Karen Gainer, M.S.W., L.G.S.w., is a psychotherapist in pri­vate practice. She also SCIVesasSocial Work and FamilySeIVicesConsultant at the Pain Institute in Chicago, Tllinois.

For reprints write Karen Gainer, M.S.W" L.C.S.W., The PainInstitute in Chicago, 325West Huron Street, Suite 220, Chicago,IL 60610.

An earlier version of this paper was presented at the NinthInternational Conference on Multiple Personality andDissociative Slates, November 15, 1992, Chicago, Illinois.

ABSTRACT

ThU paper~ an historical persputive regarding 1M role ofdi..ssfx:UUion in 1M d.nJel.opmenl of both erioiogic eMory and treot­mmt paradigms fOT schi:zopltrenia.. &femlCeS to 1M roncept ofdis­JOCi4lion art draumJrom classic writings ondementia prauox, andjromlJieukrj (1911) origi:nalconapticnofschiUJphrrniaaJa "JfJlit­ling- of1Mpersonality. An aauraJe diagno.stic distinction betwunschizoplrrenia and dissociative diJordm, such aJ disJocialive iden­lily disorder (DID) and brUfTeactivepsyclwsis (BRP), often has beendifficult 10 aJcertain due 10 Ihe preJence ofSchneiderianFm~RankSymptoms (FRS) in both lyjJes ofdisorders. The traditionalSchneiderianFRS, once thought to be indicative symptoms ojschizophrenia, noware viewed as characteristic diagnostic indicators ojDID. Researchand theory pertaining to difJenmtidl diagnosis between schizophre­nia and lrauma-related dissociative syndromes are reviewed. Earlypsychodynamic lrecumenl paradigms JOT schiUJPhrenia and con­umpqrary lreatmem paradigms for dissociative disorders are com­pared. Rek:vam diagnostic and lrMtment impli«JlionsJor flu! fUMofdis.rociative disorders are emph.asized.

INTRODUCTION

Dissociative identity disorder (DID), known as multiplepersonality disorder in DSM-Ill-R (American PsychiatricAssociation, 1987), is a clinical syndrome which first gainedr«ognition in the early nineteenth century (Bliss, 1980;Ellenberger, 1970; Greaves, 1980; Taylor & Martin, 1944).lnteresl in 010 continued to develop throughout the latterhalfof the nineleenth century and the early twentieth cen­tury. A growing number of DID cases were reported in theclinical lilerature during this period (Ellenberger, 1970;Putnam, 1989; Ross, 1989; Sutcliffe &Jones, 1962; Taylor &Martin, 1944). However, this growth trend was short-lived.Professional interest in the field of dissociation eventually

began to wane (Ellenberger, 1970; Rosenbaum, 1980;Rosenbaum & Weaver, 1980). Rosenbaum (1980) speculatesthat declining interest in DID can be correlated positivelywith Bleuler's introduction of the term ~schizophrenia»in1911. Rosenbaum also suggests that the over-inclusivenessof Blculer's conceptual framework has contributed to diffi·culties in the differential diagnosis between DID andschizophrenia and to a growing trend of misdiagnosis, inwhich many individuals suffering from DID have been mis­diagnosed as schiwphrenic. Rosenbaum quotes the follow­ing passage by F.X_ Dercum in support of his criticisms:

Because ofhis interpretation ofdementia praecoxas a cleavage or fissuration of the psychic functionsBleuler has invented and proposed the name"schizophrenia" which he believes to be preferableto dementia praecox. However, as we have seen,cleavages and fissuration of the personality are notconfined to dementia praecox. They occur in manyfarms oJmentaldisease aJ weUas in the neuros/!.f. In myjudgement [sic] the term being of such general Jig­nyU'onceofTers no advanlages over dementia prae­cox and should be rejected.(Dercum, cited in Rosenbaum, 1980, pp. 1384-1385)

A number of authors cite research findings in suppon ofthis view (Bliss, 1980; Boon & Draijer, 1993; K1uft, 1987;Putnam, Curoff, Silberman, Barban, & Post, 1986; Ross,Norton, & Wozner, 1989; and Ross et aI., 1990). NorthAmerican research findings indicale that between 25.6% to49% of DID patienlS have received a prior diagnosis ofschizophrenia (PuUlam etal, 1986; Ross et aI., 1989; Ross etal., 1990) .In the Netherlands, Boon and Draijer (1993) deter­mined that 15.6% of their 71-patient DID sample hadreceived a prior diagnosis of schizophrenia. Boon andDraijerqualify these relatively modest statistical findings withthe observation that schizophrenia traditionally has beendiagnosed with less frequency in the Netherlands than it hasbeen in North America.

Rossetal. (1994) offer the following commentary regard­ing the research findings cited above: "From these studiesit is evident that DSM-III·R criteria for schizophrenia resultin a false-positive diagnosis of schizophrenia in about onethird ofMPD patients. This isa major level ofincorrectdiag­nosis with profound treatment implications~ (p.5).

261D1SS0Cl\TIO~. \01 \'11. ~o. I, December 1994

--- - ----- ---

DISSOCIATIOK Al'\D SCHIZOPHRE:\IIA

DISSOCIATION AI\rn SCHNEIDERIANFIRST-RANK SYMPTOMS

Several authors suggest that the common presence ofSchneiderian first-rank symptoms (FRSs) in patients with dis­sociative identity disorder is a prime factor contributing toan inadequate differential distinction belWeen the syn­dromesofDIDand schizophrenia (Bliss, 1980; Boon &Draijer.1993; Goons & Milstein. 1986; Fink & Golinkorr, 1990; Kluft,1987; Putnam et al., 1986; Ross et al., 1989; and Ross et at,1990).

Schneider originally defined the First-Rank. Symptoms(FRSs) ofschi7.ophrenia as phenomenological indicators ofthe disorder in the following manner:

Audible thoughts; voices heard arguing; voicesheard commenting on one's actions; the experi­ence of influences playing on the body (somaticpassivity experiences); thought-withdrawal andother interferences with thought; delusional per­ceptions and all feelings, impulses (drives) and voli­tional aCts that are experienced by the patient asthe work or influence ofothers. When any of thesemodes ofexperience is undeniably present and nobasic somatic illness can be found. we may makethe decisive clinical diagnosis of schizophrenia.(Schneider, 1939, pp. 133-134)

The traditional Schneidcrian FRSs, once thought to be indica­tive symptomsofsch izophren ia, currcn tly are viewed as diag­nostic indicators of OlD (Kluft, 1987). The presence ofSchneiderian FRSs also has been established in connectionwith several other clinical syndromes (Andreason &Miskal,1983; Carpenter. Strauss, & Mulch, 1973).

