Dissociation: the clinical realities.

An attempt was made by the authors of DSM-III to restrict its focus to the experimental, the observable, and the measurable. The intention was to free the nosology from the influence of unproven theories, and the philosophy was driven largely by the importance of research being able to identify diagnostic categories to facilitate the study of homogeneous groups. So it is of interest that the authors accepted dissociation-an ambiguous event linked to an explicit theoretical concept that had been introduced by Janet-as the basis for classification of clinical presentations that were formerly included under the rubric of hysteria, a similarly unclear category. Since DSM-III, there have been an increasing number of reports of dissociative experiences and dissociative identity disorder (formerly known as multiple personality disorder), but neither of these clinical presentations seems able to withstand the concern that it is dramatically influenced by environmental cues, e.g., the expectations of the therapist. Thus, a restricted phenomenological perspective does not fully appreciate the distorting potential of suggestibility and imagination on the nature of the emerging clinical picture. These factors might well have contributed to and laid the conceptual groundwork for the growth in the number of reports of dissociation.

The concept of flashbacks in historical perspective.

A computer search of the literature for papers indexed under "flashbacks" produced a list of 70 references, many found in publications on the topics of substance abuse and trauma. Several of these were letters or papers written in languages other than English. In all, the author reviewed 55 papers. Although most of these papers contained comments that addressed the subject matter to some extent as recurrences or reminiscences of past happenings, the variability in the use of the term leaves many unresolved questions regarding the veridicality of the imagery. Nothing in the presentations reviewed by the author clearly demonstrates the unidimensional nature of flashbacks nor any recognizable neurophysiological correlate. The content of a flashback appears to be at least as likely to be the product of imagination as it is of memory.

A history of medical hypnosis.

From the origins of mysticism and theatrics, trivialized by stage performers, psychics, and charlatans, modern medical hypnosis has struggled to achieve and maintain a sense of professional integrity. Many of the principles of dynamic psychiatry are deeply rooted in the work of the early healers. Yet hypnosis as a clinical entity continues to fall in and out of favor over the years; again it is now being pushed beyond the limits of that which is reasonable and valid.

Hypnotizability, dissociation, and bulimia nervosa.

This study examined the levels of hypnotizability and dissociation in an outpatient sample of 17 normal-weight bulimic women and 20 healthy controls. Bulimic patients were significantly more hypnotizable than controls (p < .003) and scored higher on a self-report scale of dissociative experiences (p < .02). The results of measures of hypnotizability and dissociation showed a significant positive correlation in the combined subject group. These results are consistent with previous reports on hospitalized patients and college students and suggest that psychological factors associated with hypnotizability might play a role in the etiology and treatment of bulimia nervosa.

Adult reconstruction of childhood events in the multiple personality literature.

The author reviews the dependability of adult reports of childhood abuse and trauma, which are emerging in therapy with increasing frequency. He reviews the literature on multiple personality disorder to explore the extent to which corroboration of adult reports of childhood events is recorded. He also summarizes the relevant studies of memory both with and without the aid of hypnosis. He finds that there is minimal corroboration in the literature of the adults' reports of childhood abuse. Memories brought forth with the aid of hypnosis are undependable because of the large number of inaccuracies introduced by hypnotized subjects. Memories brought forth without hypnosis have been shown to be prone to distortion by intentional as well as by unwitting cues. The author concludes that the recent enthusiasm for the adult discovery of childhood abuse has been accompanied by little attention to factors that potentially affect recall of childhood abuse, including the bias of therapy. The use of hypnosis might well be an aggravating factor in distorted recollections of childhood abuse. Validation without corroboration by the therapist of the patient's memories has serious ethical and possibly legal consequences.

Hypnosis and relaxation in the medically ill.

Interest in the application of hypnotic techniques for patients with medical disorders seems to rise and fall over the years. Enthusiasm for this work comes both from patients and clinicians. Often, however, these techniques are offered without regard to the psychological theories that should inform their operation and the limits that clinical and experimental research suggest. This article offers a brief description of the elements of hypnosis and a review of the history of the use of hypnotic techniques with a variety of medical problems including asthma, habits such as cigarette smoking and medical symptoms such as persistent nausea and vomiting. Special attention is placed on the psychological and physiological principles that help to establish the valid use of this technique.

Hypnotizability and dissociation.

The author describes the multidimensionality of hypnosis itself and hence of hypnotizability. He also points to the lack of clarity regarding the concept of dissociation and the extent to which its roots lie in the clinical experience of hypnosis. The concept of dissociation increasingly preempts repression and other defense mechanisms in current nosological thinking. The author cautions against equating hypnotizability scores with dissociative capacity and advocates a clearer elaboration of the concept of dissociation. Meanwhile, restraint in the use of the term "dissociation" is recommended.

Failure of hypnotic suggestion to alter immune response to delayed-type hypersensitivity antigens.

The ability to alter delayed-type hypersensitivity via hypnotic suggestion was tested in 12 highly hypnotizable, untrained subjects and 30 nonhypnotized controls. Subjects were skin-tested bilaterally with a standardized panel of delayed hypersensitivity antigens and instructed either to enhance or suppress the skin test response unilaterally. Compared with results in controls, the skin test response reflected no effect of hypnotic suggestion with regard to either the area of induration or the degree of inflammation assessed histologically.

Dissociation and psychotic symptoms.

The literature on hysterical or brief reactive psychosis reflects great diversity both in clinical description and theoretical formulation. The authors describe the case of a 17-year-old girl who presented with a diagnosis of bipolar affective disorder, rapid cycling type, but who, in fact, was experiencing dissociative episodes manifested as psychotic states. The patient's successful treatment with hypnosis is described, along with the clinical and theoretical implications of the case.

The use of electroconvulsive therapy in suicidal patients.

Publications on the subjects of ECT and suicide stress the importance of ECT as a valuable treatment in appropriately selected cases of suicidal ideation or attempted suicide. There is no direct correlation between the degree of suicidality and the usefulness of ECT. In the management of cases with major affective disorder, particularly those showing delusions and vegetative signs, ECT should be considered early in the treatment. The presence of the potential for suicide provides an added incentive. However, suicidal threats or attempts on the part of patients with severe personality disorders are not likely to respond to ECT unless the picture is complicated by major depressive illness. In the absence of such affective illness, understanding and skilled psychotherapy are likely to be more effective. Antidepressant medication and ECT should be administered within a supportive, watchful, and compassionate setting.