This article was downloaded by: [FU Berlin]

On: 12 May 2015, At: 20:26

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,
37-41 Mortimer Street, London W1T 3JH, UK

Journal of Trauma & Dissociation

Publication details, including instructions for authors and subscription information:
http://www.tandfonline.com/loi/wjtd20

Different Types of “Dissociation” Have Different

Psychological Mechanisms
a
Richard J. Brown PhD and ClinPsyD
a
Academic Division of Clinical Psychology , University of Manchester
Published online: 25 Sep 2008.

To cite this article: Richard J. Brown PhD and ClinPsyD (2006) Different Types of “Dissociation” Have Different Psychological
Mechanisms, Journal of Trauma & Dissociation, 7:4, 7-28, DOI: 10.1300/J229v07n04_02

To link to this article: http://dx.doi.org/10.1300/J229v07n04_02

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained
in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the
Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and
are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and
should be independently verified with primary sources of information. Taylor and Francis shall not be liable for
any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever
or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of
the Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematic
reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://
www.tandfonline.com/page/terms-and-conditions
 Different Types of “Dissociation”
Have Different Psychological Mechanisms
Richard J. Brown, PhD, ClinPsyD

SUMMARY. The term “dissociation” has been used to describe a wide

range of psychological and psychiatric phenomena. The popular con-
ception of dissociation describes it as a unitary phenomenon, with only
Downloaded by [FU Berlin] at 20:26 12 May 2015

quantitative differences in severity between the various dissociative con-

ditions. More recently, it has been argued that the available evidence is
more consistent with a model that identifies at least two distinct categories
of dissociative phenomena–“detachment” and “compartmentalization”–
that have different definitions, mechanisms and treatment implications
(Holmes, Brown, Mansell, Fearon, Hunter, Frasquilho & Oakley 2005).
This paper presents evidence for this bipartite model of dissociation, followed
by definitions and descriptions of detachment and compartmentaliz-
ation. Possible psychological mechanisms underlying these phenomena
are then discussed, with particular emphasis on the nature of com-
partmentalization in conversion disorder, hypnosis, dissociative amne-
sia and dissociative identity disorder. doi:10.1300/J229v07n04_02 [Article
copies available for a fee from The Haworth Document Delivery Service:
1-800-HAWORTH. E-mail address: <[email protected]> Web-
site: <http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All
rights reserved.]

Richard J. Brown is affiliated with the Academic Division of Clinical Psychology,

University of Manchester.
Address correspondence to: Dr. Richard J. Brown, Academic Division of Clinical
Psychology, University of Manchester, Rawnsley Building, Manchester Royal Infir-
mary, Oxford Road, Manchester, M13 9WL, UK (E-mail: richard.james.brown@
manchester.ac.uk).
[Haworth co-indexing entry note]: “Different Types of “Dissociation” Have Different Psychological
Mechanisms.” Brown, Richard J. Co-published simultaneously in Journal of Trauma & Dissociation (The
Haworth Medical Press, an imprint of The Haworth Press, Inc.) Vol. 7, No. 4, 2006, pp. 7-28; and: Explor-
ing Dissociation: Definitions, Development and Cognitive Correlates (ed: Anne P. DePrince, and Lisa
DeMarni Cromer) The Haworth Medical Press, an imprint of The Haworth Press, Inc., 2006, pp. 7-28. Sin-
gle or multiple copies of this article are available for a fee from The Haworth Document Delivery Service
[1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

Available online at http://jtd.haworthpress.com

© 2006 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J229v07n04_02 7
 8 Exploring Dissociation: Definitions, Development and Cognitive Correlates

KEYWORDS. Dissociation, detachment, compartmentalization, bipar-

tite model

INTRODUCTION

When the term “dissociation”1 was originally popularised in the 19th

century, it was used to refer to a putative mental mechanism underlying
a relatively circumscribed set of clinical phenomena (Van der Hart &
Dorahy, in press). Since the renaissance of the concept in the 1970s,
however, and the growth of contemporary theories (e.g., Hilgard, 1977)
concerning the nature of this mental mechanism, the number of phenom-
Downloaded by [FU Berlin] at 20:26 12 May 2015

ena thought to be attributable to dissociation has expanded considerably.

As a result, the dissociation label is now applied to an extraordinary
range of psychological symptoms, states and processes (see Figure 1;
Cardeña, 1994).
On the face of it, this expansion of the dissociative domain (Cardeña,
1994) appears to be justified by the widespread view that these different
phenomena described above are produced by a common psychological
mechanism (i.e., dissociation), characterised by a breakdown in mental
integration (e.g., Bernstein & Putnam, 1986; Dell, 2006). According to
this “unitary” model, these phenomena are all qualitatively similar, with
the differences between them being accounted for by the “amount” of

FIGURE 1. Psychological symptoms, states and processes associated with

the dissociation label

Identity “Unexplained”
confusion medical symptoms Depersonalization

Derealization
Identity alteration &
multiple identifies
Intrusive
thoughts/feelings
Psychogenic
“DISSOCIATION” Flashbacks
amnesia

Loss of control &

“made” actions
Divided attention

Absorption Reduced awareness

Hypnotic Trance Possession

suggestion states
 Richard J. Brown 9

dissociation involved in each case. This idea is embodied in the concept

of the so-called dissociative continuum (Figure 2) and forms the basis
for the Dissociative Experiences Scale (DES; Bernstein & Putnam,
1986), which is commonly used to estimate individual differences in
“trait” dissociation. The model is also apparent in the DSM-IV defini-
tion of dissociation, which identifies it as “. . . a disruption in the usually
integrated functions of consciousness, memory, identity or perception
of the environment” (p. 477; APA, 1994). The unitary model is able to
account for a large body of research findings demonstrating that the
DES scores of different clinical groups vary as predicted, with the most
disabling conditions (such as DID) being associated with the highest
DES scores (see Van Ijzendoorn & Schuengel, 1996). In addition, the
Downloaded by [FU Berlin] at 20:26 12 May 2015

model provides a parsimonious and accessible account of the available

clinical data and is therefore intuitively appealing to both clinicians and
patients.
Despite the appeal of the unitary model, it is not without its critics
(see, e.g., Cardeña, 1994; Frankel, 1990, 1994; Van der Hart, Nijenhuis,
Steele & Brown, 2004). According to Frankel (1990, 1994), for exam-
ple, the dissociation concept has been over-extended to encompass al-
most any kind of symptom involving an alteration in consciousness or a
loss of mental or behavioural control. Similarly, Holmes et al. (2005)
have argued that the unitary model is based on a definition of dissocia-
tion that is too broad and which obscures fundamental differences
between the various phenomena that it encompasses. If valid, this argu-
ment has far-reaching implications. Empirically, it implies that re-

