Dissociation

What Is Dissociation?

Dissociation is a psychological mechanism in which a partial or complete splitting off of psychological functions occurs. The term designates the opposite of association - instead of creating connections, connections are severed.

Through a complex psycho-physiological process, a fragmentation occurs of:

Consciousness and cognitions
Affects and behavior
Memory and identity
Perception of self and environment

Everyday vs. Pathological Dissociation

Normal Everyday Dissociations

Daydreaming
Mind-wandering
“Highway hypnosis” (amnesia during longer drives on the same route)
Absorption in a book or film
Brief feelings of estrangement during overwork

Pathological Dissociation

In pathological dissociations, lasting disturbances of the integrative function of consciousness occur. After traumatic situations, five main dissociative symptoms appear (prevalence 2-10%):

Amnesia
Depersonalization
Derealization
Identity confusion
Identity alteration

Dissociation as a Protective Mechanism

Many physically or sexually abused individuals learn to mentally “step out” of their body, to step beside themselves, in order to endure as little as possible.

What originally served as a protective mechanism in a traumatic situation can later become autonomous and turn into a problem.

Development in Children

Consider sexual incestuous abuse: The psychological cruelty inflicted on a child here cannot be put into words and barely captures our understanding or imagination. How is a child supposed to cope with something like this?

It must find a strategy to withstand this burden. It presents to the outside: “This is not happening to me, it is happening to someone else.” To do this, it must invent other persons in its fantasy to whom these cruelties are being done.

These are then - the more frequent and massive the cruelties - increasingly internalized and form split-off aspects of one’s own personality. Since the child experiences the dissociation as successful, the brain learns to fall back on this defense mechanism. The dissociative reaction becomes ingrained and is used ever more automatically.

Forms of Dissociative Disorders

Dissociative Amnesia

This involves memory gaps regarding distressing life events.

Forms of amnesia:

Generalized - for all events within a specific time period
Localized - for circumscribed events
Selective - for some but not all events of a specific time period
Systematized - regarding aspects or categories of an event
Acute - with sometimes considerable impairments
Chronic - often covert

Prevalence: Occurs in approximately 10% of the general population following traumatic events.

Dissociative Fugue

This involves the sudden and unexpected departure of the affected person from their habitual environment:

Amnesia for the personal life situation and past
Partial assumption of another identity
Outwardly unremarkable behavior
After the end of the state, usually amnesia for the time period

This is a rather rare clinical picture. The condition usually resolves spontaneously.

Dissociative Stupor

The affected persons are motionless and silent without reaction to environmental or pain stimuli. Here too, partial or total amnesia for the state exists after resolution.

The state can last minutes to hours, in rare cases days and weeks, with a fluctuating course. The symptoms usually resolve spontaneously.

Depersonalization and Derealization Syndrome

Depersonalization - one’s own self is perceived as estranged and unreal:

Observing oneself from outside
The feeling of not being real
Physical numbness or strangeness toward one’s own body
Disturbed sensory perceptions (visual, auditory, tactile, olfactory)
Disturbed bodily needs (hunger and thirst)
The feeling of functioning like a robot
Sometimes described as “fogginess”

Derealization - the surroundings appear unreal:

Everything seems like a film or dream
Familiar places appear strange
People seem like stage props
Distorted perception of time and space

Depressive, phobic and obsessive-compulsive accompanying phenomena frequently occur. The isolated depersonalization syndrome affects younger people, with twice as frequent occurrence in women. The course is chronic in up to 50% of cases.

Trance States

This involves the temporary loss of personal identity and full awareness of surroundings:

Attention and consciousness limited to only one or two aspects of the environment
Affected persons sometimes behave as if “controlled” by another personality
These are exclusively involuntary states that interrupt everyday activities
Often accompanied by repetitive movement sequences or utterances

Dissociative Seizures

These are pseudo-epileptic seizures with a time-limited disturbance of control over motor, sensory, autonomic, cognitive, emotional and behavioral functions.

Forms:

Fainting spells - slow sinking to the ground, quiet lying with closed eyes
Rage attacks - dramatic onset, often with vocalizations, violent movements
Abreaction seizures - convulsive movements, frequent breathing disturbances
Pseudo-epileptic status conditions - not infrequently lead to intensive care treatments

Approximately 25% of treatment-resistant epilepsies are considered to be unrecognized dissociative seizures.

