i 2J.J

,rl \vn< made willi .lame-. the oiiuinal pci-orml.tV.: liypno-t-; 11 ir* ilvnimii- < M. inn-citirrs Mirroundini: thr

i r hv .lint wete tli.n iil.nl itn.l James had (-It frus- f, ippr-il defeated. Impel.--Iv tied down hv lOICCS and

with w111cl' I"’ r-ml.l I...1 ."I"’ Hi" cl'""''1 "I „ I,nil l-eill forced .Ml I.III! l-y II tl.Mlllll.il M.c IlltlllllT. lh<I \nitt-il m iinrim i' complaint- about him , in< lu.hm:

on Ins uiiinl»«»l. -"I.I n.iiitili 'l hrr extramarital

,, hrfmi' I.mi. Tin- .1- ni.in.l- ..( In- cmployi r lie f l it

\t(-."ivr, ..ml vet ho had no way of refusing to inert

lames’ la-t m e m o r y was of a *. n-r of nim intinp panic

-pnir on the m^lit of ll.r disappearance.

r is a rather typical example of dual personality

licit dements’ of fu&tic played a role at the

In a characteristic way .lim gradually built up

tabulated past in which he caiue to believe. In

rases men have developed an elaborate new life

; very convincing pa.-t history, have settled in a

ilaro, ai'd have sometimes started a new family

iiit legally disposing of the old, for which they

no memory. Such cases periodically come to

l i f t e r the old, wife nor the new can believe

die they know is capable of bigamy. Lnlikc

icmes of " th e Uemaikahle Mr. lVnnypackcr”

"Captain's Paradise,” the patient with dual per­

il y appeals to have no awareness that he has

dial might be termed a double life. Almost never

uiie of the subdominant identities of the rapidly

m<r variety of multiple personality undertake to

v 'or make other legal commitments, although

il acting out, gambling, and minor a rtif ic ia l acts

mt uncommon.

a trice was a sinplc, 32-y. nr-old jcliool teaclirr who lived■ and was considered to l»r pi ini, proper, colorless, untl a ilnrc old maul. She soupht psycliollicrapy brinuso of ..jtilr ar.d Itpadachrs a-.-o. lalcd with tliem. I'or 50111c tune .s Hillicnll to clarify wlint tin -e episodes actually eonsti- i. However, psychotherapv of a relatively noudirerti\c was initialed. Our .lay, half way Ihrouph a rather dreary'\i.*w*, in which the patient touelrssly drserilied lier un- rnii! admiral ion f*>r her strong-minded. doiuiiiatinp mother,

•inldenlv sat u]) in tin- chair. Inriietl a biipht planer oil the lr ,\f lied Hirt:itinii-ly. (nd said, ' Poe, how lone are you- t(V ; up with -ill'll a ?i|iiatr ’ T his was T rixir. On ft

]„T rh occasion- when Heiilrirr retired early with a sick

l.iclir, Trixie had l.oin !. .1 out of bed nn hour l iter, dressed

ir |i style, n II. 1 pone out on I lie town. She drank, pickcd up

in liars, frequented danrr halls, nn.J nttendrd racy movies,

was *oiitcmptnon- of P. airier, who rcniftined unaware of

if's existence tlir.nii'l. inonlh-of llierapy.

i third personality, l!o.i, bepm to rm rm r after about a

' It. a and Trixie kin w ;iIxmI P., alri. r and each otIn r. I l.ry

.vied for conlinl for i. while. I in.illv lira , a iv la liveb

nr** type with >.nur of the li.’tl.T cl.ar.i. Ir ii- lus of I...til

!.»• nlli. ls, pie.I.timnal. .1. ( i i ...lu.iII\‘ tl.. ..Ih»■ i > fa.lr.l out of

|.|.■line. The p.ill, nt and th. iat-t-1 am r .d ti.at P.-alurr was

tr.-at 1.1.%-; however, tin \' l.t.llt l.a.I m o in iu ts when they

- d tl.c naticlity but \ iva. iou- Tiixir.

t’aranraxes, pr,\chotrciiic ties mid m otor automa-

'n«, A parapraxis is a di-.-oeiated action that serves

u>efiil purpose, l’arapraxcs often occur outside of

arniess and rue ielated to the seemingly more

’‘scions but uncontrollable twitches and spasms of

psychogenic tics, and also to the apparently voluntatj

but tenacious habitual motor automatisms.

