Dissociation and the Dissociative Disorders: Past, Present, Future [2 ed.] 0367522799, 9780367522797

Citation preview

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An excellent successor to the 2009 standard work edited by Dell and O’Neil, this book is again the most complete and up-​to-​d ate source of the burgeoning theory, research and clinical practice of dissociation and the dissociative disorders. Diverging perspectives on the construct of dissociation collected together in one volume provide both an invitation for reflection and a foundation to stimulate further development in theory and clinical practice. With valuable contributions from leaders in the field, it is an absolute must for clinicians, researchers, and students interested in trauma and dissociation. Suzette Boon, PhD, co-​author of Coping with Trauma-​related Dissociation and Treatment of Trauma-​related Dissociation and author of Assessment of Trauma-​related Dissociation Leading voices in the trauma field, Drs. Dorahy, Gold, and O’Neil have created a wonderful and extremely comprehensive review of dissociation and dissociative disorders for clinicians and researchers. This updated and expanded 2nd edition consists of 49 chapters, all written by noted authorities, covering historical and conceptual issues, etiology, phenomenology, neurobiology, assessment, and multiple approaches to treatment. Notably, it unflinchingly articulates the major controversies and unresolved issues in the dissociation field and provides evenhanded synthesis and context whenever possible. Currently the most comprehensive and definitive work in the field, this book is a must-​have for anyone studying or treating dissociation. Highly recommended. John Briere, PhD, Professor Emeritus of Psychiatry & the Behavioral Sciences Keck -​ University of Southern California School of Medicine. Author of Treating risky and compulsive behavior in trauma survivors NY: Guilford, 2019 Dorahy, Gold and O’Neil have mastered the art of “herding cats” in editing an extraordinarily diverse and deeply incisive collection of erudite and wise explorations of dissociative processes, those ubiquitous discontinuities, detachments, compartmentalizations, and disruptions of human relatedness, mental coherence, subjective sense of self, and neurobiological processes that skew experience as if they had a mind of their own. It’s not just an exploration of depersonalization, derealization, amnesia, identity confusion and identity alteration. Rather, it is a deep ​d ive into what makes this dissociative world of what is strangely familiar go round and round, and then some. This is a must-read volume that will both challenge and entertain you as a fellow explorer in the land of that which is dissociative. There is something for everyone here, and nearly everything a serious clinician might want to understand as we try to help the people who struggle with complex phenomena and experiences that hide in plain sight. Get it, read it, and ponder it. You will be enriched by your efforts and those of the authors and editors who have poured their hearts into this extraordinary work. Richard A. Chefetz, M.D., Private Practice, Washington, D.C., Institute of Contemporary Psychotherapy & Psychoanalysis; Authors of Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. New York: W.W. Norton, 2015 This revision of Dissociation and the Dissociative Disorders closely follows the tradition set by the original. The editors have done a masterful job producing an updated volume primarily devoted to the conceptual/​theoretical advances about dissociation and its various expressions and disorders, written by identified experts in the field. The editors note that, at present, the understanding of the underlying principle of dissociation remains unclear and subject to debate among the chapter authors, some of whom hold very discrepant and even incompatible viewpoints. However, it is their hope and the promise of this book that the viewpoints they espouse and the advances they present consolidate in the future to ascertain that elusive underlying principle that may well be multi-​factorial and multi-​theoretical. Christine A. Courtois, PhD, ABPP, author, Healing the Incest Wound: Adult Survivors in Therapy (1988; 2010), co-​author, Treating Complex Traumatic Stress Disorders (2013), co-​editor, The Treatment of Complex Traumatic Stress Disorders (2012; 2020) This second edition is an edifying contribution to the field of psychology of trauma and dissociation that has now been updated. The strength of the book lies in its rich tapestry of chapters written by world experts echoing polyvocal ideas from divergent perspectives, using empirical evidence and theoretical developments. The multiple perspectives, whilst all connected, each carry their own distinct voice. Growth is stifled whenever absolutes are made and this book outlines the complexity and comprehensibility of dissociation as examined from different vantage points. The book is inspiring to teachers and students alike and is most welcome to practitioners of all psychological disciplines. Orit Badouk Epstein, Attachment based Psychoanalytic Psychotherapist, Editor and Writer, John Bowlby Centre, London

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DISSOCIATION AND THE DISSOCIATIVE DISORDERS

This second edition of the award-​w inning original text brings together in one volume the current thinking and conceptualizations on dissociation and the dissociative disorders. Comprised of ten parts, starting with historical and conceptual issues, and ending with considerations for the present and future, internationally renowned authors in the trauma and dissociation fields explore different facets of dissociation in pathological and non-​clinical guises. This book is designed to be the most comprehensive reference book in the dissociation field and aims to provide a scholarly foundation for understanding dissociation, dissociative disorders, current issues and perspectives within the field, theoretical formulations, and empirical findings. Chapters have been thoroughly updated to include recent developments in the field, including: the complex nature of conceptualization, etiology, and neurobiology; the various manifestations of dissociation in clinical and non-​clinical forms; and different perspectives on how dissociation should be understood. This book is essential for clinicians, researchers, theoreticians, students of clinical psychology psychiatry, and psychotherapy, and those with an interest or curiosity in dissociation in the various ways it can be conceived and studied. Martin J. Dorahy, PhD, is Professor of Clinical Psychology at the University of Canterbury, Christchurch, New Zealand, and a past president of the International Society for the Study of Trauma and Dissociation (ISSTD). Steven N. Gold, PhD, is Professor Emeritus of Psychology at Nova Southeastern University; a past president and fellow of the ISSTD and APA Division of Trauma Psychology; and a founding editor of the APA journal, Psychological Trauma. John A. O’Neil, MD, FRCPC, is a psychiatrist and psychoanalyst in Montreal, Québec, Canada, and a fellow of the ISSTD. He co-edited, with Paul Dell, the first edition of this book.

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DISSOCIATION AND THE DISSOCIATIVE DISORDERS Past, Present, Future

Second Edition Edited by Martin J. Dorahy, Steven N. Gold and John A. O’Neil

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Cover image: © Getty Images Second edition published 2023 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 selection and editorial matter, Martin J. Dorahy, Steven N. Gold, and John A. O’Neil; individual chapters, the contributors. The right of Martin J. Dorahy, Steven N. Gold, and John A. O’Neil to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2009 Library of Congress Cataloging-​in-​P ublication Data Names: Dorahy, Martin J., 1971– editor. | Gold, Steven N., editor. | O’Neil, John A., editor. Title: Dissociation and the dissociative disorders : past, present, future / edited by Martin J. Dorahy, Steven N. Gold, and John A. O’Neil. Description: Second edition. | New York, NY : Routledge, 2023. | Revised edition of: Dissociation and the dissociative disorders : DSM-V and beyond / edited by Paul F. Dell, John A. O’Neil. c2009. | Includes bibliographical references and index. | Identifiers: LCCN 2022009632 (print) | LCCN 2022009633 (ebook) | ISBN 9780367522797 (hbk) | ISBN 9780367522780 (pbk) | ISBN 9781003057314 (ebk) Subjects: LCSH: Dissociative disorders. | MESH: Dissociative Disorders. Classification: LCC RC553.D5 D54 2023 (print) | LCC RC553.D5 (ebook) | DDC 616.85/23–dc23/eng/20220330 LC record available at https://lccn.loc.gov/2022009632 LC ebook record available at https://lccn.loc.gov/2022009633 ISBN: 9780367522797 (hbk) ISBN: 9780367522780 (pbk) ISBN: 9781003057314 (ebk) DOI: 10.4324/​9781003057314 Typeset in Bembo by Newgen Publishing UK Access the Support Material: www.routle​d ge.com/​978036​7522​780

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This book is dedicated to Philip Bromberg, Giovanni Liotti, Susie Farrelly and other great departed explorers of the dissociative mind. They have left powerful maps to help us traverse and further explore confusing territory

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CONTENTS

List of Contributors  Preface  Acknowledgments  Introduction  Martin J. Dorahy and Steven N. Gold

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PART 1

Historical and Conceptual Issues 

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1 History of the Concept of Dissociation  Onno van der Hart and Martin J. Dorahy

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2 The Conceptual Unity of Dissociation: A Philosophical Argument  Stephen E. Braude

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3 The Traumatic Disintegration Dimension  Benedetto Farina and Russell Meares

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4 Dissociation Versus Alterations in Consciousness: Related but Different Concepts  Kathy Steele, Martin J. Dorahy, and Onno van der Hart

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5 The Case for the Study of “Normal” Dissociation Processes  Constance J. Dalenberg, Rachel R. Katz, Kenneth J. Thompson, and Kelsey Paulson

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6 Dissociation and Resilience  Paula Thomson

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7 Adaptive Dissociation: A Response to Interpersonal, Institutional, and Cultural Betrayal  Alexis A. Adams-​Clark, Jennifer M. Gómez, and M. Rose Barlow

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8 Dissociative Multiplicity and Psychoanalysis  John A. O’Neil

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PART 2

Etiological and Developmental Considerations 

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9 A Developmental Pathways Model of Dissociation  Linnea B. Linde-​Krieger, Tuppett M. Yates, and Elizabeth A. Carlson

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10 The Relationship Between Attachment and Dissociation: Theory, Research, and Clinical Implications  Adriano Schimmenti

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11 Attachment Trauma and the Developing Right Brain: Origins of Pathological Dissociation and Some Implications for Psychotherapy  Allan N. Schore

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12 Adverse Childhood Experiences and Dissociative Disorders: A Causal Pathway Based on the Disruptive Impacts of Cumulative Childhood Adversity and Distress-​Related Dissociation  Michael A. Quiñones

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13 Beyond Death: Enduring Incest: The Fusion of Father with Daughter  Warwick Middleton

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14 Clarifying the Etiology of the Dissociative Disorders: It’s Not All About Trauma  Paul F. Dell

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PART 3

Theoretical Approaches 

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15 The Theory of Trauma-​related Structural Dissociation of the Personality  Onno van der Hart and Kathy Steele

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16 Discrete Behavioral States Theory  Richard J. Loewenstein and Frank W. Putnam

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17 The Perceptual Theory of Dissociation  Donald B. Beere

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18 Contextual Dissociation Theory: The Dual Impact of Trauma and Developmental Deprivation  Steven N. Gold

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19 The Four-​Dimensional (4-​D) Model as a Framework for Understanding Trauma-​Related Dissociation  Paul Frewen, Serena Wong, and Ruth A. Lanius

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20 Dissociation and Unformulated Experience: A Psychoanalytic Model of Mind  Donnel B. Stern

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PART 4

The Dissociative Disorders 

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21 Dissociation in the ICDs and DSMs  John A. O’Neil

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22 Dissociative Amnesia and Dissociative Fugue  Colin A. Ross

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23 Depersonalization/​Derealization Disorder  Matthias Michal

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24 A Grounded Theory of Dissociative Identity Disorder: Placing DID in Mind, Brain, and Body  Lauren A. M. Lebois, Chloe S. Kaplan, Cori A. Palermo, Xi Pan, and Milissa L. Kaufman

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25 Psychotic Presentations of Dissociative Disorders  Vedat Şar

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26 The Other in the Self: Possession, Trance, and Related Phenomena  Etzel Cardeña, Yvonne Schaffler, and Marjolein van Duijl

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27 Dissociative Disorders in Children and Adolescents  Joyanna Silberg and Stephanie Dallam

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PART 5

Dissociation as a Transdiagnostic Process: Acute and Chronic  2 8 Peritraumatic Dissociation and Chronic Posttraumatic Symptomatology: Thirty Years and Counting  Etzel Cardeña and Catherine C. Classen

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29 Dissociation and Trauma: Clinical and Research Intersections in PTSD  Olga Winkler, Lisa Burback, Suzette Brémault-​Phillips, and Eric Vermetten

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30 Complex PTSD and Emotion Dysregulation: The Role of Dissociation  Julian D. Ford

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31 Is Dissociation an Integral Aspect of Borderline Personality Disorder, Or Is It a Comorbid Disorder?  Marilyn I. Korzekwa and Paul F. Dell

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32 The Nature of Psychotic Symptoms: Traumatic in Origin and Dissociative in Kind?  Andrew Moskowitz, Eleanor Longden, Filippo Varese, Dolores Mosquera, and John Read

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33 Somatoform Dissociation, Agency, and Consciousness  Ellert R. S. Nijenhuis

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34 Maladaptive Daydreaming is a Dissociative Disorder: Supporting Evidence and Theory  Nirit Soffer-​Dudek and Eli Somer

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35 Opioid Misuse and Dissociation: Two Powerful Modes of Distress Regulation  Eli Somer

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36 Dissociative Factors Contributing to Violence and Antisocial Orientations  Richard A. Hohfeler

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PART 6

Neurobiological and Cognitive Understandings of Dissociation 

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37 The Defense Cascade, Traumatic Dissociation and the Self: A Neuroscientific Model  Frank M. Corrigan, Ulrich F. Lanius and Brenna Kaschor

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38 Towards an Ecology of Dissociation in the Context of Trauma: Implications for the Psychobiological Study of Dissociative Disorders  Ellert R. S. Nijenhuis 39 The Neurobiology of Dissociation in Chronic PTSD  Francesca L. Schiavone and Ruth A. Lanius 40 Subjective Amnesia in Dissociative Identity Disorder: A Dual Path Model Drawing on Metacognitive Beliefs Related to Self and Memory Functioning  Martin J. Dorahy

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PART 7

Assessment and Measurement 

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41 Diagnosing the Dissociative Disorders: Conceptual, Theoretical, and Practical Considerations  661 D. Michael Coy and Jennifer A. Madere 42 True Drama or True Trauma? Forensic Trauma Assessment and the Challenge of Detecting Malingering  Bethany L. Brand and Laura S. Brown

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PART 8

Treatment Considerations and Conceptualizations 

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43 Encountering the Singularities of Multiplicity: Meeting and Treating the Unique Person  Richard P. Kluft

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44 Controversies in the Treatment of Traumatic Dissociation: The Phased Model, ‘Exposure,’ and the Challenges of Therapy for Complex Trauma  Pam Stavropoulos and David Elliott

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45 The Unconscionable in the Unconscious: The Evolution of Relationality in the Conceptualization of the Treatment of Trauma and Dissociation  Elizabeth F. Howell and Sheldon Itzkowitz

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PART 9 

Treatment Challenges and Therapist Considerations 

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46 Memory, Trauma and the Therapeutic Encounter  Sylvia Solinski

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47 Conceptual Foundations for Long-​Term Psychotherapy of Dissociative Identity Disorder  Richard J. Loewenstein

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PART 10

The Future 

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48 A Research Agenda for the Dissociative Disorders Field  Vedat Şar and Colin A. Ross

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49 Integrating Dissociation  David Spiegel

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Index

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CONTRIBUTORS

Alexis A. Adams-​Clark, MS is a Clinical Psychology Doctoral Candidate at the University of Oregon and a Research

Associate at the Center for Institutional Courage. Her research focuses on sexual violence and traumatic stress. M. Rose Barlow, PhD has been researching dissociation for two decades. She is currently at the National Center for

PTSD, VA Palo Alto Health Care System, California, USA. Other research interests include integration and switching, attachment, emotion regulation, and survey development. Donald B. Beere, PhD, ABPP is a retired psychologist. He served on the Board of Directors of ISSTD and was a Certified

Therapist and Consultant in EMDR. He was a professor for 29 years at Central Michigan University, was Director of Clinical Training and had a clinical practice for 43 years. Bethany L. Brand, PhD is a Professor of Psychology at Towson University in Baltimore, Maryland, USA. Dr. Brand has

published over 100 professional papers related to trauma including methods for distinguishing clinical vs. malingered dissociative disorders, and a series called the Treatment of Patients with Dissociative Disorders (TOP DD) studies. Stephen E. Braude, PhD is Emeritus Professor and former Chair of Philosophy at the University of Maryland Baltimore

County. He’s the author of six books, including First Person Plural as well as other works on dissociation. Suzette Brémault-​Phillips, PhD is an occupational therapist and associate professor, Faculty of Rehabilitation Medicine,

University of Alberta, and director, Heroes in Mind Advocacy and Research Consortium (HiMARC). An experienced clinician-​scientist, she has been sought out for her subject matter expertise in resilience, moral injury, spirituality, and PTSD. Laura S. Brown, PhD ABPP is a semi-​retired psychologist in Seattle WA. She was President of the APA Division of

Trauma Psychology, and serves on the editorial board of the Journal of Trauma and Dissociation. She supervises and does forensic assessments, and holds a second degree black belt in Aikido. Lisa Burback, MD is a Psychiatrist and Associate Clinical Professor of Psychiatry at the University of Alberta, Edmonton,

Alberta, Canada. She is also an EMDRIA Approved Consultant in EMDR, with clinical work and research interests focused on trauma therapy in complex populations and those with suicidal ideation. Etzel Cardeña, PhD holds the Thorsen Chair in psychology at Lund University. His areas of research include dissoci-

ation and acute posttraumatic reactions, anomalous experiences, and the neurophenomenology of hypnosis. He has more than 400 publications and is the founding editor of the Journal of Anomalous Experience and Cognition.

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List of Contributors  xv

Elizabeth A. Carlson, PhD is a Senior Research Associate and Director of the Harris Training Institute at the Institute of

Child Development, University of Minnesota, Minneapolis, Minnesota, USA. She is a co-​author of the award-​w inning book, The Development of the Person: The Minnesota Longitudinal Study of Risk and Adaptation. Catherine C. Classen, PhD is a clinical psychologist and Adjunct Professor of Psychiatry at the University of Toronto,

Toronto, Ontario, Canada and past president of the International Society for the Study of Trauma and Dissociation. She is in private practice. Frank M. Corrigan, MD, FRCPsych is a psychiatrist in private practice in Scotland. He is a trainer in Deep Brain

Reorienting, a therapy for attachment wounding and other traumatic experiences. He was a co-​author of the book The Neurobiology and Treatment of Traumatic Dissociation: Toward an Embodied Self. D. Michael Coy, MA, LICSW, EMDRIA AC/​AT presents and writes on the assessment and treatment of dissociation. He

collaborates with Jennifer Madere and Paul F. Dell to manage materials associated with the Multidimensional Inventory of Dissociation, is Fellow and current Treasurer of ISSTD and is in private practice in Bremerton, Washington, USA. Constance J. Dalenberg, PhD is Distinguished Professor of psychology at Alliant International University and Director

of the Trauma Research Institute. She is past president of APA Division 56 (Trauma Psychology) and recipient of multiple awards, including from the International Society for the Study of Trauma and Dissociation and Division 56. Stephanie Dallam, PhD, is a visiting scholar at Child USA, Pennsylvania PA, and former lead researcher at the Leadership

Council on Child Abuse and Interpersonal Violence. Paul F. Dell, PhD, is former Professor of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk,

Virginia, USA; recipient of ISSTD’s Lifetime Achievement Award; and two-​time recipient of the Society of Clinical and Experimental Hypnosis’s Ernest and Josephine Hilgard Award for best theoretical paper of the year about hypnosis.

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Martin J. Dorahy, PhD is Professor of clinical psychology at the University of Canterbury, Christchurch, New Zealand,

and past president and fellow of the International Society for the Study of Trauma and Dissociation (ISSTD). David Elliott, PhD is a former President of the Rhode Island Psychological Association (USA), and is Chair of the

Advisory Board of the International School for Psychotherapy, Counseling, and Group Leadership, in St. Petersburg, Russia. He is co-​author of Attachment Disturbances in Adults: Treatment for Comprehensive Repair. Benedetto Farina, MD, PhD is a psychiatrist, psychotherapist, neuroscientist, and Professor of Psychopathology and

Clinical Psychology at European University of Rome, Italy. He is a Member of the Scientific Advisory Board of the International Society for the Study of Trauma and Dissociation and the Editorial Board of the Journal of Trauma and Dissociation. Julian D. Ford, PhD, ABPP is Professor of Psychiatry and Law at the University of Connecticut, Director of the Center

for the Treatment of Developmental Trauma Disorders and the Center for Trauma Recovery and Juvenile Justice, and past President of the International Society for Traumatic Stress Studies. Paul Frewen, PhD, is a practicing clinical psychologist and associate professor of psychiatry at Western University,

Canada. He is the former chair of the trauma psychology division of the Canadian Psychological Association. He has published over 100 peer-​reviewed articles on trauma psychology, dissociative experiences, and sense of self. Steven N. Gold, PhD is a psychologist; professor emeritus and founding director, Trauma Resolution and Integration

Program (TRIP), Nova Southeastern University; past president and fellow of the ISSTD and APA Division of Trauma Psychology; founding editor, APA journal Psychological Trauma; author, Not Trauma Alone and Contextual Trauma Therapy; and Editor-​in-​Chief, APA Handbook of Trauma Psychology.

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xvi  List of Contributors

Jennifer M. Gómez, PhD is an Assistant Professor at Wayne State University, a 2021-​22 Fellow at the Center for

Advanced Study in the Behavioral Sciences (CASBS) at Stanford University, and a Board Member and Chair of the Research Advisory Committee at the Center for Institutional Courage. Richard A. Hohfeler, PsyD is a clinical psychologist in private practice in the Milwaukee, Wisconsin area specializing

in trauma and dissociation, and recently retired from a psychologist position at a local state prison. He has served on the ISSTD Board of Directors for two terms. Elizabeth F. Howell, PhD has written and/​or coedited five books and over 40 articles on trauma and dissociation; is

faculty, NYU Postdoctoral Program in Psychotherapy and Psychoanalysis and Manhattan Institute of Psychoanalysis; and on the Journal of Trauma and Dissociation editorial board. She conducts psychotherapy, consultations, consultation/​ reading groups in New York City. Sheldon Itzkowitz, PhD is an adjunct clinical associate professor of psychology and clinical consultant at the NYU

Postdoctoral Program, faculty member and clinical consultant at Manhattan Institute for Psychoanalysis and a Fellow and member of the Board of Directors of the International Society for the Study of Trauma & Dissociation. Chloe S. Kaplan, BA graduated from Williams College and Oxford University with highest honors in Psychology,

and works as a Clinical Research Assistant in the Dissociative Disorders and Trauma Research Program (DDTRP) at McLean Hospital. The clinical research studies she works on investigate the phenomenology and neurobiology of trauma-​related dissociation. Brenna Kaschor, MD, PhD, CCFP is a practicing Family Physician, an Adjunct Research Professor of Family Medicine

at the Schulich School of Medicine, Western University, London, Ontario, Canada, the founder and director of G.R.O.W.: Grounded Roots, Open Wings, and the Hospitalist/​Addiction Medicine Consultant at London Health Sciences Center, London, ON.

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Rachel R. Katz, MA is a Research Associate at the Trauma Research Institute and a doctoral student at Alliant

International University, San Diego, CA. Milissa L. Kaufman, MD, PhD, is Assistant Professor of Psychiatry at Harvard Medical School, Boston, Massachusetts,

USA and Director, Initiative for Integrated Trauma Research, Care and Training, Medical Director, Hill Center for Women, and Medical Director, Outpatient Trauma Clinic, McLean Hospital, Belmont, Massachusetts, USA. Richard P. Kluft, MD, PhD is Clinical Professor of Psychiatry at Temple University School of Medicine, and teaches at

the Psychoanalytic Center of Philadelphia and the China American Psychoanalytic Alliance. The author of over 270 professional papers and several books, he is also a novelist. Marilyn I. Korzekwa, BA, MD, FRCPC is an associate professor (part-​time) of psychiatry at McMaster University in

Hamilton, Ontario, Canada. She is a fellow and recipient of the Distinguished Achievement Award of the ISSTD. She has written numerous articles about Borderline Personality Disorder (BPD) and dissociation in BPD. Ruth A. Lanius, MD, PhD is a Psychiatry Professor at Western University of Canada, where she is the director of the

Clinical Research Program for PTSD. Ruth is a passionate clinician scientist who endeavours to understand the first-​ person experience of traumatized individuals throughout treatment and how it relates to brain functioning. Ulrich F. Lanius, PhD practices Clinical and Neuropsychology in Vancouver, BC. He is Fellow of the international

Society for the Study of Trauma and Dissociation, and has authored book chapters and articles on traumatic stress, including the book The Neurobiology and Treatment of Traumatic Dissociation: Toward an Embodied Self. Lauren A. M. Lebois, PhD is an Assistant Professor in Psychiatry at Harvard Medical School, and co-​d irects the

Dissociative Disorders and Trauma Research Program at McLean Hospital, Belmont, MA, USA. Dr. Lebois is a cognitive neuroscientist whose research program focuses on the neurobiology of dissociation in trauma-​spectrum disorders.

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List of Contributors  xvii

Linnea B. Linde-​Krieger, PhD, LCSW is a postdoctoral research fellow with the University of Arizona Department

of Family and Community Medicine. As a developmental psychologist and clinical social worker, Linnea’s research examines family-​level risk and protective factors, the impact of trauma on development, parent-​child attachment processes, and prevention and intervention programing. Richard J. Loewenstein, MD is Clinical Professor of Psychiatry, University of Maryland, Baltimore, MD. From 1987-​

2020 he was Founder and Medical Director of the Trauma Disorders Program at Sheppard Pratt. He is Section Editor, Dissociative Disorders, DSM-​5 Text Revision, and co-​editor of the 4th revision of the ISSTD adult treatment Guidelines for Dissociative Identity Disorder. Eleanor Longden, PhD is co-​ d irector of the Complex Trauma and Resilience Research Unit, and Service-​User

Research Manager of the Psychosis Research Unit, of the Greater Manchester (UK) Mental Health NHS Foundation Trust. She is also an honorary research fellow at the University of Manchester. Jennifer A. Madere, MA, LPC-​S, EMDRIA AC/​AT practices in Cedar Park, Texas, USA. She has presented and written

on the assessment and treatment of dissociation since 2014, and collaborates with D. Michael Coy and Paul F. Dell to update and maintain documents associated with the Multidimensional Inventory of Dissociation (MID). Russell Meares, MBBS, MD, FRCPsych, FRANZP is Emeritus Professor of Psychiatry at Sydney University, NSW,

Australia. He was foundation president of the Australian and New Zealand Association of Psychotherapy. His books include Intimacy and Alienation (2000), The Metaphor of Play (2005), and A Dissociation Model of Borderline Personality Disorder (2012). Matthias Michal, MD is Associate Professor, Department of Psychosomatic Medicine and Psychotherapy, University

Medical Center of the Johannes Gutenberg-​University Mainz, Mainz, Germany. He is a psychodynamic psychotherapist and senior consultant, with special research interests in the field of depersonalization and psychocardiology.

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Warwick Middleton, MB BS, FRANZCP, MD is Professor, School of Medicine, University of Queensland, past president

of the International Society for the Study of Trauma and Dissociation, Chair of the Cannan Institute and Director of the Trauma and Dissociation Unit, Belmont Hospital, Brisbane. He is in full-​t ime private practice. Andrew Moskowitz, PhD is Professor of Psychology at George Washington University and past president of the

European Society for Trauma and Dissociation. He has published broadly in the area of dissociation and psychosis, including, being lead editor of the influential book, Psychosis, Trauma and Dissociation (Wiley, 2008, 2019). Dolores Mosquera, MSc, psychologist, is director of the Institute for the Study of Trauma and Personality Disorders in

A Coruña, Spain. She has published many books and articles on personality disorders, trauma, and dissociation, and was given the David Servan-​Schreiber award in 2017 for outstanding contributions to the EMDR field. Ellert R. S. Nijenhuis, PhD is a Dutch psychologist, psychotherapist, and researcher. He engaged in the diagnosis and

treatment of severely traumatized patients for more than three decades, and teaches and writes extensively on the themes of trauma-​related dissociation and dissociative disorders. John A. O’Neil, MD, FRCPC is a psychiatrist and psychoanalyst in private practice, subspecialized in the diagnosis

and treatment of dissociative disorders; former Assistant Professor of Psychiatry, McGill University; ISSTD Fellow and teacher in its Psychotherapy Training Program; and recipient of ISSTD’s Pierre Janet Writing Award and its Lifetime Achievement Award. Cori A. Palermo, MA is Lab Manager for the Dissociative Disorders and Trauma Research Program at McLean Hospital.

She received her MA in Clinical Psychology from Towson University, and her BS in Psychology from Sacred Heart University. She examines the neurobiology of trauma-​related dissociation to help individuals impacted by childhood trauma.

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xviii  List of Contributors

Xi Pan, LICSW, MPA is a Senior Clinical Research Assistant, Dissociative Disorders and Trauma Research Program,

McLean Hospital, Belmont, MA, USA. Kelsey Paulson, PhD is in private practice in San Diego, CA, specializing in the treatment of trauma disorders. Frank W. Putnam, MD is Professor of Psychiatry at the University of North Carolina, Chapel Hill. Previously he was

Professor of Pediatrics at Cincinnati Children’s Hospital. His most recent research established the biological mechanisms underlying accelerated puberty, increased morbid obesity and advanced epigenetic aging in sexually abused females. Michael A. Quiñones, PhD is in clinical and forensic psychology practice in Fort Lauderdale, Florida, specializing in

trauma and dissociation. He has published on Adverse Childhood Experiences as related to trauma, dissociation, and criminal behavior, and is co-​authoring a book on employing hypnosis and other altered states in trauma treatment. John Read, PhD is Professor of Clinical Psychology at the University of East London and chair of the International

Institute for Psychiatric Drug Withdrawal. He is editor of the scientific journal Psychosis and book Models of Madness (Routledge, 2004, 2013), and on the Board of the Hearing Voices Network, England. Colin A. Ross, MD is a Past President of the International Society for the Study of Trauma and Dissociation. He is the

author of 35 books and 250 peer-​reviewed papers and directs inpatient and partial hospitalization programs in Texas that are focused on trauma and dissociation. Vedat Şar, MD is Professor and Chair of Psychiatry at the Koç University School of Medicine, Istanbul, Turkey and past

president of the International Society for the Study of Trauma and Dissociation and European Society for Traumatic Stress Studies. He is recipient of numerous awards for his studies on complex trauma and dissociative disorders. Yvonne Schaffler, PhD, is a research associate at the Department of Psychotherapy and Biopsychosocial Health,

University of Continuing Education Krems, Austria. She has been working on dissociative aspects of spirit possession as part of a research grant, funded by the Austrian Science Fund (T525-​G17), at the Medical University of Vienna. Francesca L. Schiavone, MD, FRCPC is a Lecturer in the Department of Psychiatry at the University of Toronto,

Toronto, Ontario, Canada, and a staff psychiatrist at the Centre for Addiction and Mental Health, where she works in the Borderline Personality Disorder Clinic and in the Women’s Trauma Program. Adriano Schimmenti, PhD, DClinPsy is Full Professor of Psychopathology at UKE -​Kore University of Enna, Italy. He

is also the Scientific Director of the IIPP -​Italian Institute of Psychoanalytic Psychotherapy. Allan N. Schore, PhD is on the clinical faculty at UCLA School of Medicine. He is author of eight seminal volumes, as

well as numerous peer reviewed articles and chapters. He has practiced psychotherapy for over four decades, and been recently inducted into Sigma Xi, The Scientific Research Honor Society. Joyanna Silberg, PhD was past president of the International Society for the Study of Trauma and Dissociation, is the

President of the Leadership Council on Child Abuse & Interpersonal Violence and served as Senior Psychologist and Coordinator of Trauma Services for Children and Adolescents at the Sheppard Pratt Health System. Nirit Soffer-​Dudek, PhD is a clinical psychologist and senior lecturer at the Department of Psychology at Ben-​Gurion

University of the Negev, Israel. She currently serves as head of the clinical track at her department and as the scientific director of the International Consortium for Maladaptive Daydreaming Research. Sylvia Solinski, MD, FRANZCP is a psychiatrist in private practice in Melbourne Australia. She is a member of the

International Society for the Study of Trauma and Dissociation, an international member of the American Society of Clinical Hypnosis and holds a degree in law. Eli Somer, PhD is professor emeritus of psychology at the University of Haifa, Israel and past president of the European

Society for Trauma and Dissociation and the International Society for the Study of Trauma and Dissociation. He is founder and senior researcher at the International Consortium for Maladaptive Daydreaming Research.

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David Spiegel, MD is Willson Professor, Associate Chair of Psychiatry & Behavioral Sciences, and Director of the

Center on Stress and Health at Stanford. He is Past President of the American College of Psychiatrists and the Society for Clinical and Experimental Hypnosis, and is a National Academy of Medicine member. Pam Stavropoulos, PhD, is a Sydney consultant, therapist, and clinical supervisor specializing in complex trauma and

dissociation. Previously Head of Research with Blue Knot Foundation, the National Centre of Excellence for Complex Trauma in Australia, she is co-​author of the ISSTD endorsed Practice Guidelines for Clinical Treatment of Complex Trauma. Kathy Steele, MN, CS is a psychotherapist in private practice in Atlanta, Georgia, and teaches and consults internation-

ally on Dissociative Disorders. She is an adjunct faculty at Emory University, and Fellow and Past President of the International Society for the Study of Trauma and Dissociation. Donnel B. Stern, PhD is Faculty, Training and Supervising Analyst at the William Alanson White Institute; Clinical

Consultant and Faculty, NYU Postdoctoral Program in Psychoanalysis and Psychotherapy; Faculty, New York Psychoanalytic Society and Institute. His most recent book is The Infinity of the Unsaid: Unformulated Experience, Language, and the Nonverbal. Kenneth J. Thompson, MLA, MA is a senior graduate research associate at the Trauma Research Institute and a clinical

psychology (PhD) doctoral candidate at Alliant International University, San Diego, CA. He is currently on internship at VA West Los Angeles and is a contributing editor to ISTSS’s StressPoints Newsletter. Paula Thomson, PsyD is Professor, California State University, Northridge (Department of Kinesiology), Professor

Emeritus/​Senior Scholar at York University (Canada), and licensed Clinical Psychologist in private practice (Los Angeles). She is Co-​Director of the Performance Psychophysiology Laboratory investigating risk and protective factors on performing artists and athletes. Onno van der Hart, PhD is a psychologist, retired psychotherapist, and emeritus professor of psychopathology of chronic

traumatization at Utrecht University, the Netherlands. He is a past president of the International Society for Traumatic Stress Studies. Marjolein van Duijl, MD, PhD is a psychiatrist and psychotherapist specialized in Transcultural Psychiatry and Global

Mental Health. She has extensive experience in clinical work, teaching, and organizing mental health services both in African countries and the Netherlands. Her PhD research covered Trauma, Spirit-​possession and Dissociation in Uganda. Filippo Varese, PhD is Senior Lecturer in Psychology and leads the Complex Trauma and Resilience Research Unit at

the University of Manchester. He has published extensively on trauma and psychosis, including influential meta-​analyses and clinical studies focusing on the role of childhood trauma and dissociation in psychosis. Eric Vermetten, PhD, MD, is Professor of Psychiatry at Leiden University Medical Center and Retired Colonel in the

Dutch Armed Forces. He is adjunct Professor at New York University School of Medicine and served on several panels for NATO Human Factors in Medicine and professional Traumatic Stress societies. Olga Winkler, MD, FRCPC, is an Assistant Clinical Professor of Psychiatry at the University of Alberta in Edmonton,

Canada. Her clinical work consists of treating those with chronic suicidality, dissociative disorders, and trauma and stress related disorders through integrating sensorimotor therapy with EMDR and ego state interventions. Serena Wong, PhD, is a clinical psychologist at St. Joseph’s Health Care London –​Parkwood Institute Mental Health

where she provides trauma-​informed care for adult and older adult psychiatric patients. Tuppett M. Yates, PhD is a professor in the Department of Psychology, University of California, Riverside. Her

research examines the impact of childhood adversity on pathways toward psychopathology and competence. She is the founder and Executive Director of the UCR Guardian Scholars Program, which supports emancipated foster youth in higher education.

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PREFACE Martin J. Dorahy, Steven N. Gold and John A. O’Neil

In 2009, Dell and O’Neil published Dissociation and the Dissociative Disorders: DSM-​V and Beyond. They prefaced that volume by noting the book had “no real predecessor in the dissociative disorders field” (p. xix). Rather, it came from initiatives set in motion by the International Society for the Study of Trauma and Dissociation (ISSTD) in year 2000 which ultimately had Dell, O’Neil and others grappling to develop a consensus definition of dissociation. It was a task that despite much effort, passion, debate and vision proved unachievable. However, it did lead to a chain of events that eventually culminated in the 2009 opus, which comprised the largest and most comprehensive tome ever dedicated to dissociation. Knowledge and theory regarding dissociation have continued to expand rapidly since the first edition was published. The continued growth of the study of dissociation and the implications it brings for understanding normal and disordered manifestations, as well as mental illness more broadly, has been a key instigator in the desire to update the original seminal text. The current volume follows its predecessor in taking primarily a conceptual/​theoretical look at dissociation and the dissociative disorders. Much of this work is informed by the most recent scientific findings, where authors have often integrated related and relevant empirical data with their conceptual goal. In many chapters implications for clinical interventions have been touched upon. Yet, consistent with the first edition, this is not a central focus in this revision. Many thorough and noteworthy recent books cover the topic of therapy in great depth. At the same time, some chapters in the current volume address major treatment considerations. Approximately half the chapters from the first edition have been substantially or completely rewritten to provide a fresh lens on the topic matter under consideration. The subjects covered by several chapters of the first edition remain topical and important, but have not been developed significantly since (e.g., Chronic Relational Trauma Disorder; Dissociative Subtype of Schizophrenia). Consequently, they were not included in the extensively revised second edition. These and other chapters not undergoing revision still stand in the first edition as pillars of scholarly insight into the aspects of dissociation or the dissociative disorders they addressed. Sadly, Giovanni Liotti and Philip Bromberg, who contributed to the first edition, are now deceased. Nonetheless, many of their ideas are captured in new chapters by their colleagues (Adriano Schimmenti; Elizabeth Howell and Sheldon Itzkowitz, respectively). Susie Farrelly, who co-​w rote the chapter on dissociation and psychosis in the original volume, passed away while the kindling of this revision was beginning to ignite. The primary foci of this revised edition are to: 1) Update existing chapters of ongoing importance to the field of trauma and dissociation 2) Introduce topics of current and emergent importance to the field. In the years since the publication of the first edition the study of dissociation, complex trauma and the dissociative disorders has continued to grow rapidly in scientific investigation, conceptual understanding, and treatment approaches. In keeping with the growth of the knowledge base, constructs central to the study of dissociation have been formally recognized by the psychiatric helping professions. For example, in 2013, the DSM-​5 offered a dissociative subtype of posttraumatic stress disorder, while the ICD-​11 now includes stand-​a lone diagnoses for both complex PTSD

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and partial DID. Developments such as these confer enhanced legitimacy to the study of dissociation. In addition, since 2009, dedicated trauma journals (e.g., Psychological Trauma, Journal of Trauma and Dissociation, European Journal of Psychotraumatology, Journal of Traumatic Stress) have increasingly published work on dissociation, and new journals specifically dedicated to the study of trauma and dissociation have been established (e.g., European Journal of Trauma and Dissociation). Despite continued disputation of the reality of dissociation in certain quarters, the field is flourishing, extending the existing knowledge base and expanding in new directions. This book is the sourcebook for the dissociation and dissociative disorders field. It is designed to offer a comprehensive overview of core themes written by world leaders, covering key areas. The content covers introductory, intermediate, and advanced topics in the field of trauma and dissociation, and therefore is designed to be of appeal to those wanting to know more about the field, those new to it, those with more specialized knowledge, and experts wanting the most up-​to-​d ate information on a broad range of relevant topics. The dissociation and dissociative disorders field has long found itself absorbed in fending off external challenges regarding the existence, legitimacy and importance of its topic matter. The book as a whole shows the field developing well beyond defending against attacks from without. Instead, differences of perspective and lively collegial discussions demonstrate the spirited deliberations within the field as efforts are made to hone and integrate understanding. We hope Dissociation and the Dissociative Disorders: Past, Present, Future generates new theoretical insights, a raft of applied and basic research studies and ongoing debate to help define the boundaries of dissociation from the different theoretical lenses through which it is explored. Finally, we hope that beyond anything else, you, the reader, find in the content things that interest, excite and inspire you.

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ACKNOWLEDGMENTS

The editors wish to acknowledge the contributors of this volume and especially the clients/​patients with complex trauma and dissociative disorders who have ably taught all of us. In addition, Martin especially thanks Catherine, and his parents, Roy and Jennifer, for all their love and support throughout the development of this volume. Steve thanks his wife Doris Vigo for her constant support and wishes to express his gratitude to Martin for tirelessly taking the lead on this massive project. John especially thanks his wife, Su Baker, and Paul Dell, his co-​editor for the first edition.

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INTRODUCTION Martin J. Dorahy and Steven N. Gold

Dissociation has never quite taken its place in mainstream psychiatry next to accepted symptoms, processes and disorders like depression and depressive disorders, anxiety and anxiety disorders, psychosis and schizophrenia-​spectrum disorders. Some constructs, such as depression and anxiety, appear to capture aspects of human experience that largely avoid controversy, are not reliant on swathes of science data to legitimize them and are accepted into the psychiatric and psychological lexicons with considerable ease, even if theories abound about what they actually represent (e.g., Bernaras, Jaureguizar, & Garaigordobil 2019). Dissociation captures aspects of human experience that haven’t been widely accepted in psychological thought, and in a psychiatric sense have been closely linked historically to metaphysical forces (possession by a nefarious agent) or parapsychological accounts (e.g., Alvarado, 2002; Braude, 2000). Many dissociative phenomena strongly contradict widely held assumptions about the nature of human experience and functioning that are assumed to be universal. These include dissociative phenomena that call into question the notions that human autobiographical experience is integrated, that a person’s identity is invariably unified and singular, and that consciousness extends relatively consistently to all a person’s engagements with their environment. Dissociative phenomena also challenge ideas that a person has unique control and ownership of their body, mind and experiences, a relatively sequential temporal sense of their history and day-​to-​d ay episodes in life, and a single (rather than multiple) subjectivity for their body. Dissociative experience, especially at the more extreme end, often challenges Western sensibilities associated with self-​determination/​autonomy, self-​control, and self-​agency (e.g., Chirkov, 2008; Markus & Kitayama, 2003), such as when a person under the influence of dissociation appears to engage in behavior without willful initiation or even memory, while at the same time maintaining intact reality testing. Thus, it’s perhaps not surprising that symptoms like amnesia and the existence of dissociative identities have long been disputed. It has been proposed that such symptoms are created by an iatrogenic force that tap into the suggestibility of a vulnerable person rather than something that exists as a true psychobiological manifestation independent of suggestive influences. The veridicality of other manifestations of dissociation arouse skepticism for similar reasons. For example, depersonalization and derealization are completely invisible and subjective with no behavioral signatures, so not easily mapped in a positivist sense. Furthermore, somatoform dissociative symptoms along with experiences that may capture dissociation in a more normative form, including those evident in hypnosis and trance states, have often been studied under other guises (e.g., conversion, somatic symptoms, absorption, altered states of consciousness) without an explicit link to the construct of dissociation. Yet, despite strong, and at times gale force, head winds, the study of dissociation has generated significant historical and contemporary interest and a credible and rapidly growing empirical and theoretical literature base. Dissociative symptoms are increasingly recognized in non-​d issociative disorders (e.g., Lyssenko, Schmahl, Bockhacker, Vonderlin, Bohus & Kleindienst, 2018), and controversy about the existence of specific dissociative disorders, while still evident, has ebbed as scientific data increasingly substantiate their existence and nature (e.g., Dorahy et al., 2014; Loewenstein, 2018; Lynn, Maxwell, Merckelbach, Lilienfeld, Van Heugten-​Van der Kloet, & Mickovic, 2019). This book captures both the empirical evidence and theoretical developments that have guided and serve as frameworks for interpreting the research data.

DOI: 10.4324/9781003057314-1

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2  Martin J. Dorahy and Steven N. Gold

It will be apparent upon even a cursory overview of the contents of this volume that it does not offer or arrive at a singular, cohesive, unified perspective on dissociation. That place has not been reached in the evolving study of dissociation and may not be possible given the different vantage points from which it is examined. Rather, positions diverge. Collectively, authors do not look through a single lens or speak with a single voice about dissociation. Perhaps this is inevitable, a reflection of the experiential diversity and divergence inherent in the construct of dissociation. As editors, we have neither sought to impose nor aspired to achieve a unified consensus regarding dissociation. It is our conviction that to do so would prematurely foreclose the evolution of our understanding of dissociative phenomena and the processes underlying them. We believe, therefore, that the study of dissociation is best served currently by accepting the ambiguity naturally introduced by the range of perspectives about the topic. Controversy breeds vibrancy, while vibrancy can fuel controversy. The dynamic interchange between these forces fosters debate and the productive articulation of differences in perspective that promote closer examination and greater determination to provide clarity. No scientific field that hopes to flourish can grow without different perspectives developing, challenging each other, and being tested. The book reflects this vibrant and multifaceted landscape. Debates and controversies as fundamental as how dissociation should be defined, and which phenomena warrant inclusion under the designation ‘dissociation’ are addressed throughout these pages. Other questions explored include whether absorption or hypnotizability are innate capacities necessary but not sufficient for major dissociative pathology, or whether, if intense, chronic, relational, and starting early enough, trauma alone (namely abuse) is sufficient. Several chapters examine in varying ways, whether, how, when and to what degree ruptures in attachment are associated with dissociative symptoms and disorders. Some authors question whether an attachment-​oriented focus in research, theory and therapy obscures some of the observations and findings from the 1980s associated with complex dissociative presentations, a period which marked a renaissance in the exploration of such disorders. Other areas of exploration center around whether dissociative identity disorder (DID) is a posttraumatic disorder with a similar neurobiological signature to posttraumatic stress disorder (PTSD), whether symptoms traditionally described as psychotic (e.g., hallucinations and delusions) are dissociative in nature, and the extent and type of psychotic symptoms in dissociative presentations. Another central controversy examined is whether therapy for complex trauma and dissociation is most suitably conducted by providing psychological stability before engaging in trauma-​focused work or whether only the latter and not the former is needed. Other chapters and themes in the book address the extent to which fear versus betrayal of trust is more closely associated with dissociation, how culture shapes dissociative forms of expression, including adaptive manifestations of dissociation, the degree to which psychometric tools used in forensic and mental health contexts may adequately detect dissociative disorders, and the adaptive and creative nature of dissociation, along with dissociation’s transdiagnostic prevalence. In some chapters dissociation refers to both positive and negative symptoms, in other chapters it is more aligned with experiences that capture a shut-​down in functioning. The book-​end chapters that hold the content of the revision together have a chronological emphasis in line with the revised subtitle (Past, Present, Future). In keeping with this temporal framework, the book is broken up into 10 sections, starting with Historical and conceptual issues and ending with future directions and challenges (The future).

