Child Abuse & Neglect, 23, 1193-1203.

ABSTRACT Investigated the differential effects of sexual and physical abuse in childhood on the quality of reality testing (perceptual disorders and dissociative symptoms) in later adult life. 259 women (aged 18-30 yrs) recruited from college campuses completed self-report measures assessing sexual and physical abuse in childhood as well as current perceptual impairments (reality distortions, uncertainty of perceptions, hallucinations and delusions, and psychoticism) and dissociation (amnesia, absorption and imaginative involvement, and depersonalization and derealization). Ss who reported abuse in childhood dissociated more than nonabused women, although they did not experience more perceptual distortions. Duration of abuse, number of perpetrators, and relationship of perpetrator to victim predicted difficulties in many aspects of reality testing. Ss who reported both childhood sexual abuse and physical abuse were especially prone to acknowledge dissociative phenomena. Findings suggest that college women who report abuse continue to experience acceptable accuracy in their reality testing but, in comparison to their cohorts who have not been abused, more often become "distant" from the world and their own sensory experiences.

ABSTRACT This paper explores the clinical relevance of Jung's idea of the Self in pre-Oedipal and pre-individuation psychology. Incorporating data from neurobiology and recent theories of memory and narrative reconstruction, a post-modern conception of the Self is proposed akin to what Jung called a 'dream of totality.' Such a conception of the Self is distinguished from a reified structure or a deified imago, and is considered to be that aspect of psychological functioning consonant with emerging meanings, and the birth of new psychological ground. Links are made back to T. Flournoy, W. James, and depth psychology's early interest in teleology, the occult, and the creative capacities of the psyche. Updating this mystery tradition, clinical material illustrates how narratives of the Self are present in such pre-Oedipal dynamics as dissociation and projective identification. These dynamics are understood not only as primitive defences but as reconstitutive symbolic metaphors and mythopoetic expressions of an emergent rather than a superordinate Self.

Sapolsky, Robert M. PhD (2000)
Glucocorticoids and Hippocampal Atrophy in Neuropsychiatric Disorders
Arch Gen Psychiatry. 2000;57:925-935

ABSTRACT: An extensive literature stretching back decades has shown that prolonged stress or prolonged exposure to glucocorticoidsthe adrenal steroids secreted during stresscan have adverse effects on the rodent hippocampus. More recent findings suggest a similar phenomenon in the human hippocampus associated with many neuropsychiatric disorders. This review examines the evidence for hippocampal atrophy in (1) Cushing syndrome, which is characterized by a pathologic oversecretion of glucocorticoids; (2) episodes of repeated and severe major depression, which is often associated with hypersecretion of glucocorticoids; and (3) posttraumatic stress disorder. Key questions that will be examined include whether the hippocampal atrophy arises from the neuropsychiatric disorder, or precedes and predisposes toward it; whether glucocorticoids really are plausible candidates for contributing to the atrophy; and what cellular mechanisms underlie the overall decreases in hippocampal volume. Explicit memory deficits have been demonstrated in Cushing syndrome, depression, and posttraumatic stress disorder; an extensive literature suggests that hippocampal atrophy of the magnitude found in these disorders can give rise to such cognitive deficits.

Sanders, B., & Moore, D.L. (1999)
Childhood maltreatment and date rape.
Journal of Interpersonal Violence, 14, 115-124.

ABSTRACT: 30 women college students who reported unwanted sexual experiences judged to constitute date rape were compared with 133 controls who reported no rape. Compared to controls, the date-rape group had significantly higher scores on a measure of overall childhood stress and maltreatment and scored significantly higher on the principal subscale of that measure, which assesses negative home environment/neglect. Date rape participants were also more likely to have experienced sexual abuse in childhood; however the relationship between date rape and other negative childhood experiences remained significant after sexual abuse was partialled out. Thus, forms of maltreatment that are not specifically sexual are also associated with an increased likelihood of sexual victimization later in life. Maltreatment was significantly associated with dissociation, depression, and other psychological symptoms of trauma. Findings are consistent with a model in which the psychological consequences of trauma increase the likelihood of later traumatic experiences

Sar, Vedat MD ; Gamze Akyüz, M.D., Turgut Kundakç, M.D., Emre Kzltan, M.D., and Orhan Doan, M.D.   (2004)
Childhood Trauma, Dissociation, and Psychiatric Comorbidity in Patients With Conversion Disorder
Am J Psychiatry 161:2271-2276, December 2004

ABSTRACT OBJECTIVE: The aim of this study was to evaluate dissociative disorder and overall psychiatric comorbidity in patients with conversion disorder. METHOD: Thirty-eight consecutive patients previously diagnosed with conversion disorder were evaluated in two follow-up interviews. The Structured Clinical Interview for DSM-III-R, the Dissociation Questionnaire, the Somatoform Dissociation Questionnaire, and the Childhood Trauma Questionnaire were administered during the first follow-up interview. The Structured Clinical Interview for DSM-IV Dissociative Disorders was conducted in a separate evaluation. RESULTS: At least one psychiatric diagnosis was found in 89.5% of the patients during the follow-up evaluation. Undifferentiated somatoform disorder, generalized anxiety disorder, dysthymic disorder, simple phobia, obsessive-compulsive disorder, major depression, and dissociative disorder not otherwise specified were the most prevalent psychiatric disorders. A dissociative disorder was seen in 47.4% of the patients. These patients had dysthymic disorder, major depression, somatization disorder, and borderline personality disorder more frequently than the remaining subjects. They also reported childhood emotional and sexual abuse, physical neglect, self-mutilative behavior, and suicide attempts more frequently. CONCLUSIONS: Comorbid dissociative disorder should alert clinicians for a more chronic and severe psychopathology among patients with conversion disorder.

