Dissociation debates: everything you know is wrong.

Controversy about dissociation and the dissociative disorders (DD) has existed since the beginning of modern psychiatry and psychology. Even among professionals, beliefs about dissociation/DD often are not based on the scientific literature. Multiple lines of evidence support a powerful relationship between dissociation/DD and psychological trauma, especially cumulative and/or early life trauma. Skeptics counter that dissociation produces fantasies of trauma, and that DD are artefactual conditions produced by iatrogenesis and/or socio-cultural factors. Almost no research or clinical data support this view. DD are common in general and clinical populations and represent a major underserved population with a substantial risk for suicidal and self-destructive behavior. Prospective treatment outcome studies of severely ill DD patients show significant improvement in symptoms including suicidal/self-destructive behaviors, with reductions in treatment cost. A major public health effort is needed to raise awareness about dissociation/DD, including educational efforts in all mental health training programs and increased funding for research.

La controversia acerca de la disociación y de los trastornos disociativos (TD) ha existido desde el inicio de la psiquiatría y de la psicología modernas. Incluso entre los profesionales, las creencias sobre la disociación / TD a menudo no se basan en la literatura científica. Múltiples líneas de evidencia apoyan una relación poderosa entre disociación / TD y trauma psicológico, especialmente el trauma acumulativo y / o el que ocurre en la infancia. En oposición, los escépticos plantean que la disociación produce fantasías de trauma y que los TD constituyen condiciones artificiales producidas por la iatrogénesis y / o por factores socioculturales. Casi ninguna investigación o datos clínicos apoyan esta opinión. Los TD son comunes tanto en poblaciones generales como clínicas y representan un importante grupo desatendido que tiene un alto riesgo de comportamiento suicida y de conductas autodestructivas. Los estudios prospectivos de resultados del tratamiento de pacientes con TD grave muestran una mejoría significativa en los síntomas, incluídos los comportamientos suicidas / autodestructivos, con reducciones en el costo del tratamiento. Se requiere de un gran esfuerzo de salud pública para aumentar la conciencia acerca de la disociación / TD, incluyendo los esfuerzos educacionales en todos los programas de capacitación en salud mental y un mayor financiamiento para la investigación.

Les controverses au sujet de la dissociation et des troubles dissociatifs (TD) existent depuis les débuts de la psychologie et de la psychiatrie modernes. Même parmi les professionnels, les croyances au sujet de la dissociation et des TD sont rarement fondées sur la littérature scientifique. De nombreuses sources de données appuient la thèse d'une relation forte entre dissociation, TD et traumatisme psychologique, surtout quand celui-ci est cumulatif et/ou survenu dans l'enfance. Pour les sceptiques, la dissociation génère des traumatismes fictifs et les TD sont des maladies artificielles provoquées par des facteurs iatrogènes et/ou socioculturels. Pratiquement aucune donnée clinique ou de recherche ne vient conforter cette thèse. Les TD sont répandus dans la population générale et la population clinique, et touchent un nombre important de sujets sous-médicalisés pour lesquels le risque de suicide et de comportement auto-destructeur est élevé. Des études prospectives de résultats cliniques sur des patients sévèrement atteints de TD montrent une amélioration significative des symptômes, dont les comportements suicidaires et auto-destructeurs, avec une diminution des coûts de traitement. Un effort majeur de santé publique est nécessaire pour augmenter la vigilance sur la dissociation et les TD, y compris des efforts d'éducation dans tous les programmes de formation sur la santé mentale ainsi qu'une augmentation des fonds destinés à la recherche.

