Archive for the ‘MPD / DID / PTSD’ Category
The unconscious is like a great holding area or reservoir of unprocessed events. Anything we don’t or can’t assimilate consciously goes there. The unconscious holds irrelevant things such as images of strangers we see on the street. It also holds important things that need to be brought into conscious awareness but may be too big to fit our existing system (conscious mind). There are times when people are unable to fully assimilate the significance of an overwhelming experience such as a car accident. One of the passengers calmly calls an ambulance, administers first aid, and reroutes oncoming traffic. Once the ambulance arrives, she falls apart and cries hysterically. In order to take care of the immediate priorities, she dissociated her feelings and emotions temporarily. The dissociation allowed her to break up the oversized experience into manageable pieces. These were assimilated as soon as it was safe to do so. If the accident survivor didn’t assimilate the dissociated part of her experience, she would probably suffer the PTSD symptoms.
Children are commonly seen to dissociate—not because of trauma, but because every time they get a new type of experience, they have to modify or expand their faculties in order to assimilate it. In the meantime, the experience is dissociated and held in the unconscious. There, they “play with it,” using their imagination until they work out a way to make a fit. Children go through a very high rate of new experiences and may frequently dissociate as a normal response to an unfamiliar event. They are continually modifying and expanding their system, or conscious mind. This is the process of growth and learning. As they mature, children may dissociate less and less, because there are fewer and fewer experiences that don’t fit their conscious system.
Children rely extensively on adults for interpretation. Their developing comprehension is largely fashioned after that of their parents or caregivers. If caregivers are emotionally damaged, their own skewed view of the world is imposed upon their children.
Unresolved issues in the parents’ unconscious are misinterpreted for the child. This is a common phenomenon known as projection. For example, if parents feel shame but cannot admit it, they may deny it, separate themselves from it, disown it, dissociate from it, and project it onto their children. They then condemn their children as being shameful. In psychology this is described as retaliatory defense. In other words, the shame the parents have within themselves but cannot accept is expressed by shaming the children. In fact, the less parents are able to accept the “monster” within themselves, the more readily they are able to see it in their children.
Emotionally troubled parents frequently reinforce skewed interpretations with abuse. If the abuse is extreme, as practiced by destructive families, a child’s conscious world becomes overwhelmed. The extreme abuse is dissociated into the unconscious, but it cannot be made to fit, even in a misinformed way. The trauma remains dissociated. To survive, children tap into extraordinary coping skills, fashioned from within their own unconscious.
CLINICAL (AMNESTIC) DISSOCIATION
Our instinctive reactions to an assault are fight or flight. However, neither works when children are abused by sadistic adults. The only option left is to freeze, and take flight through the mind. A common initial coping mechanism is to escape the body. It is the beginning of clinical (amnestic) dissociation, which allows a shutting out of an unbearable reality. It is held unassimilated—in effect, frozen in time. A dissociated experience can be split up to store the emotions separate from bodily sensations, and the sensations separate from the knowledge of an event. In dissociating an experience, children split off a part of their self to hold the trauma. In some cases the dissociated aspects of self, immediately or over time, form their own and separate sense of self.
A dissociated identity, like a dissociated experience, can hold the entire event or parts of it. Alters may hold only a bodily feeling, only an emotion, or only the knowledge. One hundred abusive/traumatic incidents may be held by one identity or by one hundred or more identities. It may be helpful to think of each identity as holding an abusive experience. In this context, taken together, the identities hold a person’s overwhelming traumas and express a survivor’s entire life story.
When the abuse is over, the original self “returns” and resumes “normal” life, having no/little awareness of what has just transpired. If severely abused children were forced to experience the trauma they just lived through, they would probably NOT survive.
Some children maintain a complete split between their everyday life and the abusive episodes. They may be seen smiling when posing for family photographs. Perpetrators often use such photographs to prove there is nothing bad going on.
As abused children grow, their problems typically begin to mount. The load on their unconscious becomes increasingly great, and they feel overwhelmed. As some identities stay out more and more, they may begin to take over and operate in the child’s day-to-day world. If the abuse continues or increases, the original self may stay out less and less and, in time, stop coming out at all. The survivor is then functioning through identities who “switch” to cope with day-to-day life.
In the November/December 1992 issue of The Sciences Magazine, Dr. Frank W. Putnam writes the following about survivors with dissociated identities. “The (presenting) personality is almost never the (survivor’s) original personality—the identity that developed between birth and the experience of trauma. That self usually lives dormant and emerges only after extensive psychotherapy.”