Freud's discerning inspection of many specific cx-

ninples of para praxes in everyday life— such as a

slip of the tongue or pen, a small accident, or the

misplacing of nn article, without the individual being

aware of the idea a.-sociated with the action— con­

tributed significantly to the evolution of his under­

standing of unconscious mental processes.

Most psychogenic tics arc brief, recurrent, seem­

ingly inappropriate and more or less uncontrollable

movements, which range from the almost unnoticeable

to the overtly grotesque. In the patient’s life such

movements were apparently once associated with an

emotional experience at a crucial time, but now ap­

pear either as a substitute for the emotion (thus

unconsciously manifesting it) or as its equivalent

(thus warding it o ff l. 'A tic or involuntary grimace

which includes head turning, eye closing, and the

raising of a shoulder may be the interminable repeti­

tion of a wince elicited by a face-slapping episode in

childhood, now appearing as a dissociated movement

the unconscious purpose of which is to dim inish anx­

iety. M any types of psychogenic tics or habit spasms

have been described and must be dilTcrcntiated from

those related to eticephalilic or other neurological

disorders. Torticollis, which may be more or les? tic-

like, is an example of borderline diagnostic problem

of this type.There arc many other dissociated actions which

serve no obvious purporo, which often occur without

the individual's awareness and even contrary to bis

desire, and which fat least in a number of documented

instances) contain manifestations of some encapsu­

lated, repressed emotional conflict surrounding a

traumatic episode or situation from earlier experience1.

Some of these are called “automatisms” and constitute

rather elaborate and often constantly repeated move­

ments (or verbalizations) over which the patient

seemingly has no control. Severe instances may be

seen in clinical schizophrenic or dissociative reactions.

M ilder forms arc often called “motor habits” (car

pulling, hair twisting, eye winking, etc.) and are

very common in less disturbed patients and in clin i­

cally normal people. Such motor habits can be con­

trolled to a greater or lesser extent but tend to become

worse when the individual is tense and anxious or

when his attention is distracted from conscious efforts

to control the movement?.Autom atic r iling . Of eon-i.lerabl.- hi-torieal in ­

terest, both in medicine and in fie linn (for example,

The llrnst with l'irv I'itujvrs I automatic writ ing is

seldom seen in this day ol typewriter and dictating

machine, llowevrr. it i: still useful to look for it.

Frequently such behavior can be elicit'd in the ex­

amination of a patient in a dio.-ociative Uance stale,

l ie may be mute and seem to be out of contact with

reality. However, if a pencil is put in his hand, with a

piece of paper under it, he may begin to write. A

.................. . ° f >"» i><-.<o.,nii.v , , . „ , a n vc o i iu u t.s the rx.i ii i iMcr mwl I.L.

interview ,0 ..h , Tl 1 ° f 1,11m m , ‘ J : , ‘ , a " * = o . n o t h o ac-

T l .o m H o m a . i c

"ifli.oiM.c- f ,o , „ , 1(| ,o„r It v • > ^ p o n s , v o to

n » ‘J m a v seen, 1 J ' ‘ r SiP'>ntai,,-ou>|y

i t enn lie o f ' , ^ ' ° ' ' ’m l t 'c ‘P hc rab le . V e t

C a u s e r m i m I, om«\ S on ie t im e s n i l .- , I "<1

c L S ' r - S S v ' r a k ° ' S Z n u ' l ; T ''C, ^

t o t a l l y i r re le v an t r e s p o n d to ., " S b l l t . n o t l ie is c iv c n P i l r n l ' i H ' «i*ite\ei in s t r u c t io n s

v .u r i i ia t io n .s m a v ho o il « . ) ; » ) . <v r e x a m p le . 2 |,|„. o r, ‘ aU &,,P l i t ly of), for

r f o c l o r « s a U ™ S“ " 'm , , ,C r “ i l l r n t l f i « *>«

...........m *m a l i n g e r i n g i f . „ L , " " ' ' 'a l ’0 ™ < ' » '

while "decoivinn" flm i i *J»oii(;lit ho wasuccenmg the jailers or the doctors. >

n.ssoeia .ive o x p e n ,, , , ,* rd .,U ,l

^ Z u y y t n ^ r ^ T r ! , : , , ^ d ' *

■ relative mental alertno ■ , W,1,,c 1,1 sta l« of■ »»S from si,, p. H uc„ ,,7V'‘J ^ 0,fu,,,t;i,,o". j».i awaken-