FIGURE 2. Hypothetical dissociative continuum (not to scale). N. B. The inclu-

sion of both states and disorders on a single dimensional scale is deliberate in
order to illustrate the assumption underlying the unitary model, viz. that differ-
ent dissociative states and conditions can be regarded as involving different
“amounts” of dissociation

Absorbed Hypnotic Dissociative Dissociative identity

states phenomena amnesia disorder

Transient Depersonalization Somatization

depersonalization disorder disorder

Increasing “amount” of dissociation

 10 Exploring Dissociation: Definitions, Development and Cognitive Correlates

searchers need to move beyond simply recruiting generic groups of

patients with “dissociative disorders” and instead focus on the specific
symptoms or symptom clusters in question. Clinically, it indicates that
different types of treatment may be required for different dissociative
problems, and that the “one-size-fits-all” approach implied by the uni-
tary model is invalid.
Numerous previous theorists have attempted to address the confu-
sion caused by the unitary model by identifying different and separate
“types” of dissociation (Cardeña, 1994; Allen, 2001; Putnam, 1997;
Brown, 2002a; Van der Kolk & Fisler, 1995). Holmes et al. (2005) pro-
vide a summary position based on these previous theories, arguing that
the available evidence is consistent with a model that distinguishes be-
Downloaded by [FU Berlin] at 20:26 12 May 2015

tween two qualitatively different kinds of phenomena–“detachment”

and “compartmentalization” (following Allen, 2001)–each with distinct
definitions, mechanisms and treatment implications. In the first half of
this paper, I will describe the Holmes et al. (2005) model, providing def-
initions and descriptions of detachment and compartmentalization, as
well as evidence supporting a distinction between these phenomena. In
the second half, I will elaborate on the Holmes et al. (2005) model by re-
lating it to a recent account of the cognitive mechanisms underlying
compartmentalization (Brown, 2002a, 2004; Brown & Oakley, 2004).

EVIDENCE FOR TWO TYPES OF PATHOLOGICAL

“DISSOCIATION”

Although research investigating total scores on the DES seems to

support a unitary model of dissociation, factor analytic studies of the
measure are more consistent with a multifactorial account. Numerous
studies have found that the DES has a complex factor structure with at
least three underlying factors (e.g., Carlson, Putnam, Ross et al., 1991;
Ross, Ellason & Anderson, 1995; Frischolz, Braun, Sachs, et al., 1991;
Ross, Joshi & Currie, 1991). Almost invariably, such studies have iden-
tified separate factors for absorption, depersonalization-derealization,
and amnesia related items, suggesting that these three forms of “dissoci-
ation” do not belong to the same category of phenomena. One possible
explanation for this pattern of findings is that absorption, depersonaliza-
tion-derealization, and amnesia occur at different rates in the popula-
tion, producing a misleading multi-factorial solution when the DES is
factor-analyzed (Bernstein, Ellason, Ross & Vanderlinden, 2001). This
would be consistent with the widespread view that absorption is a com-
 Richard J. Brown 11

mon and non-pathological phenomenon experienced by most people to

varying degrees, unlike “pathological” forms of dissociation such as
amnesia, depersonalization-derealization and identity alteration (e.g.,
Waller, Putnam & Carlson, 1996). While this could explain why a sepa-
rate absorption factor was identified in the Bernstein et al. (2001) study,
it is less clear how it could account for the identification of separate am-
nesia and depersonalization-derealization factors, particularly as there
was no evidence that these two had different base-rates in the general
population sample that was assessed.
According to Holmes et al. (2005), the statistical separation of amne-
sia and depersonalization-derealization items on the DES reflects the
fact that these phenomena belong to two qualitatively different catego-
Downloaded by [FU Berlin] at 20:26 12 May 2015

ries of experience–compartmentalization and detachment respectively–

that can be distinguished both empirically and conceptually. Consistent
with this, Holmes et al. (2005) point to a number of other studies sug-
gesting that depersonalization and derealization can be separated from
amnesia and other “dissociative” phenomena, such as somatoform
symptoms2 and comparable experiences produced using hypnotic sug-
gestion. Research on depersonalization disorder, for example, demon-
strates that medically unexplained (i.e., somatoform) symptoms are
relatively rare in this group (Baker et al., 2003). Similarly, patients with
depersonalization disorder fall in the average range on a sub-scale of the
DES made up of amnesia-related items, despite having elevated scores
on a depersonalization-derealization sub-scale (Simeon et al., 2003).
Furthermore, depersonalization and derealization are relatively uncom-
mon in patients with medically unexplained symptoms (Brown, Schrag
& Trimble, 2005). In contrast, patients with amnesia and dissociative
disorders such as DID often report somatoform symptoms (Saxe et al.,
1994; Nijenhuis, 2004). Patients with somatoform symptoms often
yield low scores on the DES, however, because the scale has relatively
few items pertaining to amnesia and other examples of compartmental-
ization (Brown, 2005). Indeed, the somatoform dissociation question-
naire (SDQ-20) was developed to rectify this omission in the DES
(Nijenhuis, 2004).
Probably the strongest support for the distinction between deper-
sonalization-derealization and other types of “dissociative” phenom-
ena comes from research addressing their mechanisms. This will be
considered in some detail below, following definitions and descriptions
of detachment and compartmentalization as described in the Holmes et
al. (2005) model.
 12 Exploring Dissociation: Definitions, Development and Cognitive Correlates

DETACHMENT

Definition and Description of Detachment

Holmes et al. (2005) define detachment as an altered state of con-

sciousness characterized by a sense of separation (or ‘detachment’)
from aspects of everyday experience (see also Cardeña, 1994; Allen,
2001). The sense of detachment may relate to the individual’s emotional
experience (as in emotional numbing), their sense of self (as in some de-
personalization phenomena), their body (as in out-of-body phenom-
ena), or the world around them (as in derealization; see Table 1). The
phenomena may occur in isolation although they commonly co-occur.
Downloaded by [FU Berlin] at 20:26 12 May 2015

