Diagnosis of depersonalization, derealization disorder is clinical based on the presence of the following criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, DSM-5. Patients with persistent or recurrent episodes of depersonalization, derealization, or both. Patients know that their dissociative experiences are not real, i.e., they have an intact sense of reality. Symptoms cause significant distress or significantly impair social or occupational functioning. Also, the symptoms cannot be better accounted for by another medical or psychiatric disorder, e.g. seizures, ongoing substance abuse, panic disorder, major depressive disorder, another dissociative disorder.

Depersonalization, derealization, or both. Depersonalization, experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions, e.g. perceptual alterations, distorted sense of time, unreal or absent self-emotion and or physical numbing.

Derealization. Experiences of unreality or detachment with respect to surroundings,

e.g. individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted. During the depersonalization or derealization experiences, reality testing remains intact. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance, e.g. a drug of abuse, medication, or another medical condition, e.g. seizures. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder or another dissociative disorder.

Derealization. Derealization involves a sense of unreality or unfamiliarity with one’s environment and distortions of space and time Steinberg, (1995 ).  Depersonalization and Derealization ( Steele, Dorahy, Van der Hart and Niijenhuis, 2009 ), eloquently described depersonalization as

1. the existence of an observing and experiencing ego or part of the personality ( Fromm 1965 ).
2. detachment of consciousness from the self or body i.e. feelings of strangeness or unfamiliarity with self out of body experiences.
3. detachment from aspects such as numbness
4. a sense of unreality such as being in a dream, and
5. perceptual alterations or hallucinations regarding the body  ( Noyes & Kletti, 1997 ).

This category applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of function, predominate but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class. The other specified dissociative disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific dissociative disorder. This is done by recording other specific dissociative disorder followed by the specific reason ( e.g. dissociative trance ).

Examples of presentations that can be specified using the other specified designation include the following:

1. chronic and recurrent syndromes of mixed dissociative symptoms. This category includes identity disturbance associated with less than marked discontinuities in sense of self and agency or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia due to prolonged and intense coercive persuasion.

2. Individuals who have been subjected to intense coercive persuasion ( e.g. brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, recruitment by sex cults or by terror organizations, may present with prolonged changes in or conscious questioning of their identity )
3. acute dissociative reactions to stressful events. This category is for acute transient conditions that typically last less than a month, less than three months, and sometimes only a few hours or days. These conditions are characterized by constriction of consciousness, depersonalization, derealization, perceptual disturbances, e.g. analgesia, paralysis.
4. Dissociative trance. This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness, may be accompanied by minor stereotype behaviors,( e.g. finger movements ), of which the individual is unaware and or that he or she cannot control, as well as transient paralysis or loss of consciousness.

As with DID, a therapist will likely take quite some time to make this diagnosis,

carefully listening to your symptoms and observing you in assessment, there are

four different categories used for OSDD. These can also be called subtypes or specifiers.

The four categories are: One, having chronic dissociative symptoms such as identity alteration, but the alteration and separation between identities is not as severe as in DID. There may be identity disturbance, but not the presence of clearly separated parts or amnesia. Two, having identity disturbance due to a long period of intense coercive control and persuasion. This includes the type of brainwashing or control that can occur in cults during political imprisonment or during torture. In such cases, people may begin to be confused about or question their identity. Three, having acute dissociative reactions to stressful events. These typically last less than a month and can last for hours or days at a time. These reactions can include depersonalization, small periods of amnesia, and changes in sensory motor functioning. Four, experiencing dissociative trance.

The person experiences periods of time where they lose awareness of the outer world and become unresponsive. This is not something the person may have temporary paralysis or loss of consciousness. A diagnosis is only made when this trance occurs, outside of religious, cultural practice, and when not under the influence of drugs. In some parts of the world, this might be diagnosed as trance disorder. this might be diagnosed as trance disorder.

In 1980, the DSM-III added the diagnosis of PTSD with psychogenic amnesia as a criterion symptom, discarded the term hysteria, and created diagnostic categories for somatoform and dissociative disorders. After the publication of the DSM-IV, the terms psychogenic amnesia and psychogenic fugue were replaced by dissociative amnesia, DA, and dissociative fugue, DF, respectively. Multiple personality disorder, MPD, was replaced by dissociative identity disorder, DID.

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition, DSM-5, defines dissociation as a disruption, interruption, and or discontinuity of the normal subjective integration of behavior, memory, identity, representation and motor control and behavior.

Dissociative Identity Disorder, DID

Dissociative Amnesia, DA

Depersonalization Derealization Disorder, DPDRD

Other Specified Dissociative Disorders, OSDD

Unspecified Dissociative Disorder, UDD.

In DSM-5, Dissociative Fugue, DF, is now a subtype of Dissociative Amnesia, DA, and not a separate disorder.

Dissociation is described as the involuntary disruption or discontinuity in the normal integration of one or more of the following identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements or behavior. World Health Organization ( 2018 ).

Dissociative symptoms can potentially disrupt every area of psychological functioning. American Psychiatric Association, ( 2013 ).

Cardena and Carlson, ( 2011 ), provided a concise definition for dissociation. An experienced loss of information or control. Symptoms are characterized by a loss of continuity and subjective experience with accompanying involuntary and unwanted intrusions into awareness and behavior, so-called positive dissociation, and or an inability to access information or control mental functions or behaviors manifested as symptoms such as gaps in awareness, memory, or self-identification that are normally amenable to such areas control, so-called negative dissociation, and or a sense of experimental disconnectedness that may include perceptual distortions about the self or the environment.

The DSM-5 diagnostic criteria for PTSD now include a dissociative subtype PTSD-DS. Dissociative amnesia as a symptom is a diagnostic criterion for both DID and for PTSD. PTSD-DS are that reminders of the PTSD criterion A, traumatic stressor, lead to depersonalization, derealization symptoms. In DSM-5, the DD section is specifically placed after the trauma and stressor related disorders to show their relationship to traumatic experiences. causes of dissociation.

There is no consensus yet on the exact etiological pathway for the development of dissociative symptomatology, but newer theoretical models stress impaired parent-child attachment patterns ( Barach 1991; Liotti, 1999; Ogawa, Sroufe, Weinfeld, Carlson and Egeland, 1997 ) and trauma-based disruptions in the development of self-regulation of state transitions ( Putnam 1997; Siegel 1999 ). Newer theorizing ties maladaptive

attachment patterns directly to dysfunctional brain development that may

inhibit integrative connections in the developing child’s brain ( Schore, 2001; Stein and Kendall, 2003 ).

Scientists have recently been studying specific brain structures and functions that are related to dissociation. So far, they have found that during dissociation, structures in the memory regions deep in your brain show rhythmic activity, but seem disconnected from other regions responsible for thought and planning. Cleveland Clinic.

From a neurophysiologic perspective, mental states may be viewed as arising from synchronized integration of the activity of functionally specialized brain regions. Functional neuroimaging of dissociation supports an understanding of these symptoms as disconnection syndromes.

Different identities, sometimes called a traumatic personality state and neutral personality state, demonstrate different patterns of cerebral blood flow, subjective reports, and peripheral physiologic parameters, blood pressure, heart rate. Functional imaging of traumatic dissociation shows active suppression of limbic regions, amygdala, and increased activity in dorsolateral prefrontal areas. Similarly, neuroimaging of depersonalization disorders show increased neural activity in prefrontal regions associated with affect regulation and decreased activity in emotional related areas.

Responses occur extremely rapidly. Using EEG, which allows finer temporal resolution than functional imaging studies, Kirino et al. showed reversible attenuation of a specific EEG signal within 300 MSEC during dissociative episodes. This ultra-rapid neural reflex was correlated with allocation of attentional and working memory resources, perhaps with the goal of minimizing memory activation and resurgence of affect-laden memories.

Stress-related disorders cause perturbances in neural hormonal function. Simeon et al. found a distinct pattern of stress-induced HPA axis dysregulation in dissociated patients compared with PTSD patients and healthy controls. Similar results were seen in patients with borderline personality disorder and dissociative symptoms.