Part 1:  Historical and Conceptual Issues Opening the book and starting Part 1, Van der Hart and Dorahy contrast the historical understanding and exploration of dissociation with more contemporary directions and definitions. Dissociation was of great interest during the heyday of dynamic psychiatry, when Charcot, Janet, Prince, James and the young Freud were developing insights that formed the basis for much of the subsequent thinking in psychiatry and psychology generally. Early conceptualizations tended to limit dissociation to phenomena that manifested from a specific way in which the mind was organized. Throughout much of the twentieth century dissociation was relegated to the psychiatric/​psychological wilderness, yet interest resurfaced in the 1970s and 1980s. Modern conceptualizations of dissociation have typically resiled from mental organization as a delimiter of dissociative phenomena and have focused instead on the phenomena in and of themselves that fit a broader definition of dissociation. Drawing on his philosophical lens, Braude formulates a single, unified conception of dissociation designed to capture both normal and pathological manifestations. He differentiates dissociation from related psychological phenomena like repression, suppression, and denial, while drawing attention to the loss of interest in hypnotic phenomena in many contemporary dissociation theories. In this chapter expressions of dissociation are not restricted to defensive operations, but also include classic hypnotic phenomena that are evident in both clinical and non-​clinical contexts. Farina and Meares draw on the historical theorizing and research of Pierre Janet, John Hughlings Jackson and Charles Sherrington, along with contemporary neuroscientific findings, to propose a differentiation between disintegration and

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Introduction  3

dissociation in an effort to provide further conceptual clarity to the field. They argue that dissociation has two forms and ultimately reflects the segregation and compartmentalization of content, much of which was disintegrated. However, such an organizing effort is not universal in the presence of disintegration. Disintegration is associated with coordination and inhibition difficulties of higher-​order processes (e.g., related to self and metacognition), evident in most if not all psychopathology, and especially apparent in those exposed to developmental and attachment trauma. Whilst distinct, Farina and Meares note that disintegration and dissociation may be intimately linked and can be hard to neatly conceptually disentangle. Offering a counter-​perspective to the contention that dissociation is a normal common psychological process, Steele, Dorahy and Van der Hart voice concern that the construct of dissociation has become too unwieldly with no specific definition, limiting its conceptual and scientific utility. They proposed that alterations in consciousness should be differentiated from dissociative experiences and confined to the pathological and non-​pathological phenomena that reflect dissociation at the level of personality. They argue that clearly differentiating alterations in consciousness from dissociation at the level of personality provides a sharper lens through which to examine both sets of phenomena and how they overlap and differ. Dalenberg, Katz, Thompson and Paulson use the empirical data, especially that associated with the Dissociative Experiences Scale, to argue that dissociation operates as a normal process that should not be restricted to clinical manifestations. They argue absorption is an important manifestation of dissociation that may constitute the diathesis to the trauma-​related stress that produces clinical dissociation (e.g., amnesia). They further contend that this normal form of dissociation is evident in a range of psychiatric presentations beyond the dissociative disorders. Yet, while normal dissociation (absorption) is benign at lower levels, it can manifest at pathological levels. The argument for dissociation being a normal process not limited to psychopathological expressions is expanded by Thomson, who explores not only how dissociation can be controlled and utilized to enhance artistic and athletic performance, but can also offer resilience against extreme stress. Thomson argues that for those exposed to trauma who have learned to engage and disengage dissociative capacities in the service of goal achievement or performance in extreme contexts, dissociation becomes a tool of resilience and value that provides creative options and new directions. Adams-​Clark, Gómez and Barlow explore the link between betrayal at interpersonal, institutional, and cultural levels, and how such violations of trust impact dissociation. Drawing on the accumulated body of research associated with Betrayal Trauma Theory (Freyd, 1996), they argue that dissociation provides a mechanism for solving contradictory patterns of attaching to an individual, institution or group that betrays trust and violates safety. While this has short-​term, adaptive benefits in allowing connection to be maintained when it is needed, it leaves the person vulnerable to long term harm as dissociation impacts on risk assessment and personal safety. O’Neil delves into dissociative multiplicity, the existence in one human being of multiple centers of consciousness, and the degree to which a range of central psychoanalytic models can account for the genesis and structure of such a mind. Early in his career, Freud abandoned hypnoid hysteria as a central process in neurosis, and psychoanalysis has traditionally paid short shrift to dissociation ever since. While the sophisticated conceptual models representing different schools of psychoanalytic thinking have generally remained inadequate to account for multiplicity, they still shine light on all psychopathology, including the dynamics of every center of consciousness. There has been more routine openness to dissociation, and more success in addressing dissociative multiplicity, in relational psychoanalysis, closely related to object-​relations and attachment theories. O’Neil ultimately concludes that dissociative multiplicity requires the prerequisites of disordered attachment and trauma, partially addressed by psychoanalysis, and hypnotizability, largely abandoned by psychoanalysis.

Part 2:  Etiological and Developmental Considerations Part 2 of the book opens with Linde-​K rieger, Yates and Carlson’s exploration of dissociation from the framework of developmental psychopathology. Their perspective takes as its starting point dissociation as an adaptive process which, depending on its elaborations and influences over the course of development, can become maladaptive. They argue that dissociation is a normal and adaptive component of childhood psychological functioning before greater integration at different organizational levels leads to a reduction in its frequency. When pathological dissociation begins to manifest from its adaptive origins, development progresses towards less integration and resultantly, more dissociative complexity. Several chapters in the book draw on attachment theory to elucidate their ideas (e.g., Farina & Meares; Schore), but Schimmenti has attachment as his primary focus, noting how it is connected to disintegration (i.e., a collapse in function) and dissociation (i.e., a reorganization of the mind following disintegration, that keeps systems and content segregated). Disorganized attachment is Schimmenti’s central focus. He fleshes it out in terms of Bowlby’s original

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4  Martin J. Dorahy and Steven N. Gold

conceptualization of attachment theory, Main and Hesse’s identification of the disorganized pattern, and contemporary findings and theorizing. Schimmenti tracks the association between attachment disorganization and dissociation from childhood to adulthood and shows how several of the core psychological symptoms of dissociation can be understood from an attachment lens. Integrating interdisciplinary perspectives, Schore provides an account of how early relational experiences influence right brain development and provide the basis for dissociative defenses. These dissociative defenses operate in the absence of more adaptive emotional regulation abilities and may become habituated and persist. Interactions with primary caregivers, including those characterized by abuse and neglect, are etched into right hemisphere systems along with dissociation as a last-​d itched defensive effort, which is then drawn upon non-​consciously in future stressful interpersonal engagements. For Schore, dissociation reflects a parasympathetically-​dominant shut-down state, is a counterpoint to hyperarousal and sympathetic activation, and is specifically associated with a vertical loss of connectivity between right hemisphere cortical and subcortical limbic areas. The experience of traumatic stress has long been associated with dissociative symptoms and disorders. In examining this connection, Quiñones outlines how each of the three categories of Adverse Childhood Experiences (abuse, neglect, household dysfunction) relate to pathological dissociation. From this foundation, Quiñones demonstrates how ACEs give rise to distress, disruption and disconnection that underpin 1) disturbed attachment dynamics, 2) heightened threat and deprivation, and 3) deficits in behavioral and emotional skills. These three factors in turn increase the likelihood of dissociative adaptation in the form of symptoms and disorders. The existence and prevalence of child sexual abuse challenges the sensibilities of most individuals, including mental health professionals, and widespread acceptance has been very slow in coming. Ongoing incestuous abuse into adulthood has faced even tougher resistance in being recognized, and presents considerable challenges for therapists. Middleton has been at the forefront of raising awareness of this form of abuse, its characteristics, and psychological impacts. He outlines the key features, along with what ongoing incestuous abuse might tell us about the etiology of DID and how complex attachment dynamics meld victims to perpetrators. In a provocative chapter examining the role of hypnotizability in the development of major dissociative disorders, Dell challenges the field to look beyond trauma as a dominant explanatory pathway. He argues that hypnotizability is the key factor interacting with trauma to produce a dissociative disorder. Without it, he argues, no manner, intensity or chronicity of trauma will produce a dissociative outcome. He also argues that integration failure without the hypnotizability trait will not produce a dissociative disorder.

Part 3:  Theoretical Approaches Part 3 addresses in greater depth and with more specificity, theoretical approaches to dissociation and the dissociative disorders. Van der Hart and Steele commence the section by providing an integrated review of their theory of trauma-​ related structural dissociation of the personality in light of developments over the past 20 years. Central to their model is the understanding that dissociative phenomena are limited to those symptoms which have their origin in dissociation at the level of personality. Their model also deviates from many others, in that it does not view dissociation primarily as a defense. Rather, dissociation first and foremost reflects a failure of integration, that could be caused by several factors (e.g., sleep deprivation, exhaustion, trauma) not motivated by defense, although it may have secondary defensive benefits. Discrete Behavioral States (DBS) theory is explored by Loewenstein and Putnam with regard to how it helps account for dissociation and the dissociative disorders. The theory itself goes beyond a specific focus on dissociative experiences and disorders, instead integrating them into a broader understanding of human psychological functioning, both at normal and pathological ends. Dissociative experiences capture DBS (e.g., absorption) and also changes in them (e.g., shifting between dissociated DBS). Dissociative disorders reflect pathological states of being that dramatically alter a person’s sense of self and their experience of their body, mental functions, and physiological reactivity. Beere provides a contemporary update on his Perceptual Theory of Dissociation, which stands in stark contrast to structural models of dissociation, by having as a starting point phenomenological exploration. He shows that dissociative symptoms and disorders can be well accommodated in a theoretical framework that privileges the background elements (as opposed to ground and figure components) of identity, mind, body, world, and time. Different dissociative phenomena are associated with loss of one or more of these background elements when attention is profoundly drawn to percepts of crucial significance. From the vantage point of the Perceptual Theory of Dissociation, dissociative phenomena are not isolated to threat and trauma, and are not universally associated with defense and coping.

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Introduction  5

Gold’s contextual trauma theory advocates for a particular variation of phase-​oriented trauma work. He contends that the prolonged child abuse (PCA) which frequently fosters dissociative psychopathology and complex PTSD almost invariably occurs in a family context that not only provides insufficient support for the attainment of secure attachment, but also fails to supply adequate interpersonal resources needed to foster adaptive psychological development, acculturation, and socialization. According to Gold, dissociation arises from the dual impact on survivors of abuse trauma and restricted psychological development, manifested in the weakening of neuropsychological capacities such as focused attention, resilient memory, and robust integrative functioning. Phase one of tripartite phase-​oriented trauma treatment therefore aims to build stabilization and resiliency derived from developmentally remediative forms of intervention. Frewen, Wong and Lanius argue that their 4-​Dimensional (4-​D) model of dissociation is an organizing and explanatory framework that accounts for different conceptualizations of dissociation and offers testable hypotheses of its merit. The model addresses trauma-​related alterations in consciousness experienced in time, thought, body and emotion, and specifies how these alterations differ from normal waking consciousness in these domains. From their model they demonstrate how dissociation in the form of detachment, compartmentalization and structural dissociation differ. Stern offers an updated summary of his theory of dissociation, wedded in philosophical and psychoanalytic thought, including his relational frame of reference. Unlike repression, where formulated experience is actively held from awareness, dissociation and the inaccessibility to states of mind it brings is associated with experiences being unformulated in 1) a verbal reflective sense that impedes articulation and meaning, and 2) a nonverbal sense that prohibits realization. He outlines two forms of dissociation, one where unformulated experience is more passively turned away from (dissociation in the weak sense) and one where unformulated experience is actively unconsciously avoided, associated with Sullivan’s ‘not-​me’ (dissociation in the strong sense).

Part 4:  The Dissociative Disorders Part 4 is set in motion with O’Neil’s absorbing analysis of the complex, changing and at times conceptually contradictory categorizations of dissociation and dissociative disorders in the histories of the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). These classification systems have had periods of conceptual overlap and periods of quite unique positioning of dissociation and the dissociative disorders. They have aligned more closely in recent times but still have differences in where they place and how they conceive of pathological manifestations of dissociation. O’Neil notes that the ICD and DSM by their very nature will always primarily follow rather than lead the field as they draw on empirical data and contemporary conceptualizations. Yet, they both continue to have a central place for dissociation that expands beyond the dissociative disorders. Dissociative amnesia and dissociative fugue have not escaped controversy in the psychological literature. Yet, as Ross points out, while both are commonly found in complex dissociative disorders like DID, they have attracted sparse attention as circumscribed disorders, and may be relatively rare in isolation. He notes that those with amnesia and no other trauma-​related or dissociative psychopathology often do not experience other dissociative symptoms, and so may not be easily detected. In addition, the stressors associated with both amnesia and fugue are milder, briefer and less frequent than those often reported in complex dissociative disorder presentations. Michal provides a contemporary review of the literature and clinical presentations of depersonalization and derealization, with a central focus on depersonalization/​derealization disorder. He notes that despite the symptoms and disorder being relatively common, they are rarely entertained in clinical practice and differential diagnosis, and are often misattributed as psychotic manifestations, or dismissed. Michal argues that depersonalization/​derealization reflect both consequences of anxiety in the absence of good regulation and defensive operations to cloak psychological reality. This reality is often associated with early attachment ruptures rather than gross incidences of child abuse and neglect. DID has never been far from controversy, yet Lebois, Kaplan, Palermo, Pan and Kaufman show that scientifically it is underpinned by a rich and developing neurobiological and psychophysiological empirical base that has predominately focused on differences between dissociative identities, or self-​states. They draw on work from grounded cognition to conceptually frame a self-​state, and argue that empirical findings demonstrate that DID self-​states are “dynamic, distributed networks of brain activity that prepare the body [and mind] to interact with the world in a particular way.” They further argue that the findings are aligning with DID as a posttraumatic condition lying on a continuum with PTSD, viewing DID as a “posttraumatic developmental adaptation.” In his exploration of the subtleties of psychosis in dissociative disorders, Şar notes the points of connection, but also, importantly, where they demarcate. He also outlines at what point psychosis begins to become a feature of dissociative disorders, and how symptoms of DID, for example, that might be viewed as psychotic (e.g., belief in other internal

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existences –​dissociative identities), do not represent psychotic symptoms. Acute reactive dissociative psychosis is one bridge between psychotic psychopathology and dissociative disorders. Cardeña, Schaffler and Van Duijl provide a nuanced differentiation between various forms of trance and possession in their chapter on Spirit Possession and Trance Phenomena. They also draw distinctions between adaptive, culturally/​religiously sanctioned, and socially cohesive experiences and those more consistent with psychopathological manifestations. Dissociation is implicated in both adaptive and psychopathological forms of possession, with the latter being characterized by less control over dissociation and, typically, a history of more traumatic life experiences. Silberg and Dallam outline advancements made in the understanding, assessment and treatment of dissociation in children and adolescents. In summating the accruing literature in these areas, they then provide a review of the relationship between trauma and dissociation relevant for child and adolescent groups before exploring dissociative manifestations from preschool to adolescents. Dissociative symptoms in these populations are usually not as solidified as in adults, and are therefore less stable and less resistant to change than in adult dissociative disorders.

Part 5:  Dissociation as a Transdiagnostic Process –​Acute and Chronic Part 5 starts with an exploration of peritraumatic dissociation (PD), that is, dissociation during or immediately after exposure to a potentially traumatizing event. PD has attracted considerable empirical interest on account of its ability to predict the later development of posttraumatic stress disorder (PTSD). Cardeña and Classen explore the scientific literature on PD. They note that both PTSD and its precursor, acute stress disorder, are not unified psychiatric presentations, but instead may look different across cases, where PD may have a greater or lesser impact and presence depending on the presentation. The predictive ability of PD for later PTSD is explored in the later part of the chapter with both PD and persistent dissociation solid predictors of posttraumatic stress disorder and symptoms, especially more severe manifestations. Yet, the complexities of prediction, the variables at plays and the factors associated with PD, mean simple conclusions are best avoided. Arguing for the pervasiveness of dissociation in PTSD, Winkler, Burback, Bremault-​Phillips and Vermetten show the different manifestations of dissociation in the various symptoms of PTSD. They start with the premise that dissociation is characterized by two related groups of phenomena: the inaccessibility of internal experience and intrusions of this seemingly inaccessible material upon awareness without volitional control. They suggest that the introduction of the dissociative subtype of PTSD in the DSM-​5 highlighted the importance of dissociative symptoms in PTSD, but also shone a light on how often other symptoms of PTSD are ignored as dissociative. Demonstrating the different manifestations of dissociation in PTSD, they point to how central dissociation is to the construct of PTSD and to pathological adaptation to traumatic stress generally. More complicated variants of PTSD have been a conceptual and empirical hotspot since Herman (1992) first conceived of complex PTSD to capture the wider array and more severe symptoms reported by adults experiencing repeated interpersonal or development traumas. Ford explores this complex literature with a specific emphasis on emotion dysregulation that cuts across all formulations, and where dissociation fits. He argues for a dissociative subtype of complex PTSD, modelled on the dissociative subtype of PTSD. Ford draws on empirical and theoretical literatures to argue that not all complex PTSD presentations are characterized by dissociative features. Korzekwa and Dell take a deep dive into the somewhat elusive relationship between borderline personality disorder (BPD), dissociation and the dissociative disorders. They argue that dissociation is common in BPD but not integral to it. The significant number of BPD patients who experience considerable dissociation present as clinically different from those without such symptoms. Thus, dissociative symptoms color the clinical presentation of BPD. Korzekwa and Dell critically argue that BPD is a neurodevelopmental disorder with dissociation being a developmental outcome in those with the necessary environmental (e.g., trauma), cognitive, genetic and attachment (e.g., major ruptures) factors. DID, on the other hand, has its foundation in the interaction between childhood trauma (including major parental misattunement) and a genetic predisposition for hypnotizability. Moskowitz, Longden, Varese, Mosquera and Read persuasively argue that many symptoms historically and currently connected to schizophrenia and other psychotic presentations have dissociation at their heart. For example, many of Schneider’s first rank symptoms can be understood through the theoretical lens of dissociation. Among their many insights is that the dissociative structure of DID may reduce the level of delusional distortions of traumatic memories, because content can be contained in a dissociative identity. In psychotic disorders, dissociation does not render such content inaccessible, thus delusions may make the origins of traumatic memories less identifiable, with such processes (i.e., delusional explanations) helping to manage the affective and cognitive content.

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Somatoform or sensory-​motor symptoms represent a confusing set of psychologically-​derived phenomena that are inconsistently understood in psychiatric classificatory systems. Using advances from the Theory of Structural Dissociation of the Personality that explore dissociative parts in terms of organism-​environment interactions, Nijenhuis provides an incisive and confronting look at somatoform disorders and the symptoms which comprise them, noting that dissociation underpins central somatoform presentations such as conversion. He suggests that trauma, particularly that of a relational nature, is a causal factor in somatoform dissociation and therefore of the somatic symptoms emanating from it. Soffer-​Dudek and Somer outline the recently constituted construct of maladaptive daydreaming (MD) and offer the formulation for its pathological manifestation. Underpinning maladaptive daydreams is dissociative absorption. They argue this is a form of dissociative compartmentalization that may give rise to major dissociative pathology such as DID. Thus, they argue for MD being a dissociative disorder grounded in pathological absorption (i.e., a dissociative absorption disorder). They go on to propose an etiological framework nesting MD along a continuum of agency and control, and arguing its underpinnings are in a diathesis to engage in absorption and imaginative involvement that is positively and/​or negatively reinforced (e.g., to avoid stress), creating pathological manifestations. Somer’s chapter on opioid misuse and dissociation explores the thesis that in traumatized individual opioids provide a “chemical dissociation” as a second stage strategy when psychological dissociation breaks down or does not have the capacity to dull intolerable affect and related trauma memories. He sets this chapter in the context of the opioid epidemic in the US and the global pandemic of COVID-​19 that swept the world in 2020 and had lasting ripple effects. Opioid use becomes a self-​medication dissociation strategy for traumatized and overwhelmed individuals. After years of working with dissociative processes and disorders in incarcerated individuals, Hohfeler turns his clinically attuned eyes to addressing the relationship between dissociation and antisocial behaviors, particularly violence. He notes how common developmental trauma and dissociation are in those incarcerated, pointing out that dissociation in particular is rarely recognized. Hohfeler explores violence associated with a dissociative disorder, such as dissociative identities organized around violent enactments, as well as the emergence of dissociative disorders through acts of violence. Social, cultural and sub-​cultural influences are explored as Hohfeler connects dissociation with rage and antisocial behaviors. He notes how shame and humiliation are potent drivers in such connections.

Part 6:  Neurobiological and Cognitive Understandings of Dissociation Corrigan, Lanius and Kaschor open Part 6 with a detailed outline of the neurobiological underpinnings of the defense cascade, which reflects various, well organized and evolutionarily-​sequenced responses to immediate threat (e.g., fight, flight, freeze, collapsed immobility). Of particular interest is the periaqueductal gray (PAG) and the different aspects of it that regulate different basic affect circuits and different defensive responses. The opioid-​induced analgesia associated with different defensive engagements is argued to underlie peritraumatic dissociative responses, while structural dissociation reflects a long-​term outcome of this neurochemical dissociation associated with distinct circuitry. In exploring the psychobiology of dissociative disorders, Nijenhuis uses the Theory of Structural Dissociation of the Personality (TSDP) to construct a set of hypotheses that explore findings taken from neuroimaging and other neurophysiological methodologies. He demonstrates that the findings to date are consistent with TSDP and inconsistent with the sociocognitive model of DID that argues suggestibility, fantasy proneness and iatrogenic factors are the primary contributors to DID. He then shifts to exploring the philosophical bases of the connection between brain (matter) and mind, particularly with regard to how findings should be interpreted and how dissociative disorders should be understood. The dissociative specifier of PTSD, commonly referred to as the dissociative subtype of PTSD (PTSD+​DS), was formulated from neurobiological findings. Schiavone and Lanius discuss the original corticolimbic model that sought to provide a neurological conceptualization accounting for how PTSD+​DS differed from PTSD. They then build on this foundational work, linking PTSD+​DS with the defense cascade. In this exploration they note developments that are coalescing to suggest, with regard to the brain areas implicated and the key features phenomenologically evident, that PTSD+​DS can be considered a disorder of sensory integration. Recent empirical work has begun to question the standard understanding that reported amnesia across dissociative identities is associated with memory processes like retrieval deficits. This challenge has been prompted by work showing that memory representation for which amnesia is reported are accessible, suggesting a subjective rather than objective amnesia. To account for these findings, Dorahy proposes a dual path model for inter-​identity amnesia based on metamemory processes associated with ‘feeling of knowing’ and the initiation and termination of search processes, along with ownership of internal experiences.

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Part 7:  Assessment and Measurement The assessment of dissociative disorders is a complex enterprise, owing to factors such as the subtlety of many dissociative manifestations, the possibility of over or under-​reporting symptoms, due, for example, to having amnesia for them or malingering them, and the risk of misdiagnosis with other disorders. Part 7 begins with Coy and Madere providing a state-​of-​the-​art explication of the complexity of dissociative assessment. They focus on four leading tools from different traditions of assessment, including structured, semi-​structured, and self-​report measures. They outline the uses, format, advantages, and challenges in the Office Mental Status Exam for Complex Chronic Dissociative Symptoms and Multiple Personality Disorder, the Dissociative Disorders Interview Schedule, the Structured Clinical Interview for Dissociative Disorders, and the Multidimensional Inventory of Dissociation. In expanding assessment considerations to challenging populations, Brand and Brown explore the unique difficulties presented when malingering is a possible confound in assessing for dissociative and trauma disorders. They take a hypothesis-​generating approach to pose questions that can be assessed by different tools to maximize the probability of accurately detecting true and malingered cases of dissociative disorders. This chapter notes the significant problems of relying on validity measures in some well-​established instruments when assessing for dissociative disorders, as they include dissociative symptoms and therefore can produce false positives for malingering. Particular emphasis is given to the Minnesota Multiphasic Personality Inventory-​2 and Personality Assessment Inventory, but accurate detection is also drawn from assessing the nuances of a genuine trauma and dissociative disorder symptom profile.

Part 8:  Treatment Considerations and Conceptualizations The assessment and treatment of dissociative identity disorder (DID) brings with it unique challenges not limited to those associated with 1) amnesia’s impact on providing a coherent life narrative, 2) actions, ideas and feelings that seems alien, and 3) assessing for and treating difficulties often outside the purview of other practitioners. Part 8, Treatment considerations and conceptualization, is initiated with Kluft, in the case study tradition, using carefully detailed clinical material to provide a salutary reminder of the distinctiveness of each case and where generalities and treatment principles exist despite considerable variations of presentations. The chapter also offers caveats on putting too much emphasis on attachment ruptures versus abuse in the development of dissociative pathology, and stresses that posttraumatic symptoms are not a universal feature of DID. Stavropoulos and Elliott address treatment tensions for therapists working with those experiencing complex trauma presentations, especially with regard to the debate about how quickly trauma-​focused work should be implemented and whether a stabilization phase is needed beforehand. They explore the challenges to phase-​oriented therapy from 1) exposure therapies for PTSD, that have been extended to complex trauma, and 2) therapy models more designed with complex trauma therapy in mind, but which do not self-​identify as phase approaches. They also explore attachment considerations and a treatment modality with this focus that puts less emphasis on trauma exposure in therapy. The relational school of psychoanalysis has placed great emphasis on the reality of childhood trauma in shaping the internal structure for the human psyche. Dissociation has also played a dominant role in shaping the internal world in much relational thinking, and for some authors is a core feature both in healthy and unhealthy functioning (e.g., Bromberg, 2009). Howell and Itzkowitz explore the relational turn in thinking from Ferenczi, through Sullivan and the interpersonalists, via some object-​relations thinkers to the contemporary contributors, where trauma and dissociation have been front and center in both theorizing and clinical application. Dissociated rather than repressed mental content, and horizonal rather than solely vertical psychic organization that characterize relational thinking are outlined in the chapter, and are proposed to give rise to dissociative enactments in both patient and therapist, and the existence of ‘not-​me’ modes of being.

Part 9:  Treatment Challenges and Therapist Considerations Part 9 cherry picks core issues that often create particularly acute challenges for therapists working with complex trauma and dissociative disorders. The complexity of human memory functioning, especially associated with the encoding, consolidation, and retrieval of traumatic experience, in conjunction with the various non-​memory processes related to trauma memories (e.g., dissociation), can create conceptual and technical challenges for therapists. In a compelling chapter, Solinski encourages therapists to be informed about the nature of memory and its connection with self and

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trauma, topic areas she draws out and explores. The chapter provides a scientific understanding of human memory, in its multiple manifestations, while applying it to clinical presentations in traumatized patients. Trauma memories are influenced by dissociation and resultantly are often fragmented in nature and prone to encoding and retrieval problems (e.g., different degrees of amnesia). Solinski demonstrates from an empirical and conceptual base, using case study material, that memories can be accurate, wholly inaccurate or anything in between. Therapy with those diagnosed with DID presents innumerable challenges, from those associated with the therapist’s faulty reification of dissociative identities to the enactment of trauma dynamics from both patient and therapist. Shame, abandonment, betrayal, attachment drives and defenses against them abound and underpin the self-​state organization in DID. Loewenstein systematically addresses these therapeutically thorny issues, pitfalls for therapists and the relational dynamics that characterize the therapeutic journey which need to be addressed in order to avoid treatment failure via direct rupture without repair or endless transference/​countertransference repetitions.

Part 10:  The Future A solid, developing, and lasting understanding of dissociation and dissociative disorder is reliant on robust, methodologically sound research and the empirical data it produces. In the final section of the book, Şar and Ross provide a far-​ reaching review of the studies that would illuminate areas within the field that currently lack or need more supportive research. They make recommendations for research in areas as diverse as the definition of dissociation, the differential diagnostic domain of the dissociative disorders, the presence and nature of dissociative symptoms in non-​d issociative disorders and the treatment of dissociation and its pathological manifestations. This chapter is a treasure trove for young as well as seasoned researchers looking for areas to advance the scientific understanding of dissociation, and also offers lay, clinical and theoretical readers an appreciation of the broad domain of dissociation and where gaps lie in empirical knowledge. The book is closed with Spiegel, a contributor to the dissociative literature since its revitalization in the late 1970s and early 1980s, addressing the degree to which the study of dissociation has been integrated into the scientific literature and is underpinned by a solid scientific foundation. This allows him to address the question of whether dissociation is likely to remain a subject of rigorous empirical and clinical investigation or whether it will fade from interest as it did in the early twentieth century. Spiegel examines the association between dissociation, trauma, basic psychological processes and neurobiological substrates. He concludes that while dissociation is underrecognized and often disrespected as a core psychological/​psychiatric process, it continues to be integrated into mainstream studies and thought, with interest waxing, not waning.

Concluding Thoughts As data accrue about the nature of the underpinnings of dissociation, old debates (e.g., the existence of DID as a naturally occurring diagnostic entity) are settled and herald the rise of new challenges and points of division. Yet, the fundamental questions of what phenomena dissociation does and does not consist of, and the underlying mechanisms and causes responsible for them continue to be grappled with. There appears to be agreement that dissociation reflects the phenomena that come from, and the organization that makes up, a mind that is segregated into different distinct functions and processes (including self processes) that would normally be integrated. Whilst not totally overlapping concepts, dissociation of this kind has been referred to as compartmentalization or structural dissociation. Debate is more lively and agreement is not universal regarding whether phenomena often described as dissociation that are not captured by compartmentalization or structural dissociation should also be considered dissociative. This debate is unlikely to lessen any time soon, as different theoretical frameworks make solid cases for their respective positions, amass supportive data based on studies underpinned by their definition of dissociation, and have proponents with different degrees of tolerance for accepting single versus multiple underlying psychoneurobiological mechanisms to capture the boundaries of what dissociation is. There is unquestionably a paradox that a field which seeks to define and explain phenomena characterized by the fragmentation of functioning is itself marked by the disjointedness of divergent and seemingly incompatible viewpoints. However, as mentioned earlier in this introduction, this very quality, rather than being problematic, may be an asset. What seem like irreconcilable viewpoints may eventually be found to capture the richness and intricacy of a network of phenomena that on the surface appear to be divergent, but which may ultimately be found to have an underlying principle that unites them.

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References Alvarado, C. S. (2002). Dissociation in Britain during the late nineteenth century. Journal of Trauma & Dissociation, 3, 9–​33. Bernaras, E., Jaureguizar, J., & Garaigordobil, M. (2019). Child and adolescent depression: A review of theories, evaluation instruments, prevention programs, and treatments. Frontiers in Psychology, 10, 543. Braude, S. E. (2000). Dissociation and latent abilities: The strange case of Patience Worth. Journal of Trauma & Dissociation, 1, 13–​48. Bromberg, P. M. (2009). Multiple self-​states, the relational mind, and dissociation: A psychoanalytic perspective. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-​V and beyond (pp. 637–​652). New York: Routledge. Chirkov, V. I. (2008). Culture, personal autonomy and individualism: Their relationships and implications for personal growth and well-​being. In G. Zheng, K. Leung, & J. G. Adair (Eds.), Perspectives and progress in contemporary cross-​cultural psychology: Proceedings from the 17th International Congress of the International Association for Cross-​Cultural Psychology. https://​schol​a rwo​rks.gvsu.edu/​iaccp​ _​pap​ers/​10/​ Dorahy, M. J., Brand, B. L., Şar, V., Krüger, C., Stavropoulos, P., Martínez-​Taboas, A., Lewis-​Fernández, R., & Middleton, W. (2014). Dissociative identity disorder: An empirical overview. Australian and New Zealand Journal of Psychiatry, 48, 402–​417. Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Harvard, MA: Harvard University Press. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books. Loewenstein R. J. (2018). Dissociation debates: Everything you know is wrong. Dialogues in Clinical Neuroscience, 20, 229–​242. Lynn, S. J., Maxwell, R., Merckelbach, H., Lilienfeld, S. O., Van Heugten-​Van der Kloet, D., & Mickovic, V. (2019). Dissociation and its disorders: Competing models, future directions, and a way forward. Clinical Psychology Review, 73, 101755. Lyssenko, L., Schmahl, C., Bockhacker, L., Vonderlin, R., Bohus, M., & Kleindienst, N. (2018). Dissociation in psychiatric disorders: A meta-​a nalysis of studies use the Dissociative Experiences Scale. American Journal of Psychiatry, 175, 37–​46. Markus, H. R., & Kitayama, S. (2003). Models of agency: Sociocultural diversity in the construction of action. Nebraska Symposium on Motivation, 49, 1–​57.

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PART 1

Historical and Conceptual Issues

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1 HISTORY OF THE CONCEPT OF DISSOCIATION Onno van der Hart and Martin J. Dorahy

Dissociation may be regarded as the first fruit of psychopathology. It was a conception built up by a strictly scientific method, it illuminated a vast field of phenomena which had hitherto baffled every attempt at explanation and it opened up the way to therapeutic possibilities in which that control of phenomenal experience which is the ultimate goal of science was abundantly satisfied. Bernard Hart (1925, p. 236) The study of dissociation in the scientific literature has a long and diverse theoretical and clinical history. Initial observations by the early proponents of animal magnetism and hypnosis led to dissociation being associated with divisions or ‘splits’ in consciousness—​often used interchangeably with terms like personality, mind, psyche, or ego. Whilst not commonly recognized, it is generally understood that consciousness cannot be divided or ‘split,’ it is indivisible. Rather, such terminology reflects a multiplication of consciousness, instead of an integrated whole, involving two or more separate conscious systems, each with its own first person perspective (Nijenhuis, 2015; O’Neil, 2009). Key here is not a multiplication of a whole person, but a division into multiple organized and self-​conscious parts. In more recent years, these parts have been denoted by various labels, such as personality states, identity states, ego states, self-​states, dissociative parts, and even aspects. However, in the historical literature ‘personalities’ was the most often used term, although it has not always been clear whether the term ‘personality’ referred to a single entity or dynamic system that is divided into dissociative subsystems (Moskowitz & Van der Hart, 2020), or whether personality referred to something less core to the individual’s self-​ structure where dissociation reflected the multiplication or proliferation of personalities (see O’Neil, Chapter 8, this volume). Using these different metaphors authors were trying to conceptualize the same issue, dissociation at the structural level of the psyche, but they have different starting points (a single personality divided into parts [division metaphor] versus personalities duplicated to provide not parts of one, but one of more [multiplication metaphor]). Given the literature is not always clear, and to avoid favouring one metaphor over the other, we have adopted in this chapter the interchangeable use of the division and multiplication metaphors, with the reader encouraged to utilize the conceptualization that fits for them. The division of the personality or multiplication of personalities, to which the concept of dissociation referred, was used to explain hysteria and hysterical symptoms, with multiple personality disorder regarded as the most complex form. Although the dominant conception at the time limited dissociation to the psychiatric arena, theoreticians working in other areas began to describe various nonclinical psychological phenomena in terms of dissociation. With the beginning of the twentieth century, psychoanalytic thinking began to produce a change in clinical language and theory. Over time these psychoanalytic innovations brought about a commensurate change in the conceptualization of dissociation. At the same time that theoretical speculation was producing changes in previous views of dissociation, the original clinical observations that related dissociation to divisions of the personality/​multiplication of personalities were being replicated during and after World War I and World War II. As a result, army psychiatrists and other clinicians began to rediscover and to elaborate on earlier theoretical ideas about trauma-​generated dissociation and its treatment. The late 1960s saw an increased

DOI: 10.4324/9781003057314-3

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academic interest in altered states of consciousness, which eventually became synonymous with dissociation. During the early 1970s, empirical and theoretical work in cognitive psychology recaptured one of the initial conceptualizations of dissociation (i.e., division of “consciousness”; Hilgard, 1977, 1986). Shortly thereafter, clinical interest in pathological dissociation reignited; this led to the proliferation of ideas, models and empirical directions that are evident today (see Loewenstein, Frewen, & Lewis-​Fernández, 2017). In this chapter, we will provide a detailed history of dissociation.

Origins of Dissociation in the Scientific Literature Dissociation as Division/​Multiplication of Personality/​Consciousness/​Psyche In Germany, Eberhardt Gmelin (1791) published the first treatise on a case of ‘double personality,’ and in the same year the Reverend Joseph Lathrop described another case in a letter to Ezra Stiles, the President of Yale University (Carlson, 1981; Crabtree, 1993). In the early nineteenth century, S. L. Mitchill (1816) presented Mary Reynolds, who was to become a famous American case of multiple personality disorder (Ellenberger, 1970; Goodwin, 1987). Before this time, other such cases were reported but were regarded as individuals possessed by devils and demons (e.g., the sixteenth-​ century case of Jeanne Fery; Bourneville, 1886; cf., Van der Hart, Lierens, & Goodwin, 1996). The initial observations and investigations of dissociation, however, did not begin with these cases of ‘split’ personality. Instead, the initial reports of dissociation came from the French pioneers and early investigators of animal magnetism, hypnosis, and ‘double personality.’

Amand de Chastenet de Puységur Franz Anton Mesmer was the father of animal magnetism. In Vienna, he developed his treatment approach of inducing a so-​called magnetic (convulsive) crisis. One of his students, Amand-​Marie-​Jacques de Chastenet, Marquis de Puységur (1751–​1825), discovered that some subjects entered a remarkable state of consciousness. In this state, subjects were aware of no one except the magnetizer whose commands they executed; when they emerged from this state, the subjects were amnesic for all that had occurred during the state. Because of its resemblance to natural somnambulism, this induced state was called among other things (e.g., magnetic sleep), artificial somnambulism (Crabtree, 2019); much later Braid (1843) was to call this condition “hypnosis.” Puységur and colleagues (including his brothers) quickly became aware that the essence of both somnambulism and artificial somnambulism was a dissociation or multiplication of ‘existences’ or personalities (Crabtree, 1988, 1993; Van der Hart, 1997). This led Puységur to assert that “La demarcation est si grande, qu’on peut regarder ces deux états comme deux existences differentes”: “the line of demarcation [in the personality during artificial somnambulism] is so complete that these two states may almost be described as two different existences” (Crabtree, 1993, p. 42). Puységur pointed out that these two different existences typically exhibited discordant personality traits (Crabtree 1993). He observed that an individual in a somnambulistic state (either natural or artificially-​induced) displayed two separate streams of thought and memory, in which, at any particular moment, one stream operated outside conscious awareness (Crabtree, 1988, 1993). In conjunction with this multiplication of ‘existences,’ Puységur and colleagues also observed and explained certain discrete dissociative phenomena, especially the psychogenic amnesia that followed hypnotic states (Crabtree, 1988, 1993; Ellenberger, 1970). Puységur observed, “I have noticed that in the magnetic state the patients have a clear recollection of all their doings in the normal state, but in the normal state, they can recall nothing of what has taken place in the magnetic condition” (cited in Forrest, 1999, p. 95; see also Deleuze, 1819).

Jacques Moreau de Tours Initially, the division of the personality as an integrated whole was not referred to as dissociation. The French psychiatrist, Moreau de Tours (1845), was probably the first to use the term dissociation in a manner that is consistent with understandings of the concept as a division of the personality or multiplication of personalities1 (Crabtree, 1993; Van der Hart & Horst, 1989). According to Moreau de Tours, who studied the psychological effects of hashish, dissociation—​or disaggregation (désagrégation)—​was the ‘splitting off’ or isolation of ideas. If ideas had been aggregated, or integrated, they would have become part of the normal harmonious whole. Moreau de Tours’ work preceded fictional representations of chemically-​ induced dissociative states, such as that depicted in the psychological battle between good and evil in Robert Louis Stevenson’s Dr Jekyll and Mr Hyde. Although Moreau de Tours first dealt with chemically-​induced dissociation, he

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subsequently studied purely psychological phenomena such as hysterical psychosis (Moreau de Tours, 1865, 1869; Van der Hart, Witztum, & Friedman, 1993).

Gros Jean Gros Jean (1855), a pseudonym for Paul Tascher (Crabtree, 1993), posited the concept of a secondary personality. Tascher broke new psychological ground with his speculation that certain nervous disorders—​specifically, possession states, magnetism, and automatic writing—​involved a division or multiplication. Tascher argued that these phenomena derived from the existence of a second personality—​capable of “romantic fabrications” and “digressions”—​which concurrently existed with the ordinary personality. This notion was new; it went well beyond the idea of a multiplication of personalities that was induced by hypnosis or chemicals. Tascher’s theory presented a novel means of understanding behaviours that originated outside the conscious awareness of the primary personality.

Hippolyte Taine Like Tascher, the French philosopher, critic, and historian, Hippolyte Taine (1828–​1893), in a major work on psychology, De l’intelligence, described automatic writing as involving a profound doubling of existences (Taine, 1878): In spiritistic manifestations themselves we have shown the coexistence in the same individual of two thoughts, of two wills, of two distinctive actions, of one of which the subject is conscious, but the other of which he has no consciousness and which he attributes to invisible beings. The human brain is thus a theatre where at the same time several different pieces are played, on different stages of which one is in the spotlight… I have seen a person who, while chatting and singing, wrote complete sentences without looking at the paper, without being conscious of what she wrote… When she reads it she is astonished and sometimes alarmed. The handwriting is quite different from her usual style. The movement of the fingers and pencil is stiff and seems automatic … We certainly find here a doubling of the ego [dédoublement du moi], the simultaneous presence of two parallel and independent series, of two centers of action, or, if you wish, two moral persons side by side in the same brain—​one on the stage and the other behind the scenes. pp. 16–​17 Taine made an important addition to this account, noting that these two ‘lives’ are neither clearly nor completely separated. Thus, the initial study of dissociative phenomena such as amnesia following artificial somnambulism and automatic writing explained dissociation in terms of a doubling of consciousness. Many nineteenth-​century clinicians used this same explanatory dynamic to account for hysteria and hysterical symptoms.

Division or Doubling of Consciousness and Clinical Dissociation: Hysteria and Hysterical Symptoms By the mid-​1800s clinicians were detecting a link between the division into multiple centres of consciousness or personalities in hypnosis and the clinical phenomena of hysteria.2 In the same work in which he presented his famous DID patient Estelle, Charles Despine (1840) argued that hypnosis was clearly connected to hysteria (Fine, 1988; Kluft, 1986). Similarly, Briquet (1859) reported that most people who were called magnetic somnambules [hypnotics] were hysterical women. Charcot (1887) further developed these ideas when he theorized that hysterical symptoms (e.g., paralyses, contractures) were based on subconscious ideas that had become separated from consciousness. Finally, Pierre Janet came to view somnambulism as paradigmatic for the dissociative nature of hysteria (Van der Hart, 1997; Van der Hart & Friedman, 2019). In other words, Janet considered both somnambulism and hysteria to be based upon a division of the personality ( Janet, 1889/2022a,b, 1907). In the late 1800s, many clinicians and theorists advanced two theses: (1) that dissociation is a division or ‘splitting’ of the personality or multiplication of centres of consciousness or existences or personalities, and (2) that dissociation underlies hysterical symptoms and hysterical phenomena (Binet, 1890, 1892; Gilles de la Tourette, 1887; Legrand du Saule, 1883; Myers, 1887; Ribot, 1885; Richet, 1884). In 1888, Jules Janet used the model of ‘double personality’ to explain dissociative psychological phenomena. Although his model of the ‘double personality’ left no room for the notion of multiple personalities, it offered a succinct model of hysteria. Jules Janet claimed that each person has two personalities, one conscious and one unconscious (inconçue =​unconceived). In normal individuals, the two personalities are equal and in harmony with each other; in

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hysterical patients, the two personalities are unequal and unbalanced. In hysterics, the first personality is incomplete (i.e., exhibits hysterical losses, i.e., negative dissociative symptoms; cf. Nijenhuis & Van der Hart, 1999) and the second personality is “perfect.” In 1893, Stéphanie Feinkind, a student of Charcot at the Salpêtrière in Paris, published a treatise on “natural somnambulism” and hysterical attacks in the form of somnambulism. Feinkind argued that both kinds of somnambulism are characterized by “doubling (dédoublement de la personnalité) or rather dissociation of the personality, in the psychological sense of the word” (p. 139). In both instances, the individual’s return from the somnambulistic episode is almost always characterized by forgetfulness (l’oublie). That forgetfulness, Feinkind insisted, was “previously explained [dit] by the dissociation between two personalities, more or less completely ignorant of each other” (p. 140).

Pierre Janet Although often assumed, it was not Pierre Janet (1859–​1947) who introduced the term “dissociation.” However, of the many theorists of dissociation, he unquestionably presented the most detailed and articulate account of the connection between division in the personality/​multiplication of personalities (i.e., dissociation) and hysteria (cf., Meares & Barral, 2019; Perry & Laurence, 1984; Putnam, 1989a; Van der Hart & Friedman, 2019; Van der Kolk & Van der Hart, 1989). Originally a philosopher and experimental psychologist, in his position as psychiatrist at the Salpêtrière, Janet became the leading scientist in the study of hysteria. His thesis for the doctorat ès-​lettres, L’automatisme psychologique: Essai de psychologie expérimentale sur les formes inférieures de l’activité humaine ( Janet, 1889), can be regarded as history’s most important work on dissociation (Nemiah, 1989). An Italian translation appeared in 2013, and an English one in 2022. Janet considered hysteria to be “an illness of the personal synthesis” ( Janet, 1907, p. 332). By this, he meant “a form of mental depression [i.e., lowered integrative capacity] characterized by the retraction of the field of consciousness and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute personality” ( Janet, 1907, p. 332). Although Janet was not always explicit about this, he thought that these dissociative “systems of ideas and functions” had their own sense of self, as well as their own range of affect and behaviour (Nijenhuis, 2015). Janet’s definition of hysteria makes it clear that he distinguished between retraction of the field of consciousness and dissociation. For him, retraction of consciousness merely implied that individuals have “in their conscious thought a very limited number of facts” ( Janet, 1907, p. 307). Nowadays many students of dissociation subsume phenomena related to retraction of the field of consciousness, such as absorption and imaginative involvement, under the label of dissociation. Janet acknowledged a role for constitutional vulnerability in illnesses of personal synthesis, but he regarded physical illness, exhaustion, and, especially, the vehement emotions inherent in traumatic experiences as being the primary causes of this integrative failure ( Janet, 1889/2022a,b, 1909, 1911; cf., Van der Hart & Rydberg, 2019). In linking vehement emotions with their impact on the personality, he notes, “except in the most extreme cases, they do not really destroy the elements of thought; they let them exist but disaggregated, isolated from each other, sometimes up to a point where their functions are almost suspended” ( Janet, 1898, p. 475). In keeping with Janet’s formulation, the most obvious of these dissociative systems contains traumatic memories, which he originally described as primary idées fixes ( Janet, 1894b, 1898). These systems consisted of “psychological and physiological phenomena, of images and movements of a multiform character” ( Janet, 1919/​25, p. 597). When these systems are reactivated, patients are “continuing the action, or rather the attempt at action, which began when the [trauma] happened; and they exhaust themselves in these everlasting recommencements” (Janet, 1919/​25, p. 663). Janet actually observed that dissociative patients alternate between experiencing too little and experiencing too much of their trauma: [T]‌he illness consists of two simultaneous things: 1) the inability of the subject to consciously and voluntarily recall the memories, and 2) the automatic, irresistible and inopportune reproduction of the same memories. Janet, 1904/​11, p. 528 Janet (1889, 1904, 1928) observed that, especially when the individual encounters salient reminders of the trauma, traumatic memories/​fi xed ideas not only may alternate with the habitual personality, but also may intrude upon it. Janet also drew upon traumatic memories to explain the distinction between the mental stigmata and the mental accidents that characterize hysteria ( Janet, 1893, 1894a, 1907, 1911; cf., Nijenhuis & Van der Hart, 1999). Emphasizing that mind and body are one and the same, he did not make any distinction between dissociation of the mind and dissociation of the body in mental stigmata and mental accidents. And, like his contemporaries, he regarded symptoms pertaining

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to movements and sensations as dissociative in nature. The mental stigmata are negative dissociative symptoms that reflect functional losses, such as losses of memory (amnesia), sensation (anæsthesia), and motor control (e.g., paralysis). The mental accidents are positive dissociative symptoms that involve acute, often transient intrusions, such as additional sensations (e.g., pain), movements (e.g., tics) and perceptions, up to the extremes of complete interruptions of the habitual part of the personality. These complete interruptions are due to a different part of the patient’s personality that was completely immersed in re-​experiencing trauma. Related to primary idées fixes (i.e., traumatic memories), were secondary idées fixes (i.e., fixed ideas not based on actual events, but nevertheless related to them, such as fantasies or dreams). For example, a patient might develop hallucinations of being in hell secondarily related to an extreme sense of guilt during or following a traumatic experience. Such dissociative episodes were called hysterical psychosis, and more recently relabelled as (reactive) dissociative psychosis (Van der Hart, Witztum, & Friedman, 1993; Van der Hart & Witztum, 2019). According to Janet, the more an individual is traumatized, the greater is the fragmentation of that individual’s personality: “[Traumas] produce their disintegrative effects in proportion to their intensity, duration, and repetition” ( Janet, 1909, p. 1556). Janet regarded multiple personality disorder as the most complex form of dissociation and he noted the differences in character, intellectual functioning, and memory among different personalities ( Janet, 1907). He observed that certain dissociative parts had access only to their own past experience, while other parts could access a more complete range of the individual’s experience. Dissociative parts could be present side by side and/​or alternate with each other. Importantly, Janet noted that dissociative parts each had their own first-​person perspective or ‘sense of self,’ a theme explored by World War I psychiatrists, like Mitchell and McDougall (see below). In short, for Janet, vehement or violent emotions lead to integrative failure which lead to the division of the personality into dissociative “systems of ideas and functions” ( Janet, 1907) that had their own phenomenal awareness. These dissociative (sub)systems were not restricted to DID, but occurred in many, less developed forms of hysteria (Nijenhuis, 2015; Van der Hart & Rydberg, 2019). Unlike more psychoanalytic views of dissociation, any defensive purpose this failed integration has is secondary to it rather than teleological of it. Janet (1898, 1911, 1919/​25) developed a phase-​oriented three-​stage treatment approach avant la lettre: (1) stabilization and symptom reduction, aimed at raising the patient’s integrative capacity; (2) treatment of traumatic memories, aimed at the resolution or completion of the unfinished mental and behavioral actions inherent in these traumatic memories; and (3) personality (re)integration and rehabilitation, i.e., the resolution of dissociative (sub)systems and fostering of further integrative development (Van der Hart, Brown, & Van der Kolk, 2019). Janet observed that following integration of dissociative (sub)systems, somnambulistic states could no longer be evoked as the structural organization of the person’s psyche now was unable to give rise to them.