Sar, Vedat MD ; Kundakci, Turgut; Kiziltan, Emre; Yargic, L Ilhan; Tutkun, Hamdi; Bakim, Bahadir; Bozkurt, Oya; Ozpulat, Tuba; Keser, Vehbi; Ozdemir, Ozay.   (2003)
The Axis-I dissociative disorder comorbidity of borderline personality disorder among psychiatric outpatients
Journal of Trauma and Dissociation (ISSN: 1529-9732), v. 4, no. 1, pp. 119-136 (2003). 5-25

ABSTRACT The aim of this study was to determine the frequency of dissociative disorders among psychiatric outpatients with borderline personality disorder (BPD). In order to ascertain the extent of the overlap between two diagnostic groups, the overall prevalence of both disorders were evaluated. 240 consecutive patients who presented to a university outpatient psychiatry unit were screened using the self-report questionnaire version of the BPD section of Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II), the Dissociative Experiences Scale (DES), and the Somatoform Dissociation Questionnaire (SDQ). 129 participants who had a score above the cut-off point on at least one of these instruments were evaluated using the interview version of the BPD section of the SCID-II, the Dissociative Disorders Interview Schedule (DDIS), and the PTSD module of the Structured Clinical Interview for DSM-III-R (SCID-I). All participants who were diagnosed as having BPD or a dissociative disorder were evaluated then with the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). 25 participants (10.4 percent) had BPD and 33 participants (13.8 percent) had dissociative disorder in the final evaluation. 16 participants (64.0 percent) with BPD had the Axis I diagnosis of a dissociative disorder; all 6 participants (2.5 percent) with dissociative identity disorder were among them. The findings demonstrate that a significant part of psychiatric outpatients who fit the criteria of BPD have a DSM-IV dissociative disorder on Axis I. The presence of dissociative symptoms as a part of BPD should not lead to overlooking the possibility of a co-occurring dissociative disorder.

Sar, Vedat MD ; Ozturk, Erdinc; Kundakci, Turgut.   (2002)
Psychotherapy of an adolescent with dissociative identity disorder: change in Rorschach patterns.
Journal of Trauma and Dissociation (ISSN: 1529-9732), v. 3, no. 2, pp. 81-95 (2002).

ABSTRACT A female adolescent with dissociative identity disorder was assessed using structured interviews and the Rorschach test before and after one year of individual psychotherapy. In addition to improvement in several comorbid psychiatric disorders, according to the structured evaluation, criteria for neither dissociative identity disorder nor borderline personality disorder were met at the second evaluation. The main differences on the Rorschach assessments before and after integration were in the development of form-dominated color and human movement responses and a diminution in the externally focused coping style. The differences were interpreted as improvement in aggressiveness, impulsivity, anxiety, and better identification with social environment. This case study suggests that the Rorschach test can be used to evaluate the change of patients with dissociative identity disorder in psychotherapy. KEY WORDS: dissociative identity disorder, borderline personality disorder, psychotherapy, Rorschach test

Sar, Vedat MD ; Seher N. Unal, MD; Emre Kiziltan, MD; Turgut Kundakci, MD; Erdinc Ozturk, MA   (2001)
HMPAO SPECT Study of Re gional Cerebral Blood Flow in Dissociative Identity Disorder
Journal of Trauma and Dissociation, Vol.:2, nr.2 2001; 5-25

ABSTRACT The aim of the study was to investigate if there were any characteristics of regional cerebral blood flow (rCBF) in dissociative identity disorder. Fifteen patients with dissociative identity disorder and eight healthy volunteers participated in the study. The clinical diagnosis of dissociative identity disorder was confirmed using the Structured Clinical Interview for DSM-IV Dissociative Disorders. The Structured Clinical Interview for DSM-III-R was also administered to all patients in order to screen comorbid psychiatric conditions. Regional cerebral blood flow was studied using a SPECT system with Tc99m-hexamethyl propylenamine (HMPAO) as a tracer. The rCBF ratio was de creased in orbito-frontal region bilaterally and increased in left (dominant hemisphere) lateral temporal region among patients with dissociative identity disorder when compared to the control group. The structured in ter view diagnoses of concurrent or life time major de pression, PTSD, psychotic disorder, or ongoing drug treatment were not significantly related to perfusion in these regions. There was no statistically meaningful difference in rCBF ratios between host and alter personality states. Our findings suggest that orbito-frontal and left (dominant hemisphere) lateral temporal regions are affected in dissociative identity disorder. A replication of this study on a larger group of drug-free dissociative patients and various psychiatric control groups would lead to more definitive findings.

Sar, Vedat MD ; Hamdi Tutkun , Behiye Alyanak, Bahadir Bakim, Isin Baral   (2000)
Frequency of Dissociative Disorders among psychiatric outpatients in Turkey
Journal Comprehensive Psychiatry (may-june) - Turkey

ABSTRACT The aim of this study was to determine the frequency of dissociative disorders among psychiatric outpatients in Turkey. 150 consecutive outpatients admitted to the psychiatry clinic of a university hospital were screened with the Dissociative Experiences Scale. Twenty-three (15.3 %) patients with a Dissociative Experiences Scale score above 30 and a comparison group selected from the same outpatient population who scored below 10 on the scale were then interviewed with the Dissociative Disorders Interview Schedule in a blind fashion. According to the Dissociative Disorders Interview Schedule, eight-teen patients (12.0 %) were diagnosed as having a dissociative disorder. 83.3 % (N=15) of the dissociative patients reported neglect, 72.2 % (N=13) emotional abuse, 50.0 % (N=9) physical abuse, and 27.8 % (N=5) sexual abuse during childhood. Dissociative disorders are not rare among psychiatric outpatients. Self-rating instruments and structured interviews can be used successfully for screening dissociative disorders which are usually underrecognized. Neglect was the most frequently reported type of childhood trauma suggesting the importance of other childhood experiences in addition to sexual and/or physical abuse in the development of dissociative psychopathology.

Sar, Vedat MD ; Dogan, O.;  Yargic, L.I.; Tutkun, H. (1999)
Frequency of dissociative identity disorder in the general population in Turkey
Comprehensive Psychiatry, 40, 151-159. - Turkey

ABSTRACT Determined the prevalence of dissociative identity disorder in the general population. The Dissociative Experiences Scale (DES) was administered to 994 subjects in 500 homes who constituted a representative sample of the population of Sivas City, Turkey. The mean DES score was 6.7+-6.1. Of the 62 respondents who scored above 17 on the DES, 32 could be contacted during the 2nd phase of the study. They were matched for age and gender with a group of respondents who scored below 10 on the scale, and the Dissociative Disorders Interview Schedule (DDIS) was then administered to both groups. 17 subjects received a diagnosis of dissociative disorder according to the structured interview. In the third phase, 8 of 17 subjects who had a dissociative disorder on the structured interview could be contacted for a clinical evaluation. Four of 8 subjects were diagnosed clinically with dissociative identity disorder, yielding a minimum prevalence of 0.4%. Data suggest that dissociative identity disorder cannot be considered simply an iatrogenic artifact, a culture-bound syndrome, or a phenomenon induced by media influences.

