ArticlePDF AvailableLiterature Review

Hypnotizability and traumatic experience: A diathesis-stress model of dissociative symptomatology

Authors:

Abstract

The authors propose a diathesis-stress model to describe how pathological dissociation may arise from an interaction between innate hypnotizability and traumatic experience. To support the proposition that pathological dissociation may reflect autohypnotic process, the authors highlight clinical and research data indicating parallels between controlled hypnotic dissociative states and uncontrolled pathological dissociative symptoms and summarize evidence of hypnotizability in persons with psychiatric disorders that manifest these symptoms. The authors present this evidence by examining dissociative symptomatology in four psychological domains: perception, behavior and will, affect, and memory and identity. In addition, modern cognitive and neuropsychological models of dissociation are briefly reviewed. Several lines of evidence converge in support of the role of autohypnosis in pathological dissociation. There is considerable evidence that controlled formal hypnosis can produce a variety of dissociations of awareness and control that resemble many of the symptoms in uncontrolled pathological dissociative conditions; and it is possible to discern in dissociative pathology the features of absorption, dissociation, and suggestibility/automaticity that characterize formal hypnotic states. There is also accumulating evidence of high levels of hypnotic capacity in all groups with dissociative symptomatology that have been systematically assessed. In addition, the widespread and successful therapeutic use of hypnosis in the treatment of many dissociative symptoms and conditions (and the potential for hypnosis to induce dissociative symptomatology) also supports the assumption that hypnosis and pathological dissociation share an underlying process. High hypnotizability may be a diathesis for pathological dissociative states, particularly under conditions of acute traumatic stress.
... Others have taken issue with the concept of a "trance state" and simply describe hypnosis as a heightened state of relaxation or a state of focused attention (Kirsch & Lynn, 1995). Finally, investigators from the Stanford hypnosis research lab have elucidated the commonalities of hypnosis with dissociation, a mental separation of components of experience that would ordinarily be processed together (Butler et al., 1996;Spiegel, 1991). ...
... Hypnotized individuals can display a dissociation of content (Butler et al., 1996), in which their attention is so completely absorbed in the immediate narrow experience that other material (e.g., affective, behavioral, and perceptual data) is relegated to the periphery of consciousness where it is temporarily inaccessible. Examples of this include your natural ability to block out unnecessary sensory data, such as the ongoing sounds of a computer motor or of a ceiling fan, or being so absorbed in a movie (or a book chapter) that you are largely unaware of restricted personal space or the precise location of your left elbow. ...
... Hypnotized persons can also display a dissociation of context (Butler et al., 1996), where the narrowing of attention and increased absorption temporarily suspends higher order reflective cognitive structures and processes; the individual has the sense that internal experiences are beginning to happen all by themselves (autonomously). This dissociation of context is often what leads the individual to be more susceptible to hypnotic suggestions. ...
Chapter
Full-text available
The Western medical approach has traditionally been oriented toward differential diagnosis , leading to pharmacological curative agents and/or surgical procedures. In the new mind-body paradigm, we now understand that "alternative" treatments can bring about symptomatic relief that is often equivalent, if not superior, to drug outcomes. One such approach is hypnosis. With hypnosis, one can evoke physiologic changes that were once thought beyond voluntary control. For example, subjects have shown "voluntary control" over sympathetic tone, vasoconstriction/vasodilation, heart rate, muscle tension, and so forth. Hypnosis is similar to biofeedback in that physiologic change is brought under a patient's voluntary control. In bio-feedback, however, a patient is taught how to do this using external feedback from their physi-ologic systems, whereas in hypnosis, control over these physiologic processes is evoked from within the person.
... In particular, there has been recent debate between researchers who attribute DDs to trauma exposure (Dalenberg et al., 2012), and those maintaining that dissociative symptoms and trauma memories are induced and shaped by suggestibility, iatrogoenesis, and false memories (Lynn et al., 2014(Lynn et al., , 2019. This debate has largely neglected the hypothesis that high hypnotic suggestibility functions as a risk factor for DDs and related conditions (Butler et al., 1996) in favour of conceiving suggestibility as a causal variable that produces dissociative symptoms (Lynn et al., 2014). In turn, these debates have not considered potential evidence for elevated suggestibility in DDs from measures of direct verbal (hypnotic) suggestibility, instead focusing on indices closely related to compliance (e.g., interrogative suggestibility) (Gudjonsson, 2013), which are distinct from direct verbal suggestibility (Polczyk, 2016) and arguably less relevant to treatment (Poole et al., 2010), differential diagnosis (e.g., suggestive symptom induction; Popkirov et al., 2015), and underlying mechanisms (e.g., Brown and Reuber, 2016). ...
