What is Dissociative Disorder?

Introduction

Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception.

People with dissociative disorders use dissociation as a defence mechanism, pathologically and involuntarily. The individual experiences these dissociations to protect themselves. Some dissociative disorders are triggered by psychological trauma, but depersonalisationderealisation disorder may be preceded only by stress, psychoactive substances, or no identifiable trigger at all.

The dissociative disorders listed in the American Psychiatric Association’s DSM-5 are as follows:

  • Dissociative identity disorder (formerly multiple personality disorder): the alternation of two or more distinct personality states with impaired recall among personality states. In extreme cases, the host personality is unaware of the other, alternating personalities; however, the alternate personalities can be aware of all the existing personalities.
  • Dissociative amnesia (formerly psychogenic amnesia): the temporary loss of recall memory, specifically episodic memory, due to a traumatic or stressful event. It is considered the most common dissociative disorder amongst those documented. This disorder can occur abruptly or gradually and may last minutes to years depending on the severity of the trauma and the patient. Dissociative fugue was previously a separate category but is now treated as a specifier for dissociative amnesia.
  • Depersonalisation-derealisation disorder: periods of detachment from self or surrounding which may be experienced as “unreal” (lacking in control of or “outside” self) while retaining awareness that this is only a feeling and not a reality.
  • The old category of dissociative disorder not otherwise specified is now split into two: other specified dissociative disorder, and unspecified dissociative disorder. These categories are used for forms of pathological dissociation that do not fully meet the criteria of the other specified dissociative disorders; or if the correct category has not been determined; or the disorder is transient.

The ICD 11 lists dissociative disorders as:

  • Dissociative neurological symptom disorder.
  • Dissociative amnesia.
  • Dissociative amnesia with dissociative fugue.
  • Trance disorder.
  • Possession trance disorder.
  • Dissociative identity disorder.
  • Partial dissociative identity disorder.
  • Depersonalisation-derealisation disorder.

Cause and Treatment

Dissociative Identity Disorder

Cause

Dissociative identity disorder is caused by ongoing childhood trauma that occurs before the ages of six to nine. People with dissociative identity disorder usually have close relatives who have also had similar experiences.

Treatment

Long-term psychotherapy to improve the patient’s quality of life.

Dissociative Amnesia

Cause

A way to cope with trauma.

Treatment

Psychotherapy (e.g. talk therapy) counselling or psychosocial therapy which involves talking about your disorder and related issues with a mental health provider. Psychotherapy often involves hypnosis (help you remember and work through the trauma); creative art therapy (using creative process to help a person who cannot express his or her thoughts); cognitive therapy (talk therapy to identify unhealthy and negative beliefs/behaviours); and medications (antidepressants, anti-anxiety medications, or sedatives). These medications help control the symptoms associated with the dissociative disorders, but there are no medications yet that specifically treat dissociative disorders. However, the medication pentothal can sometimes help to restore the memories. The length of an event of dissociative amnesia may be a few minutes or several years. If an episode is associated with a traumatic event, the amnesia may clear up when the person is removed from the traumatic situation. Dissociative fugue was a separate category but is now listed as a specifier for dissociative amnesia.

Depersonalisation-Derealisation Disorder

Cause

Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable; however, this disorder can also acutely form due to severe traumas such as war or the death of a loved one.

Treatment

Same treatment as dissociative amnesia. An episode of depersonalisationderealisation disorder can be as brief as a few seconds or continue for several years.

Dissociative disorders, especially dissociative identity disorder (DID), while being the result of extraordinary abuse and trauma in childhood, it should not be attributed exotic status. DID would be better examined through a more holistic lens, taking into considering the social, cognitive, and neural components, and how they interact with one another.

Medications

There are no medications to treat dissociative disorders, however, drugs to treat anxiety and depression that may accompany the disorders can be given.

