Öz
Dissosiyatif kimlik bozukluğunun (DKB) doğası gelişimsel, nörobiyolojik, psikofizyolojik, bilişsel ve dilsel boyutlarıyla bütüncül bir şekilde ele alınabilir. DKB, çocuklukta maruz kalınan kronik ve ezici travmalara karşı geliştirilen bir savunma ve uyum mekanizması olarak tanımlanmakta, kimlik değişimleri, dissosiyatif amnezi ve parçalanmış benlik-durumları ile karakterize edilmektedir. DKB yalnızca klinik bir tanı kategorisi değildir; aynı zamanda travmatik çevresel koşullara karşı gelişimsel bir adaptasyon biçimi olarak anlaşılabilir. Benlik-durumları kavramı, modern bilişsel kuramlarla doğrudan uyumlu olup, bireyin öznel deneyimlerinin farklı biçimlerini temsil eder. DKB’de bu durumlar arasında süreksizlik ve öznellik kaymaları gözlenirken, ego-state yaklaşımı bu deneyimlerin erken yaşantılardan kaynaklanan duygusal ve davranışsal örgütlenmeler olduğunu açıklar. Nörogörüntüleme çalışmaları, benlik-durumları arasında belirgin beyin aktivite farklılıklarını ortaya koymuş, özellikle hipokampus, amigdala ve parahippokampal girus gibi yapılarla ilişkili işlevsel ve yapısal değişikliklere dikkat çekmiştir. Ayrıca, DKB’nin bedensel boyutunu vurgulamak çok önemlidir. Farklı benlik-durumlarında kalp atış hızı, deri iletkenliği ve kas aktivitesi gibi periferik psikofizyolojik parametrelerde farklılıklar bulunmuştur. Bellek işleyişi ise bozukluğun merkezinde yer almakta; otobiyografik bellekte süreksizlik, travmatik anıların parçalı depolanması ve “duruma bağlı hafıza” olgusu kimlik sürekliliğini zedeleyen temel mekanizmalar olarak tanımlanmaktadır. Son olarak, dilin rolü hem kavramsallaştırmada hem de öznel deneyimlerin aktarımında merkezi bir öneme sahiptir. “Benlik-durumları” teriminin tercih edilmesi, damgalamayı azaltırken; bireylerin “bana ait değil” gibi ifadeleri dissosiyatif süreçlerin fenomenolojik boyutunu görünür kılmaktadır. Bu çok katmanlı yaklaşım, DKB’nin patolojik bir bozukluk olmanın ötesinde, zihin, beyin, beden, bellek ve dilin kesişiminde yer alan karmaşık bir adaptasyon biçimi olarak anlaşılmasını sağlamaktadır.
Anahtar Kelimeler:
Beyin, dissosiyatif kimlik bozukluğu, zihinsel süreçler, hafıza, dil
Kaynaklar
1
Van der Kolk BA. The body keeps the score: brain, mind, and body in the healing of trauma. New York, NY, US: Viking, 2014.
2
Diagnostic and Statistical Manual of Mental Disorders: DSM-5TM. 5th ed., Arlington, VA, US: American Psychiatric Publishing, Inc., 2013.
3
Howell EF. The dissociative mind. 1st ed., New York: Routledge, 2005.
4
Steele K, van der Hart O, Nijenhuis ER. Phase-oriented treatment of structural dissociation in complex traumatization: overcoming trauma-related phobias. J Trauma Dissociation. 2005;6(3):11-53.
5
Herman JL. Trauma and recovery: the aftermath of violence--from domestic abuse to political terror. New York: Basic Books; 1992.
6
Lebois LAM, Kaplan CS, Palermo CA, Pan X, Kaufman ML. A grounded theory of dissociative identity disorder: placing DID in mind, brain, and body. In: Dissociation and the dissociative disorders: past, present, future, Dorahy MJ, Gold SN, O'Neil JA (editors). 2nd ed., Routledge; 2022:392-408.
7
Sar V. The many faces of dissociation: opportunities for innovative research in psychiatry. Clin Psychopharmacol Neurosci. 2014;12(3):171-179.
8
Dorahy MJ, Middleton W, Seager L, Williams M, Chambers R. Child abuse and neglect in complex dissociative disorder, abuse-related chronic PTSD, and mixed psychiatric samples. J Trauma Dissociation. 2016;17(2):223-236.
9
Reinders AATS, Willemsen ATM, den Boer JA, Vos HPJ, Veltman DJ, Loewenstein RJ. Opposite brain emotion-regulation patterns in identity states of dissociative identity disorder: a PET study and neurobiological model. Psychiatry Res. 2014;223(3):236-243.
10
Ogden P, Minton K, Pain C. Trauma and the body: a sensorimotor approach to psychotherapy. 1st ed., New York: W. W. Norton & Company; 2006.
11
Brand BL, Schielke HJ, Putnam KT, Putnam FW, Loewenstein RJ, Myrick A, et al. An online educational program for individuals with dissociative disorders and their clinicians: 1-year and 2-year follow-up. J Trauma Stress. 2019;32(1):156-166.
