The state of consciousness: From perceptual alterations to dissociative forms. Analysis of neurobiological and clinical profiles

The term derives from the Latin “conscientia”, in turn derived from “conscire”, which is “to be aware”, “to know” and indicates the awareness that the person has of himself and of his mental contents. In this sense the term “consciousness” is generically assumed not as the fi rst stage of immediate apprehension of an objective reality, but as a synonym of “awareness” in its reference to “the totality of the experiences lived, at a given moment or for a certain period of time”. Etymology shows how the two terms consciousness and awareness have a different chronological origin, and how at the beginning there was no need to distinguish between the meaning of consciousness and “being aware”: the term “coscienza” enters the Italian language in the 13th century, deriving from the Latin “conscientĭa”, while the term “consapevolezza” enters the Italian language in the 17th century, deriving from the Italian “consapevole” [2,3].

Bewusstsein) is a quality of mind that usually includes other qualities such as subjectivity, self-awareness, knowledge and the ability to identify the relationships between oneself and one's surroundings. In common parlance, consciousness is understood as awareness of one's surroundings and the ability to interact with them; this is in contrast to unconsciousness. The expression 'levels of consciousness' indicates that consciousness seems to vary according to different mental states (such as imagination and daydreaming). Unconsciousness is defi ned, by negation, as the mental state in which consciousness is absent. In some strands of thought, especially religious ones, consciousness is not extinguished after death and is present even before birth. But, just beyond common perception, consciousness is very diffi cult to defi ne or identify.
Many cultural and religious traditions locate consciousness in a soul separate from the body. In contrast, many scientists and philosophers consider consciousness to be something inseparable from the neural functions of the brain. However, if classical psychology revolved around consciousness, to the point of inducing Wundt to defi ne psychology itself as the science of facts and states of consciousness, in the following decades various researchers, among whom Külpe, investigated above all the dynamic processes of consciousness and perceptual processes, from the Gestalt school to the cognitivebehavioural and constructivist schools [5,6].
In these studies, activation is a biological function, consisting of the state of vigilance of the central nervous system, understood as the optimal state of consciousness for the performance of certain tasks; if, however, activation is the general state of the organism, vigilance is the ability to keep the state of consciousness active. The main theoretical models are [7,8]: 1) The 'Arousal theory of activation': According to this theory, the person is motivated to reach and maintain an optimal level of 'arousal' (physiological activation threshold). Thus, if it is too low, he seeks stimulation; if it is too high, he seeks a way to relax (Palomba). In neuropsychology, arousal is therefore a temporary condition of the nervous system, in response to a signifi cant stimulus of varying intensity, internal or external, of a general state of arousal, characterised by an increased attentional-cognitive state of vigilance and prompt reaction to external stimuli. During arousal, both the central nervous system and the peripheral and vegetative ones are involved, with a consequent increase in heart rate and blood pressure, in order to generate a general condition of greater sensory alertness, mobility and readiness of refl exes throughout the body. In fact, many experimental studies show a functional inverted U-shaped relationship between activation and performance: the best human performance is obtained at intermediate levels of arousal, while reduced arousal (as in sleep or deep relaxation) or excessive arousal (as in panic attacks) is incompatible with good cognitive functioning.
Medium arousal therefore produces a state of consciousness of full alertness and motivation towards the task at hand.
The psychologist Eysenck has identifi ed in the spontaneous tendencies to search for an optimal level of arousal, a real dimension of personality related to introversion/extroversion: introverted subjects have a basal level of arousal that is already quite high, and would therefore tend to reduce the excessive increase in activation through diversifi ed forms of social and cognitive avoidance of further stimuli. Extroverts, on the other hand, have a lower level of arousal and try to raise it through the search for exciting stimuli of various kinds. Emotions and feelings, according to some authors, are linked to an increase in the level of arousal and prompt behaviour aimed at restoring homeostasis. Thus, the underlying mood would be determined by events of modest hedonic signifi cance involving a low level of arousal, which does not produce a behavioural response.
2) The 'sleep-wake theory of vigilance': According to this theory, sleep is not a loss of consciousness but a precise