Stress-related neurohormonal perturbations are known to affect critical neural structures, including the hippocampus. Using MRI, Vermetten et al. found significantly decreased amygdala and hippocampal volumes in patients with dissociative identity disorder. Dissociative disorders unclear? Think rainbows from pain blows, McDonald K. ( 2008 ).

Research tends to show that dissociation stems from a combination of environmental and biological factors. The likelihood that a tendency to dissociate is inherited genetically is estimated to be zero. Simeon et al. ( 2001 ). Most commonly, repetitive childhood physical and or sexual abuse and other forms of trauma are associated with the development of dissociative disorders, ( e.g. Putnam, 1985 ).

In the context of chronic severe childhood trauma, dissociation can be considered adaptive because it reduces the overwhelming distress created by trauma. However, if dissociation continues to be used in adulthood when the original danger no longer exists, it can be maladaptive. The dissociative adult may automatically disconnect from situations that are perceived as dangerous or threatening without taking time to determine whether there is any real danger. This leaves the person spaced out in many situations in ordinary life and unable to protect themselves in conditions of real danger.

Dissociation may also occur when there has been severe neglect or emotional abuse, even when there has been no overt physical or sexual abuse ( Anderson and Alexander 1996, West; Adam, Spreng and Rose 2001 ). Children may also become dissociative in families in which the parents are frightening, unpredictable, are dissociative themselves or make highly contradictory communications ( Blizzard 2001; Liotti, 1992, 1999a, 1999b ).

A parent who accuses his spouse or ex-spouse of being a horrible person and or abusing the child may be just describing reality or may be caught in a self-reinforcing cycle of fear and anger without the opportunity to disconfirm his or her perceptions. Various psychological motivations come together to keep this cycle going. 1. Anger and vengefulness. 2. Fear that his or her own trauma history will be repeated on the child. 3. Projecting his or her own abusiveness onto the partner. 4. Unmet childhood needs which causes parents to need the child as a totally supportive partner or parent. Miller Allison, Dissociated Parental Alignment, (1999 ).

When a parent is intermittently abusive either to the partner or to the child, the child is likely to develop dissociative states. In my article, The Dissociative Dance of Spouse Abuse, published in Treating Abuse Today in 1998, I describe the dissociative interactions between the spouse abuser and his or her partner ( Miller, A. 1998 ).

Even though the child’s own eyes and ears tell him otherwise, the child also has to keep the secret of what it is like at home. This is a prime breeding ground for dissociation or

At least of the development of fairly separate ego states  ( Miller, A, 1999 ).

Nijenhuis, Van der Hart, O. and Steele point to the theory of trauma-related structural dissociation of the personality, “ The traumatic event is not integrated into the memory

in the usual way and aspects of the personality that are associate with the trauma are cut off from consciousness. It is then as if the person alternates between two selves:

an apparently normal personality, which functions as if the trauma never occurred, and an emotional personality, which functions as if under continuous threat. ” ( Nijenhuis,

E, van der Hart, O., Steele, K. 2010 ). Trauma-related structural dissociation of the personality.

When faced with overwhelming traumatic situations from which there is no physical escape, a child may resolve to going away in his or her head. This ability is typically used by children as an extremely effective defence against acute physical and emotional pain or anxious anticipation of that pain. By this dissociative process thoughts, feelings, memories, and perceptions of the traumatic experiences can be separated off psychologically, allowing the child to function as if the trauma had not occurred. Giller, E. ( 2018 ). Longitudinal studies demonstrate disorganized and attachment predicts dissociation and dissociative disorders ( Kate, Maryann, 2022 ).

Early loss of a close member can be traumatic and can overwhelm the coping responses of a child that can interfere with his self-regulation mechanisms ( S. Goodman, depression and early adverse experiences in handbook of depression,

2002 ).

Research indicates very young children are more prone to dissociate because they don’t have the coping mechanisms to handle fearful or stressful situations independently ( Solomon and George, Eds, 1999; Perry, 2001; Lyons-Ruth K., 2003; Lyons-Ruth et al., 2004; Agarwal et al., 1997; Carlson, 1989. 1989 ).

A variety of factors predict a relationship to amnesia for trauma interpersonal trauma, early life trauma close personal relationship with the perpetrator, violence of the trauma repeated trauma sexual trauma, and level of betrayal, particularly by a childhood caregiver all have been associated with later dissociative amnesia dissociation debates. Everything you know is wrong. Lowenstein R. ( 2018 ).

Fouche, et al. ( 2008 ) found individuals from a lower socioeconomic status are more likely to dissociate.

A number of lines of evidence support conceptualizing dissociation as the human equivalent of the animal freeze or feigning death protective response in the face of life-threatening danger where fight, flight has failed or would be more dangerous. Autonomic changes may include a decrease or no change in blood pressure, heart rate, heart rate variability, lowered skin conductance, and decrease in skeletal muscle tone. The polyvagal theory of Stephen Porges posits that as fight-flight sympathetic stress responses fail, dominance by the primitive vagal parasympathetic system results leading to the freeze response. This may result in a shutdown state characterized by dense trance, increase in pain threshold and stupor, even to the extent of catatonic-like non-responding ( Elbert T. Schauer, M. Dissociation Following Traumatic Stress, Porges, S.W. 2010 ).

Studies in clinical and non-clinical populations have identified neural network patterns associated with dissociative amnesia, D.A., and dissociative fugue, D.F., that involve top-down inhibition by frontal systems of hippocampal, temporal, and occipital lobe areas involved in autobiographic memory. Lowenstein R. ( 2018 ).

In an MRI study, women with DID had significantly reduced hippocampal and amygdala volumes compared to healthy controls. Many studies have shown a relationship to trauma and reduced hippocampal volume, especially to chronic trauma, thought to be related to the impact on the hippocampus of repeated release of glucocorticoids. Loewenstein, R., ( 2018 ).

Studies of amygdala volume in maltreated children and adults with a history of childhood adversity show that early cumulative trauma as reported by most DID patients predicts stress-related reduction in amygdala volumes hypothesized as also due to the impact of repeated glucocorticoid release.

Higher dissociation scores were associated with poorer performance and significantly correlated with lower cortisol levels. The cortisol dissociation finding supports the model that dissociation is related to decreased activation of the sympathetic stress system. Similar results were found in Norwegian naval cadets undergoing a POW simulation experience and soldiers undertaking the grueling combat diver qualification course ( Morgan C. A., Southwisk S. M., Hazlett G., Stefan G., Symptoms of Dissociation in Healthy Military Populations. 2007 ).

PTSD-DS subjects show patterns of increased brain activation of frontal systems, medial and or ventral prefrontal cortex, dorsal anterior cingulate, and decreased activation of amygdala and insula, they show a pattern of decreased or no change in blood pressure and heart rate associated with these neural network patterns. Similarly, in response to aversive stimuli, depersonalization, derealization disorder, patients demonstrate inhibition of limbic arousal by increased activation of frontal systems along with autonomic blunting.

The development of dissociative disorders in adulthood appears to be related to the intensity of dissociation during the traumatic experience increases the likelihood of generalization of such mechanisms following the events. The experience of ongoing trauma in childhood significantly increases the likelihood of developing dissociative disorders in adulthood. ISSTD, 2002; Kisiel & Lyons, 2001; Martinez-Tboas & Guillermo, 2000;  Nash, Hulsey, Sexton, Harrelson and Lambert 1993, Siegel 2003, Simeon et al. 2001, Simeon, Goralnik and Schmeidler 2001, Spiegel and Cardina

1991; see -Cleveland Clinic )

Genetic studies of dissociation suggest that there is a complex interplay between genetic factors and type, timing, and chronicity of trauma. Studies comparing child and adult cohorts of adoptive parents, fraternal and identical twins, suggest that genetics account for around 50% of the interindividual variants and dissociation symptoms, with non-shared stressful environmental experiences accounting for most of the additional variants. Studies have linked dissociation to the interaction or traumatic experiences with specific single nucleotide polymorphisms in genes related to the HBA axis, KFBP5, serotonergic  5-HTTLPR, Dopaminergic COMT and BDNF systems.

Gene by adversity interactions have been described for FKBP5, an endogenous regulator of the stress neuroendocrine system, conferring risk for a number of psychiatric disorders including major depressive disorder PTSD and for dissociation.

