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 Splitting (Psychology)?

Introduction

Splitting (also called black-and-white thinking or all-or-nothing thinking) is the failure in a person’s thinking to bring together the dichotomy of both positive and negative qualities of the self and others into a cohesive, realistic whole.

It is a common defence mechanism. The individual tends to think in extremes (i.e. an individual’s actions and motivations are all good or all bad with no middle ground).

Splitting was first described by Ronald Fairbairn in his formulation of object relations theory; it begins as the inability of the infant to combine the fulfilling aspects of the parents (the good object) and their unresponsive aspects (the unsatisfying object) into the same individuals, instead seeing the good and bad as separate. In psychoanalytic theory this functions as a defence mechanism.

Refer to Emotional Conflict and Psychological Projection.

Relationships

Splitting creates instability in relationships because one person can be viewed as either personified virtue or personified vice at different times, depending on whether they gratify the subject’s needs or frustrate them. This, along with similar oscillations in the experience and appraisal of the self, leads to chaotic and unstable relationship patterns, identity diffusion, and mood swings. The therapeutic process can be greatly impeded by these oscillations, because the therapist too can come to be seen as all good or all bad. To attempt to overcome the negative effects on treatment outcome, constant interpretations by the therapist are needed.

Splitting contributes to unstable relationships and intense emotional experiences. Splitting is common during adolescence, but is regarded as transient. Splitting has been noted especially with persons diagnosed with borderline personality disorder. Treatment strategies have been developed for individuals and groups based on dialectical behaviour therapy, and for couples. There are also self-help books on related topics such as mindfulness and emotional regulation that claim to be helpful for individuals who struggle with the consequences of splitting.

Borderline Personality Disorder

Refer to Borderline Personality Disorder.

Splitting is a relatively common defence mechanism for people with borderline personality disorder. One of the DSM IV-TR criteria for this disorder is a description of splitting: “a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation”. In psychoanalytic theory, people with borderline personality disorder are not able to integrate the good and bad images of both self and others, resulting in a bad representation which dominates the good representation.

Narcissistic Personality Disorder

Refer to Narcissistic Personality Disorder.

People matching the diagnostic criteria for narcissistic personality disorder also use splitting as a central defence mechanism. Most often narcissists do this as an attempt to stabilise their sense of self-positivity in order to preserve their self-esteem, by perceiving themselves as purely upright or admirable and others who do not conform to their will or values as purely wicked or contemptible.

The cognitive habit of splitting also implies the use of other related defence mechanisms, namely idealisation and devaluation, which are preventive attitudes or reactions to narcissistic rage and narcissistic injury.

Depression

In depression, exaggerated all-or-nothing thinking can form a self-reinforcing cycle: these thoughts might be called emotional amplifiers because, as they go around and around, they become more intense. Typical all-or-nothing thoughts:

  • My efforts are either a success or they are an abject failure.
  • Other people are either all good or all bad.
  • I am either all good or all bad.
  • If you’re not with us, you’re against us.

Janet, Bleuler and Freud

Refer to Pierre Janet, Eugen Bleuler, and Sigmund Freud.

Splitting of consciousness (“normal self” vs. “secondary self”) was first described by Pierre Janet in De l’automatisme psychologique (1889). His ideas were extended by Bleuler (who in 1908 coined the word schizofrenia from the Ancient Greek skhízō [σχῐ́ζω, “to split”] and phrḗn [φρήν, “mind”]) and Freud to explain the splitting (German: Spaltung) of consciousness – not (with Janet) as the product of innate weakness, but as the result of inner conflict. With the development of the idea of repression, splitting moved to the background of Freud’s thought for some years, being largely reserved for cases of double personality. However, his late work saw a renewed interest in how it was “possible for the ego to avoid a rupture… by effecting a cleavage or division of itself”, a theme which was extended in his Outline of Psycho-Analysis (1940a [1938]) beyond fetishism to the neurotic in general.

His daughter Anna Freud explored how, in healthy childhood development, a splitting of loving and aggressive instincts could be avoided.

Melanie Klein

Refer to Melanie Klein.

There was, however, from early on, another use of the term “splitting” in Freud, referring rather to resolving ambivalence “by splitting the contradictory feelings so that one person is only loved, another one only hated … the good mother and the wicked stepmother in fairy tales”. Or, with opposing feelings of love and hate, perhaps “the two opposites should have been split apart and one of them, usually the hatred, has been repressed”. Such splitting was closely linked to the defence of “isolation … The division of objects into congenial and uncongenial ones … making ‘disconnections’.”