Amnestic dissociation may be used for other purposes as well. Some identities are created to protect fragile, delicate, or creative and expressive parts of the child. An example is how the cult can manipulate dissociation to have a child create identities to serve their purposes.
Fear and resistance are typical initial survivor responses to learning about dissociated parts or selves. Multiplicity can feel frightening if a survivor doesn’t know what it is. Dissociated experiences/identities are frequently greeted with awe. It’s natural to fear the unknown. How ever, once survivors understand the ingenuity of their own system, most develop admiration and respect for it. They no longer see it as awful but awesome.
There’s a saying that “necessity is the mother of invention.” Pushed beyond normal limits, people have discovered extraordinary abilities. These abilities are in evidence by survivors who used their powers of the mind to survive. We as multiples are introducing the world to new realms of possibilities that have yet to be fully understood. With knowing and understanding comes appreciation. Regardless of an identity’s name, description, or personality, its main and common purpose is always to protect the child. Alters can manage extraordinary feats in their determination to keep the child safe. Sometimes these feats are beyond the range of normal human experience or comprehension.
Initially for survival, and later for managing day-to-day life, some survivors have developed extraordinary coping skills. Although these abilities may be wonderful in some respects, they have come at an exhorbitant price. While no two survivors are alike, some of the more commonly observed abilities in multiples are perfect memory, ability to heal unusually fast, ability to tolerate extreme levels of pain, and ability to self-anesthetize. By “switching,” some survivors are also able to work almost continually with minimal rest. Some report the ability to perceive paranormally.
Each identity within the same person may have unique neurological and physiological responses. For example, some identities may require glasses, while others have perfect vision: some identities are allergic to smoke, while others may be chain smokers: some identities are almost deaf, while others have exceptionally good hearing: different alters within one person will register unique electroencephalogram, electrocardiograph, blood pressure, and pulse readings. Alters may have different allergies and different ailments and unique responses to medications. One identity may be diagnosed with an ailment, but a different identity may be “out” when the medication is taken. In this case, the original alter isn’t helped, and the receiving alter may have unfavorable side effects. Prescribing medication to survivors who are multiple should be done with special care and extra monitoring.
In the same way that alters protected the child, once survivors get to know their inner parts, most develop a strong reciprocal protectiveness and appreciation of them.
Aftereffects of trauma are still being researched, and diagnostic terminology continues to evolve. Some existing terms are being retired and new terms are being proposed. In keeping with evolving trends and thinking, we will use the term post-traumatic reactions to indicate the overall condition; and the terms post-traumatic fear, dissociative experience, and dissociative identity to indicate the most prevalent reactions. Professionals are recognizing that post-traumatic reactions exist on a continuum, and many survivors use more than one coping strategy to survive. Trying to arrive at an exact diagnosis using existing terminology can be complex. It is sometimes more confusing than helpful to try to find the right “label.”
The current list of specific diagnosis includes but is not limited to PTSD, also know as Post-Traumatic Stress Syndrome (PTSS); various dissociative disorders, which include Depersonalization Disorder, Dissociative Fugue, Dissociative Amnesia, and Dissociative Disorder-Not Otherwise Specified (DD-NOS); Dissociative Identity Disorder (DID), formally referred to as Multiple Personality Disorder (MPD); and catatonia or catalepsy. Regardless of which way or ways a child splits, the mechanism of repression and dissociation and therefore the basic approaches to treatment are the same. Recognizing this, the current trend among professionals is to group survivor post-traumatic reactions under a single umbrella that may soon get its own name.
Survivors have mixed reactions to the proposed changes. Many survivors have difficulties with change because there are so many selves affected, and each self has a unique reaction. Some worked a long time to accept and feel comfortable with the term multiple personality and so may be reluctant to change. Others prefer the term dissociative identity because it describes the coping strategy rather than the symptom. Some survivors also feel that it sounds less extreme than multiple personality, which has often been given sensationalized treatment in the media. The terms dissociative identity and dissociative experience help to desensationalize and normalize the survivor experience.
The most frequent misdiagnosis is identifying secondary symptoms as the primary problem. Because most survivors are not aware of their traumatic past, they rarely seek help for post-traumatic reactions. However, the aftereffects of trauma often include a variety of symptoms, which survivors usually identify as “the problem.” Related secondary diagnosis’ include depression, physical ailments, chemical dependency, and eating disorders.
The symptoms of unintegrated trauma are very similar to and therefore often confused with various personality or mental disorders. Common misdiagnoses may include: paranoid schizophrenic, borderline personality, bipolar personality, anxiety disorder, attention deficit disorder, clinical depression, and psychosis. While these conditions may be present in survivors, they, too, are often secondary, not primary, problems.
