Post-traumatic stress disorder: hypnosis and the divided self.

Post-traumatic stress disorder: Hypnosis and the divided self

New research is challenging the official psychiatric description of post-traumatic stress disorder (PTSD) as an anxiety response. Based on PTSD victims' high susceptibility to hypnosis, the recent findings indicate that a more fundamental "splitting of the self" is at the root of the disorder. If the findings are confirmed, they will have important implications for the treatment of PTSD.

Vietnam veterans suffering from PTSD sometimes describe themselves as "split personalities" who have to "keep the tiger in its cage." That tiger, says psychiatrist Bruce I. Goderez of the Veterans Administration Medical Center in Northampton, Mass., is their combat self -- hyperalert, belligerent, destructive and well adapted to survival in a war zone. At times, notes Goderez in Military Psychiatry: Learning From Experience (W. Walter Menninger, ed., The Menninger Foundation, 1987), the tiger may claw its way out, replacing a veteran's civilian personality that aspires to satisfactions such as marriage and a steady job but is hounded by shame and guilt over wartime actions, such as sadistic or indiscriminate killing, as well as by continuing destructive impulses of the combat self. The internal personality clash leads to failures in all aspects of life, increasing depression and hopelessness, impulsive violence and even suicide.

The struggle between a combat and civilian personality has similarties to multiple personality disorder, which falls under the diagnostic heading of what psychiatrists call "dissociative disorders." Dissociation is a defense against the immediate experience of painful, overwhelming events. Horrifying emotions and memories are psychologically isolated to allow a sense of control to emerge, although a price is paid by splitting the sense of self. For example, a new identity may be imposed on a person's customary identity, as in cases of multiple personality, or the sense of one's self may be temporarily replaced by an emotionally detached feeling of unreality. In some instances, there is amnesia for switches in identity or consciousness.

Yet PTSD, first recognized in the official psychiatric diagnostic manual in 1980, is classified as an "anxiety disorder." It is characterized by the re-experiencing of an unsually stressful trauma in dreams, flashbacks or thoughts; emotional detachment or numbing of responsiveness to the external world; and at least two persistent symptoms of increased arousal, such as difficulty sleeping and violent outbursts.

Combat-related PTSD appears to be rooted in dissociation, not anxiety, says psychiatrist David Spiegel of Stanford University. In the March AMERICAN JOURNAL OF PSYCHIATRY, Spiegel and his colleagues report that Vietnam combat veterans with PTSD are much more easily hypnotized than people with other psychiatric diagnoses, including anxiety disorder, and are also more hypnotizable than healthy control subjects.

Hypnotic susceptibility involves dissociation in a structured setting, says Spiegel. It is like the view through a telephoto lens: One idea is brought into focus while the field of vision is narrowed and all competing thoughts are omitted. The hypnotized individual does not consider consequences or alternatives to the focused idea and becomes extremely open to suggestion.

Among psychiatric patients, says Spiegel, a high level of hypnotizability appears to be a marker of a dissociative disorder. People without psychiatric disorders, he adds, tend to be relatively susceptible to hypnosis, but not to the same degree as PTSD patients. Spiegel and his colleagues compare 65 Vietnam combat veterans with PTSD to 83 healthy controls, 23 schizophrenic patients, 18 patients with excessive and unrealistic anxieties, 56 patients with mood disorders such as severe depression and 16 patients with other psychiatric diagnoses. Each subject is hypnotized through a series of instructions designed to focus attention, and then is asked to imagine that one hand feels like a helium balloon. The researchers score different aspects of the subject's response: whether the hand rises, whether the hand feels out of control and whether details of the incident are remembered after the trance is over. Higher scores on a 10-point scale indicate greater hypnotic susceptibility.

The PTSD patients had the highest average score. They were followed by the controls, then the other patients groups; veterans with PTSD were twice as hypnotizable as anxiety patients.

On an individual basis, two-thirds of the veterans were moderately or highly hypnotizable, while 15 percent scored extremely low on the hypnotizability scale. The latter group, says Spiegel, tended to have additional psychiatric disorders, and have proved harder to treat than the other PTSD patients.

In separate studies, Spiegel and psychiatrist Bennett Braun of Rush-Presbytebyterian-St. Luke's Hospital in Chicago also find that people with multiple personality disorder, already classified as a dissociative disturbance, score as highly in hypnotic susceptibility as the PTSD patients. Individuals with multiple personalities often have experienced severe trauma early in life, such as child abuse, and, according to Spiegel and Braun, their disorder is probably a type of PTSD.

"In general, the role of dissociation in PTSD has been underestimated," says psychiatrist Arthur S. Blank, head of the Veterans Administration's Vietnam Veteran Outreach Program in Washington, D.C. Blank, a member of the committee that drew up the official PTSD diagnosis, says that dissociation may not be universal in PTSD, but when it is present the disorder is more difficult to recognize because traumatic memories and emotions are shut out of consciousness and often cannot be talked about by the survivor.

"At first dissociation is a positive adaptation to severe trauma, but once the self is divided in a powerful way it becomes difficult to reintegrate the personality," says Spiegel. One way to foster reintegration, he explains, is to use hypnosis to help a PTSD patient gain access to isolated traumatic memories while maintaining a sense of physical control. Unresolved feelings of grief, such as those surrounding the loss of a war buddy, can then be dealt with in counseling sessions.

This is not a novel approach. Hypnosis was used successfully with some cases of what was called "combat neurosis" following World War II, but it has not been a common part of such treatment. "The relevance of hypnosis for PTSD is not understood by many mental health professionals," says Blank.

Many combat veterans do not require hypnosis, he adds, because their dissociations can be uncovered with regular counseling.

Whether or not hypnosis is used with Vietnam veterans suffering from PTSD, the goal of treatment should not be to eliminate the combat personality that emerged as a last-ditch survival strategy, says Goderez. In many cases, counselors devote months or years to helping a veteran's combat self learn to deal with various stresses in a nonviolent way. But guilt associated with violent excesses during war often remains an enduring part of what Goderez terms the "combat survivor syndrome."

In severe cases, antianxiety and antidepressant drugs are also part of the treatment.

Even as the importance of dissociation in PTSD gains recognition, says Spiegel, important questions remain. Does the experience of trauma enhance hypnotizability, or are highly hypnotizable people more sensitive to combat trauma? Perhaps people with low hypnotizability turn to alcohol and drugs to keep intrusive combat memories and emotions at bay and receive fewer diagnoses of PTSD.

A closer look at Vietnam veterans with and without PTSD is expected soon, says Blank. Preliminary results of a national survey of about 3,000 Vietnam veterans, commissioned by the Veterans Administration, will be presented to Congress in April. A final report will be delivered later this year. B. Bower