RESEARCH PERSPECTIVES ON DISSOCIATIVE DISORDERS 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 now. Epidemiology 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. References: .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: 119-126,2003. 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- 159,1999. 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, 2001. 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).