BASK MODELr9i.re ~kr~~iiY of ransrefs#r~ a19 ~y # . esaAmat~yu 4 ~oiedser~ siy iar~ r~ ;>? The BASK Model of Dissociatio n Bennett G . Braun, M .D . ABSTRACT The BASKmodelconceptualizes the complex phenomenology ofdissociation alongwith dimensions of Behavior,Affect,Sensa- tion, andKnowledge. The process of dissociation itself, hypnosis, and the clinicalmentaldisorders that constitute the dissociativ e disorders are described in terms of thismodel, and iIIustrated. Dissociation as a concept in psychiatry and as a descriptor of phenomena observed in mental disorder s is derived from the doctrine of "association," which held that memories are brought to consciousness by way o f association of ideas; thus, memories not available to be associated are termed "dissociated ." Dissociation is today taken to mean the separation of an idea or though t process from the main stream of consciousness. The Revised Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (America Psychiatric Association, 1987, p. 269) states that, "The essential feature of these (dissociative) disorders isa disturbance or alteration in the normally integrate d functions of identity, memory or consciousness. The disturbance or alteration may be sudden or gradual, an d transient or chronic. If it occurs primarily in identity, the person's customary identity is temporarily forgotten , and a new identity may be assumed or imposed (as i n Multiple Personality Disorder), or customary feeling of one's own reality is lost and replaced by feelings of unreality (as in Depersonalization Disorder). If the disturbance occurs primarily in memory, importan t personal events cannot be recalled (as in Psychogenic Amnesia and Psychogenic Fugue)." Dissociative phenomena include hypnosis, dissocia- tive episodes associated with strong affective states such as fear, and dissociative disorders currently defined i n psychiatry . Multiple personality disorder is at the extreme of dissociative phenomena . Post-traumatic stress disorder also may be placed on a continuum o f dissociation. Dissociation may be regarded as a coping mechanism . The term "dissociation" is commonly attributed t o Pierre Janet, who used it first in 1889 (Ellenberger, 1970) Having studied hysteria and other forms of psychopa- thology, he developed a theory of psychological automa- tism that Kihlstrom (1987) believes anticipated some current concepts of connectionism or parallel distribute d processing. Kihlstrom (1987) also states that dissociation may hold important clues to the cognitive unconscious , one of the key concepts of current cognitive psychology. The conceptualization of dissociation was hindered for decades when Freud rejected dissociation in favor of repression as a central mechanism of the mind's defen- sive organization. In 1881-82, Breuer had concluded that a splitting of consciousness is present in every hysteria- that a tendency to dissociation and abnormal states o f consciousness is the basic phenomenon of hysteria. This explanation for divided consciousness was different from the one that Freud later proposed . Freud eventu- ally stated that the ideas unavailable to consciousness are "repressed" into the unconscious where they ar e bound up with affective impulses, and enter conscious- ness indirectly as physical symptoms (Decker, 1986). Breuer's hypothesis was that amnesia occurs because certain memories are not usually available due to a divided consciousness . Breuer had priority of discovery regarding dissociation, but Janet published first . Breuer and Freud at first acknowledged Janet's claim, but late r the entire issue of repression and dissociation became controversial and the relationship between Janet and th e analysts became acrimonious. Freud's concept of repres- sion finally overrode competing ideas. Rosenbaum (1980) offered two additional reasons for the rapid fall of concepts of dissociation, multiple personality and hypnosis . These were: (1) Bleuler's introduction in 1911 of the term "schizophrenia" to cover many of the symptoms found in multiple person- ality disorder; and (2) the growing suspicion that multi- ple personality disorder and hysteria were