Download the use of hypnosis in children with dissociative disorders

494
KLtlFf
Psychiatric Press Review of Psychiatry, vol 10. Washington, American Psychiatric
Press, 1991, pp 145-160
53. Riley RL, Mead J: The d"ve!opment of symptoms of multiple personality disorder in
a child of three. Dissociation 1:41--46, 1988
54. Rosenberg OK Bolttum j, Gershon S: Textbook of Pharmacotherapy for Child and
Adolescl>nt Psychiatric Disorders. Ncw York, Brunner/Mazel, 1994
55. Ross CA: Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment.
New York, Wiley, 1989
56. Sauzier M: Disclosure of child sexual abuse. Psychiatr Clin North Am 12:455-470, 1989
57. Schultz R: Secrets of adolescence: Incest and develpmental fixations. In Kluft RP
(cd): Incest-Related Syndromes of Adult Psychopathology. Washington, American
Psychiatric Press, 1990, pp 133-182
58. Schwartz E, Perry B: The post-traumatic response in children and adolescents. Psychi­
,1tr Clin North Am 17:311-326, 1994
39. Terr L: Childhood traumas: An outline and overview. Am J Psychiatry 148:10-20,1991
'in. Terr L: Forbidden games. J Am Acad Child Adolesc Psychiatry 2:741-760, 1981
'>1. Terr L: Too Scared to Cry. New York, Harper & Row, 1990, pp 283-365
'>2. Ten L: Treating psychic trauma in children: A preliminary discussion. Journal of
Traumatic Stress 2:3-20, 1989
)3. Turkus JA: Psychotherapy and case management for multiple personality disorder:
Synthesis for continuity of care. Psychiatr Clin North Am 14:649-675, 1991
.1 Watkins HH, Watkins JG: Ego-state therapy in the treatment of dissociative disorders.
III Kluft RP, Fine CG (cds): Clinical Perspectives on Multiple Personality Disorder.
Washington, American Psychiatric Press, 1993, pp 277-300
Address reprint requests to
Richard P. Kluft, MD
The Institute of Pennsylvania Hospital
111 North 49th Street
Philadelphia, PA 19139
DISSOCIATIVE IDENTITY DISORDER/
MULTIPLE PERSONALITY DISORDER 1056--4993/96 $0.00
+ .20
THE USE OF HYPNOSIS
IN CHILDREN WITH
DISSOCIATIVE DISORDERS
Daniel T. Williams, MD, and Louis Velazquez, MD, MPH
The use of hypnosis in the treatment of children and adolescents
with dissociative disorders has been advocated by many with clinical
experience in this area. IO• 20.24, 35, 50 It should be noted that, although
abundant clinical experience and opinion exist to support this applica­
tion, therapeutic efficacy has not yet been established in controlled
clinical trials. As is so often the case under such circumstances, clinicians
would do well to consider applying therapeutic strategies reported
effective by those with considerable experience in the field, while
awaiting more definitive validation. In this spirit, we review some of
the history of, rationale for, and techniques of application of hypnosis
in the treatment of children with dissociative disorders.
HISTORICAL CONSIDERATIONS
Since its introduction to modem medicine by 18th-century Austrian
physician Franz Anton Mesmer, hypnosis has had difficulty escaping
the shamanistic shadow cast on it py the conceptual mlsformulation of
animal m,agnetism as its psychobiologic m~hanism.41 It. was not until
Jean-Martin Charcot's luminous tenure at the Saltpetriere in 19th7'century
Paris that hypnosis was taken seriously by the .medical establishment
From the Pediatric Neuropsychiatry Service, Columbia-Presbyterian Medical Center, New
York, New York (DTW); Columbia University College of Physicians and Surgeons,
New York, New York (DTW); and St. Mary's Regional Medical Center, Lewiston,
Maine (LV)
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA
VOLUME 5 • NUMBER 2 • APRIL 1996
495
as an effective treatment? Charcot's student Pierre Janet wrote L'Auto­
matisme Psychogique in 1889; it was in this doctoral thesis that Janet
advocated the use of abreaction and age-regression hypnotherapy for
the treatment of dissociative sequelae of forgotten traumas. 32, 44, 46, 47
Janet viewed dissociation as a response to trauma in which there is
a disorder of memory that interferes with effective action. The failure to
abreact and master the traumatic experience leads, in Janet's view,
to dissociation from the traumatic memories and their expression as
fragmentary reliving experiences. Janet suggested that the traumatized
individual becomes attached to the trauma and therefore is arrested
in personality development. The uncovering of traumatic memories,
facilitated by hypnosis, was viewed as an essential ingredient of recov­
ery from dissociative disorders.
Freud was initially significantly influenced by Janet's belief that
dissociative symptoms were the results of actual early trauma, usually
sexual, that had been long forgotten. 45 Freud later abandoned this seduc­
tion theory in favor of the notion of the repressed oedipal conflict.
