Karen Gainer, M.S.W., L.G.S.w., is a psychotherapist in pri­ began to wane (Ellenberger, 1970; Rosenbaum, 1980; vate practice. Shealso SCIVesasSocial Workand FamilySeIVices Rosenbaum & Weaver, 1980). Rosenbaum (1980) speculates Consultant at the Pain Institute in Chicago, Tllinois. that declining interest in DID can be correlated positively with Bleuler's introduction of the term ~»in For reprintswrite Karen Gainer, M.S.W" L.C.S.W., The Pain 1911. Rosenbaum also suggests that the over-inclusiveness Institute in Chicago, 325 West HuronStreet, Suite 220, Chicago, of Blculer's conceptual framework has contributed to diffi· IL 60610. culties in the differential diagnosis between DID and schizophrenia and to a growing trend of misdiagnosis, in An earlier version of this paper was presented at the Ninth which many individuals suffering from DID have been mis­ International Conference on Multiple Personality and diagnosed as schiwphrenic. Rosenbaum quotes the follow­ Dissociative Slates, November 15, 1992, Chicago, Illinois. ing passage by F.X_ Dercum in support ofhis criticisms:

ABSTRACT Because ofhis interpretation ofdementia praecox as a cleavage orfissuration ofthe psychic functions ThU paper ~ an historical persputive regarding 1M role of Bleuler has invented and proposed the name di..ssfx:UUion in 1M d.nJel.opmenl ofboth erioiogic eMory and treot­ "schizophrenia"which he believes to be preferable mmt paradigms fOT schi:zopltrenia.. &femlCeS to 1M roncept ofdis­ to praecox. However, as we have seen, JOCi4lion artdraumJrom classic writings on dementia prauox, and cleavages and fissuration ofthe personalityare not jromlJieukrj (1911) origi:nalconapticnofschiUJphrrniaaJa "JfJlit­ confined to dementia praecox. Theyoccur in many ling-of1M personality. An aauraJe diagno.stic distinction betwun farms oJmentaldisease aJ weUas in the neuros/!.f. In my schizoplrrenia and dissociative diJordm, such aJ disJocialive iden­ judgement [sic] the term being of such general Jig­ lily disorder (DID) and brUfTeactive psyclwsis (BRP), often has been nyU'onceofTers no advanlages over dementia prae­ difficult 10 aJcertain due 10 Ihe preJence ofSchneiderianFm~Rank cox and should be rejected. Symptoms (FRS) inboth lyjJes ofdisorders. The traditionalSchneiderian (Dercum, citedin Rosenbaum, 1980, pp. 1384-1385) FRS, once thought to be indicative symptoms ojschizophrenia, now are viewed as characteristic diagnostic indicators ojDID. Research A number of authors cite research findings in suppon of and theory pertaining to difJenmtidl diagnosis between schizophre­ this view (Bliss, 1980; Boon & Draijer, 1993; K1uft, 1987; nia and lrauma-related dissociative are reviewed. Early Putnam, Curoff, Silberman, Barban, & Post, 1986; Ross, psychodynamic lrecumenl paradigms JOT schiUJPhrenia and con­ Norton, & Wozner, 1989; and Ross et aI., 1990). North umpqrary lreatmem paradigms for dissociative disorders are com­ American research findings indicale that between 25.6% to pared. Rek:vam diagnostic and lrMtment impli«JlionsJor flu! fUM 49% of DID patienlS have received a prior diagnosis of ofdis.rociative disorders are emph.asized. schizophrenia (PuUlam etal, 1986; Ross etaI., 1989; Ross et al., 1990) .In theNetherlands, Boon and Draijer (1993) deter­ INTRODUCTION mined that 15.6% of their 71-patient DID sample had received a prior diagnosis of schizophrenia. Boon and Dissociative identity disorder (DID), known as multiple Draijerqualifythese relatively modeststatistical findings with personality disorder in DSM-Ill-R (American Psychiatric the observation that schizophrenia traditionally has been Association, 1987), is a clinical which first gained diagnosed with less frequency in the Netherlands than it has r«ognition in the early nineteenth century (Bliss, 1980; been in North America. Ellenberger, 1970; Greaves, 1980; Taylor & Martin, 1944). Rossetal. (1994) offer the following commentaryregard­ lnteresl in 010 continued to develop throughout the latter ing the research findings cited above: "From these studies halfofthe nineleenth century and the early twentieth cen­ it is evident that DSM-III·R criteria for schizophrenia result tury. A growing number of DID cases were reported in the in a false-positive diagnosis of schizophrenia in about one clinical lilerature during this period (Ellenberger, 1970; third ofMPD patients. This isa major level ofincorrectdiag­ Putnam, 1989; Ross, 1989; Sutcliffe &Jones, 1962; Taylor & nosis with profound treatment implications~ (p.5). Martin, 1944). However, this growth trend was short-lived. Professional interest in the field of dissociation eventually