Alfred Binet The experimental psychologist Alfred Binet (1857–​1911), a contemporary of Janet, was the Director of the Laboratory of Physiological Psychology at the Sorbonne, Paris. Although most recognized as the creator of the first formal test of cognitive ability, Binet is a wrongly forgotten pioneer in the field of dissociation. Ross (1989) has pointed out that his experimental studies on hypnosis addressed what Hilgard (e.g., 1977) later described as the “hidden observer” phenomenon. Initially Binet (1890) emphasized the ‘doubling of consciousness’ (i.e., the personality) into parts. However, in 1891 he had clearly broadened his view: In general, observers have only noted two different conditions of existence in their subjects; but this number two is neither fixed nor prophetic. It is not perhaps, even usual, as is believed; on looking closely we find three personalities in the case of Félida, and still a greater number in that of Louis V. That is sufficient to make the expression “double personality” inexact as applied to these phenomena. There may be duplication, as there may be division in three, four, etc., personalities. Binet, 1892/​96, p. 38 In his excellent experimental studies, Binet confirmed many of the findings established by Janet. He also established that even when “states of consciousness” are unknown to each other, there may take place between them an exchange of perceptions, thoughts, feelings, images, etc. The nature and extent of the information exchanged is still the focus of experimental investigation by contemporary researchers (e.g., Huntjens, Verschuere, & McNally, 2012; Marsh et al., 2018).

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Society for Psychical Research in Britain At the same time that the French were investigating the dissociative basis of hysteria, the British were studying dissociative phenomena under the auspices of the Society for Psychical Research (SPR). In his analysis of the SPR between 1882 and 1900, Alvarado (2002) noted that the study of dissociative phenomena in Britain was largely (though not exclusively) dominated by non-​clinical subjects and non-​clinical dissociative experiences. In contrast, clinical participants and clinical phenomena constituted the bulk of dissociation studies in France.3 SPR members vigorously studied hypnosis, mediumship, automatic speaking and writing, telepathy, double and multiple personality, fugue, trance states, creativity, and secondary and subconscious consciousness. These diverse psychological phenomena were believed to be based upon multiplications of existences (i.e., dissociation). For example, Frederic Myers (1887) initially proposed the concept of ‘multiplex personality’ to explain how multiple personalities and hypnosis derived from the multiplication of personalities. He then proposed that the psychic structure was made up of a supraliminal self that operated at a consciousness level and a subliminal self that operated outside conscious and volitional awareness. Automatic writing, and various other phenomena where explained by one self impinging on the other. In further developing his theoretical ideas, Myers (1903) sought to bring together under his concept of the ‘subliminal mind’ various phenomena which he believed were characterized by multiplication of personalities, such as hypnotic trance, telepathy, hysteria and creativity (Alvarado, 2002; Crabtree, 2007). In their studies of hysterical patients, many French clinicians, such as Janet, viewed dissociation (the division of the personality/​multiplication of personalities) as a pathological organization or process. However, for British SPR members, dissociation had both pathological and non-​pathological expressions. Alvarado (2002) pointed out that SPR literature also placed less emphasis on the connection between dissociation and trauma. As a consequence, it is unclear what proportion of their participants, especially those with profound mediumship ability, acquired their dissociative “skills” courtesy of trauma-​induced divisions of their personality.

Nineteenth-​century Conceptualizations of Dissociation It is interesting to note that nineteenth-​century literature did not commonly use the term ‘dissociation.’ Still, famous cases such as Félida X (Azam, 1876a,b, 1887; cf. Hacking, 1995; Van der Hart, Faure, Van Gerven, & Goodwin, 1991) and Louis Vivet (Bouru & Burot, 1888; Camuset, 1882; cf., Faure et al., 1997; Hacking, 1995) were the subjects of intense scientific discussion. Other terms were often used in lieu of “dissociation.” Beginning with Gmelin’s (1791) terminology, Table 1.1 provides a comprehensive but not exhaustive list of alternative terms. Many of these concepts are directly related to the division of the personality as an integrated whole. However, in his comments on some of these concepts, O’Neil (1997; see Chapter 8, this volume) argued that they basically refer to two metaphors, one pertaining to a division or ‘splitting,’ and the other to a doubling or multiplication of consciousness or the personality. As Binet (1890) concluded and modern views have confirmed (e.g., Braude, 1995; Ross, 1989), dissociative personalities may appear separate and even display no conscious awareness of one another. But together these divided or doubled systems or dissociative parts make up the individual’s complete psychological experience, and they may influence each other more than is commonly assumed.

Dissociation in North America William James William James was a diligent and eager student of dissociation. He was influenced and richly inspired by the writings of Janet4 and other French investigators (e.g., Binet, Charcot), as well as by the ideas of SPR members such as Gurney and Frederic Myers. James was the first to convey European ideas about dissociation to American scholars and clinicians. Although James gave some coverage to dissociation in his magnum opus, The Principles of Psychology (1890), his 1896 Lowell lectures on Exceptional Mental States (Taylor, 1983) were the culmination of his ideas about the various normal and abnormal manifestations of dissociation. Like many others at the time, James spoke of dissociation in terms of the plurality of consciousness. For example, in Lecture 3 of this series, James began by presenting F. Myers’ notion of the subliminal self, where the psyche is represented by ‘double (or multiple) consciousness,’ one operating above the threshold of awareness and the other (or others) operating simultaneously outside awareness. Drawing on observations from French clinicians, James used ‘splits’ in consciousness to account for various hysterical (i.e., dissociative) symptoms. These symptoms included visual anæsthesia, that is, a subjective inability to see. James described a case of hysterical blindness in the left eye: “[t]‌he mind is split in two. One part agrees not to see anything with the left eye alone, while

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1 2 3 4 5 6 7 8 9

Authors

Alternative terms for dissociation

Puységur, 1784 Gmelin, 1791 Dwight, 1818 Baillarger, 1845 Gros Jean/​Tascher, 1855 Lemoine, 1855 Gros Jean/​Tascher, 1855 Richet, 1884 Gros Jean/​Tascher, 1855 Gros Jean/​Tascher, 1855 Gros Jean/​Tascher, 1855

Two different existences (deux existences différentes) Exchanged personality (Umgetauschte Persönlichkeit) Two souls Intellectual duality (dualité intellectuelle)

10 Gautier, 1858 Baillarger, 1861, 1862 Azam, 1876b Séglas, 1891 Bœteau, 1892 Bourneville, 1892 11 Littré, 1875 Azam, 1887 Binet, 1890 Breuer & Freud, 1893 Hyslop, 1899 12 Azam, 1876a 13 Taine, 1878 Delbœuf, 1879 14 Ribot, 1885 J. Janet, 1888 15 Ribot, 1885 16 Bérillon, 1886 17 Beaunis, 1887 18 Myers, 1887 Osgood Mason, 1895 19 Janet, 1887 20 Bourru & Burot, 1888 21 Bourru & Burot, 1888 22 P. Janet, 1889/2022a,b Binet, 1892 23 Binet, 1890 24 Dessoir, 1890 25 Binet, 1892 Laurent, 1892 26 Binet, 1892/​1896; Janet, 1946 27 Laurent, 1892 28 Myers, 1893 29 Bruce, 1895 30 Osgood Mason, 1895 31 James, 1896 (in Taylor, 1983)

Schism of the personality (scission de la personnalité) Intellectual doubling (dédoublement intellectuelle) Doubling of the intelligence (dédoublement de l’intelligence) Intellectual division (division intellectuelle) Intellectual schism (scission intellectuelle) Schism between the will and the over-​active organism (scission entre la volonté et l’organisme suractif ) Doubling of the personality (dédoublement de la personnalité)

Double consciousness (double conscience)

Doubling of life (dédoublement de la vie) doubling of the ego (dédoublement du moi) (also translated as “dual ego” or “doubling of the self ”) Double personality (double personnalité) Dissolution of the personality Dissolution of indissoluble phenomena Doubling of memory and consciousness (dédoublement de la mémoire et de la conscience) Multiplex personality Dissociation of psychological phenomena Multiple personality Variations of the personality Psychological disaggregation (désagrégation psychologique) Disaggregation of psychological elements Duplication of personality Double ego (Doppel-​Ich) Alterations of the personality Division of personality The existence of secondary states (états seconds) Subliminal consciousness Dual brain action Duplex personality Alternating personality

the other sees with the right eye perfectly well” (Taylor, 1983, p. 59). In describing this and other cases of anæsthesia, James concluded that “[s]omething sees and feels in the person, but the waking self of the person does not” (p. 60). Having covered dreams, hypnotism, automatism, and hysteria, James began his fourth lecture by stating: “we are by this time familiar with the notion that a man’s consciousness need not be a fully integrated thing … But we must pass now to cases where the division of personality is more obvious” (Taylor, 1983, p. 73). This lecture addressed the topic of multiple personality; in such individuals, there exists intelligent and seemingly independent dissociative personalities.

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James favoured Myers’ model of subliminal consciousness because, he argued, Myers model could explain both Janet’s pathological fragmentations from the primary personality as well as the nonpathological cases of mediumship. Following James’ interest in dissociation, especially its clinical manifestations, Boris Sidis and Morton Prince were probably the most important American clinicians who studied dissociation at the beginning of the twentieth century.

Boris Sidis Sidis provided a developmental perspective on the ætiology of simultaneous, discontinuous streams of consciousness (Sidis, 1902; Sidis & Goodhart, 1904). In their book, Multiple Personality: An Experimental Investigation into the Nature of Human Individuality, Sidis and Goodhart argued that, “under the influence of hurtful stimuli, be they toxic or traumatic in nature, the first stage of functional degeneration may give rise to functional dissociations…” (Sidis & Goodhart, 1904, p. 53). For Sidis and Goodhart, loss of memory was the essential indicator of the dissociative effects of “hurtful stimuli”: The breaks and gaps in the continuity of personal consciousness are gauged by loss of memory. Mental systems not bridged over by memory are so many independent individualities, and if started on their career with a good supply of mental material, they form so many independent personalities. For, after all, where memory is gone the dissociation is complete. p. 44 Sidis relied on case studies to exemplify his ideas about multiple personality, including a famous case that had been described by his New England contemporary, Morton Prince.

Morton Prince A keen clinical observer and researcher of dissociation, Prince (1854–​1929) is probably best known for his celebrated multiple personality case, Miss Beauchamp (Prince, 1906a). Actually, however, Prince was probably more interested in the unconscious than dissociation. He spent most of his career using the many manifestations of dissociation (e.g., induced, such as hypnosis; spontaneous, such as dissociative disorders) to undercover and understand the unconscious (Hales, 1975). Although his ideas about dissociation were primarily influenced by the French theories of Pierre Janet, and others (e.g., Charcot), Prince did not uniformly accept all French ideas about dissociation. For example, he was critical of the formulations of dissociation that were offered by Jules Janet and Azam. Prince (1906b) argued that these individuals misunderstood the structural nature of the psyche in patients with hysteria, especially in terms of what constituted the “first” and “second” personalities. Prince’s view was the reverse of that offered by J. Janet and Azam. They considered the “hysteric” personality to be the original or first state, and the “normal” personality to be the dissociated secondary state. Prince (1906b), on the other hand, claimed that the “hysteric” state was the secondary, dissociative, or disintegrated state that was characterized by both positive and negative “physiological” (i.e., somatic) and psychological symptoms.The first or normal personality, according to Prince, displayed no symptoms. In a prescient anticipation of modern thinking, Prince (1906b) argued that these “personalities” (especially the hysteric personality state) were able to ‘split’ further, thus moving from double to multiple personality. In the case of multiple personality, the personalities of “hysterics” may alternate with one another or with the “normal” personality: “Where there are more than two personalities, we may have two hysteric states successively changing with each other, and it may be, with the complete healthy person [normal personality]” (p. 172). Like many of his contemporaries (e.g., Janet, 1907; Sidis, 1902; Sidis & Goodhart, 1904), Prince was interested in the structure of personality organization and the divisions (‘splits’) and multiplications that it manifested. He devoted a great deal of his academic writing to the development of a structural model of personality. This structural model accounted for both the integrated functioning that is evident in the normal population and the disintegrated (dissociated) functioning that he observed in his dissociative patients, such as Miss Beauchamp and B.C.A. (e.g., Prince, 1921, 1924). Prince was one of the first to conceive of dissociation as a mechanism which was not solely pathological, but which could operate as a part of normal psychological functioning (Prince, 1909). However, unlike contemporary ideas of a continuum of dissociative experience that emphasize dissociative phenomenology, Prince remained firmly focused on the structural elements of psychic functioning and how psychological systems and complexes (associated ideas) become disconnected and synthesized. The structure and dynamics of personality functioning seemed to have a greater interest to Prince than the etiological factors which gave rise to dissociations in the otherwise integrated organization of “unitary complexes and systems” (Prince, 1921, p. 408). According to Prince (1906b), different structural elements of the psyche (i.e., the “hysteric” and

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“normal” personality states) in double or multiple personality could be evoked (or caused to alternate) by “the hypnotizing process … or as a result of emotional shock [trauma], … or it may be without demonstrable cause” (p. 174). Prince’s greater concern for (a) the structure/​dynamics of personality than (b) the ætiology of dissociation, is the reverse of what we see in the contemporary study of dissociation and dissociative disorders. Today, etiological factors seem to attract more attention than the dissociated structure and organization of personality.

Dissociation in British Psychiatry During and After World War I As noted above, dissociation received much attention in the early twentieth century through the work of F. Myers, Sidis, Prince (e.g., F. Myers, 1903; Prince, 1906a; Sidis, 1902), and others (e.g., W. F. Prince, 1917). Less well-​k nown is the interest of several British Army psychologists, especially Charles Samuel Myers (1916, 1920–​21, 1940; cf., Van der Hart, Van Dijke, Van Son, & Steele, 2000; Van der Hart, Nijenhuis, & Steele, 2006).

Charles Myers Myers (1873–​1946) found Janet’s dissociation theory of great clinical value for the diagnosis and treatment of traumatized combat soldiers (cf. Van der Hart & Brown, 1992). In reflecting on his clinical experiences with acutely traumatized WWI combat soldiers, Myers (1940) found that the mental condition in which his patients (re)experienced their trauma could best be described as a (dissociative) personality, i.e., an ‘emotional’ personality. The failure to integrate the various sensory and psychological aspects of horrific experiences had led to a division into an “apparently normal personality” and an “emotional personality.” Myers’ conceptual formulation (i.e., of the apparently normal personality and the emotional personality) can be regarded as an important precursor to modern claims that acute stress disorder and posttraumatic stress-​d isorder are actually dissociative disorders (cf., Chu, 1998; Spiegel & Cardeña, 1991; Nijenhuis, 2015; Van der Hart et al., 2006). Myers described an acutely traumatized patient in a stuperous state as follows: At this stage, the normal personality is in abeyance. Even if it is capable of receiving impressions, it shows no signs of responding to them. The recent emotional [i.e., traumatic] experiences of the individual have the upper hand and determine his conduct: the normal has been replaced by what we call the ‘emotional’ personality. Gradually or suddenly an ‘apparently normal’ personality usually returns—​normal save for the lack of all memory of events directly connected with the shock, normal save for the manifestation of other (‘somatic’) hysterical disorders indicative of mental dissociation. Now and again there occur alterations of the ‘emotional’ and the ‘apparently normal’ personalities, the return of the former being often heralded by severe headache, dizziness or by a hysteric convulsion. On its return, the ‘apparently normal’ personality may recall, as in a dream, the distressing experiences revived during the temporary intrusion of the ‘emotional’ personality. The ‘emotional’ personality may also return during sleep, the ‘functional’ disorders of mutism, paralysis, contracture, etc., being then usually in abeyance. On waking, however, the ‘apparently normal’ personality may have no recollection of the dream state and will at once resume his mutism, paralysis, etc. p. 66–​67 Following the therapeutic lead of Janet, Myers (1920-​21; cf. Van der Hart & Brown, 1992) emphasized the integration of traumatic memories rather than abreaction. This approach implies the integration of both personalities (Myers, 1940).

Thomas Mitchell and William McDougall Several post-​World War I British psychiatrists and psychologists were also very interested in dissociation (e.g., McDougall, Mitchell and Hart). Mitchell (1922) summarized the then current state of knowledge regarding dissociation: It is now very generally admitted by psychologists that in some persons consciousness may become split up into two or more parts. The split-​off or dissociated portion may be but a fragment of the whole self, or it may be so extensive, so complex, and so self-​sufficient as to be capable of all the functions of a personal consciousness. In hysteria we find isolated paralyses or localized anæsthesias which are due to the dissociation of relatively simple ideas, or we may find a splitting so deep, a dissociation of so many kinds of mental activity, that it leads to a complex change of the personality. p. 105

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Both Mitchell (1921, 1922) and McDougall (1926) took issue with what they perceived as Janet’s mechanistic view of the construct; they thought that Janet was describing separate mental systems that had no ‘sense of self.’ Mitchell and McDougall’s may have derived this understanding of Janet by reading only The Major Symptoms of Hysteria ( Janet, 1907), which was available in English. In many of his original French publications, Janet had emphasized the sense of self as a basic characteristic of dissociative mental states (e.g., Janet, 1889/2022a,b). Nevertheless, Mitchell and McDougall shone light on an issue that is still difficult to grasp. For Mitchell (1922), that which is dissociated always becomes part of, or forms the basis for, another personality. Discussing Janet’s dissociation theory, he wrote: [I]‌t cannot be too often repeated and insisted on that we have absolutely no knowledge of any such isolated mental material. If normally an experience that passes out of consciousness is conserved as a psychical disposition, it is as a psychical disposition of some personality. If it is not dissociated, it remains part of the normal personality and retains the privilege of being able to reappear above the normal threshold. But if its passage out of consciousness is accompanied by dissociation, it may continue to exist as an unconscious psychical disposition or as a coconscious experience, and forms an integral part of some personality which may or may not be wider than that which manifests in waking life. p. 113/​4, emphasis added In his major work on abnormal psychology, McDougall (1871–​1938) concurred with Mitchell: [W]‌e must interpret the minor phenomena of dissociation in the light of the major cases, the extreme cases in which the phenomena lend themselves better to investigation. In all such major cases, we find the dissociated activity to be not something that can be adequately described as an idea or a group or train of ideas, but rather the self-​conscious purposive thinking of a personality; and, when we study the minor cases in the light of the major cases, we see that the same is true of them. 1926, pp. 543/​4 For McDougall, Mitchell, and many others (e.g., Janet, Prince, C. Myers), what was dissociated was not simply an isolated, non-​integrated psychological element of an experience (e.g., the memory of the event) that existed in an agent-​less vacuum. Rather, what was dissociated formed another personality, with its own sense of self, perceptions, thoughts, feelings, images, etc, within the individual. Why? Because the dissociated material (1) was made up of multiple elements of psychological experience (e.g., memories, emotions, conations, sensations), (2) had a sense of self (e.g., the ability to introspect and the capacity to remember autobiographical experiences knowing that they are one’s own) and, (3) operated more or less independently of the dominant personality (or, in the case of DID, operated more or less independently of other personalities). In short, the personality or personalities that were developed by the failure to integrate, perceptions, thoughts, feelings, images, etc., into a unified personality were more or less independent psychobiological organizations that had a sense of self.

Italian Cases of Dissociative Identity Disorder from the Early Twentieth Century While more commonly recognized in France and Great Britain in the early twentieth century, perhaps because students of dissociation were more versed in French and English writing, cases of dissociative disorder were evident elsewhere. For example, Ellenberger (1970) noted in Italy Morselli’s case of Marisa from the early 1900s, where EEG recordings were taken on two of her dissociative identities. Yet, he drew most attention to Morselli’s important DID case study of Elena F., published in 1930. Recently, Schimmenti (2017) presented a more extensive description of this case not previously available in the international literature and summarized it as follows: The case of Elena has been considered in literature as one of the most remarkable cases of multiple personality ever published. In fact, before treatment, Elena showed alternating French-​and Italian speaking personalities, with the Italian personality knowing nothing of her French counterparts. After a difficult treatment involving recovered memories of incestuous attacks by her father, which were proven to be true, Elena fully recovered from her symptoms. p. 1 Schimmenti also discussed Elena’s psychoform and somatoform symptoms according to a contemporary perspective on the relationally traumatic origins of dissociation and dissociative identity disorder.

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Dissociation in the Psychoanalytic Literature Josef Breuer and Sigmund Freud Although it may often be understated, downplayed, or ignored, dissociation takes pride of place as the first identified mechanism of ego defence in psychoanalysis (Vaillant, 1992). In 1893, Breuer and Freud wrote: …we have become convinced that the splitting of consciousness which is so striking in the well-​known classical cases under the form of ‘double conscience’5 is present in a rudimentary degree in every hysteria, and that a tendency to such a dissociation, and with it the emergence of abnormal states of consciousness (which we shall bring together under the term ‘hypnoid’), is the basic phenomena of this neurosis. In these views we concur with Binet and the two Janets. … These hypnoid states share with one another and with hypnosis … one common feature: the ideas which emerge in them are very intense but are cut off from associative communication with the rest of the content of consciousness. p. 12, italics and footnote in original Breuer’s concept of hypnoid states (see quotation above) was his adaptation of the French expression for somnambulistic states. Yet despite their general agreement with French observations and thoughts, Breuer and Freud (1893) claimed that “splitting of the mind” or “splitting of consciousness” was not related to a constitutional predisposition to mental weakness; but rather that mental weakness was brought about by dissociation. This idea contradicted what was believed to be Pierre Janet’s formulation that psychological weakness (manifesting in low integrative capacity) was a biological predisposing factor for the “splitting of consciousness” (i.e., dissociation) that gave rise to hysteria. In passing, it should be noted that it would be an oversimplification of Janet’s ideas to concentrate on biological predisposition. As outlined above, Janet was very aware of factors other than biological predisposition that contributed to a lowering of integrative capacity (e.g., physical ill-​health). Furthermore, like Breuer and Freud, Janet emphasized the disintegrative effect of the vehement emotions experienced during and after trauma (Van der Hart & Rydberg, 2019). Freud himself initially perceived dissociation as an ego defence against the intense affect that manifested in hysterical paralysis (Freud, 1893). He also initially gave childhood trauma, especially abuse, a core etiological role in hysteria (Freud, 1896). However, his focal interest in dissociation and abuse were short-​lived. Two years later he began to work on his repression model (e.g., Freud, 1895) and turned his attention away from dissociative phenomena in general and multiple nuclei of consciousness in particular6 (See O’Neil, Chapter 8, this volume). In addition, he quickly came to place great emphasis on the etiological role of instinctual drives and intrapsychic conflict in the development of hysteria and other neurotic forms. Freud did briefly return to the topic of multiple centers of consciousness in 1912 (cf., Crabtree, 2007), where in his ‘a note on the unconscious,’ he argues against the existence of a “consciousness of which its owner himself is not aware” (p. 263), preferring to speak of “oscillating between two different psychical complexes which become conscious and unconscious in alternation” (p. 263). It seems he correctly understood that consciousness could not be divided within a single owner, but he did not have room for multiple consciousnesses with different owners. This notion is quite distinct from how DID, for example, is conceptualized, where with multiple centers of consciousness come multiple owners and first person perspectives (see Nijenhuis, 2015, for further and wider discussion). Discussion of dissociation was largely absent from early twentieth-​century psychoanalytic literature (Hart, 1926). However, neither dissociation nor trauma vanished from the rise and evolution of psychoanalytic ideas (e.g., Alexander, 1956); over time conceptualizations of dissociation were developed from psychoanalytic frameworks. Perhaps Erdelyi (1994) said it best when he stated that “dissociationism itself was not abandoned or absorbed, but rather a dissociationism different from Janet’s was pursued” (p. 9). In the psychoanalytic literature, dissociation is often referred to as a defence,7 be it immature or neurotic (see Vaillant, 1992). From this perspective, integrated functioning temporarily (and defensively) gives way in order to minimize the impact of internal and external stressors. The core of the difference between this psychoanalytic view of dissociation and the nonpsychoanalytic views that were prevalent in the late nineteenth and early twentieth centuries is the following. Nonpsychoanalytic investigators conceptualized dissociation in terms of two aspects: (1) integrated functioning that temporarily gave way—​i.e., integrative failure (Liotti, 2009)—​in the face of stressors, and (2) the concomitant development of a separate, ‘split off,’ psychic organization, personality, or stream of consciousness. This separate organization was made up of the unintegrated or only partly integrated perceptual and psychological elements of the traumatizing event. This psychic organization operated outside of the individual’s conscious awareness and could be accessed by various means including hypnosis and automatic writing. It was the division into multiple centers of consciousness or personalities (i.e., dissociation) that

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caused such hysterical (dissociative) symptoms as amnesia and contractures. For nonpsychoanalysts, dissociation referred not only to insufficient integration, but also to a psychical organization or structure (i.e., a dissociative psychic organization). Early Freudians, on the other hand, limited their view of dissociation solely to the first aspect (i.e., the process of failed integration, which, for the analysts, was motivated by the ego in the service of defence). The nonpsychoanalytic understanding of dissociation differed substantially from Freud’s general framework and guiding principles. This made direct application from one model to another conceptually difficult (Hart, 1926). A clearer conceptualization of dissociation as a psychical or structural (systemic) organization remained a task for later psychoanalytic writers, such as Ferenczi and several object relations and relational theorists (Tarnopolsky, 2003; Howell & Itzkowitz, 2016; See Howell & Itzkowitz, Chapter 45, this volume).

Sándor Ferenczi Being schooled in the psychological effects of trauma during his time as a World War I army psychiatrist, Ferenczi was probably the earliest psychoanalytic writer to give serious attention to dissociation. In 1933, Ferenczi noted that dissociation or “splits in the personality” reflecting the structure of the psyche, were related to childhood trauma: If the shocks [traumas] increase in number during the development of the child, the number and the various kinds of splits in the personality increase too, and soon it becomes extremely difficult to maintain contact without confusion with all the fragments, each of which behaves as a separate personality yet does not know of even the existence of the others. p. 229 Although he probably overstated the degree of separateness of these dissociative personalities, Ferenczi provided in the early 1930s a rudimentary prototype of the contemporary posttraumatic model of dissociation and DID (e.g., Kluft, 1985; Putnam, 1989b, 1997; Ross, 1989, 1997; Howell & Itzkowitz, 2016). Also, he was the first to distinguish perpetrator introjects in abused individuals, which constitute a major focus in modern dissociative disorder treatment (e.g., Schwartz, 2013).

Ronald Fairbairn The object relations theorist Fairbairn (1944/​1992), argued that dissociation was the basis of hysteria: Here it may be added that my own investigations of patients with hysterical symptoms leaves me in no doubt whatever that the dissociation phenomena of ‘hysteria’ involves a split of the ego fundamentally identical with that which confers upon the term ‘schizoid’ its etymological significance. p. 92 Thus, for Fairbairn, “dissociation,” “schizoid,” and “splitting of the ego” were interchangeable terms that referred to a specific type of division in psychic organization.

Bridging Psychoanalysis and Hypnosis: Herbert Spiegel In 1963, Herbert Spiegel (1963) took up the term dissociation and used it in two related, but quite different ways: (1) dissociation as a defensive process, and (2) dissociation as a conceptual framework (i.e., the dissociation-​association continuum). In reference to defensive process, Spiegel (1963) viewed dissociation as a “fragmentation process that serves to defend against anxiety and fear (or instinctual demands)” (p. 375). With reference to conceptual framework, Spiegel offered dissociation as one pole on a dissociation-​association continuum that subsumed the phenomena explained by repression. The dissociation-​ a ssociation continuum provided a dynamic model of psychological experience that was not constrained by continual references to instinctual conflict. Spiegel’s dissociation-​a ssociation continuum stretches from (a) evasive defence strategies which minimize anxiety and are associated with constricted awareness, through (b) strategies designed to sustain an adaptive level of awareness, to (c) the resurfacing and (re)integration of dissociated ‘fragments’ which leads to a more expanded level of awareness, and creativity and growth. Thus, for Spiegel, dissociation referred to (1) the dis-​integration of otherwise associated ideas and (2) the constriction of awareness. Spiegel emphasized the defensive rather than the organizational aspects of dissociation.

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Psychoanalytic studies of dissociation proliferated in the 1970s (e.g., Gruenewald, 1977; Lasky, 1978) and early 1980s (e.g., Berman, 1981; Marmar, 1980). The psychoanalytic understanding and treatment of dissociation continue to evolve (e.g., Blizard, 2001; Brenner, 2018; Bromberg, 1998, 2017; Chefetz, 1997, 2015; Davies & Frawley, 1994; Howell, 2005, 2011; Howell & Itzkowitz, 2016; Kluft, 2000; Loewenstein & Ross, 1992; O’Neil, 1997; Schwartz, 2013; Stern, 1997, see Chapter 20, this volume).

The Renaissance of Dissociation: Non-​Pathological and Pathological Manifestations Dissociation attracted only minimal attention in the 1940s and 1950s (e.g., Lipton, 1943; Maddison, 1953; Taylor & Martin, 1944), but did produce the famous DID case of “Eve” (Osgood & Luria, 1954; Thigpen & Cleckley, 1954, 1957). The general dearth of interest in dissociation continued during the 1960s even though one clinical paper argued that multiple personality was far more prevalent than generally assumed (Morton & Thoma, 1964). The end of the 1960s, however, was marked by a rise in academic, non-​clinical interest in dissociation (or, at least, dissociation-​ like experiences). Unlike previous work, this new interest led to a broadening of the concept of dissociation; the concept of dissociation began to be applied to experiences that were unrelated to the division of the personality as an integrated whole (or what, at times, had been referred to as ‘splits’ in the personality), and also to experiences that went beyond dissociation as a defense. At that time, dissociation was increasingly described in two ways: (1) as a continuum of phenomena that stretched from normal experiences (e.g., daydreaming, hypnotic trance) to clearly pathological experiences (e.g., multiple personality), and (2) as being synonymous with alterations in consciousness. Experiences that fell at the lower end of the dissociation continuum (e.g., daydreaming, trance) exemplified the emerging tendency to equate dissociation with alterations of consciousness. This new view of dissociation paid particular attention to phenomenal changes in conscious experience from a normal waking state (as opposed to the earlier focus on structural (systemic) divisions of the personality or multiplications in personalities—​which, of course, also have phenomenal correlates). Some alterations of consciousness may still entail a “breakdown” in integrated functioning,8 the sine qua non of the American Psychiatric Association’s (2000) definition of dissociation, and also evident in the DSM-​5 -TR’s characterization of dissociative disorders.9 For example, during a daydream, the person may not integrate stimuli from the outside world into his or her conscious experience. The crucial point, however, regarding dissociation-​a s-​a lterations-​of-​consciousness is that the origin of the phenomenal experience is not derived from a division into personalities, but rather a failure to encode information. That is, a duality or plurality of personalities (or dissociative parts of the personality) is not necessary to have this type of “dissociative” experience. Echoing the thoughts of F. Myers in the nineteenth century, this view of dissociation holds that dissociative experiences are neither the exclusive domain of the clinical world, nor are they restricted to symptoms. However, unlike F. Myers, and others (e.g., M. Prince), this modern view focuses largely on phenomenal expressions rather than underlying psychic organization.

Charles Tart and Arnold Ludwig In 1969, Charles Tart published his monumental edited volume, Altered States of Consciousness. This work outlined the alterations in consciousness that were induced by psychedelic drugs, hypnosis, and meditation. In addition, the volume examined specific altered states of consciousness (ASC) such as depersonalization, derealization, trance states, absorption, and some of the residual effects of such states (e.g., subsequent amnesia). Of most interest to the current discussion is the opening chapter by Arnold Ludwig, a reprinting of his 1966 paper, “Altered States of Consciousness.” The importance of this chapter lies in Ludwig’s definition of ASC. He does not view ASC as analogous to dissociation, but his definition of ASC is clearly comparable to contemporary understandings of the dissociative continuum. Ludwig defined ASC …as any mental state(s), induced by various physiological, psychological or pharmacological maneuvers or agents, which can be recognized subjectively by the individual himself (or by an objective observer of that individual) as representing a sufficient deviation in subjective experience or psychological functioning from certain general norms for that individual during alert, waking consciousness. This sufficient deviation may be represented by a greater preoccupation than usual with internal sensations or mental processes, changes in the formal characteristics of thought, and impairments of reality testing to various degrees. p. 11

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In advance of, but consistent with, contemporary continuum ideas, Ludwig (1969) argued, “that ASC might be regarded…as a ‘final common pathway’ for many different forms of human expression and experience, both adaptive and maladaptive” (p. 20). The year after Ludwig published this idea (1966), West (1967) made similar assertions: Dissociation could be experienced in both pathological and non-​pathological forms. In later work, Ludwig (1983) clearly implied a continuum of dissociative experience when he suggested that both daydreams and multiple personality are examples of dissociation. Still, he grappled with two questions: (1) What should fall under the banner of “dissociation?” and (2) Is “dissociation” analogous to ASC? …[I]‌t is difficult to know the extent to which many other altered states of consciousness, such as transcendental meditative states, Yoga, alpha rhythm and peak experiences, should be regarded as examples of dissociation or whether dissociative states should be regarded as a subcategory of altered states of consciousness. Ludwig, 1983, p. 94 The question of what does and what does not constitute dissociation continues to be a source of disagreement; this, in turn, has serious consequences for the definition, theoretical utility, and descriptive value of the concept (e.g., Cardeña, 1994; Dell, 2009). Recently, Nijenhuis, Van der Hart, and Steele (2002; cf., Nijenhuis & Van der Hart, 2011; Van der Hart et al., 2006) have drawn upon both clinical and basic research to argue that, for the sake of clarity and clinical accurateness, dissociation should revert to its original Janetian understanding. By this they mean that dissociation pertains to the development of two or more parts of the personality that are insufficiently integrated with each other; most of these dissociative parts are characterized by a significant retraction of the field of consciousness. However, there are also other perspectives on these matters that attempt to provide clarity. Yet, if this view were adopted, dissociative episodes and ASC would be distinct psychological phenomena (though they may occur together). However, the relationship between ASC and dissociation of the personality is asymmetrical. Whereas the latter implies the presence of the former (because structural dissociation does not inhibit ASC), ASC do not necessarily imply a dissociation of the personality, or multiplication of personalities.

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Henri Ellenberger and the 1970s A remarkably rich and fertile volume that regenerated clinical interest in dissociation was published in 1970—​Henri Ellenberger’s monumental monograph, The Discovery of the Unconscious. In a highly detailed and stunning piece of scholarship, which provided a detailed overview of many historic DID cases, Ellenberger reintroduced the modern reader to Pierre Janet and his dissociative model of hysteria. Ellenberger demonstrated the importance of Janet’s ideas not only to his contemporaries, but also to the evolution of dynamic psychiatry. The Discovery of the Unconscious has influenced both clinical and non-​clinical scholars and researchers; it continues to be a valuable source of historical information today. At least four significant developments occurred in the early 1970s: (1) the publication of Sybil (Schreiber, 1973); (2) the publication of several papers that outlined treatment approaches for multiple personality disorder (MPD; e.g., Allison, 1974; Bowers et al., 1971; Gruenewald, 1971; Howland, 1975); (3) the publication of one of the first controlled attempts to examine the transfer of cognitive experiences across so-​called dissociative barriers in MPD (Ludwig, Brandsma, Wilbur, Benfeldt, & Jameson, 1972); and (4) with the publication of Hilgard’s neo-​d issociation theory, mainstream cognitive psychology became seriously interested in dissociation.

Ernest Hilgard Coming from a long background in hypnosis research (Hilgard, 1973), and being captivated by the secular interests in altered states of consciousness that were occurring at that time, Hilgard became deeply interested in dissociation. In 1974, he induced in highly hypnotizable students analgesia for cold-​pressor pain (i.e., from immersion of an arm in ice-​ cold water). To his initial surprise, Hilgard discovered that he could use automatic writing or talking to communicate with a “subconscious” part of the individual that reported feeling the pain and discomfort that the hypnotized person did not feel. Hilgard (1977) later referred to this “subconscious” part as the “hidden observer” (see also Hilgard, 1992). From this and further experiments with hypnosis, Hilgard developed his neo-​d issociation theory, which explicitly acknowledged the influence of Janet in particular, and other early investigators of dissociation who had identified “vertical splits in consciousness” that seemed to account for various psychiatric and psychological phenomena. Yet, unlike classic models of dissociation that emphasized (1) structural divisions of the personality (2) in order to understand

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the phenomena of hypnosis, somnambulism, and hysteria, neo-​d issociation theory emphasized (1) mental activities or structures (2) in order to explain the simultaneous or near-​simultaneous performance of different activities such as automatic writing and monitoring unfelt pain. Janet called such consciously unwilled activities as automatic writing, psychological automatisms, orginating from deliberate actions from other personalities. For neo-​d issociation theory, mental structures (rather than personality structures) and their ostensibly concurrent yet somewhat independent functioning were the focus of attention. However, both neo-​d issociation theory and classic dissociation theory addressed the misapprehension that the mind is unitary. Otherwise, their respective concentration on cognitive structures and personality structures were in keeping with the dominant discourse of their times. Unlike previous models of dissociation, neo-​d issociation theory brought into the domain of dissociation the simultaneous performance of two cognitive activities (e.g., driving a car while simultaneously being deeply absorbed in a daydream or conversation). Turning to more clinical phenomena, Hilgard (1973) argued that because neo-​d issociation theory was focused on the simultaneous operation of control processes it might provide a framework for understanding multiple personality, which he called an example of “dissociation par excellence” (p. 216, italics in original). Following Hilgard’s lead, Kihlstrom has used neo-​d issociation theory to understand various manifestations of clinical dissociation (e.g., Kihlstrom, 1992a, 1992b; Kihlstrom, Tataryn, & Hoyt, 1993). During the 1970s, academic and non-​clinical interest in dissociation gave way to a significant rejuvenation of clinical interest in dissociation. Like much of the nineteenth-​century fin-​de-​siècle interest in dissociation, the study of clinical dissociation in the late 1970s focused primarily on multiple personality. A rapidly growing number of cases of multiple personality were identified in North America. In the absence of suitable outlets for exchange (i.e., dedicated conferences and journals on dissociation), clinicians communicated their ideas, thoughts and experiences informally, in what Ross (1997) and others have called an oral tradition (e.g., letters, telephone correspondence, generic conferences). Kluft (2003) has provided a personalized account of the clinical developments and enthusiasm that characterized that time. Greaves (1993) has described the skepticism in mainstream psychiatry evoked by the rejuvenation of clinical interest in multiple personality.

1980 and Beyond Without doubt, 1980 was a watershed year for the study of dissociation. Not only did that single year see the publication of several articles on MPD (e.g., Bliss, 1980; Coons, 1980; Rosenbaum & Weaver, 1980), including Greaves’ (1980) classic review, but the DSM (1980) moved to a phenomenological classification of psychiatric illness in which the dissociative types of hysterical neurosis were grouped with depersonalization under a new major heading: Dissociative Disorders. The 1980 publications were soon followed by various other pioneering articles and books (e.g., Crabtree, 1985; Putnam, 1989b; Ross, 1989), and especially a series written by Richard Kluft in which he highlighted the link between dissociation and hypnosis (e.g., Kluft, 1982, 1983, 1984a,b). The consolidation of the Dissociative Disorders in DSM-​III, however, came at a cost; the conversion type of hysterical neurosis, which represented somatoform expressions of dissociation, so central to earlier conceptualizations of dissociation, was regrouped under another new major heading, Somatoform Disorders, together with somatoform conditions not classically considered as dissociative. The DSM-​5 has gone some way to mending this artificial division by including alterations in sensory-​motor functioning (i.e., somatoform dissociation; Nijenhuis, 1999) as part of the diagnostic criteria for DID. A further issue with DSM-​III was that its focus on phenomenology shifted attention (1) away from the structure or organization of the personality/​psyche, and (2) onto observable or reported symptoms (i.e., phenomena), such that in the dissociation field dissociative phenomena became disconnected from their structural origins. This development was paralleled by a tendency to substitute the term ‘multiple personalities’ for concepts such as ‘personality states,’ ‘identity states,’ ‘ego states,’ ‘self-​states,’ ‘dissociative parts,’ or even ‘aspects’ (cf. Moskowitz & Van der Hart, 2020). Despite the sidelining of somatoform expressions of dissociation and the shift of emphasis away from the structure of personality/​psyche, DSM-​III had an immense and salutary impact on the study of dissociation. Because the phenomenological view is not tied to an underlying structure/​organization, dissociation became understood more broadly as a psychologically-​derived “breakdown” in normal integrated functioning. This focus on phenomenology supported the growing trend to conceptualize dissociation along a continuum that stretched from (1) phenomena that represented basic everyday “breakdowns” in integrated functioning like daydreams to (2) severe pathological “breakdowns” in integrated functioning, such as symptoms and disorders (e.g., Braun, 1988). Based on discrete phenomenological experiences, self-​report dissociation questionnaires began to be developed during the mid-​1980s.10 These measures have tended to focus on a wide range of phenomena that are regarded as

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dissociative in contemporary thinking. As one of the authors of the Dissociative Experiences Scale (DES) notes: “The definition of dissociation incorporated into the DES was intentionally broad. The authors attempted to include as wide a range of items as possible in the DES. … Consequently, the authors included many different kinds of experiences that had been previously associated with dissociation” (Carlson, 2005, p. 42, italics added). Most measures of dissociation have not been restricted to assessing phenomena that originate from a dissociative personality structure (which was the focus of attention for scholars of dissociation until contemporary times). The Somatoform Dissociation Questionnaire (SDQ-​ 20) is one of few exceptions in this regard, because its authors derived the scale directly from symptoms which manifest from one or more dissociative parts of the personality (Nijenhuis et al., 1996; see Chapter 33, this volume). Measures of peritraumatic dissociation (e.g., Peritraumatic Dissociative Experiences Questionnaire, Marmar, Weiss, & Metzler, 1997) are even further removed from the historical understanding of dissociation as division/​multiplication, but fit with more phenomenological approaches towards dissociation. Trait dissociation measures like the DES include items that tap the influence of one personality on another (e.g., identity alteration; voice hearing, for example Mazzotti et al., 2016). Peritraumatic measures, however, tend to focus primarily on narrowing of the field of consciousness, alterations in sensory perception, and the activation of multiple streams of consciousness. Peritraumatic dissociation researchers do not deny dissociative division of the personality, which may be derived from dissociative episodes at the time of a trauma (see Marmar, Weiss, & Metzler, 1997). However, such instruments assess phenomenological experiences that occur around the time of a trauma (i.e., during or immediately after). As such they (1) do not fully capture the phenomena that are associated with dissociative divisions of the personality (because such phenomena may not start until after the trauma, once the personality has been multiplied), and (2) peritraumatic phenomena may be unrelated to the development of dissociative identities and may represent mere alterations of consciousness (e.g., seeing the world as a fog). The development and use of dissociation questionnaires provided a basis for the empirical examination of clinically observed developmental, affective, experiential, and environmental correlates of dissociation (e.g., Coons & Milstein, 1986; Putnam, Guroff, Silberman, Barban, & Post, 1986). Moreover, because many self-​report measures of dissociation are based on the continuum model of dissociation, hypotheses that were drawn from clinical cases of dissociation could be legitimately tested in large, non-​clinical samples. In addition, the continuum model suggests that the findings from non-​clinical studies of dissociation could enlighten clinical understanding. In short, the combination of (1) dissociation questionnaires and (2) the recent dominance of the continuum model have allowed an integration of clinical and non-​clinical research and theory. However, both (a) the continuum model and (b) questionnaires that are based upon that model may create obstacles to a clear understanding of the concept of dissociation, as they remove a discernible structural foundation for, and therefore a clearly defined set of, dissociative phenomena.11 Most forefathers of the study of dissociation employed a much narrower domain of dissociative phenomena that was limited to those experiences that resulted from a dissociative structure that gave rise to the multiplication of personalities. The many phenomena that are considered to be “dissociative” by the continuum model (and which are assessed by most dissociation questionnaires) have many different psychological origins (Holmes et al., 2005). The original domain of dissociative phenomena had just one psychological origin—​d ivision of the personality into dissociative parts and the multiplication of centers of consciousness.

Changes in the Concept of Dissociation: Progress in Understanding or Conceptual Drift? The concept of dissociation in the eighteenth, nineteenth and early twentieth centuries related to a division of the personality/​multiplication of personalities. This division/​multiplication was best illustrated by actions that were performed outside the personal awareness of the individual. Initially, it was thought to be due to artificial somnambulism (e.g., the Marquis de Puységur). As the psychological phenomena resulting from a division/​multiplication began to be appreciated, clinicians came to understand hysterical symptoms and hysterical neurosis in terms of dissociation. Janet was the first to recognize the connection between hysterical divisions/​multiplications and exposure to traumatizing events12 (see Dorahy & Van der Hart, 2007 for an historical analysis of the link between trauma and dissociation). In the case of traumatic stress, Janet believed that an alternate ego or personality was created, which was composed of the unintegrated psychological and behavioral elements of the trauma. According to Janet, dissociation as a division of the personality/​multiplication of personalities could be caused by traumatizing events or severe illness. He understood hysterical symptoms as dissociative in nature. He could access the hidden personalities responsible for these symptoms using artifical somnambulism, automatic writing or related interventions. Janet viewed dissociation and dissociative phenomena as forms of psychological pathology. Several of his contemporaries (e.g., F. Myers, M. Prince) did not restrict dissociative phenomena to clinical symptoms and expressions. Yet, they still conceptualized dissociation in structural terms. The careful clinical observations of the classic

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historical cases map-​on very neatly to the phenomena evident today in dissociative disorders, particularly DID (Van der Hart, 2016). Yet, the latter half of the twentieth century increasingly presented a much broader version of dissociation. As noted above, several sources contributed to this change: (1) the study of altered states of consciousness (e.g., Ludwig, 1966; Tart, 1969) and the subsequent acceptance of a dissociative continuum which came to equate almost any altered state of consciousness with dissociation; (2) DSM-​III’s strict adherence to non-​conceptual, phenomenological descriptions of mental disorders; and (3) dissociation questionnaires that used phenomena rather than structure as their starting point. Those phenomena encompassed a broad range of clinical and non-​clinical experiences that were believed to exemplify a “breakdown” in integrated functioning. Despite being ill-​defined, almost any psychologically-​derived “breakdown” in integrated functioning was considered to exemplify “dissociation.” These included episodes of selective inattention, where the stimuli ‘split-​off’ from conscious awareness are irrelevant to the task at hand or the experience being retrieved (Meares & Barral, 2019). Everyday non-​clinical “breakdowns” in integrated functioning were conceptualized as operating on the same psychological continuum as the most pathological expressions of dissociation. This heterogeneous version of dissociation led to an inevitable result—​the implicit hypothesis that different “dissociative” phenomena had different causes (Holmes et al., 2005) and correlates. Some nonpathological alterations in perceptual experience were considered to have many possible causes. Other “dissociative” phenomena were believed to be due to the operation of simultaneous independent streams of consciousness. Finally, pathological phenomena such as amnesia or dissociative identities were explained as being due to a trauma-​induced division/​multiplication. So-​called “breakdowns” in integrated functioning were the basis from which dissociative phenomena were derived and understood. Historically, structural divisions between personalities or centers of consciousness were the basis from which dissociative phenomena were derived and understood. The broader understanding of dissociation, which does not have conceptual linkages to the original descriptions of Janet and others, brought with it a variety of disadvantages, the most serious being a fuzzy, all-​encompassing meaning (Frankel, 1994; Marshall, Spitzer, & Liebowitz, 1999; Meares, 2012) and a concomitant lack of clearly definable phenomenological boundaries (Cardeña, 1994; Dell, 2009; Nijenhuis & Van der Hart, 2011; Van der Hart, Nijenhuis, Steele, & Brown, 2004). Arguably, this conceptual confusion about what dissociation is has not reduced in the past decade, despite diverse efforts to provide clarity about specific understandings (e.g., Chefetz, 2015; Frewen & Lanius, Howell & Itzkowitz, 2016; Meares, 2012; Nijenhuis, 2015, 2019; Ross, 2013; Van der Hart et al., 2004). The widening breadth and increased complexity of the construct from historical times, efforts to measure it in conceptually diverse ways and the impact divergent understandings of dissociation have on neurobiological, psychological, somatic and social functioning, along with the different theoretical lens that can be brought to bear on it, may render it unlikely that a unified, universally-​accepted conceptualization of dissociation is possible. As Braude (1995) has noted, “we needn’t assume that dissociation is a neat enough concept to be captured by a single, crisp, and comprehensive philosophical or scientific analysis” (p. 94). Nonetheless, it behoves researchers and theoretician working in the dissociative field to be clear how they are utilizing the term (Dell, 2009). The question that theorists in the field of dissociation grapples with is whether it makes sense to refer to a large diversity of principles and phenomena by one name, and do the benefits of this approach outweigh the costs.

