SUCCESSFUL INTEGRATED
HYPNOTIC AND
PSYCHOPHARI4'IACOLOGICAL
TREATMENT OF A WAR-ABATED
POST-TRAUMATIC
PSYCHOLOGICAL AND
SOMATOFORM DISSOCIATIVE
DISORDER OF
TWO YEARS DURATION
(PSYCHOGENIC COMA)
Silvana Cagiada . Psi: D.
Luigi Canidio, M .D.
Ambrogio Pennati, M .D.
Silvana Cagiada, Psy .D., and Luigi Canidio, M .D., are with
the Department of Clinical Psychology at the Azienda
Sanitaria Locale 24, in Crema, Italy_ Ambrogio Pennati, M .D.,
is with the Department of Psychiatry at Azienda Ussi 39, in
Milan, Italy.
For reprints write Silvana Cagiada, Psy .D., Servizio Psicologia
Clinica, Osperdale Maggiore di Crema, via Macalle n . 14,
Crema, Italy.
ABSTRACT
This report describes the treatment of Basile, a young African boy
who slipped into what might best be described as a psychogenic coma
with numerous additional dissociative features of two years 'dura-
tion after having been kidnapped by bandits and witnessing the
wounding and death of a friend who had been kidnapped with him.
His treatment by a team of mental health professionals who used
psychopharmacology, hypnosis in many forms, and a computer in
connection with both hypnotic metaphors and the expressive poten-
tial of a graphics program is recounted . Despite profound and long-
standing impairment, Basile was able to recover and resume his edu-
cation . The authors conclude that such patients, despite their
complexity and duration, may be accessible to a systematic and deter-
mined approach to therapy that mobilizes numerous resources and
modalities on their behalf.
The modern literatures of hypnosis, trauma, and the dis-
sociative disorders, although rich in their description of post-
traumatic stress and dissociative identity disorder and their
treatment, make little mention of the post-traumatic psy-
chopathologies that bear a close resemblance to the post-
traumatic hysterias so clearly described in the literature of
the nineteenth century (see Ellenberger [19'70] for a review
of such clinical manifestations) . However, such patients con-
tinue to present for treatment on occasion, especially in and
from cultures other than North American and Western
European.
In this report we describe the evolution of a complex
post-traumatic dissociative mental disorder which was diag-
nosed in Basile (a pseudonym), an 11-year-old African boy,
and its successful resolution in the course of psychotherapy
that integrated several modalities of treatment and the efforts
of a number of clinicians . Many identifying details are omit-
ted in the interests of the confidentiality and safety of Basile
and his family . At times we have sacrificed narrative coher-
ence and continuity for these reasons.
CASE REPORT
Basile was born in a North American country in 1983,
where his father, a member of the diplomatic corps of an
African nation, was on the staff of that country's embassy.
One month later, his father was transferred to Moscow in
the former Soviet Union, and Basile's family relocated there.
When he was old enough to begin his education, he attend-
ed a French school . When Basile was seven, his family, again
in connection with changes in his father's career, moved hack
to their native country in Africa, where there was consider-
able unrest.
In April of 1994, civil war broke out . Basile and his fam-
ily left their home in the capital and escaped to one of the
safer regions of the country . Throughout this period of time,
the family faced the danger of capture and execution, not
only by those factions that might perceive Basile's father as
a political enemy, but also by disorganized bands of soldiers
and former soldiers functioning as bandits . Even in this "safe "
area, their circumstances were precarious.
One day a guerrilla squad took Basile and several of his
friends prisoner, holding them for ransom . To make the par-
ents aware of their son's peril and motivate a prompt pay-
ment of the requested ransom, one of the soldiers stuck one
of Basile 's friends in the back with a spear . He was severely
wounded, and Basile and the other boys were terrorized with
threats of harm and death . Basile 's family paid the ransom,
and the boys were released except for the boy stabbed with
a spear, who had died of his wounds.