Alterations in the state of consciousness
The altered state of consciousness corresponds to a state of consciousness with different dynamic characteristics than the lucid waking state. It can be defi ned in opposition to the latter, considering the waking state as the ordinary one, which the subject recognises as "normal", because it corresponds to the psychic and physical dynamics of thoughts, sensations and feelings, with which the subject is most familiar or which he has experienced most of his life. The use of the term "altered" could generate the misunderstanding that we are dealing with a pathological state, but this is only true in certain cases (i.e. when the functional alteration affects the cognitive processes of memory, reasoning and perception, as well as identity and psychophysical faculties in general); it has therefore been proposed to use the term "non-ordinary state of consciousness" [9].
It is not possible to defi ne the waking state in a clear-cut manner, as it is subjective and does not correspond to exact parameters, but rather can be identifi ed in a range of values relating to various parameters, including age, gender and state of psychophysical health. The normality of the ordinary state of consciousness is dictated by biological and cultural needs, and this ordinariness may therefore vary according to the cultural or environmental context in different parts of the world.
Usually, the waking state is considered to be the ordinary state of consciousness because it corresponds to a balance between the amount of information reaching the brain and the amount of information the brain itself is able to process. However, this is not a parameter to characterise it intrinsically, as it only emphasises the ability to maintain control over the fl ow of information, without defi ning the quality of processing. The waking state (or ordinary state of consciousness) is only one of the many possible structures that the mind assumes. It may vary in intensity and/or quality over the course of a day, or a lifetime, of the subject concerned [10].  [6,7]. Some of these states are:

