Dissociative identity as a continuum from healthy mind to psychiatric disorders: Epistemological and neurophenomenological implications approached through hypnosis.

The topic of multiple personality, redefined as Dissociative Identity Disorders (DIDs) in the DSM-5, is an intriguing and still debated disorder with a long history and deep cultural and epistemological implications, extending up to the idea of possession. Hypnosis is an appealing and valuable model to manipulate subjective experience and get an insight on both the physiology and the pathophysiology of the mind-brain functioning; it and has been closely connected with DIDs and possession since its origin in 18th century and as recently proved the capacity to yield a loss of sense of agency, mimicking delusions of alien control and spirit possession. In this study we report on five very uncommon "hypnotic virtuosos" (HVs) free from any psychiatric disorder, spontaneously undergoing the emergence of multiple identities during neutral hypnosis; this allowed us to check the relationship between their experience and fMRI data. During hypnosis the subjects underwent spontaneous non-intrusive experiences of other selves which were not recalled after the end of the session, due to post-hypnotic amnesia. The fMRI showed a significant decrease of connectivity in the Default Mode Network (DMN) especially between the posterior cingulate cortex and the medial prefrontal cortex. Our results and their contrast with the available data on fMRI in DIDs allows to draw the hypothesis of a continuum between healthy mind - where multiple identities may coexist at unconscious level and may sometimes emerge to the consciousness - and DIDs, where multiple personalities emerge as dissociated, ostensibly autonomous components yielding impaired functioning, subject's loss of control and suffering. If this is the case, it seems more reasonable to refrain from seeking for a clear-cut limit between normality (anyway a conventional, statistical concept) and pathology, and accept a grey area in between, where ostensibly odd but non-pathological experiences may occur (including so-called non-ordinary mental expressions) without calling for treatment but, rather, for being properly understood.

[Ego-state Therapy: Psychotherapy for Multiple Personality Disorders].

The author describes ego-state therapy. This psychotherapy is used for treating multiple personality disorders. The author mentions the theoretical background of this method, and practical points. Initially, ego-state therapy was developed as a type of hypnotherapy, but it evolved as a safe therapeutic method in combination with trauma processing therapies. The author presents a case study, and discusses the clinical significance of this treatment.

Catching a Wave: The Hypnosis-Sensitive Transference-Based Treatment of Dissociative Identity Disorder (DID).

In this article, I will describe the way in which I work with enactment-prone dissociative patients in the transference. This approach requires an appreciation of the phenomena of hypnosis and the auto-hypnotic aspects of some forms of dissociation. Essentially, I learn from the patient and my interactions with the patient how hypnotic phenomena and auto-hypnotic defenses manifest themselves in the therapeutic relationship in order both to understand them and ultimately to bring them under conscious control. Because of the fluidity and turbulence of these states, I use the analogy of catching a wave, in which timing and balance are essential, albeit elusive factors in effecting a successful treatment. The importance of having experience with many patients, attending conferences, seeking supervision, and undergoing one's own therapy will be also discussed as important prerequisites for the clinician endeavoring to utilize this type of approach. This preparation, this quest for such a "balance," is modeled after the so-called tripartite model of training employed in psychoanalytic training institutes. I will offer clinical material to illustrate this approach, which I have described as "psychoactive psychotherapy." In such treatments, the clinician may be taken by surprise and is likely to be thrown "off balance" from time to time. The mutually shared understanding of such moments is essential to regaining clinical balance in the therapeutic setting, and can lead to if not create important turning points in the treatment process.

Jay Haley's Supervision of a Case of Dissociative.

This is a transcript of a supervision session with a young therapist caught in the complex world of a woman with multiple personality. Occurring very early in the written literature about treating multiple personalities, the highlight of this paper is the supervision style and technique of Jay Haley. His approach to supervision will make the reader wish that he or she could be in the room during this session.

Hypnotic Seminar.

In this transcription of a lecture given in 2000, Jay Haley begins by answering the question, "What is hypnosis?"  Haley reviews the circumstances of Gregory Bateson encouraging him to meet with Milton Erickson to discuss the history of hypnosis and the paradoxical nature of trance induction. Haley expresses many original thoughts about multiple personalities, regression to past lives, and how to handle memories that historically may be false. Sophisticated and subtle, this is Haley at his best.

An eye for an I: a 35-year-old woman with fluctuating oculomotor deficits and dissociative identity disorder.

Physiologic changes, including neurological or pseudo-neurological symptoms, occur across identity states in dissociative identity disorder DID) and can be objectively measured. The idea that dissociative phenomena might be associated with changes in brain function is consistent with research on the brain effects of hypnosis. The authors report a case of psycho-physiologic differences among 4 alter personalities manifested by a 35-year-old woman with DID. Differences in visual acuity, frequency of pendular nystagmus, and handedness were observed in this patient both when the alter personalities appeared spontaneously and when elicited under hypnosis. The authors consider several diagnostic possibilities for these findings and discuss whether prevailing treatment recommendations for DID patients could possibly be modified to ameliorate such visual and neurologic symptoms.