... In contrast with both models, multiple researchers have proposed that high hypnotic suggestibility confers risk for TSDs and DDs in response to trauma (L. D. Butler et al., 1996;Dell, 2019) (see also Keynejad et al., 2019). In support of this view, hypnotic suggestibility has been repeatedly shown to be positively associated with posttraumatic stress symptoms (Bryant et al., 2001;Bryant et al., 2003;DuHamel et al., 2002;Keuroghlian et al., 2010;Yard et al., 2008). ...
Article
Full-text available
Elevated responsiveness to verbal suggestions is hypothesized to represent a predisposing factor for dissociative disorders (DDs) and related conditions. However, the magnitude of this effect has not been estimated in these populations nor has the potential moderating influence of methodological limitations on effect size variability across studies. This study assessed whether patients with DDs, trauma- and stressor-related disorders (TSDs), and functional neurological disorder (FND) display elevated hypnotic suggestibility. A systematic literature search identified 20 datasets. A random-effects meta-analysis revealed that patients displayed greater hypnotic suggestibility than controls, Hedges’s g=0.92 [0.66, 1.18]. This effect was observed in all subgroups but was most pronounced in the DDs. Although there was some evidence for publication bias, a bias-corrected estimate of the group effect remained significant, g=0.57 [0.30, 0.85]. Moderation analyses did not yield evidence for a link between effect sizes and methodological limitations. These results demonstrate that DDs and related conditions are characterized by elevated hypnotic suggestibility and have implications for the mechanisms, risk factors, and treatment of dissociative psychopathology.
... In particular, there has been recent debate between researchers who attribute DDs to trauma exposure (Dalenberg et al., 2012), and those maintaining that dissociative symptoms and trauma memories are induced and shaped by suggestibility, iatrogoenesis, and false memories (Lynn et al., 2014(Lynn et al., , 2019. This debate has largely neglected the hypothesis that high hypnotic suggestibility functions as a risk factor for DDs and related conditions (Butler et al., 1996) in favour of conceiving suggestibility as a causal variable that produces dissociative symptoms (Lynn et al., 2014). In turn, these debates have not considered potential evidence for elevated suggestibility in DDs from measures of direct verbal (hypnotic) suggestibility, instead focusing on indices closely related to compliance (e.g., interrogative suggestibility) (Gudjonsson, 2013), which are distinct from direct verbal suggestibility (Polczyk, 2016) and arguably less relevant to treatment (Poole et al., 2010), differential diagnosis (e.g., suggestive symptom induction; Popkirov et al., 2015), and underlying mechanisms (e.g., Brown and Reuber, 2016). ...
... In contrast with both models, multiple researchers have proposed that high hypnotic suggestibility confers risk for TSDs and DDs in response to trauma (L. D. Butler et al., 1996;Dell, 2019) (see also Keynejad et al., 2019). In support of this view, hypnotic suggestibility has been repeatedly shown to be positively associated with posttraumatic stress symptoms (Bryant et al., 2001;Bryant et al., 2003;DuHamel et al., 2002;Keuroghlian et al., 2010;Yard et al., 2008). ...
Preprint
Elevated responsiveness to verbal suggestions following a hypnotic induction is hypothesized to represent a predisposing factor for dissociative disorders (DDs) and germane conditions. However, the magnitude of this effect has not been estimated in these populations nor has the potential moderating influence of methodological limitations on effect size variability across studies. This study quantitatively assessed whether patients with DDs, trauma- and stressor-related disorders (TSDs), and functional neurological disorder (FND) display elevated hypnotic suggestibility. A systematic literature search identified 20 datasets. A random-effects meta-analysis revealed that patients displayed greater hypnotic suggestibility than controls, Hedges’s g=0.92 [0.66, 1.18]. Elevated hypnotic suggestibility was observed in all subgroups but was most pronounced in the DDs. Although there was some evidence for publication bias, a bias- corrected estimate of the group effect remained significant. Moderation analyses did not yield evidence for any link between effect sizes and methodological limitations. These results demonstrate that DDs and germane conditions are characterized by heightened hypnotic suggestibility and have implications for the mechanisms, risk factors, and treatment of dissociative psychopathology.
... Our results further indicate that dissociative tendencies interact with trauma in the prediction of SAEF such that dissociation is more strongly associated with SAEF in those with high trauma exposure. However, these suggestibility and trauma-dissociation effects on SAEF were mostly independent: in contrast with a diathesis-stress model [11,33], we did not find evidence for the proposal that suggestibility confers risk for SAEF in response to trauma. ...