• of time (seconds to m m u t ! " ■ . * -bricf ,,CriodthoiiKh it win nL.Vej. , Tj ’ " / t,,c Patient feels as

hodily movement is di ■ or 7 ° ! r'C t0ta! caPaci<-v f°r

■ tional controls The cvUmhT , 7 " ' l,K' " Sual vo,‘- ( ( ;« i l factors invnlvrd in V| ‘ ' ’^ ' " P '^ i o l o g -

‘ Hvo tved in ep isodes o f s f c n , n , “ lv i i " a y ' *may he that for c„„. Pai.il\m > is unclear. It

‘ ' " " “ b n T t Z Z Z T ™ * " " kc' " " s. dreaming:) sleei) Or,!,, > i 4. - ,novPHici)t or

the most ' r ’ 13 thc timc of Sl«-P inentire hodv obtains- 'th^ nul.>lMI,ar ro|axa(ion of the

c r e e d > i i » »

: c ° ‘ — z

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

t e m a t ie M m l ie . MI|li, j J , ' ' ' Vl‘ ' ™ i >vs-

in c ide nce o r o f i|. 1:00,1 its

dissociative svmpUm,. ,|IL " " h „ (|,er

,JC " 'o r e th a n one attack^ \ ^ T h e re n .a v

" , a y ° 0cur " 'o n H 's or even y e a rs a p a r t ’ ^ ° ,,iSO,,CS

‘•""irw: lh- -I.V'V\V',k'in, ; ^ n ! . n r ' , |.0 ''.'’ CV,’" ' " L'! u l, i l ' •«>>-ll"ii.f| I,, 11:iii wnI, |,|, , ‘ •' lllc . n I’-ycliiMlri-l i„ . r,.

in-., f,:r 1 ,h,.... . ^MIII'.'OI, rx|irrs.<i>,| ( , s ■"'nK roll.-, (i ll. Tin-

" l . r n („• Icaincil u t ,,( 11,,.x-<Vv«.ro11V'111'"*'K IV- .1 Mory of l,:,i|„L. 11('r , lllfo t' .lls. Ill- tllrn

I II■ llidHKlit It vv.is for,,,1 I'r ll." 1 for yeans.

k<-«-|.iTiK it .1 5i i'M't f„ r f,..ir tl, ,f l ' 1' '' , " ' lls «*'' 1 •« »n I•-lv

Mr,,,,*.!,,-!,. I,,. |,,(l' »»■«• uplo in ,i|s.,„t i|„,L.s a I'oml.mm.oM of a„t,-

-ttnefc. ,n,| .l.U ronnm l c , I . ^ '" '" V K .,n ,l ,„ a| u-ork. ini|»nct.ii„inf? to m nintm n a lortnos for f.is

'■‘■conic aw arV of'h is m I ^ L i' X ir 1' n at n.cl.t,move. I.vine in l,cd hi- u , , I I i3' J Inm sflf muililc to

o r c v ,1, h , r„ ^ v r r. , r ;nt 1̂ . y1V ,r5,,'Ti,!H -V "■ <M>" ° ’il.J I ’inallv, It von lil r ^ r ! ' " f ' ' ' ' ’ " V " 1,1 1 1,1 r-!|■,,,.*»|lto iry out. A> -onn ■ ti i I'um t lliat ln> «;,< njj|I;

«l>ility to n ,m e , 1 " S l ,npcnr^ ' would ic itivcr the

F o l l o w i n g this il is , l o - „ r r 1 n , 1 , icarnr-i l o u t . I r M l lN ' r o . r ,, , " a s

r a t , o n « a s , I im o n l i , „ 1(, | S , , , , , , ! . r , ' " ' r ' h -

Fr‘ <’ of rrli. f. ............ (|,(, ‘ " ■ ; l . roudi t a

tune to tin if. S iiiu ' |,e < to o ,, i,r fiou ,

llirraiiy, no itfort »■#, ,„a.|0 , !1' 1(J, a of I'-y ho-

wlntli ap|.rarcrl to hr id a l id to^n tT'. f' 'y< factors,pa>>ivo s t r i v in ^ s . '* r uncortst 10115

Slccii-tftlJ.injr ntl([ sIcrit-Hnll i n f V i i

n o ,i„ .n u o c cu rr in g , 1,,,-i,,,. ,|o c , i „ c f i , l ’ l !c -i n t o ado lescence a n d a . h . h h Z i t , l l l l i u n l n a -v P « « i s t

n p o o r lv u n d e r s to o d l-.H , ®S *• , n a n i f est .nt ion o f ^V ' te n i -r ; o f n i a t u i a t i o n o f the nervou-,