We find little support for the hypothesis that the dissociative trauma relationship is due to fantasy proneness or confabulated memories of trauma. Lowenstein, R., ( 2018 )

DPDRD, is strongly related to a history of childhood emotional abuse, but not to physical or sexual abuse. Emotional abuse has been linked to adverse psychological outcomes, including higher dissociation scores in non-clinical general population samples. Emotion dysregulation was associated with heightened dissociative symptoms and greater endorsement of self-injury.

Trauma survivors with a history of self-injury report greater levels of emotion dysregulation than those without self-injury. Bedi, Muller, and Classen, 2014, and greater self-reported emotion dysregulation is associated with greater self-injury frequency ( Titelius et al. 2018 ).

The addition of engaging in self-injury rather than feeling emotions may further inhibit patients ability to regulate their emotions ( DePrince, AP and Freyd, JJ, 1999 ).

Cross-sectional and longitudinal studies have established a relationship between trauma history and general emotion dysregulation, including difficulty controlling emotions when distressed, difficulty concentrating or accomplishing tasks when experiencing unwanted emotions, and difficulty using adaptive forms of coping when upset ( Seligowski, Lee, Bardeen, and Orcutt, 2015 ).

It is recommended that clinicians examine emotion dysregulation when assessing for dissociation and self-injury risk, as heightened emotional dysregulation may indicate an increased risk for dissociative symptoms and or self-destructive behaviors. Dissociative disorder patients demonstrated remarkable difficulty regulating their emotions. In fact, dissociative disorder patients struggled with regulating their emotions more than other samples of individuals with PTSD symptoms, ( e.g. Radomski and Reed, 2016 ), and severe self-injury, ( e.g. Chan and Chun 2019 ), emphasizing  the  severity of emotion ( Chen, Chun, 2019 ). Emphasizing the severity of emotion dysregulation, DD patients experience.

The parents of these children need help to grasp that their individual and interactive use of their child as an object for their unconscious pathological needs is what delays or disrupts the child’s developing autonomy and can set into motion dissociative coping mechanisms that in its extreme form results in a fragmented sense of self. Unfortunately, many patients who put their children into this kind of a bind are unable or unwilling to see what they are doing. Dissociative Parental Alignment, Miller, A. ( 1999 ).

“ I think that in dismissing parental alienation syndrome because of Gardner, we are throwing the baby out with the bathwater. Perhaps we need a new term, dissociative parental alignment. Very few of the cases I’ve seen have involved sexual abuse allegations. All of them have involved a parent who desperately needs the child to accept his or her extremely negative view of the other parent and a child who succumbs to the pressure from that parent to reject hate and fear the other parent. “ Miller A. ( 1999 ).

The repeated experience of dissociative detachment in childhood associated with the interaction with abusing caregivers ( or simply scared: see before ), may very seriously hamper the ability to integrate traumatic experiences and memories in a coherent representation of self and others.

Therefore, together with other pathogenetic mechanisms related to complex trauma, such as stress hormones hampering neurogenesis, synaptic plasticity, myelination, and neural and neural network development, ( DeBellis and Zisk, 2014; Teicher et al.,

2016.) Dissociative detachment generates failures in affect regulation, supported by the integration between the functions of the limbic system and those of the neural cortex, and leads to the fragmentation of mental activities, behavioral strategies, and autobiographic memories, as well as of the sense of self. Sense of Self ( Carlson et al. 2009; Liotti 2009; Schore, 2009; Teacher et al., 2010; Braun and Rock, 2011; Mears

2012 ).

Consistently several neuroscientific studies have partially demonstrated that dissociation relates to alterations of widely distributed cortical connectivity networks that underpin order integrative mental functions ( Hopper, et al., 2002; Lanius, et al., 2005; 2018; Wolf, et al., 2011;  Aikens, et al., 2017 ).

The role of attachment trauma and disintegrative pathogenesis, pathogenic processes in the traumatic dissociative dimension ( Farina B., 2019 ).

Cumulative developmental trauma, CDT, also known as early relational trauma due to the interpersonal nature of the traumatic experiences ( Isobel et al., 2017 ), refers to different types of stressful and traumatic events that occur repeatedly and cumulatively over a period of time, and within specific relationships and contexts SAR 2011, which are in most cases about 80% perpetrated by parents or other caregivers, U.S. Department of Health and Human Services 2017. For this reason, it has also been proposed as the expression attachment trauma ( Isobel et al. 2017 ). Dissociative symptoms in children have been associated with parental neglect ( Brunner, Parzer, Schold and Reich, 2000; Aguilar et al. 1997; Sanders and Gheolis 1991 ).

Dissociative symptoms in children have also been associated with parenting styles that are rejecting and inconsistent ( Mann and Saunders, 1994 ).

Other factors found associated in the backgrounds of children displaying dissociative symptoms include A. repetitive loss of attachment figures, B. chronic living instability, C. emotional abuse.

The combination of overprotection, overcontrol, intrusion presented as love and care, and emotional neglect, on the other hand, represents a double bind in the relationship with the caretaker. This is a kind of betrayal (Freyd 1994 ). A phenomenon which leads experiences to be traumatic by disrupting the subject’s perception of reality, Sarr et al. 2021. Overprotection, overcontrol is in fact a type of intrusion presented as normative, careful caretaking. Typically these parents are oppressive, restrictive, and prone to boundary violations

Different than the verbal emotional abuse, the relatively invisible quality of this type of emotional abuse creates both anger and guilt. Such interpersonal interference may have started very early ( Sar et al., 2021 )

If a parent responds in a frightening or contradictory manner, the child can neither approach the caregiver for comfort nor flee the very person on whom his life depends. The child’s limited cognitive and behavioral systems for maintaining attachment may break down, leading to dazing confusion and rapid alteration between approach and avoidance, these disorganized responses appear to activate the neurophysiological mechanism which involves dissociative adaptive response, i.e. staring, unresponsivity, hypalgesia, depersonalization, and derealization ( Perry 2001 ). This calls for

clinicians to be particularly heedful of dissociative indicators in infants and young children given their neurobiological capacity to dissociate when in the face of resisting threat.

Yet the significance of their responses often continues to be minimized or mis-

interpreted because professionals erroneously believe that this population, contrary to current research, isn’t affected by frightening and or unresponsive caretakers ( Waters F, 2005 ). When treatment fails with traumatized children

DIS refers to unwanted intrusions into awareness and behavior with accompanying deficits in the continuity of subjective experiences, e.g. identity fragmentation, depersonalization, derealization or the inability to access information or control mental functions, e.g. amnesia, dysphonia, paralysis ( Spiegel D, Lewis Fernandez R, Lannis R, et al. 2013 ), dissociative disorders in DSM-5.

Dissociative psychopathology can manifest as amnesia, depersonalization, derealization or identity alterations and can be accompanied by positive,(  e.g. psychotic-like symptoms; Schiavone, McKinnon & Lanius, 2018 ) and negative ( e.g. somatosensory deficits ) symptoms ( Sar, 2014 ).

Young children from traumatic backgrounds may present with a variety of dissociative symptoms such as trans-like states, perplexing forgetfulness and behavioral and emotional fluctuations. In young children, fluctuating behavior may include unpredictable eruptions into tantrums of surprising intensity that appear out of context to what is going on around them. Although regressive behavior is frequently present, it may be hard to detect unless the child is assessed over time. Fagan J. McMahan, incipient multiple personality in children. Riley R. L. Mead J., Development of symptoms of multiple personality in a child of three, dissociation.

Along the continuum of moderate to severe range of dissociation, children may stare off or zone out when they want to escape due to anxiety or traumatic reminders. With chronically abused children, trans behavior can become habitual even with mild stressors, which are often noted by teachers. During those times the children may have difficulty reporting what transpired just before they zoned out or what motivated such behavior. Sometimes because of embarrassment they will say that they were bored in school.