261 D1SS0Cl\TIO~. \01 \'11. ~o. I, December 1994 ------DISSOCIATIOK Al'\D SCHIZOPHRE:\IIA

DISSOCIATION AI\rn SCHNEIDERIAN ed historyofchildhood trauma. Accordingto RossandJoshi: FIRST-RANK SYMPTOMS Schneiderian symptoms arc linked to other disso­ Several authors suggest that the common presence of ciative symptom clusters characteristic ofindividu­ Schneiderian first-rank symptoms (FRSs) in patients with dis­ als subjected to chronic childhood trauma. Ifthese sociative identity disorder is a prime factor contributing to findings are replicated andaccepted, they may lead an inadequate differential distinction belWeen the syn­ to a reconceptuaJization ofmany"psychotic"symp­ dromesofDIDandschizophrenia (Bliss, 1980; Boon &Draijer. toms as post-traumatic and dissociative in nawre. 1993; Goons& Milstein. 1986; Fink & Golinkorr, 1990; Kluft, (Ross &Joshi, 1992, p. 272) 1987; Putnam et al., 1986; Ross et al., 1989; and Ross et at, 1990). DISSOCIATION AND BLEULER'S CONCEPT Schneider originally defined the First-Rank. Symptoms OF SCHIZOPHRENIA (FRSs) ofschi7.ophrenia as phenomenological indicators of the disorder in the following manner: Schneider's empirically-derived FRSs initially promised to offer more reliable diagnostic criteria than previously had Audible thoughts; voices heard arguing; voices been offered by Bleuler's original diagnostic schema. heard commenting on one's actions; the experi­ ence of influences playing on the body (somatic The concept of specific or pathognomonic symp­ passivity experiences); thought-withdrawal and toms began with Bleuler, who focused on demen­ other interferences with thought; delusional per­ tia praecox and renamed it schizophrenia. Unlik.e ceptionsand all feelings, impulses (drives) andvoli­ Kraepelin - who was interested primarily in the tional aCts that are experienced by the patient as objective portrayal ofpsychopathologic phenome.­ the work or influence ofothers. When any ofthese na and generally refrained from speculation about modesofexperience is undeniably presentand no the origin of schizophrenic symptoms - Bleuler basic somatic illness can be found. we may make devoted himself to understanding the basic mech­ the decisive clinical diagnosis of schizophrenia. anisms that caused these symptoms. His search led (Schneider, 1939, pp. 133-134) him to what are now referred to as thr. fOllr "Bleularian A's"orsimply the "fourA's" thatinclude Thetraditional Schneidcrian FRSs, oncethought tobeindica­ associative loosening.affective blunting, autism, and tive symptomsofschizophrenia, currcntly areviewed asdiag­ ambivalence. Bleuler worked in an era when ass0­ nostic indicators of OlD (Kluft, 1987). The presence of ciation psychology was preeminenL Psychological Schneiderian FRSs also has been established in connection theorists were preoccupied with determining how with several other clinical syndromes (Andreason &Miskal, thoughts were encodedorformulated in the mind; 1983; Carpenter. Strauss, & Mulch, 1973). the prevailing theory was that the process ofthink· Kluft (J987) reports that 100%ofa303-patient DlDsam­ ingandrememberingwasguided byassociative links pieendorsed the presenceofSchneiderian FRSs, with a mean between ideas and concepts. Bleuler believed that FRS index of 3.6 per patient. In a similar study, Ross et a1. the most important deficit in schizophrenia was a (1989) used a sample of 236 DID patiems, and obtained a disruption in these associative threads. mean FRS index of 4.5 per patient. A replication study by (Andreason & Akiskal, 1983, p. 42) Rossetal. (1990) yieldcdamean FRSs indexof6.4, in a series ofl02 patients. Additionally. FinkandGolinkoff(1990) have Bleuler'sconceptualizationofschizophrenia was innuenced reponed that94% oftheir J&.paticnt DID sample positively by the prevailing association psychology of the era. Bleuler endorsed one or more Schneiderian FRS, with a mean FRS (J911/1950) hypothesized thatan underlying processofass0­ index of4.8. The lauer authors also report findings from a ciative loosening was the fundamental pathognomonic fea­ comparisonstudyinvolving II schizophrenicpaticnts,which ture of schizophrenia, and he described a variety of disso­ yielded a mean FRSs index of 5.6. Fink and