The term "dissociation" arose from the understanding that "memories are brought to consciousness by way of association of ideas" (Braun, 1988). Dr. Bennett Braun describes dissociation as "the separation of an idea or thought process from the main stream of consciousness" (Braun, 1988). This mechanism is used to cope with trauma by "not knowing" about the traumatic event (Braun, 1988). Dissociation, according to Braun, fits on one extreme of a continuum of awareness "running from full awareness through suppression, denial, and repression, to neuropsychophysiologically mediated dissociation" (Adams, 1984). Similarly, "dissociative processes can occur on a continuum ranging from normal to psychopathological" (AGPA, 1993). Most healthy people unconsciously use dissociation to screen out "irrelevant stimuli," thus aiding their "integrative functioning" (AGPA, 1993). Dissociation "may be regarded as a coping mechanism" (Braun, 1988). At the pathological extreme, however, this defense becomes problematic because dissociated memories often surface in ways that interfere with a person's life but cannot be understood and processed so that healing can occur. Two of the most complex dissociative disorders are Post Traumatic Stress Disorder (PTSD) and Dissociative Identity Disorder (DID), also known as Multiple Personality Disorder (MPD).
Heinz Kohut describes "two kinds of splitting in the organization of self-experience: horizontal splitting (repression) and vertical splitting (disavowal) (Kohut, 1971). In repression something which would create unbearable conflict if conscious, is pushed into the unconscious. This creates a horizontal split in consciousness (imagine the levels of consciousness from top to bottom: conscious, preconscious, and unconscious). Conversely, dissociation is a vertical split of consciousness. As a result, one particular ego state, or altar-ego, can exist "in depth" with a conscious, preconscious, and unconscious component, separate from the other ego states or from the central ego (Sikes, 1998). Victims of trauma distance themselves "from the terror and pain of abuse by an extreme form of disavowal, rendering that which is unbearable into "not me" experience via vertical splitting" (AGPA, 1993). One explanation for this phenomenon is "neuropsychophysiologic (NPP) state-dependent learning (SDL)" (Braun, 1988). This theory proposes that material learned in one bio-chemical state is forgotten in another. Likewise, the material may be recalled if the original bio-chemical state reoccurs: "something that is learned in one NPP state is most expeditiously retrieved under the same NPP state" (Braun, 1988). Trauma can cause a hypnoid state in which one's entire body and brain chemistry changes. Experiences occurring in this state may be lost to a normal conscious state, but are stored in this NPP state with its own conscious, preconscious, and unconscious existence. The hypnoid state, besides acting as a defense from fully experiencing, also causes learning during these experiences to occur at a particularly profound level that is difficult to influence in the future. The sooner a person can receive help after a traumatic experience, the better.
People who have outside support to help them cope with trauma are less likely to experience dissociation. In fact, most well-supported adults and children can face extremely traumatic events without developing dissociative defenses (Sikes, 1998). Trauma victims need someone to help them see that life is still worth living, regain their self-esteem, and understand what happened. Trauma is defined by some existentially as "the loss of faith that there is order and continuity in life" (Adams, 1994). Trauma often results in a feeling of hopelessness, a feeling "that one's actions have no bearing on the outcome of one's life" (Adams, 1994). Children who were raped by an adult need someone to help them deal with their disappointment in the world, to understand why an adult would behave that way, and to keep them from blaming themselves: "the psychological disequilibrium that follows trauma [stems] from the shattering of the victim's fundamental assumptions that the world is essentially benevolent, that our lives and life events have meaning, and that we are essentially worthy and lovable" (Adams, 1994). Those who have support will probably be able to metabolize the painful experience. Unfortunately, without outside help, especially if traumatic events happen repeatedly, the trauma may be overwhelming and impossible for the victim to process: the "magnitude of exposure, prior trauma, and social support appear to be the three most significant predictors for developing chronic PTSD" (Van der Kolk, 1987).
