Complex Dissociative Disorders Research Articles

Helpful and meaningful aspects of a psychoeducational programme to treat complex dissociative disorders: a qualitative approach

ABSTRACT Purpose: Complex dissociative disorders (CDDs) are prevalent among psychotherapy clients, and research suggests carefully paced treatment for CDDs is helpful. The purpose of the present study is to qualitatively explore helpful and meaningful aspects of the TOP DD Network programme, a web-based adjunctive psychoeducational programme for the psychotherapeutic treatment of clients with CDDs. Methods: TOP DD Network programme participants (88 clients and 113 therapists) identified helpful and meaningful aspects of their participation in response to two open textbox questions. Framework analysis was used to qualitatively analyze client and therapist responses. Findings: Participants found the TOP DD Network programme helpful and meaningful in nuanced ways. Three themes were created: (1) Components of the Programme (subthemes: content, structure), (2) Change-Facilitating Processes (subthemes: heightened human connection, receiving external empathy and compassion, contributing to something bigger, improved therapeutic work and relationship), and (3) Outcomes (subthemes: insight, increased hope, self-compassion, increased safety and functioning). The most emphasized theme was components of the programme, which captured its content and structure. Conclusion: Clients and therapists in the TOP DD Network programme described the programme’s components and processes as helpfully facilitating positive outcomes in the treatment of CDDs. Therapists may consider integrating the components and processes in the programme into their practice with clients with CDDs.

“Now there are fewer of me". A qualitative study of the impact of psychoeducative groups for complex dissociative disorder

ObjectiveThis study aimed to explore the experience and impact of participating in psychoeducative group therapy based on an explanatory model for dissociative symptoms. We further explored the potential significance this may have for the participants healing process. MethodsA total of 26 participants with Complex Dissociative Disorder (CDD) were interviewed 6 months after finishing a 20-week psychoeducative group therapy that included skills training. The research team analyzed the data with an interpretative interview-based qualitative research method. ResultsThe analysis resulted in two main categories with 12 subcategories. The first main category was “Developing a more coherent self”, describing an initial change in the participants' self-experience from confused and fragmented to increased coherency. The second main category “Increased sense of agency” represented a new way of relating to and helping oneself. The results are presented in a model which points towards some possible connections between the categories. ConclusionsOur results suggest that the psychoeducative group therapy contributed to a movement towards increased self-awareness which permits a sense of coherence among various parts of the self and an increased sense of agency. The model resulting from this work identifies crucial elements of change that can be applied to improving treatment.

Autopilot functionality and self-destructive behavior in patients with complex dissociative disorders-A qualitative study.

Dissociative disorders are common in psychiatric patients and severely impact patients' lives. They are, however, underdiagnosed, thus preventing patients from accessing timely and adequate therapy. Identifying how patients with dissociative disorders relate to themselves could improve diagnostics. However, this question has not been explored in detail. The aim of the study was to gain insights into how people with complex dissociative disorders relate to themselves. We conducted semistructured qualitative interviews with ten women diagnosed with complex dissociative disorders who had previously completed trauma-focused therapy. Data were analyzed through reflexive thematic analysis. Participants described their behavior toward themselves before the start of the therapy as "autopilot-functional" and "self-destructive." The "autopilot functionality" was characterized by being outward-oriented and ignoring one's own needs. Hence, participants only appeared to be functional. "Self-destructive behavior" was described as a spectrum of various destructive behaviors (e.g., eating disorders, self-harm, excessive exercise, and substance abuse) that participants perceived as a cohesive complex. The participants illustrated that both behaviors were driven by a lack of self-empathy and connected to suppression and poor perception of bodily stimuli. "Autopilot functionality" seems to be a hallmark in patients with complex dissociative disorders. With patients hiding their self-destructive behavior, health personnel may misjudge the severity of these patients' mental illness. Neither "autopilot functionality" nor "self-destructive behavior" should be judged (neither negatively nor positively), but one should understand both as a coping mechanism for trauma-related disorders. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Supplemental Material for Autopilot Functionality and Self-Destructive Behavior in Patients With Complex Dissociative Disorders—A Qualitative Study

Supplemental Material for Autopilot Functionality and Self-Destructive Behavior in Patients With Complex Dissociative Disorders—A Qualitative Study

Personality disorder traits, maladaptive schemas, modes and coping styles in participants with complex dissociative disorders, borderline personality disorder and avoidant personality disorder.

