SCH Imment I 2016

Psychoanalytic Psychology © 2014 American Psychological Association
2016, Vol. 33, No. 1, 106 –128 0736-9735/16/$12.00 http://dx.doi.org/10.1037/a0038019
LINKING THE OVERWHELMING WITH

THE UNBEARABLE:
Developmental Trauma, Dissociation, and the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Disconnected Self
Adriano Schimmenti, PhD Vincenzo Caretti, PsyD
UKE–Kore University of Enna LUMSA University
In this article, we propose a developmental trauma model of psychopathology,

grounded in convergent findings in psychoanalytic, developmental, and affective
neuroscience research. We suggest that dissociation is a key variable in understand-
ing clinical disorders that have their roots in relationally traumatic experiences
during childhood. Dissociation links the overwhelming with the unbearable: it
inextricably binds the experiences of abuse, neglect, and disrupted communication
with attachment figures during childhood with the development of unbearable
self-experiences that cannot be integrated into the consciousness and therefore
continue to disturb the individual throughout his or her entire life. In fact, devel-
opmental trauma often initiates maladaptive psychological and biological pathways
in the individual’s life, for on both an emotional and cognitive level, it is too much
for a child to tolerate. In this case, dissociation may paradoxically protect the
traumatized child from a fragmentation of the self through multiple disconnections
in the self, occurring at both mental and bodily levels. These disconnections can
derive from overt experiences of abuse and neglect, which may directly lead to
intense affect dysregulation and lack of integration between self-states; or they can
be more actively arranged to cope with perceived threats derived from procedural
memories of the caregivers’ specific failures to respond. Implications for treatment
of adult patients who suffered from developmental trauma are discussed.
Keywords: trauma, dissociation, self-states, development, treatment
This article was published Online First October 13, 2014.

Adriano Schimmenti, PhD, Faculty of Human and Social Sciences, UKE–Kore University of
Enna, Italy; Vincenzo Caretti, PsyD, Department of Human Sciences, LUMSA University, Rome,
Italy.
Correspondence concerning this article should be addressed to Adriano Schimmenti, PhD,
Facoltà di Scienze dell’Uomo e della Società, UKE–Università degli Studi di Enna “Kore,”
Cittadella Universitaria, 94100 Enna, Italy. E-mail: adriano.schimmenti@unikore.it
106
LINKING THE OVERWHELMING WITH THE UNBEARABLE 107
Research suggests that a strong connection exists between developmentally adverse

experiences within the attachment relationship, such as parental abuse, neglect, and
failures of care, and the presence and severity of dissociative symptoms in adulthood
(Chu, Prey, Ganzel, & Matthews, 1999; Dalenberg et al., 2012; Egeland & Susman-
Stillman, 1996). In the last few years, several articles have been published that convincingly argue
that time has come for a comprehensive appreciation of the role played by dissociative mechanisms
derived from such developmentally traumatic experiences in exacerbating or even inducing psy-
chopathology. Many researchers who work in the field have shared this idea for a long time now
(e.g., Herman, 1992; Ross, 2000; van der Kolk et al., 1996), and recent reviews on the topic (e.g.,
Dalenberg et al., 2012; Farina & Liotti, 2013; Nijenhuis & Van der Hart, 2011) have aptly
summarized a wealth of theoretical and empirical findings illustrating how these experiences might
dramatically damage the possibility of organizing mental states into a cohesive higher-order
structure, what clinicians usually call the self.
While this perspective seems to be well accepted among many analysts, particularly among
relational analysts who also helped to initiate and develop the trauma-based model of dissociation
(e.g., Bromberg, 1998; Davies, 1996; Schwartz, 2000), there are other authors—both from
psychoanalytic (e.g., Busch, 2005) and other traditions (e.g., Lynn et al., 2014)—who questioned
the generalizability of psychopathological models based on developmental trauma. Especially
within the ego psychology tradition, some analysts have highlighted the role of internal conflict
rather than dissociation in the onset of problematic behaviors and posttraumatic responses among
individuals who were exposed to child abuse and neglect (e.g., Sugarman, 2008), and they have also
raised the question of whether the trauma-dissociation model of psychopathology in fact denies the
role played by children’s minds in the process of representing the traumatic experiences (Bohleber,
2007; Leuzinger-Bohleber, 2008). Outside the psychoanalytic field, a number of critiques were
made against the trauma model of dissociation. For example, Lynn and colleagues (2014) stated
that there is a lack of sufficient evidence to attribute a central etiological role to trauma in
dissociative disorders, and they argued that a fantasy model (which posits that fantasy proneness,
suggestibility, cognitive failures, and other variables usually foster dissociation) can help explain the
patients’ resorting to dissociation.
However, empirical research consistently supports the hypothesis that abuse, neglect, and
failures of care in childhood may result in dissociation and may foster psychopathology (see
Dalenberg et al.’s [2014] response to Lynn and colleagues). Therefore, a better
understanding of the relationship between developmental trauma and dissociation may
broaden our knowledge of psychic functioning and, subsequently, on the clinical
process: in fact, psychotherapy with patients who suffer from dissociative symptoms
and dissociative disorders can be effective only if treatment corresponds with a deeper
understanding of the possible negative influences exerted on the individual by child-
hood traumatic experiences. In this article, we hypothesize that current advances in
affective neuroscience, developmental research, and psychoanalysis can constitute a
fruitful theoretical framework through which many clinical issues related to dissoci-
ation might be better identified, understood, and addressed. However, before going
into further discussion, a clarification of the theoretical constructs discussed in this
article is necessary.
Trauma
Research has already demonstrated that even adult-onset trauma is able to disorganize
mental functioning. In the words of Wilson (2004), “trauma’s impact on the individual is
108 SCHIMMENTI AND CARETTI
holistic in nature” (p. 12), because trauma causes injuries that always go beyond the
exposure to an actual threat to the body. In fact, trauma causes injury to the mind and its
inherent functions and processes, including the ego, identity, and self-structure. In trauma,
an external distressing event affects the internal psychological phenomena at multiple
levels of functioning and in conscious and unconscious modalities of awareness and
behavior. Posttraumatic response may involve intrusion symptoms (e.g., involuntary
distressing memories of the traumatic events), avoidance symptoms (e.g., effort to avoid
external reminders of trauma), negative alterations in cognition and mood (e.g., dissocia-
tive amnesia regarding an important aspect of the traumatic event), and alterations in
arousal and reactivity (e.g., hypervigilance; American Psychiatric Association, 2013).

Thus, trauma is, by definition, emotionally overwhelming: it causes severe distress on the
psychobiological level; it challenges the individual’s belief systems and world views
concerning meaning, faith and expectations about life; and it may also alter the patterns
of intimacy, interpersonal relationships, and conceptions of oneself and personal identity.
If just a single traumatic event may potentially evoke such a disorganization in an
adult’s psychological and behavioral functioning, then it is likely that even more dys-
regulated responses can emerge when children are chronically exposed to traumatic
experiences in the attachment relationships, in other words when children are neglected or
abused by those parental figures who should protect their young and provide them a sense
of security. As attachment research has demonstrated, children need caring, responsive,
and predictable attachment figures to safely explore their own minds and the external
world, thus having the possibility to fully develop their mentalizing abilities (Fonagy,
Gergely, Jurist, & Target, 2002; Jurist, Slade, & Bergner, 2008). Conversely, if the
attachment figures are traumatizing by being unloving, neglecting, or abusing, children
will probably resort to those psychic mechanisms already available for their developmen-
tal stage to minimize the impact of the trauma. And among these mechanisms, we will
often find dissociation with its own cluster of symptoms, such as derealization and
depersonalization, and its specific way of functioning (e.g., trauma-specific reenactments
in which the child feels or acts as if the traumatic events were recurring; American
Psychiatric Association, 2013, pp. 273–274).
Developmental Trauma
Research has suggested that childhood experiences of neglect, abuse, and disrupted
communication with caregivers are able to generate a condition of vulnerability to
dissociation, which can be observed in many clinical disorders (Dutra et al., 2009).
Nevertheless, to better understand how these early negative experiences are linked to the
development of dissociative symptoms and structural dissociation (the dissociation be-
tween functions or parts of the personality), a crucial distinction must be made between
the concepts of developmental trauma and developmental trauma disorder.
Developmental trauma disorder refers to a specific diagnostic category (albeit not
included in the official psychiatric taxonomy), where chronic exposure to one or more
forms of developmentally adverse interpersonal trauma (such as abandonment, betrayal,
physical assaults, sexual assaults, threats to bodily integrity, coercive practices, emotional
abuse, witnessing violence, and death) has already generated patterns of repeated dys-
regulation (van der Kolk, 2005), and where several primary domains of impairment can
be observed (e.g., attachment, biology, affect regulation, dissociation, behavioral control,
cognition, and self-concept; Cook et al., 2005).
Developmental trauma is a more theoretically driven construct, which refers to a

potentially traumatic configuration of the relational field between the child and his or
her caregivers, characterized by a lack of emotional reciprocity and a disavowal of the
child’s affective needs (Bromberg, 2013). In developmental trauma, the child’s
affective needs are disowned and entirely subdued by parental demands, desires,
conflicts, fears, and projections (Borgogno, 2007). Whether developmental trauma
does or does not include overt material neglect and abuse of the child, it always
embraces a series of negative child– caregiver interactions such as emotional neglect,
intense role-reversal, or parental behaviors directed at the psychological domination
of the child (Schimmenti, 2012). This definition of developmental trauma partially