Actual sexual trauma was not necessary, as repression of an instinctual
wish for the sexual conquest of the parent of the opposite sex sufficed
in this formulation to result in hysteria. Freud restated Janet's notion of
attachment to the trauma as repetition compulsion, which was viewed
as a function of repression. Freud did not emphasize a link between
repression and dissociation in the genesis of hysteria, although this point
has been elaborated by Nemiah.27 Freud early on abandoned the use of
hypnosis in favor of the more gradual and time-consuming psychoana­
lytic method. At least part of this change was related to early concerns
regarding sexualization of the transference. 8 In subsequent years, how­
ever, Freud became more comfortable with the prospect of a more active
role for the psychotherapist, as he foresaw that public health needs
would reactivate a role for the psychodynamically informed use of
hypnosis. This would allow more widespread therapeutic applications
of psychoanalytic insights than the protracted and expensive method of
psychoanalysis could permit.9
Contemporary research has led to the recognition that the sexual
abuse of children and adolescents is a much greater public health prob­
lem than Freud realized. 13, 18,32 Although actual childhood trauma and
intrapsychic conflict regarding forbidden oedipal wishes or other matters
each may contribute independently to childhood psychopathology, the
contemporary clinician is best advised to assess each clinical case with
a primary focus on available and appropriately elicitabledata, rather
than relying on ideologically based preconceptions. Furthermore, an
appreciation of the impprtant role of dissociation in the phenomenology
of somatoform disorders, the current repository of hysteria, enables the
clinician to formulate a rational basis for the application of hypnosis in
these disorders.
Putnam31 has outlined some of the historical issues associated with
the decline of interest in multiple personality disorder (MPD) and other
dissociative disorders during the early to mid-20th century, followed by
a renewed interest in the 1970s and 1980s. This culminated in the
inclusion of MPD and other dissociative disorders in DSM-III.l Concomi­
tantly, a renewed interest in the systematic study of hypnosis provided
a parallel track for the exploration of dissociative phenomena in both
adults14, 15, 41 and children. 28,49
DSM-IV2 categorizes five disorders formally under the rubric of
dissociative disorders: dissociative amnesia, dissociative fugue, dissociative
identity disorder (DID; formerly MPD), depersonalization disorder, and
dissociative disorder not otherwise specified. (The phenomenology of
these disorders is further addressed elsewhere in this issue.) Acute stress
disorder (ASD) and post-traumatic stress disorder (PTSD) are classified
under the anxiety disorders, although their symptom profiles are
strongly dissociative. Finally, somataform disorders, also inherently dis­
sociative, are categorized separately to emphasize the necessity of con­
sidering a careful medical-neurologic differential diagnosis. Despite the
disparate groups in the formal nosology, it can be said reasonably that
these disorders all present substantial dissociative phenomena. Hypnosis
has been used with clinically reported benefits in the treatment of
children in all of the general categories of dissociative disorders.~o, ~H, 50
RATIONALE FOR USING HYPNOSIS IN CHILDREN"
WITH DISSOCIATIVE DISORDERS
Most experts in the formal study of hypnosis and its clinical applica­
tions concur in viewing hypnosis as a structured dissociative experience.
Thus, Spiegepa defines hypnosis as a "state of intensely focused concen­
tration, with a relative suspension of peripheral awareness." He de­
scribes hypnosis as having three essential components-absorption, dis­
sociation, and suggestibility. Absorption denotes the characteristic state
of attentive, receptive focal concentration that is essential to hypnosis.
Dissociation denotes .the relative . suspension of peripheral awareness
that is a by-product of absorption. Inherent in this process, less emotion­
ally invested perceptions, which would ordinarily be part of conscious­
ness, become split off and repressed during the trance experience. Sug­
gestibility denotes the tendency to accept instructions uncritically in
trance, a reflection of the receptive, trusting rapport that is another key
feature of hypnosis.
How do these features of hypnosis relate to the pathologicdissocia­
tive symptoms that so often characterize children and adolescents who
have been traumatized? In this regard, delineation of the
and discontinuities between normal and pathologic dissociation
portant.
Both clinical experience and experimental studies!!' indicate that
children normally exhibit Significantly more dissociative behavior than
adults and are more hypnotizable. Hilgard 16 observed that one of the
factors in childhood associated with later high hypnotizability in college
students was a history of punishment in childhood thnt was uncorre­
,lUU UJU Vt' U l l l .... 'J.;Jh].u'l \"".lllLLlt\.crv n l l n
lated with parental warmth. (Other, more healthy correlates were histo­
ries of imaginative involvements and positive identification with par­
ents.) Nash and Lynn26 found that a majority of students with a' history
of abuse were more hypnotizable than control subjects. Lynn and Rhue 23
found that students with a history of abuse were not more hypnotizable
than nonabused students but were better fantasizers. Frischolz et al ll
have replicated and extended previous findings that adult patients with
dissociative disorders are more hypnotizable on standardized scales
than both normal patients and other psychopathologic groups. LineF'
explored the role of early childhood abuse and trauma in the develop­
ment of dissociative defenses in a group of sexually and physically
abused children and a matched control group who were not abused
but were receiving outpatient psychiatric care. Abused children had a
significantly higher prevalence of dissociative symptoms, both as ob­
served by parents and as reported by the children themselves, than
nonabused children. In addition, abused children were more highly
hypnotizable than the comparison group. These studies provide support
for the numerous clinical reports suggesting benefits from the use of
hypnosis in treatment of children with dissociative disorders, to be
outlined later.
Reflecting on this one may conceptualize normal hypnotic capacity,
which is measurable in the majority of the population, as a relatively
stable part of the healthy individual's repertoire of adaptive capacities.
