Trauma and Dissociation in Context:
Personal Life, Social Process,
and Public Health
To what extent are individuals and societies ready to face and to ac-
cept truth? Criticizing the “university discourse,” which he considered
pursued as a defense against truth.” He even doubted the existence of
true “science” until he discovered the “hysterical (dissociative) dis-
course” which he saw as truly “scientific.” While maintaining the pri-
macy of subjective division, the hysterical (dissociative) person calls
“knowledge” into question rather than explaining everything with the
knowledge he or she already has (Fink, 1998). Thus, historically,
psychoanalytic discoveries while proving to clinicians and researchers
the inadequacies of their presumed knowledge and know-how.
Journal of Trauma & Dissociation, Vol. 9(1) 2008
Available online at http://jtd.haworthpress.com
© 2008 by The Haworth Press. All rights reserved.
FACES OF REALITY:
TO KNOW OR NOT TO KNOW
Fortunately, psychiatrists and psychologists today are more likely
to ask direct questions to their clients than they were previously.
Rather than being initiated by profound psychoanalytic thought and
experience, this shift results simply from the introduction of struc-
tured clinical diagnostic interviews and standardized diagnostic crite-
ria in the last few decades, which have been designed both to increase
reliability in clinical assessment and to do away with theoretical as-
sumptions which lack clear empirical evidence. Curiously, asking
questions is important with traumatized and dissociative patients in
particular, since they often withhold information highly relevant to
their diagnosis and treatment unless the clinician shows an interest. It
ing questions about patients’ dissociative symptoms during psychiat-
ric examination (Chodoff, 1997).
Many dissociative patients seek out clinical settings because of a cri-
sis condition due to flashbacks, mental intrusions, hallucinations, loss
of behavioral control, and suicidal ideas (Sar, Koyuncu et al., 2007). In
fact, they come in for treatment when their dissociative defenses are
in contrast to their reserved attitude in ordinary times, when in a crisis,
dissociative patients spontaneously disclose traumatic aspects of their
For a clinician working with crisis-prone patients in particular (e.g., in
general psychiatric inpatient units and emergency psychiatric wards),
somewhat paradoxically, a dissociative disorder refers to a phase of
whispered realities rather than one of maintained silence.
part of it has to be excluded. Therefore, in Lacan’s terms, daily “sym-
bolic” reality never reflects the “Real,” which is most often expelled
acceptable part of truth outside daily reality is relieving and also dis-
turbing, because the aspect of reality foreclosed from awareness still
causes pain as it undermines the experience of wholeness. Tragically,
the plurality of the internal world of a single individual: this is complex
2JOURNAL OF TRAUMA & DISSOCIATION
BETWEEN PAST AND FUTURE:
TRAUMATIZED PERSON AS A SUBJECT
The definition of trauma usually refers to an extremely stressful life
experience. However, this definition does not reflect one aspect: the
ing implied by the term PTSD, trauma is neither limited to nor identical
with a noxious event; there are both subjective and objective compo-
nents of the situation (Fischer and Riedesser, 1999). Moreover, trauma
is not merely a situational phenomenon, but rather a longitudinal pro-
cess which develops over time and follows a course. Thus, the explora-
center of the trauma and inquire about the person’s subjective experi-
only, but also to the future of the individual. Loss of positive expectan-
cies about the self leads to dysimagination where the distance between
the “me” one wishes to be (“ideal me”) and the “present me” is elimi-
results in an increasingly one-sided assessment of the present from the
vidual can define neither him or herself nor reality under these condi-
tions. However, defining oneself and reality is such an urgent need that
the individual tries to differentiate the self and reality through perceiv-
ing them from multiple contexts. Yet the individual cannot free him or
herself from observing, from the point in time of the traumatic experi-
reality from multiple contexts while feeling bound to the perspective of
the trauma leaves the individual in a traumatic whirlpool (Sar and
Not every frustration is trauma. Rather, optimal frustration and well-
established boundaries are prerequisites for healthy development and
growth. In his monumental book on childhood and society, Erikson
(1963) stated: “Ultimately, children become neurotic not from frustra-
sonalities, he stated further: “. . . the bizarreness and withdrawal in the
behavior of many very sick individuals hides an attempt to recover
social mutuality by a testing of the borderlines between senses and
physical reality, between words and social meanings” (p. 248). He con-
sidered the re-establishmentof a stateof trust as a basic requirementfor
successful psychotherapy in these cases.