Contemporary Understandings and Challenges This review and analysis of the history of the concept of dissociation has identified at least five important portrayals of dissociation: (1) dissociation was first utilized to describe a particular psychological organization (i.e., a division of personality or ego that gave rise to personalities or egos); (2) dissociation was reinterpreted by Freud and others as a defense (and is often subsumed under the concept of repression by psychoanalytic thinkers); (3) dissociation has been viewed as a process, which, for example, characterizes the initial division of the personality into dissociative parts following trauma and also the switching between dissociative identities; (4) dissociation came to be seen as a very broad set of experiences and symptoms that are characterized by a so-​called “breakdown” in integrated psychological functioning; and (5) today, dissociation is widely believed to lie on a continuum (or continua) that stretch from normal experiences to pathological symptoms. From our analysis of the historic and contemporary literatures, explanation of dissociation from its birth as a topic of scientific investigation till just after the middle of the twentieth century drew on a structural understanding where personality was divided/​multipled into dissociative identities which manifest dissociative symtoms. At least two important versions of this structural conceptualization of dissociation were present: (1) hypnotically-​induced divisions of the personality, and (2) trauma-​induced divisions of the personality.

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The hypnotic version of the structural conceptualization of dissociation applies to divisions of personality or multiplications in consciousness, that are (1) hypnotically-​induced by either self or other, and (2) transient in nature. The leading examples where dissociation is induced by another are (1) the eighteenth and nineteenth-​ century studies of artificial somnambulism13 and hypnosis, and (2) Hilgard’s studies of the ‘hidden observer’ phenomenon. Self-​ i nduced (hypnotic) divisions/​ multiplications are probably best exemplified by mediums, such as those studied by members of the Society for Psychical Research in Britain. Following the hypnotic-​ induction procedure, the minds of these mediums divided into multiple ‘streams of consciousness’ that have a first person perspective. In mediums who acquired their skills through the use of auto-​hypnosis, at least one ‘stream of consciousness’ operated outside his or her awareness. While for many mediums that stream could regularly be called upon, the divided psychic organization or structure was nonetheless transient in nature. That is, when the hypnotic state was terminated, the structural organization of the psyche also changed (i.e., the separate streams of consciousness were no longer easily accessible and were not spontaneously triggered while negotiating the environment, as is the case with trauma-​induced structural dissociation. Rather, the hypnotic induction activated a structural dissociation, no matter how frequent it occurred, where this temporary organization remitted after the trance ended). It is essential to note that hypnotically-​induced divisions of mind (and their accompanying hypnotic phenomena) are not the exclusive domain of the clinical world; such hypnotically-​induced divisions of mind reflect a capacity that is possessed by many normal and healthy individuals. Dell (2017) has recently rekindled interest in the autohypnosis hypothesis of pathological (structural) dissociation. He concludes that hypnosis is a trait priming the development of dissociative disorders in the presence of trauma and other necessary factors (see Dell, Chapter 14, this volume). The structural conceptualization of trauma-​induced dissociation applies to a posttraumatic division of the personality into dissociated parts that are either (1) avoidant (phobic) of traumatic memories, or (2) fixed in these traumatic memories. Prominent historical scholars of clinical dissociation (e.g., Janet and C.S. Myers) espoused this view, which saw acute divisions/​multiplications solidified and maintained through what in current times would be called affect dysregulation, and intense fear of mental content and external stimuli (i.e., Janet’s phobia of traumatic memory; Van der Hart & Rydberg, 2019). This posttraumatic dissociative personality structure generates dissociative symptoms; these dissociative symptoms are both positive and negative, psychoform (cognitive-​a ffective) and somatoform (sensorimotor). Thus, in contrast to the hypnotic structural version of dissociation, the posttraumatic structural version of dissociation refers only to psychopathology. The divisions of the personality/​multipications of personalities which characterize dissociative psychopathology are relatively fixed and stable, and crucially have their own sense of self or first-​person perspective (Nijenhuis, 2015), which differentiates them from other constructs, like states, complexes and schemas that are hypothesized to be present in healthy individuals (Moskowitz & Van der Hart, 2020; Nijenhuis, 2017). The memory composition, emotional range and behavioral patterns of self-​conscious dissociative parts remain highly organized and divided. In the absence of effective treatment, the dissociated functioning of these parts will continue. In contemporary times this trauma-​induced narrow version of dissociation is evident in theories accounting for dissociative identity disorder (Kluft, 2013), Bromberg’s structural organization of the self following exposure to traumatizing events (Bromberg, 2009), Meares’ (2012) dissociative theory of borderline personality, and Van der Hart et al.’s structural theory of dissociation of the personality (Nijenhuis, 2015; Van der Hart et al., 2006), to name a few. These frameworks have different foci and emphases, and to a greater or lesser extent overlap with Janet’s theory, but each views trauma as central to division or dissociation at the level of personality or self, and each refer to phenomena that emanate from such a division.14 The two versions of the structural conceptualization of dissociation are not mutually exclusive and both apply the term dissociative only to the phenomena produced by the divided mind or divided personalities, and therefore dissociative phenomena have a single origin (i.e., division in the personality/​multiplication of personalities). Since the 1980s the structural conceptualization of dissociation, while still dominant as an account of DID, has been overshadowed and largely set aside in favour of a phenomenologically-​based conceptualization of dissociation, where phenomena are grouped together under the term ‘dissociation’ based on being characterized by a failure to integrate or be aware of different elements of psychological experience or the environment. One root of this phenomenological understanding is the continuum model of dissociation which focuses on the phenomena themselves (rather than on their putative underlying ætiology, or the structural foundation which gives rise to them). The phenomenological conceptualization of dissociation is quite eclectic with regard to the ætiology of these phenomena. They may be due to (1) parallel ‘streams of consciousness,’ (2) a narrowing of the field of consciousness, (3) alterations in conscious experience, (4) defensive efforts to restrict conscious awareness, (5) a posttraumatic, divided/​multipled personality structure, and so on. Accounts of dissociation drawn from this perspective have generated an immense body of important clinical and experimental research, and lead to the clinically useful but conceptually fraught DSM-​5 diagnosis of dissociative PTSD (i.e., the dissociative subtype of PTSD, APA, 2013), i.e., “PTSD with dissociative symptoms” (Dorahy & Van der Hart,

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2015; Nijenhuis, 2017). Some conceptualizations of dissociation are narrow and exclude (typically positive) dissociative phenomena (e.g., flashbacks), perceiving dissociation more akin to ‘shutdown’ (e.g., hypoarousal, dorsal vagal collapse); others conceive of dissociation as very expansive, capturing a wide range of phenomena associated with a breakdown of integration that is exemplified in the concept of a dissociative continuum. While these vastly different views impact on the precision of the construct of ‘dissociation’ (e.g., Marshall, Spitzer, & Liebowitz, 1999), they have lead to a growing interest in phenomena described as dissociation in clinical and non-​clinical populations. Significant efforts have been made to develop rich models of dissociation that offer more conceptual clarity and a tighter focus on dissociation than broad sweeping breakdowns in integrated functioning, even though their foundation does not lie in dissociation at the level of personality division/​multiplication (e.g., Chefetz, 2015; Frewen & Lanius, 2015; Gold, 2020).

Conclusion In conclusion, the dissociation field has experienced a shift from it roots. Historical formulations of dissociation had divisions of the personality/​multiplication of personalities as the essence of dissociation and manifestations from such a structure delimited the positive and negative dissociative phenomena. Each dissociative structure had its own first-​person perspective and sense of self, akin to awareness of its own existence. Alterations of consciousness were not considered dissociative in nature. Many contemporary formulations of dissociation have tended to take a broader approach based on phenomenological definitions in terms of what constitutes dissociative symptoms and experience, and their origins may differ. It may be difficult, or even undesirable, to reconnect these formulations with historical conceptualizations. Thus, scholars and clinicians need to be clear in how they are conceptualizing dissociation. Clarity may be assisted by clearly differentiating and defining the following ambiguous terms and how they relate to one another: dissociation, personality, consciousness, identity, state (i.e., mental state, state of consciousness, ego state, identity state, self-​state), alter personality, dissociative personality and dissociative parts of the personality (cf., Nijenhuis, 2015). Because many of these terms are effectively synonymous, it would probably be helpful to decide which terms are the preferred ones (e.g., Moskowitz & Van der Hart, 2020). Despite the current challenges around conceptual clarity, and perhaps as result of them, the study of dissociation continues to grow and expand.

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Acknowledgments The authors want to thank Ellert Nijenhuis, PhD; Adam Crabtree, PhD; and John O’Neil, MD, for their helpful comments on previous drafts of this chapter.

Notes 1 Despite the fact that dissociative phenomena were recognized well before 1812 (e.g., in the 1791 cases of multiple personality, Crabtree, 1993; or Mary Reynolds, the first American case of ‘double personality,’ S.L. Mitchell, 1816; S.W. Mitchell, 1888; see also Van der Hart, Lierens, & Goodwin, 1996, for a retrospective 16th century case of dissociative identity disorder, DID), the American physician, Benjamin Rush, devoted a chapter of his 1812 psychiatric text to what he named “dissociation.” This may be the earliest medical use of the term (Carlson, 1986). Rush used the term to refer to patients who were “flighty,” “hairbrained,” or “a little cracked.” According to Rush, dissociation came from “an association of unrelated perceptions, or ideas, from the inability of the mind to perform the operations of judgment and reason.” Such dissociation was seen in patients with “great volubility of speech” and “rapid bodily movements.” 2 In the clinical domain, dissociation was also linked to other disorders. For example, James (1995) noted that in the early 1860s, both Maury’s (1861) famous study on dreams and Baillarger’s (1862) review of this study proposed that certain psychotic patients were characterized by a doubling of the personality (dédoublement de la personnalité). Not long after, Littré’s (1875) article on double conscience used the concept of dissociation to describe depersonalization. 3 However, some cases of clinical dissociation were reported by British physicians, such as the extreme case of H.P. (Bruce, 1895). Bruce attributed the radically different behaviors observed in two distinct states to alterations in the dominance of left and right hemispheres. Around this time, the British physician John Hughlings Jackson was developing his understanding of dissociation (see Meares, 2012). Hacking (1991) has presented several clinical cases of dissociation in Britain from the period of 1815–​1875. 4 James’ admiration for Janet’s work is explicit in his 1894 review of Janet’s ideas in which he suggested that “every psychologist should make their acquaintance” (p. 198). 5 The French term for ‘dual consciousness.’ 6 Erdelyi (1985) has argued that Freud used the terms repression and dissociation interchangeably. 7 Dissociation as a defence in psychoanalytic thinking can be distinguished from dissociation as insufficient psychological capacity for integrated functioning (e.g., Liotti, 2009). In the latter Janetian sense, dissociation may come to have a secondary defensive value.

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However, unlike the psychoanalytic understanding, Janet’s dissociation does not occur for the primary purpose of psychic defence (i.e., ego-​derived expulsion or ‘splitting off’ of noxious internal experience). 8 In the contemporary dissociation literature the term “breakdown” is used synonymously with the term “disruption.” It remains unclear exactly what these terms actually mean. For example, is a state of absorption in a book or television program accurately categorized as a “breakdown” or “disruption” in integrated processing in the same way as a failure to integrate traumatizing elements of an event? On account of their ambiguity these terms are often loosely applied and utilized. 9 Dissociative disorders in DSM-​5 (APA, 2013) are characterizes by a disruption of and/​or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291). 10 Many self-​report measures of dissociation now exist, with common as well as more recent ones, including the Dissociative Experiences Scale (Bernstein & Putnam, 1986; Carlson & Putnam, 1993); the Multidimensional Inventory of Dissociation (MID; Dell, 2006); Multiscale Dissociation Inventory (MDI; Briere, 2002); the Somatoform Dissociation Questionnaire (Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1996), The Dissociation Tension Scale (Stiglmayr et al., 2010); Dissociative Symptoms Scale (Carlson et al., 2018), The Detachment and Compartmentalization Inventory (Butler, Dorahy & Middleton, 2019). 11 The problem of conceptual ambiguity in the contemporary understanding of dissociation has been identified before and one solution was sought with the DES-​Taxon (DES-​T ). The DES-​T is a subset of DES items which emerged statistically from studies of patients with dissociative and non-​d issociative disorders. Taxon items represent a statistically derived cluster of symptoms experienced by those with a dissociative illness but not by individuals with a non-​d issociative illness. The DES-​T offered a measure of pathological dissociation as opposed to nonpathological dissociation. However, some pathological symptoms in the taxon model are not per se related to underlying division/​multiplication and may have their foundation in other psychological sources; for example, some episodes of severe depersonalization (e.g., DES item 12: “some people have the experience of feeling that their body does not seem to belong to them”). With its basis in phenomena and not underlying psychological structure, the Taxon model does not provide an effective resolution to conceptual ambiguity in the modern understanding of dissociation. 12 In contemporary times the association between trauma and dissociation, and DID more specifically, has been a battle ground of vigorous debate, that has pitted the so-​called trauma model against the so-​called socio-​cognitive model. On the one hand, trauma is argued as a primary (though not only) variable in the development of dissociative symptoms and some disorders, while on the other trauma is wrested from having explanatory value, and sleep disruptions, cognitive failures, suggestibility, fantasy proneness, social influences and iatrogenic factors are commandeered to account for a person believing they were traumatized or having a dissociative disorder (e.g., Boysen & VanBergen, 2013; Dalenberg et al., 2012; Kate, Hopwood, & Jamieson, 2020; Lynn, Lilienfeld, Merckelbach, Giesbrecht, & Van der Kloet, 2012). Increasing efforts are being made to bring together trauma and socio-​cognitive influences for the development of dissociation and the dissociative disorders (e.g., Şar & Öztürk, 2013; Somer, 2016) or find areas of connection for where they might meet (e.g., Lynn et al., 2019). 13 We would hold that not all cases of artificial somnambulism displayed the induction of a transient division of personality, that is evident in hypnosis. In several classic cases of artificial somnambulism (e.g., Puységur’s case of Victor Race) it seems that more stable dissociative parts of the person were evoked. Cases such as this are consistent with trauma-​induced divisions of the personality as a whole. 14 It should be noted that Bromberg (e.g., 1998, 2009, 2017) views the healthy self as characterised by adaptive and fluid self-​states partitioned by dissociation, but following traumatic relational experiences that compromise adaptive functioning, these self-​ states become further isolated so they exist more independently and produce a range of dissociative phenomena.

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2 THE CONCEPTUAL UNITY OF DISSOCIATION A Philosophical Argument Stephen E. Braude

Psychologists and psychiatrists have studied dissociative phenomena since the late nineteenth century. However, they demonstrate surprisingly little agreement about what dissociation is and about which phenomena exemplify it. Of course, many agree that certain florid phenomena count as dissociative –​for example, fugue states and dissociative identity disorder (DID). But when mental health professionals tackle the topic of dissociation theoretically and attempt to define it, they do so in ways that often conflict with one another, and (perhaps most surprising of all) they tend to overlook a large and important class of phenomena. Historically –​and contrary to what the recent clinical literature would lead one to believe –​most (if not all) hypnotic phenomena have been regarded as dissociative (see, e.g., Gauld, 1992; Van der Hart & Dorahy, Chapter 1, this volume). In the late nineteenth and early twentieth centuries, researchers of hypnosis were trying to study systematically the same sorts of subconscious mental divisions they believed occurred spontaneously in hysteria and to some extent in somnambulism. Indeed, some considered hypnotically-​induced systematized anesthesia or negative hallucination to be paradigmatic instances of dissociation. Yet when clinicians now try to analyze dissociation, they typically ignore hypnotic phenomena and focus primarily on dissociation as it relates to trauma. Despite evidence to the contrary (e.g., Crabtree, 1993, Braude, 1995; Van der Hart & Dorahy, 2009), historians of psychology usually credit Pierre Janet with having originated the concept of dissociation, although he regularly used the term “désagrégation” instead. But what matters is that Janet focused on a distinctive and relatively limited type of trauma-​induced psychopathology, one which he considered to be a kind of weakness, a failure (in the face of disturbing events) to integrate parts of consciousness and maintain conscious unity. However, thinking about trauma and psychological fragmentation has evolved in the century since Janet tackled the subject. Contemporaries of Janet –​for example, James, Binet, Myers, Liègeois, and Sidis –​also recognized an apparent causal link between trauma and dissociative pathology. But they tended to agree that the processes Janet was describing from cases of hysteria (including conversion disorder and double consciousness) were also at work in a wider variety of phenomena, drawn not just from psychopathology but also from experimental psychology and even everyday life (see e.g., Binet, 1896; Myers, 1903; Sidis, 1902). And along with that, they tended to view dissociation not as a weakness, but as a kind of capacity (not necessarily maladaptive) to sever familiar links with one’s own mental states. Significantly, this evolution of the concept of dissociation happened quite rapidly. Other turn-​of-​the-​twentieth century researchers, interested at least as much in hypnosis as in psychopathology, were eager to explore the ways in which hypnotic states seemed to produce a kind of division or doubling of consciousness, or creation of seemingly autonomous sets of mental processes (for a quick history of these developments, see Braude, 1995; Van der Hart & Dorahy, Chapter 1, this volume. For a more detailed account, see Gauld, 1992). As Messerschmidt (1927) eventually made clear, these apparent divisions weren’t as fully autonomous as they seemed. But that didn’t undermine the view that the phenomena in question could arise either experimentally or spontaneously or, for that matter, pathologically or nonpathologically. These nonpathological (including hypnotic) contexts, in which the concept of dissociation has historically played an important role, tend to be neglected by most clinicians. Given their pressing clinical concerns, perhaps that is not

DOI: 10.4324/9781003057314-4

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surprising. However, trying to grasp dissociation by considering it only as a disorder, as something pathological and of importance only (or primarily) to psychotherapy, is as misguided as trying to understand immaturity by focusing only on its relevance to marriage counselling. Moreover, examining what pathological and nonpathological dissociative phenomena have in common may bring clarity to other issues, such as the difference (if any) between dissociation and apparently similar or related concepts –​in particular, repression. In a fairly recent development, some clinicians have examined the concept of dissociation by using diagnostic surveys like the Dissociative Experiences Scale (DES; Carlson & Putnam, 1993) and the Multiscale Dissociation Inventory (MDI; Briere, 2002) –​to consider how dissociative symptoms cluster. These survey instruments were designed as screening devices, to assess the presence or absence of phenomena already believed by the test designers to be dissociative. However, in subsequent studies of thousands of survey results, researchers have occasionally seemed to aim for something more ambitious –​namely, to determine more precisely what dissociation is. But data of the sort elicited by these surveys can’t tell us what the concept of dissociation is. After all (as I noted above), the surveys look only for symptoms antecedently judged as relevant by their designers, who are limited by their selective grasp of the history of the concept. What they most clearly tend to neglect are the many nonpathological hypnotic phenomena that have been considered dissociative (Dalenberg et al., Chapter 5, this volume), but which simply fall outside the purview of the surveys. In some cases, the studies in question are even more problematical than these remarks might suggest. For example, Briere et al. (2005) apply the MDI to determine whether dissociation is a multidimensional construct, and they conclude that it is, and that “the notion of ‘dissociation’ as a general trait was not supported” (p. 221). Apparently, then, the authors see themselves as trying to settle the issue of what sort of thing dissociation is, generally speaking. Indeed, on the basis of their survey they claim that “the term dissociation may be a misnomer to the extent that it implies a single underlying phenomenon” (p. 230). We’ll consider shortly whether dissociation can in fact be regarded as a single underlying phenomenon. But for now, I want only to observe that Briere et al. can’t possibly have shown that it isn’t (quite apart from concerns about using survey instruments for conceptual analysis). Briere et al. purport to uncover what dissociation is on the basis of a survey that tracks relationships among a handful of factors –​of course, factors they antecedently determined to be relevant. Moreover, one of those factors is identity dissociation and, obviously, one can’t analyze the concept of dissociation by appealing to that very concept. Thus, if Briere et al. are (as it seems) trying to analyze the concept of dissociation, their attempt is blatantly circular. So I believe we need to do some conceptual and methodological housecleaning. I agree with Cardeña (1994; also Nijenhuis, 2015; Prince, 1905) that when clinicians attempt to characterize dissociation, they tend either to exclude too much or include too much. However (and apparently unlike Cardeña), I think it may be possible to pull together many of the varied intuitions about and approaches to dissociation and come up with a single, general, and useful characterization of dissociation (e.g., not just traumatic dissociation) that covers both its pathological and nonpathological forms, including many of those once deemed important but largely ignored today. I shall attempt to define a single inclusive concept of dissociation that rests only on reasonable and recurrent assumptions distilled from more than a century’s literature on the subject. I start by identifying specific assumptions underlying typical uses of the term “dissociation,” then see if they can be stated plausibly, and then see whether we can extract from them a definition that has both generality and utility.1 To be clear, this is not to deny the importance of more specialized uses of “dissociation” (primarily in clinical contexts). Rather, it’s an effort to see how successfully we can craft a general definition of the term, useful in both clinical and nonclinical contexts, and ranging over both pathological and nonpathological cases.

Assumptions We can begin with an observation about terminology. The term “dissociation” can be used in a number of different ways, but in the present context two in particular deserve our attention. First, “dissociation” can pick out an occurrent state (i.e., the state of being dissociated), and second, it can pick out a disposition or ability to dissociate (i.e., a capacity to experience occurrent dissociative states). As we will see again shortly, in this respect the term “dissociation” parallels many other psychological terms. For example, the term “empathy” has both occurrent and dispositional senses. In the former, it picks out the discernible mental state of experiencing empathy; in the latter it picks out the disposition or capacity to experience such states. This observation leads to the first assumption underlying the concept of dissociation: that dissociation is not simply an occurrent psychological condition or state, but also something for which we may have a capacity –​in fact, a capacity that

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may have both positive and negative personal consequences. This seems to be a sensible move away from Janet’s view of dissociation as a failure of integration, and it’s continuous with the way we treat a great many other areas of human cognition and performance. It is also why we can sensibly ask whether everyone can dissociate, and to what degree. So the first assumption is the capability assumption.

Capability Assumption Dissociation is one of many capacities people have –​that is, it’s one of many things which (at least some) people are able to do. So, in that respect, dissociation is analogous to, for example, irony, patience, indignation, dishonesty, kindness, sarcasm, self-​deception, empathy and sensuality. Although my list of other capacities here was restricted to psychological attributes that people express in varying degrees and with respect to which some people are clearly either impaired or gifted, notice that the issue here is not whether the capacity to dissociate must be cognitive or even whether it’s subject to voluntary control. As far as we need to suppose, talk of dissociation might be analogous to talk of various noncognitive organic capacities that are typically not subject to voluntary control. For example, yogis can control many organic functions which most of us can influence only to a very limited degree or only involuntarily –​for example, breathing, vasoconstriction and vasodilation. Yet it is still proper to speak about our capacity for pulmonary functioning, vasoconstriction, etc. In fact, those capacities are things that can change after a period of study on a Tibetan mountaintop, and also with (say) disease and old age. The capability assumption leads smoothly to the non-​uniqueness assumption.

Non-​uniqueness Assumption 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. In other words (and failing evidence to the contrary), we should not assume that dissociation is completely unprecedented in the realm of human cognition and performance, however distinctive it may be in certain of its details. The third assumption is particularly important, and we will see later how it figures in a prominent contemporary debate. We begin by observing that capacities generally are things that people express in different ways and to varying degrees. For example, the capacities for self-​deception, intimidation, malice, neatness, self-​criticism and generosity can range from extreme to very moderate forms, and they can be expressed in highly idiosyncratic ways. So it seems reasonable to assume the diversification assumption.

Diversification Assumption Like other capacities, dissociation (a) assumes a variety of (possibly idiosyncratic) forms (e.g., DID, automatic writing, hidden observer phenomena, negative hallucinations), (b) affects a broad range of states (both occurrent and dispositional), including systematized anesthesia and post-​hypnotic suggestions, and (c) spreads out along various continua –​for example, of pervasiveness, frequency, severity, completeness, reversibility, degree of functional isolation, and importance to the subject. So, for instance, studies of hypnotic and conversion anesthesia reveal that subjects have made themselves anesthetic in areas not corresponding to natural anatomical regions (i.e., the kind that would be caused by real nerve damage). For example, some have experienced anesthesia in a belt or band around the arm, or a glove pattern on the hand, or an anesthetic eyeglass pattern around the eyes in cases of dissociative blindness (see Braude, 2014). Another important assumption allows us to distinguish dissociation from what we might call cognitive or sensory filtering. Of course, the term “filtering” also has many meanings, and to appreciate the distinction in question we must now use the term more carefully and narrowly than we might ordinarily. In the sense of “filtering” that matters here, the term picks out a total blocking of information from a subject. Examples of this sort of filtering would be blindfolding, audio band-​pass filtering, or local chemical anesthesia. Compare those states of affairs to the rather different situations we find in (say) hypnotic anesthesia or negative hallucination, where subjects merely fail to experience consciously what they are nevertheless aware of subconsciously or unconsciously (e.g., Binet, 1892/​1896/​1977; Hilgard, 1986; Orne, 1971, 1972). So the relevant differences between filtering (as the term is used here) and dissociation is that in filtering, information never reaches the subject (consciously or otherwise), whereas dissociation merely blocks the subject’s conscious awareness of information or sensations that had otherwise registered. So, the next important assumption is the ownership assumption.

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Ownership Assumption The things dissociated from a person are always the person’s own states –​for example, sensory, cognitive, volitional, and physical states. Granted, it’s common to say that information or data is dissociated. But I believe that’s a careless way of speaking. Strictly speaking, what is dissociated are the subjects’ states –​for example, sensory perceptions, volitions, knowledge (e.g., the knowledge that …, or the knowledge how to …), beliefs, memories, dispositions and, sometimes, behavior (as in automatic writing). The ownership assumption connects with a fifth and very important assumption. At least since the early detailed accounts of multiple personality (e.g., Prince, 1905), researchers have noted that when a state is dissociated, it is not totally obliterated or isolated completely from the subject, although retrieving the state might be quite difficult in both experimental and real-​l ife contexts. That is, dissociated states may be subjectively hidden or psychologically remote, but they are always potentially knowable, recoverable, or capable of re-​a ssociation. So our final assumption is the accessibility assumption.

Accessibility Assumption Dissociation is a theoretically (but perhaps not practically) reversible functional isolation of a state from conscious awareness. Before moving on, we should also note that the relation “x is dissociated from y” is nonsymmetrical, like “x loves y” (even though x loves y, y may not love x). We see this nonsymmetry clearly in cases of one-​way amnesia in DID or in hidden observer experiments, where states of a hypnotically-​h idden observer may be dissociated from those of the hypnotized subject, even though the subject’s states may not be dissociated from those of the hidden observer (see Braude, 1995; Braun, 1988; Cardeña, 1994; Hilgard, 1986).

Dissociation Relative to Other Named Phenomena Shortly, we will consider how these assumptions play a role in specifying what pathological and nonpathological forms of dissociation have in common. But to reach that point, we must first consider how to distinguish dissociation from at least superficially similar phenomena.

Repression Repression may be the concept most often confused with that of dissociation. Granted, neither concept is precise, and so we shouldn’t expect the distinction between dissociation and repression to be sharp. Nevertheless, there seems to be a distinction worth making. While repression and dissociation both concern psychological barriers that prevent one’s states from reaching conscious awareness, the two concepts rest on different presuppositions, and the barriers differ clearly in scope, function and vulnerability. That enables us to distinguish those barriers clearly enough to show that they belong to different (if occasionally overlapping) classes of phenomena. Consider: Writers often describe repression as a barrier preventing only certain mental states from becoming conscious, whereas the dissociative barrier can hide both mental and physical states from conscious awareness. For example, during hypnotically-​induced anesthesia one can dissociate bodily sensations and permit radical surgery, but that sort of phenomenon has never been offered as an instance of repression. Moreover, as Hilgard (1986) has noted, writers tend to employ different metaphors when describing the psychological barriers of repression and dissociation. Typically, they characterize repressive barriers as horizontal, whereas dissociated barriers are described as vertical. As a result, repressed material is usually considered to be psychologically deeper than what we can access consciously. By contrast, dissociated states are not necessarily deeper than consciously accessible states. For example, in hypnosis trivial or emotionally neutral states can be dissociated (e.g., the ability to say the letter “r,” tactile sensitivity to a band around the arm, or the perception of a chair in one’s visual field). This alleged difference connects with the different roles repression and dissociation ostensibly play in a person’s psychological economy. Ordinarily, repression is linked to dynamic psychological forces and active mental defenses that inhibit recall. Granted, some writers likewise describe dissociation as a defense or avoidance mechanism (primarily, one producing amnesia), but that view seems needlessly restrictive. In fact, paradigm cases of dissociation need not involve any impairment of memory, and dissociation may have nothing to do with the urgent needs of psychological survival –​ that is, it needn’t be defensive. For example, systematized anesthesia does not affect memory, and posthypnotic amnesia can concern virtually any kind of state or material, important or unimportant. (For more on shortcomings with particular definitions of “dissociation,” see Braude, 1995 and Cardeña, 1994.)

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Historically, the concept of repression is bound up with the psychoanalytic concept of a dynamic unconscious, which (according to the standard view) acts as the repository for repressed material. But most important, on that view we gain access to repressed material only by indirect methods, or at least methods more circuitous than those by which we identify dissociated states. Thus, according to the traditional and still standard view of repression, we learn about the unconscious through its by-​products (e.g., dreams, or slips of the tongue), and expressions of unconscious material tend to be distorted, either symbolically or by means of more primitive primary-​process thinking. So one important difference between repression and dissociation is that repressed mental activities can only be inferred from their behavioral or phenomenological by-​products, whereas dissociated states can be accessed relatively directly, as in automatic writing, hypnosis, and interactions with alter identities in cases of DID. Another way of putting this point would be to say that third-​and first-​person knowledge of dissociated –​but not unconscious –​states can be as direct as (respectively) third-​and first-​person knowledge of non-​d issociated states. For example, I can (at least in principle) have direct access to some of my own dissociated states (e.g., beliefs, memories), because they can eventually be retrieved with the help of hypnosis or other interventions. And others can have third-​ person access to my dissociated states even when I don’t. For instance, we have evidence –​that is, third-​person access to the fact –​that in hidden-​observer studies, the hypnotized subject feels pain even when that person’s non-​h idden-​ observer state does not. And that third-​person access is as direct as it would be to ordinary non-​d issociated states. In both cases, we learn about the other person’s sensations or other internal states through that person’s behavior. In both hidden observer studies and ordinary cases, we learn that a person feels pain through their pain behavior (e.g., wincing, limping, saying “ouch”). So we can say that if x is repressed for S (in this sense of “repressed”), then (a) S is not consciously aware of (or has amnesia for) x, and (b) third-​and first-​person knowledge of x is indirect as compared (respectively) with third-​and first-​person knowledge of both conscious and dissociated states (i.e., it must be inferred from its possibly distorted or primitive cognitive, phenomenological, or behavioral by-​products). Of course, the directness of third-​person access to another’s mental states is a matter of degree, and that access requires both inferences and interpretation no matter whether the other person’s states are conscious, dissociated or repressed. For example, you may be directly aware of your anger, but I can be aware of your anger only by virtue of drawing an inference from your behavior and assuming you’re not feigning anger.2 When you dissociate your anger and I elicit a hypnotically-​induced report of your angry feelings, my knowledge of your anger again requires me to infer that your verbal or other behavior is a reliable guide to what’s happening to you subjectively. In these two cases, I would say that third-​person access to your anger is comparably direct, requiring little more than assumptions about behavior-​reliability. But when you repress your anger, I don’t have at my disposal anything as straightforward as a report from you that you’re feeling angry or other relatively transparent outbursts of angry behavior. I might have suggestive word-​a ssociations, slips of the tongue, or intriguing constrictions of behavior (e.g., obsessive behavior, sexual frigidity), but usually nothing as blunt as reports of angry feelings, overtly hostile remarks, or punches in the nose. Not surprisingly, many cases are not this clear-​cut. So not surprisingly (and also not alarmingly), this way of characterizing repression allows for an appropriate range of borderline cases. Consider, for example, behavior that reveals hidden feelings but whose interpretation is clear even to the person exhibiting it (e.g., forgetting an appointment you prefer to avoid). In fact, in some cases the only difference between a repressed and a dissociated state may be the conceptual framework in terms of which it is treated clinically. For example, obsessional or compulsive behavior might be approached psychoanalytically, using indirect methods (e.g., free association) to uncover the reasons for the behavior. Or, it might be treated as a dissociative disorder, using hypnosis to reveal hidden memories lying at the root of the problem. So, which diagnosis we choose could easily (and appropriately) depend on whether the clinician treated the patient by means of hypnosis, EMDR, free association, or something else. Therefore, in some cases at least, there may be no preferred or privileged answer to the question, “Is this state dissociated or repressed?” The world may not have a sharp cleavage here, and there is no need for our concepts to do so. We might even want to say that, for ambiguous cases at least, there is but one psychological condition, which is simply identified and treated according to different criteria and methods. And presumably, the indeterminacy of our description is no more unusual or objectionable than it would be in many ordinary cases where we can describe the same state from different perspectives, each of them revealing and valuable in its own way. For example, from one perspective it might be useful to view a person’s actions as shy, and from another perspective as cowardly. Similarly, it might be illuminating to see a person’s behavior as exemplifying both arrogance and insecurity. Each of those descriptive categories allows us to systematize the person’s behavior in a different way, neither of which is inherently preferable to the other, and both of which may give us genuine and distinctive insights into the person’s behavioral regularities. Moreover, both can (in different contexts) explain the phenomena, because giving causal explanations is akin to giving directions from point A to point B. Which path we prefer will typically be context-​dependent, not categorically preferable to the other.3

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Suppression The concept of suppression is also a bit difficult to pin down, and certainly the term “suppression” gets used in various ways (often as a synonym for “repression”). To the extent that there is a standard view of the difference between suppression and repression, there seem to be two distinguishing features. First, suppression is always a conscious activity, and second, “amnesia is absent in suppression, present in repression” (Hilgard, 1986, p. 251). So suppression seems to be “a conscious putting-​out-​of-​m ind of something we don’t want to think about” (Braun, 1988, p. 5). Thus, if we agree to use “suppression” in this fairly narrow technical sense, we can say that when x is suppressed for S, (a) S consciously diverts attention from x (i.e., puts x “out of mind”), and (b) S does not have amnesia for x.

Denial Although Braun regards denial as yet another distinct point on a continuum of awareness, I submit that if we define the relevant terms as I suggest here, a distinct category of denial is gratuitous. I propose instead that we consider using the term “denial” in a descriptive rather than explanatory sense and analyzing it in terms of repression, suppression and dissociation. For example, one handy (if slightly oversimplified) approach would be the following. Let’s suppose first that the difference between unconscious and subconscious mental states is that the former can only be accessed relatively indirectly (as explained above), whereas the latter can be accessed relatively directly. Then we can regard repression as unconscious denial, dissociation as subconscious denial, and suppression as conscious denial.

What Dissociation Is With these considerations in mind, I offer the following provisional analysis of dissociation –​in particular, the general expression-​form “x is dissociated from y.” We can then see how this analysis bears on current debates about dissociation. So let’s say “x is dissociated from y” if and only if: (1) x is an occurrent or dispositional state, or else a system of states (as in traits, skills, and alter identities) of a subject S; and y is either a state or system of states of S, or else the subject S.4 (2) y may or may not be dissociated from x (i.e., dissociation is a nonsymmetrical relation). (3) x and y are separated by a phenomenological or epistemological barrier within S (e.g., anesthesia or amnesia). (4) S is not consciously aware of erecting the barrier between x and y. (5) The barrier between x and y can be broken down, at least in principle. (6) Third-​and first-​person knowledge of x may be as direct as (respectively) third-​and first-​person knowledge of S’s non-​d issociated states. Condition (1) takes the capability, ownership, and diversification assumptions into account, and condition (5) acknowledges the accessibility assumption. Since condition (4) requires S to erect the dissociative barrier either subconsciously or unconsciously, it provides a way of ruling out cases of suppression. Similarly, condition (6) rules out a large set of cases ordinarily classified as instances of repression. Condition (3) is designed to rule out a large class of cases we would presumably not count as dissociative, but in which the S’s states seem to lie behind an epistemological barrier. In particular, this condition rules out many examples of conceptual naveté and inevitable forms of self-​ignorance. For example, S might desire or dislike something but lack the introspective or conceptual sophistication, or the relevant information, needed to recognize those states. So condition (3) will rule out cases where infants, small children, or nave or mentally challenged adults lack the conceptual categories to identify their own mental states. The epistemological barrier in these cases is not something they erect. Similarly, many conceptually sophisticated adults may fail to recognize they have certain mental states, either because they are insufficiently introspective or because they lack relevant information. For example, S might be unaware she detests the sound of a fortepiano, because she has not yet heard enough examples for that disposition (or regularity in her preferences) to become clear. She might mistakenly think she dislikes only the one or two fortepianos she has heard. That is clearly not a case of dissociation, and condition (3) rules it out as well. Moreover, my proposed criteria of dissociation countenance a large range of phenomena as instances. Naturally (and predictably), classic forms of pathological dissociation satisfy the criteria, including DID and dissociative fugue. Moreover, other familiar impressive phenomena likewise satisfy the criteria –​for example, hypnotic amnesia, anesthesia or analgesia, and automatic writing. Perhaps more interesting, the criteria are apparently satisfied by a range of normal phenomena many want to regard as dissociative. These include, for example, blocking out the sound of ongoing conversation while

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reading (but being able to respond when your name is mentioned), and shifting gears and obeying traffic lights while driving but consciously focusing only on your conversation with your passenger. I consider it a virtue of these criteria that they undergird a variety of disparate intuitions about which phenomena are instances of dissociation. As noted earlier and as I detail further in the next section, most prevailing approaches to analyzing dissociation reflect clinical interests. Accordingly –​and appropriately – t​hey focus on dissociative disorders and traumatic dissociation, and they limit their attempts at explication and definition to that domain. For example, Dell (2019) states explicitly that he wants to clarify what a dissociative disorder is. Similarly, Nijenhuis (2015) takes dissociation in trauma as his target for analysis. These and others are worthy efforts. However, they would fail as attempts to analyze the general concept of dissociation, because (as one would expect) they’re either too restrictive or over-​inclusive. Nijenhuis (2015) attempts to gets around this issue by categorizing as alterations in consciousness phenomena that others identify as normal, non-​clinical dissociative phenemona (e.g., absorption, daydreaming). By contrast, I believe the account of dissociation I provide here is sufficiently general to complement and unify the various analyses or definitions of dissociation scattered throughout the clinical and experimental literature.

What Dissociation Is Not Many writers on dissociation are less clear than Dell and Nijenhuis about the limitations of their analyses. Among prevailing (and less careful) approaches to dissociation, some (1) characterize dissociation as a defensive response to trauma or stress. But as we’ve noted, that can’t be the whole story, because it rules out the vast majority of hypnotic phenomena and also many widely-​accepted examples of (often quite mundane) dissociation in everyday life. Some have said (2) that dissociation is the absence of conscious awareness of impinging stimuli or ongoing behaviors. But if that were the case, then sleep, chemical anesthesia, and subliminal perception would count –​incorrectly –​as dissociative. Others take dissociation to be (3) ongoing behaviors or perceptions that are inconsistent with a person’s introspective verbal reports. But if that were true, dissociation would encompass far too much –​for example, cases of self-​deception, cognitive dissonance or confusion, or outright ignorance or stupidity. For instance, it would include a person simply failing to grasp that simultaneously-​held beliefs are inconsistent. And incredibly, it would also include Cartesian or Humean skepticism about the external world –​that is, the philosophical position implied by someone who, while leaning against a wall, says (in a state of philosophical seriousness) that he can’t be certain the wall exists. Still others say (4) that dissociation is an alteration of consciousness in which one feels disconnected from the self or from the environment. That, indeed, might be a feature of some forms of dissociation –​for example depersonalization/​derealization. But as a definition of “dissociation,” it first of all rules out what many have taken to be a paradigm instance of dissociation –​namely, negative hallucination. In classic cases of this phenomenon, the subject doesn’t feel disconnected from the self or environment –​merely consciously unaware of certain items in the vicinity. Second, it too seems over-​inclusive, because it apparently includes as dissociative the experience of paralysis, sleep, and sensory deprivation. Finally, some say (5) that dissociation is the co-​existence of separate mental systems or identities that are ordinarily integrated in the person’s consciousness, memory, or identity. But this approach is either empty or also too inclusive. Consider: what does it mean to refer to “separate” mental systems? In the absence of a description of what the separateness amounts to (e.g., of the sort I’ve provided), that term either has no clear meaning or else it seems merely to be a synonym for “dissociated,” in which case the definition would be circular. The likely alternative to this would be to let “separate” stand for something like “distinguishable.” But in that case the definition would, after all, be too inclusive, because it would then cover ordinary (retrievable) forgetting and the common (though perhaps only occasional) failure to juggle disparate roles in life (e.g., the person who sometimes has trouble coordinating the different mindsets required for being both a loving parent and mob assassin, or –​to keep it personal –​philosopher and musician). Some proposed definitions of “dissociation” commit more than one of the errors already noted. For example, Marlene Steinberg claimed that dissociation is “an adaptive defense in response to high stress or trauma characterized by memory loss and a sense of disconnection from oneself or one’s surroundings” (Steinberg & Schnall, 2001, p. 3). As we have seen, this definition errs in several respects. First, dissociation is not just a defensive response, and (as we noted earlier) it doesn’t always involve memory loss. Second, this definition excludes most (if not all) hypnotic phenomena.

Inclusivity vs Exclusivity Earlier, when I surveyed assumptions underlying the concept of dissociation, I described what I called the diversification assumption. According to that assumption, dissociation manifests in many different forms, affects a wide variety of

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states, and spreads out along a number of different continua, including pervasiveness, frequency, severity, completeness, reversibility, degree of functional isolation, and importance to the subject. I argued that the diversification assumption is one of several ways in which dissociation resembles many (if not most) other human capacities. For example, courage, sensuality, and wit are human capacities that likewise vary greatly in their range of manifestations and in the degree to which they are expressed along a number of different dimensions. People are not simply more or less courageous, sensual or funny. They manifest these capacities in different ways and in different styles, and to different degrees. Human behavior generally is so complex and varied that it would be incredible if dissociation failed to exhibit a similar range and diversity of expression. However, an interesting modern development in the study of dissociation has apparently led some to challenge the diversification assumption. Officially, the issue was whether normal, experimental and pathological dissociation are all forms of a single phenomenon (let’s call that the inclusivity position), or whether pathological and non-​pathological dissociation are radically distinct, lacking any significant unifying features (the exclusivity position). This rapidly became a very hotly-​debated and even polarizing topic in the dissociative disorders field, although interest in the debate declined not long thereafter. That’s a good thing; the debate was ill-​conceived from the start. Initially, most clinicians and experimenters seemed to embrace the inclusivity position (although, granted, the issues were never expressed very clearly). But then, on the basis of taxonometric analyses by Waller, Putnam, and Carlson (1996), and several subsequent studies by other investigators, some claimed that pathological and non-​pathological dissociation are sharply distinct categories. Accordingly, they argued that dissociation is not a single phenomenon and that it is a mistake to regard normal and pathological dissociation as continuous (see e.g., Putnam, 1997; Waller et al., 1996; Boon & Draijer, 1993; Ogawa et al., 1997; Briere et al., 2005). However, the underlying reasoning here is flawed. First, even if pathological and non-​pathological forms of dissociation differ consistently and dramatically (so that many properties of one are never properties of the other), that could not by itself show that dissociation is not a unitary or single phenomenon embracing both pathological and nonpathological forms. That conclusion would follow only in conjunction with an apparently unjustified assumption about the distribution of dissociative phenomena –​namely, that if pathological and non-​pathological dissociation were instances of the same class of phenomena, we’d expect to find a fairly even distribution of dissociative phenomena along a dissociative continuum. And because according to some diagnostic surveys dissociative phenomena seem instead to cluster into two distinct groups –​not the relatively smooth distribution to which the inclusivity view (or diversification assumption) is allegedly committed –​some believed that there was no longer justification for treating dissociation as a concept unifying the varied occurrences that have been considered dissociative. But in fact there is no reason to insist that the distribution between normal and pathological dissociation has to be smooth. On the contrary, uneven distributions are clearly compatible with treating dissociation as a single concept unifying a quite motley range of manifestations. At least some leading researchers have recognized this (e.g., Nijenhuis, 1999, pp. 175f ). For example, pathological lying and ordinary lying may indeed differ dramatically in degree, enough to warrant treating cases of the former (but not the latter) as a special class deserving of clinical attention. But both are still types of lying, and to ignore what they have in common is to miss an important theoretical or conceptual unity. Similar observations can be made about the differences between normal orderliness and pathological or compulsive orderliness, and between ordinary anxiety and panic attacks. The situation is the same with regard to pathological and nonpathological dissociation. The former seems clearly to be distinguishable from the latter in several respects (as one would expect). But both remain forms of dissociation, as we acknowledge tacitly by using the term “dissociation” in both cases. Interestingly, Waller et al. (1996) seemed not to make the error of concluding on the basis of their data that there is no viable general concept of dissociation uniting the phenomenon’s various manifestations. In fact, although they criticize the DES for not capturing certain observed and significant regularities in the data, they conceded that pathological and nonpathological dissociation are nevertheless “related” (p. 301) and are both forms of dissociation. They even stated explicitly that there are “nonpathological or healthy forms of dissociation” (p. 302, italics added). It is less clear whether Briere et al. (2005) avoided the error. Like some others, they claimed to have shown (in their case with the MDI) that the “notion of ‘dissociation’ as a general trait was not supported” (p. 221, emphasis added). Instead, they maintained that “dissociation may represent a variety of phenomenologically distinct and only moderately related symptom clusters whose ultimate commonality is more theoretical than empirical” (ibid). More specifically, they claimed that the “finding of discrete dissociation factors supports a view of dissociation as a multifaceted collection of distinct, but overlapping, dimensions, as opposed to a unitary trait” (p. 228). As noted earlier they also stated explicitly that on the basis of their survey, “the term dissociation may be a misnomer to the extent that it implies a single underlying phenomenon” (p. 230).