Diagnosis and Prevalence

The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients. Diagnosis can be made with the help of structured clinical interviews such as the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R), and behavioural observation of dissociative signs during the interview. Additional information can be helpful in diagnosis, including the Dissociative Experiences Scale or other questionnaires, performance-based measures, records from doctors or academic records, and information from partners, parents, or friends. A dissociative disorder cannot be ruled out in a single session and it is common for patients diagnosed with a dissociative disorder to not have a previous dissociative disorder diagnosis due to a lack of clinician training. Some diagnostic tests have also been adapted or developed for use with children and adolescents such as the Adolescent Dissociative Experiences Scale, Children’s Version of the Response Evaluation Measure (REM-Y-71), Child Interview for Subjective Dissociative Experiences, Child Dissociative Checklist (CDC), Child Behaviour Checklist (CBCL) Dissociation Subscale, and the Trauma Symptom Checklist for Children Dissociation Subscale.

Dissociative disorders have been found to be quite prevalent in outpatient populations, as well as within low-income communities. One study found that in a population of poor inner-city outpatients, there was a 29% prevalence of dissociative disorders.

There are problems with classification, diagnosis and therapeutic strategies of dissociative and conversion disorders which can be understood by the historic context of hysteria. Even current systems used to diagnose DD such as the DSM-IV and ICD-10 differ in the way the classification is determined. In most cases mental health professionals are still hesitant to diagnose patients with Dissociative Disorder, because before they are considered to be diagnosed with Dissociative Disorder these patients have more than likely been diagnosed with major depressive disorder, anxiety disorder, and most often post-traumatic stress disorder (PTSD). It has been found from interviews with those who may be afflicted with dissociative disorders may be more effective at getting an accurate diagnosis than self-scoring assessments and scales.

The prevalence of dissociative disorders is not completely understood due to the many difficulties in diagnosing dissociative disorders. Many of these difficulties stem from a misunderstanding of dissociative disorders, from an unfamiliarity diagnosis or symptoms to disbelief in some dissociative disorders entirely. Due to this it has been found that only 28% to 48% of people diagnosed with a dissociative disorder receive treatment for their mental health. Patients who are misdiagnosed are often those more likely to be hospitalised repeatedly, and lack of treatment can result in intensive outpatient treatment and higher rates of disability.

An important concern in the diagnosis of dissociative disorders in forensic interviews is the possibility that the patient may be feigning symptoms in order to escape negative consequences. Young criminal offenders report much higher levels of dissociative disorders, such as amnesia. In one study it was found that 1% of young offenders reported complete amnesia for a violent crime, while 19% claimed partial amnesia. There have also been cases in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present. The world-wide prevalence of dissociative disorders is not well understood due to different cultural beliefs surrounding human emotions and the human brain

Children and Adolescents

Dissociative disorders (DD) are widely believed to have roots in adverse childhood experiences including abuse and loss, but the symptoms often go unrecognised or are misdiagnosed in children and adolescents. However, a recent western Chinese study showed an increase in awareness of dissociative disorders present in children These studies show that DD’s have an intricate relationship with the patient’s mental, physical and socio-cultural environments. This study suggested that dissociative disorders are more common in Western, or developing countries, however, some cases have been seen in both clinical and non-clinical Chinese populations. There are several reasons why recognising symptoms of dissociation in children is challenging: it may be difficult for children to describe their internal experiences; caregivers may miss signals or attempt to conceal their own abusive or neglectful behaviours; symptoms can be subtle or fleeting; disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders.

Another resource, Beacon House, informs us of dissociative disorder in children, suggesting that it is a survival mechanism that often goes unnoticed in children that have been traumatised. Dr. Shoshanah Lyons suggests that traumatised children often continue to dissociate even though they might not be in any danger, and that they are often unaware that they are dissociating. In addition to developing diagnostic tests for children and adolescents (see above), a number of approaches have been developed to improve recognition and understanding of dissociation in children. Recent research has focused on clarifying the neurological basis of symptoms associated with dissociation by studying neurochemical, functional and structural brain abnormalities that can result from childhood trauma. Others in the field have argued that recognising disorganised attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders. In their 2008 article, Rebecca Seligman and Laurence Kirmayer suggest the existence of evidence of linkages between trauma experienced in childhood and the capacity for dissociation or depersonalisation. They also suggest that individuals who are able to utilise dissociative techniques are able to keep this as an extended strategy to cope with stressful situations.