GolinkoJI have ciative automatisms as primary schizophrenic symptoms. concludedthatthe DID andschizophreniacomparisongroups Bleulerlisted thesesymptomsas folJows: "Blocking"ofmove­ showed no signijicant differences regarding mean number ment, speech or thoughts (including various forms ofcata­ ofSchneiderian FRSs (F (1.35)=.72 p<.4I). In a similar com­ tonic stupor or negalivism); echolalia and echopraxia; parison, Ross et aI. (1990) have combined outcome data thought withdrawal; "made" thoughts, fcelings or actions; from several previous studies, and have hypothesized thal and "dissociated thinking." Bleuler defined the term ~di..... Schneidcrian FRSs are more characteristic of OlD than of sociated thinking" as "the disconnecting ofordinarily ass0­ schizophrcnia_ The authors report an average of4.9 FRSs in ciated threads in thought and language... [in which] all the a series of368 DID patients. as compared with an average of association threads fail and the thoughtchain is totally inter­ 1.3 FRSs in a series of 1,739 schizophrenic patients. Other rupted." (1950, pp. 21-22). relevant findings by Ross andJoshi (J992) suggest that the Bleuler's definitions of the primary dissociative symp­ presence ofSchneiderian F'RSs can be correlated both with toms of schizophrenia bear similarity to Schneider's phe­ other clusters of dissociative symptoms. and with a report- nomenological descriptions ofthe first-rank symptoms. It is

262 possible that both sets ofdiagnostic criteria might identify name is the disintegration of consciousness in a dissociative symptom cluster which accompanies dementia praecox, hence the sejunction of con­ schizophrenia, butwhich does notreflectan inherentaspecl sciousness. The sejunction concept Cross natural­ of the disorder. ly took from Wernicke. He couldjust as well have Bleuler (1950) oudined his ideasregardingthe conceptual taken the older synonymous idea of dissociation relationship between schizophrenia and dissociation in the (Binet,janet). Fundamentally, dissociation ofcon­ following manner: sciousness means the same thing as Cross's disin­ tegration of consciousness .... The application I call dementia praecox "schizophrenia" because made by Cross of this theory ofdementia praecox (as I hope to demonstrate) the ~splitting" of the is new and imponanL Concerning his fundamen­ different psychic functions isone ofits mostimpor­ tal idea the author expressed himself as follows: tant characteristics....In every case we are con­ 'i)isintegrntion of consciousness in any sense sig­ fronted with a more or less clear-cutsplitting ofthe nifies the simultaneous flow of functionally sepa­ psychic functions. Ifthe disease is marked, the per­ rated series ofassociations. ~ (p. 23) sonality loses its unity; at different times, different psychic complexes seem to represent the person­ A quote from one ofBleuler's (1924) later works illustrates ality. Integration ofdifferent complexes and striv­ his continuing speculation about the dissociative aspects of ings appears insufficient or even lacking...one set schizophrenia: "It is not alone in hysteria that one finds an ofcomplexesdominates the personality for a time, arrangementofdifferent personalities, one succeeding the while the other groups of ideas or drives are "split other. Through similar mechanisms schizophrenia pro­

off" andseem eitherpardyorcompletelyimpotent. duces different personalities existing side by side. M (p. 138) (pp.8-9) It is notable thatJung and Bleuler had based lheir con­ ceptualizationsaboutdementia praecox andschizophrenia, Bleuler's original conception of schizophrenia as a "split­ at least partially, on their respective studies of the famous ting" of the psyche was influenced by Janet's (1889) con­ patient, Daniel Paul Schreber.Schreber had beendiagnosed cepts of "association" and "dissociation." Bleuler also drew by his doctors, Flechsig and Weber, as sufferingfrom a para­ upon Janet's notion of psychasthenia as a basis for his the­ noid (Lothane, 1992).Jung has offered an inter­ ory about the primary symptoms ofschizophrenia. pretation ofSchreber's psychotic symptoms in his 1907 pub­ lication, TheP5"'jC~ofDemenliaPr(UCOx.AlthoughJungdid Bleuler professed a theory that would be organo­ not specifically address the question ofdifferential diagno­ dynamic today .... In the chaos of the manifold sis, the indusion ofSchreber's case history inJung's book symptoms ofschizophrenia, he