Dissoziation ist ein Abwehrmechanismus gegen Schmerz und Hilflosigkeitkeit als Folge traumatischer Erfahrungen. Ein fall von dissoziativer Identitätsstörung wird beschrieben. Die Patientin litt unter multipler Sklerose, einer Vielzahl von somatischer Symptome sowie posttraumatischer Belastungsstörung und dissoziativen Symptomen. Sie wurde mit Hypnose und Ego-State-Therapie behandelt. Die Therapie konzentrierte sich darauf, die dissoziativen Schranken durchlässiger zu machen, dissozierte Persönlichkeitsanteile zu integrieren und verdrängte Erinnerungen an sexuellen Mißbrauch in der Kindheit bewußt zu machen. Dieses Vorgehen trug zu positiven Veränderungen in der beruflichen wie sozialen Beziehungen der Patientin ebenso bei wie zu einer Verbesserung der MS-Symptomatik.

Dissociation är ett försvar mot hjälplöshet, som orsakats av traumatiska händelser. Ett möjligt fall av dissociativ identitetsstörning presenteras. Patienten hade multipel sclerosis (MS) och ett flertal symptom på somatisering, posttraumatisk stress och dissociation. Hon behandlades med hypnos och ego-state terapi. Terapin fokuserade på att lösa upp den dissociativa avspaltningen och integrera dissocierade delar av personligheten, som visade sig dölja bortträngda upplevelser av sexuella övergrepp. Behandlingen bidrog till förbättringar i patientens relationer och yrkesliv, samt en avsevärd minskning av MS-symptomen. Författarna menar att jag-tillstånd, som kommer fram i terapi, inte nödvändigtvis är dissocierade personlighetsfragment, men användandet av diagnostiska instrument och kunskap om dissociativa mekanismer kan bidra till en adekvat diagnostisering av dissociativa störningar.

BACKGROUND

Dissociative identity disorder (DID), formerly known as multiple personality disorder (MPD), is a failure of integration of various aspects of identity, memory, and consciousness. The problem, as someone has stated, is not having more than one personality, but having in fact less than one personality.

Although DID was first reported from Europe (Völgyesi, 1966), it has been described as a culture-bound phenomenon, indigenous to the United States (Fahy, 1988). Recent research has shown, however, that this is not the case.

Coons, Bowman, Kluft and Milstein (1991) sent a questionnaire to 132 clinicians in 27 countries outside of North America. These clinicians had requested reprints of articles on DID. The clinicians were asked about the number of cases of DSM-III-R multiple personality disorder and dissociative disorder not otherwise specified (DDNOS) they had seen, and asked, if relevant, to describe a single case of MPD. Coons and his collegues received 34 responses from 10 different countries. Added to the previously known cases, dissociated identities have thus been reported from at least 20 countries (Karilampi, 1993).

Boon and Draijer (1993) have published an extensive Dutch study on reliability and validity of the diagnosis DID. Their study is the first to describe a large group of DID patients outside of North America. They found that Dutch DID patients displayed a stable set of core symptoms comparable to those found in several North American studies.

In Norway, all inpatients at the psychiatric clinic in Stavanger have been tested for dissociative disorders. Although the results have not been published yet, patients with dissociative disorders were found, and a few short case studies have been described (Bøe, Haslerud & Knudsen, 1993).

Dissociation is believed to be a defense mobilized against the pain and helplessness caused by traumatic experiences such as rape, incest and combat. It provides protection from immediate experiences rather than unconscious memories or wishes (Spiegel, 1986).

This definition has been empirically tested by Boon and Draijer (1993). They analysed the trauma histories of 146 patients: 82 patients with a dissociative disorder and 64 patients with other psychiatric disorders. Boon and Draijer found that childhood traumatic experiences are not specific to the background of dissociative disorder patients, but that traumatic experiences, particularly physical abuse and sexual abuse, were significantly more prevalent in the childhood of dissociative disorder patients than in that of psychiatric control patients without a dissociative disorder. There was also a significant difference in severity of both physical abuse and sexual abuse between the dissociative patients and other psychiatric patients: patients with a dissociative disorder reported the most severe abuse histories, and were repeatedly traumatized. Also, the dissociative disorder patients differed significantly from the other psychiatric patients in the age at which physical and sexual abuse had started. The abuse histories of dissociative disorder patients had started at an early age (before age six), while trauma histories of the other patients had begun mostly at an older age (after age six and up to early adolescence).
Boon and Draijer came to the conclusion that the severity of the dissociative symptomatology is closely related to the presence and severity of trauma experienced in childhood, in particular sexual abuse. They believe that DID can be considered to be a specific and complicated posttraumatic disorder which develops in early childhood in response to severe and chronic abuse.