The morning of the day after his release, Basile had dif-
ficulty waking up on his first day at home . He felt ill, he could
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DISSOCIATION, Vol .X.No September 1997
CAGIADA/ CANIDIO /PENNATI
hardly move, and he had an elevated temperature . Despite
treatment with quinine and antipyretic, Basile became more
and more asthenic . He was unable to feed himself ; nor could
he stand by himself . Finally, he became unable to move his
arms at all, and could not speak . He became increasingly
detached from himself and his body, and slowly began to
have difficulty relating to his family members on the basis
of their actual relationships . He was taken to the hospital,
but conditions in his country continued to deteriorate, and
his family removed him from the hospital and escaped to an
adjacent nation, where he was rehospitalized . In this hospi-
tal, he was originally thought to be suffering a septicemia,
and antibiotics and antipyretics were administered . However,
soon another diagnosis was considered : tuberculosis of the
lumbar spine . In addition to medications thought to be
appropriate, Basile was required to wear a plaster corset or
cast for two periods of 15 days . The second such corset was
removed because Basile had collapsed into a state of com-
plete inertia . Unable to feed himself, he was given alimen-
tation through a nasogastric tube.
Gradually, Basile entered into a deepening coma . At first
he appeared comatose for a few hours a day, but his periods
of time in this state of apparent coma became longer and
longer . By the end of 1994, he was almost always in coma,
emerging into an awakened state no more frequently than
once in every three or four days.
In February of 1995 Basile and his mother relocated to
Italy, although the remainder of his family remained in Africa.
When he was admitted to our hospital in Crema his condi-
tion was as has been described above . We also learned that
he no longer recognized his family members for who they
were . After our evaluation he was evaluated in two subsequent
hospitalizations at the Gaslini Institute in Genoa, and at the
Neurophysiopathology Department at the University of Pisa.
In October of 1995 he was returned to Crema with the diag-
nosis of "coma of unknown nature ." His comatose state by
now had persisted for nearly a year, essentially unimproved.
In Crema a religious group gave Basile and his mother
assistance in what is called a "family house ." A "family house"
is a group of volunteers who accept into their family or reli-
gious community members of other families who are having
difficulties.
In March, 1996, nineteen months after the onset of his
symptomatology, the nursing assistants who were helping the
volunteers at the "family house" requested consultation and
intervention from the Clinical Psychology Unit of the Crema
branch of the National Health Service . The Clinical
Psychology Unit includes clinicians who are specially trained
to administer and provide rehabilitation programs for
patients in coma . It accepted the responsibility of planning
and carrying out a specific treatment program for Basile.
After having examined Basile's clinical presentation and
considered the family history, the team formulated the work-
ing hypothesis that his symptomatology had been caused and
determined by traumatic stress . Therefore, the diagnosis of
"coma of unknown nature " was replaced with the diagnosis
of "psychogenic coma" (Nemiah, 1989 ; West, 1967) . A pro-
tocol for an adequate treatment was developed consistent
with this diagnostic impression . The main elements of the
treatment were : 1) psychotherapeutic support for Basile's
mother ; 2) psychotherapeutic treatment for Basile himself,
integrated with psychopharmacological treatment . In addi-
tion, as the remainder of Basile's family arrived in Italy, psy-
chotherapeutic support was extended to all family members.
The central clinical fact was that Basile was in a coma
almost all of the time when he came under our observation,
and that we hypothesized that this coma was a severe com-
plication of a trauma-related illness, caused by traumatic stress
and accompanied by a severe depressive state consistent with
major depression . In this case, the most likely causes of the
illness were indeed the many traumata about which we
learned as we came to appreciate Basile's history . These
included the murder of his friend, experiencing threats of
murder, and having spent a long time in a pile of corpses;
there were many additional traumatic events about which
we learned later . Nor should we forget the trauma occasioned
by the two periods of confinement in plaster corsets, osten-
sibly for the treatment of tuberculosis of the spine.
Psychopharmacological treatment was provided to
reduce the symptoms of depression, to reduce the over-
whelming impact of sensory inputs, and to control halluci-
natory symptomatology that maintained Basile in a hyper-
aroused state bombarded by virtually incessant flashbacks
(Kosten, Frank, & Dan, 1991) . That is, Basile was depressed,
and suffered a wide range of post-traumatic symptoms, includ-
ing avoidance, withdrawal, hyperarousal, dissociative, somato-
form, and intrusive phenomena.