artifacts o f hypnotic suggestion. Over most of the twentieth cen- tury, the central concepts of behaviorist psychology, with its relative disinterest in intrapsychic functions an d processes, also deterred interest in dissociation. Dr. Braun is Director of the Dissociative Disorders Program at the Sheridan Road Hospital . For reprints write Bennett G . Braun, M .D., Director, Dissociative DisordersProgram and Inpatient Unit, Rush-Presbyterian-St . Luke's Medical Center, 1753 W. CongressParkway, Chicago, Illinois 60612 4 DISSOCIATION 1 :1, March 1988 ,~g~,`sappy%A~s~ X~ irr~i~~/yfaiifr~/1l//fFi~ :urn'f~ifcf~~~sG .FYissr~,ss/rr~r.-~rmi~lo'~kvee~sr/.v1r .cre%/.m ~ia~,'.~cd~irr~ihfiffr%6i~'1/./.fird~ .~'6r:1~'n/'rl/.C4f.`r/~/~I! .. BRAUN DISSOCIATION TODA Y Dissociation is today a powerful concept for looking at human coping mechanisms. The overriding influenceof "repression" has dwindled, and no longer stands i n the way of scientific investigators' taking a new look at dissociation . Hilgard (1977) suggested that the major difference between dissociation and repression is in the flow an d content of the dissociated and/or repressed material . In a dissociation context, there is an amnestic barrier that prevents the interchange of different memories. Ina repression formulation, there is only an amnesia for unacceptable impulses . Spiegel (1963) proposed a two-directional model of dissociation-e .g., a dissociation/association continuum , whereas repression was seen as unidirectional . Frankel (in press) pointed out that the unpleasan t side effects of dissociation such as amnesia, depersonal- ization, and derealization make it less than an idea l protective mechanism. Frankel noted that it is neverthe- less clear that in multiple personality disorder, fugues , and conversion symptoms, dissociation provides som e escape from conflict. The escape is often maladaptive, and that leads the patient to the therapist, to prison, or t o a life of misery. The therapist hopes to help the patient reshape th e dissociative experience, and provide the patient with a helpful way to deal with an untenable conflict . Helping the therapist to help the patient is the aim of a proposa l for a new model of dissociation that provides an expla- nation of the dissociative process and a methodology for the therapist . In 1984, I proposed a speculative concept of multiple personality and other dissociative phenomena . It brought together a number of approaches to under - standing dissociation under the rubric of neuropsy- chophysiologic (NPP) state-dependent learning (SDL). In that paper, I proposed that multiple personalit y disorder represents an extreme point on a continuum o f response patterns that includes hypnosis, repression , ego states, and dissociative disorders . Although multiple personality disorder has its place on the continuum , neither hypnosis nor dissociation alone can create multiple personality . Multiple personality disorder is created by means of repeated dissociations that occur under extreme stress, usually the extreme stress of child abuse. These dissociations often have similar NPP affective states that allow them to be linked together, permitting the association of facts, the development of congruent, stable memories, ranges of emotion, and response patterns . Central to the proposal is that the linked affective states are NPP-based. The inclusion of NPP is what differentiates this concept of dissociation from those that are solely psychological. The NPP state is central to the concept of memory linked to state-dependent learning . The basic tenet of state-dependent learning is that something that i s learned in one NPP state is most expeditiously retrieve d under the same NPP state. Personalities are formed , shaped, and expressed through the individual's continu- ous interaction with the environment . Behaviorsare expressed, and shaped by environmental responses . If the reinforcement of behavior occurs in a sufficiently disparate, dissociated NPP state, the effects of that interaction will not be available under the usual NP P state. If the NPP states are too disparate, retrievalis not possible. If enough