The schema mode model offers a new conceptualisation of complex dissociative disorders (CDD) as it explains shifts between identities as shifts between schema modes. Furthermore, in this model CDD is conceived as personality pathology, incorporating core features of personality disorders. This study tested the assumptions of this schema mode model of CDD. Questionnaires measuring personality disorder traits, schemas, schema modes and coping styles were filled out by patients with CDD, borderline personality disorder and avoidant personality disorder (N = 210), and their scores on the various constructs were compared. Participants with CDD were characterised by specific schizoid, schizotypal, borderline and avoidant personality traits and early maladaptive schemas in the domains of disconnection and rejection and over-vigilance and inhibition. The most pronounced schema modes were the dysfunctional parent modes, avoidant coping modes and the vulnerable child mode. For coping styles, no differences were found between the diagnostic groups. On all outcome measures participants with CDD scored at the level of personality disorders and showed a unique pattern different from participants with borderline and avoidant personality disorder. This suggests that CDD shows features akin to a personality disorder. A clinical implication is that an adapted form of schema therapy might present a viable treatment option for CDD.

Functional connectivity changes in the delta frequency band following trauma treatment in complex trauma and dissociative disorder patients.

ObjectivePhase-oriented trauma treatment is efficacious in the treatment of complex trauma and dissociative disorder patients. However, the neural correlates of this therapeutic effect are not yet well-understood. In the current study we investigated whether patients show a strengthening in functional network connectivity in the delta frequency band (1–3.5 Hz) over the course of phase-oriented inpatient trauma treatment while they performed an emotion regulation task. Further, we examined whether neural changes were associated with symptom reduction and improvement in emotion regulation skills.MethodsBefore and after 8 weeks of treatment, electroencephalography (EEG) was acquired in patients (n = 28) with a complex posttraumatic stress disorder (cPTSD) or complex dissociative disorder (CDD). They also completed clinical and emotion regulation questionnaires. To delimit data variability, patients participated as one dissociative part that is referred to as Apparently Normal Part (ANP). Patients' data were compared to a matched healthy control croup (n = 38), also measured twice.ResultsPrior to treatment, functional connectivity was significantly lower in patients compared to controls during cognitive reappraisal of unpleasant pictures and passive viewing of unpleasant and neutral pictures. These hypoconnected networks largely overlapped with networks typically activated during the recall of (emotional) autobiographical memories. Functional connectivity strength within these networks significantly increased following treatment and was comparable to controls. Patients showed symptom reduction across various clinical domains and improvement in the use of cognitive reappraisal as emotion regulation strategy. Treatment-related network normalizations were not related to changes in questionnaire data.ConclusionPhase-oriented treatment may strengthen connections between regions that are activated during autobiographical recall. These findings encourage further investigation of this circuitry as a therapeutic target in cPTSD and CDD patients.Clinial trial registrationwww.ClinicalTrials.gov, identifier: NCT02459340, https://www.kofam.ch/de/studienportal/suche/149284/studie/26681.

Group treatment for complex dissociative disorders: a randomized clinical trial

BackgroundPatients with complex dissociative disorders (CDD) report high levels of childhood- abuse experiences, clinical comorbidity, functional impairment, and treatment utilization. Although a few naturalistic studies indicate that these patients can benefit from psychotherapy, no randomized controlled trials have been reported with this patient-group. The current study evaluates a structured protocolled group treatment delivered in a naturalistic clinical setting to patients with CDD, as an add-on to individual treatment.MethodsFifty nine patients with CDD were randomized to 20 sessions of stabilizing group–treatment, conjoint with individual therapy, or individual therapy alone, in a delayed-treatment design. The treatment was based on the manual Coping with Trauma-Related Dissociation. The primary outcome was Global Assessment of Functioning (GAF), while secondary outcomes were PTSD and dissociative symptoms, general psychopathology, and interpersonal difficulties.ResultsMixed effect models showed no condition x time interaction during the delayed treatment period, indicating no immediate differences between conditions in the primary outcome. Similar results were observed for secondary outcomes. Within-group effects were non-significant in both conditions from baseline to end of treatment, but significant improvements in psychosocial function, PTSD symptoms, and general psychopathology were observed over a 6-months follow-up period.ConclusionIn the first randomized controlled trial for the treatment of complex dissociative disorders, stabilizing group treatment did not produce immediate superior outcomes. Treatment was shown to be associated with improvements in psychological functioning.Trial registrationClinical Trials (NCT02450617).

