Vous êtes sur la page 1sur 6

Volume 53, Number 3, Summer 1999

Special Section:
Dissociative Disorders
Richard P. Kluft, M.D. and Brad Foote, M.D., Guest Editors
Dissociative Identity Disorder: Recent Developments
Richard P. Kluft, M.D., Brad Foote, M.D.

In recent years Dissociative Identity Disorder (DID), formerly


known as Multiple Personality Disorder (MPD), despite the
controversy that surrounds virtually every aspect of the
phenomenology, diagnosis, and treatment of this condition, has been
diagnosed and treated with increasing frequency. Careful studies
using reliable and valid screening measures and structured interviews
have demonstrated that previously undiagnosed DID is a rather
common disorder, occurring in between 36% of psychiatric
inpatients and 518% of patients in substance-abuse treatment
settings (studies summarized in Ross [1] and Kluft [2]). Although
some have argued that DID is a North American culture-bound
condition, the inpatient studies summarized have included cohorts
from the United States, Canada, the Netherlands, Norway, and
Turkey, and all demonstrated roughly comparable findings. Although
cultural forces may have been prevalent in the North American
cohorts, and to a lesser extent, in the Netherlands patients, DID was
not part of the popular or professional cultures of either Norway or
Islamic Turkey. This offers a substantial challenge to the "culturebound syndrome" and iatrogenesis hypotheses, because if DID were
indeed culture-bound and determined by social psychological factors,
and if the iatrogenic creation of DID symptoms were widespread, one
would expect significantly more DID patients to be found in those
nations in which it had become part of the professional and cultural
idioms, and in which the clinicians were presumably more "adept" at
inducing its features.
An Overview of the Psychotherapy of Dissociative Identity
Disorder
Richard P. Kluft, M.D.

Dissociative Identity Disorder (DID) is identified and studies with


increasing frequency. However, the controversy that often surrounds
DID can make it difficult to approach its treatment in a circumspect
manner. This paper will provide an overview of DID treatment as it is
practiced by those experienced and skilled in the treatment of this
group of patients. The treatment of DID resembles the treatment of

other traumatized populations in that it is stage-oriented, beginning


with supportive and strengthening work. Various stances toward the
treatment of DID are reviewed, and specific issues that arise in the
psychotherapy of DID are addressed, such as pragmatic
arrangements, informed consent, work with alters, and the use of
specific techniques, such as hypnosis. The employment of
therapeutic modalities and ancillary therapies is discussed. The
heterogeneity of DID patient is reviewed, and the characteristics of
three general groups of DID patients, high, intermediate, and low in
both function and prognosis, are explored. Considerations in the
matching of DID patients to either exploratory or supportive
treatments are discussed, and observations are made about both
trauma work and the supportive psychotherapy of DID.
Dissociative Identity Disorder and Pseudo-Hysteria
Brad Foote, M.D.

The diagnostic validity of dissociative identity disorder (DID)


continues to inspire controversy, with some commentators claiming
that DID is a modern variant of "hysteria"; that is, attention-seeking
behavior. The author asserts that DID is indeed a valid psychiatric
disorder, and believes that this skeptical reaction can largely be
attributed to a specific set of transference/countertransference
interactions that these patients tend to inspire. The paper delineates
several clinical features of DID that can easily be mistaken for
hysterical phenomena, and attempts to find the roots of this confusion
in the DID patient's experience of interpersonal powerlessness, which
lead them to present their symptoms in an unconvincing, "hysterical"
manner. Confusion between the vertical split seen in the dissociative
disorders and the horizontal split characteristic of the classic
hysterical personality is discussed, as is the powerful effect of
observer bias in creating hysterical-appearing phenomena. The term
"pseudo-hysteria" is used to denote a situation in which a genuine
psychiatric disorder, DID, is perceived as an hysterical production.
Deconstructing DID
Ira Brenner, M.D.

The author contends that a psychoanalytically informed approach to


the patient with dissociative identity disorder (DID) can be very
useful. However, there are difficulties conceptualizing this condition
without extending existing theory or applying in new ways what is
already known. It is also difficult to put DID in a proper context
relative to all the other disorders known to occur in the human mind.
Depending on one's clinical experience, level of skepticism, and
appreciation of history, DID may be seen as either: a) the
psychological "missing link" that realizes Freud's goal of uniting the

psychology of dreams with psychopathology, or b) a fraudulent


condition that is wittingly or unwittingly manufactured in the
therapist's office, or c) a population of disturbed and disturbing
patients, once the subject of great scientific interest, which, exiled
like a "Lost Tribe," is now back in the fold of legitimacy. The author
has had extensive clinical experience with psychic trauma, and bases
his own views of DID on three assumptions: 1. that dissociation may
be seen as a complex defense; 2. that DID may be thought of a as a
"lower level dissociative character"; and 3. that there is a unique
psychic structure, the "dissociative self" whose function is to create
"alter personalities" out of disowned affects, memories, fantasies, and
drives. This "dissociative self" must be dissolved in order for
integration of "alter personalities" to occur. A clinical vignette is
offered to illustrate how he addresses some of the challenges of
developing a therapeutic alliance at this end of the dissociativecharacter-pathology continuum, and how he grapples with the
difficulty of integrating clinical phenomena, such as the appearance
of "alters," with the psychoanalytic model of the mind.
The Tactical-Integration Model for the Treatment of
Dissociative Identify Disorder and Allied Dissociative
Disorders
Catherine G. Fine, Ph.D.

