What is dissociation?
Dissociation is a word that is used to describe the disconnection or lack of connection between things usually associated with each other. Dissociated experiences are not integrated into the usual sense of self, resulting in discontinuities in conscious awareness. In severe forms of dissociation, disconnection occurs in the usually integrated functions of consciousness, memory, identity, or perception. For example, someone may think about an event that was tremendously upsetting yet have no feelings about it. Clinically, this is termed emotional numbing, one of the hallmarks of post-traumatic stress disorder.
There are five main ways in which the dissociation of psychological processes changes the way a person experiences living: depersonalization, derealization, amnesia, identity confusion, and identity alteration.
What is the cause of dissociation and dissociative disorders?
Most commonly, repetitive childhood physical and/or sexual abuse and other forms of trauma are associated with the development of dissociative disorders (e.g., Putnam, 1985). In the context of chronic, severe childhood trauma, dissociation can be considered adaptive because it reduces the overwhelming distress created by trauma. However, if dissociation continues to be used in adulthood, when the original danger no longer exists, it can be maladaptive. The dissociative adult may automatically disconnect from situations that are perceived as dangerous or threatening, without taking time to determine whether there is any real danger. This leaves the person “spaced out” in many situations in ordinary life, and unable to protect themselves in conditions of real danger.
Dissociation may also occur when there has been severe neglect or emotional abuse, even when there has been no overt physical or sexual abuse. Children may also become dissociative in families in which the parents are frightening, unpredictable, are dissociative themselves, or make highly contradictory communications.
The development of dissociative disorders in adulthood appears to be related to the intensity of dissociation during the actual traumatic event(s); severe dissociation during the traumatic experience increases the likelihood of generalization of such mechanisms following the event(s). The experience of ongoing trauma in childhood significantly increases the likelihood of developing dissociative disorders in adulthood.
How does affect dysregulation influence dissociation?
One of the core problems for the person with a dissociative disorder is affect dysregulation, or difficulty tolerating and regulating intense emotional experiences. This problem results in part from having had little opportunity to learn to soothe oneself or modulate feelings, due to growing up in an abusive or neglectful family, where parents did not teach these skills. Problems in affect regulation are compounded by the sudden intrusion of traumatic memories and the overwhelming emotions accompanying them (Metcalfe & Jacobs, 1996; Rauch, van der Kolk, Fisler, Alpert, Orr et al., 1996).
The inability to manage intense feelings may trigger a change in self-state from one prevailing mood to another. Depersonalization, derealization, amnesia and identity confusion can all be thought of as efforts at self-regulation when affect regulation fails. Each psychological adaptation changes the ability of the person to tolerate a particular emotion, such as feeling threatened. As a last alternative for an overwhelmed mind to escape from fear when there is no escape, a person may unconsciously adapt by believing, incorrectly, that they are somebody else. Becoming aware of this kind of fear is terrifying. Therein lies one of the central problems in treatment for a person with a dissociative disorder: “How do I learn to approach things I fear when to understand that I am afraid is itself frightening?” Skillful clinical approaches are required to help build confidence in a person’s ability to tolerate their feelings, learn, and grow as a person.
What is depersonalization?
Depersonalization is the sense of being detached from, or “not in” one’s body. This is what is often referred to as an “out-of-body” experience. However, some people report rather profound alienation from their bodies, a sense that they do not recognize themselves in the mirror, recognize their face, or simply feel not “connected” to their bodies in ways which are challenging to articulate.
What is derealization?
Derealization is the sense of the world not being real. Some people say the world looks phony, foggy, far away, or as if seen through a veil. Some people describe seeing the world as if they are detached, or as if they were watching a movie.
What is dissociative amnesia?