overlaps with other psychoanalytic constructs related to childhood trauma such as
“cumulative trauma” (Khan, 1963) or “strain trauma” (Kris, 1956). These constructs
highlight the accumulation of frustrating tendencies that derive from a longstanding
external noxious force (especially a disturbance in the mother’s role as a protective
shield), which constantly pressures the child to maintain defenses against overwhelm-
ing anxiety and that becomes in itself traumatic. However, our way of conceiving
developmental trauma is more in line with Ferenczi’s (1929) understanding of the
unwelcome child and Shengold’s (1989) concept of soul murder, where particular
attention is given to the dysfunctional affective climate in which the child grows up
and its polarization of the parent’s rather than the child’s needs. In fact, the focus here
is on parental disavowal and denial of parts of the child’s existence, in particular those
parts which go beyond the parental urges, wishes, and projections. In other words, it
is as if the parents do not recognize a psychological existence of the child (Schim-
menti, 2013), and thus they may be impersonal and affectionless in caregiving
(Winnicott, 1971); or they may use the child as an “evacuatory object”; that is, as a
garbage can of their disturbed mental states (Shengold, 1989), or they may even
violently introduce mental content into the child that can satisfy at a conscious or
unconscious level their own needs, to the detriment of the child’s natural develop-
ment, such as in Ferenczi’s (1932/1988) concept of alien transplant. As Shengold
(1989, p. 24) elegantly stated, “our identity depends initially on good parental care and
good parental caring— on the transmitted feeling that it is good to be here,” while the
intimate affective climate of developmental trauma may represent the exact opposite
condition, such as “it is no good that you are here; you are only a problem”
(Schimmenti, 2012, p. 198).
Dissociation
In actuality, the construct of dissociation also involves several complex problems regard-
ing its definition. For example, Cardeña (1994) observed that dissociation can theoreti-
cally refer to: (a) nonconscious or nonintegrated mental modules or systems (as happens
with dissociative amnesia and other compartmentalization symptoms); (b) an alteration in
consciousness wherein disconnection from the self or the environment is experienced (as
happens with depersonalization, derealization, and other detachment symptoms); (c) a
defense mechanism (as described in the psychoanalytic tradition of psychic functioning).
These different uses for the same term still exist, and studies in the field of affective
neuroscience have added another indicator to the previous list, (d) dissociation as a
psychobiological mechanism (Frewen & Lanius, 2006; Siegel, 1999), which concerns the
process of functional disassociation among brain structures. Moreover, it should be
considered that, as a defense mechanism, dissociation represents an adaptive rather than

maladaptive functioning of the mind, a basic process that enhances the integrating
functions of the self by screening out excessive or irrelevant stimuli, thus allowing specific
self-states to function optimally when full immersion in a single reality is exactly what is
called or wished for (Bromberg, 1998; Young, 1988).
All these different indicators of dissociation can be intertwined and overlapping on a
clinical level, and this can only exacerbate the theoretical problems related to this
construct. Incidentally, it is likely that such a large number of theoretical domains related
to the construct of dissociation has reinforced the beliefs of some contemporary research-
ers that the most severe dissociative disorders, such as dissociative identity disorder, do
not even exist and only are factitious disorders determined by the clinicians’ indoctrina-
tion of the patient (e.g., Piper & Merskey, 2004), despite the convincing evidence
regarding the validity of these diagnostic classes (e.g., Brand, Classen, McNary, & Zaveri,
2009).
Regarding the different uses of the term dissociation, two review articles, one by
Brown (2006) and the other by Holmes and colleagues (2005), have suggested that
compartmentalization and detachment symptoms can be intended as two qualitatively
distinct forms of dissociation— corresponding to the (a) and (b) points in Cardeña’s list,
respectively. This distinction between compartmentalization and detachment symptoms
(which is well accepted in contemporary literature and current definitions of dissociative
symptoms; see Cardeña & Carlson, 2011) can be traced back to the works of Pierre Janet
(1907), who differentiated the dissociation of systems of functions related to memory and
identity and constituting the personality from the retraction of the field of consciousness
involving a reduction of the attentional span (Nijenhuis, Spinhoven, Vanderlinden, Van
Dyck, & Van der Hart, 1998).
Perhaps in an attempt to have the best of both worlds, Farina and Liotti (2013)
have recently proposed a developmental pathway of dissociation, where “repeated
recourse to dissociative processes of detachment during development, because of
recurring conditions of inescapable threat, together with other pathogenetic mecha-
nisms associated with the triggering of neuroendocrine stress or epigenetic responses
[. . .] may permanently hinder a person’s integrative capacity, causing compartmen-
talization symptoms and structural dissociation of personality” (p. 13). With these
words, Farina and Liotti seem to propose a two-step sequential model of structural
dissociation where detachment symptoms precede compartmentalization symptoms
and may even cause them. We are convinced that such a model, however fascinating,
is not applicable to all forms of structural dissociation, being inconsistent with other
theoretical and clinical evidence that are strongly supported by neurobiological
findings as well as developmental research. In contrast, we advance that the relation-
ship between developmental trauma and dissociative responses involves more com-
plex, nonlinear, processes (Perry, 2008; Schore, 2009).
A Developmental Perspective on Childhood Trauma and Dissociation
It has been demonstrated that childhood experiences of neglect, abuse, and disrupted
interactions with caregivers can produce significant alterations in the developing right
brain, the hippocampus, the amygdala, the prefrontal cortex, the hypothalamic-pituitary
axis, the concentrations of corticotrophin release hormone, the noradrenergic system, and
so on. Accordingly, the network of cortical and subcortical interactions that produces the
ability to organize self-states may be damaged because of developmental trauma (Schim-

menti, 2012; Schore, 2009).
Therefore, when neglect and abuse begin early in childhood, when these adversities
are extreme and prolonged, they can foster the development of severely impairing and
long-lasting disorders related to a lack of personal synthesis in personality (Janet, 1907).
Several studies have indeed shown that the neurochemicals released when a significant
stressor is experienced (among them norepinephrine, epinephrine, glucocorticoids, endog-
enous opiates) are particularly concentrated in brain regions that are related to the
execution of integrative mental actions, thus they can interfere with normal development,
decreasing the individual’s ability to integrate experiences (McGaugh, 1990). When this
occurs, dissociation may concern a structural disassociation between discrete self-states
that have never been associated (i.e., a sort of “psychobiological compartmentalization”),
as Frank Putnam proposed in his theory of dissociation as nonintegration of discrete
behavioral states. Putnam (1997) suggested that the child develops discrete behavioral
states (i.e., specific and unique sets of psychological, physiological and behavioral
variables) in different environments and situations. Progressively, during development the
sense of self consolidates and becomes integrated when these discrete states eventually
coalesce and unify. For this reason, Putnam (1997) describes structural dissociation as a
process “arising from a traumatic disruption in the early developmental acquisition of
control and integration of basic behavioral states” (p. 152).
In fact, developmental research strongly suggests that dissociation can emerge from
repeated episodes of affect dysregulation during childhood. For instance, Sander’s studies
on emotion regulation in infancy (Sander, 1987) showed that when infants experience
significant stressors, they first produce signals manifesting hyperarousal (such as crying);
later, if they receive no response and the distress becomes overwhelming, they usually fall
asleep. This is a normal self-regulation response of conservation-withdrawal, a metabolic
shutdown also observed in other animals and mediated by primitive brain regions which
allow the infants to protect themselves from stressful situations through a passive disen-
gagement aimed at conserving energy and fostering survival (Porges, 1997, 2001; Schore,
2009). However, if the lack of appropriate responses is particularly frequent, it can hinder
the development of more mature strategies of affect regulation, impairing the possibility
to integrate emotional states into a consistent system of meanings where these emotional
states are embodied, represented, linked with their related behavioral states, and poten-
tially evoked.
Therefore, the emotional response of the neglected and abused child, with its psycho-
biological correlates, can be crucial for the development of dissociation. It is even possible
that the most extreme alexithymic conditions (Taylor, Bagby, & Parker, 1997), where
people show serious difficulties in identifying, distinguishing, and describing feelings
together with an impoverished fantasy life, and where they seem almost unable to use
feelings as a guide for their behaviors, have their psychological origins in episodes of early
relational trauma. In fact, the processing of emotions usually works— even at the brain
level— on parallel systems with different levels of complexity. In particular, Bucci’s
(1997, 2000, 2003) multiple code theory of emotional processing postulates that emotion
schema are comprised of subsymbolic processes (patterns of sensory and visceral sensa-
tions and motoric activity associated with states of emotional arousal), and symbolic
elements (images and words) which come to be represented in the mind and linked with
subsymbolic processes during early development. Bucci attributes the links between the
subsymbolic and symbolic elements to a referential process that allows the meanings in
the subsymbolic system to be represented symbolically and translated into logically
organized speech. According to this model, alexithymia may be conceived as a conse-