distinguished pri­ may be interpreted to imply a diagnosis ofdementia prae­ mary or physiogenic symptoms caused directly by cox. Bleuler (1911/1950) also referred to Schreber in his the unknown organic processes [sic], and sec­ book, Dt7Mntia Praewx (Jr lhe Group ofSchiwphTt:TJias. ondaryor psychogenicsymptomsderivingfrom the primary symptoms. This distinction was probably Bleulerwas impressed with a number ofSchreher's inspired by Janet's concept of psychaslhenia. Just clinical features, which he had classed as as janet distinguished a basic disturbance in psy­ schizophrenic, as had already been done byJung.,. chasthenia, that is, the lowering of psychological Bleuler assessed the first episode ofillness as a mild tension, so did Bleuler in much the same way con­ schizophrenic episode and the second as an acute ceive the primarysymptomsofschizophrenia to be protractedepisodeofcatatonia thatdeveloped into a looseningofthe tension ofassociations, in a man­ a chronicparanoidschizophrenicpsychosis butnot ner more orless similar to what happens in dreams paranoiain Kraepelin'ssense. In this, then, Bleuler or in daydreams .... The autism, that is the loss of also rejected Weber's diagnosis. contact with reality, was in Bleuler's original con­ (Lothane,I992,pp.323,345) cept a consequence ofthe dissociation. (Ellenberger, 1970, p. 287) A number of contemporary authors have suggested that Schreber's psychiatric symptoms were caused and/or exac­ Blculer also was influenced by Jung's ideas about the role erbated by traumatic childhood experiences (deMause, ofdissociation in the psychologyofdementia praecox.Jung's 1987; Goodwin, 1993; Niederland, 1959, 1960, 1974, 1984; work hadserved to integrate the conceptofdissociation along Schatzman, 1971; Shengold, 1989; van der Kolk & Kadish, with a number ofrelevant and foundational writings by ear­ 1987). Lothane (1992) also identifies Schreber's extended lier theorists. According toJung (1909): involuntary hospitalization as a primarystressor responsible for Schreber's deteriorating psychiatric condition. Lothane New and independent views on the psychology of additionally draws a parallel between the Schreber case and dementia praecox were brought forth by Otto that ofanother case history also discussed by Freud. Cross. He proposes the expression dementiasejunc­ tiva for the name ofthe disease. The reason for this Freud'sdynamicviewofpsychosis led him to invoke

263 DlSSOCHTlO:\ \'01 \ n.:\o ~. [)erfm/)('r 19Q4 • - DISSOCIATIOX fu~D SCHIZOPHREl\'1A

his teacher Meyncrt's delineation ofparanoiaas an the syndrome of hysterical psychosis may be sim­ acute syndrome, Meyncrt's amentia (Freud, 19 II, plified and understood best by reference to the pro­ p. 75).Thecase Freud (1894) describedasMeynert's found hypnotic trance states of which such indi~ amentia, or acute hallucinatorr , seemed viduals are capable. From this poim of view such to resemble Schreber's acute hallucinatory phase hystericaJ symptoms as fugue states, amnesia, and .... Mcynert's amentia qualifies as a traumadc psy­ hallucinations are understood as spontaneous, chosis .... For Freud. the general idea that psy­ undisciplined trancestates. Some individuals, in the chosis was a defense (thus a neuropsychosis of face ofdramatic stress within their family, at their defense) abrainsl a lraumatic experience was the job, or social pressure ofother kinds may succumb dynamic underlying both forms of disorder, hal­ to a psychotic form ofcommunication which is dif­ lucinatory confusion, orMeyneTt's amentia (1894) ferent from schizophrenia in phenomenology. and paranoia (1896), the formercaused byan adult course, and prognosis. (p. 779) traumaticsituation, the latleT traced born to infan­ tile seduction and to current conflicts. A numberofadditionalauthorsconcurwith this distinction, (Lothanc, 1992, pp. 330-331) emphasizing the role of high hypnotizability as an impor­ tant factor in the differential diagnosis between hysterical This type ofdynamic viewpoint suggests that acute halluci­ psychosis and schizophrenia (Copeland & Kitching, 1937; natory and delusional sympLOms sometimes may accompa­ Gross, 1980; Gruenewald, 1978; Hirsch & Hollender, 1969; ny the syndrome of traumatic hysterical psychosis. It also Mallet & Gold, 1964; Steingard & Frankel, 1985; D. Spiegel raises questions regarding the Ydlidi tyof]ung'sandBleuler's & Greenleaf, 1992; H.Spiegcl, 