1.
Falling in love: In the human species, it is a drive that provokes a variety of feelings and behaviours characterised by strong emotional involvement with another person, which, depending on the case, is associated with intense sexual attraction. The anthropologist Fisher discovered, using brain MRI on people in love, that falling in love is a drive that activates parts of the deep brain with the production of characteristic hormones and can be traced back to three separate specifi c mental states that are more or less simultaneous or consequential: sexual desire (oestrogen, endogenous, endorphins), romantic love (dopamine, norepinephrine, serotonin), attachment (oxytocin, vasopressin). Sexual desire is characterised by promiscuity, romantic love by exclusivity, and attachment by the desire for closeness, which can also be acted out with different partners at the same time. Falling in love can last up to several years and is the cause of great pleasure as well as great pain and is present in almost all ancient and modern cultures with different cultural emphases. Psychologists in general have not given a particular role to falling in love and have usually seen it as a sign of immaturity.
Within the framework of modern psychological theories, character and personality disorders are unequivocally referred to a defect in personal maturation, that is to say to a 'halt' in development, or even to a 'regression', and thus to the persistence of early infantile or adolescent phases in adult life; phases characterised by dependence, the need for confi rmation, the inability to resolve the debt with the past, to separate from mother or father or family, the inability to become autonomous. And falling in love has itself been seen as a regression, as a return to a state of dependence no longer on the mother, but on someone who has taken her place. The lover is, in Freud's eyes, an individual animated only by the need to satisfy his sexual needs; to do this adequately he has learned, by falling in love, to maintain a stable relationship with his 'sexual object'. According to Freud, love derives directly from the sexual drive and dies with its extinction. It survives only when sexuality is 'sublimated', i.e. controlled, and the relationship is fi lled with extrinsic factors: affection, mutual aid, esteem. In fact, once the sexual goal has been reached, love could end, if this does not happen it is because the individual, according to Freud, 'can safely rely on the resurgence of need, and this is the fi rst reason for making a lasting investment in the sexual object and for loving it even in the intervals of time when passion does not manifest itself...'; and this, consequently, happens in the case where love is unilateral, i.e. not reciprocated by the beloved subject: dependence on it cannot end. For Freud, then, love is a control over the partner dictated by selfi sh needs. In Freud's wake, most psychoanalytic theorists, both men and women, have described love as a subjective mystifi cation (sublimation) intended to cover a primary sexual need. For Fromm, falling in love is a state of madness and the two lovers realise a two-way egoism. Couple love is not a sui generis force, it is not a paradigm of search and adventure, it is only a minor expression of the more general need for security. Jung's conception is much more in-depth and sees in the love encounter a process of growth, maturation, enrichment thanks to the reunion with one's own animus (in the female) or with one's own soul (in the male). A similar concept will be supported by Winnicott with the concept of transitional object that allows the transition from one state to another state of one's identity. Neurophysiological studies have confi rmed that in the early stages of the love process there are particular experiences and therefore an expression such as falling in love is justifi ed. Research has also tried to explain each of these experiences by particular neurotransmitters. According to some, at the fi rst meeting, the midbrain, the area of the brain that controls visual and auditory refl exes, begins to release dopamine, a neurotransmitter that produces pleasure and euphoria. The hypothalamus, on the other hand, commands the body to send signals of attraction and pleasure. As the relationship continues, dopamine levels increase and the levels of two other dopamine-related neurotransmitters increase: norepinephrine and phenylethylamine. As the relationship deepens, the hypothalamus stimulates the production of oxytocin, which stimulates feelings of tenderness and warmth.
Another hormone, vasopressin, which is linked to memory, encourages fi delity and monogamy. After a period of 18 to 30 months from the beginning of the relationship, however, the brain has become accustomed to the "cocktail" of chemicals and no longer reacts as it did before. We can therefore consider the falling in love phase to be over. Recent studies have, however, denied that there is a physiological time limit to falling in love. Falling in love is not just a set of emotions, sensations, perceptions and impulses as appears from neurophysiological studies but a complex process in which two individuals enter into a relationship, transform themselves and create a new society and a new life project. It is therefore a complex process in which there are obligatory stages such as telling each other one's whole life story so that the other can get to know him and understand how he has seen the world. In this way, lovers come to love not only the person as he or she is today, but as he or she was as a child, as an adolescent, in his or her joy and sorrow [11][12][13][14][15][16][17]. naturalistic explanation, believing that organic phenomena were infl uenced by gravitational magnetism and that illness was caused by the alteration in the body of a fl uid needed to connect humans to the celestial bodies: healing could be achieved by applying magnets to the body that rebalanced the biocosmic fl uid. Mesmer understood the value of the therapeutic link and reduced the use of magnets in favour of relationships, but few understood its importance and hypnosis was delegated to street theatres who encouraged its popular use. Mesmer formulated the theory of animal magnetism in 1779, according to which a magnetic fl uid permeated the universe and formed the basis of the interconnection between creatures, and health depended on its proper circulation, while disease was caused by its alteration. His therapies were initially met with a mixture of success and criticism, but his theories were condemned by the Academy of Sciences and the Faculty of Medicine in Paris in 1784. An