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These lines from both the poet Walt Whitman and the Beatles span about 150 years. Like the best art, they have a depth of meaning that can be predictive and prescient.

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In American culture, we are witnessing a rapid evolution of public processing of our personal identities. On a basic level, this includes taking “selfies” and posting Facebook profiles. On another level, socially acceptable aspects of our identities are being expanded.

Gay marriage is rapidly becoming socially acceptable. As gay marriage has become legal in more and more states, it has changed the meaning of the personal identify of each of the spouses. However, the counter reaction to gay marriage is resulting in the anticipated Supreme Court ruling on this development. There is also more public expression of a variety of sexual preferences.

We also are observing and participating in a rapid public processing of gender identity preference. Twenty years ago, when I first began to work with those with gender identity disorders, public disclosure was rare due to prejudice, discrimination, and misunderstanding. Now, Caitlyn Jenner can come out on the cover of the July issue of 

The New Girl in School: Transgender Surgery at 18.

 For the most part, I saw patients who had a firm sense since early childhood of an identity opposite to their physical appearance and gender. Today, a preference to change one’s gender, to some extent, seems that it can be based on a desired social identity, besides-or even instead of-any sense of biological necessity.

From the racial or cultural standpoint, a critical uproar has occurred about a former Spokane NAACP official who posed and presented herself as “black.”Her “white” parents deny this claim.  Whether she was being intentionally deceptive or not, little has been said about the positive social aspects of someone from a majority cultural group wanting to be part of a minority group. We also have seen a rising interracial (and interfaith) marriage rate.

Most recently, we have the tragic killing in Charleston, South Carolina, of black Americans while they attended Church, by a young white male-an act of racial hatred. The perpetrator had a history of substance abuse, but nothing is yet clear about possible other mental disorders.


DSM-III classified identity disorder and focused especially on the difficulty adolescents have in forming a comfortable personal identity. This seemed relevant to the cultural psychiatry seminars I had with psychiatric residents, and allowed us to address how difficult it was for people who were culturally discriminated against to form a positive personal identity. In DSM-IV, identity disorder was omitted and replaced by the more innocuous “identity problem” under the additional codes section. In DSM-5, there is no identity classification. However, we have continued to use related and more specific identity terminology, such as dissociative identity disorder or gender identity disorder.

A similar progression has occurred with the recent international ICD codes. ICD-9 listed identity disorder of childhood or adolescence. In ICD-10, this code, 313.82, converted to the much more generic F93.8, other childhood emotional disorders.


These societal phenomena indicate how fluid identity is becoming. Yet, such rapid changes can be discomforting and challenging, both to those who are undergoing psychological change and to those who are uncomfortable with shifting societal norms. When we are uncomfortable with aspects of ourselves, we often psychologically project that onto others, and thereby hate that in others. Moreover, we are evolutionarily hard-wired to prefer our own in-group for security and safety reasons.

So often, therefore, for every two steps forward toward social tolerance, a counter-reaction produces one step backward. Perhaps some people with certain kinds of untreated or unrecognized mental problems and vulnerabilities can be even more sensitive and disturbed by rapid social changes.


Despite the disappearance of identity variations in diagnostic classifications, here are some ways we can contribute to solving social challenges:

• Educate the public about the psychological processes in developing a personal identity, including Erik Erikson’s work  on psychosocial development
• Affirm the normality of newer expressions of personal identity
• Offer help to those distraught by rapid social changes
• Convey the importance of early evaluation of emerging psychosis
• Provide access to early treatment of people with substance abuse
• Become part of police teams that address potentially violent cultural confrontations
• Be available to help with the grieving process for all affected by trauma and loss


Our challenge is to develop identities along the lines suggested by Walt Whitman and the Beatles, on both a local and international level. Only through a strong global identity can we make our common needs a priority, whether war or climate change. Indeed, as the Pope recently implied, our environment needs and the condition of the earth must be part of our valued identity.

So, yes, we all have a multitude of identities within us. We have aspects of both genders to one degree or another. We have a spectrum of sexual desires. We can imagine our older selves, and even now obtain computer projections of how we are likely to look as elders. We remember our childhood selves. We are close to 100% similar racially than different. Various cultural groups emphasize overlapping values. Our religious beliefs have many similarities. The Bible teaches us that we all are created in the image of God. Atheists and agnostics may share the same moral values as many religions.

A part of us should even identify with the walrus, and with the eggman, even if the Beatles thought they were nonsense terms. Nonsense would be to deny the many aspects of our human identity.

Despite the disappearance of identity variations in diagnostic classifications, psychiatrists can contribute to solving social challenges.

Changes and Challenges in Our Psychological Identities

[Editor’s note: In June 2014, we published “

Reforming Mental Health Care: How Ending ‘Recovered Memory’ Treatments Brought Informed Consent to Psychotherapy

” by R. Christopher Barden, PhD, JD. Dr Barden’s commentary elicited a number of lively responses. Here we present two letters, along with Dr Barden’s response to the first. This exchange marks the culmination in print of what began with Dr Richard Noll’s article, “Speak, Memory” and the “repressed recovered memory/multiple personality disorder” iatrogenic epidemic of the late 1980s and 1990s. We welcome your comments.]