1991;vanderHart&D.Spiegei, theories on dementia praecox and schizophrenia. In par­ 1993; van der Hartetal., 1993).SteingardandFrankel (1985) ticular,]ung and Bleuler may have neglected to consider also discuss the connection between high hypnotizabilityand the differential diagnosis of hysterical psychosis as relevant dissociation in this clinical population: to their respective formulations regarding the diagnostic parameters ofdementia praecox and schizophrenia. Oneimportantmechanism thatwe believeaccounts for one type oftransient or recurrent event ofpsy­ HYSTERICAL PSYCHOSIS AND SCHIZOPHRENIA choric proportionsis dissociation. Although theolder literature on hypnosis Oanet., 1965) and its history The diagnosis of hysterical psychosis (HP) gained (Ellenberger, 1970) and on dissociation (Nemiah, widespread recognition during the nineteenth century; but 1975; Frankel & Orne, 1976) have provided ample like the diagnosis ofmultiple personality disorder, the diag­ evidence of unusual behavior in patients who dis­ nosis ofHP eventually faded from use. sociate easily and, at times, spontaneously, DSM-JIl failed to note the important coexistence of high The concept of hysterical psychosis (HP) suffered hypnotizability and dissociative events. (p. 954) a curious fate in the history of . During the second half of the 19th century this disorder Also supporting this view are van der Hartctal. (1993), who was well known and thoroughly studied, particu­ discuss their concerns regarding the confusion in diagnos­ larly in French psychiatry. In the early 20th centu­ tic nomenclature pertaining to this clinical population: ry the diagnosis ofhysteria, and ofHP, fell into dis­ use. Patients formerly considered to sufferfrom HP The Index of the DSM-/fl-R (American Psychiatric were diagnosed schizophrenicsor malingers. A few Association, 1987) comains HP, then refers read­ clinicians have attempted to reintroduce this diag­ ers to eitherBriefReactive Psychosis orto Factitious nostic category, butithas notregainedofficial recog­ Disorder with psychological symptoms .. _. In the nition. case of reactive psychosis, we use the traditional (van der Hart, W1lZtum, & Friedman, 1993, p. 44) nomenclatureofHPin reviewing the literatureand propose a new category of ­ The role of traumatically-induced dissociation in the etiol­ Reactive DissociativePsychosis (RDP). RDP integrates ogyand clinical phenomenologyofhysterical psychosis has the classical features of HP with the most recent been recognized by a growing number of contemporary thinkingon trauma-induced psychosis.... We believe authors, who differentiate this form of psychotic disorder that the essential characteristic for accuraLC diag­ from schizophrenia (Hirsch & Hollender, 1969; Hollender nosis of RDP is not a short duration, but a disso­ & Hirsch, 1964; Mallett & Cold, 1964; Spiegel & Fink, 1979; ciative foundation....Thedissociative foundation of Steingard & Frankel, 1985; van der Hart & Spiegel, 1993; RDP is a more meaningful explanatory principle van def HartetaI., 1993). Spiegel and Fink (1979) make the than an hysterical or histrionic character as cur­ following distinctions between the diagnoses ofschizophre­ rently indicated in DSM·IlJ-R. (pp. 44-45, 58) nia and hysterical psychosis: H. Spiegel (1991) expressesan additionalconcern: "'Without Our thesis is that the phenomena associated with a careful differential diagnosis, hysterical psychosis and mul-

264 DlSSOCl\TlO~ \'0\ \Il.~o ~ Dl'U'CIh.--r 199-\ GAINER ~

riple personalitydisorderarcoften diagnosed as schizophre­ ment. Dynamically speaking, they owe their incep­ nia" (p. 164) .Asan example. Murray (1993) offersa fe-inter­ tion to the bursting-through into awareness ofcer­ pretation of me autobiographical aceoun!., J Neuer Promised tain dissociated impulses which become so over­ You a Rose Gard,en (Greenberg, 1964/1981). This classic tale whelmingly strong that they cannot be retrieved in rraditionallyhas been presentedasa casestudyonschizophre­ dissociation. nia (Coleman & Broen, 1972). Murray's analysis questions (Fromm-Reichmann, 1950, p. 173) Ihe diagnosis ofschizophrenia and focuses on the lraumat­ ic origins of!.he presentingsymptomatology. Gainer (1992) Otherrelated comments by Fromm-Reichmann have unmis­ similarly focuses on Greenberg'saccountofchildhood trau­ takable relevance forcontemporarypsychotherapeuticwork ma, and identifies a number of the heroine's