This paper proposes a model that explains the response to complex psychological trauma and dissociation. This tri-modal reaction model tries to account for the mental striving of the traumatized individual in dealing with unbearable pain when fighting for overall survival. Rather than conceptualizing this process in consecutive phases, the response of the individual to developmental trauma is described in three modes which often co-occur: Acute reaction, chronic process, and alienation. Each mode operates in a window of overmodulation and undermodulation of emotions. This tri-modal model resembles medical conceptualizations of injury, response, and illness as they occur to the body. Psychotherapeutic intervention to trauma-related conditions has to consider the possible co-presence of the three modes. Such three-dimensional understanding of respo nse to trauma has also implications for mental integration. Namely, the latter is a multidimensional phenomenon rather than a linear sum of parts.
Riferimenti bibliografici
Allen J., Fonagy P., Bateman A. (2008). Mentalizing in clinical practice. Washington: American Psychiatric Press.
American Psychiatric Association (2013). Dia gnostic and statistical manual of mental disorders (DSM-5) (5th ed.). Washington, DC: American Psychiatric Association.
Basmacı-Kandemir S., Bayazıt H., Selek S. , Kılıçaslan N., Kandemir H., Karababa I. F., Çeçe, H. (2016). Tracking down the footprints of bad paternal relationship in dissociative disorders: a DTI study. Journal of Trauma & Dissociation, 17(3): 371-381. doi: 10.1080/15299732.2015.1111282.
Bloom J.S., Hynd G.W. (2005). The role of the corpus callosum in interhemispheric transfer of information: excitation or inhibition? Neuropsychology Review, 15(2): 59-71. doi: 10.1007/s11065-005-6252-y.
Brand B.L., Classen C.C., McNary S.W., Zaveri P. (2009). A review of dissociative disorders treatment studies. Journal of Nervous and Mental Disease, 197: 646-654. doi: 10.1097/NMD.0b013e3181b3afaa.
Breuer J., Freud S. (1893). On the psychical mechanism of hysterical phenomena:
preliminary communication. The standard edition of the complete psychological works of Sigmund Freud, volume II (1893-1895): Studies on Hysteria, 1-17.
Briere J., Scott C., Weathers F. (2005). Peritraumatic and persistent dissociation in the presumed etiology of PTSD. American Journal of Psychiatry, 162: 2295-2301. doi: 10.1176/appi.ajp.162.12.2295.
Bromberg P.M. (1998). Standing in the spaces. Essays on clinical process trauma &
dissociation. Hilsdale, NJ: The Analytic Press.
Chefetz A.R., Bromberg P.M. (2004). Talking with “me” and “not-me”. A dialogue.
Coan J.A., Allen J.J. (2004). Frontal EEG asymmetry as a moderator and mediator of emotion. Biological Psychology, 67(1): 7-50. doi: 10.1016/j.biopsycho.2004.03.002.
Cohen R.A., Grieve S., Hoth K.F., Paul R.H., Sweet L., Tate D., Hitsman B. (2006). Early life stress and morphometry of the adult anterior cingulate cortex and caudate nuclei. Biological Psychiatry, 59(10): 975-982. doi: 10.1016/j.biopsych.2005.12.016.
Crandell J., Morrison R.,Willis K. (2002). Using psychomotor to treat dissociative identity disorder. Dissociation, 3: 57-80.
DePierro J., D’Andrea W., Frewen P., Todman M. (2018). Alterations in positive affect: relationship to symptoms, traumatic experiences, and affect ratings. Psychological Trauma: Theory, Research, Practice, and Policy. doi: 10.1037/tra0000317.
DePrince A.P., Huntjens R.J.C., Dorahy M.J. (2015). Alienation appraisals distinguish adults diagnosed with DID from PTSD. Psychological Trauma: Theory, Research, Practice and Policy, 7: 578-582. doi: 10.1037/tra0000069.
Depue B.E., Curran T., Banich M.T. (2007). Prefrontal regions orchestrate suppression of emotional memories via a two-phase process. Science, 317(5835): 215-219. doi: 10.1126/science.1139560.
Dhabbar F.S. (2018). The short-term stress response- mother nature’s mechanism for enhancing protection and performance under conditions of threat, challenge, and opportunity. Frontiers in Neuroendocrinology, 49: 175-192. doi: 10.1016/j.yfrne.2018.03.004.
Diehl R.R. (2017). The target of vasovagal syncope is homeostasis and not heart
Ensink K., Bégin M., Normandin L., Godbout N., Fonagy P. (2017) Mentalization and dissociation in the context of trauma: Implications for child psychopathology, Journal of Trauma & Dissociation, 18, 1: 11-30. doi: 10.1080/15299732.2016.1172536.