quence of dissociations within and between the symbolic and subsymbolic elements in the
emotion schema (Taylor & Bagby, 2013). Therefore, the problem in alexithymia is not
simply a lack of words for feelings, but rather a lack of symbols for somatic states: if the
subsymbolic and symbolic systems do not “talk together,” the integration between
emotion and cognition is hindered. As a consequence, a sense of self-integrity could not
be reached and state-dependent responses to physiological activation are developed
instead. Notably, empirical research suggest a strong relationship between alexithymia
and dissociation (Bob, Selesova, Raboch, & Kukla, 2013; Franzoni et al., 2013; Grabe et
al., 2000).
The research involving the Still Face Paradigm (Tronick, Als, Adamson, Wise, &
Brazelton, 1978) can help us in further understanding how developmental trauma can lead
to affect dysregulation and dissociation. The Still Face is an experimental procedure
where the mother begins by maintaining eye contact with the infant; at some point, she
suddenly becomes unresponsive through the inhibition of emotional facial expressions,
vocalization, and gestures. Research with this procedure shows that children usually try to
repair the relational breakdown experienced during the Still Face using specific sets of
behaviors and signals that become more and more disorganized as the mother continues
to be unresponsive. Specifically, children sequentially activate a consistent pattern of
behaviors that goes from more evolved, such as the ones related to the cooperative
motivational system (for instance, they can direct their gaze at the mother’s eyes seeking
contact with her, or they can use ostensive signals to catch her attention), to more
primitive systems of interpersonal regulation (such as grabbing and grasping movements
that should be able to activate the caregiving system in the parent, which involves the
hyper-activation of the sympathetic system), until they show psychomotor agitation
suggesting that a defensive system is activated and that hyperarousal has become so
overwhelming it has led to behavioral disorganization. Subsequently, children will go into
a psychobiological state involving parasympathetic activation and resembling the extreme
detachment symptoms observed in adults. The break in connection during the Still Face
is followed by loss of postural control, withdrawal, gaze aversion, sad facial expression,
and self-soothing behaviors in the child, with physiological correlates including increased
heart rate, cortisol level and skin conductance, whereas vagal tone decreases (Mesman,
Van Ijzendoorn, & Bakermans-Kranenburg, 2009). Therefore, the infant immediately
becomes hypervigilant when the mother starts to become unresponsive; after that, to try
attuning to her and repairing the relational failure, the child rapidly shifts through different
behavioral states operating at different levels of complexity, and this usually happens
before the child shows extreme signals of detachment. The Still Face Paradigm illustrates
how a severe breakdown in attachment bonds can generate a sequence of behaviors related
to affect dysregulation in the child. It also shows that the sequence of the child’s behavior
could involve a sudden switch from sympathetic hyperarousal to parasympathetic hy-
poarousal. However, it must be highlighted here that the Still Face is an experimental
procedure, and when relating to the child outside the laboratory the caregivers could
respond to the child’s sequence of behaviors (usually going from hyperarousal to with-
drawal) in a different manner and at different times. More important, disorganized,
depressed, neglectful, and/or abusive caregivers may show inconsistent patterns of re-
sponse to the child’s activation. For example, at times they may try to repair the relational
breakdown when seeing the child in a state of hyperarousal; at other times they may try
to restore the disruption when they perceive a response of disengagement in the child;
sometimes they may not respond at all while at other times they could even frighten or
further abuse the child because they are not able to tolerate his or her emotional state. Such
inconsistent behavior can damage the child’s possibility of integrating the emotional and
relational experiences into a cohesive structure of meaning. Moreover, because these
caregivers’ responses may be confusing and may result unpredictable to the child, he or
she will often be in an alarmed state. Such a condition can lead to the consolidation of
state-dependent responses of hypervigilance and avoidance, and later the child could even
respond to ordinary experiences as though they are threatening (Perry, 2008).
Notably, developmental trauma has important biological correlates. For instance, child
abuse and neglect can slow down the myelination of the prefrontal medial cortex (PFMC),
which is implicated in executive functioning and in regulating peripheral response to