12
Damasio A. Self comes to mind: constructing the conscious brain. New York: Pantheon/Random House; 2010.
13
Siegel DJ. The developing mind: how relationships and the brain interact to shape who we are. 2nd ed., New York: The Guilford Press; 2012.
14
Stern DN. The interpersonal world of the infant: a view from psychoanalysis and developmental psychology. New York: Basic Books; 1985.
15
Prebble SC, Addis DR, Tippett LJ. Autobiographical memory and sense of self. Psychol Bull. 2013;139(4):815-840.
16
Freud S. The ego and the Id. 1st ed., London: Hogarth Press; 1923.
17
Kernberg OF. The inseparable nature of love and aggression: clinical and theoretical perspectives. The British Journal of Psychiatry: The Journal of Mental Science. 2012;201(5):414-415.
18
Atwood GE, Stolorow RD. Structures of subjectivity: explorations in psychoanalytic phenomenology and contextualism. 2nd ed., New York: Routledge/Taylor & Francis Group; 2014.
19
Bromberg PM. Standing in the spaces: essays on clinical process, trauma, and dissociation. Mahwah, NJ, US: Analytic Press; 1998.
20
Mitchell SA. Relationality: from attachment to intersubjectivity. Psychoanalytic Psychology. 2001;18(3):582-596.
21
Nijenhuis E, Van der Hart O, Steele K. Trauma-related structural dissociation of the personality. Act Nerv Super. 2010;52(1):1-23.
22
Watkins JG, Watkins HH. Ego states: theory and therapy. New York: W.W. Norton; 1997.
23
Van der Hart O, Nijenhuis ERS, Steele K. The haunted self: structural dissociation and the treatment of chronic traumatization. New York, NY, US: W. W. Norton & Company; 2007.
24
Howell EF. The dissociative mind. 2nd ed., New York: Routledge; 2020.
25
Putnam FW. Dissociation in children and adolescents: a developmental perspective. New York: Guilford Press; 1997.
26
Sierra Siegert M. Depersonalization: a new look at a neglected syndrome. Cambridge: Cambridge University Press; 2009.
27
Liotti G. Trauma, dissociation, and disorganized attachment: three strands of a single braid. Psychotherapy: Theory, Research, Practice, Training. 2004;41(4):472-486.
28
Schore AN. The science of the art of psychotherapy: the latest work from a pioneer in the study of the development. New York: WW Norton & Company; 2012.
29
Siegel DJ. The developing mind: how relationships and the brain interact to shape who we are. 3rd ed., New York: The Guilford Press; 2020.
30
Schlumpf YR, Nijenhuis ER, Chalavi S, Weder EV, Zimmermann E, Luechinger R, et al. Dissociative part-dependent biopsychosocial reactions to backward masked angry and neutral faces: an fMRI study of dissociative identity disorder. Neuroimage Clin. 2013;3:54-64.
31
Vermetten E, Dorahy MJ, Spiegel D. Traumatic dissociation: neurobiology and treatment. Washington, DC: American Psychiatric Pub, 2007:137-153.
32
Vermetten E, Schmahl C, Lindner S, Loewenstein RJ, Bremner JD. Hippocampal and amygdalar volumes in dissociative identity disorder. Am J Psychiatry. 2006;163(4):630-636.
33
Brand BL, Lanius RA. Dissociation and the dissociative disorders: past, present, future directions. J Trauma Dissociation. 2014;15(1):1-9.
34
Lanius RA, Vermetten E, Loewenstein RJ, Brand B, Schmahl C, Bremner JD, et al. Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry. 2010;167(6):640-647.
35
Reinders AA, Willemsen AT, Vos HP, den Boer JA, Nijenhuis ER. Fact or factitious? A psychobiological study of authentic and simulated dissociative identity states. PLoS One. 2012;7(6):e39279.
36
Chalavi S, Vissia EM, Giesen ME, Nijenhuis ER, Draijer N, Cole JH, et al. Abnormal hippocampal morphology in dissociative identity disorder and post-traumatic stress disorder correlates with childhood trauma and dissociative symptoms. Hum Brain Mapp. 2015;36(5):1692-1704.
37
Lebois LAM, Li M, Baker JT, Wolff JD, Wang D, Lambros AM, et al. Large-scale functional brain network architecture changes associated with trauma-related dissociation. Am J Psychiatry. 2021;178(2):165-173.
38
Muehsam D, Lutgendorf S, Mills PJ, Rickhi B, Chevalier G, Bat N, et al. The embodied mind: a review on functional genomic and neurological correlates of mind-body therapies. Neurosci Biobehav Rev. 2017;73:165-181.
39
Strouza AI, Lawrence AJ, Vissia EM, Kakouris A, Akan A, Nijenhuis ERS, et al. Identity state-dependent self-relevance and emotional intensity ratings of words in dissociative identity disorder: a controlled longitudinal study. Brain Behav. 2023;13(10):e3208.
40
Pole N. The psychophysiology of posttraumatic stress disorder: a meta-analysis. Psychol Bull. 2007;133(5):725-746.
41
Schalinski I, Schauer M, Elbert T. The shutdown dissociation scale (shut-d). Eur J Psychotraumatol. 2015;6:25652.