According to Steinberg, Rousanville and Cicchetti (1991), difficulties in detection of the dissociative disorders may be due to:

1. the intricacies of the syndromes themselves,
2. low clinical awareness, or
3. lack of systematic assessment.

The DES, created by Bernstein (now Bernstein Carlson) and Putnam in 1986, is a brief, self-report measure of the frequency of dissociative experiences in the daily lives of subjects. The scale is a 28-item questionnaire in which the subject is asked to mark what percentage of the time (from 0 to 100 %) the described experience has happened to him or her. The items include questions about amnestic dissociation, absorption and imaginative involvement, depersonalization and derealization, and other types of dissociative experiences.
The DES has been shown to have good test-retest reliability and internal reliability. Studies of the DES scores for different diagnostic groups and studies of the convergent and discriminant validity of the DES all provide evidence for the construct validity of the scale (Bernstein Carlson & Putnam, 1993).
For clinical use, to identify patients who are likely to have a dissociative disorder, a score of 40 predicts a dissociative disorder in all cases, assuming a prevalence of dissociative disorders of 15%; but one misses those dissociative patients (approximately 35 % of them) who score below 40. In a random clinical sample, a cut-off score of 25 is optimal (Boon & Draijer, 1993).

The DES is a screening instrument, and a diagnostic interview is necessary to confirm true positive cases of dissociative disorders.
The SCID-D was designed by Steinberg et al. (1990) It contains 200 items, including follow-up questions, that are designed to evaluate five symptom areas (amnesia, depersonalization, derealization, identity confusion, and identity alteration), and the DSM-III-R or DSM-IV criteria for dissociative disorders.
According to a study by Boon and Draijer (1993), SCID-D showed levels of inter-rater reliability in the excellent range of clinical significance for the absense or presence of a dissociative disorder, and in the good-to-excellent range for specific dissociative symptoms. The SCID-D also discriminated significantly subjects with a dissociative disorder from subjects with other psychiatric diagnoses. Also, there was a high correlation between SCID-D total score and the DES-score. Boon and Draijer conclude that the SCID-D is a reliable and valid diagnostic instrument to make an assessment of dissociative symptoms and disorders.

Dissociative symptoms are more often covert than overt and have to be inquired for in a systematic fashion. If one does not know what to look for, the symptoms may go undetected, especially as it may take some time in therapy before the symptoms show up (as in the case described in this article).

According to DSM-III-R (American Psychiatric Association, 1987), the essential feature of the dissociative disorders is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. The disturbance or alteration may be sudden or gradual, and transient or chronic.

In DES, various types of dissociative experiences are described. In addition to them, one can look for the following signs:

• having had several psychiatric diagnoses
• no improvement despite many treatments
• unusual reactions to adequate medication
• requires extreme doses for therapeutic effect or has side-effects at non-therapeutic doses
• multiple suicide attempts
• self-mutilation, especially if no pain is felt or remembered
• recurrent nightmares
• intractable headaches
• pseudoseizures
• great changes in energy level: being most energetic or very tired
• sudden changes in mood: panic attacks, crying attacks, rage
• quick or sudden changes of the topic of discussion
• being disorientated in space, time or person
• denying having said something; talking with a child's voice
• becoming suddenly mute

The list above is not a complete one but is meant to give the reader some idea of what dissociative symptoms can be like. Naturally it is significant if one individual displays a multitude of the above symptoms. We will illustrate some symptoms by describing a case of possible dissociated identity disorder.

Marie, a married woman in her thirties, requested hypnotherapy (of which she knew very little) in order to be relieved from symptoms which had not disappeared despite a two-year psychotherapy a few years earlier. The remaining symptoms were nightmares with a recurrent theme of witnessing murder; and feelings of fading away and loosing her breath before falling asleep. These symptoms appeared whenever her multiple sclerosis (MS) took a turn for the worse. The initial interview disclosed some marital problems and a family history without any memories of closeness and trust.
For further reading, the reader should know that the therapist had not introduced any suggestions about hypnotic, dissociative, or trance phenomena.

