Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives

During my psychiatric residency some 25 years ago, we received virtually no training in dissociative disorders. Some of our patients were reading Sybil(1), which did little to enhance the credibility of multiple personality disorder in our minds. Like most of my colleagues, I spent the first several years of my practice assuming that multiple personality disorder was either rare, factitious, or iatrogenic. Eventually, intensive therapeutic work with several dissociative patients convinced me that these disorders are quite real and not rare, and reading the extensive literature in the field helped me shift to a new paradigm in conceptualizing the etiology, phenomenology, and treatment of these illnesses. Therefore, I was pleased to get this book for review. I advise the prospective reader who is relatively unfamiliar with the burgeoning literature in this area, however, to begin with a text by a single author to provide bearings (reference2, for example). Then there are several multiauthored books I would recommend (references 3–6, for example) over the one under review.

But what about Handbook of Dissociation? It is full of peaks and valleys of quality, interest, and readability. The editors have assembled a book that includes excellent chapters by some leading authorities in the field but that also is riddled with poor organization and egregious assaults on the English language. The book is marred by poor grammar, numerous typographical errors, and stylistic abominations. (Did no one notice that the lengthy list of “therapeutic tasks” starting on page 495 is virtually a repeat of the one starting on page 454?)

Enough said about the book’s faults. It also has many strengths. In addition to examining dissociative identity disorder (formerly multiple personality disorder), the book also explores many other aspects of normal and pathological dissociation, including its role in borderline personality disorder, acute stress disorder, and posttraumatic stress disorder (PTSD). I can highlight only a few of the chapters in this lengthy book. Ross notes that the prevalence of dissociative identity disorder in the general population may be as high as 1% and that dissociative identity disorder has extensive comorbidity, most frequently with depression, panic disorder, PTSD, substance abuse, and eating disorders.

Goodwin and Sachs list the several forms of memory distortion that may occur in dissociative patients, but they note that “when corroborative data have been available, time and again the therapeutic conclusion has been that the end result of these distortions had led to minimization, rather than exaggeration, of the extent of the childhood abuse” (p. 95; compare this with the work of Lewis et al.[7]). Goodwin and Sachs highlight the extreme and sadistic forms of childhood trauma that lead to dissociative disorders: “in the sexual abuse cases, these patients seem more likely to have experienced incest pregnancies, instrumentation with physical damage to genitalia, involvement of multiple sexual abusers, involvement of siblings and other children as covictims, threats of death or threats with weapons [typically, to coerce the child not to disclose the abuse], and beating or bondage associated with the sexual contact” (p. 93). Of the several types of childhood trauma, sexual abuse has received the most attention as a source of adult psychopathology, but Goodwin and Sachs remind us that other important forms of childhood trauma (which often coexist) include physical or emotional abuse, physical or emotional neglect, abandonment, and witnessing violence. They also anticipate an important aspect of our psychological response to this book and its subject matter in observing that “patients [with dissociative identity disorder] and incest victims require us to believe things about parents [and other perpetrators of childhood trauma] that we would prefer not to know” (p. 102).

Main and Morgan summarize fascinating research on attachment behavior in infants and present their speculations about possible connections between certain forms of “disorganized/disoriented” attachment status and subsequent dissociative behavior. Hornstein’s chapter, “Dissociative Disorders in Children and Adolescents,” made me reflect on the crucial role of mental health professionals who work with children in the primary and secondary prevention of posttraumatic pathology by identifying and protecting abused children. Hornstein lists six categories of dissociative symptoms that may be misdiagnosed as other disorders.

Cardeña and Spiegel argue that somatization disorders should be classified as dissociative disorders, and they note the close connection between conversion and dissociative disorders. They go on to explain the changes made in the dissociative disorders section from DSM-III-R to DSM-IV, including the controversial renaming of multiple personality disorder as dissociative identify disorder (Kluft writes that the DSM-IV committee was polarized and contentious and that the criteria were influenced by “the power of skeptical authorities insistent on promoting their opinions” [p. 341]).

Loewenstein has an excellent chapter on dissociative amnesia as a disorder and especially as a symptom in the various dissociative disorders, acute stress disorder, PTSD, and somatization disorder. In fact, he writes that a DSM-IV work group recommended a new category of trauma disorders that might include all of these, along with conversion disorder. Loewenstein faults analysts for neglecting the role of extreme trauma in pathogenesis and for not integrating dissociative disorders into our theoretical system, despite the fact that patients such as Anna O probably had dissociative disorders. He conceptualizes dissociation as “a basic part of the psychobiology of the human trauma response: a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma” (p. 312). He notes that psychogenic amnesia affects explicit but not implicit memory (I wish the book had devoted far more attention to the role of implicit memory in trauma and dissociation). Loewenstein reviews evidence that single, brief childhood trauma tends to be remembered verbally, whereas trauma that begins earlier in childhood and is more severe, repetitive, and physically harmful—with multiple perpetrators who are emotionally close to the child and who threaten to harm the child for disclosure—is more likely to result in amnesia. However, amnesia for severe or preverbal trauma coexists with a record of the trauma in implicit memory, which leads to “often uncannily” accurate behavioral reenactments of the trauma. Loewenstein calls the establishment of safety the most important but also the most frequently neglected aspect of treating dissociative patients. Although he values the potential usefulness of hypnosis, he reassures those of us who are not trained in its use by affirming that dissociative patients “can and have been successfully treated without the use of formal…hypnosis” (p. 325). Addressing forensic issues, Loewenstein warns that clinical recovery from abuse does not require that patients confront or prosecute their abusers and that such confrontations may result in a poor outcome for both the accuser and the accused (not to mention the clinician).

Kluft counters the stereotype of dissociative identity disorder as an exhibitionistic attempt by the patient to draw attention to the various “personalities” (this description fits only 6% of dissociative identity disorder patients). To the contrary, he calls the purest form of dissociative identity disorder “isomorphic,” and he emphasizes the covertness of the disorder, which is congruent with the patient’s efforts to forget and conceal the childhood traumata that shaped it. Alters characteristically “determine behavior from behind the scenes without emerging” and “commonly try to pass for one another.” The patient’s manifest behavior “often is the combined vector of numerous influences, functioning as a system” (p. 340). Most patients with dissociative identity disorder spend much of their lives with their illness so covert that they sometimes fulfill diagnostic criteria for dissociative disorder not otherwise specified but not criteria for dissociative identity disorder. Alters often experience their interactions with other alters as if they were interactions among separate people, based on the patient’s childhood interactions with perpetrators of abuse, so that sadomasochistic experiences are internalized and repeated. So-called Schneiderian first-rank symptoms of schizophrenia may reflect the impact of one alter on another in a patient with dissociative identity disorder. For example, one study found command hallucinations in 82% of dissociative identity disorder patients. Although there is now excellent documentation of the history of childhood trauma in dissociative identity disorder, “the account that the dissociative identity disorder patient gives of his or her traumatization may include elements of inaccuracy and distortion” (p. 353). Iatrogenesis has not been shown to cause dissociative identity disorder, but the therapist’s fascination or ineptitude can worsen it. Neural network and information-processing models show promise as explanatory models for dissociative identity disorder.

Despite its limitations, this book has much to offer readers who wish to expand their knowledge of dissociation and dissociative disorders.