Saxe GN , Chawla N, Van der Kolk B. (1999)
Department of Child and Adolescent Psychiatry, Boston University School of Medicine, MA, USA.
Self-destructive behavior in patients with dissociative disorders.
Suicide Life Threat Behav 2002 Fall;32(3):313-20

ABSTRACT Highrates of self-injury have been reported in patients with dissociative disorders, yet no prior study has directly compared these patients with other psychiatric patients. The present study assesses self-destructive behavior in a group of inpatients who have dissociative disorders compared to those who report few dissociative symptoms. These patients more frequently engage in self-destructive behaviors, use more methods of self-injury, and begin to injure themselves at an earlier age then patients who do not dissociate. Results have important implications for understanding the relationship between dissociation, childhood trauma, and self-injury and for assessment and treatment of patients with dissociative disorders.

Scheflin AW (2000)
The evolving standard of care in the practice of trauma and dissociative disorder therapy.   
Bull Menninger Clin 2000 Spring;64(2):197-234

ABSTRACT The standard of care for the delivery of mental health services has recently undergone a dramatic change spurred on by hundreds of lawsuits against therapists and by erupting controversies in the science of trauma and dissociative disorders. The nature of these changes and the forces that created them are discussed. Risk management suggestions are provided.

Schmahl CG, Elzinga BM, Vermetten E, Sanislow C, McGlashan TH, Bremner JD. (2003)
Neural correlates of memories of abandonment in women with and without borderline personality disorder.  
Biol Psychiatry. 2003 Jul 15;54(2):142-51.

ABSTRACT BACKGROUND: Borderline personality disorder (BPD) is a common psychiatric disorder that is often linked to early stressors. One particularly salient feature of the disorder is fear of abandonment. This pilot study was conducted to measure neural correlates of memories of abandonment in women with and without BPD. METHODS: Twenty women with a history of childhood sexual abuse underwent measurement of brain blood flow with positron emission tomography imaging while they listened to scripts describing neutral and personal abandonment events. Brain blood flow during exposure to abandonment and neutral scripts was compared among women with and without BPD. RESULTS: Memories of abandonment were associated with greater increases in blood flow in bilateral dorsolateral prefrontal cortex (middle frontal gyrus, Brodmann's areas 9 and 10) as well as right cuneus (area 19) in women with BPD than in women without BPD. Abandonment memories were associated with greater decreases in right anterior cingulate (areas 24 and 32) in women with BPD than in women without BPD. CONCLUSIONS: These findings implicate dysfunction of dorsolateral and medial prefrontal cortex including anterior cingulate, left temporal cortex, and visual association cortex in memories of abandonment in women with BPD. These brain areas may mediate symptoms of BPD.

Shielagh R. Shusta-Hochberg PhD (2004)
Therapeutic Hazards of Treating Child Alters as Real Children in Dissociative Identity Disorder   
Journal of Trauma and Dissociation: vol. 5 issue 1 , 2004 Page Range: 13 - 27 DOI: 10.1300/J229v05n01_02

ABSTRACT Dissociative identity disorder (DID), with its typical etiology of extreme, repetitive childhood trauma, usually includes manifestations of childlike ego-states, among others. For many patients, these ego-states, originating with the initial traumatic insults to the psyche in childhood, have been called forth again and again as new situations evoke the earlier trauma. When clinicians, family and friends react to them with warmth, nurturing, and empathy, this may exacerbate the illusion that such ego-states are indeed actual children. This can result in a patient becoming increasingly resistant to working through the issues and experiences by which these ego-states have become fixed, with the risk of therapy reaching an impasse. Attitudes, interventions, and approaches to move past such impasses are addressed.

Schneider JA. (2003)
Institute for Psychoanalytic Studies, Department of Psychiatry, University of California, San Francisco, USA. drjaschneider@yahoo.com
Working with pathological and healthy forms of splitting: a case study.   
Bull Menninger Clin. 2003 Winter;67(1):32-49.

ABSTRACT The author illustrates through a case discussion how he understands the concept of splitting and how he makes use of that understanding in tracking, and at times, interpreting movement of the unconscious transference and countertransference. He views splitting not simply as a primitive defense but also as essential to early emotional development and to healthy psychological maturation in the course of analytic work. In the analytic relationship discussed in this article, the author presents both aspects of splitting--as a primitive defense and as a healthy movement toward new and more complex object relatedness. Difficulties arise when one fails to distinguish pathological from healthy but immature forms of splitting. Healthy splitting in its beginnings represents an important developmental step that serves as a transition to ambivalence and mature integration. The author demonstrates the importance of the analyst's capacity to distinguish pathological splitting from healthy splitting during periods of analytic impasse.

Schooler, Jonathan W. (2001)
Discovering memories of abuse in the light of meta-awareness.  
Journal of Aggression, Maltreatment and Trauma (ISSN: 1092-6771), v. 4, no. 2, pp. 105-136 (2001).

ABSTRACT Discovered memories of abuse are often viewed with marked skepticism due to the relative dearth of well-corroborated evidence for their occurrence and the absence of a compelling theory to explain them. This article addresses these concerns by reviewing seven recovered (or, as will be explained, what I prefer to term "discovered") memory cases in which there was independent corroborative evidence for the alleged abuse. These cases are considered within the context of a theory of meta-awareness that assumes that experiential consciousness (i.e., the contents of phenomenological experience) can be distinct from meta-awareness (i.e., one's consciousness of their consciousness). In this context, discovered memories can be understood as involving changes in individuals' meta-awareness of the abuse. In some cases, discovered memories may involve the gaining of a different meta-awareness of the meaning of an experience. The discovery of this new meaning may become confused with the discovery of the memory itself, leading to the (sometimes erroneous) belief that the memory is just now being accessed for the first time. In other cases, the discovery may involve the regaining of a prior meta-awareness of the experience that either deliberately or non-deliberately may have been avoided for some time. In still other cases, the discovery may actually involve the gaining of a previously non-existent meta-awareness of the experience. A variety of factors ranging from the very straightforward (e.g., age, lack of discussion, stress) to the more esoteric (e.g., dissociation, nocturnal cognitive processing) may prevent incidents of abuse from being initially encoded with meta-awareness. Such non-reflected memories, particularly when they are aschematic and disjunctive with other experiences, may continue to elude meta-awareness until a specific (and potentially obscure) contextual retrieval cue is encountered. Once recalled in the alarming light of meta-awareness, individuals may understand what happened to them, and this discovery may fundamentally change their view of their personal histories.