Dissociative Movement Disorders

Usually this involves the partial or complete loss of the ability to move one or more body parts:

Complete or partial paralysis
Ataxia, astasia, abasia
Exaggerated trembling of multiple extremities
Apraxia, akinesia
Aphonia, dysphonia, dysarthria, dyskinesia

Dissociative Disturbances of Sensation and Perception

Anesthesias and paresthesias
Visual disturbances as loss of visual acuity
Hearing disturbances and anosmia

Typically, the symptoms do not correspond to known anatomical structures and physiological mechanisms.

Ganser Syndrome

This is an exceedingly rare, complex disorder characterized by “approximate answers” (Vorbeiantworten).

Dissociative Identity Disorder (DID)

Formerly referred to as “Multiple Personality Disorder.” DID represents, alongside dissociative amnesia, dissociative fugue and dissociative depersonalization disorder, a separate category in the DSM.

Main symptoms:

Amnesias
Feelings of estrangement
Hearing voices inside one’s head
Manifestation of identity switches (spontaneous age regression, inner verbal or written dialogues, finding things one cannot remember acquiring)

The main feature is the presence of at least two distinguishable partial identities that repeatedly assume control over the person’s behavior, combined with dissociative amnesias. The alternate selves are perceived as not belonging to one’s own personality.

Frequent accompanying symptoms:

Impulse breakthroughs and self-injury
Anxiety symptoms
Substance abuse
Somatization or eating disorders
Severe depression, suicidal impulses and attempts
Strong fluctuations in affective and general functional level
Various forms of personality disorders (borderline, avoidant/insecure, dependent)

Epidemiology: The disorder is diagnosed three to nine times more frequently in women than in men. Usually three preliminary diagnoses are made with a latency of 6 to 22 years until the adequate diagnosis is established.

Post-Traumatic Stress Disorder (ICD-10 F43.1)

Trigger: Exceptionally threatening or catastrophic event

Intrusions

Flashbacks
Memories with present-time quality
Repetitive dreams
Inner distress in situations connected with the traumatic one

Constriction

Emotional numbness
Blunting
Apathy

Hyperarousal

Difficulty falling and staying asleep
Irritability
Outbursts of rage and panic
Concentration difficulties
Increased startle response
Partial or complete inability to remember important aspects of the trauma
Suicidal thoughts
Auto-destructive behavior
Dissociative states
Avoidance behavior

Dissociative Flashbacks

Affected persons frequently experience:

Agonizing fears from life-threatening distress
Painful bodily sensations
Without being able to directly recall the traumatizing event

This is a consequence of the disturbed hippocampal function, which prevents episodic remembering.

Intrusive Memories

Intrusive memories can escalate to agonizing hypermnesias:

Non-suppressible memories
Almost constantly present
Easily triggered

Emotional Numbness

Traumatized individuals frequently experience a general flattening of their responsiveness:

Emotionally dull, blunted and lacking in emotional range
Feeling of detachment or estrangement
Bottomless loneliness and emptiness
The feeling of having a foreshortened future

Enduring Personality Change After Catastrophic Experience (ICD-10 F62.0)

A post-traumatic stress disorder (F43.1) may have preceded this form.

Trigger: Extreme stress from life-threatening situations

Symptoms:

Feelings of hopelessness and/or emptiness
Nervousness
Feelings of being threatened
Auto-destructive behavior (alcohol excesses, use of psychotropic substances, overt self-injury)
Binge eating
Feelings of estrangement
Mistrustful or hostile attitude toward the outside world
Social withdrawal
Restriction of social functioning

Triggers and Reactivation

The reactivation of traumatic memories can occur through various stimuli:

Sounds - certain tones or voices
Smells - perfume, sweat, certain scents
Similarities with perpetrators - voices, gestures, appearance
Places - certain rooms or environments
Seasons - anniversaries of the trauma
Physical touch - certain types of contact

Physical Manifestations

The body remembers what was experienced, without requiring words or understanding:

In Oral Traumatization

Chest pressure
Gagging reflexes
Asthma, hyperventilation
Coughing
Lump in the throat
Unbearable disgust

In Sexual Traumatization

Lower abdominal complaints
Menstrual cycle disturbances
Sexual disorders
Sometimes complete anesthesia of the lower abdomen

General

Chronic pain conditions (often head and back)
Psychogenic paralysis
Somatization disorders

The Connection with Borderline

In borderline disorder, dissociative mechanisms play a central role. The borderline personality dissociates in certain situations - particularly in situations that represent an enormous, no longer tolerable burden for the psyche, or in which the brain would allow remembering traumatic experiences.

Difference from DID

The person with borderline does not switch into another person as in DID, but rather goes into a different inner world - one could also say “they leave themselves.” However, both have something in common: Behavior can - for reasons not apparent to us - suddenly change from one minute to the next, as if it were a completely different person.

