Notes on Dissociation and Dissociative Identity Disorder

During the past three decades there has been renewed interest in psychological trauma. This interest has been fuelled by the experience of American veterans of the Vietnam War and by an acknowledgement of the widespread incidence of emotional, physical and sexual abuse in Western culture. These factors have, in turn, generated a renewal of interest in the mental defence of dissociation and to a debate about multiple personality disorder or dissociative identity disorder (MPD/DID).

The term dissociation was first used in the mid 1890s by Pierre Janet to describe a changed state of consciousness in patients who had suffered traumatic experiences. Following Janet, Herman (1992) defines dissociation as an altered, detached state of consciousness which is automatically induced as a mental defence against psychological trauma involving pain, danger, terror and helplessness. She argues that the traumatic event has the effect of overwhelming and disorganising the person’s normal fight/flight responses, with the consequence that part of mental functioning becomes separated from other activities. Herman (1992) suggests that in such situations, events become disconnected from their ordinary meaning and that perception is distorted, with partial loss of memory occurring. Experience takes on a dream-like, unreal quality and the traumatised person feels as though the event is not happening to him or her.

In reviewing the research on sample populations diagnosed as suffering from dissociative disorders, Steinberg (1993) concludes that five primary symptoms are involved: amnesia, depersonalisation, derealisation, identity confusion and identity alteration. She recommends that these dissociative symptoms should routinely be evaluated when interviewing clients with histories of trauma. Davies and Frawley (1994) take the view that dissociation exists on a continuum, with MPD representing the most extreme form of this defence. This opinion is shared by Mollon (1996) who, while acknowledging the startling clinical phenomena of MPD, contends that the disorder “…inherently involves pretence and simulation…” (p. 114). Further, he points to the overlap between MPD and other psychiatric disorders such as borderline personality disorder, antisocial personality disorder and somatisation disorder. In this context, Mollon (1996) questions whether MPD should be conceptualised as part of a broad grouping of trauma-based psychiatric disorders or as a unique form of personality organisation deriving from dissociative and post-traumatic factors.

From a psychobiological perspective, it is thought that altered states of consciousness result from the release of endogenous opioids within the central nervous system and that this biological reaction is triggered by the traumatic event itself (Herman, 1992). Following van der Kolk (1989; 1994), de Zulueta (1993) thinks it probable that a similar psychobiological process is involved in attachment behaviour and comes into operation in reaction to separation trauma and bereavement. In reviewing studies pointing to the underlying physiology of attachment, van der Kolk (1989; 1994) suggests that endorphin releasers are laid down in the early months of life in the context of attachment to caregivers with different styles of caregiving. He concludes that affectively intense experiences are accompanied by the release of endorphins and that this process comes to be associated both to states of security and trauma. With these findings in mind, Mitchell (2000) observes that the seemingly addictive propensity repeatedly to forge interpersonal relationships redolent of ties to early objects, even when these are traumatic, may reflect neurochemical as well as psychological derivatives. In this context, Herman (1992) points out that dissociated traumatic experiences may become frozen in time. She, in concert with Davies and Frawley (1994), avers that a process of mourning within a secure, holding environment is needed to facilitate the integration of split off cognitive-affective states and of verbal and mental representations associated symbolically with the traumatic events.

The clinical picture described above would seem to be supported by adult attachment research using the Adult Attachment Interview (AAI) (Main, et al., 1985). In a follow-up study, Main (1991) found that secure/autonomous individuals had secure children, as predicted five years previously. This prediction was based on the subjects’ capacity both to reflect on their experience and interpret their own and others’ mental states (metacognitive monitoring/mentalization). By contrast, and again as predicted, parents who had manifested signs of mental disorganisation and disorientation during discussions of traumatic events, such as loss or abuse, had disorganised children, as classified by the Strange Situation Procedure.

