Download Dissociation and the dissociative disorders

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).
Dissociation
Primary 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
Dissociation
Secondary structural dissociation
Dividedness amongst dissociative self-aware systems
Trauma
Emotional part of the
personality (EP): e.g.,
Submit
Fight
Freeze
flight
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
Tertiary Structural dissociation
Emotional part of the
personality (EP)
Fight
Submit
Freeze
flight
________________________________
functions dedicated to
the survival of the individual
Apparently normal part of the
personality (ANP): e.g.,
Worker
Mother Lover
__________________________
functions dedicated to the
survival of the species & daily life
Van der Hart et al., 2006; Nijenhuis, Van der Hart & Steele, 2002
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

One-way (asymmetric) amnesia

A

Mutual awareness

A
I
I
(Janet, 1907; Ellenberger,1970; Putnam, 1989; Huntjens et al., 2003, 2012)
B
B
B
Dissociative disorders
DSM-IV/DSM-IV-TR
DSM-5
Dissociative amnesia
Dissociative amnesia
• Without Fugue
• With Fugue (purposeful travel with
amnesia for identity/autobio mem.)
Depersonalisation disorder
Dissociative Fugue
Dissociative Disorder NOS
(DDNOS)
Dissociative Identity Disorder
(DID; Formerly MPD
Depersonalisation/derealisation
disorder
With amnesia
Other Specified Dissociative
Disorders
Unspecified dissoc. disorders
Dissociative identity disorder
Pathways to dissociation
Child A&N
Adult Dissociation
Disrupted
parent-infant
dialogue
Psychological
unavailability
of caregiver
-Lack of positive maternal affective
involvement/attunement
-- maternal flatness
--disrupted communication
-Flashback
-Amnesia
-Depersonal.
-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 (LyonsRuth)
 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
Lyons-Ruth, 2000; Fisher, 2003

Frightening

Looming, attack
posture

Sudden movements

Mocking, teasing

Intrusive

Emotionally reactive

Loud, startling noises
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