It is quite understandable why psychologist-attorney Christopher Barden should want to take credit for psychiatric reform and for bestowing informed consent on psychotherapy patients; in this chaotic, complex, multifactorial world one must, I imagine, take credit when one can. It is also understandable that an attorney, even if also a psychologist, might present only one side of a case (that is what they do); for completeness, however, it may be instructive to identify some factors omitted in regard to the changes he noted.

The role of malpractice insurers is omitted. After a few of the huge runaway jury awards to which Dr Barden refers, insurers became quite prompt in settling such cases as, presumably, a form of damage control, especially since dozens, if not hundreds, of such cases, valid and bogus alike, were waiting in the wings. As research on the “other side” began to emerge-studies of how memory actually worked-and defense attorneys learned how to defend such cases successfully, there was a sharp drop in cases when prompt settlement could no longer be relied on. “Reform” did not happen so quickly merely because of successful litigation against practitioners. Indeed, many of us who testify in such cases have not even heard of such a case in years.

The role of the 1992 Lanning report is omitted. The FBI’s Kenneth Lanning became the actual Fox Mulder (

 protagonist) when he began to be assigned satanic ritual abuse cases that were claimed to have interstate manifestation, hence, an FBI issue. Approaching, from a pure law enforcement perspective, the claims about murdered persons, ritually sacrificed babies, and the like, he found no physical traces of such events in any instance. That was a tipping point that had no relationship to actual litigation.

The normal role of recall in psychotherapy-and medicine-is omitted (“When did you have your last vaccination?” “I don’t recall, let me think: oh, yes.”). Normal life is rife with memory recovery, as is psychotherapy. Since psychotherapeutic exploration often goes in unexpected directions with unexpected recollections and unexpected effects, it is especially problematic for patients to give informed consent to so many unknowns. When a patient reveals something previously long unrecalled, is that repression? Avoidance? Dissociation? Simple forgetting? It is not often possible to distinguish among these phenomena.

It may be useful to recall that evidence-based practice began in general medicine first, as the ability of the field increased so as to obtain data from an ever-widening pool of sources. While identifying such an evidence base is inherently more complex in psychotherapy, I would agree with Dr Barden that that is probably a good thing.

Dr Gutheil is Professor of Psychiatry at Harvard Medical School, Boston, and a member of the Psychiatric Times editorial board. He has written extensively on forensic memory issues, often pleading for non-hysterical and non-extreme conceptualizations. In the one “memory” case for which Dr Gutheil testified for the defense against plaintiff’s attorney Dr Barden, the defense prevailed. Given the vicissitudes of juries, Dr Gutheil refrains from taking credit for that.

Many of my colleagues and I spoke out regarding informed consent rights in psychotherapy in 1994: to the US Congress; to juries; to audiences at CME, CPE, and CLE activities; and to the national media.

We focused on several goals in Memory Wars I:

• Protecting vulnerable patients and the public from reckless and abusive repressed recovered memory/multiple personality disorder (RRM/MPD) pseudo-treatments

• Relying on the power of the US legal system and the wisdom of citizen juries to enforce important systemic reforms over the objections of powerful, well-financed mental health industry interests (eg, the American Psychiatric Association [APA], the American Psychological Association)

• Using the newly minted Daubert legal process to exclude unreliable theories such as RRM/MPD from courtrooms

• Teaching, enforcing, and protecting the fundamental human right of informed consent for psychotherapy patients

As history clearly shows, in just a few short years (1994-1997), our multidisciplinary methods essentially achieved these goals, thus bringing rapid, yet profound reforms to the US mental health system. Although Memory Wars I brought informed consent to psychotherapy, closed many MPD clinics, revoked the licenses of leaders of the RRM/MPD movement, and informed/warned millions of consumers via international media, the ongoing debate over the role of the science of memory in mental health, law, and public policy-Memory Wars II-continues.

For those who have not had a chance to review actual case files of RRM/MPD clinics, please read the article, “Cult of Madness” by Ann Zimmerman

 to see the kinds of abusive practices we sought to end in Memory Wars I.

Dr Gutheil refers to me as a psychologist-lawyer but omits that I was trained and practiced as a child, family, and adult psychotherapist and researcher. I practiced in universities, hospitals, and medical schools, studying coping and resilience in children and families struggling with serious diseases and disabilities.

 In my early career in health care, I never anticipated becoming a lawyer, much less a litigator for mental health reform.

In mid-1997, as Memory Wars I raged nationwide, I gave Dr Gutheil an opportunity to publicly support the universal right of informed consent. He missed the chance. I recall Dr Gutheil answering my cross-examination by saying, “I guess the question is whether there really is any informed consent to psychotherapy, which I’m not convinced about.”

 A few months after Dr Gutheil’s testimony, the $10.6 million settlement in the Burgus v Braun case and the resulting international media firestorm were the final straws in the dramatic collapse of the RRM/MPD industry. Just a few years later, in 2001, following a string of ongoing licensing revocations and Daubert litigation victories, Dr Gutheil reversed course and publicly adopted our 1994 reform position-that psychotherapy patients should receive the protections of informed consent.

Further proof that our coordinated collapse of the RRM/MPD industry and the resulting wave of licensing revocations did indeed bring informed consent to psychotherapy includes the work of Dr Paul Fink, former President of the APA. Dr Fink provided documentary evidence that well into the 1990s prominent leaders in psychiatry simply did not believe psychotherapy patients deserved informed consent protections. Dr Fink

 wrote, “The foes of psychotherapy have developed an interesting tactic-a demand for informed consent for psychotherapy.”