stress (De Bellis, 2005). Without the mitigating effects of the PFMC, the amygdala is left
on its own to evaluate the potential threat and, if sensitized to negative emotional stimuli,
it will most likely produce a signal activating the fear system (Panksepp, 1998). At that
point, the child’s adrenal gland releases cortisol, a corticosteroid hormone that stimulates
gluconeogenesis-activating antistress pathways in the body. However, excessive exposure
to cortisol can damage the cells in the hippocampus, which is responsible for converting
short-term memories of emotional events into long-term memories, thus impairing the
creation of new memories and inhibiting memory retrieval of already stored information
(Joseph, 1999). This is consistent with psychobiological perspectives suggesting that
dissociation may arise from a brain-based regulatory response to fear or other extreme
emotion (e.g., Lanius et al., 2010), and it is possible that this biological process initiates
one of the most important developmental pathways leading to the most severe forms of
dissociation, particularly among those patients suffering from dissociative amnesia, dep-
ersonalization, and even dissociative identity disorder: the implicit, emotional memories
of relational threatening stimuli can be stored at a sensory level, but no episodic memory
related to the traumatic event and its circumstances seem to be retrievable (Nadel &
Jacobs, 1998). In this case, it is possible that the brain produces automatic, state-dependent
responses reflecting what was once experienced—internally and/or externally—at a sen-
sory and bodily level or, on the contrary, it replicates (i.e., it dissociatively reenacts) the
same self-regulation strategy originally used to face the perceived threat. In fact, devel-
opmental research has shown that children can remember early events across short delays,
but after long delays these memories may no longer be consciously accessible (Cordón,
Pipe, Sayfan, Melinder, & Goodman, 2004; Terr, 1988). Research has also demonstrated
that under certain circumstances, early memories of trauma can be retrieved (Cordón et al.,
2004), and this may particularly apply to children (Gaensbauer, 1995, 2000); nonetheless,
these memories may have a dream-like quality, because the effects of psychobiological
dysregulation can prevent the rehearsal of such memories, leading to the decay of
trauma-related details (Fivush & Schwarzmueller, 1995). This suggests that the mecha-
nisms involved in the dialectic between compartmentalization and detachment are devel-
opmentally complex and are likely related to a difficulty in integrating the emotions into
a cohesive structure of meaning when a child goes through self-experiences that rapidly
shift from one side to another.
The difficulty for severely abused and neglected children in selecting an integrated
response system with consistent affect regulation strategies can also be inferred from the
Strange Situation Procedure (Ainsworth, Blehar, Waters, & Wall, 1978). The Strange
Situation is an experimental procedure for assessing attachment styles in children between
the ages of 9 and 24 months. As the caregiver and a stranger enter and leave the room, the
researchers observe the child’s reactions in terms of the amount of exploration the child
engages in throughout the experiment: the interaction with the stranger, and the responses
to the departure and return of the caregiver. Main and Solomon (1986) identified a group
of children, highly represented among those who have suffered neglect and abuse, who
exhibited a disoriented/disorganized attachment (the “Type D” attachment style) and
whose behaviors phenotypically resembled dissociative states (Main & Morgan, 1996).
Some of these children showed extreme detachment symptoms, similar to animal re-
sponses of freezing (i.e., paralysis responses) when faced with an inescapable shock
(Nijenhuis et al., 1998), perhaps because the parent represented for them a threat-
associated stimulus, automatically eliciting the “feigned death” or other similar response.
However, there are other disorganized children who show different patterns of behavior
that rapidly shift from one to another. For example, a child can appear paralyzed looking
at the wall, after which he turns his head back looking frightened at his caregiver, and
immediately after he closes his eyes and starts violently moving his head back-and-forth.
Another child can appear in a feigned death state in the arms of her caregiver, when she
suddenly arches her back unnaturally and throws herself backward. Levine (1997) noted
that animals emerging from freezing often manifest repetitive, almost seizure-like motor
activity, postulating that these stereotyped motor responses serve to allow the completion
of the motor sequences of successful escape or defense strategies. As a consequence, Van
der Hart, Nijenhuis, and Steele (2005) have postulated that the behaviors of disorganized
children during the Strange Situation include concurrent or successive activation of the
attachment action system and the defense action system, as was observed before with the
Still Face Paradigm.
Therefore, compartmentalization and detachment are two sides of the same coin; that
is, the psychobiological dysregulation deriving from early relational trauma and the
development of competitive self-states that cannot be integrated into consciousness.
Unintegrated Mental States
Several authors have speculated that dissociation develops from attachment disorganiza-
tion in infancy, which negatively affects the processes of mental integration in the child.
For example, Liotti (1992) suggested some developmental pathways linking attachment
disorganization with pathological dissociation. One of these pathways is directly impli-
cated in developmental trauma disorder: the disorganized/disoriented child suffers from
ongoing relational stressors and repetitive severe trauma, thus he or she experiences
continued reinforcement of unintegrated—simultaneous or sequential— contradictory in-
ternal working models of self and other. However, Liotti suggested another important
pathway of pathological dissociation, where parent– child interactions continue to be
inconsistent and contradictory but the child does not encounter severe abuse or neglect.
These interactions involve a strong activation of the attachment system that, although not
overtly comprising maltreatment, can induce a failure in the integrative functions of
consciousness in the child. Current empirical research mentions the importance of incon-
sistent and contradictory child– caregiver interactions in the development of dissociative
symptoms, even in the absence of severe abuse and neglect. Research shows that hostile
or intrusive parental behavior is only partially related to later dissociation, whereas
the caregiver’s disrupted communication, flatness of affect and lack of positive affective
involvement are strong predictors of dissociation (Amos, Furber, & Segal, 2011; Dutra et
al., 2009; Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006). As stressed by Dutra and
colleagues (2009, p. 87), “what is notable about these types of maternal interactions is that
they all serve to subtly override or ignore the infant’s needs and attachment signals, but
without overt hostility.”
These considerations are mirrored in many theoretical studies. Several authors have
speculated that patients who suffer from developmental trauma (not necessarily from
developmental trauma disorder) often present unintegrated mental states that may qualify
them as structurally dissociated, regardless of the disorders they suffer and even in the
absence of a dissociative disorder diagnosis. In fact, they show a part of their psychic
functioning, which seems to operate independently from the other parts (Steele, Van der
Hart, & Nijenhuis, 2009). This part does not occur at random; it appears at specific
moments and/or with specific interactions, and it likely involves a system of traumatic
memories with their related emotional, behavioral and physiological states (Meares, 2000;
Schimmenti & Caretti, 2010; van der Kolk, 1995). These unintegrated mental states have
been given different names in literature, in relation to the authors’ original approach to the
problem of dissociation and its origins. For example, Bowlby (1980) refers to these states
as “segregated systems”; Pizer (1998) describes them in terms of “dissociated islands in
the self’s memorial system”; similarly, Chefetz (2004) refers to them as “isolated sub-
jectivities”; Steiner (1993) has conceived them in terms of “psychic retreats” while we
prefer to say “psychic pits” (Schimmenti & Caretti, 2010); Bromberg (2006) calls them
“dissociated self-states,” while Dorahy (2010) refers to them simply as “internal states.”
However, regardless of the name given to these parts of the mind that seem to function
independently from its other parts, we may posit that they are related to developmental
trauma and that they foster the development and maintenance of clinical and subclinical
conditions of psychic suffering. We suggest that these unintegrated mental states are
generated from recurrent episodes of disruption and irreparable relational breakdowns in
the child-caregiver interactions. The presence of these states in a patient does not
necessarily imply exposure to severe abuse or neglect but they always emerged from
significant failures in the caregiver’s abilities of mirroring, elaborating and/or sharing
emotions and cognitions according to the patient’s emotional needs during childhood
(Schimmenti & Bifulco, 2013; Schimmenti, Guglielmucci, Barbasio, & Granieri, 2012). It
is possible that the extent of the unintegrated mental states depends directly on the degree
of the caregiver’s difficulties in mentalizing and attuning to the child’s emotional needs.
Bromberg (2013) has elegantly described the process that can lead to the development of
dissociative parts in the self in the absence of overt neglect and abuse. He has argued that
during childhood “things never go perfectly well, and it is inevitable that to some degree
self-other wholeness will be compromised early in life by developmental trauma that has
no cognitive representation because developmental trauma is attachment-related and
organized procedurally rather than symbolically” (pp.10 –11, original italics).
Other contemporary perspectives on childhood trauma in the psychoanalytic field,
which tend to be based on the Freudian (1892/1895) concept of Nachträglichkeit (i.e.,
deferred action), suggest instead that traumatic childhood memories are retroactively
remodeled in later developmental stages through the conflicted eyes of an individual who
has already processed the trauma according to his or her internal factors and way of
functioning and has already given an unconscious meaning to the trauma (e.g., Bohleber,
2007; Busch, 2005). Within this perspective, the traumatic memories always contain
traces of the historical truth. Following this line of reasoning, Leuzinger-Bohleber (2008)
has suggested that “memories result from constructive processes on the one hand, but on
the other hand they are influenced by the ‘historical truth,’ which means, for example, the
historically first constituted processes dealing with a (traumatic) situation, which constrain
the recategorization of the new analogous situation. In this sense recategorizations in later
interactional situations are related to the original trauma” (p. 1174). Considerations of the
constructive and reconstructive processes within the memory system might even lead
some clinicians to question whether in a developmental trauma model of psychopathol-
ogy, as presented in this article, “the baby has been thrown out with the bathwater”
(Leuzinger-Bohleber, 2008, p. 1165).
We would say that this is not the case. It is likely that more or less active strategies
of self-organization are implied in the development of the unintegrated, procedural mental
states. When discussing the child’s response to the Still Face Paradigm, we argued that in
natural environments caregivers may respond to the child’s distress in different ways.
However, they can also respond with specific timing, in relation to their own awareness
of the child’s distress and their own ability to tolerate a specific state of dysregulation in
the child. It is then possible that the child learns at a procedural level which behaviors are
more effective for generating favorable responses from caregivers in order to proactively
prevent the return of dysregulation. By doing so and thus preserving the attachment bond,
the child might encapsulate or exclude from the developing self-representations and
internal working models those self-states leading to dysregulation according to his or her
temperament, personality traits, and other internal factors. However, the possibility to
actively exclude these states does not correspond with the possibility of erasing them from
the mind, thus they continue to condition the individual as procedural and embodied
memories of self-other interactions. These mental states may fail to integrate into con-
sciousness: in this case, they will be impenetrable to cognitive elaboration, and yet they
will limit self-reflectivity, metacognitive monitoring and mentalizing abilities, because
they act as “smoke detectors” (van der Kolk, 1995) whose work is to hire the entire self
and its functions at any time to avoid perceived or even potential threats that could trigger
affect dysregulation. Moreover, unintegrated mental states will not always be silent, and
under specific conditions they could be activated with all their flood of dysregulation, for
instance when the individual is exposed to particularly stressful or overwhelming events.
On another level, studies on memory have observed that strong aversive stimuli—such
as disrupted communication with caregivers could be for a child— can lead to strong
association in memory between these stimuli and the selected response, thus enhancing the
memory of the response (e.g., Vriends et al., 2011). However, studies on memory have
also suggested that the reconsolidation of memory, the ability to recall specific informa-
tion about an event, can be impaired in these cases (e.g., Park, Zoladz, Conrad, Fleshner,
& Diamond, 2008), most likely because of the negative effects of glucocorticoids on the
hippocampus. These properties of memory under the condition of developmental trauma
can prevent episodic memory (i.e., the memory that “I was there; this happened to me”)
from being retained in the first place, whereas the procedural memory and emotional
learning may remain operative (Solms & Turnbull, 2002). This could help us understand
the oscillation and alternation in states of mind among individuals who were exposed to
developmental trauma and suffer from dissociative symptoms, their uncanny experiences
of doubled knowing/not knowing their trauma (something may become simultaneously
deeply familiar and frighteningly unknown) and their fear and pain of remembering
trauma-based emotions before they are ready to do so (Sugarman, 2008). At the same time,
because the memory of the response can be enhanced rather than weakened when a trauma occurs,
it is possible that deeply exploring the experiential dimensions underlying the dissociative
responses and their possible links to childhood experiences may help, with time, some
patients in reconsolidating and then cognitively representing the traumatic memories with
their dissociated emotions. As Bohleber (2007) stated, “if an encapsulated traumatic part
of the self becomes permeable again, it can also be better interconnected associatively”
(p. 343). However, as we will suggest later, it is possible that it will take a long time before
the patient will feel sufficiently safe (Bromberg, 2006, 2011, 2013) to explore the
developmentally traumatic, encapsulated contents of his or her own mind.
Unintegrated Bodily States
The unintegrated mental states represent a central aspect of dissociation. However, it must
be stressed here that dissociation operates even at a somatic level. Early descriptions of
patients suffering from hysteria (Breuer & Freud 1892/95; Janet, 1907) are consistent with
current research on somatoform dissociation, a construct describing “dissociative symp-
toms that phenomenally involve the body” (Nijenhuis, 2004, p. 12); that is, those
phenomena such as motor inhibitions and anesthesia/analgesia that are manifestations of
a lack of integration of somatoform experiences, reactions, and functions. Janet (1889,
1907) has provided many clinical examples of hysterical patients who showed dissociated
sensory, motor, and other bodily reactions and functions in addition to unintegrated mental
states. In fact, as every psychodynamic-oriented clinician knows, the term “hysteria” was
originally used to describe symptoms other than those concerning only what the current
psychiatric literature classifies as conversion disorders, and it included a wider class of
symptoms in the somatic symptom disorders, posttraumatic stress disorders, personality
disorders and, of course, dissociative disorders.
Current research shows that somatoform dissociation is associated with psychological
dissociation (Nijenhuis, 2004) and, in general, that psychogenic somatic symptoms are
related to developmental trauma and dissociation (Sar et al., 2004; van der Kolk et al.,
1996). In addition, the relationship between dissociative disorders and what were once
called somatoform disorders and are now known as somatic symptom and related
disorders (American Psychiatric Association, 2013) has been established (Brown et al.,
2007; Roelofs, Keijsers, Hoogduin, Näring, & Moene, 2002), with both these diagnostic
classes involving disruptions in the normal controlling functions of consciousness, at least
in terms of self-experiences and perceptions (Kihlstrom, 1992).
Empirical and theoretical studies suggest that even somatoform dissociation and
somatic symptom disorders can derive from developmental trauma. For example, Guthrie
(1995) has argued that deficiencies in the early caregiver– child relationship leave the
individual with an inability to use imagination and language to describe and master
distress. This can result in difficulty processing emotional experiences and an impover-
ished fantasy life (both of which are characteristics of the alexithymic individuals, as we
have noted before), together with a susceptibility to somatic complaints as the focus of
attention is given to bodily signals and sensations that are fathomless, unintelligible and
therefore nameless.
Guthrie’s perspective is consistent with the idea that childhood experiences of neglect,
abuse and disrupted communications in attachment relationships can lead to an arrest in
affect development and desomatization of emotions (Krystal, 1997). In this case, emotions
and bodily sensations cannot be linked to representations of affect and feelings, and they
cannot be used as a guide for behavior. On the contrary, bodily states do not coalesce and
therefore remain unintegrated.
As we have already mentioned, Wilma Bucci (1997) further explained this process:
she argued that in normal development individuals establish representations of self,
objects and events that include memories and interpretations with their related emotional,
somatic and motor associations. Nevertheless, when a dissociation occurs between the
cognitive representations (the symbolic level) and their related somatic elements (the
subsymbolic level), individuals may experience significant emotional responses when
confronted with particular stimuli, but they are not able to understand why these responses
occur and they have neither clues nor the language to describe and resolve this experience.
As a consequence, they experience alarming bodily states that are impenetrable to
cognitive elaboration, and this condition can in turn activate the psychobiological re-
sponses connected to a perceived threat.
Affect dysregulation is again central to this process: patients who suffered from
developmental trauma can have damaged self-regulation and interpersonal regulation
abilities, thus they could perceive disturbing or ambiguous bodily states as overwhelming
because of a reduced “window of tolerance” between the extremes of hyper- and
hypoarousal (Siegel, 1999). Very often, the extreme intensity of physiological arousal
cannot be processed by these patients without disrupting the functioning of the entire
system. Rather, somatic symptoms can emerge that testify to the embodied memories of
trauma with their dysregulated emotional states and the lack of integration between bodily
sensations and their representations.
Developmental Trauma, Dissociation, and Disorders
We have stressed that developmental trauma and dissociation can impair affect regulation
abilities as well as the ability to form mental representations, with possible severe
consequences to the individual’s mental, somatic and behavioral functioning. The pro-
cesses by which developmental trauma and dissociation can evolve into clinical syn-
dromes are likely the most important aspects to explore regarding clinical diagnosis and
treatment. In this section, we summarize our theoretical model on the pathogenic mech-
anisms of developmental trauma and dissociation. This model is graphically represented
in Figure 1.
As Figure 1 shows, in our view pathological dissociation directly emerges from
developmental trauma, prevents normal development from occurring, and involves two
Figure 1. A developmental trauma model of dissociation and psychopathology.