Under the cumulative impact of adverse and chronic, overwhelming life
stresses, this dissociative capacity may become overutilized in a way
that becomes maladaptive and symptomatic of a dissociative disorder. 39
To the extent that patients with dissociative disorder tend to be highly
hypnotizable, this technique can be a valuable method through which
the clinician can help the patient identify this vulnerability and restruc­
ture it under the protective and redirective rubric of the psychotherapy
process.
It seems reasonable to review relevant clinical applications of hyp­
nosis not only with DID/MPD itself but also with other dissociative
t\ disorders. Some of these, ~uch as ASD and PTSD, may be common
antecedents of DID/MPD. O.thers, such as somatoform disorders, may
be comorbid with and clinically related to DID/MPD.
t
~
~
lV
.
{'/
~
rf.'It;:; ~ ~\,~ -'~~ "~~y'
HYPNOSIS IN DID/MPD
Other articles in this issue review the substantial data delineating
the traumatic precipitants of DlD/MPD and the initially adaptive role
of dissociation in mitigating overwhelming trauma during childhood
physical and sexual abuse. The most compelling contemporary model
of DID/MPD is based on evidence that repeated childhood trauma
enhances normal dissociative capacities, which in turn provide the basis
for the creation and elaboration of alternate personality states over time.
The use of hypnosis with DID/MPD patients should always be
LJl,::x,\JLlAllVt Ul~KUt:l<::>
lt~
construed as a therapeutic adjunct and never as a sufficient treatmer
by itself. Hence, the clinician will need to be versed in overall treatmer
strategies for such patients, as outlined in other articles in this issw
before considering application of hypnosis. Noting this, it can be sai,
reasonably that there is no convincing evidence that appropriate clinic,
use of hypnosis iatrogenically engenders DID/MPD symptoms.37 FUl
thermore, a consensus exists among experienced clinicians and researd
ers in the field that hypnosis is a valuable therapeutic adjunct in workin
with these patients?l, 31, 34, 39
Presuming that one has established a therapeutic rapport with th
childand family, the probability of a diagnosis of DID/MPD, and the
abuse is not ongoing, one is in a position to consider applications (
hypnosis. Diagnostically, a significant advantage of hypnosis is its capac
ity, in the hands of a benevolently perceived therapist, to diminis
the host personality's suppression of other alternates, allowing thei
emergence. If there is any reason to believe, however, that legal proceec
ings may be necessary, it is wise to document clearly what has bee
discovered prior to hypnosis and to videotape the hypnotic assessment.:
The admissibility of hypnotically retrieved information varies widel
among jurisdictions. 43 Also, one must be cautious in interpreting clinict
data, elicited with or without hypnosis; and look for independent corrol:
oration of reports pointing to child abuse. n, 12. 48
Tactically, recommendations regarding initial therapeutic uses c
hypnosis in DID/MPD focus on the cognitive benefits of identifyin:
trance capacity and the ability then to generate benign tranc
"relaxation" experiences. These have the effect of enhancing the patient'
comfort as well as the therapeutic rapport. In children, particularly
there may be tangible gratification evident in the youngster's havin:
acquired a new "skill" to help master troubling symptoms.
Hypnotic techniques involving ego~strengthening often have valu
for demoralized or phobic youngsters with a dissociative disorder. The:
allow lhe youngster to rehearse in trance difficult tasks, particularl:
those involving assertiveness or confronting frightening situations. Th
well-established behavioral strategy of combining relaxation with pro
gressive desensitization can thus be facilitated. With adolescents, direc
suggestion with a cognitive emphasis may be most effective; witl
younger children, identification with a culturally sanctioned superhen
who overcomes adversity may be more appropriate.
One of the most valued applications of hypnosis in adult patient
with DID /MPD is to penetrate amnestic barriers for the purposes 0
contacting alternates and abreacting past traumas. 31 These two task
appropriately are viewed as essential for both diagnostic clarificatiOl
and eventual therapeutic integration. In children, versatility in hypnoti<
metaphor, such as using evocative play therapy, can be helpful,21 It i
important to note that following an abreaction, the therapist needs tI
help the patient "restructure" the experience by supportively identifyin)
residual affects and doing some preliminary processing of the material
In this context, focusing the child's attention on something constructivi
that the child had done to protect himself or herself or a sibling in an
. abuse situation can help vitiate the feelings of terror, powerlessness, and
demoralization that otherwise can be the overwhelming residue of an
unstructured abreaction.
Because immature, helpless alternates are often evident in child
DID/MPD patients, hypnosis-facilitated age-progression fantasies, usu­
ally involving imagery, often can be helpful in implicitly suggesting and
progressively fostering integration. Previously disparate personalities
begin to feel more alike and are encouraged to communicate, reconcile,
and eventually integrate. 19. 20
Case Illustration.
a 12-year-old girl of Caribbean family background,
was referred to a child psychiatry outpatient department because of episodic
strange behavior of several months' duration. She had been evaluated by the
pediatric neurology service because of apparent altered states of consciousness.
Repeated neurologic evaluations, including repeated electroencephalogram stud­
ies, failed to substantiate a diagnosis of seizure disorder. Careful review of the
history clarified that the altered states of consciousness involved voice modula­
tion, with varying speech content and body language, sometimes aggressive and
violent (subsequently clarified to represent the Devil) and sometimes regressive
and suggestive of a much younger child.
The father, who declined to participate in the psychiatric evaluation, was
reportedly a strong believer in voodoo and reportedly had erratic behavior. The
mother, whose brother reportedly had a history of epilepsy, became convinced
that both Carla and Carla's younger brother, age 7 years, had epilepsy as well.