Clinicians and researchers stress the importance of using a developmental model to understand both symptoms and the future course of DDs. In other words, symptoms of dissociation may manifest differently at different stages of child and adolescent development and individuals may be more or less susceptible to developing dissociative symptoms at different ages. Further research into the manifestation of dissociative symptoms and vulnerability throughout development is needed. Related to this developmental approach, more research is required to establish whether a young patient’s recovery will remain stable over time.

Current Debates and the DSM-5

A number of controversies surround DD in adults as well as children. First, there is ongoing debate surrounding the aetiology of dissociative identity disorder (DID). The crux of this debate is if DID is the result of childhood trauma and disorganized attachment. A proposed view is that dissociation has a physiological basis, in that it involves automatically triggered mechanisms such as increased blood pressure and alertness, that would, as Lynn contends, imply its existence as a cross-species disorder. A second area of controversy surrounds the question of whether or not dissociation as a defence versus pathological dissociation are qualitatively or quantitatively different. Experiences and symptoms of dissociation can range from the more mundane to those associated with PTSD or acute stress disorder (ASD) to dissociative disorders. Mirroring this complexity, the DSM-5 workgroup considered grouping dissociative disorders with other trauma/stress disorders, but instead decided to put them in the following chapter to emphasize the close relationship. The DSM-5 also introduced a dissociative subtype of PTSD.

A 2012 review article supports the hypothesis that current or recent trauma may affect an individual’s assessment of the more distant past, changing the experience of the past and resulting in dissociative states. However, experimental research in cognitive science continues to challenge claims concerning the validity of the dissociation construct, which is still based on Janetian notions of structural dissociation. Even the claimed etiological link between trauma/abuse and dissociation has been questioned. Links observed between trauma/abuse and DD are largely only present from a Western cultural context. For non-Western cultures dissociation “may constitute a “normal” psychological capacity”. An alternative model proposes a perspective on dissociation based on a recently established link between a labile sleep-wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality.

Debates around DD also stem from Western versus non-Western lenses of viewing the disorder, and associated views of causes of DD. DID was initially believed to be specific to the West, until cross-cultural studies indicated its occurrence worldwide. Conversely, anthropologists have largely done little work on DD in the West relating to its perceptions of possession syndromes that would be present in non-Western societies. While dissociation has been viewed and catalogued by anthropologists differently in the West and non-Western societies, there are aspects of each that show DD has universal characteristics. For example, while shamanic and rituals of non-Western societies may hold dissociative aspects, this is not exclusive as many Christian sects, such as “possession by the Holy Ghost” share similar qualities to those of non-Western trances.

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What is the Dissociative Experiences Scale?

Introduction

The Dissociative Experiences Scale (DES) is a psychological self-assessment questionnaire that measures dissociative symptoms.

Background

It contains twenty-eight questions and returns an overall score as well as four sub-scale results.

DES is intended to be a screening test, since only 17% of patients with scores over 30 will be diagnosed with having dissociative identity disorder. Patients with lower scores above normal may have other post-traumatic conditions.

The DES-II contains the same questions but with a different response scale.

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What is Dissociation (Psychology)?

Introduction

Dissociation, as a concept that has been developed over time, is any of a wide array of experiences, ranging from a mild emotional detachment from the immediate surroundings, to a more severe disconnection from physical and emotional experiences. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a loss of reality as in psychosis.

The phenomena are diagnosable under the DSM-5 as a group of disorders as well as a symptom of other disorders through various diagnostic tools. Its cause is believed to be related to neurobiological mechanisms, trauma, anxiety, and psychoactive drugs. Research has further related it to suggestibility and hypnosis, and it is inversely related to mindfulness, which is a potential treatment.

