Evidence for associations among somatoform dissociation, psychological dissociation and reported trauma in patients with chronic pelvic pain.

This study investigates somatoform as well as psychological dissociation, somatization and reported trauma among patients with chronic pelvic pain (CPP). Women with CPP (n = 52) who were newly referred to a gynecology department, or whose pain had resisted treatment, completed standardized self-report questionnaires and received a structured interview for DSM-IV dissociative disorders. The prevalence of dissociative disorders in the sample was very low. As hypothesized, self-reported somatoform dissociation was positively correlated with self-reported psychological dissociation and features of DSM-IV dissociative disorders; women who reported more serious psychic trauma, in particular sexual and physical abuse, experienced more somatoform and psychological dissociation than women reporting less trauma, or no trauma at all; and the association of somatoform dissociation and reported trauma was stronger than the association of psychological dissociation and trauma. Physical abuse/life threat posed by a person predicted somatoform dissociation best. The results are consistent with findings among psychiatric patients, and, therefore, strengthen the thesis that somatoform dissociation, (features of) dissociative disorder, and reported trauma are strongly intercorrelated phenomena.

Generalized dissociative amnesia: episodic, semantic and procedural memories lost and found.

OBJECTIVE: This review tests Ribot's classic twofold categorization of generalized amnesia (GA) into Type I, total loss of episodic memory, and Type II, additional more or less extensive loss of semantic and/or procedural memory. It also explores his law of regression, according to which, cast in modern terms, recovery of lost procedural and semantic memories precedes recovery of episodic memory, as well as reported aetiological factors. METHOD: Clinically and formally assessed cases of GA, published since 1845, were surveyed and further analysed. RESULTS: Over and above authentic episodic memory loss, cases differed widely in the extent of impairment of semantic and procedural memory. Recovery of semantic and procedural memory often preceded recovery of episodic memory. This particularly applied to authenticated trauma memories. To an extent, lost memories affected current functioning, and in some cases were associated with alternating dissociative personalities. Severe memory distortions upon memory recovery were not reported. Most cases were trauma or stress related, while in some cases the aetiology remained unknown. CONCLUSIONS: Contrary to the view expressed in DSM-IV, which states that dissociative amnesia pertains to an inability to recall personal information, GA may also involve loss and recovery of semantic and procedural memories. Since the loss of various memory types in GA is dimensional rather than categorical, Ribot's typological distinction does not hold. Some of the reviewed cases suggest a trauma-related aetiology. Generalized amnesia of varying degrees of severity can involve delayed retrieval of trauma memories, as well as the loss and delayed retrieval of the premorbid personality.

Somatoform dissociation discriminates among diagnostic categories over and above general psychopathology.

OBJECTIVE: The primary aim of this study was to investigate the hypothesis that somatoform dissociation would differentiate among specific diagnostic categories after controlling for general psychopathology. METHOD: The Somatoform Dissociation Questionnaire (SDQ-20), the Dissociative Experiences Scale, and the Symptom Checklist-90-R were completed by patients with DSM-IV diagnoses of dissociative disorders (n = 44), somatoform disorders (n = 47), eating disorders (n = 50), bipolar mood disorder (n = 23), and a group of consecutive psychiatric outpatients with other psychiatric disorders (n = 45), mainly including anxiety disorders, depression, and adjustment disorder. RESULTS: The SDQ-20 significantly differentiated among diagnostic groups in the hypothesised order of increasing somatoform dissociation, both before and after statistically controlling for general psychopathology. Somatoform dissociation was extreme in dissociative identity disorder, high in dissociative disorder, not otherwise specified, and increased in somatoform disorders, as well as in a subgroup of patients with eating disorders. In contrast with somatoform dissociation, psychological dissociation did not discriminate between bipolar mood disorder and somatoform disorders. CONCLUSIONS: Somatoform dissociation is a unique construct that discriminates among diagnostic categories. It is highly characteristic of dissociative disorder patients, a core feature in many patients with somatoform disorders, and an important symptom cluster in a subgroup of patients with eating disorders.

Trauma-induced dissociative amnesia in World War I combat soldiers. II. Treatment dimensions.

OBJECTIVE: This is the second part of a study of posttraumatic amnesia in World War I (WW I) soldiers. It moves beyond diagnostic validation of posttraumatic amnesia (PTA), to examine treatment findings, and relates these to contemporary treatment of dissociative amnesia, including treatment of victims of civilian trauma (e.g. childhood sexual abuse). METHOD: Key WW I studies are surveyed which focus on the treatment of PTA and traumatic memories. The dissociation-integration and repression-abreaction models are contrasted. RESULTS: Descriptive evidence is cited in support of preferring Myers' and McDougalls' dissociation-integration treatment approach over Brown's repression-abreaction model. CONCLUSION: Therapeutic findings in this paper complement diagnostic data from the first report. Although effective treatment includes elements of both the dissociative-integrative and abreactive treatment approaches, cognitive integration of dissociated traumatic memories and personality functions is primary, while emotional release is secondary.

