494 KLtlFf

Psychiatric Press Review of Psychiatry vol 10 Washington American Psychiatric Press 1991 pp 145-160

53 Riley RL Mead J The dveopment of symptoms of multiple personality disorder in a child of three Dissociation 141--46 1988

54 Rosenberg OK Bolttum j Gershon S Textbook of Pharmacotherapy for Child and Adolesclgtnt Psychiatric Disorders Ncw York BrunnerMazel 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 12455-470 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 Psychishy1tr Clin North Am 17311-326 1994

39 Terr L Childhood traumas An outline and overview Am J Psychiatry 14810-201991 in Terr L Forbidden games J Am Acad Child Adolesc Psychiatry 2741-760 1981 gt1 Terr L Too Scared to Cry New York Harper amp Row 1990 pp 283-365 gt2 Ten L Treating psychic trauma in children A preliminary discussion Journal of

Traumatic Stress 23-20 1989 )3 Turkus JA Psychotherapy and case management for multiple personality disorder

Synthesis for continuity of care Psychiatr Clin North Am 14649-675 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--499396 $000 + 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 IObull 2024 35 50 It should be noted that although abundant clinical experience and opinion exist to support this applicashytion 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 magnetism as its psychobiologic m~hanism41 It was not until Jean-Martin Charcots luminous tenure at the Saltpetriere in 19th7century 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 Marys Regional Medical Center Lewiston Maine (LV)

CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 5 bull NUMBER 2 bull APRIL 1996 495

as an effective treatment Charcots student Pierre Janet wrote LAutoshymatisme 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 traumas32 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 Janets 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 recovshyery from dissociative disorders

Freud was initially significantly influenced by Janets belief that dissociative symptoms were the results of actual early trauma usually sexual that had been long forgotten45 Freud later abandoned this seducshytion 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 Janets 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 Nemiah27 Freud early on abandoned the use of hypnosis in favor of the more gradual and time-consuming psychoanashylytic method At least part of this change was related to early concerns regarding sexualization of the transference8 In subsequent years howshyever 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 permit9

Contemporary research has led to the recognition that the sexual abuse of children and adolescents is a much greater public health probshylem than Freud realized13 1832 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-IIIl Concomishytantly 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 children2849

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 disshysociative are categorized separately to emphasize the necessity of conshysidering 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 applicashytions concur in viewing hypnosis as a structured dissociative experience Thus Spiegepa defines hypnosis as a state of intensely focused concenshytration with a relative suspension of peripheral awareness He deshyscribes hypnosis as having three essential components-absorption disshysociation 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 emotionshyally invested perceptions which would ordinarily be part of consciousshyness become split off and repressed during the trance experience Sugshygestibility 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 pathologicdissociashytive 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 Hilgard16 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 uncorreshy

lated with parental warmth (Other more healthy correlates were histoshyries of imaginative involvements and positive identification with parshyents) Nash and Lynn26 found that a majority of students with a history of abuse were more hypnotizable than control subjects Lynn and Rhue23

found that students with a history of abuse were not more hypnotizable than nonabused students but were better fantasizers Frischolz et alll

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 developshyment 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 obshyserved 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 individuals 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 disorder39

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 restrucshy

t ture it under the protective and redirective rubric of the psychotherapy process

It seems reasonable to review relevant clinical applications of hypshy~ nosis not only with DIDMPD itself but also with other dissociative ~ t disorders Some of these ~uch as ASD and PTSD may be common

antecedents of DIDMPD Others such as somatoform disorders may be comorbid with and clinically related to DIDMPDl V rfIt ~ ~~ -~~ ~~y HYPNOSIS IN DIDMPD

~ Other articles in this issue review the substantial data delineating the traumatic precipitants of DlDMPD and the initially adaptive role of dissociation in mitigating overwhelming trauma during childhood physical and sexual abuse The most compelling contemporary model of DIDMPD 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 DIDMPD patients should always be

lUU UJU Vt Ulll JJh]ul lllLLltcrv nlln LJlxJLlAllVt Ul~KUtlltgt 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 DIDMPD symptoms37 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 patientsl 31 34 39