presenting with the DID client: ~ptomsas characteristic examples of tr.mmatic dissocia­ tion. The psychoanalyst, as he works with a disturbed I Ncverf'rrmriwI You a R.ou Garden tells the sLOryofa trou­ schizophrenic, is not only treating a child at qif­ bled adolescent who is diagnosed with schizophrenia and is ferent ages butalso, and at the same time, an adult hospitalized atan inpatientfacility for long-tenn psychiatric person ofthe chronological age in which he comes care. AuthorJoanne Greenberg, who originally published into treaunenL...Psychiatristswhoare notsufficient1y her book under the pseudonym of Hannah Green, has flexible may find it difficult to address themselves acknowledged thestory's parallel with herown real life expe­ simultaneously to both sides of the schizophrenic riences as a patient under the care of Dr. Freida Fromm­ personality. Theymaybehavelike rigid parentswho Reichmann, atChestnutLodgeduring the 1940'sand 1950's refuse to realize that their children have grown up. (Goodwin, 1993; Murray, 1993; Rubin, 1972). According to The undesirable results ofthe psychiatrist's reluc­ Goodwin: "In those fouryearsofanalytic treaUDenl, Fromm­ tance to communicate with the adult part in the Reichmann and the patient unraveled the connections patient's personality and hisaddressing himselfonly between these florid symptoms and the extensive medical to the regressive parts in the patient have been dis­ trauma in early childhood that had .schooled Joanne into cussed before. escapes into fantasy" (Goodwin, 1990, p. 188). If on the other hand, Lhe psychotherapist Fromm-Reichmann (1950) has described a case study addresses himself to the adult patient only, out of which bearsa strong resemblance to Greenberg's story, and an erroneous identification wiLh the patient, he which also illustrates Fromm-Reichmann'sapproach in treat­ renounces comprehension ofand alertness to cru­ ing dissociative symptoms with a traumatic origin. cial parts of the .schizophrenic psychopathology. (Fromm-Reichmann, 1948, p. 271) Asked jfshe could remember when being deceived had been linked up for the first time with the ether DISSOCIATION AND PSYCHODYNAMIC gun, she immediately recalled an operation which TREATMENT APPROACHES TO SCHIZOPHRENIA had been performed on her at the age of three. She had been told that it wouldn'tbeshe who would Fromm-Reichmann's (1948) approach was influenced be operated on, but her doll. Ether was the anes­ by the theoretical work of Paul Federn. Many of Federn's thetic used. The ether was administered suddenly ideas, developed from his studies onschizophrenia,are appli­ while she was still expecting to see what was to be cable to the study ofdissociative disorders. done to herdoll. Itwas as ifsomeone hadshotether Watkins and Watkins (1991) have used Federn's (1943) ather. Before she was really under, things and peo­ concept of "cgo-states~ to develop "ego-state therapy~, an ple appeared tremendous, and the picture of the approach which has been utilized in the contemporarytreat­ doctorwho had operated on her had been retained ment ofDID. Federn (1947b) discusses the concept ofego­ in her memory ever since as that of a giant. Here states as applied to the treatment of schizophrenia in the was deception on the part ofboth of the patient's following manner: parents and of the doctor. It was connected with thesuddenexperienceofthesmell ofetherimposed One mustencourage the patient to recognize how on her by a huge man. This, then was the actuaJ his previous ega-states interfere with his present experiencewhich gave rise to the hallucinatory rep­ ones. It is not generally recognized by psychoana­ etition ofthe experience which the patient under­ lysIS that, normally as well as pathologically, ego­ went when she expected to be deceived by Lhe psy­ states are repressed; successfully in nonnaJ people, chiatrist. unsuccessfully in neurotics and in psychopaths. (Fromm-Reichmann, 1950, p. 174) Psychotic patients are able to recognize this fact; frequently they recognize itspontaneouslyand bet­ Fromm-Reichmann conceptualizesin the following manner. ter than is possible with most healthy persons. By virtue of Lhe Lherapeutic influence, favor­ I?escriptively speaking, hallucinations are percep­ able cases react in agratifying manner. By theirown tions without sensory foundation in the environ- repeated attempts the patients learn successfully to