42
Frewen P, Lanius R. Healing the traumatized self: consciousness, neuroscience, treatment. New York: W. W. Norton & Company, 2015:88-92.
43
Corrigan FM, Hull AM. Recognition of the neurobiological insults imposed by complex trauma and the implications for psychotherapeutic interventions. BJPsych Bull. 2015;39(2):79-86.
44
Fisher J. Healing the fragmented selves of trauma survivors: overcoming internal self-alienation (1st ed.). Routledge; 2017.
45
Spiegel D, Loewenstein RJ, Lewis-Fernández R, Sar V, Simeon D, Vermetten E, et al. Dissociative disorders in DSM-5. Depress Anxiety. 2011;28(9):824-852.
46
Terr LC. Childhood traumas: an outline and overview. Am J Psychiatry. 1991;148(1):10-20.
47
Dell PF. A new model of dissociative identity disorder. Psychiatr Clin North Am. 2006;29(1):1-26, vii.
48
Moskowitz A, Schäfer I, Dorahy MJ. Psychosis, trauma and dissociation: emerging perspectives on severe psychopathology. 2nd ed., Hoboken, NJ: Wiley Blacwell; 2023:156-162.
49
North CS, Ryall J-EM, Ricci DA, Wetzel RD. Multiple personalities, multiple disorders: psychiatric classification and media influence. New York, NY, US: Oxford University Press, 1993.
50
Shyamalan M. Split [Film]. Universal Pictures, 2016.
51
Wardani WA. Figurative language used in the Split movie. Language Horizon: Journal of Language Studies. 2022;10(3):1-8.
52
Perrine L. Literature : structure, sound, and sense. 5th ed., Fort Worth : Harcourt Brace, 1992:135-142.
53
Leech GN. Semantics : the study of meaning. 2nd ed., Harmondsworth, Middlesex, England ; New York, N.Y., U.S.A. : Penguin, 1981:10-45.
54
Lakoff G, Johnson M. Metaphors we live by. Chicago: University of Chicago Press; 1980.
55
Monaco J. How to read a film: movies, media, and beyond. Oxford: Oxford University Press; 2009:210-226.
56
Semino E, Demjén Z. Metaphor in discourse about mental health. Cambridge: Cambridge University Press; 2017:58-74.
57
Hinzen W, Rosselló J. The linguistics of schizophrenia: thought disturbance as language pathology across positive symptoms. Front Psychol. 2015;6:971.
58
Dell PF, O'Neil JA. Dissociation and the dissociative disorders: DSM-V and Beyond. New York: Routledge/Taylor & Francis Group; 2009.
59
Merckelbach H, Devilly GJ, Rassin E. Alters in dissociative identity disorder. Metaphors or genuine entities? Clin Psychol Rev. 2002;22(4):481-497.
60
Putnam FW. Diagnosis and treatment of multiple personality disorder. New York: Guilford Press. 1989.
61
Dorahy MJ, Hart OVD. Relationship between trauma and dissociation: a historical analysis. American Psychiatric Association Publishing; 2007.
62
Steele K, Boon S, Van der Hart O. Treating trauma-related dissociation: a practical, integrative approach. New York: W. W. Norton & Company; 2017:89-105.
63
Hopper JW, Frewen PA, van der Kolk BA, Lanius RA. Neural correlates of reexperiencing, avoidance, and dissociation in PTSD: symptom dimensions and emotion dysregulation in responses to script-driven trauma imagery. J Trauma Stress. 2007;20(5):713-725.
64
Sar V, Ross C. Dissociative disorders as a confounding factor in psychiatric research. Psychiatr Clin North Am. 2006;29(1):129-144, ix.
65
Simeon D, Abugel J. Feeling unreal: depersonalization disorder and the loss of the self. Oxford: Oxford University Press; 2006.
66
Sar V. Epidemiology of dissociative disorders: an overview. Epidemiology Research International. 2011.
67
Ross CA. Dissociative identity disorder: diagnosis, clinical features, and treatment of multiple personality. Hoboken, NJ, US: John Wiley & Sons Inc, 1997:56-73.
68
Liotti G. Attachment and dissociation. In: Dissociation and the dissociative disorders: DSM-V and Beyond, Dell PF, O'Neil JA (editors). Routledge, 2010.
69
Lyons-Ruth K, Jacobvitz D. Attachment disorganization: genetic factors, parenting contexts, and developmental transformation from infancy to adulthood. In: Handbook of attachment. Cassidy J, Shaver PR (editors). New York, NY, US: The Guilford Press, 2016:667-695.
70
Liotti G, Farina B. Sviluppi traumatici: eziopatogenesi, clinica e terapia della dimensione dissociativa. Milan: Raffaello Cortina; 2011. Italiano.
71
Schore AN. The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal. 2001;22(1-2):201-269.
72
Hacking I. Rewriting the soul: multiple personality and the sciences of memory. Princeton, NJ, US: Princeton University Press; 1995.
73
Brand BL, Loewenstein RJ, Lanius RA. dissociative identity disorder. 2nd ed., Oxford: Oxford University Press; 2014.