To her sixth session Marie brought with her a drawing of her MS. She had made the drawing in a state of automaticy. Her associations about this drawing were centered on the atmosphere in her childhood home. While associating, Marie spontaneously entered a trance state and imagined herself inside her drawing. She was surrounded by a slimy wall, and managed to find a way out only after considerable struggle. Then the image changed and Marie discovered that she had got a shadow. The shadow was large, bright, turquoise, and very cold, making her body literally shiver on the couch.

As Marie spontaneously had entered a trance state and since her symptoms seemed ego alien, her therapist chose to use ego-state therapy (Watkins, 1981). The therapist talked directly to the shadow and asked about it's function. The shadow said it's function was to protect Marie, but when asked what it was protecting Marie from, the shadow refused to answer because "it would make her so sad". Upon further inquiry, the shadow part said it had entered Marie's life at the age of five. It was willing to co-operate with the therapist and stay in the background in order to let Marie learn to set her own limits.
Marie experienced a partial amnesia for the trance, namely for what the shadow had said, and that it had answered questions at all. She asked: "What is the shadow? I didn't know I had one."

At the next session, Marie felt fear and sorrow, which she believed was due to the situation at her job. Indicentally and as if of no importance, she told her therapist that her father used to touch her breasts every time her parents visited her. She objected to this by avoiding physical closeness with him. She then remembered that she never went to her parents bedroom as a child, but sought comfort in the dog's basket.

The nightmares continued. Marie dreamt that the murder was committed in the area where she lived as a child, and she said in a child's voice: "It is dangerous to go there". Marie also had nightmares about men trying to rape women. In one dream, she tried to get help from women, but they were frightened and unreachable. Marie's associations to this dream was that the women were her mother and the men were her father. She remembered that her mother had always wanted Marie to sit in her father's lap until she was thirteen, even though Marie herself did not want to.

Through a so called "affect bridge", a hypnotic technique (Watkins, 1971), Marie made a connection between her breathing problems and a situation in her childhood when she was five years old, sitting in her father's lap. He was forcing her towards him and holding her body in a steady grip. She fought to get away and finally succeeded. Her father was disappointed, sad and hurt.

Therapist: "Now I want you to be a grown-up mother coming in, seeing Marie in daddy's lap."Marie shouted: "You son of a bitch, let her loose! She doesn1t want to sit there! You just don't do such things to kids! Never touch her again the way you did - if you do, I'll beat the shit out of you!!"
The "mother Marie" helped "Marie the child" loose, but Marie told the therapist that the child didn't understand what was going on.
Therapist: "What is it that you, the grown-up woman, can see that little Marie can't see?"Marie: "He is behaving like a dirty old man. That is the reason why he can't let her loose at once. He is too excited."

Marie felt very sad and recognized having the exact same feeling as when she woke up from the nightmares. She summarized that the hardest part so far in her therapy, had been the realization that her father's feelings were sexual and that he was intimate with her at bedtime. She had pushed him away and been left with feelings of guilt.
In the still ongoing nightmares, Marie now dreamt that she had a child to protect and that she received support from "unconventional people".

Before her summer vacation, Marie's MS got worse. She also suffered from tinnitus and found it difficult to sleep. What kept her awake were feelings of anger. In therapy, she engaged her entire body in an abreaction, shouting: "No! I don't want to! Go away! Leave me alone! NO!!" After this abreaction she relaxed. She had no idea as to what or whom she protested. During trance, however, she remembered being a small child and her mummy saying that Marie was so good to daddy. "No one is as good to daddy as I am", the child part of Marie said. Then suddenly she felt the taste of mint. "Mummy and daddy gave me a coin because I'm so good to daddy. I am buying mint sweets. I am good because daddy is sitting on the side of my bed and hugging me goodnight... I don't want to be there again!!" The therapist encouraged Marie to experience what was going on, by asking the protective part of Marie to step aside in order to let the child part describe what was happening and what she was feeling. The child part reported that she was feeling very heavy as her father was weighing her down. "He is touching me in the wrong places", Marie cried. She didn't want her father to touch her but was unable to express it.