In each case, the individual’s sense of reality testing during the detach-
ment experience is preserved. Phenomenological descriptions of de-
tachment include an absence or alteration of emotional experience,
feelings of being “spaced out,” “disconnected,” “unreal” or “in a dream,”
a sense of being an outside observer of one’s body, and perceptions of
the external world as flat, lifeless and “strange” (Noyes & Kletti, 1977;
Steinberg, 1994; Butler, Duran, Jasiukaitis, Koopman & Spiegel, 1996;
Allen, Console & Lewis, 1999; Sierra & Berrios, 2001; Baker et al.,
2003). In some cases, detached states are associated with memory dis-
turbances and amnesia (Allen et al., 1999). On the face of it, detach-
ment-related memory dysfunction can be difficult to distinguish from
amnesia as a compartmentalization phenomenon. According to the
Holmes et al. (2005) model, however, the mechanisms responsible for
detachment-related memory loss are different to those operating in
compartmentalization (see below).
Detachment phenomena may manifest as a disorder in their own
right, as in depersonalization disorder, or in the context of another con-

TABLE 1. Detachment and compartmentalization phenomena

Detachment phenomena Compartmentalization phenomena

Emotional numbing Unexplained neurological symptoms
Depersonalization Hypnotic phenomena
Derealization “Made” actions
Out-of-body experiences Multiple identities
Amnesia due to encoding deficit Amnesia due to retrieval deficit
Identity confusion*
* Identity confusion is a non-specific symptom that can be associated with either detachment or com-
partmentalization
 Richard J. Brown 13

dition, such as an anxiety or affective disorder (Hunter, Sierra & David,

2004). Detachment is also commonly experienced during, or immedi-
ately after, traumatic events, a phenomenon known as “peri-traumatic
dissociation,” which is a defining feature of acute stress disorder (ASD)
in DSM-IV.3 In addition, many individuals report mild and transient de-
tachment experiences during periods of fatigue, intoxication or stress.
As such, detachment phenomena can be arranged on a continuum of in-
creasing distress and disability, ranging from mild and non-pathological
experiences of detachment to extremely disabling symptoms, such as
those seen in depersonalization disorder.
In the original Holmes et al. (2005) model, all depersonalization phe-
nomena were regarded as examples of detachment. In the formulation
Downloaded by [FU Berlin] at 20:26 12 May 2015

of the model that is outlined here, however, “made” actions, which are
routinely identified as examples of depersonalization, are regarded as
cases of compartmentalization (see below).

Mechanisms of Detachment

Holmes et al. (2005) follow Sierra and Berrios (1998) in assuming

that detached states result from a hard-wired biological defence mecha-
nism evolved to minimize the potentially debilitating effects of extreme
affect in threatening situations. By this view, detachment arises when an
increase in anxiety causes the medial prefrontal cortex to inhibit emo-
tional processing by the limbic system, thereby reducing sympathetic
output (Sierra & Berrios, 1998). The result is a state devoid of emotional
experience that facilitates adaptive behavior in the face of threat. Al-
though this detached state is adaptive in the short term, it may be highly
aversive and debilitating if it persists over time, as in depersonalization
disorder. Hunter, Phillips, Chalder, Sierra and David (2003) suggest
that chronicity may develop when the individual misinterprets the state
of detachment itself as a threat (e.g., of impending mental breakdown),
perpetuating anxiety and emotional inhibition.
There is a growing body of evidence in favour of this account of the
mechanisms of detachment. It is well documented, for example, that de-
personalization and derealization are commonly associated with anxi-
ety, both normal (e.g., Sterlini & Bryant, 2002) and pathological (e.g.,
Cassano et al., 1989; Simeon, Gross, Guralnik, Stein, Schmeidler &
Hollander, 1997; Marshall, Schneier, Lin, Simpson, Vermes & Leibowitz,
2000). Compared to normal and anxious control participants, deperson-
alization disorder patients also show significantly reduced skin conduc-
tance amplitudes and increased skin conductance latencies (both measures
 14 Exploring Dissociation: Definitions, Development and Cognitive Correlates

of emotional reactivity) to unpleasant stimuli, but not to neutral, un-

pleasant or non-specific stimuli (Sierra et al., 2002). Similarly, compared
to anxious and normal controls, depersonalization disorder patients
show reduced neural responses in brain regions typically activated by
emotional stimuli (insula and occipto-temporal cortex) and increased
neural responses in regions associated with emotional regulation (right
ventral prefrontal cortex) when exposed to aversive pictures (Phillips et
al., 2001). Other evidence provides indirect support for the idea that de-
tachment is associated with a hard-wired neurophysiological profile, in-
cluding the stability of depersonalization disorder semiology over time
(Sierra & Berrios, 2001) and the occurrence of detachment phenomena
in neurological conditions and drug states (Lambert, Sierra, Phillips &
Downloaded by [FU Berlin] at 20:26 12 May 2015

David, 2002).

COMPARTMENTALIZATION

Definition and Description of Compartmentalization

Following Cardeña (1994), Holmes et al. (2005) provide the follow-

ing definition of compartmentalization phenomena: (i) the phenomenon
involves a deficit in the ability to deliberately control processes or ac-
tions that would normally be amenable to such control; (ii) the deficit
cannot be overcome by an act of will; (iii) the deficit is reversible, at
least in principle; and (iv) it can be shown that the apparently disrupted
functions are operating normally and continue to influence cognition,
emotion and action. This definition encompasses dissociative amnesia,
fugue, DID and the various physical symptoms characteristic of the con-
version disorders and some somatoform disorders (e.g., somatization dis-
order; for other examples of “somatoform dissociation” see Nijenhuis,
2004). Similar phenomena (i.e., amnesia, anaesthesia, pseudohalluc-
inations, motor disturbances, etc.) that can be produced using hypnotic
suggestion are also included in this category (see Oakley, 1999; Brown,
2004). In addition, unlike the original formulation of the Holmes et al.
(2005) model, the current account of compartmentalization also encom-
passes actions that the individual does not feel they are controlling
(so-called “made” actions; Dell, 2004), which are typically regarded as
examples of depersonalization (see, e.g., Steinberg, 1994).
Compartmentalization phenomena can also be regarded as occupy-
ing their own continuum of distress and disability, ranging from non-
pathological experiences produced using hypnotic suggestion, through
 Richard J. Brown 15

milder pathological states such as transient amnesias and conversion dis-

orders, to chronic and extremely disabling conditions like somatization
disorder and DID. In each case, the apparently disrupted functions are
said to be “compartmentalized.”
Rather than providing a detailed account of the psychological mecha-
nisms underlying compartmentalization, Holmes et al. (2005) describe
laboratory examples that illustrate this phenomenon and distinguish it
from detachment. Probably the most compelling empirical demonstra-
tion of pathological compartmentalization is an innovative study by
Kuyk, Spinhoven and Van Dyck (1999). Kuyk et al. (1999) compared a
group of patients with amnesia following generalized non-epileptic sei-
zures (NES; a form of compartmentalization according to the current
Downloaded by [FU Berlin] at 20:26 12 May 2015

