Cognitive Behavioural Approaches to the Understanding and Treatment of Dissociation

Fiona Kennedy, Helen Kennerley, David Pearson, Fiona Kennedy, Helen Kennerley, David Pearson

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135050030
• Edition: 1
• Topic: Psychologie
• Subtopic: Posttraumatische Belastungsstörung (PTBS)

The study of dissociation is relevant to anyone undertaking research or treatment of mental health problems. Cognitive Behavioural Approaches to the Understanding and Treatment of Dissociation uses a cognitive approach to de-mystify the processes involved in linking traumatic incidents to their effects.

Kennedy, Kennerley and Pearson present a full and comprehensive understanding of mental health problems involving dissociative disorders and their treatment, bringing together an international range of experts. Each chapter addresses a single topic in full, including assessment of previous research from a cognitive perspective, recommendations for treatment and case studies to illustrate clinical approaches. Using an evidence-based scientific approach combined with the wisdom of clinical experience, the authors make the relevance of dissociation immediately recognisable to those familiar with PTSD, dissociative identity disorder, eating disorders, hallucinations and a wide range of psychological and non-organic physical health disorders.

Designed to provide new perspectives on both research and treatment, Cognitive Behavioural Approaches to the Understanding and Treatment of Dissociation includes a wide range of material that will appeal to clinicians, academics and students.

Chapter 1

---

The development of our understanding of dissociation

Fiona C. Kennedy

Helen Kennerley

---

We have both presented workshops about dissociation and the topic seems to evoke an unusual level of both intrigue and clinical concern. Intrigue because it is fascinating, curious and even rather exotic in some of its presentations and concern because we still lack good guidance on recognizing and managing dissociative symptoms, some of which can be life threatening, so that clinicians are justifiably wary of working with patients with such presentations. This chapter presents an overview of the construct of dissociation. We recognize the wide variety of presentations but bring them together to help clinicians understand and formulate dissociative phenomena and provide researchers with an historical context to their endeavours. In doing this, we review ideas spanning centuries and phenomena which have links with sorcery and celebrity. We also highlight ongoing controversies, as the term dissociation itself and its relevance is still far from clear.

Defining dissociation

Dissociation is described as a ‘disruption of the usually integrated functions of consciousness, memory, identity or perception of the environment’ (Diagnostic and Statistical Manual, text revision edition (DSM IV-TR) American Psychiatric Association, 2000, p. 811). A simple example of ‘integrated functions’ is a mother hearing a buzzing sound as she pushes her infant in its buggy. She immediately ‘sees’ an image of a wasp in her mind’s eye, accesses memories of wasps and the knowledge that they can sting. She has a frisson of alarm and she looks down to check her baby is safe. In an instant, perception, memory and emotion are integrated, leading to rapid and appropriate action. In dissociation, this integration is disturbed. DSM IV-TR states that dissociative phenomena should not be considered inherently pathological, recognizing that we all experience a degree of normal and benign dissociation. For example, the mother might later smell the heavy scent of honeysuckle and for a moment be transported back to a pleasant childhood memory — she will have had a pleasurable flashback — or she might have day-dreamed and not realized that she had walked the length of the park.

The current DSM definition captures many of the qualities of dissociation, but debate around definition continues. A great variety of seemingly disparate

Table 1.1 Phenomena which have been considered dissociative

Memory

amnesia for past events (e.g. a childhood trauma)

amnesia for the recent past (e.g. yesterday’s therapy session)

amnesia for important personal information (e.g. one’s address)

fugue states (where the person lives for a time as a another person with no memory of the past)

‘reliving’ of traumatic events (where a memory is experienced as if here and now)

Sense of Self

depersonalization (feeling like an alien, or disconnected from the body)

derealization (the sense that the environment is not real)

age regression (the person experiences him/herself as a child)

identity confusion (e.g. sexual orientation, political affiliation, opinions, are unclear/undecided)

identity alteration (e.g. changes from a peace-loving to an aggressive personality)

multiple personalities (two or more ‘selves’ alternately/simultaneously control the body) (Dissociative Identity Disorder)

possession states (e.g. angelic/demonic possession)

intermittent loss of skills (e.g. one day the individual can drive, the next day she says she has no idea how to)