Kluft (J987) reports that 100%ofa303-patient DlDsam­pieendorsed the presenceofSchneiderian FRSs, with a meanFRS index of 3.6 per patient. In a similar study, Ross et a1.(1989) used a sample of 236 DID patiems, and obtained amean FRS index of 4.5 per patient. A replication study byRossetal. (1990) yieldcda mean FRSs indexof6.4, in a seriesofl 02 patients. Additionally. Finkand Golinkoff (1990) havereponed that 94% of their J&.paticnt DID sample positivelyendorsed one or more Schneiderian FRS, with a mean FRSindex of 4.8. The lauer authors also report findings from acomparison study involving II schizophrenicpaticnts,whichyielded a mean FRSs index of 5.6. Fink and GolinkoJI haveconcluded that the DID and schizophreniacomparison groupsshowed no signijicant differences regarding mean numberofSchneiderian FRSs (F (1.35)=.72 p<.4I). In a similar com­parison, Ross et aI. (1990) have combined outcome datafrom several previous studies, and have hypothesized thalSchneidcrian FRSs are more characteristic of OlD than ofschizophrcnia_ The authors report an average of4.9 FRSs ina series of368 DID patients. as compared with an average of1.3 FRSs in a series of 1,739 schizophrenic patients. Otherrelevant findings by Ross and Joshi (J992) suggest that thepresence ofSchneiderian F'RSs can be correlated both withother clusters of dissociative symptoms. and with a report-

ed historyofchildhood trauma. Accordingto RossandJoshi:

Schneiderian symptoms arc linked to other disso­ciative symptom clusters characteristic ofindividu­als subjected to chronic childhood trauma. If thesefindings are replicated and accepted, they may leadto a reconceptuaJization of many "psychotic"symp­toms as post-traumatic and dissociative in nawre.(Ross &Joshi, 1992, p. 272)

DISSOCIATION AND BLEULER'S CONCEPTOF SCHIZOPHRENIA

Schneider's empirically-derived FRSs initially promisedto offer more reliable diagnostic criteria than previously hadbeen offered by Bleuler's original diagnostic schema.

The concept of specific or pathognomonic symp­toms began with Bleuler, who focused on demen­tia praecox and renamed it schizophrenia. Unlik.eKraepelin - who was interested primarily in theobjective portrayal of psychopathologic phenome.­na and generally refrained from speculation aboutthe origin of schizophrenic symptoms - Bleulerdevoted himself to understanding the basic mech­anisms that caused these symptoms. His search ledhim to what are now referred to as thr. fOllr"Bleularian A's" or simply the "four A's" that includeassociative loosening. affective blunting, autism, andambivalence. Bleuler worked in an era when ass0­

ciation psychology was preeminenL Psychologicaltheorists were preoccupied with determining howthoughts were encoded or formulated in the mind;the prevailing theory was that the process of think·ingand rememberingwasguided byassociative linksbetween ideas and concepts. Bleuler believed thatthe most important deficit in schizophrenia was adisruption in these associative threads.(Andreason & Akiskal, 1983, p. 42)

Bleuler'sconceptualization ofsch izoph ren ia was inn uencedby the prevailing association psychology of the era. Bleuler(J911/ 1950) hypothesized thatan underlying processofass0­

ciative loosening was the fundamental pathognomonic fea­ture of schizophrenia, and he described a variety of disso­ciative automatisms as primary schizophrenic symptoms.Bleuler listed these symptomsas folJows: "Blocking"ofmove­ment, speech or thoughts (including various forms of cata­tonic stupor or negalivism); echolalia and echopraxia;thought withdrawal; "made" thoughts, fcelings or actions;and "dissociated thinking." Bleuler defined the term ~di.....sociated thinking" as "the disconnecting ofordinarily ass0­

ciated threads in thought and language... [in which] all theassociation threads fail and the thought chain is totally inter­rupted." (1950, pp. 21-22).

Bleuler's definitions of the primary dissociative symp­toms of schizophrenia bear similarity to Schneider's phe­nomenological descriptions of the first-rank symptoms. It is

262

possible that both sets of diagnostic criteria might identifya dissociative symptom cluster which accompaniesschizophrenia, butwhich does notreflectan inherentaspeclof the disorder.

Bleuler (1950) oudined his ideas regarding the conceptualrelationship between schizophrenia and dissociation in thefollowing manner:

I call dementia praecox "schizophrenia" because(as I hope to demonstrate) the ~splitting" of thedifferent psychic functions isone ofits mostimpor­tant characteristics....In every case we are con­fronted with a more or less clear-cut splitting of thepsychic functions. If the disease is marked, the per­sonality loses its unity; at different times, differentpsychic complexes seem to represent the person­ality. Integration of different complexes and striv­ings appears insufficient or even lacking...one setofcomplexes dominates the personality for a time,while the other groups of ideas or drives are "splitoff" and seem either pardyor completely impotent.(pp.8-9)

Bleuler's original conception of schizophrenia as a "split­ting" of the psyche was influenced by Janet's (1889) con­cepts of "association" and "dissociation." Bleuler also drewupon Janet's notion of psychasthenia as a basis for his the­ory about the primary symptoms of schizophrenia.

Bleuler professed a theory that would be organo­dynamic today .... In the chaos of the manifoldsymptoms of schizophrenia, he distinguished pri­mary or physiogenic symptoms caused directly bythe unknown organic processes [sic], and sec­ondaryor psychogenic symptomsderiving from theprimary symptoms. This distinction was probablyinspired by Janet's concept of psychaslhenia. Justas janet distinguished a basic disturbance in psy­chasthenia, that is, the lowering of psychologicaltension, so did Bleuler in much the same way con­ceive the primary symptoms ofschizophrenia to bea loosening of the tension ofassociations, in a man­ner more or less similar to what happens in dreamsor in daydreams .... The autism, that is the loss ofcontact with reality, was in Bleuler's original con­cept a consequence of the dissociation.(Ellenberger, 1970, p. 287)

Blculer also was influenced by Jung's ideas about the roleofdissociation in the psychologyofdementia praecox.Jung'swork had served to integrate the conceptofdissociation alongwith a number of relevant and foundational writings by ear­lier theorists. According toJung (1909):

New and independent views on the psychology ofdementia praecox were brought forth by OttoCross. He proposes the expression dementiasejunc­tiva for the name of the disease. The reason for this

name is the disintegration of consciousness indementia praecox, hence the sejunction of con­sciousness. The sejunction concept Cross natural­ly took from Wernicke. He could just as well havetaken the older synonymous idea of dissociation(Binet,janet). Fundamentally, dissociation ofcon­sciousness means the same thing as Cross's disin­tegration of consciousness .... The applicationmade by Cross of this theory ofdementia praecoxis new and imponanL Concerning his fundamen­tal idea the author expressed himself as follows:'i)isintegrntion of consciousness in any sense sig­nifies the simultaneous flow of functionally sepa­rated series of associations. ~ (p. 23)

A quote from one ofBleuler's (1924) later works illustrateshis continuing speculation about the dissociative aspects ofschizophrenia: "It is not alone in hysteria that one finds anarrangement ofdifferent personalities, one succeeding theother. Through similar mechanisms schizophrenia pro­duces different personalities existing side by side. M (p. 138)

It is notable thatJung and Bleuler had based lheir con­ceptualizationsaboutdementia praecox and schizophrenia,at least partially, on their respective studies of the famouspatient, Daniel Paul Schreber. Schreber had been diagnosedby his doctors, Flechsig and Weber, as suffering from a para­noid psychosis (Lothane, 1992).Jung has offered an inter­pretation ofSchreber's psychotic symptoms in his 1907 pub­lication, TheP5"'jC~ofDemenliaPr(UCOx.AlthoughJung didnot specifically address the question of differential diagno­sis, the indusion of Schreber's case history inJung's bookmay be interpreted to imply a diagnosis of dementia prae­cox. Bleuler (1911/1950) also referred to Schreber in hisbook, Dt7Mntia Praewx (Jr lhe Group ofSchiwphTt:TJias.

