创伤和分离障碍

THEORYOFSTRUCTURALDISSOCIATIONOFTHEPERSONALITYEllertR.S.Nijenhuis,Ph.D.MentalHealthCareDrenthe,Assen,TheNetherlandstheoryofstructuraldissociationofpersonalityAdaptivehumanfunctioningrequiresalargelycoherentpsychobiosocialsystemthatisanindividual’spersonality.Traumatizationinvolvesamoreorlesscomplexdivisionofpersonalityintotwoormoredifferent,butmoreorlessintenselyinteractingprototypicalcomponents,eachwithitsownpsychobiologicalunderpinnings(Nijenhuis,VanderHart,&Steele,2004;VanderHart,Nijenhuis&Steele,2006).Traumaisnotaneventbutapsychobiosocialwoundinthatthepersonalityofindividualswithtrauma-relateddisordershasbecomedivided.Thatis,traumasurvivorsarecharacterizedbyadegreeofstructuraldissociation.Janet’sViewofHysteriaandSupportiveContemporaryResearchThisconceptualizationoftraumaanddissociationfollowsJanet’soriginaldefinitionofhysteria,the19thcenturycategorythatincludedthespectrumofcontemporarytrauma-relateddisorders.Janet(1907,p.332)statedthat“hysteriainvolvesaformofmentaldepressioncharacterizedbyaretractionofthefieldofconsciousnessandatendencytothedissociationandemancipationofthesystemsofideasandfunctionsthatconstitutepersonality”.Janet’sViewofHysteriaandSupportiveContemporaryResearchcontemporaryfindingssuggestthathighlystressfulexperiencescanloweranindividual’smentallevel,leadingtointegrativefailurethatmanifestsinalterationsofconsciousnesssuchasanunduenarrowingandloweringofthefieldofconsciousness,andperitraumaticandposttraumaticdissociativesymptoms(Ozeretal.,2003).Alackofsocialsupportalsoimpairsthementallevel,particularlyinchildren(Schore,2003).Janet’sViewofHysteriaandSupportiveContemporaryResearchResearchfindingsforageneticpredispositionforstructuraldissociationiscontradictory(Jangetal.,1998;Waller&Ross,1997)Someauthorsstronglydoubtarelationshipbetweentraumatizingeventsandsymptomsaswellasdisordersofstructuraldissociation.Theycommonlymaintainthatmemoriesofextremelythreateningeventsofpatientswithdissociativedisordersaretypicallyartifactsofsuggestion.DissociativeSymptomsThesymptomsofstructuraldissociationincludepsychoformandsomatoformphenomena,someofwhicharenegativesymptomsandsomepositive.positivedissociativesymptomsensueforadissociativepartofthepersonalitywhenthisparthearsthevoiceorfeelstheemotionsofanotherdissociativepart(psychoformdissociativesymptoms),sensesthelatterpart’sbodilyfeelings,orengagesininvoluntarilymovementsthat,infact,arecontrolledbythisotherpart(somatoformdissociativesymptoms;Nijenhuis,2004).DissociativeSymptomsAdissociativeparthasnegativedissociativesymptomswhenthispart,unlikeoneormoreotherdissociativepartsdoesnotrecall,feelcertainemotions(psychoformdissociativesymptoms)orbodilyfeelings,orisunabletomoveanarmorleg(somatoformdissociativesymptoms),orcontrolothermentalphenomenaandfunctions.分离症状心理症状躯体症状阴性症状遗忘人格解体情感麻木无痛感躯体麻木运动抑制阳性症状幻听重新体验创伤（情感、感知）局部疼痛再体验创伤（躯体）StructuralDissociationandActionSystemsInevolutionarypsychology,thepersonalityisseenasaconstellationofadaptations(Barkow,Cosmides&Tooby,1992;Buss,2002).Adaptationsareresolutionstoexternal(i.e.,extra-organismic)andinternal(i.e.,intra-organismic)challengesthathumansfacedoverevolutionarytime.Indeed,manyadaptationsarefunctionallyspecializedtoproduceactionsthatsolveadaptationalproblemssuchasmateselection,languageacquisition,familyrelationships,andcooperation.Adaptationsareorganizedwithintheframeworkofself-organizingactionsystems.Eachoftheseactionsystemencompassesseveraladaptationsorsubsystems.Forexample,eating,asubsystemoftheenergymanagementactionsystem,involvescollecting,storing,preparing,andconsumingfood.StructuralDissociationandActionSystemsPersonalityinvolvestwomajorgroupsofactionsystems(Langetal.,1998).Thefunctionofonegroupistosecureattractivestimuli,andbasicallyinvolvesbehavioralandmentalapproach.Theothermaingroupofactionsystemsforemostaddressesriskassessmentandbehavioralandmentaldefensefromactualandperceivedthreat.StructuralDissociationandActionSystemsTrauma-relatedstructuraldissociationwouldinitsbasicforminvolvealackofintegrationofthesetwodifferentsetsofactionssystems.Thisprimarystructuraldissociation,thusinvolvesalackofnormativeintegrationbetweenactionsystemsforapproachingattractivestimuli,andactionsystemsforbehavioralmamilliandefense.Inthecontextofintegrativefailure,themoderateormorefar-fetcheddivisionbetweenthesetwodifferentsetsofactionsystemscanserveaprotectivefunction.初级创伤与分离创伤前人格EP应对危险适应个体生存ANP日常活动适应种族延续StructuralDissociationandActionSystemsForexample,youngchildrenwhoareabusedandneglectedbytheirnextofkinmayadaptmoretodailylifewhentheydonotornotfullyrealizetheproportionsandimplicationsoftheirmaltreatment.Intermsofmetaphorsofthetheoryofstructuraldissociation,thesechildrenmayastheApparentlyNormalPartoftheirpersonality(ANP)livewiththefamilyandperformatschoolbecausetheybelievethatoractasifnothingmuchiswrong.Meanwhile,theyaretoadegreedepersonalized,andemotionallyandphysicallynumb.AstheEmotionalPart(EP)oftheirpersonality,theyarefixatedonthetraumatizingevents.StructuralDissociationandActionSystemsAlthoughEPmayintrudeAN