Our assumption was that in connection with his long state
of coma, Basile experienced a total psychic detachment from
his body (a state of profound depersonalization [Spiegel,
19911), and was separated from his environment by strong
dissociative defenses . The psychopharmacological treat-
ment consisted of the administration of a therapeutic dose
of tricyclic antidepressants (i .e., as much as 125 mg/day of
clomipramine) ; a low dose of benzodiazepines (alprazolam
0.25 mg T .I.D.) a low dose of neuroleptics (no more than 1
mg/day of haloperidol ; and a low dose of a selective sero-
tonin uptake inhibitor (paroxetine 10 mg/day) . Our goal
was Basile's complete recovery, and we conceptualized our
interventions in terms of strategic and tactical steps to attain
this objective.
The aim of the first stage of treatment was to allow Basile
to express his own feelings, especially those concerning his
somatic experiences . For this we decided to utilize a hypnotic
treatment, since both on scientific grounds and on the basis
of our clinical experience, hypnosis can be considered an
effective, powerful, and reliable technique in trauma-relat-
ed illnesses (Pennati, 1992a, 1992b, 1993, 1994) . It is well
183
DISSOCIATION, vol . X,No. 3, September 1997
SUCCESSFUL TREATMENT OF A WAR-RELATED DISORDER
appreciated that there is a deep link between hypnotic and
dissociative phenomena and traumatic experiences (Frankel,
1990) . Traumatic events experienced in childhood can lead
to the extensive use of the mechanism of dissociation
(Putnam, 1991 ; van der Kolk, 1987) . In this case, through
emotional, sensory, and kinesthetic detachment from his
body and feelings, Basile no longer was in contact with either
his sensations or his emotions the vast . majority of the time.
Basile's psychotherapy was focused on, among other mat-
ters, the recovery of perceptions of events, sensations, and
circumstances that in fact no longer were active threats, but
were experienced still as menaces in the here and now of
his daily life (McCann & Pearlman, 1990) . When he was not
comatose, Basile showed signs of extreme anguish when he
realized that any other human being was coming near to him.
We approached Basile 's treatment using Ericksonian mod-
els of hypnosis and Ericksonian techniques (Rossi & Cheek,
1988) . We constructed fables written just for Basile, and devel-
oped metaphors designed to bring about ego-strengthening
(Hammond, 1993) . Later, we would also employ abreactive
techniques, age-regression, visual-kinesthetic dissociation,
and story changes in the ser v
1988) .
With regard to the visual-kinesthetic dissociation (Dilts,
Bandler, & Grinder, 1982), about three and a half months
after beginning his treatment, when Basile had begun to show
some recognizable signs of contact with the surrounding envi-
ronment, we began to work with the concept of a comput-
er, in order to establish, both metaphorically and concrete-
ly, a "virtual kinesthetic dissociation" based on its possessing
a physical screen . Of course, screen metaphors and screen
techniques are well-known among clinicians familiar with the
use of hypnosis . First, the idea of a computer and its use was
introduced with hypnosis, and the protective dissociative
potential of its screen (as a means of allowing Basile to know
and to communicate without being overwhelmed by fully re-
experiencing past traumata) was suggested, and practiced
in the course of hypnotic treatment . Then, an actual com-
puter was provided . For Basile, the use of the computer was
a strong motivator, a powerful cognitive stimulus, and pro-
vided him with the means to begin an indirect and less anx-
iety-provoking relationship with the therapist.
Building upon the metaphor and the tangible fact of the
computer screen, Basile immediately became able to visu-
alize, in the safety of a well-structured situation, the over-
whelming responses he had had to his own traumatic expe-
riences, but, at the same time, was able to detach himself
emotionally from these shocking events . In the same session
that this sort of work was begun, his therapist introduced a
suggestion for a "change-of-history" intervention, designed
to change the perceived consequences of the traumatic facts
of his life, and to allow Basile to understand that they no
longer needed to be experienced as threatening.
The psychotherapy program, which began on March 18,
1996, required hypnosis sessions three times a week as well
as a program of graduated exposure (in visualizations) to
environmental stimuli . Both the sessions and the evocative
images were introduced in the French language . Thereafter
the ensuing dialogue occurred in both French and Italian.
During the fifth session, which took place on April 1, a reas-
suring character was proposed to Basile : Papa Noel (Father
Christmas, Santa Claus, etc .) . His therapist suggested that
Basile envision a scene with a wonderful green lawn arid a
cloudless blue sky . Basile was sitting with his back leaning
against a strong and secure tree . He dreamed that this tree
transformed itself into Papa Noel ; now Papa Noel was
behind him, could protect him, and could slowly become
transformed into a source of strength that would always
remain inside him . Shortly after these interventions, but still
within the same session, Basil was noted to have clonic shakes
and tremors in his previously immobile upper limbs.