Trauma-induced dissociative amnesia in World War I combat soldiers.

OBJECTIVE: This study relates trauma-induced dissociative amnesia reported in World War I (WW I) studies of war trauma to contemporary findings of dissociative amnesia in victims of childhood sexual abuse. METHOD: Key diagnostic studies of post-traumatic amnesia in WW I combatants are surveyed. These cover phenomenology and the psychological dynamics of dissociation vis-à-vis repression. RESULTS: Descriptive evidence is cited for war trauma-induced dissociative amnesia. CONCLUSION: Posttraumatic amnesia extends beyond the experience of sexual and combat trauma and is a protean symptom, which reflects responses to the gamut of traumatic events.

Degree of somatoform and psychological dissociation in dissociative disorder is correlated with reported trauma.

In this study, the prevalence and severity of traumatic experiences as reported by patients with dissociative disorders and with other DSM-IV psychiatric diagnoses were compared. Furthermore, the predictive value of emotional, physical, and sexual trauma with respect to somatoform and psychological dissociation was analyzed. In contrast with comparison patients, dissociative disorder patients reported severe and multifaceted traumatization. Physical and sexual trauma predicted somatoform dissociation, sexual trauma predicted psychological dissociation as well. According to the memories of the dissociative disorder patients, this abuse occurred in an emotionally neglectful and abusive social context. Pathological dissociation was best predicted by early onset of reported intense, chronic and multiple traumatization. Methodological limitations restricting causal inferences between reported trauma and dissociation are discussed.

Memories of sexual abuse: Janet's critique of Freud, a balanced approach.

Since the late nineteenth century explanations of sexual trauma have invoked unconscious mental mechanisms of forgetting. Memories have been seen as submerged only to be therapeutically recovered. Explanations and related therapies have tended to be either hotly advocated or decried, not the least were those of Janet and Freud. Once again there is a vigorous debate surrounding the status of recovered memories. This paper was undertaken to contribute to reasoned and balanced dialogue by exploring an historical dimension. There is a renaissance of interest in the oeuvre of Janet. In this article Janetian sources are examined in which he criticised Freud's views on sexual trauma and elaborated his own position, a position which is yet significant today.

Apparent amnesia on experimental memory tests in dissociative identity disorder: an exploratory study.

Dissociative identity disorder (DID; called multiple personality disorder in DSMIII-R) is a psychiatric condition in which two or more identity states recurrently take control of the person's behavior. A characteristic feature of DID is the occurrence of apparently severe amnestic symptoms. This paper is concerned with experimental research of memory function in DID and focuses on between-identity transfer of newly learned neutral material. Previous studies on this subject are reviewed and a pilot study with four subjects is described. This study is specifically concerned with the question whether self-reported asymmetries in between-identity transfer can be replicated on experimental memory tests. A secondary aim was to examine whether, in the absence of explicit transfer, implicit transfer of information would occur. The results showed that the apparent amnestic asymmetry for explicit information was substantiated in the laboratory, although at least some leakage was present between the apparently amnestic identities. No evidence was found for better performance on implicit than on explicit memory tests in the apparently amnestic identities. In the discussion, parallels between apparent amnesia in DID and state-dependent memory are drawn, and the question of simulated amnesia is addressed.

Somatoform dissociative symptoms as related to animal defensive reactions to predatory imminence and injury.

The authors hypothesized that there would be a similarity between animal defensive responses to variable predatory imminence and injury and certain somatoform dissociative symptoms of trauma-reporting patients who have dissociative disorder. As a first test of this hypothesis, 12 somatoform symptom clusters consisting of clinically observed somatoform dissociative phenomena were constructed. All clusters discriminated between patients with dissociative disorders (n = 50) and patients with other psychiatric diagnoses (n = 50). Those expressive of the hypothesized similarity--freezing, anesthesia-analgesia, and disturbed eating--belonged to the 5 most characteristic symptoms of dissociative disorder patients. Anesthesia-analgesia, urogenital pain, and freezing symptom clusters independently contributed to predicted presence of dissociative disorder. Using an independent sample, it appeared that anesthesia-analgesia best predicted presence of dissociative disorder after controlling for symptom severity. The results were largely consistent with the hypothesized similarity.

Psychometric characteristics of the somatoform dissociation questionnaire: a replication study.