Farina B., Speranza A.M., Dittoni S., Gnoni V., Trentini C., Vergano C.M., Della Marca G. (2014). Memories of attachment hamper EEG cortical connectivity in dissociative patients. European Archives of Psychiatry and Clinical Neuroscience, 264(5): 449-458. doi: 10.1007/s00406-013-0461-9.
Fischer G., Riedesser P. (1999). Lehrbuch der Psychotraumatologie (Textbook of
psychotraumathology). München: Ernst Reinhardt Verlag.
Fonagy P., Allison E. (2012). What is mentalization ? The concept and its foundations in developmental research. In: Midgley N., Vrouva I. (eds.), Minding the child: mentalization-based interventions with children, young people, and their families. Routledge Press, New York, pp. 11-34.
Fonagy P., Gergely G., Jurist E., Target M. (2002). Affect regulation, mentalization, and the development of the self. New York: Other Press.
Frankel A.S., O’Hearn T.C. (1996). Similarities in responses to extreme and unremitting stress: Cultures of communities under siege. Psychotherapy: Theory, Research, Practice, Training, 33: 485-502. doi: 10.1037/0033-3204.33.3.485.
Frewen P.A., Lanius R. (2014). Trauma-related altered states of consciousness (TRASC): Exploring the 4-D model. Journal of Trauma and Dissociation, 15(4): 436-456. doi: 10.1080/15299732.2013.873377.
Fr eyd J.J. (1994). Betrayal trauma: Traumatic amnesia as an adaptive response to
Jaspers K. (1913). Allgemeine Psychopathologie (General psychopathology), Berlin: Springer Verlag.
Kim S., Kim J.S., Jin M.J., Im C.-H. Lee S.-H. (2017). Dysfunctional frontal lobe activity during inhibitory tasks in individuals with childhood trauma: An eventrelated potential study. Neuroimage:Clinical, 17: 935-942. doi: 10.1016/j.nicl.2017.12.034.
Kleindienst N., Priebe K., Görg N., Dyer A., Steil R., L yssenko L., Winter D., Schmahl C., Bohus M. (2016). State dissociation moderates response to dialectical behavior therapy for posttraumatic stress disorder in women with and without borderline personality disorder. European Journal of Psychotraumatology, 7: 30375. doi: 10.3402/ejpt.v7.30375.
Lan ius R.A., Vermetten E., Loewenstein R.J., Brand B., Schmahl C., Bremner J.D.,
Spiegel D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167(6): 640-647. doi: 10.1176/appi.ajp.2009.09081168.
Laugharne J., Kullack C., Lee C.W., McGuire T., Brockman S., Drummond P.D., Starkstein S. (2016). Amygdala volumetric change following psychotherapy for posttraumatic stress disorder. Journal of Neuropsychiatry and Clinical Neurosciences, 28(4): 312-318. doi: 10.1176/appi.neuropsych.16010006.
Lewis D.O., Yeager C.A., Swica Y., Pincus J.H., Lewis M. (1997). Objective documentation of child abuse and dissociation in 12 murderers w ith dissociative identity disorder. American Journal of Psychiatry, 154: 1703-1710. doi: 10.1176/ajp. 154.12.1703.
Lobo I., de Oliveira L., David I.A., Pereira M.G., Volchan E., Rocha-Rego V., Figueira I., Mocaiber I. (2011). The neurobiology of posttraumatic stress disorder: dysfunction in the prefrontal-amygdala circuit? Psychology & Neuroscience, 4, 2: 191-203. doi: 10.3922/j.psns.2011.2.004.
MacDonald K., Thomas M., Sciolla A., Vogel M., Wingenfeld K. (2016). Minimization of childhood maltreatment is common and consequential: results from a large, multinational sample using the Childhood Trauma Questionnaire. PLOSeONE, 11(1): e0146058. doi: 10.1371/journal.pone.0146058.
Markowitsch H.J., Staniloiu A. (2011). Amygdala in action:relaying biological and social significance to autobiographical memory. Neuropsychologia, 49: 718-733. doi: 10.1016/j.neuropsychologia.2010.10.007.
Martin E. (2008). A dictionary of biology (6th ed.). Oxford: Oxford University Press, pp. 315-316.
Merckelbach H.L. (2015). The role of frontal EEG asymmetry in post-traumatic stress disorder. Biological Psychology, 108: 62-77. doi: 10.1016/j.biopsycho.2015.03.018.
