[Dissociative disorders: from Janet to DSM-IV].
I reviewed the literature on dissociation and dissociative disorders from Pierre Janet to DSM-IV, and examined the current trends in research. Janet's theory on hysteria is multifaceted, and is based on three psychological models. Based on a hierarchical model, Janet related hysteric symptoms to the activities within the lower strata of mental hierarchy (automatisms psychologiques), which were demonstrably shown in somnambulism. A second model was based on the concept of a psychological system, which was hypothetically composed of ideas, images, feelings, sensations, and movements. According to this model, dissociation of psychological functions was fundamental to the mechanism of hysteria: loss of integration was thought to engender fixed ideas (ideas fixes) and to lead to the development of a system totally isolated from the whole personality system. Janet also attempted to explain various mental disorders using an economic model. He referred to a loss of equilibration between psychological force and psychological tension. Thus, an unexpected emotional experience was conceived to cause a consumption of reserved psychological force, which was in turn followed by exhaustion associated with hysteric symptoms. Whereas most current researchers regard Janet as the first to study psychological trauma as a principal cause of dissociation, I feel it is important to note that he also emphasized the role of stigmata, i.e., permanent traits of hysteric patients, which were represented as a suggestibility and a tendency toward a narrowing of the consciousness field. Discussion about dissociation and its relation to trauma all but disappeared after Janet. However, during the Second World War and post-war period, some psychiatrists began to pay attention to two emerging phenomena: a high incidence of dissociative symptoms such as fugue and amnesia among combatants, and traumatic neurosis frequently observed among ex-inmates of concentration camps. In the 1970s, interest in dissociation and trauma was revived in different areas: the feminism movement was linked with concerns about child sexual abuse, public curiosity about multiple personalities was heightened by novels and movies, and recognition of posttraumatic stress disorder (PTSD) among Vietnam War veterans. In 1980, dissociative disorders were finally adopted as a diagnostic category in the official nomenclature of DSM-III. Although current research on dissociation is being carried out in various fields, two basic assumptions, reflected in the definition of DSM-IV, can be made. One is the "trauma-genic hypothesis," and the other is the great importance attached to multiple personality disorder (MPD). According to the predominantly held view, dissociation represents a reaction to early traumatic experience, especially sexual and physical abuse in childhood. In contrast, some authors argue that the causality of childhood traumatic experience has not been empirically confirmed, and other factors such as the influence of the environment and the predisposition of patients should be taken into consideration. MPD, which was originally described as an unusual phenomenon in classical literature, is currently thought to be a common type of dissociation. However, the reported rapid increase in the number of MPD patients in North America may be partially due to over-diagnosis and inclusion of iatrogenic cases. Significance is also given to MPD in respect to classification of dissociative phenomena. According to the widely held scheme of a "dissociative continuum," which ranges from normal experiences such as daydreams to pathological states, MPD is placed at the extreme end of the continuum. Furthermore, most researchers tend to classify MPD as the severest dissociative disorder due to chronic trauma. On this point, there seems to be confusion about "extremity" and "severity" of MPD. I conclude that the trauma-genic hypothesis of dissociation and the overemphasis placed on MPD should be reexamin
Nakatani
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Institute of Community Medicine, University of Tsukuba.
D000328:Adult; D002648:Child; D004213:Dissociative Disorders / Q000523:psychology*; D009105:Dissociative Identity Disorder / Q000523:psychology; D006801:Humans; D008960:Models, Psychological; D011574:Psychoanalytic Theory