" . c ; s a ...............................................o“ -

n ie n ts d u r i im <UTl) .... ' , g-- ° ' P ' ° ss h o d l l-v "tove-

• im i l a r to th em <,' T ,aU '<l M “ U,S t l , a t a PP< a r

a n y s , „ r ; ; ; « > » * u » . i n v „ h , , ,

p la ce d u r in p .1 s lo iv w a v ™ s le e p ' 1 T l f lc“ ’k '

E S r « n r . r i 7

^ w i i . « ' w " m ,m ' " r ' " s c lv c s

in, ..... t —

'........................... " ! " " h "

' " " i t e d , an . l n o c t , „ „■,! TI " P 'o f o tm d . self-

on e la h n ra te ' r \ l u * >•’ ''t-d a n d r n r r y

c m cn t lv I, iv i ' f(,r " l i i e h t l iev -tih-e-

« « t w . 1 , ; , ................... .......... .. , i i . , , i , y

S r c t i o n C . 1 .3

mil] s tum b l in g evi l ob jects , n o r l ike tlio-c a d u l t s w ho

'crni i " k in d of :i con fused s ta le d u r i n g

jlo'V wave .^krp when it is r|iiite poss ib le th ey

may full, in ju ie tlu ni-.-Ix . s, or engage in lu m p u r p o s iv c

|.i!:avior. U n l ik e such s leep-walkers , the d is soc ia ted

fuiiinanilMili.st launches in to in vo lv ed , c o m p l i c a t e d ,

m'i.I h igh ly m e a n in g fu l a c t iv i ty , w h ic h on n u m e r o u s

«i;liM'inicnt occasions can be observed In o ccu r a g a in

nml ngnin in very m u c h the s m i c p a t te rn .

llius iI. appears that between normal sleep-talking

imi-I bodily movements on one hand, and clear ciU

linnet' behavior or dissociated somnambulism on the

oilier, joino varietic.-. of sleep-walking and -talking

r\i#t us dissociative phenomena ielated to sleep in

nnysnotycl fully undersiood (Kales et a l.l.

Enuresis. In young children,' enuresis occurs dur­

ing the dicpest peiiod of slow wave sleep, usually'

prior to, and perhaps in some wav as a substitute for

l!.<- first dream of the night.. The idea that, such n

fluid is somehow unconsciously electing to pour out

Ins hostility toward hi* parents in this fashion is not

ll0,~if&>Ut ^ *IU’ < lcctroonrt*Pl|:i!<'"iaphic fact.-. IIow- 7 ' W Cn'ics " llcrr c"'nc.-is persists into adolescence dit'ii' are conflicting data.

Some adolescents and young adults have been ob-

-trvet who become (bioelcctr.cailv speaking) awake

•uttvl.uJic qui.-tly in bed as though in a trance, empty

r “kidders, and then return to physiological

' ' ° l v ‘- "V1 cP'-codcs u s u a l ly o ccu r a f te r 5 o r G hour?

normal sleep. These eases mav manifest various

••"Serin to substantiate a diagnosis of dissociative

H'.ution; if so, they can be treated successfully and

•vm» draiiintically. They must be distinguished from

:0;t- l*«>wlme cases where the bed wetting repre-

M,,ne ‘yi’P’of maturational failure of the nervous

\ «rological disease, or perhaps even nocturnal 'iizines.

Sottirtolcniia or t i e d r u n k e n n e s s . T h is cond i-

' i" adults seems to be a dissociative persistent

^■st.Hon 01 night terrors in children. In som-

•;'U.a the patient seems to be neither asleep nor

. ls chancJenslically disoriented, and to a

; ; ; ; L 3r l< S|H'1' CN,ta,t , t '1̂ u> "iglUmarisl, mental ii, sometimes becoming licnzied or violent.

