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Book Review   |    
Dissociation in Children and Adolescents: A Developmental Perspective
Andrea S. Moskowitz, M.D., Ph.D.
Psychiatric Services 1999; doi:
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by Frank W. Putnam, M.D.; New York City, Guilford Press, 1997, 423 pages, $38.95

Dr. Putnam, a world-renowned expert in dissociative disorders and author of the classic Diagnosis and Treatment of Multiple Personality Disorder (1), has now written a comprehensive and accessible work on dissociative disorders in children and adolescents. This book, which is clinically oriented, helps the practitioner understand how pathological dissociation arises from traumatic experiences in childhood and how this dissociation represents a failure in basic developmental processes.

The book covers a lot of ground and provides the reader with a firm theoretical background for understanding dissociative processes. It starts with a discussion of the effects of childhood trauma and maltreatment and then moves on to discuss pathological dissociation, including multiple models of how to understand dissociative phenomena as well as everyday examples of dissociation and how they differ from pathological dissociation. Clinical issues in diagnosis and treatment are then considered. Notably, the book also includes copies of diagnostic instruments, developed by Dr. Putnam and coworkers, that are not covered by copyright and that the reader is encouraged to duplicate and use.

Dr. Putnam has succeeded in cohesively organizing the data on the effects of trauma and maltreatment and what is known about the phenomenology and pathology of dissociative disorders in children and adolescents using the discrete behavioral states model. This model provides an excellent framework for organizing the broad range of research presented, which includes work on the effects of trauma and maltreatment in children and adolescents, the phenomenology and genesis of dissociation in children, normal infant and child development, memory functions, and the effects of stress. An excellent critical review of theories of multiple personality disorder is also provided.

The discrete behavioral states model is heavily emphasized, and although it does seem to provide the most satisfactory framework currently for understanding dissociative disorders, it would have been helpful to also discuss the shortcomings of the model. A brief attempt is made to relate nonlinear dynamics and chaos theory to the model. I found this part fairly confusing and thought that a fuller explanation was needed if this point was to be brought up.

The more clinical sections of the book provide thorough descriptions of the range of dissociative disorders seen in children and adolescents, although the author has a slight tendency to focus more on multiple personality disorder. I found the discussion of normal versus pathological dissociative phenomena in children particularly helpful, especially the differences in the presentation and uses of imaginary companions in both groups.

The treatment section thankfully eschews a cookbook or manual-based approach to these difficult and complex disorders; instead it focuses on general principles involved in dealing with the therapeutic and behavioral issues that arise. There is an excellent discussion of placement issues, including the difficulties encountered in foster care and residential treatment settings. The treatment section ends with a well-organized, critical review of what is known about psychopharmacological treatments for children with dissociative disorders.

In Dissociation in Children and Adolescents, Dr. Putnam has provided us with a work that emphasizes research and theory along with clinical application. Given the unfortunately high incidence of childhood trauma and maltreatment, this book, which is comprehensive and generally highly readable, should be an invaluable reference for any clinical practitioners who work with children, adolescents, or families.

Dr. Moskowitz is in the private practice of child and adolescent psychiatry in Los Angeles and is a consultant psychiatrist at Vista del Mar, a residential treatment center.

Putnam FW: Diagnosis and Treatment of Multiple Personality Disorder. New York, Guilford, 1989
 
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References

Putnam FW: Diagnosis and Treatment of Multiple Personality Disorder. New York, Guilford, 1989
 
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