Brief History

French philosopher and psychologist Pierre Janet (1859-1947) is considered to be the author of the concept of dissociation. Contrary to some conceptions of dissociation, Janet did not believe that dissociation was a psychological defence.

Psychological defence mechanisms belong to Sigmund Freud‘s theory of psychoanalysis, not to Janetian psychology. Janet claimed that dissociation occurred only in persons who had a constitutional weakness of mental functioning that led to hysteria when they were stressed. Although it is true that many of Janet’s case histories described traumatic experiences, he never considered dissociation to be a defence against those experiences. Quite the opposite: Janet insisted that dissociation was a mental or cognitive deficit. Accordingly, he considered trauma to be one of many stressors that could worsen the already-impaired “mental deficiency” of a hysteric, thereby generating a cascade of hysterical (in today’s language, “dissociative”) symptoms.

Although there was great interest in dissociation during the last two decades of the nineteenth century (especially in France and England), this interest rapidly waned with the coming of the new century. Even Janet largely turned his attention to other matters.

There was a sharp peak in interest in dissociation in America from 1890 to 1910, especially in Boston as reflected in the work of William James, Boris Sidis, Morton Prince, and William McDougall. Nevertheless, even in America, interest in dissociation rapidly succumbed to the surging academic interest in psychoanalysis and behaviourism.

For most of the twentieth century, there was little interest in dissociation. Despite this, a review of 76 previously published cases from the 1790s to 1942 was published in 1944, describing clinical phenomena consistent with that seen by Janet and by therapists today. In 1971, Bowers and her colleagues presented a detailed, and still quite valid, treatment article. The authors of this article included leading thinkers of their time – John G. Watkins (who developed ego-state therapy) and Zygmunt A. Piotrowski (famed for his work on the Rorschach test). Further interest in dissociation was evoked when Ernest Hilgard (1977) published his neodissociation theory in the 1970s. During the 1970s and 1980s an increasing number of clinicians and researchers wrote about dissociation, particularly multiple personality disorder.

Carl Jung described pathological manifestations of dissociation as special or extreme cases of the normal operation of the psyche. This structural dissociation, opposing tension, and hierarchy of basic attitudes and functions in normal individual consciousness is the basis of Jung’s Psychological Types. He theorised that dissociation is a natural necessity for consciousness to operate in one faculty unhampered by the demands of its opposite.

Attention to dissociation as a clinical feature has been growing in recent years as knowledge of post-traumatic stress disorder (PTSD) increased, due to interest in dissociative identity disorder (DID), and as neuroimaging research and population studies show its relevance.

Historically the psychopathological concept of dissociation has also another different root: the conceptualization of Eugen Bleuler that looks into dissociation related to schizophrenia.

Diagnosis

Refer to Dissociative disorder.

Dissociation is commonly displayed on a continuum. In mild cases, dissociation can be regarded as a coping mechanism or defence mechanism in seeking to master, minimise or tolerate stress – including boredom or conflict. At the non-pathological end of the continuum, dissociation describes common events such as daydreaming. Further along the continuum are non-pathological altered states of consciousness.

More pathological dissociation involves dissociative disorders, including dissociative fugue and depersonalisation disorder with or without alterations in personal identity or sense of self. These alterations can include: a sense that self or the world is unreal (depersonalisation and derealisation), a loss of memory (amnesia), forgetting identity or assuming a new self (fugue), and separate streams of consciousness, identity and self (dissociative identity disorder, formerly termed multiple personality disorder) and complex post-traumatic stress disorder (CPTSD). Although some dissociative disruptions involve amnesia, other dissociative events do not. Dissociative disorders are typically experienced as startling, autonomous intrusions into the person’s usual ways of responding or functioning. Due to their unexpected and largely inexplicable nature, they tend to be quite unsettling.