Schuengel, C., Bakermans-Kranenburg, M.J., Van IJzendoorn, M.H. (1999)
Universiteit Leiden, The Netherlands  
Frightening maternal behavior linking unresolved loss and disorganized infant attachment(click for reprint)
Journal of Consulting and Clinical Psychology, 67, 54-63.

ABSTRACT Main and Hesse's (1990) model in which frightening (threatening, frightened, or dissociated) parental behavior explains why infants of parents with unresolved loss develop disorganized attachment relationships was tested. Unresolved loss using the Adult Attachment Interview in a nonclinical middle-class sample of 85 mothers who had experienced the loss of someone important was assessed. Disorganized attachment was examined in the Strange Situation. Parental behavior was recorded during 2 2-hr home visits. The model applied to mothers with currently insecure attachment representations. Secure mothers with unresolved loss displayed less frightening behavior than other mothers, and unresolved loss in secure mothers did not predict disorganized attachment of their infants. Frightening behavior predicted infant disorganized attachment irrespective of maternal security.

Schuffa, Norbert Thomas C. Neylanb, Maryanne A. Lenocib, An-Tao Dua, Daniel S. Weissb, Charles R. Marmarb and Michael W. Weinera, (2001)
Decreased hippocampal N-acetylaspartate in the absence of atrophy in posttraumatic stress disorder
JBiological Psychiatry,Volume 50, Issue 12,15 December 2001,Pages 952-959

ABSTRACT Background: Previous magnetic resonance imaging studies of posttraumatic stress disorder reported hippocampal volume loss. The goals of this study were 1) to determine the relationship between hippocampal atrophy and posttraumatic stress disorder in the absence of alcohol abuse, and 2) to test if loss of N-acetylaspartate (a neuron marker) in the hippocampus of posttraumatic stress disorder occurs separate from atrophy. In addition, volume changes in the entorhinal cortex were also explored. Methods: Eighteen male patients with combat-related posttraumatic stress disorder (mean age 51.2 ± 2.5 years) and 19 male control subjects (mean age 51.8 ± 3.2 years) were studied using magnetic resonance imaging and Proton magnetic resonance spectroscopic imaging. Both groups had no alcohol and drug abuse during the past 5 years. Results: Posttraumatic stress disorder and control subjects had similar volumes of hippocampus and entorhinal cortex. In contrast to volume, N-acetylaspartate was significantly reduced by about 23% bilaterally in the hippocampus of posttraumatic stress disorder when compared with control subjects, and creatine-containing compounds were reduced by 26% in the right hippocampus of posttraumatic stress disorder. Conclusions: N-acetyl asparate and creatine reductions imply that there are hippocampal abnormalities in posttraumatic stress disorder. Furthermore, these metabolite changes seem to be better indicators of posttraumatic stress disorder pathology than volume losses.

Scroppo, Joe C.; Drob, Sanford L.; Weinberger, Joel L.; Eagle, Paula (1998)
Identifying dissociative identity disorder: A self-report and projective study.
Journal of Abnormal Psychology. 1998 May Vol 107(2) 272-284

ABSTRACT This study compared 21 female adult psychiatric patients diagnosed with dissociative identity disorder (DID) with 21 female adult nondissociative psychiatric patients to determine whether DID patients exhibit a distinguishing set of clinical features, and perceptual, attentional, and cognitive processes. Participants were assessed with the Dissociative Disorders Interview Schedule to assess diagnostic status. Group scores on the Dissociative Experiences Scale, Tellegen Absorption Scale, Childhood Trauma Questionnaire, Brief Symptom Inventory, and the Rorschach test were compared. DID participants reported earlier and more severe childhood trauma, more dissociative symptoms, and a greater propensity for altered states of consciousness. The DID participants also exhibited increased projective and imaginative activity, a diminished ability to integrate mental contents, a complex and driven cognitive style, and a highly unconventional view of reality. (PsycINFO Database Record (c) 2002 APA, all rights reserved)

Segman RH, Shalev AY. (2003)
Department of Psychiatry, Hadassah Hebrew University Medical Center, Jerusalem, Israel. sronen@md2.huji.ac.il
Genetics of posttraumatic stress disorder.
CNS Spectr. 2003 Sep;8(9):693-8.

ABSTRACT Posttraumatic stress disorder (PTSD) is a prevalent anxiety disorder marked by behavioral, physiologic, and hormonal alterations. PTSD is disabling and commonly follows a chronic course. The etiology of PTSD is unknown, although exposure to a traumatic event constitutes a necessary, but not sufficient, factor. A twin study of Vietnam veterans has shown significant genetic contribution to PTSD. The fact that PTSD's underlying genotypic vulnerability is only expressed following trauma exposure limits the usefulness of family-based linkage approaches. In contrast to the other major psychiatric disorders, large studies for the search of underlying genes have not been described in PTSD to date. Complementary approaches for locating involved genes include association-based studies employing case-control or parental genotypes for transmission dysequilibrium analysis and quantitative trait loci studies in animal models. Identification of susceptibility genes will increase our understanding of traumatic stress disorders and help to elucidate their molecular basis. The current review provides an up-to-date outline of progress in the field of PTSD.

Shapiro, F. (1999)
Eye Movement Desensitization and Reprocessing (EMDR) and the anxiety disorders: clinical and research implications of an integrated psychotherapy treatment   
Journal of Anxiety Disorders Vol. 13 (1999), no.1-2 (jan-apr), pag. 35-67

ABSTRACT Four recent, independent, rigorously controlled studies of Eye Movement Desensitization and Reprocessing (EMDR) have reported that 84 to 100% of single-trauma victims no longer maintain the posttraumatic stress disorder diagnosis after the equivalent of three 90-minute sessions. The rapidity of EMDR treatment effects makes many ancillary research opportunities available. Specifically, the increased number of cases resolved in a relatively short period of time allows investigation of neurophysiological phenomena, patterns of cognitive and emotional processing, component analyses of a large range of procedural factors, and evaluation of the efficacy of application to diverse clinical populations. Unfortunately, some research has been conducted that has been severely hampered by insufficient treatment fidelity and lack of clinical validity. Consequently, this article will attempt to describe the procedures and protocols that are believed to contribute to EMDR's clinical effects and are, therefore, suggested for the EMDR treatment and research of the anxiety disorders. This is particularly relevant given the misconceptions that have abounded due to the unfortunate naming of the procedure after the eye movements, which have proved to be only one of many useful types of stimulation, and only one of many components of this complex, integrated treatment.