Often people do not look for assistance or can find none, especially when painful events are inflicted by the parent(s). It is therefore difficult for them to recover self-esteem, correct distortions in perspective, or feel emotions that should be connected to the trauma. These people will most likely dissociate the memories and live with the effects or seek help later in life when it is more difficult to diagnose and treat. When these people present themselves for therapy, it takes time for many therapists to uncover the trauma behind whatever symptoms brought them there: "Depending on the severity of the abuse, the patient may have mild to moderate dissociative pathology hidden beneath the presenting problems of character pathology, loneliness, and difficulties in relationships" (Adams, 1994). Though recently psychologists are more aware of the possibility of dissociate disorders, "Survivors of childhood abuse often accumulate many different diagnoses before the underlying problem of a complex post-traumatic syndrome is recognized" (Adams, 1994).
Some people can dissociate more easily than others. Those that dissociate extremely easily may lose consciousness of surrounding events in response to minor anxiety. Dissociation can be a gift or ability in a living environment of constant negative experiences (Sikes, 1998). In fact, it is hypothesized that not only chemical differences, but the ability to dissociate, separates those who develop a dissociative disorder from those who are schizophrenic or psychotic, unable to protect their central egos from the information of painful life events. Dissociative people are able to separate disturbing events from everyday consciousness so they will not interfere with everyday functioning. However, the memories of these events, though hidden or separated into pieces, do not disappear. They often intrude into the people's lives in impairing ways:
Patients often experience repetitive intrusions of elements of the traumatic experience despite all efforts at denial and suppression; these repetitions may include recurrences in thought (e.g., nightmares, recurrent obsessive ideas) or emotions (e.g., panic attacks or weeping episodes with or without conscious awareness of association with the trauma), or behavioral reenactments of aspects of the trauma (e.g., compulsive verbalizations, recurrent expressions of the traumatic experience through gesture, movement, or artistic production). Adams, 1994
The way people later experience dissociated events partly depends on the way the memories are stored. Those traumatized during adult life, for instance, tend to capsulize a traumatic occurrence together so that if the memory is triggered, the entire memory or coherent parts are reexperienced. Children, conversely, often divide dissociated memories so that only one aspect of an event can be triggered at a time. This defense makes memories, when they surface, less overwhelming but also difficult to understand. Braun describes a model for this type of division of a traumatic memory called "The BASK Model of Dissociation" (Braun, 1988).
The acronym "BASK" stands for four components of consciousness: behavior, affect, sensation, and knowledge. "Behavior" is the physical action associated with an event. If a boy was huddled in a ball during a traumatic experience, he may find himself suddenly in this physical position as an adult without knowing why. "Affect" refers to the emotions one had in response to the event. An adult who felt terror during certain childhood experiences might feel extreme terror in particular situations that are not actually dangerous. "Sensation" refers to the physical sensations the victim felt during the traumatic experience. For example, a child forced to perform oral sex might feel gagging sensations and not understand why. Finally, "knowledge" occurs when the person is aware of the event but does not have any of the associated feelings, affects, or sensations--feeling as if the event happened to someone else. Therapy aims to unite these confusing pieces of experience into the cohesive memory (if the patient has enough ego strength, which will be discussed later) instead of unexplainable memory intrusions: "In this model, mental health is the congruence over time of the BASK components" (Braun, 1988). Either method of storing traumatic memories leads to the simultaneous knowing and not knowing of disturbing information. Clearly, any dissociative pattern has profound effects on a person. Post Traumatic Stress Disorder and Dissociative Identity Disorder are two resulting psychological disorders.
Post Traumatic Stress Disorder occurs when a traumatic experience or series of experiences never get integrated or processed. One way to decrease the likelihood of developing PTSD is to maintain a mental connection to the outside world during the traumatic event(s) (Sikes, 1998). A victim should therefore attempt to think about someone who values him/her during a traumatic experience. In PTSD, experiences are dissociated because the person is unable to integrate them. They therefore intrude into the person's life in more indirect ways and effect his or her ability to function. Dissociated material (like repressed material) acts in opposition to the pleasure principle in that it seems to press to get expressed in unpleasurable ways that can be both disturbing and confusing to the victim (Sikes, 1998). One way dissociated experiences surface is through a repetition compulsion. This compulsion is the need to repeat behavior compulsively to allow a memory to express itself through activity. One of Dr. Sikes's patients found himself constantly sleeping with other men, when he was not homosexual. The patient was confused by this compulsive activity until he began remembering forced sexual experiences with his father as a child, which he had been reenacting. A person suffering from Post Traumatic Stress Disorder may become jumpy and be easily startled. One's general feeling of safety is affected by a traumatic event in which something out of control or unexpected occurs.