La histeria moderna: Parte III trastornos disociativos y conversión / The modern hysteria: Part III dissociative disorders and conversion

La conciencia: característica esencial de esta dimensión de autorepresentación es la interpretación de ciertos estados internos del propio cuerpo como identidad mental y somática. La neurociencia de la conciencia sugiere fuertemente que un nivel de sincronización y unión entre varias partes del cerebro hasta cierto punto refleja la accesibilidad de varios contenidos mentales. Janet (1889) propuso el término désagrégation para referirse a los fenómenos de «no integración¼ y lo situó en el terreno de la anormalidad. Trastornos disociativos: en estos trastornos hay pérdida parcial o completa de la integración normal entre ciertos recuerdos del pasado, la conciencia de la propia identidad, ciertas sensaciones inmediatas y el control de los movimientos corporales (conversión)

The conscience: essential feature of this dimension of self-representation is the interpretation of certain internal states of the body itself as mental and somatic identity. The neuroscience of consciousness strongly suggests that a level of synchronization and union between various parts of the brain to some extent reflects the accessibility of various mental contents. Janet (1889) proposed the term désagrégation to refer to the phenomena of "non integration" and placed it in the terrain of abnormality. Dissociative disorders: in these disorders there is partial or complete loss of normal integration between certain memories of the past, awareness of one's own identity, certain immediate sensations and control of bodily movements (conversion)

Possessions Including Poltergeist: "Are You There, Madness?"

Beliefs involving the devil and possession figured in the nosography of mental illness that alienists gradually established during the 19th century. The description of this form of cenesthetic hallucination resulted in "the possessed" being viewed as patients, which protected them from the trials and punishments they so frequently faced in earlier centuries. According to psychologists, this illusion of mental duality is linked to impairment of introspective capacities. Current brain imaging suggests inappropriate activity of the default mode network, which interferes with attentional systems during the hallucinatory episode.

The Phenomenon of Pathological Dissociation in the Ancient Chinese Medicine Literature.

Dissociative symptoms and disorders have been reported in many different cultures. If pathological dissociation is naturally occurring and related to adverse experiences, such phenomena should have been witnessed and portrayed before the modern age. To investigate whether this is the case, the author made use of the rich ancient Chinese medicine literature and looked for descriptions of pathological dissociation in medical documents written by ancient Chinese medical practitioners. In this paper, the author presents six cases selected from the ancient Chinese medicine literature. The phenomenon of pathological dissociation is observed in these cases. This is the first report of case descriptions of pathological dissociation documented in Chinese cultures before 1900.

The possessions at Loudun: tracking the discourse of dissociation.

Embedded in the history of dissociation is the best known case of possession in European history, the 17th century possessions at Loudun, France (1632-1638). The exorcisms and the trial drew crowds from all over Europe, the outcome prefiguring the direction in which the Western science of mind would be carried. The published debate about the possessed and obsessed Ursuline nuns of Loudun spans four centuries. One can track how theorizing about dissociation changed over time, with psychological contributions by Jean Martin Charcot, Georges Gilles de la Tourette, Pierre Janet, Michel Foucault and Michel de Certeau. Freud's psychoanalytic notion of demonological neurosis emphasized defensive strategies and a diabolic parody of adulthood. Jung's concepts of demonism and possession highlighted dissociated complexes that assimilate the ego and unseat the self, rendering a life 'provisional'. Dissociation as possession provides a through-line in Jung's Collected Works, from his 1902 dissertation to one of the last essays he wrote, in 1961. Within the context of psychotherapy, therapists and patients work towards psychological containment, consciously reorienting themselves to the presence of unconscious factors, personifying, embodying and thereby incorporating images of dissociated Otherness into the experience of selfhood.

Sydenham on Hysteria.

This historical essay outlines early ideas and clinical accounts of hysteria. It reproduces verbatim parts of a remarkable text of Thomas Sydenham. This provides the most detailed description of hysterical symptoms, contemporary treatment and particularly Sydenham's opinions about the nature of the disorder. His portrayal is compared to later and modern concepts and classification.

Voices from the past: Mental and physical outcomes described by American Civil War amputees.