Shapiro DL, Levendosky AA (1999).
Department of Psychology, Michigan State University, East Lansing 48824, USA.  
Adolescent survivors of childhood sexual abuse: the mediating role of attachment style and coping in psychological and interpersonal functioning.   
Child Abuse Negl 1999 Nov;23(11):1175-91

ABSTRACT OBJECTIVE: To examine attachment style and coping strategies as potential mediating variables between childhood sexual abuse (CSA) and psychological and interpersonal functioning in an attempt to explain variability in extent of disorder and level of functioning. METHOD: Eighty adolescent females, aged 14-16 years, answered questions regarding abuse history, attachment style, coping with an interpersonal stressor, depression and trauma symptomatology, and conflict with a best friend. RESULTS: Structural equation modeling analyses indicated that attachment style mediates the effects of CSA and child abuse and neglect on coping and psychological distress. The indirect effects of CSA and other abuse through attachment accounted for most of the effects on coping and psychological distress. Avoidant and cognitive coping strategies also served as mediators in the models, accounting for most of the effects of the other variables on interpersonal conflict. CONCLUSIONS: The findings indicate that attachment style and coping strategies influence psychological and interpersonal functioning, mediating the direct effects of CSA and other types of child abuse and neglect. These results have implications for therapeutic intervention with children and adolescents who have experienced child abuse.

ABSTRACT Controversies have centered on the prevalence of dissociative symptoms and disorders in children and adolescents, recommended treatment approaches, and the potential effects of of suggestive interpersonal influences. Convergence among diverse practioners describing dissociative children and adolescents with similar symptoms and maltreatment histories supports the occurrence of these symptom patterns. Although prevalence information has not been well studied, dissociative symptoms may be found in children from a a variety of settings across a continuum of severity. There is not yet agreement on exact treatment protocols, but successful treatment outcomes have been reported. A challenge for future research is to develop assessment protocols that are derived from multiple sources of data, and to incoporate the latest developmental research findings into theory development that adressess psychobiological , family and cultural factors. The study of dissociatation in children and adolescents has the potential to clarify some puzzling child and adolescent presentations and to identify a process by which some children respond and adapt to traumatic environments.

ABSTRACT The purpose of this study was to investigate psychological testing features of children and adolescents with dissociative disorder diagnoses to provide diagnostic information that might facilitate early intervention. The psychological testing protocols of 30 children diagnosed with dissociative disorders were compared with the testing protocols of 30 consecutive admissions to the Sheppard Pratt Hospital who did not receive a dissociative identity disorder (DID; formerly termed multiple personality disorder) or dissociative disorder not otherwise specified (DDNOS) diagnosis. A rater, blind to the diagnosis, scored these protocols for the presence or absence of behavioral and testing response variables hypothesized to discriminate between the dissociative patients and the mixed group of other diagnoses. Behavioral features significantly more common in the dissociative group included forgetting, staring, unusual motor behaviors, dramatic fluctuations, fearful and angry reactions to stimuli, physical complaints during testing, and expressions of internal conflict. Significant indications of dissociation in the test responses included images of multiplicity, malevolent religiosity, dissociative coping, depersonalized imagery, emotional confusion, extreme dichotomization, images of mutilation and torture, and magical transformation. A combination of these behavioral and response variables was able to select 93% of the dissociative sample. These results add support to the discriminant validity of DID and DDNOS as diagnostic categories in childhood and provide clinical information that may be useful for early diagnosis of traumatized children with dissociative pathology.

ABSTRACT OBJECTIVE: The purpose of this study was to investigate temperamental, psychodynamic, and cognitive factors associated with dissociation. METHOD: Fifty-three subjects with DSM-IV-defined depersonalization disorder and 22 healthy comparison subjects were administered the Dissociative Experiences Scale, the Tridimensional Personality Questionnaire, the Defense Style Questionnaire, and the Schema Questionnaire. RESULTS: Subjects with depersonalization disorder demonstrated significantly greater harm-avoidant temperament, immature defenses, and overconnection and disconnection cognitive schemata than comparison subjects. Within the group of subjects with depersonalization disorder, dissociation scores significantly correlated with the same variables. CONCLUSIONS: Particular personality factors may render individuals more vulnerable to dissociative symptoms. Risk factors associated with dissociative disorders merit further study.

ABSTRACT OBJECTIVE: In contrast to trauma’s relationship with the other dissociative disorders, the relationship of trauma to depersonalization disorder is unknown. The purpose of this study was to systematically investigate the role of childhood interpersonal trauma in depersonalization disorder.
METHOD: Forty-nine subjects with DSM-IV depersonalization disorder and 26 healthy comparison subjects who were free of lifetime axis I and II disorders and of comparable age and gender were administered the Dissociative Experiences Scale and the Childhood Trauma Interview, which measures separation or loss, physical neglect, emotional abuse, physical abuse, witnessing of violence, and sexual abuse.
RESULTS: Childhood interpersonal trauma as a whole was highly predictive of both a diagnosis of depersonalization disorder and of scores denoting dissociation, pathological dissociation, and depersonalization. Emotional abuse, both in total score and in maximum severity, emerged as the most significant predictor both of a diagnosis of depersonalization disorder and of scores denoting depersonalization but not of general dissociation scores, which were better predicted by combined emotional and sexual abuse. The majority of the perpetrators of emotional abuse were either or both parents. Although different types of trauma were modestly correlated, only a few of these relationships were statistically significant, underscoring the importance of comprehensively considering different types of trauma in research studies.
CONCLUSIONS: Childhood interpersonal trauma and, in particular, emotional abuse may play a role in the pathogenesis of depersonalization disorder. Compared to other types of childhood trauma, emotional maltreatment is a relatively neglected entity in psychiatric research and merits more attention.