Amnesia refers to the inability to recall important personal information that is so extensive that it is not due to ordinary forgetfulness. Most of the amnesias typical of dissociative disorders are not of the classic fugue variety, where people travel long distances, and suddenly become alert, disoriented as to where they are and how they got there. Rather, the amnesias are often an important event that is forgotten, such as abuse, a troubling incident, or a block of time, from minutes to years. More typically, there are micro-amnesias where the discussion engaged in is not remembered, or the content of a conversation is forgotten from one moment to the next. Some people report that these kinds of experiences often leave them scrambling to figure out what was being discussed. Meanwhile, they try not to let the person with whom they are talking realize they haven’t a clue as to what was just said.
What are the different types of dissociative disorders?
There are four main categories of dissociative disorders as defined in the standard catalogue of psychological diagnoses used by mental health professionals in North America, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The four dissociative disorders are: Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder, and Depersonalization Disorder (American Psychiatric Association, 2000; Frey, 2001; Spiegel & Cardeña, 1991).
DISSOCIATIVE AMNESIA is characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. The amnesia must be too extensive to be characterized as typical forgetfulness and cannot be due to an organic disorder or DID. It is the most common of all dissociative disorders, frequently seen in hospital emergency rooms (Maldonado et al., 2002; Steinberg et al., 1993). In addition, Dissociative Amnesia is often embedded within other psychological disorders (e.g., anxiety disorders, other dissociative disorders). Individuals suffering from Dissociative Amnesia are generally aware of their memory loss. The memory loss is usually reversible because the memory difficulties are in the retrieval process, not the encoding process. Duration of disorder varies from a few days to a few years (American Psychiatric Association, 2000; Frey, 2001; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993).
DISSOCIATIVE FUGUE is characterized by a sudden, unexpected travel away from home or one’s customary place of work, accompanied by an inability to recall one’s past and confusion about personal identity or the assumption of a new identity. Individual’s suffering from Dissociative Fugue appear “normal” to others. That is their psychopathology is not obvious. They are generally unaware of their memory loss/amnesia (American Psychiatric Association, 2000; Frey, 2001; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993).
DEPERSONALIZATION DISORDER is characterized by a persistent or recurrent feeling of being detached from one’s own mental processes or body. Individuals suffering from Depersonalization Disorder relate feeling as if they are watching their lives from outside of their bodies, similar to watching a movie (American Psychiatric Association, 2000; Frey, 2001; Guralnik, Schmeidler, & Simeon, 2000; Maldonado et al., 2002; Simeon et al., 2001; Spiegel & Cardeña, 1991). Individuals with Depersonalization Disorder often report problems with concentration, memory and perception (Guralnik et al., 2001). The depersonalization must occur independently of DID, substance abuse disorders and Schizophrenia (Steinberg et al., 1993).
DISSOCIATIVE IDENTITY DISORDER (previously known as Multiple Personality Disorder) is the most severe and chronic manifestation of dissociation, characterized by the presence of two or more distinct identities or personality states that recurrently take control of the individual’s behavior, accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. It is now recognized that these dissociated states are not fully-formed personalities, but rather represent a fragmented sense of identity. The amnesia typically associated with Dissociative Identity Disorder is asymmetrical, with different identity states remembering different aspects of autobiographical information. There is usually a host personality who identifies with the client’s real name. Typically, the host personality is not aware of the presence of other alters (American Psychiatric Association, 2000; Fine, 1999; Frey, 2001; Kluft, 1999; Kluft, Steinberg & Spitzer, 1988; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993). The different personalities may serve distinct roles in coping with problem areas. An average of 2 to 4 personalities/alters are present at diagnosis, with an average of 13 to 15 personalities emerging over the course of treatment (Coons, Bowman & Milstein, 1988; Maldonado et al., 2002). Environmental events usually trigger a sudden shifting from one personality to another (Maldonado et al., 2002).
DISSOCIATIVE DISORDER NOT OTHERWISE SPECIFIED (DDNOS): DDNOS includes dissociative presentations that do not meet the full criteria for any other dissociative disorder (American Psychiatric Association, 2000; Steinberg et al., 1993). In clinical practice, this appears to be the most commonly presented dissociative disorder, and may often be better characterized by Major Dissociative Disorder with partially dissociated self states (Dell, 2001).