Disorientation in the AAI took the form of lapses in the monitoring of reasoning and discourse. For example, the prospective parent would leave illogical statements hanging in the air unelaborated. Main (1991) suggests that such lapses may indicate the existence of parallel, incompatible belief and memory systems regarding a traumatic event that may have become dissociated. Lapses in the monitoring of discourse also suggest the possibility of “state shifts”. Here, the individual may enter a peculiar, compartmentalised state of mind involving a particular traumatic experience. Shifts of state of this kind may result in frightened and/or frightening behaviour on the part of the parent (Main and Hesse, 1990). The authors conclude that parental behaviour of this kind results in disorganised/disoriented behaviour by the child.

Liotti (1992), following Main (1991), posits a connection between disorganised/disoriented attachment and dissociative disorders. According to Liotti’s hypothesis, the child’s disorganised/disoriented attachment behaviour corresponds to the construction of an internal working model of self and attachment figure that is multiple and incoherent, as opposed to singular and coherent. Liotti (1992) suggests that a multiple internal working model of this kind may predispose the child to enter a state of dissociation in the face of further traumatic experiences.

Tyson and Tyson (1990) utilise Freud’s early affect-trauma model. They argue that, given optimal development, affects come to serve a signal function, enabling the child to master and regulate his or her own affects, instead of being overwhelmed by their disorganising effects. However, following Kohut (1971), the authors contend that where there is a failure of parental empathy or traumatic interference of one form or another, this process is disrupted. Hence the development of a coherent sense of self is compromised, leading to fragmentation of experience and, therefore, of personality, and to the manifestation of psychopathology in the form of destructive and self-destructive patterns of behaviour.

In line with infant research (Stern, 1985; Beebe and Lachmann, 1992), Mitchell (1993) points out that the concept of self to be found in relational theories emphasises its multiplicity and discontinuity. From this perspective, subjective experience is portrayed as being embedded in particular relational contexts. It follows that psychic organisation and representational structures are built up through, and shaped by, self-other patterns of interaction. This model, then, suggests that self-experience is discontinuous, being composed of different selves with different others, rather than consisting of a singular, continuous entity. Moreover, at times the individual may identify with an aspect of the self or an aspect of the other. Mitchell (1993) avers that these different identifications will affect the way in which experience is organised and meaning constructed.

Somewhat paradoxically, Mitchell (1993) contends that despite the discontinuous aspect to self-experience, given a good enough environment an enduring and continuous sense of self is retained. He depicts this process in Winnicottian terms as consisting of an unbroken line of subjective experience which forms the core of the personality. However, Mitchell (1993) concedes that if it is accepted that self-experience is both multiple and discontinuous and integral and continuous, a creative tension arises that requires a balance to be struck. As he puts it, where there is too much discontinuity there is a dread of fragmentation, splitting and dislocation. By contrast, where there is too much continuity there is a dread of paralysis and stagnation. In formulating this paradox, Mitchell (1993) acknowledges Winnicott’s (1988) concepts of the true and the false selves. He also refers to McDougall’s (1990) clinical description of normopathic characterological traits and to Bollas’s (1994) concept of the normotic personality, arguing that pseudo-normality is the clinical problem of our time.

As with Mitchell (1993), Bromberg (1998) views self-experience as comprising multiple and shifting self-organisations and self-states generated in interpersonal and social fields. While acknowledging that psychological trauma may lead to the pathological use of dissociation, Bromberg (1998) contends that even the normal personality structure is shaped by dissociation, as well as by repression and intrapsychic conflict. This view receives support from Davies and Frawley (1994) whose clinical experience lead them to argue that trauma-based dissociative pathology, of varying degrees, plays a significant role in intra-psychic organisation.

As is readily apparent, the various perspectives alluded to above view trauma in interpersonal terms and traumatic affect as playing a part in organising mental functioning. As we have seen, in such instances painful, split off affect may become a significant motivating force in the development of false self adaptations (Winnicott, 1988) and pathological reactions, such as violent behaviour and attempts at control and self-soothing through, for example, addiction, eating disorders, compulsive sexuality and self-harm (Tyson and Tyson, 1990).