scheme) and a group with amnesia following generalized epileptic sei-

zures (ES). Participants in both groups were hypnotized some time after
a seizure and given suggestions for the recovery of memories concern-
ing events occurring during the ictus. All information recovered using
this procedure was corroborated independently. On this basis, Kuyk et
al. (1999) found that 85% of their NES patients recalled information
about the seizure for which they were previously amnesic, compared to
0% of patients in the ES group. The findings of this study clearly dem-
onstrate that the NES patients had encoded information about events
occurring during their seizure, but the compartmentalization of this in-
formation within the cognitive system had rendered it unavailable for
deliberate retrieval. Hypnotic suggestion had later been able to over-
turn this retrieval failure, allowing recall to take place. The ES patients,
in contrast, did not recover ictal information following hypnosis pre-
sumably because a generalized brain dysfunction had prevented mate-
rial from being encoded during the seizure (Brown, 2002b). Following
Allen et al. (1999), we assume that amnesia associated with a period of
profound detachment also reflects an encoding failure, thereby distin-
guishing it from the inability to retrieve stored information in amnesia
associated with compartmentalization. At present, this remains a con-
ceptual assumption that requires empirical validation.
Other published demonstrations of compartmentalization can be
found in single case studies of so-called implicit perception (Kihlstrom,
1992) in conversion disorder patients. Bryant and McConkey (1989),
for example, tested a patient (DB) with unilateral conversion blindness
using a forced-choice visual decision paradigm. In this, DB was pre-
sented with three visual stimuli (triangles) to his affected eye and he was
asked to generate a response indicating which of the three stimuli was
oriented differently to the other two. Using this procedure, Bryant and
 16 Exploring Dissociation: Definitions, Development and Cognitive Correlates

McConkey (1989) showed that DB responded correctly on 74% of the

trials, an above-chance response rate indicating that his performance
was influenced by the visual information available, despite the fact that
he continued to report a lack of visual experience in his affected eye.
This is clearly consistent with the definition of compartmentalization
outlined above. DB’s response rate also improved following feedback
suggesting that his performance was affected by the visual information
and improved further still when he was given instructions designed to
increase his motivation. These latter findings indicate that the nature of
the compartmentalization associated with DB’s blindness was rela-
tively fluid and subject to modification through top-down influences.
Other single-case studies of implicit perception associated with com-
Downloaded by [FU Berlin] at 20:26 12 May 2015

partmentalization are described in Kihlstrom (1992).

Although the study reported by Kuyk et al. (1999) and single case
studies such as that of Bryant and McConkey (1989) provide compel-
ling examples of compartmentalization, they do not provide a detailed
explanation of the mechanisms underlying these phenomena, which is
largely lacking from the Holmes et al. (2005) model. In a bid to address
this issue, the second half of this paper extends the Holmes et al. (2005)
model by relating it to the integrative cognitive model described by
Brown (2002a, 2004; Brown & Oakley, 2004; also Oakley, 1999a, b),
which has been used recently to account for a range of compart-
mentalization phenomena.

Mechanisms of Compartmentalization

The integrative cognitive model was originally developed as an ac-

count of the mechanisms underlying certain somatoform symptoms as
well as comparable experiences produced using hypnotic suggestion,
both of which are examples of compartmentalization according to
Holmes et al. (2005). The integrative model is based on the assumption
that these phenomena result from subtle disturbances in the processes
underlying consciousness and mental control. To this end, the model
provides a detailed account of the cognitive structures and processes as-
sociated with normal consciousness and control, which is then applied
to atypical cases such as compartmentalization phenomena.

Consciousness and Cognitive Control

The basic cognitive architecture according to this approach is pre-

sented in Figure 3. In line with much cognitive theorising, the model
 Richard J. Brown 17

FIGURE 3. Structures and processes involved in the generation of conscious-

ness and control of cognition and action

EARLY PERCEPTUAL PROCESSES

ENCODING AND SPREAD OF ACTIVATION IN

ASSOCIATIVE MEMORY

ACTIVATION OF PERCEPTUAL HYPOTHESIS

Synthesis PRIMARY ATTENTIONAL

of hypotheses SYSTEM (PAS)
with sense data
Downloaded by [FU Berlin] at 20:26 12 May 2015

“Primary awareness”
(in gray)
PRIMARY REPRESENTATIONS
Unwilled action
ACTIVATION OF
SECONDARY REPRESENTATIONS THOUGHT/ACTION
SCHEMATA
Willed action

“Secondary awareness”
(in white)
SECONDARY ATTENTIONAL
SYSTEM (SAS)

assumes that the contents of consciousness represent a working inter-

pretation of the environment that is generated for the control of cogni-
tion and action. In this architecture, the contents of consciousness are
generated at a relatively late stage in the processing chain, following ex-
tensive pre-attentive analysis of incoming information (Velmans, 2000).
In the first instance, the receipt of sensory information triggers simple
perceptual analyses that represent its basic features (Kosslyn, 1996).
The resulting representations are then encoded in memory, triggering a
parallel spread of activation through related representations within
memory (Logan, 1988). This spread of activation in associative memory
acts as an interpretive process (Sloman, 1996) that produces a number of
possible “hypotheses” about the input based on previous experience
(Marcel, 1983). These hypotheses are repeatedly sampled by a primary
attentional system (PAS), which selects one of the hypotheses as the
most appropriate account of the current situation. The PAS then inte-
 18 Exploring Dissociation: Definitions, Development and Cognitive Correlates

grates the chosen hypothesis with relevant sensory information, pro-

ducing multi-modal units or primary representations. These primary
representations correspond to the basic contents of consciousness and
provide a working model of the world that can be used to guide action.
Primary representations serve as input to a hierarchical network of behav-
ioral programs or “schemata” (cf. Hilgard, 1977; Norman & Shallice,
1986) that describe the processing operations required for the execution
of specific acts. At the top of this hierarchy are high-level programs cor-
responding to general situations such as “driving a car” or “going to a
restaurant.” Within each of these high-level programs are simpler sche-
mata corresponding to different acts within that situation, such as “re-
versing” or “ordering food.” Each of these schemata has even simpler
Downloaded by [FU Berlin] at 20:26 12 May 2015

