1646 Am J Psychiatry 163:9, September 2006 LETTERS TO THE EDITOR ajp.psychiatryonline.org Dr. Spiegel Replies T O THE EDITOR: What’s in a name? Dr. Nakdimen concurs that dissociative identity disorder is underdiagnosed, but crit- icizes the current DSM-IV-TR nosology for removing multi- plicity of identity from the name and for not including hid- denness among the diagnostic criteria, which is more like the DSM-III criteria. Undoubtedly, there are multiple ways of naming and describing the identity disturbance of such indi- viduals, some emphasizing fragmentation, others the prolif- eration of partial competing identities. The diagnostic criteria themselves make it clear that the problem is the presence of “more than one identity or personality state.” The current title emphasizes the failure of integration rather than multiplicity of identities, which has the advantage of indicating that the “personalities” are not really personalities but rather frag- ments of identity indicative of a damaged personality. It is true that hiddenness is not explicitly mentioned in the diag- nostic criteria, but that is also characteristic of many psychi- atric symptoms, such as delusions in schizophrenia, which are sometimes jealously guarded and only mentioned in re- sponse to specific inquiry. Clearly, the exact title of the disor- der will again be explored, and hopefully more attention will be paid to the diagnosis and treatment of dissociative disor- ders. They have been with us for a long time. A rose is a rose is a rose. DAVID SPIEGEL, M.D. Stanford, Calif. Pierre Janet and the Concept of Dissociation T O THE EDITOR: In his important plea for a greater recognition and appreciation of traumatic dissociation, David Spiegel, M.D., refers to Pierre Janet’s dissociationist model of psycho- pathology, stating that “Janet used the term desaggregation mentale, which is poorly translated by the word ‘dissociation’.” Apart from mentioning that the French concept is désagréga- tion, it should be pointed out that, here, Dr. Spiegel repeated a common misunderstanding among North American students of dissociation (e.g., 1). It is true that in L’automatisme psychologique (2), Janet spoke of désagrégation, actually désagrégation psychologique. As far as we have been able to ascertain, it was only the sec- ond (1893 edition) that he also used the expression désagréga- tion mentale. However, both before and after this monumen- tal publication (3), he regularly used the term dissociation (e.g., 4, 5), thereby following a tradition that may have started with Moreau de Tours (6, 7). Consequently, Janet’s use of the term dissociation in his Harvard lectures (published in 1907) (8), for example, was not the simple result of translation. Rather, his use of the word dissociation reflected prior usage of the term by himself and others in French publications. Thus the term dissociation as evidenced in the literature to- day was present in the French literature prior to Janet and does not owe its psychiatric existence to being the closest En- glish translation for the French term désagrégation. References 1. Perry C, Laurence, JR: Mental processing outside of awareness: The contribution of Freud and Janet, in The Unconscious Re- considered. Edited by Bower K, Meichenbaum D. New York, Wiley, 1984, pp 9–48 2. Janet P: L’automatisme psychologique. Paris, Félix Alcan, 1889 3. Nemiah JC: Janet redivivus: The centenary of L’automatisme psychologique. Am J Psychiatry 1989; 146: 1527–1529 4. Janet P: L’anesthésie systématisée et la dissociation des phénomènes psychologiques. Revue Philosophique 1887; 23: 449–472 5. Janet P: L’amnésie et la dissociation des souvenirs par l’émo- tion. Journal de Psychologie 1904;1:417–453 6. Moreau de Tours JJ: Du haschish et de l’Aliénation mentale: Études Psychologiques. Paris, Fortin, Masson, and Cie, 1845, English edition. Hashish and Mental Illness. New York, Raven Press, 1973 7. Van der Hart O, Horst R: The dissociation theory of Pierre Janet. J Traumatic Stress 1989; 2:397–412 8. Janet P: The Major Symptoms of Hysteria: Fifteen Lectures Given in the Medical School of Harvard University. New York, MacMillan, 1907 ONNO VAN DER HART, PH.D. MARTIN DORAHY, PH.D. Utrecht, the Netherlands Dr. Spiegel Replies T O THE EDITOR: My point in referring to Pierre Janet’s use of the term desagregation mentale was not to misattribute the English term dissociation to a poor translation of Janet’s lan- guage, but rather to highlight his superior understanding of the phenomenon, which involves not a mere separation of el- ements of identity, memory, and consciousness but rather a failure of the normal processes of integration of these ele- ments that would normally aggregate. While Janet may have used the more common term dissociation as well, it is clear that he thought of the problem as a failure of integration rather than a mere separation. At a time when modern neuroscience is uncovering specific brain regions (perirhinal cortex and hip- pocampus) involved in binding previously disparate aspects of perception (1), it behooves us to recognize early thinkers who identified problems in integration of various aspects of perception, identity, memory, and consciousness, rather than merely describing their dissociation or disintegration. Reference 1. Taylor KI, Moss HE, Stamatakis EA, Tyler LK: Binding cross- modal object features in perirhinal cortex. Proc Natl Acad Sci U S A 2006; 103:8239–8244 DAVID SPIEGEL, M.D. Stanford, Calif. Using a Medical Model With Psychotic Patients T O THE EDITOR: In the March 2006 issue of the Journal, Dou- glas Turkington, M.D., and colleagues (1) provided a useful re- view of the state of the field regarding cognitive behavior ther- apy in treating schizophrenia. While we eagerly await further study and greater availability of this treatment modality for patients with schizophrenia, we were dismayed by the au- thors’ characterization of a medical approach. The authors presume a “biomedical” medical model in which one is “more likely to ignore” (p. 367) aspects of the pa- tient’s experience, “forbids any exploration of a personal meaning (formulation) of psychotic experiences” (p. 370), and goes about in an effort to “persuade or force the patient to agree that he or she has symptoms of a mental illness” (p.