Dissociative disorders are sometimes triggered by trauma, but may be preceded only by stress, psychoactive substances, or no identifiable trigger at all. The ICD-10 classifies conversion disorder as a dissociative disorder. The DSM groups all dissociative disorders into a single category and recognises dissociation as a symptom of acute stress disorder, posttraumatic stress disorder (PTSD), and borderline personality disorder.

Misdiagnosis is common among people who display symptoms of dissociative disorders, with an average of seven years to receive proper diagnosis and treatment. Research is ongoing into aetiologies, symptomology, and valid and reliable diagnostic tools. In the general population, dissociative experiences that are not clinically significant are highly prevalent with 60% to 65% of the respondents indicating that they have had some dissociative experiences.

Diagnostic and Statistical Manual of Mental Disorders

Diagnoses listed under the DSM-5 are dissociative identity disorder, dissociative amnesia, depersonalisation/derealisation disorder, other specified dissociative disorder and unspecified dissociative disorder. The list of available dissociative disorders listed in the DSM-5 changed from the DSM-IV-TR, as the authors removed the diagnosis of dissociative fugue, classifying it instead as a subtype of dissociative amnesia. Furthermore, the authors recognised derealisation on the same diagnostic level of depersonalisation with the opportunity of differentiating between the two.

The DSM-IV-TR considers symptoms such as depersonalisation, derealisation and psychogenic amnesia to be core features of dissociative disorders. The DSM-5 carried these symptoms over and described symptoms as positive and negative. Positive symptoms include unwanted intrusions that alter continuity of subjective experiences, which account for the first two symptoms listed earlier with the addition of fragmentation of identity. Negative symptoms include loss of access to information and mental functions that are normally readily accessible, which describes amnesia.

Peritraumatic Dissociation

Peritraumatic dissociation is considered to be dissociation that is experienced during and immediately following a traumatic event. Research is on-going related to its development, its importance, and its relationship to trauma, dissociative disorders, and predicting the development of PTSD.

Measurements

Two of the most commonly used screening tools in the community are the Dissociative Experiences Scale and the Multiscale Dissociation Inventory. Meanwhile, the Structured Clinical Interview for DSM-IV – Dissociative Disorders (SCID-D) and its second iteration, the SCID-D-R, are both semi-structured interviews and are considered psychometrically strong diagnostic tools.

Other tools include the Office Mental Status Examination (OMSE), which is used clinically due to inherent subjectivity and lack of quantitative use. There is also the Dissociative Disorders Interview Schedule (DDSI), which lacks substantive clarity for differential diagnostics.

Peritraumatic dissociation is measured through the Peritraumatic Dissociative Scale.

Aetiology

Neurobiological Mechanism

Preliminary research suggests that dissociation-inducing events, drugs like ketamine, and seizures generate slow rhythmic activity (1-3 Hz) in layer 5 neurons of the posteromedial cortex in humans (retrosplenial cortex in mice). These slow oscillations disconnect other brain regions from interacting with the posteromedial cortex, which may explain the overall experience of dissociation.

Trauma

Dissociation has been described as one of a constellation of symptoms experienced by some victims of multiple forms of childhood trauma, including physical, psychological, and sexual abuse. This is supported by studies which suggest that dissociation is correlated with a history of trauma.

Dissociation appears to have a high specificity and a low sensitivity to having a self-reported history of trauma, which means that dissociation is much more common among those who are traumatised, yet at the same time there are many people who have suffered from trauma but who do not show dissociative symptoms.

Adult dissociation when combined with a history of child abuse and otherwise interpersonal violence-related PTSD has been shown to contribute to disturbances in parenting behaviour, such as exposure of young children to violent media. Such behaviour may contribute to cycles of familial violence and trauma.

Symptoms of dissociation resulting from trauma may include depersonalisation, psychological numbing, disengagement, or amnesia regarding the events of the abuse. It has been hypothesized that dissociation may provide a temporarily effective defence mechanism in cases of severe trauma; however, in the long term, dissociation is associated with decreased psychological functioning and adjustment.