important revision of Mesmer's theories was proposed by the English physician Braid, who gave a physiological interpretation to the phenomenon studied and introduced the term hypnosis in addition to the term neuro-hypnotism in his work published in 1843, in order to overcome the Mesmerian hypothesis of the magnetic fl uid and introduce the theory that hypnotic phenomena depended exclusively on an impression on the nerve centres. Subsequent developments in the interpretation of hypnosis are due to the work of Liébeault, a doctor from Nancy, and Bernheim, a famous Parisian neurologist. Together they founded the Nancy School. The Nancy School had to oppose studies and theories on hypnosis to the Charcot School, which operated at the Salpêtrière Hospital in Paris. Whereas the Nancy school considered hypnosis to be a normal psychological phenomenon and all its phenomena could be explained by suggestion, Charcot considered hypnosis to be a pathological phenomenon, an artifi cial hysterical neurosis. Hypnosis also had applications in surgery: the fi rst to experiment with hypnosis for surgical analgesia were Elliotson and Forbes in England. On 12 April 1829, Cloquet performed the fi rst operation under hypnotic anaesthesia in France, removing a breast from a hypnotised patient, who felt no pain and had no memory of the operation when she woke up. In 1830, Dudet extracted the fi rst tooth under hypnotic anaesthesia, and in 1880 Liébeault produced total analgesia in a 22-hour labour. S. Freud also worked on hypnosis, but the transience of the therapeutic results, the laboriousness of hypnotic procedures, the limitation of therapeutic applications and, perhaps not least, his identifi cation of a 'mysterious element' of a sexual nature, led Freud to abandon hypnosis and create a new method: psychoanalysis. With Charcot's death in 1893 and the beginning of psychoanalysis, a period of decline began for hypnosis. Interest in hypnosis was reawakened during the First World War, when it was used to treat traumatic war neuroses, but it was not until after the Second World War that the scientifi c community's attitude towards hypnosis improved. In particular, it was during this period that M. Erickson, taking up the lesson of one of Charcot's pupils, Leguirec, developed a hypnotherapy called "Ericksonian hypnosis", defi ning it as a special psychological and neuro-physiological condition in which the person functions in a special way, a way in which the person can think, act and behave as in the normal state of consciousness or even better, thanks to the intensity of his attention and the strong reduction of distractions. This type of hypnosis is very similar to a normal conversation and induces a hypnotic trance in the subject. Since the second half of the 20th century, there has been a growing interest in hypnosis, and in particular in recent years, new opportunities for study have been created by the development of brain imaging techniques, which make it possible to visualise changes in brain activity during a state of hypnosis. The subject in hypnosis can alter his perception of the external world; he can perceive stimuli that are not actually there and fail to perceive those that are present; he can distort perceptions of stimuli that actually exist, creating illusions. Thus it becomes possible to perceive, for example, a non-existent smell, light or noise, or to perceive as pleasant a very annoying smell, such as that of ammonia, as ringing a low-pitched sound, green as red colour, or to develop insensitivity in every sense organ. In hypnosis, it is possible to modify the sensory experience, the experience of the bodily scheme and in particular pain control. The subject in hypnosis can easily direct his introspection in the different sectors of his organism, he can amplify or reduce the sensations that come from inside his body, he can alter the perceptible physiological parameters such as heartbeat, respiratory rate, skin temperature. For example, suggestions of cold and heat can lead to vasoconstriction and vasodilation respectively. Simple suggestions to increase or decrease the frequency of the heartbeat and breathing, to increase or decrease the arterial tension, or to increase or decrease muscle fatigue and anxiety or to calm down, are also capable of actually causing an increase or decrease in the frequency of the pulse, breathing or arterial tension. With hypnosis it is possible to enter one's own history and change the criteria for processing the incoming information; it is possible to change the meanings that the subject has given to his experiences in the past by making use of the alternatives he possessed. It is possible to obtain changes in the continuity of memory (partial or total amnesia). On the other hand, it has been proven that the possibility of remembering past events of which one has no memory is almost nil: investigations have shown that such therapies are often the cause of false memories or inaccurate memories, dictated by the patient's imagination or misinterpretation. Through hypnosis the subject can learn to dampen his emotional resonance. The ego-sense can be detached from a wide variety of types of information and situations to which it is normally applied. In a subject in age regression, the emergence of a memory with a particularly affecting affective tone may be experienced not as its own experience but simply as neutral information drawn from memory. The sense of the Ego may also be detached from one's own body as is the case with the non-perception of pain. In hypnosis there is the possibility of altering the quality and quantity of the control of voluntary musculature, motility and in particular of modifying certain modes of functioning of our organism, believed to be beyond any voluntary control, such as those of the neurovegetative system, the neuroendocrine system and the immune system. All the behavioural possibilities listed above cannot of course be thought of as achievable at the same level by all subjects, at least immediately, as genetic predisposition and learning times are involved [18][19][20][21][22][23][24][25][26]. Non-REM sleep deals with conscious-relative memory, and REM sleep deals with relative and unconscious memory (procedural memory). Zhang assumed that, during REM sleep, the unconscious part of the brain is busy processing procedural memory; meanwhile, the level of activity in the conscious part of the brain drops to a very low level as contributions from the sensorium are basically disconnected. This causes the 'continuous-activation' mechanism that generates a fl ood of data from the stored memory to the conscious part of the brain.