Bleuler was impressed with a number ofSchreher'sclinical features, which he had classed asschizophrenic, as had already been done byJung.,.Bleuler assessed the first episode ofillness as a mildschizophrenic episode and the second as an acuteprotracted episodeofcatatonia that developed intoa chronic paranoid schizophrenic psychosis but notparanoia in Kraepelin 's sense. In this, then, Bleuleralso rejected Weber's diagnosis.(Lothane,I992,pp.323,345)

A number of contemporary authors have suggested thatSchreber's psychiatric symptoms were caused and/or exac­erbated by traumatic childhood experiences (deMause,1987; Goodwin, 1993; Niederland, 1959, 1960, 1974, 1984;Schatzman, 1971; Shengold, 1989; van der Kolk & Kadish,1987). Lothane (1992) also identifies Schreber's extendedinvoluntary hospitalization as a primarystressor responsiblefor Schreber's deteriorating psychiatric condition. Lothaneadditionally draws a parallel between the Schreber case andthat ofanother case history also discussed by Freud.

Freud'sdynamic viewofpsychosis led him to invoke

263

•DlSSOCHTlO:\ \'01 \ n.:\o ~. [)erfm/)('r 19Q4

-

DISSOCIATIOX fu~D SCHIZOPHREl\'1A

his teacher Meyncrt's delineation ofparanoia as anacute syndrome, Meyncrt's amentia (Freud, 19 II,p. 75).The case Freud (1894) describedasMeynert'samentia, or acute hallucinatorr paranoia, seemedto resemble Schreber's acute hallucinatory phase.... Mcynert's amentia qualifies as a traumadc psy­chosis .... For Freud. the general idea that psy­chosis was a defense (thus a neuropsychosis ofdefense) abrainsl a lraumatic experience was thedynamic underlying both forms of disorder, hal­lucinatory confusion, or MeyneTt's amentia (1894)and paranoia (1896), the former caused byan adulttraumatic situation, the latleT traced born to infan­tile seduction and to current conflicts.(Lothanc, 1992, pp. 330-331)

This type of dynamic viewpoint suggests that acute halluci­natory and delusional sympLOms sometimes may accompa­ny the syndrome of traumatic hysterical psychosis. It alsoraises questions regarding the Ydlidi ty of]ung'sand Bleuler'stheories on dementia praecox and schizophrenia. In par­ticular,]ung and Bleuler may have neglected to considerthe differential diagnosis of hysterical psychosis as relevantto their respective formulations regarding the diagnosticparameters of dementia praecox and schizophrenia.

HYSTERICAL PSYCHOSIS AND SCHIZOPHRENIA

The diagnosis of hysterical psychosis (HP) gainedwidespread recognition during the nineteenth century; butlike the diagnosis of multiple personality disorder, the diag­nosis of HP eventually faded from use.

The concept of hysterical psychosis (HP) suffereda curious fate in the history of psychiatry. Duringthe second half of the 19th century this disorderwas well known and thoroughly studied, particu­larly in French psychiatry. In the early 20th centu­ry the diagnosis of hysteria, and ofHP, fell into dis­use. Patients formerly considered to suffer from HPwere diagnosed schizophrenics or malingers. A fewclinicians have attempted to reintroduce this diag­nostic category, but ithas notregained official recog­nition.(van der Hart, W1lZtum, & Friedman, 1993, p. 44)

The role of traumatically-induced dissociation in the etiol­ogy and clinical phenomenology of hysterical psychosis hasbeen recognized by a growing number of contemporaryauthors, who differentiate this form of psychotic disorderfrom schizophrenia (Hirsch & Hollender, 1969; Hollender& Hirsch, 1964; Mallett & Cold, 1964; Spiegel & Fink, 1979;Steingard & Frankel, 1985; van der Hart & Spiegel, 1993;van def HartetaI., 1993). Spiegel and Fink (1979) make thefollowing distinctions between the diagnoses ofschizophre­nia and hysterical psychosis:

Our thesis is that the phenomena associated with

264

the syndrome of hysterical psychosis may be sim­plified and understood best by reference to the pro­found hypnotic trance states of which such indi~

viduals are capable. From this poim of view suchhystericaJ symptoms as fugue states, amnesia, andhallucinations are understood as spontaneous,undisciplined trance states. Some individuals, in theface ofdramatic stress within their family, at theirjob, or social pressure ofother kinds may succumbto a psychotic form ofcommunication which is dif­ferent from schizophrenia in phenomenology.course, and prognosis. (p. 779)

A number ofadditional authors concur with this distinction,emphasizing the role of high hypnotizability as an impor­tant factor in the differential diagnosis between hystericalpsychosis and schizophrenia (Copeland & Kitching, 1937;Gross, 1980; Gruenewald, 1978; Hirsch & Hollender, 1969;Mallet & Gold, 1964; Steingard & Frankel, 1985; D. Spiegel& Greenleaf, 1992; H.Spiegcl, 1991;vanderHart&D.Spiegei,1993; van der Hartetal., 1993). Steingardand Frankel (1985)also discuss the connection between high hypnotizabilityanddissociation in this clinical population:

One important mechanism that we believeaccountsfor one type of transient or recurrent event ofpsy­choric proportions is dissociation. Although the olderliterature on hypnosis Oanet., 1965) and its history(Ellenberger, 1970) and on dissociation (Nemiah,1975; Frankel & Orne, 1976) have provided ampleevidence of unusual behavior in patients who dis­sociate easily and, at times, spontaneously, DSM-JIlfailed to note the important coexistence of highhypnotizability and dissociative events. (p. 954)

Also supporting this view are van der Hartctal. (1993), whodiscuss their concerns regarding the confusion in diagnos­tic nomenclature pertaining to this clinical population:

The Index of the DSM-/fl-R (American PsychiatricAssociation, 1987) comains HP, then refers read­ers to either BriefReactive Psychosis or to FactitiousDisorder with psychological symptoms .. _. In thecase of reactive psychosis, we use the traditionalnomenclature ofHP in reviewing the literature andpropose a new category of psychopathology ­Reactive DissociativePsychosis (RDP). RDP integratesthe classical features of HP with the most recentthinking on trauma-induced psychosis.... We believethat the essential characteristic for accuraLC diag­nosis of RDP is not a short duration, but a disso­ciative foundation....The dissociative foundation ofRDP is a more meaningful explanatory principlethan an hysterical or histrionic character as cur­rently indicated in DSM·IlJ-R. (pp. 44-45, 58)

H. Spiegel (1991) expressesan additional concern: "'Withouta careful differential diagnosis, hysterical psychosis and mul-

DlSSOCl\TlO~ \'0\ \Il.~o ~ Dl'U'CIh.--r 199-\

GAINER~

riple personalitydisorder arc often diagnosed as schizophre­nia" (p. 164) .Asan example. Murray (1993) offers a fe-inter­pretation of me autobiographical aceoun!., J Neuer PromisedYou a Rose Gard,en (Greenberg, 1964/1981). This classic talerraditionally has been presen ted as a case studyon schizophre­nia (Coleman & Broen, 1972). Murray's analysis questionsIhe diagnosis ofschizophrenia and focuses on the lraumat­ic origins of !.he presenting symptomatology. Gainer (1992)similarly focuses on Greenberg's account ofchildhood trau­ma, and identifies a number of the heroine's presenting~ptomsas characteristic examples of tr.mmatic dissocia­tion.