sub-programs describing the various elements of the act (e.g., “chang-

ing gear” or “reading the menu”) and so on. These programs are acti-
vated to varying degrees by the current primary representation. When a
threshold level of activation is reached, the program is triggered auto-
matically and the associated behavior is executed using the primary rep-
resentation as a template of the current environment. This behavior will
then run until completion unless it is impeded or inhibited by other in-
formation in the system. This automatic activation of schemata provides
the system with an efficient way of controlling processing in routine sit-
uations and is comparable to the contention scheduling mechanism de-
scribed by Norman and Shallice (1986). Processes controlled by the
automatic activation of schemata are regarded as voluntary but unwilled
(cf. Jahanshahi & Frith, 1998). Processing at this level is perceived as
effortless and is associated with an intuitive or pre-reflective subjective
character labelled primary awareness.
In cases where the network of behavioral programs is unable to pro-
duce adaptive behaviour, such as novel situations, a secondary attentional
system (SAS)4 may intervene to bias the activation levels of relevant pro-
grams. The SAS operates via general-purpose problem-solving algo-
rithms, the construction of goals (or secondary representations) and the
analysis and manipulation of primary representations. Primary repre-
sentations that are subjected to focal-attentive processing (Velmans,
2000) by the SAS are in the foreground of perceptual experience; those
that are not currently being processed by the SAS form the perceptual
background. Processing controlled by the SAS is willed (cf. Jahanshahi
& Frith, 1998), effortful, deliberate and associated with a subjective
character of self-awareness (i.e., an awareness of being awareness) la-
belled secondary awareness.
 Richard J. Brown 19

This model of the cognitive architecture has important implications

for the explanation of somatoform symptoms, hypnotic experiences and
other types of compartmentalization phenomena. In particular, the model
assumes that sensation and the contents of experience need not match,
as the latter are shaped by both sensory and memorial information and
may therefore be “over-determined” by memory. Any discrepancies be-
tween sensation and experience will not be experienced directly by the
individual (although they may be inferred post hoc) as the processes in-
volved in the creation of experience are unavailable to introspection. As
a result, the individual may engage in behaviour that is consistent with
the interpretation of events that is currently dominating their experi-
ence, irrespective of whether that interpretation is correct. The model
Downloaded by [FU Berlin] at 20:26 12 May 2015

also assumes that many, if not most, behaviours are governed by the au-
tomatic activation of behavioral programs (i.e., the PAS) rather than via
deliberate selection and control by the individual (i.e., the SAS). As
such, many complex behaviours can be performed with minimal rep-
resentation in conscious experience (or, at least, self-conscious ex-
perience; cf. Hilgard, 1977). In addition, there can be significant
discrepancies between automatically controlled behaviours and goals
in self-awareness.

Compartmentalization Phenomena and Incongruous

Memory Retrieval

According to the current approach, all compartmentalization phe-

nomena are similar in that they arise from disturbances in the memory
retrieval processes associated with the construction of consciousness
and/or automatic control of action. By this view, the nature of specific
compartmentalization phenomena will vary according to the type of in-
formation (or “rogue representation”) involved in the retrieval process.
Phenomena characterised by a distortion in conscious experience, such
as unexplained (or suggested) pain, pseudohallucinations, sensory al-
terations/loss, etc., arise from the retrieval of inappropriate (i.e., incon-
sistent with sense data) perceptual hypotheses from memory during the
creation of primary representations by the PAS. The result is a compel-
ling distortion in the perceptual world related to the content of the inap-
propriately selected memory. Phenomena characterised by a loss of
deliberate control over processes that are normally amenable to such
control, such as unexplained (or suggested) paralysis, seizures, urinary
retention, amnesia, etc., result from the automatic selection of inappro-
priate behavioral programs corresponding to the experience in question.
 20 Exploring Dissociation: Definitions, Development and Cognitive Correlates

Thus, amnesia may result from a program specifying the inhibition of

certain memory content, while a paralysis may arise from a program
inhibiting bodily movements. Behavioral programs may be activated
either directly or through the creation of a distorted primary represen-
tation that is consistent with the program content (e.g., an experience of
stiffness in the arm triggering a program inhibiting arm movement).
Broadly speaking, then, compartmentalization phenomena arise when
the cognitive system misinterprets information in memory (i.e., rogue
representations) as the most appropriate account of, or response to, cur-
rent circumstances. Rogue representations can be acquired from a num-
ber of different sources, both internal (e.g., direct experience of the
symptom, imagery/fantasy, verbal auto-suggestion) and external (e.g.,
Downloaded by [FU Berlin] at 20:26 12 May 2015

exposure to symptoms in others, media images, hetero-suggestion; see

Brown, 2004; also Johnson & Raye, 1981). In each case, the symptom is
generated at a late stage in the processing chain, either during the con-
struction of primary representations by the PAS or via the automatic ac-
tivation of behavioral programs by those representations. As these
processes operate prior to focal processing by self-conscious systems
(i.e., the SAS), the individual experiences a subjectively compelling
deficit that is outside their willed control. Importantly, the apparently
damaged functions or systems operate normally prior to attentional se-
lection by the PAS: it is only the conscious representation of these sys-
tems’ output that is disrupted. Moreover, the affected systems can still
influence on-going thought and action by their effect on other, non-af-
fected, aspects of processing. In these senses, symptoms generated in
this way can be regarded as archetypal examples of compartmen-
talization.
The misinterpretation underlying compartmentalization is driven by
the over-activation of rogue representations in memory; as such, any
factor that increases this activation will increase the likelihood of a
rogue representation being selected and therefore moderate the occur-
rence of compartmentalization (see Brown, 2004; Brown & Oakley,
2004). In some cases, this may be cognitive factors such as symptom
checking, catastrophic thinking and illness worry/rumination; in others,
motivational factors (e.g., avoidance of alternative memory content)
may be central.
At present, the integrative cognitive model has been applied to medi-
cally unexplained symptoms (including amnesia and pseudohalluc-
inations) but not other forms of pathological compartmentalization
such as “made” actions. On the face of it, the sense of involuntariness
that accompanies such actions is akin to that associated with appar-
 Richard J. Brown 21

ently automatic behaviours in the hypnotic context (the so-called “clas-

sic suggestion effect”). According to Brown and Oakley (2004), this
phenomenon arises when an unwilled act (i.e., one governed by the au-
tomatic activation of a behavioral program) is misinterpreted as coming
from an external source, due to certain information about that act within
the cognitive system. In some cases, this information may be the ab-
sence of an advance prediction about the sensory consequences of the
act (see Blakemore, Wolpert & Frith, 2002; Blakemore, Oakley & Frith,
2003) and/or the activation of a goal specifying that the behavior should
be experienced as involuntary (Kirsch & Lynn, 1997). In others, it may
be the activation of a goal that is inconsistent with the act, particularly if
the individual is motivated not to experience it as their own due to its
Downloaded by [FU Berlin] at 20:26 12 May 2015

“unacceptability.”