environmental interactions occur unde r similar NPP states, as in circumstances in which a child endures abuse frequently but also experiences more positive interactions (Braun & Sachs, 1985), the informa- tions learned under the NPP state of abuse will be linke d together. This chaining of knowledge, memory and interactive patterns forms an alter personality with it s own response patterns, life history, and range of affect . The dissociation model presented in this paper is a further development of the theoretical proposals of 1984. Later in this paper, the model is extended to discussio n of multiple personality disorder and its treatment . THE BASK MODE The complex phenomena of dissociation can be conceptualized in a BASK (B-A-S-K) model. The four letters of the acronym represent Behavior, Affect, Sensation and Knowledge, processes that function in parallel on a time continuum represented by the arrow s in Figure 1. If we continue to define dissociation as the separation of an idea or thought process from the mai n stream of consciousness, then we may use the BAS model (Figure 1) to illustrate that dissociation can occur on any one or more of the levels - e .g., on Behavior as i might in automatism, on Affect and Sensation as when hypnosis is used to create an anesthesia. Dissociation may occur in all the processes at once for a greater or lesser period of time. In this model, mental health is the congruence over time of the BASK components Before proceeding to use of the BASK model t formulate models of dissociative disorders, the phe- nomenon of dissociation may be brought into sharpe r focus. Dissociation can be shown as one extreme ona continuum of awareness (Figure 2). The continuum run s from full awareness-through suppression, which is a conscious putting-out-of-mind of something we don' t want to think about-through denial, which is a mecha- nism we use until we have the capacity to cope in other ways-through repression, which Freud identified a s being due to pathological psychological conflict-t o dissociation itself, which I believe includes repression, but unlike the classical definition of repression, has a major NPP component. Although there is a vertical bar in the Figure at each point where we name a succes- sively severe diminution of awareness, the progression DISSOCIATION 1 :1, March 1988 5 BASK MODEL i;;a's6;df/ri::',Y:r.. a19~so"fi:;~S:li %io').sF:s;-i,' fq'.tltiFlir .s%~r~:rY.t~:r'~.?iikBS^a ixe5ta',.%N~,so;.Jrrffe/-f~LcLysr /rr6~%'.Ito-?Saaridafd'cmfm? .C.t~'~.asc~%f:'tr.4rir` l~a;>.~lr':w~s~~ ~i from left to right should be seen as the gradual shading s of a true continuum . A static model of the dynamic continuum of disso- ciation also is useful to comprehension of the BASK model (Figure 3). As with maps of the world, not everyone will agree with where the lines are drawn ; some will agree, some disagree with the placement o f "repression" as a "dissociative episode ." I also propose that, on the horizontal axis between "dissociative disorder and "atypical dissociative disorder," w e should place "post traumatic stress disorder ." A strong case can be made for identifying post traumatic stress disorder (PTSD) as a dissociative disorder, and this line of reasoning will be discussed later under PTSD. Moving from the far left side of the continuum, we see that some dissociative phenomena are quite normal . Hypnosis is an interactive dissociative phenomenon i n the case of heterohypnosis: one person, the subject responds to suggestions offered by another person, th e hypnotherapist, for experiences involving alterations i n perception, memory and action. Returning to the BASK model, we can look at the functioning of the model in describing the relatively simple phenomenon of hypnotic anesthesia . Figure4 illustrates the process of hypnotic induction, whereb y the hypnotherapist's use of an hypnotic ceremon y induces the subject to focus attention very narrowly, an d alter awareness . For the purposes of surgical anesthesia, the hypnotherapist and subject separate the subject' s Affect and Sensation from his/her ongoing Behavior and Knowledge that a surgical procedure is taking place . Kihlstrom (1987) believes that hypnosis represents a special case of the cognitive unconscious, saying that "post-hypnotic suggestion seems to expand the domai n of nonconscious mental processes" and "hypnoti c analgesia and posthypnotic amnesia appear to expan d the domain of nonconscious structures ." As conceptual- ized in the BASK model, hypnotic induction focuses the subject's attention and then proceeds to decrease his/he r General Reality Orientation (GRO) by creating a illusion that the subject can agree with and incorporat e into the hypnotic process (Shor, 1970). This further focuses attention and decreases GRO. As attention is focused on an aspect of BASK-e .g. sensation of muscl contraction and relaxation-there is progressive relaxa- tion induction . One can see that as trance is achieved attention is focused on Sensation over the other elements of BASK, and the foundation of dissociation is con- structed . In the BASK model presentation of repression asa dissociative episode, there is a break of all BASK proc- esses across the time continuum, although the physiol- ogic component is less evident (Figure 5). We see represented by double-ended arrows at the bottom o f the Figure, that in relation to actual elapsed time the patient has the perception of having been in a conditio n of total awareness. Certain memories, however, are not available to conscious recall. They may be retrievable in psychotherapy . In the traditional Freudian model o f repression, it is affect-loaded conflict which causes the loss. In this model, affect effects the NPP state but its effect is less obvious than in other classic cases of dissociation. A dissociative disorder is characterized by a disrup- tion of memory (Figure 6) and a disruption of identit y (Figure 7). It is differentiation between memory of knowledge that is often a critical factor in making or missing the diagnosis of multiple personality . The creation of memory requires the dynamic involvemen t of all four BASK processes seein Figure 6 a repre- sentation of what may occur in the instance of a multipl e personality. Along the time continuum of Behavior, we see two phenomena occurring : ongoing, external Behav- ior represented by the digital-like vertical bars, and physiological Behavior by the sine wave. We can look at the disruption in the BASK continuum at the left side of the Figure as a representation that "something hap- pened" to cause activity in Affect, Behavior, Sensation and Knowledge which is encoded. This flurry of activity is the BASK representation of ""memory encoding." Two types of retrieval, memory and knowledge, are repre- sented on the right. The multiple personality who i s "covering his tracks," so to speak, may be able to present Knowledge so convincingly that it appears to be mem- ory. The alter personality who was not present durin g encoding of an event may still be able to report the facts that constitute Knowledge, but altogether lacking will b e the demonstrative Affect, Sensation, and to a lesser extent the Behavioral components that accompany a recalled memory of a significant event. An example might be the civilian who can tell you very knowledgea- bly about an event in the Vietnam War, but has no true memory of the event because he was never in Vietnam. The reporting of knowledge may be misperceived by the therapist as memory, and the diagnosis of disso- ciative disorder will be missed. The reporting of knowl- edge as memory may occur intentionally, to cover up and keep the secret of multiple personality disorde r (MPD), or because the distinction between memory an d knowledge has never been made by the patient or th e therapist. One's perception of one's own identity depends o n the congruence of one's image of self and one's behav- ior. You may check this for yourself by saying aloud "My name is (your name)," and noting both you r psychological and physiological responses. Next say a s if you mean it, ""My name is John Fitzgerald Kennedy,"" and note your responses . Most people have a reaction t o the "lie," usually some kind of anxiety response . This is in essence an error signal or a mismatch in TOTE, an acronym for Test-Operate-Test-Exit in computer termi- nology. We carry a BASK monitor image that is a template of experience, and we feel quite comfortable when this 6 DISSOCIATION 1 :1, March 1988 ~i~i/i .