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                                    Vedat Sar, M.D.
                      Professor of Psychiatry, Istanbul University

          Emerging of studies on trauma-related dissociation in Turkey
          Studies on dissociative disorders as trauma-related conditions appeared in Turkey
in 1990ies after one decade of the rise of the studies in North America and the Netherlands
(1)..Turkish studies emerged from original local observations, thus without any American
or European influence, and in absence of any media effect. The emergence of this scientific
endevour in turkish psychiatry requires a sociological analysis on its own, however, it
extends the limits of this presentation.
        The first diagnosed cases of dissociative identity disorder in Turkey were mostly
young women living in peripheric districts of metropolitan Istanbul. These are transitional
areas in sociological sense where migrants from Anatolian villages and towns have settled
after 1950’ies, accelerated in 1980’ies. These female patients applied to psychiatric
emergency wards mostly in dissociative psychosis (called hysterical psychosis formerly) or
acute somatoform dissociation (former conversion disorder) which were crisis conditions
superimposed to a long-lasting and unrecognized chronic complex dissociative disorder
(either DID or DDNOS) related to childhood traumata (2,3,4). The treatment usually
included hospitalization (5). Many cases were recognized among psychiatric inpatients. The
case load increasingly shifted to conditions which mimic borderline personality disorder.
The increasing expertise resulted in a shift to outpatient treatment primarily. We have
recognized a rise in the rate of male dissociative patients recently and adolescents and
children with dissociative disorders apply increasingly (6,7). Diverse clinical conditions
such as obsessive compulsive disorder, sexual conflicts, marital problems, schizophrenic
disorder with dissociative features have entered our field. On the other hand, subtle
dissociative mechanisms among less severe psychiatric conditions can be detected easier

          The frequency of dissociative disorders was 10.2 % among psychiatric inpatients
(8). This rate was 12.0% both for psychiatric outpatients and psychiatric emergency unit
applications (9,10). An epidemiological study was conducted on a representative female
sample derived from the Sivas–City in Turkey (11). The screening of 628 women using the
DDIS yielded a 18.3 % prevalence of DSM-IV dissociative disorders. (Dissociative identity
disorder=1.1%, dissociative disorder not otherwise specified=8.3%, dissociative
amnesia=7.3%, depersonalization disorder=1.4%, dissociative fugue=0.2%). It is of
particular interest that the most prevalent category was the DDNOS.

        Gender issues
        Although most of the disociative patients in clinical populations are female,
an epidemiological study conducted on 994 participants (male and female) representative
for the Sivas-City in Turkey demonstrated that there was no difference between men and
women in the Dissociative Experiences Scale scores (12). However, more women than men
were among subjects with a score above the cut-off point on the scale. This observation can
be interpreted as there being more traumatized women in the general population or that
women use dissociation more frequently as response to trauma. On the other hand, it is
quite possible that women more readily report their dissociative experiences whereas men
hide them frequently. A study conducted on a male prison population in Sivas-City (10.2%
of the subjects had dissociative disorder) led to observations suggesting the latter
hypothesis ( 13 )..

        Hysterical psychosis
        Tutkun,Yargic and Sar propose that hysterical psychosis is a presentation form of
chronic dissociative disorders such as dissociative identity disorder and DDNOS (2).
Hysterical psychosis in chronic dissociative patients is a result of decompensation after an
acute stressful life event leading to struggle for control and influence between alter
identities carrying frightening, fearful, aggressive or delusional features, some of whom
may had been dormant for a long time previously. This is an observation important for
general psychiatry in particular. The category of hysterical psychosis is still used
traditionally by clinicans who are aware of the difference between an acute schizophrenic
episode and psychotic-like dissociative ("hysterical") syndromes but who are not familiar
with dissociative identity disorder and its incomplete forms (DDNOS). The concept of
hysterical psychosis would be one of the starting points for recognition of dissociative
disorders in countries, where professionals are more familiar with traditional categories.

        Borderline personality disorder
        We observed that many patients with an allegedly borderline personality disorder
can be treated in a relatively short time period based on treatment for dissociative disorder
(14). Indeed, a screening study among outpatients demonstrated that 2/3 of BPD cases had
a dissociative disorder in the first Axis (15). Most of them had either dissociative identity
disorder or DDNOS. We propose that trauma-related borderline conditions are dissociative
disorders rather than being personality disorders.

        Orbitofrontal hypothesis
        A brain imaging study using the SPECT technology demonstrated that subjects
with dissociative identity disorder had decreased perfusion in orbitofrontal regions
bilaterally and increased perfusion in left (dominant hemisphere) lateral temporal region
(16). Most of the brain imaging studies on traumatized subjects were focused on
hypocampus (17). However, an orbitofrontal hypothesis (18) of dissociative identity
disorder seems to be possible in the light of previous studies (19).