Presuming that one has established a therapeutic rapport with th childand family the probability of a diagnosis of DIDMPD 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 personalitys 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 jurisdictions43 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 abusen 12 48

Tactically recommendations regarding initial therapeutic uses c hypnosis in DIDMPD 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 youngsters 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 DIDMPD is to penetrate amnestic barriers for the purposes 0

contacting alternates and abreacting past traumas31 These two task appropriately are viewed as essential for both diagnostic clarificatiOl and eventual therapeutic integration In children versatility in hypnotilt metaphor such as using evocative play therapy can be helpful21 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 childs 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 DIDMPD patients hypnosis-facilitated age-progression fantasies usushyally 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 studshyies failed to substantiate a diagnosis of seizure disorder Careful review of the history clarified that the altered states of consciousness involved voice modulashytion 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 Carlas 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 overshywhelmed by what she perceived as illness in aU the members of her family acknowledged having a labile temper and resorting frequently to physical punshyishment of the children

Carla was admitted to the child psychiatry inpatient unit for further evaluashytion 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 assessshyment 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 termishynate these symptoms with a ~tructured strategy suggested to her by the therashypist 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 ltan 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 shy

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 metashyphor of the Devil represented intense angry feelings which needed to b( acknowledged and addressed Acknowledging and encouraging more approshypriate expression of anger made progressively less necessary the alternate extreme forms of passive submissionrepression replaced at intervals witt explosive satanic rage

Similar supportive imagery and verbal structuring was llsed in taped hyp nltgtsis 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 Carlas 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 DIDMPD It appears that a larger proporti0l1 experience earlier-onset dissociative and anxiety symptoms charactershyized 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 psychiashytrists in this area4 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 sympshytoms 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 aftershymath35

Uncovering or abreacting Under the protective rubric of a therashypeutically 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 regard1 As with DIDMPD the therashypist must be sensitive to the potential for retraumatization from proceeding prematurely or too aggressively Hence there is poshytential value for coupling the uncovered material with protective imagery and offering suggestions that allow for temporary amneshysia which can be dispelled gradually at a pace the child can tolerate Suggestions about the capacity of the therapeutic relashytionship to foster greater self-protective efficacy in the patient can further mitigate the need for unwarranted reliance on maladapshytive 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 manner40 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 perpetrashytor 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 sympshytoms 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

Sams trauma with adjunctive use of hypnosis Psychotherapy actively but supportively addressed the issues noted previously as well as Sams 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 homeshybased 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 Sams 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 patients and mothers apprehensions regarding drug dependence led to discontinuashytion 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 component51 This is exemplified by the curious phenominon of a conversion paralysis that involves intact innervation of the voluntarymusculature 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 envishyronmental stresses symptoms as nonverbal communication the role of depression and neurophysiologic predisposition Nevertheless the recognition that dissociation is an essential ingredient inmiddot the symptom formation of somatoform disorders makes hypnosis a valuable therapeushytic resource

By demonstrating in a routine hypnotic induction experience how an environmental influence (the therapist) can generate the altered pershyceptions inherent in the trance experience the frequently difficult conshy

develop a sense of greater control over the trauma and its aftershymath35

Uncovering or abreacting Under the protective rubric of a therashypeutically 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 regard1 As with DIDMPD the therashypist must be sensitive to the potential for retraumatization from proceeding prematurely or too aggressively Hence there is poshytential value for coupling the uncovered material with protective imagery and offering suggestions that allow for temporary amneshysia which can be dispelled gradually at a pace the child can tolerate Suggestions about the capacity of the therapeutic relashytionship to foster greater self-protective efficacy in the patient can further mitigate the need for unwarranted reliance on maladapshytive 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 manner40 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 perpetrashytor 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 sympshytoms 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