THE APPARENTLY NORMAL FAMILY
AND THE SOCIOLOGICAL SELF
Thus, the trauma process is not only an individual but a social en-
deavor. Jung (1912) underlined both the dissociative character of any
“neurosis” and the reciprocity between the internal world of the person
and the embedded external reality: “Neurosis is intimately bound up
with the problem of our time and really represents an unsuccessful at-
tempt on the part of the individual to solve the general problem in his
own person. Neurosis is self-division.”
Given both its subjective aspects and its relation to daily “symbolic”
reality and the socially determined meaning system wherein the indi-
vidual lives, trauma may happen in diverse and also in subtle ways. De-
spite their ordinary outside appearances, certain covertly dysfunctional
or trauma-laden family types may make important contributions to the
transgenerational transmission of trauma and to the development of
dissociative disorders (Ozturk and Sar, 2005). One common strategic
feature of these “apparently normal” families is the promotion of a “so-
ciologicalself” in their offspring (Sar and Ozturk, 2007). The hypertro-
phied sociological self interferes with the development of a complete
healthy self, because it inhibits the development of the psychological
self. This is one of the sources of everyday dissociation and clinical
ception in the new generation, the society and the family may support
the development of sociological self. Subjects with a hypertrophied so-
ciological self lack the ability of dialectical thinking, which is a tool to
an enlarged and detached sociological self may learn how to become
capacities somewhere within contemporary society. However, tragi-
cally, a hypertrophied sociological self may turn out to be a malevolent
family and society.
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CHALLENGE TO PSYCHIATRIC NOSOLOGY:
IS “HYSTERIA” REALLY ERADICATED?
Prominent nosologists are proud to announce that revisions in classi-
fication systems of psychiatric disorders will be evidence-based; i.e.,
they will be based on published empirical research. Most of the scien-
tific work is produced by wealthy countries with a rather stable and
nantly young population, with limited resources of scientific know-
how, and with deficient mental-health delivery systems? The resulting
ical categories, but also closes avenues of further research. What would
happen if a biased approach hits the field of dissociative disorders
which are virtually epidemic among young generations in various parts
of the world (Sar et al., 2006)?
applying biologically-based treatments, alongside psychotherapy, in
accordance with a diagnostic system. Psychiatry also has to respond
professionally to other medical specialty areas in the context of consul-
tation services and legal institutions regarding forensic issues. It has to
adhere to the highest scientific achievements in the frame of profes-
sional ethics and standards. The crucial role of psychiatry in delivery of
effective services to individuals who suffer mental health problems is
beyond debate. Thus, it is vital how psychiatry perceives and conceptu-
alizes the mental health problems of those who are suffering.
ceptions of mental illness among professionals. Mental illnesses which
originate largely from genetic or biological origin such as bipolar dis-
order, schizophrenia, or organic mental disorders are not a target of
minimizing approaches. However, environmentally-caused psychopath-
ological conditions including dissociative disorders are more likely to
be omitted. Such an omission would mean redefinition and declaration
of the limits and responsibilities of psychiatry.
Being an illness with thousands of years of history, hysteria (a
dissociative disorder) itself has suffered a nosological fragmentation in
modern psychiatry (Harris, 2005). The North American approach has
tried to deconstruct hysteria by nosologically fragmenting it into con-
version disorder, somatization disorder, dissociative disorders in a nar-
row sense, borderline personality disorder and some sorts of acute
psychosis (former hysterical psychosis) (American Psychiatric Associa-
of dissociative disorders with dissociative identity disorder in most
professional circles and non-user friendly diagnostic criteria in the
DSM-IV which make it difficult to detect patients who have complex
dissociative disorders and a broad range of dissociative symptom-
atology without the classical triad of dissociative identity disorder. Re-
cent epidemiological data (17.3% lifetime prevalence among women)
demonstrate that the whole spectrum of dissociative disorders (albeit
conversion disorder not included) constitutes a public health problem
which extends the 1.1% prevalence of dissociative identity disorder
many times (Sar, Akyüz, et al., 2007; Sar et al., in press). Accurate rep-
resentation of dissociative disorders in the upcoming DSM-V with new
user-friendly polythetical diagnostic criteria and an expanded nosology
is of crucial importance. This is not merely a scientific endeavor but
fer from a personal psychological disturbance in the magnitude of a
public health problem.