Studies of trauma commonly concentrate on the psychological and physiological effects of recent violent events. Although today connections are becoming more explicitly drawn, early studies of the aftermath of amputation serve to shed light on modern understanding of the interaction of the physical and emotional. The study of combat amputation, dissociation, and related posttraumatic stress largely began with the work of 19th-century Philadelphia physician Silas Weir Mitchell, who brought attention to the phenomenon of phantom limb pain. Less known, however, are the data he and his son, John K. Mitchell, also collected on the mental outcomes of trauma. Using an archived collection of original surveys of double-amputee patients dating largely from 1893 housed at the Historical Medical Library at the College of Physicians of Philadelphia, an interdisciplinary team explored the historical, anthropological, and psychological background of the study of combat trauma. Almost 30 years following the end of hostilities, the majority of the sample of U.S. Civil War veterans indicated that their general disposition, general health, and sleeping or eating patterns had changed following limb amputation. More telling, possibly, are the written comments on the surveys and letters that indicate frustration with the continuous suffering and the knowledge of their mental and physical changes. These data illustrate the value of historical archives in documenting the development of the study of trauma and modern concepts of combat experiences.

[Pierre Janet observes history]. / Pierre Janet beobachtet die Geschichte.

Janet, philosopher and physician, Freud's junior by three years, not only described traumatic dissociation and pathogenic subconscious ideas; he outlined a comprehensive system of psychology. Still, he considered his concepts to be mere linguistic tools, designed to grasp mental phenomena as precisely as possible. His prime interest was in observations - his own and those of others, whether his contemporaries at home and abroad or predecessors of all kinds. Janet never regarded himself as a historian, but his works as well as his way of thinking are most interesting from a historiographical point of view. His three-volume Médications psychologiques of 1919 contains a wealth of material about the history of psychotherapy. Furthermore, he dealt with his sources in a critical and historically reflexive manner. The later Janet considered any explanation and theory to be "inventions", more or less useful and basically open to change. By working with the notion of "narration", he described scientific statements as narratives, different from lies, fairy-tales or novels only in their claim to be verifiable. Every narration, however, is placed in a social context: narrators always wish to evoke a particular image of the real in their audience. Thus Janet established the link between scientific edifices and individual motivation, an unsettling link in terms of the history of science and certainly alien, if not positively abhorrent to Freud.

Contemporary concepts of dissociation.

The concept of dissociation was developed in the late 19th century by Pierre Janet for conditions of "double consciousness" in hypnosis, hysteria, spirit possession and mediumship. He defined dissociation as a deficit in the capacity of integration of two or more different "systems of ideas and functions that constitute personality", and suggested that it can be related to a genetic component, to severe illness and fatigue, and particularly to experiencing adverse, potentially traumatizing events. By the late 20th century, various and often contradictory concepts of dissociation were suggested, which were either insufficient or exceedingly including when compared to the original idea. Currently, dissociation is used to describe a wide range of normal and abnormal phenomena as a process in which behaviour, thoughts and emotions can become separated one from another. A complete presentation of mechanisms involved in dissociation is still unknown. Scientific research on basic processes of dissociation is derived mainly from studies of hypnosis and post-traumatic stress disorder. Given the controversies in modern concepts of dissociation, some researchers and theorists suggest return to the original understanding of dissociation as a basic premise for the further development of the concept of dissociation.

[Dissociative disorder--the concept and its history].

Dissociative disorder is both an old and a new mental disorder. Its forerunner, hysteria, was a poorly understood and often grossly misconceived notion that might date back as far as human societies existed, but it has been treated as a new disorder since it emerged in the DSM-III. A century ago, Sigmund Freud and Pierre Janet, two giants in the history of dynamic psychiatry, were deeply influenced by dissociative phenomena, and created their own theory of human mind with very different orientations. The reemergence of dissociative disorders in the current psychiatry has several implications. It helps clinicians understand mental conditions that they did not know how to define and classify based on the traditional psychiatry. It also allows clinicians to identify a population that was misdiagnosed with other diagnostic categories, such as borderline personality disorder and schizophrenia.