Additional proof that our Memory Wars I victory of 1997 brought informed consent to psychotherapy includes the 1996 APA “Principles of Informed Consent in Psychiatry,” Section 7, which states: “Psychotherapy: Informed consent developed in the context of invasive procedures and has since been extended to treatment with medication. 

There has always been uncertainty as to the extent to which the doctrine of informed consent is applicable to psychotherapy

 In stark contrast, following our tsunami of coordinated litigation and licensing cases, virtually all experts in psychotherapy, mental health, ethics, public policy, or law-including the once-skeptical Dr Gutheil-have adopted our 1994 reform position that psychotherapy patients do indeed have a fundamental right to informed consent protections. This new and universal acceptance of informed consent protections for psychotherapy patients was surely one of our greatest victories in Memory Wars I.

Dr Gutheil also noted that he testified in the 

 case-a unique defense verdict. Fortunately for the mental health reform movement, the Green defense verdict had a powerful, paradoxical impact on the settlements of many other cases. Shortly after the Green verdict, the defense attorneys made the extraordinary error of seeking payment of all costs and legal fees from an indigent plaintiff. I remember when defense counsel carefully documented defense costs and fees of over $1.2 million compared with the $40,000 expended by the tiny local plaintiff’s law firm I assisted in that case. Following the Green case “loss,” our settlements were larger and more rapidly obtained. As one defense attorney put it, “The Green case showed us it was possible to defeat you in court, Dr Barden, but only if we outspent you $30 to $1” and “only if we spent over $1 million per patient defending these [RRM/MPD] cases.” In effect, the Green case enhanced our reform work.

As the public record demonstrates, multidisciplinary team efforts rapidly and successfully ended Memory Wars I. These efforts closed abusive MPD clinics, ended the national wave of criminal prosecutions based solely on “recovered memory” testimony tainted by suggestive therapy, restricted or revoked the licenses of reckless founders of the RRM/MPD movement, informed millions worldwide via media exposes, generated powerful advances in the science of memory and false memory, and ended debate as to whether informed consent protections should be available to psychotherapy patients.

Although this history of reform is well documented, an essential question remains. Why were these extraordinary multidisciplinary team efforts necessary to stop such clearly abusive and dangerous pseudotreatments? Why did Ken Lanning and the FBI have to spend millions investigating and debunking rather obvious pseudomemories? Why didn’t the mental health “guilds”-psychiatry, psychology, and social work-move to end the RRM/MPD industry, voluntarily bring informed consent protections to psychotherapy, issue national health warnings against dangerous RRM/MPD “treatments,” and quickly close one of the most tragic chapters in the history of the mental health system? Why did they leave it to our multidisciplinary teams, citizen juries, and licensing boards to do the heavy lifting of reform? A final question involves our future mental health system. The next time dangerous mental health quackeries stalk the land, will the guilds act to protect patients, or once again circle the wagons and protect colleagues?

I look forward to working with talented professionals like Dr Gutheil to continually improve the mental health system and ensure that patients receive the fundamental protections of informed consent as well as treatments proven safe and effective by credible, reliable science.

 Barden RC, Meehl PE, Campbell TW, et al. Joint letter to the Congress of the United States of America regarding reform of the mental health system. 

. Montreal: Robert Davies Publishing; 1996.

. October 14, 1999. http://www.dallasobserver.com/1999-10-14/news/cult-of-madness. Accessed July 10, 2014.

 Barden RC, Kinscherff R, George W III, et al. Emergency medical care and injury/illness prevention systems for children: an economic-medical-legal-psychological analysis and legislative proposals. I. 

 Barden RC. The effects of craniofacial deformity, chronic illness, and physical handicaps on patient and familial adjustment: research and clinical perspectives. In: Lahey BB, Kazdin AE, eds. 

. Vol 13. New York: Plenum Press; 1990:343-375.

 Barden RC. Cross-examination of Thomas Gutheil, MD, in 

, Case No. 96-CVS-5235, Mecklenburg County, North Carolina; 1997:138.

 Beahrs JO, Gutheil TG. Informed consent in psychotherapy. 

 American Psychiatric Association Council on Psychiatry and Law. Principles of Informed Consent in Psychiatry. June 1996. http://www.tn.gov/didd/provider_agencies/ProviderManual/Appendix%20U%20-%20APA%20Informed%20Consent.pdf. Accessed July 14, 2014.

Denying Dissociation and Attacking Mental Health Care

Diagnosing dissociation does not make it happen, and denying it does not make it go away. Dr Barden has a vested interest in advocating for a certain point of view in suing psychotherapists. But he has not always prevailed. When he took the Susan Greene case to a North Carolina jury in 1998, the jury found for all defendant mental health professionals, and not for Barden’s client.

It seems that Barden is not well informed about dissociative identity disorder (DID) research and treatment. Contrary to his claims, the literature has shown for decades that DID patients improve during treatment. Research on DID treatment includes 10 publications based on an international treatment outcome study involving 280 therapists and their patients (Treatment of Patients with Dissociative Disorders [TOP DD] study).