Article
Full-text available
Symptoms associated with environmental factors (SAEF; also known as idiopathic environmental intolerance) include the presentation of various common symptoms that are causally attributed to normally benign environmental triggers, such as electromagnetic fields, odors, and chemicals. SAEF are typically conceptualized as psychogenic in origin, and multiple models have proposed that dissociation and responsiveness to suggestions may contribute to the manifestation or expression of these symptoms. This preregistered study sought to characterize these variables’ independent and interactive predictive utility. Participants ( N = 294) completed psychometric measures of dissociative tendencies, trauma, SAEF, and a behavioral scale indexing responsiveness to direct verbal suggestions. Moderation analyses were used to evaluate predictions derived from different models regarding whether these variables would uniquely and interactively predict individual differences in the reporting of SAEF. Responsiveness to verbal suggestions individually predicted SAEF, but no clear evidence was observed for an interaction with dissociation or trauma. Dissociation similarly individually predicted SAEF with additional evidence that this association was moderated by trauma such that the positive association between dissociation and SAEF was only significant in those with moderate-to-high trauma exposure. These results align with the proposal that environmental factors may function as suggestions that trigger involuntary symptoms in some individuals. Our findings further suggest that among individuals with a history of trauma exposure, those with dissociative tendencies may be at an increased risk of experiencing SAEF.
... One's inability to emotionally cope with the severity of the trauma such as this individual experienced as a child, can lead to a phenomenon that I am labeling dissociation or psychological detachment (ICD 10), Butler LD et al. [2]. I have observed that dissociative patterns are directly associated with bodily awareness. ...
... They experience changes in the size, shape and relational configuration of their body and of the world, which may appear/ feel flat, lifeless or non-specifically strange. Individuals may describe seeing/ feeling a transposition of body parts and report views of the world as though it were splintered or fragmented in pixel-like fashion (Baker et al., 2003;Butler, Duran, Jasiukaitis, Koopman, & Spiegel, 1996;Sierra & Berrios, 2001). Some patients describe profound states of detachment whereby they are blank or in a void for a period of hours and appear to be comatose or catatonic. ...
... The capacity to respond to direct verbal suggestions (suggestibility) provides a potential route to further elucidate how DDD fits within the dissociative disorders taxonomy. Hypnotic suggestibility, which is characterized by pronounced distortions in the sense of agency (Lush et al., 2017;Polito et al., 2014), and dissociation are historically intertwined (Ellenberger, 1970;Janet, 1889;Putnam, 1989) and have long been theorized to have overlapping mechanisms (Butler et al., 1996;Hilgard, 1986;Woody and Sadler, 2008). A recent meta-analysis (Wieder et al., 2022) found moderate-to-large effect sizes of elevated hypnotic suggestibility relative to controls in dissociative identity disorder and mixed dissociative disorders, and two germane conditions (trauma and stressor-related disorders and functional neurological disorder) (see also Wieder et al., 2022;Bell et al., 2011;Dell, 2017;Terhune and Cardeña, 2015). ...
Article
Full-text available
The dissociative disorders and germane conditions are reliably characterized by elevated responsiveness to direct verbal suggestions. However, it remains unclear whether atypical responsiveness to suggestion is similarly present in depersonalization-derealization disorder (DDD). 55 DDD patients and 36 healthy controls completed a standardised behavioural measure of direct verbal suggestibility that includes a correction for compliant responding (BSS-C), and psychometric measures of depersonalization-derealization (CDS), mindfulness (FFMQ), imagery vividness (VVIQ), and anxiety (GAD-7). Relative to controls, patients did not exhibit elevated suggestibility (g = 0.26, BF10 = .11) but displayed significantly lower mindfulness (g = 1.38), and imagery vividness (g = 0.63), and significantly greater anxiety (g = 1.39). Although suggestibility did not correlate with severity of depersonalization-derealization symptoms in controls, r=-.03 [95% CI: -.36, .30], there was a weak tendency for a positive association in patients, r=.25, [95% CI: -.03, .48]. Exploratory analyses revealed that patients with more severe anomalous bodily experiences were also more responsive to suggestion, an effect not seen in controls. This study demonstrates that DDD is not characterized by elevated responsiveness to direct verbal suggestions. These results have implications for the aetiology and treatment of this condition, as well as its classification as a dissociative disorder in psychiatric nosology.
Article
Previous research has shown that the relationship between childhood abuse and the presence of auditory hallucinations is mediated by dissociation, specifically depersonalization and absorption. The current study assessed dissociation as a mediator of the relationship between childhood abuse and auditory hallucination frequency, characteristics and associated distress in those with dissociative identity disorder (DID; n = 50) and schizophrenia spectrum disorders (SSD; n = 49). It also tested whether dissociation mediated the relationship between childhood abuse and the presence of non-auditory hallucinations. Participants completed measures of childhood abuse, dissociation, auditory hallucination frequency, characteristics, distress, and non-auditory hallucinations. With distress associated with auditory hallucinations as the outcome, depersonalization was a mediator in the DID group. For non-auditory hallucinations, in the DID group depersonalization and amnesia were mediators between childhood abuse and the presence of visual, tactile and olfactory hallucinations. In the SSD group absorption mediated between childhood abuse and visual, olfactory and gustatory hallucinations. Results suggest that the presence of non-auditory hallucinations in DID and SSD are associated with different dissociative experiences.