After some more sessions of supportive therapy, the therapist contacted once more the protective part, who told her "Now I am only watching, resting and giving energy to the grown-up Marie".
"Are there any more parts?" the therapist asked. "Yes", was the answer, "a creative part and one responsible for the MS".
Without any suggestions to do so, before leaving the trance state, Marie counted the parts of her to be seven or eight. The therapist had no intention to examine these parts, since there was no reason to believe that they were hindering the therapeutic process.

After some more months of strengthening Marie's immune system, her therapist contacted the protective part again. The protector now had a calmer, deeper, and more confident voice. It said that it now wanted Marie to remember, so the therapist asked for little Marie. The protector asked: "Why should she come in?" Eventually, little Marie was allowed to come forward. She did not want to tell, though, what her daddy had done.

The therapist suggested that the child part, the protecting part and other more diffuse parts should hold a trance meeting in a room downstairs (as a metaphor for the unconscious). The child part was now very hesitant to talk about herself and had no words to express herself. She was really troubled.
Close to the couch where Marie was lying was a pad, pastel crayons, and water colors. The therapist asked the child part to use these to show the rest of the personality parts what she was feeling. After a few seconds Marie rose from the couch without seemingly aware of her surroundings, obviously still in a trance state. She painted and cried, and laid down on the couch again in slow-motion. Her therapist suggested to her to integrate all the parts which now were able to see her and to affirm her. After she woke up from the trance, Marie said: "It is really nice to have access to all my parts. It must be possible to heal the child, mustn't it." She entered a period of feeling sorry for herself and painting a lot in her leisure time.

The next step towards integration of memories and feelings was triggered by a near-death-experience. Marie had a piece of a cookie stuck in her throat and lost her breath for such a long time that she felt herself leaving her body, entering a feeling of total calm, and returning to her body as she felt that she did not want to die. Afterwards she had a period of sleepless nights, stress symptoms and tinnitus. She also experienced amnesia concerning this near-death experience, and thought that her stress symptoms were due to some trouble at her work. In trance, however, her unconscious mind showed her another reason for her tinnitus: she suddenly remembered that she had almost choked the time she got the cookie piece in her throat. When asked if this reminded her of anything, she said she was paralyzed and couldn't do anything to help herself. In a deepened trance, she remembered experiencing the same feeling at the age of four. "I cannot breath. Daddy is stopping me from breathing. I am scared. I cannot breath because he is on my throat and mouth and my whole face is covered."
This time she spontaneously came out of trance. She said: "I was so scared", and started to cry. While leaving the therapy session, she said: "Next time I want to literally push him away with all my anger and all my might. Can we do that?"

Marie arrived to the next session announcing that she was prepared to do as planned, even though she was very frightened. During induction the therapist asked the child part to experience what had happened in order to do what she needed to do, and the protector to supply the child with the necessary strength to go through the experience. After a while the child described the situation: her arms were stucked, and her body weighed down, totally immobilized, under her father's body. "I am almost dying", she cried. She was shivering with fright and couldn't move her arms. The therapist asked the protector to help the child gather strength enough to push her father away. Ambivalently, Marie raised her arm, and pushed the armchair offered by the therapist amazingly hard, shouting loudly. Afterwards she hyperventilated for a while, and then relaxed, totally calm.
Marie: "It was I who pushed him away. I had to help her. She could not push him away herself. She is very sad now." (Apparently, the protector was talking.) She continued: "I have difficulty moving away. I am terribly tired."Therapist: "Okay, take your time, have som rest.. and while you are resting, little Marie can realise that she is not left alone."Marie evaluated her therapy thus: "Today I was very scared. I knew it would be very difficult, maybe too difficult. I used to believe that if I only knew the reason for my anxiety, the sun would start to shine. But instead of anxiety, I felt so much sorrow. This sorrow is easier to live with than the anxiety."

A follow-up one year after the termination of the therapy confirmed the progress made. The trouble breathing and the nightmares were gone. The progress was most obvious in her marriage; she had gained an extraordinary ability to say "no" to destructive patterns in favor of constructive possibilities. She was confidently engaged in social activities. She didn't have to go about on crutches, and even started to bicycle to and from work.

