Recovered memories of childhood sexual abuse. Implications for clinical practice

Women's Auto/Biography and Dissociative Identity Disorder: Implications for Mental Health Practice

Dissociative Identity Disorder (DID) is an uncommon disorder that has long been associated with exposure to traumatic stressors exceeding manageable levels commonly encompassing physical, psychological and sexual abuse in childhood that is prolonged and severe in nature. In DID, dissociation continues after the traumatic experience and produces a disruption in identity where distinct personality states develop. These personalities are accompanied by variations in behaviour, emotions, memory, perception and cognition. The use of literature in psychiatry can enrich comprehension over the subjective experience of a disorder, and the utilisation of 'illness narratives' in nursing research have been considered a way of improving knowledge about nursing care and theory development. This research explores experiences of DID through close textual reading and thematic analysis of five biographical and autobiographical texts, discussing the lived experience of the disorder. This narrative approach aims to inform empathetic understanding and support the facilitation of therapeutic alliances in mental healthcare for those experiencing the potentially debilitating and distressing symptoms of DID. Although controversies surrounding the biomedical diagnosis of DID are important to consider, the lived experiences of those who mental health nurses encounter should be priority.

DID in resurgence, not retreat

Contrary to the assertion of Paris, diverse indicators suggest that the diagnosis and treatment of dissociative identity disorder (DID) are resurgent rather than retreating. This commentary reviews the evidence that justifies the description of this condition as controversial, including research into dissociative amnesia. The potential harm that can result from a diagnosis of DID and risky treatment techniques, including hypnosis and abreaction, are described. It is suggested that this scientifically unproven and potentially harmful treatment model should be confronted and quelled and its diagnosis and treatment subjected to critical clinical review, including randomised controlled trials, as a matter of urgency. A plea is made for the Royal College of Psychiatrists to update its 1997 guidance document and for professional training to incorporate updated psychological and neurobiological research on human memory.

DECLARATION OF INTEREST

None.

Prevention and management of false memory syndrome

As with most issues in medicine, the prevention and management of a problem is best understood when the origins are known. The term ‘false memory syndrome’ (FMS) came into use in March 1992 with the foundation of the False Memory Syndrome Foundation (FMSF), a non-profit-making organisation established in the USA by a group of families in which one or more of the parents was accused. The parents in these families were reacting to a phenomenon which developed in a characteristic form in the preceding decade and had become common enough by 1991 for a number of them to realise that they were not alone, and to join in setting up the Foundation with a professional and scientific advisory board.

Survey of the use of abreaction by consultant psychiatrists

Aims and Method

To find out current practice in the use of abreaction by consultant psychiatrists a survey was conducted, by postal questionnaire, of all consultant psychiatrists working with adult patients in the Yorkshire area.

Results

Out of 170 consultants, 133 (78%) returned the questionnaire; 64 consultants (48%) had used abreaction at some point in their career and 20 (15%) had done so in the past 5 years. The median number of times abreaction had been used in the previous 5 years was two and only seven consultants (5%) had supervised a trainee in using abreaction.

Clinical Implications

Abreaction is used rarely and only by a minority of consultants. Few consultants have supervised trainees in the use of abreaction. Future psychiatrists are unlikely to be skilled in the use of abreaction and its use will decline.

The Roots of Chronic Posttraumatic Stress Disorder: Childhood Trauma, Information Processing, and Self-protective Strategies

BACKGROUND

Although childhood endangerment often precedes adult posttraumatic stress disorder (PTSD), the mechanism from danger to disorder is unclear. We proposed a developmental process in which unprotected and uncomforted danger in childhood would be associated with "shortcuts" in information processing that, in adulthood, could result in PTSD if the adult experienced additional exposure to danger. Information processing was defined as the basic associative, dissociative, and integrative processes used by all humans. Individual differences in parents' (or primary caregivers') protective and comforting behavior were expected to force unprotected children to use psychological shortcuts that linked early trauma to later vulnerability for PTSD.

METHOD

We compared 22 adults with chronic PTSD to (a) 22 adults with other psychiatric diagnoses and (b) 22 normative adults without any diagnosis, in terms of information processing around childhood danger. The Adult Attachment Interview was used to derive information processing variables, including self-protective strategies, childhood traumas, and depression.

RESULTS

The two patient groups differed from the normative group on all variables. Adults with chronic PTSD differed from other psychiatric patients in having more childhood traumas and using more transformations of associative and dissociative processes. Within the PTSD group, there were three psychologically different subgroups.