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But this position is simply confused. First, strictly speaking, dissociation is not a trait. Dissociability, however, would be. Moreover (and more seriously), the position betrays a failure to appreciate the force and antecedent plausibility of the diversification assumption. Most general concepts (including trait terms) are exemplified in a wide variety of ways (“distinct, but overlapping dimensions”). In that respect, “dissociability” is semantically on a par with “immaturity,” “reliability,” “honesty,” “humility,” irascibility,” “greediness,” “politeness,” “stinginess,” “laziness,” “callousness,” “friendliness,” and so on. These terms all capture genuine psychological and behavioral regularities (the grasp of which is crucial for successfully navigating through life’s perils and obstacles); they are all proper candidates for attempted general definitions; and they can all be expressed (exemplified) in an endless number of different ways and to different degrees. Of course, what’s at issue in this chapter is precisely the theoretical question of whether the variety of dissociative phenomena can be plausibly construed as falling under a general concept. And the definition I provided earlier shows that it can. Now I grant that my multi-​part analysis is complex and arguably cumbersome –​perhaps something that only a philosopher could love. But an accurate and illuminating general account of “dissociation,” sufficiently abstract to capture the wide range of phenomena that exemplify the concept, is something that we would demand or attempt in the first place only in a philosophical state of mind. It requires operating at a level of abstraction that would be inappropriate in the clinical literature. As I’ve noted, clinicians focus instead (as they should) on matters related to treatment, and thus on specific varieties of dissociation (such as traumatic dissociation) and corresponding limited domains of phenomena. (See e.g., Nijenhuis & Van der Hart, 2011; Nijenhuis, 2015, for efforts that also happen to be unusually sophisticated conceptually.) It’s also worth noting that the appearance in diagnostic surveys of sharply distinct classes or taxons of dissociative phenomena may simply be an artifact of the categories and form of questions used in the surveys from which the data were gathered. Questions and their embedded descriptive categories are like conceptual grids. To put the matter picturesquely, depending on the shape and size (e.g., fineness or coarseness) of the grids, objects of only certain sizes and shapes will pass through. That means that items on questionnaires will, from the start, allow only certain kinds of responses and thereby permit only certain kinds of results or types of discriminations. The appearance of dissociative taxons might therefore reveal little more than the inevitably theory-​laden biases or coarseness of the distinctions permitted by the questionnaire. For example, from Briere’s et al. use of the MDI, we cannot conclude anything more than that dissociative phenomena can be parsed nonarbitrarily in a way that reveals no underlying connectedness. And of course, that’s no more revelatory or theoretically interesting than the observation that the things in this room can be divided nonarbitrarily into nomologically anomalous classes each one of which exhibits its own distinctive regularities –​for example, when insurance agents, household movers, or interior decorators classify them into heavy things, big things, green things, valuable things, fragile things, and appallingly ugly things. But in that case, if my foregoing conceptual analysis shows that the concept can indeed be made to unify and cover the broad range of phenomena that have been considered dissociative, and if application of the MDI (or another survey instrument) fails to capture that unity and systematicity, there’s little reason to think it captures or helps analyze the concept of dissociation. Moreover, we’ve already noted one reason to doubt the ability of current diagnostic surveys to illuminate the whole concept of dissociation –​namely, their neglect of hypnotic phenomena. Even when the surveys were administered both to clinical and non-​clinical populations, their questions were not designed to distinguish, say, those who are good hypnotic subjects from those who are not, much less those who are hypnotizable to varying degrees. So right from the start, they cannot identify one clear group of dissociators or tease out what they have in common. So then they can’t be expected to reveal what ordinarily hypnotizable persons have in common with those experiencing clinically interesting forms of dissociation, much less whether there’s a smooth transition from the former class of subjects to those suffering from pathological dissociation –​or failing that smooth transition, something theoretically relevant that they have in common. It appears, then, that proponents of the exclusivity position set up a straw man when they stated the inclusivity view. In fact, there are two signs of this. We’ve already considered the first: namely, assuming unjustifiably that the distribution of dissociative phenomena must be smooth if the inclusivity view is correct. The second apparent instance of straw-​ man reasoning is this. Contrary to what proponents of the exclusivity view seemed to suggest, to say that normal and pathological dissociative phenomena are continuous is not to say that there is a single dissociative continuum along which those forms of dissociation spread (unevenly or evenly). Holmes et al. (2005) seem to make a similar error, in arguing for the division of dissociative phenomena into two qualitatively distinct forms: detachment and compartmentalization. But that’s a needlessly simple and antecedently incredible formulation of the inclusivity position, and it’s all too easy to overturn. Presumably, one can always select a list of allegedly relevant properties in such a way that the classes of normal and pathological dissociation appear to be profoundly separate. But on different characterizations of dissociation, or using

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different lists of relevant properties, the two forms of dissociation might turn out to overlap or distribute quite evenly. In fact, we saw that the criteria of dissociation I listed above countenance both normal and pathological forms of dissociation. So we know already that dissociation can in fact be characterized in a way that embraces the phenomenon in all of its widely recognized forms and which still allows dissociation to be distinguished from repression, etc. Moreover, it’s clear that dissociative phenomena satisfying those criteria spread out (smoothly or otherwise) along several continua (e.g., pervasiveness, frequency, severity, degree of functional isolation, and degree of personal importance to the subject). So it seems to me that the debate over taxons was much ado about nothing, at least so far as it purported to be a debate over the concept of dissociation. However, none of this is to deny the importance –​or the clinical necessity –​of recognizing and focusing on the manifest disparities between pathological and non-​pathological forms of dissociation. (But notice, I refer to both –​as one should –​as forms of dissociation.) For the clinician, the differences are what matter, and perhaps the distinctive aspects of pathological dissociation are the only features that deserve their attention. In that sense, it’s pragmatically defensible to regard pathological dissociation as a phenomenon distinct from non-​pathological dissociation. Similarly, it’s defensible for clinicians to focus on pathological lying as a phenomenon of interest, but not the everyday lies we tell to protect another’s feelings, to avoid embarrassment, and to avert countless other mini-​conflicts. But it’s still confused to think that warrants rejection of the inclusivity view. And as I believe we can now see, to reject that view is to lose sight of the interesting properties that seem to link all forms of dissociation and which justify, for the time being at least, treating dissociation, in all its richness and variety, as a legitimate and single object of psychological and theoretical inquiry.

Acknowledgments I am grateful to Paul Dell and John O’Neil for very helpful criticisms of an ancestor of this chapter, and to Martin Dorahy and Steven Gold for valuable suggestions on this update. Any remaining defects are entirely their responsibility.

Notes 1 Much of what follows draws from, and I believe (or at least hope) improves upon, a more wide-​ranging discussion of the concept of dissociation in Braude (1995). 2 Some might think instead that we are immediately aware of another person’s anger or pain (say), and then only later, upon reflection, wonder whether the anger or pain is feigned. That is certainly a respectable alternative view, and one whose viability can’t be adequately addressed here. For now, our concern is with the relative directness or indirectness of first-​and third-​person knowledge of mental states. To that end I believe it’s sufficient to say that we need to focus on what we might call the “logical” as opposed to the “historical” order of ideas. No matter how instinctively and reliably we might accept uncritically various behaviors as indicators of another person’s mental states, our third-​person knowledge of those states can be analyzed plausibly as involving interpretations and assumptions not required for first-​person knowledge of our own states. 3 For example, suppose we want to know what caused my heartburn. That request may be answered correctly in many different ways, depending on such things as who is asking, and how much and what sort of knowledge of the situation is presupposed and relevant to the request for an explanation (i.e., how much one needs to know). Thus, if we simply want to isolate which of my activities that day was causally relevant to my heartburn, it might be enough to observe that I had eaten Mexican food for dinner. But in response to different requests for explanation or needs to understand, it might be more appropriate and illuminating to trace different causal lines. For example, we might prefer to connect my heartburn to the ingredients present in my dinner, the chemical structure of those ingredients, or the physiological disposition of my body (or of my stomach in particular). Or, it might be more appropriate to connect my heartburn to the psychological factors (say, my relationship with my parents) that contributed to my developing a nervous or weak stomach, or the way in which the chef ’s preoccupation with his divorce led to an excess of hot spices in my meal, or perhaps even the cultural tradition and geographical factors that culminated in a Mexican propensity for preparing “picante” dishes, etc. 4 The syntactic complexity of this condition reflects the fact that we assert the presence of dissociation under a great variety of conditions. For example, we can say that a subject has dissociated a memory, trait, or alter identity. But we also sometimes say that one memory or skill is dissociated from another.

References Binet, A. (1892/​1896/​1977). Les altérations de la personnalité. Paris: F. Alcan. English edition: Alterations of personality. New York: D. Appleton & Company, 1896. Reprint: University Publications of America/​Washington, DC, 1977. Boon, S., & Draijer, N. (1993). Multiple personality disorder in the Netherlands: A study on reliability and validity of the diagnosis. Lisse: Swets & Zeitlinger Publishers. Braude, S. E. (1995). First person plural: Multiple personality and the philosophy of mind. Rev. Lanham, MD: Rowman & Littlefield.

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Braude, S. E. (2014). The creativity of dissociation. In Crimes of reason: On mind, nature, and the paranormal. Lanham, MD: Rowman & Littlefield. Braun, B. G. (1988). The BASK (Behavior, Affect, Sensation, Knowledge) model of dissociation. Dissociation, 1(1), 4–​23. Briere, J. (2002). Multiscale Dissociation Inventory. Odessa, Florida: Psychological Assessment Resources. Briere, J., Weathers, F. W., & Runtz, M. (2005). Is dissociation a multidimensional construct? Data from the Multiscale Dissociation Inventory. Journal of Traumatic Stress, 18(3), 221–​231. Cardeña, E. (1994). The domain of dissociation. In S. J. Lynn & J. W. Rhue (Eds.), Dissociation: Clinical and theoretical perspectives (pp. 15–​31). New York, NY: Guilford Press. Carlson, E. B., & Putnam, F. W. (1993). An update on the dissociative experiences scale. Dissociation, 6(1), 16–​27. Crabtree, A. (1993). From Mesmer to Freud: Magnetic sleep and the roots of psychological healing. New Haven, CT: Yale University Press. Dell, P. F. (2019). Reconsidering the autohypnotic model of the dissociative disorders. Journal of Trauma & Dissociation, 20, 48–​78. Gauld, A. (1992). A history of hypnotism. Cambridge. MA: Cambridge University Press. Hilgard, E. R. (1986). Divided consciousness: Multiple controls in human thought and action (Expanded Edition). New York, NY: Wiley-​Interscience. Holmes, E. A., Brown, R. J., Mansell, W., Fearon, R. P., Hunter, E. C. M., Frasquilho, F., & Oakley, D. A. (2005). Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical Psychology Review, 25, 1–​23. Messerschmidt, R. (1927). Quantitative investigation of the alleged independent operation of conscious and subconscious processes. Journal of Abnormal & Social Psychology, 22, 325–​340. Myers, F. W. H. (1903). Human personality and its survival of bodily death. London: Longmans, Green & Co. Nijenhuis, E. R. S. (1999). Somatoform dissociation. Assen: Van Gorcum. Nijenhuis, E. R. S. (2015). The trinity of trauma: Ignorance, fagility, and control-​-​Vol. 1+​2: The evolving concept of trauma /​T he concept and facts of dissociation in trauma. Bristol, CT: Vandenhoeck & Ruprecht. Nijenhuis, E. R. S., & Van der Hart, O. (2011). Dissociation in trauma: A new definition and comparison with previous formulations. Journal of Trauma & Dissociation, 12, 416–​4 45. Ogawa, J. R., Sroufe, L. A., Weinfeld, N. C., Carlson, E. A., & Egeland, B. (1997). Development and the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Development & Psychopathology, 9, 855–​879. Orne, M. T. (1971). The simulation of hypnosis: Why, how, and what it means. International Journal of Clinical and Experimental Hypnosis, 19, 183–​210. Orne, M. T. (1972). On the Simulating Subject as a Quasi-​control Group in Hypnosis Research: What, Why, and How. In E. Fromm & R. E. Shor (Eds.), Hypnosis: Developments in Research and New Perspectives (pp. 399–​4 43). Chicago, IL: Aldine-​Atherton. Prince, M. (1905). Dissociation of a personality. Oxford: Oxford University Press. Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York: Guilford Press. Sidis, B. (1902). Psychopathological researches: Studies in mental dissociation. Boston, MA: Richard G. Badger. Steinberg, M., & Schnall, M. (2001). The stranger in the mirror: Dissociation –​the hidden epidemic. New York, NY: Harper Collins. Van der Hart, O., & Dorahy, M. J. (2009). History of the concept of dissociation. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation & the Dissociative Disorders: DSM-​V & Beyond. New York, NY: Routledge. Waller, N. G., Putnam, F. W., & Carlson, E. B. (1996). Types of dissociation and dissociative types: A taxometric analysis of dissociative experiences. Psychological Methods, 1, 300–​321.

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3 THE TRAUMATIC DISINTEGRATION DIMENSION Benedetto Farina and Russell Meares

Despite the high prevalence of dissociation in psychiatric disorders and general agreement regarding its relevance as a marker of clinical severity and poorer treatment response (Lebois et al., 2021; Lyssenko et al., 2018), there is no consensus on its definition and pathogenesis (e.g., Brown, 2006; Nijenhuis & Van der Hart, 2011). Indeed, after more than a century of debate and empirical study, the meaning of dissociation remains controversial, not having achieved a clear, common and scientifically validated definition of its nature (Lynn et al., 2019; Van der Hart & Dorahy, Chapter 1, this volume). We hypothesize that diverse dissociative manifestations are generated by different yet interplaying pathogenic processes: traumatic disintegration and what is more properly called dissociation, that we distinguish in two forms: disinhibited and inhibitory dissociation. This chapter describes these distinctions, which we believe are relevant for treatment and research.

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Distinguishing Between Traumatic Disintegration and Dissociation Dissociation is generally defined as a deficiency of internal and external awareness with a sense of separation and fragmentation of self-​experience. This definition includes a wide and diverse group of symptoms (See Linde-​ Krieger, Yates & Carlson, Chapter 9, this volume). Most contemporary scholars agree it is unlikely that so many different manifestations could be generated by the same pathogenic process (Brown, 2006; Frewen & Lanius, 2014; Meares, 2012; Nijenhuis & Van der Hart, 2011). In fact, psychopathological, clinical and neuroscientific data demonstrate that traumatic dissociative symptoms are not explained by a one-​d imensional approach to dissociation. However, there is no agreement among scholars on how to distinguish the various forms of dissociation and the corresponding differing pathogenic processes underlying each of them. We address this problem by reintroducing and renewing the disintegration theory originally proposed by Janet and showing how it is consistent with current clinical and neuroscientific research, including the evolutionary psychology of attachment and its role in survival and defense.

Traumatic Disintegration Traumatic disintegration can be defined as the weakness or lack of integrative capacity that affects high-​order mental functions, including executive functions and self-​consciousness. Psychological trauma activates different neurobiological pathogenic mechanisms, such as epigenetic editing, stress hormones and inflammation, at different levels. The effects on these types of mechanisms are especially pronounced in response to long-​lasting, interpersonal, and repeated trauma occurring during early development, as in the case of traumatic attachment. In these instances, neurobiological pathogenic mechanisms interplay with genetic predisposition to alter the balance between integration and segregation of information and functions (Deco et al., 2015; Gordon et al., 2018; Lord et al., 2017; Park & Friston, 2013). Disintegrative processes lead to very different psychopathological symptoms depending on which mental function they compromise, from altered states of consciousness to sudden emotional and behavioural dysregulations, fragmentation

DOI: 10.4324/9781003057314-5

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of self-​experience or metacognitive breakdown. The more a mental function depends on integration and the more it develops in relationship with the environment, especially the interpersonal environment, the more it could be affected by traumatic disintegration. At the top of this failure to develop a co-​ordination among the elements of the brain/​m ind system there is the impaired emergence of self and consciousness (Meares, 2012). The effect of disintegration leads to both negative symptoms, related to the weakening of an integrative function (i.e., lack of executive functioning, fragmentation of self-​experience or failures of metacognitive monitoring), and positive symptoms caused by the dysregulated emergence of mental functions or contents no longer coordinated or inhibited (i.e., traumatic memories, flashbacks or intense affective states) (Farina et al., 2005; Meares, 2012). The weakness of integrative capacity could be viewed as a trait vulnerability acquired during development and affecting personal coherence, self-​continuity, and organized states of mind (that Janet called “personal synthesis”). These mental functions are not innate, but rather result from the cognitive and affective coordination with attachment figures (Carlson et al., 2009; Huang et al., 2020; Meares, 2021; Schore, Chapter 11, this volume). Developmental trauma interferes with these functions, leading to fragmentation of self-​experience that occurs with shifting of different ego states, chaotic behaviours, a sense of painful incoherence, emptiness, and blank spells (Meares, 2012, Liotti & Farina, 2016; Şar, 2017). Furthermore, traumatic disintegration in combination with contradictory and threatening experiences with a caregiver leads to disaggregated implicit relational and explicit traumatic memories, fostering dissociation (as described below). Additionally, traumatic disintegration’s weakening inhibitory and executive control functioning produces temporary affective and behavioural dysregulation, flashbacks, consciousness alterations and failures in metacognitive monitoring (Liotti & Farina, 2016; Meares, 2012; Meares et al., 2011). This last effect also causes a state dependent disintegrative vulnerability occurring when the person finds themselves in painful, harmful or threatening conditions, which are frequently provoked by the emergence of implicit relational traumatic memories. It has been hypothesized that painful and harmful conditions usually activate the attachment system and its implicit memories (internal working models) (Bowlby, 1969/​72). In the case of attachment trauma, implicit memories convey dramatic self-​representations of being in danger and helpless, with the caregiver represented as abusing or abandoning, or simply powerless and scared. In patients with attachment trauma histories this process becomes particularly evident in close interpersonal contexts, especially in those based on care systems, like the therapeutic relationship (Farina et al., 2019; Luyten et al., 2020). The activation of implicit relational traumatic memories and its relative hyperaroused emotional state triggers state dependent disintegration with lowering of 1) self-​continuity, 2) metacognition, and 3) inhibition control, that leads to affective and behavioural disturbances which, circularly, deepens the disintegrative effect and self-​fragmentation. It is noteworthy that, from a neurophysiological standpoint, all these affective and behavioural psychopathological manifestations are characterized by anatomical and functional connectivity disturbances (Adenzato et al., 2019; Meares et al., 2011; Teicher et al., 2016; Terpou et al., 2019), a point that will be extensively discussed below. Interestingly, most conceptualizations of dissociation, including those in DSM-​5 (APA, 2013) and ICD-​10 (WHO, 1992), are based on the concept of “disruption of normal integration” of very different mental functions, some of which are directly related to disintegration.

Disintegration Without Dissociation A main feature of disintegration in the absence of dissociation is captured by C.S. Myers term, the “apparently normal personality” (Myers, 1916, p. 467, 1940). His shellshocked soldiers, having recovered from the acute symptoms of their trauma, were somewhat changed. The change was subtle and not readily observable. It involved loss or impairment of higher order functions involving the capacity to hold two things in mind at the same time, such as inner and outer, past and present (Meares, 2016). Symbolic function was reduced and manifest in a concrete style of conversation (Meares, 2021). Autobiographical memory was diminished. Williams and his colleagues demonstrated the nature of the disturbance. They studied people likely to have suffered cumulative trauma (e.g., suicide attempters; Williams & Broadbent, 1986) and BPD ( Jones et al., 1999). Autobiographical memory in these people had become “overgeneralized,” resembling semantic memory. What is disabling, however, lies behind this “front” of normality. It is illustrated by the case of Adele, reported by Meares (2012). On first meeting with this young woman there was no evidence of disorder. Her demeanour was pleasant, and she had a nice smile. After about 15 minutes, the “front” cracked and she began to cry. She spoke of “a barely expressible pain of living, of moving not merely from day to day, but from minute to minute, each step seeming impossible, as if paralysed by an overwhelming sense of emptiness” (p. 2). Underlying it, and without shape or object, was fear. “Some of it involves aloneness. Time by herself is barely to be endured yet in the presence of others she feels

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an isolate and unknown” (p. 2). There was a central disturbance of the sense of self. She said: “I don’t know who I am… When I look in the mirror I don’t see me” (p. 2). Despite all this, she managed to maintain a job. Her work colleagues found it hard to believe there was anything wrong with her. The underlying “psychic pain” (Zanarini et al., 1998) was belied by her behaviour. It may be the most enduring central aspect of disintegration of personality brought about by cumulative trauma (Zanarini et al., 2008). There remains a core of “painful incoherence” (Liotti & Farina, 2016; see Meares, 2012, p. 42–​44).

Dissociation of Two Kinds: Disinhibited Dissociation and Inhibitory Dissociation Dissociation is understood here as a state arising from a matrix of brain-​m ind systems and units which are not adequately integrated or differentiated and become recomposed in a more or less stably segregated way. Since our main theme concerns disintegration, we do not extend our discussion to the vast array of dissociative experiences beyond the commonest ones. For example, we do not consider those dissociations which are typically the outcome of severe trauma, in which fragments of the trauma are represented as movements, imprints on the skin, flashbacks, and so forth. We focus instead on two main forms of dissociation, both differentiated from disintegration, brought about by two different processes, active and passive. The passive concept we owe to Janet. We are calling it ‘disinhibited dissociation.’ A second kind of dissociation distinguished in the chapter, we refer to as ‘inhibitory.’ It is the most commonly identified form of dissociation, characterized by “zoning out.” It is associated with the activation of inhibitory mechanisms (see for example, Lanius et al., 2006).

Disinhibited Dissociation Janet studied patients with what he called a “mental disease.” There is no precise modern equivalent. Janet’s mental disease was a polysymptomatic personality disorder involving more or less stably segregated brain-​m ind systems, the identifying features of which were loss of function, most particularly of sensation, memory, and motor power ( Janet, 1901). He called these manifestations of the illness “stigmata.” The main feature of the disease was a “weakening of the faculty of personal synthesis” (1901, p. 527). This was an effect of traumatic impacts on the personal system, bringing about disintegration. These impacts, producing “vehement emotions,” lead to “cerebral exhaustion” (p. 527). As Van der Hart and Dorahy (2009) note, “vehement emotions inherent in traumatic experiences [are] the primary causes of this integrative failure” (p. 7). Janet stated that traumas “produce their disintegrative effects in proportion to their intensity, duration and repetition” ( Janet, 1909, p. 1556). Thirty years after his original formulations, apparently exasperated by the misunderstandings surrounding his work, Janet attempted to provide the clearest account that he could of his main thesis. It concerned “a particular modification of consciousness that I tried to describe in 1889 under the name subconsciousness through disintegration. This dissociation, this migration of certain psychological phenomena into a special group, seemed to me connected with exhaustion brought on by various causes, and in particular by emotion” ( Janet, 1924, p. 40). He distinguished then, two processes, one of disintegration (i.e., désagrégation), and a subsequent elaboration of disintegration, dissociation. Dorahy and Van der Hart (2015) have pointed out the English translations of Janet’s désagrégation, have assumed that it is merely a synonym of dissociation. This has led to considerable conceptual confusion. The same authors speak of dissociation as a “division of the personality into dissociative systems of ideas and functions” (Van der Hart & Dorahy, 2009, p. 8). They quote Janet (1946): “these divisions of the personality offer us a good example of dissociations which can be formed in the mind when the laboriously constructed syntheses are destroyed [disintegration]. The personal unity, identity, and initiative are not primitive characteristic of psychological life. They are incomplete results acquired with difficulty after long work and they remain very fragile (…) and the end of the illnesses of the mind is dissociation…” (Van der Hart & Dorahy, 2009, p. 8). In other words, traumatic development interferes with integration of personal unity and identity fostering the division of the personality into dissociative systems that we call dissociation proper (see below for further discussion). Integration is not a given. It arises out of a developmental process, beginning at birth. Every stage in this process requires an appropriate relational provision, characterized by connectedness. The outcome is a hierarchically organized self system involving successive “layers,” all of which contribute to the experience of self. The “layers” become progressively more coordinated. Each one involves a “higher” or more refined system of inhibition, which controls the earlier ones. Tulving conceived a three-​tiered hierarchical structure of memory. The earliest and most fundamental forms are procedural memory and perceptual representations (Tulving & Schacter, 1990). These are unconscious. The next level,

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the “semantic”, becomes first evident at about 18 months (Tulving, 1983). It concerns facts, known without awareness of their origin. It is partly conscious, or “subconscious” to use Janet’s term. The highest level of memory, autobiographical, can be demonstrated after about four years of age (Nelson, 1992), when the first manifestations of “self ” appear (Meares & Orlay, 1988). A number of parallel hierarchies have been proposed. The nineteenth-​century neurologist, Hughlings Jackson also envisaged a three-​tier system of brain development, based on neurological representation of an environmental event (discussed in more detail below). His conception of representation, re-​representation, and re-​re-​representation has been extensively elaborated by Gerald Edelman (1992). A seven-​layered hierarchy made of relation and emotion is a necessary addition (Meares, 2016, p. 70–​82). Trauma causes a retreat down a hierarchy of mental function such that the unity of mental life is lost. Janet’s concept of dissociation is somewhat mysterious. He saw it as a phenomenon in which traumatic material separates from the rest of mental life in a figurative “migration” ( Janet, 1924, p. 40). How can this occur when, in his view, no inhibitory mechanisms are involved ( Janet, 1907)? His implication is that it is due to a difference in structure. The organization of traumatic material has a form which differs from that of ordinary consciousness. It is lower on a hierarchy of mental life (that can range from lower-​order reflexive behaviors, to higher-​order integrate capacity underpinning a sense of self existing currently and overtime). Traumatic material is both “restricted” and less coordinated. It becomes foreign. Janet saw such alien matter as indissoluble in the flow of ordinary consciousness. This idea underlies his approach to the treatment of traumatic matter by “mental liquidation” (which faciliated an abreaction that promoted integration with higher mental levels; Janet, 1925, p. 589). Since the traumatic material, organized as a “fixed idea”, is somewhat down in a hierarchy of mental life, it depends upon a memory system which is more limited than normal consciousness. It is partial, or “subconscious”, to use Janet’s term. It offers no defence and, typically, has no “purpose”. It is simply an occurrence. It is a very common clinical presentation. Janetian dissociation is often subtle in its manifestation, and triggered by minor events, such as a perceived slights or devaluations. Here is an example. A middle-​aged couple take turns at night in cooking and setting the table. One night the wife is cooking and the husband is setting the table. She says “why don’t we use the new tablecloth?”, “Ok”, he says and changes the cloth. The next night he cooks while she sets the table. He says “why don’t we use the other knives?” She erupts, “Do you think I am so stupid that I can’t even set a table”. Mystified by her vehemence, the husband responds angrily. Soon they are fighting (Meares, 2000, p. 53). She had a past of relational trauma. She had lived in a family milieu in which she would expect belittling and criticism, leading to the brain-​m ind system that became “weak or enfeebled by a succession of slight forgotten shocks” ( Janet, 1924, p. 275). Memories of these “shocks” are aggregated into an unconscious traumatic memory system, Janet’s “fixed idea”. It is triggered by events which resemble these memories, however slightly. This woman interpreted her husband’s suggestion as criticism. She did not realise that she was in the grip of the past. She was unaware of the origin of her vehemence. In this sense, she was dissociated.

Inhibitory Dissociation The second kind of dissociation is, unlike the first, defensive and dependent upon inhibitory activity. It is most saliently manifest in symptoms of coarse, or global, loss of function (e.g., paresis, amnesia). However, it also operates at a finer level. Janet described a form of dissociation which always arises from a pre-​existing state of disintegration. We believe that this is also the case for the second kind of dissociation, which we are calling inhibitory dissociation. Disintegration may be an enduring background condition in these subjects who have suffered cumulative trauma. In such people, a dis-​coordination between brain systems which usually work together can be demonstrated (Meares, 2012; Meares et al., 2005). The stress inducing the symptom may be relatively mild. In other cases of inhibitory dissociation, no such enduring disintegrative background can be demonstrated. We assume that in these circumstances a considerable “shock” is needed to precipitate the protective inhibitory “shield”. A very simple example is as follows. A trainee nurse is ordered to set out a dead body for the first time. She is apprehensive as she approaches the body. When she bends over the face, she feels a click in her spine. Her arms go weak. She cannot continue her task. A neurologist finds no abnormality to explain her paresis. Afterwards, she was able to speak of her experience, during which time she recovered the strength in her arms. She remembered the “shock” when she looked into the face. It reminded her of her mother, with whom she did not get on well. “The shock” was presumably disintegrative and was immediately followed by coarse inhibitory activation (dissociation), causing a temporary loss of power in her arms. This young woman had no biography suggesting that she harboured a traumatic disintegration dimension which might give rise to dissociation. People having sudden severe “shocks”, such as a wartime event, may have a brief episode

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of inhibitory dissociation with no evidence, as indicated electrophysiologically, of underlying disintegration (Meares & Horvath, 1972). Although Janetian (disinhibitory) dissociation and inhibitory dissociation can be distinguished: the kind of dissociation proposed by Janet is a reflection of failure of higher order inhibition, whereas the second kind of dissociation depends upon an activation of coarser and more global inhibition. This latter dissociation is defensive and protective; the former has no psychological purpose or function. They are sometimes active together. For example, the protective function of inhibitory dissociation may be recruited in order to shield from consciousness the traumatic material at the core of disinhibited dissociation. The differentiation between disintegration and dissociation is much less clear during the attachment period, before about age 4 when the first evidence of self is manifest in autobiographical memory (Nelson, 1992), and the child has the capacity to hold simultaneously in mind two different realities. Adverse childhoods characterized by repeated, severe and long-​lasting disintegrative processes in combination with extremely traumatic or contradictory experiences with caregivers can lead to inhibitory dissociation (Farina et al., 2019; Liotti, 1992). However, in the period before 4, when the self is less fully formed (Meares & Orlay, 1988; Wimmer & Perner, 1983) and integration may be rudimentary and inhibitory function undeveloped, the distinction between disintegration and inhibitory dissociation becomes blurred. Each shifting conscious state can be called both dissociated and disintegrated.

The Hierarchy of Hughlings Jackson Janet’s description of disintegration and dissociation needs elaboration. Further clarity depends upon a hierarchical conception of human consciousness. This approach became highly developed in Janet’s later work (Barral & Meares, 2019). However, the hierarchy had already been envisioned by the great English neurologist John Hughlings Jackson (1835–​ 1911). His work contributes to an understanding of what Janet meant by dissociation (Farina et al., 2005; Meares, 1999). Jackson proposed a view of the making and breaking of what he called self which shows a remarkable resonance with Janetian ideas, at least in terms of the breaking. He conceived the brain-​m ind as a hierarchical organization which, reflecting the history of evolution, integrates increasingly complex inter-​coordinated levels as it rises. Every superior level modulates and is co-​ordinated with the lower ones. At the highest levels, the mind represents itself, integrating the activity of its lower components (Meares, 1999). This re-​representation in the dynamic play at the highest levels of mind has been rediscovered by Nobel prize winner Gerald Edelman (1992) in his conceptions of different levels of consciousness based on organization-​structuring and complexity, that he calls primary and higher-​ order consciousness. Jackson saw the evolution of self as a cooperation between two opposing themes of organization. The first involves an increasing coordination between the basic elements of neural function. The second theme is inhibitory, concerning a force which disconnects these developing unities. It fosters discrimination between them. At each “level” of evolutionary progress, a new degree of inhibitory competence is gained, allowing a finer disconnection and discrimination between the unities. For example, prefrontal cortex executive functions develop for inhibition of impulses or intense affective states related to threatening situations in favour of a more refined defence response. The new level of inhibitory activity has a controlling effect over earlier levels. It is evident that Jackson had somehow anticipated the present neuroscientific knowledge on integration-​segregation balance of mental functioning described below (Deco et al., 2015). There can be a retreat down the evolutionary trajectory which Jackson called “dissolution”. There are two main consequences: a relative failure of connection between brain elements and a loss of higher-​order inhibitory function with low-​level mental functions emerging uncontrolled and separated. An example is a momentary failure of executive functions with the emergence of exaggerated emotionality and dysregulated behavioural reactions to threat. There is a progressive failure of voluntary control over the movements of mental life, which becomes more automatic, less complex and more fragmented. Earlier developed functions are dis-​coordinated and exaggerated (Meares, 1999).

Sherrington and the Discovery of Inhibition as a Coordinative Factor Hughlings Jackson was working during the first phases of neurological science, before fundamental concepts like the synapse were named. It was Charles Sherrington who, in 1897, introduced the term ‘synapse’ for the special membrane between neurons via which impulses are conducted from one neuron to the next. Sherrington built on the skeletal foundation of Hughlings Jackson’s theory. Over the next decade Sherrington (1906) showed that the great function of the nervous system is the integration of all bodily phenomena, to enable an appropriate motor output. The integration includes not only the conscious functions of volitional movement but also those that are unconscious, autonomic, and

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proprioceptive. Sherrington was the first to use the term proprioception and described much of the system that generates it, ruled by the cerebellum. Sherrington’s whole system was based on his discovery of inhibition and its essential role in the integration dynamics of brain function as described in the coming sections. He showed that a particular kind of neuron, which he called “internuncial,” now called interneuron, had an inhibitory function. Modern neuroscience shows that inhibitory interneurons are crucial for integration and segregation balance because they “serve to coordinate networks” (Kepecs & Fishell, 2014, p. 6) by gating information flow within a given circuit, providing feed-​forward inhibition and other computational functions in order to regulate and coordinate higher-​order brain functions. Indeed, their density and functioning are considered to be an indicator of cortical maturity (Umemori et al., 2018). The neocortex has the largest number of interneuron types, but they are also numerous in the hippocampus and other limbic structures such as the amygdala. Indeed, it has been demonstrated that inhibitory interneurons play a crucial role for fear learning, emotional control, memory functions, executive functions, consciousness and many other high level coordinating mental functions impaired by psychological trauma (Ferguson & Gao, 2018). Sherrington highlighted the significance of inhibitory systems in his Nobel speech in 1932. He made its starting point Jackson’s release phenomenon, which manifests a failure of inhibition. Jackson had called the nervous system “a sensori-​ motor mechanism, a co-​ordinating system from top to bottom” ( Jackson, 1958, II, p.41). Sherrington’s lecture, entitled “Inhibition as a co-​ordinative factor”, gave an indication of how the co-​ordination may come about.

“Normal Integration” and the Dynamic Network Organization of the Brain To best understand the pathogenic power of traumatic disintegration anticipated by Janet, we first need to clarify the concept of normal integration within the hierarchical network architecture of the brain as predicted by Janet, Hughlings Jackson and Sherrington. “The healthy human brain segregates and integrates information” (Deco et al., 2015, p. 430). Modern neuroscience experiments have demonstrated that the brain is a highly integrated and dynamic system which connects functionally segregated systems (Biswal et al., 2010; Fukushima & Sporns, 2020; Lord et al., 2017; Park & Friston, 2013). The brain also operates to segregate information into distinct modules that execute specialized local computations, functions, and mental contents (Deco et al., 2015). The optimal functioning of the human brain is an interplay between segregation and integration, which is essential for balancing effective local processing and global communication of neural information between specific areas, in turn supporting high-​level mental functions (Deco et al., 2015; Fukushima & Sporns, 2020; Lord et al., 2017). Segregation and integration operate through the dynamic activity of a complex organization of neural networks involving several brain areas, rather than through single anatomical structures (Gordon et al., 2018; Park & Friston, 2013). The structural connectivity architecture of the brain (axons, white matter tracts) includes both short and local connections organized in modules and large-​scale connections. The large-​scale connections integrate different segregated modules in a heterarchical manner, supporting local and global integration that operates a flexible top-​down control over low level cognitive, sensory, and motor networks (Deco et al., 2015; Gordon et al., 2018; Lord et al., 2017; Park & Friston, 2013). This connectivity architecture of neural communities and interconnected hubs allows many possible patterns of functional segregation and integration of neural information organized in functional networks that change their dynamic configuration according to different tasks and mental states in response to momentary demands from the environment (Fukushima & Sporns, 2020; Gordon et al., 2018; Park & Friston, 2013). Large scale functional networks support global and efficient processing of information, integrating different local segregated modules: “brain function or cognition can be described as global integration of local integrators” (Park & Friston, 2013, p. 580). In this regard integration and segregation are not specific mental functions, but emergent intrinsic properties of optimal mental functioning. As Janet stated more than a century ago: “mental health is characterized by a high capacity for integration” ( Janet, 1889, p. 460). Recent scientific literature leads to the consideration of major psychiatric disorders as alterations of the balance of integration and segregation (Bassett et al., 2018; Lord et al., 2017). As anticipated by Sherrington, to achieve an optimal interplay between integration and segregation the brain must regulate the level of excitatory and inhibitory neuronal activity (Lord et al., 2017). The balance between excitatory and inhibitory neurotransmission, particularly in the prefrontal cortex, amygdala, hippocampus and other limbic structures, is essential for executive functioning, working and declarative memory, emotion processing and regulation, social and fear response, behavioural control, high-​level cognitive functioning and metacognition (Ferguson & Gao, 2018). A key role for the regulation of excitatory and inhibitory equilibrium is played by the inhibitory interneurons. They have a

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prominent part in the integration and segregation processes through inhibition of neighboring excitatory pyramidal neurons that warrants fine-​t une network regulation (Ferguson & Gao, 2018). Overall, there is increasing evidence that among the effects of child maltreatment and developmental trauma is a disruption of the balance between integration and segregation (Lanius et al., 2020; Teicher et al., 2016). We thus hypothesize that most of the psychopathological phenomena described as dissociative are manifestations of normal integration and segregation, through inhibition failures.

Disintegration and Failed Inhibition The hypothesis advanced here is that disintegration is the outcome of enduring failure of higher-​order inhibitory mechanisms. This proposal, first put forward in 1980 (Horvath & Meares, 1979), was based on findings from a study of 11 patients who had identifying features very much like Janet’s cases of désagrégation. They had a polysymptomatic history, including episodes of loss of function (e.g., paralysis, anaesthesia, aphonia, blindness, amnesia, or coma) for which no organic cause could be found. These symptoms of dissociation proper were in remission. Episodes of tremor, ataxia, dystonia and other movements sometimes representative of fragments of a traumatic experience, were not included in the criteria for fear of misdiagnosing an organic condition. The characteristic features of this group of patients seemed to epitomize the nature of traumatic disintegration dimension (TDD). We are, then, suggesting that TDD is largely synonymous with Janet’s enduring background condition of désagrégation. These patients were compared with 10 patients with anxiety in terms of electrophysiological indices of arousal and inhibition described by Lader (1975). Arousal was shown by the rate of spontaneous fluctuation of skin resistance. Inhibition was reflected by the habituation rate to meaningless sound. It is understood as a measure of the capacity to screen out redundant stimuli, a capacity obviously dependent upon inhibitory competence. The outstanding finding was total failure of habituation in the désagrégation-​like group (i.e., inhibition failure) (Horvath & Meares, 1980). Habituation failure is usually the outcome of high arousal. The consequences of inhibitory failure are numerous. They include dysregulation of arousal through lost inhibitory control. The loss of relationship between inhibitory control and arousal indicates, at least in this study, a disconnection between parasympathetic and sympathetic systems. This observation is supported by work from Porges and his colleagues (Austin et al., 2007). They studied BPD patients from the perspective of his polyvagal theory (Porges, 2009). This model proposes that the parasympathic, and inhibitory, vagus nerve, evolves in two stages. The early part of the nerve is unmyelinated; the later evolved section is myelinated and has a greater series of functions than the primitive section. These functions include linking the rhythms of the heart to those of breathing, producing respiratory sinus arrhymia (RSA). Under stress, the borderline patients showed diminishing RSA while the controls showed increasing RSA (Austin et al., 2007). Porges and his colleagues saw the change in BPD patients as an example of Jackson’s “dissolution”, a stress induced reversal of the evolutionary trajectory, with the late evolved and higher-​order functions being lost first. Using the Adult Attachment Interview (AAI), Farina and colleagues (2015) observed that the retrieval of childhood attachment experiences in individuals with a DD was associated with a change in heart rate variability (HRV) patterns that could reflect arousal and emotion dysregulation of the disintegrative psychopathological process. The results for DD patients were similar to those replicated in other trauma-​related clinical samples, such as Posttraumatic Stress Disorder (PTSD; Park et al., 2019) and, as we have just noted, in BPD (Austin et al., 2007; Luyten et al., 2020), and are consistent with those from developmental psychopathology. Indeed, Oosterman and colleagues (2010) found that children with a background of neglect and those with disordered attachment showed more sympathetic reactivity and less vagal regulation. Appropriate levels of arousal sharpen sensory awareness and vigilance, promote motivated behaviours, regulate emotions, and improve cognitive and executive functions. Dysregulated high arousal states, on the contrary, are associated with an impairment in prefrontal dependent top-​down regulation of motivated behaviours, emotion dysregulation, and altered impulse control that are core symptoms of childhood and later traumas ( Jung et al., 2019; Young et al., 2017). Thus, dysregulated levels of arousal have a negative impact on higher-​order integrative and inhibition functions worsening emotional and behavioural control ( Jung et al., 2019).

Traumatic Attachment and Disintegration Integration of the personality is most profoundly disturbed by insults occurring during the early developmental period. Yet, these events might not appear to be insults to an observer. They are, to repeat Janet’s words “a succession of slight forgotten shocks” ( Janet, 1924, p. 275). The most characteristic shocks are those the child experiences when the mother’s

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response are out of kilter with his/​her own. If the rhythm of the mother-​infant interplay is repeatedly upset it provides the background to the formation of disorganized attachment (DA). A large body of empirical studies demonstrate that attachment relationships during the first year of life become disorganized as a consequence of the caregiver being 1) overtly aggressive or 2) responding to the child in a vulnerable, frightened, neglectful but not actively maltreating way (Granqvist et al., 2017; Liotti, 2017). Thus, parents are perceived by the child as a source of nurturance, while simultaneously being a source of threat (Granqvist et al., 2017; see Schimmenti, Chapter 10, this volume). Although DA does not necessarily indicate active maltreatment, situations where the parent is at the same time the source of and the solution to the child’s fear are capable of disorganizing the child’s mental processes. Thus, DA represents a type of traumatic experience insofar as it constitutes an inescapable threatening experience in the face of which the child is powerless. In addition, as Guérin-​Marion and colleagues (2020) reminded us, the caregiver is an external regulator of the infant’s stress response, both at a neurovegetative level and coping strategy level. Cognitive, affective and neurovegetative misattunement from a hyperaroused and dysregulated caregiver can impair the formation of stable self-​regulation responses and harmonious physiological and socioemotional development in a child, constituting a “hidden trauma.” In accordance with Liotti and many others, we consider DA as traumatic in nature, especially if severe, prolonged, and reinforced in the course of child development and adolescence by other traumatic experiences (Liotti, 2017). Because of its traumatic nature, DA fosters the impairment of high-​order integrative mental functions and neurovegetative regulation, leading to disorganized mental processes evidenced by both developmental psychopathology and neuroscientific studies (Farina et al., 2014). Liotti furthermore hypothesized that the threatening and paradoxical intersubjective experience of DA may constitute a predisposition to dissociation (Liotti, 1992). This hypothesis was later supported by longitudinal controlled studies (Dutra et al., 2009; Ogawa et al., 1997) and neuroscientific experiments (Farina et al., 2014). In more recent work, Liotti refined his hypothesis, arguing that the relationship between DA and dissociation may be due also to the simultaneous and conflicting activation of the motivational systems governing attachment and survival defenses in the infant (Liotti, 2017). According to Liotti, children exposed to a caregiver perceived simultaneously as a source of safety and threat face an unsolvable conflict between two inborn and powerful dispositions: the tendency to seek help and soothing, regulated by the attachment system, and the evolutionary archaic defence system located in the brain stem that is responsible for animal defensive responses. The contradictory behaviour of the caregiver cannot be assimilated in the same memory system of the child and, in addition to the disintegrative effect, leads to a fragmented and segregated self-​representation that compromises the serial organization of autobiographical memory and self-​consciousness, and therefore to inhibitory dissociation (i.e, dissociation proper; Farina et al., 2019; Liotti, 2009).

The Neurobiological Effect of Traumatic Stress on Mental Integration An increasing and convergent body of empirical data demonstrates that at a neurobiological level early life stress, along with developmental and later trauma, hamper mental integrative capacity, disturbing both local and large-​scale structural networks and their functional connectivity (Lord et al., 2017; Teicher et al., 2016; Massullo et al., 2022). Researchers have proposed multiple potential neurobiological mechanisms by which maltreatment and trauma increase risk for impaired brain connectivity: from epigenetic processes and gene expression to neuroendocrine and immune responses. For instance, it has been proposed and partially demonstrated that the environmental deprivation of neglect (the most frequent form of child maltreatment) hijacks the developmental process of synaptic pruning, resulting in accelerated and extreme synapse elimination (McLaughlin et al., 2020). Although synaptic changes are a primary mechanism of experience-​dependent plasticity, other mechanisms take part in the alteration of brain connectivity and poor white matter integrity related to adverse childhood experiences such as reduced myelination and axon-​sprouting through myelin gene expression changes (Lutz et al., 2017). Another growing body of studies suggests that the neurophysiological substrate of integrative capacity is impaired by the defensive neurobiological response to neglect and abuse during development, and that this impairment is mediated by catecholamines, corticosteroids and inflammatory responses (Weems et al., 2019). Numerous studies have reported an association between childhood trauma and increased levels of pro-​inflammatory markers: C-​reactive protein, cytokines such as interleukin-​6, and tumor necrosis factor-​α (Baumeister et al., 2016). A systematic review and meta-​ analysis reports that interleukin 1β, interleukin 6, and interferon γ levels are higher in patients with PTSD than in healthy controls; the authors suggest that inflammatory markers could explain neurophysiological impairments in PTSD

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(Passos et al., 2015). Recent neuroimaging findings have demonstrated that increased trauma-​related inflammation can alter functional connectivity of the major brain regions associated with higher-​order mental functions, and that altered functional connectivity and inflammation correlate with the severity of clinical symptoms (Kim et al., 2020). Clinical studies report an association between childhood abuse, lifetime exposure to trauma, level of inflammation, dissociative symptoms, and other trauma-​related disintegrative psychopathology, such as emotional dysregulation (Powers et al., 2019). Furthermore, several experimental findings converge to suggest that both developmental trauma, and stress at different stages, including adult traumatic events, have a pathogenic effect on functioning of inhibitory interneurons through corticosteroids, oxidative stress and inflammatory cytokines. These pathogenic inhibitory effects, in turn, hamper integration and segregation processes and could lead to alterations of emotional control, memory, metacognition and other typical symptoms of trauma-​related disorders (Holland et al., 2014; Regev-​Tsur et al., 2020). Recent evidence shows that memory alterations in trauma-​related disorders, such as traumatic intrusive memories, could be provoked by a failed inhibition in hippocampal-​cortical networks activated by stress reactions (Guo et al., 2018; Regev-​ Tsur et al., 2020). The exact contribution of different neurobiological processes involved in the “disintegrative effect” remains unclear. Nevertheless, there is evidence that a child’s neurobiological response to maltreatment and trauma has a direct negative effect on connectivity and inhibition and, therefore, on the balance between integration and segregation.

Neurophysiology of Disintegration Psychopathology The majority of psychopathological, clinical and neuroscientific studies indicate that the most affected mental functions of child maltreatment and trauma are those underpinned by high-​level integrative functions and their large-​scale brain networks. These include arousal modulation, emotional processing and regulation, executive functions, social cognition, self-​identity, autobiographical memory and other self-​referential processes (Krause-​Utz et al., 2017; Lanius et al., 2020; Teicher et al., 2016). Experimental data lead also to the view that the disintegrative effect could be manifest either as trait disintegration vulnerability (TDV) or a state dependent propensity to disintegration (SDD). TDV should be understood as the background psychopathological vulnerability caused by the trauma-​related weakness of integrative and inhibitory brain structures. It refers to a trait vulnerability which is a more or less permanent and stable feature of the personality. It should be distinguished from the SDD which refers to the propensity for momentary and transient failures of integrative or inhibitory functioning. The two are not mutually exclusive but rather tightly related. Indeed, SDD usually is the result of a TDV that becomes evident only in response to specific triggers. Many neuroimaging studies show resting state alterations of structural and functional connectivity suggesting a TDV affecting different mental functions. In other studies, instead, the aberrant functional connectivity emerges only after a task or a trauma trigger. For example, Farina et al. (2014) evaluated cortical connectivity modifications in subjects with DA and dissociative disorders compared to healthy controls, before and after retrieval of personal attachment-​related autobiographical memories through the AAI. While before the interview the two groups did not differ, afterwards functional connectivity decreased in the DA dissociative patients compared to controls. Thus, it is possible to argue that a TDV becomes manifest with a SDD, evidenced by disorganized state of mind associated with the AAI, only in the case of a specific trigger such as a traumatic memory or a specific interpersonal situation interpreted as potentially threatening, that heavily impacts high-​level mental functioning. Regarding SDD, we hypothesize it is a consequence of TDV and worsens because of the typical arousal dysregulation of developmental trauma, with threat overvaluation circularly activated by the re-​surfacing of implicit relational traumatic memories. In most cases it is difficult to disentangle disintegrative disturbances because they are closely interwoven by a circular causality where hyperarousal has a worsening effect on cognitive functions that usually regulate affective and arousal states. However, we offer a brief and synthetic overview of the most common disintegration alterations in trauma-​related disorders.