The list of physical problems identified as primary rather than secondary diagnosis is almost endless. Survivors may be diagnosed with or without corroborative test results. A common, although certainly not an exhaustive, list of misdiagnoses may include temporal lobe epilepsy, allergies, thyroid problems, dyslexia, genital problems, digestive and elimination tract disorders, chronic infections, skin disorders, and asthma.
Although it is important to treat all symptoms, treating the secondary diagnoses alone without addressing their traumatic source will not yeild satisfactory results over the long term. Unless a physician or therapist has made a point of learning the signs and symptoms of unintegrated trauma, survivors may remain undiagnosed or misdiagnosed for long periods of time. A recent study showed that it took an average of seven years before a person with dissociated identity was properly diagnosed. The best indicator of possible misdiagnosis, physical or psychological, is unresponsiveness to treatment.
Basics of proper treatment include getting a correct diagnosis, understanding coping strategies, establishing a safety-oriented healing environment, accessing, connecting with, and healing dissociated experiences. Unlike many other conditions, proper treatment for trauma survivors yields excellent results.
POST-TRAUMATIC STRESS DISORDER (PTSD)
The development of characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience. The characteristic symptoms involve re-experiencing the traumatic event, avoidance of stimuli associated with the event or numbing of general responsiveness and increased arousal. This group of symptoms was initially recognized in conjunction with other types of trauma. Professionals noticed that some survivors of car accidents had reactions similar to those of soldiers returning from combat. In the past this group of symptoms was alternately called shell shock, battle fatigue, or combat neurosis.
With PTSD, aspects of the traumatic event are dissociated, but the event is not forgotten. Treatment usually focuses on processing the unassimilated parts of the trauma by giving expression to it, thereby healing the aftereffects. The trauma may be re-experienced through dreams, behaviors, emotions, and bodily responses. Sometimes the trauma or aspects of it are re-experienced through flashbacks, nightmares, night terrors, and/or startle responses.
Although symptoms of PTSD may feel frightening and are a cause of great distress, they are the body/mind’s attempt to heal. The trauma is breaking through into conscious awareness, where it can be assimilated and healed. (DSM-IV)
PTSD is characterized by:
— recurrent or intrusive distressing recollections of an event( images, thoughts, perceptions)
— re-experiencing the trauma of the event through dreams or flashbacks
— feelings of emotional numbness and detachment from others
— irritability or exaggerated startle responses, or hyper-vigilance
— sleep difficulties
— anger or anxiety
— difficulty concentrating
— physiological responses to situations or events that symbolize or resemble the original stressful event or situation
Symptoms of the disorder may occur within hours of the stressful event. Or they may not appear until months or years later.
Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling like one is in a dream).
B. During the depersonalization experience, reality testing remains intact.
C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance(e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy). (DSM-IV)
A. The predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with inability to recall one’s past.
B. Confusion about personal identity or assumption of a new identity (partial or complete).
C. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).
D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (DSM-IV)
A. The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
B. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder, Dissociative Fugue, Post traumatic Stress Disorder, Acute Stress Disorder, or Somatization Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a neurological or other general medical condition (e.g., Amnestic Disorder Due to Head Trauma).
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (DSM-IV)
DISSOCIATIVE DISORDER–NOT OTHERWISE SPECIFIED (DD-NOS)
This category is included for disorders in which the predominant feature is a Dissociative symptom (i.e., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific Dissociative Disorder. Examples include
1. Clinical presentations similar to Dissociative Identity Disorder that fail to meet full criteria for this Disorder. Examples include presentations in which a) there are not two or more distinct personality states, or b) amnesia for important personal information does not occur.
2. De-realization (A feeling of unreality or detachment from the environment, is frequently present in addition to the sense of estrangement from self.) unaccompanied by depersonalization in adults.
3 States of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought re-form, or indoctrination while captive).
4. Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. Dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one’s control. Possession trance involves replacement of the customary sense of personal identity by a new identity, attributed to the influence of a spirit, power, deity, or other person, and associated with stereotyped “involuntary” movements or amnesia. Examples include amok (Indonesia), bebainan (Indonesia), latab (Malaysia), pibloktoq (Arctic), ataque de nervios (Latin America), and possession (India). The Dissociative or trance disorder is not a normal part of a broadly accepted collective cultural or religious practice.