 The TOP DD study showed that consistent treatment based on DID expert consensus guidelines is associated with decreased dissociation, PTSD, depression, distress, self-harm, suicide attempts, physical pain, and hospitalizations as well as improved functioning-including increased socializing and better school attendance.

 found that symptoms of DID (eg, amnesia) failed to improve when clinicians did not focus on DID symptoms, although other symptoms improved. A meta-analysis of 8 dissociative disorders treatment studies found moderate to large pre- and post-effect sizes across 7 types of symptoms (mean = 0.71).

The claims that DID treatment is harmful are based on anecdotal cases, opinion pieces, reports of damage that are not substantiated in the scientific literature, misrepresentations of the data, and misunderstandings about DID treatment and the phenomenology of DID. Given the severe symptomatology and disability associated with DID, iatrogenic harm is far more likely to come from depriving DID patients of treatment that is consistent with expert consensus, treatment guidelines, and current research.

Dr Barden wrongly assumes that memory “recovery” is the primary focus of treatment. A survey of DID experts found that at no stage in treatment was the processing of trauma memories one of the most frequently recommended treatment interventions, not even during the middle phase when DID patients occasionally discuss trauma in detail.

 The experts preferentially advocated teaching of symptom management techniques and practicing containment of traumatic memories. Containment techniques are the opposite of exploring trauma memories and assist patients in achieving greater distance from, and mastery over, intrusive flashbacks of traumatic memories; that actually permits the successful resolution of traumatic memories in treatment.

Barden seems oddly uninformed about research involving the empirically established link between trauma and dissociation published in numerous scientific journals.

 This type of research is the reason why DID and a new dissociative subtype of PTSD are included in DSM-5.

Dissociation existed long before psychiatry did. We didn’t create it. Treating it well is the least we can do.

Clinical Professor, Dept of Psychology
Towson University
Towson, Md

Clinical Professor, Dept of Psychiatry
University of Maryland School of Medicine, and Sheppard Pratt Health System
Baltimore

Willson Professor and Associate Chair
Dept of Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Stanford, Calif

 Brand B, Classen C, Lanius R. A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians. 

 Brand B, Loewenstein RJ. Does phasic trauma treatment make patients with dissociative identity disorder treatment more dissociative? 

 Brand BL, Lanius R, Vermetten E, et al. Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. 

 Jepsen EK, Langeland W, Heir T. Impact of dissociation and interpersonal functioning on inpatient treatment for early sexually abused adults. 

 Brand BL, McNary SW, Myrick AC, et al. A longitudinal, naturalistic study of dissociative disorder patients treated by community clinicians. 

 Brand BL, Classen CC, McNary SW, Zaveri P. A review of dissociative disorders treatment studies. 

 Brand BL, Loewenstein RJ, Spiegel D. Dispelling myths about dissociative identity disorder treatment: an empirically based approach. 

 Brand BL, Myrick AC, Loewenstein RJ, et al. A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. 

 Dalenberg CJ, Brand BL, Loewenstein RJ, et al. Reality versus fantasy: reply to Lynn et al. 

 Dalenberg CJ, Brand BL, Gleaves DH, et al. Evaluation of the evidence for the trauma and fantasy models of dissociation. 

 Lanius RA, Vermetten E, Loewenstein RJ, et al. Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. 

 Stein DJ, Koenen KC, Friedman MJ, et al. Dissociation in posttraumatic stress disorder: evidence from the world mental health surveys. 

 Dorahy MJ, Brand BL, Sar V, et al. Dissociative identity disorder: an empirical overview. 

 Spiegel D, Loewenstein RJ, Lewis-FernÃ¡ndez R, et al. Dissociative disorders in DSM-5. 

 Spiegel D, Lewis-FernÃ¡ndez R, Lanius R, et al. Dissociative disorders in DSM-5. 

This exchange follows what began with Dr Richard Noll’s article, “Speak, Memory” and the “repressed recovered memory/multiple personality disorder” iatrogenic epidemic of the late 1980s and 1990s.

Letters to the Editor: Response to “Reforming Mental Health Care”

In the midst of dictating a letter, Sherwood Anderson (1876-1941), then president of the Anderson Manufacturing Company, stopped speaking and began to stare down at his feet. His astonished secretary inquired, “Are you feeling ill?” Anderson continued to look down and spoke cryptically, “My feet are cold, wet, and heavy from long wading in a river. Now I shall go walk on dry land.”

 He is reassuring in a note he wrote to his wife, Cornelia: “There is a bridge over a river with cross ties before it. When I come to that I’ll be alright. I’ll write all day in the sun and the wind will blow through my hair . . .”

That day, November 27, 1912, was pivotal in his life. When he closed the door to his company, he walked for 4 days along the railroad tracks, 30 miles from Elyria to Cleveland, Ohio. He wound up at a pharmacy, disoriented and disheveled, and he was taken to the psychiatric ward of a hospital.

After discharge, Anderson relocated to Chicago where he joined a literary group, sent for his wife and 3 children, divorced her in 1914, immediately married someone else, and began to write 

Winesburg, Ohio: A Group of Tales of Ohio Small-Town Life

 The book, published in 1919, would be proclaimed a masterpiece. The flourishing writer’s group-the Chicago Literary Renaissance-along with Theodore Dreiser, Vachel Lindsay, Edgar Lee Masters, and Carl Sandburg, depicted the contemporary urban environment, decrying the loss of traditional rural values in an increasingly industrialized and materialistic American society. They noted the failure of the romantic promise that hard work would automatically bring material and spiritual rewards.