ABSTRACT OBJECTIVE: The goal of this study was to assess brain glucose metabolism and its relationship to dissociation measures and clinical symptoms in DSM-IV depersonalization disorder. METHOD: Positron emission tomography scans coregistered with magnetic resonance images of eight subjects with depersonalization disorder were compared to those of 24 healthy comparison subjects. The two groups did not differ in age, sex, education, performance on a baseline neuropsychological battery, or performance on a verbal learning task administered during [18F]fluorodeoxyglucose uptake. A cortical analysis by individual Brodmann’s areas was performed. RESULTS: Compared to the healthy subjects, subjects with depersonalization disorder showed significantly lower metabolic activity in right Brodmann’s areas 22 and 21 of the superior and middle temporal gyri and had significantly higher metabolism in parietal Brodmann’s areas 7B and 39 and left occipital Brodmann’s area 19. Dissociation and depersonalization scores among the subjects with depersonalization disorder were significantly positively correlated with metabolic activity in area 7B. CONCLUSIONS: Depersonalization appears to be associated with functional abnormalities along sequential hierarchical areas, secondary and cross-modal, of the sensory cortex (visual, auditory, and somatosensory), as well as areas responsible for an integrated body schema. These findings are in good agreement with the phenomenological conceptualization of depersonalization as a dissociation of perceptions as well as with the subjective symptoms of depersonalization disorder.

ABSTRACT Objective: In contrast to the recent surge of interest in other dissociative disorders, DSM-III-R depersonalization disorder has not been thoroughly investigated and characterized. The authors systematically elucidated its phenomenology, comorbidity, traumatic antecedents, and treatment history. Method: Thirty adult subjects (19 women and 11 men) were consecutively recruited and administered various structured and semistructured interviews as well as the self-rated Dissociative Experiences Scale. An age- and sex-matched normal comparison group was also recruited. Results: The mean age at onset of depersonalization disorder was 16.1 years (SD = 5.2). The illness had a chronic course that was usually continuous but sometimes episodic. Severe distress and high levels of interpersonal impairment were characteristic. Unipolar mood and anxiety disorders were common, but none emerged as specifically related to the depersonalization. A wide variety of personality disorders was manifested; avoidant, borderline, and obsessive-compulsive were most common. Although not highly traumatized, the subjects with depersonalization disorder reported significantly more childhood trauma than the normal comparison subjects. Depersonalization had been typically treatment refractory; only serotonin reuptake inhibitors and, to a lesser extent, benzodiazepines had been of any therapeutic benefit. Conclusions: This study supports the conceptualization of depersonalization disorder as a distinct disorder with a characteristic course that is independent of mood, anxiety, and personality symptoms. A subtle relationship may exist between childhood trauma and depersonalization disorder that merits further investigation. The disorder appears to be highly treatment refractory, and prospective treatment trials are warranted.

ABSTRACT OBJECTIVE: The authors describe obstacles to children’s disclosure of their sexual abuse experiences. METHOD: Ten children's descriptions of 102 incidents of sexual abuse and the process of disclosing these incidents during police interviews were studied. Children's self-reports of the abuse were compared to videotapes of the incidents made by the lone perpetrator. RESULTS: There was a significant tendency among the children to deny or belittle their experiences. Some children simply did not want to disclose their experiences, some had difficulties remembering them, and one child lacked adequate concepts to understand and describe them. CONCLUSIONS: Failure by children to disclose their experiences of sexual abuse might have diverse explanations. Professionals will most likely never be able to identify all cases of sexual abuse on the basis of children's narratives.

Child Abuse Negl 2000 Feb;24(2):273-87

ABSTRACT OBJECTIVE: This study sought to gather representative data regarding the length of time women who were raped before age 18 delayed prior to disclosing such rapes, whom they disclosed to, and variables that predicted disclosure within 1 month. METHOD: Data were gathered from 3,220 Wave II respondents from the National Women's Study (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993), a nationally representative telephone survey of women's experiences with trauma and mental health. Of these, 288 retrospectively reported at least one rape prior to their 18th birthday. Details of rape experiences were analyzed to identify predictors of disclosure within 1 month. RESULTS: Fully 28% of child rape victims reported that they had never told anyone about their child rape prior to the research interview; 47% did not disclose for over 5 years post-rape. Close friends were the most common confidants. Younger age at the time of rape, family relationship with the perpetrator, and experiencing a series of rapes were associated with disclosure latencies longer than 1 month; shorter delays were associated with stranger rapes. Logistic regression revealed that age at rape and knowing the perpetrator were independently predictive of delayed disclosure. CONCLUSIONS: Delayed disclosure of childhood rape was very common, and long delays were typical. Few variables were identified that successfully predicted disclosure behavior, but older age and rape by a stranger were associated with more rapid disclosure. This suggests that the likelihood of disclosure in a given case is difficult to estimate, and predictions based on single variables are unwarranted.

ABSTRACT Dissociative Identity Disorder (DID) is a controversial diagnosis and empirical data on the efficacy of treatment modalities are scanty. The objective of this study was to explore the frequency of the diagnosis, the types and efficacy of prevailing treatment practices, and to examine demographic data on patients in the Netherlands. A questionnaire, including questions on one selected DID patient, was mailed to 1,452 Dutch psychiatrists. The response rate was 46.7%. A total of 273 psychiatrists reported having made the diagnosis at least once. The diagnosis was made in a statistically significant manner more frequently by female psychiatrists, by psychiatrists aged 50 years or younger, and by those certified after 1982. No correlation was observed with primary theoretical orientation or the type or topography of work facility. The mean age of the selected patients was 33.2 and the male:female (M:F) ratio 1:9. The majority of patients were seen once a week in an outpatient setting. Individual psychotherapy and adjunctive anxiolytic or antidepressant medications were the most widely endorsed treatment modalities. Hypnosis was rarely used. We conclude that the diagnosis of DID is not to be dismissed as a local eccentricity. It is warranted as an explanatory framework in the context of a psychotherapeutic treatment.

ABSTRACT The Multidimensional Inventory of Dissociation (MID; Dell, 2004b) has 168 dissociation items and 50 validity items. The MID assesses 14 major facets of dissociation, 23 symptoms of dissociation, and has 5 validity scales. The MID operationalizes (a) the subjective/ phenomenological domain of dissociation, and (b) 23 hypothesized symptoms of dissociative identity disorder (DID). This article describes the development of a Hebrew version of the MID (H-MID). In a sample of clinical and nonclinical research participants, the H-MID had strong internal consistency, temporal stability, and strong structural, convergent, discriminant, and construct validity. In addition, mean H-MID scores demonstrated incremental validity over the Hebrew Dissociative Experiences Scale (H-DES) by predicting an additional 17% of the variance in weighted trauma scores on the Traumatic Experiences Questionnaire (TEQ). Factor analysis of the H-MID extracted a single factor: dissociation. Both the MID and the subjective/phenomenological concept of pathological dissociation appear to have applicability not only in North America, but also in a heterogeneous Middle Eastern culture.