The Working Self and Compartmentalization in Dissociative

Amnesia and DID

One of the basic assumptions of the Holmes et al. (2005) model is that
similar mechanism are operating in all compartmentalization phenom-
ena. How might the integrative cognitive model account for the various
symptoms of DID, such as the occurrence of multiple identities and
inter-identity amnesia? Although an extensive discussion of this issue is
beyond the scope of this article, some theoretical speculations are in or-
der. As with other aspects of the model, the most appropriate approach
is to begin by understanding the nature and development of the self un-
der normal circumstances. The self-memory system model of Conway
and Pleydell-Pearce (2000; also Conway, 2005) provides a number of
important insights into this process that could be used to develop the in-
tegrative cognitive model in this respect. According to Conway and
Pleydell-Pearce (2000), the self (or working self in their terminology)
consists of a set of hierarchically-organized goals in working memory
constructed to reduce discrepancies between current and desired states
of the system; these discrepancies are associated with negative emo-
tional experiences, which provide the motivating force behind goal
development and maintenance. The working self has access to an auto-
biographical knowledge base that represents information about previ-
ous events that pertain to system goals. The retrieval of individual
autobiographical memories occurs when a stable pattern of activation
develops within the autobiographical knowledge base that is linked to
current goals in the working self. This may occur through the creation of
 22 Exploring Dissociation: Definitions, Development and Cognitive Correlates

a deliberate retrieval plan by the working self or via direct activation of

the knowledge base by cues from the environment.
Although developed for quite different purposes, the model of
Conway and Pleydell-Pearce’s (2000) is consistent with many aspects
of the integrative cognitive model described above. Thus, the goal hierar-
chy that constitutes Conway and Pleydell-Pearce’s working self would be
an important aspect of the control structures that make up the secondary
attentional system, whereas the autobiographical knowledge base would
be one part of associative memory. By this view, autobiographical
memories will be retrieved when their activation patterns in associative
memory are sufficient for them to be selected by the PAS during the cre-
ation of primary representations. This may occur via the creation of new
Downloaded by [FU Berlin] at 20:26 12 May 2015

retrieval programs by the SAS, the activation of old retrieval programs

by primary representations, or the direct activation of associative mem-
ory by environmental cues.
One important feature of the Conway and Pleydell-Pearce model that
is not explicit in the integrative cognitive model is the idea that autobio-
graphical memory retrieval is strongly constrained by the goals of the
working self. According to Conway and Pleydell-Pearce (2000), one
important goal of the working self is to limit the retrieval of autobio-
graphical memories that may be destabilizing to the system, such as
those that are associated with strong affect and/or highlight discrepan-
cies between goals and knowledge. The working self does this by creat-
ing retrieval programs that specify inhibition of memory content of this
sort, which remains compartmentalized in the system. Conway and
Pleydell-Pearce suggest that this may be one route to the development of
traumatic amnesia in PTSD, an idea that could conceivably be extended
to all forms of dissociative memory loss. The account of dissociative am-
nesia provided by the integrative cognitive model is entirely consistent
with this notion if one assumes that the process is similar whether the in-
hibitory retrieval program (i.e., rogue representation) is established in
memory or created on-line by the SAS.5
The idea that self goals determine what is available for autobiograph-
ical recall could also help account for the occurrence of dissociative am-
nesia in patients with DID, although a more complex explanation is
probably required here. In normal circumstances, the working self will
have a high degree of internal consistency, such that the various goals
within the structure are mutually compatible. In cases where there is a
discrepancy between conflicting goals (e.g., the goal to develop a ro-
mantic relationship vs. the goal to avoid rejection at all costs), negative
 Richard J. Brown 23

affect (e.g., anxiety) will arise. This affect can be managed by reducing
the discrepancy between the conflicting goals, either through adaptive
(e.g., adopting a more realistic goal in relation to rejection) or mal-
adaptive means (e.g., avoiding romantic relationships). In chaotic or
traumatic environments, however, it may be impossible to reduce dis-
crepancies between basic behavioral goals (e.g., the goal to be close to
attachment figures and the goal to avoid physical or emotional pain).
One way for the cognitive system to manage the resulting anxiety would
be to prevent the simultaneous activation of the conflicting goals. If this
were to happen often enough, separate goal hierarchies (or working
selves) could develop over time, each comprising the goals and sub-
goals that were co-active with the conflicting goal in question. Each
Downloaded by [FU Berlin] at 20:26 12 May 2015

goal hierarchy would have access to the autobiographical memories as-

sociated with its component goals, while memories associated with the
conflicting goal would either be inhibited or unavailable due to the lack
of relevant links in the knowledge base.6 Such a fragmented goal hierar-
chy could account for the gaps in time experienced by many patients
with DID, as well as the occurrence of multiple identities with inter-
identity amnesia. The characteristic behavioral pattern of each identity
would reflect the type of goals that make up the goal-hierarchy in ques-
tion. It is likely that these will be organised around fundamental behav-
ioral goals or action tendencies such as those described by Nijenhuis,
Van der Hart and Steele (2004).
According to this account, the compartmentalization operating in
less pathological phenomena such as simple conversion disorders or
circumscribed dissociative amnesias involves a separation (or “dissoci-
ation”) between different levels of processing within the cognitive sys-
tem (i.e., the results of low level processing are separated from the SAS
by the PAS). In DID, the compartmentalization is not only between the
PAS and SAS, but also within SAS structures themselves. In many
ways, this distinction is similar to that between the different levels of
structural dissociation (i.e., primary and secondary vs. tertiary) in the
Nijenhuis et al. (2004) model.
This account of compartmentalization in DID is clearly both specula-
tive and in need of further development. Nevertheless, it provides some
indication of how the symptoms of DID might be understood using cog-
nitive models such as those of Conway and Pleydell-Pearce (2000) and
Brown (2004), suggesting that this may be a fruitful avenue for future
investigation.
 24 Exploring Dissociation: Definitions, Development and Cognitive Correlates

IMPLICATIONS AND CONCLUSIONS

The model of Holmes et al. (2005) has a number of important empiri-

cal and clinical implications. In particular, the model emphasises that
total scores on the DES may not be the most useful way of describing
the “dissociative” tendencies of subject groups and that sub-scales of
the DES, or more specific measures of detachment and/or compart-
mentalization, may be more appropriate for research or clinical pur-
poses. Similarly, the model demonstrates the importance of selecting
diagnostically pure groups in research studies in this area, rather than
heterogeneous groups of “dissociative disorder” patients (or individuals
scoring high on the DES in non-clinical studies). Further evidence for
Downloaded by [FU Berlin] at 20:26 12 May 2015

the model could, however, be obtained from cluster analytic studies us-
ing mixed diagnostic groups and multiple measures of detachment and
compartmentalization. In addition, further studies investigating the
mechanisms of detachment and compartmentalization, using cognitive,
neurophysiological and neuroimaging methods are urgently required.
Clinically, the model indicates that a “one size fits all” approach to
treatment is invalid and highlights the importance of developing idio-
syncratic formulations of dissociative disorder patients, based on an un-
derstanding of the specific psychological mechanisms of the problem in
question. Recent evidence suggests that CBT using an adapted anxi-
ety-disorder model is an effective treatment for pathological detach-
ment (Hunter, Baker, Phillips, Sierra & David, 2005). Other forms of
treatment may be more appropriate for pathological compartmen-
talization (for discussion see Holmes et al., 2005). Finally, the model
questions the unqualified use of the term “dissociation” and emphasises
the need to be much more specific about the kinds of phenomena that
are being referred to when we use the label.