Other symptoms sometimes found along with dissociation in victims of traumatic abuse (often referred to as “sequelae to abuse”) include anxiety, PTSD, low self-esteem, somatisation, depression, chronic pain, interpersonal dysfunction, substance abuse, self-harm and suicidal ideation or actions. These symptoms may lead the victim to present the symptoms as the source of the problem.

Child abuse, especially chronic abuse starting at early ages, has been related to high levels of dissociative symptoms in a clinical sample, including amnesia for abuse memories. It has also been seen that girls who suffered abuse during their childhood had higher reported dissociation scores than did boys who reported dissociation during their childhood. A non-clinical sample of adult women linked increased levels of dissociation to sexual abuse by a significantly older person prior to age 15, and dissociation has also been correlated with a history of childhood physical and sexual abuse. When sexual abuse is examined, the levels of dissociation were found to increase along with the severity of the abuse.

A 2012 review article supports the hypothesis that current or recent trauma may affect an individual’s assessment of the more distant past, changing the experience of the past and resulting in dissociative states.

Psychoactive substances

Refer to Dissociative Drug.

Psychoactive drugs can often induce a state of temporary dissociation. Substances with dissociative properties include ketamine, nitrous oxide, alcohol, tiletamine, amphetamine, dextromethorphan, MK-801, PCP, methoxetamine, salvia, muscimol, atropine, ibogaine, and minocycline.

Correlations

Hypnosis and Suggestibility

There is evidence to suggest that dissociation is correlated with hypnotic suggestibility, specifically with dissociative symptoms related to trauma. However, the relationship between dissociation and hypnotic suggestibility appears to be complex and indicates further research is necessary.

Aspects of hypnosis include absorption, dissociation, suggestibility, and willingness to receive behavioural instruction from others. Both hypnotic suggestibility and dissociation tend to be less mindful, and hypnosis is used as a treatment modality for dissociation, anxiety, chronic pain, trauma, and more. Difference between hypnosis and dissociation: one is suggested, imposed by self or other, meaning dissociation is generally more spontaneous altering of awareness.

Mindfulness and Meditation

Mindfulness and meditation have shown an inverse relationship specifically with dissociation related to re-experiencing trauma due to the lack of present awareness inherent with dissociation. The re-experiencing episodes can include anything between illusions, distortions in perceived reality, and disconnectedness from the present moment. It is believed that the nature of dissociation as an avoidance coping or defence mechanism related to trauma inhibits resolution and integration.

Mindfulness and meditation also can alter the state of awareness to the present moment; however, unlike dissociation, it is clinically used to bring greater awareness to an individual’s present state of being. It achieves this through increased abilities to self-regulate attention, emotion, and physiological arousal, maintain continuity of consciousness, and adopt an approach to the present experience that is open and curious. In practice, non-judgmental awareness has displayed a positive relationship with lower symptoms of PTSD avoidance, which can relate to greater opportunities for success with exposure therapy and lowering PTSD symptoms of hypervigilance, re-experiencing, and overgeneralization of fears.

When using mindfulness and meditation with people expressing trauma symptoms, it is crucial to be aware of potential trauma triggers, such as the focus on the breath. Often, a meditation session will begin with focused attention and move into open monitoring. With severe trauma symptoms, it may be important to start the meditation training and an individual session at the peripheral awareness, such as the limbs. Moreover, trauma survivors often report feeling numb as a protection against trauma triggers and reminders, which are often painful, making it good practice to start all trainings at the limbs as a gradual exposure to body sensations. Doing so will also increase physical attachment to the present moment and the sense of grounding, thereby increasing tolerance to trauma reminders and decreasing the need and use of dissociation.