Article
Full-text available
Psychogenic fugue and psychogenic amnesia consist of sudden, temporary alterations in consciousness accompanying amnesia. The use of hypnosis has been generally restricted to removing the amnesia, although as early as 1898 Janet remarked that, in cases of fugues, hypnosis can also be used for uncovering and acting upon the subconsciously fixed idea that leads to the persistent recurrence of these fugues. A case history is presented of a client who often gave in to the urge to wander, at times due to a conscious decision to escape from a difficult situation, but frequently in a mental state which could be placed somewhere between psychogenic amnesia and psychogenic fugue. He summarized his situation with the words 'I see no way out', a statement considered to be the fixed idea responsible for his dissociative states. Hypnosis was used as a medium for metaphoric and symbolic imagery work comprising a series of positive transformations of the original metaphorical statement. A few sessions of this type resulted in dramatic changes in the patient's everyday life.
Article
Scientific study of sleep has shown that sleepwalking and night terrors occur in stage 4 sleep. Both run in families, and are precipitated by various specific trigger factors. Behavior can be complex and purposeful and frequently may lead the sleeper into danger. Murder and assault while asleep do rarely occur, and the aggressive acts can appear purposeful, directed, and coordinated. Sleepwalking in the United Kingdom is considered a sane automatism and a successful plea of not guilty leads to an acquittal. Therefore, sleepwalking should only be accepted as a defense by forensic psychiatrists after establishing beyond reasonable doubt that the characteristics of a sleepwalking episode are present. The law on automatism in England is muddled and requires revision.
Article
Describes the formulations of double consciousness current in mid-19th century Britain. Criteria for its diagnosis overlap with but are not identical to those now used for multiple personality disorder. The disorder was uniformly regarded as rare, but there was a steady flow of case reports. This paper cites a number that have long been ignored, and allusions to less florid unpublished observations, including prepubertal cases. Also included are references to continental cases, described in the 18th century as cataleptic somnambulism. The preeminence of the concept of double consciousness, which emerged early in the 19th century, ended in 1875. It was replaced by the concept of multiple personality. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
PRELIMINARY RESEARCH INDICATES THAT HYPNOTICALLY INDUCED DEAFNESS MAY REDUCE THE SPEECH INHIBITING EFFECTS OF DELAYED AUDITORY FEEDBACK (DAF). REAL AND SIMULATING HYPNOTIC SS WERE COMPARED WITH RESPECT TO THE IMPROVEMENT IN SPEECH CONSEQUENT TO THE SUGGESTION OF DEAFNESS. RESULTS INDICATE VERY SIMILAR IMPROVEMENTS OF DAF SPEECH FOR BOTH GROUPS. AN INCIDENTAL FINDING IS THAT REAL SS HAD LONGER SIMPLE READING TIMES UNDER HYPNOSIS THAN DID SIMULATING SS. (GERMAN + SPANISH SUMMARIES) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Tested for momentary awareness of critical words in a nonattended message during shadowing. On only 1 out of 42 occasions when there was a significant galvanic skin response to critical nonattended words did undergraduates signal awareness. This finding supports the hypothesis that there can be some semantic processing without awareness. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Examined how the characteristics of hypnotizability and absorption relate to 3 sub-dimensions of dissociation, as measured by 3 subscales of the Dissociative Experiences Scale (DES). 53 normal Ss (aged 17–60 yrs) completed the DES and the Tellegen Absorption Scale (TAS) and were assessed for hypnotizability on the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C). The DES Absorption subscale was found to correlate strongly with both the SHSS:C and TAS, the DES Depersonalization subscale less strongly, and the DES Amnestic Experiences subscale only weakly with the SHSS:C and not at all with the TAS. Results are interpreted as supporting J. R. Hilgard's (1970) theory of 2 developmental pathways to hypnotizability, 1 through absorption and the other through experience of trauma. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The very existence of hysterical psychosis as a diagnostic entity has been questioned as part of the general difficulty in defining both hysteria and psychosis. However, several recent investigations have documented a syndrome that usually involves brief and intense periods of psychotic behavior, generally with graphic decompensation, severe environmental stress, and rapid recompensation, in individuals with other hysterical features. The authors assert that such a syndrome does exist as a clinical entity and that the differential diagnosis can be facilitated by using a standardized measure of hypnotic trance capacity. They hypothesize that patients with hysterical psychosis are highly hypnotizable, while those who are schizophrenic and psychotic have low hypnotizability. The authors review the literature and present two case examples.