NOTES
1. Or, strictly speaking, desagrégation, which was subsequently translated into its
English form.
2. This paper distinguishes between “symptoms” and “experiences.” Both of these
may be regarded as consciously identifiable subjective events; the assumption here is
that only the former is associated with some kind of pathological process. The term
“phenomena” is used as a collective label for both symptoms and experiences.
3. Amnesia is also identified as a symptom of peri-traumatic dissociation in ASD.
In the Holmes et al. (2005) model, amnesia is a non-specific symptom that can be asso-
ciated with either detachment or compartmentalization.
 Richard J. Brown 25

4. The SAS is comparable to the supervisory attentional system in the Norman and
Shallice (1986) model.
5. The on-line generation of inhibitory programs by the SAS may play an important
role in hypnotic and post-hypnotic amnesias (see Brown & Oakley, 2004).
6. The degree to which different working selves would have access to memories re-
lated to other selves would presumably also reflect the degree to which the goal hierar-
chies were in conflict.

REFERENCES
Allen, J. G. (2001). Traumatic relationships and serious mental disorders. New York,
NY: John Wiley and Sons.
Allen, J. G., Console, D. A., & Lewis, L. (1999). Dissociative detachment and memory
Downloaded by [FU Berlin] at 20:26 12 May 2015

impairment: Reversible amnesia or encoding failure. Comprehensive Psychiatry,

40, 160-171.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Men-
tal Disorders (4th ed.). Washington, DC: Author.
Baker, D., Hunter, E., Lawrence, E., Medford, N., Patel, M., Senior, C., et al. (2003).
Depersonalisation disorder: Clinical features of 204 cases. British Journal of Psy-
chiatry, 182, 428-433.
Bernstein, E., & Putnam, F. W. (1986). Development, reliability and validity of a dis-
sociation scale. Journal of Nervous and Mental Disease, 174, 727-735.
Blakemore, S-J., Wolpert, D.M., & Frith, C. D. (2002). Abnormalities in the awareness
of action. Trends in Cognitive Sciences, 6, 237-242.
Blakemore, S-J., Oakley, D. A., & Frith, C. D. (2003). Delusions of alien control in the
normal brain. Neuropsychologia, 41, 1058-67.
Brown, R. J. (2002a). The cognitive psychology of dissociative states. Cognitive
Neuropsychiatry, 7, 221-235.
Brown, R. J. (2002b). Epilepsy, dissociation and nonepileptic seizures. In M. R.
Trimble, & B. Schmitz (Eds.), The neuropsychiatry of epilepsy (pp. 189-209). Cam-
bridge, UK: Cambridge University Press.
Brown, R. J. (2004). The psychological mechanisms of medically unexplained symp-
toms: An integrative conceptual model. Psychological Bulletin, 130, 793-812.
Brown, R. J., & Oakley, D. A. (2004). An integrative cognitive model of hypnosis and
high hypnotisability. In M. Heap, R. J. Brown, & D. A. Oakley (Eds.), The highly
hypnotizable person: Theoretical, experimental and clinical issues (pp. 152-186).
London: Brunner-Routledge.
Butler, L. D., Duran, E. E., Jasiukaitis, P., Koopman, C., & Spiegel, D. (1996).
Hypnotizability and traumatic experience: A diathesis-stress model of dissociative
symptomatology. American Journal of Psychiatry, 153, 42-63.
Cardeña, E. (1994). The domain of dissociation. In S. J. Lynn, & J. W. Rhue (Eds.),
Dissociation: Clinical and Theoretical Perspectives (pp. 15-31). New York, NY,
USA: The Guilford Press.
Cassano, G. B., Petracca, A., Perugi, G., Toni, C., Tundo, A., & Roth, M. (1989).
Derealization and panic attacks: Evaluation on 150 patients with panic disorder/ag-
oraphobia. Comprehensive Psychiatry, 30, 5-12.
 26 Exploring Dissociation: Definitions, Development and Cognitive Correlates

Conway, M. A. (2005). Memory and the self. Journal of Memory and Language, 53,
594-628.
Conway, M. A., & Pleydell-Pearce, C. W. (2000). The construction of autobiographi-
cal memories in the self-memory system. Psychological Review, 107, 261-288.
Dell, P. F. (2006). The multidimensional inventory of dissociation (MID): A compre-
hensive measure of pathological dissociation. Journal of Trauma & Dissociation,
7(2), 77-106.
Frankel, F. H. (1994). Dissociation in hysteria and hypnosis: A concept aggrandized. In
S. J. Lynn & J. W. Rhue (Eds.), Dissociation: Clinical and Theoretical Perspectives
(pp. 80-93). New York, NY, USA: The Guilford Press.
Hilgard, E. R. (1977). Divided consciousness: Multiple controls in human thought and
actions. New York: Wiley.
Holmes, E., Brown, R. J., Mansell, W., Fearon, R. P, Hunter, E., Frasquilho, F., &
Oakley, D. A. (2005). Are there two qualitatively distinct forms of dissociation? A
Downloaded by [FU Berlin] at 20:26 12 May 2015