It was the latter sense of the term that was predominantly adopted and exploited by Melanie Klein. After Freud, “the most important contribution has come from Melanie Klein, whose work enlightens the idea of ‘splitting of the object’ (Objektspaltung) (in terms of ‘good/bad’ objects)”. In her object relations theory, Klein argues that “the earliest experiences of the infant are split between wholly good ones with ‘good’ objects and wholly bad experiences with ‘bad’ objects”, as children struggle to integrate the two primary drives, love and hate, into constructive social interaction. An important step in childhood development is the gradual depolarization of these two drives.

At what Klein called the paranoid-schizoid position, there is a stark separation of the things the child loves (good, gratifying objects) and the things the child hates (bad, frustrating objects), “because everything is polarised into extremes of love and hate, just like what the baby seems to experience and young children are still very close to.” Klein refers to the good breast and the bad breast as split mental entities, resulting from the way “these primitive states tend to deconstruct objects into ‘good’ and ‘bad’ bits (called ‘part-objects’)”. The child sees the breasts as opposite in nature at different times, although they actually are the same, belonging to the same mother. As the child learns that people and objects can be good and bad at the same time, he or she progresses to the next phase, the depressive position, which “entails a steady, though painful, approximation towards the reality of oneself and others”: integrating the splits and “being able to balance [them] out … are tasks that continue into early childhood and indeed are never completely finished.”

However, Kleinians also utilize Freud’s first conception of splitting, to explain the way “In a related process of splitting, the person divides his own self. This is called ‘splitting of the ego’.” Indeed, Klein herself maintained that “the ego is incapable of splitting the object—internal or external—without a corresponding splitting taking place within the ego”. Arguably at least, by this point “the idea of splitting does not carry the same meaning for Freud and for Klein”: for the former, “the ego finds itself ‘passively’ split, as it were. For Klein and the post-Kleinians, on the other hand, splitting is an ‘active’ defence mechanism”. As a result, by the close of the century “four kinds of splitting can be clearly identified, among many other possibilities” for post-Kleinians: “a coherent split in the object, a coherent split in the ego, a fragmentation of the object, and a fragmentation of the ego.”

Otto Kernberg

Refer to Otto Kernberg.

In the developmental model of Otto Kernberg, the overcoming of splitting is also an important developmental task. The child has to learn to integrate feelings of love and hate. Kernberg distinguishes three different stages in the development of a child with respect to splitting:

  • The child does not experience the self and the object, nor the good and the bad as different entities.
  • Good and bad are viewed as different. Because the boundaries between the self and the other are not stable yet, the other as a person is viewed as either all good or all bad, depending on their actions. This also means that thinking about another person as bad implies that the self is bad as well, so it’s better to think about the caregiver as a good person, so the self is viewed as good too. “Bringing together extremely opposite loving and hateful images of the self and of significant others would trigger unbearable anxiety and guilt.”
  • Splitting – “the division of external objects into ‘all good’ or ‘all bad'” – begins to be resolved when the self and the other can be seen as possessing both good and bad qualities. Having hateful thoughts about the other does not mean that the self is all hateful and does not mean that the other person is all hateful either.

If a person fails to accomplish this developmental task satisfactorily, borderline pathology can emerge. “In the borderline personality organization”, Kernberg found ‘dissociated ego states that result from the use of “splitting” defences’. His therapeutic work then aimed at “the analysis of the repeated and oscillating projections of unwanted self and object representations onto the therapist” so as to produce “something more durable, complex and encompassing than the initial, split-off and polarized state of affairs”.

Horizontal and Vertical

Heinz Kohut has emphasized in his self psychology the distinction between horizontal and vertical forms of splitting. Traditional psychoanalysis saw repression as forming a horizontal barrier between different levels of the mind – so that for example an unpleasant truth might be accepted superficially but denied in a deeper part of the psyche. Kohut contrasted with this vertical fractures of the mind into two parts with incompatible attitudes separated by mutual disavowal.

Transference

Refer to Transference.

It has been suggested that interpretation of the transference “becomes effective through a sort of splitting of the ego into a reasonable, judging portion and an experiencing portion, the former recognizing the latter as not appropriate in the present and as coming from the past”. Clearly, “in this sense, splitting, so far from being a pathological phenomenon, is a manifestation of self-awareness”. Nevertheless, “it remains to be investigated how this desirable ‘splitting of the ego’ and ‘self-observation’ are to be differentiated from the pathological cleavage … directed at preserving isolations”.