Dissociation.pptx

DISSOCIATION

Overview • What is dissociation • What Dissociation is not

• Different types of Dissociation • Theories

What is Dissociation ?

ICD-10 Partial or complete loss of the normal integration between: Past memories

Control of bodily movements

Immediate sensation

Awareness of your identity

DSM-5 “A Disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment. The disturbance may be sudden, gradual, transient or chronic.”

Deficits in integrative memory, disturbances of identity, passive influence experiences, and trance- absorption phenomena that are not better accounted for by organic pathology

American Psychiatric Association, 1994; Putnam, 1997.

Five basic assumptions. • Capability : Dissociation is one of many capacities people have. So, in that respect, dissociation is analogous to, for example, irony, patience, dishonesty etc.

• No uniqueness : Although dissociation has distinctive features, insofar as it’s a

capacity, it will be similar in broad outline to most other human capacities, that is, it will share features found generally in human (or just cognitive) capacities.

• Diversification: dissociation assumes a variety of forms, affects a broad range of states and spreads out along various continua—for example, of pervasiveness, frequency, severity, completeness, reversibility, degree of functional isolation, and importance to the subject.

• Ownership: The things dissociated from a person are always the person’s own states—for example, sensory, cognitive, volitional, and physical states.

• Accessibility: Dissociation is a theoretically (but perhaps not practically) reversible functional isolation of a state from conscious awareness.

Inclusivity versus Exclusivity Inclusivity Position- normal, experimental, and pathological dissociation are all forms of a single phenomenon. Also called as Continuum model . Proponents: • Diversification assumption • Dissociation as a trait

Exclusivity Position- pathological and nonpathological dissociation are radically distinct, lacking any significant unifying features. Also called as Taxonal model

Proponents: • Dissociation as a multifaceted collection of distinct, but overlapping, dimensions, as opposed to a unitary trait. From the perspective of development, dissociation may be viewed as a continuum process; at the level of diagnosis, dissociative phenomena may be categorical (Putnam, 1995).

What Dissociation is not

It is not just a defence • Vast majority of hypnotic phenomena and also widely accepted examples of dissociation in everyday life cannot be explained by viewing Dissociation as a

defence against stress and trauma.

• Attachment theorists view Dissociation as a maladaptive state and not as a defence against the trauma.

Dissociation is not just the absence of conscious awareness Because if that were the case than these would count incorrectly as dissociative

Sleep

Chemical Anaesthesia

Subliminal perception

It is not just the inconsistency between a person ongoing behaviour or perception and his introspective verbal reports Because if that were true, dissociation would encompass far too much—for example, cases of selfdeception Outright ignorance or stupidity

Cognitive dissonance

Dissociation is not just the coexistence of separate mental systems and identities that are ordinarily integrated in persons consciousness Because this definition would have been too inclusive and would have included ordinary phenomenon like: Multiple Roles of a person

Retrievable forgetting

Dissociation: Branch A (Dell and O’Neil, 2009)

Branch A

Dissociation for convenience

Consists mainly of “normative” types of dissociative activity that are not caused by trauma. It includes : Absorption

Highway Hypnosis

Daydreaming

Voluntary Identity alteration

Absorption

Ability to be “carried away” in a narrowed, concentrated focus of attention, to become so immersed in a central experience that context loses its frame.

Putnam, 1997

It has been classified as dissociation because the intense focal concentration can result “in the exclusion (dissociation) of other contents from the phenomenal field

Highway Hypnosis

In which the driver of an automobile travels a well-known route and arrives at the destination without remembering the drive.

Putnam, 1997

What happens here is that the driver, focally attending to other thoughts than the road, is able to perform the drive automatically. It is an example of automatic dual tasking.

Daydreaming Detachment from one’s surroundings, during which a person’s contact with reality is

blurred and partially substituted by thoughts, hopes or ambitions

Maladaptive Daydreaming characterizes individuals who engage in vivid, fanciful daydreaming for hours on and, neglecting real-life relationships and responsibilities, resulting in clinical distress and functional impairment. Nirit saffer-Dudek et.al, 2018

Voluntary Identity Alteration

Trance State- A trance is said to occur when someone experiences a temporary marked alteration in state of consciousness or identity (but with no replacement by an alternative identity).

It is usually associated with either a narrowing of awareness of the immediate surroundings, or stereotyped behaviors or movements that are experienced as beyond one’s control.