review and some clinical implications. Clinical Psychology Review, 25, 1-23.
Hunter, E. C. M., Phillips, M. L., Chalder, T., Sierra, M., & David, A. S. (2003). Deper-
sonalization disorder: A cognitive behavioural conceptualisation. Behaviour Re-
search and Therapy, 41, 1451-1467.
Hunter, E. C. M., Baker, D., Phillips, M. L., Sierra, M., & David, A. S. (2005). Cogni-
tive-behaviour therapy for depersonalisation disorder: An open study. Behaviour
Research and Therapy, 43, 1121-1130.
Hunter, E. C. M., Sierra, M., & David, A. S. (2004). The epidemiology of depersonali-
sation and derealisation: A systematic review. Social Psychiatry and Psychiatric
Epidemiology, 39, 9-18.
Jahanshahi, M., & Frith, C. D. (1998). Willed action and its impairments. Cognitive
Neuropsychology, 15, 483-533.
Johnson, M. K., & Raye, C. L. (1981). Reality monitoring. Psychological Review, 88,
67-85.
Kihlstrom, J. F. (1992). Dissociative and conversion disorders. In D. J. Stein, & J. E.
Young (Eds.), Cognitive science and clinical disorders (pp. 247-270). San Diego,
CA7 Academic Press.
Kihlstrom, J. F. (1994). One hundred years of hysteria. In S. J. Lynn, & J. W. Rhue
(Eds.), Dissociation: Clinical and theoretical perspectives (pp. 365-394). New
York: Guilford Press.
Kirsch, I., & Lynn, S. J. (1997). Hypnotic involuntariness and the automaticity of ev-
eryday life. American Journal of Clinical Hypnosis, 40, 329-348.
Kosslyn, S. M. (1996). Image and brain. Cambridge, MA: MIT Press.
Kuyk, J., Spinhoven, P., & Van Dyck, R. (1999). Hypnotic recall: A positive criterion
in the differential diagnosis between epileptic and pseudoepileptic seizures. Epilepsia,
40, 485-491.
Lambert, M. V., Sierra, M., Phillips, M. L., & David, A. S. (2002). The spectrum of or-
ganic depersonalization: A review plus four new cases. Journal of Neuropsychiatry
& Clinical Neurosciences, 14, 141-154.
Logan, G. D. (1988). Toward an instance theory of automatization. Psychological Re-
view, 95, 492-527.
Marcel, A. J. (1983). Conscious and unconscious perception: An approach to the rela-
tions between phenomenal experience and perceptual processes. Cognitive Psy-
chology, 15, 238-300.
 Richard J. Brown 27

Marshall, R. D., Schneier, F. R., Lin, S., Simpson, H. B., Vermes, D., & Leibowitz, M.
(2000). Childhood trauma and dissociative symptoms in panic disorder. American
Journal of Psychiatry, 157, 451-453.
Nijenhuis, E. R. S., Spinhoven, P., Van Dyck, R., Van der Hart, O., & Vanderlinden, J.
(1996). The development and the psychometric characteristics of the Somatoform
Dissociation Questionnaire (SDQ-20). Journal of Nervous and Mental Disease,
184, 688-694.
Nijenhuis, E. R. S. (2004). Somatoform dissociation. New York: Norton.
Nijenhuis, E.R.S., Van der Hart, O., & Steele, K. (2004). Trauma-related structural dis-
sociation of the personality. Trauma Information Pages website, January 2004:
http://www.trauma-pages.com/nijenhuis-2004.htm
Norman, D. A., & Shallice, T. (1986). Attention to action: Willed and automatic con-
trol of behavior. In R. J. Davidson, G. E. Schwartz, & D. Shapiro (Eds.), Conscious-
ness and self-regulation: Vol. 4. Advances in research and theory (pp. 1-18). New
Downloaded by [FU Berlin] at 20:26 12 May 2015

York: Plenum Press.

Noyes, R., & Kletti, R. (1977). Depersonalization in response to life-threatening dan-
ger. Comprehensive Psychiatry, 8, 375-384.
Oakley, D. A. (1999a). Hypnosis and conversion hysteria: A unifying model. Cogni-
tive Neuropsychiatry, 4, 243-265.
Oakley, D. A. (1999b). Hypnosis and consciousness: A structural model. Contempo-
rary Hypnosis, 16, 215-223.
Phillips, M. L., Medford, N., Senior, C., Bullmore, E. T., Brammer, M. J., Andrew, C.,
et al. (2001). Depersonalization disorder: thinking without feeling. Psychiatry Re-
search. Neuroimaging, 108, 145-160.
Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental per-
spective. New York: The Guilford Press.
Saxe, G. N., Van der Kolk, B. A., Berkowitz, R., Chinman, G. et al. (1993). Disso-
ciative disorders in psychiatric inpatients. American Journal of Psychiatry, 150,
1037-1042.
Sierra, M., & Berrios, G. E. (1998). Depersonalization: Neurobiological perspectives.
Biological Psychiatry, 44, 898-908.
Sierra, M., & Berrios, G. E. (2001). The phenomenological stability of depersonaliza-
tion: Comparing the old with the new. Journal of Nervous and Mental Disease, 189,
629-636.
Sierra, M., Senior, C., Dalton, J., McDonough, M., Bond, A., Phillips, M. L., et al.
(2002). Autonomic response in depersonalization disorder. Archives of General
Psychiatry, 59, 833-838.
Simeon, D., Gross, S., Guralnik, O., Stein, D. J., Schmeidler, J., & Hollander, E.
(1997). Feeling unreal: 30 cases of DSM-III-R Depersonalization Disorder. Ameri-
can Journal of Psychiatry, 154, 1107-1113.
Sloman, S. A. (1996). The empirical case for two systems of reasoning. Psychological
Bulletin, 119, 3-22.
Steinberg, M. (1994). Structured clinical interview for DSM-IV dissociative disorders
(SCID-D), revised. Washington, DC: American Psychiatric Press.
Sterlini, G. L., & Bryant, R. A. (2002). Hyperarousal and dissociation: A study of nov-
ice skydivers. Behaviour Research and Therapy, 40, 431-437.
 28 Exploring Dissociation: Definitions, Development and Cognitive Correlates

Van der Hart, O. & Dorahy, M. J. (in press). Dissociation: History of a concept. In P. F.
Dell & J. O’Neill (Eds.), Dissociation and the dissociative disorders: DSM-V and
beyond. Chicago: International Society for the Study of Dissociation.
Van der Hart, O., Nijenhuis, E., Steele, K., & Brown, D. (2004). Trauma-related disso-
ciation: Conceptual clarity lost and found. Australian and New Zealand Journal of
Psychiatry, 38, 906-914.
Van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the fragmentary nature of
traumatic memories: Overview and exploratory study. Journal of Traumatic Stress,
8, 505-525.
van Ijzendoorn, M.H. & Schuengel, C. (1996). The measurement of dissociation in
normal and clinical populations: Meta-analytic validation of the Dissociative Expe-
riences Scale (DES). Clinical Psychology Review, 16, 365-382.
Velmans, M. (2000). Understanding consciousness. London: Routledge.
World Health Organization. (1992). The ICD-10 classification of mental and behav-
Downloaded by [FU Berlin] at 20:26 12 May 2015

ioural disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzer-

land: Author.

doi:10.1300/J229v07n04_02