A more severe form of dissociation is the presence of self-states. Young children who have auditory or visual hallucinations of people may identify them as imaginary friends and not distinguish them as self-states until they are older and able to assimilate their meaning. These imaginary friends, however, may express intense affect and conflicts with each other ( Frost, Silberg and McIntee, 1996, and cause considerable distress to the child. I have treated a number of small children who have emphatically insisted that their imaginary friends or angry voice are real and not pretend.

Children can create self-states ages with different roles, affect, and behaviors that may directly relate to their traumatic experiences ( Waters and Silberg, 1998 ). They may be given names that describe their function and have special significance to the child’s mood, behavior, sensations, thoughts, and relationships. Some state selves who identify with the perpetrator engage in aggressive or self-states are simply reporters of traumatic memories without any affect. This presentation can confuse professionals who may doubt that the trauma was really experienced or they may minimize the traumatic impact on the child, but as Steele explained in the training DVD, Trauma and Dissociation in Children,  ( Waters, 2007 ) , this is a hallmark of dissociation. It didn’t happen to me, or it happened to me, and it doesn’t really matter.There’s no affect to it. There’s no feeling tone to it. There’s no sense of personal ownership. This is also a sign of depersonalization.

Because chronically traumatized dissociative children are easily sensitized to even minor stimuli, they can rapidly switch self states when triggered. These trance states can appear and disappear suddenly without apparent provocation and may contain only specific memories related to their own experiences. Their awareness of other self states or their current environment may be precarious depending on protective barriers between each other. They can emerge after being hidden for years by taking executive control over the child’s body or harass the child from within with degrading comments or pressure the child to engage in self-destructive or aggressive acts. Self-states can appear, engage in aggressive behavior and then disappear, leaving the child bewildered. These children are often accused of lying when they deny such behavior.

Dissociative children can switch so rapidly that it’s easy to overlook the shifts or attribute them to other reasons, such as the child is nervous or just has a cognitive impairment. However, it is these shifts that can be clues to dissociation.

Sudden staring or glazed look when talked to. Rapid blinking, fluttering, or eye rolling without any warning. Other facial changes biting lip or burrowed frown. Voice changes in tenor, inflection, or language such as baby talk or demanding adult tone. Body posture from relaxed to stiff or from coordinated to clumsy. Contradictory thoughts noted in the same sentence such as enjoying drawing in office to hating it, shifts in awareness of what was just said by the child or therapist, or confusion, discrepancy, or denial of earlier report of traumatic and non-traumatic events. young traumatized children who exhibit dissociative states contrary to children who engage in fantasy play (  Fran S. Waters, 2005 ). Recognizing dissociation in preschool children.

Dissociative disorders are associated with a range of psychiatric syndromes. Brand et al., 2009; Schiavone et al., 2018 ), including emotion and behavior dysregulation, as well as chronic self-injury. In fact, up to 86% of dissociative individuals self-injure. ( Ross and Norton, 1989; Saxe, Chawla, and Van der Kolk, 2002 ), which is more frequent than is found in other populations (  Calati, Bensassi & Courtet, 2017;, Saxe et al., 2002 ).

People with dissociative disorders may experience any of the following: depression, mood swings, suicidal tendencies, sleep disorders, insomnia, night terrors and sleepwalking, panic attacks and phobias, flashbacks, reactions to stimuli or triggers, alcohol and drug abuse, compulsions and rituals, psychotic-like symptoms, including auditory and visual hallucinations, and eating disorders.

In addition, individuals with DID can experience headaches, amnesias, time loss, trances, and out-of-body experiences. Some people with dissociative disorders have a tendency toward self-persecution, self-sabotage, and even violence, both self-inflicted and outward directed. Giller, E. ( 2018 ).

While dissociation as an escape from overwhelming experiences, emotions and memories can put an individual at risk for developing a dissociative disorder. Dissociative Disorders, Putnam, ( 2016 ). The Way We Are, How States of Mind Influence Our Identities, Personality, and Potential for Change.

Moreover, as per the existing literature, dissociative symptoms may sometimes also include post-traumatic symptoms such as avoidance and numbing, intrusive thoughts and memories, nightmares, flashbacks, traumatic reenactments, and hypogogic hallucinations. International Society for the Study of Dissociation Guidelines for the Evaluation and Treatment of dissociative symptoms in children and adolescents,

( 2004 ).

For some, self-injury may be a pathway to dissociate such that the individual

becomes detached from their mind and body while engaging in self-injury ( Klonsky, 2007; Klonsky, E.D. and Mullenkamp, J.J., 2007 ). Self-injury, a research review

for the practitioner. New paragraph. Clinical literature has noted that dissociative disorder patients with childhood trauma histories may be terrified of their own

emotions and those of others and make a considerable effort to avoid experiencing them. Steele, Boon and Van der hart, ( 2017 ). Treating trauma-related dissociation,

a practical integrative approach.

Amnesia refers to the inability to recall important personal information that is so extensive that it is not due to ordinary forgetfulness. Most of the amnesia typical of dissociative disorders are not of the classic fugitive type, variety, where people travel long distances and suddenly become alert, disoriented as to where they are and how they got there. Rather, the amnesias are often an important event that is forgotten, such as abuse, a troubling incident, or a block of time from minutes to years. More typically, there are micro-amnesias where the discussion engaged in is not remembered, or the content of a conversation is forgotten from one moment to the next. Some people report that these kinds of experiences often leave them scrambling to figure out what was being discussed. Meanwhile, they try not to let the person with whom they are talking realize they haven’t a clue as to what was just said. ( Maldonado et al., 2002; Stein-

berg et al., 1993, Steinberg, 1995 ).

An inability to recall important autobiographical information, usually of a traumatic or stressful nature that is inconsistent with ordinary forgetting. Note, dissociative amnesia most often consists of localized or selective amnesia for a specific event or events or generalized amnesia for identity and life history. The symptoms cause clinically significant distress or impairment in social, occupational, and other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance, e.g. alcohol or other drug of abuse, a medication of a neurological or other medical condition, e.g. partial complex seizures, transient global amnesia, sequelae of a closed head injury, traumatic brain injury, other neurological condition. The disturbance is not better explained by dissociative identity disorder, post-traumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.

The main symptom of dissociative amnesia is memory loss that is inconsistent with normal forgetfulness. The amnesia may be localized, selective, generalized. Rarely dissociative amnesia is accompanied by purposeful travel or bewildered wandering called fugue, from the Latin word fugue to flee.

Localized amnesia involves being unable to recall a specific event or events or a specific period of time. These gaps in memory are usually related to trauma or stress. For example, patients may forget the months or years of being abused as a child or the days spent in intense combat, the amnesia may not manifest for hours, days or longer after the traumatic period, usually the forgotten time period, which can range from minutes to decades, is clearly demarcated. Typically patients experience one or more episodes of memory loss.

Selective amnesia involves forgetting only some of the events during a certain period of time or only part of a traumatic event. Patients may have both localized and selective amnesia.

In generalized amnesia, patients forget their identity and life history, e.g. who they are, where they went, to whom they spoke, and what they did, said, thought, experienced, and felt. Some patients can no longer access well-learned skills and lose formerly known information about the world.

Generalized dissociative amnesia is rare. It is more common among combat veterans, people who have been sexually assaulted and people experiencing extreme stress or conflict. Onset is usually sudden.

In systemized amnesia, patients forget information in a specific category such as all information about a particular person or about their family.

In continuous amnesia patients forget each new event as it occurs.

There are also seven factors which predict amnesia namely abuse by the caregiver, explicit threats demanding silence, alternative realities in an environment, isolation during abuse, young at age of abuse, alternative reality defining statements by caregiver, and lack of discussion about abuse ( Dallam, 2005 ).

The etiology of dissociative amnesia appears to be related to extreme stress,

especially if the individual is experiencing trauma for the second time. Dissociative amnesia was formerly known as psychogenic amnesia. Dissociative amnesia is also caused by internal conflicts such as guilt, criminal offences, and interpersonal difficulties. The Merck Manual ( 2006 ).

Dissociative amnesia can also be caused by epilepsy.

Fouche, et al. ( 2008 ) found the etiology for dissociative amnesia appears to be related to extreme stress, especially if the individual is experiencing trauma for the second time and dissociative amnesia is caused by a number of factors, one of which is abuse. Fouche, et al., ( 2008 ).