Mother became very invested in substantiating this diagnosis and securing a
disability status for both children. Finally, mother, who was clearly over­
whelmed by what she perceived as illness in aU the members of her family,
acknowledged having a labile temper and resorting frequently to physical pun­
ishment of the children.
Carla was admitted to the child psychiatry inpatient unit for further evalua­
tion and treatment. After thorough review of the history and mental-status
examination, the psychiatrist first presented a diagnostic formulation to the
mother, outlining the reasons why a dissociative disorder plausibly accounted
for the presenting symptoms and epilepsy did not. He then explained that
hypnosis could be a helpful, added diagnostic and treatment resource when
integrated with ongoing individual and family psychotherapy. This supportive
explanation was then reviewed with Carla, who, on subsequent formal assess­
ment, proved to be highly hypnotizable. Hypnosis was used in the context of
ongoing psychotherapeutic endeavor to recreate the dissociative symptoms in a
controlled; therapeutic environment and to helpCarla see that she could termi­
nate these symptoms with a ~tructured strategy suggested to her by the thera­
pist. This strategy included visualizing God, embodied as a warrior, helping her
to fight off the Devil, who had frequently appeared and frightened her during
the violent dissociative episodes, sometimes speaking through her in <an altered
voice. An associated dialectic formula was recorded on audiotape for Carla
to use as a reinforcing self-hypnosis exercise between sessions. This dialectic
formula read
­
1. Frightened feelings can build up inside a person and create a picture of
the Devil.
2. By getting help to understand and overcome these feelings, I can get rid
of the Devil and I can feel better.
Concomitantly, psychotherapy sessions addressed the fact that the meta­
phor of the Devil represented intense, angry feelings, which needed to b(
acknowledged and addressed. Acknowledging and encouraging more appro­
priate expression of anger made progressively less necessary the alternate
extreme forms of passive submission/repression, replaced at intervals witt
explosive, satanic rage.
Similar supportive imagery and verbal structuring was llsed in taped hyp
n<;>sis exercises to help integrate the regressed alternate, "baby Carla." A mah)l
focus was placed on enabling Carla to gradually become able to discuss mon
directly in sessions a variety of feelings, but particularly fear and anger, tha
had previously been repressed and shunted into dissociative symptoms. Con
comitant ongoing counseling of Mother and family-therapy efforts were gearcc
to address both the reported abusive pattern of interaction at home and thE
misguided pursuit by the mother of a disability status for her children. A1
psychotherapy efforts were pursued on all these fronts, Carla's "vrnntmy"
abated, permitting discharge from the hospital after 6 weeks. Weekly
and family sessions were continued on an outpatient basis, and the dissociatiVE
symptoms subsided completely over a period of 6 months.
HYPNOSIS IN ASD AND PTSD
It is clear that only a minority of traumatized children proceed tc
develop a full-blown DID/MPD. It appears that a larger proporti0l1
experience earlier-onset dissociative and anxiety symptoms, character­
ized in DSM-IV2 as either ASD (lasting 2 days to 4 weeks) or PTSC
(lasting more than a month). The inclusion of PTSD with its designated
criteria in DSM-IIP prompted an increased interest among child psychia­
trists in this area. 4 Terr42 described four characteristics common to all
traumatized children:
Strongly visualized memories or perceived memories
Repetitive behaviors
Trauma-specific fears
Changed attitudes about people, aspects of life, and the
She proceeded to distinguish between two types of traumas. Type 1
traumatic conditions (single-blow traumas) have characteristic symp­
toms including full, detailed memories; preoccupation with omens; and
misperceptions. Type II traumatic conditions (repeated or long-standing
traumas) have characteristic symptoms including denial and psychic
numbing, dissociative symptoms, and rage. These formlllations appear
to have been influential in the formulation of the DSM-IV categories of
ASD and PTSD.
FriedrichlO has outlined considerations and strategies regarding
therapeutic use of hypnosis with traumatized children. Applications of
hypnosis to address cognitive, affective, and behavioral consequences of
trauma include
Symptom stabilization and removal. This can be facilitated
teaching self-hypnosis for use as a relaxation exercise at times
distress or agitation. Stabilizing overt symptoms helps the child
develop a sense of greater control over the trauma and its after­
math. 35
Uncovering or abreacting. Under the protective rubric of a thera­
peutically induced trance, the child can be led through a symbolic
reworking of the traumatic event or events, with a subsequent
more direct revivification if necessary. Age regression may be a
helpful technique in this regard?1 As with DID/MPD, the thera­
pist must be sensitive to the potential for retraumatization from
proceeding prematurely or too aggressively. Hence, there is po­
tential value for coupling the uncovered material with protective
imagery and offering suggestions that allow for temporary amne­
sia, which can be dispelled gradually at a pace the child can
tolerate. Suggestions about the capacity of the therapeutic rela­
tionship to foster greater self-protective efficacy in the patient can
further mitigate the need for unwarranted reliance on maladap­
tive dissociative symptoms.
Reintegration at a more healthy developmental level. Insofar as
cognitive, affective, and behavioral symptoms in the traumatized
child are viewed as regressions in the face of overwhelming
stress, working through the traumatic material in the manner
described previously allows the child to relinquish symptomatic
regression as he or she feels more secure about coping in a
developmentally more appropriate manner. 40 For example, the
child may utilize trance as a way of identifying with idealized
self-representations whom the therapist presents as overcoming
adversity with metaphorically depicted therapeutic intervention
and eventually achieving restitution to full functioning.