CARRIER OF A UNIQUE PERSPECTIVE TO THE FUTURE
The International Society for the Study of Trauma and Dissociation
mier professional organizationdevoted to disseminationof information
on trauma and dissociative disorders, the ISSTD has been the carrier of
a unique tradition for a quarter of century: maintenance of diverse per-
This doctrine is not a result of eclecticism; rather, it is a reflection of
the very nature of the human psychological self: diversity, richness,
productivity, creativity, and a problem-solving capacity based on dia-
lectical operations. Although the 21st century is characterized rather by
individualism and almost as many realities exist as the number of indi-
viduals, we are aware that an individual trauma becomes a disaster in a
context. However, any treatment is helpful if carried out in the context
societies’. Thus, the treatment of the traumatic self requires empathy
and flexibility on the side of the therapist.
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The unique perspective of the ISSTD has its guarantee in multi-
disciplinarity and in respect for universality of science and knowledge.
believe that the treatment of trauma helps to restore the human will-
power and freedom. Last but not least, the desire for learning both
among our patients and ourselves is one of the driving forces of this
Vedat ?ar, MD
Vedat ?ar, MD
International Society for the Study of Trauma and Dissociation
Professor of Psychiatry
Founder and Director
Clinical Psychotherapy Unit and Dissociative Disorders Program
Department of Psychiatry
Istanbul University Istanbul Medical Faculty Hospital
Disorders, Ed. III. Washington DC: American Psychiatric Association.
Disorders, Ed. IV. Washington DC: American Psychiatric Association.
Chodoff, P. (1997). Turkish dissociative identity disorder. The American Journal of
Erikson, E.H. (1963). Childhood and society. New York:Norton.
Fink, B. (1998). The master signifier and the four discourses. In: D. Nobus (ed), Key
concepts of Lacanian psychoanalysis. London: Rebus Press, pp. 29-47.
Fischer, G. & Riedesser, P. (1999). Lehrbuch der Psychotraumatologie (Textbook of
psychotraumathology). München: Ernst Reinhardt Verlag.
Harris,J.C.(2005). AclinicallessonattheSalpêtrière.Archivesof GeneralPsychiatry
Jung, C.G. (1912). On the psychology of the unconscious. In: Collected works vol. 7:
Lacan, J. (1966). Le Séminaire XIII, L’objet de la psychanalyse (1965-66), unpub-
lished, seminar of 19 January 1966 (cited in Fink, 1998).
Lee, J.S. (1990). Jacques Lacan. Boston: The University of Massachussetts Press.
Öztürk, E. & Sar, V. (2005). “Apparently normal” family: a contemporary agent of
transgenerational trauma and dissociation. Journal of Trauma Practice 4 (3-4),
287-303. (Also in: Trauma and dissociation in international perspective. Not just a
North American phenomenon. Eds: G. Rhoades & V. Sar, New York: Haworth Download full-text
Sar, V., Akyüz, G., & Dogan, O. (2007). Prevalence of dissociative disorders among
women in the general population. Psychiatry Research, 149(1-3): 169-176.
Sar, V., Akyüz, G., Dogan, O., & Öztürk, E. (in press). The prevalence of conversion
symptoms in women from a general Turkish population. Psychosomatics.
Sar, V., Akyüz, G., Kugu, N., Öztürk, E., & Ertem-Vehid, H. (2006). Axis-I dissoci-
ative disorder comorbidity in borderline personality disorder and reports of child-
hood trauma. Journal of Clinical Psychiatry, 67 (10):1583-1590.
Sar, V., Koyuncu, A., Öztürk, E., Yargic, L.I., Kundakçi, T., Yazici, A., Kuskonmaz,
E., Aksüt, D. (2007). Dissociative disorders in the emergency psychiatric ward.
General Hospital Psychiatry, 29 (1):45-50.
tice, 4(1-2), 7-20. (Also in: Trauma and dissociation in international perspective.
Not just a North American phenomenon. Eds: G. Rhoades & V. Sar, New York:
Sar, V., & Öztürk, E. (2007). Functional dissociation of the self: a sociocognitive ap-
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