Failures of the Inhibition Control System and Executive Functions Executive functions reflect deliberate, self-​d irected processes that regulate psychological functioning to best adapt to natural and social environments (such as suppression of behaviour from immediate, short-​term goals in order to maximize the long-​term outcomes or support social behaviours for cooperative and competitive strategies). The core of executive functioning is based essentially on affective and behavioural inhibition and flexibility for decision making (Del Giudice, 2018) that is underpinned by neuronal connectivity and compromised by childhood maltreatment and trauma. There

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is, indeed, a wide consensus among clinicians and researchers that emotional and behavioural dysregulations are core aspects of childhood maltreatment and trauma-​related disorders ( Jaffee, 2017; Mayes, 2006). Both emotional and behavioural regulation are based on a sum of functions that includes initial emotional detection, orienting toward emotional cues (emotional reactivity), emotional processing (i.e., appraising facial expression) and executive control of emotional and behavioural responses either as modulatory/​inhibition and/​or cognitive re-​interpretation of evocative stimuli to reduce negative affect. All emotional regulation functions are widely demonstrated to be compromised by either structural and functional connectivity impairments related to early and later adverse experiences. Additionally, all trauma-​related disorders are characterized by emotional and impulse alterations related to connectivity dysfunctions (Bertsch et al., 2018; Terpou et al., 2019). In particular, neuroimaging studies repeatedly and consistently find disturbed modulatory control of cortical over subcortical regions related to reduced connectivity between prefrontal cortex (PFC), hippocampus and amygdala and within the Central Executive Network in all stages of affective processing and control (Lei et al., 2019; Wang et al., 2020). The widely demonstrated disturbed modulatory control of cortical over subcortical regions is not the only disintegrative driver for the exaggerated emotionality and dysregulated behavioural reactions of trauma-​related patients. As already mentioned apropos of the segregation process of DA IWMs, disintegrated traumatic implicit relational memories triggered by a social or interpersonal cue (e.g., a gesture, or tone of voice or facial expression suggesting devaluation or threat) can unconsciously trigger the pathological disintegration described above, causing or worsening affective dysregulation (Huang et al., 2020; Luyten et al., 2020; Meares, 2012). In this regard several researchers argue that the hippocampus, due to its inhibitory coordination operated by interneurons (as predicted by Sherrington), is implicated in sophisticated threat stimulus discrimination and safety processing influencing reactivity of fear-​inhibition with its interactions with the PFC. Failures of this coordinating network reduce hippocampal responses to ambiguous threats and can promote threat overgeneralization that, circularly, increases affective hyperactivation and hyperarousal (Lange et al., 2019).

Altered Pattern Separation and Threat Overgeneralization Lecei and Van Winkel (2020) recently proposed a key role for altered pattern separation in psychopathological vulnerability following childhood adversity. Pattern separation is a cognitive process operated by the hippocampus and coordinated with the amygdala and ventromedial prefrontal Cortex (vmPFC) to differentiate similar memories, and reduce recall errors and interpretation interferences in affective stimuli. Pattern separation is supposed to discriminate a threatening cue from a safe one based on previous experiences. The numerous animal and human experiments reviewed by Lecei and Van Winkel led them to hypothesize that chronic stress alterations associated with childhood adversity reduces hippocampal subfields’ inhibitory activity and also their connectivity with the amygdala and vmPFC, preventing the pattern separation modulatory effects from extinguishing fear in the absence of threat. They propose that these failures of pattern separation play a key role in socially ambiguous situations, causing the social threat hypervigilance and overinterpretation typical in maltreated children.

Relational and Social Functioning: Disintegration of Social Cognition and Metacognition Traumatic impairment of integration could also affect empathic abilities, prosocial inclination, group affiliation, cooperative abilities, mentalization and perceived trustworthiness (Teicher et al., 2016). Like emotional and behavioural control, these interpersonal abilities and social cognitions are based on a complex network of sophisticated mental functions underpinned by integration of higher-​order cognitive processes and, therefore, of large-​scale network connectivity. Recent fMRI studies revealed that individual differences in trait empathy and empathic concern are mediated by patterns of connectivity between self-​other resonance and top-​down control functional brain networks (Christov-​ Moore et al., 2020). Similarly, a number of studies demonstrate the key role of functional connectivity integration for social cognition. Most of them implicate the Default Mode Network (DMN). The DMN reflects the neural activity of different brain areas and is proposed to be involved in self-​consciousness, self-​processing and introspection functions, including emotional awareness, processing, and mentalizing in social interactions (Mars et al., 2012). Mentalizing and other social cognition abilities are affected by child maltreatment, attachment trauma and later traumatic experiences. Huang and colleagues recently pointed out: Attachment and mentalizing may interact in a complex causal way, in which early experiences of maltreatment lead to disruptions of the attachment system, which in turn causes mentalizing failure when the attachment system is activated. This vulnerable mentalizing triggers cascades of arousal, which then undermine mentalizing even

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further … that mentalizing difficulties increase the risk of development of dissociative experiences after exposure to childhood trauma. Huang et al., 2020, pp. 55–​56 In other words, since mentalizing and other social cognitive functions require high-​level cognitive operations, and, consequently, high levels of integrative capacity, they are easily impaired by hyperarousal and emotional dysregulation.

Traumatic Disintegration of Self-​Related Processes One of the most important and characteristic effects of child maltreatment, attachment trauma and later traumatic events is impairment of tightly intertwined self-​referential mental processes (SRP), such as autobiographical memory, sense of agency and self-​consciousness, with its properties of self-​coherence, self-​continuity, and self-​embodiment (Lanius et al., 2020; Luyten et al., 2020; Meares, 2012; Terpou et al., 2020). To some extent, every psychopathological consequence of trauma involves a disturbance of self-​consciousness felt as fragmentation of self-​experience. Disintegrative fragmentation of self-​experience usually leads to “painful incoherence” and chaotic behaviours (Liotti & Farina, 2016; Şar, 2017, Meares, 2021). Even dysregulated affective reactions or somatization are experienced as somewhat estranging and alienating in trauma-​related disorder patients (Meares, 2000). As previously mentioned, the alterations of DMN connectivity are extensively considered one of the most representative neurophysiological signatures of every form of self-​referential disturbances; a large body of evidence suggests that exposure to both chronic early stress and all forms of trauma alters DMN connectivity (Lanius et al., 2020; Teicher et al., 2016). For the purpose of this chapter it is important to note that most of the effects of developmental and complex trauma impact the DMN, altering its connectivity and creating disintegration of self-​referential processes, from self-​consciousness to body awareness and control, both in resting and in task-​dependent states (Adenzato et al., 2019; Lanius et al., 2020).

Lateralization of Disintegration and the Impairment of Right Hemisphere Language Meares and colleagues (2005) investigated the brain’s coordination of two main neural networks for processing of a strange, or “odd”, stimulus in BPD patients by Event-​Related Potential (ERP). They found that unlike controls in which the two networks were coordinated, producing a single ERP waveform, BPD patients showed a double peaked waveform, revealing that the two networks were no longer synchronized. In a further experiment, Meares, Schore and Melkonian (2011) demonstrated, as previously claimed by Schore (see Chapter 11, this volume), that the impaired coordination and inhibitory failures of BPD patients are mainly confined to the right hemisphere, which is more vulnerable to relational trauma. Meares (2021) recently argued that the lateralization of disintegration in the right hemisphere accounts for the language deficiencies of those suffering relational trauma, which manifest in a form of language, or more particularly, conversation, which is largely asymbolic.

Trait and State Disintegration and their Circular Causality As described above, a disintegrative effect could be manifested both as trait vulnerability and a state dependent propensity to disintegration. Indeed, some scholars argue that the detrimental effects of childhood maltreatment and/​or trauma may act through the altered development of the DMN and other brain networks, resulting in a trait-​dependent vulnerability factor (Lanius et al., 2020). As we have previously observed, it is also repeatedly demonstrated that stressful or painful stimuli and trauma-​related memory tasks dynamically worsen this vulnerability in both non-​ clinical and clinical samples, impairing emotional, metacognitive and self-​referential functions (Adenzato et al., 2019; Lanius et al., 2020). For emotive control and cognitive functions, as well as for social cognition and self-​referential processes, it is possible to argue that in individuals with early adverse relational experiences the functional connectivity abnormalities worsen and become clinically symptomatic only when the system is overloaded by affectively relevant and hyperarousing stimuli in a dimensional manner. Finally, in the study of early relational trauma and disintegration processes we should consider the continuing interplay between alterations of biological structures (e.g., functional connectivity), the development of mental functions (e.g., emotional control, continuity of self-​experience or mentalization), the interpersonal environment (e.g., attachment figures) and pathogenic beliefs that take shape within the traumatic environment in an attempt to adapt to it. In this sense

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the traumatic disintegration could have a compounding negative impact on development: it hinders high-​level mental functioning, leading to the abovementioned difficulties (e.g., executive functions, social cognition, self-​consciousness), while it worsens, through a circular causation, the effects of the pathogenic beliefs and the relationship with the interpersonal and social environment, hampering “healthy personality functioning that should be characterized by openness to experience, flexibility, adaptability… flexibility of cognitive-​a ffective schemas… the capacity to constantly re-​evaluate the sense of self and relatedness in the course of development” (Luyten et al., 2020, p. 90). The overall effect of these complex interactions is also the impairment of cooperative predisposition and trust (both epistemic and affiliative) that contribute to make these patients so resistant to psychotherapy (Liotti & Farina, 2016). Regrettably, many neuroscientific studies are limited by a lack of distinction between disintegration and inhibitory dissociation (Krause-​Utz et al., 2017). Furthermore, they do not distinguish between two forms of dissociation, one described by Janet, involving a drifting apart by one part of mental life from the rest (disinhibited dissociation), and another form dependent on inhibitory activation (dissociation proper).

The Traumatic Disintegrative Dimension and Diagnostic Categories Clinical observations and empirical data suggest that disintegration and dissociation processes are not confined to specific diagnostic categories such as dissociative identity disorder, PTSD, complex PTSD or BPD, but rather can be displayed by patients across almost all psychiatric disorders as a psychopathological dimension. We thus propose the existence of a traumatic disintegrative dimension manifesting to varying degrees in the psychopathological profile of all patients with histories of developmental trauma. Child maltreatment and attachment trauma are considered the most potent predictors of poor mental health across the life span and characterize patients with more severe symptomatology and poorer responses to standard treatment approaches across diagnoses (Lippard & Nemeroff, 2020; McCrory et al., 2017). Consistently, traumatic disintegrative symptoms are linked to symptom severity and predictors of poor responses in psychotherapeutic treatments across diagnosis (Farina et al., 2019; Lyssenko et al., 2018). Arousal, behavioural and affective dysregulation, self-​related process disturbances, state of consciousness alterations, mentalization problems, memory and identity disruptions, together with their consequences in terms of alterations in systems of meaning and relational difficulties have been hypothesized, and partially demonstrated, to worsen prognosis and lead to specific therapeutic difficulties regardless of diagnostic category. These findings indicate and implicate disintegration as a key variable in the assessment and treatment of psychopathology, especially in cases where developmental, attachment or omission (e.g., neglect) traumas are present.

Conclusions This chapter has discussed the concept of the traumatic disintegration dimension, a term that identifies a specific group of phenomena making up a main axis of the structure of traumatic consciousness. The psychopathological, clinical and neuroscientific evidence reviewed in this chapter leads to the distinction between different trauma-​related pathogenic processes: traumatic disintegration and dissociation. Disintegration should be understood as the failure of higher-​order inhibitory functions. Higher-​order functions, as Vygotsky taught us, do not develop by themselves alone. They need a facilitating environment. That environment is one in which the responses of the caregiver, or caregivers, are, in general, harmonious with the child’s essential reality. The mother needs to set up periods of continuing interplay, a quasi-​rhythmic in-​out engagement, manifest in direction of gaze of both partners. The out, or off, mode depends upon finely adjusted inhibitory mechanisms, which the child is able to draw upon, thus fostering their eventual firm emergence of self and regulatory processes. The opposite of this condition, resulting from disorganized and traumatic attachment, is thus the model for traumatic disintegration. Higher-​order mechanisms cannot properly evolve. Consciousness cannot be coordinated in the way Sherrington had proposed. Neuroscientific research seems also to support the neo-​Jacksonian prediction that the traumatic disintegrative process will have a basic structure of impaired coordination between brain systems that usually work together, allied with a relative failure of inhibitory control. This general disintegrative process, affecting high-​order mental functions, explains in part the vast heterogeneity of psychopathological traumatic outcome. Dissociation is conceived as segregated multiplicity of mental contents and functions, such as autobiographical memories, self-​other representations or identities, and states of consciousness. Trait disintegrative vulnerability is, thus, the precondition to develop both types of dissociation, regarded as the pathological “functional re-​organization of the mind into enduring parallel-​d istinct structures which operate side by side without being fully integrated with each other” (Şar, 2017).

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More than a century ago Jackson stated: “We have multitudes of facts, but we require, as they accumulate, organizations of them into higher knowledge; we require generalizations and working hypotheses” ( Jackson quoted by Hodes, 1974, p. 364). We hope that our working hypothesis to distinguish traumatic disintegration from dissociation, that derives directly from Pierre Janet’s conceptions, can be of some utility to clinicians and theoreticians in overcoming the confusion and disagreement regarding the concept of traumatic dissociation that contemporary scholars have often lamented, and can promote new research in the field (Frewen & Lanius, 2014).

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4 DISSOCIATION VERSUS ALTERATIONS IN CONSCIOUSNESS Related but Different Concepts Kathy Steele, Martin J. Dorahy, and Onno van der Hart

Since the 1980s there has been two conceptualizations of dissociation. In the first, the focus is on the etiology of dissociative phenomena arising from a structural or organizational difficulty at the level of personality. The dissociative structure is one in which experience is not sufficiently integrated into the whole of the personality, but rather is compartmentalized such that the personality is no longer unified but becomes divided when using the metaphor of each person starting with a single personality or multiplied when using the metaphor of each person not being limited to one personality (see O’Neil, Chapter 8, this volume; Van der Hart & Dorahy, Chapter 1, this volume).1 In the second approach various symptoms are grouped together under the term ‘dissociation’ and characterized by the individual’s general failure to integrate or be aware of different elements of psychological experience or the environment. This conceptually broad approach focuses on symptoms (primarily cognitive and attentional) rather than etiology. Etiology can vary in a phenomenological model and include (1) the activation of parallel streams of consciousness; (2) changes in consciousness for various reasons, such as fatigue, stress, illness or medications; (3) hypnotic trance states, (4) defensive efforts to restrict conscious awareness, (5) and a posttraumatic, divided personality structure. Each of these etiologies may require a different treatment approach, even though some of the symptoms may at first sight appear to be the same. The original definition of dissociation was more specific than that evident in modern psychiatry and psychology. According to Janet’s original definition, dissociation denoted a division of the personality ( Janet, 1889/2022a,b, 1907; cf., Myers, 1940; Prince, 1905; Van der Hart & Dorahy, Chapter 1, this volume).2 In contemporary terms it has been referred to as structural dissociation, denoting an overly rigid and divisive organization of the personality (Nijenhuis, Van der Hart, & Steele, 2004;  Van der Hart, Nijenhuis, & Steele, 2006;  Van der Hart & Steele, Chapter 15, this volume). Structural dissociation theory proposes a dimension of dissociation of the personality with three prototypical structures ranging in structural complexity (i.e., primary, secondary, tertiary). Since the 1980s, dissociation has been much more broadly and vaguely defined as “a disruption of and/​or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (APA, 2013, p. 291), which could include almost any psychological symptom and can be found in any disorder.

Alterations in Consciousness Alterations in consciousness that are currently considered under the umbrella of dissociation include anomalies in perception, absorption, spaciness, daydreaming, imaginative involvement, and hypnotic trance (e.g., Bernstein & Putnam, 1986; Butler, 2004; Ray, 1996; Ross, Joshi, & Currie, 1991). They also include what has been called “dissociation of context” (Butler, Duran, Jasiukaitis, Koopman, & Spiegel, 1996), “dissociative detachment” (Allen, Console, & Lewis, 1999), or simply, “detachment” (Holmes et al., 2005). More recently, traumatic hypoarousal has been included (Levine, 2010; Porges, 2001, 2011; Schauer & Elbert, 2010; Schalinski, Schauer, & Elbert, 2015), and is likely the physiological underpinning of detachment. Alterations in consciousness on the milder end of a spectrum are ubiquitous in both normal and clinical populations (Giesbrecht, Merckelbach, Geraerts, & Smeets, 2004). They certainly occur in traumatized individuals but are not

DOI: 10.4324/9781003057314-6

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limited to them. Some of these mental and behavioral actions can be highly adaptive under the right circumstances, such as absorption in a work project or sport, creative daydreaming, and meditation. Others include ubiquitous oscillations of consciousness during temporary times of stress, fatigue, illness, and hypnagogic and hypnopompic experiences. Some are more specific to traumatizing events, especially when they are pervasive and chronic, and tend to be maladaptive. As Frewen and Lanius (2015) propose, prolonged trauma (i.e., traumatizing events), especially early in development, may lead to “altered forms of consciousness [that] become more sensitized, stable and trait-​like” (p. 26).

A Continuum of Dissociation? Some authors who adhere to the broad conceptualization of dissociation have proposed a continuum from everyday alterations in consciousness ranging from mild and transitory, through severe and chronic (pathological), to dissociation of the personality. However, there is evidence that even though general and pathological alterations of consciousness are related to structural dissociation, they appear to be different categories of experience (e.g., Mazzotti et al., 2016; Rodewald, Dell, Wilhelm-​Gossling, & Gast, 2011; Waller, Putnam, & Carlson, 1996). In other words, the literature tends to distinguish two different dimensions of dissociation, one pertaining to degrees of structural complexity, and the other to alterations in consciousness that can be more or less complex, (mal)adaptive, or (un)common, and which are not derived from dissociation at the level of the personality. The single dimension theory creates confusion as there is more than one etiology of these experiences, and manifestations of dissociation of the personality are not merely more severe expressions of alterations in consciousness, but rather a different type of experience (Boon & Draijer, 1993; Holmes et al., 2005; Ogawa et al., 1997; Putnam, 1997; Van der Hart, et al., 2006; Waller et al., 1996; Watson, 2003). We might consider two related but different continua: One of more general alterations in consciousness and another of structural dissociation. Both have a wide range of symptoms and expressions, with individuals who experience structural dissociation having many accompanying alterations in consciousness, but with some individuals with a range of normal to severe alterations having no structural dissociation.

A Continuum of Alterations in Consciousness A continuum of alterations in consciousness can have varying degrees of normality and pathology, for example, severe detachment (Allen et al., 1999) and maladaptive daydreaming (Somer, 2002) are both pathological. To the degree that we can reasonably discern it, conscious awareness involves the breadth or field of awareness, and the level of awareness. It also can be described along other dimensions, including degree to which consciousness can be controlled voluntarily and its appropriateness for a given situation. The field of consciousness can range from very wide to extremely narrow (retracted) ( Janet, 1907). Both field and level can combine and alternate in normal and pathological ways, in normal populations and in traumatized individuals (Frewen & Lanius, 2015; Nijenhuis, 2015). Unfortunately, it is impossible to objectively record exactly how much of the present experience is being tended to, because much awareness is implicit and not within conscious awareness (Bayne, Hohwy, & Owen, 2016). However, clinicians do have a generally accurate sense of whether an individual is able to attend sufficiently enough to the present to be adaptive in daily life. Thus, we have rough, if imperfect, guides to determine what constitutes “normal” and “pathological” alterations in consciousness in each patient. The width of our field of consciousness naturally fluctuates over the course of time and is generally adaptive. Sometimes it is most adaptive to focus narrowly on specific cues, such as while working or reading a book. At other times, it is most adaptive to attend to a broad range of stimuli, such as while hiking on a trail. We are limited, however, in the number of cues to which we can consciously attend at a given time. We simply cannot perceive (and remember, i.e., store, consolidate and retrieve) everything. Even if we could, the task would rapidly become overwhelming, and we would not be able to focus (Luria, 1968). Some changes in our field of consciousness are voluntary (e.g., intentional concentration, guided imagery, meditation, acting in a role); others are involuntary (e.g., inability to concentrate and selectively attend when tired or stressed). The quality of our mental functioning largely involves the level of consciousness. Efficient and effective mental actions require adequate intensity and integration. According to Janet, these involve specific actions that he described as synthesis, personification, presentification, and realization.3 Common forms such as temporary inattentiveness and daydreaming, may or may not reduce and impair mental functioning, but concentration problems due to fatigue, anxiety, stress, or illness are usually marked by some degree of impairment. Less common forms of lowered consciousness include depersonalization and derealization, such as feeling unreal, staring down a tunnel, feeling foggy or detached; pathological trance states; time distortion; and detachment (Allen et al., 1999; Van der Hart & Steele, 1997). These are

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common in a range of mental disorders; they are not specific to the dissociative disorders or posttraumatic stress disorder (PTSD) alone. Low levels of conscious awareness can result in disorganization, forgetfulness, spaciness, and undue drowsiness, while extremely low forms include the loss of consciousness in pseudoseizures (Bowman, 1998; Kuyk, 1999), and psychogenic stupor and coma (Porges, 2011). Extremely low levels involved in traumatizing events pertain to shutdown reactions in the face of inescapable confrontation with life threat (Porges, 2001, 2011). In healthy individuals, adaptive field and level of consciousness wax and wane in moderated oscillations throughout the day. Periods of increased alertness and concentration with narrow or broader focus are interspersed with periods of drowsiness, fatigue, or distraction. Alterations in consciousness are pathological when they are excessive, frequent, inflexible, and cannot be consciously controlled, that is, when they significantly interfere with daily life. For example, some people need to “stare at the wall” for a few minutes before they can get going in the morning to overcome the rather low level, and retracted field, of consciousness normally present upon waking. But, if “staring at the wall” continues for hours, re-​occurs for long periods, or cannot be voluntarily interrupted, then it is pathological as it causes difficulties in daily life. Daydreaming can be healthy and normal, but not if the person is lost in fantasy for hours at a time when he/​she should be more immersed in daily life ( Janet, 1903; see Soffer-​Dudek & Somer, Chapter 34, this volume). It is not unusual for a person who is preoccupied to miss an exit while driving or to be unaware of a brief passage of time. It is pathological, however, if the person is regularly and intensely absorbed in daydreams or ruminations, and as a result constantly misses exits, gets lost, or drives dangerously. Sometimes lowering of the level of consciousness is adaptive, as when we relax or go to sleep. It is maladaptive when we fail to perceive and remember significant facts and experiences that are needed to be effective and efficient (i.e., adaptive) in daily life. Even high levels of consciousness can be maladaptive if a person invests too much mental and/​ or physical effort in matters that should be of little concern. Sharon, a patient with Complex PTSD (promoted to its own specific diagnosis in ICD-​11 as 6B41 Complex posttraumatic stress disorder) tried to avoid flashbacks by cleaning obsessively to the extent that she was chronically late for therapy and work: “If only I could be aware of needing to get someplace on time, but I can only think of what I have to clean at the moment!” While alterations in consciousness can be normal or pathological, they can be present with and without structural dissociation. Etty, a patient who had DID, dealt with dissociative intrusions by intentionally retracting (narrowing) her field of consciousness to an extreme degree. She tried to ignore persecutory voices of dissociative parts by drowning them out by listening simultaneously to the TV, radio, and stereo while trying to focus on the sound of one instrument on the stereo.

Hypoarousal and Dissociation The view of dissociation as hypoarousal is primarily proposed by authors who note that detection of perceived life threat results in parasympathetic activation and immobilization (e.g., Levine, 2010, Porges, 2001, 2011; Schauer & Elbert, 2010; Schalinski, Schauer, & Elbert, 2015). Alterations in consciousness from hypoarousal involve a temporary reduction or absence of psychomotor as well as cognitive and attentional capacities, including emotional and physical numbing. Some traumatized patients have habituated dorsal vagal reactions, involving pervasive difficulties with alertness, awareness, and attention (Steele, Boon, & Van der Hart, 2017; Van der Hart et al., 2006). Encoding of experience is reduced during severe hypoarousal, as well as related cognitive, emotional and behavioral activity. However, any extreme arousal that is outside a window of tolerance –​be it high or low –​involves alterations in consciousness, so it is puzzling as to why only hypoarousal is labeled as dissociative. Without doubt, chronic activation of the parasympathetic nervous system in childhood can disrupt integrative capacity across development (see Schore, Chapter 11, this volume), but so can chronic sympathetic activation, and both can include alterations in consciousness. For example, highly hyperaroused individuals can be completely unable to focus on the present moment, absorbed in ruminations, going over and over an episode of perceived rejection or abandonment. Or in a blind rage, they may be unable to think or focus on the present adaptively. Significant symptoms in dissociative disorders such as Dissociative Identity Disorder (DID) involve both high and low arousal, not merely hypoarousal. In addition, patients with dissociative disorders like DID also have many positive (intrusive) symptoms which are not found in hypoarousal states that involve loss of functions (negative symptoms).

Hypnotizability and Dissociation Hypnotic capacity has long been associated with dissociation and trauma (Dell, 2018; Janet, 1889/2022a,b; Kluft, 1982, 2012; Spiegel, 1988, 2003; Van der Hart, 2019). What has been somewhat lost in the last few decades is the role of

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hypnotizability and trance in the formation and maintenance of DID and related disorders (Kluft, 2012). Dell (2018) recently proposed that since the majority of patients with DID are highly hypnotizable, auto-​hypnosis is a major vulnerability factor in developing DID (see Chapter 14, this volume). High hypnotizability may be a strong link between alterations in consciousness and the development of structural dissociation, but further research is needed to clarify the nature of this possible relationship.

Peritraumatic Alterations in Consciousness During traumatizing events, severe and involuntary alterations in consciousness usually occur, such as time distortion, blanking or spacing out, being on automatic pilot and other forms of depersonalization. Referred to as “peritraumatic dissociation,” we contend that some of these symptoms reflect alterations in consciousness, while others may mark the beginning of structural dissociation. During threat, it is adaptive to narrow attention and awareness to what really matters; this requires intense focus (i.e., an alteration in consciousness). There is also a place for hypoarousal and minimal awareness and attention when dorsal vagal activation is more adaptive in situations that are perceived as life threatening. A low level of awareness which is said to involve dorsal vagal activation inhibits movement and protects against pain and suffering. It is when these temporarily adaptive alterations continue chronically that problems arise. Hypervigilance and hyperarousal during a traumatic experience may exhaust the individual, that is, bring about a significant drop in energy level with lowered awareness and attention. This was frequently observed in “shell-​shocked” soldiers during World War I (e.g., Culpin, 1931; Léri, 1918; Myers, 1940). Myers (1940, p. 66) noted that there was “a certain loss of consciousness. But this may vary from a very slight, momentary, almost imperceptible dizziness or ‘clouding’ to profound and lasting unconsciousness.” Even where the level of awareness seemed extremely low with related narrowing of the field (i.e., to the point of unconsciousness), some World War I clinicians observed that the traumatic experience dominated awareness (Culpin, 1931). In the words of Léri (1918), the soldier’s “whole field of attention is occupied by the haunting memory of the traumatic event itself ” (p. 78; cf., Culpin, 1931; Myers, 1940). Similarly, many survivors of chronic child abuse report a severe drop of attention and awareness in the immediate aftermath of abuse episodes. They anecdotally report hiding in closets, under blankets, or in other “hiding places.” They describe themselves as “zoning out,” being “unable to think,” unable to concentrate, getting “lost in my head,” and feeling spacey. Again, these experiences can occur with or without structural dissociation.

Depersonalization and Derealization The literature has long held that depersonalization and derealization are dissociative symptoms (see Michal, Chapter 23, this volume), despite their sui generis status in DSM-​II and the ICDs up to ICD-​10 (see O’Neil, Chapter 21, this volume). Depersonalization has been described as (1) the existence of an observing and experiencing ego or part of the personality (Fromm, 1965); (2) detachment of consciousness from the self or body (i.e., feelings of strangeness or unfamiliarity with self, out-​of-​body experiences); (3) detachment from affect, that is, emotional numbness; (4) a sense of unreality, as if being in a dream or on a stage; and (5) perceptual alterations or hallucinations regarding the body (Noyes & Kletti, 1977). This is quite a wide range of symptoms. Derealization involves a sense of unreality or unfamiliarity with one’s environment, and distortions of space and time (Steinberg, 1995). The primary difficulty in depersonalization is a failure to engage in ownership of experience, that is, personification, according to Janet: “This body, this action, this feeling does not feel like it belongs to me.” Both depersonalization and derealization occur with intact reality testing (Steinberg, 1993); neither necessarily involves a division of the personality. Depersonalization and derealization symptoms, like other alterations in consciousness, are ubiquitous in both normal and clinical populations, and thus are rather non-​specific (Hunter, Sierra, & David, 2004). In fact, these symptoms are so prevalent that Cattell and Cattell (1974) found them to be the third most common complaints in psychiatric patients (following anxiety and depression). Mild to severe forms of transient depersonalization and derealization are found in anxiety disorders, depression, schizophrenia, substance abuse disorders, borderline personality disorder (BPD), seizure disorders, and dissociative disorders (Boon & Draijer, 1993; Dell, 2002; Steinberg, 1995). In normal individuals, transient depersonalization and derealization may be related to stress, elation/​euphoria, hypnagogic or hypnopompic states, fatigue, illness, medication, or intoxication. Typically, these temporary phenomena do not imply structural dissociation. However, further study should be conducted on which specific symptoms of depersonalization are present under which conditions. Depersonalization and derealization are common in trauma victims (e.g., Cardeña & Spiegel, 1993; Carrion & Steiner, 2000; Darves-​Bornoz, Degiovanni & Gaillard, 1999). They are prominent in trauma-​related disorders like

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acute stress disorder (ASD; Harvey & Bryant, 1998, 1999), PTSD (Bremner et al., 1993), BPD (Şar et al., 2003; Zanarini, Ruser, Frankenburg, & Hennen, 2000), and complex dissociative disorders such as DID (Boon & Draijer, 1993; Dell, 2002; Steinberg, 1995). Depersonalization/​Derealization Disorder requires these symptoms to be severe, pervasive, and chronic, and interfere with social and occupational functioning (APA, 2013). Again, the need to assess for underlying causes of the symptoms is essential to accurate treatment. An out-​of-​body experience may stand alone as an acute phenomenon in anxiety, panic, or other severe distress, or a reaction to medication. However, it is often also a sign of structural dissociation, in which one part is observing another part. Victims of childhood sexual abuse (Gelinas, 1983; Putnam, 1997), victims of motor vehicle accidents (Noyes & Kletti, 1977), and soldiers in combat (Cloete, 1972) have described a division between an observing part and an experiencing part of the personality. Schwartz (2000) illustrates an out of body experience involving structural dissociation in a sexually abused patient: When they made me dance … in front of all those men, I just took three steps backwards, and then there was some girl there and she was dancing for them, and I watched her do it from far away … she was not me, but I could see her. I didn’t like her, and I didn’t like what she was doing. Even though I know she is me, she is not really me. p. 40 It can be difficult to determine whether structural dissociation is present in a person who exhibits depersonalization (Van der Hart & Rydberg, 2019; Van der Hart & Steele, 1997 ). Simeon (2004) has suggested that depersonalization/​ derealization disorder does not involve any of the notable disturbances of memory or identity that are consistent with structural dissociation, although these individuals also have a high rate of childhood traumatization, especially of emotional maltreatment (Simeon & Abugel, 2006). Thus, examining other manifestations of structural dissociation, like amnestic episodes, posttraumatic flashbacks and hearing voices, can assist in differential diagnosis. Both individuals with depersonalization/​derealization disorder and those with structural dissociation share some similar neurobiological correlates such as HPA axis dysregulation, and serotonergic, endogenous opioid, and glutamatergic NMDA pathway disturbances (e.g., Nijenhuis, Van der Hart, & Steele, 2002; Simeon et al., 2000). But there are differences as well. We contend that these facts support our clinical observation that structural dissociation and depersonalization are closely related but they have different underlying etiologies. The DSM-​5 (APA, 2013) has added a specifier of “with dissociative symptoms” to the PTSD diagnosis (Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012). In addition to the standard criteria for PTSD, this specifier is limited to depersonalization and derealization. Patients with this specifier tend to have more severe PTSD symptoms and represent a distinct subset of PTSD patients. The dissociation specifier is reminiscent of older attempts to classify PTSD as a dissociative disorder, when DSM-​III and I​ V were still labeling PTSD as an anxiety disorder (Brett, 1996). Several authors have noted the dissociative underpinnings of PTSD (e.g., Braun, 1993; Chu, 2011; Nijenhuis, 2015, 2017; Nijenhuis et al., 2004; Spiegel, 1998; Van der Hart et al., 2004). However, one of the challenges is the chronic inconsistency in defining dissociation. For example, “Dissociative reactions (e.g. flashbacks)” and “dissociative amnesia” are cited in DSM-​5’s diagnostic criteria B and D for PTSD, but only depersonalization or derealization count for the specifier of “dissociative symptoms.”

Trauma-​related Structural Dissociation of the Personality According to Janet, dissociation involves insufficient integration among two or more “systems of ideas and functions that constitute personality” (1907, p. 332). Each of these psychobiological systems has its own unique combination of perception, cognition, affect, behavior, and sense of self, no matter how rudimentary (e.g., Mitchell, 1922; Prince, 1905). From a systems perspective, structural dissociation involves a relatively rigid instability among various conscious subsystems, with their own first-​person perspective, that comprise personality as a whole system. Thus, it prevents a more natural developmental progression of a more adaptive (i.e., both fluid and stable) personality and sense of self across time and contexts. Janet (1889, 1907) proposed that low integrative capacity or a temporary lowering of this capacity is at the root of trauma-​ related structural dissociation, such that some memories of experiences are not integrated into the personality as a whole. Janet (1907) stated that deficits in integrative capacity could result in other psychological disruptions, such as pathological alterations in consciousness, greater emotivity, and reactive behaviors and beliefs. He distinguished these phenomena from structural dissociation, even though they certainly accompany it.

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While prospective longitudinal research is lacking, we propose that dissociation is not only a defense, but also the result of integrative deficits. This hypothesis is based on anecdotal clinical experience and on Janet’s thesis that dissociation can emerge from a limited integrative capacity during extemely stressful events ( Janet, 1889, 1911). Thus, the likelihood of traumatization from a stressful event significantly depends on the individual’s existing integrative capacity. Children have lower integrative capacity than adults, due in part to immaturity of integrative brain structures, making them more vulnerable to dissociation under stress. Thus, research suggests that age at the time of traumatization is associated with structural dissociation (Boon & Draijer, 1993; Fullerton et al., 2000; Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1998; Ogawa et al., 1997).

Action Systems as the Foundation For Trauma-​Related Structural Dissociation of the Personality Personality is a construction that comprises a range of innate psychobiological motivational (Toates, 1986), behavioral (Cassidy, 1999), or emotional operating systems (Panksepp, 1998), also known as action systems (Nijenhuis et al., 2002; Chapter 38, this volume). There are two major categories of action systems (Carver, Sutton, & Scheier, 2000; Lang, Bradley, & Cuthbert, 1998) that shape our personalities. One category guides activities of daily living. These systems are primarily pro​social in nature (e.g., attachment, caregiving, collaboration, competition/​ranking, and sexuality), but at a more primitive level also include physiological regulation of energy (eating, sleeping) and a learning and exploration (seeking) system based on curiosity and interest (Liotti, 2017; Liotti & Gilbert, 2011; Steele, in press). A different category of action systems mediates physical defense under threat (e.g., fight, flight, freeze, and faint). It has been proposed that these two broad categories of innate actions systems serve as the basic fault lines in dissociation of the personality following traumizing events (Nijenhuis, 2015; Steele et al., 2017; Van der Hart et al., 2006). Perhaps at the core of DID is the division among these two types of action systems that characterize dissociative parts of the personality to solve the impossible dilemma of having simultaneous prosocial and defensive goals toward the same person, that is the abusive/​neglectful caregiver. This insoluble dilemma is the foundation for disorganized attachment and subsequent dissociative symptoms (Liotti, 2006, 2017; Nijenhuis, 2015; Ogawa et al., 1997; Steele et al., 2017; Van der Hart et al., 2006). It is also a central tenet of betrayal trauma theory that posits children are so overwhelmed by the betrayal of a caregiver or other person in trusted authority that they are unable to recall the events of the betrayal (Freyd, 1998; Kaehler, Babcock, DePrince, & Freyd, 2015).

Dissociative Parts of the Personality As noted above, there are two main prototypes of dissociative parts of the personality; each is mediated by different action systems or constellations of action systems (e.g., the defense action system vs. the prosocial action systems of daily life (Van der Hart & Steele, Chapter 15, this volume). We metaphorically call parts that are mediated by actions systems of daily life the Apparently Normal Parts of the Personality (ANP), and those mediated by the action systems of defense the Emotional Parts of the Personality (EP). These terms derive from the writings of British psychologist and psychiatrist, Charles S. Myers, who noted their presence in acutely traumatized World War I combat soldiers (Myers, 1940). Dissociative parts of the patient that exert functions in daily life (ANPs) fear or are ashamed of the retrieval or integration of traumatic memories; they prevent this via mental avoidance and escape strategies. We hypothesize that these phobic mental actions involve the natural tendency of different action systems waxing and waning based on achievement of goals and perception of the need to change goals. Thus dissociative parts that focus on daily life (ANP) would not be able to play or socialize well when they are intruded upon by dissociative parts that are rooted in defensive action systems (EP). These prototypical dissociative parts have at least a rudimentary sense and idea of self and first-​person perspective; each retrieves some memories that other parts do not retrieve.

Dissociative Symptoms In Structural Dissociation Dissociative symptoms in dissociative disorders such as DID are generally manifestations of an underlying organization of the personality characterized by divisions (i.e., structural dissociation; Nijenhuis & Van der Hart, 1999; Nijenhuis, Van der Hart, & Steele, 2004; Van der Hart, Nijenhuis, Steele, & Brown, 2004; Van der Hart et al., 2006). Negative dissociative symptoms such as dissociative amnesia occur when one or more parts are not able to retrieve mental contents (e.g., memories or emotions) or engage in normal functions (e.g., movement of an arm) that are nonetheless available in

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another part, at least in principle. Positive dissociative symptoms occur when the experiences held in one part (e.g., thoughts, emotions, behaviors, memories) intrude into the functioning or consciousness of another part. Negative and positive symptoms can be classified as either psychoform or somatoform. Psychoform dissociative symptoms are psychological experiences typically associated with episodic memory or other mental functions or contents that do not involve the body per se (e.g., hearing voices of other parts). Somatoform dissociative symptoms manifest in the body more generally, and include anesthesia, analgesia, the inability to move some part of the body, or the inability to inhibit particular movements. Clients with DID or Other Specified Dissociative Disorder, e­ xample 1 (hereafter OSDD-​1; essentially subthreshold DID) also typically have serious alterations in consciousness along with other symptoms described above. Each dissociative part may have a different experience, with some alert and focused, and others shutdown and spacey. Individual parts may have a wide or extremely limited range of dysregulation and attentional problems. Parts fixed in freeze or faint (dorsal vagal activation) may also have dissociative detachment. But while one part may be unaware, often there are other parts that are observing the present and can accurately report what is happening. It is important for clinicians to understand if a given symptom such as spaciness belongs to the person as a whole or only to a specific part of the personality, as treatment will differ. We hypothesize that DID and OSDD-​1 (promoted to a specific diagnosis in ICD-​11 as 6B65 Partial dissociative identity disorder) involve divisions of the personality that are the result of a specific combination of vulnerability factors. These include (1) integrative deficits in the face of traumatizing events; (2) subsequent defensive phobic avoidance of experience that maintains dissociation; and (3) an autohypnotic milieu rich with pathological alterations in consciousness in response to trauma, trauma reminders and to ongoing chronic dysregulation (both hypo-​and hyper-​arousal). Action systems provide natural evolutionary fault lines along which different senses of self may arise in this soup of hypnotic trance and alterations in consciousness during the course of trauma and afterwards. Thus, DID and OSDD-​1 are the result of complex interactions among alterations in consciousness that result from chronic dysregulation, and a division of personality that includes different first-​person perspectives within action systems in highly hypnotizable patients who are seriously traumatized in early development. The authors have also proposed that some degree of structural dissociation is present in PTSD and Complex PTSD (Nijenhuis, 2017; Van der Hart et al., 2005, 2006). Structural dissociation is related to chronic integrative deficits, difficulties in developing a cohesive and coherent sense of self across time and contexts, and difficulties managing smooth and harmonious transitions among motivational or action systems, not merely alterations in consciousness. It involves both positive and negative symptoms (intrusions and absence of cognitive and psychomotor functions), as well as both cognitive/​affective (psychoform) and sensorimotor (somatoform) symptoms.

Differences Between General Alterations in Consciousness and Structural Dissociation As alluded to above there are several similarities and differences between alterations in consciousness and structural dissociation. These include: (1) failures in perception and memory; (2) sense of self; (3) field and level of consciousness in dissociative parts of the personality; and (4) complexities of distinguishing between alterations in consciousness and structural dissociation.

Failures of Perception and Memory More than a century of clinical observations (e.g., Culpin, 1931; Janet, 1889/2022a,b, 1907; Kardiner, 1941; Myers, 1940; Putnam, 1989) and newer research (e.g., Lanius, et al., 2002; Van der Kolk, Burbridge, & Suzuki, 1997) have confirmed that patients with dissociative disorders retrieve memories differently from those who have not been seriously traumatized (see Solinski, Chapter 46, this volume). Dissociative parts may share episodic and semantic memories (Elzinga, Phaf, Ardon, & Van Dyck, 2003; Huntjens, Postma, Peters, Woertman, & Van der Hart, 2003). Some parts may hold memories for which other parts are not aware, and there are clear deficits in working memory (Dorahy, 2001). Different dissociative parts have different patterns of psychobiological reaction to narratives of traumatic memories (see Nijenhuis, Chapter 38, this volume). Serious and prolonged alterations of consciousness can impair the creation of episodic and semantic memories ( Janet, 1889, 1907; Myers, 1940; Van der Hart, Van Dijke, Van Son, & Steele, 2000). When we are very tired or “spacey” we may remember our experiences poorly, if at all. When we are absorbed in an experience, our focus is more limited, and we remember little beyond the absorbing experience. Such limitations of episodic memory do not require the existence of dissociative parts of the personality. For example, Ted, a business executive, described leaving stressful meetings with

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little conscious awareness of what had been discussed. He did not have structural dissociation, but during these meetings he was unable to concentrate and had recurring experiences of daydreaming and absent mindedness (i.e., “blank mind”). Severe alterations in consciousness also occur during and often after traumatizing events, creating an environment in which it is difficult to properly encode and retrieve memory. Mary, a woman with a history of child abuse and neglect, had large gaps in her memory of childhood. She had dissociative parts, but even after she had substantially integrated them and was functioning well, some of her childhood recollections of normal experiences remained hazy. When she described the unrelenting stress of her daily life as a child, it was clear that little memory was encoded for much of her childhood, and thus no parts of her could report more than fragmentary memory: People thought I was a space cadet. I kept my nose in a book. I tried not to pay attention, but just stayed focused on what was in front of me. I could never remember the details of things. Sometimes I can remember when I watched TV or read a book, I could almost feel this wall coming between me and the rest of the world. I didn’t have to know about certain things that way. Mary had developed a habit of “checking out” and not paying attention. This co-​occurred with structural dissociation, creating two ways of managing stressful and overwhelming experiences. But chronic alterations of consciousness in childhood seemed to permanently impair her memory for that time. This presents a challenging therapeutic question: Does Mary actually have additional dissociative parts so that some memories remain dissociated, or is this the most complete memory of childhood she will have? When Mary terminated therapy she had no symptoms of dissociation and reported that all her dissociative parts were integrated, so we can only assume that lack of clarity in memory is due to something else.

Sense and Idea of Self: First-​Person Perspective The sense and idea of self and first-​person perspective in mentally healthy individuals is relatively stable across time and contexts, yet also is continually adapted to new experiences. Thus, it is flexible and changing. It is comprised of multiple ego-​or self-​states that operate in a relatively harmonious way without amnesia, undue conflict, or unusual degrees of separateness. When non-​d issociative individuals experience alterations in consciousness, their singular first-​person perspective remains relatively stable and consistent over time and experience. The first-​person perspective of patients with structural dissociation is more seriously compartmentalized and is relatively rigid. Thus, many dissociative parts –​though not all –​are not very adaptive and do not change based on new experiences. A dissociative part that experiences itself as seven years old, for example, may remain forever seven; a rageful part tends to remain rageful and does not experience sadness or joy (or attempts to avoid these emotions). While non-​d issociative individuals may shift ego states (e.g., from mother to friend to teacher to a younger self ), they experience each of these as “me.” The sense of self in dissociative individuals alternates and involves multiple and contradictory senses of self and mental representations of others (Liotti, 2006; Van der Hart et al., 2006).

Field and Level of Consciousness in Dissociative Parts of the Personality Since fluctuating attention and awareness are inherent features of consciousness, it follows that this is true of dissociative parts of the personality. However, attention and awareness are much more limited in most dissociative parts, often chronically restricted by the need to avoid certain reminders of trauma or unresolved conflicts. Also, each part is more rigidly organized by specific goals and action systems rather than being able to harmoniously shift among action systems. When ANP parts are activated, patients tend to avoid traumatic reminders, restricting their awareness. They may be chronically emotionally numb and perhaps depersonalized. When EPs are activated, the patient will experience alterations in consciousness related to threat (hyper-​or hypoarousal related to flight, fight, freeze or faint). Thus, both types of parts have alterations in consciousness, but symptoms may appear differently in each part with some tending toward hypoarousal and others toward hyperarousal. Thus, while one part may be more shut down and spacey, another may be highly agitated and angry, a third part may be alert and responsive; and a fourth part may be narrowly focused on threat cues. Similarly, while one part’s entire consciousness is focused on traumatic memory, or a particular feeling or sensation, another part may be focused on a wide variety of activities of daily life. Finally, although dissociative parts may share some conscious awareness, they tend to limit inner attention to assiduously avoid any reminders of each other.

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Although switching between parts can happen so smoothly that no alteration in consciousness is noted, it is not uncommon to observe some degree of hypoarousal or other indicators of trance. The patient may become unfocused, drowsy, appear not to be very present, and even close his or her eyes as if going to sleep. Janet (1907) described the lowering of the level of consciousness that can precede a switch: When the change is sudden, there is, as it seems, a loss of consciousness, a half faint. When the change is slow, one may easily observe the abasement of mental activity; the patient pays no more attention to exterior events; he understands less and less what you tell him, and he answers with difficulty, is absent-​m inded, works more slowly, or interrupts his work. p. 32

Complexities of Distinguishing between Structural Dissociation and Alterations in Consciousness In theory, it is relatively simple to distinguish between symptoms of structural dissociation and pathological alterations of conscious awareness. The former involves a division of the personality where the latter does not. In practice, however, these phenomena are easily confused because a given symptom may have different underlying causes. For example, when patients become completely unresponsive in therapy, there are at least two possible explanations. First, they may not be perceiving the current situation because they are hypoaroused and shut down. In this case, patients experience a pathological alteration in consciousness, but no structural dissociation. In other cases, structural dissociation is present, and a defensive part of the personality is in a collapsed state, while other parts may be quite aware. For a further illustration, consider the DES item, “Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was said.” There may be several possible reasons for this: (1) the person was thinking about or preoccupied with something else (absorption); (2) the person became hypoaroused and shut down, with resulting difficulty in processing experience and unable to think; or (3) the person switched to another part and had amnesia for some or all aspects of the conversation. It often takes time, careful clinical observation, and open-​ended questioning to discern the difference between trauma-​related alterations of consciousness and the manifestations of structural dissociation. Often the distinction can be made by additional symptoms in DID, such as (1) some Schneiderian first-​rank symptoms, including hearing voices, and intrusions or withdrawals of sensations, emotions, thoughts, and acts (Dorahy et al., 2009; Kluft, 1987a; Loewenstein, 1991; Vogel, Braungardt, Grabe, Schneider, & Klauser, 2013); (2) chronic dissociative symptom clusters that go beyond alterations of awareness and attention (Loewenstein, 1991; Steele et al., 2017), and (3) somatoform dissociative symptoms (see Nijenhuis, Chapter 33, this volume). The correct treatment intervention depends upon this distinction (e.g., Allen et al., 1999; Butler et al., 1996; Steele et al., 2017).