Sleepwalking:
Zhang proposes that, with the involvement of the thinking and associative systems, dreaming causes the dreamer's brain to maintain the same memory until its next insertion occurs. to breathe on his own. It is different from sleep, which is a self-limiting process, whereas it is not possible to 'wake' a comatose person at will [35].

6.
Meditation: Meditation is, in general, a practice that is used to achieve greater mastery of the activities of the mind, so that it becomes capable of concentrating on a single thought, on a lofty concept, or on a precise element of reality, ceasing its usual background chatter and becoming absolutely quiet, peaceful. Related to meditation is contemplation, by which is meant the ability to let the mind rest in its natural state.
It is therefore a practice aimed at self-realisation, which can have a religious, spiritual, philosophical purpose, or with a view to improving psychophysical conditions. This practice, in different forms, has been recognised for many centuries as

Sense-perceptual disorders
Sensation' is the fi rst step in the perceptual process.
Sensations use the sense organs to detect external stimuli, place them in space-time parameters and re-elaborate them, becoming "perception" (passive) or "mental representations" i.e. the hyperactivity of the dopaminergic neurotransmitter in the mesolimbic area and the alteration of consciousness with a reduction in the action of the higher centres on the lower ones [49].

Perceptual falsifi cations
Perceptual falsifi cations are false perceptions related to an external stimulus (output) a) Illusions: They are visual distortions of perceived objects that derive from the distorted changes of concrete perceptions, and these outputs congregate with the psyche to create a whole, which are completely at variance with reality. They can affect any sensory organ and are not psychopathological because they can occur even in the absence of a mental defi cit. However, in the vast majority of cases they are related to states of intoxication by psychoactive substances, dementia, disorders of consciousness and exhaustion. There are three subtypes of delusions: "completion or inattention delusions" (they can be physiological or integrative and consist of a fragmentary perception without meaning being slightly altered by the use of memory or imagination, so that it becomes meaningful); "emotional or affective" (they are short-term, have to do with the phobic mood state and vanish when the phobia fades, as for example happens when a child wakes up late at night and taken by fear mistakes a towel hanging on the wall for a ghost); "pareidolics or paraidolics (very frequent in children and characterised by a combination of perception and imagination when faced with an enigmatic stimulus, such as comparing the shapes of clouds we see with animals that come to mind. The person experiencing them admits that the stimulus does not really exist, but cannot deny what they see. They are involuntary and accepted with passivity).

b)
Hallucinations: These are perceptions without object endowed with physical forms, they are subjective and cannot be shared. They are false perceptions that do not correspond at all to reality, but appear as original and occur concomitantly with real perceptions. They occur in the absence of external stimuli, are automatic, are perceived as a sensation, affect behaviour and are independent of an abnormal psychic state. Often, the patient is not convinced that others can share his or her experience; in fact, hallucinatory phenomena are subjective and cannot be shared with others. Hallucinations may be reported by the subject out of unawareness of their bizarre nature. Such phenomena come from 'inside', even though they are experienced as coming from 'outside'. Hallucinations frequently occur in cases of epilepsy, tumours and severe vascular diseases, personality disorders, bipolarism, severe depression, dissociative disorders and psychosis; they can be triggered by strong emotions, psychopathologies and neurological disorders. Hallucinations can be categorised according to the sense organ involved (sight, hearing, smell, taste, touch) including the soma in its complexity, intensity, emotional involvement, consequences on behaviour and level of awareness. Hallucinations can be simple and elementary (e.g. whistles and buzzing, fl ashes and circles of light) and complex or integrated (e.g. sounds, 3D visions, epidermal sensations, paresthesias, delusions, circadian rhythm alterations, convulsions). Finally, there are 'functional hallucinations' (i.e. those involving the same sense organ, e.g. hearing water fl owing from the tap is functional to the sense of hearing, so the hallucination is auditory) and 'refl ex hallucinations' (i.e. those caused by sensory stimulation of another sensory organ, e.g. hearing water fl owing from the tap is functional to the sense of hearing, but the sense of sight is stimulated, so a sensory channel inadequate to the situation. Refl ex hallucinations produce synesthesia: a stimulus in one senseperceptual channel triggers a hallucination in another). There are also some very specifi c forms of hallucinations: Hypnagogic and hypnopompic hallucinations, which represent the 'state of consciousness in the waking and sleeping phase' (they occur in falling asleep -hypnagogic-or on awakening -hypnopompic-, and can be visual, auditory and tactile); Flashbacks, which occur in the form of memories of a given event, with intense emotional and sensory involvement (affecting patients with post-traumatic stress disorder, anxious patients incapable of self-control and hallucinogenic drug abusers); The phantom limb phenomenon, in which the patient feels that he has a limb that has been amputated either because the afferent nerves that innervated it are compromised (the subject is aware of the existence of that limb and describes thermal sensations, tactile proprioception and pain referring to that missing limb).