265 D1SSOCl\TIO\, \01 \11. :\0. t December 19Q-I - - - DISSOCIATIOI\' A.'\D SCHIZOPHRE:-iIA

adhere to the normal adult ego state for periods of AnothercentralelementofRosen's treatmentparadigm increasing length. This concept is similar to that is therapeutic "re-parenting."Thisapproach is similartosome emphasized by Adolph Meyer in his basic goal, the ofthe early, naive treaunentapproaches utilized in the con­ re-jOlegration of the slowly diseased personality. temporary treatment of OlD, which had been criticized by (Federn, 1947b, pp. 130-131) a number of authors (Greaves, 1988; Kluft. 1985; Putnam, 1989). Other therapists who have developed treatment Federn (1952) hypothesized that psychotic symptoms (such methodologies utilizing direct re-parentingofschizophren+ as hallucinations) could result from dissociation which ics have included Laing. best known forhisbook, TheDivided occurredwhen thoughlSwere"objectcathected, ~ ratherthan Seif(I965); and Sechehaye (1951a & b), who pioneered the "ego cathected. ~ According to Federn, reduction in "ego treatment methodology of "symbolic realization." cathexis" would result in an analogous loss ofreality testing In contrast LO direct rt.."-parenting, are the "reality based" for the psychotic individual. Fedem's (1943) descriptions approachesofArieti (1974); Fromm-Reichmann (1939, 1943, of the complex "split transfercncesM of the schizophrenic 1948, 1950); Searles (1959, 1965); and Sullivan (1931-32. patient also are relevant to the treatmentofpatients suffer­ 1947, 1962). This school of thought emphasizes therapeu­ ing from DID. tic contact which reinforces the age-appropriate behaviors and responsibilities ofthe patient, while simultaneously val­ In psychotics, these different ego-states, with their idating the negative impact of past traumatic experiences. loves and hatreds, are independently orga­ Contemporary therapists can benefit from the wisdom nized....Therefore. to use the transference of lhe developed by these pioneering therapists. Clinical expertise psychotic, me analyst has to adjust to the fact mat in the treatmentofregressed adult patients has evolved over ambivalence is replaced by two (or more) ego­ many years, and is reflective of a growing awareness of the states....The separation of the ego-states remains relationship between psychic trauma and the onset of psy­ unconscious in the normal individual and becomes chiatric symptoms. a real split in lhe psychotic....By the schizophrenic AI; an example, Sullivan (1962) correlates the onset of process, previouscgO-Slates temporarilybecomeiso­ a schizophrenic youth's acute episode of "catatonic dissoci­ lated. Psychoanalysis deals with these states in full ation" with the reawakeningofthe patient'straumatic mem­ acknowledgementoftheirff>:l.lity by tellingthe patient ories ofchildhood scxudl abuse. Sullivan discusses his treat­ lhat they are revived child-states of his ego. When ment approach with this patient as follows: we treataschizophrenic we treatin himseveral chil­ dren ofseveral ages. Energy is expended chiefly in reconstructing the (1943, pp. 253--254, 256, 482-483) actual chronology ofthe psychosis. AJI tendencies to "smooth over" lhe events are discouraged and Several contemporaries ofFedern and Fromm-Reichmann free-associational technique is introduced at inter­ offer additional commentary which is relevatlt to lhe treat­ vals to fill in "failures of memory." The role ofsig· ment ofDID, and which predates any modern discussion of nificant persons and their doings is emphasized... DID by approximately 35 years. In 1948, an expert panel on that however mysteriously the phenomena origi· schizophreniawas sponsored by theAmerican Psychoanalytic nated, everything that has befallen him is related Association (Cohen, 1948). Members of the panel concen­ to his actual living among a relatively small num­ trated theirdebate on treatmentapproachesaimed towards berofsignificant people, in a relativelysimple course the "regressed infant and child" (Rosen, 19(7), which ofevents. Psychotic phenomena recalled from the seemed to be evident in the psychotic patient. As an exam­ moredisturbed periodsare subjected to studyas to ple, Rosen's direct psychoanalysis focused upon "._.dealing their relation to these people. mostly with that level ofmentation which occurs in the pre­ (Sullivan, 1962, pp. 277-278) verbal period of life and shortly thereafter" (Rosen, 1947, p. 21). Ft..'