Sams trauma with adjunctive use of hypnosis Psychotherapy actively but supportively addressed the issues noted previously as well as Sams 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 homeshybased 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 Sams 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 patients and mothers apprehensions regarding drug dependence led to discontinuashytion 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 component51 This is exemplified by the curious phenominon of a conversion paralysis that involves intact innervation of the voluntarymusculature 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 envishyronmental stresses symptoms as nonverbal communication the role of depression and neurophysiologic predisposition Nevertheless the recognition that dissociation is an essential ingredient inmiddot the symptom formation of somatoform disorders makes hypnosis a valuable therapeushytic resource

By demonstrating in a routine hypnotic induction experience how an environmental influence (the therapist) can generate the altered pershyceptions inherent in the trance experience the frequently difficult conshy

1Ut VVILLIAIVCgt 6t VtLALlUCL

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 chanshyneled therapeutically in the service of symptom alleviation49

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 simplisshytic and heavy-handed use of authoritarian suggestion without generatshying insight and more adaptive coping strategies in the patient Enlightshyened clinical use of hypnosis in youngsters with somatoform disorders however emphasizes the need for a thorough initial diagnostic evaluashytion 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 modifishycation strategies to deal with secondary gain and psychopharmacothershyapy when indicated49

50

It is noteworthy that in describing the clinical phenomenology of child and adolescent dissociative disorders Hornstein and Putnam17 list somatoform symptoms as four of the seven items defining the dissociashytive symptoms factor that characterizes these disorders It is not possishyble 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 disorders552 or on broader-spectrum surveys of somatization disorders30 have found substantial comorbidity rates including high incidences (jf trauma and particularly histories of physishycal 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 intervenshytions appropriate for treating children with these disorders Further studies are clearly needed to refine our knowledge regarding both treatshyment 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 ugt UI t1 YlIlUgtl- IN ~tllLlJl(bN WI I H UI~UUATJVE DSORDERS 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 psychogenilt 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 intermiddot 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 Bobs abnormal movements as observed in the hospital had similarities to shaking chills that Bob had clearly observee during his mothers 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 Bobs unconscious affiliation with his mother~ symptoms in reaction to a variety of accumulated stresses These stresses inmiddot 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 conmiddot version symptoms

A multimodal treatment program was started in the hospital includinF alprazolam 025 mg twice daily and 05 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 patients 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 particushylarly 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 dissociativeshysymptom 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

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7 Frankel F HypnOSiS Trance as a Coping Mechanism New York Plenum Medical Book 1976

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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

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20 Kluft R Treating children who have multiple personality disorder 111 Braun B Treatment of Multiple Personality Disorder Washington American Pvchiatric 1986 p 79

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25 Morgan A Hilgard E Age differences in susceptibility to lnt J Clin EXF Hypn 2178 1973

26 Nash M Lynn S Child abuse and hypnotic ability Imagination Cognition [ll1d Person ality 5211 1986

27 Nemiah J Dissociative disorders In Friedman AM Kaplan HI (eds) Comprehensiv( Textbook of Psychiatry Id 4 Baltimore Williams and Wilkins F l85 p 924 Olness K Gardner GHypnosis and Hypnotherapy with Children ed 2 Philadelphia Grune and Stratton 1988

29 Orne MT The use and misuse of hypnosis in court Int J C1in Exp 273111979 30 Pribor Ef Yutzy5H Dean JT et al Briquets syndrome dissociation abuse Am

Psychiatry 1501507 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

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Stress 2413 1989 34 Putnam FW Lowenstein RJ Treatment of mUltiple personality disorder A survey 0

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Int J Clin Exp Hypn 39198 1991 36 Rhue J Lynn S Henry S et al Child abuse imagination l11d hypnotizability

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Am J ClinHypn 32991989 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 JClin Psychia y 51391990