These contentions accord with the findings of van der Kolk and Fisler (1995) whose work also acknowledges the seminal exploration of trauma-based dissociation by Pierre Janet. On discussing their research into dissociation and the fragmentary nature of traumatic memories, the authors stress the existence of declarative or explicit memories and non-declarative or implicit memories. They argue that the explicit memory system may fail during conditions of high arousal. In line with adult attachment research (Main, et al., 1985; Main and Hesse, 1990; Main, 1991), van der Kolk and Fisler’s (1995) findings suggest that traumatic memories are dissociated, being encoded and stored as sensory fragments without a coherent semantic/linguistic component. Lacking the words to describe what has happened, the traumatised individual is left in a state of “speechless terror”. The traumatic incident is, instead, “remembered” in the form of fragmented somatosensory experiences that have been encoded and stored in the implicit memory system (van der Kolk, 1994). Flashbacks of the traumatic event may occur in a variety of discrete sensory modalities: visual, olfactory, affective, auditory and kinaesthetic (van der Kolk and Fisler, 1995).

Similarly, McDougall (1985; 1989) argues that cumulative trauma consequent on a mother’s insensitive way of handling and interacting with her infant may, during the course of development, lead to a split between word-presentations and affect-laden experiences. She adopts Sifneos’ (1973) and Nemiah’s (1978) concept of alexithymia, that is the inability to recognise, describe and express discrete emotional states, postulating that affective reactions associated with the traumatising care-giving process are either avoided or rapidly ejected from consciousness. As a result of this developmental failure, the individual may be vulnerable to psychosomatic illness in later life.

In comparing childhood trauma with adult trauma, van der Kolk and Fisler (1995) conclude that the former results in more pervasive biological dysregulation. Significantly, they found that clients who had a history of childhood trauma experience greater difficulty in regulating internal states than those first traumatised in adulthood. The findings in respect of both groups in their sample population indicate that the enhancement and intensification of discrete sensory modalities stemming from the dissociated traumatic experience helps to bring these fragmented modalities into consciousness in unified form. This narrative process, in turn, allows the intrusive somatosensory elements (implicit memories) to be transcribed into explicit or declarative memories.

From a neurobiological perspective, Schore (1994) contends that a primitive splitting occurs between the right and left hemispheres of the brain. He contends that the interactive regulation of heightened emotional states enables the client to link non-verbal and verbal representational domains, and thence to transfer implicit information in the right hemisphere to explicit or declarative systems in the left.

Genetic variables notwithstanding, developmental studies, adult attachment research, trauma research and neurobiological research may help to elucidate the question as to why individuals respond differently to the same, or qualitatively similar, traumatic incident. Research has demonstrated that children with a secure pattern of attachment organisation develop the capacity to stay attentive and responsive to the environment and use error-correcting information to construct a coherent narrative (Main et al., 1985; Main and Hesse, 1990; Main, 1991). Secure/autonomous individuals may, therefore, possess the mental resources to process information more readily in the aftermath of a traumatic event without developing full-blown post-traumatic stress disorder (PTSD) than the insecure, disorganised subject whose ability to regulate states of arousal was compromised during early development.

As Beebe, Jaffe and Lachmann (1992) have shown, children subjected to misattuned, insensitive and over-arousing care-giving may typically inhibit responsivity and enter prolonged and severe states of withdrawal as an “emotional regulation strategy” (Schore, 1994). Given these various findings, it would seem reasonable to hypothesise that people with dismissing, preoccupied or unresolved/disorganised adult attachment styles, and a concomitant compromised discourse style and capacity to regulate states of arousal at moments of stress, may be more vulnerable to trauma-based dissociative disorders and PTSD than individuals with a secure/autonomous pattern of attachment organisation.

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