Anderson later described the events that led to his hospitalization as “escaping from his materialistic existence.” A psychiatrist in the Cleveland hospital where he was a patient might have diagnosed what 

DSM-5 currently terms dissociative amnesia

Dissociative amnesia (DSM-5 300.12) (subtype dissociative fugue) and Journey of the Traumatized Hero


Although it is conjectural for a psychiatrist to make a diagnosis 

 presumably Sherwood Anderson appears to have had a condition DSM-5 terms “dissociative amnesia, subtype dissociative fugue.”

 This condition is characterized by a marked but reversible impairment of recall of important personal information, too extensive to be explained by ordinary forgetfulness.

There is a connection between the events of Anderson’s life and an archetypal human odyssey I coin the “

In this journey, the first step is “trauma,” and PTSD follows, with symptoms of re-experiencing trauma in flashbacks, nightmares, or fearful daydreams; avoidance symptoms (eg, psychic numbing, emotional anesthesia with trouble remembering the precipitating event); and hyperarousal symptoms (eg, being easily startled, feeling tense, jittery, or “on edge”). The journey is an internal-not geographic-process, but physical relocation (as in Anderson's fugue) may occur. If successful, 

, a boon is acquired, and egocentricity ends.

Anderson’s inability to move beyond the abyss led to a psychiatric impasse (

). In Chicago he was able to shift from participant-observer to the role of a 

 and transform the misery of the first 3 decades of his life into literature.


•On December 3, 1926, Agatha Christie, disappeared, only to reappear 11 days later with no memory of the events during that time. On the day of her disappearance, Agatha’s husband, Archie, revealed that he was in love with another woman and wanted a divorce. The couple quarreled, and Archie left their house in Sunningdale, Berkshire, to spend the weekend with his mistress at Godalming, Surrey. Around 9:45 in the evening, without warning, Agatha drove away from the house, having first gone upstairs to kiss her sleeping daughter, Rosalind.

Her abandoned Morris Cowley was later found down a slope at Newlands Corner near Guildford. There was no sign of her, and the only clue was a letter for her secretary saying that she was going to Yorkshire. Her disappearance caused an outcry from the public, many of whom were admirers of Agatha Christie’s novels. Despite a massive manhunt, there were no results at all. Eleven days after her disappearance, Christie was identified as a guest at the Swan Hydropathic Hotel

in Harrogate, where she was registered as “Mrs Teresa Neele” from Cape Town.

Christie gave no explanation for her disappearance. Doctors diagnosed amnesia or a fugue state brought about by depression, exacerbated by her mother’s death earlier that year, and the discovery of her husband’s infidelity. Others speculated Christie was trying to make the police think her husband killed her as revenge for his affair.

, went missing in 1985 and was found 12 years later in Sitka, Alaska, living under the name of “Jane Dee Williams.” While there were some initial suspicions that she had been faking amnesia, some experts have come to believe that she genuinely suffered a protracted fugue state.

•David Fitzpatrick entered a fugue state on December 4, 2005, and he is still working on regaining his entire life’s memories.

•Hannah Upp, a teacher from New York, disappeared missing on August 28, 2008, and was rescued from the New York Harbor

on September 16 with no recollection of the time in between. The episode was diagnosed as dissociative fugue.

•Jeff Ingram appeared in Denver in 2006 with no memory of his name or where he was from. After appearing on national television to appeal for help, his fiancÃ©e Penny called Denver police and identified him. The episode was diagnosed as a dissociative fugue. Jeff has experienced 3 incidents of amnesia: in 1994, 2006, and 2007.


To understand the psychodynamics of the dissociative fugue, one may analyze some of the characters in 

It is a collection of interrelated vignettes set in small town America, loosely connected by the narrator, journalist George Willard, Anderson’s alter ego. It is a remarkable literary venture.

“America should read this book on her knees,” Hart Crane

 wrote. “It constitutes an important chapter in the Bible of her consciousness.” Through George, Anderson gave voice to those who had entrusted him with the story of their lives.

The book begins with an elderly writer who hires a carpenter to rebuild his bed so that it is level with his window and he can see the trees across the way in the morning. After work is completed, the writer lies in the bed and reflects about death. As sleep approaches, in a hypnogogic hallucination, all the people he has ever met pass slowly before his eyes, seen by him as “grotesques”

some amusing, some terribly sad, and some horrifying. Immediately after this experience, he climbs out of bed and writes down everything that he saw in a book, which he calls “The Book of the Grotesque.” The old man conjectures that the world is full of different truths, all of them beautiful, but when a person seizes on and tries to live by one truth alone, that person’s life becomes distorted. He writes obsessively for hundreds and hundreds of pages, but in the end, he never publishes the book.

The “grotesques” live in a mental jail, detached from others, in a town where communication is impossible. They are, however, able to communicate with the perceptive newspaper reporter of the 

, George Willard, to whom they tell their stories, hoping he will find meaning in them and perhaps give expression to it in his writing. Dr Parcival hopes that George Willard “will write the book I may never get written,” and for Enoch Robinson, Willard represents “the youthful sadness, young man’s sadness, the sadness of a growing boy in a village at the year’s end [which may open] the lips of the old man.”