Using a MDMA- and LSD-Group Therapy Model in Clinical Practice in Switzerland and Highlighting the Treatment of Trauma-Related Disorders.

The Swiss Federal Act on Narcotics allows for the restricted medical use of scheduled psychotropic drugs in cases of resistance to standard treatment, and preliminary evidence of efficacy of the scheduled drug for the particular condition. Since 2014, the authors have obtained 50 licenses on a case-by-case basis and developed a psychedelic-assisted group therapy model utilizing MDMA and LSD. The majority of the patients taking part in the psychedelic group therapy suffered from chronic complex post-traumatic stress disorder (c-PTSD), dissociative, and other post-traumatic disorders. Treatment modalities, typical developments and problems encountered during and after the psychedelic experiences are described. Recurrent depression poses a frequent problem, and requires special attention. Symptoms of c-PTSD predominantly addressed by the psychedelic experiences are the regulation of emotions and impulses, negative self-perception, alterations in relationships to others, as well as meaning, recall, and processing of traumatic memories. C-PTSD needs a larger number of psychedelic experiences in contrast to PTSD resulting from single trauma. In this model MDMA was most often used in the first phase to enhance motivation to change, strengthen the therapeutic alliance, allowing it to become more resilient, stress-relieved and less ambivalent. When emotional self-regulation, negative self-perception and structural dissociation had also begun to improve and trauma exposure was better tolerated, LSD was introduced to intensify and deepen the therapeutic process. The majority of participants improved by clinical judgement, and no serious adverse events occurred. A short case vignette describes a typical process. The experiences with this model can serve to further develop the method of psychedelic-assisted psychotherapy (PAP) and to give directions for future research.

A Model of Post-Traumatic Stress Disorders and Dissociative Identity Disorder from the perspective of Social Emotions

Post-Traumatic Stress Disorder, Complex Post-Traumatic Stress Disorder and Dissociative Identity Disorder are conditions caused by exposure to one or more stressful events of extraordinary magnitude and/or repeated over many years. The traumatic experience(s) may have different outcomes in different persons: some people fully recover within a short time, while others go on to develop one of these three disorders, whose interdependencies are still poorly understood. The present work utilises an updated version of a model of mental functioning, that has been previously applied to schizophrenia, to provide an interpretation of the aforementioned conditions. The model, built through the method of Artificial Life and with the toolset of Artificial Intelligence, foresees that the mind is subject to two forces: trauma, which represents the attack on the mind, and dissociation, which embodies the mind defence in both physiological and pathological conditions. The balance between these forces determines the pathological outcome.

The challenge of being present with yourself: Exploring the lived experience of individuals with complex dissociative disorders

AimThe objective of this study was to explore how clients with severe dissociative symptoms describe their experiences of being present in their everyday life. The data in this study stems from a large study conducted at a trauma–outpatient clinic in Oslo, Norway. Method16 participants underwent in-depth interviews six months after a twenty- week group treatment based on psychoeducational stabilization for dissociative disorders. These interviews and participants were part of a larger study, and the interviews in this article are the first 16 of many interviews. Hermeneutic-phenomenological thematic analysis was used to analyze the transcripts. ResultsFour themes were identified: (1) “Being present: To be here and now, and remember it afterward,” (2) “To not be present: avoiding challenges but challenged by their inner life,” (3) “Being present in a Fragmented Sense of Self,” and (4) “Bearing the consequences of not being present in your own life.” DiscussionThe findings are discussed in relation to existing theory and research, and reflexivity in the process and limitations of the study are considered. ConclusionThe results indicate that the experience of being present is an important part of the struggles the participants describe in their everyday lives, as well as a part of the challenges of living with a dissociative disorder. ImplicationsThe findings indicate that focusing on the ability of staying present could be an important part of treatment of and how we meet and understand dissociative disorders.

