ABSTRACT Ecological understandings of mind and behavior are derived from Bateson's notion of an "ecology of mind," in which different aspects of individual functioning (such as self-representation, cognition, emotion, action) are viewed as organised into coherent modes of response to the social and physical world as locally understood. Geoffrey Samuel's multimodal framework is discussed to exemplify this approach. An illness narrative describing a case of aphonia, paralysis, and spirit possession in a young Indian woman is analyzed from an ecological perspective. The young woman's family view her illness as iatrogenic (caused by a lumbar puncture) or due to spirit possession. She is not held personally responsible for her symptoms. The moral implications of different understandings of dissociation, including those typical of medicine and psychiatry, are discussed. It is argued that the local moral appraisal of dissociative phenomena is likely to be a key constraint on their presentation and course. Dissociative phenomena are contrasted with psychogenic epileptic seizures, in order to illustrate how a patient's appraisal of their situation can influence 'organic' as well as 'non-organic' illness presentations. It is concluded that episodes of diverse illnesses can be regarded as manifestations of distress in the ecologically embedded individual. Ecological perspectives may in future allow clinicians to better understand the relations between mind, body, and culture as they
eventuate in presentations of illness.

R. van Reekum, M.D., F.R.C.P.C., Tammy Cohen, B.A.(H) and Jenny Wong, B.A.(H) (2000).
Can Traumatic Brain Injury Cause Psychiatric Disorders?
J Neuropsychiatry Clin Neurosci 12:316-327, August 2000

ABSTRACT Traumatic brain injury (TBI) may cause psychiatric illness. This article reviews the evidence on the basis of an established set of causation criteria. The evidence is convincing for a strong association between TBI and mood and anxiety disorders. Substance abuse and schizophrenia are not strongly associated with TBI, and there is little research into the rates of personality disorders after TBI. Evidence for a biologic gradient is lacking, but such a gradient may not be relevant to TBI. Evidence for the correct temporal sequence is present. Preliminary evidence suggests a biologic rationale for TBI causing psychiatric illness. Further and methodologically improved research is supported and required.

A. A. T. S. Reinders , E. R. S. Nijenhuis, A. M. J. Paans, J. Korf, A. T. M. Willemsen and J. A. den Boer
a) Department of Biological Psychiatry, Groningen University Hospital, The Netherlands
b) Mental Health Care (Assen)/Cats-Polm Institute (Zeist), The Netherlands
c) PET-center, Groningen University Hospital, The Netherlands
One brain, two selves
NeuroImage; volume 20; 14 November 2003

ABSTRACT There is increasing evidence that chronic stress leads to morphological changes in the brain which subsequently lead to functional impairments. As a result of molecular biological changes, stress compromises neuronal plasticity, and also induces morphological changes, such as a reduced volume of the hippocampus. At a clinical level these changes may be accompanied by the syndromes of depression, posttraumatic stress disorder (PTSD), and when there are severe and persistent traumatic stressors by the development of dissociative identity disorder (DID). In severe PTSD as well as DID there may be disturbances in autobiographical memory as parts of the personality appear to be separated from access to autobiographical memory. In a recent study in patients suffering from DID using functional neuroimaging we were able to demonstrate two different parts of the personality, each with its own access to autobiographical trauma-related memory. We found different regional cerebral bloodflow patterns for different dissociative parts involving a different sense of self. These findings challenge traditional notions of self, which are often characterized by an uninterrupted, temporal continuity between a persons present conscious recollection and past experience. Traditional ideas of the ‘self’ imply that someone can focus upon what remains identical through time, which is not only the subjectivity of experience, but also the experience of an undivided and uninterrupted access to autobiographical memory. In patients with DID our findings suggest that access to parts of autobiographical memories are altered during the dominance of different parts of the personality, and our findings support this notion by showing that different neural networks in the brain are activated as neural correlate of these different dissociative parts.