interrelated psychopathological pathways (these are represented as separate in the figure

for conceptual clarity).
The first pathogenic pathway of pathological dissociation concerns mental states: as a
consequence of lack of care and abuse in attachment relationships, the child can have
difficulty forming consistent self-representations. As a consequence, competitive and
unintegrated internal working models of self, others, and self-other relationships might
develop. These working models are specifically arranged to cope with external stimuli in
relation to perceived threats and procedural memories of the caregiver’s responses to the
child’s self-states. The competitive internal working models may easily lead to disruptions
in self-other relatedness, as the representations of one’s own state of mind as well as that
of others can be altered according to the defensive needs of the individual rather than
environmental and relational clues. It is rather clear that the final destination of this
pathway can only be a mental disorder because mental states are unintegrated and social
support with its regulatory function is difficult to obtain because of negative expectations
and disconnection from others involved in the process.
The second pathogenic pathway of pathological dissociation concerns somatic and
bodily states: developmental trauma impairs at the deepest level the possibility of
identifying and representing internal states, which in the earliest stage of development
mainly consists of enteroceptive perceptions with their related somatic and sensory
correlates (see Stern, 1985). On the one hand, the damage done by developmental trauma
can hinder the maturation of self-regulation strategy, but this damage may also involve the
ability to distinguish between bodily sensations and their associated emotions. This can be
related to discontinuities and possible distortions in the perception of one’s own body
which might be experienced as a conglomerate of unintelligible, disconnected sensations
rather than as a unitary whole. The reduced ability in integrating and cognitively repre-
senting the bodily states can easily lead to distressing somatic complaints, concerns and
symptoms, together with abnormal thoughts, feelings, and behaviors in response to them,
which testify to a dysregulated and reduced window of tolerance for both psychic and
somatic pain, as expressed in the diagnosis of somatic symptoms and related disorders.
A cautionary note regarding this model is necessary for purposes of clarity: the model
should be viewed as a schematic representation of what we intend as some of the most
important factors that may be involved in the onset of psychopathology when a develop-
mental trauma has occurred and the individual’s personality is organized around path-
ological dissociation. There is evidence showing that this model is consistent with both
empirical and theoretical research but, like every graphical representation of complex
psychological processes, our figure can only consider a few select theoretical variables
among a number of other important factors which have been omitted. Therefore, this
model must be considered a visual representation of a possible “developmental cascade”
where the selected variables overlap and combine generating psychopathology, even when
arrows and lines indicate otherwise. It should also be noted that a number of genetic,
temperamental, and environmental factors, as well as important life events, may intervene
at any point in the process, exerting positive or negative influences on each of the
mechanisms described above and on the relationships between them.
Implications for Treatment
The concept of unintegrated mental and bodily states can help us better understand the
results of several studies which show that dissociation scores can be high even among
individuals who show psychiatric disorders but have not received a diagnosis of disso-
ciative disorder. It is likely that the presence of unintegrated states more or less impairs
the functioning of many people who suffer from clinical disorders and maladaptive
behaviors.
Regardless of its extent, pathological dissociation always implies processes of multiple
disconnection in self-experience. In fact, on a phenomenological level, pathological
dissociation involves: (a) a disconnection with reality, where symptoms of detachment
and/or compartmentalization prevent the dissociated individuals from experiencing the
world with a sense of continuity and spontaneity; (b) a disconnection in interpersonal
relationships, because dissociation disrupts the experience of intersubjectivity and the