I Ncverf'rrmriwI You a R.ou Garden tells the sLOryofa trou­bled adolescent who is diagnosed with schizophrenia and ishospitalized at an inpatient facility for long-tenn psychiatriccare. Author Joanne Greenberg, who originally publishedher book under the pseudonym of Hannah Green, hasacknowledged the story's parallel with herown real life expe­riences as a patient under the care of Dr. Freida Fromm­Reichmann, at ChestnutLodge during the 1940's and 1950's(Goodwin, 1993; Murray, 1993; Rubin, 1972). According toGoodwin: "In those four yearsofanalytic treaUDenl, Fromm­Reichmann and the patient unraveled the connectionsbetween these florid symptoms and the extensive medicaltrauma in early childhood that had .schooled Joanne intoescapes into fantasy" (Goodwin, 1990, p. 188).

Fromm-Reichmann (1950) has described a case studywhich bears a strong resemblance to Greenberg's story, andwhich also illustrates Fromm-Reichmann'sapproach in treat­ing dissociative symptoms with a traumatic origin.

Asked jfshe could remember when being deceivedhad been linked up for the first time with the ethergun, she immediately recalled an operation whichhad been performed on her at the age of three.She had been told that it wouldn't be she who wouldbe operated on, but her doll. Ether was the anes­thetic used. The ether was administered suddenlywhile she was still expecting to see what was to bedone to her doll. It was as ifsomeone had shotetherather. Before she was really under, things and peo­ple appeared tremendous, and the picture of thedoctor who had operated on her had been retainedin her memory ever since as that of a giant. Herewas deception on the part of both of the patient'sparents and of the doctor. It was connected withthe sudden experienceofthe smell ofether imposedon her by a huge man. This, then was the actuaJexperience which gave rise to the hallucinatory rep­etition of the experience which the patient under­went when she expected to be deceived by Lhe psy­chiatrist.(Fromm-Reichmann, 1950, p. 174)

Fromm-Reich man n conceptualizes in the following manner.

I?escriptively speaking, hallucinations are percep­tions without sensory foundation in the environ-

ment. Dynamically speaking, they owe their incep­tion to the bursting-through into awareness ofcer­tain dissociated impulses which become so over­whelmingly strong that they cannot be retrieved indissociation.(Fromm-Reichmann, 1950, p. 173)

Other related comments by Fromm-Reichmann have unmis­takable relevance for con temporary psychotherapeutic workwith the DID client:

The psychoanalyst, as he works with a disturbedschizophrenic, is not only treating a child at qif­ferent ages but also, and at the same time, an adultperson of the chronological age in which he comesinto treaunenL...Psychiatrists who are notsufficient1yflexible may find it difficult to address themselvessimultaneously to both sides of the schizophrenicpersonality. Theymay behave like rigid parents whorefuse to realize that their children have grown up.The undesirable results of the psychiatrist's reluc­tance to communicate with the adult part in thepatient's personali ty and his addressing himselfonlyto the regressive parts in the patient have been dis­cussed before.

If on the other hand, Lhe psychotherapistaddresses himself to the adult patient only, out ofan erroneous identification wiLh the patient, herenounces comprehension ofand alertness to cru­cial parts of the .schizophrenic psychopathology.(Fromm-Reichmann, 1948, p. 271)

DISSOCIATION AND PSYCHODYNAMICTREATMENT APPROACHES TO SCHIZOPHRENIA

Fromm-Reichmann's (1948) approach was influencedby the theoretical work of Paul Federn. Many of Federn'sideas, developed from his studies on schizophrenia, are appli­cable to the study of dissociative disorders.

Watkins and Watkins (1991) have used Federn's (1943)concept of "cgo-states~ to develop "ego-state therapy~, anapproach which has been utilized in the contemporary treat­ment of DID. Federn (1947b) discusses the concept of ego­states as applied to the treatment of schizophrenia in thefollowing manner:

One must encourage the patient to recognize howhis previous ega-states interfere with his presentones. It is not generally recognized by psychoana­lysIS that, normally as well as pathologically, ego­states are repressed; successfully in nonnaJ people,unsuccessfully in neurotics and in psychopaths.Psychotic patients are able to recognize this fact;frequently they recognize it spontaneouslyand bet­ter than is possible with most healthy persons.

By virtue of Lhe Lherapeutic influence, favor­able cases react in agratifying manner. By theirownrepeated attempts the patients learn successfully to

265D1SSOCl\TIO\, \01 \11. :\0. t December 19Q-I

- - -

DISSOCIATIOI\' A.'\D SCHIZOPHRE:-iIA

adhere to the normal adult ego state for periods ofincreasing length. This concept is similar to thatemphasized by Adolph Meyer in his basic goal, there-jOlegration of the slowly diseased personality.(Federn, 1947b, pp. 130-131)

Federn (1952) hypothesized that psychotic symptoms (suchas hallucinations) could result from dissociation whichoccurred when thoughlSwere "objectcathected, ~ rather than"ego cathected. ~ According to Federn, reduction in "egocathexis" would result in an analogous loss of reality testingfor the psychotic individual. Fedem's (1943) descriptionsof the complex "split transfercnces M of the schizophrenicpatient also are relevant to the treatment ofpatients suffer­ing from DID.