~Y/iir,~~d-rrys;LY.stt~,rrir,':~/r,:r,N.xsf~/r~ssyi~%.rr:~i~/ic,F~ir o~;!~Y.rf.;err.:~ s!ss-rll~iiaerrd~ol~o5.s~vFn~/~rG?FHiifirf/raf.,n.Yrr .by: fGr!iyidr~frnYr,N~-f~frri!6s:~a%ii,R".6r/rPi1/lN~Y~Y.~ssii~ BRAUN expectation matches experience. At the top of Figure7 we see the BASK representation of the monitor image of self in concert with the image of immediate action to the statement of one's name . No error signal occurs because of the match of the expected name and the stated name . At the bottom of Figure 7 we see images becoming separated, resulting in an error signal, or a changed identity. The TOTE principle is based upon work don e by Bernstein in the 1930s, published in 1967; the work was further cited and developed by Pribram (1971). In a dissociative disorder the error signal becomes overwhelming . There may be a loss of encoded informa- tion, or an inability to retrieve encoded information (Braun, 1984), as in psychogenic amnesia. In psycho- genic amnesia there is a sudden inability to recall important personal information that is too extensive t o be explained by ordinary forgetfulness . The disturbance is not due to an organic disorder such as blackout s during alcohol intoxication . The amnesia is of sudden onset, and is generally of localized or systematized form. Generalized and continuous amnesia are less common . The patient is usually aware of a disturbance of recall, but may be indifferent to the recall failure. The four types of amnesia may be conceptualized on the BASK model (Figure 8). In LOCALIZED amnesia, all events for a period of time are lost. In GENERALIZED amnesia almost everything before a given event is lost, although some memory for very fundamental activitie s such as how to eat is usually retained ; there is encoding of memory for everything after the given event. In SYSTEMATIZED amnesia information for a very specific and related event is lost, such as memory of several clandestine meetings because of unacceptable memories of other events or persons that are associated with th e events; however, some memories of events that occurred in the same period of time are available. CONTINUOUS amnesia is most commonly organic, and each successive event is forgotten as it occurs. At the very bottom of Figure 8, we see a representation of total time covered by available memories in relation to actual elapsed time, for each type of amnesia. Psychogenic fugue (Figure 9) is characterized by: Sudden, unexpected travel away from home o r customary place of work, with inability to recall one's past . Assumption of a partial or complete new identity . Absence of any organic mental disorder, although heavyalcohol use may be an associated factor. Conflicts over sexuality, aggression or money may be present. In fugue we see a condition in which a person becomes overwhelmed by life experience. The person "splits" psychologicallyand in the colloquial sense of leaving home. In the BASK model, fugue is represented by dislocation of the middle portion of the continuum . Actual time elapsed is represented by the double-heade d arrow. Perceived Time A represents memories available for the periods on both sides of the dislocation; per- ceived Time B represents memories for time during th e fugue itself. Ultimately, all or nearly all memories are available to retrieval. In many ways, psychogenic fugu e is closer to multiple personality disorder than to psycho - genic amnesia. Any discussion of depersonalization disorder (Figure 10) requires a caveat ence a condition that is probably akin to depersonaliza- tion disorder as a normal event of adolescence. The characteristics of depersonalization disorder are: One or more episodes of depersonalization suffi- cient to produce significant impairment in social or occupational functioning; The symptom is not due to any other disorder , such as schizophrenia, affective disorder, organic mental disorder, anxiety disorder, or epilepsy . The clinical features of