sharing of personal affects and meanings by disembodiment, somatic symptoms, and the
sudden emergence of unintegrated mental states, which can make the interactions in
relationships unpredictable and unwanted; (c) a disconnection in behaviors, because they
are procedurally tied to the detection and avoidance of potential threats, rather than being
naturally and freely directed at the exploration of environments and relationships; (d) a
disconnection in the self, where there is limited dialogue and integration between self-
states with their related commitments, responsibilities, ways of processing information
coming from the inside and from the outside; (e) a disconnection or a reduced connection
between the different components of the individual states, with little or no integration
between emotional activation and its representation, and the alternation of competing
responses to the same stimulus testifying to the early disorganization.
These considerations can have important implications for the treatment of patients
who have suffered from developmental trauma. Dissociation links the overwhelming with
the unbearable: it inextricably binds the experiences of abuse, neglect and/or disrupted
communication in childhood which subsequently initiated a psychobiological maladaptive
pathway— because they were too much for a child to tolerate—with the development of
unbearable self-experiences. These self-experiences continue to disturb the individual,
who appears unable to integrate them into the consciousness— either because of the
inadequate development of neural circuits related to the functional integration, or because
of the necessity to defensively exclude from awareness these experiences, as Bowlby
(1980) argued, to maintain a minimum sense of integrity and continuity of the self.
We propose that the extent of these overwhelming and unbearable self-experiences
should be the first indicator when considering the treatment of patients who suffered from
developmental trauma and who show significant dissociative symptoms. In fact, dissoci-
ation paradoxically protects the patient who was exposed to developmental trauma from
a fragmentation of the self through multiple disconnections in the self. Therefore, when
the patient shows symptoms such as alternate personalities, primitive defense responses
(e.g., freezing), and important functional losses (e.g., amnesia, but also somatic symptoms
such as analgesia), clinicians must be aware that dissociation “has crossed the line,” and
they have to be prepared for a complex treatment (International Society for the Study of
Trauma & Dissociation, 2011; Steele, Van der Hart, & Nijenhuis, 2005). Under these
conditions, the initial work (which may last for a long time, even many years) is focused
on symptom control, self-care, support for normal functioning, as well as on fostering the
affect regulation abilities and constantly negotiating the therapeutic alliance up to its
stabilization. At the halfway point, treatment mainly concerns working through develop-
mental trauma and its reconstruction at a pace tolerable for the patient with his or her
developing mentalizing abilities. This is also a critical time when encapsulated traumatic
memories can emerge and can be addressed. Late-stage work includes integration and
consolidation of the skills acquired in the earlier phases. Luckily, treatment programs for
complex dissociative disorders have been demonstrated to be effective (e.g., Brand et al.,
2009; Coons & Bowman, 2001).
The theoretical principles that guide the treatment of the most complex dissociative
disorders can also be applied to patients whose negative childhood experiences produced
less severe impairments in self-integrity. In particular, we believe that these patients can
find effective results in treatments that are sensible to the embodied memories of trauma
(Leuzinger-Bohleber, 2008) and are able to address their problems with affect dysregu-
lation. Notably, these patients may particularly benefit from clinical interventions aimed
at enhancing their mentalized affectivity (Jurist, 2005, 2010, 2013); that is, the experiential
discovery of the subjective meanings of one’s own feelings as well as those of others in
a way that extends well beyond intellectual understanding.
In addition, like patients whose exposure to ongoing abuse and neglect in childhood
leads to a developmental trauma disorder, even patients who show only specific and
limited unintegrated mental and/or bodily states may suffer from multiple dissociative
disconnections in the self. These disconnections are often linked to implicit memories of
relational failures in attachment bonds, which lead to phobia of mental contents and
phobia of attachment. As we have observed before, the phobia of mental contents is often
counteracted by excluding from awareness the disturbing mental contents and bodily
sensations that could evoke the early dysregulation, thus limiting the integration of the
experiences in the environment (through symptoms like derealization and emotional
numbing) and in the self (through symptoms like amnesia). This can result in difficult
treatments: particularly in the early stages of therapy, patients might perceive the clini-
cian’s interventions as threatening, so they may activate dissociative responses paradox-
ically aimed to protect the sense of self-integrity.
The previously mentioned problem is related to another clinical issue which is very
difficult to address in treatment. As a result of developmental trauma, these patients
usually show an attachment phobia (Steele, Van der Hart, & Nijenhuis, 2005). Their desire
to relationally repair and integrate the disconnected parts of the self can be blocked by an
intense fear of the clinician’s rejection, abuse, and ultimate abandonment, which likely
replicates what the patients once experienced in the interactions with their caregivers.
Therefore, they can feel trapped in a porcupine dilemma (Schopenhauer, 1851/2000),
inconsistently desiring a relational recognition of (and a repair for) their trauma and the
fear of recognizing it, the fear of perceiving the overwhelming intensity of the dissociated
feelings without finding a safe haven in the clinical relationship, thus the fear of being
traumatized once again (Schimmenti, 2014). Patients can enact the attachment phobia in
many ways, through disruptive behaviors and attempts to manipulate or captivate the
therapist in order to control him or her, for example. Therefore, respect for—and
protection of—the therapeutic boundaries, which is a crucial aspect of any effective
treatment, is even more important for patients who could abruptly enact dissociated
self-states during the therapy session, because these self-states might threaten the entire
clinical process.
At the same time, patients who have suffered from developmental trauma need to
perceive the clinician as a secure base (Liotti, 2006), as a figure who is capable of
tolerating their dissociated self-states with all the accompanying fears and dysregulation;
however, the clinician “has no way of knowing what will be secure for a patient and what
will not” (P. M. Bromberg, personal communication to A. Schimmenti, 5 December
2009). Therefore, these patients must feel sufficiently confident about the clinician’s
commitment to thinking about their potential for affect dysregulation before they can
engage in the threatening process of cognitively and affectively elaborating on what
happens in the therapeutic relationship without dissociation. This may require a particular
effort in attuning with patients’ self-experience and nonverbal communication within the
clinical situation (Arizmendi, 2008; Leuzinger-Bohleber, 2008), an approach to listening
that often goes beyond words and is able to convey with time a sense of security in the
patient (Granieri & Schimmenti, 2014), because it can help patients explore their mental
states linked to developmental trauma without too much fear of dysregulation (Bromberg,
2006). At the same time, verbal interpretation and working through conflictual rather than
dissociative states, as in the tradition of ego psychology, should be integrated in psycho-
therapy because they can result critical for the development of therapeutic alliance and
even for the outcome of treatment (Sugarman, 2008). These are some of the reasons why
clinicians must be very careful and why they must use as much tact as possible when
treating patients who have suffered from developmental trauma (Borgogno, 2007).
Conclusions
One of the main treatment objectives for patients who have suffered from developmental
trauma concerns the integration of self-experiences that have been dissociated before on
a mental, bodily, and relational level, but still pertain to the patients’ history, behavior, and
way of processing thoughts and feelings.
Psychotherapy is an opportunity for these patients to develop a sense of a connected
self. In fact, if they can experience an interpersonal relationship characterized by consis-
tency, care and commitment, this can serve as a base for mitigating the effects of
dissociated states concerning their childhood experiences of abuse and neglect. As a
consequence, attachment phobia, fear of dysregulation, and the constant use of dissocia-
tion may decrease. This, in turn, can increase the patients’ chances of cognitively
elaborating their unintegrated mental and bodily states, until these states eventually
coalesce with the other parts of the self. Such a process promotes the patients’ sense of
self-integrity and self-continuity, together with their capability of becoming genuinely
connected with other individuals.
We also hypothesize that the clinician’s ability to recognize the dissociative symp-
toms, the extent of the unintegrated mental and bodily states, and the developmental and
relational processes that led a patient to organize his or her mental and behavioral
functioning around pathological dissociation, can make all the difference in the outcome
of many treatments.
References
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A
psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Publishing.
Amos, J., Furber, G., & Segal, L. (2011). Understanding maltreating mothers: A synthesis of
relational trauma, attachment disorganization, structural dissociation of the personality, and
experiential avoidance. Journal of Trauma & Dissociation, 12, 495–509. doi:10.1080/
15299732.2011.593259
Arizmendi, T. G. (2008). Nonverbal communication in the context of dissociative processes.
Psychoanalytic Psychology, 25, 443–457. doi:10.1037/0736-9735.25.3.443
Bob, P., Selesova, P., Raboch, J., & Kukla, L. (2013). “Pseudoneurological” symptoms, dissociation
and stress-related psychopathology in healthy young adults. BMC Psychiatry, 13, 149. doi:
10.1186/1471-244X-13-149
Bohleber, W. (2007). Remembrance, trauma and collective memory: The battle for memory in
psychoanalysis. The International Journal of Psychoanalysis, 88, 329 –352. doi:10.1516/V5H5-
8351-7636-7878
Borgogno, F. (2007). Ferenczi’s clinical and theoretical conception of trauma: A brief introductory
map. The American Journal of Psychoanalysis, 67, 141–149. doi:10.1057/palgrave.ajp.3350022