5. Loss of consciousness, stupor, or coma not attributable to a general medical condition.
6. Ganser syndrome: the giving of approximate answers to questions (e.g., “2 plus 2 equals 5”) when not associated with Dissociative Amnesia or Dissociative Fugue. (DSM-IV)
DISSOCIATIVE IDENTITY DISORDER (DID)
A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person’s behavior.
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). In children, the symptoms are not attributable to imaginary playmates or other fantasy play. (DSM-IV)
Catatonia: An extreme form of withdrawal in which the individual retreats into a completely immobile state, showing a total lack of responsiveness to stimulation.
Catalepsy: a physical state in which muscles of the face, body, and limbs take on a condition of suspended animation; trancelike or unresponsive state of consciousness; also called anochlesia; may last for many hours; body position or expression does not alter and limbs remain in whatever position they are placed (known as flexibilitas cerea, or waxy flexibility); associated with hysteria, epilepsy, and schizophrenia in humans, and with organic nervous disease in animals; may also be caused by brain disease and some drugs.
Excerpted from Compton’s Interactive Encyclopedia
짤 Copyright 1997-2001 Healinghopes.org
The Spectrum of Dissociative Disorders: An Overview of Diagnosis and Treatment
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.
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.
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.
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 has been adapted by Barry M. Cohen, M.A., A.T.R., for publication in this format. 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.
LEVEL OF DEFENSIVE OPERATIONS IN BORDERLINE PERSONALITY
In contrast to neurotic personality organization, in which the patient’s defensive organization centers on repression and other advanced or high-level defensive operations, borderline and psychotic levels of organization manifest predominately primitive defenses centering on the mechanism of splitting. Splitting and other mechanisms related to it (for example, primitive idealization, projective identification, denial, omnipotent control, and devaluation) protect the ego from conflict by dissociating contradictory experiences of the self and of significant others.
The presence of splitting and its related primitive defense mechanisms may be elicited in the analysis of the patient’s personality, as reflected in interactions both with significant others and with an interviewer.
The division of self and external objects into “all good” and “all bad” results in sudden and complete reversals of all feelings and conceptualizations about one’s self or views about a particular person.-Primitive Idealization.
This mechanism exaggerates the tendency to see all external objects as good. The qualities of goodness in others are exaggerated in a pathological way, to the exclusion of commonplace human defects. The patient does not tolerate any imperfection in the idealized person. The counterpart of idealization is the complete devaluation of others, or the perception of others as persecutory and dangerous.-Early forms of Projection; Projective Identification.
In contrast to higher levels of projection, characterized by attributing to other persons an impulse that the patient has repressed, projective identification is characterized by: (1) the tendency to continue to experience the impulse, which is at the same time projected onto the other person; (2) fear of the other person, who is viewed as being characterized by or under the sway of that projected impulse; and (3) the need to control that person, often done in such a way as to elicit behaviour in the person that seemingly validates the projection. Thus, whereas projection is based on an ego structure centered on repression as a defense, projective identification is based on a structure centered on splitting, or primitive dissiciation.-Denial.
In borderline patients denial is exemplified by the presence of emotionally independent areas of consciousness. These patients are aware that their perceptions, thoughts, and feelings about themselves or others at some times are completely opposite those entertained at other times, but this recognition has no emotional relevance and cannot influence their current state of mind.-Omnipotence and Devaluation.
Both omnipotence and devaluation are derivatives of splitting and are represented by the activation of ego states that reflect a highly inflated grandiose, omnipotent self and that relate to depreciated and devaluated representations of others, including the projection of devalued aspects of the self. A corollary of the omnipotence fantasy is the devaluation of other people, the patient’s conviction of his superiority over them, including the therapist. -The Subjective Experience of Emptiness.
There are patients who describe a painful and disturbing subjective experience which they frequently refer to as a feeling of emptiness. In typical cases, it is as if this emptiness were their basic modality of subjective experience from which they attempt to escape by engagement in many activities or in frantic social interaction, by the ingestion of drugs or alchohol, or by attempts to obtain instinctual gratifications through sex, aggression, food, or compulsive activities that reduce their focusing on their inner experience. Other patients, in contrast, seem to succumb to this experience of emptiness and to aquire what might be described as a mechanical style of life -going through the motions of daily activities with a deadening sense of unreality or a blurring of any subjective experience, so that they seem to merge, so to speak, with whatever immediate inanimate or human environment surrounds them… This experience becomes particularly strong when active mechanisms of primitive dissociation or splitting constitute a predominant defense against intrapsychic conflict.-Self Harm/Mutilation.