Dissociation: Branch B

Branch B

Pathological Trauma based etiology

More persistent than are Branch A symptoms and are regarded as more pathological. It includes: • Dissociative Amnesia • Dissociative Fugue • Dissociative Identity Disorder • Depersonalization • Derealization • Conversion

Types of Dissociative Amnesia • Localized amnesia- Inability to recall events related to a circumscribed period of

time. • Selective amnesia- Ability to remember some, but not all, of the events occurring

during a circumscribed period of time. • Generalized amnesia-Failure to recall one’s entire life

• Continuous amnesia- Failure to recall successive events as they occur • Systematized amnesia- Amnesia for certain categories of memory, such as all memories relating to one’s family or to a particular person.

Dissociative Amnesia

failure to recall previously stored personal information (retrograde amnesia) when that failure cannot be accounted for by ordinary forgetting.

The gaps in memory most often occur following intolerably stressful circumstances (Maldonado

In this disorder, apparently forgotten personal information is still there beneath the level of consciousness, as sometimes becomes apparent in interviews conducted under hypnosis or narcosis.

Dissociative Fugue Dissociative fugue has all the features of dissociative amnesia, plus

an apparently purposeful journey away from home or place of work during which self-care is maintained.

In some cases, a new identity may be assumed, usually only for a few days but occasionally for long periods of time and to a surprising degree of completeness.

Dissociative Identity Disorder

dramatic dissociative disorder in which a patient manifests two or more distinct identities that alternate in some way in taking control of behavior.

There is also an inability to recall important personal information that cannot be explained by ordinary forgetting.

Each identity may appear to have a different personal history, selfimage, and name.

Depersonalization One’s sense of one’s own self and one’s own reality is temporarily lost.

Persistent or recurrent experiences of feeling detached from (and like an outside observer of) their own bodies and mental processes. They may even feel they are, for a time, floating above their physical bodies.

During periods of depersonalization, unlike during psychotic states, reality testing remains intact.

Derealization One’s sense of the reality of the outside world is temporarily lost

external world is perceived as strange and new in various ways, may also occur.

Conversion It involves a pattern in which symptoms or deficits affecting the senses or motor behavior without any known medical condition. A few typical examples include partial paralysis, blindness, deafness, and pseudo seizures. la belle indifference- Most people with conversion disorder show very little of the anxiety and fear that would be expected in a person with a paralyzed arm or loss of sight.

la belle indifference actually occurs in only about 20 percent of patients with conversion disorder, so it was dropped as a criterion from recent editions of the

DSM (Stone et al., 2006, 2011).

In describing the clinical picture in conversion disorder, it is useful to think in terms of four categories of symptoms: (1) Sensory (2)motor (2) Seizures

(4)mixed presentation (APA, 2013).

Theories

Pierre Janet Psychological

illness of the personal synthesis

Disaggregation

A form of mental depression [i.e., lowered integrative capacity]

Causes

1. Constituent vulnerabilities 2. Traumatic experiences

These traumatic Experiences lead to formation of Different systems which constitute specific ideas and function which resides in one’s Subconscious.

Mechanism

When these systems are reactivated the person alternate between experiencing too little or too much of their trauma

Two apparently contrasting phenomena constitute a syndrome:

1) the inability of the subject to consciously and voluntarily recall the memories 2) the automatic, irresistible and inopportune reproduction of the same memories. underlying mental mechanisms of somatoform and dissociative disorders are similar

Babinski Pithiatism- Nihilistic view that all hysteria was caused by suggestion and could be removed by persuasion or countersuggestion.

This view continues today, most prominently in the thinking of Paul McHugh, a

vehement critic of the current trauma-based theories of dissociation and also in the socio-cognitive theory of dissociation.

Freud Double Conscience

Causes

Ego defence against the intense affect. Where integrated functioning temporarily (and defensively) gives way in order to minimize the impact of internal and external stressors.

Instinctual drives and intrapsychic conflicts

Myers The mental condition in which person reexperience their trauma could best be described as a dissociated personality. The failure to integrate the various sensory and psychological aspects of horrific experiences had led to a division of the personality into an “apparently normal personality” and an “emotional personality.” This conceptual formulation can be regarded as an important precursor to modern claims that acute stress disorder and posttraumatic stress disorder are actually dissociative disorders.