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 14810 1991 43 Tuite P Braun BG Frischholtz E Hypnosis and eyewih1ess testimony Psychiatr Ani

16911986 44 Van-der-Hart 0 Brown P Van-der-Kolk BA Pierre Janets treatment of post-traumati

stress Journal of Traumatic Stress 2379 1989 45 Van-der-Kolk BA Van-der-Hart 0 The intrusive past The flexibility of memory an

the engraving of trauma American Imago 4425

va VV lLL1AlVl amp V bLfL-U IV

46 Van-der-Kolk BA Van-der-Hart 0 Pierre Janet and the breakdown of adaptation in psychological trauma Am J Psychiatry 1461530 1989

47 Van-der-Kolk BA Brown P Van-der-Hart 0 Pierre Janet on post-traumatic stress Journal of Traumatic Stress 2365 1989

48 Wakefield H Underwager R Recovered memories of alleged sexual abuse Lawsuits against parents Behavioral Sciences and the Law 10483 1992

49 Williams DT Hypnosis In Kestenbaum q Williams DT (eds) Handbook of c1inical 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 Adolesshycent 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 NewYork University Press 1988 p 743

52 Williams DT Ford B Fahn S Phenomenology and psychopathology related to psyshychogenic movement disorders In Weiner WI lang 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

DISSOCIATIVE IDENTITY DISORDER MULTIPlE PERSONALITY DISORDER 1056-499396 $000 + 2(

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 dissocishyation This perspective can expand the capacity of clinicians to evaluate and treat individuals with dissociative disorders This article provides an introduction to relevant cognitivescience concepts and their clinical applica tions

Cognition and Mental Models

The brain is composed of billions of neurons interconnected by trillions of synapses1A Activation of patterns of neurons or a neumillet is the basic activity of the brain56 Further the brain is capable of bull 67

multiple parallel processes occurring simultaneously many of which are out of conscious general awareness41 Infinite combinations of neuralshynetwork activations form the basis of cogrzititJ( processes Thus phenomshyena such as thinking remembering feeling seeing self-reflection and speaking are all forms of cognition that are products of neural net activations56 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

CHllD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 5 NUMBER 2middot APRIL 1996 509

va VV lLL1AlVl amp V bLfL-U IV

46 Van-der-Kolk BA Van-der-Hart 0 Pierre Janet and the breakdown of adaptation in psychological trauma Am J Psychiatry 1461530 1989

47 Van-der-Kolk BA Brown P Van-der-Hart 0 Pierre Janet on post-traumatic stress Journal of Traumatic Stress 2365 1989

48 Wakefield H Underwager R Recovered memories of alleged sexual abuse Lawsuits against parents Behavioral Sciences and the Law 10483 1992

49 Williams DT Hypnosis In Kestenbaum q Williams DT (eds) Handbook of c1inical 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 Adolesshycent 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 NewYork University Press 1988 p 743

52 Williams DT Ford B Fahn S Phenomenology and psychopathology related to psyshychogenic movement disorders In Weiner WI lang 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

DISSOCIATIVE IDENTITY DISORDER MULTIPlE PERSONALITY DISORDER 1056-499396 $000 + 2(

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 dissocishyation This perspective can expand the capacity of clinicians to evaluate and treat individuals with dissociative disorders This article provides an introduction to relevant cognitivescience concepts and their clinical applica tions

Cognition and Mental Models

The brain is composed of billions of neurons interconnected by trillions of synapses1A Activation of patterns of neurons or a neumillet is the basic activity of the brain56 Further the brain is capable of bull 67

multiple parallel processes occurring simultaneously many of which are out of conscious general awareness41 Infinite combinations of neuralshynetwork activations form the basis of cogrzititJ( processes Thus phenomshyena such as thinking remembering feeling seeing self-reflection and speaking are all forms of cognition that are products of neural net activations56 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

CHllD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 5 NUMBER 2middot APRIL 1996 509