A.A.T.S.Reinders, J.Quak, E.R.S. Nijenhuis, H.P.J.Vos, A.M.J.Paans, A.T.M.Willemsen, J.Korf, J.A. den Boer.
Department of Biological Psychiatry: Groningen University Hospital
Identity state-dependent processing of neutral and traumatic scripts in Dissociative Identity Disorder as assessed by PET

ABSTRACT Introduction: Patients with Dissociative Identity Disorder (DID) have two or more different identities with their own pattern of perception, reaction and thinking. DID, formerly known as Multiple Personality Disorder (MPD), can be a consequence of childhood trauma from which "traumatic" identities emerged with their own particular reaction to the recollection of, or emotional responses to, the traumatic memories. Furthermore "neutral" identities were developed with no, or in any case less, recollection of these traumatic memories. DID is described in many case studies, but almost no objective psycho-physiological multi-subject studies have been reported. Aim: Study the regional cerebral blood flow (rCBF) in DID patients, listening to autobiographic texts in different identity states, to objectify identity dependent information processing in this psychiatric disorder. Hypothesis: Patients exposed to the autobiographical traumatic text show differences in rCBF dependent on their identity state (neutral versus traumatic). These rCBF patterns differ from identity state dependent changes in rCBF when patients listen to the autobiographical neutral text. Methods: Seven women, meeting DSM-IV criteria for DID, were, in two different identity states, exposed to two auditory autobiographical texts while undergoing 3D PET imaging. The rCBF was measured with the Siemens EXACT HR+ after intravenous injection of [15O]-H2O (500 MBq), obtaining 90-second scans. Four different conditions were obtained twice, resulting in eight scans. The complete scanning sequence was always Nn, Nt, Tn, Tt, Tn, Tt, Nn and Nt. The first character indicates the personality state (Neutral or Traumatic) and the second character indicates the content of the autobiographical text (neutral or traumatic). Data was spatially registered, normalised and statistically analysed using statistical parametric mapping (SPM software, Wellcome Department of Cognitive Neurology, Londen, UK). Results: Different brain activation patterns were found between the traumatic identity state and the neutral identity state while listening to the autobiographical traumatic text (condition Tt versus Nt). However, no difference in rCBF was found between these two identity states while listening to the autobiographical neutral text (condition Tn versus Nn). These results show a difference in (emotionally) processing of only the traumatic text not of the neutral text, between the two identity states. Conclusion: These results confirm our hypotheses i.e. that the rCBF depends on the identity state of patients when listening to an autobiographical traumatic text. However, the rCBF is independent of identity state when listening to an autobiographical neutral text. We conclude that brain activation in patients with DID is state dependent, because differential dissociation, thus state dependent rCBF was found. Identity state dependent information processing is, in this study, shown in an objective way. These findings contribute to the scientific objectivity on the subjective experience of patients with DID.

Reinvang I (1998).
Department of Psychology, University of Oslo, Norway.
Amnestic disorders and their role in cognitive theory.
Scand J Psychol 1998 Sep;39(3):141-3

ABSTRACT Amnesia refers to a disorder of memory, and classical amnesia with continuous problems in acquiring new information is the most studied type of amnesia. The integration into a memory systems model of clinical studies of classical amnesia, cognitive theory, and studies with neuroimaging methods is one of the prime success stories in modern cognitive neuroscience. The clinical spectrum of amnesia encompasses a wide range of disorders ranging from specific encoding deficits for language or visuospatial information to psychogenic amnesia with confusion and loss of memory for personal identity. Two cases are reviewed, one with selective verbal amnesia and the other with focal retrograde amnesia, presenting some puzzles and challenges to current modular thinking about memory that may lead to theoretical advances. An interactive model emphasizing the communication between brain codes and regions in memory may have promise. MeSH Terms: Adult Amnesia/psychology Amnesia/diagnosis* Amnesia, Retrograde/psychology Amnesia, Retrograde/diagnosis Anomia/psychology Anomia/diagnosis Aphasia/psychology Aphasia/diagnosis Case Report Cognition Disorders/psychology Cognition Disorders/diagnosis* Female Human Middle Age Neuropsychological Tests

ABSTRACT This study examined the use of a Spanish version of the Child Dissociative Checklist (CDC) in Puerto Rico. The CDC was administered to the primary caretakers of three groups of children: 31 with documented abuse histories, 30 with Attention Deficit Hyperactivity Disorder (ADHD), 33 with no abuse or psychiatric record. Results confirmed the reliability and validity of the CDC and revealed that Puerto Rican children with abuse histories showed significantly higher levels of dissociation than the children in the other two groups. Moreover, more than half of the abused children had a score above the usual cut-off point of 12 in the CDC, while only a handful of the ADHD children and none in the control group evidenced such a pattern. The results also showed that there were significant correlations between the CDC and the duration of the abusive experiences. Implications of our findings and subsequent clinical recommendations are offered.