In psychotics, these different ego-states, with theirloves and hatreds, are independently orga­nized....Therefore. to use the transference of lhepsychotic, me analyst has to adjust to the fact matambivalence is replaced by two (or more) ego­states....The separation of the ego-states remainsunconscious in the normal individual and becomesa real split in lhe psychotic....By the schizophrenicprocess, previouscgO-Slates temporarily become iso­lated. Psychoanalysis deals with these states in fullacknowledgementoftheir ff>:l.lity by telling the patientlhat they are revived child-states of his ego. Whenwe treataschizophrenic we treat in him several chil­dren of several ages.(1943, pp. 253--254, 256, 482-483)

Several contemporaries of Federn and Fromm-Reichmannoffer additional commentary which is relevatlt to lhe treat­ment of DID, and which predates any modern discussion ofDID by approximately 35 years. In 1948, an expert panel onschizoph renia was sponsored by the American PsychoanalyticAssociation (Cohen, 1948). Members of the panel concen­trated their debate on treatment approaches aimed towardsthe "regressed infant and child" (Rosen, 19(7), whichseemed to be evident in the psychotic patient. As an exam­ple, Rosen's direct psychoanalysis focused upon "._.dealingmostly with that level of mentation which occurs in the pre­verbal period of life and shortly thereafter" (Rosen, 1947,p. 21). Ft..'<Iern comments below on Rosen's melhodology:

His method insists in auacking by direct psychan­alytical understanding traumatic events of infancyand childhood, and copingwilh them as being stillthere, because there is regression to the ego-statesof infancyand childhooo. Ouroptimisticviewpointassumes that this method removes so much of thecause that a satisfactory maturation ofthe egocatch­es upwith the previous failures ofdevelopment andwith gaps in integration. Rosen's good results canbe explained - without advancing any new the~

ry - by atuibuting a great traumatic effect to earlysex experiences....Rosen·s findings revive this eti~logical factor in psychotic cases.(Fedcrn, 1947a, pp. 25-26)

Another cen tralelementofRosen 's treatmen tparadigmis therapeutic "re-parenting."Thisapproach is similar to someof the early, naive treaunent approaches utilized in the con­temporary treatment of OlD, which had been criticized bya number of authors (Greaves, 1988; Kluft. 1985; Putnam,1989). Other therapists who have developed treatmentmethodologies utilizing direct re-parenting ofschizophren+ics have included Laing. best known for his book, TheDividedSeif(I965); and Sechehaye (1951a & b), who pioneered thetreatment methodology of "symbolic realization."

In contrast LO direct rt.."-parenting, are the "reality based"approachesofArieti (1974); Fromm-Reichmann (1939, 1943,1948, 1950); Searles (1959, 1965); and Sullivan (1931-32.1947, 1962). This school of thought emphasizes therapeu­tic contact which reinforces the age-appropriate behaviorsand responsibilities of the patient, while simultaneously val­idating the negative impact of past traumatic experiences.

Contemporary therapists can benefit from the wisdomdeveloped by these pioneering therapists. Clinical expertisein the treatment ofregressed adult patients has evolved overmany years, and is reflective of a growing awareness of therelationship between psychic trauma and the onset of psy­chiatric symptoms.

AI; an example, Sullivan (1962) correlates the onset ofa schizophrenic youth's acute episode of "catatonic dissoci­ation" with the reawakeningof the patient's traumatic mem­ories ofchildhood scxudl abuse. Sullivan discusses his treat­ment approach with this patient as follows:

Energy is expended chiefly in reconstructing theactual chronology of the psychosis. AJI tendenciesto "smooth over" lhe events are discouraged andfree-associational technique is introduced at inter­vals to fill in "failures of memory." The role ofsig·nificant persons and their doings is emphasized...that however mysteriously the phenomena origi·nated, everything that has befallen him is relatedto his actual living among a relatively small num­ber ofsignificant people, in a relatively simple courseofevents. Psychotic phenomena recalled from themore disturbed periods are subjected to study as totheir relation to these people.(Sullivan, 1962, pp. 277-278)

In another example. Stoller (1973) hypothesized that adissociative, trauma-based etiology accounted for the audi­tory hallucinations suffered by one of his schizophrenicpatients. Stoller's (1973) book, Splitting: A Case oj FemaleMasculinity, chronicles the author's diagnostic and psy­chotherapeutic explorations with lhis challenging patient.The book also attempts to clarify the interface between psy­chosis and dissociative disorders. According to Stoller (1973):

Discussions of psychological treatments ofschizophrenia require that the descriptions of thepatients be adequate to differentiate me disorderscurrently called schizophreniform or reactivesc.hizophreniaor hysterical psychosis - all ofwhichare known (0 have a good prognosis - from the

266

-------------------_.

fixed and usually incurable schizophrenia.(Stoller, 1973, p. 318)

Stoller describes his observations of the patient's shift­ing levels of consciousness in the following manner: '"Onecan watch Mrs. G. slide up and down levels ofawareness andmove from talking to me in the office to being again backin the past, Ialking to others whose replies onlyshe can hear"(Stoller. 1973. p. 324).

As the ueatment progressed, Stoller had begun to re­evaluate the symptomatic function of his patient's "halluci­natory voices," and to re-evaluate his therapeutic stance inrelation to the voices:

I automatically, asa psychiatrist, I have to be againstvoices and that's what I've always been; but you'remaking me mink there's something different nowfor the first time. I'm not sure that I have to destroyit....l·m asking to become acquainted with yourvoice....Voices have always been to me nothing butsickness. But if rget to know better what your voicereally is, I am not sure that I would take the sameposilion .... It·s possible that the voice is you in thesame way as the voices that the rest of us have thatwe don't hear...but your voice is too separated fromthe rest ofyou. You see, I would never think ofny­ing to get rid ofyourvoice...thatpartofitthat's likemyvoice...I don't want to destroy you. I don't wantto destroy that part of you which is your judgmentor your conscience. I would hope that the voicewould stop making sounds orconfusingyouor fright­ening you or threatening you or getting you intotrouble, buLl don'twant to destroy the voice. Becauseifl understand you right, then I would have to agreewith you: To destroy the voice would be to destroyyou!(Stoller, 1973, pp. 33-34)

Stoller's treatment gradually guided the patient towardsan integration of both her personal identity and her emo­tional well-being. This process included the use of thera­peutic france, recall, and abreaction. Notably, Stoller's ther­apeutic repertoire foreshadowed the development of manycurrent-day stratagems in the treaunem of DID and otherdissociative disorders.

Another relevant contribution La the field of dissocia­tive disorders was the development of the "double bind"the­ory of communication by Bateson, Jackson, Haley, andWeakland (1956). This model wascanceptualized as an inter­personal, etiologic model of schizophrenia and was incor­porated into the treatment paradigmsafLaing (1965); Lidz(1952,1973); and Searles (1965). In recent years, the dou­ble bind model also has proved relevant fa the etiologic studyof DID (Braun & Sachs, 1985; Fine, 1991; Hughes, 1991;Spiegel,1986).

A long-term challenge for clinicians in the field ofschizophrenia has involved allegations of iatrogenic cre­ation/exacerbation of the disorder (Federn, 1943). Similar

GAINER

concerns currently pose a challenge for clinicians involvedin the trearmentofdissociative disorders (Braun, 1989;Caions,1989; Fine. 1989; Greaves, 1989; Klun. 1989; Torem,1989).

Paul Federn (1943) examines this concern, as relatedto the treatment of schizophrenia:

Psychiatrists who disapprove ofpsychoanalysis neverfail to point out those cases in which psychoanaly­sis, far from having been helpful, created disasters.This statement is both true and false. A series ofeven ts does nOl necessarily representcause and effectMany prepsychotic patients come to the psycho­analyst only when they already feel within them­selves some uncanny menace of the threateningpsychosis. The psychosis would have caught themanyhow wifh or without psychoanalysis .... On theother hand, when psychosis is near the threshold,psychoanalysis breaksdown some egCHitructures andmanifest psychosis results .... Psychoanalysis mustlearn not to provok.e latent psychoses,and even moreto prevent any psychosis from being the terminalstate of a neurosis.(Federn, 1943. pp. 12-14)

Fedem'scommentscontinue to be very relevant to con­temporary practitioners treating individuals diagnosed withDID, and renect only one aspect ofa large heritage ofappli­cable knowledge which has been developed over time bytheorists/clinicians working within the field of schizophre­nia.