BACKGROUND: The present study aimed to replicate the results of previous studies concerning the development of two versions of the Somatoform Dissociation Questionnaire. The SDQ-20 evaluates the severity of somatoform dissociative phenomena, and the SDQ-5 is a dissociative disorders screening instrument. METHODS: Thirty-one patients with dissociative disorders and 45 consecutive psychiatric outpatients with other DSM-IV diagnoses completed the SDQ-20 and SDQ-5 as well as the Dissociation Questionnaire which measures psychological dissociation. RESULTS: Mokken scale analysis showed that the items of the SDQ-20 are strongly scalable on a latent unidimensional scale. Internal consistency was high. The SDQ-20 convergent validity was supported by high intercorrelations with the DIS-Q. Dissociative patients obtained significantly higher scores than comparison patients. Patients with dissociative identity disorder scored significantly higher compared to patients with dissociative disorder nos. Sensitivity (94%) and specificity (98%) of the SDQ-5 were very satisfactory, as were, at an estimated prevalence rate of dissociative disorders of 10% among psychiatric patients, positive predictive value (84%) and negative predictive value (99%). CONCLUSIONS: All results replicated the first findings, and therefore corroborate the conclusion that the SDQ-20 and SDQ-5 are instruments of sound psychometric quality, and that somatoform dissociative phenomena are core symptoms of complex dissociative disorders.

The development of the somatoform dissociation questionnaire (SDQ-5) as a screening instrument for dissociative disorders.

Using cases of dissociative disorder (n=50) and other DSM-IV diagnoses (n=50), a somatoform dissociation self-report questionnaire was developed and its capacity to function as a screening device for dissociative disorders was analysed. A list of 75 items was constructed which, according to clinical experience and expert judgement, could reflect instances of somatoform dissociation. Statistical analyses revealed the 20 best discriminating items. Stepwise forward logistic analysis detected five items which, as a group, provided optimal discrimination between the two groups. At an estimated prevalence rate of dissociative disorders of 10% among psychiatric patients the sensitivity would be 94%, the specificity would be 96%, the positive predictive value would be 72%, and the negative predictive value would be 99%. Cross-validation in an independent sample (n=33/42) largely corroborated the initial findings. The SDQ-5 can be used as a brief screening device for dissociative disorders.

The development and psychometric characteristics of the Somatoform Dissociation Questionnaire (SDQ-20).

According to 19th century French psychiatry and contemporary clinical observations, dissociation pertains to both psychological and somatoform components of experience, reactions, and functions. Because such an instrument was lacking, we aimed to develop a self-reporting questionnaire measuring what we propose to call somatoform dissociation. Patients with dissociate disorder and with other DSM-IV psychiatric diagnoses completed a list of 75 items that, according to clinical experience and expert judgment, could reflect instances of somatoform dissociation. Separate logistic analyses and determination of discriminant indices per item revealed 20 items that best discriminated between those with and without dissociative disorders. Mokken analysis showed that these items are strongly scalable on a dimensional latent scale interpreted to measure somatoform dissociation. Reliability of the scale was high. Construct validity was supported by high intercorrelations with the Dissociation Questionnaire, which measures psychological dissociation, and higher scores of patients with dissociative identity disorder compared with patients with dissociative disorders not otherwise specified. In conclusion, the Somatoform Dissociation Questionnaire (SDQ-20) is a scale of good psychometric quality, which measures somatoform dissociation. The symptoms pertain to negative and positive dissociative phenomena, which were well known in 19th century French psychiatry as the mental stigmata and mental accidents of hysteria.

Janet and Freud: revealing the roots of dynamic psychiatry.

OBJECTIVES: Interest in the work of Pierre Janet is presently undergoing a scholarly revival and, in the process, his contribution to dynamic psychiatry is increasingly being recognised. This article compares and contrasts Pierre Janet's early studies on hysteria and the neuroses with those of Freud. METHOD: The study surveys original works by Janet and Freud and contemporary scholarly exegeses. It particularly focuses on ideation and memory, consciousness and dissociation, psychological trauma, the self, therapeutic influence, and treatment by integration versus abreaction. RESULTS: Grounds are presented for either preferring Janet's notions to Freud's or for integrating them. CONCLUSIONS: It is concluded that a number of Janet's contributions to psychopathology and psychotherapy, particularly in the field of dissociative disorders, deserve further exploration and application.

Hypnotic assessment and treatment of trauma-induced psychoses: the early psychotherapy of H. Breukink and modern views.

The role of hypnotizability assessment in the differential diagnosis of psychotic patients is still unresolved. In this article, the pioneering work of Dutch psychiatrist H. Breukink (1860-1928) during the 1920s is used as early evidence that hypnotic capacity is clinically helpful in differentiating highly hypnotizable psychotic patients with dissociative symptomatology from schizophrenics. Furthermore, there is a long tradition of employing hypnotic capacity in the treatment of these dissociative psychoses. The ways in which Breukink used hypnosis for diagnostic, prognostic, and treatment purposes are summarized and discussed in light of both old and current views. He felt that hysterical psychosis was trauma-induced, certainly curable, and that psychotherapy using hypnosis was the treatment of choice. Hypnosis was used for symptom-oriented therapy, as a comfortable and supportive mental state, and for the uncovering and integrating of traumatic memories. For the latter purpose, Breukink emphasized a calm mental state, both in hypnosis and in the waking state, thereby discouraging emotional expression, which he considered dangerous in psychotic patients. In the discussion, special attention is paid to the role and dangers of the expression of trauma-related emotions.