CONCLUSION

Our findings suggest that (1) prediction of risk for adult PTSD may be possible, (2) treatment might be facilitated by provision of a protective and supportive therapist, (3) who included a focus on correction of information processing errors and use of more adaptive strategies, and (4) subgroups of adults with PTSD may require different forms of treatment.

Dissociative amnesia

Dissociative amnesia is one of the most enigmatic and controversial psychiatric disorders. In the past two decades, interest in the understanding of its pathophysiology has surged. In this report, we review new data about the epidemiology, neurobiology, and neuroimaging of dissociative amnesia and show how advances in memory research and neurobiology of dissociation inform proposed pathogenetic models of the disorder. Dissociative amnesia is characterised by functional impairment. Additionally, preliminary data suggest that affected people have an increased and possibly underestimated suicide risk. The prevalence of dissociative amnesia differs substantially across countries and populations. Symptoms and disease course also vary, indicating a possibly heterogeneous disorder. The accompanying clinical features differ across cultural groups. Most dissociative amnesias are retrograde, with memory impairments mainly involving the episodic-autobiographical memory domain. Anterograde dissociative amnesia occurring without significant retrograde memory impairments is rare. Functional neuroimaging studies of dissociative amnesia with prevailing retrograde memory impairments show changes in the network that subserves autobiographical memory. At present, no evidence-based treatments are available for dissociative amnesia and no broad framework exists for its rehabilitation. Further research is needed into its neurobiology, course, treatment options, and strategies to improve differential diagnoses.

People who expect to enter psychotherapy are prone to believing that they have forgotten memories of childhood trauma and abuse

We asked 1004 undergraduates to estimate both the probability that they would enter therapy and the probability that they experienced but could not remember incidents of potentially life-threatening childhood traumas or physical and sexual abuse. We found a linear relation between the expectation of entering therapy and the belief that one had, but cannot now remember, childhood trauma and abuse. Thus individuals who are prone to seek psychotherapy are also prone to accept a suggested memory of childhood trauma or abuse as fitting their expectations. In multiple regressions predicting the probability of forgotten memories of childhood traumas and abuse, the expectation of entering therapy remained as a substantial predictor when self-report measures of mood, anxiety, post-traumatic stress disorder symptom severity, and trauma exposure were included.

Symptom overreporting and recovered memories of childhood sexual abuse

The authenticity of recovered memories is a much debated issue. Surprisingly, no study has systematically looked at symptom overreporting in people claiming recovered memories of childhood sexual abuse (CSA). In a first sample we administered the Structured Inventory of Malingered Symptomatology (SIMS) to individuals who said they had recovered CSA memories (n=66), individuals who said their CSA had always been accessible (continuous CSA memory group; n=119), and controls who said they had no CSA experiences (n=83). In a second sample individuals reporting recovered (n=45) or continuous (n=45) CSA memories completed the Morel Emotional Numbing Test (MENT). Our aim was to compare these groups with regard to their tendency to overreport symptoms. The results indicate that people with recovered memories do not score higher on the SIMS and the MENT than other CSA survivors suggesting that symptom overreporting is not typical for people reporting recovered memories.

Freudian Repression, the Common View, and Pathological Science

A sustained misconceptualisation of a theory leading to invalid applications and inferences indicates a failure in the scientific process. This has repeatedly occurred with Freud's theory of repression, a cornerstone of psychoanalytic theory. This paper traces the development of Freud's theory of repression and compares this with the “common view” found in mainstream psychology: the motivated forgetting of trauma. A fixation with Freud's original, and superseded theory (1893–1897) ignores the theoretical developments that constitute mature psychoanalysis (1900–1940), and has impacted upon attempts to test Freudian theory and the current “recovered memory” debate. Although certain accidental factors contribute to this misunderstanding, the sustained failure to comprehend Freudian repression reveals a breakdown in the process of critical inquiry. Implications for psychology as a whole are discussed.

Did Freud mislead patients to confabulate memories of abuse? A reply to Gleaves and Hernandez (1999)

Gleaves and Hernandez have argued that skepticism about the validity of Freud's seduction theory, including by Powell and Boer, is largely unjustified. This paper contends that their analysis is in many ways both inaccurate and misleading. For example, we did not, as they implied, reject the possibility that some of Freud's early patients were victims of childhood sexual abuse. We also maintain that the weight of the available evidence indicates that false memories of traumatic events probably can be implanted, and that Freud's (1896/1962a) original evidence for the validity of his patients' recovered memories remains lacking in several respects-particularly in view of the extremely suggestive procedures he often used to elicit such memories.

