfingerS,eds.ReviewofPsychiatry.Vol10.Washington,DC:AmericanPsychiatricPress;1991:161-181.14.SteinbergM.StructuredClinicalInterviewforDSM-IVDissociativeDisorder.Washington,DC:AmericanPsychiatricPress;1993.15.BernsteinE,PutnamF.Development,reliabilityandvalidityofadissociationscale.JNervMentDis.1986;174:727-735.


19/24

16.CarlsonE,PutnamF,RossC,etal.ValidityoftheDissociativeExperiencesScaleinscreeningformultiplepersonalitydisorder:Amulticenterstudy.AmJPsychiatry.1993;150:1030-1036.17.EllasonJ,RossC.Two-yearfollow-upofinpatientswithdissociativeidentitydisorder.AmJPsychiatry.1997;154:832-839.18.LoewensteinR.Diagnosis,epidemiology,clinicalcourse,treatment,andcosteffectivenessoftreatmentfordissociativedisordersandmultiplepersonalitydisorder:ReportsubmittedtotheClintonadministrationtaskforceonhealthcarefinancingreform.Dissociation.1994;7:3-11.19.DennettD.ConsciousnessExplained.Boston,Mass:Little,Brown;1991.20.ChurchlandP.Neurophilosophy.Cambridge,Mass:MITPress;1986.21.PutnamF.DiagnosisandTreatmentofMultiplePersonalityDisorder.NewYork,NY:GuilfordPress;1989:45.22.KluftR,ed.ChildhoodAntecedentsofMultiplePersonalityDisorder.Washington,DC:AmericanPsychiatricPress;1985.23.RossCA,MillerSD,BjornsonL,ReagorGA,

FraserGA.Abusehistoriesin102casesofmultiplepersonalitydisorder.CanJPsychiatry.1991;36:97-101.24.ChuJA,DillDL.Dissociativesymptomsinrelationtochildhoodphysicalandsexualabuse.AmJPsychiatry.1990;147:887-892.25.KirbyJS,ChuJA,DillDL.Correlatesofdissociativesymptomatologyinpatientswithphysicalandsexualabusehistories.ComprPsychiatry.1993;34:258-263.26.MacMillanHL,FlemingJE,TroomeN,etal.Prevalenceofchildphysicalandsexualabuseinthecommunity.JAMA.1997;278:131-135.

27.BryerJB,NelsonBA,MillerJB,KrolP.Childhoodsexualandphysicalabuseasfactorsinadultpsychiatricillness.AmJPsychiatry.Summer1998183


20/24

1987;144:1426-1430.

28.SaxeGN,vanderKolkBA,BerkowitzR,etal.Dissociativedisordersinpsychiatricinpatients.AmJPsychiatry.1993;150:1037-1042.29.AndersonG,YasenikL,RossCA.Dissociativeexperiencesanddisordersamongwomenwhoidentifythemselvesassexualabusesurvivors.ChildAbuseNegl.1993;17:677-686.30.KluftRP.Thenaturalhistoryofmultiplepersonalitydisorder.In:KluftRP,ed.ChildhoodAntecedentsofMultiplePersonality.Washington,DC:AmericanPsychiatricPress;1985:198-238.31.GilliganJ.Violence:OurDeadlyEpidemicandItsCauses.NewYork,NY:Grosset/Putnam;1996.32.LewisDO,YeagerCA,SwicaBA,PincusJH,LewisMB.Objectivedocumentationofchildabuseanddissociationin12murdererswithdissociativeidentitydisorder.AmJPsychiatry.1997;154:1703-1710.33.WiltS,OlsonS.PrevalenceofdomesticviolenceintheUnitedStates.JAmMedWomensAssoc.

1996;51:77-82.34.LoftusEF,DondersK,HoffmanHG,SchoolerJW.Creatingnewmemoriesthatarequicklyaccessedandconfidentlyheld.MemCognit.1989;17:607-616.35.LoftusEF,HoffmanHG.Misinformationandmemory:Thecreationofnewmemories.JExpPsycholGen.1989;118:100-104.36.vanderKolkBA.Thebodykeepsthescore.HarvRevPsychiatry.1994;1:253-65.37.PitmanR,OrrS.Theblackholeoftrauma.BiolPsychiatry.1990;27:469-471.38.RauchS,vanderKolkBA,FislerR,etal.A

symptomprovocationstudyofposttraumaticstressdisorderusingpositronemissiontomographyandscript-drivenimagery.ArchGenPsychiatry.1996;53:380-387.39.PutnamF.DissociationinChildrenandAdolescents:ADevelopmentalPerspective.NewYork,NY:Guilford;1997:267.40.HopenwasserK.Listeningtothebody:Somaticrepresentationsofdissociatedmemory.In:AronL,AndersonFA,eds.RelationalPerspectivesontheBody.NewYork,NY:TheAnalyticPress.Inpress.41.KrystalJH,BennettAL,BremnerJD,South-

wickSM,CharneyDS.Towardacognitiveneuroscienceofdissociationandalteredmemoryfunctionsinpost-traumaticstressdisorder.In:FriedmanMJ,CharneyDS,DeutchAY,eds.NeurobiologicalandClinicalConsequencesofStress.PhiladelphiaPa:Lippincott-Raven;1995.

42.CrickF.TheAstonishingHypothesis:TheScientificSearchfortheSoul.NewYork,NY:Scribners;1994.


21/24


22/24


23/24

forpost-traumaticstressdisorder.In:NathanP,GormanJ,eds.TreatmentsThatWork.NewYork,NY:OxfordUniversityPress;1998:403.78.ClinicalHypnosisandMemory:GuidelinesforCliniciansandforForensicHypnosis.DesPlaines,Ill:AmericanSocietyofClinicalHypnosisPress;1995.79.MaldonadoJR,SpiegelD.Usinghypnosis.In:ClssenC,ed.TreatingWomenMolestedinChildhood.SanFrancisco,Calif:Jossey-Bass;1995:163-186.80.MaldonadoJR,SpiegelD.Treatmentofposttraumaticstressdisorder.In:LynnSJ,RhueJW.Dissociation.NewYork,NY:Guilford;1994:215-241.184JAMWAVol.53,No.4


24/24

Documents

JAMWA Article.hopenwasser