CONTEMPORARY THEORY ON DISSOCIATIONAND SCHIZOPHRENIA

Current think.ing about the role of dissociation in thedevelopment, maintenance, and rreatmentofpsychiatric dis­turbances continues to evolve and to challenge our tradi­tional ideas regarding disorders such as dissociative identi­ty disorder, schizophrenia, and brief reactive psychosis. Inaddtion, the current system of diagnostic classification con­tinues to be challenged by the work of contemporaryresearchers. Newly-proposed diagnostic schemas currentlyinclude the categories of reactive dissociative psychosis (vanderHartetal., 1993) and ofadissociative typeofschizophre­nia (Ross, Anderson, & Clark, 1994).

The latter authors present data suggesting that "theremay be tWO pathways to positive symptoms ofschizophrenia,a childhood trauma pathway and a biological disease path­wayM (Ross et a1., 1994, p.2). Bellak, Kay, and Opler (1987)have provided an historical precedent for this kind of diag­nostic subtyping via their proposal of an attention deficitdisorder psychosis. This diagnostic subtype is difTerntiatedclearly by Bellak et a1. (1987) from any of the existing sub­groupings within the traditional schi7..0phrenic matrix, andmay serve as a useful model for the study.

In further discussion on this topic, Bellak (1994) quotesa relevant passage by R.W. Heinricks:

267

_= ----.J_'---- _

DISSOCIATIOl\ A.\'D SCHIZOPHREl\'L\

The failure to achieve a rigorous grasp of the het·erogeneityprohlem has created an uncertainty thathinders schizophrenia research at all levels.The likelihood that researchers are studying dif·ferent illnesses without being able to specify thesedifferences must be recogni7.ed as the superordi­nate problem. It is not a subproblem which can beignored. It is the majorobsW::le to scientific progress.(Heinrichs, cited in Bel1ak, 1994, p. 27)

In summary, consideration from an historical perspec­tive suggeslS that continued collaboration by mental healthpractitioners across specialized fields of endeavor can yieldsignificant contributions to OUf basic knowledge regardingthe role ofdissociation in mental functioning.•

REFERENCES

American Psychiatric A5s0ciation (1987). Diagnostic and jUUistialJ.manual of mental di.wtrkn (Third Edition, Revised). Washington,DC: Author.

Andreason. N.G,&Akiu.al. H.S. (1983). The~ificityofBlc::ulerianand Schneiderian symptoms: A critical reewluation.~ClinicsoJNrmh AmniaJ, 6,41-54.

Arieti, S. (1974). InterpretatWn oJschi1.ophreni(J (Second Edition).New York: Basic Books.

Bateson, G.,Jacbon, D., Halc:y,j., &. Weakland,j. (1956). Towarda theory of schizophrenia. &Muioral Scitna, I, 251-264.

Bellak, L. (1994). Theschilophrenicsyndrome and auention deficitdisorder: Thesis, antithesis, and synthesis? American Aydwlogist, 49(I), 25-29.

Bellak. L., Kay, S., & Dpler, L. (1987). Att.ention deficit disorderpsychosis as a diagnostic category. Psychiatric Developments, J, 239­263.

Bleukr, E. (1911). Dementia praecox, oder gruppe der schizophre­nia. In Aschaff'cnburg, Handb1U:h derprychiatrU. Spezieller Teil, 4,Abt., I. Vienna; F. Deuticke.

Bleuler, E. (1924). Tat-booit ojpsychia.try. (A. A. Brill, tram). NewYork: MacMillan Publishing Co., Inc.

Bleukr, E. (1950). DementiapraeeoxorthegrouPoJschiwphrenias. U.Zinkin. trans). New York: International Universities Press, Inc.

Bliss, E. (1980). Multiple personalities: A report of founeen caseswith implicatiorn for schizophrenia and hysteria. Archives oJGennalP.tychiatry. 37, 1388-1397.

Boon, S., & Draier, N. (1993). Multiple personality disorder in theNetherlands: Adinical investigation of71 patients. It1MriamJournalojPsydrialry, 150, 489494.

Braun. B.G. (l989). Iatrophilia and iatrophobia in the diagnosisand treatment ofMPD. DfSSOClAT/ON, 2(2),66-69.

Braun, B., & Sachs, R (1985). The development of multiple per­sonality disorder: I>redisposing, precipitating, and perpetuatingfactors. In R. P. KJuft (Ed.), Childhood antecedents of multiple person­ably (pp. 37-64). Washington, DC: American Psychiatric Press.

Carpenter. W.T., Strauss.J.S., &.Mulch, S. (197~).Are there pathog­nomonic symptoms in schb:ophrenia: An empiric investigation ofSchneider's first rank symptoms. Archives oJGerwai PJychialTJ, 28,847-852.

Cohen, M.B. (1948). [Review of Panel discussion on the theoryand treatment ofschizophrenia]. Bul/din oftheAm.triron PsychomuJJyticAuociation, 4, 15-20.

Coleman,j., & Broen, W.E. (1972). AbnctmalpsyclwWgjand modemliJe (Fourth Edition). Glenview, llIinois: Scou. Foresman andCompany.

Coons,P.M. (1989). Iatrogenic factors in the misdiagnosisofMPD.DlSSOClA.170N, 2(2), 70-76.

Goons, P.M., & Milstein, V. (1986). Ps)'chosexual disturbanC6 inmuhiple personality: Characteristics, etiology. and tre-.t.(JTIent.JounwlofainicalPsychiQhy, 47, 106-110.

Copeland, C.L.. & Kitching, EA. (1937). Hypnosis in mental hos­pital practice. Journal ofMenJ.al ScUna, 83, 316-329.

deMause, L. (1987). Schreberand the history ofchildhood.JournalojPsyclwhisf.Qry, 15, 423-430.

Ellenberger, H. (1970). The diJtmlt!f'J oj /he unamscious. New York.:Basic Book.!!.

Federn, P. (1943). Psychoanalysis ofpsychosis. P5Jchialm Q;u:lrterby,17,3-19.246-257.480-487.

Federn, P. (l947a). DUcussion ofJ.N. Rosen (1947). The treat­mentofschizophrenic psychosis by direct analytic therapy. PsydtiatricQ;u:lrurly, 21, 25-28.

Fedem, P. (1947b). Principiesofpsychotherapyin latent schizophren­ics. Ameriam journal. ojPsychotheraPJ, J, 129-144.

Fcdem, P. (1952). Egp psychology and the p5Jdwses. (E. Weiss, Ed.).New York: Basic Books.

Fine, C.G. (1989). Treatment error.; and iatrogenesis across ther­apeutic modalities in MPD and allied dissociative disordef$. Drs­SOCJATlON, 2(2), 77-82.