Reuber M, House AO, Pukrop R, Bauer J, Elger CE. (2003).
Academic Unit of Neurology, Division of Genomic Medicine, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield, England S10 2JF, UK. mreuber@doctors.org.uk
Somatization, dissociation and general psychopathology in patients with psychogenic non-epileptic seizures.
Epilepsy Res. 2003 Dec;57(2-3):159-67.

ABSTRACT The etiology of psychogenic non-epileptic seizures (PNES) remains uncertain. Previous studies have shown that PNES patients are characterized by high levels of somatization, dissociation and general psychopathology but a correlation of measures of these features and PNES severity or outcome has never been demonstrated, although this would strengthen a possible etiological link. This study measured somatization (Screening Test for Somatoform Symptoms-2), dissociation (Dissociative Experience Scale, DES), and general psychopathology (Symptom Checklist-90-Revised, SCL-90) in 98 patients with PNES and 63 patients with epilepsy. All mean scores were raised in the PNES compared to the epilepsy group. However, only measures of somatization and general psychopathology discriminated between patients with PNES and epilepsy in a logistic regression model (even when patient gender was controlled for). In PNES patients, high somatization scores correlated with poor outcome and greater seizure severity even after correction was made for dissociation and psychopathology. Dissociation and psychopathology scores were not independently associated with outcome or severity. The results suggest that, as a group, patients with PNES are best characterized by their tendency to express psychosocial distress by producing unexplained somatic symptoms which are brought to medical attention. Although dissociation may be relevant in some individuals it does not appear to be an independent factor across the whole PNES patient group.

Rieber, R.W.  (1999)
Hypnosis, False Memory, and Multiple Personality: a trinity of affinity.
History of Psychiatry, 10, 3-11

ABSTRACT This paper presents a discussion of the relationship between hypnosis, false memory and multiple personality. Since Morton Prince's classic case of multiple personality (Prince 1906), only two other cases rival Prince's original work (Thigpen and Cleckley 1957, Schreiber 1973) in popularity. This paper illustrates startling new material regarding the third most famous of multiple personality cases, that of Sybil. Tape recordings recently discovered document the fraudulent construction of multiple personality. The importance of the role of hypnosis is discussed in this presentation. The author of this paper knew the author of Sybil, Flora Schreiber, though many years before her death and therefore is able to present first-hand information about the author and her work.

Rifkin A, Ghisalbert D, Dimatou S, Jin C, Sethi M  (1998)
Hillside Hospital Division of Long Island Jewish Medical Center, Glen Oaks, NY 11004, USA.  
Dissociative identity disorder in psychiatric inpatients.
Am J Psychiatry 1998 Jun;155(6):844-5

ABSTRACT OBJECTIVE: The aim of this study was to replicate reports of a high rate of dissociative identity disorder in psychiatric inpatients. METHOD: Subjects were 100 randomly selected women, 16-50 years old, who had recently been admitted to an acute psychiatric hospital. Diagnoses were made by two interviewers through use of the Structured Clinical Interview for DSM-IV Dissociative Disorders. RESULTS: One percent (N = 1) of the interviewed subjects had dissociative identity disorder. CONCLUSIONS: Contrary to previous studies, the authors found a low rate of dissociative identity disorder, perhaps because of the different methodology used.

Rivera, Margo (2002)
Informed and supportive treatment for lesbian, gay, bisexual and transgendered trauma survivors.
Journal of Trauma and Dissociation (ISSN: 1529-9732), v. 3, no. 4, pp. 33-58 (2002).

ABSTRACT It is widely acknowledged that sexuality is often a key area of conflict for individuals who have been traumatized and exploited in childhood. Most treatment regimens for trauma survivors include some focus on enhancing client's capacity to create a healthy adult sexuality, with the goal of replacing rigid, maladaptive beliefs and behaviors, rooted in childhood patterns of oppressive sexuality, with those that enable them to develop a mature and satisfying life. However, though sexuality is emphasized as a significant aspect of human functioning and one in which a traumatized individual frequently needs help, there is often little acknowledgement that there are a range of healthy expressions of sexuality and gender. Though most clients and most therapists are heterosexual, those clients who do not fit the norm in this regard need a therapeutic context in which their expressions of gender identity and sexual orientation are acknowledged and clearly supported, so that their psychotherapy process will enable them to learn to live freely and fully, rather than reinforcing the marginalization they experienced as abused children and as adults who practice sexualities which are not widely accepted and fully supported in our society. KEY WORDS: gay, lesbian, bisexual, transgender psychotherapy