During the tenth session, on April 19, Basile actually
moved his right hand ; then he opened his eyes suddenly and
was very frightened . During the session of June 12, 1996,
which took place three months after the beginning of the
treatment, his sister Francoise was present . She translated
from French to the native language of Basile 's home coun-
try, and from the native tongue to French . This allowed us
to use in treatment the language associated with the trau-
matic experience . While Basile was instructed to imagine him-
self in a classroom with his former classmates, he was asked
to write down what his teacher had written on the blackboard.
He lifted his hand, and moved it as if her were writing . After
this session Basile, who is right-handed, wrote his name down
on a sheet of paper in his left hand.
On June 26, Basile was presented with a computer space-
time guidance program . It was based on simple questions:
inquiries about one's actual age, gender, first name, date and
place of birth, and the names of one's parents (Canidio,
Cagiada, & Domenichini, 1992) . The next day he was taught
the use of the mouse, and instructed in a simple drawing
program . Following a post-hypnotic suggestion to this effect,
Basile was informed that he could write and draw what he
liked on the computer, and was reassured that he could delete
his work soon after, if he chose . This created a "virtual" visu-
al kinesthetic dissociation . On July 2, he spontaneously drew
the lawn mentioned above, Papa Noel, and a boy with wavy
black hair (see Figure 1).
After this, Basile made it clear, with explicit gestures, that
he no longer wanted his sister, who was present for this
session, to remain in the room . Significantly, the therapy ses-
sion (which had, until that moment, been conducted in
French, Italian, and the language of Basile 's home country)
continued in Italian alone . It appeared that Basile had both
identified with his therapist and psychiatrist, and had inter-
nalized the reassuring figure of Papa Noel . We confirmed
this by hypnotic inquiry.
The next day Basile was asked to draw the things that
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DISSOCIATION, Vol. X, No. 3, September 1997
CAGIADA/ CANIDI O / PENNATI
FIGURE 1
Basile and Dr . Cagiada at work.
frightened him . Thus began a period of treatment in which
Basile, for the first time, was able to draw some of the dra-
matic events that he had experienced . Drawings of this type
alternated with others that had primarily metaphoric or sym-
bolic content, even if they referred quite directly to his dif -
ficult experiences (See Figure 2).
Basile drew a little rabbit in a cage, and a child who was
giving him some carrots . After he was asked who had put the
rabbit in the cage, Basile drew a terrible looking man . When
he was asked to write down the man's name, he spelled out
"bandit ." We were able to understand what Basile was com-
municating in Italian, even though he often used French
spelling for Italian words . We reminded
Basile that behind the shoulder of the boy
he had drawn, there was Papa Noel, pro-
tecting and guiding him . At once, Basile
drew Papa Noel into the picture . Papa Noel
is striking out at the bandit, and Basile then
crossed out the depiction of the bandit, writ-
ing the word, "boom!"
Such sessions took place every day, and
Basile's artistic productions became even
more explicit as time went on . For exam-
ple, Basile drew a sequence of children play-
ing and a soldier comes and kills them, while
he, Basile, manages to escape and to hide
among the trees (see Figures 3-9).
Finally (Figure 9) Basile was able to see
himself as safe, dreaming of Papa Noel dis-
posing of the bandit figure.
Basile's reflections upon himself and
his perceptions of his mind at work became
increasingly clear . He drew an evocative
image of his own brain (Figure 13), depict-
ing it as containing three labyrinths : a tri-
angular labyrinth in the frontal area, a
square labyrinth in the parietal area, and a circular labyrinth
in the cerebellar area (see Figure 10).
Basile informed us that he had already gone through
the triangular labyrinth . In his next drawings (Figures 11 &
12) he depicted his post-traumatic defensive adaptation and
withdrawal into coma . He drew his own brain (Figure 13),
writing inside, "and I hide myself in my mind ." In the fol-
lowing nine hypnosis sessions, he was helped to go through
all of the labyrinths of his own mind, accompanied by Papa
Noel and his therapist ( who stood for positive paternal and
maternal figures).
