Dissociative Disorders

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Dissociation has long been considered an integral part of PTSD and posttraumatic reactions. After a traumatic event, survivors have often reported "leaving their bodies" or of "observing themselves from the outside". One's sense of time can be distorted, and there can be a sense of unreality. Dissociation can be defined as a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. Bessel van der Kolk has proposed that at least in one sense, dissociation may be functional by allowing a trauma victim to observe the experience from a safe, less intense distance, protecting his or her awareness from the trauma. In this sense it may serve as a form of psychological shock, a form of protective detachment.

Peritraumatic dissociation refers to a state of immediate dissociation at the time of the actual event (Marmar et al., 1997). Marmar et al. provides the following list of peritraumatic experiences:

Altered time sense

Feelings of unreality

Out-of-body experiences

Bewilderment

Confusion/disorientation

Altered pain perception

Altered body image

Feeling disconnected from body

Tunnel vision van der Hart, van der Kolk, and Boon (1998) identify three variations of dissociation: (1) primary dissociation, (2) secondary dissociation, and (3) tertiary dissociation. Primary dissociation refers to a state in which percepts are fragmented. Sounds, smells, images, and so on can be experienced partially or in pieces. There is a lack of integration into consciousness and memory. This is a state in which concrete perceptions are separate from actual experiences. Secondary dissociation refers to a state in which the mind engages in distancing maneuvers, such as out-of-body experiences, with feelings and emotions beings separated from awareness, actual experience, and conscious memory. There are alterations in time, place, or space, and person with a feeling of unreality, confusion, and even periods of memory loss or amnesia, which are sometimes called blackouts. Tertiary dissociation refers to the state most commonly known as multiple personalities or Dissociative Identity Disorder (DID). In this state of dissociation, distinct ego states develop, each with its own personality, to such a profound sense that the consciousness of the actual person may or may not be aware of this state of mental operation.

Jon G. Allen discusses the concept of a continuum of dissociation he calls the continuum of detachment. Detachment refers to relatively milder forms of dissociation in which one feels disconnected from the outside world. He states,

When you are in a state of alert consciousness, you can be fully aware of the external environment, as well as having a sense of self that includes awareness of your body and your own actions. In a state of alert consciousness, you remain grounded by flexible awareness of both the outer and inner worlds. I contrast alert consciousness with three levels of detachment: mild (absorption), moderate (depersonalization and derealization), and extreme (unresponsiveness). (p. 177)

Mild detachment or absorption is characterized by a breakdown in the ability to notice external events and sometimes experiencing an altered sense of self. Moderate detachment involves having the experience of unreality and may include depersonalization or derealization. Depersonalization, as defined in the DSM-IV-TR (p. 822), refers to a state in which a person feels "detached from, and as if one is an outside observer, of one's mental processes or body (e.g., feeling like on is in a dream)." Derealization refers to a feeling that the world is unreal or strange in a significant sense. Allen states,

Some clients complain about feeling spacey, foggy, or fuzzy. They feel as if they are floating or drifting. Others feel as if they are acting in a play, watching themselves from a distance, or dreaming. Some feel isolated as if in a shell, a bubble, or behind glass. (p. 178)

Allen (2001) describes extreme detachment as a state of unresponsiveness in which a person might sit, stare blankly, act comatose or catatonic, or have no sense of self-awareness and no sense of time. This can occur for minutes, hours, or even days.

Allen (2001) discusses a form of dissociation beyond these milder forms of detached that is related to Dissociative Amnesia, Dissociative Fugue, and DID called compartmentalization. Compartmentalization refers to a form of dissociation that "goes beyond detachment in excluding whole realms of experience from consciousness" (p. 183). Compartmentalization is seen as a form of dissociation that preserves some sense of coherence and unity in consciousness.

According to Allen (2001), Dissociative Amnesia "exemplifies compartmentalization" (p. 186). Dissociative Amnesia is defined in the DSM-IV-TR as "one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature" (p. 519). Another example of a compartmentalization disorder is Dissociative Fugue, defined by the DSM-IV-TR as "sudden, unexpected travel away from home or one's customary place of work, with inability to recall one's personal past" (p. 519).

Allen proposes that DID represents the most dramatic example of compart-mentalization. The DSM-IV-TR defines Dissociative Identity Disorder as "presence of two or more distinct identities or personality states. . . [which] recurrently take control of the person's behavior" (p. 519). Dissociative Identity Disorder is often associated with severe trauma from child abuse. It is important to note that DID is considered a controversial disorder, and its very existence is challenged by some in the field. As was mentioned previously, DID represents a form of tertiary dissociation consistent with van der Hart et al.'s (1998) classification. Dissociative Identity Disorder represents a somewhat rare disorder in mental health practice in that a large percentage of mental health practitioners have very little experience with this disorder. Dissociative Identity Disorder is a very complex disorder, and its treatment equally complex and extensive. A thorough discussion of DID can fill several volumes of books in and of itself. However, a brief mention of treatment recommendations is warranted here. van der Hart et al. (1998) outline the treatment for DID in the following steps:

1. Psychoeducation about DID.

2. Fostering cooperation between identities participating in daily life.

3. Building a working alliance with persecutory states of mind.

4. Contacting identities.

5. Teaching techniques for coping with reactivated traumatic memories.

6. Cognitive therapy techniques for cognitive distortions.

7. Family and couples therapy if implicated.

8. Medication, including antidepressants, anxiolytics, and anticonvulsants.

9. Developing a protocol for crisis intervention, including short-term psychiatric admissions.

10. Overcoming the phobia of traumatized memories.

11. Overcoming the phobia of everyday life.

Dissociative failure to integrate traumatic memories, perceptions, cognitions, and bodily memories during the acute stage and the immediate posttrauma period is a risk factor for developing PTSD. Prior episodes of dissociation increase the likelihood of recurrence and a lowered threshold for dissociation in the future. Risk factors for dissociation include younger age of victim, higher levels of stress exposure, greater subjective experiences of threat, poorer general psychological health and adjustment, weaker or more vulnerable identity formation, greater sense of external locus of control, and more use of escape-avoidance and emotion-focused coping strategies (Marmar, Weiss, Metzler, & Delucchi, 1996). van der Kolk considers a reliance on the external world for a sense of security as a risk factor. Spiegel, Hunt, and Dondershire (1988) propose that dissociation may be related to a heritable trait for a tendency to dissociate under extreme stress that is "aggravated by early trauma exposure and correlated with hypnotizability" (Marmar et al., 1997, p. 419).

With regard to treatment, there is very little research on treatment for dissociation specifically. Kluft (1993) recommends individual psychodynamic psychotherapy and some use of hypnosis and medication. The use of hypnosis is suggested as a means to induce a state of calm under which processing of trauma material can be undergone. van der Hart et al. (1998) recommend a three-phase treatment model that includes (1) stabilization and symptom reduction, including establishing a therapeutic relationship and psychoeducation, (2) treatment of traumatic memories, and (3) reintegration and rehabilitation.

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