Dissociation and the dissociative disorders Martin Dorahy NZAP

Dissociation and the dissociative disorders Martin Dorahy NZAP AGM, May 8 th, 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? w Symptom/phenomenology (continuum model) w Process (breakdown in integrative functioning), corollary defense w Structure of the personality/identity/mind w 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 B B B (Janet, 1907; Ellenberger, 1970; Putnam, 1989; Huntjens et al. , 2003, 2012)

Dissociative disorders DSM-IV/DSM-IV-TR DSM-5 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 Disorders Unspecified dissoc. disorders Dissociative identity disorder Dissociative Identity Disorder (DID; Formerly MPD

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 (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 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

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