Fouche et al.( 2008 )  identified five different types of memory loss within the dissociative amnesia diagnosis.

Localized amnesia, when an individual cannot remember certain periods of time and events.

Generalized amnesia, when an individual has lost memory of everything including their identity.

Continuous amnesia refers to no memory or events up to the present time as well as the present time.

Systemized amnesia, when the individual has lost their memory for particular categories of information.

Selective amnesia  refers to an individual who can remember some of the events that have taken place during a limited period of time, but not all of the events.

The Encyclopedia of Mental Disorders (  2006 ). Fouche, Paul and Pieterse and Geyer, T. ( 2008 ). Dissociative amnesia related to trauma a systemic review.

Dissociative amnesia is also caused by life stressors such as abandonment, financial worries, death of a loved one or marriage and it is also caused by internal conflicts such as guilt, criminal offences, and interpersonal difficulties. The Merck Manual ( 2006 ).

Dissociative amnesia can also be caused by epilepsy. Trauma is however one of the most common causes of dissociative amnesia and war, abuse, and natural disasters are the most common causes of this disorder relating to trauma. Dissociative amnesia is more likely to take place if these traumas are severe, chronic, occur in combination, and associated with post-traumatic stress ( Breyer, 2006 ),

Dissociative amnesia can happen in any age group. However, it is more common among young adults due to the fact that if the traumatic expression occurred later during childhood, the memories may only be recalled in adulthood ( Fouche, et al., 2008 ).

Fouche, et al., (2008 ), also found dissociative amnesia occurs in children when they experience derealization, the feeling of emotional detachment from the people you care about.

Fouche et al.(  2008 ) also found amnesia tends to increase with severity of the trauma and is particularly high in victims of combat.

Screening is important for OCD, eating disorders, PTSD, RAD, reactive attachment disorder, ADHD, affective disorders, subtrance abuse disorders.

Screening is important for OCD, ED disorders, PTSD, RAD, reactive attachment disorder, ADHD, affective disorders, substance abuse disorders, and specific developmental disorders ( Hornstein 1999; Peterson 1998 ).

In cases of complex trauma-related psychopathology, dissociation can lead to complex PTSD, dissociative disorder, not otherwise specified, and DID ( Stolbach B., 2005 ).

Unique to DD patients, self-injury can occur in a state of dissociation resulting in later amnesia such that the patient does not recall injuring themselves. Up to 60% of DD patients report amnesia before, during, or after self-injuring (Coons and Milstein, 1990 ).

Dissociative disorder patients may also have specific self-states, sometimes referred

to as parts, identities, or alters, whose role or function is to self-injure. Dissociative disorder patients can find evidence of hurting themselves without any memory of engaging in such behaviors. The secrecy about and inconsistent awareness of potentially self-destructive and lethal behaviors may amplify the risk of danger of those behaviors among individuals with dissociative disorders. The secrecy about and inconsistent awareness of potentially self-destructive and lethal behaviors may amplify the risk of danger of those behaviors among individuals with dissociative disorders.

The majority of individuals with dissociative disorders report engaging in self-injury. Up to 86% of dissociative individuals report a history of non-suicidal self-injury, NSSI, and up to 72% attempt suicide in their lifetime ( Footie, Smolin, Neft and Lipschitz, 2008; Putnam, Guroff, Silberman, Barban and Post, 1986; Ross and Norton, 1989;  Saxe, Chawla and Van de Kulk, 2002 ).

Dissociation is associated with self-injury and is an established mediator of the relationship between trauma and self-injury.( e,g.. Dorahy, Carrell, and Thompson, 2019; Rossi, et al., 2019 ).

The vast majority of dissociative disorder patients, 92.31%, reported being at least partially unaware of what leads them to have self-injury urges and many individuals with dissociative disorders experience some reasons for self-injury that are different from those with other disorders.

There is some research that suggests the reason some dissociative patients self-injure, is to stop feelings of depersonalization or numbness ( Klonsky, 2007;  Klonsky and Glenn, 2009 ).

Symptoms of dissociation are seen in populations of children and adolescents with other disorders such as post-traumatic stress disorder, ( Putnam, Hornstein, and Peterson 1996 ), obsessive compulsive disorder, OCD ( Stein and Walters 1999 ),

and reactive attachment disorder as well as in general populations of traumatized and hospitalized adolescents, ( Sanders and Giolas 1991;  Atlas Weissman and Leibowitz 1997 ), and delinquent adolescents ( Carrion and Steiner 2000 ). The guidelines identify general principles applicable to dissociative processes regardless of the child’s presenting diagnosis.

The diagnosis of dissociative disorder not otherwise specified DDNOS is the most common in populations of dissociative children and adolescents ( Putnam et al.

1996 ) even though no diagnostic criteria have been set for this diagnosis. While individual case studies of children with puzzling and atypical dissociative presentations described variously as depersonalization  ( Allers, White and Mullis, 1997; Dissociative Amnesia or Dissociative Fugue, Coons, 1996; Keller and Shaywitz, 1986; and D.I.D. Jacobson, 1995 ) continue to be published in peer-reviewed journals.

There is still no real consensus about the typical case and thus no consensus about diagnostic criteria. For this reason, in these guidelines, the perspective on assessment and treatment is symptom-based. ISSTD Child and Adolescent Treatment Guidelines

for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents, ( 2003 ).

CDT is associated as being the genesis of well-defined clinical pictures such as post-traumatic stress disorder, PTSD ( Terock et al., 2016; Williamson et al., 2017), borderline personality disorder, BPD ( Ford and Courtois, 2014; Liotti and Farina,

2016, Cattane et al., 2017), Somatoform disorders, SDs, ( Carlier et al. 2016;

Roelofs and Pasman 2016 ), eating disorders, EDs, ( Caslini et al 2016; Pignatelli,

et al 2017 ); Trottier and MacDonald, 2017 ) ,sleep disorders (  Kajeepeta et al

2015 ), mood disorders ( Was et al, 2016; Iaworska-Andryszwwska and

Rybakoiwski, 2018 ), paychosis, ( Mayo et al 2017; Williams et al 2018 ),

substance related and addictive disorders Edalatti and Krank, 2016; Konkoly,

Thege et al, 2017 ) and obsessive compulsive disorder, ( Belli, 2014 ).Trauma, dissociation, and post-traumatic stress frequently co-occur in survivors of maltreatment and we add cumulative developmental trauma.

Trauma-Related disorders ( TRDs ), dissociative disorders and personality disorders

are more rural than the exception in patients who report childhood trauma and emotional neglect. More insight on the course of comorbidities could help to guide treatment and to develop a more integrative and dimensional view on psychopathology following childhood trauma. We recommend that future research pays more attention to these comorbidities by using less exclusion criteria and looking at psychopathology in a more transdiagnostic way instead of a categorical manner. Furthermore, our study showed that the course of psychopathology differs significantly among men and women, pointing to the need for more attention on gender differences in treatment and future research.

The strength of our study is the extensive and repeated assessment of TRDs, DDs, and PDs using structured clinical interviews, whereas other studies often rely on self-report questionnaires, ( i.e. Brand et al, 2019; Dorrepaal et al, 2012 ). The course of comorbid trauma-related dissociative and personality disorders, two-year follow-up of the Friesland study, cohort Swart, S. et al. ( 2020 ).

Inquire about somatic symptoms ( e.g. headache, stomach aches, other undiagnosed pain ) as well as somatoform dissociation, which includes symptoms of loss of physical sensations, unusual pain tolerance or pain sensitivity and other sensory perceptual anomalies ( Nijenhuis Spinhoven, Van Dyck, Van der Hart and Vanderlinden, 1996 ).

ISSTD ( 2003 ).

These include positive symptoms such as nightmares, night terrors, disturbing, hypnagogic hallucinations, intrusive traumatic thoughts and memories, re-experience

or flashbacks, and traumatic re-enactments, as well as negative symptoms such as numbing and avoidance.

Sexually reactive or sexually offending behavior may occur in traumatized children and may co-occur with dissociative symptomatology. Distinguishing between normal sexual behaviors, sexual reactive, and sexually molesting behaviors in children and adolescents, and evaluate the role dissociation plays in the maintenance of these ( Friedrich, et al. 2001; Johnson, 2002 ).