Trauma-related dissociative (conversion) disorders in children and adolescents--an overview of assessment tools and treatment principles

A high proportion of patients in child and adolescent psychiatry with significant dissociative symptomatology after early childhood traumatization may go undiagnosed, be wrongly diagnosed and/or inappropriately treated. The diagnostics and treatment of dissociative disorders have been limited by lack of comprehensive, reliable and valid instruments and the ongoing polarization and fierce controversy regarding treatment. However, recent neurobiological findings of neurochemical, functional and structural cerebral consequences of early stressful childhood experiences point out a need for active, early and effective identification and treatment interventions. We present an update on assessment tools available in the Nordic countries, and an overview of different appropriate therapeutic intervention models for children and adolescents. A systematic overview of studies of dissociation in children and adolescent published over the last decade disclosed a total of 1019 references. The 465 papers describing aspects of assessment tools and/or treatment were studied in detail. Reliable and valid screening questionnaires and diagnostic interviews for children and adolescents now allow for effective early identification of dissociative disorders. A combination of individual psychotherapy, pharmacotherapy and family therapy are often required to handle dissociative disorders in children and adolescents. Cognitive-behavioural therapy, hypnotherapy, Eye-Movement Desensitization-Reprocessing (EMDR), psychodynamic therapy and an integrated approach are the main described psychotherapeutic approaches, but treatment of dissociation in children and adolescent does not require allegiance to any one particular treatment model. However, achievement of physical safety by providing a safe environment is a primary goal that supersedes any other therapeutic work. Assessments tools are now available, and appropriate therapeutic intervention models may hopefully contribute to reduce the risk of wrong diagnoses and inappropriate treatment of dissociative symptomatology in children and adolescents. However, controlled clinical trials of the various interventions and longitudinal outcome studies are needed.

The persistence of folly: a critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept

OBJECTIVE

To examine the concept of dissociative identity disorder (DID).

METHOD

We reviewed the literature.

RESULTS

The literature shows that 1) there is no proof for the claim that DID results from childhood trauma; 2) the condition cannot be reliably diagnosed; 3) contrary to theory, DID cases in children are almost never reported; and 4) consistent evidence of blatant iatrogenesis appears in the practices of some of the disorder's proponents.

CONCLUSIONS

DID is best understood as a culture-bound and often iatrogenic condition.

The concept of schizophrenia and phase-specific treatment: cognitive-behavioral treatment in pre-psychosis and in nonresponders

The development of psychosis is often described as a process that goes through different linear stages such as a premorbid and a prodromal phase, with the onset of psychosis as the end state. In this article we elaborate a hierarchical model in which psychosis is understood at different levels of abstraction: we differentiate an etiological, a descriptive, and a therapeutical level, and finally a level of understanding. We regard coping as a special psychological process that starts when symptoms of psychosis first emerge (often many years before treatment is initiated) and continues throughout therapy. In patients who do not respond very well to standard treatment (approximately 15-20% of all patients who suffer from schizophrenia), coping strategies are probably some of the most important long-term prognostic factors. Two cognitive-oriented treatment programs are described: the German model for possible pre-psychosis and the UK tradition for treatment of chronic psychotic symptoms (nonresponders). We conclude that psychological treatment that focuses on coping strategies might be of help both in possible pre-psychotic stages and in nonresponders.

Allegations of abuse: the need for responsible practice

The current UK child protection process has evolved reactively out of scandals. This has led to a culture of support and empathy with those making allegations of abuse while offering no robust means by which false claims can be recognised. Information has been collected from 22 families who became subject to criminal or civil proceedings when a female adolescent or young adult developed a mental health problem. The resultant outcomes were mostly disastrous, for the young person and the family. In every case there was no evidence supporting the allegations of abuse, and substantive evidence they were false, yet this crucial information had not been sought. Each of the 22 families complained that enquiries began from a presumption of guilt. The families documented common and recurring problems, which led them to feel alienated from professionals. Claims of innocence were taken as evidence of guilt, and information was interpreted in a manner that fitted only this presumption while factual evidence to the contrary was ignored. The reasons underlying this professional behaviour are considered. Among the presumed 'victims', outcomes were positively correlated with the level of residual contact between the alleged victim and their family, especially the mother. However, this did not hold true in cases where allegations of abuse arose in the context of an acrimonious parental relationship breakdown. There were no good outcomes where parents were completely excluded. It is not clear that families and alleged 'victims' will fare any better under recently revised guidance and framework.