Mutluer T., Şar V., Kose-Demiray C., Arslan H., Tamer S., Ünal S., Kaçar A.Ş. (2018). Lateralization of neurobiological response in adolescents with PTSD related to severe childhood sexual abuse: the tri-modal reaction (T-MR) model of protection. Journal of Trauma and Dissociation, 19(1): 108-125. doi: 10.1080/15299732.2017.1304489.
Nijenhuis E.R.S. (2017). Ten reasons for conceiving and classifying posttraumatic
stress disorder as a dissociative disorder. European Journal of Trauma and Dissociation, 1: 47-61. doi: 10.1016/j.ejtd.2017.01.001.
Ogawa J.R., Sroufe L.A., Weinfield N.S., Carlson E.A., Egeland B. (1997). Development and the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Development and Psychopathology, 9: 855-879.
Öztürk E., Şar V. (2005). Apparently normal family: A contemporary agent of transgenerational trauma and dissociation. Journal of Trauma Practice, 4(3/4): 287-303. doi: 10.1300/J189v04n03_06.
Öztürk E., Şar V. (2016a). Formation and functions of alter personalities in dissociative identity disorder: A theoretical and clinical elaboration. Journal of Psychology and Clinical Psychiatry, 6, 6: 00385. doi: 10.15406/jpcpy.2016.06.00385.
Öztürk E., Şar V. (2016b). The trauma-self and its resistances in psychotherapy. Journal of Psychology and Clinical Psychiatry, 6, 6: 00386. doi: 10.15406/jpcpy.2016.06.00386.
Popkirov S., Flasbeck V., Schlegel U., Juckel G., Brüne M. (2018). Childhood trauma and dissociative symptoms predict frontal EEG asymmetry in borderline personality disorder. Journal of Trauma and Dissociation. doi: 10.1080/15299732.2018.1451808.
Putnam F.W. (1997). Dissociation in children and adolescents: A developmental
perspective. New York, NY: Guilford Press.
Quinn C.R., Rennie C.J., Harris A.W., Kemp A.H. (2014). The impact of melancholia
versus non-melancholia on resting-state, EEG alpha asymmetry: Electrophysiological evidence for depression heterogeneity. Psychiatry Research, 215(3): 614-617. doi: 10.1016/j.psychres.2013.12.049.
Ross C.A. (1997). Dissociative identity disorder. Diagnosis, clinical features, and
treatment of multiple personality. New York: Wiley Press.
Ross C.A., Browning E. (2018). Altered states of consciousness among inpatients in a trauma program. Journal of Trauma and Dissociation. doi: 10.1080/15299732.2018.1451807.
Ross C.A., Goode C., Schroeder E. (2015). Hippocampal volumes in a sample of trauma patients: a possible neuro-protective effect of dissociation. The Open Psychiatry Journal, 9(1): 7-10.
Şar V. (2011). Developmental trauma, complex PTSD and the current proposal of DSM-5. European Journal of Psychotraumatology, 2: 5662. doi: 10.3402/ejpt.v2i0.5622.
Şar V. (2017a). Parallel-distinct structures of internal world and external reality:
Disavowing and re-claiming the self-identity in the aftermath of traumagenerated dissociation. Frontiers in Psychology, 8: 216. doi: 10.3389/fpsyg.2017.00216.
Şar V. (2017b). Identity revised: a clinician’s perspective on how an identity-based model of mind would look like. In: Identity flexibility during adulthood: perspectives on adult development, Jan Sinnott (ed.), Springer Publ., New York.
Sar V., Akyüz G., Özt ürk E., Alioğlu F. (2013). Dissociative depression among women in the community. Journal of Trauma & Dissociation, 14(4): 423-438. doi: 10.1080/15299732.2012.753654.
Şar V., Alioğlu F., Akyüz G. (2017). Depersonalization and derealization in selfreport and clinical interview: the spectrum of borderline personality disorder, dissociative disorders, and healthy controls. Journal of Trauma and Dissociation, 18(4): 490-506. doi: 10.1080/15299732.2016.1240737.
Şar V., Alioğlu F., Akyüz G., Karabulut S. (2014a). Dissociative amnesia in dissociative disorders and borderline personality disorder: self-rating assessment in a college population. Journal of Trauma and Dissociation, 15(4): 477-493. doi: 10.1080/15299732.2014.902415.
Şar V., Alioğlu F., Akyüz G., Tayakısı E., Öğülmüş F.E., Sönmez D. (2017). Awareness of identity alteration and diagnostic preference between borderline personality disorder and dissociative disorders. Journal of Trauma and Dissociation, 18(5): 693-709. doi: 10.1080/15299732.2016.1267684.