Consciousness/Perception

hallucinations and pseudo-hallucinations (seeing, hearing, smelling or feeling things which are not actually there)

absorption (e.g. reading a book with reduced awareness of one’s surroundings)

hypnotic and other trance states such as automatic writing and medium trance states

‘losing time’ (where the person ‘comes to’ in a given time and place and cannot remember the immediately preceding events)

flashbacks (where an individual re-experiences past events vividly and emotionally)

Somatic/Bodily Symptoms

non-organic pain

auto-anaesthesia (being unable to feel pain)

somatic symptoms such as gait disturbances, problems urinating

some unexplained medical symptoms (not all unexplained symptoms are dissociative)

motor inhibition (e.g. being unable to perform certain actions, being rooted to the spot)

‘made behaviors’ (automatic behaviors carried out without feeling in control)

non-epileptic seizures

Other Phenomena

emotional numbness

mental blanking (inability to think)

inability to speak

psychological phenomena have been described as dissociative (not all recognized by DSM). Table 1.1 summarizes some of the phenomena which have been described as dissociative: you can see the diversity.

Dissociative states also occur in other psychological disorders, for example: acute stress disorder, PTSD, somatization disorder, panic disorder, schizophrenia, major depressive disorder, eating disorders, borderline personality disorder (BPD) and other personality disorders.

Understanding (and treatment) of dissociation has been hampered by factors such as:

• lack of conceptual clarity: different researchers and clinicians may not use the same language in referring to their work

• isolated study of disparate disturbances associated with dissociation: thus general conclusions are hard to draw

• a dearth of testable models of dissociation undermines understanding and classification of relevant psychological or neurological processes

The function of dissociation

Despite the above debate, research indicates dissociation has well-established links with traumatic events (Van der Kolk, McFarlane, and Weisaeth, 1996), and that dissociation mediates the relationship between trauma and psychopathology (Becker-Lausen, Sanders, and Chinsky, 1995; Griffin, Resick, and Mechanic, 1997; Zatzick, Marmar, Weiss, and Metzler, 1994). It is thought that it serves to reduce awareness of intolerable (traumatic) information (both internally- and externally-derived): exactly how this is achieved is just beginning to be explored, particularly through neurobiological approaches (see Kennerley and Kischka chapters, this volume).

A common view is that dissociation is a defence preventing emotionally unacceptable material from entering consciousness, but there are other views. Brown (2006a, and in this volume) proposes that memory, rather than current experience, may ‘over-determine’ perception and activate a ‘program’, a built-in response to a past situation, although the current situation does not warrant that response. Many factors can influence whether rogue memories dominate responses, only one of which is a traumatic past. Worrying about one’s health can increase one’s vulnerability to rogue representations and produce somatoform symptoms; or traumatic past memories can cause a woman to freeze when having to squeeze past a stranger in a doorway. Mansell and Carey (this volume) show how our perceptual hierarchy naturally splits to allow us to use our imagination and planning capacities, as well as different aspects of ourselves in different situations.

Brown, Gilbert, Kennedy, Mansell and Carey, Pearson and Van der Hart and Steele (all in this volume), and others argue that the fragmentation of the sense of self in dissociative identity disorder (DID, American Psychiatric Association, 2000) and other dissociative presentations may function to resolve conflict between a child’s need to attach and the need to protect themselves from harm which arises when a caregiver is dangerous. The function of dissociation may change and develop over time. For example, a child might have learnt to ‘space out’ when abused by her father but as an adult finds herself doing so when her therapist invites her to review emotionally painful material. In both situations this detachment is negatively reinforced (because it provides escape) but its function has subtly changed.

The next section of this chapter describes the evolution of thinking about dissociation, emphasizing recent cognitive approaches to provide a context for the book. Keen historians can find a more detailed review in Van der Hart and Dorahy (2009).