fixed and usually incurable schizophrenia. concerns currently pose a challenge for clinicians involved (Stoller, 1973, p. 318) in the trearmentofdissociative disorders (Braun, 1989;Caions, 1989; Fine. 1989; Greaves, 1989; Klun. 1989; Torem,1989). Stoller describes his observations of the patient's shift­ Paul Federn (1943) examines this concern, as related ing levels ofconsciousness in the following manner: '"One to the treatment ofschizophrenia: can watch Mrs. G. slide up and down levels ofawareness and move from talking to me in the office to being again back Psychiatristswhodisapprove ofpsychoanalysisnever in the past, Ialking to otherswhose replies onlyshecan hear" fail to point out those cases in which psychoanaly­ (Stoller. 1973. p. 324). sis, far from having been helpful, created disasters. As the ueatment progressed, Stoller had begun to re­ This statement is both true and false. A series of evaluate the symptomatic function ofhis patient's "halluci­ even ts doesnOl necessarilyrepresentcauseandeffect natory voices," and to re-evaluate his therapeutic stance in Many prepsychotic patients come to the psycho­ relation to the voices: analyst only when they already feel within them­ selves some uncanny menace of the threatening I automatically, asa psychiatrist, I have to beagainst psychosis. The psychosis would have caught them voices and that's what I've always been; but you're anyhow wifh orwithout psychoanalysis .... On the making me mink there's something different now other hand, when psychosis is near the threshold, for the first time. I'm notsure thatI have to destroy psychoanalysisbreaksdown someegCHitructures and it....l·m asking to become acquainted with your manifest psychosis results .... Psychoanalysis must voice....Voices have always been to me nothing but learn notto provok.e latentpsychoses,and even more sickness. But ifrget to know betterwhat your voice to prevent any psychosis from being the terminal really is, I am not sure that I would take the same state ofa neurosis. posilion....It·s possible that the voice is you in the (Federn, 1943. pp. 12-14) same way as the voices that the rest ofus have that we don't hear...butyourvoice is tooseparated from Fedem'scommentscontinue to be very relevant to con­ the rest ofyou. You see, I would never think ofny­ temporary practitioners treating individuals diagnosed with ing to get rid ofyourvoice...thatpartofitthat's like DID, and renect only one aspectofa large heritage ofappli­ myvoice...I don't want to destroy you. I don't want cable knowledge which has been developed over time by to destroy that part ofyou which is yourjudgment theorists/clinicians working within the field ofschizophre­ or your conscience. I would hope that the voice nia. wouldstop making sounds orconfusingyouorfright­ ening you or threatening you or getting you into CONTEMPORARY THEORY ON DISSOCIATION trouble, buLl don'twantto destroythevoice. Because AND SCHIZOPHRENIA ifl understand you right, then I would have to agree with you: To destroy the voice would be to destroy Current think.ing about the role of dissociation in the you! development, maintenance,and rreatmentofpsychiatric dis­ (Stoller, 1973, pp. 33-34) turbances continues to evolve and to challenge our tradi­ tional ideas regarding disorders such as dissociative identi­ Stoller's treatmentgraduallyguided the patienttowards ty disorder, schizophrenia, and brief reactive psychosis. In an integration of both her personal identity and her emo­ addtion, the current system ofdiagnostic classification con­ tional well-being. This process included the use of thera­ tinues to be challenged by the work of contemporary peutic france, recall, and abreaction. Notably, Stoller's ther­ researchers. Newly-proposed diagnostic schemas currently apeutic repertoire foreshadowed the development ofmany include the categoriesofreactive dissociative psychosis (van current-day stratagems in the treaunem of DID and other derHartetal., 1993) and ofadissociative typeofschizophre­ dissociative disorders. nia (Ross, Anderson, & Clark, 1994). Another relevant contribution La the field of dissocia­ The latter authors present data suggesting that "there tive disorders was thedevelopmentofthe "double bind"the­ may be tWO pathways to positive symptomsofschizophrenia, ory of communication by Bateson, Jackson, Haley, and a childhood trauma pathway and a biological disease path­ Weakland (1956).This model wascanceptualizedasan inter­ wayM (Ross et a1., 1994, p.2). Bellak, Kay, and Opler (1987) personal, etiologic model ofschizophrenia and was incor­ have provided an historical precedent for this kind ofdiag­ porated into the treatment paradigmsafLaing (1965); Lidz nostic subtyping via their proposal of an attention deficit (1952,1973); and Searles (1965). In recent years, the dou­ disorder psychosis. This diagnostic subtype is difTerntiated ble bindmodelalso has proved relevant fa the etiologic study clearly by Bellak et a1. (1987) from any ofthe existing sub­ of DID (Braun & Sachs, 1985; Fine, 1991; Hughes, 1991; groupings within the traditional schi7..0phrenic matrix, and Spiegel,1986). may serve as a useful model for the study. A long-term challenge for clinicians in the field of In further discussion on this topic, Bellak (1994) quotes schizophrenia has involved allegations of iatrogenic cre­ a relevant passage by R.W. Heinricks: ation/exacerbation ofthe disorder (Federn, 1943). Similar

267 _= ----.J_'---- _ DISSOCIATIOl\ A.\'D SCHIZOPHREl\'L\

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