Fine, e.G. (1991). Treatment stabilization and crisis prevention:Pacing the ther.lpy of the multiple personality disorder patientPsydJialTic CIinia ojNorth AmeriaJ, 14, 661-676.

Fink, D., & Golinkoff, M. (1990). MPD, borderline personality dis­order and schizophrenia: A comparative study of clinical features.DlSSOClAT/ON,3,127-134.

Frankel, F.H., & Orne, M.T. (1976). Hypnotizability and phobicbehavior. AnhiutS oJ~aJPsychialry. )3, 1259-1261.Fromm-Reichmann, F. (1939). Transference problems inschizophrenics. Psychoanalytic Quarterfy, 8, 412-426.

268_____~_L-..------

Fromm-Reichmann, F. (1943). Psychoanalytic psycholhcrapywilhpsychotics. /?jdtiaJry, 6, mom.

Fromm-Reichmann, F. (1948). NOleS on Lhedevelopmenloftreal­mentorschizophreniabypsychoanalytic psychotherapy. Psydtialry.11, 263-27~.

Fromm-Reichmann, F. (1950). PrimipltsoJinteruiw~.Chicago: University of Chicago Press.

Gainer, K. (1992, November). TheroltoJlhuQnaptoJdissociationin!he historital~t ofWories ofschiwphrmia; -/ never promisedyou arostgardm -,-roiYittd. Paperpresentcdat the Nimh InternationalConference on Multiple Personality and Dissociative States, Chicago,Illinois.

Goodwin,J.M. (Ed.). (1993). Redisroveri"¥Jchildhood trauma: HistoricalwsebQQk mid clinical applications. Washington, DC: AmericanPsychiatric Press.

Greaves, G.B. (1980). Multiple personality: 165 years after MaryReynolds. 1'1uJournal ojNervous and Mental Disease, 168 (1 0). 577­596.

Greaves, C.B. (1988). Common clTors in the treaunent of multi­ple personality disorder. DlSSOClATJON, 1(1),61-66.

Greaves. G.B. (1989). O~rvationson the claim ofialrogenesis inthe promulgation ofMPD: A discussion. DJSSOCJATlON, 2(2),99-104.

Greenberg,]. (Green, H.) (1964/1981). I nnJt:r1JrmrliWJOU a rougartkn.. New York: Holt, Rinehan, and Winston, Inc.

Gross, M. (1980). Hypnosis as a diagnostic lOOI. Clinical Hypnosis,23(1),47-51.

Gruenewald, D. (1978). Analogues of multiple personality in psy­chosis. Inlemau(maJJournal oJOinical and Expnimrotal Hypnosis, 26(I), 1-8.

Hirsch, Sj., & Hollender, M.H. (1969). Hysterical psychosis:Clarification of the concept. AmericanJournal oJPsychiatry, ]25(7),81-87.

Hollender, M.H., & Hirsch, SJ. (1964). Hysterical psychosis.AmmcanJounuU ofPsychiatry, 120, 1066-1074.

Hughes, D. (1991, November). ApplicabililJoJdf.JubkbindtheqrytmdtmnsamtextuoJiuuion w tIu! study oJ MPD. Paper presented at theEighLh Imemational Conference on Multiple Personality andDissociative States, Chicago, Dlinois.

Janet, P. (1889). L'aut.omati.sme~Paris:A1can.

Jung, C. (1907). TheJn'JdwlogJof~fJ'ra«<»'.(F. Peterson. &A.. A.. Brill, tr.\ns.). NcwYork:joumalofNervowand MentaiDiseasePublishing Co. Original work published in 1907.

Klufl, R.P. (1985). The lreaunent of multiple personality disorder:Current concepts. Dirutions in psydiiatry, 5(24), 3-9.

!?uft, RP. (1987). First-rank symptoms as a diagnostic due to mul­tiple peroonality disordcr. Americo.nJoumal ofPsychw.lry, 144,293­298.

GAINER

KJuft, RP. (1989). lau-ogcnic creation of new alter personalities.DISSOCJATlON, 2(2), 83-91.

Laing. RD. (1965). 'J"M di.vidD;i. stJf New York: Penguin Books.

Lid1., R., & Lidz, T. (1952). Therapeulic consideration arising fromthe intense symbiotic needs of Lhe schizophrenic palienl. In £.B.Brody & F.C. Redlich (Eds.), J~fJ'jwilhs~C$. NewYork: lnternational Universities Press.

Lidz, T. (1973). TMoriginandlrMtmeruofsdtizoflhnnicdisO'l'dns. NewYork: Basic Books.

Lipton, S.D. (1943). Dissociated personatily:Acase report. J>sychitJl'rUQuarnrly, 17, 33-56.

Lipton, S.D., & KC1.Ur, E. (1948). Dissociated personality: Status ofa case after five years. Psychiatric Quarterly, 22, 252-256.

Latham:, Z. (1992). In rkf/!'l"tU ofSchreber: Sotd murder and psychiatry.Hillsdale, NJ The Analytic Press.

Mallett. 8.. & Gold, S. (1964). A pscudo-schizophrenic hysterialsyndrome. BrilishJoumai ofMedical Psychdogy. 37, 59-70.

Mellor, C.S. (1970). First-rank symplOms ofschizophrenia. BritishjounuU ofPrycJUotry, J I 7, 15-23.

Murray, Bj. (1993). I ntVtr promisld JOU a mst gardtn.. Compulsiveself-mutilation. InJ.M. Goodwin (Ed.), ~dIildJwodtrau­ma: Histf}ria,l casebook and cunical applicalions (pp. 191-199).Washington, DC: American Psychiatric PreMo

Nero iah.J.C. (1975) . HYSlerical neurosis-dis.sociative Lype.1n A.M.Freedman, H.I. Kaplan. & BJ. Sadock (Eds.), Comfmhtnsitlt let­book ofpsychiatry (Second Edition: Vol. 2., pp. 619-624). Baltimore:Williams & Wilkins.

Niedcrland, W.G. (1959). Schreber. father and son. PsychoanalyticQuarterly. 28, 151-169.

Niederland, w.e. (1960). Schrcber's father.JournaloflheAmericanPsychoanalytic Association, 8, 492-499.

Nicdcrland, w.e. (1968). Schreber and Flechsig: A further con­tribution to the ~kernel of truth in Schrcber's delusional system. M

JounuUoftM Amt7'ican PsychoanalJtk Auociation, 16, 740-749.

Niederland, W.G. (1974). TIlL Schreber case: Psychoanafjtic profile ofa pamru:Jid ~rmality. New York: Quadrangle Press.

Niederland. W.G. (1984). The Sdtrtber case: Psychoarwlytic profile ofopamncid!JeDona/ily. AnexpantUd tdilWn. Hill.sd.ale, NJ: The AnalyticPress.

Putnam, F.W. (1989). Diagnosis and frtatmcnl ofmu1lipie pnwnalit]diMJrder'. New York: Guilford Press.

PUUlam, F.W.• Guroff,JJ., Silberman, E.K.. Barban, L.,& POSl, R.N.(1986). The clinical phenomenology of multiple personality dis.­order: A review of 100 recenl cases.J()llrnaJ ofC1inimlPsychiatry, 47,285-293.