En torno a la construcción social de la locura. Ian Hacking y la historia cultural de la psiquiatría / On the social construction of madness. Ian Hacking and the cultural history of psychiatry

El objetivo de este trabajo es analizar la contribución del filósofo de la ciencia Ian Hacking a la historia cultural de la psiquiatría. Partiendo de conceptos propuestos por el autor, como "enfermedad mental transitoria" o "inventar/construir gente", se reflexiona en torno a la construcción socio-cultural de la enfermedad mental. Se examinan y discuten los dos estudios de caso propuestos por Hacking: la fuga disociativa y la personalidad múltiple, identificando las fortalezas y debilidades de sus planteamientos y la posible aplicación de los mismos a la historia y a la teoría psicopatológica (AU)

The aim of this paper is to analyze the contribution of philosopher of science Ian Hacking to the cultural history of psychiatry. Based on ideas proposed by this author, as "transient mental illness" or "making up people", some reflections on the socio-cultural construction of mental illness are offered. The examination and discussion the two case studies proposed by Hacking, dissociative fugue and multiple personality, allow to identify the weaknesses and strengths of his approaches and its applicability to the history and theory of psychopathology (AU)

[Pierre Janet's views on the etiology, pathogenesis and therapy of dissociative and conversion disorders ("hysterias")]. / Atiologie, Pathogenese und Therapie der dissoziativen und Konversionsstörungen (Hysterien) nach Pierre Janet.

Pierre Janet (1859-1947) is one of those more or less forgotten authors whose approach differed significantly from Freud's psychoanalysis. In the first part of this paper, Janet's conception of hysteria is discussed and his place in French psychiatry described. Different aspects of Janet's diathesis-stress-approach are presented (particularly his important pathogenic concept of fixed ideas) which refer not only to a conception of hysteria, but also to traumatic (stress) disorders and other psychological disturbances. The second part of the paper details the varieties of Janetian therapeutic treatments for these disorders: the 'liquidation' of fixed ideas by hypnosis and suggestion, confrontation techniques which resemble contemporary cognitive behavioural approaches, and special cognitive ("logagogic") interventions. Finally, we also discuss the various treatment strategies Janet proposes for dealing with symptoms, such as asthenic or depressive states, from his psycho-economic perspective.

Trauma theory in Sándor Ferenczi's writings of 1931 and 1932.

The author states that it is Ferenczi 's writings of 1931 and 1932 that exhibit the most conspicuous departures from Freud 's ideas and at the same time contain Ferenczi 's most original contributions. The texts concerned - Confusion of tongues between adults and the child (Ferenczi, 1932a), the Clinical Diary (Dupont, 1985), and some of the Notes and fragments (Ferenczi, 1930-32), all of which were published posthumously - present valuable and original theories on trauma which are significant not only in historical terms but also because the ideas concerned are relevant to our conception of clinical psychoanalysis today. The aim of this paper is to give an account of Ferenczi 's trauma theory as it emerges from his writings of 1931-32 and to specify the points on which he differs from Freud.

Note on online books and articles about the history of dissociation.

Students of the history of dissociation will be interested in the materials on the subject available in the digital document database Google Book Search. This includes a variety of books and journals covering automatic writing, hypnosis, mediumship, multiple personality, trance, somnambulism, and other topics. Among the authors represented in the database are: Eugène Azam, Alfred Binet, James Braid, Jean-Martin Charcot, Pierre Janet, Frederic W.H. Myers, Morton Prince, and Boris Sidis, among others. The database includes examples of case reports, conceptual discussions, and psychiatric and psychological textbook literature.

[Stigmatisation and absence of nutrition in the case of Therese Neumann (1898-1962)]. / Zur Stigmatisation und Nahrungslosigkeit der Therese Neumann (1898-1962).

