378 CHAPTER 8
Follow-up on Anna O.
Anna O.’s symptoms do not fit neatly into any of the
disorders discussed in this chapter. She had hallucinations
and dissociative and bodily symptoms, but they probably
wouldn’t meet the diagnostic criteria for somatization dis-
order. Today, she would probably be diagnosed with more
than one disorder.
Anna’s symptoms cleared up near the end of her treat-
ment with Breuer. However, after their fi nal session, she
had a major relapse, and Breuer refused to continue to treat
her. He found the therapy sessions with Anna too time- and
energy-consuming, and, given her relapse, he was not opti-
mistic about her prognosis.
Anna’s history for the 6 years after her treatment with
Breuer remains largely unknown, although we do know
that she was hospitalized several times, some of which
were for her dependence on morphine and chloral hydrate,
which Breuer had prescribed for her. Despite Breuer’s
negative prognosis, Anna O. went on to accomplish great
things. Her real name was Bertha Pappenheim, and she
became a social worker, the director of an orphanage, and
the founder of a home for unwed mothers that was dedi-
cated to teaching the women skills to support themselves and their children. For
the rest of her life, she strove to improve the lives of poor women and children
(Freeman, 1990).Despite Breuer’s poor prognosis
for Anna’s future, she went on
to live a full life, becoming an
accomplished advocate for and
benefactor of poor women and
children. In Anna’s time, having
a psychological disorder was
neither a personal disaster nor
a signal that life had to become
constrained and unrewarding.
This is still the case.
SUMMING UP
Summary of
Dissociative Disorders
Dissociation involves a separation of mental
processes that are normally integrated—a
dissociation of perception, consciousness,
memory or identity. To qualify as a dissocia-
tive disorder, this separation must cause sig-
nifi cant distress or impair functioning. Specifi c
symptoms of dissociative disorders include
amnesia, identity problems, derealization,
and depersonalization. Dissociative disorders
are rare and often may arise in response to
traumatic events.
Dissociative amnesia is characterized by
significantly impaired memory for important
experiences or personal information that can-
not be explained as ordinary forgetfulness or
accounted for by another psychological disorder,
substance use, or a medical condition. Dissocia-
tive amnesia most often occurs after some trau-
matic event. The amnesia may spontaneously
disappear, particularly after the person leaves
the traumatic situation.
Dissociative fugue is characterized by sud-
den, unplanned travel and difficulty remem-
bering the past, which in turn leads to identityconfusion. Apparently, the frontal lobes of
patients with this disorder are not as effective
at accessing stored memories, particularly
about the self. Not much is known about the
factors that contribute to dissociative fugue;
what is known is that people who have had
this disorder are more hypnotizable and dis-
sociate more easily than do others.
Depersonalization disorder is charac-
terized by the persistent feeling of being
detached from oneself, which may be accom-
panied by derealization. This disorder appears
to involve an under-reaction to emotional
stimuli, and is more common among people
who experienced severe chronic emotional
abuse during childhood than among people
who did not have this experience.
Dissociative identity disorder (DID)
hinges on the presence of two or more distinct
alters, each of which takes turns controlling
the person’s behavior; some alters seem to
be unaware of the existence of other alters.
The DSM-IV-TR diagnostic for DID criteria
have been criticized for being vague and the
symptoms are easy to fake. Although neu-
roimaging studies of patients with DID fi nd
that their brains function differently whendifferent alters are dominant, such studies
have not generally used appropriate control
groups. People with this disorder are more
hypnotizable and dissociate more readily
than do people who do not have this disor-
der. The diagnosis of DID is controversial.
The posttraumatic model proposes that
DID is caused by severe, chronic physical
abuse during childhood, which leads to dis-
sociation during the abuse; the dissociated
states come to constitute alters, with their
own memories and personality traits. The so-
ciocognitive model proposes that DID arises
as the result of interactions between a thera-
pist and a suggestible patient, in which the
therapist inadvertently encourages the pa-
tient to behave in ways consistent with the
diagnosis. Both interpretations are consistent
with the fi nding that severe childhood trauma
is associated with the disorder.
The goal of treatment for DID, and for dis-
sociative disorders in general, ultimately is
to reduce the symptoms themselves and to
lower the stress they induce; hypnosis may be
used to help integrate dissociated perceptions
and memories. According to the posttrau-
matic model, therapists should help patients,Jewish Museum, Frankfurt am Main, Germany