Dissociation and the dissociative disorders

Martin Dorahy

NZAP AGM, May 8th, 2014

Nowadays

Amnesia – inability to recall seemingly unforgettable events

Depersonalisation – alterations in perception of self

Derealisation – alterations in perception of world

Trance/drifting

Identity alterations

Pseudoneurological symptoms (temp. blindness, deafness, paralysis, anesthesia, pain)

Pierre Janet (1859-1947)

“a form of mental depression [i.e., lowered integrative capacity] characterized by the retraction of the field of consciousness and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute personality” (Janet, 1907, p. 332).

DissociationPrimary structural dissociation

Dividedness amongst dissociative self-aware systems

Trauma

Emotional part of the personality (EP)

Driven by animal defense-like psychobiological systems. E.g.,• Fight • Freeze• Flight • Submit• Attachment cry

Apparently normal part of the personality (ANP)

Driven by psychobiological systems of daily functioning• Attachment • Play• Seeking • Self definition

Survival of the individual,Functioning under threat

Survival of the species,Functioning in daily life

Van der Hart et al., 2006; Nijenhuis, Van der Hart & Steele, 2002

Breuer & Freud (1893)

…we have become convinced that the splitting of consciousness which is so striking in the well known classical cases [of DID] is present in a rudimentary degree in every hysteria… In these views we concur with Binet and the two Janets...

What is dissociation?

Symptom/phenomenology (continuum model)

Process (breakdown in integrative functioning), corollary defense

Structure of the personality/identity/mind

Dissociative disorders

Secondary structural dissociationDividedness amongst dissociative self-aware systems

Trauma

Emotional part of the personality (EP): e.g.,

Apparently normal part of the personality (ANP)

Driven by psychobiological systems of daily functioning• Attachment • Play• Seeking • Self definition

Van der Hart et al., 2006; Nijenhuis, Van der Hart & Steele, 2002

Fight

flightFreeze

Submit

Dissociation

Tertiary Structural dissociation

Emotional part of the personality (EP)

Apparently normal part of the personality (ANP): e.g.,

Van der Hart et al., 2006; Nijenhuis, Van der Hart & Steele, 2002

Fight

flightFreeze

Submit

__________________________ functions dedicated to the

survival of the species & daily life

________________________________functions dedicated to

the survival of the individual

MotherWorkerLover

Core features of DID The existence of 2 or

more personalities/ identities that take recurrent control of behaviour

Psychogenic amnesia for seemingly unforgettable autobiographical events

Dissociative identities Identities: cognitions,

emotions, behaviours, defenses -Trauma fixated & trauma avoidant.

Two-way (symmetric) amnesia

A I B

One-way (asymmetric) amnesia

A I B

Mutual awareness A B(Janet, 1907; Ellenberger,1970; Putnam, 1989; Huntjens et al.,

2003, 2012)

Dissociative disordersDSM-IV/DSM-IV-TR DSM-5

Dissociative amnesia Dissociative amnesia• Without Fugue• With Fugue (purposeful travel

with amnesia for identity/autobio mem.)

Depersonalisation disorder Depersonalisation/derealisation disorder

Dissociative Fugue With amnesia

Dissociative Disorder NOS (DDNOS)

Other Specified Dissociative DisordersUnspecified dissoc. disorders

Dissociative Identity Disorder (DID; Formerly MPD

Dissociative identity disorder

Pathways to dissociation

Adult Dissociation

Child A&N

Disrupted parent-infant

dialogue

Psychological

unavailability of

caregiver-Lack of positive maternal affective involvement/attunement-- maternal flatness--disrupted communication

- Flashback- Amnesia- Deperson

al.-Derealisat

.

Attachment & Dissociation

Disorganised/disoriented attachment strong predictor of dissociative symptoms (e.g., Ogawa et al., 1997; Lyons-Ruth, 2008)

Conflictual (non-fluid) behaviours in infant in presence of parent

Quality of early maternal care (emotional unavailability) predicts ≈ 50% of variance in dev.of dissociative symptoms

Therefore abuse not only causal factor for dissociation, but also infant disorganisation/parental emotional withdrawal

Attachment and dissociation (cont).

How does D-type come about

Frightened or frightening care giving (‘fright without solution’)-parents communicating fear (Main, Hesse)

Failure to serve as source of comfort/containment after fear - Thus fear from anyone/anything and failure of parents to soothe (Lyons-Ruth)

Dissociation as intrapsychic defense/process and interpersonal phenomena (way of relating to others) - not to know (intrapsychic), not to speak (interpersonal)

Thus, dissociation is fragmentation of coherent relational self (Lyons Ruth, 2008)

Frightened & Frightening caregiving

Frightened

Backing away

Frightened voice

Dazed expression

Exaggerated startle

Withdrawn

Non-responsive

Frightening

Looming, attack posture

Sudden movements

Mocking, teasing

Intrusive

Emotionally reactive

Loud, startling noises

Lyons-Ruth, 2000; Fisher, 2003

Dissociation in the transference

Thus, dissociative experiences become a means of regulating interpersonal contact and therefore become transferentially important

Experiences like trance, drifting, switching (or even flashback, bodily pain) are evident in transference

Experiences like amnesia, depersonalisation and derealisation may not be evident, and need to be inquired about

Still face

http://www.youtube.com/watch?v=apzXGEbZht0