Measures of Dissociation Measures of dissociation have typically not been designed to distinguish between alterations in consciousness and structural dissociation. For example, the DES (Bernstein & Putnam, 1986) assesses absorption, depersonalization, and amnesia based on some factor analytic studies, but the total score does not distinguish among them. Only later was a taxon identified to help distinguish “pathological” dissociation (see Waller, et al., 1996), and at least five of the DES-​T’s eight “pathological” items (see Waller et al., 1996) suggest structural dissociation (e.g., being commanded by voices, observing one’s body from a distance, and the experience of feeling like two or more different “people”). But even then, the DES does not address significant pathological dissociation that we associate with structural dissociation such as somatoform symptoms and loss of control of emotions and behavior, among others. Assessment tools focused on diagnosing pathological dissociation by default differentiate between alteration in consciousness and dissociation (e.g., the Multidimensional Inventory of Dissociation, Dell, 2006; the Dissociative Disorders Interview Scale, Ross et al., 1989; Ross & Browning, 2017; the Structured Clinical Interview for Dissociative Disorders, SCID-​D; Steinberg, 1995). A relatively new instrument, the Detachment and Compartmentalization Inventory (DCI), is the first to seek to distinguish between symptoms of compartmentalization and symptoms of detachment (Butler, Dorahy, & Middleton, 2019). It would be necessary to determine which symptoms of compartmentalization are related to structural dissociation and which might have other causes (i.e., compartmentalization associated with structural dissociation versus compartmentalization unrelated to structural dissociation). Ideally, all

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measures of dissociation should discriminate between manifestations of structural dissociation and alterations in consciousness for diagnostic and treatment purposes.

Alterations in Consciousness and Dissociative Symptoms: Research Findings Research supports the idea that retraction and lowering of consciousness often accompany, but differ from, structural dissociation. The absorption factor of the Dissociation Questionnaire (DIS-​Q; Vanderlinden, Van Dyck, Vandereycken, Vertommen, & Verkes, 1993), which is a form of alteration in consciousness, has only modest correlations with the DIS-​Q’s other three factors (i.e., amnesia, identity fragmentation, loss of control); conversely, the other three factors, which are indicative of structural dissociation, correlate highly with one another. Similarly, scores on the Somatoform Dissociation Questionnaire (SDQ-​20; Nijenhuis et al., 1996) –​a strong measure of structural dissociation (Nijenhuis et al., 1997, 1998) –​correlate more weakly with the DIS-​Q absorption factor than they do with the DIS-​Q’s other three factors (Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1996). The severity of alterations in consciousness has been found to be associated with general psychopathology; this was true for both dissociative and nondissociative patients (Leavitt, 2001). These findings reiterate two points: (1) alterations in consciousness are not unique to dissociative individuals and (2) some alterations of consciousness fall outside the normal range (cf., Carlson, 1994). Lanius and Frewen have attempted to make distinctions among alterations in Normal Waking Consciousness (NWC) and Trauma-​related Alterations in Consciousness (TRASC; Frewin & Lanius, 2014; see Frewen, Wong & Lanius, Chapter 19, this volume). One way to summarize these findings is to say that alterations in consciousness are sensitive but not specific indicators of structural dissociation. That is, individuals with structural dissociation typically display alterations in consciousness (both normal and pathological), but only a minority of individuals with alterations in consciousness have structural dissociation. It may also hold that a small subset of individuals with structural dissociation may not display significant alterations in consciousness. Holmes and colleagues (2005) found that “detachment” (a form of altered consciousness) and “compartmentalization” (some of which may reflect structural dissociation) are qualitatively distinct phenomena. Although they warn that more research is needed, they asserted that the emerging evidence of a qualitative distinction between detachment and compartmentalization “directly contrasts with the common notion (since DSM-​III (1980)) that these experiences lie on the same continuum … somewhere between ‘daydreaming’ and ‘Dissociative Identity Disorder’ ” (p. 12). They contend that detachment and compartmentalization are different in kind, rather than degree.

Diagnostic Confusion in the DSM and ICD Confusion between alterations in consciousness and structural dissociation appears to derive from two related diagnostic problems. First, as noted, dissociation has been defined too broadly and vaguely, and is used in different ways by different authors and defined differently in measurement instruments. Second, there is a lack of clarity in the two diagnostic classification systems. There seems to be general agreement in the literature that DID is the most extreme outcome of traumatization, making it the most severe trauma-​related disorder (e.g., Chu, 2011; Dell, 1998; Reinders & Veltman, 2021; Spiegel, 1988, 1993) and the core pathology of DID is (structural) dissociation, not alterations in consciousness per se (e.g., Boon & Draijer, 1993; Kluft, 1996; Putnam, 1989; Ross, 1989). There is agreement that peritraumatic dissociation is a common precursor to PTSD, and that “dissociation” (which in most publications includes abnormal alterations in consciousness) occurs in Acute Stress Disorder, PTSD, and trauma-​related BPD. In fact, one study found that nearly half (48%) of a cohort of BPD patients also have OSDD-​1 (24%) or DID (24%) (Korzekwa, Dell, Links, Thabane, & Fougere, 2009; see Korzekwa & Dell, Chapter 31, this volume). Typically, however, dissociation is only listed as one of many symptoms; it is not thought of as an underlying psychobiological organization or structure as is the case in DID (e.g., Feeny, Zoellner, Fitzgibbons, & Foa, 2000; Harvey & Bryant, 1999; see Gershuny & Thayer, 1999, for a review). Even when the dissociative nature of trauma-​related disorders is noted, as in Acute Stress Disorder (e.g., Spiegel, Koopman, Cardeña & Classen, 1996), this recognition of dissociation does not extend to acknowledging the possibility of an underlying structure (that manifests itself in dissociative symptoms). The reluctance of the trauma field to recognize and research structural dissociation as a possible underlying psychobiological organization has contributed to the tendency to dismiss dissociation as “irrelevant” to clinical conceptualization and treatment. The overly wide range of symptoms that are considered to be dissociative, coupled with failures to distinguish different underlying etiologies can render the therapist less effective in treatment. Our specific focus in this chapter is on the failure to recognize that structural dissociation may underlie more complex behaviors and symptoms

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such as recurrent substance use, affect dysregulation, suicidality and self-​harm, or chronic difficulties in relationships. We also aimed to show that alterations in consciousness are distinct from (structural) dissociation. A hallmark of structural dissociation is that many dissociative symptoms are not immediately obvious; they may even be intentionally hidden by a frightened or ashamed individual (Kluft, 1987b, 1996; Loewenstein, 1991; Steinberg, 1995).

Discussion There is major conceptual confusion regarding the term dissociation. We believe this confusion has at least four sources: (1) the concept of dissociation originally was intended to mean a division of the personality, but contemporary discussions of dissociation have added overly generalized symptoms of alterations in consciousness (See Van der Hart & Dorahy, Chapter 1, this volume); (2) in traumatized individuals, structural dissociation and alterations in consciousness typically co-​occur; (3) the emphasis has been on dissociative phenomena rather than underlying etiology, which has major treatment implications; and (4) structural dissociation has been relegated to psychiatric conditions where it is clearly observable (DID and OSDD-​1), rather than a possibility to explore in all highly traumatized individuals who present with other problems, such as mood disorders, substance abuse, somatization, other posttraumatic disorders, or other psychiatric disorders. These factors have resulted in a lack of consensus about assessment and treatment strategies. Some have suggested that the term dissociation be abandoned (e.g., Holmes et al., 2005). Nonetheless, dissociative pathology remains, regardless of what it is called; we need to adequately conceptualize and appropriately treat it. Others have proposed that dissociation is a multidimensional concept that involves diverse experiences such as disengagement, depersonalization, emotional constriction, multiplicity, amnesia, gaps in awareness, absorption, and imaginative involvement (e.g., Bernstein & Putnam, 1986; Briere, 2002). At the least, researchers and clinicians should be aware of the many underlying foundations of these highly varied symptoms, and the fact that they may overlap, so that treatment is clearly targeted. We have presented conceptual and empirical evidence that manifestations of structural dissociation and alterations in field and level of consciousness are different but related phenomena that frequently co-​occur but should be distinguished for theoretical and treatment purposes. The theory of structural dissociation of the personality outlines the psychobiology of trauma-​related dissociation. This allows the manifestations of structural dissociation to be differentiated from both normal and pathological alterations in consciousness. Much research remains to be done in understanding the relationship between these complex phenomena in traumatized individuals, particularly those who have experienced traumatizing events throughout early development. From the perspective of the theory of structural dissociation, PTSD, Complex PTSD, OSDD-​1, and DID involve relative divisions of the personality that are developed due to integrative deficits in the face of traumatizing events. These individuals experience chronic hypo-​and hyper-​arousal, which lend themselves to further chronic alterations in consciousness (Frewen & Lanius, 2015). The individual’s different motivations and intentions, and related action systems provide the fault lines around which different senses of self and first-​person perspectives may arise during hypnotic trance and alterations in consciousness during the course of trauma. Thus, disorders like DID and OSDD-​1 involve complex interactions among alterations in consciousness, altered sense of self associated with different action systems, and generalized chronic dysregulation in patients who were seriously traumatized in early development. The utility and accuracy of this proposition is dependent upon its clinical and empirical validation.

Acknowledgment We thank Ellert Nijenhuis for his co-​authorship of the first edition of this chapter in 2009, as well as for his valuable comments on the present version.

Notes 1 As this chapter is discussed from the perspective of the Theory of Structural Dissociation (Van der Hart, Nijenhuis & Steele, 2006), personality is conceptualized as being singular and defined as “the dynamic, biopsychosocial system as a whole that determines [the individual’s] characteristic mental and behavioral actions” (Nijenhuis & Van der Hart, 2011, p. 418). Therefore, the metaphor of division is used rather than multiplication. 2 For example, Janet (1911) used the term “division de la personnalité” (e.g., pp. 371, 545, 553, 614, 615, 616, 634). 3 According to Janet, synthesis is the binding (linking) and differentiation of experience. Personification involves ownership, that is, personal awareness and acceptance of experience as one’s own: “That happened to me and I am aware of how it helped shape who I am”; “These are my feelings and my actions.” Personification also includes agency (e.g., “I am doing this”). Presentification

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involves being in the present with a synthesis of a sufficient degree of personified experiences –​past, present, and anticipated future –​such that adaptive decision-​making and action can occur. Realization is the integrative combination and result of adequate personification and presentification (Van der Hart et al., 2006; Van der Hart et al., 2010).

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The Polyvagal Theory: Neurophysiological foundations of emotions, attachment, communication, and self-​regulation. New York: Norton. Prince, M. (1905). The dissociation of a personality. London: Longmans, Green & Co. Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford. Putnam, F. W. (1997). Dissociation in Children and Adolescents: A Developmental Perspective. New York: Guilford. Ray, W. J. (1996). Dissociation in normal populations. In L.K. Michelson & W.J. Ray (Eds.), Handbook of Dissociation: Theoretical, empirical, and clinical perspectives (pp. 51–​66). New York: Plenum Press. Reinders, A. A. T. S., & Veltman, D. (2021). Editorial: Dissociative identity disorder: Out of the shadows at last? British Journal of Psychiatry, 291, 413–​414. Rodewald, F., Dell, P. F., Wilhelm-​Gossling, C., & Gast, U. (2011). Are major dissociative disorders characterized by a qualitatively different kind of dissociation?. Journal of Trauma & Dissociation, 12(1), 9–​24. Ross, C. A. (1989). Multiple Personality Disorder: Diagnosis, clinical features and treatment. New York: Wiley. Ross, C. A., & Browning, E. (2017). The self-​report Dissociative Disorders Interview Schedule: A preliminary report. Journal of Trauma & Dissociation, 18, 31–​37. Ross, C. A., Heber, S., Norton, G. R., & Anderson, D. (1989). The Dissociative Disorders Interview Schedule: A structured interview. Dissociation, 2, 169–​189. Ross, C. A., Joshi, S., & Currie, R. (1991). Dissociative experiences in the general population: A factor analysis. Hospital and Community Psychiatry, 42, 297–​301. Şar, V., Kundakçı, T., Kızıltan, E., Yargıç, I. L., Tutkun, H., Bakım, B., Aydıner, O., Özpulat, T., Keser, V., Özdemir, Ö. (2003). The axis-​I dissociative disorder comorbidity of borderline personality disorder patients among psychiatric outpatients. Journal of Trauma & Dissociation, 4(1), 119–​116. Schalinski, I., Schauer, M., & Elbert, T. 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Schwartz, H. L. (2000). Dialogues with Forgotten Voices: Relational Perspectives on Child Abuse Trauma and Treatment of Dissociative Disorders. New York: Basic Behavioral Science. Simeon, D. (2004). Depersonalisation disorder: A contemporary overview. CNS Drugs, 18, 343–​354. Simeon, D. & Abugel, J. (2006). Feeling Unreal: Depersonalization Disorder and the loss of the self. Oxford: Oxford University Press. Simeon, D., Guralnik, O., Hazlett, E. A., Spiegel-​Cohen, J., Hollander, E., & Buchsbaum, M. S. (2000). Feeling unreal: A PET study of depersonalization disorder. American Journal of Psychiatry, 157, 1782–​1788. Somer, E. (2002). Maladaptive daydreaming: A qualitative study. Journal of Contemporary Psychotherapy, 32, 197–​212. Spiegel, D. (1988). Dissociation and hypnosis in post-​t raumatic stress disorders. Journal of Traumatic Stress, 1, 17–​33. Spiegel, D. (1993). Multiple posttraumatic personality disorder. In R. P. Kluft & C. G. Fine (Eds.), Clinical Perspectives on Multiple Personality Disorder (pp. 87–​99). Washington, DC: American Psychiatric Press. Spiegel, D., Koopman, C., Cardeña, E., & Classen, C. (1996). Dissociative symptoms in the diagnosis of acute stress disorder. In L.K. Michelson & W.J. Ray (Eds.), Handbook of Dissociation (pp. 367–​380). New York: Plenum. Spiegel, D. (2003). Hypnosis and traumatic dissociation: Therapeutic opportunities. Journal of Trauma & Dissociation, 4(3), 73–​90. Steele, K. (in press). Understanding motivational systems in complex trauma and dissociation. In D. Siegel, A. Schore, & L. Cozolino (Eds.), Interpersonal Neurobiology and Clinical Practice. New York. Norton. Steele, K., Boon, S., & Van der Hart, O. (2017). Treating Trauma-​related Dissociation: A practical integrative approach. New York: Norton. Steinberg, M. (1993). The spectrum of depersonalization: Assessment and treatment. In D. Spiegel (Ed.), Dissociative Disorders: A clinical review (pp. 79–​103). Lutherville, MD: Sidran Press. Steinberg, M. (1995). Handbook for the Assessment of Dissociation: A clinical guide. Washington, DC: American Psychiatric Press. Toates, F. M. (1986). Motivational Systems. Cambridge: Cambridge University Press. Van der Hart, O. (2019). The value of hypnosis in the resolution of dissociation: Clinical lessons from World War I on the integration of traumatic memories. Quaderni di Psicoterapia Cognitiva, 1127–​6347, n. 44/​2019, 11–​49. Van der Hart, O., & Rydberg, J. A. (2019). Vehement emotions and trauma-​generated dissociation: A Janetian perspective on integrative failure. European Journal of Trauma and Dissociation, 3(3), 191–​201. Van der Hart, O., Nijenhuis, E. R. S., & Solomon, R. (2010). Dissociation of the personality in complex trauma-​related disorders and EMDR: Theoretical considerations. Journal of EMDR Practice and Research, 4, 76–​92. Van der Hart, O. Nijenhuis, E. R. S., Steele, K., & Brown, D. (2004). Trauma-​related dissociation: Conceptual clarity lost and found. Australian and New Zealand Journal of Psychiatry, 38, 906–​914. Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2005). Dissociation: An under-​recognized major feature of Complex PTSD. Journal of Traumatic Stress, 18, 413–​424. Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The Haunted Self: Structural dissociation and the treatment of chronic traumatization. New York/​L ondon: Norton. Van der Hart, O., & Steele, K. (1997). Time distortions in dissociative identity disorder: Janetian concepts and treatments. Dissociation, 10, 91–​103. Van der Hart, O., Van Dijke, A., Van Son, M., & Steele, K. (2000). Somatoform dissociation in traumatized World War I combat soldiers: A neglected clinical heritage. Journal of Trauma and Dissociation, 1(4), 33–​66. Van der Kolk, B. A., Burbridge, J. A., & Suzuki, J. (1997). The psychobiology of traumatic memory: Clinical implications of neuroimaging studies. Annals of the New York Academy of Science, 821, 99–​113. Vanderlinden, J., Van Dyck, R., Vandereycken, W., Vertommen, H., & Verkes, R. J. (1993). The Dissociation Questionnaire (DIS-​ Q): Development and characteristics of a new self-​report questionnaire. Clinical Psychology and Psychotherapy, 1, 1–​7. Vogel, M., Braungardt, T. Grabe, H. J., Schneider, W., & Klauser, T. (2013). Detachment, compartmentalization, and schizophrenia: Linking dissociation and psychosis by subtype. Journal of Trauma and Dissociation, 14, 273–​287. Waller, N. G., Putnam, F. W., & Carlson, E. B. (1996). Types of dissociation and dissociative types. Psychological Methods, 1, 300–​321. Watson, D. (2003). Investigating the construct validity of the dissociative taxon: Stability analyses of normal and pathological dissociation. Journal of Abnormal Psychology, 112(2), 298–​305. Zanarini, M. C., Ruser, T., Frankenburg, F. R., & Hennen, J. (2000). The dissociative experiences of borderline patients. Comprehensive Psychiatry, 41, 223–​227.

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5 THE CASE FOR THE STUDY OF “NORMAL” DISSOCIATION PROCESSES Constance J. Dalenberg, Rachel R. Katz, Kenneth J. Thompson, and Kelsey Paulson

The concept of dissociation has exploded into the awareness of scientists in the last several decades. Exploring the PTSD pubs database (formerly PILOTS), a search engine devoted exclusively to trauma-​related research, the keyword “dissociation” returns seven studies per year in the 1980s, 70 per year in the 1990s, and over 100 per year in the last two decades (2000–​2019). A clear turning point for this increase was the 1986 publication of Bernstein and Putnam’s Dissociative Experiences Scale (DES), the first validated instrument available both to detect dissociative experiences and symptoms and to screen for dissociative disorders. Since then, a variety of screening instruments have come into use, including the Phillips Dissociation Scale (Phillips, 1994), the Dissociation Questionnaire (DIS-​Q; Vanderlinden et al., 1993), the Child Dissociative Checklist (CDC; Putnam et al., 1993), the Somatoform Dissociation Questionnaire (SDQ; Nijenhuis et al., 1997), and the Dissociative Symptoms Scale (DSS; Carlson et al., 2018). Several measures designed to diagnose dissociative disorders have been created as well. Diagnostic interviews include the Structured Clinical Interview for DSM-​I V Dissociative Disorders-​Revised (SCID-​D; Steinberg, 1994) and the Dissociative Disorders Interview Schedule (DDIS; Ross et al., 1989). Self-​report instruments include the Multidimensional Inventory of Dissociation (MID; Dell, 2006), the Steinberg Dissociation Questionnaires (Steinberg & Schnall, 2000), and the first normed and T-​scaled dissociation measure available for clinical use, the Multiscale Dissociation Inventory (MDI; Briere, 2006). With the addition of a dissociative subtype of posttraumatic stress disorder (PTSD-​D) in the 5th edition of the Diagnostic and Statistical Manual (DSM-​5; American Psychiatric Association, 2013), specific instruments to assess this subtype were developed, such as the Dissociative Subtype of Posttraumatic Stress Disorder Scale (DSPS; Wolf et al., 2017). The current chapter perceives dissociative phenomena in the broadest sense –​as a set of correlated but nonidentical experiences (see later sections), which create disconnections between normally connected mental processes. The available literature now includes numerous studies that relate dissociation to trauma using increasingly sophisticated designs. The many correlational and quasi-​experimental studies (e.g., Berg et al., 2005; Briere, 2006; Narang & Nijenhuis, 2005) have been augmented by prospective studies in which dissociation is measured before and after known high-​level stressors and/​or followed over time (e.g., Diseth, 2006; Zamir et al., 2018). Neuroscientists have been drawn to the study of dissociation by findings that dissociative episodes may have characteristic physiology (Ebner-​Priemer et al., 2005; Seligowski et al., 2019), that individuals with dissociative disorders may have characteristic f MRI results (Lanius et al., 2002; Perez et al., 2018), and that dissociation is highly comorbid with numerous non-​d issociative psychiatric conditions, such as borderline personality disorder (Shah et al., 2020), major depression (Fullerton et al., 2000; Fung et al., 2020), chemical dependency (Ellason et al., 1996) and psychosis (Perona- ​G arcelán et al., 2016). Thus, dissociation has passed into the hands of researchers who are not centrally focused on the study of dissociative disorders, which may have contributed to complaints about the muddiness of the definition of dissociation (see Braude, Chapter 2, this volume). Marshall et al. (1999), for instance, refer to dissociation as a “vague term used to describe a broad range of phenomena” (p. 1681). Certainly, the breadth of application of the term cannot be denied. Table 5.1 includes a partial list of terms that have been associated with dissociation.

DOI: 10.4324/9781003057314-7

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82  Constance J. Dalenberg et al. TABLE 5.1  Concept Related to Dissociation

Depersonalization Perceptual Alteration Derealization Absorption Hypnotizibility Imaginative Involvement Cognitive Avoidance Fugue State Dissociative Amnesia Hypnotic Analgesia Dissociative Detachment Altered consciousness

Disengagement Emotional constriction Isolation Dissociative Stupor Conversion Disorders Flashbacks Compartmentalization Out- ​of-​Body Experiences Spacing Out Freezing Numbing

In general, dissociation has been used to describe a disconnection between mental processes that are ordinarily integrated, ranging from a sense of conscious dyscontrol to a relatively complete lack of awareness of emotional reactions, sensations, or behaviors. Thus, dissociation has been used to describe individuals who report a persistent sense of the unreality of their worlds, claim amnesia for an important and typically memorable event, report a distressing event without accompanying emotion, or become so immersed in behaviors (e.g., sports) that there is a lack of awareness of salient events occurring around them. Many authors point out the complexity of the dissociation symptom presentation (see Briere et al. [2016] for a particularly important discussion of this point). Researchers have been spurred on to refine their use of “dissociation,” typically through positing two distinct dissociative categories. Most often, the dichotomy rests (or teeters) on a distinction between “normal” dissociation and “pathological” dissociation. In rare instances, “normal” dissociation is argued not to be dissociation at all (cf. Briere, 2006). Steele et al. (Chapter 4, this volume), for instance, distinguish changes in the level or field of consciousness, typically categorized as normal dissociation, from changes deriving from dissociative divisions at the level of personality typically, but not exclusively, reflecting pathological dissociation.

What Do We Mean by Normal And Pathological Dissociation? Although a distinction between normal and pathological dissociation is woven throughout the literature, the nature of the distinction has not itself been well articulated. As different writers attempt to make use of the dichotomy, they appear to be using different criteria to distinguish “normal” from “pathological.” Broadly, there appear to be six different criteria in use. 1. Type. Some theoreticians argue that certain “types” of dissociation are normal and others are not. Thus, pathological dissociation might include amnesia (Waller et al., 1996), depersonalization (Simeon et al., 2003), or identity diffusion (e.g., Dissociative Identity Disorder [DID]; Waller et al., 1996), whereas normal dissociation might include absorption (Banos et al., 1999), grade 5 hypnotizability (Dell, 2017; Spiegel, 1974), or detachment/​numbing (Briere, 2006). The dissociative subtype of PTSD in the DSM-​5 requires that the dissociation be of a specific type (i.e., depersonalization or derealization; APA, 2013). 2. Level. Other authors refer to a continuum of dissociation, a view championed by Steven Gold. In a plenary address at the annual meeting of the International Society for the Study of Dissociation, Gold (2004) proposed that structural dissociation (such as that seen in DID) represents the upper end of a dissociative continuum, whereas more common dissociative experiences (such as absorption) represent the lower end of that continuum. This view has been expressed by Ross (1996), Ray et al. (1992), and Eisen and Carlson (1998), all of whom refer to absorption as a mild form of dissociation. 3. Timing. Recent years have seen the emergence of the terms “peritraumatic dissociation” and “posttraumatic dissociation” (Duagani Masika et al., 2019; Marmar et al., 1994) to distinguish between dissociation occurring during or after a traumatic event, respectively. Although peritraumatic dissociative reactions may predispose an individual to PTSD (Ozer et al., 2003), it is generally regarded as normal to experience (a) fleeting “out of body” experiences immediately after trauma, (b) temporary dampening of awareness of pain during crisis, or (c) “shock” accompanied by perceptual distortion and amnestic phenomena in a period immediately after receipt of unexpected, horrifying news. Butler (2006) argues that dissociative disorders are “disorders” due “not to the fact that dissociation per se is

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present, nor that it was deployed in the face of trauma as a tactic (or reflex) of immediate survival, but rather that severe dissociation and its fallout continue in the absence of such conditions” (p. 54). In this conceptualization, dissociation in the context of a trauma is normal if it is short-​lived and pathological if it persists. 4. Relationship to defense. Butler (2006), Hilgard (1986), Leavitt (2001) and Putnam (1997) have written of normal dissociation as a process operating through the allocation of attention. In absorption, for example, normal dissociation focuses attention on one aspect of experience, thereby avoiding or blocking other aspects. The neglected material, poorly elaborated and lacking integration into various neural networks, sits at the outskirts of consciousness or attention and may be poorly recalled at a later time. In contrast, in pathological dissociation, the material is described as more fully encoded but actively blocked in a defensive process. 5. Purpose. The role or function of dissociation in a given instance may also serve to define its normal or pathological status. For instance, numbing would likely be seen as normal and adaptive in a soldier who ignores the pain of a combat wound in the midst of an enemy engagement, but pathological and maladaptive in a soldier who ignores the distress of a spouse to avoid the emotional pain that such distress evokes. This type of distinction is made by Ludwig (1983) in his argument for the positive evolutionary functions of dissociation: protection of experience through isolation or compartmentalization of catastrophic experience, conservation of energy through efficiency of effort during dissociative flow states, or resolution (through avoidance) of irreconcilable conflicts. Each of these functions has its place in healthy life experience; pathological dissociation thus might represent the hijacking of a normative process. 6. Frequency. Finally, the “normal” in normal dissociation at times refers to frequency or base rate of the symptom in a given population. The base rates of absorption items on the DES, for instance, are higher than the base rates of amnesia or depersonalization items (Waller et al., 1996).

Current Operationalization Of Normal And Pathological Dissociation Given these differing conceptualizations of dissociation, it is unsurprising that normal and pathological dissociation have been operationalized in several ways. Most commonly, pathological dissociation is defined through use of the dissociative taxon (Waller et al., 1996), eight items on the DES. The taxon items differ in type (depersonalization/​a mnesia rather than absorption), level (associated with more severe dissociative symptoms) and base rate (rarer in the population than non-​t axon items). Individuals who are taxon-​positive are diagnosed with pathological dissociation, whereas taxon negative individuals are not. The word “taxon” also implies that the underlying pathological dissociation symptom set is dichotomous. That is, dissociative symptoms are not spread continuously across the population, forming a normal curve, with the extreme positive end representing dissociative disorder. Rather, pathological dissociation is thought to be taxonic, with the majority of individuals never experiencing such symptoms and a minority experiencing extreme symptoms. Taxon studies of dissociation have typically found that DES taxon-​positive participants are more likely to have a dissociative disorder and that the eight taxon items are a better screen for dissociative disorders than the complete DES. For instance, Waller et al.’s (1996) original mixed sample (228 normal controls and 228 patients with clinically diagnosed DID) provided evidence for a non-​continuous distribution of “pathological dissociation.” However, it is likely that Waller et al.’s decision to combine a sample diagnosed with an extreme form of dissociation and a normal control group (rather than to compose a sample of participants from the entire continuum of DES scores) may have contributed to their taxonic results. Similar findings on smaller samples have subsequently been reported. For example, seven of Modestin and Erni’s (2004) ten dissociative disorder patients had a higher average DES-​Taxon (DES-​T ) score compared to the average total DES score; this was true for only one of the patients not diagnosed with a dissociative disorder. Unfortunately, it is not clear if the DES-​T is a stable measure. Watson (2003) replicated Waller et al.’s (1996) analysis with 465 undergraduates, calculating four indices of pathological dissociation: (1) the sum of the eight DES-​T items, (2) the Bayesian probability of taxon membership calculated by the Statistical Analysis System (SAS) scoring program developed by Waller and Ross (1997), (3) a dichotomous measure of taxon membership using a 0.50 probability cutoff, and (4) a dichotomous measure of taxon membership using a 0.90 cutoff. Watson found that the four indices had two-​ month stability coefficients of 0.62, 0.34, 0.29, and 0.27 respectively. The Big Five Inventory, a measure of basic personality traits that Watson administered concurrently with the DES, yielded stability coefficients between 0.79 and 0.89. The “unimpressive short-​term stability” of the taxon as shown by Watson raises concerns about the appropriateness of the taxon model. This concern gains credence from growing evidence that artificial dichotomization of continuous measures often produces a loss of reliability and validity (cf., Cohen, 1983; Widiger, 1992). Markon et al. (2011) have

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more recently found that continuous measures of psychopathology, on average, show 15% better reliability and 37% more validity than comparable dichotomous measures. It should be noted, however, that (for reasons related to the statistical issues that Markon et al. [2011] raise) temporal stability is likely to be greater in clinical samples, where the base rate of the taxon is higher and greater numbers of individuals score decidedly above the taxon cutoff scores. In most research, normal dissociation and pathological dissociation are each defined more continuously, either through use of different scales or factors within the DES and other instruments, or through contrasting scales across measures. For example, level of normal dissociation has been defined by the score on the Absorption factor of the DES or as the overall score on the Tellegen Absorption Scale (Tellegen & Atkinson, 1974). Level of pathological dissociation then could be defined as the score on the Amnesia or Depersonalization/​Derealization factor of the DES, as a continuous score on taxon items of the DES, as Identity Impairment/​Diffusion on the MDI, etc. When this methodology is used, the researcher is conceding that pathological dissociation may be measured continuously but also is implicitly or explicitly arguing that certain “types” of dissociation, such as absorption, are benign (i.e., normal) at any level. Arguments that those with dissociative disorders have a qualitatively different experience of dissociation have not been particularly convincing. Rodewald et al. (2011), arguing for this qualitative difference, noted that three groups –​ controls, those with clinical diagnoses other than dissociative disorders, and those diagnosed with a dissociative disorder –​differed in a stepwise manner on a variety of dissociation tests and on severity of psychological distress, with each group differing from the other two. After correcting for general psychopathology, Rodewald and colleagues found that the clinical non-​d issociative group and controls no longer differed on dissociation, a result they attributed to the qualitatively different dissociation experienced by individuals with clinical dissociation. A plausible alternative hypothesis, however, is that controlling for general psychopathology (which does not include dissociation) removed the only distinction between the controls and the clinical non-​d issociative group while preserving the difference between those with clinically elevated dissociation and the other groups.

Are Normal And Pathological Dissociation Distinct? While we know that taxon-​positive individuals, or those high on pathological dissociation, almost always have high absorption scores, the reverse is not true. Researchers studying both forms of dissociation find large numbers of individuals high on absorption who do not receive high DES-​Taxon scores. For example, Table 5.2 shows the results from the Trauma Research Institute data bank for 828 adults who completed the Dissociative Experiences Scale Revised (DESR; Dalenberg et al., 2014). The DESR contains the identical stems from the original DES but the response format is changed to a frequency scale (“never,” “no more than once a year,” etc.) rather than the original percentile scale (occurs x% of the time). The DESR taxon scale correlates over 0.90 with the original DES taxon scale in several of our studies, while the absorption scale correlates from 0.84 to 0.92 with the original absorption scale (if the two are given simultaneously). In a test-​retest sample, however, the new absorption scale outperformed the original in terms of reliability. The six-​month temporal stability coefficient for the new absorption scale was 0.84, while the same figure for the original version was 0.67 (with a college sample). Using the sample cutoff shown to be most similar to taxon results for the original DES scores (a mean item score of 1.75 on the taxon items), 5.6% of our sample was taxon-​positive. As can be seen in Table 5.2, 44 of these 46 individuals also scored positively on the absorption scale. Of the two individuals who were taxon-​positive and low-​absorption, it should be noted that one individual missed the cutoff by one hundredth of a point. The one remaining exception may plausibly be attributed to measurement error. TABLE 5.2  Relationship between Taxon Membership and Absorption Level

Low Absorption

High Absorption

Nontaxon Member N =​792

Taxon Member N =​46

n =​455 99.6 %1 56.9 %2 n =​337 88.5 % 43.1 %

n =​2 0.4 % 4.3 % n =​44 11.5 % 95.7 %

1  Percentage within absorption category; 2  Percentage within taxon category

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Are Definitions Of Dissociation Related to the Dissociative Subtype of PTSD Overly Restrictive? A case example of the cost of delimiting pathological dissociation by type is the decision to define the dissociative subtype of PTSD solely through depersonalization and derealization. In a well-​designed recent dissertation, Brandi Naish (2020) examined 100 adults with PTSD verified by gold standard instruments. Noting that individuals with the dissociative subtype are repeatedly identified as having more comorbid disorders (one justification for the addition of the subtype), Naish examined the capability of three dissociation instruments to identify highly comorbid PTSD patients. All dissociation instruments replicated the finding that high dissociation was related to greater comorbidity. However, in examining the Dissociative Subtype of PTSD Scale (Wolf et al., 2017), a dissociation instrument that includes multiple subscales (i.e., Depersonalization & Derealization, Loss of Awareness, & Psychogenic Amnesia), Naish found that inclusion of the broader definition of dissociation (rather than Depersonalization and Derealization alone) doubled the variance accounted for by dissociation in comorbidity. Naish’s (2020) finding fits with Briere et al.’s (2016) important work on dissociative complexity. Using the MDI (Briere, 2006), Briere et al. tested the predictive power of levels of six dissociation subscales in the prediction of suicidality and substance abuse in community and incarcerated samples. In both cases, a dissociative complexity variable (the number of elevations above two standard deviations across dissociative subscales) predicted symptom elevation even when controlling for generally elevated dissociation (level). Findings were discussed in the context of Cloitre et al.’s (2009) model, which suggests that multiple types or extreme levels of trauma may overwhelm self-​regulatory capacity, leading to elevation within –​and proliferation across –​types of dissociation. It thus appears premature to restrict the definition of dissociation within the dissociative subtype to depersonalization and derealization, although it is still possible that these dissociative types have stronger relationships to PTSD than do other dissociative symptom manifestations.

Normal Uses For Dissociation Processes Of all the distinctions between “normal” and “pathological” dissociation listed earlier, the timing dimension appears to have the most empirical support. Theoretical arguments have been presented which show that the use of amnesia to temporarily (or permanently) forget an incident of mistreatment by a valued other may be quite practical, as long as it does not damage the person’s ability to function and to assess risk (Freyd, 1996). Empirical evidence demonstrates that this form of amnesia is not rare in traumatic circumstances (Dalenberg, 2006). A process such as absorption, implemented to avoid negative affect, may be an effective emotion-​regulation tool in the short term. Similarly, processes that sever the connection between body and self (e.g., depersonalization, conversion) are reported by individuals with chronic pain (Duckworth et al., 2000) and may allow temporary or permanent relief of some unbearable physical experience. Acute elevations in general dissociation, across subtypes, have been noted in skydivers who are engaging in a behavior that is concurrently exciting and frightening (Sterlini & Bryant, 2002). Dissociation has also been found in individuals undergoing a religious piercing ritual ( Jegindø et al., 2013). In each case, the individual is using dissociation as a form of temporary self-​protection –​to ward off physical and/​or mental pain until it is safe to experience it. Peritraumatic dissociation is thought to be frequent enough to be considered part of a normal biological stress response. Through a constellation of dissociative strategies, the individual under attack cuts ties between ongoing mental processes, particularly when the trauma is perceived to be inescapable (Bandler et al., 2000; Bastos et al., 2016). If overused, this strategy leaves the person lacking internal anchors, bereft of coherent self-​understanding, and without the basic data that could allow reappraisal of action rather than suppression of affect (John & Gross, 2004). Such internal incoherency places the individual at risk for a variety of psychiatric disorders, both dissociative and nondissociative. Finally, dissociative processes, which can free the individual from the constraints of reality, have been associated with positive feelings by several authors (Butler & Palesh, 2004; Herbert, 2013). Absorption, for instance, may not only protect the individual from the negative but also immerses the individual in a contrasting positive state (see Thomson, Chapter 6, this volume). To be “absorbed” in a novel or movie is typically a positive experience, independent of whether one consciously chose to absorb in order to avoid or reject a traumatic memory.

Can An Extreme Elevation In “Normal Dissociation” Be Pathological? Taken as a whole, the discussion thus far suggests that normal dissociation is a common but temporary response to trauma, mild or even positive in its effects, and minimally related to pathology. Conversely, pathological dissociation is taxonic, negative in its effects, and highly related to trauma and pathology. In the more extreme version of the argument for pathological dissociation (wherein “normal” dissociation is not dissociation at all), one would also expect that

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absorption would not relate well to dissociative (or even nondissociative) psychopathology. So, how does the scientific evidence speak to these hypotheses? Absorption does appear as a separate factor in several factor analyses of the DES (Olsen et al., 2013; Soffer-​Dudek et al., 2015; Stockdale et al., 2002), and the Dissociative Continuum Scale (Coe et al., 1995; Dalenberg & Palesh, 2004). Amnesia-​related items correlate at least marginally better with other amnesia-​related items than they do with absorption-​related items. DES factors are highly correlated with each other, enough to call into question any notion that they represent entirely separate processes. Levin and Spei (2004), for instance, found a correlation of 0.80 between the taxon and the Absorption factor. Further, pathological dissociation (as defined by the amnesia factor, the depersonalization factor, or the taxon) rarely correlates more strongly with other predictors of dissociation than does absorption. Leavitt (2001) provided a telling example of the comparative relationships of normal and pathological dissociation to other psychological symptoms. Leavitt broke a large psychiatric sample into two groups based on normal dissociation scores (a median split on the absorption factor). Large and significant differences appeared between high and low absorption groups on eight of the 10 MMPI scales; a third of the variance was accounted for by absorption in Schizophrenia and Psychasthenia scales. When Leavitt separated his sample by the presence or absence of a dissociative disorder, few differences emerged. Thus, absorption was highly related to psychiatric pathology in general ( just as it correlates with dissociative pathology in particular). In support of the latter point, Leavitt (1999) also found incrementally higher numbers of absorption cases in groups of increasing pathological dissociation severity. He concluded that the case frequency of high normal dissociation rises in a linear fashion with successive levels of abnormal dissociation. Levin and Spei’s (2004) findings supported Leavitt’s results. Pathological and normal dissociation were equally related to depression (r’s =​0.38 and.36, respectively) and equally related to anxiety (r’s =​0.32 and 0.30, respectively). A set of pathology measures accounted for 36% of the variance in the taxon and 33% of the variance in absorption, while a set of imagination and fantasy immersion variables (fantasy proneness, poor attentional control, daydreaming) accounted for 24% of the variance in the taxon and 24% of the variance in absorption. Levin and Spei noted that positive-​constructive daydreaming correlated significantly with absorption but not with the taxon, a finding in keeping with the normal/​ abnormal dichotomy. However, the significant and nonsignificant correlations fall only slightly on either side of the 0.05 probability line and are not significantly different from each other. The findings from Leavitt (1999, 2001) as well as Levin and Spei (2004) have been replicated and extended. Merritt and You (2008) studied a college sample consisting of a pathological dissociation group, a non-​pathological dissociation group, and a non-​d issociative group, comparing them on the MMPI. Results showed that the two dissociation groups did not differ from each other on any of the MMPI clinical or validity scales. Both groups scored higher on the MMPI psychotic tetrad and on scale F (i.e., unusual response set), as well as lower on scale K (i.e., defensiveness), compared to the non-​d issociative group. Similarly, Zingrone et al. (2009) found that both the DES-​T and the rest of the DES correlated positively with aura experiences, and Longden (2014) found that in patients with psychosis who were hearing voices, pathological and normal dissociation were equally related to general psychological distress. Additionally, the DES and DES-​T were similarly related to general distress, as well as to all subscales of depression, anxiety, and stress. In a series of studies from the Menninger Clinic, Allen and colleagues began their research with the assumption that absorption represented the “mild, normal, and benign” form of dissociation and that amnesia represented the most pathological form. They were surprised to find that absorption correlated more strongly with psychotic symptomatology (Allen & Coyne, 1995) and general distress (Allen et al., 1996) than did amnesia. Allen et al. (1997) concluded that dissociative absorption is decidedly not benign in psychiatric or traumatized populations, noting that “to be absorbed in one facet of experience is to be detached from every other” (p. 332). The detachment, they believe, suspends the higher-​order reflection and reappraisal that would, in the view of Butler et al. (1996), normally “control or constrain thoughts and actions” (p. 44). Using similar reasoning, Tatli et al. (2018) noted the importance of absorption in obsessive compulsive disorder (OCD), concluding that absorption had a stronger relationship to obsessive and compulsive symptoms than did other aspects of dissociation. Absorption appears to have a unique relationship with OCD symptoms (Aardema & Wu, 2011; Soffer-​Dudek, 2014; Tatli et al., 2018), thought to be a function of poor confidence in reality monitoring (Soffer-​Dudek, 2014). In fact, Aardema and Wu (2011) found that absorption was a significant positive predictor of obsession, and that depersonalization was a negative predictor. Absorption has also been found to temporally precede obsessive and compulsive symptoms (Soffer-​Dudek et al., 2015). Finally, research has found a connection between dissociative absorption and varying sleep disturbances, a key feature of post-​t raumatic reactions. Fassler et al. (2006) found absorption to be a strong correlate of unusual sleep experiences. Further, when other aspects of dissociation were controlled, absorption remained a strong predictor, while the remaining

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dissociative factors did not contribute to the variance. This result is in keeping with the findings of Soffer-​Dudek et al.’s (2017) sample of remotely piloted aircraft officers and air force jet pilots, for whom absorption was the only dissociative factor consistently predicting an increase in sleepiness following both sleep loss and recovery sleep.

Could Normal Dissociation be a Diathesis To Pathological Dissociation? The process of repeatedly turning away from a thought by means of absorption in a competing thought has known negative effects on memory (cf. Levy & Anderson, 2002), particularly errors of omission stemming from reduced accessibility to self-​actions and intentions (Bregman-​H ai et al., 2020). Thus, the absorption in trauma-​related cognitions that is characteristic of one subset of traumatized survivors may undermine memory of positive facets of the experience (such as assistance from friends). This cognitive strategy or mechanism may explain Harvey et al.’s (1998) finding that highly dissociative survivors often lose memories for positive aspects of their experience. Conversely, absorption in a positive distractor (arguably more difficult, given the pull of an immediate negative event) may lead to impairment of trauma memory. A similar process lies at the heart of “unformulated experience” (Stern, 1997). Describing therapy patients who feel able to turn toward a negative experience previously avoided, Stern writes: The refusal to formulate –​to think –​is a different solution to the problem of defense than repression, which is a matter of keeping unconscious thoughts that already exist. Instead of positing the intentional removal and continuing exclusion of content from awareness, as the repression hypothesis does, lack of formulation as defense means never allowing ourselves to interpret our experience in the first place. The refusal to formulate is quite simple; one just restricts one’s freedom of thought, and the “offending” experience is never created. p. 63 Unlike repression, then, where the repressed memories are alleged to be “forever leaning against the door of consciousness, just waiting for a chance to overcome resistance and tumble into the room” (Stern, 1997, p. 69), unformulated experiences are sitting rather quietly in isolated corners of our memories (see Stern, Chapter 20, this volume). Absorption and repeated inattention may create unformulated experiences, such that the unrehearsed and poorly conceptualized experience could become irretrievable. Certainly, such lack of formulation and attention limits the number of available (neural) connections to the memory. The direct relationship between rehearsal of a memory and later recall is one of the most replicable findings in the memory literature (cf., Levy & Anderson, 2002). Butler (2006) appears to be making a related point in arguing that normal and pathological dissociation have in common the “telescoping of the attentional field to concentrate on a narrow range of experience and the concomitant exclusion of other material (internal or external) from awareness, and, to some degree, from accessibility” (p. 45). Normal dissociation thus may be a diathesis for pathological dissociation, providing either a developmental foundation or an attentional pathway for pathological dissociation. Dell (2017) makes the same argument for high hypnotizability as a diathesis (see Dell, Chapter 14, this volume), resting his theory in part on Putnam et al.’s (1995) findings that 83% of highly dissociative individuals show high hypnotizability (a well-​supported correlate of absorption). In her classic studies of “virtuoso” hypnotic subjects, Barrett (2010) found individuals with high dissociation and hypnotizability showed more amnesia during hypnosis, suggesting a route to the amnesia after hypnosis that required a pre-​existing cognitive set or state. A telling finding was that a large number of Barrett’s group showed amnesia when it was not suggested in the hypnotic context, adding to the likelihood that dissociators were using their attention differently rather than simply responding with greater compliance to suggestion. Table 5.3 shows the correlations of the DESR-​Taxon and DESR-​Absorption scales with various measures that are often associated with dissociation –​the Violence History Questionnaire (VHQ, which measures frequency of physical discipline in childhood), fearful attachment, the Beck Depression Inventory (BDI), self-​report of sexual abuse, and five scales from the Trauma Symptom Inventory (TSI). In each case, the correlations of the dissociative subscales with the associated measures are relatively similar. Further, when the taxon scores and absorption scores are used to predict the report of failure to remember an important event, both scales are similarly predictive. Finally, in conducting regressions using absorption and the taxon to predict the TSI scales, it is the shared variance in absorption and the taxon that best predicts most values, rather than the unique variance of either the “pathological” or “normal” scales. With the exception of TSI Dissociation, the variables in Table 5.3 are not dissociative disorder variables. Yet, they do provide a foundation for the argument that skills, talents, or vulnerabilities possessed by high absorption individuals are either necessary to the development of a dissociative disorder (in this case, indicated by taxon score) or highly facilitative

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88  Constance J. Dalenberg et al. TABLE 5.3  Relationship of Taxon and Absorption to Trauma-​related Variables

VHQ

BDI

Sexual Abuse

Fearful Attachment

TSI Anxious Arousal

TSI Re-​experiencing

TSI Defensive Avoidance

TSI Dissociation

TSI Dysfunctional Sexual Behaviors

Taxon

Absorption

0.199** 0.001 n =​816 0.258* 0.028 n =​73 0.313** 0.001 n =​127 0.213** 0.001 n =​473 0.338** 0.001 n =​245 0.395** 0.001 n =​245 0.359** 0.001 n =​245 0.565** 0.001 n =​245 0.280** 0.001 n =​245

0.199** 0.001 n =​816 0.246* 0.036 n =​73 0.314** 0.001 n =​127 0.218** 0.001 n =​473 0.392** 0.001 n =​245 0.453** 0.001 n =​245 0.421** 0.001 n =​245 0.571** 0.001 n =​245 0.409** 0.001 n =​245

Note: VHQ: Violence History Questionnaire; BDI: Beck Depression Inventory; TSI: Trauma Symptom Inventory

of that development. To say that the “structural” dissociator is doing something different than showing extreme absorption is by definition true, given that most high absorption participants are not taxon-​positive (see Table 5.2). We contend, however, that extending the argument to a conclusion that high absorption is unrelated to pathological dissociation, or not a form of dissociation at all, may destroy a very precious link in a causal chain. It is possible, as argued earlier, that “normal” dissociation plays a crucial role in the development and/​or maintenance of pathological dissociation, and that normal dissociative processes should be assessed as part of the general trauma battery in the service of the construction of more useful preventive and early treatment plans. By way of analogy, consider that absorption may be related to pathological dissociation as diabetes mellitus relates to diabetic retinopathy. Retinopathy (a deterioration of the retina) occurs in only 10.2% of diabetic persons older than 50 (Saaddine et al., 2004). Yet if we were to uncouple diabetic retinopathy and diabetes (arguing that each is distinct from the other), we would be less likely to conduct a yearly dilated eye examination as part of diabetes management. Our knowledge that diabetes is a risk factor for retinopathy and our knowledge that retinopathy is part of the diabetic syndrome guide our management of the disease. If absorption is a precursor, facilitator, or foundation for structural dissociation (i.e., DID, Dissociative Amnesia, Other Specified Dissociative Disorder), then this process could occur in a number of ways. In a diathesis-​stress model, absorption would be the underlying vulnerability; additional stress (or in this case, additional trauma) would be necessary to produce structural dissociation. Gold (2004) proposes a “phase shift” at a given level of the dissociative continuum, where a set of dissociative strategies (including reliance on absorption), perhaps in interaction with trauma, might manifest differently. Relatively minor trauma in someone with high constitutional absorption could trigger a cascade into a severe dissociative disorder, provoking structural change, whereas relatively severe trauma may be required to produce the same result in someone with low constitutional absorption. If the narrowing of attention typically cited as a characteristic mechanism of absorption succeeds in cutting back the number of associations to the memory, the result could be an individual with extreme state-​dependence who lacks ready access to trauma-​related memories.