From possession to hysteria: the sixteenth-nineteenth century

Early cases of possession and witchcraft

‘Possession’ and ‘witchcraft’ can be interpreted, with hindsight, as instances of extreme dissociation, as these cases illustrate (Van der Hart, Lierens, and Goodwin, 1996):

In the 16th century Jeanne Fery, a French Dominican nun, claimed identitiesincluding Mary Magdalene, and ‘devils’ Namon and Belial. An eatingdisorder seemed related to Jeanne’s sexual abuse, aged 4, by a ‘demon’named Cornau who gave her sweets. She described self harm caused bya ‘devil’, Sanguinaire, who wanted pieces of her flesh. The devil Gargaprotected her from feeling pain but re-enacted childhood beatings by head-banging, throat-cutting and self-strangulation. She suffered seizures, rageattacks, age regression, sleep disturbance, conversion blindness, mutism,intermittent loss of knowledge, skills, and amnesia.

In 1623 Sister Benedetta of Italy was ‘possessed’ by ‘boys’ who causedchronic pain and spoke in different dialects. One, a nine year old, Splenditello,had a sexual relationship with another nun. She also self-mutilated andsuffered eating problems.

Although classified as ‘possession’ you can see that these accounts reflect many dissociative phenomena, along with other responses which typically occur alongside dissociation, such as self-harm, suicidal gestures, aggression, mood lability and disordered eating.

Multiple personality

More familiar clinical terminology appeared in the eighteenth and nineteenth century when cases of ‘double’ personality, with two self-states, were reported by Gmelin in Germany (1791), Mitchell in America (1888) and Azam in France (1876). Myer’s case of Louis Vivet (1886) is reported by Faure, Kersten, Koopman and Van der Hart (1997) as the first explicitly described case of multiple personality.

Vivet was born of a ‘child mother’, neglected, beaten, abandoned at the ageof seven. He showed many personality states, ‘hysterico-epileptic seizures’,intermittent paralysis, varying food preferences (e.g. either craving ordisliking wine), aggression and stealing interspersed with calm politeness.

At that time (Camuset, 1882) and recently (Hacking, 1995) authorities questioned whether some or all ‘personalities’ were the iatrogenic result of treatment in the asylum, and there was questioning by authority of the genuineness of the symptoms, a theme which recurs throughout history. Notable here is the prevalence of somatic symptoms, which commonly occur in dissociation. A further recurring theme is a background of severe child abuse and neglect.

Mediums, automatic writing, hypnosis and hysteria

From the late eighteenth century interest grew in non-pathological dissociation, and in ‘hysteria’, a pathological disorder (now called conversion or somatoform disorder). Alternating states of consciousness were observed and investigated and our understanding of dissociation moved forward considerably.

Puységur, (1751–1825) a student of Mesmer, noted that when he used magnetism to induce convulsions, some people entered a state which he called ‘artificial somnambulism’ (later ‘hypnosis’). Subjects seemed to have two separate streams of consciousness which were divided from each other during this state, and subsequent amnesia (Van der Hart and Dorahy, 2009).

Moreau de Tours first used the term ‘dissociation’ (‘désagrégation’) in France in 1845, understanding it as a lack of integration of ideas, causing a split in the personality. Gros-Jean (1855) and Taine (1878) applied his ideas to automatic writing and to possession states in spiritualist mediums, claiming that two personality states existed concurrently while a ‘trance’ was occurring. Later, Charcot (1887) used artificial somnambulism/hypnotic states as a model to explain ‘hysterical’ symptoms such as paralysis, claiming that these symptoms occurred in separated-off states of consciousness.

In summary, by the late nineteenth century scientists had noticed the connection between divided states of consciousness and psychopathology in terms of ‘hysteria’ and multiple personality.

The late nineteenth-early twentieth century:vehement emotions and repression

Janet, Binet and James

Pierre Janet (1859–1947) made a huge contribution to the study of dissociation, describing flashbacks perhaps for the first time. A contemporary of Freud, Breuer and Charcot, his theoretical model described ‘idées fixes’ or traumatic memories, with associated ‘vehement emotions’ as well as images, movements and physiological ‘phenomena’. These could alternate with an apparently normal personality state and cause intrusions when triggered by traumatic reminders. While accessing one per...