This case demonstrates some characteristic features of patients who have a non-volitional habit of dissociating. Marie's experiencing the shadow in a literal, not metaphorical sense, could falsely be mistaken for a psychotic trait, and hypnosis regared therefore as risky. If Marie hadn't chosen hypnotherapy and a therapist well acquainted with spontaneous trance states, her dissociated parts might never have been discovered.From the perspective of dissociation/integration, the therapy uncoverd repressed experiences and dissociated aspects of the personality, loosened up Marie's dissociative barriers, integrated parts of herself, and contributed to positive outcomes in her professional and social relations, as well as in her symptoms of MS.

Marie's total DES-score was 35.7. This score has a positive predictive value of 0.90 (Boon & Draijer, 1993). She could thus be diagnosed as suffering from dissociated identity disorder. In that case, Marie could be characterized as what is called a "high-funtioning multiple personality". Kluft (1986) defines an individual of this subgroup of DID as somebody who has had histories of sustained and uninterrupted superior performances, with no evidence of major life disruption, severe psychopathology, major medical problems, or seizure disorders, and whose pathology has been extremely well disguised in both his/her life and clinical presentation. Marie doesn't quite fit this description as she does have a major medical problem (her multiple sclerosis), but she hasn't been hospitalized or treated for any personality disorder and has a successful professional career.

Caution has to be used, though, when diagnosing DID in hypnotherapy. Ego states, or subpersonalities, defined by Rowan (1991) as a semi-permanent and semi-autonomous region of the personality capable of acting as a person, seem to be a quite frequently occurring phenomenon. Therapeutic techniques like hypnosis, based on inducing altered states of consciousness, can bring out these subpersonalities. Even though they are qualitatively different from dissociated parts of a personality, an unexperienced therapist might believe them to be pathological. Further research will provide us with a deeper understanding of the components of the mind.

AMERICAN PSYCHIATRIC ASSOCIATION (1987) Diagnostic and statistical manual of mental disorders, third edition-revised. Washington, D.C.: American Psychiatric Association.

BERNSTEIN, E M & PUTNAM, F W (1986) Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis, 174, 727-735.

BERNSTEIN CARLSON, E & PUTNAM, F W (1993) An update on the Dissociative Experiences Scale. Dissociation, VI, 16-27.

BOON, S & DRAIJER, N (1993) Multiple personality disorder in the Netherlands: A study on reliability and validity of the diagnosis. Amsterdam/Lisse: Swetz & Zeitlinger B.V.

BØE T, HASLERUD, J & KNUDSEN, H (1993) Multippel personlighet - et fenomen også i Norge? Tidskr Nor Lægeforen, 26, 3230-3232.

COONS, P M, BOWMAN, E S, KLUFT, R P & MILSTEIN, V (1991) The cross-cultural occurrence of MPD: Additional cases from a recent survey. Dissociation, IV, 124-128.

FAHY, T A (1988) The diagnosis of multiple personality disorder: A critical review. Br J Psychiatry, 153, 597-606.

KARILAMPI, U (1993) Introduktion till dissociation [unpublished Master1s thesis]. University of Gothenburg: Department of Psychology.

KLUFT, R P (1986) High-functioning multiple personality patients: Three cases. J Nerv Ment Dis, 174, 722-726.

ROWAN, J (1991) Subpersonalities: The people inside us. London and New York: Routledge.

SPIEGEL, D (1986) Dissociating damage. Am J Clin Hypn, 29, 123-131.

STEINBERG, M, ROUSANVILLE, B & CICCHETTI, D (1990) The Structured Clinical Interview for DSM-III-R Dissociative Disorders: Preliminary report on a new diagnostic instrument. Am J Psychiatry, 147, 76-82.

STEINBERG, M, ROUSANVILLE, B & CICCHETTI, D (1991) Detection of dissociative disorders in psychiatric patients by a screening instrument and a structured diagnostic interview. Am J Psychiatry, 148, 1050-1054.

VöLGYESI, F A (1966) Hypnosis of man and animals. London: Bailliére, Tindall & Cassell.

WATKINS, H (1981) Ego state therapy. In: WATKINS, J G (Ed.) The therapeutic self. New York: Human Sciences Press, 360-398.

WATKINS, J G (1971) The affect bridge: A hypnoanalytic treatment. Int J Clin Exp Hypnosis, 19, 21-27.

Back to top!