Self-injurious behavior is common among dissociative teens which may include cutting, burning, scratching, or head banging. This behavior may be secret, may serve an affect-regulating function, and may be performed in a dissociative trance state, or used to facilitate or interrupt such a state. Gently inquire about all stages of self-harm, cutting, burning, hitting, etc. i.e. planning, preparing, doing, and recuperation, as some or all stages may be done in a dissociated state. ( depersonalized, numbed, trance state, robotic state, dreamlike state, etc.c)

Some children may show the presence of internal others, alters, ego states, self states, personalities, etc. For the purpose of these guidelines, all these terms are synonymous. Disorders are frequently misdiagnosed because of their comorbid symptomatology like attention deficit and hyperactivity disorders, conduct disorders or oppositional defiant disorders, schizophrenia, various forms of epilepsy and affective disorders. In early childhood, the associated aspect of the self –  do not tend to have a well elaborated sense of autonomy. Instead, feelings, thoughts, and impulses that the child experiences as foreign may be projected onto transitional objects such as dolls or fantasy playmates.

Dissociative disorders in children and adolescents and their personality profile: a competitive study ( Rana et al. 2015 ).

People control unwanted memories by engaging systems evolved to inhibit habitual responses to inhibit memories, making them harder to remember. The mechanisms that achieve this function are not exotic special-purpose responses to trauma, but rather are applications of broad mechanisms that achieve cognitive control. Thus, the tools to understand motivated forgetting are readily available in the armamentarium of cognitive neuroscience. The process begins as an intentional act. For these reasons, the present mechanism does not address cases where memories are forgotten abruptly via an unconscious defence mechanism. Accounting for such cases requires one to provide additional arguments to why a process that normally develops with practice can be applied abruptly with dramatic effect, and with accompanying meta memory amnesia.

After an unpleasant event, many people confront challenges in memory control, particularly if reminders are inescapable. The memories are recent and accessible. Given motivation to control awareness, however, intrusions diminish with time and effort. It is thus unavoidable that living with the demand to control an unwanted memory forces a person to improve with practice, as happens with all skills.

This improvement will take the form of one or more habitual cognitive, or affective responses to unwelcome reminders that suppress the experience and redirect thought. If practice continues over years, people may get very well adapted to the task. Thus, protracted practice is a critical feature of real cases of motivated forgetting that is not easily studied in the laboratory.

Although the intentionality shift theory is speculative, it may account for an important feature of recovered memories. People not only forget the original experience, but also how they came to forget it. This forgetting of the cognitions that one has about one’s memories, including cognitions about intentional forgetting, might be termed metamemory amnesia. A complete account of motivated forgetting thus requires an explanation both for how the memory itself was forgotten and how the forgetting itself was forgotten ( Anderson and Huddleston, 2012 ).

Research on inhibitory phenomena such as retrieval-induced forgetting indicate that memories suppressed by inhibitory processes are actually more susceptible to distortion via misinformation effects than memories that have not been inhibited ( see: McLeod and Saunders, 2008, for a review ). Thus, suppressing unwanted memories over a long time may fragment the experience and render it subjected to distortion and reconstruction processes ( Erdelyi, 2006 ).

According to Dahlem, 2005, scientific evidence shows that it is not rare for traumatized individuals to experience a delayed recall for the trauma ( Dahlem S, 2005 ). Questions and answers regarding dissociative amnesia.

When people repeatedly confront reminders to an unwanted memory and take mental action to limit awareness of that memory, processes are engaged that achieve at least two basic outcomes. (a ), they deprive a memory of the normal facilitation it would enjoy, and ( b ), they disrupt retention of the excluded trace compared to when no reminders appear. Both of these actions, on average, reduce long-term accessibility of this suppressed trace.

When dissociative disordered individuals perceive their emotions as unwanted, overwhelming, or threatening, they can employ cognitive strategies that isolate these emotions from the forefront of their awareness ( DePrince and Freyd, 1999 ).

The fact that traumatic life experience predicts the negative control effect in the laboratory suggests that it measures mechanisms that may be engaged in everyday life. This suggests that the negative control effect provides a good model of motivated forgetting outside the laboratory ( Hulbert, M.C., Shivde. G.S. and Anderson, M.C. 2011 ), Evidence against associative blocking as a cause of cue independent retrieval-induced forgetting, (2011 ).

Goldberg, L.R., & Freyd J.J. ( 2006 ). Self Reports of Potentially Traumatic

Experiences in an Adult Community Sample, Gender Differences and Test-Retest Stabilities of the Items in a Brief Betrayal Trauma Survey.

This research provides an existence proof of a process that could in principle explain real cases of motivated forgetting, including cases of recovered memories.

Cognitive control improves across late childhood and early adolescence, and a number of investigators have argued that this development reflects increasing effective inhibitory control, ( e.g. Harnishfeger and Pope, 1996; Wilson and Kipp, 1998 ). If so, one should observe a developmental progression in the ability to suppress unwanted memories with negative control effects emerging in middle childhood, 10 to 12 years of age. This was tested by Paz- Alonso, et al. ( 2009 ). Strikingly, the negative control effect increased with age, being absent for the youngest group but present in the middle childhood and in adulthood on both the same probe and independent probe tests. There was a continuous improvement with age within childhood and the size of the negative control effect. Of interest, this negative control effect during middle childhood years occurred against a backdrop of overall improvements in declarative memory over this age range.

It seems uncontroversial to assume that the victim would be motivated to keep the abuse out of mind, regardless of who the perpetrator is. Importantly, however, the person abused at the hands of a family member faces a far greater and more consistent challenge in achieving this goal precisely because reminders to it would be inescapable, perhaps for many years. Keeping the abuse out of mind despite constantly confronting reminders requires a way to stop the reminder from eliciting the trace and a way to retrain memory to elicit other thoughts upon seeing the abuser. Basically, if one cannot escape reminders, one must adapt one’s internal landscape by retrieving diversionary thoughts unrelated to the abuse when the abuser is present, which we call the

Selective Retrieval Hypothesis, Anderson, ( 2001 ). See also Bjork et al., ( 1998 ). If Freyd is correct, this motivated selective retrieval of non-abuse information would be especially likely in the case of parental abuse. The child would have powerful motives for not thinking of the abuse if they are to sustain a necessary attachment relationship with the parent. The abuse cannot be on their minds as it would undermine the ability

to behave and feel appropriately. Thus, when motives to control awareness are present, constant reminders actually set the occasion for the engagement of processes that

limit awareness of the memory, impairing retention. Anderson, M.C. ( 2001 ) Active forgetting, evidence for functional inhibition as a source of memory failure.

DePue et al. ( 2010 ) observed a negative correlation between stop signal reaction time on a motor response task, negative ( -.58 ), and the proportion of emotionally negative pictures items successfully forgotten after retrieval suppression. Thus the faster people were able to stop an initial motor action, the more memory inhibition they showed, indicating that motor stopping speed is related to retrieval suppression and stopping tasks correlated with engagement of right lateral prefrontal cortex during retrieval suppression, suggesting that the mechanisms underlying performance on these tasks may be related.

Neuroimaging studies of attention deficit disorder have shown that individuals with ADHD do not engage right lateral prefrontal cortex as effectively as controls during motor response suppression ( Booth et al. 2005; Casey et al, 1997; Depue et al.,

2010; Rubia, Brammer, Tonne &Taylor, 2005; Tamm, Menon, Ringel & Reiss, 2004 ).

Findings are consistent with the hypothesis that fronto-hippocampal modulation is a crucial neural mechanism underlying the suppression of unwanted memories, and with the view that ADHD in part reflects a deficit in inhibitory control. They further suggest that adults with attention deficit disorder should have difficulty with controlling intrusive memories.

As mentioned earlier, behavioral work has established an increasing efficacy at suppressing unwanted memories in middle childhood. Ogle and Paz-Alonso in

prep, Paz-Alonso et al., ( 2009 ). Recently, Paz Alonso et al., ( 2011 ), have studied

the neural basis of this shift.