-269

DISSOWTlON, \'01 \11,:\0 t [)twnb~r 1994

- .-

DISSOCIATION M'D SCHIZOPHRENIA

Rosen ,J.(1947) .The treatmentofschizophrenic psychosis bydireclanalytic therapy. Prychiatric QJ.uIrter/.y, 21, 3-37, 117-119.

Rosenbaum, M. (1980). The role oflhe term schi:wphrenia in thedecline of diagnoses of multiple personality. ArcJUws of GmeraIhJchiatry, J7, 1383-1385.

Rosenbaum, M., & Weaver, a.M. (1980). Dissociated state: Statusof a case after 38 years. Journal ofNeroous and Mmlal DiYJose. 168(10),597-603.

Ross, G.A. (1989). Mullipk pcmmaWy disorder: Diagnosis, clinical/ea­tures, and treatment. New York: John Wiley and Sons.

Ross, CA., Anderson, C., & Clark, P. (1994). A dissoeiatiwsu~of sdIiwphnnia. Unpublished manuscript. Chancr Hospital ofDall.a.$.

Ross, CA.,Anderson, G.• CIark. P" Fraser,CA, Bjornson, 1-, Reagor,P., & Miller, S.D. (1994). Diffemuioling multiple pmonaUt'j di.wrderand schi1.ophrrnia. Unpublished manuscript Charter Hospital ofDallas.

Ross, CA., &Joshi. S. (1992). Schnciderian symptoms and child­hood trauma in the general population. Comprthmsfue Psyehimry.JJ, 269-273.

Ross, CA, Miller, S.D., Reagor. P.. Bjornson. 1.., Fraser, GA. &Anderson. C. (1990). Schneiderian sympoomsin multiple personalitydisorder and schizophrenia. Comprehensive ~Iry, Jl(2), 111­118.

Ross, C.A., & Norton, G.R (1988). Multiple personality disorderpatienuwith a priordiagnosis ofschizophrenia. DISSOClATION, 1(2).39-42.

Ross, CA, Norton, G.R. & Wozney, K.. (1989). Multiple person­a1itydisorder. An analysis of236cases. Canadianj()ll.maJofPsJdlialry,J4,413-418.

Rubin, $.E. (1972). Conversationswith the authorof I7Ieverpromistdyou a rose garden. Psychoanalytic &view, 59, 201-215.

Schatzman. M. (1971). Paranoia or perstlution persecution: Thecase of Schreber. Family Process, 10, 177-207.

Schneider, K.. (1939). PsJdWhtr Ixfund und ps,dlialri.scJu diagn4se.English translation (1959). CliniaJl prychopa.lJwlogJ (Fifth edition).New Yorl:.: Crune and Strauon.

Searles, H. (1959). The effort to drive the other person crazy: Anelcmemin the aetiologyand psychotherapy ofschizophrenia. Britishjournal ofMedical Psychology, J2, 1·18.

Searles. H. (1965). CAll«ted papen on sdaizDphrmia and rdaUd sub­frets. New York.: International Uni~nitiesPres.

Sechehaye, M. (195101). AulobiograplrJ of a sdWophrmic girL NewYork: Grune and Stratton, Inc.Sechehaye, M. (l95Ib). Symholic realizalion - a new mdJwd ofPSY-­eJwtherapy applied ro a CeMe ofschizophrenia. New York: InternationalUniversities Press.

Shengold,1.. (1989). SouL murder: TIu effects of childhood abust anddefnivation. New Haven: Yale University Press.

Spiegel. D. (1986). Dissociation, double binds and posl-traumaticstress disorder in multiple personality disorder. In B.G. Braun (Ed.).TrMlmnUofmultipUpermn4lit]discrder(pp. 61-77). Washington, DC:American Psychiatric Press.

Spiegel. D., & Fink, R (1979). Hysterical psychosis and hypnotiz.­ability. Americal'lJournalofPlychiatry, lJ6(6) , 777-781.

Spiegel. H. (1991). Invited discussion of ~An exploratory study ofhypnotic capacity of schiazophrenic and borderline patientls in aclinical setting." Ameri<an journal of Clinical HYJmosis, JJ(3), 162­164.

Spiegel, H., & Greenleaf, M. (1992). Personality style and hypno­tizability; The fix-flex continuum. PS]Chiatri(;Mtdidtu. 10(1),13-24.

Steingard, S.• & Frankel, F.H. (1985). Dissociation and psychoticsympLOrns. AmericanJournal ofPsychiatry, 142(8), 953-955.

Stoller, R (1973). splitting: A case offemak masculinity. New York:Quadrangle Books.

Sutcliffe,j.P., &Jones.,J. (1962). Personal identity, multiple per­sonality, and hypnosis. InlernatiorudJotJ.T7l4loJCJiniaJJ.and~H~ 10,231-269.

Sullivan, H.S. (1931-1932). The modified psychoanalytic treatmentof schizophrenia. Amtrican journal ofPsychiatry, 88, 519-540.

Sullivan. H.S. (1947). NOleS on investigation. therapy and educa­tion in psychiatry and their relations to schizophrenia. AmtricanjournalQfPs,chiahy, 10,271-280.

Sullivan, H.S. (1962). Sdliwphrmia as a human preuss. New York.:Norton and Company, Inc.

Taylor, W., & Martin, M. (1944). Multiple personality. Journal ofAbnonnal Social Psychology, J9, 281-300.

Torem. M. (1989). Iatrogenic factors in the perpetuation ofsplilo

ting and multiplicity. DISSOCIATION, 2(2). 92-98.

van der Hart, 0., & Spiegel, D. (1993). Hypnotic asses5ment andtreatment of trauma-induced psychoses: The early psychotherapyofH. Breukinkand modem views. ThelnlerftatiqnalJuumalofCIinWJand&pmmmtaiH,pnosis, 41(3), 191-209.

van der Hart, 0., Witztum, E., & Friedman. B.• (1993). From hys­terical psychosis LO reactive dissociative psychosis.JournalojTraumaticS~ 6(1).4~.

v.illl derKolk, B.A., & Kadish, W. (1987). Amnesia, dissociation andthe return ofthe repressed. In B.A. van der Kolk (Ed.).~Imuma (pp.173-190). Washington. DC:American Psychiatric Press.

Watkins,j.G. & Watkins, H.H. (1981). Ego Slale therapy. In Rj.Corsini (Ed.). Handbock ofinnovaliut psydwthempits (pp. 252-270).New York: Wiley.

270____________1.-------<

Watkins,J.G. & Walkins, H.H. (1991, April). H1Jr1wtic IllchniquesJorMPD therapisls. Workshop presemed at the Sixth Regional Conferenceon Multiple Personality and Dis.sociativc States. Akron, Ohio.

Weakland,J. (1960). The Mdouble-bind~hypothesis orschizophre­nia and three-party interaction. In D.Jackson (Ed.), TIu! etiology oJsdlit.oplrrmia. New York: Basic Books.

271

D1SSOC1\TIO\. \'01 \lL :\0. t. Dmmbtr 19'H