c)
Pseudo-hallucinations: They come from one's own mind and do not show signs of delirium. These are hallucinogenictype sense-perceptual disturbances that come from one's own mind (internal voices are heard and one's own thoughts are listened to), are not psychopathological and do not show signs of delirium, although they are particularly intense and vivid. They are experienced in full consciousness, recognised as surreal perceptions, and are subjective and automatic. Among the pseudo-hallucinations there is a very particular and pathological form: the 'Kandisky-Clerambault pseudohallucinations', identifi ed as a syndrome of a hallucinatoryparanoid nature and characterised by psychotic symptoms, bipolarity and obsessions perceived by the patient as not his own and infl uenced by forces external to him.

d)
Hallucinosis: Psychosensory defi cits caused by neurovegetative dysfunction or hyperesthesia. They are elementary perceptions and differ from psychotic hallucinations. They are independent of hallucinations, distort environmental perception and are revealed when the eyes are closed. They occur in cases of alcoholism, LSD and ketamine abuse (anaesthetics that cause hallucinosis in high doses), brainstem damage, temporal and occipital damage and prolonged insomnia.

Sensory dysfunctions
These include alterations in intensity or quantity (hyperesthesia or high intensity of sensations, or hypoesthesia or reduced/absent perception of intensity), quality, space and time. For example: Macropsy/micropsy: objects are perceived as larger or smaller; Dyschromatopsia: colour changes of objects; Palinacusia: auditory hallucination in which a correctly perceived word is heard over and over again for a certain time, as if it were a kind of echo; Dismegalopsia: objects perceived larger on both sides; Xanthopsy: yellow vision of white objects and violet vision of dark objects; Erythropsia: red vision of objects; Chloropsia: green vision of objects; Porropsia: illusion that objects move away and shrink; Paraprosopia: illusion that people's faces take on a monstrous appearance; Alloesthesia: objects placed on the left are perceived on the right; Metamorphopsia: changes in the shape of objects; Teleopsia: objects appear distant; Pelopsia: objects appear close; Hyperschemazia / Hyposchemazia / Aschemazia: amplifi ed perception/reduced perception/absence of perception of body parts; Paraschemazia: body parts are perceived distorted from the rest of the body; Hemiasomatognosia: loss of one side of the body, such that the person acts as if half of the body is missing.

Dissociative disorders
Dissociative disorders are conditions involving a discontinuity in the normal integration of consciousness, identity, memory, emotions, perception, behaviour and motor control. Individuals with dissociative disorders use dissociation, as a defence mechanism, pathologically and involuntarily. Such disorders may be triggered by psychological trauma, but some, such as depersonalisation or derealisation disorder, may be preceded by stress, psychoactive substance use, or no identifi able cause [7].