The ebb and flow of the diagnosis of Dissociative Identity Disorder


(DID) and other dissociative conditions has led the evolution of
theories and treatment modalities to resolve the fluctuating and
ephemerous symptoms of these conditions. This paper summarizes
the structured cognitive-behavioral-based treatment of dissociative
disorders that will foster not only symptom relief but also an
integration of the personalities and/or ego states into one mainstream
of consciousness. This model of DID therapy is called the tactical
integration model; it promotes proficiency over posttraumatic and
dissociative symptoms, is collaborative and exploratory, and conveys
a consistent message of empowerment of the patient.
Case Study
Successful Treatment of Refractory ObsessiveCompulsive Disorder
Shielagh R. Shusta, Ph.D.

A case study is presented of a 40-year-old man with obsessivecompulsive disorder (OCT). He had been treated with long-term
institutional placement, electroconvulsive therapy, exhaustive
pharmacotherapy, and psychodynamic and cognitive-behavioral
psychotherapy. Nothing had relieved his excessive hand washing and
door checking. Records from previous treatment revealed a diagnosis
of dissociative identity disorder (DID). This information led to

reconceptualization of the OCD symptoms as manifestations of the


patient's ego fragmentation. When his fragments were catalogued and
addressed, all overt OCD symptoms abated within weeks. It is
believed that the patient's most anxious ego fragment communicated
dread from the background of the patient's psyche, the executive
component only being aware of the anxiety and not the triggering
stimulus. The patient was taught to address this fragment verbally to
elicit its cooperation, whereupon the fragment stopped sounding
alarm, creating anxiety and driving the patient to check and recheck,
wash and rewash. Symptoms have returned only when the patient has
suspended his announcing behavior and have abated when this was
resumed. Connections between OCD and DID are addressed.
Conclusion: patients exhibiting refractory OCD symptoms should be
assessed for dissociative symptomology.
The "Adualistic" Representation of Trauma: On Malignant
Internalization
Russell Meares, M.D.

This paper suggests that traumatic memories are represented in a


way that is qualitatively different from nontraumatic memories. The
argument depends upon a concept of self, derived from Hughlings
Jackson and William James, which is double, involving not only
mental life but reflection upon it. Trauma is seen as causing and
uncoupling, or redoubling, of consciousness. The traumatic subjectobject distinction in psychic life has several main effects. First, there
is a change in the form of consciousness to a state which is focused
on the present and on immediate stimuli. Secondly, the memory
system in which the traumatic events are recorded is nonepisodic,
lacking the reflective component. In this way, it is unconscious.
Thirdly, the traumatized-traumatizer dyad is represented not as two
persons in relation but more nearly as a fused monad. This
representation is not integrated into the system of self as the stream
of consciousness but remains relatively sequestered. This
sequestration is "unstable," determining rapidly oscillating, and
opposite, forms of relatedness, termed "reversals." Finally, in an
"uncoupled" state, the interpretation of the "meaning" of the
traumatic event is impaired. Its construction is determined by affect.
Edgar Allan Poe's "Ligeia": An Object-Relational
Interpretation
Carrie Zlotnick-Woldenberg, M.A..

This paper argues that Poe's short story, "Ligeia," in which the
narrator experiences the death of his adored first wife (Ligeia), a
second marriage to the despised Rowena, and ultimately the death of
Rowena and the revivification of Ligeia, is not a supernatural tale,
but rather a psychological one. According to this reading, the

poisoning of Rowena and the revivification of Ligeia are hallucinated


by the narrator in the course of an opium-induced psychotic break.
The antecedents to this break are explored in light of object relations
theory, with particular emphasis placed on the way in which the two
women function as part objects. Ligeia represents the narrator's
romantic and spiritual side and is associated with the good mother,
while Rowena, who represents his more mundane and materialistic
side, is associated with the rejecting mother. It is argued that the
narrator, functioning primarily in the schizoid position and
employing such defense mechanisms as splitting and projection
which already require a high degree of fantasyis not an unlikely
candidate for such a break.
From the Literature
Dialectical Behavior Therapy: A New Treatment Approach
for Suicidal Adolescents
Alec L. Miller, PSY.D.

Suicide accounts for more adolescent deaths in the United States


than all natural causes combined and ranks as the third leading cause
of death among 15-to-19-year-olds. It is estimated that in 1990,
almost 300,000 high school students in the United States made
suicide attempts that required medical attention. Follow-up studies
find that about 1015% of adolescents who attempt suicide make
future attempts, and up to 11% of adolescent attempters eventually
die by suicide. Nearly all adolescents who engage in suicidal
behavior have a diagnosable psychiatric disorder such as affective
disorder, substance use disorder, conduct disorder, or borderline
personality (BPD), with high rates of comorbid Axis I and Axis II
disorders being the rule rather than the exception. Many of these
teens are at high risk for dropping out of school, substance abuse,
violence, and high-risk sexual behaviors, which contribute to teenage
pregnancy and HIV transmission. Unfortunately, up to 77% of
adolescent suicide attempters will not attend or will drop out of
treatment before learning how to better tolerate distress and regulate
their emotions with skills that would serve to reduce suicidal and
other extreme behaviors.

The American Journal of Psychotherapy (ISSN 0002-9564) is


published four (4) times per year by the:
Association for the Advancement of Psychotherapy,

Belfer Education Center


Room 405
1300 Morris Park Avenue
Bronx, New York 10461
Phone: (718)430-3503 Fax: (718)430-8907
Email: info@ajp.org

(C) 1994 -2000 All Information is copyrighted material

Vous aimerez peut-être aussi