Case Illustration. Sam was the 13-year-old son of divorced, immigrant
parents, living in an urban ghetto with his mother and younger sister. He was
brought by his mother to the emergency room with a history of persistent
headaches, nightmares, and daytime "flashbacks" after having been shot in the
face by a male "friend" 2 years previously. There was no discemable precipitant
of the attack, although this friend had a history of physical attacks against the
patient and others in the past. Sam permanently lost vision in his left eye as a
result of the wound and began experiencing in both daytime and nighttime
recurring images of the attack that would disrupt his ability to concentrate in
class or to sleep at night. His mother did not press charges against the perpetra­
tor for fear of retribution from his family, leavingSam with a great residue of
rage as well as a continuing fear and sense of vulnerability regarding the
minimally punished grave trauma that had been inflicted upon him. The symp­
toms noted, coupled with those of anxiety, depression, and social withdrawal,
led to a diagnosis of chronic-type PTSD.
After several psychotherapy sessions geared to history-taking, clarifying the
diagnosis, and establishing a therapeutic rapport, a treatment plan was outlined
to Sam and his mother. This included, first, the use of cJonazepam to improve
sleep and attenuate the anxiety-symptom component of the PTSD syndrome. ,
Second, a format of ongoing psychotherapy was recommended involving both
Sam and his mother, to deal with the unresolved psychological residue of
Sam's trauma, with adjunctive use of hypnosis. Psychotherapy actively but
supportively addressed the issues noted previously, as well as Sam's previously
unaddressed grief reaction to the loss of binocular visual capacity essential to
his prior fantasies of becoming a baseball or basketball star. Hypnosis was used
initially to illustrate the dissociative phenomenon inherent in the "flashback"
experience. The suggestion then was made that the patient could, by
self-hypnosis, learn to control this dissociative phenomenon, diminishing or
preventing its spontaneous, disruptive emergence during school or sleep, by
restricting it to controlled review either in therapy sessions or in regular, home­
based self-hypnosis sessions. Sam was taught a "split-screen" technique for
processing and controlling dissociative phenomena: In the hypnotic trance state,
he focused first on the "left" screen in his mind, on which he visualized the
painful memories of the past trauma, acknowledging both his rage about what
happened and the need to take precautions in evaluating prospective new
friends or social situations. He was then encouraged to shift to the
screen in his mind, on which he visualized a pleasant, relaxing vacation scene
in a secure setting, which he could share with friends who had earned his trust
by demonstrated sensitive and considerate behavior. The hypnosis exercise was
integrated with psychotherapy geared to strengthen Sam's confidence in his
ability to make appropriately self-protective judgements in social situations imd
to find satisfying and achievable goals despite a circumscribed and limiting but
not disabling visual deficit.
Sam and his mother reported that with the initiation of treatment, both
sleep and daytime school functioning improved conSiderably, with diminished
frequency of nightmares, headaches, and daytime "flashbacks." The patient's
and mother's apprehensions regarding "drug dependence" led to discontinua­
tion of clonazepam within 1 to 2 weeks, but symptom attenuation has continued
over several months with continued supportive psychotherapy and adjunctive
use of self-hypnosis.
SOMATOFORM DISORDERS
As noted earlier in this article, consideration of the phenomenology
of somatoforrn disorders discloses a $ignificant dissociative component,51
This is exemplified by the curious phenom!i!non of a conversion paralysis
that involves intact innervation of the voluntary'musculature but is, by
definition, not under the conscious, voluntary control of the patient. This
presents a conceptual paradox that is best understood in the framework
of dissociation. There are many other significant etiologic considerations
relevant to an adequate understanding of the child with a soma to form
disorder, including psychodynamic conflicts, dependency needs, envi­
ronmental stresses, symptoms as nonverbal communication, the role
of depression, and neurophysiologic predisposition. Nevertheless, the
recognition that dissociation is an essential ingredient in· the symptom
formation of somatoform disorders makes hypnosis a valuable therapeu­
tic resource.
By demonstrating in a routine hypnotic induction experience how
an environmental influence (the therapist) can generate the 'altered per­
ceptions inherent in the trance experience, the frequently difficult con­
;:1U't
VVILLIAIVC:> 6t V.t'.LAL\,.lUC,L,
ceptual formulation for patients of how psychological phenomena can
, generate physical symptoms becomes more plausible. With the help of
the ceremony of hypnosis, the patient and family can come to appreciate
how dissociation, as a manageable psychological attribute, can be chan­
neled therapeutically in the service of symptom alleviation.49
Admonitions sometimes expressed against the use of hypnosis with
such youngsters by clinicians uncomfortable with its use are based on
the erroneous assumption that hypnosis necessarily involves the simplis­
tic and heavy-handed use of authoritarian suggestion, without generat­
ing insight and more adaptive coping strategies in the patient. Enlight­
ened clinical use of hypnosis in youngsters with somatoform disorders,
however, emphasizes the need for a thorough initial diagnostic evalua­
tion and for establishing an effective therapeutic rapport with the patient
and family, as well as the integration of hypnosis with other modalities,
including both individual and family psychotherapy, behavior modifi­
cation strategies to deal with secondary gain, and psychopharmacother­
apy when indicated. 49 , 50
It is noteworthy that in describing the clinical phenomenology of
child and adolescent dissociative disorders, Hornstein and Putnam 17 list
somatoform symptoms as four of the seven items defining the "dissocia­
tive symptoms" factor that characterizes these disorders. It is not possi­
ble from the data presented in their report to discern what portion
of their patient sample manifested these four symptoms (involuntary
movements, conversion symptoms, fluctuating somatic complaints, and
pseudoseizures), but it seems reasonable to postulate that somatoform
symptoms are a frequently presenting clinical component in youngsters
with DSM-IV-defined dissociative disorders.