Bowlby, J. (1980). Attachment and loss, Vol. III. Loss: Sadness and Depression. New York, NY:
Basic Books.
Brand, B. L. Classen, C. C., McNary, S. W., & Zaveri, P. (2009). A review of dissociative disorders
treatment studies. Journal of Nervous and Mental Disease, 197, 646 –654. doi:10.1097/
NMD.0b013e3181b3afaa
Breuer, J., & Freud, S. (1892/95). Studies in hysteria. Standard Edition, 2, 21–47.
Bromberg, P. M. (1998). Standing in the spaces: Essays on clinical process, trauma, and dissoci-
ation. Hillsdale, NJ: The Analytic Press.
Bromberg, P. M. (2006). Awakening the dreamer: Clinical journeys. New York, NY: The Analytic
Press.
Bromberg, P. M. (2011). The shadow of the tsunami and the growth of the relational mind. New
York, NY: Routledge.
Bromberg, P. M. (2013). Prefazione [Foreword]. In V. Caretti, G. Craparo, & A. Schimmenti (Eds.),
Memorie traumatiche e mentalizzazione. Teoria, ricerca e clinica (pp. 7–12). Roma, Italy:
Astrolabio Ubaldini.
Brown, R. J. (2006). Different types of “dissociation” have different psychological mechanisms.
Journal of Trauma & Dissociation, 7, 7–28. doi:10.1300/J229v07n04_02
Brown, R. J., Cardena, E., Nijenhuis, E. R. S., Sar, V., & Van der Hart, O. (2007). Should
conversion disorder be reclassified as a dissociative disorder in DSM V? Psychosomatics:
Journal of Consultation and Liaison Psychiatry, 48, 369 –378. doi:10.1176/appi.psy.48.5.369
Bucci, W. (1997). Psychoanalysis and cognitive science: A multiple code theory. New York, NY:
Guilford Press.
Bucci, W. (2000). The need for a “psychoanalytic psychology” in the cognitive science field.
Psychoanalytic Psychology, 17, 203–224. doi:10.1037/0736-9735.17.2.203
Bucci, W. (2003). Varieties of dissociative experiences: A multiple code account and a discussion
of Bromberg’s case of William. Psychoanalytic Psychology, 20, 542–557. doi:10.1037/0736-
9735.20.3.542
Busch, F. (2005). Conflict theory/trauma theory. Psychoanalytic Quarterly, 74, 27–45. doi:10.1002/
j.2167-4086.2005.tb00198.x
Cardeña, E. (1994). The domain of dissociation. In S. J. Lynn & J. W. Rhue (Eds.), Dissociation:
Clinical and theoretical perspectives (pp. 15–31). New York, NY: New York: Guilford Press.
Cardeña, E., & Carlson, E. B. (2011). Acute stress disorder revisited. Annual Review of Clinical
Psychology, 7, 245–267. doi:10.1146/annurev-clinpsy-032210-104502
Chefetz, R. A. (2004). Re-associating psychoanalysis and dissociation. Contemporary Psychoanal-
ysis, 40, 123–133. doi:10.1080/00107530.2004.10747240
Chu, J. A., Prey, L. M., Ganzel, B. L., & Matthews, J. A. (1999). Memories of childhood abuse:
Dissociation, amnesia, and corroboration. The American Journal of Psychiatry, 156, 749 –755.
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., . . . van der Kolk, B. A.
(2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 390 –398.
Coons, P. M., & Bowman, E. S. (2001). Ten-year follow-up study of patients with dissociative
identity disorder. Journal of Trauma & Dissociation, 2, 73–89. doi:10.1300/J229v02n01_09
Cordón, I. M., Pipe, M. E., Sayfan, L., Melinder, A., & Goodman, G. S. (2004). Memory for
traumatic experiences in early childhood. Developmental Review, 24, 101–132. doi:10.1016/
j.dr.2003.09.003
Dalenberg, C. J., Brand, B. L., Gleaves, D. H., Dorahy, M. J., Loewenstein, R. J., Cardeña, E., . . .
Spiegel, D. (2012). Evaluation of the evidence for the trauma and fantasy models of dissociation.
Psychological Bulletin, 138, 550 –588. doi:10.1037/a0027447
Dalenberg, C. J., Brand, B. L., Loewenstein, R. J., Gleaves, D. H., Dorahy, M. J., Cardeña, E., . . .
Spiegel, D. (2014). Reality versus fantasy: Reply to Lynn et al. (2014). Psychological Bulletin,
140, 911–920. doi:10.1037/a0036685
Davies, J. M. (1996). Dissociation, repression and reality testing in the countertransference: The
controversy over memory and false memory in the psychoanalytic treatment of adult survivors
of childhood sexual abuse. Psychoanalytic Dialogues, 6, 189 –218. doi:10.1080/
10481889609539115
De Bellis, M. D. (2005). The psychobiology of neglect. Child Maltreatment, 10, 150 –172.
doi:10.1177/1077559505275116
Dorahy, M. J. (2010). The impact of dissociation, shame, and guilt on interpersonal relationships in
chronically traumatized individuals: A pilot study. Journal of Traumatic Stress, 23, 653–656.
doi:10.1002/jts.20564
Dutra, L., Bureau, J.-F., Holmes, B. M., Lyubchik, A., & Lyons-Ruth, K. (2009). Quality of early
care and childhood trauma: A prospective study of developmental pathways to dissociation.
Journal of Nervous and Mental Disease, 197, 383–390. doi:10.1097/NMD.0b013e3181a653b7
Egeland, B., & Susman-Stillman, A. (1996). Dissociation as a mediator of child abuse across
generations. Child Abuse & Neglect, 20, 1123–1132. doi:10.1016/0145-2134(96)00102-0
Farina, B., & Liotti, G. (2013). Does a dissociative psychopathological dimension exist? A review
on dissociative processes and symptoms in developmental trauma spectrum disorders. Clinical
Neuropsychiatry: Journal of Treatment Evaluation, 10, 11–18.
Ferenczi, S. (1929). The unwelcome child and his death instinct. The International Journal of
Psychoanalysis, 10, 125–129.
Ferenczi, S. (1988). The clinical diary. Cambridge, MA: Harvard University Press. (Original work
published 1932)
Fivush, R., & Schwarzmueller, A. (1995). Say it once again: Effects of repeated questioning on
children’s event recall. Journal of Traumatic Stress, 8, 555–580. doi:10.1002/jts.2490080404
Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization, and the
development of the self. New York, NY: Other Press.
Franzoni, E., Gualandi, S., Caretti, V., Schimmenti, A., Di Pietro, E., Pellegrini, G., . . . Pellicciari,
A. (2013). The relationship between alexithymia, shame, trauma, and body image disorders:
Investigation over a large clinical sample. Neuropsychiatric Disease and Treatment, 9, 185–193.
doi:10.2147/NDT.S34822
Frewen, P. A., & Lanius, R. A. (2006). Toward a psychobiology of posttraumatic self-dysregulation:
Reexperiencing, hyperarousal, dissociation, and emotional numbing. Annals of the New York
Academy of Sciences, 1071, 110 –124. doi:10.1196/annals.1364.010
Gaensbauer, T. J. (1995). Trauma in the preverbal period: Symptoms, memories, and developmental
impact. The Psychoanalytic Study of the Child, 50, 122–149.
Gaensbauer, T. J. (2000). Psychotherapeutic treatment of traumatized infants and toddlers: A case report.
Clinical Child Psychology and Psychiatry, 5, 373–385. doi:10.1177/1359104500005003007
Grabe, H.-J., Rainermann, S., Spitzer, C., Gänsicke, M., & Freyberger, H. J. (2000). The relationship
between dimensions of alexithymia and dissociation. Psychotherapy and Psychosomatics, 69,
128 –131. doi:10.1159/000012380
Granieri, A., & Schimmenti, A. (2014). Mind-body splitting and eating disorders: A psychoanalytic
perspective. Psychoanalytic Psychotherapy, 28, 52–70. doi:10.1080/02668734.2013.872172
Guthrie, E. (1995). Treatment of functional somatic symptoms: Psychodynamic treatment. In R.
Mayou, C. Bass, & M. Sharpe (Eds.), Treatment of functional somatic symptoms (pp. 144 –160).
New York, NY: Oxford University Press.
Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma.
Journal of Traumatic Stress, 5, 377–391. doi:10.1002/jts.2490050305
Holmes, E. A., Brown, R. J., Mansell, W., Fearon, R. P., Hunter, E. C. M., Frasquilho, F., & Oakley,
D. A. (2005). Are there two qualitatively distinct forms of dissociation? A review and some
clinical implications. Clinical Psychology Review, 25, 1–23. doi:10.1016/j.cpr.2004.08.006
International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating
Dissociative Identity Disorder in adults, third revision. Journal of Trauma & Dissociation, 12,
115–187. doi:10.1080/15299732.2011.537247
Janet, P. (1889). L’Automatisme Psychologique [Psychological authomatism]. Paris, France: Félix
Alcan.
Janet, P. (1907). The major symptoms of hysteria. New York, NY: Macmillan. doi:10.1037/10008-
000
Joseph, R. (1999). The neurology of traumatic “dissociative” amnesia: Commentary and literature
review. Child Abuse & Neglect, 23, 715–727.
Jurist, E. L. (2005). Mentalized affectivity. Psychoanalytic Psychology, 22, 426 –444. doi:10.1037/
0736-9735.22.3.426
Jurist, E. L. (2010). Mentalizing minds. Psychoanalytic Inquiry, 30, 289 –300. doi:10.1080/
07351690903206496
Jurist, E. L. (2013). Posfazione [Afterword]. In V. Caretti, G. Craparo, & A. Schimmenti (Eds.),
Memorie traumatiche e mentalizzazione. Teoria, ricerca e clinica (pp. 297–312). Roma, Italy:
Astrolabio Ubaldini.
Jurist, E. L., Slade, A., & Bergner, S. (Eds.). (2008). Mind to mind: Infant research, neuroscience,
and psychoanalysis. New York, NY: Other Press.
Khan, M. M. R. (1963). The concept of cumulative trauma. Psychoanalytic Study of the Child, 18,
286 –306.
Kihlstrom, J. F. (1992). Dissociation and dissociations: A comment on consciousness and cognition.
Consciousness and Cognition: An International Journal, 1, 47–53. doi:10.1016/1053-
8100(92)90044-B
Kris, E. (1956). The recovery of childhood memories in psychoanalysis. The Psychoanalytic Study
of the Child, 11, 54 –88.
Krystal, H. (1997). Desomatization and the consequences of infantile psychic trauma. Psychoana-
lytic Inquiry, 17, 126 –150. doi:10.1080/07351699709534116
Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J. D., & Spiegel,
D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a
dissociative subtype. The American Journal of Psychiatry, 167, 640 –647. doi:10.1176/
appi.ajp.2009.09081168
Leuzinger-Bohleber, M. (2008). Biographical truths and their clinical consequences: Understanding
“embodied memories” in a third psychoanalysis with a traumatized patient recovered from
severe poliomyelitis. International Journal of Psychoanalysis, 89, 1165–1187.
Levine, P. (1997). Waking the tiger: Healing trauma. New York, NY: North Atlantic Books.
Liotti, G. (1992). Disorganized/disoriented attachment in the etiology of dissociative disorders.
Dissociation: Progress in the Dissociative Disorders, 5, 196 –204.
Liotti, G. (2006). A model of dissociation based on attachment theory and research. Journal of
Trauma & Dissociation, 7, 55–73. doi:10.1300/J229v07n04_04
Lynn, S. J., Lilienfeld, S. O., Merckelbach, H., Giesbrecht, T., McNally, R. J., Loftus, E. F., . . .
Malaktaris, A. (2014). The trauma model of dissociation: Inconvenient truths and stubborn
fictions. Comment on Dalenberg et al. (2012). Psychological Bulletin, 140, 896 –910. doi:
10.1037/a0035570
Lyons-Ruth, K., Dutra, L., Schuder, M., & Bianchi, I. (2006). From infant attachment disorgani-
zation to adult dissociation: Relational adaptations or traumatic experiences? Psychiatric Clinics
of North America, 29, 63–86. doi:10.1016/j.psc.2005.10.011
Main, M., & Morgan, H. (1996). Disorganization and disorientation in infant Strange Situation
behavior: Phenotypic resemblance to dissociative states? In L. Michelson & E. W. Ray (Eds.),
Dissociation: Clinical and theoretical perspectives (pp. 107–138). New York, NY: Plenum
Press. doi:10.1007/978-1-4899-0310-5_6
Main, M., & Solomon, J. (1986). Discovery of a new, insecure-disorganized/disoriented attachment
pattern. In T. B. Brazelton & M. Yogman (Eds.), Affective development in infancy (pp. 95–124).
Norwood, NJ: Ablex.
McGaugh, J. L. (1990). Significance and remembrance: The role of neuromodulatory systems.