Roelofs K , Keijsers GP, Hoogduin KA, Naring GW, Moene FC. (2002)
Department of Clinical and Health Psychology, University of Leiden, Leiden The Netherlands.
Childhood abuse in patients with conversion disorder.
Am J Psychiatry 2002 Nov;159(11):1908-13

ABSTRACT OBJECTIVE: Despite the fact that the assumption of a relationship between conversion disorder and childhood traumatization has a long history, there is little empirical evidence to support this premise. The present study examined this relation and investigated whether hypnotic susceptibility mediates the relation between trauma and conversion symptoms, as suggested by Janet's autohypnosis theory of conversion disorder. METHOD: A total of 54 patients with conversion disorder and 50 matched comparison patients with an affective disorder were administered the Structured Trauma Interview as well as measures of cognitive (Dissociative Experiences Scale) and somatoform (20-item Somatoform Dissociation Questionnaire) dissociative experiences. RESULTS: Patients with conversion disorder reported a higher incidence of physical/sexual abuse, a larger number of different types of physical abuse, sexual abuse of longer duration, and incestuous experiences more often than comparison patients. In addition, within the group of patients with conversion disorder, parental dysfunction by the mother-not the father-was associated with higher scores on the Dissociative Experiences Scale and the Somatoform Dissociation Questionnaire. Physical abuse was associated with a larger number of conversion symptoms (Structured Clinical Interview for DSM-IV Axis I Disorders). Hypnotic susceptibility proved to partially mediate the relation between physical abuse and conversion symptoms. CONCLUSIONS: The present results provide evidence of a relationship between childhood traumatization and conversion disorder.

Rohleder N, Joksimovic L, Wolf JM, Kirschbaum C. (2004)
Department of Psychology (NR, JMW, CK), Institute of Experimental Psychology II, University of Dusseldorf, Dusseldorf, Germany.
Hypocortisolism and increased glucocorticoid sensitivity of pro-Inflammatory cytokine production in Bosnian war refugees with posttraumatic stress disorder.
Biol Psychiatry. 2004 Apr 1;55(7):745-51. doi:10.1016/j.biopsych.2003.11.018

ABSTRACTBACKGROUND: Posttraumatic stress disorder (PTSD) is associated with dysregulation of the hypothalamus pituitary adrenal (HPA) axis. Alterations include various responses to HPA axis stimulation, different basal hormone levels, and changes in glucocorticoid receptor (GR) numbers on lymphocytes. The functional significance of these latter changes remains elusive. METHODS: Twelve Bosnian war refugees with PTSD and 13 control subjects were studied. On 2 consecutive days, they collected saliva samples after awakening and at 11, 15, and 20 hours. Glucocorticoid (GC) sensitivity was measured by dexamethasone (DEX) inhibition of lipopolysaccharide (LPS)-induced interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) production in whole blood. RESULTS: The PTSD patients showed no cortisol response after awakening and had lower daytime cortisol levels (F = 14.57, p <.001). Less DEX was required for cytokine suppression in PTSD patients (IL-6: t = -2.82, p =.01; TNF-alpha: t = 5.03, p <.001), reflecting higher GC sensitivity of pro-inflammatory cytokine production. The LPS-stimulated production of IL-6, but not TNF-alpha, was markedly increased in patients (IL-6: F = 10.01, p <.004; TNF-alpha: F =.89, p =.34). CONCLUSIONS: In refugees with PTSD, hypocortisolism is associated with increased GC sensitivity of immunologic tissues. Whether this pattern reflects an adaptive mechanism and whether this is sufficient to protect from detrimental effects of low cortisol remains to be investigated.

Roller B, Nelson V (1999).
Berkeley Group Therapy Education Foundation, California, USA.
Group psychotherapy treatment of borderline personalities.
Int J Group Psychother 1999 Jul;49(3):369-85

ABSTRACT Borderline personalities have been treated in psychotherapy groups for over 40 years. This article elaborates some of the characteristics pertinent to the treatment of these patients. Combined treatment of group and individual therapy addresses the needs for object constancy, the integration of object and self representations, and the possibility of attachment to others. Collaboration with individual therapists in this process is essential and there are specific conditions that allow this to occur as well as guidelines to help them make referrals. Cotherapy can be especially beneficial if the cotherapy team is knowledgeable and experienced. The group therapist must have special training and supervision to conduct groups of such intensity and affectively laden content. 