■ '•''/> /"tllm-ir ,iions. In addition lo the liallu-

ni>evpenence- u| normal dream* there are other

■ a licet, m which hallucinations occur in rela-

, 0 1 " 'I ’- ^ ,I,IU' of Ihe.-e aie common in normal

.......... " V " t;(,|l<'ln l ,v h y p n a g o g ic l ia l lu-

• V ‘ ; y . are ^ » » H y v isu a l bu t m a v be aud i-

, une.s, ,e|ir ; ,|1( y m a y occu r w h i le f a l l i n g

, I , Ulc ,1.v l’ " n ! ' ° " ic s t a i d or w h i le a w a k c n in -

; *• ’.V l . im po n ip ic s la le ) . U su a l ly these h a l lu e in a -

^ ^ l ^ n c n c e d very briefly d u r i n g a m o m e n t a r y

period Iw iu cell sleep a n d wakefu lne .ss

;iil,„ , lu ‘.v e n d m e f o r a lon-er pe, iod o r r . .„ ,e

, I '' " ' " ' I H ' H m g de f in i te e p is o d e , in

l( pa t ien t >1 n igg les lo t d i i i i n a l e the ha l lu-

Dissocintivc K eaction J197

cinosis by “waking up” but cannot do so. Such attacks

of sleep hallucinations arc very similar in some ways

to sleep paralysis. 1 hey are subjectively quite dif-

fm n t from dreams, that the patient is partially

j . ° f lns rcaI surroundings, like D ickens’ Scroore during his conversation with .Marley’s ghost.

I iigue. The element tlial charactemes fueue mo>t

e early is flight usually entered into rather abruptly

1' lorn a stressful life situation, the individual wanders

with a col’" ' l 7 ‘ t,aZC‘ ° r Confns<‘ci state, often. n C0mldctc amnesia, sometimes without care for

n ^ r r ? ° r 1° ’ his. s,,r,'ountli»Ks. Jn more elaborate ' batL's’ 'vllcrc t!'c element of acute trauma is not

as great a precipitating factor, the patient may func­

tion f°i days or weeks in a seemingly normal way.

Period''i* ’ H i \ ’ l!‘at cl,a™ tem c.s him during this

ie l lM ,r " i i IS l.T 'Cl,nB- Ht? " ,:‘y COniC t() 1,i,n-where he is. C° U W,t1' » "«"■ »«» of how he got

mi N of a I V 10 Ono nflcn .oon , in the

from ' nr>°l f — foun.l lo !„•

«]»r rf I! 'JU,V A S° ' lim n in terv iew pro-

i < 1 Xn' cnt«. com r .7 ! , I ° 1,8,1 U:,S « n ilt °'-*'r l|K- dc;itl. o f

■Ulrr 72 I r f ' K’' ’" n ° n !’ |,!" ro1 in tllP pl«-v; v .. S r I'fa'T sedation, lie aw aken'd to

rejoi«'V?-’T n ir °U *"TV" '4' !,t *V'S ««nound ii.K.s an.i a desire to

r i l irv * n',,,irMc f,,r ,i,c fuK,H'- A ftn u,,° ii,' rm ill I ' " :,S lK'n , l ' t l, d to return |lis

r " n . , ! l iK, r m l o f the

J iii’k S in ilh a .v-.iy looking «li.|,«;,s!,cr in an Okl d ,„iu t

! " l k S ^ , . J<: ,r i . S7 ; n r ,i h i s r mr , l °-V,:r an( l c , l s * o n i er s b y'•\Vli.r T ! i ''"“ l W.VI11R, in cu ltiv a te d tones, \h, C ,m i ,1 ;in; 1 wl,»l I <li»iiig here?" Sc-c.-.inplv n ,lr f

out of pitv lie iT TT' , ,,11,L,V',t;rf0rC l'" ‘« ,''^1 h-.i cm,,loved' u " • IIc .identified Inn,.-elf „s ftonald WortliiiiKton M

a M e th o d ,.t ter froI1, M a , , „ l ,u s e . I , . H , hud no reeo l’

he nenH °"i 'T"'" " 1V <>ld:ihom,i. nnr cou ld

wveks! "B " ml l,:" 1 ' r,,,'S'”r,d tlie I'tev iou 'i (!

A -hi.-,trir flin ty reve led n variety of ,,er„,„.,l m ,d „ro-

o'f'The turn iV F I " " " '<■ o L - tt in 1 n “ , f " l 'l« r . '..t ly I,m l,h iked Im lfwav ac,o>s

is 1 ,1 ' ‘ ' '" ' 'r 10 " ork ;,t ° l|d jobs.u Ja. lv (*li.. name of. a h.-ind.vnun who had worked for his grindf;if|it'r .10 yonr-s lu fon ) J | f» r iiin 'i! lirtl iitivti'lii M.i * «i . r • r.mit ci .1 l»f( I#* pruinnin.itv

Vn 1 \ ^ ,H’ Uf ,l,S ,V;“ tlUn Un' ,« rt»ok In ..M ain definitive j,>.vehnthi,apy upon rc t„ ,„ i„K w „h m.ved (, ..|i,2to Ins co iw eca .ion , his wife, and his mother-in-law.