Consciousness withdraws in order to escape the overwhelming negative emotions.

Splitting as a Dissociative Process

Affected persons must split between “good” and “bad” objects:

There is only black or white
Feelings are often split off
Frequently only the great rage finds expression
This serves to defend against closeness and relationships

Disturbed Ego Functions

People with borderline disorder have:

Great difficulties in forming relationships
Never experienced good and stable relationships
Difficulties regulating emotions
No clear identity image due to their ego fragments (this is not an identity disorder)

Professional Discussion

Many professionals discuss combining dissociative identity disorder (DID), multiple personality disorder and borderline disorder together with post-traumatic stress disorder under the term “Disorder of Extreme Stress.” This is because both DID and borderline are difficult to diagnose and some professionals are of the opinion that the reality of these individuals is only described by approximately two-thirds in the current diagnoses.

Neurobiological Foundations

Through the flooding with complex physiological stress reactions and disturbances in the neurotransmitter system in the brain, post-traumatic and dissociative symptoms are induced.

Influence on the Brain

Secure attachment and an empathic primary object protects the hippocampus and the orbital prefrontal cortex from damage by the stress hormones norepinephrine/dopamine and glucocorticoids through the elevation of the stress threshold
Accumulated stress experiences in childhood damage (through the elevated glucocorticoid level) both the hippocampus with losses in declarative memory and (through elevated dopamine/norepinephrine levels) the orbital prefrontal cortex
The disturbance of the hippocampus impairs short-term memory and leads through the disturbed dynamic-associative linking of experiential content to dissociations
The dysfunction of the orbital prefrontal cortex persistently disturbs cognitive stress management (coping, action planning and organization, inhibition of unsuitable responses)

Children with Disorganized Attachment Style

Children with disorganized attachment style show increased episodes of trance-like states.

History of the Concept

These are not new clinical pictures. Between 1840 and 1880, the topic of the split personality was one of the most frequently discussed subjects among psychiatrists and philosophers.

Pierre Janet (1859-1947), the French psychiatrist, introduced the concept of dissociation as disintegration and fragmentation of consciousness to the professional world. As the most important trigger, he named (1889) real experienced traumas, which lead to a disturbance of ego function, integration and to the so-called “idees fixes.”

Morton Prince based his work on Janet’s dissociation concept, in which he described connections between early traumatic experiences and dissociative identity disorder. He called it “alternating personality” and introduced the term “co-consciousness.”

Sigmund Freud developed his drive-theoretical models in parallel and provided a model for understanding hysterical disorders.

Treatment

Dissociative disorders as a consequence of traumatization require specialized trauma-therapeutic treatment.

Therapy Forms by Disorder

For dissociative amnesia:

In isolated occurrence: psychodynamic short-term therapy
In combinations with other dissociative disorders: psychodynamic long-term therapy, possibly supplemented by specific trauma confrontations

For dissociative identity disorder: The treatment guidelines provide for high-frequency outpatient individual therapy with psychodynamic and cognitive-behavioral (alongside hypnotherapeutic and family therapy) approaches. The therapy duration extends over four to eight years.

The Four Phases of Therapy for DID

Phase 1: Stabilization

Building a sustainable, trusting therapeutic relationship
Working alliance with all partial identities
Assessment and stabilization of the current life situation
Work on personal resources
“Mapping” - exploration of the individual personality systems

Phase 2: Promoting Communication

The previously mutually amnestic alternate selves encounter each other
They make contact with each other, get to know each other
First cooperations are attempted

Phase 3: Trauma Processing and Integration

Controlled elicitation of traumatic memories (trauma synthesis)
Reconstruction of traumatic experiences
Controlled exposure in a highly structured setting
Various techniques (screen, observer, EMDR)

Phase 4: Post-Integrative Psychotherapy

Grief work over the lost childhood and the experienced injuries
Building new coping strategies
Reorientation in experiencing, reacting and social behavior

Therapy Goals

Main goal: Patients should develop a sense of a unified and everyday-functional self, up to a permanent integration of all partial identities into the overall personality.

Minimum goal: Extensive cooperation of all alternate selves in daytime consciousness without amnesias, with conscious control by the patient over the individual parts and without splitting off or rejection of individual parts.

Dissociation Stop in Acute States

In acute dissociative stupor, the affected persons are:

Greeted in a neutral tone of voice
Spatial, temporal and situational orientation is assessed
Asked to breathe calmly and count from one to five in time with inhalation and exhalation
Very firmly asked to make eye contact and return to the here-and-now situation
After announcement, the affected person may be touched on the forearm