        A new concept in understanding dissociation: the sociological self
        Sar and Ozturk (20 ) point out to the differences between the change of the position
of the individuum in the society throughout the 20th century.                    Urbanization,
industrialization, and the development of mass media created a new type of individual who
is increasingly influenced, infiltrated, and even controlled by the social environment.
Based on this observation, Sar and Ozturk propose that two aspects of mental life should
be considered as crucial in a new approach to treatment of dissociative disorders:
sociological self and psychological self (20). The authors believe that one of the first issues
taught to the individuum by the society is to deny some aspects of his or her self. He or she
is forced to hide them. The social environment is usually in conflict with the psychological
self. The psychological self is based on psychological reality which is different than the
sociological reality. Sociological self is, however, based on sociological reality. This is a
dilemma for the individual.
        The sociological self develops in time due to socialization, i.e. it is defined as the
self created by others. The cooperation between the sociological self and the psychological
self leads to healthy adaptation. The presence of developmental differences between the
two selves is a basic dilemma. In such a situation, one part is (psychological self) saved as
a hidden self and is remained frozen wheras the other part (sociological self ) developes to
an extreme degree and exclusivity. This is main source of dissociation. Remaining in a
distance from psychological self leads to estrangement of the person and to an enlargement
of the sociological self.
        Trauma disturbs the cooperation between the sociological and psychological selves.
Both of these instances can be fragmented further forming multiple sociological and
psychological selves under the influence of traumatic experiences. The authors propose
that, to a large extend, the sociological self perceives the noxious event as trauma rather
than the psychological self. The result is the loss of ballance between the two instances and
the enduring enlargement of the sociological self. This structural change is aimed to
preserve the psychological self. It prevents the probable pathological development of the
psychological self but paradoxically restricts the psychological self. Thus, dissociation is
initiated through the neglect of psychological self by the society.
        The authors hope that this conceptualization will be helpful in developing of new
approachs which will shorten the psychotherapeutic treatment of dissociative disorders.

.1. Sar V, Yargic LI, Tutkun H : Structured interview data on 35 cases of dissociative
    identity disorder in Turkey..Am J Psychiatry 153:1329-1333,1996

2. Tutkun, H.; Yargıç,L.I.; Sar,V. : Dissociative Identity Disorder Presenting as Hysterical
Psychosis. DISSOCIATION 9:241-249, 1996.

3.Sar V, Kundakci T, Kiziltan E, Bakim B, Bozkurt O Differentiating dissociative
disorders from other diagnostic groups through somatoform dissociation in Turkey . Journal
of Trauma and Dissociation 1 (4): 67-80,2000.

4.Sar V, Akyuz G ,Kundakci T, Kiziltan E, Dogan O : Reported childhood trauma,
dissociation and psychiatric comorbidity of conversion disorder (submitted manuscript).

5.Sar V, Tutkun H : The treatment of DID in Turkey: A case presentation . Dissociation
10: 146-152,1997

6. Zoroglu,SS.; Yargic L.I.; Tutkun,H.; Ozturk M; Sar,V. : Dissociative Identity Disorder in
Childhood:Five Turkish Cases. Dissociation 9:250-257,1996

 7. Zoroglu SS, Tüzün U, Sar V, Tutkun H, Savas HA, Oztürk M , Alyanak B,
Eröcal-Kora M :Suicide attempt and self-mutilation among Turkish high-school students in
relation with abuse, neglect and dissociation. Psychiatry and Clinical Neurosciences, 57:

 8.Tutkun H, Sar V, Yargic LI, Özpulat T, Yanık M, Kızıltan E : Frequency of
dissociative disorders among psychiatric inpatients in a turkish university clinic. Am J
Psychiatry 155:800-805,1998.

 9. Sar V, Tutkun H, Alyanak B, Bakim B, Baral I : Frequency of dissociative disorders
among psychiatric outpatients in Turkey . Compr Psychiatry 41:216-222, 2000.

10.Sar V, Koyuncu A, Oztürk E et al :Prevalence of dissociative disorders among
emergency psychiatric admissions. Paper to be presented in the ISSD Annual Conference,
November 2-4,2003, Chicago.
11.Sar V, Akyuz G, Kundakci T,Dogan O, Erkek S: Frequency of dissociative disorders in
the general population: an epidemiological study in Turkey. Paper presented at the 15th
Annual Conference of the International Society for the Study of Dissociation, Seattle,1998.

12.Akyüz G, Dogan O, Sar V, Yargic LI, Tutkun H: Frequency of dissociative identity
disorder in the general population in Turkey. Comprehensive Psychiatry 40: 151-

13. Sar V, Akyuz G: Frequency of childhood traumata and dissociative disorders among
male prisoners.19th Annual Conference of the International Society for the Study of
Dissociation, Baltimore, November 9-12, 2002

14.Sar V, Oztürk E, Kundakci T: Psychotherapy of an adolescent with dissociative identity
disorder: Change in Rorschach patterns. Journal of Trauma and Dissociation 3: (2), 81-
95 ,2002.

15. Sar V, Kundakci T, Kiziltan E, Yargic IL, Tutkun H, Bakim B, Aydiner O,
Ozpulat T, Keser V, Ozdemir O: Axis I dissociative disorder comorbidity in borderline
personality disorder among psychiatric outpatients. Journal of Trauma and Dissociation 4
(1): 119-136,2003.

16.Sar V, Ünal SN, Kiziltan E, Kundakci T , Oztürk E :HMPAO SPECT study of cerebral
perfusion in dissociative identity disorder. Journal of Trauma and Dissociation 2 (2): 5-25,

17.Nijenhuis ERS, Van der Hart O, Steele K: The emerging psychobiology of trauma-
related dissociation.and dissociative disorders. In: H.D’haenen, JA Den Boer, P Willner
(eds), Biological Psychiatry, John Wiley Sons, New York,2002.

18.Shore AN: The experience-dependent maturation of a regulatory system in the orbital
prefrontal cortex and the origin of developmental psychopathology. Development and
Psychopathology 8:59-87,1996.

19.Forrest KA: Toward an etiology of dissociative identity disorder: a neurodevelopmental
approach. Consciousness and Cognition 10:259-293,2001.

20.Sar V, Ozturk E: A new core psychological structure in understanding dissociation: the
sociological self. Newsletter, International Society for the Study of Dissociation (in press).