This is problematic for George, who does not know how to interact with or understand them. He is an outsider, and on the continuum between “observer” and “participant,” an observer. As he matures, he becomes more engaged with others in town. Literary critic Irving Howe

 notes that George does not meet the needs of the inhabitants of Winesburg nor they his.

What the grotesques really need is each other, but their estrangement is so extreme they cannot establish direct ties-they can only hope for connection through George Willard. The burden this places on the boy is more than he can bear. He listens to them attentively, he is sympathetic to their complaints, but finally he is too absorbed in his own dreams. The grotesques turn to him because he seems “different”-younger, more open, not yet hardened-but it is precisely this “difference” that keeps him from responding as warmly as they want. It is hardly the boy’s fault; it is simply in the nature of things. For George Willard, the grotesques form a moment in his education; for the grotesques, their encounters with George Willard come to seem like a stamp of hopelessness.

Ultimately, Sherwood Anderson’s dissociative fugue was a gradual shift in psychological stance from observer to participant-observer to

, Anderson became a creative participant, finally giving voice to the grotesques whom the elderly writer describes in the prologue: “Some [who] were amusing, some almost beautiful, and one, a woman all drawn out of shape, hurt the old man by her grotesqueness. When she passed he made a noise like a small dog whimpering . . . All of the men and women the writer had ever known.”


Dissociative amnesia, subtype psychogenic fugue, is characterized by reversible amnesia for personal identity.

 The state is usually short-lived (ranging from hours to days but can last months or longer); usually involves unplanned travel or wandering; and is sometimes accompanied by the establishment of a new identity. Fugues are usually precipitated by a stressful episode. Upon recovery, amnesia of the original stressor may occur (dissociative amnesia

When he had his breakdown, Anderson entered what Campbell

 calls an “abyss”-a psychogenic fugue or other dissociative process that involves the disintegration of the ego and a breakthrough expansion of consciousness. During Anderson’s lifetime, he had 4 wives, 3 children, 2 careers, and 1 masterpiece, 

 In a dissociative fugue Anderson's unconscious mind closed a trap door and he ventured on the journey of the traumatized hero. His words come to mind:

All men lead their lives behind a wall of misunderstanding they have themselves built, and most men die in silence and unnoticed behind the walls. Now and then a man, cut off from his fellows by the peculiarities of his nature, becomes absorbed in doing something that is personal, useful and beautiful. Word of his activities is carried over the walls.

As the dust settles over the literature of past century, Sherwood Anderson, “cut off from his fellows by the peculiarities of his nature”

 (dissociative amnesia), creates a literary masterpiece out of the adversities of his life.

Sherwood Anderson: A Writer in America, Volume 1.

 Madison, Wisc: University of Wisconsin Press; 2006.


. Psych Central. pro.psychcentral.com/2013/dsm-5-changes-dissociative-disorders/004410.html. Accessed June 5, 2013.


Spiegel D, Lewis-FernÃ¡ndez R, Lanius R, et al. Dissociative disorders in DSM-5. 

. New York: William Sloane Associates;1951.


 New York: Princeton University Press, 1949.

To understand the psychodynamics of the dissociative fugue, Dr Michael Sperber analyzes some of the characters in a collection of interrelated vignettes set in small town America. 

Dissociative Amnesia (Psychogenic Fugue) and a Literary Masterpiece

I like to work with people who genuinely want to change their lives . . . who don’t just want to feel better, but who really want to give themselves new options. Some people have a tremendous drive to change and to make their lives better. You treat them to increase their freedom, to make choices. If they want to change, they’ll change; if they want to stay the way they are, they will remain the way they are. But at least they are able to make a free decision about what to do. They are not encumbered by neurotic conflicts.

A neurotic conflict is something that keeps you from doing what a major part of you really wants to do. You want to live a certain way or have a particular kind of relationship, but you find yourself not living that way or not having that relationship. Something stops you . . . be it fear, guilt, anger. You either can’t go ahead with what you want or you don’t know what you want. Therapy is a matter of cleaning the dust off so that you can see what’s underneath.

You have to go layer by layer. You want the information, but not in a form that the patient can’t deal with it. You have to ease the patient into it. Things are hidden, covered up because they are intolerable. If you just expose it, a patient can have a dissociative reaction, or can be in denial. There is no point. You can’t script somebody and say, “Okay, now go ahead and do it.” It does not work that way. It’s not constructive.

I can’t draw some people out, and that’s very difficult. Every now and then, something gets through and there is a glimmer of some movement. I probe and might even provoke to get some kind of reaction. People are so well defended or so afraid to crack the surface. And you cannot cure everybody. That’s a hard thing to accept.

In my office, I keep a lot of plants and flowers. They create an atmosphere. The light illuminates things. You see very clearly with the light. It nurtures you. This is where people grow, develop, and evolve. People and plants.

If the plants are not doing well, some patients get very upset. They wonder what I am doing wrong. They might say, “What’s the matter with that plant?” I think they want me to make the plant better rather than to discard it. The fear is that if the plant does not get better, I will throw it out. And some plants die.

Being a therapist can be draining. I was tired one day and one of my kids asked, “Mom, why are you so tired? I explained, “I had a long day in the office.” He laughed, “All you do is sit around all day and listen to people’s stories.” It’s true: you sit and listen to people’s stories. But it’s extremely active listening. And that’s hard work.