Frenzied violent Males ,,r dissociated liel.av-

lu ,e oeri.i as an ile di,soei:itive leaclim.s under

a wide vain ly of eire,i„i>|;„ lc,..< and cnllural sellings

. Iin: ,,f onset, brief duration, and abruptlam ina tion with amnesia for most, if not all of the

091] I s% r h f in c u r o l i c Ib s o r d c r s

a t t a c k . I Ik* ep isodes r on t fn i i e le m e n ts o f v io k 'n t ,

f i o n ? i c d , «M11 l .m d is l i or w i ld ly b iz a r re b eh av io r . 'J 'hoy

m us t lie d i f l c ie i i t i a l c d f m m te m p o r a l lobe seizures.

Amok, lirrsri li, Inlnh. " I ‘mining amok" among

the Malays is a ttntr* in which a previously normal

prison suddenly becomes violent, characteristically

seizing a knife nr hhiic other weapon and raging

through I In' village, Jit t:n-Kinp; pt oplc ai random until

exhausted, overcome by force. or killed. In our own

culture there arc many situations in which individuals

suddenly In-romp violent, attacking others in a state

of frenzy and great emotional display, for which the

term amuck” is used. Characteristically, the patient

experiences amnesia for the episode, which frequently

is found to lie related to some immensely frustrating

life situation in which he feels hopelessly trapped.

Although such frenzies are not necessarily homicidal

or suicidal, it is possible for an individual under these

Circumstances to injure others or himself.

Berserk or "going berserk" is a term often med

synonymously with amuck as a state of violent rage

or frenzy. It was originally applied to certain Nordic

v.iyjiors (Rarsatkcrs) who intoxicated themselves

piior to hat lie bv eating psychotogenie mushrooms.

Latah, a brief frenzied state among M alayan women,

was compand by Wengroke with amok and with

Arctic hysteria; all are culturally defined behavioral

abnormalities that, appear to meet our domestic cri­

teria for acute dissociative reactions. There are un­

doubtedly many other varieties of dissociative be­

havior reaction, differing widely in relation to the

particular culture of the patient.

Palho lnp ica l in tnx irati,,,,. This is usually classi­

fied under alcoholism. However, manv cases of patho­

logical intoxication are probably acute dissociative

reactions precipitated in predisposed persons by rel­

atively small amounts of alcohol. Characteri,tieally

the syndrome includes a rather abrupt onset, an

impaii ment of consciousness, and a varictv of p-y-

chopathologic.il manifestations. including violent be­

havior. Such episodes are of uncertain duration, last­

ing from 1 to af> hours, usually followed by sleep or

stupor, following which there is typically an amnesia lor {In* rxpri iriico.

Ihss.'-im ivc d e lir ium . T in s is a reac t ion s im i l a r

to p a t h o lo g ic a l in t o x ic a t io n b u t w i t h t y p ic a l s y m p ­

to m s o f florid p s y c h o p a th o lo g y , i n c l u d in g h a l lu c in a-

• ‘-’" ' o t i o n a l o u tp o u r in g s , a n d s e c m in g lv u n ­

co n t ro l le d u-lease o f p r im a r y process m a te r ia l , w i t h a

c e r t a m a m o u n t o f a g i t a t i o n , b u t not c h a ra c te r iz e d

d a ng e ro u s v io lence . It m a y occu r as a p u re d is ­

s o c ia t iv e reac t ion in response to e m o t io n a l stress

w i th o u t a n y k n o w n b io log ic a l p r e c i p i t a t i n g fa c to rs ;

or som e r e la t iv e ly m in o r c hange , in b r a in ’ f u n c t io n '

M ! tlio administration 0f a simple sedative in’

tael ;C’ ' " ay Pli'y ,U|° ^ at-

I l y t t c ' i c l fit. This old-fashioned term is Mill

sometimes used to describe dissociative reaction, in

whirl. the patient is "seized" to act out, in an elal

rate and dramatic fashion, some complex and i>,

longed fanta-ies, during which there is appaient I.

of contact with the environment and a marked em

tional display with a strong histrionic llavor S»i

displays frequently include coital movement-. It u

Perhaps on this basis that the reactions were cl

o r " ) ™ hysterical fits or convubi,,,-light degrees of brain damage sometimes found

these patients are probably best viewed as contiil„

<"g to the predisposition toward dissociative rcactu rather than as directly causative of the fits.

D iagnosis, Prognosis, and Treatm ent

The dissociative reactions arc generally held to

primarily psychogenic in origin and psychoneurot

>i. character. However, there are areas in which tl„

mcige with certain types of seizure disorder, into.x

cation, behavior disorder, or psychosis. Different!

diagnosis can be very difficult but should be p««j|, in most instances.