A common symptom of Post Traumatic Stress Disorder, another way trauma invades the victim's life, is flashbacks. Flashbacks can be whole or partial. A person experiencing a whole flashback lives through a full-blown recurrence of the event. They typically feel as if the imagined situation is actually happening. Partial flashbacks are also felt as a present experience rather than a memory. During a partial flashback a person only recalls certain aspects of the memory (BASK), becoming suddenly enraged or experiencing a choking sensation (from the earlier example). In the case of this kind of flashback, the person has no explanation for his/her experiences and may feel like a lunatic (Sikes, 1998). Many try to justify their emotions, actions, or feelings by blaming them on someone they are interacting with or on any aspect of their situation at the time, though these are usually unrelated to the problem. While this may temporarily keep the person from feeling crazy because his/her experience is out of context, after repeated occurrences he/she may begin to admit that these reactions to particular situations are not appropriate. Therefore, the most common form of treatment involves helping patients with this form of flashbacks to realize they are having memories, not present experiences. This realization is often a relief and comfort to them, despite the difficult past that they must then face. One who has fits of terror, for instance, would finally take comfort in the knowledge that there is no real danger.
Hypnosis is a technique used to help patients recover dissociated memories and put the pieces of their experience(s) back together. When this technique is successful, a traumatic experience becomes a bad memory to work through, rather than a permanent disruptive dissociation. Because of the powerful effect of hypnosis in revealing people's repressed or dissociated past experience(s), in the past many therapists have taken advantage of this technique enthusiastically without considering whether a patient is ready to face the memories that may surface (Sikes, 1998). Because therapists allowed memories to surface too soon, when patients were not ready to properly handle them, outside on-lookers became skeptical of the truth in these "recovered" memories and said that people making these discoveries had "false-memory syndrome" (Sikes, 1998). "False Memory Syndrome" was of course blamed on the therapists. Now responsible therapists are more sensitive to judging the patient's ego strength before starting the flow of what could be an overwhelming number of traumatic memories, and are also careful not to make any suggestions while the patient is in a hypnotic state. Therapists also must not ask leading questions, even when the patients are not under hypnosis, because dissociative patients are highly suggestible and are often in a trance state even when the therapist has not induced one (Adams, 1998). Some of the kinds of "ego strengths" essential for processing dissociated experiences without enormously disrupting the patient's life are "the abilities to soothe oneself, reality-test, seek help, put things in perspective, and understand and accept one's human nature."
In addition to the usefulness of putting traumatic experiences back together consciously and understanding symptoms as stemming from memories and not present experience, patients also benefit from reliving their experiences, this time with outside support. As patients begin to remember traumatic events and therefore reexperience them, putting back together the behavior, affect, sensation, and knowledge, therapists must keep the patients simultaneously present. This technique allows patients to share the pain with another person that they know will understand and help them endure it: "because the core experiences of psychological trauma are disempowerment and disconnection from others, healing derives from the empowerment of the survivor and from the creation of new connections" (Adams, 1994). Without the connection to the present, the reexperiencing of the traumatic event is only retramatizing. The therapist strives to reframe (correct reality distortions) the event as and after the patient relives it. This process of "reliving, putting together the pieces of BASK, and reframing" is called an "abreaction" (Adams, 1998).