Therapy is a matter of cleaning the dust off so that you can see what's underneath.

Intimate Portrait: Marsha D. Rosenberg, MD

In psychiatric practice, many depressed patients lack an optimal course of treatment-ie, a “simple” antidepressant medication, with or without psychotherapy-that results in complete symptom remission. The simplest definition of treatment-resistant depression (TRD) is “failure to achieve a response to a medication to any degree short of remission.”

 Addressing the complicating factors that may be responsible for TRD early may improve treatment outcomes.

The role of subtyping and bipolarity in TRD was discussed in Part 1 of this 2-part article

Confounding Factors in TRD Part 1: The Role of Subtyping and Bipolarity

). Here we review a number of the most common confounding factors of TRD but limit our scope to comorbidities that can be directly addressed and treated by psychiatrists. Subtle maladaptive personality traits or inherent temperamental factors may play a role in sustaining depression in certain individuals. Axis I diagnoses, such as eating disorders, anxiety disorders, and sleep disorders, complicate the treatment of depression unless they are directly addressed. Dissociative disorders may also complicate the treatment of depression.

The role of anxiety and anxiety disorders in TRD

Clinicians have long recognized that treatment of depression may be unsuccessful if accompanying anxiety disorders are not recognized and addressed. Even comorbid subsyndromal anxiety symptoms can complicate the treatment of depression and lead to TRD. Anxiety and depression co-occur frequently, sometimes with one or the other as the primary and preceding diagnosis, but often with a mixture of depressive and anxiety symptoms that is difficult to disentangle historically or clinically.

In their examination of generalized anxiety disorder (GAD) and its association with major depression, Moffitt and colleagues

 followed a group of approximately 1000 New Zealanders from birth to age 32. In this cohort, either MDD or GAD presented as the initial illness. High comorbidity of the two illnesses was demonstrated: 72% of patients with GAD had lifetime MDD, and 48% of MDD patients had lifetime GAD. The extent of the association between depression and anxiety disorders in general is further illustrated by the National Comorbidity Survey, which found that an anxiety disorder was present in 58% of the patients with a lifetime history of depression.

Anxiety symptoms may make depression harder to treat. Studies have shown that comorbid anxiety in depression is associated with greater severity and longer time to recovery; poorer response to medication; multiple drug trials; more frequent relapses and recurrences; increased social and vocational disability; and perhaps most importantly, an increased rate of suicide, especially in the first year of treatment.

One dissenting study found no association between GAD and TRD; however, this study had a small sample size, and it was a retrospective analysis of failed drug studies.

 Furthermore, this negative study focused narrowly on GAD, while confirmatory studies look more broadly at anxiety disorders and include subsyndromal symptoms, such as psychic anxiety, worry, phobic symptoms, and somatic anxiety.

 Subsyndromal symptoms can be debilitating, even when they do not meet DSM criteria. A comprehensive evaluation for an accompanying DSM-IV-TR anxiety disorder in patients with depression should include screening for agoraphobia, GAD, obsessive-compulsive disorder, panic disorder, PTSD, social phobia, and specific phobia (formerly simple phobia). Although any of these might accompany a specific depression diagnosis, the most commonly reported are social phobia, specific phobia, and PTSD.

The increased risk of treatment resistance in depressed patients with anxiety symptoms has also been demonstrated in the geriatric population. A recent study of patients older than 70 years with major depression used a self-rating scale for anxiety and found that elevated scores on this scale were associated with poorer response to treatment, increased rate of recurrence in the first 2 years of illness, and increased rate of treatment drop-out.

 Anxiety was viewed in this population as creating a “brittle response” to standard antidepressant treatment. Interestingly, in this study, adjunctive lorazepam (added to paroxetine) did not improve outcomes. The authors suggest that further studies of adjunctive use of psychotherapies and atypical antipsychotic medications in the elderly are needed.

What are the implications of this strong association between anxiety and depression? The most dreaded outcome of depression is suicide, and the destabilizing effect of anxiety in patients who are struggling with suicidal impulses in the setting of major depression increases this risk. Fawcett

 exemplifies this with case reports of 3 patients who ultimately committed suicide and who serve as object lessons for those who care for patients with major depression in both inpatient and outpatient settings.

These cautionary tales illustrate the importance of monitoring for anxiety and agitation in depressed patients. Be particularly aware of escalating anxiety that can accompany the onset of treatment with antidepressants, including SSRIs and TCAs. Because patients with anxiety disorders tend to be very sensitive to the adverse effects of medications, consider beginning antidepressants at lower than usual dosages and slowly titrating the dosage in depressed patients with comorbid anxiety.

The increased suicide risk in the first year of treatment mandates that follow-up psychiatric treatment should be well-designed and reliable. The ongoing suicide risk assessment of patients with depression should give special valence to accompanying anxiety, and its presence may call for increased monitoring or hospitalization.

Pharmacological management of patients with mixed anxiety-depression might include benzodiazepines, but their risks of sedation and dependence must be considered. Although many of the SNRIs and SSRIs have received separate indications for various anxiety disorders, there may be differential responses to these medications. For instance, one study reported better outcomes with the SNRI venlafaxine than with the SSRI fluoxetine for patients with MDD and GAD.