Psychological Science, 1, 15–25. doi:10.1111/j.1467-9280.1990.tb00060.x
Meares, R. (2000). Intimacy and Alienation: Memory, trauma and personal being. London,
England: Routledge.
Mesman, J., Van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2009). The many faces of the
Still-Face Paradigm: A review and meta-analysis. Developmental Review, 29, 120 –162. doi:
10.1016/j.dr.2009.02.001
Nadel, L., & Jacobs, W. J. (1998). Traumatic memory is special. Current Directions in Psycho-
logical Science, 7, 154 –157. doi:10.1111/1467-8721.ep10836842
Nijenhuis, E. R. S. (2004). Somatoform dissociation: Phenomena, measurement and theoretical

issues. New York, NY: Norton and Company.

Nijenhuis, E. R. S., Spinhoven, P., Vanderlinden, J., Van Dyck, R., & Van der Hart, O. (1998).
Somatoform dissociative symptoms as related to animal defensive reactions to predatory threat
and injury. Journal of Abnormal Psychology, 107, 63–73. doi:10.1037/0021-843X.107.1.63
Nijenhuis, E. R. S., & Van der Hart, O. (2011). Defining dissociation in trauma. Journal of Trauma
& Dissociation, 12, 416 –473. doi:10.1080/15299732.2011.570599
Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. New
York, NY: Oxford University Press.
Park, C. R., Zoladz, P. R., Conrad, C. D., Fleshner, M., & Diamond, D. M. (2008). Acute predator
stress impairs the consolidation and retrieval of hippocampus-dependent memory in male and
female rats. Learning & Memory, 15, 271–280. doi:10.1101/lm.721108
Perry, B. D. (2008). Child maltreatment: A neurodevelopmental perspective on the role of trauma
and neglect in psychpathology. In T. P. Beauchaine & S. P. Hinshaw (Eds.), Textbook of child
and adolescent psychopathology (pp. 93–128). New York, NY: Wiley.
Piper, A., & Merskey, H. (2004). The persistence of folly: A critical examination of dissociative
identity disorder. Pt. 1. The excesses of an improbable concept. Canadian Journal of Psychiatry,
49, 592–600.
Pizer, S. (1998). Building bridges: The negotiation of paradox in psychoanalysis. Hillsdale, NJ: The
Analytic Press.
Porges, S. W. (1997). Emotion: An evolutionary by-product of the neural regulation of the
autonomic nervous system. Annals of New York Academy of Sciences, 807, 62–77. doi:10.1111/
j.1749-6632.1997.tb51913.x
Porges, S. W. (2001). The polyvagal theory: Phylogenetic substrates of a social nervous system.
International Journal of Psychophysiology, 42, 123–146. doi:10.1016/S0167-8760(01)00162-3
Putnam, F. (1997). Dissociation in children and adolescents: A developmental perspective. New
York, NY: Guilford Press.
Roelofs, K., Keijsers, G. P., Hoogduin, K. A., Näring, G. W., & Moene, F. C. (2002). Childhood
abuse in patients with conversion disorder. The American Journal of Psychiatry, 159, 1908 –
1913. doi:10.1176/appi.ajp.159.11.1908
Ross, C. A. (2000). The trauma model: A solution to the problem of comorbidity in psychiatry.
Richardson, TX: Manitou Communication.
Sander, L. W. (1987). Awareness of inner experience: A systems perspective on self-regulatory
process in early development. Child Abuse & Neglect, 11, 339 –346. doi:10.1016/0145-
2134(87)90007-X
Sar, V., Akyüz, G., Kundakçi, T., Kiziltan, E., & Dogan, O. (2004). Childhood trauma, dissociation,
and psychiatric comorbidity in patients with conversion disorder. American Journal of Psychi-
atry, 161, 2271–2276. doi:10.1176/appi.ajp.161.12.2271
Schimmenti, A. (2012). Unveiling the hidden self: Developmental trauma and pathological shame.
Psychodynamic Practice: Individuals, Groups and Organisations, 18, 181–194. doi:10.1080/
14753634.2012.664873
Schimmenti, A. (2013). Trauma evolutivo: Origini e conseguenze dell’abuso e della trascuratezza
nell’infanzia [Developmental trauma: On the origins and consequences of child abuse and
neglect]. In V. Caretti, G. Craparo, & A. Schimmenti (Eds.), Memorie traumatiche e mentaliz-

zazione. Teoria, ricerca e clinica (pp. 7–12). Roma, Italy: Astrolabio Ubaldini.
Schimmenti, A. (2014). Il trauma evolutivo e la ricerca dell’intimità: una prospettiva relazionale
[Developmental trauma and the search for intimacy: A relational purview]. Ricerca Psicoana-
litica, 5, 31–53. doi:10.3280/RPR2014-001004
Schimmenti, A., & Bifulco, A. (2013). Linking lack of care in childhood to anxiety disorders in
emerging adulthood: The role of attachment styles. Child and Adolescent Mental Health.
doi:10.1111/camh.12051
Schimmenti, A., & Caretti, V. (2010). Psychic retreats or psychic pits? Unbearable states of mind
and technological addiction. Psychoanalytic Psychology, 27, 115–132. doi:10.1037/a0019414

Schimmenti, A., Guglielmucci, F., Barbasio, C., & Granieri, A. (2012). Attachment disorganization
and dissociation in virtual worlds: A study on problematic Internet use among players of online
role-playing games. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 9, 195–202.
Schopenhauer, A. (1851/2000). Parerga and paralipomena. Oxford, NY: Clarendon Press.
Schore, A. N. (2009). Attachment trauma and the developing right brain: Origins of pathological
dissociation. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders:
DSM-V and beyond (pp. 141–153). New York, NY: Routledge.
Schwartz, H. L. (2000). Dialogues with forgotten voices: Relational perspectives on child abuse,
trauma, and the treatment of severe dissociative disorders. New York, NY: Basic Books.
Shengold, L. (1989). Soul murder: The effects of childhood abuse and deprivation. New Haven, CT:
Yale University Press.
Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New
York, NY: Guilford Press.
Solms, M., & Turnbull, O. (2002). The brain and the inner world: An introduction to the
neuroscience of subjective experience. New York, NY: Other Press.
Steele, K., Van der Hart, O., & Nijenhuis, E. R. S. (2005). Phase-oriented treatment of structural
dissociation in chronic traumatization: Overcoming trauma-related phobias. Journal of Trauma
& Dissociation, 6, 11–53. doi:10.1300/J229v06n03_02
Steele, K., Van der Hart, O., & Nijenhuis, E. R. S. (2009). The theory of trauma-related structural
dissociation of the personality. In P. F. Dell & J. O’Neill (Eds.), Dissociation and the dissociative
disorders: DSM-V and beyond (pp. 239 –258). New York, NY: Routledge.
Steiner, J. (1993). Psychic retreats: Pathological organizations of the personality in psychotic,
neurotic and borderline patients. London, England: Routledge. doi:10.4324/9780203359839
Stern, D. N. (1985). The interpersonal world of the infant. New York, NY: Basic Books.
Sugarman, A. (2008). The use of play to promote insightfulness in the analysis of children suffering
from cumulative trauma. The Psychoanalytic Quarterly, 77, 799 –833. doi:10.1002/j.2167-
4086.2008.tb00360.x
Taylor, G. J., & Bagby, R. M. (2013). Psychoanalysis and empirical research: The example of
alexithymia. Journal of the American Psychoanalytic Association, 61, 99 –133. doi:10.1177/
0003065112474066
Taylor, G. J., Bagby, R. M., & Parker, J. D. A. (1997). Disorders of affect regulation: Alexithymia
in medical and psychiatric illness. New York, NY: Cambridge University Press. doi:10.1017/
CBO9780511526831
Terr, L. C. (1988). What happens to early memories of trauma? A study of twenty children under
age five at the time of documented traumatic events. Journal of the American Academy of Child
and Adolescent Psychiatry, 27, 96 –104. doi:10.1097/00004583-198801000-00015
Tronick, E. Z., Als, H., Adamson, L., Wise, S., & Brazelton, T. B. (1978). The infant’s response to
entrapment between contradictory messages in face-to-face interaction. Journal of the American
Academy of Child & Adolescent Psychiatry, 17, 1–13. doi:10.1016/S0002-7138(09)62273-1
Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2005). Dissociation: An under-recognized major
feature of Complex PTSD. Journal of Traumatic Stress, 18, 413–424. doi:10.1002/jts.20049
van der Kolk, B. A. (1995). The body, memory, and the psychobiology of trauma. In J. L. Alpert
(Ed.), Sexual abuse recalled: Treating trauma in the era of the recovered memory debate (pp.
29 –60). Northvale, NJ: Jason Aronson.
van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for
children with complex trauma histories. Psychiatric Annals, 35, 401–410.
van der Kolk, B. A., Pelcovitz, D., Roth, S., Mandel, F. S., McFarlane, A., & Herman, J. L. (1996).
Dissociation, somatization, and affect dysregulation: The complexity of adaptation to trauma.
The American Journal of Psychiatry, 153(Suppl.), 83–93.
Vriends, N., Michael, T., Blechert, J., Meyer, A. H., Margraf, J., & Wilhelm, F. H. (2011). The
influence of state anxiety on the acquisition and extinction of fear. Journal of Behavior Therapy
and Experimental Psychiatry, 42, 46 –53. doi:10.1016/j.jbtep.2010.09.001

Wilson, J. P. (2004). PTSD and complex PTSD: Assessing psychological trauma and PTSD (2nd
ed., pp. 7–44). New York, NY: Guilford Press.
Winnicott, D. W. (1971). Playing and reality. New York, NY: Penguin Books.
Young, W. C. (1988). Psychodynamics and dissociation: All that switches is not split. Dissociation:
Progress in the Dissociative Disorders, 1, 33–38.

SCH Imment I 2016

Uploaded by

Copyright:

Available Formats

You might also like

SCH Imment I 2016

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

SCH Imment I 2016

Uploaded by

Copyright:

Available Formats

Psychoanalytic Psychology © 2014 American Psychological Association

2016, Vol. 33, No. 1, 106 –128 0736-9735/16/$12.00 http://dx.doi.org/10.1037/a0038019

LINKING THE OVERWHELMING WITH

In this article, we propose a developmental trauma model of psychopathology,

Keywords: trauma, dissociation, self-states, development, treatment

This article was published Online First October 13, 2014.

Research suggests that a strong connection exists between developmentally adverse

arousal and reactivity (e.g., hypervigilance; American Psychiatric Association, 2013).

Developmental trauma is a more theoretically driven construct, which refers to a

of the child (Schimmenti, 2012). This definition of developmental trauma partially

considered that, as a defense mechanism, dissociation represents an adaptive rather than

A Developmental Perspective on Childhood Trauma and Dissociation

ability to organize self-states may be damaged because of developmental trauma (Schim-

organized speech. According to this model, alexithymia may be conceived as a conse-

which is implicated in executive functioning and in regulating peripheral response to

Unintegrated Mental States

Unintegrated Bodily States

Developmental Trauma, Dissociation, and Disorders

Figure 1. A developmental trauma model of dissociation and psychopathology.

interrelated psychopathological pathways (these are represented as separate in the figure

Implications for Treatment

relationships, because dissociation disrupts the experience of intersubjectivity and the

McGaugh, J. L. (1990). Significance and remembrance: The role of neuromodulatory systems.

Nijenhuis, E. R. S. (2004). Somatoform dissociation: Phenomena, measurement and theoretical

issues. New York, NY: Norton and Company.

neglect]. In V. Caretti, G. Craparo, & A. Schimmenti (Eds.), Memorie traumatiche e mentaliz-

and technological addiction. Psychoanalytic Psychology, 27, 115–132. doi:10.1037/a0019414

and Experimental Psychiatry, 42, 46 –53. doi:10.1016/j.jbtep.2010.09.001

You might also like