Dissosiativ identitetsforstyrrelse i utredning av barn og ungdom: Teori og kliniske utfordringer

Background: Clinical practice and recent research indicate that dissociative symptoms and disorders are left unidentified and undiagnosed by health professionals. Based on a clinical case from our work setting, this article describes relevant literature regarding dissociation and dissociative disorders to add to the knowledge of the theoretical and phenomenological features of complex dissociative disorders. Further, we describe differential diagnostic challenges that may arise in clinical practice. Methods: The authors work in specialized health care and have extensive clinical expertise in complex dissociative symptomatology in children. Both systematic and non-systematic literature searches were performed. Findings: Recent research shows the Trauma model to be central to understanding dissociative disorders. Symptoms can be mistaken for cognitive difficulties, oppositional issues or other somatic symptoms. Quantitative measures, systematic observations and clinical evaluations are fundamental for identifying dissociative symptoms and disorders. Implications: There is potential for identifying and evaluating dissociative symptoms at an earlier stage. Interdisciplinary and differential diagnostic evaluations are crucial to provide adequate understanding, assessment, and treatment of these patients. Keywords: Dissociative identity disorder, dissociation, somnambulism, biopsychosocial framework, clinical practice

Resting-state functional connectivity in patients with a complex PTSD or complex dissociative disorder before and after inpatient trauma treatment.

IntroductionRecent research suggests that traumatized patients are characterized by disrupted resting‐state functional connectivity. We examined whether neural networks involved in resting‐state change over the course of a phase‐oriented inpatient treatment for complex traumatized and dissociative disorder patients. We also investigated associations between these network alterations and clinical symptoms and emotion regulation skills.MethodsPre‐ and post‐treatment, electroencephalography (EEG) was recorded during resting‐state in patients (n = 23) with a complex dissociative disorder (CDD) or complex posttraumatic stress disorder (cPTSD). Patients also completed clinical and emotion regulation questionnaires. To reduce variance in the collected data, patients were exclusively tested as one prototypical dissociative part referred to as Apparently Normal Part (ANP). Functional network connectivity was examined and compared with a matched healthy control group (n = 37), also measured twice.ResultsPrior to treatment and compared with controls, patients had a significantly lower functional connectivity strength within eyes‐open and eyes‐closed resting‐state networks in the theta and alpha frequency band. Following treatment, functional connectivity strength within these networks was comparable to the control group and comprised areas belonging to the default mode network (DMN) and prefrontal as well as anterior cingulate control regions. Treatment‐related network normalizations in the theta frequency band were associated with a self‐reported increase in the use of cognitive reappraisal strategies and reduction in emotion regulation difficulties.ConclusionPhase‐oriented trauma treatment can strengthen resting‐state network connectivity and can increase the capacity of complex traumatized and dissociative patients as ANP to handle emotional challenges effectively.

Negative affective responses to positive events and stimuli in patients with complex dissociative disorders: a mixed-methods pilot study

ABSTRACT Background: Research suggests that individuals exposed to (childhood) trauma are not only unable to experience pleasure, known as hedonic deficit (HD), but also experience ‘negative affective responses to positive events’, known as negative affective interference (NAI). The clinical relevance and prognostic features of NAI have increasingly been recognized. To date, no studies have focused on NAI in patients with complex dissociative disorders (CDDs) who were abused early in life. Objective: In this pilot study, we quantitatively and qualitatively investigated how NAI is related to trauma-related symptoms and how this phenomenon can be understood in a selected group of adult CDD patients. Method: CDD patients (N = 25) referred to an inpatient dissociation-focused treatment programme completed the Hedonic Deficit & Interference Scale (HDIS), and measures of trauma-related symptoms and interpersonal functioning, as well as a qualitative questionnaire addressing possible inner conflicts and phobias with respect to the experience of positive events. A convergent mixed-methods design was used to obtain different but complementary data on NAI to gain a more complete understanding of the phenomenon. Results: The quantitative analyses showed a significant relationship between NAI and trauma-related symptoms and interpersonal functioning. NAI seems to be more strongly associated with these symptoms than HD. The qualitative analysis revealed three themes – fear, shame, and aggressive ‘parts’ – preventing positive emotions, which provided a possible interpretation of the quantitative results. The integrated findings were discussed in light of theories of structural dissociation of the personality and attachment. Conclusions: These findings indicate that NAI is related to a spectrum of trauma-related symptoms and interpersonal functioning in patients with a CDD to a larger degree than HD and that different dissociative identities are involved. Studies of the relationship between changes in HDIS (particularly the NAI subscale) and changes in trauma-related symptoms and interpersonal functioning following treatment are warranted.