Treatment Specific to Type of Dissociative Disorder:
Dissociative Amnesia: No empirical studies have assessed the treatment of dissociative amnesia. Current information is based upon case studies and will be discussed briefly. Prior to beginning treatment, it is essential to determine that the amnesia is dissociative in origin. That is, neurological and/or medical causes must be ruled out. Clients with acute onset are type.
Acute amnesia. In clients with acute presentation of amnesia it is first necessary to provide a safe therapeutic environment. In fact, researchers have demonstrated that sometimes simply removing threatening stimuli and providing an individual with a safe environment has enabled spontaneous retrieval of memory. Barbiturates can be used to pharmacologically facilitate the interviewing process. Most commonly used are sodium amobarbital and sodium pentobarbital. No studies have empirically investigated the effectiveness of hypnosis in treating Dissociative Amnesia. However, hypnosis has been used successfully in the recovery of dissociated and repressed memories. Once the amnesia has been reversed it is important to explore and identify events that triggered the Dissociative Amnesia. The therapist should reinforce the use of effective coping mechanisms and the clients’ failure to use dissociation as their primary coping strategy.
Chronic amnesia. Pharmacologically facilitated intervention is not recommended. Hypnosis may be beneficial in recovering and working through traumatic memories at a pace comfortable for the client. Reframing of the traumatic experiences can occur during the hypnotic process. The goal of therapy is the integration of dissociated material. Treatment of chronic Dissociative Amnesia is typically long-term.
Dissociative Fugue: To date, there are no empirical studies that have addressed the treatment of Dissociative Fugue. All current information is derived from case studies and will be briefly discussed. A safe therapeutic environment, strong therapeutic alliance, recovery of one’s own identity, identification of triggers associated with fugue onset, reprocessing trauma and integrating trauma into one’s current being are essential components in the treatment of Dissociative Fugue. Drug-facilitated interviews and hypnosis may be helpful. Treatment should begin as soon as possible following the fugue.
Dissociative Identity Disorder: Treatment of Dissociative Identity Disorder typically includes the following components: a strong therapeutic relationship, a safe therapeutic environment, appropriate boundaries, development of no self- or other-harm contracts, an understanding of the personality structures, working through traumatic and dissociated material, the development of more mature psychological defenses, and the integration of states of self. Guidelines for treatment of adults and children are available from the International Society for the Study of Trauma and Dissociation, www.ISST-D.org. Integration of traumatic memories is an essential aspect of treatment (Fine, 1999; Kluft, 1999; Lazrove & Fine, 1996; Maldonado et al., 2002). Hypnosis can aid in allowing the client to gain control over the dissociative episodes and in the integration of memories (Fine & Berkowitz, 2001; Maldonado et al., 2002). Treatment of Dissociative Identity Disorder is typically long and challenging. Spontaneous remission will not occur. Studies have shown that cognitive behavioral treatment of Dissociative Identity Disorder can be beneficial (Fine, 1999; Maldonado et al., 2002). Electroconvulsive therapy (ECT) is not generally recommended (Maldonado et al., 2002). Eye-Movement Desensitization and Reprocessing (EMDR) can be used in the treatment of DID although it needs to be implemented with great caution (Fine & Berkowitz, 2001). EMDR is a newer psychological treatment designed to accelerate the processing of information and to facilitate integration of fragmented trauma memories (Fine & Berkowitz, 2001; Lazrove & Fine, 1996).
Depersonalization Disorder: As holds true for the other dissociative disorders, no controlled studies have addressed the treatment of Depersonalization Disorder. Treatments currently used include a variety of models including cognitive and behavioral approaches, psychoanalysis, and psychopharmacology (as cited in Maldonado et al., 2002; Simeon et al., 2001). Clinical findings are inconsistent. The lack of empirical treatment studies on depersonalization adversely impacts the understanding and treatment of other dissociative disorders due to the fact that depersonalization is often a component of these disorders (Simeon et al., 2001). Depersonalization Disorder has been described as resistant to psychopharmacological and psychotherapeutic treatment interventions (Guralnik et al., 2001).