ABSTRACT Objectives: The purpose of this research was to explore the validity of the concept of dissociation as measured by a Hebrew version of the Dissociative Experiences Scale (H-DES) in Israel. Design: The first study examined the reliability and validity of the H-DES by assessing 340 consecutive admissions to an Israeli out patient clinic, and 290 non-clinical subjects. The second study explored the construct validity of the concept of dissociation by studying relationships between reported past traumatization and current levels of dissociation among a different cohort of 70 women Israeli out patients. Results: The H-DES has good test re test and split-half reliability in clinical and non-clinical subjects, and is in ternally consistent. Its convergent validity with the MMPI 2 Philips Dissociation Scale is good, and it has good criterion related validity with DSM-IV dissociative disorder diagnoses. The concept of dissociation as measured in Israel by the H-DES has high reliability and validity. Conclusions: The reliable identification of dissociative experiences in Israel as well as in several cultures out side North America supports dissociation as a valid psychological construct with wide spread cross-cultural applicability. This study contradicts claims that dissociation is merely a passing North American professional fashion.

ABSTRACT BACKGROUND: The lack of prospective studies and data on male victims leaves major questions regarding associations between child sexual abuse and subsequent psychopathology. AIMS: To examine the association between child sexual abuse in both boys and girls and subsequent treatment for mental disorder using a prospective cohort design.
METHOD: Children (n=1612; 1327 female) ascertained as sexually abused at the time had their histories of mental health treatment established by data linkage and compared with the general population of the same age over a specified period.
RESULTS: Both male and female victims of abuse had significantly higher rates of psychiatric treatment during the study period than general population controls (12.4% v. 3.6%). Rates were higher for childhood mental disorders, personality disorders, anxiety disorders and major affective disorders, but not for schizophrenia. Male victims were significantly more likely to have had treatment than females (22.8% v.10.2%).
CONCLUSIONS: This prospective study demonstrates an association between child sexual abuse validated at the time and a subsequent increase in rates of childhood and adult mental disorders.

ABSTRACT The current nosology, while less than perfect, has both been refined and has stood the test of time in describing the specific phenomenology associated with the failure in integrative processes that we know as the dissociative disorders. [Text, p. 56]

ABSTRACT In the debate on memories of traumatic events (especially childhood abuse), traumatic memories and dissociative amnesia are central topics. These phenomena are frequently described as dissociative memory problems. The aim of the present article is to assess to what extent memory mechanisms as identified in experimental research (such as encoding, storage and retrieval factors) are adequate in explaining memories of traumatic experiences. It will be argued that dissociative memory problems can partly be accounted for by processes as identified in experimental laboratory studies, especially diminished rehearsal, intentional forgetting, encoding specificity, and implicit memory. A limitation of available experimental studies, however, is that ethics preclude other designs than inducing artificial, nontraumatic stress to mostly normal subjects. This research strategy may obscure the existence of a possible inverse relationship between stress and memory functions.

ABSTRACT The White Bear Suppression Inventory (WBSI) aims to measure the general tendency to suppress unwanted negative thoughts. The aims of the present study were: (1) to assess the psychometric properties of the WBSI in a clinical population; (2) to evaluate the association of the WBSI with dimensional and categorical measures of psychopathology; and (3) to explore the relationship of the WBSI with measures for dissociation while controlling for level of psychopathology. In a sample of 254 consecutive psychiatric outpatients (mean age 35.7 yrs) the factor structure and internal consistency of the WBSI were found to be good. Moreover, WBSI scores were significantly and positively related to all of the dimensional measures for psychopathology of the Symptom Checklist-90 and did not differ between patients with a Mental Disorders-IV (DSM-IV) anxiety disorder, affective disorder, or no psychiatric diagnosis. Finally, WBSI scores were unrelated to measures for proneness to dissociation while controlling for level of psychopathology. It is concluded that (1) thought suppression is a common phenomenon among psychiatric patients with various complaints; and (2) that dissociation is not related to thought suppression.

ABSTRACT In the debate on memories of traumatic events (especially childhood abuse), traumatic memories and dissociative amnesia are central topics. These phenomena are frequently described as dissociative memory problems. The aim of the present article is to access to what extent memory mechanisms as identified in experimental research (such as encoding, storage, and retrieval factors) are adequate in explaining memories of traumatic experiences. It is argued that dissociative memory problems can be partly be accounted for by processes as identified in experimental laboratory studies, especially diminished rehearsal, intentional forgetting, encoding specificity, and implicit memory. A limitation of available experimental studies, however, is that ethics preclude other designs than inducing artificial, nontraumatic stress to mostly normal Ss. This research strategy may obscure the existence of a possible inverse relationship between stress and memory.

ABSTRACT : A working party of the Royal College of Psychiatrist has issued a report on retrieved recollections of sexual abuse during childhood and drawn up guidelines for the coping with such recollections. In contradiction to what the working party is asserting, amnesia for sexual abuse in the past may not be excluded. The working party's conclusion that false recollections of negative events can be induced in susceptible persons may be endorsed. As the working party also states, extreme caution is to be exercised in coping with retrieved recollections of childhood traumas, in which no reliable distinction can be made between true and false recollections because independent and objective evidence is often lacking.

ABSTRACT Although there is a large psychiatric literature on various "borderline" conditions, there has been no agreement as to the definition of the concept. A review of the literature reviewed two major uses of the term: Borderline Schizophrenia and Borderline Personality. Two item sets were developed to provide diagnostic criteria for the two concepts. High sensitivity and specificity were demonstrated for both item sets using data describing 808 borderline and 808 control patients. These criteria will be used in the forthcoming DSM-III classification for the categories of Borderline Personality Disorder and Schizotypal Personality Disorder

ABSTRACT This study compared the reports of satanic, sexual, and physical abuse of persons instructed to role-play either dissociative identity disorder (DID) (n = 33), major depression (n = 33), or a college student who experienced minor adjustment problems ("normal") (n = 33) across a number of trials that included role-played hypnosis. As hypothesized, more of the participants who were asked to role-play DID reported at least one instance of satanic ritual abuse and sexual abuse compared with those who role-played depression or a college student with minor adjustment problems. DID role-players reported more incidents of sexual abuse and more severe physical and sexual abuse than did the major depression role-players. Further, the DID role-players differed from the normal role-players on all the measures of frequency and severity of physical and sexual abuse. Participants in all groups reported more frequent and severe incidents of physical abuse after role-played hypnosis than they did prior to it.