Participants from three age groups, 15  8-9 year olds, 14  11-12 year olds, and

14 young adults, were scanned as they performed the Think-No-Think task.

Aggregating across all 43 participants showed robust engagement of right

dorsolateral prefrontal cortex and ventrolateral prefrontal cortex during retrieval suppression and a clear reduction in hippocampal activity during suppressed trials, consistent with the foregoing imaging studies by Anderson et al., ( 2004 ), and
DePue et al., ( 2007 ).

Moreover, activity in dorsolateral prefrontal cortex was functionally related to activity

in the hippocampus during retrieval suppression, indicating an interaction between these regions that helps to implement the process of retrieval suppression. Age group reveal neural changes that characterize the development of memory control. First, whereas younger adults engaged lateral prefrontal cortex and posterior parietal cortex while effectively suppressing memory retrieval, eight to nine-year-olds, did not effectively engage these regions ( C. Anderson, M.C. and Bungee S. 2011 ),

pneumonic control relies on a frontal parietal hippocampal network that is strengthened over childhood.

The emergence of the capacity to suppress unwanted memories reflects increasingly effective active engagement of prefrontal cortex to control hippocampal activity, and importantly, tighter coupling of the fronto-parietal hippocampal network of regions involved in this process.

The strong engagement of control regions during suppression indicates that this goal is accomplished not by a passive failure to engage retrieval, but by engaging processes to prevent unwanted memories from coming to mind. Importantly, these findings support the idea that common brain regions may control stopping both unwanted memories and unwanted actions. Anderson et al. ( 2004 ) identified brain regions that were less active during suppressed trials compared to respond trials. Importantly, there was a reduction in hippocampal activity bilaterally. This difference suggests that subjects can strategically down-regulate mnemonic activity in the hippocampus to prevent conscious recollection and disrupt latter memory.

Cue independence previously demonstrated in the context of retrieval-induced forgetting ( Anderson and Spellman 1995; C. Anderson 2003 ) for review, has been observed in a number of studies of retrieval suppression ( Anderson and Green

2001; Anderson et al. 2004;  Anderson, Reinholz, Kuhn and Mayr 2011; Paz-Alonso,

Ghetti, Matlin, Anderson and Bunge, 2009; Tomlinson, Huber, Rieth, and Davelaar 2009; Tramoni et al., 2009 ).

DePue et al. observed several additional findings that may prove important to understanding retrieval suppression more broadly. First, suppressing retrieval reduced activation in right hippocampus. This reduction is consistent with the view that retrieval suppression reduces hippocampal activity to disrupt conscious recollection and broadly replicates earlier findings by Anderson et al. ( 2004 ), despite considerably more complex naturalistic stimuli. Second, retrieval suppression significantly reduced amygdala activity, which fits with the broadly established role of this structure in emotion processing. Depe et al. ( 2007 ).

Many studies have found that the size of the negative control effect increases with the number of times people attempt to suppress retrieval. For instance, averaged over the three studies, ( n = 96 ), in Anderson and Green ( 2001 ), participants recalled 87%, 85%, 83% and 80% of the items after 0, 1, 8 and 16 suppression attempts. More recently, Anderson-Reinhold’s Kuhn and Mayr ( 2011 ) found 84%, 81%, 79% and 76% across the same levels of repetition for younger adults. Similar parametric functions have been found by others ( Joormann et al. 2009; Kim, Yi, Yang and Lee. 2007; Hanslmeyer, Leipold, and Bauml. 2010;  Joormann, Hertel, Brozovich, and Gottlieb. 2005;  Lampert et al 2010; Lee,-Lee & Tsai, 2007 ).

Converging support from electrophysiological research has established several indices of retrieval suppression and the likely engagement of response override. The extent to which response override mechanisms are engaged, predicts forgetting of the suppressed trace, and individual differences in the function of these systems appears

to be related to how well people control unwanted memories. Towards a Cognitive and Neurological Model of Motivated Forgetting, Anderson and Huddleston, ( 2012 ).

As the foregoing review illustrates, people clearly can control retrieval as indexed both by the total control effect and the negative control effect. Nearly every study conducted on retrieval suppression shows a total control effect indicating that reminders do not intrinsically improve accessibility to related memories, rather, whether one benefits from reminders depends upon one’s intentions and motivations and whether those lead to the engagement of processes that shut down retrieval and terminate the normal benefits that would be expected by reminders.

The negative control effect indicates that retrieval stopping is accomplished by one or more processes that disrupt retention of the suppressed trace. The negative control effect has been replicated widely and in the aggregate yields clear evidence that retrieval suppression causes memory disruption. Both thought substitution and direct suppression without thought substitutes induce negative control effects.

Other investigators, however, have argued that thought substitution is a superior method for forgetting unwanted memories and have experimentally manipulated this behavior. In an early study, Hertel and Calcaterra, ( 2005 ), gave participants alternative words to associate to the suppressed cues and asked them to retrieve these thought substitutes as a way of preventing the unwanted memory from coming to mind whenever its respective suppressed cue word appeared. They found a significantly larger negative control effect with thought substitutes, 15% compared to an unaided group. Colleagues have reported robust negative control effects with thought substitutes ( Hertel and McDaniel, 2010;. Joormann, Hertel, Lemoult, & Gottlieb, 2009;  LeMoult,, Hertel, and Joormann, 2010 ).

Research on thought substitution demonstrates that learning to retrieve alternative diversionary thoughts in response to a reminder can be an effective way to hasten the forgetting of an unwanted memory. This finding fits well with the Selective Retrieval Hypothesis, Anderson, ( 2001 ), of the enhanced forgetting of parental abuse

described at the outset. According to that hypothesis, victims of abuse who are faced with inescapable reminders to an unwanted memory are forced into a situation of retraining their memory response to the reminder by selectively retrieving alternative thoughts and memories about the abuser. Anderson, M.C. and Green, C. ( 2001 ), Suppressing unwanted memories by executive control.

Reductions in accessibility are likely to be accomplished by several mechanisms, including direct suppression and thought substitution. Regardless of how these reductions are accomplished, however, one can certainly no longer say that there is

no way in principle for motivated forgetting of abuse experiences to occur.

Cues help participants recall items that would have been forgotten. It would suggest that encountering related cues in everyday life should increase the chances of a suppressed memory being recovered. Whether some cues might be more powerful in eliciting recovery than others is also a question of interest. For instance, reinstatement of spatial or emotional context may be important. Smith, S.M. and Moynan, S.C., ( 2008 ), Forgetting and Recovering the Unforgettable.

Reminders of an unpleasant experience such as abuse may be threatening during childhood, but as circumstances change and a person grows to be more self-sufficient, secure, and independent of the abuser, feelings of threat that drive maintenance of memory control may subside. If the mode of driving memory control no longer dominates, recovery may be possible. Pavlov, I.P., ( 1927 ), Conditioned reflexes;

Rescorla, RA, ( 2004 ), Spontaneous recovery, learning and memory; Wheeler, MA,

1995, improvement in recall over time without repeated testing, spontaneous recovery revisited.

The foregoing description assumes that forgetting becomes increasingly successful as people practice. Truly upsetting experiences may be characterized by periodic resurgence in which the experience, not altogether forgotten, intrudes again, either in response to diminished capacity, new powerful reminders to the experience, or spontaneous recovery. These periodic challenges demand that retrieval suppression be reinstated. This may take the form of return to intentional suppression or, instead, a resumption of diversionary thoughts.

Undoubtedly, reminders of the unwanted experience are unpleasant, as are thoughts about the experience of being reminded. For these reasons, reinstatement or suppression will not merely be targeted at the original experience, but also thoughts that one has about it during the period of reminding. If we remember our thoughts, whether about perceptions or other thoughts, it is because these thoughts are stored in episodic memory as part of the content of experience. If a new trace is stored that encodes our thoughts about the memory, this new trace will share much in common with the original memory and be a natural target for retrieval suppression. Anderson and Huddleston, ( 2012 ).