Three cases of dissociative identity disorder and co-occurring borderline personality disorder treated with dynamic deconstructive psychotherapy.

Dissociative Identity Disorder (DID) is an under-researched entity and there are no clinical trials employing manual-based therapies and validated outcome measures. There is evidence that borderline personality disorder (BPD) commonly co-occurs with DID and can worsen its course. The authors report three cases of DID with co-occurring BPD that we successfully treated with a manual-based treatment, Dynamic Deconstructive Psychotherapy (DDP). Each of the three clients achieved a 34% to 79% reduction in their Dissociative Experiences Scale scores within 12 months of initiating therapy. Dynamic Deconstructive Psychotherapy was developed for treatment refractory BPD and differs in some respects from expert consensus treatment of DID. It may be a promising modality for DID complicated by co-occurring BPD.

The therapeutic release of anger: Helen Watkins's silent abreaction and subsequent elaborations of the anger rock.

This paper summarizes Helen Watkins's (1980) silent abreaction technique for releasing anger and the subsequent elaborations it has inspired. Discussion of Watkins's seminal article incorporates her verbatim account of the technique, 2 clinical applications, and her encouragement of further adaptations. Other scholars' subsequent contributions include an adaptation for dissociative identity disorder, brief treatment of constant pain syndrome, and inpatient treatment of a suicidally depressed, dissociative survivor of sexual abuse. Commonalities and distinctions among Watkins's work and these modifications are discussed. New case material from the author's practice illustrate further elaborations, with emphasis on the role of releasing anger in the resolution of dissociative defenses and internal fragmentation in dissociative clients. To enhance the clinical utility of this paper, verbatim passages are included for all case illustrations in H. H. Watkins (1980), the 3 published elaborations, and the new case material.

Fostering internal cooperation through the use of imagery in the treatment of dissociative identity disorder.

Most clinicians working with dissociative identity disorder (D.I.D.) recognize the importance of working towards a cooperative system especially during the initial stages of treatment. However, achieving this can be a monumental task given the inner war that goes on inside the mind of an individual diagnosed with D.I.D. From an ego-state theoretical framework, this article will demonstrate through clinical cases and artwork, the value of imagery techniques in changing internal perceptions, especially with regards to introject ego states. These changes can assist in eliciting more internal cooperation, a necessary task prior to working towards a collaborative, co-conscious system or what some theorists would call integration.

[Identity and dissociation in cyberspace. A case of dissociative identity disorder associated with internet role playing]. / Identität und Dissoziation im Cyberspace. Kasuistik einer dissoziativen Identitätsstörung im Zusammenhang mit einem Internet-Rollenspiel.

OBJECTIVE: By mediating dissociative experiences, the Internet can challenge the boundaries of people's sense of identity. To illustrate this hypothesis, a case of dissociative identity disorder (DID) is presented. CLINICAL PICTURE: A young unemployed woman created and frequently played several characters in an online game. For more than 2 years she spent up to 12 h a day in the Internet, assuming various personalities, which in return intruded upon her neglected real life. TREATMENT AND OUTCOME: During the course of an inpatient psychotherapeutic treatment, the clinical diagnosis of DID was confirmed by psychometric testing. After 12 weeks of psychotherapy, the patient had managed to identify her fragmented identities as character traits and integrated them into her core personality. She rearranged her real everyday life, found a new job, and reduced her online activities. DISCUSSION: Even though the patient's psychopathology stems from a disposition in terms of a personality disorder with histrionic and narcissistic features, excessive internet role play obviously functioned as a trigger to develop DIS. Conclusively, cyberspace's anonymous interactivity may offer the possibility to explore one's identity while also putting at risk its coherence.

Early trauma and narcissism-autism bipolarity.

The analyst makes a series of considerations taken--a posteriori--from the analysis of a small number of patients. These patients have saved themselves from an early narcissistic catastrophe by developing precocious mental processes, while affective relationships rudimentarily repeat the impact with the original trauma. Primitive defences, essentially denial and vertical splitting, dissociate the tear in the psyche and structure a 'narcissism-autism bipolarity', revealed in aspects of the character which oblige the patient to automatically repeat a single matrix of experience. In therapy, it is necessary to construct a 'first time of the trauma', by finding and linking threads of the primary relationship and strengthening them in the analytic relationship. This reconstruction of the background, a screen to project what had originally been rejected, is the prerequisite for coming out, in deferred action, from the hold of the pathological identifications. The author dedicates particular attention to the undifferentiated background, the nature-environment torn by the trauma, and to the need to reconstruct this fabric of experience in the analytical relationship, as a fundamental element to the recomposition of the dissociated nuclei. In the clinical case, the analyst describes in particular how the analyst's words encounter an unbridgeable gap, a failure in the capacity for representation when opening the autistic nucleus. Through a regression lasting for about a year, a patient was able to live the experience of 'primitive agonies' and that of an unbearable helplessness and, at the same time, was able to feel how the analyst supported her sense of existence. Subsequently, the patient was able to give shape, through visual images, to deep states of being and start the process of metabolising and symbolising the trauma.