Trauma, PTSD, and the course of severe mental illness: an interactive model

Traumatic life events, as defined by DSM-IV, are common among persons with severe mental illnesses (SMI) such as schizophrenia. Limited evidence suggests concomitantly high rates of posttraumatic stress disorder (PTSD) in this population. However, conceptual models do not exist for understanding the interactions between trauma, PTSD, and SMI. We propose a model, which is an extension of the stress-vulnerability model, in which PTSD is hypothesized to mediate the negative effects of trauma on the course of SMI. Our model posits that PTSD influences psychiatric disorders both directly, through the effects of specific PTSD symptoms including avoidance, overarousal, and re-experiencing the trauma, and indirectly, through the effects of common correlates of PTSD such as retraumatization, substance abuse, and difficulties with interpersonal relationships. We discuss the evidence supporting this model, and consider several intervening variables that are hypothesized to moderate the proposed relationships between PTSD and SMI, including social support, coping and competence, and antisocial personality disorder. Theoretical and clinical implications of the model are considered, as well as several methodological and nosological issues. We conclude with a brief discussion of directions for future research aimed at evaluating components of the model.

The validity and appropriateness of methods, analyses, and conclusions in Rind et al. (1998): A rebuttal of victimological critique from Ondersma et al. (2001) and Dallam et al. (2001)

The authors respond to 2 victimological critiques of their 1998 meta-analysis on child sexual abuse (CSA). S. J. Dallam et al. (2001) claimed that B. Rind, P. Tromovitch, and R. Bauserman (1998) committed numerous methodological and statistical errors, and often miscoded and misinterpreted data. The authors show all these claims to be invalid. To the contrary, they demonstrate frequent bias in Dallam et al.'s criticisms. S. J. Ondersma et al. (2001) claimed that Rind et al.'s study is part of a backlash against psychotherapists, that its suggestions regarding CSA definitions were extrascientific, and that the moral standard is needed to understand CSA scientifically. The authors show their suggestions to have been scientific and argue that it is Ondersma et al.'s issue-framing and moral standard that are extrascientific. This reply supports the original methods, analyses, recommendations, and conclusions of Rind et al.

Fact or fantasy? A review of recovered memories of childhood sexual abuse

More than a century ago Freud provoked a bitter controversy concerning alleged recollections of childhood sexual abuse: Were they fact or fiction? This debate is still ongoing, with some professionals stubbornly holding on to deeply entrenched and polarised positions. On the one side there are those who continue to deny the veracity of all 'recovered memories', and thus also of the implicated psychological defenses of repression and dissociation. At the other extreme are those therapists who simplistically assume that particular symptoms invariably imply sexual abuse. Over the decades there is a growing corpus of anecdotal, clinical and, more recently, research evidence supporting the contention that childhood sexual abuse, like all other trauma, can be forgotten for days, and even for many years, before being recalled. However, the reconstruction of these memories is a complex and, at times, a rather fallible process.

Canadian and American psychiatrists' attitudes toward dissociative disorders diagnoses

OBJECTIVE

To compare the opinions of Canadian psychiatrists regarding dissociative disorder diagnoses with those of previously surveyed American psychiatrists.

METHOD

We sent a 1-page questionnaire to a stratified representative sample of 550 Canadian psychiatrists.

RESULTS

Eighty percent of Canadian psychiatrists responded. Fewer than one-third replied that dissociative amnesia and dissociative identity disorder should be included without reservations in the DSM-IV; fewer than 1 in 7 felt that the validity of these diagnoses was supported by strong scientific evidence. French- and English-speaking Canadians had similar opinions. Overall, Canadians were significantly less accepting than Americans.

CONCLUSION

Both Canadian and American psychiatrists show little consensus regarding the diagnostic status or scientific validity of dissociative amnesia and dissociative identity disorder.

The role of psychiatric disorders in fibromyalgia

The cardinal features of fibromyalgia are chronic widespread pain in the presence of widespread tenderness as measured by multiple tender points. Despite extensive investigations, the etiology of this syndrome remains unclear. Increased rates of psychiatric disorders, particularly depressive, anxiety, and somatoform disorders, are apparent in clinic populations. Epidemiologic evidence suggests that this is also true for community subjects. Depression, generalized psychological distress, and other psychological factors have been shown to be associated with the onset and persistence of fibromyalgia symptoms. However, the bodily processes through which such factors may lead to the onset of fibromyalgia are unclear. Recent investigations have demonstrated altered stress system responsiveness, most notably the hypothalamic-pituitary-adrenal stress axis, in patients with fibromyalgia. These findings, and one promising avenue for investigating the interaction between psychological and biological factors in the onset of chronic pain syndromes including fibromyalgia, are discussed.