From another perspective, clinical studies that have focused either
on specific somatoform disorders, such as psychogenic seizures3, .5,.~ and
psychogenic movement disorders,5,52 or on broader-spectrum surveys
of somatization disorders30 have found substantial comorbidity rates,
including high incidences (jf trauma and particularly histories of physi­
cal and sexual abuse.
It thus seems reasonable not only to view somatoform disorders
phenomenologically as part of the spectrum of. dissociative disorders,
but also to use hypnosis as part of the spectrum of therapeutic interven­
tions appropriate for treating children with these disorders. Further
studies are clearly needed to refine our knowledge regarding both treat­
ment specificity and efficacy.
.
Case Illustration. Bob, an II-year-old boy of Indian descent, was transferred
to the pediatric neurology service of our medical center from another hospital
because of worsening headaches over a 6-day period, blurred vision of 3 days'
duration, and the associated emergence of abnormal movements, The latter wen~
noted to be at times quick and jerking or writhing in nature, which raised
the suspicion of myoclonus or chorea, and at times rhythmic and continuous,
suggestive of a coarse tremor. The abnormal movements were diminished when
Bob was engrossed in conversation, increased with worsening complaints of
Hi"
u:>"
UI' .t1 Yl'I'lU:>l:-' IN ~.tllLlJl(bN WI I H UI.~UUATJVE
D!SORDERS
50:
pain, and absent in sleep. A neurologic work-up included spinal tap, electroen
cephalogram, computed-tomography scan, magnetic resonance imaging, and f
variety of routine and special laboratory studies, all of which were withir
normal limits.
Psychiatric consultation was requested to evaluate possible psychogeni<
factors contributing to a highly atypical clinical picture, not clearly suggestlvt
of a neurologic disorder. Interviews of the patient and parents disclosed or
prior personal or family psychiatric history. Bob previously had been an "A'
student, enrolled in several enrichment classes. He was noted to have an inter·
nalizing temperament, with high expectation of himself both academically ane
interpersonally. Recent stresses included the death of his favorite aunt frorr
breast cancer and the return of his mother from a trip to India, ill with malaria
The evaluating psychiatrist noted that Bob's abnormal movements, as observed
in the hospital, had similarities to shaking chills that Bob had clearly observee
during his mother's recent illness.
A psychodynamic formulation was discussed first with the parents and ther
with Bob, to help explore the diagnostic impression of a conversion disorder ir
Bob. This formulation induded Bob's unconscious affiliation with his mother'~
symptoms in reaction to a variety of accumulated stresses. These stresses in·
duded anxiety and fear regarding illness and death of dose relatives ane
associated concern regarding his own vulnerability in this regard. Furthermore
pressures from parents for high academic achievement, coupled with a lad
of adequate outlets for expression of distress or disagreement with parenta
imperatives, predisposed Bob to the development of unconsciously based con·
version symptoms.
A multimodal treatment program was started in the hospital, includinF
alprazolam, 0.25 mg twice daily and 0.5 mg at bedtime for symptoms of anxiety
depression, and insomnia; physical therapy to encourage ambulatiol1, becaUSE
Bob had been bed-bound; and hypnosis as an adjunctive aid in helping Bob t(
better understand and overcome the psychodynamic issues contributing to hi!
apparent conversion symptoms. Bob was a good hypnotic subject and wm
offered the following dialectic to review as part of a self-hypnosis exercise:
1. Worried feelings can cause tension.
2. Tension can bring on physical sympt9ms.
3, By relaxing this way, I can reduce the tension and help overcome thE
symptoms.
Within 6 days, Bob was sufficiently improved, with diminished headachE';
markedly less abnormal movements, and independent ambulation, that he coule
be discharged from the hospital for return to home and school with follow
up outpatient psychotherapy. Within 2 months, the headaches and movemen
symptoms had fully cleared; ambulation was normal and schooiattendanci
regular. Medication, the patient's use of self-hypnosis, and family-oriented psy
chotherapy all were tapered over the next 2 months and discontinued as BoE
continued to remain symptom-free.
SUMMARY
Hypnosis can be a valuable tool in the treatment of children wiH
dissociative disorders, by virtue of its capacity to bridge the sometime:
gaping chasm between normal and pathologic dissociative experience
The vast majority of normal children are hypnotizable, reflecting a
dissociative capacity that is a relatively stable part of their psychological
repertoire. Numerous studies support the contention that dissociative
disorders represent a chronic and maladaptive overutilization of this
dissociative capacity in response to overwhelming life stresses, particu­
larly those occurring in childhood. The technique of hypnosis, as part of
a comprehensive treatment plan, can provide a powerful resource in
helping the patient to understand and reverse the process of dissociative­
symptom formation. The effectiveness of hypnosis in such a venture
depends on several variables, including the severity and chronicity of
pathogenic environmental stressors, the capacities of the patient and
family to respond to therapeutic interventions, and the skill of the
clinician in integrating hypnosis with other elements of an effective
treatment plan.