The value of hypnosis in the resolution of dissociation: Clinical lessons from World War I on the integration of traumatic memories

Some World War I clinicians related the symptoms of traumatized servicemen to an underlying dissociation of their personality, consisting of two prototypical conditions: one involving functioning in daily life (inspired by Myers, whose work is also discussed in this article, and which will be labeled apparently normal part of the personality [ANP]) and one involving fixation in the traumatic experience and related attempts at defense (emotional part of the personality [EP]). These authors described two dissociative patterns. As illustrated in this article, one pattern consisted in the presentation of a dominant ANP suffering from constant or frequent intrusions from EP. The other pattern consisted in repeated complete alternations between ANP and EP. Instead of the use of purely symptom-oriented approaches, for the dissociative symptoms to be really resolved, an integration of traumatic memory in the personality, that is, between EP and ANP had to take place. These clinicians used hypnosis to access the traumatic memory and EP and to foster such integration; they agreed on the importance of the quality of the therapeutic relationship in this regard. However, they differed in opinion and practice as to the need to assists patients in their expression of traumatic emotions during this process. When the trauma was related merely to war experiences, such therapeutic processes took place within a simple phase-oriented treatment model, while in the presence of a history of previous trauma and related dissociation of the personality, this model had more complex applications. This is similar to modern treatment approaches of the sequelae—such as a complex dissociative disorder—of chronic (childhood) traumatization.

Maladaptive Daydreaming, Dissociation, and the Dissociative Disorders.

ObjectiveStudies on maladaptive daydreaming have shown that it has a number of comorbidities including dissociative disorders, yet no studies have examined the reciprocal relationship. The aim of this study was to determine the frequency of maladaptive daydreaming in a sample of psychiatric inpatients with high levels of dissociation.MethodsThe Dissociative Experiences Scale (DES), Self‐Report Dissociative Disorders Interview Schedule, Maladaptive Daydreaming Scale‐16 (MDS‐16), Structured Clinical Interview for Maladaptive Daydreaming, and the Obsessive Compulsive Inventory were administered to a sample of 100 inpatients in a psychiatric hospital program specializing in dissociative disorders.ResultsOf the 100 participants, 93 reported childhood physical and/or sexual abuse, 33 met criteria for dissociative identity disorder; 56 met criteria for other specified dissociative disorder, 49 met criteria for maladaptive daydreaming disorder, and 23 met criteria for unspecified maladaptive daydreaming. The average score on the DES was 39.1 and the average score on the MDS‐16 was 33.9. Individuals with maladaptive daydreaming disorder scored significantly higher than those without on many different symptom clusters.ConclusionsThis sample of 100 highly traumatized and dissociative inpatients reported high levels of maladaptive daydreaming along with many other forms of comorbidity. Maladaptive daydreaming is a previously under‐recognized aspect of complex dissociative disorders and requires further attention in both research and clinical practice.

Complex Trauma: Missed and Misdiagnosis in Forensic Evaluations

Forensic evaluators frequently utilize diagnoses as a way to document the nature and severity of impairment and/or injury in civil and criminal cases despite diagnostic manuals being primarily created for use in clinical and research setting (Frances and Halon, Psychological Injury and Law, 6, 336-344, 2013). Psychological trauma holds a unique place in diagnostic nosology, as it is both an experience and various sets of persistent symptoms that are required to meet criteria for the diagnoses that are most commonly associated with exposure to adverse/traumatic event(s) (Dalenberg et al. 2017; Smith, Temple Law Review, 84(1), 1-70, 2011). A problem exists with being able to directly diagnose complex posttraumatic reactions, including complex PTSD (CPTSD) and dissociative disorders, which are the result of repeated, prolonged, and inescapable abuse most often perpetrated during childhood (Courtois and Ford 2013; Herman, Journal of Traumatic Stress, 5, 377-391, 1992, 1993, 1997; Terr, American Journal of Psychiatry, 148, 10-20, 1991), although also seen in persons tortured or held as prisoners of war as adults. Although a large research and clinical literature has developed to describe this phenomenon CPTSD has only recently been introduced into the International Classification of Diseases-11th Edition (World Health Organization [WHO], 2018), and remains absent from the DSM. The author will discuss the importance of assessing a person’s lifetime exposure to traumatic events in forensic evaluations, emphasizing exposure to multiple and/or inescapable trauma early in development. This article will also explore the very broad range of posttraumatic conditions—particularly those on the more complex end of the spectrum that are frequently either invisible or baffling to forensic evaluators whose training has not included this emerging area of study.