ABSTRACT The theory of structural dissociation of the personality proposes that patients with complex trauma-related disorders are characterized by a division of their personality into different prototypical parts, each with its own psychobiological underpinnings. As one or more “apparently normal” parts (ANPs), patients have a propensity toward engaging in evolutionary prepared action systems for adaptation to daily living to guide their actions. Two or more “emotional” parts (EPs) are fixated in traumatic experience. As EPs, patients predominantly engage action systems related to physical defense and attachment cry. ANP and EP are insufficiently integrated, but interact and share a number of dispositions of the personality (e.g., speaking). All parts are stuck in maladaptive action tendencies that maintain dissociation, including a range of phobias, which is a major focus of this article. Phase-oriented treatment helps patients gradually develop adaptive mental and behavioral actions, thus overcoming their phobias and structural dissociation. Phase 1--symptom reduction and stabilization—is geared toward overcoming phobias of mental contents, dissociative parts, and attachment and attachment loss with the therapist, Phase 2-- treatment of traumatic memories--is directed toward overcoming the phobia of traumatic memories, and phobias related to insecure attachment to the perpetrator(s), particularly in EPs, and. In Phase 3--integration and rehabilitation--treatment is focused on overcoming phobias of normal life, healthy risk-taking and change, and intimacy. To the degree that the theory of structural dissociation serves as an integrative heuristic for treatment, it should be compatible with other theories that guide effective treatment of patients with complex dissociative disorders.

ABSTRACT Dependency is a major and ubiquitous issue in the treatment of chronically traumatized patients, such as those with complex PTSD, trauma-related borderline personality disorder, and dissociative disorders. Within this context, the concept of dependency is often paired with pejorative adjectives, and is dichotomized and negatively compared to a preferred state of independence. This paper explores prevailing sociocultural and theoretical beliefs regarding dependency in the psychotherapy of trauma survivors, provides a working definition of dependency, offers an analysis of its complex nature, and describes the theory of structural dissociation, which helps illuminate the often contradictory manifestations of dependency in chronically traumatized patients. A distinction is made between secure and insecure dependency. Finally, this paper outlines the collaborative therapeutic process required to manage insecure dependency productively within a phase-oriented treatment model. Countertransference responses that interfere with a patient's conflicts regarding dependency are also discussed.

ABSTRACT This article presents guidelines for the systematic evaluation of dissociative symptoms in clinical and forensic cases using the Structured Clinical Interview for DSM-IV Disorders- Revised(SCID-D-R). Since dissociation is a posttraumatic defense which serves as protection from overwhelming trauma, evaluation of dissociative symptoms is particularly relevant to the assessment of the dissociative disorders as well as posttraumatic stress disorder (PTSD). The authors review specific SCID-D-R interview criteria that support the accuracy of dissociative diagnosis based on extensive scientific investigations by providing standardized methods that can assist in distinguishing valid versus simulated dissociation. The application of the SCID-D-R in a forensic case is presented to illustrate the utility of this diagnostic tool in the courtroom.

ABSTRACT I agree that we should update the criteria for DID for the next edition of DSM so that it is consistent with our latest research findings. However, while the changes Dell proposes for new subtypes of the dissociative disorders are certainly creative, they are unfortunately not founded on scientific evidence. [Adapted from Text, p. 59]

ABSTRACT A comprehensive assessment of dissociative symptoms is recommended for effective treatment of trauma survivors. The author reviews the systematic detection of dissociative symptoms and disorders using the Structured Clinical Interview for DSM-IV Dissociative Disorders–Revised (SCID-D-R) in adolescents and adults (Steinberg, 1994b). Numerous investigations have reported good-to-excellent reliability and validity of the SCID-D-R, both in the United States and abroad. Clinical applications, including the SCID-D-R's utility for psychological and forensic evaluations, treatment planning, differential diagnosis, and evaluation of malingering, are reviewed.

ABSTRACT OBJECTIVE: This review examines the clinical outcomes associated with exposure to chronic intrafamilial trauma and explores the treatment of the psychological, biological, and cognitive sequelae. METHOD: The existing research literature on the subject was collected, using Index Medicus/MEDLINE, Psychological Abstracts, and the PILOTS database. The research findings were supplemented with clinical observations by the authors and other clinical writings on this topic. RESULTS: Children with histories of exposure to multiple traumatic experiences within their families or in medical settings usually meet criteria for numerous clinical diagnoses, none of which capture the complexity of their biological, emotional, and cognitive problems. These are expressed in a multitude of psychological, cognitive, somatic, and behavioural problems, ranging from learning disabilities to aggression against self and others. CONCLUSIONS: Exposure to intrafamilial violence and other chronic trauma results in pervasive psychological and biological deficits. Treatment needs to address issues of safety, stabilise impulsive aggression against self and others, promote mastery experiences, compensate for specific developmental deficits, and judiciously process both the traumatic memories and trauma-related expectations.

ABSTRACT If a helpless newborn infant does not form an attachment to its care-giver, even an abusive one, its chances of survival diminish, so evolution should strongly favour attachment by the infant, regardless of the quality of care-giving. As a part of the brain called the amygdala is critical for learned fear in adult animals, we investigated whether the development of learned avoidance behaviour could be delayed by late maturation of amygdala function. We found that very young rat pups exposed to various odours associated with shock treatment learn an approach response to that odour, whereas older pups learn odour avoidance. We show that the origin and development of learned odour-avoidance behaviour is associated with enhanced neural responses in the amygdala during odour-shock conditioning.

ABSTRACT While pathological self-mutilating behavior has been clinically examined for over 65 years, and much of the literature hypothesizes some function for the behavior, there has been little attempt to integrate or differentiate between different functional ideas. This review uses six functional models extracted from the literature to organize a discussion of the multiple functions of self-mutilation, acknowledging the overdetermined nature of the behavior and attempting to understand how self-mutilation can serve multiple functions simultaneously. Contextual information about the definition, prevalence, phenomenology, patient characteristics, associated diagnoses, and associated symptoms of self-mutilation is first presented. Six functional models are then presented: the environmental model, the antisuicide model, the sexual model, the affect regulation model, the dissociation model, and the boundaries model. Support for these models in the empirical and theoretical literature is presented and treatment implications are explored