The wreathing protocol: the imbrication of hypnosis and EMDR in the treatment of dissociative identity disorder and other dissociative responses. Eye Movement Desensitization Reprocessing.

Dissociative Identity Disorder (DID), a chronic childhood onset posttraumatic stress disorder, is currently recognized as a treatable condition. It is considered the paradigmatic dissociative condition and carries with it extreme posttraumatic symptomatology. Therapists skilled in the treatment of DID are typically fluent in the uses of hypnosis for stabilization, affect management, building a safe place and grounding to name of few. EMDR, which has come to the forefront of clinical awareness in the last ten years, seems aptly suited for the treatment of trauma, but can be destabilizing. This paper proposes a protocol, called Wreathing Protocol, for the imbricated use of EMDR and hypnosis in the treatment of not only DID (though this will be the primary focus of the paper), but also Dissociative Disorder Not Otherwise Specified (DDNOS) and chronic Posttraumatic Stress Disorder (PTSD). This protocol is useful to advanced clinicians skilled in both modalities independently. The sequential steps of the Wreathing Protocol will be described and illustrated by a clinical vignette on DID. The clinical implications of the use of the Wreathing Protocol will be discussed in DID as well as the chronic post traumatic spectrum.

The effects of hypnosis on dissociative identity disorder: a reexamination of the evidence.

OBJECTIVE: To examine the possibility that hypnosis has significant iatrogenic effects on dissociative identity disorder (DID). METHOD: This paper reexamines previously published data that have been interpreted as indicating that hypnosis does not exert significant iatrogenic effects on DID. RESULTS: The use of hypnosis is associated with differences in DID phenomenology and number of DID patients in treatment. CONCLUSION: Hypnosis may have significant iatrogenic effects on DID.

Health care applications of complexity science. Life at the edge of chaos.

The authors explore complexity science, a relatively new field of inquiry, which holds for both clinicians and health care leaders the real possibility of stimulating fresh insights and approaches to health and medical care-both its provision and its organization. Two case studies are presented to illustrate how complexity theory can provide health care leaders with a new perspective on how to address the myriad challenges they confront daily: (1) a patient with dissociative identity disorder; and (2) a physician task group charged to advise on hospital medical staff reorganization and governance. These case studies help clinicians and leaders of health care organizations understand how complexity: (1) may be relevant, even helpful, as they consider difficult challenges in both patient and organizational management; and (2) might emerge as a synthesizing force as they face the extraordinarily complicated task of jointly creating integrated health care systems. A resource section is provided for those who may wish to further pursue the topic.

Cognitive therapy of dissociative symptoms associated with trauma.

The presentation of dissociative symptoms is not uncommon in clinical settings, particularly when the client has suffered trauma. The phenomenon of dissociation ranges from benign incidents, such as daydreaming, to potentially life-threatening experiences when it precipitates self-harm. Its presentation may be subtle, belying the distress which it can provoke. Cognitive therapists are well equipped to help clients formulate a working conceptualization of the dissociative episode and to develop a range of coping skills to manage and overcome the experience. This paper discusses practical ways in which the cognitive therapist can use standard and schema-focused cognitive therapy to help clients to better deal with the distressing aspects of dissociation.

Collusion and entanglement in the therapy of a patient with multiple personalities.

S.'s therapy demonstrates some of the ways in which countertransference interferes with therapy of a case presenting with multiple personalities. Fascination with S.'s alter personalities and the desire to prove their genuineness, made her therapist search for them and then repeatedly invoke their appearance. Part of the reason was his inexperience with such cases that induced him to "play it by the book," and use "personality-centered procedures" (looking for a different part, giving it a name, speaking to it, etc.) that have yet to be scientifically validated, instead of adhering to the basic principles of psychotherapy. At a deeper level, however, his excessive preoccupation with S.'s personalities was one kind of collusion with her resistance to deal with the focal issue of her sexual ambivalence. Proof of this resistance also surfaced later as a motivated shift of focus in therapy, and a weakening of the therapeutic alliance. By the time this was evident, sabotage of therapy had already occurred.