References
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disor­
ders, ed 3. Washington, American Psychiatric Association, 1980
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disor­
ders, ed 4. Washington, American Psychiatric Association, 1994
3. Bowman H: Etiology and clinical course of pseudoseizures: Relationship to trauma,
depression and dissociation. Psychosomatics 34:333, 1993
4. Eth S, Pynoos RS (eds): Post-Traumatic Stress Disorder in Children. Washington,
American PsychiatriC Press, 1985
5. Ford B, Williams DT, Fahn S: Treatment of psychogenic movement disorders. In
Kurian R (ed): The Treatment of Movement Disorders. Philadelphia, JB Lippincott,
1994, p 475
6. Frankel F: Adult reconstruction of childhood events in the multiple personality litera­
ture", Am J Psychiatry 150:954, 1993
7. Frankel F: HypnOSiS: Trance as a Coping Mechanism. New York, Plenum Medical
'
Book, 1976
8. Freud S: An autobiographical study. In Strachey J (ed): The Standard Edition of the
Complete Psychological Works of Sigmund Freud, vol 20. London, Hogarth Press,
1955, p 3
9. Freud S: Lines of advance in psychoanalytic therapy. In Strachey J (ed): The Standard
Edition of the Complete Psychological Works of Sigmund Freud, vol 17. London,
Hogarth Press, 1955, p 157
10. Friedrich W: Hypnotherapy with traumatized children.lnt J Clin Exp Hypn 39:67, 1991
11. Frischolz EJ, Lipman LS, Braun BG, et al: Psychopathology, hypnotizability ~nd dissoci­
ation. Am J Psychiatry 14?:1521, 1992
. .
12. Goodwin J: Credibility problems in multiple personality disorder patients and abused
children. In Kluft RP (ed); Childhood Antecedents of Multiple Personality. Washington,
American Psychiatric Press, 1985, p 1
13. Goodwin JM (ed): Rediscovering Childhood Trauma: Historical Casebook and Clinical
Applications. Washington DC, American Psychiatric Press, 1993
14. Hilgard ER: The Experience of Hypnosis. New York, Harcourt Brace and World, 1965
15. Hilgard ER, Hilgard JR: Hypnosis in the Relief of Pain. Los Altos, Calif, Walter
Kaufman, 1975
16. Hilgard JR: Personality and Hypnosis: A Study of Imaginative Involvement. Chicago,
University of Chicago Press, 1970
17. Hornstein N, Putnam F: Clinical phenomenology of child and adolescent dissociative
disorders. J Am Acad Child Adolesc Psychiatry 31:1077, 1992
18. Kaplan S, Pelcovitz D (ed8): Child Abuse: Child and Adolescent Psychiatric Clinics 01
North America. Philadelphia, WB Saunders, 1994
persona Ii ty
19. Kluft R: Basic principles in conducting the psychotherapy of
disorder. In Kluft RP, Fine CG (eds): Clinical Perspectives on
Personality
Disorder. Washington, American Psychiatric Press, 1993, p 19
20. Kluft R: Treating children who have multiple personality disorder. 111 Braun B
Treatment of Multiple Personality Disorder. Washington, American P"vchiatric
1986, p 79
21. Kluft R: The use of hypnosis with dissociative disorders. Psychiatr Med 10:31, 1992
22. Liner D: Dissociation and Hypnotizability in Abused Children [doctoral dissertation]
Atlanta, Georgia State University, 1989
23. Lynn 5, Rhue J: Fantasy proneness: Hypnosis, developmental ant('cedents, and psycho·
pathology. Am Psychol 43:35, 1988
24. McMahon PP, Fagan J: Play therapy with children with
personality disorder
In Kluft RP, Fine CG (eds): Clinical Perspectives on
Personality Disorder
Washington, American Psychiatric Press, 1993, p 253
25. Morgan A, Hilgard E: Age differences in susceptibility to
lnt J Clin EXF
Hypn 21:78, 1973
26. Nash M, Lynn S: Child abuse and hypnotic ability. Imagination, Cognition [ll1d Person
ality 5:211, 1986
27. Nemiah J: Dissociative disorders. In Friedman AM, Kaplan HI (eds): Comprehensiv(
Textbook of Psychiatry, I'd 4. Baltimore, Williams and Wilkins, F l 85, p 924
Olness K, Gardner G:'Hypnosis and Hypnotherapy with Children, ed 2. Philadelphia
Grune and Stratton, 1988
27:311,1979
29. Orne MT: The use and misuse of hypnosis in court. Int J C1in Exp
30. Pribor Ef, Yutzy5H, Dean JT, et al: Briquet's syndrome, dissociation
abuse. Am.
