494

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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

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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

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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.

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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

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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 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,

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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

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