From a physiological perspective, "profound alterations in stress hormone secretion and memory processing" are found in people suffering from PTSD. Due to "ascending amine projections," soldiers with PTSD showed the physical symptoms of "flexor changes in posture, hyperkinesis, violently propulsive gait, tremor at rest, masklike faces, cogwheel rigidity, gastric distress, urinary incontinence, mutism, and a violent startle reflex" (Van der Kolk, 1987). Kolb first proposed that "excessive stimulation of the CNS at the time of the trauma may result in permanent neuronal changes that have a negative effect on learning, habituation, and stimulus discrimination" (Van der Kolk, 1987). Dr. Bessel van der Kolk explains that traumatic memories are stored at the "implicit" memory level which changes a person's "biological stress response" to those memories (Van der Kolk, 1987). Because these memories are processed outside of the "hippocampally mediated memory system," they are difficult to "extinguish" (Van der Kolk, 1987). Implicit memories also are different from normal memories, called narrative, semantic, or declarative, in that they are not stored verbally. Because they are so physiologically overwhelming, they bypass verbal encoding and processing and are stored in the more primitive, "somatosensory or iconic," part of the brain as sensations, images, and feelings. These memories are stored as "emotional responses, skills and habits, and sensorimotor sensations related to experience" (Van der Kolk, 1987). "Speechless terror" can be used to describe a traumatic event in which the "emotional impact...interfere[d] with the capacity to capture the experience in words or symbols" (Van der Kolk, 1987). Conversely, declarative memories are formed by attaching to "existing mental schemata: once an event or a particular bit of information is integrated into existing mental schemes, it will no longer be accessible as a separate, immutable entity," contrasted with traumatic memories that dissociate and remain separate from the central ego (Van der Kolk, 1987). The two types of memory stimulate different parts of the brain, as observed on a PET scan. When implicit memory is recalled, instead of being evaluated rationally, the memories are more likely to stimulate a fight or flight reaction. People with PTSD have trouble over-riding their physical responses to memory-triggering stimuli because they have no verbal connection to the memories with which to mediate (Adams, 1998).
One hypothesized explanation for the repetition compulsion, the unconscious desire to elicit from others behavior similar to repeated treatment experienced as traumatic in the past, is that the endorphins released to ease the anguish of traumatic events can become physically addictive after repeated traumas (Sikes, 1998). Dr. van der Kolk reports that "Intense stress is accompanied by the release of endogenous, stress-responsive neurohormones, such as cortisol, epinephrine and norepinephrine (NE), vasopressin, oxytocin and endogenous opioids" (Van der Kolk, 1987). These give an organism necessary energy to deal with the stress. Norepinephrine also plays a major role in "memory consolidation" (Van der Kolk, 1987). Likewise, endogenous opioids cause a "relative blunting of the emotional response to the traumatic stimulus" (Van der Kolk, 1987). They also keep the victim from feeling physical pain while defending him/herself. "Serotonin reuptake blockers are effective pharmacological agents in the treatment of PTSD" (Van der Kolk, 1987). These drugs help the person more accurately assess the actual situation during a stress response. Tricyclic antidepressants and monoamine oxidase inhibitors (MAO) also improve "intrusive (imipramine) or numbing (amitryptiline)" symptoms of PTSD patients. Fluoxetine is more effective for treating all the symptoms of PTSD and has faster results than the tricyclics.
Another treatment for PTSD, developed recently by Dr. Francine Shapiro, has shown promising research results. Eye Movement Desensitization and Reprocessing (EMDR) was used to treat war veterans who had suffered from PTSD for twenty-five years without successful help from other therapy. These vets had their symptoms "relieved" after only six sessions of talking about their memories while performing eye tracking (Shapiro, 1997). It seems emotional learning is enhanced if a person thinks about something, noticing his/her feelings and body sensations, while moving his/her eyes from left to right, crossing the midline (Shapiro, 1997). EMDR "assists survivors in the immediate aftermath of violent trauma by breaking through the walls of denial, shock, grief, and anger...allow[ing] for a rapid processing of even deeply rooted memories" (Shapiro, 1997). Because this technique began with eye tracking, it received the name "Eye Movement Desensitization and Reprocessing," but researchers are finding that the technique works for other bilateral stimulations, possibly any activity that brings attention from one hemisphere to the other (Sikes, 1998). The drawback of EMDR is that once dissociative barriers are lowered as the treatment begins, patients may receive more memories than they expected and not be able to treat them quickly enough to avoid great psychological pain during the times between each treatment session, until all of the traumatic experiences are reprocessed. So, as with other processing of dissociative memories in therapy, a certain level of ego strength is essential. No good theory for why this process is effective has been accepted. Some propose that people have an automatic ability to process trauma that can become blocked and that EMDR loosens this block. This process is similar to Rapid Eye Movement (REM) sleep which is thought to facilitate the processing of trauma in dreams (Sikes, 1998).