Treatment

When receiving treatment, patients are assessed to discover their level of functioning. Some patients might be higher functioning than others. This is taken into account when creating a patient’s potential treatment targets. To start off treatment, time is dedicated to increasing a patient’s mental level and adaptive actions in order to gain a balance in both their mental and behavioural action. Once this is achieved, the next goal is to work on removing or minimising the phobia made by traumatic memories, which is causing the patient to dissociate. The final step of treatment includes helping patients work through their grief in order to move forward and be able to engage in their own lives. This is done with the use of new coping skills attained through treatment. One coping skill that can improve dissociation is mindfulness due to the introduction of staying in present awareness while observing non-judgmentally and increasing the ability to regulate emotions. Specifically in adolescents, mindfulness has been shown to reduce dissociation after practicing mindfulness for three weeks.

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What is Reaction Formation?

Introduction

In psychoanalytic theory, reaction formation (German: Reaktionsbildung) is a defence mechanism in which emotions and impulses which are anxiety-producing or perceived to be unacceptable are mastered by exaggeration of the directly opposing tendency.

The reaction formations belong to Level 3 of neurotic defence mechanisms, which also include dissociation, displacement, intellectualisation, and repression.

Theory

Reaction formation depends on the hypothesis that:

“[t]he instincts and their derivatives may be arranged as pairs of opposites: life versus death, construction versus destruction, action versus passivity, dominance versus submission, and so forth. When one of the instincts produces anxiety by exerting pressure on the ego either directly or by way of the superego, the ego may try to sidetrack the offending impulse by concentrating upon its opposite. For example, if feelings of hate towards another person make one anxious, the ego can facilitate the flow of love to conceal the hostility.”

Where reaction-formation takes place, it is usually assumed that the original, rejected impulse does not vanish, but persists, unconscious, in its original infantile form. Thus, where love is experienced as a reaction formation against hate, we cannot say that love is substituted for hate, because the original aggressive feelings still exist underneath the affectionate exterior that merely masks the hate to hide it from awareness.

In a diagnostic setting, the existence of a reaction-formation rather than a ‘simple’ emotion would be suspected where exaggeration, compulsiveness and inflexibility were observed. For example:

“[r]eactive love protests too much; it is overdone, extravagant, showy, and affected. It is counterfeit, and […] is usually easily detected. Another feature of a reaction formation is its compulsiveness. A person who is defending himself against anxiety cannot deviate from expressing the opposite of what he really feels. His love, for instance, is not flexible. It cannot adapt itself to changing circumstances as genuine emotions do; rather it must be constantly on display as if any failure to exhibit it would cause the contrary feeling to come to the surface.

Reaction formation is sometimes described as one of the most difficult defences for lay people to understand; this testifies not merely to its effectiveness as a disguise, but also to its ubiquity and flexibility as a defence that can be utilised in many forms. For example:

“solicitude may be a reaction-formation against cruelty, cleanliness against coprophilia”,

and it is not unknown for an analyst to explain a client’s unconditional pacifism as a reaction formation against their sadism. In addition:

“[h]igh ideals of virtue and goodness may be reaction formations against primitive object cathexes rather than realistic values that are capable of being lived up to. Romantic notions of chastity and purity may mask crude sexual desires, altruism may hide selfishness, and piety may conceal sinfulness.”

Even more counter-intuitively, according to this model:

“[a] phobia is an example of a reaction formation. The person wants what he fears. He is not afraid of the object; he is afraid of the wish for the object. The reactive fear prevents the dreaded wish from being fulfilled.

The concept of reaction formation has been used to explain responses to external threats as well as internal anxieties. In the phenomenon described as Stockholm syndrome, a hostage or kidnap victim ‘falls in love’ with the feared and hated person who has complete power over them. Similarly, paradoxical reports exist of powerless and vulnerable inmates of Nazi camps creating ‘favourites’ among the guards and even collecting objects discarded by them. The mechanism of reaction formation is often characteristic of obsessional neuroses. When this mechanism is overused, especially during the formation of the ego, it can become a permanent character trait. This is often seen in those with obsessional character and obsessive personality disorders. This does not imply that its periodic usage is always obsessional, but that it can lead to obsessional behaviour.