By July 17, Basile said that he had worked his way through
all of the labyrinths of his mind . Soon thereafter, he began
to write and to draw directly on paper, and used the com-
puter outside of the therapy just to play . His relationship
with his therapist started to become more direct, and medi-
ation of any kind (such as through the computer) was not
necessary any longer.
In the following days he began to describe his experi-
ences by writing down some of the subjective physical sen-
sations he had experienced . He now seemed oriented in time
and could understand and actually relate to recent facts and
events in the course of his treatment . He still did not rec-
ognize his relatives for who they really were, but he did have
a clear perception of both the person and the role of his
therapist.
On July 19, he asked for a diary, in which he could write
even when he was alone . He began to ask his relatives for
confirmation of his now returning memories of his life, begin-
ning the slow and difficult recovery of his personal autobi-
ography .
185
FIGURE 2
Basile's hope for his future .
IIISSOCEATION . Vol . X. Nu . 3. September 1997
SUCCESSFUL TREATMENT OF A WAR RELATED DISORDER
186
DISSOCIATION, Vol . X. No . 3, September 1997
CAGIADA/ CANIDIO /PENNATI
FIGURE 9
Basile is hiding in the woods .
FIGURE 10
Basile in Bed ; the Brain ; the Flashbacks;
the Pathway to Healing
FIGURE I1
Basile in bed ; the Bear ; the detachment of the mind . FIGURE 12"And I hide myself ."
a73
EN1I
!'ff35LOco
On July 25, Basile began to experience the tumultuous
recovery of his full faculties . Despite this major leap forward,
Basile and his treatment team were confronted with a crisis.
It soon would be medically necessary to replace his feeding
tube with a gastrostomy, involving a surgical procedure every-
one hoped to avoid . Furthermore, Basile was concerned
about the loss of the tube through which he had been fed
during his coma . To him it represented the loss of the "umbil-
ical cord" through which he had been sustained over these
many months, and all that this symbolized to him . We want-
ed to avoid an operation, which we were concerned might
prove to be still another traumatic event, so we decided to
try to speed up the rate of recovery of the functions that were
still impaired, but which if corrected, would allow Basile to
become more self-sufficient . Despite his considerable
improvement, he was not yet able to swallow or to ingest
liquids . Therefore, while Basile was still at home in the "fam-
ily house, " 189
intravenous alimentation was carried out, and attention was
focused on enhancing the function of the muscles used in
the act of swallowing, through hypnosis and learning and
learning theory-based techniques such as modeling and shap-
ing .
On July 29, Basile was able to swallow a small quantity
of liquids from a baby bottle . The next day, for the first time,
he sat up for a brief period of time and began to move his
187
DISSOCIATI0N, vol . X, No
SUCCESSFUL TREATMENT OF A WAR-RELATED DISORDER
mouth muscles with difficulty, pronouncing the word "mum, "
and then "Veronique," and other names.
On July 31, Basile got up and began to walk ; in the after-
noon he began to eat some solid food . On August 2, he
expressed himself with correct diction, in a voice so low that
it seemed as if he were afraid of the sound of his own voice.
Later on the same day he came to the clinical psychology
consulting room for his hypnosis-facilitated therapy session.
Treatment centered upon reinforcing a positive self-image,
and on the further elaboration and processing of the many
other traumata that had emerged, little by little, from
Basile's memory . As the summer progressed, he continued
to improve in all areas of function.
Basile was able to take the admission examination for
the second class of Scuola Media (Middle School) . On
September 15, 1996, Basile resumed attending school.
Beyond the human sympathy that moved and motivat-
ed all of the experts involved in Basile's care, his successful
treatment raises additional clinical considerations . Our first
observation is of a technical matter . It was possible to prove
that seriously traumatized patients afflicted with profound-
ly disabling symptoms may be able to make a complete recov-
ery when they receive dedicated and intense integrated psy-
chopharmacological and psychotherapeutic treatment,
involving the use of hypnosis . Our second observation is no
less important than the first : Basil's recovery from psy-
chogenic coma, and perhaps his very survival, was achieved
by the planning, orchestration, and implementation of a com-
plexly organized set of interventions, not by a single modal-
ity or health care professional (Galli, 1995) . The "network
treatment" that was put in place in responding to Basile's
situation made it possible to address a challenging situation
which, were it not successfully resolved, might have had a
lethal outcome . a73
188
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