The presence of brain damage does not mean lb

n bona fide dissociative or conversion reaction ma

not also be present and vice versa. M any cliniciai

>cic\e that there is a substantially higher th-

chance relationship here, even though' the nature •

the biam disorder may vary widely, and the de-'ic

of impa.iment may range from g,o,s to minim-

Jemporary minor alterations in the state of tl

brain--such as those produced by fever, sodium aim

barbital other barbiturates, gas anesthesia, alcoho

or psyehotogeme drugs-m ay release the manifest:

tions of dissociative phenomena where the. propen-it

is strong jiatural changes in brain functio-

such as those occurring in relation to the sleet, cvd,

may serve to permit dissociative behavior to cmeree.

• mce d is soc ia t iv e p h e n o m e n a are l ik e ly to increa-

m th e face o f m o u n t i n g a n x ie ty , such s y m p t o m s f,<

q i t o m ly o ccu r d u r i n g the e a r ly s tages of a sch iz , .

I ’ h re m c il lness. I t is im p o r t a n t , t h a t the d if fe ren t i i

d ia g n o s is he m a d e in s u ch in s tances because th

a p p r o a c h to t re a tm en t , w i l l be a ffec ted . A c u t e d i w w h

l i v e r e a c t io n , m a y be d i f f ic u l t to d is t i n g u is h f n m

n c u tc p s y c h , ...... ( c a t a to n ic or m a n i c ) s y n d ro m e s Y e

careful ob-ervatmn of the psyehopalhology, a goo,

lu s to ij, and close observation of the patient over

period of time under treatment, will usually clarify

the issue. Dissociative phenomena may be seen in •

;ude variety of diagnostic categories,' ranging frou

epilepsy to schizophrenia. This should not prevent tl,.

clinician from making the diagnosis of psychoneuro

sis, dissociative reaction, when the clinical lindin- Warrant it. *'

A no te co nce rn in g m e d ic o le g a l p r o b le m s ra ised bv

Certa in d i l u t i v e r eac t io n s i- in o rder . Is the un

d iv o rc e d le m a r r ie d m a n w i t h d u a l p e r s o n a l i t y

j i im .e s ,a a b ,g a n , .- t ? Is the p a t i e n t in a seem im - lv

I ' ^ - h o t i c e p isode d u r i n g a d is s o c ia t iv e f re n zv

oi p a t h o lo g ic a l i n t o x ic a t io n c r im i n a l l y r e s p o n s ib le 0

u> MiliIiiT with fugue n deset ter? Since dissociative

lion is classified as a p>ychoiieurosis. the courts

■ often licld .'lull patient- fully responsible. Each

will (if course In' Irii'il (>ii it- merits. However, a

I title of t hum 11 fur the clinician called upon to

an opinion should lie this: let the psvchopathol-

:t( the time of the alleged oficn>e determine the

icolegal opinion. Unquestionably some circum-

| H'il psychotic reactions are dissociated, in the

! i- that they represent a break with a relatively

i ;'(r!itcd personality functioning before and after

j episode. However, this leaves some important

ilcms unsolved. A murderous episode of the type

vl “catathymic crisis” by Wertham may be all

■artly dissociated. W hat is socictyto do with such

uircleicr, who has recovered his sanity before he

i conics to trial? I; he guilty? 1' lie committable?

I even the rule of thumb noted above is hard to

!y usefully to the problem of the dual personality'.

<■ is nn area worthy of considerable attention by

I foi/j^sf psychiatrist.

! rogmSSs of the dissociative reactions, like the

nr psychoncuroics. must be individualized in terms

motivation, age, intelligence, ego structure, char-

■rological factors, duration of illness, secondary

j is, ctc. As a rule the prognosis for the acute

icl; or episode is good; the long term outlook is

v fair and perhaps guarded.