What neuroscience and neurofeedback can teach psychotherapists in the fieid of complex trauma: Interoception, neuroception and the embodiment of unspeakable events in treatment of complex PTSD, dissociative disorders and childhood traumatization

Some reflections are given on neuroplasticity and traumatization. Today, we know that the verbal narrative of a traumatic event rarely is sufficient to resolve more complex mental traumatization. The ultimate goal of phase-oriented trauma therapy (Herman, 1992) is integration of the often-fragmented sensory and emotional elements of nonverbal memory. Otherwise, the nonverbal experience fragments may remain for many years after traumatic experiences, sometimes lifelong. Therefore, it is important that psychotherapy activates curiosity and joy and at the same time soothes and lowers feelings of fear, shame, self-hatred and suspicion. We need to offer methods that lead to more stable windows of tolerance (Siegel, 1999) and activate positive states and resources. Then patients can be active and investigative and thus can change their brains and their lives. How the posttraumatic conditions can be eased and ultimately healed is reflected on in relation to the neurofeedback (Niv, 2013; Kirk et al., 2016), as an example of a method aiming at implicit regulation.

Mentalising in complex trauma and dissociative disorders

While mentalising theory has become more widely known and utilized in recent years, there is not yet adequate integration of the theory and practice in the treatment of individuals who have developmental trauma and subsequently suffer from complex PTSD or dissociative disorders. This paper attempts to bridge that gap. The losses, inhibitions, or weakening of mentalising capacities in trauma are explained, along with how mentalising can be misused for personal gain in some situations, particularly to control and harm children who are abused. The relationship between neuroception – the neural detection of safety, danger or life threat – and mentalising is discussed, as well as how various motivational systems impact mentalising capacity. Therapists must be aware of clients’ loss of mentalising functions and the necessary interventions that are likely to restore these capacities, as well as their own inevitable lapses in mentalising that can serve as experiences that lead to relational repair and safety.

Can the Trauma Symptom Inventory-2 distinguish coached simulators from dissociative disorder patients?

The first objective was to understand how individuals with complex dissociative disorders (CDD) score on the Trauma Symptom Inventory-2 (TSI-2). These individuals have high elevations on many psychological measures' validity and clinical scales because of the severe traumatic reactions they experience; thus, creating a challenge for clinicians who seek to determine whether these individuals are exaggerating reported symptoms. The second objective was to compare coached CDD simulators to CDD profiles on the TSI-2s clinical and validity scales. The third objective was to examine the utility rates of the TSI-2s Atypical Response Scale (ATR) in distinguishing feigned CDD from clinical CDD. This study compared 39 CDD inpatients to 51 coached CDD simulators on the TSI-2. A profile analysis compared the CDD group and coached simulators on the TSI-2 scales, and post hoc 1-way analysis of covariances (ANCOVAS) examined significant differences between the groups. The CDD patients elevated on most of the TSI-2 clinical scales and factors. There were significant differences between CDD patients' and CDD simulators' TSI-2 profiles, with simulators failing to endorse some of the co-occurring symptoms common in CDD. The ATR correctly classified only 60-73% of participants and its specificity scores were low. It is important to understand how CDD individuals score on the TSI-2 so that their results can be recognized and meaningfully interpreted. The TSI-2 may not be a useful measure for distinguishing feigned CDD from CDD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Value of Hypnosis in the Resolution of Dissociation: Clinical Lessons from World War I on the Integration of Traumatic Memories

Some World War I clinicians related the symptoms of traumatized servicemen to an underlying dissociation of their personality, consisting of two prototypical conditions: one involving functioning in daily life (inspired by Myers, whose work is also discussed in this article, and which will be labeled apparently normal part of the personality [ANP]) and one involving fixation in the traumatic experience and related attempts at defense (emotional part of the personality [EP]). These authors described two dissociative patterns. As illustrated in this article, one pattern consisted in the presentation of a dominant ANP suffering from constant or frequent intrusions from EP. The other pattern consisted in repeated complete alternations between ANP and EP. Instead of the use of purely symptom-oriented approaches, for the dissociative symptoms to be really resolved, an integration of traumatic memory in the personality, that is, between EP and ANP had to take place. These clinicians used hypnosis to access the traumatic memory and EP and to foster such integration; they agreed on the importance of the quality of the therapeutic relationship in this regard. However, they differed in opinion and practice as to the need to assists patients in their expression of traumatic emotions during this process. When the trauma was related merely to war experiences, such therapeutic processes took place within a simple phase-oriented treatment model, while in the presence of a history of previous trauma and related dissociation of the personality, this model had more complex applications. This is similar to modern treatment approaches of the sequelae - such as a complex dissociative disorder - of chronic (childhood) traumatization.