Interpersonal Theory- Sullivan,1953 Sullivan described the interpersonal genesis of dissociation. As a result of unbearable anxiety arising from interactions with caregivers, including extreme parental disapproval, certain kinds of experiences may become dissociated and part of “not-me.”

Selective inattention to anxiety-fraught areas of experience leads to experience remaining unformulated, and hence dissociated

Fairbairn – Object relation theorist Dissociation phenomena of “hysteria” involves a split of the ego fundamentally identical with that which confers upon the term “schizoid” its etymological significance.

Thus, for Fairbairn, “dissociation,” “schizoid,” and “splitting of the ego” were

interchangeable terms that referred to a specific type of division in psychic organization.

Object Relation perspective Object-relations perspectives conceptualize the psychological phenomenon of dissociation in terms of internal dynamics whereby trauma necessitates the premature maturation of a “false” self that rigidifies and obscures more

spontaneous authentic experience (the “true” self) (Winnicott, 1965, 1971)

Perceptual theory- Beere, 1995 Everyday experience involves a constant flow of different figure/ground perceptions.

Time, world, body, mind, and identity are usually present in the background.

The lived-integration of figure-ground-background constitutes meaningful livedexperience

During dissociation, the background is lost or loses constancy, thus meaningful livedintegration is ruptured.

Betrayal Trauma theory – Freyd, 1996 proposes that dissociation is one mechanism by which traumatized individuals can be unaware of information that could threaten an important relationship.

Under this theory, the purpose of dissociation is not escape from pain, but the maintenance of the attachment relationship by notknowing about information that would threaten it.

Socio-cognitive theory- Lilienfeld & Lynn,1999

which claims that DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities, mostly because

clinicians have inadvertently suggested, legitimized, and reinforced them

and because these different identities are geared to the individual’s own personal goals

Neo-Dissociation theory- Hilgard It proposes that hypnotic phenomenon are produced through a dissociation within executive control system (ECS) into different streams. Part of the ECS functions normally, but is unable to represent itself in conscious awareness due to the presence of an 'amnesic barrier’. Inspired by his experiments with the 'hidden observer' phenomenon.

Consciousness as Modularistic –Gazzaniga, 1985 Research in cognitive psychology, neurophysiology, and child development indicates that the brain, the mind, and the self are normally multiple and that the idea of the unity of self is an illusion. We fill in the gaps of experience; we imagine ourselves in control of our hearts and minds when we are not. Gazzaniga views consciousness as modularistic, and says that the notion of “linear unified conscious experience is dead wrong”.

Developing self and Dissociation Dissociative processes both affect and are affected by developing self Passive Dissociation- The mind of the young child naturally fractionates prior to the development of the ability to process complex or contradictory experiences (e.g., compartmentalizing content into positive versus negative, good versus bad) Active Dissociation- a motivated response to extreme or traumatic experience, capitalizes on the child’s natural proclivity for compartmentalizing affect and experience. Putnam 1991

Dissociative behaviors may be more natural (and prevalent) in early childhood; however, with the appearance of more advanced modes of thought, the significance and complexity of dissociative behavior as an indicator of psychopathology may increase with age.

Putnam, 1997

Behavioural Perspective

Conceptualizes DID as a complex Phobia whose stimulus is combination of memories, feelings and environmental cues.

Just as Individuals tend to withdraw from the phobic situation, the executive self tends to retreat behind the alters in the phobic situation.

Attachment theory

In Disorganized attachment the infants organizing functions of consciousness, memory and identity appear to have failed.

In DA, infants display contradictory behavior patterns

approaching the parent while averting the head so as to avoid meeting his/her gaze

This suggests an obstacle to the construction and operation of the normally unitary IWM representing the self and the parent

Main and Morgan 1996

Any human being is endowed with two systems that have evolved to deal with environmental threat:

Defense system

Attachment System

In DA both systems become simultaneously active in a conflicting manner: they

motivate both flight from and approach to the caregiver Such an insoluble conflict reflects itself in the collapse of any attempt at developing an organized strategy of attention and behavior.

Cultural Factors • Certain symptoms may be emphasized above others when experiencing or describing disorders (e.g., psychological vs.somatic aspects of depression). For example, conversion-like dissociative symptoms are more common in India than in certain affluent settings in the United States. • various cultural factors account for the secondary structuring of the dissociative

process into the individualized identities characteristic of a given person in a given culture.

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