Therese Neumann, from Konnersreuth in Bavaria, developed stigmata at the age of 29 and allegedly lived without any food for 36 years. After a fire accident in 1918, she suffered from paralysis, deafness, and blindness. Later she developed stigmata on her extremities and left side of the thorax, bleeding lesions in the skin, bleeding in the eye region, and altered states of consciousness in the form of "visions" of religious content. On the basis of a report by her physician, Dr. Otto Seidl, to the Bishopric Ordinariate of Regensburg (1927) and a manuscript for presentation before the Catholic Medical Society of the Netherlands (1928) Seidl had no doubt of the authenticity of these phenomena, and he diagnosed hysteria. While under surveillance by four nuns for 14 days, Neumann exhibited no intake of nourishment; weight measurements and urine tests however suggest the opposite. Investigation in a clinic was refused. Her case is interpreted here in the light of contemporary psychiatry. As far as medical records go, Therese Neumann's is one of a series of surprisingly similar cases of stigmata development, conversion disorder, and alleged absence of nutrition. In nosological terms, these would be classified today as dissociative disorders.

[Diagnostic categories and gender: two examples in contemporary Spanish medicine, chlorosis and neurasthenia (1877-1936)]. / Categorías diagnósticas y género: los ejemplos de la clorosis y la neurastenia en la medicina española contemporánea (1877-1936).

Chlorosis and Neurasthenia are two classical examples of pathological dissociations and the difficulties involved in approaching their diagnosis using scientific-naturalistic criteria. In the realm of those difficulties, the study examines the androcentric viewpoint and the ideological perspective of Contemporary Spanish Medicine when addressing the feminine nature and women's pathologies. Moreover, based on the similarities with present-day pain and fatigue syndromes, the study underlines the need to review the clinical approach to these illnesses by attempting to overcome the existing biomedical limitations.

Chaos, brain and divided consciousness.

Modern trends in psychology and cognitive neuroscience suggest that applications of nonlinear dynamics, chaos and self-organization seem to be particularly important for research of some fundamental problems regarding mind-brain relationship. Relevant problems among others are formations of memories during alterations of mental states and nature of a barrier that divides mental states, and leads to the process called dissociation. This process is related to a formation of groups of neurons which often synchronize their firing patterns in a unique spatial maner. Central theme of this study is the relationship between level of moving and oscilating mental processes and their neurophysiological substrate. This opens a question about principles of organization of conscious experiences and how these experiences arise in the brain. Chaotic self-organization provides a unique theoretical and experimental tool for deeper understanding of dissociative phenomena and enables to study how dissociative phenomena can be linked to epileptiform discharges which are related to various forms of psychological and somatic manifestations. Organizing principles that constitute human consciousness and other mental phenomena from this point of view may be described by analysis and reconstruction of underlying dynamics of psychological or psychophysiological measures. These nonlinear methods in this study were used for analysis of characteristic changes in EEG and bilateral electrodermal activity (EDA) during reliving of dissociated traumatic and stressful memories and during psychopathological states. Analysis confirms a possible role of chaotic transitions in the processing of dissociated memory. Supportive finding for a possible chaotic process related to dissociation found in this study represent also significant relationship of dissociation, epileptiform discharges measured by typical psychopathological manifestations and characteristic laterality changes in bilateral EDA in patients with schizophrenia and depression. Increased level of psychopathological symptoms indicates close relationship to the right-left EDA asymmetry and asymmetry of information entropy calculated by non-linear recurrence quantification analysis of EDA records. Because epileptiform activity has specific chaotic behaviour and calculated information entropy from EDA records reflects the complexity of the deterministic structure in the system there is a relevant assumption that unilaterally increased complexity may produce interhemispheric disbalance and increased chaoticity which hypothetically may serve as a dynamic source of epileptiform discharges related to trauma induced kindling mechanism. Specific form of chaotic inner organization which cannot be explained only as a consequence of external causality support also psychophysiological data that lead to the so-called self-organizing theory of dreaming by Kahn and Hobson. This study suggests that self-organizing theory of dreaming is particularly important with respect to problem of memory formation and processing during dissociative states characteristic for dreams. Recent data and also findings of this study support the research utility of chaos theory in psychology and neuroscience, and also its conceptual view of dynamic ordering factors and self-organization underlying psychological processes and brain physiology.