Some patients have tendencies toward self-mutilation, and tend to relieve tension of any origin by inducing pain in themselves (by cutting themselves, burning their skin, etc.). One [may even] observe a real pleasure or pride in the power of self-destruction.[From ‘Borderline Conditions and Pathological Narcissism’, and ‘Psychodynamic Psychotherapy of Borderline Patients’ by Otto Kernberg]
The Diagnostic Interview for Borderlines, Revised
Gunderson and his colleague, Jonathan Kolb, tried to make the diagnosis of BPD by constructing a clinical interview to assess borderline characteristics in patients. The DIB was revised in 1989 to sharpen its ability to differentiate between BPD and other personality disorders. It considers symptoms that fall under four main headings:
- chronic/major depression
- anger (including frequent expressions of anger)
- odd thinking
- unusual perceptions
- nondelusional paranoia
- Impulse action patterns
- substance abuse/dependence
- sexual deviance
- manipulative suicide gestures
- other impulsive behaviors
- Interpersonal relationships
- intolerance of aloneness
- abandonment, engulfment, annihilation fears
- stormy relationships
The DIB-R is the most influential and best-known “test” for diagnosing BPD. Use of it has led researchers to identify four behavior patterns they consider peculiar to BPD: abandonment, engulfment, annihilation fears; demandingness and entitlement; treatment regressions; and ability to arouse inappropriately close or hostile treatment relationships.
The DSM-IV gives these nine criteria; a diagnosis requires that the subject present with at least five of these. In I Hate You — Don’t Leave Me! Jerold Kriesman and Hal Straus refer to BPD as “emotional hemophilia; [a borderline] lacks the clotting mechanism needed to moderate his spurts of feeling. Stimulate a passion, and the borderline emotionally bleeds to death.”
Traits involving emotions:
Quite frequently people with BPD have a very hard time controlling their emotions. They may feel ruled by them. One researcher (Marsha Linehan) said, “People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.”
1. Shifts in mood lasting only a few hours.
2. Anger that is inappropriate, intense or uncontrollable.
Traits involving behavior:
3. Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more than once
4. Two potentially self-damaging impulsive behaviors. These could include alcohol and other drug abuse, compulsive spending, gambling, eating disorders, shoplifting, reckless driving, compulsive sexual behavior.
Traits involving identity
5. Marked, persistent identity disturbance shown by uncertainty in at least two areas. These areas can include self-image, sexual orientation, career choice or other long-term goals, friendships, values. People with BPD may not feel like they know who they are, or what they think, or what their opinions are, or what religion they should be. Instead, they may try to be what they think other people want them to be. Someone with BPD said, “I have a hard time figuring out my personality. I tend to be whomever I’m with.”
6. Chronic feelings of emptiness or boredom. Someone with BPD said, “I remember describing the feeling of having a deep hole in my stomach. An emptiness that I didn’t know how to fill. My therapist told me that was from almost a “lack of a life”. The more things you get into your life, the more relationships you get involved in, all of that fills that hole. As a borderline, I had no life. There were times when I couldn’t stay in the same room with other people. It almost felt like what I think a panic attack would feel like.”
Traits involving relationships
7. Unstable, chaotic intense relationships characterized by splitting (see below).
8. Frantic efforts to avoid real or imagined abandonment
- Splitting: the self and others are viewed as “all good” or “all bad.” Someone with BPD said, “One day I would think my doctor was the best and I loved her, but if she challenged me in any way I hated her. There was no middle ground as in like. In my world, people were either the best or the worst. I couldn’t understand the concept of middle ground.”
- Alternating clinging and distancing behaviors (I Hate You, Don’t Leave Me). Sometimes you want to be close to someone. But when you get close it feels TOO close and you feel like you have to get some space. This happens often.
- Great difficulty trusting people and themselves. Early trust may have been shattered by people who were close to you.
- Sensitivity to criticism or rejection.
- Feeling of “needing” someone else to survive
- Heavy need for affection and reassurance
- Some people with BPD may have an unusually high degree of interpersonal sensitivity, insight and empathy
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
This means feeling “out of it,” or not being able to remember what you said or did. This mostly happens in times of severe stress.
Miscellaneous attributes of people with BPD:
- People with BPD are often bright, witty, funny, life of the party.
- They may have problems with object constancy. When a person leaves (even temporarily), they may have a problem recreating or remembering feelings of love that were present between themselves and the other. Often, BPD patients want to keep something belonging to the loved one around during separations.
- They frequently have difficulty tolerating aloneness, even for short periods of time.
- Their lives may be a chaotic landscape of job losses, interrupted educational pursuits, broken engagements, hospitalizations.
- Many have a background of childhood physical, sexual, or emotional abuse or physical/emotional neglect.