Psychiatry 150:1507, 1993
31. Putnam F: Diagnosis and Treatment of Multiple
Disorder. New York
Guilford Press, 1989
32. Putnam F: Dissociative disorders in children: Behavioral profiles and problems. Chile
Abuse Negl 17:39, 1993
33. Putnam FW: Pierre Janet and modern views of dissoci,1tion. Journal of Traumati<
Stress 2:413, 1989
34. Putnam FW, Lowenstein RJ: Treatment of mUltiple personality disorder: A survey 0
current practices. Am J Psychiatry 150:1048, 1993
abused children
35. Rhue J, Lynn S: Storytelling, hypnosis and the treatment of
Int J Clin Exp Hypn 39:198, 1991
36. Rhue J, Lynn S, Henry S, et al: Child abuse, imagination 'l11d hypnotizability.
tion, Cognition and Personality 10:53, 1990
37. Ross C, Norton G: Effects of hypnosis on the features of multi pic personulHydisordeT
Am J ClinHypn 32:99,1989
38. Spiegel D: Hypnosis. In Hales RE, Yudofsky SC, Taloott JA (eds): American
Press Textbook of Psychiatry. Washington, American Psychiatric Press, 1988, p 907
39. Spiegel D: Multiple posttraumatic personality disorder. Til Kluft RP, Fine CF (eds)
Clinical Perspectives on Multiple Personality Disorder. Washington. American
atric Press, 1993, p~
40. Spiegel D, Cardena
ew uses of hypnosis in the treatment of posttraumatic stres
disorder. J Clin Psychia y 51:39,1990
41. Spiegel H, Spiegel D: Trance and Treatment: Clinical Uses of Hypnosis. New Yod
Basic Books, 1978
42. Terr L: Childhood traumas: An outline and overview. Am J Psychiatry 148:10, 1991
43. Tuite P, Braun BG, Frischholtz E: Hypnosis and eyewih1ess testimony. Psychiatr Ani
16:91,1986
44. Van-der-Hart 0, Brown P, Van-der-Kolk BA: Pierre Janet's treatment of post-traumati
stress. Journal of Traumatic Stress 2:379, 1989
'
45. Van-der-Kolk BA, Van-der-Hart 0: The intrusive past: The flexibility of memory an.
the engraving of trauma. American Imago 4:425,
;,va
VV lLL1AlVl" &
V bLf\L"-!U IV.
DISSOCIATIVE IDENTITY DISORDER! MULTIPl.E PERSONALITY DISORDER
1056-4993/96 $0.00 + .2( 46. Van-der-Kolk BA, Van-der-Hart 0: Pierre Janet and the breakdown of adaptation in
psychological trauma. Am J Psychiatry 146:1530, 1989
47. Van-der-Kolk BA, Brown P, Van-der-Hart 0: Pierre Janet on post-traumatic stress.
Journal of Traumatic Stress 2:365, 1989
48. Wakefield H, Underwager R: Recovered memories of alleged sexual abuse: Lawsuits
against parents. Behavioral Sciences and the Law 10:483, 1992
49. Williams DT: Hypnosis. In Kestenbaum q, Williams DT (eds): Handbook of c..1inical
Assessment of Children and Adolescents. New York, New York University Press,
1988, p 1129
50. Williams DT: Hypnosis. In Wiener JM (ed): American Academy of Child and Adoles­
cent Psychiatry Textbook of Child and Adolescent Psychiatry. Washington, American
Psychiatric Press, 1991, p 227
51. Williams DT, Hirsch G: The somatizing disorders: Somatoform disorders, factitious
disorders, and malingering. In Kestenbaum q, Williams DT (eds): Handbook of
Clinical Assessment of Children and Adolescents. New York, New.York University
Press, 1988, p 743
52. Williams DT, Ford B, Fahn S: Phenomenology and psychopathology related to psy­
chogenic movement disorders. In Weiner WI, l.ang AE (OOs): Behavioral Neurology of
Movement Disorders. New York, Raven Press, 1995, p 231
53. Williams DT, Walczak T, Berten W, et al: Psychogenic seizures. In Mostofsky D,
Loyning Y (eds): The Neurobehavioral Treatment of Epilepsy. Hillsdale, NJ, Lawrence
Erlbaum Associates, 1993, p 83
Address reprint requests to
Daniel T. Williams, MD
3003 New Hyde Park Road
Room 204
New Hyde Park, NY 11042
COGNITION, MEMORY, AND
DISSOCIATION
Daniel J. Siegel, Mr:
OVERVIEW OF COGNITIVE SCIENCE
The cognitive sciences offer insights into the functioning of the
human min~ and brain that can help inform an understanding of dissoci­
ation. This perspective can expand the capacity of clinicians to evaluate
and treat individuals with dissociative disorders. This article provides
an introduction to relevant cognitive..:science concepts and their clinical
applica tions.
Cognition and Mental Models
The brain is composed of billions of neurons interconnected by
trillions of synapses. 1A Activation of patterns of neurons, or a neumillet,
is the basic activity of the brain.56• 67 Further, the brain is capable of
multiple parallel processes occurring simultaneously, many of which are
out of conscious, general awareness. 41 Infinite combinations of neural­
network activations form the basis of cogrzititJ(! processes. Thus, phenom­
ena such as thinking, remembering, feeling, seeing, self-reflection, and
speaking are all forms of cognition that are products of neural net
activations. 56 Cognition is a term applied to the processes that occur
between "input" and "output" in the standard information processing
modeP9 Thus, concepts such as imaging, attention, memory (short,
working, long-term), thought, generalization, differentiation (noting sim-
From the Infant and Preschool Service, Division of Child and Adolescent Psychiatry,
University of California Los Angeles Neuropsychiatric Institute and HospitaJ; and nie
Institute for Developmental and Clinical Neuroscience, Los Angeles! California
CHll,D AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA
VOLUME 5' NUMBER 2· APRIL 1996
509