'lie approach to treatment of the dissociative

clions is primarily that of a dynamically oriented

cliotlicrapy that carefully takes into account the

lificance of unconscious factors, makes note of the

dominating mental mechanisms at work, utilizes

I to some degree analyzes transference and coun-

traiisfeicnce factors in the doctor-patient relafion-

p. mid generally works toward the development of

icater degree of emotional maturity in the patient,

cial techniques, such as hypnosis and narcosynthe-

(’u:i he employed if rapid relief of symptoms isired.!V f large, the diswissions of diagnosis, progno-

amVi^i>atiii('nt in 1110 chapter on conversion reac-

i apply equally well to dissociative reaction.

i gpCsleil Cross References

or a discussion of the mental mechanism of dis-

lation on a psychmlvnamic level of description, the

. 'id' is referred to Mack and Seinrad’s section on

choanalysis (Section f i l l . In addition, see Ne-

! dis section on the closely related disorder, conver-

II reaction (Section 23.21. Fundamental ncurophys-

•Hical considerations may la- found hi Seel inns 2 5

~.!l on iieiiroanatouiy and hcurnplivsiology in An a

"ii the basic behavioral sciences. That same area

11 contains sections on sensorv depnvation, sleep

ihcaius, and hallucinogens I Sect inns 5.5, 2.1,

I'i.'l, respectively) llypuo-is is discussed in greater

,l'l by Spiegel in Section 3-1.-1, in Area (.!, on

.*ihiatrie treatment. Some of the disorders men­

tioned in this section, such as amok, berserk, and

latah, are more fully described in Lehmann's section

on unusual psychiatric disorders not included in

American . Psychiatric Association's nomenclature

(Section 32.11. Enuresis is described by Pierce in

Section '10.5, in Area II, on child psychiatry, and

pathological intoxication by Chafetz. in Section 27.3

on alcoholism.

R E F E R E N C E S

Aliso, I ). \\ . Ily'.lc.nn and llclntrd Mental Disorders: An Orien­tation to Psychological Medicinc. John W ii^h t <!: Sons, Bristol, 100G.

AmcricHti Psychiatric Asviciation. Dinrjmislir and Statistical Manual, Mental fJimnU r.<. American 1'nvchiatric As.-ocia- tion, Wn-diim!ton, 10.72.

Buckr, R . M . Cosmic (or Illum ination), ed. 22.E . P. J )u lto n , New Y o ik . 1001.

Cameron, N . Pcrsonahty l/cvrf'ipmrnt and Psychopathology: A Dynamic Approach. Houghton M itllin . Boston, 1003.

Dcckrrt, Ci. II., am) West. h. J. Hypnosis iind experimental psychopathology. Aiucr. J. C lin . H ypn ., 5: 25fi, 100.1.

Freud, S. 'J lie forgetting of dn ams. In The Standard Edition of the Cnmph tc Psychological l l ’oi/.'.? of Sigmund Freud, vol. 5, p. 521. Hng.irtii l ’n -s, London, 1953.

H ilcard, E.. H. Ihipnotic Susceptibility. Harrourt, Bruce and World. New York, 1005.

Kales, A., Jaroli-nn, A., Paulson, M . J., Kales, J . D ., and Walter. R . J).. S onm am l'n lisn t: I ’syrltophysiological correlates. I. A11 - n: ̂ 111 llllC ; studc-s; I I . J’svi lnalric interviews, psycho­logical testing and di=cus>ion. Arch. Clen. J’sVchiat., in press.

Prince, M . Dis.-ociotian oj a Personality. Longmans. Green, New Y o ik , l'.KJS.

Thigpen, C . I I ., Thigpen. II . , and Clerk ley, I I . M . The Three faces of / .'it . McGraw-Hill, New Y o ik , 1057.

W rgrocki, 11. J . A tritii|ii<* of cultural and statistical concepts of almoi m ality . In Pi rs'innlity in S'ltture, Socii.hj anil Culture, C. K liieklm lm , I I . A. M urray , and I). M . Schneider, editors, p. GOO. A lftcil A. Knopf, New "S'oik. 105;).

Weil zcnhofTer, A. M . II iipnntism: Objective Study in Suggest­ibility. W iley, New W ill; , 1053. ■

West, b . J . l ’svelioplivsicilnry of hypnosis. J . A. M . A., 172: 672, 1000.

West, L. J . Hallucinations. U iuni: <k Stratton, New York , 1902.

23.4- P1 IO IH C R E A C T IO N

S IIE R Y E H T 11. F R A Z IE R , M .D .

A R T H U R C. C A R R , Pu.I3.

D efin ition

The diagnostic designation phobic, reaction is re­

served for those disorders in which a phobia is the

predominant, symptom and in which reality testing is

generally intact. As a disorder in which there is neither

gross distortion of externa! real'lly nor evidence of

structural or organic eliangi , the phobic reaction is

technically classified under the heading of psycho-

neurotie disorders.

The disorder ‘ was formerly classified as nr.xicty

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Collection Number: AK2216 AGGETT, Dr Neil, Inquest, 1982 PUBLISHER:Publisher:- Historical Papers Research ArchiveLocation:- Johannesburg©2013

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