ABSTRACT: OBJECTIVE: The purpose of the study was to examine strategies for developing effective interventions for clients who have both serious mental illness and posttraumatic symptoms. METHODS: The authors conducted searches for articles published between 1970 and 2000, using MEDLINE, PsycLIT, and PILOTS. They assessed current practices, interviewed consumers and providers, and examined published and unpublished documents from consumer groups and state mental health authorities. RESULTS AND CONCLUSIONS: Exposure to trauma, particularly violent victimization, is endemic among clients with severe mental illness. Multiple psychiatric and behavioral problems are associated with trauma, but posttraumatic stress disorder (PTSD) is the most common and best-defined consequence of trauma. Mental health consumers and providers have expressed concerns about several trauma-related issues, including possible underdiagnosis of PTSD, misdiagnosis of other psychiatric disorders among trauma survivors, incidents of retraumatization in the mental health treatment system, and inadequate treatment for trauma-related disorders. Despite consensus that trauma and PTSD symptoms should be routinely evaluated, valid assessment techniques are not generally used by mental health care providers. PTSD is often untreated among clients with serious mental illness, or it is treated with untested interventions. It is important that policy makers, service system administrators, and providers recognize the prevalence and impact of trauma in the lives of people with severe mental illness. The development of effective treatments for this population requires a rational, orderly process, beginning with the testing of theoretically grounded interventions in controlled clinical trials.

Psychol Rep 1999 Jun;84(3 Pt 2):1109-10

ABSTRACT Methodological criticisms of a recent study on treatment outcome of dissociative identity disorder are accurate: however, the outcome study is more methodologically sound than any previous work and therefore advances the field. The design of other studies and the conclusions to be drawn from the study under discussion are reviewed.

ABSTRACT Fifty veterans diagnosed with posttraumatic stress disorder (PTSD) each recalled four autobiographical memories: one from the 2 years before service, one non-combat memory from the time in service, one from combat, and one from service that had often come as an intrusive memory. For each memory, they provided 21 ratings about reliving, belief, sensory properties, reexperiencing emotions, visceral emotional responses, fragmentation, and narrative coherence. We used these ratings to examine three claims about traumatic memories: a separation of cognitive and visceral aspects of emotion, an increased sense of reliving, and increased fragmentation. There was evidence for a partial separation of cognitive judgments of reexperiencing an emotion and reports of visceral symptoms of the emotion, with visceral symptoms correlating more consistently with scores on PTSD tests. Reliving, but not fragmentation of the memories, increased with increases in the trauma relatedness of the event and with increases in scores on standardized tests of PTSD severity.

ABSTRACT Investigated the relationship between the five-factor model of personality and dissociation in a large sample (N = 719) of university students (aged 18-20 yrs). Participants were administered a battery of self-report measures that assessed personality, dissociation and childhood trauma and/or abuse. Significant correlations were found between the dimensions of the five-factor model of personality and dissociation. Cluster analytic techniques were also used to identify personality subtypes among participants scoring above average on the dissociation measure. Three reliable subtypes were identified with one subtype having a profile resembling personality profiles found in samples determined to have psychopathology. Differences among the subtypes were found in the levels of remembered childhood sexual abuse and amnestic dissociative experiences. Possible implications of these results for understanding the relationship between personality, dissociation, and dissociative pathology are discussed.

ABSTRACT The principal aim of this study was to investigate possible neurophysiological underpinnings of self-injurious behavior in women with borderline personality disorder (BPD). Pain report and EEG power spectrum density during a laboratory pain procedure, a 4-min 10 degrees C cold pressor test (CPT), were compared among four groups; female inpatients with BPD who do (BPD-P group, n = 22) and do not (BPD-NP group, n = 19) report pain during self-injury, female inpatients with major depression (n = 15), and normal women (n = 20). The BPD-NP group reported less pain intensity during the CPT compared to the other groups. Total absolute theta power was significantly higher in the BPD-NP group compared to the Depressed (P = 0.0074) and Normal (P = 0.0001) groups, with a trend toward being significantly higher compared to the BPD-P group (P = 0.0936). Dissociative Experience Scale scores were significantly higher in the BPD-NP group compared to the Depressed and Normal groups (maximum P = 0.0004), and significantly higher in the BPD-P group compared to the Normal group (P = 0.0016). Beck Depression Inventory and Sheehan Patient Rated Anxiety Scale scores were significantly lower in the Normal group compared to all patient groups. Theta activity was significantly correlated with pain rating (Pearson partial r = -0.43, P = 0.0001) and Dissociative Experiences Scale score (Pearson partial r = 0.32, P = 0.01).