Şar V., Dorahy M.J., Krüger C. (2017). Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychology Research and Behavioral Management, 10: 137-146. doi: 10.2147/PRBM.S113743.
Şar V., Önder C., Kılınçaslan A., Zoroğlu S.S., Alyanak B. (2014b). Dissociative identity disorder among adolescents: Prevalence in a university psychiatric outpatient unit. Journal of Trauma and Dissociation, 15(4): 402-419. doi: 10.1080/15299732.2013.864748.
Şar V., Öztürk E. (2005). What is trauma and dissociation? Journal of Trauma Practice, 4(1-2): 7-20.
Şar V., Öztürk E. (2007). Functional dissociation of the self: a sociocognitive approach to trauma and dissociation. Journal of Trauma & Dissociation, 8(4): 69-89. doi: 10.1300/J229v08n04_05.
Şar V., Ozturk E. (2013). Stimulus deprivation and overstimulation as dissociogenic agents in postmodern oppressive societies. Journal of Trauma and Dissociation, 14(2): 198-212. doi: 10.1080/15299732.2013.724346.
Şar V., Ross C.A. (2006). Dissociative disorders as a confounding factor in psychiatric research. Psychiatric Clinics of North America, 29: 129-144. doi: 10.1016/j.psc.2005.10.008.
Şar V., Unal S.N., Kiziltan E., Kundakci T., Ozturk E. (2001). HMPAO SPECT study of regional cerebral blood flow in dissociative identity disorder. Journal of Trauma & Dissociation, 2(2): 5-25.
Şar V., Unal S. N., Ozturk E. (2007). Frontal and occipital perfusionu changes in dissociative identity disorder. Psychiatry Research: Neuroimaging, 156(3): 217-223. doi: 10.1016/j.pscychresns.2006.12.017.
Schimmenti A., Şar V. (submitted). Investigating the domains of dissociation: a
correlation network analysis of dissociative experiences. Journal of Trauma and Dissociation.
Shore A. (2009). Relational trauma and the developing right brain an interface of
psychoanalytic self psychology and neuroscience. Self and systems. Annales of New York Academy of Sciences, 1159: 189-203. doi: 10.1111/j.1749-6632.2009.04474.x.
Siegel D. (1999). The developing mind. New York: Guilford.
Solms M., Panksepp J. (2012). The “Id” knows more than the “Ego” admits:
neuropsychoanalytic and primal consciousness perspectives on the interface between affective and cognitive neuroscience. Brain Science, 2: 147-175. doi: 10.3390 /brainsci2020147.
Stern D.N. (2004). The present moment in psychotherapy and everyday life. New York: Norton Company.
Teicher M., Ito Y., Glod C., Schiffer F., Gelbard H. (1994). Early abuse, limbic system dysfunction, and borderline personality disorder. In: Silk K. (ed.), Biological and neurobehavioral studies of borderline personality disorder. Washington, DC: American Psychiatric Association Press, pp. 177-207.
Childhood neglect is associated with reduced corpus callosum area. Biological Psychiatry, 56: 80-85. doi: 10.1016/j.biopsych.2004.03.016.
Tench C.R.,Tanasescu R., Jethwa K.D., Constantinescu C.S. (2018). Coordinate based meta-analysis of whole-brain voxel-based morphometry studies does not show evidence of grey matter loss specific to PTSD. bioRxiv 265496. doi: 10.1101/265496.
Tursich M., Neufeld R.W.J., Frewen P.A., Harricharan S., Kibler J.L., Rhind S.G., Lanius R.A. (2014). Association of trauma exposure with proinflammatory activity: a transdiagnostic meta-analysis. Translational Psychiatry, 4: e413. doi: 10.1038/tp.2014.56.
Van der Hart O., Nijenhuis E.R.S., Steele K. (2005). Dissoci ation: An insufficiently
recognized major feature of complex posttraumatic stress disorder. Journal of Traumatic Stress, 18(5): 413-423. doi: 10.1002/jts.20049.
Van der Hart O., Nijenhuis E.R., Steele K. (2006). The haunted self: structural
dissociation and the treatment of chronic traumatization. New York: Norton.
Van der Kolk B.A., Van der Hart O. (1991). The intrusive past: The flexibility of memory and the engraving of trauma. American Imago, 48(4): 425-252. https://
www.jstor.org/stable/26303922.
Weinbrecht A., Niedeggen M., Roepke S., Renneberg B. (2018). Feeling excluded no matter what? Bias in the processing of social participation in borderline personality disorder. Neuroimage: Clinical. doi: 10.1016/j.nicl.2018.04.031.