1.
Dissociative identity disorder: The diagnostic criteria for DDI are: the presence of two or more distinct identities or personality states, each with its own relatively constant ways of perceiving, relating to, and thinking about oneself and one's environment; at least two or more of these identities or personality states recurrently assume control of the person's behaviour; inability to recall important personal information that cannot be explained by a trivial tendency to forget; the alteration is due neither to the direct physiological effects of a substance nor to a general medical condition. This disorder seems to represent the precipitate of a failure in the processes of integration between the various aspects of memory, consciousness and identity associated with severe trauma; the alternation of different personality states may cause diagnostic confusion due to the emergence of symptomatic formations of discontinuity of consciousness common to other psychopathologies, as well as a wide range of 'secondary symptoms' (anxious, obsessive-compulsive, depressive, phobic, psychotropic substance abuse symptoms, eating disorders, antisocial behaviour, etc.) on which clinicians often focus) on which clinicians often erroneously focus, inevitably leading to incorrect diagnoses and ineffective treatments.

2.
Dissociative fugue: This is a sudden, unexpected departure from one's environment, with inability to remember one's past, confusion about one's identity and partial or complete assumption of a new personality. It is a very rare disorder that appears to be related to traumatic experiences (natural disasters, wars, repeated sexual violence and abuse during childhood) that produce an altered state of consciousness 'dominated by the will to escape the trauma and forget'. It has a very limited duration, usually resolving within hours or a few days. Cases lasting several months have been described, with movements of up to several kilometres. Sometimes there may be residual amnesia due to the traumatic events that often precede and are therefore closely related to the onset of the clinical picture.

3.
Dissociative Self. This is what happens, for example, in those who were repeatedly sexually abused in childhood. It has been found that among psychiatric patients depersonalisation is most often diagnosed as a symptom associated with other disorders such as schizophrenia, dissociative identity disorder, depression, anxiety disorders, rather than as a pure disorder.  the priority is safety, stabilisation and strengthening of the patient, with a view to working through the traumatic material and managing problematic personalities. Objectives include maintaining personal safety, symptom control, modulation of affect, stress tolerance, improvement of basic life functions, and development of interpersonal skills. Psycho-education is often used, advising the patient on specifi c readings, providing information and explanations with the aim of 'normalising' their experience. The therapeutic relationship becomes the ground for corrective emotional experiences of the attachment system and the experience of new collaborative and equal forms of interpersonal relationships. In the second phase the patient is helped to process the painful episodes of his past, and to bear the pain of losses and other negative consequences of trauma. The work of this phase is to remember, tolerate, process and integrate the intense past events by planning strategies to maintain control over the emerging traumatic material. The exploration and integration of traumatic memories can be defi ned as a form of exposure therapy that allows the patient to transform traumatic memories in order to integrate personalities or achieve interaction between them. The processes of the second phase allow the patient to understand that traumatic experiences belong to the past, to understand their impact on one's life, to develop a more complete and coherent personal history and sense of self. Cognitive restructuring of traumatic experiences and recognition of the adaptive responses the patient had during those experiences are used to counteract irrational guilt and shame. In the third phase, patients begin to experience a stable and solid sense of self and new feelings about how to relate to others and the outside world. They gain a sense of coherence in their history that is also related to the problems they face in the present, they begin to turn their attention away from their traumatic past, directing their energy to living in the present and developing future perspectives [1,7,57].

Derealisation disorder:
Strategic psychotherapy can also be a functional orientation for dissociative conditions, also because of the strategies of the theoretical model [58].

Conclusions
States of consciousness allow us to interact with our environment and to be present to ourselves: if this does not happen, because an alteration occurs, our plane of reality is also compromised [59]. On the basis of the alteration it is then possible to assess the severity of the impairment, also in function of the individual cognitive processes [1,7,10,60,61] and of the morbid conditions in comorbidity or as a consequence of them , but also of previous psychological traumas [88,89] and of the subject's defence mechanisms [90].
According to the theoretical model underlying the PICI-1 questionnaire (TA version) [91,92] and its fi rst revision [93], dissociative disorders fall within a specifi c personality disorder in terms of symptoms and nosography, as well as representing individual traits of other morbid conditions of the borderline and psychotic groups. In the light of this, all dissociative hypotheses regarding alleged mystical and occult experiences, such as near-death experiences and projection of the spiritual and soul body, also play a central role [94][95][96][97].