 There may also be a role for other medications in patients with depression accompanied by anxiety, including low-dose atypical antipsychotics, anticonvulsants (divalproex, carbamazepine, gabepentin, lamotrigine, and topiramate have shown effects in smaller studies), and buspirone.

 Î²-Blockers are useful in blocking peripheral manifestations of anxiety, but caution is advised when treating depressed patients because of the possible depressogenic effect.

Dissociative phenomena and their relationship to TRD

In the evaluation and treatment of patients with depression, dissociation in one of its many forms is easily overlooked as a contributing factor for treatment resistance. In DSM-IV-TR, dissociative disorders are Axis I disorders in which there are significant disruptions in memory, consciousness, identity, or the perception of the environment. There are currently 5 dissociative diagnoses in DSM-IV-TR: dissociative identity disorder (formerly known as multiple personality), dissociative amnesia, dissociative fugue, depersonalization disorder, and dissociative disorder not otherwise specified (NOS).

A thorough psychiatric evaluation includes screening questions for dissociative phenomena, especially when a patient presents with a known history of trauma or abuse. However, patients may not be open about abuse histories and may also fail to spontaneously disclose dissociative experiences, especially if the focus of the evaluation is on mood symptoms. Psychiatrists who treat large numbers of patients with dissociative disorders find that in many, the condition has been undiagnosed for a number of years.

Depression and dissociative disorders both represent final common pathways for patients who have suffered abuse in childhood or have undergone traumatic incidents as adults. For this reason, when a patient has such a history, it may be important to consider using a structured interview for dissociative disorders, such as the Structured Clinical Interview for DSM-IV (SCID-D), or a screening tool, such as the Dissociative Experiences Scale.

Using these instruments, one inpatient study of 171 consecutively admitted patients to a state hospital in Massachusetts found that 15% of these patients met criteria for a dissociative disorder. In this study, the most common dissociative diagnoses were dissociative identity disorder, dissociative amnesia, and dissociative disorder NOS. Furthermore, and relevant for considerations of TRD, there was a high rate of comorbid depressive illness among the patients with the various dissociative disorders.

Dissociative phenomena can be mistaken for psychosis. Marcum and colleagues

 reported the case of a 29-year-old man who had failed to respond to a high-dose antidepressant and antipsychotic regimen for what was presumed to be a major depression with psychotic features. This patient had experienced childhood sexual abuse at the hands of an older brother. A sodium amytal interview gave strong evidence for dissociative identity disorder, and the patient subsequently responded to hypnotherapeutic sessions, with a marked decrease in depressive symptoms and normalization of biological markers for depression.

Disturbance of sleep is a common complaint among patients with MDD and other Axis I disorders. In the initial treatment approach for a patient who presents with insomnia and depressed mood, a sedative/hypnotic or low-dose trazodone at bedtime is often used to supplement the main full-dose antidepressant. Usually, sleep quality and quantity improve with depression. However, when mood symptoms fail to respond to adequate psychotropic management or psychotherapy, TRD should be suspected. Further workup for comorbid medical issues or review of the differential diagnoses is necessary.

Multiple factors related to sleep may contribute to poor response in depression treatment. Lack of exercise, insufficient time for sleep, shift work, and disruptive drugs and substances (eg, excessive or ill-timed use of alcohol and caffeine) can lead to poor sleep quality, daytime sleepiness, or fatigue.

Perhaps less identified in psychiatry offices are sleep-related breathing problems-most commonly obstructive sleep apnea (OSA). OSA is a sleep disorder characterized by repeated obstruction of the upper airways resulting in apnea (complete) or hypopnea (partial), with corresponding oxygen desaturations and arousals from sleep.

OSA is common in both clinical and general populations. The estimated prevalence of OSA in Veterans Health Administration patients is 2.91%.

 This compares well with the 2.1% prevalence observed in a general population, cross-sectional telephone survey in Western Europe.

 However, approximately 20% of patients with MDD also have a breathing-related sleep condition.15 The converse relationship yielded a similar concurrence rate. These data confirm that depressed patients are at higher risk for sleep apnea.

While OSA and depressed mood commonly occur together, it is unclear whether depression is a primary process or the manifestation of disordered sleep. Excessive daytime sleepiness, impaired concentration, low libido, memory difficulties, and neuropsychological testing deficits are among the consequences of OSA. These symptoms overlap with MDD. Treatment of both disorders are needed to minimize their effects on the patient.

The role of subtyping and bipolarity in TRD was discussed in Part 1 of this 2-part article. Here we review a number of the most common confounding factors of TRD but limit our scope to comorbidities that can be directly addressed and treated by psychiatrists.

Dissociative Identity Disorder

Changes and Challenges in Our Psychological Identities

Letters to the Editor: Response to “Reforming Mental Health Care”

Dissociative Amnesia (Psychogenic Fugue) and a Literary Masterpiece

Intimate Portrait: Marsha D. Rosenberg, MD

Confounding Factors in Treatment-Resistant Depression (Part 2): Comorbidities and Treatment Resistance

Sybil Exposed: A Look at Dissociative Identity Disorder

Anesthesia Advances Add to Safety of ECT

Witness to an Extreme Century: A Memoir

Assessment and Diagnosis of Posttraumatic Stress Disorder

Ketamine: A Possible Role for Patients Who Are Running Out of Options?