depersonalization disorde r include: *Alteration of the perception or experience of the self, with a loss of a sense of one's own reality, and with associated changes in body image (such as a perception that "this arm is not mine ."). Rapid onset and disappearance . Feeling of loss of control of one's actions and speech. Episodes last for many minutes to hours and recu r frequently. Derealization (loss of feeling of the world's reality) and perceived changes in size and shape of external objects. In the BASK model of depersonalization, Behavior, Affect and Knowledge are unperturbed . However, Sensation, in regard to Self, is distorted; for example, "this arm does not belong to me." This may result i n anxiety and/or other disturbances in affect . In derealization, it is Sensation with regard to the world that is altered, and that may also ultimately caus e a disturbance in Affect. Posttraumatic stress disorder (PTSD) is character- ized as a dissociative disorder on the continuum o f dissociation disorders (Figure 3). PTSD is represented as being farther from "normal" dissociation than the amnesias, fugue and depersonalization . Since there are many sub-types of PTSD, I have not yet been able to develop a satisfactory BASK representation. I have proposed that PTSD should be reclassified as a dissociative disorder in the next revision of the Diag- nostic and Statistical Manual of Mental Disorders. This proposal is made on the basis that many major an d essential symptoms of PTSD are dissociative symptoms. DISSOCIATION 1 :1, March 1988 7 BASK MODEL :i!f/,ys~!irf~!fuiy-i-ri~,saY/1.k/ff:%/1/..~/.6.`ri.~i.W,l~ei.%iruF.':iG~XaY.eiz T .~C ;,mfa'F cries'~GY~' %;< r,~blf~i~a19~iifrii/y~l/i /.fhyirSl~eJitSL.vr//.istw P ATMt!? :'# . BRAUN DISSOCIATIVE DISORDER NOS (Atypical Dissociative Disorder) Automatisms B A * S K * Polyfragmented Atypical Dissociative Disorder * Out fAwareness B A S K Atypical Dissociative Disorder with features of MPD B A Same chainin as MP but only qualif for fragments (Deficien life histories)Cummulative Life Experiences Personality A f Fragment B 1 FragmentFragmentC Figure 11 . The BASK representation of Atypical Dissociative Disorder . The ADD is the sam e chaining as in MPD, but the duration of history is only sufficient to qualify for B, C, and D as fragments . C 1988, Bennett G . Braun, M .D. DISSOCIATION:1,March 1988 17 BASK MODEL : lra19`ro:0.:r.wrrWu.. .r?Ra. ~63GAk r c . ad~G ' oox~r a~~ i ATYPICAL MULTIPLE PERSONALITY DISORDER - ENIFEU -M -- ira- gl - M-41' A Affect Hin - Mr -M- W -EF-010 S Sensation K Knowledge Continuous In All Personalitie s Actual Tim e Perceived Time Fragment B I FragmentCI Personality D - IFigure 12 . The BASK representation of Atypical Multiple Personality. The grey areas indi- cate periods of co-consciousness. Therefore, it can be seen that the histories of Fragment s B and C, when added to the histories of Personalities A and D, create a summated life experience greater than the actual passage of time . MULTIPLE PERSONALITY DISORDER S S --gl Eff K Knowledge Actual Time Perceived Time Figure 13. The BASKL representation of Multiple Personality Disorder. The grey areas indicate periods of co-consciousness. Therefore, it can be seen that the histories of Frag- ments B and C, when added to the histories of Personalities A and D, create a summated life experience greater than the actual passage of time. C 1988, Bennett G . Braun, M .D . Personality A -i Fragment BIFragment CI- Personality A 18 DISSOCIATION 1 :1, March 1988 X :50 -1,useko. c9si~raiiP~i~s /.aa~aOrrrr.aii stoS~o-x BRAU N PREDISPOSING FACTOR S 1. INDIVIDUA L 4 4a . Biolog y b.Psychodynamic s 2. FAMILY DYNAMIC S External- . u on : famil:::.::::: p Y.:.:unit:_via::members ::::: ::::::....... . ......................... ... ........ ............ .............. ....... ....................................... :: ::Internal- : upon:fam.... members : Figure 14. The influence of the three P's (Predisposing Factors, Precipitating Events, Per- petuating Phenomena) on the creation of Multiple Personality Disorder. Solid arrow - heads indicate a greater degree of influence than do open arrowheads. (From page 5 3 in R. Kluft, M .D., (Ed.) Childhood Antecedents of Multiple Personality, American Psychiat- ric Press, Inc., Washington, D.C., 1985). Reprinted with permission) . DISSOCIATION 1:1, March 1988 19 TREATMEN POST- TRAUMATI DISSOCIATIVE DISSOCIATIVE STRESS NORMAL EPISODE DISORDER DISORDER ATYPICAL POLYFRAGMENTED ATYPICAL MULTIPLE MULTIPLE MULTIPLE DISSOCIATIVE PERSONALITY PERSONALITY PERSONALITY DISORDER DISORDER DISORDER DISORDER WHO? - Name WHEN? - Age create d and current age WHY? - Created ; Present now WHERE? - Physically create d in real world; inside head and in power structure WHAT? - Function ; problems ; issues HOW? - Created Trust - Therapeutic Alliance 2. Diagnosis (patient and therapist) 3. Communication with personalities 4. Contracting: therapy, suicide/homicide, other 5. Individual and system history gatherin g 6. Working the issues of each personalit y 7. Special procedures 8. Interpersonality communications 9. Resolution - integration 10. New coping skills 11. Social Networking 12. Solidifying skills 13. Follow-up Figure 15. The Treatment of MPD and ADD . The 13 issues need to be dealt with, bu t often one goes back and forth with or without skips during real treatment as the thera- peutic situation dictates . (Adapted from page 19 in B . Braun, M.D., (Ed.) Treatment of Multiple Personality, American Psychiatric Press, Inc., Washington, D.C., 1986. Reprinte d with permission) . 0h i 0 1986, Bennett G. Braun, M.D. ~ C .~kfisirl~c x :' ,er issc % . ; GX x Zda~'x Y~3fo~e b .eed l i/'fe l?ax~r~~4wd~ ;cai ;eo'~ nra se~asD BRAU N THOUGH BEHAVIOR AFFECT Behavior Affect Thought Sensation (TOTE using old BASK Figure16shows the dynamic model of BASK-BATS where Thought as an active process is substituted for knowledge, a static phenomenon. It also shows the interactions of 2, 3, and 4 of the BATS dimensions BEHAVIORAL CLUE D. Cal m Affect / N S Loud Ringing Pain in hea d Sticky Headach e Noise in cars i Discontinue d Sensation i K Blood ~ - "It's over " Sho t Knowledge l Figure 17. The use of a behavioral clue in psychotherapy. First behavior noticed was patient staring and rocking DISSOCIATION 1:1, March 1988 21 Congruenc e B Paralysis, Rocking Hand ~~ Norma l Staring Wringin g Behavior 1A Terror __ -------- -- Trigger Clue C 1988, Bennett G. Braun, M.D. BASK MODEL 5, 6P56G8 4 .ws `:-4 . 4' 6&'f i e AFFECT CLUE Congruenc e Headache & i f pain in back 1 I of head \ 1 Memory of L That was the n M hitting her and this is no w with can e Agitate d Figure 1 8 . Rage and agitation reported and observed. SENSATION CLUE (Somatic Memory) Trigger Clue Congruenc e B Talking Decreased Increased Communicate s Behavio r A Talking Talking in Therap y Anxiety Anger r Appropriat e Affec t S Burn Increased Decreased Norma l pai Burnin g na Burning I (No Symptoms ) Figure 1 9. The use of a sensation clue is a somatic memory, in psychotherapy. Clu e observed by therapist: burn blister on left arm as well as blister on right arm withou t thermal injury . O 1988, Bennett G. Braun, M.D. S Sensatio n K Knowledge Observes patien t hit with cane G nt t not to hur t B 4Behavio r A Affect Rag e Trigger Hands cane Breaks Wanders & Grabs cane to staff T} unit door return s Clue Appropriat e r Calme r 4 Muscle tensio n + "Sandy feeling " } Pai n Sensation \ K M burned her I ("Don't tell") I r "Now I understand " Knowledg e (History of Burns ) 22 DISSOCIATION 1:1, March 1988 BRAU NSENSATION CLUE (Psychosomatic Illness Trigger Clue reported Congruenc e to Therapis t B Relates wel l to roommat eBehavior A Anxiety Fea r Safe . Decreased Anxiet yAffect / S Vision, Stuffy - a73 Nausea No symptoms w nos eSensation Jail I Presen tK Memory rien cKnowledge Figure 20 . Clue reported to therapist: stuffy nose and nausea. KNOWLEDGE CLUE Cowering, I Communicate s Clenched Teeth in Therap y A Fear Increased Affec t S Fear Calme r Pain Nausea Abdominal pain I Decreased Pain , in head Pelvic pain Cleaner Breathin gSensation & Asthm a K Large, dark F rap e Shape f Present tim e Knowledge I orientatio n (Dream ) Figure 21 . The knowledge was report o the dream. Q 1988, Bennett G. Braun, M.D. Trigger Clu e B Behavior Congruenc e DISSOCIATION 1:1, March 1988 23