In Cameron’s ( 1993 ) study  72% of people abused by a parent reported a period of forgetting followed by recovery, whereas only 90% of those abused by a non-parent reported any period of forgetting. Similar patterns were observed in Feldman, Summers, and Pope’s data, 53% versus 30% forgetting for those abused by a parent or stranger, respectively. Increased subjective reports of forgetting for caregiver-related abuse has been subsequently reported in other studies, ( e.g. Freyd, de Prince and Zurbriggen, 2006; Schultz, Passmore and Yoder, 2003, C. Freyd, DePrince and Gleaves, 2007;

DePrince et al., 2012 ), this volume for reviews.

A gradual shift from a direct suppression approach to selective retrieval may ultimately permit people to forget not only the unpleasant experience but also the process of suppressing it. There are two mechanisms by which this type of goal forgetting may occur. First, shifting from direct suppression to retrieval of particular thoughts. Although the initial purpose of retrieving distracting thoughts is to intentionally suppress retrieval, this goal may be forgotten over time. If retrieval of thought substitutes reinstates inhibition of the unwanted event or further exaggerates interference, the shift from intentional suppression to selective retrieval should facilitate unawareness of the mental actions people take to avoid awareness of the unwanted memory. Second, as people become more practiced in retrieving diversionary thoughts in response to reminders, retrieval may become relatively automatic. Memories of earlier efforts to suppress are themselves associated to the reminder. This shift to retrieving alternative thoughts may ultimately suppress memories of control as well. This shift to retrieving alternative thoughts may ultimately suppress memories of control as well.

This study systematically reviewed  available research and  literature (from the year 1992-2006) on the etiology, description, biographical variables related to, and the treatment of dissociative amnesia related to traumas, such as war, abuse, and natural disasters. Quantitative and qualitative studies were screened and utilized in this review of literature. More specifically, text-books, journal articles, and electronic databases were utilized to conduct this systematic review. The strategy that the reviewer used to organize, synthesize, and review the data was an integrative, and systematic review (Davies & Crombie, 2001). Systematic review is a way of summarising research evidence already available and relies on a scientific design. The findings indicated that the etiology of dissociative amnesia appears to be related to extreme stress, especially if the individual is experiencing trauma for the second time. The results further indicated that men were more likely to dissociate than women and children relating to war traumas, as they are more directly involved. Children and women are more likely to dissociate relating to abuse traumas, as they were more prone to be abused. In addition, children dissociate more freely than adults. Individuals from a lower socio-economic status are more likely to dissociate because they experience the event as more traumatic in the light thereof that they are more vulnerable and experience a lesser degree of security. Treatments for dissociative amnesia include cognitive therapy; medication; hypnosis and hospitalisation.

Dissociative amnesia is the “inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness” (Sharon, 2005, p.1). Dissociative amnesia was formerly known as psychogenic amnesia. This type of disorder is different to simple amnesia, with the fact that the memories are still present, only they are deep within the mind of the individual, and cannot be recalled. However, these memories may surface if “triggered” by the individual’s environment, or they might return on their own (The Cleveland Clinic, 2006). There are five different types of memory loss that has been identified within individuals with dissociative amnesia. These types include localized amnesia, which is when an individual cannot remember certain periods of time or events. Generalized amnesia is when an individual has lost memory of everything, including their identity. Continuous amnesia includes the individual having no memory of events up to the present time, as well as the present time. Systematized amnesia takes place when the individual has lost their memory for particular categories of information (Sharon, 2005), and lastly, selective amnesia, which is when the individual can remember some of the events that has taken place during a limited period of time, but not all of the events (The Encyclopedia of Mental Disorders, 2006). Dissociative amnesia is caused by a number of factors, one of which is traumatic events. These include war, abuse, rape, accidents, head injuries, and natural disasters. Dissociative amnesia is also caused by life stressors, such as abandonment, financial worries, death of a loved one, or marriage, and it is also caused by internal conflict, such as guilt, criminal offences, and interpersonal difficulties (The Merck Manual, 2006). Dissociative amnesia can also be caused by epilepsy. Trauma is, however, one of the most common causes of dissociative amnesia, and war, abuse, and natural disasters are the most common causes of this disorder relating to trauma. Dissociative amnesia is more likely to take place if these traumas are severe, chronic, occur in combination, and associated with posttraumatic stress (Briere, 2006).

The primary aim of this study is to explore and describe dissociative amnesia related to war, abuse, and natural disaster traumas.

1. To explore and describe dissociative amnesia in terms of etiology related to trauma.
2. To explore and describe dissociative amnesia in terms of symptoms related to trauma.
3. To explore and describe dissociative amnesia in terms of biographical variables related to trauma.
4. To explore and describe dissociative amnesia in terms of treatment related to trauma.

The methodology that the reviewer used is a systematic review. Systematic reviews find all relevant studies, which may be published or unpublished, assess each study, synthesise the findings in an unbiased way, and present a balanced and impartial summary of the findings, taking consideration to any flaws in the evidence (Davies & Crombie, 2001). Systematic review is a way of summarising research evidence already available, and relies on a scientific design, therefore becoming more comprehensive, reliable, and minimizes the chance of bias. This can be done by the use of a grid. Not all published systematic reviews have been produced with extreme care. However, therefore the findings may, at times, mislead, and as a result, a series of questions can uncover deficiencies of reports (Davies & Crombie, 2001). The advantages of systematic reviews include reducing the quantity of data, assessing the consistency of relationships, explain data inconsistencies and conflicts, reduce bias, make efficient use of existing data, and may also be a valuable source for decision makers. Many studies give confusing, unclear, or contradictory results. However, a systematic review can effectively eliminate useless or incorrect information, and present a more consistent, clearer picture (Davies & Crombie, 2001). The disadvantages of systematic reviews include an expensive budget, due to it developing over a long period, and it also involves a large amount of literature to be consulted. Systematic reviews may be conducted poorly and present false information, topics may not be well defined, and the criteria for inclusion of studies may not be clearly described, and fairly applied (Davies & Crombie, 2001).

The target population for the study is all available data relevant to the research topic. The data that the researcher sampled included scholarly journals, books, and computerized databases. However, theses and dissertations were excluded due to the vast number of these studies present and the limited amount of time the researcher had to compose this study. The researcher used both qualitative and quantitative studies so as not to limit the study, and the researcher also used both national and international search strategies, due to the limited amount of studies done in South Africa. The data needed for this review was located by using the following sources and databases:

• OPAC (Online Public Access Catalogue): A computerized catalogue of the books, serials, videos, theses, audio cassettes and CD-ROMS owned by the Nelson Mandela Metropolitan University .
• EBSCHOHOST: An on-line reference system offering easy access to a wide variety of databases, of which the reviewer used PsycInfo, Academic Search Premier, MEDLINE, MasterFile Premier, and Educational Resource Information Centre (ERIC).
• OCLC (On-line Computer Library Centre, Inc.): A web system that the reviewer used to search many on-line databases for books, articles, and reference information.
• SABINET: Provides access to bibliographic information on books, periodicals, and government publications in various databases.
• GALENET INFOTRAC: InfoTrac OneFile is part of this database and covers news and periodical articles on a wide range of topics.
• NISCDISCOVER: Contains journal articles.
• SACat: Contains bibliographic information on books, periodicals, audiovisual items, and other information resources kept in South African libraries.

There are seven steps in the systematic review procedure. These include:

1. Define and Refine a Topic
2. Designing a Search
3. Locating Reports
4. Searching the Literature
5. Assessing the Studies
6. Combining the Results
7. Placing the Findings in Context

Data synthesis includes collating and summarising the results of the included studies, and synthesis can be descriptive, (non-quantitative) (Kitchenham, 2004). It can be possible to complement a descriptive synthesis with a quantitative summary, and by using statistical techniques, a quantitative synthesis can be obtained, and referred to as “meta-analysis” (Kitchenham, 2004). The reviewers synthesized and combined the results after the studies were selected for inclusion, and it was determined if there were any differences or discrepancies in the studies. The reviewers also noted the outcomes of different studies, attempted to classify each study, searched for flaws in research designs, noted the samples used and limitations, and designed a grid for each article meeting the inclusion criteria. The grid enabled the reviewers to question each article, and allow for a more systematic, organized, and objective view. An integrative review is the strategy the reviewer used, and this strategy summarized what is known at this point, and assessed all the available information.

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