Another dissociative disorder, Disociative Identity Disorder (DID), is on the extreme end of the dissociative continuum. In this disorder, memories are divided more by altar-egos than into the categories in the BASK model (Sikes, 1998). As discussed before, state-specific learning can occur in a particular, hypnotic, NPP state at the time of trauma and cannot be remembered in another state. This is one explanation for the formation of different "altars" (well-developed personalities within one person that take turns "controlling" the body and have had only some of the experiences of the actual person). Dr. Kathleen Adams explains, "evolving states of consciousness become increasingly structuralized, beginning as conscious attempt at mastery and gradually becoming internalized into a fixed mental structures (altar personalities) that function with increasing independence" (Adams, 1994). Because similar experiences occur in the same physiological state (repeated rapes), they are linked together and an altar personality may develop. Therefore, one personality may conclude that rape only happens to Jane, another of his/her personalities that formed in the NPP state assumed during rape. According to Bennett Braun, DID is characterized by "The existence within the individual of two or more distinct personality states, each of which is dominant at a particular time; the personality state that is dominant has executive control over the individual's behavior; and each personality state is complex and integrated with its own unique behavior patterns and social relationships" (Braun, 1988).
Altars can also be based on restitutive fantasies that become altar-egos by dissociating because they too have too many painful affects to be tolerated. For example, the girl who is repeatedly raped may begin to imagine that she is an enormous wrestler that can beat up her rapist. Yet, to have this fantasy she is aware of her rape experiences and therefore may dissociate the wrestler into another altar. Dr. Sikes recalls one of her multiple personality patients admitting that her husband did not know he was sleeping with a man. The altar ego that appeared during her sexual encounters could be, for instance, like the wrestler. The extent of the abuse a person underwent correlates with the amount of fragmentation (number of different personalities) that the person may have (Sikes, 1998).
Some alter-egos do not know that other alters exist. When they are aware of each other, however, different alter-egos can, and often do, argue and compete. The alter that wants to stay up all night doing art may not understand or get along with the alter that will get up in the morning for his/her business job. One can imagine the turmoil a person with this disorder must experience. The organization of internal systems varies from person to person. What is universal is that the system (including all of the altars) is created to protect the person. A multiple may lie during treatment to cover up his/her internal fragmentation for extended periods. The alter-ego who originally presents him/herself for treatment is usually the least knowledgeable about the entire system. Treatment aims to slowly integrate these personalities into a single person again, conscious of his/her entire past. At first a therapist must facilitate the personalities working together (Sikes, 1998). Though this process may be extremely difficult, multiple personalities are far more concrete than other people and usually can be counted on to keep a clear agreement or promise (Adams, 1998). This may help the therapist slowly to work out agreements between the personalities that will keep them out of conflict.
A therapist must also help the patient discover and integrate memories and personalities at a rate he/she can handle. Often DID patients vacillate between not wanting to explore at all and wanting to know everything and get it over with in one session. Once memories begin to flow, more than the patient is ready to deal with could surface unless the therapist regulates the pace of discovery. Another challenge therapists face with this disorder is to keep an alter-ego present during the uncomfortable moments. Multiple personalities dissociate so easily that they can give control of the person to another alter-ego if the situation becomes unpleasant. The therapist must teach each alter-ego to stay present and deal with negative emotions and to be aware of when he/she is switching between personalities.
Dissociation can be an adaptive way to forget pain or not fully experience a traumatic event by entering a hypnoid state and by not remembering what is too hurtful to integrate. Though a person may not be able to handle the reality of the experience in its entirety at the time it occurs, and therefore benefit temporarily from dissociation, the memories will then appear in other forms and negatively effect his/her life. Severe trauma must be processed before the dissociative symptoms will subside. People with dissociative disorders should seek help from professionals where they can build up their "ego strength" and develop a trusting relationship with their therapists so that they can begin to face past traumatic experiences and metabolize them.
As per http://s99.middlebury.edu/PY204A/STUDENTS/That%20other%20group/dissociative_disorders.htm