Trauma: Symptoms of Dissociation and Treatment

The DSM describes main feature of dissociation as a disruption of memory, consciousness and identity or perception. Dissociation is a protective mechanism. Human beings have at their disposal to survive traumatic events.

Abusive painful experiences and memories are put away into isolated compartments in the mind, and separated from regular memories.

Read also: Traumatic and Non-Traumatic Memories

Dissociation is a way the mind organizes information

Dissociation refers to a compartmentalization of experience: elements of an experience are not integrated into a unitary whole but are stored in isolated fragments (van der Hart et.al., 1998).

Exposed to trauma, the mind splits. The part of the brain that continues with the daily functioning of life (the left brain), and the emotional part of the self that holds the traumatic memories (the right brain) and its survival impulses of the moment of trauma becomes unintegrated with each other. This leaves the person with a split sense of self.

In trauma, the left and right hemispheres of the brain becomes more split and less integrated.

Experiencing a split sense of self can be disturbing. To notice the phenomenon as it happens is to gain agency.

The disruption of integration of the hemispheres of the brain leads to the experience of feeling something and “not making sense” of the feelings. The feelings come in the form of emotions, perceptions or physical pain.

The experience of not making sense of what one feels, can be disturbing. As human beings we need to make meaning and understand things about ourselves to feel safe. When such splitting occurs, the trauma survivor experiences blankness and confusion. This contributes to more insecurity. Oftentimes the need to make meaning results in thoughts that are paranoid in nature, intrusive and/or obsessive.

In therapy, clients are guided to 1. first identify the feelings and sensations that make no sense, 2. accept these feelings without making meaning. 3. observe the nature of thoughts that arise from attempt to make meaning, and 4. allowing these sensations to pass (through relaxation or somatic exercises). Each of these steps are tedious and challenging, needing full attention of both therapist and client. This is also solid mindfulness work. The result is the client gaining of agency of the self.

Splitting leaves the client fragmented into parts of personality. As different times the person’s right brain may trigger experience in him/herself a part that is raging and wants to fight or take revenge, a part that is terrified, a part that is ashamed, a part that is needy and/or a part that wants to run away. When these parts are traumatized, they feel out of control.

The left brain engages the other parts of the person that wants agency. These parts manage daily function, the part that is sociable, and the part that is responsible.

Noticing split-off and traumatized parts

One can notice that splitting has occurred through phenomena like experiencing chronic inability to make decisions, continually relapsing into addictive behavior, having intrusive emotions that seem to arise out of nowhere, intrusive thoughts, shifts in mood or behavior, going numb, getting hyper-aroused, collapsing, feeling suicidal, hearing voices, loss of ability to connect with others, difficulty communicating, withdrawal from society, feelings in the body and somatic symptoms that are not based on medical logic.

There are different severity levels of dissociation

Dissociative symptoms can be severe in some people to a point of rendering them incapacitated. Many individuals, however, experience dissociative symptoms, and are still able function and be successful in life.

Treatment of dissociative symptoms with therapy in functioning individuals is a measure to keep the person healthy and functioning. While we can cope with dissociative symptoms, these symptoms do not disappear on their own. Symptoms get worse with age, and are exacerbated by crises in life. This is why and how some seemingly functioning people experience sudden psychological breakdown.

Signs to look out for in functioning individuals

It is clear that severe dissociative symptoms require professional attention. Less obvious or hidden signs of dissociation are worth noticing: 1. difficulties putting things together, not being able to remember conversations, forgetting appointments, or inability to recount coherently what happened in certain situations, 2. experience of doing things that does not seem to add up, like having sexual relationship with someone one finds unattractive, 3. having unexplained chronic pain or somatic symptoms, 4. chronic experience of stuck in life, 5. experience of identity confusion, 5. experience of self-harming or suicidal thoughts.

Therapy that focusses on mindful observation of these symptoms, its triggers and the trauma underlying lead to successful outcome in providing clients with agency over his/her life.

Bibliography

van der Hart, O., van der Kolk, B. A., & Boon, S. (1998). Treatment of dissociative disorders.

What is Dissociation?

Meanings for the term “dissociation” continue to evolve. Dissociation was originally seen as a type of hysteria, related to conversion, and distinct from depersonalization. It included amnesia, fugue, certain altered states (e.g., somnambulism), and multiple personality.

Dissociation is a criteria in DSM III for diagnosis of PTSD and ASD, as “flashback or dissociative episodes”. While flashbacks denotes sensing of something there that is not (positive symptoms), dissociative episodes denotes absence of sensing what is there –detachment, reduced awareness, derealization, depersonalization and amnesia (negative symptoms).

In Borderline Personality Disorder, dissociation in DSM-5 is described as “transient, stress-related…severe dissociative symptoms” with depersonalization as example.

3 distinct meanings of dissociative experiences (p.180):

  1. Dissociation of some of one’s mental functions or faculties. The DSM-5 definition: “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291). “Negative” dissociative symptoms involve the withdrawal of something, such as dissociation of memory (amnesia), sensation (conversion anesthesia), or affect (emotional blunting). “Positive” dissociative symptoms involve the intrusion of something, such as the sensory reexperiencing of a trauma (flashback), or any other intrusion of affect, knowledge, sensation (in any modality), or behavior (action, unintended vocalization, etc.). Most of these symptoms may occur within a single consciousness.
  2. Depersonalization/derealization. These may be experienced as the withdrawal of the sense of reality. These are also considered as intrusions in the DSM.
  3. Dissociative multiplicity. This is a plurality of consciousness, in which the first two types of dissociation commonly co-occur; thus, there is always the possibility that cases featuring the first two types of dissociation may have covert multiplicity as well. The DSM-5 definition does not really work for multiplicity because once there is more than one self occupying the center of consciousness, there is more than one center of subjective experience and consequently more than one set of symptoms.

Dissociation in Childhood Experience of Abuse

Freud and his colleague Josef Breuer (1895) identified the root of hysteria in women as child sexual abuse, specifically incest. Freud eventually reversed that emphasis to focus on a child’s fantasies of sex instead of the reality of sexual abuse. Other contemporaries—notably Pierre Janet (1889) outside the psychoanalytic movement, and Sandor Ferenczi (1949) within it—retained a focus on the trauma of childhood abuse, positing dissociation rather than repression as the main method a child (and later an adult) uses to cope. They observed that if the trauma were not worked through and resolved at some point, its residual effects would often have a lifelong (and negative) influence across various domains.

Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 182). The Guilford Press. Kindle Edition.

Dissociative effects of PTSD

Dissociation is PTSD is not psychosis. The person has a flashback — a momentary out of sync with reality, and reliving an experience in a traumatic past experience.
Dissociation is an altered state of consciousness. Unlike psychosis, the individual is functioning but loose track of time/space, etc. The persons may also have a sense of watching him/herself and not being there.

Dissociative effects from Childhood Neglect

The video above addresses dissociation from own feelings. This happens to children of child abuse from narcissistic parent. Most likely the condition of suffering is not unlike complex PTSD.

Bibliography

Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 179). The Guilford Press. Kindle Edition.