Implications of the Memory Controversy for Clinical PracticeAn Overview of Treatment Recommendations and Guidelines

The controversy surrounding delayed and recovered memories of incest/child sexual abuse has had a profound impact on clinical practice. This article first provides an overview of the positions taken by both sides in the dispute, the “false memory” proponents and the traumatic stress proponents. It then presents the major findings of several of the professional task forces charged with reviewing the controversy and arriving at recommendations for research, clinical practice, and forensic practice regarding delayed recall of memories for sexual abuse. The current status of scientific and clinical knowledge is discussed, especially in terms of its implications for therapists and clinical practice. Nineteen recommendations and practice guidelines are presented for therapists working with individuals who report or suspect childhood sexual abuse on the basis of continuous and/or recovered memory.

Characteristics, context and consequences of memory recovery among adults in therapy

BACKGROUND

There are concerns that memories recovered during therapy are likely to be the result of inappropriate therapeutic techniques.

AIMS

To investigate systematically these concerns.

METHOD

One-hundred and eight therapists provided information on all clients with recovered memories seen in the past three years, and were interviewed in detail on up to three such clients.

RESULTS

Of a total of 690 clients, therapists reported that 65% recalled child sexual abuse and 35% recalled other traumas, 32% started recovering memories before entering therapy. According to therapists' accounts, among the 236 detailed client cases very few appeared improbable and corroboration was reported in 41%. Techniques to aid recall were used in 42%, but only in 22% were they used before memory recovery started.

CONCLUSIONS

Some of the data are consistent with memories being of iatrogenic origin, but other data clearly point to the need for additional explanations.

The association between tender points, psychological distress, and adverse childhood experiences: a community-based study

OBJECTIVE

To examine the hypothesis that characteristics of somatization and illness behavior, and their childhood antecedents, are associated with the presence of multiple tender points.

METHODS

Two hundred eighty-nine subjects who had demonstrated psychological distress (General Health Questionnaire score > or =2) had a tender point examination and in-depth psychological evaluation. In addition, subjects were interviewed about a number of adverse childhood experiences. The 99 subjects with 5 or more tender points were compared with the remaining 190 subjects.

RESULTS

A high tender point count (> or =5) was associated with low levels of self-care (odds ratio [OR] 2.4, 95% confidence interval [95% CI] 1.1-5.0), reports of a greater number of somatic symptoms (OR 2.2, 95% CI 1.0-4.9), high levels of fatigue (OR 3.3, 95% CI 1.7-6.3), and a pattern of illness behavior characterized by increased medical care usage (OR 4.2, 95% CI 2.1-8.4). Those with high tender point counts were substantially more likely to report adverse childhood experiences, including loss of parents (OR 2.1, 95% CI 1.1-3.9) and abuse (OR 6.9, 95% CI 2.0-24.6). These results were not explained by the presence of chronic pain.

CONCLUSION

These data add further weight to the hypothesis that tender points, as part of the fibromyalgia syndrome, are strongly associated with specific components of psychological distress as well as characteristics of somatization and its antecedents. It is possible that these features contribute to the development of the syndrome of fibromyalgia.

Unreliable admissions to homicide. A case of misdiagnosis of amnesia and misuse of abreaction technique

BACKGROUND

The past decade has witnessed a recognition that unsafe criminal convictions may be occasioned by unreliable confessions.

AIMS

To present a case which illustrates the dangers of using abreaction interview techniques in a legal context and demonstrate the relevance of the memory distrust syndrome to an unsafe confession to murder.

METHOD

We under took a detailed assessment of a person appealing against his original murder conviction, 'the appellant', and a careful scrutiny of all the relevant papers in the case.

RESULTS

The appellant served 25 years in prison before his conviction was quashed as 'unsafe' on the basis of fresh psychological and psychiatric evidence.

CONCLUSIONS

Amnesia for an offence had been misdiagnosed, and the use of repeated abreaction interviews had further confused both the appellant and the original court. At the Appeal Court, the advice was that the man had experienced a form of source amnesia which resulted in an unreliable confession.