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At this juncture, it is reasonable to conclude that normal dissociation (e.g., absorption) is highly related to psychopathology. Therefore, at high levels, normal dissociation is not always benign. There is also evidence that normal dissociation may be related to the loss of memory for traumatic or negative experience, a phenomenon that is more typically associated with pathological dissociation. Furthermore, absorption is clearly related to pathological dissociation itself. Accordingly, we contend that it is unreasonable to argue that absorption is not a form of dissociation, given that absorption (a) relates strongly to other dimensions of dissociation and (b) relates to other general phenomena (e.g., amnesia) typically understood as dissociative.

Conclusions In conclusion, we argue that: 1. Empirical evidence, the evidence that should ultimately guide us, suggests that “normal” dissociation, or absorption, is a form of dissociation. 2. “Normal” dissociation may well differ qualitatively from “pathological” dissociation, but the two constructs correlate too well to ignore their relationship. Both normal and pathological dissociation correlate with trauma variables and dissociation-​relevant pathology. 3. “Normal” and “pathological” dissociation may have positive and negative functions, depending on nature and chronicity of use. As such, they deserve the intense interest they are generating in the greater scientific community. 4. Cutting the linkages between the more common dissociative strategies, such as absorption, and the rarer forms, such as dissociative amnesia and DID, may lead us to ignore precursors and vulnerability factors that are essential to the development of these disorders. 5. Attention should be given in further work to the possibility of absorption as a diathesis for pathological dissociation and to the complexity of dissociative processes present for a given client.

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Steinberg, M. (1994). Interviewer’s guide to the structured clinical interview for DSM-​I V dissociative disorders (SCID-​D) (Rev. ed.). American Psychiatric Association. Steinberg, M., & Schnall, M. (2000). The Stranger in the Mirror. New York: Cliff Street Books. Sterlini, G., & Bryant, R. (2002). Hyperarousal and dissociation: A study of novice skydivers. Behaviour Research and Therapy, 40, 431–​437. Stern, D. (1997) Unformulated Experience: From dissociation to imagination in psychoanalysis. Hillsdale, NJ: Analytic Press. Stockdale, G., Gridley, B., & Balogh, D. (2002). Confirmatory factor analysis of single-​and multiple-​factor competing models of the Dissociative Experiences Scale in a nonclinical sample. Assessment, 9, 94–​106. Tatlı, M., Cetinkaya, O., & Maner, F. (2018). Evaluation of relationship between Obsessive-​Compulsive Disorder and dissociative experiences. Clinical Psychopharmacology and Neuroscience, 16, 161–​167. Tellegen, A. & Atkinson, G. (1974). Openness to absorbing and self-​a ltering experiences (‘absorption’), a trait related to hypnotic susceptibility. Journal of Abnormal Psychology, 83, 268–​277. Vanderlinden, J., Van Dyck, R., Vandereycken, W., Vertommen, H. and Verkes, R. J. 1993. The Dissociation Questionnaire (DIS-​ Q): Development and characteristics of a new self-​report questionnaire. Clinical Psychology & Psychotherapy, 1, 21–​27. Waller, N., Putnam, F., & Carlson, E. (1996). Types of dissociation and dissociative types: A taxometric analysis of dissociative experiences. Psychological Methods, 1, 300–​321. Waller, N., & Ross, C. (1997). The prevalence and biometric structure of pathological dissociation in the general population: Taxometric and behavior genetic findings. Journal of Abnormal Psychology, 106, 499–​510. Watson, D. (2003). Investigating the construct validity of the dissociative taxon: Stability analyses of normal and pathological dissociation. Journal of Abnormal Psychology, 112, 298–​305. Widiger, T. (1992). Categorical versus dimensional classification: Implications from and for research. Journal of Personality Disorders, 6, 287–​300. Wolf, E., Mitchell, K. S., Sadeh, N., Hein, C., Fuhrman, I., Pietrzak, R. H., & Miller, M. W. (2017). The Dissociative Subtype of PTSD Scale: Initial evaluation in a national sample of trauma-​exposed Veterans. Assessment, 24, 503–​516. Zamir, O., Szepsenwol, O., Englund, M. M., Simpson, J. A. (2018). The role of dissociation in revictimization across the lifespan: A 32-​year prospective study. Child Abuse and Neglect, 79, 144–​153. Zingrone, N., Alvarado, C., & Agee, N. (2009). Psychological correlates of aura vision: Psychic experiences, dissociation, absorption, and synaesthesia-​Like Experiences. Australian Journal of Clinical and Experimental Hypnosis, 37, 131–​168.

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6 DISSOCIATION AND RESILIENCE Paula Thomson

Traumatic Exposure and Resilience Resilience, as a concept, has existed throughout human recorded history. Literary works throughout the ages and across all cultures portray individuals or groups who encounter adversity and thrive despite experiencing traumatic event(s). This pattern of exposure to adversity without acquiring negative psychological symptoms is the essence of resilience (Kaye-​Tzadok & Davidson-​A rad, 2016). During adversity, resilient individuals do experience feelings of horror and overwhelm but they quickly adapt (Aitcheson et al., 2017; Bonanno & Burton, 2013). According to trauma and resilience studies, the majority of people are resilient with only a small percentage of individuals suffering prolonged trauma-​ related symptoms (Bonanno & Mancini, 2012; Masten, 2001). The early investigative focus in psychology was directed toward determining the etiology of psychopathology (Bonanno & Diminich, 2013). Later, developmental psychologists recognized that a significant group of children who were reared in extremely harsh and abusive conditions entered into adulthood as highly functional individuals (McGloin & Widow, 2001). A new field of positive psychology developed to understand this group of resilient individuals (Bonanno & Diminich, 2013). Factors associated with resilience were first identified and then a group of interdisciplinary researchers demonstrated the underlying interactive processes of genetics, neurobiology, and complex layers of individual, family, and social networks (Masten, 2004; Hobfoll, 2001). As a result of these important findings both pathology and resilience are now examined as operating on a complex continuum as well as co-​ occurring dimensions (Cicchetti, 2013; McNally, 2018). Although resilience factors are often evidenced across different trauma-​exposed individuals, there are variations (Fincham et al., 2009). Resilience studies have investigated a variety of groups, for example groups who suffered complex developmental trauma, polyvictimization in adolescence and adulthood, political upheavals (i.e., prisoners of war, refugees, child soldiers), mass terror attacks, domestic violence, gang and drug warfare, systemic racism, and repeated medical trauma exposure (Klasen et al., 2010; Mgoqi-​Mbalo, Zhang, & Ntuli, 2017; Nevarez, Yee, & Waldinger, 2017). Across these traumatized groups consistent resilient coping strategies and protective factors have been identified. They include more robust physiologic stress systems (Mgoqi-​Mbalo et al., 2017), secure attachment history (Nevarez, Yee, & Waldinger, 2017; Wilkins et al., 2014), adequate resources (social, financial, community, medical, housing, education; Ponce-​Garcia, Madewell, & Brown, 2016; Wilkins et al., 2014), skill acquisition (Lee et al., 2016), optimistic perceptions (Klasen et al., 2010), religious or spiritual practices (Klasen et al., 2010; Perkins & Allen, 2006), strong social order and ethnic identity (Aitcheson et al., 2017), and/​or a capacity to imagine and create successful opportunities (Aguiar et al., 2017; Watt, Watson, & Wilson, 2007). The hallmark of resilient individuals is that they are able to function at school or work, demonstrate no behavioral problems, and do not suffer major psychiatric disorders (Klasen et al., 2010). Resilient individuals have been exposed to maltreatment, trauma, and loss and yet they emerge from these experiences without pathology (Miller-​Graff & Howell, 2015).

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Dissociation and Resilience Dissociation as a coping mechanism is unconsciously deployed to manage intense negative feelings, including those that had their origins in maltreatment or trauma. It provides a temporary buffer from painful feelings or sensations (Seligman, 2005). Unfortunately, dissociation also interferes with the integration of traumatic events, which is typically associated with increased likelihood of developing PTSD (Nothling et al., 2015). When dissociation becomes a pathological disorder, functioning and wellbeing are diminished. It can undermine optimal performance such as entering flow states (Thomson & Jaque, 2012), inhibit focused attention, learning, and memory retention (Swart, Van Niekerk, & Hartman, 2010), and in cases of severe dissociative pathology, it undermines a sense of a cohesive self. Generally, dissociation compromises function and wellbeing; however, it can also promote adaptation and resilience. For example, experiences of loss and/​or maltreatment may be effectively managed by strategies such as disengaging from emotional responses or compartmentalizing painful experiences (Bonanno, 2004; Lassri et al., 2016). Similarly, some dissociative-​prone individuals with cumulative childhood trauma histories gain skills at efficiently shifting between different tasks, a survival skill required in unpredictable and uncertain environments (Mittal et al., 2015). They may also develop an adaptive skill of dividing attention in order to monitor threat while simultaneously attending to non-​ threatening stimuli (De Ruiter et al., 2003). These adaptive attentional skills require an ability to access, modulate, and relinquish dissociative states as they rapidly disengage from emotional responses. These forms of dissociation, whether activated during the immediate effects of a traumatic event or later, may support adaptation and enhance resilience (Bonanno, 2004).

Volitional Dissociation: Facilitative and Debilitative The long tradition of mediumship and shamanism demonstrates how dissociation may support adaptation and resilience. These practices recognize the potentially adaptive characteristics often exhibited by individuals with a predilection to dissociate, including somatic dissociation (Seligman, 2005). After they are trained to become mediums or shamans, dissociative processes (i.e., compartmentalization, state-​dependent memory with dissociative amnesia, depersonalization, derealization, diffuse sense of self, intense absorption) are transformed into a mechanism of healing (Stolovy, Lev-​ Wiesel, & Witztum, 2015; see Cardeña, Schaffler & Van Duijl, Chapter 26, this volume). Within these communities trained individuals are socially elevated and respected; it is a position of power in contrast to the common pre-​t raining states of emotional distress and vulnerability many of them may have experienced. Some of the typical training practices for mediums and shamans are to master trance entry and exiting via induction stimuli such as singing, dancing, drumming, and elaborate sacred rituals. Experiences of identity diffusion, depersonalization, and derealization before training are often associated with disorientation and an alienation from self and others; however, training increases awareness, emotional tolerance, and connection to self and others. The trainees learn to accept psychological and somatic dissociation as a gift as they master an ability to volitionally control dissociative behaviors and perceptions (Seligman, 2005; Stolovy et al., 2015). Athletes, performing artists, and military personnel also learn to employ volitional dissociative processes to manage painful training and in vivo conditions increase the quality and consistency of their performance. For example, they are able to become creatively immersed in the portrayal of a character or endure extremely stressful physical and psychological conditions. Studies indicate that this dissociative predilection is often stronger in individuals with traumatic histories (Sarkar & Fletcher, 2014). When dissociation is fully present, whether it is during a traumatic event or during a stressful performance situation, these individuals may lose an awareness of bodily sensations and pain, often fail to encode memories of particular events due to the absorbed state they are in, experience significant forms of depersonalization and derealization, and often have identity blurring or even identity confusion (Panero, 2019; Thomson, Keehn, & Gumpel, 2009; Thomson, Kibarska, & Jaque, 2011; Wanner et al., 2006). With years of training, high performing individuals typically learn to deliberately mobilize dissociative states in order to compartmentalize and distance from personal emotional or physical pain while training or performing. Through repeated practice they focus on external details rather than on internal somatic or psychological perceptions. This becomes a self-​regulating strategy as well as a skill that may promote expert status (Morgan & Taylor, 2013). These volitional attentional dissociative states can be sustained for prolonged periods of time; however, unlike individuals suffering a dissociative disorder, high performing individuals have the capacity (and skill) to consciously shift out of dissociative states. Similar to entering into a volitional dissociative state, they focus on immediate physical sensations and environmental stimuli, but in this situation they become aware of their own internal relationship to the stimuli. It is important to note that during the training to become high performing individuals, some may have an increased predilection for dissociative processes even if they do not have a trauma history, whereas others do not engage in any

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form of dissociative processes during training. For those with dissociative tendencies, they often need to first learn to recognize when they dissociate and then they are trained to consciously mobilize dissociation in order to distance painful sensations encountered during training or performance (Connolly & Janelle, 2003). Unfortunately, for high functioning individuals who deploy dissociation as a self-​regulating strategy (regardless if they have a trauma history or not), the risk of emotional exhaustion and burnout may increase in direct relationship to their dissociative tendencies and practices (Ager et al., 2012). Increased risk for burnout may be associated with a diminished awareness of physical or psychological fatigue. When fatigue increases in high performance individuals, especially if they consistently dissociate these sensations out of awareness, then injury or illness may increase, which ultimately undermines resilience and wellbeing (Andersen & Williams, 1988; Vogel et al., 2019). This negative trajectory is evident in athletes and performers who over-​t rain. They fail to acknowledge any somatic or psychological needs as they focus on skill acquisition. Likewise, actors who merge with the character they are portraying absorb emotional states and postures that may compromise their personal psychological and physical wellbeing (Burgoyne et al., 1999). These attentional dissociative states block all indicators of fatigue or strain. This obsessional performance pattern, one that is often reinforced by dissociative tendencies, has the potential to lead to career ending injury or burnout (Guglielmucci et al., 2019). Volitional control is invariably lost when obsessive drives and dissociation obscure important somatic and psychological warning cues (Guglielmucci et al., 2019; Mittal et al., 2015). Ultimately, controlled dissociative processes, like anxiety, can be either facilitative or debilitative; it is dependent on the self-​regulatory abilities and task competency of the individual (Eys et al., 2003).

Dissociative Resilience Investigating resilience is fundamentally an interdisciplinary field. It directly examines the complex effects of various forms of adversity and it promotes pathways where individuals and communities can find dignity while attempting to alleviate suffering (Southwick et al., 2014). In general, childhood adversity studies demonstrate a consistent pattern. It often has a curvilinear trajectory; no adversity and high adversity are detrimental to resilience, whereas some childhood adversity actually operates as a form of inoculation to stress (Mittal et al., 2015). Despite this general pattern, some individuals with high childhood adversity exposure may also respond with increased resilience, even when they also employ higher levels of dissociative processes. They value engaging in the creative process or high performance activities (Thomson & Jaque, 2018). Many learn to deploy dissociative processes during their training, which helps them become elite performers, special-​forces military personnel, or Olympic medalists (Morgan & Taylor, 2013; Rees et al., 2016). They rely on their controlled volitional capacity to dissociate in order to intentionally block physical and emotional pain, including painful memories that may distract them from concentrating on the task at hand. They cultivate a skill set that promotes more dissociative compartmentalization during stressful situations (Coifman et al., 2007). Survival skills gained in a maladaptive childhood, such as flexibly shifting between tasks in order to manage unpredictable environments, are transferred into adult careers (Mittal et al., 2015). Individuals reared in uncertain conditions may actually acquire increased tolerance for unpredictable career trajectories that are inherent in the performing arts, arts, sport, and the military. The ability to adapt necessitates task-​oriented coping strategies rather than collapsing into more pathological processes such as emotional rumination and psychological dysregulation. Resilient individuals may learn to deploy dissociative compartmentalizing and emotional distancing as a way to solve problems and successfully manage tasks (Thomson & Jaque, 2019). The ability to mobilize fantasy and explore creative activities is often associated with increased dissociative tendencies (Perez-​Fabello & Campos, 2011, 2011a; Van Heugten–​Van der Kloet et al., 2015). Creative engagement may also mitigate the negative effects of psychopathological disorders, including dissociative disorders (Thomson & Jaque, 2018). Successful adaptation to adversity may be influenced by a complex combination of biopsychosocial factors that determine the trajectory towards pathological versus creative self-​regulating dissociation. Examining multiple factors and how they interact may provide a fuller understanding regarding optimal versus debilitating dissociative tendencies (de Oliveira-​Maraldi & Krippner, 2013). Dissociation, with its origins in past adversity, may also become a powerful motivator for maltreated individuals to achieve success. In most adverse situations, including high performance training settings, individuals must endure conditions of pain (psychological and physical) and discomfort. Controlled volitional dissociation often enhances an ability to perform under challenging conditions; it is a process that facilitates pain management and can optimize performance (Gute et al., 2008; Rees et al., 2016). It can transmute the negative effects of adversity and stress and promote creative problem solving and goal-​oriented achievement. In such cases, volitional controlled dissociation has the potential to become a resource to enhance resilience and adaptation.

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Mittal, C., Griskevicius, V., Simpson, J. A., Sung, S., & Young, E. S. (2015). Cognitive adaptations to stressful environments: When childhood adversity enhances adult executive functioning. Journal of Personality and Social Psychology, 109, 604–​621. Morgan, C. A. 3rd, & Taylor, M. K. (2013). Spontaneous and deliberate dissociative states in military personnel: Are such states helpful? Journal of Traumatic Stress, 26, 492–​497. Nevarez, M. D., Yee, H. M., & Waldinger, R. J. (2017). Friendship in war: camaraderie and prevention of posttraumatic stress disorder prevention. Journal of Traumatic Stress, 30, 512–​520. Nothling, J., Lammers, K., Martin, L., & Seedat, S. (2015). Traumatic dissociation as a predictor of posttraumatic stress disorder in South African female rape survivors. Medicine, 94(16), 1–​9. Panero, M. E. (2019). A psychological exploration of the experience of acting. Creativity Research Journal, 31, 428–​4 42. Perez-​Fabello, M. J., & Campos, A. (2011). Dissociative experiences and creativity in fine arts students. Creativity Research Journal, 23, 38–​41. Perez-​Fabello, M. J., & Campos, A. (2011a). Dissociative experiences, imagination, and artistic production in students of fine arts. Thinking Skills and Creativity, 6, 44–​48. Perkins, S. L., & Allen, R. (2006). Childhood physical abuse and differential development of paranormal belief systems. Journal of Nervous and Mental Disease, 194, 349–​355. Ponce-​Garcia, E., Madewell, A. N., & Brown, M. E. (2016). Resilience in men and women experiencing sexual assault or traumatic stress: Validation and replication of the scale of protective factors. Journal of Traumatic Stress, 29, 537–​545. Rees, T., Hardy, L., Gullich, A., Albernethy, B., Cote, J., Woodman, T., Montgomery, H., Laing, S., & Warr, C. (2016). The great British Medalists Project: A review of current knowledge on the development of the world’s best sporting talent. Sports Medicine, 46, 1041–​1058. Sarkar, M., & Fletcher, D. (2014). Ordinary magic, extraordinary performance: Psychological resilience and thriving in high achievers. Sport, Exercise, and Performance Psychology, 3, 46–​60. Seligman, R. (2005). Distress, dissociation, and embodied experience: Reconsidering the pathways to mediumship and mental health. Ethos, 33, 71–​99. Southwick, S. M., Bonanno, G. A., Masten, A. S., Panter-​Brick, C., & Yehuda, R. (2014). Resilience definitions, theory, and challenges: interdisciplinary perspectives. European Journal of Psychotraumatology, 5, 25338. Stolovy, T., Lev-​Wiesel, R., & Witztum, E. (2015). Dissociation: Adjustment or distress? Dissociative phenomena, absorption and quality of life among Israeli women who practice channeling compared to women with similar traumatic history. Journal of Religion and Health, 54, 1040–​1051. Swart, I., van Niekerk, C., & Hartman, W. (2010). Trauma-​related dissociation as a factor affecting musicians’ memory for music: Some possible solutions. 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7 ADAPTIVE DISSOCIATION A Response to Interpersonal, Institutional, and Cultural Betrayal Alexis A. Adams-​Clark, Jennifer M. Gómez, and M. Rose Barlow

Dissociation often involves a profound fragmentation of the self and is bidirectionally related to physiological activation, cognition, and social interaction. The connection between trauma and the development of dissociation is well established in prior literature, and dissociation has been identified as a common reaction to interpersonal trauma, such as abuse and violence. Numerous studies have confirmed high rates of trauma (e.g., sexual, physical, and emotional abuse) among adults and children with high levels of dissociation (Briere et al., 2008; Dimitrova et al., 2020; Trickett et al., 2011; Vonderlin et al., 2018; Zlotnick et al., 1996), and severe dissociative disorders are consistently related to childhood trauma (for review see Dalenberg et al., 2012). Dissociation has also been linked to other forms of interpersonal violence, including sexual harassment (Adams-​Clark et al., 2020b). As the connection between dissociation and interpersonal trauma has become readily established in the empirical literature, attention has shifted to elucidating the specific aspects of traumatic experiences most closely linked to the development and maintenance of dissociation. Some studies report that the risk of developing a dissociative disorder increases with an earlier age of trauma exposure (Vonderlin et al., 2018), greater trauma severity (Carlson et al., 2012), and higher trauma frequency/​chronicity (Vonderlin et al., 2018). There is also growing evidence that a specific aspect of interpersonal trauma –​betrayal –​is particularly important in the development of dissociation in the wake of a traumatic experience (e.g., Freyd, 1996; Freyd et al., 2005). The role of interpersonal, institutional, and cultural betrayal in the context of a traumatic event, as well as its relationship to dissociation, will be the primary focus of this chapter. Whereas betrayal trauma theory (Freyd, 1996) emphasizes the power of interpersonal betrayal, institutional betrayal (Smith & Freyd, 2014) and cultural betrayal trauma theory (Gómez, 2019d) have adapted the original theory to incorporate the influence of specific institutional and socio-​cultural contexts.

Betrayal Trauma Theory: Theoretical Foundations Betrayal trauma theory (BTT; Freyd, 1996) provides a theoretical foundation for conceptualizing the role of betrayal and the victim-​perpetrator relationship in the development of trauma-​induced dissociation. Simply put, BTT’s main premise is that the interpersonal context of trauma matters. In order to understand the development of trauma-​related symptoms such as dissociation, we must first assess who the perpetrator was and how they related to the victim. Many theories of trauma symptomatology have linked posttraumatic outcomes to events that are highly fearful and terror-​ inducing (Brown & Freyd, 2008; DePrince & Freyd, 2002), yet few authors in mainstream psychology have discussed the role of the victim-​perpetrator relationship and the larger context in which abuse occurs. Building upon prior research studying incest (Courtois, 1988), BTT proposes two important orthogonal dimensions of traumatic events –​the degree of fear/​terror produced in the victim and the degree of interpersonal or social betrayal involved. If these two dimensions were axes on a coordinate plane, each traumatic event would exist at a specific point in one of the four quadrants based on its positions along these two continua (see Figure 7.1). According to this conceptualization, some traumatic events may involve a high degree of terror and fear yet little social betrayal, such as a natural

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F I G U R E 7.1   Betrayal

trauma theory, reprinted with permission

disaster. Other types of traumatic events, such as abuse that involves “grooming” by a trusted authority figure (Bennett & O’Donohue, 2014; Veldhuis & Freyd, 1999; Wolf & Pruitt, 2019), may involve less direct or overt terror or threat to life, but are a profound betrayal. Still other traumatic events may involve a high degree of both fear and interpersonal betrayal, such as violent physical or sexual abuse by a caregiver. Importantly, according to BTT, the degree of social betrayal may not only exacerbate posttraumatic outcomes, but it may also be particularly important in the development of dissociated information processing tendencies because of the complex human attachment system (Freyd, 1996). BTT relies on two basic premises derived from social contract theory (Cosmides, 1989): (1) infants need attachment relationships for survival; and (2) humans need to detect betrayals of trust in important relationships (Freyd, 1996). As infants, humans are dependent on their caregivers not only for basic physical needs like food and warmth, but also for emotional needs such as love, care, safety, and relational connections. In line with Bowlby’s (1969) theorizing, such attachment enables infants to survive. Parents bond with their offspring and take care of them; in return, babies learn what they need to do to maximize this security and affection. At the same time, humans also have a strong need for caretakers to be reliable and relatively consistent, creating a motivation to avoid being “cheated” or betrayed like other social primates (see Freyd, 1996, for further discussion of “cheater detectors”). The most adaptive response to betrayal is to either confront the betrayer or to withdraw from further contact. Empowered individuals may do both, but disempowered individuals must navigate the two competing demands of attachment versus betrayal detection. Someone who has been abused by a caregiver –​a victim of a high betrayal trauma –​is an example of such a disempowered individual (Freyd, 1996). The victim is caught in a difficult bind, as the person who they trust and/​or depend upon is the very same one who betrays their trust by abusing them. When a young child is abused by a parent or caregiver, the need to attach and the need to avoid betrayers come into direct conflict. Withdrawing from or confronting the betrayer threatens survival in direct and indirect ways. Losing basic care may lead to physical starvation, whereas losing or damaging the attachment relationship may lead to emotional starvation. In such situations, it is more adaptive to not know that traumatic betrayal has occurred or is occurring. Thus, someone who is victimized may be, in part, motivated to isolate abuse-​related information from conscious awareness (Freyd, 1996). Betrayal trauma theory thus proposes that people engage in betrayal blindness to the extent that being aware of abuse would threaten a relationship upon which they are profoundly dependent (Freyd, 1996; Freyd & Birrell, 2013). Betrayal blindness refers to a phenomenon in which the individual who has been betrayed forgets the event(s) by isolating recognition of the betrayal from awareness. The “not knowing” that constitutes betrayal blindness may take the form of dissociation (e.g., amnesia) or other forms of knowledge isolation. It need not be conscious to be effective. Betrayal blindness is important to understanding the development of dissociation among children experiencing a betrayal trauma. Because attachment is vitally important –​the child’s survival depends on the reliability of the caretaker –​abused children cannot psychologically or physically afford to completely disconnect from their abusive caregivers. These children are left to rely on parents who actively undermine their growth and safety. Although BTT was originally developed to explain why some victims of childhood sexual abuse experience disruptions in their memory and awareness of the abuse (Freyd, 1996), the role of betrayal has more recently been linked to multiple forms of dissociation and disintegration of psychological and cognitive processes (Gómez et al., 2014).

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According to BTT (Freyd, 1996), the purpose of this dissociation is not to escape from pain, but to maintain an attachment relationship by not-​k nowing about information that would threaten it (Goldsmith et al., 2004). The more important the relationship, the stronger the motivation to preserve it. Thus, abuse by a parent or other trusted caregiver is more likely to evoke dissociation than is abuse by a stranger. In BTT (Freyd, 1996), we conceptualize dissociation as an adaptive survival response to an abusive and harmful situation, rather than a pathological outcome of trauma. Dissociation creates short-​term advantages for the victim of a high betrayal trauma that may be less necessary for victims of medium betrayal traumas (interpersonal violence perpetrated by a not-​close other) and low betrayal traumas (non-​ interpersonal traumatic events). Although it serves this important function in the short term, dissociation can negatively affect the functioning of a victim of high betrayal trauma in the long term by filtering out information needed to maintain interpersonal safety.

Betrayal Trauma Theory: Research Evidence Memory Early BTT research focused primarily on testing the relationship between high betrayal trauma and direct memory and awareness of abuse –​the outcome at the crux of early betrayal trauma theory development (see DePrince et al., 2012, for a more extensive review of memory in relation to betrayal trauma). While initially conceptualizing BTT, Freyd (1996) re-​analyzed previous data from multiple studies of sexual abuse (e.g., Chu & Dill, 1990) and found that the closer the victim was to the perpetrator, the greater the memory impairment for abuse. Similarly, Schultz and colleagues (2003) found that greater memory disturbance for abuse was related to the closeness of the relationship between victim and perpetrator. As evidence demonstrating a relationship between betrayal and disrupted memory for abuse accumulated, research questions expanded to identify global cognitive and emotional processes that may promote this unawareness, such as dissociation. For instance, one study found that sexually abused participants who had specific memory loss for the abuse reported higher dissociative tendencies generally (i.e., not simply localized to memory for abuse) and were more likely to have been abused by someone close to them, compared to sexually abused participants without memory loss (Sheiman, 1999). Analogously, in a study of Dissociative Identity Disorder (DID) patients, betrayal by trusted family and caregivers was reported by participants as the aspect of the trauma that most disrupted their internal organization of self (Steele, 2003). Other research suggests that multiple domains of memory functioning may be affected by betrayal trauma in complex ways. In a study of DID participants with histories of betrayal trauma, Barlow (2011) found that DID patients performed worse than control participants when recalling the details of a fearful vignette verses a neutral vignette. However, the same DID participants responded faster than control participants when asked to produce an autobiographical memory (Barlow, 2011). There is growing evidence that the fracturing of the self in DID impairs the ability to consciously access autobiographical memory (Lebois et al., 2020), possibly due in part to functional changes in neuroanatomy (Blihar et al., 2020; Lebois et al., 2021). In fact, it may be that disruptions of the sense of self are an important part of the pathway through which high betrayal trauma in childhood leads to dissociation in adulthood (Chiu et al., 2019). That is, dissociation associated with early betrayal has a fracturing impact on the sense of self that, in the absence of remedial factors, may see dissociation persist into adulthood. A related line of research used a different methodology to examine dissociation as a trauma-​related information processing strategy among “high” dissociators and “low” dissociators in college student samples. In a directed forgetting paradigm, DePrince and Freyd (2004) found that “high” dissociators recalled fewer trauma words (but not fewer neutral words) in a divided attention task, whereas “low” dissociators showed the opposite pattern of results. Unsurprisingly, the “high” dissociator group reported experiencing a significantly higher rate of betrayal trauma. This finding suggests that higher rates of betrayal trauma may be related to higher dissociation, which in turn may serve to block traumatic and threatening information in situations and contexts where that information could not normally be ignored.

Beyond Memory: Betrayal Trauma, Shame, and Dissociation BTT research has evolved from measuring memory of abuse specifically to measuring trauma and dissociative tendencies generally. In one study, Freyd and colleagues recruited a sample of 99 community adults experiencing chronic pain or illness. They found that trauma involving a high degree of betrayal predicted trait dissociation, even when controlling for exposure to low betrayal trauma (Freyd et al., 2005). Bernstein and colleagues (2015) found a similar association among separate samples of university students. Interestingly, Klest and colleagues (2013) found that, among a

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large, ethnically diverse sample in Hawaii (N =​833), both high betrayal trauma and low betrayal trauma were similarly associated with dissociative symptoms when controlling for gender, educational attainment, and employment status. In another study, the relative contribution of low betrayal trauma, medium betrayal trauma, and high betrayal trauma in the prediction of dissociative symptoms was further examined and directly compared. Although each type of trauma significantly predicted dissociation, high betrayal trauma was the strongest predictor (Martin et al., 2013). Gómez (2021b) replicated this pattern of results in relation to sexual trauma specifically in a study of 368 university students. In this study, high betrayal sexual trauma predicted dissociation scores, even when controlling for experiences of medium betrayal sexual trauma. Gómez also identified an interaction between trauma history and gender, such that the link between high betrayal sexual trauma and dissociation was stronger for women than for men (Gómez, 2021b). Taken together with prior research indicating that women experience higher rates of betrayal trauma than do men (Goldberg & Freyd, 2006; Martin et al., 2013; Tang & Freyd, 2012), these results suggest that women may be particularly at risk for trauma-​related dissociation. This difference likely occurs because, on average, women are exposed to higher rates of betrayal trauma than men, and they exist in a societal context saturated in gender inequality (Gomez et al., 2016). Rosenthal and Freyd (2017) expanded the research on the relationship between betrayal trauma and trait dissociation by relating these factors to dissociative symptoms, such as feeling “out-​of-​body,” specifically during sexual activity, and sexual communication. In two separate studies of undergraduate students, they found support for a multiple mediator model in which high betrayal was associated with sexual communication through trait dissociation and sexual dissociation in serial. Ultimately, these results suggest that “betrayal trauma in childhood appears to initiate a trajectory wherein survivors’ trauma symptoms inhibit their capacity to communicate clearly with sexual partners” (Rosenthal & Freyd, 2017, p. 14). In addition to general dissociative tendencies, high betrayal trauma has been associated with changes in state dissociation and shame during laboratory tasks. Platt and Freyd (2015) used an experimental design to study the links between trauma history, shame, and dissociation. They randomly assigned participants (all of whom had a history of either high betrayal trauma or low betrayal trauma) into two conditions: the interpersonal threat condition and the non-​interpersonal threat condition. Prior to, as well as after exposure to, the respective threat, participants reported their dissociative, shame-​related, and fear-​related symptoms. In addition to baseline elevations in dissociation and shame for participants with a history of high betrayal trauma versus low betrayal trauma, the high betrayal group reported increased levels of dissociation and shame after being presented with the interpersonal threat (compared to participants with low betrayal trauma). Participants with a history of low betrayal trauma reported increased levels of fear after being presented with a non-​interpersonal threat (Platt & Freyd, 2015). These results suggest that individuals with a history of high betrayal trauma may be particularly prone to dissociation and shame, especially in contexts of interpersonal threat. In a follow up study, Platt and colleagues (2017) argued that shame may serve a similar function as dissociation in the context of betrayal trauma. Although shame has been proposed as a painful state that can be “bypassed” through dissociation (Lewis, 1971), shame may instead promote relationship attachment by locating the responsibility for the betrayal within oneself, rather than in the betrayer (Platt et al., 2017). Other research has begun to examine the associations between high betrayal trauma and hallucinations. Although some scholars argue that hallucinations are primarily characteristic of psychosis, others suggest that some hallucinations may emerge from dissociation and thus may be relevant to the study of betrayal trauma. For instance, research has suggested that Schneiderian first rank symptoms of schizophrenia may be more closely associated with dissociation than with psychosis (e.g., Ellason & Ross, 1995; Kluft, 1987; Mokowitz & Corstens, 2007; See Moskowitz et al., Chapter 32, this volume). Accordingly, Gómez and colleagues (2014) conducted a three-​study investigation of the relationship between hallucinations, dissociation, and high betrayal trauma in multiple undergraduate student samples. While providing further evidence of the association between high betrayal trauma and dissociation, their results also demonstrated a significant association between high betrayal trauma and hallucinatory experiences (Gómez et al., 2014). In a follow up study, high betrayal sexual trauma was found to be related to hallucinations, and dissociation mediated this relationship (Gómez & Freyd, 2017). Additionally, research has focused on the link between high betrayal trauma and borderline personality disorder symptoms, which are characterized by costly emotion regulation strategies such as dissociation and self-​injury (Calati et al., 2017; Ford & Gómez, 2015). These strategies often emerge in individuals with a history of complex trauma. An initial study using an undergraduate sample found that both high betrayal trauma and medium betrayal trauma experiences were unique predictors of borderline personality disorder traits, whereas low betrayal trauma was not a significant predictor (Kaehler & Freyd, 2009). A subsequent study replicated the original association between high betrayal trauma and borderline personality disorder characteristics (Yalch & Levendosky, 2019); this association has been found to be mediated in part by lower feelings of connectedness to one’s larger community (Belford et al., 2012).

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Emotion regulation problems and dissociation may be mechanisms through which trauma in childhood leads to borderline symptoms in adulthood (Van Dijke et al., 2018). More recent research has found that emotion dysregulation meditated the relationship between betrayal trauma and self-​injury in justice-​involved Singaporean adolescents (Keng et al., 2019). Problems with emotion regulation may also mediate the relationship between betrayal trauma and PTSD symptoms (Barlow et al., 2017). Although the field of emotion regulation is a wide one, it has not yet been fully brought into communication with the field of dissociation. Future research is needed in this area.

Betrayal Trauma, Dissociation, and Revictimization The robust association between high betrayal trauma and dissociation in the empirical literature provides substantial evidence to support one of the primary assertions of BTT, namely that victims abused by trusted others may utilize dissociation as a way to remain unaware of betrayal (Freyd & Birrell, 2013). As discussed previously, this response is quite understandable and potentially advantageous in the short term. However, other research suggests that there may be a significant cost to such a response in the long term. Dissociation as it emerges from a high betrayal trauma may be a costly form of information processing that could decrease an individual’s ability to track future interpersonal violations and make it more likely for future perpetrators to abuse them again (DePrince, 2005). DePrince and colleagues (2008) measured the ability to detect interpersonal violations (termed “deontic reasoning”) among children exposed to interpersonal violence and compared them to children not exposed to interpersonal violence. Results indicated that dissociation was negatively associated with children’s ability to detect interpersonal rule violations (DePrince et al., 2008). These results and others indicate that dissociation could disrupt social cognition in a way that future perpetrators may capitalize on to commit further abuse (Herzog et al., 2019). Using a different methodology, Gobin and Freyd (2017) examined the relationship between high betrayal trauma, dissociation, and betrayal awareness among 216 university students. Participants viewed a sexually ambiguous drawing that could be interpreted as an instance of child sexual abuse. Consistent with prior research, high betrayal trauma history was related to higher levels of state dissociation while looking at the drawing, and higher state dissociation was also related to a lower ability to detect betrayal (Gobin & Freyd, 2017). Although high betrayal trauma history on its own was not linked to betrayal awareness, these results may suggest that high betrayal trauma is indirectly linked to betrayal awareness through dissociation, rather than directly linked. A prospective study of 80 women provides further evidence of the role of dissociation in revictimization. Zamir and colleagues (2018) followed participants from birth until age 32, and found that dissociation partially mediated the relationship between childhood abuse and adulthood intimate partner violence. Participants who were exposed to childhood sexual or physical abuse reported higher levels of dissociation during adolescence, which then subsequently put them at greater risk for intimate partner violence during adulthood. Gobin and Freyd (2009) quantified the risk of revictimization after a high betrayal trauma. They found that those who experienced high betrayal trauma in childhood were 4.31 times more likely to be victimized again in adolescence and 5.44 times more likely to be victimized in adulthood. In addition, among participants with a history of high betrayal trauma, those who reported more frequent revictimization also reported higher levels of dissociation. The authors concluded that betrayal trauma may disrupt social and cognitive mechanisms that aid in defending onself against harm in interpersonal relationships (Gobin & Freyd, 2009). Trauma-​related dissociation is not only a mechanism capitalized upon by perpetrators to begin or continue abuse, but may also inadvertently relate to the intergenerational transmission of both trauma and dissociation. Chu and DePrince (2006) recruited 72 mothers of children aged 7 to 11 and measured mothers’ betrayal trauma history and dissociation, as well as the children’s level of dissociation. Mothers’ betrayal trauma history was related to mothers’ level of dissociation, and children’s dissociation was related to both mothers’ dissociation and children’s betrayal trauma history. Children whose mothers had a betrayal trauma history were more likely to have experienced a betrayal trauma themselves (Chu & DePrince, 2006). It is possible that mothers who have betrayal trauma histories experience more dissociative symptoms that may interfere with 1) parenting and monitoring their children, and 2) their information processing abilities that allow them to detect threat to their children. Hulette and colleagues (2011) found a similar pattern of results among a sample of 67 mother-​child dyads, with one important elaboration: Mothers who were revictimized themselves had higher levels of dissociation, and mothers’ revictimization was related to the childrens’ own victimization status. Among the children who had experienced interpersonal violence, 72% had a mother who had been revictimized (Hulette et al., 2011). Thus, mothers’ dissociation, trauma history, and potential continued trauma exposure are related to another person perpetrating against their children.

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Betrayal Trauma, Dissociation, and Other Posttraumatic Outcomes In addition to dissociation and related symptoms, high betrayal trauma has been associated with a variety of other mental and physical health outcomes, including depression (Goldsmith et al., 2012; Klest et al., 2013), anxiety (Freyd et al., 2005; Goldsmith et al., 2012; Klest et al., 2013), suicidal ideation (Gómez, 2020c), sleep problems (Dimitrova et al., 2020; Klest et al., 2013), PTSD symptoms (Barlow et al., 2017; Goldsmith et al., 2013; Kelley et al., 2012), and physical illness (Freyd et al., 2005; Goldsmith et al., 2012). As is the case for dissociation, many of these links persist even when controlling for other trauma exposure (e.g., Freyd et al., 2005). Importantly, however, a minority of these research studies has tested a mediation model in which dissociation operates as a transdiagnostic mechanism through which high betrayal trauma influences this diverse array of outcomes. Goldsmith and colleagues (2012) found that posttraumatic symptoms, including dissociation, mediated the relationship between high betrayal trauma and physical health symptoms. Among a sample of 192 college students, Gómez (2020c) found that dissociation mediated the relationship between high betrayal sexual trauma and suicidal ideation. Barlow and Goldsmith (2014) found that dissociation mediated the relationship between trauma history and the use of active thought control methods such as reappraisal and worry. Such results indicate that dissociation may serve as an important mechanism through which high betrayal trauma affects a whole host of functioning domains (Vang et al., 2018).

Institutional Betrayal Although BTT highlights the deleterious nature of betrayal, it is limited by its primary focus on the interpersonal context of relational trauma. Recent extensions of BTT have drawn attention to the manifestation of betrayal within the broader social context of trauma (see also Adams-​Clark et al., 2020a). The concept of institutional betrayal posits that institutions as a whole have the capacity to commit betrayal (Smith & Freyd, 2014). Similar to trusted caregivers, institutions (e.g., universities, the government, the legal system, the medical system) are often trusted by individuals who depend upon them to provide them with services, protect their safety, and advocate for their needs. Within this system of power and dependence, a breach of trust by an institution can constitute a betrayal. This institutional betrayal can have harmful consequences, including dissociation, akin to the harm caused by interpersonal betrayal (Smith & Freyd, 2014). Institutional betrayal occurs in situations in which a member of an institution has been victimized within the context of the institution (e.g., a university student sexually assaulted at a fraternity on campus), and the institution has either failed to prevent such an instance and/​or has failed to respond appropriately once it occurs (Smith & Freyd, 2014). Institutional betrayal can manifest as an offense of commission (e.g., a university that actively retaliates against the student for filing a formal complaint) or offenses of omission (e.g., a university that fails to establish and enforce policies for reporting and investigating campus sexual assaults; Smith & Freyd, 2014). Such events can also be either apparently isolated (e.g., an ostensibly aberrant instance in which evidence of a sexual assault was destroyed) or systemic (e.g., campus “rape culture”). Unfortunately, institutional betrayal often coincides with and reflects institutional racism and discrimination (Freyd & Birrell, 2013; Smith & Freyd, 2017). Institutions often fail to protect and respond adequately to the needs of marginalized communities who experience the most pervasive rates of violence. The logic linking dissociation to interpersonal betrayal can be expanded to experiences of institutional betrayal. When an individual is betrayed by an institution that they depend upon (e.g., a student by their university, a citizen by their government, a patient by the hospital, a soldier by the military), they have to navigate a difficult situation with competing demands. They can either choose to revoke their membership to the institution, which is not always possible or requires them to give up necessary resources, or they can choose to remain attached to the very institution that is causing them distress. In order to retain the attachment, dependent institutional members may dissociate or otherwise isolate such knowledge from their conscious awareness. Empirical research provides some evidence for an association between institutional betrayal and dissociation, as well as a range of trauma-​related symptoms. The first empirical study examined experiences of sexual assault and institutional betrayal among 345 university women (Smith & Freyd, 2013). Sexual assault was, unsurprisingly, associated with dissociation and other trauma symptoms. As hypothesized, institutional betrayal significantly strengthened these relationships, such that women who reported both sexual assault and institutional betrayal reported exacerbated dissociation, anxiety, and sexual symptoms (Smith & Freyd, 2013). Although the prior study suggested that institutional betrayal may interact with and intensify already existing trauma symptoms of interpersonal violence, other research suggests that institutional betrayal is also associated with dissociation (Smith & Freyd, 2017) and trauma-​related symptoms generally (Lee et al., 2019; Lind et al., 2020; Pinciotti & Orcutt, 2021), independent of interpersonal trauma history. Smith and Freyd (2017) recruited university students and

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collected information regarding their interpersonal trauma history, experiences of institutional betrayal, and dissociation and health-​related symptoms. Even when statistically controlling for the influence of betrayal trauma, they found that experiences of institutional betrayal were related to both dissociation and health symptoms. Although more research needs to be conducted, nascent studies suggest that the principles underlying BTT in individuals may extend to institutions, with such experiences heightening dissociation.

Cultural Betrayal Trauma Theory BTT (Freyd, 1996) and institutional betrayal (Smith & Freyd, 2014) have collectively provided a strong foundation for cultural betrayal trauma theory (CBTT) (e.g., Gómez, 2012; Gómez & Gobin, 2020). Gómez (2012) developed CBTT, an extension of BTT, to incorporate the sociocultural context of inequality for marginalized populations that exists across the lifespan. Because of societal trauma, some marginalized individuals develop special bonds with one another that can include feelings of love, loyalty, connection, attachment, responsibility, and solidarity (Gómez & Gobin, 2020). Known as (intra)cultural trust, this form of attachment serves as a protective buffer against marginalization and structural discrimination (see Figure 7.2). Therefore, analogous to trauma that occurs within trusted familial or institutional relationships, within-​g roup violence (e.g., violence that occurs within a community that is marginalized due to racism, homophobia, religious discrimination, etc.) violates (intra)cultural trust. Such violence is termed cultural betrayal trauma. In addition to predicting typical abuse outcomes such as dissociation, cultural betrayal traumas also predict cultural outcomes, such as internalized prejudice (Gómez, 2019c). An additional important sociocultural facet of CBTT is (intra)cultural pressure (Figure 7.2). Defined as a transformation of (intra)cultural trust (Gómez & Gobin, 2020), (intra)cultural pressure occurs when other marginalized people, such as other U.S. Black people, explicitly place the perceived needs of the perpetrator(s), and the Black community as a whole, above those of the person victimized. Similar to the demands of racial loyalty (Bent-​Goodley, 2001; Tillman et al., 2010), (intra)cultural pressure can be a form of silencing that occurs under the guise of fighting oppression by protecting the in-​g roup. As a result of society’s oppression of the marginalized group, as well as in-​g roup (intra)cultural pressure, a distinct outcome of cultural betrayal trauma is dissociation. Prior literature suggests that beyond cultural betrayal trauma,

F I G U R E 7. 2   Cultural

Betrayal Trauma Theory, reprinted with permission

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societal trauma in general (e.g., racism, institutionalized violence) may foster dissociation (Polanco-​Roman et al., 2016), as a mechanism for reducing distress (Douglas, 2009). Although it may be associated with dissociation, the oppression from outside the marginalized group can also promote strong intra-​g roup identification, providing strength and resilience against societal trauma. However, when cultural betrayal trauma occurs, awareness of the within-​g roup trauma could threaten the attachment of the individual to the group. As a manipulative mechanism to ostensibly maintain group unity within the context of societal oppression, (intra)cultural pressure can further threaten attachment to the group, which may in turn foster dissociation. Although likely costly in the long term, dissociation as a result of (intra)cultural pressure can act as a means to maintain allegiance with one’s marginalized community by preserving the support necessary to survive the broader presence and impact of societal trauma. Like betrayal blindness in BTT (Freyd, 1996), cultural betrayal unawareness can constitute a way to protect one’s bond with their marginalized community. Intitial CBTT research examined the hypothesized link between cultural betrayal trauma and dissociation in diverse marginalized young adult populations. Several studies have found that cultural betrayal trauma is associated with dissociation in Black (Gómez, 2019a) and diverse marginalized (Gómez & Freyd, 2018) young adults. Additional work has demonstrated that cultural betrayal impacts dissociation above and beyond mere exposure to trauma in Asian American/​Pacific Islander young adults (Gómez, 2017), Latino young adults (Gómez, 2021), young women of Color (Gómez, 2019b), and ethnic minority college students across genders (Gómez, 2019c). Some of this work (Gómez, 2019b) has identified (intra)cultural pressure as a mediator between cultural betrayal trauma and dissociation. Finally, work has differentiated the impact of cultural betrayal trauma from that of high betrayal trauma. Specifically, in diverse young adults of Color, cultural betrayal trauma was associated with dissociation, even when controlling for both between-​g roup trauma and high betrayal trauma (Gómez, 2019c, 2021a). Such research suggests that cultural betrayal is distinct from traumas high in interpersonal betrayal and makes independent contributions to dissociation. Taken together, these findings show that, as conceptualized and tested through CBTT (Gómez & Gobin, 2020), the broader context of inequality and cultural betrayal in trauma explains additional variance in dissociation among various diverse marginalized young adults.

Future Directions Although evidence for the link between betrayal, dissociation, and other mental health outcomes in the empirical literature is extensive, longitudinal research is wanting. A significant portion of the research on betrayal trauma and dissociation is cross-​sectional in design; thus, no conclusive causal claims can be made. Although resource-​intensive, larger-​scale longitudinal studies will allow a disentanglement of the time course of many trauma-​related outcomes, including dissociation. For instance, a longitudinal study with multiple time points would allow confirmation and elucidation of the transdiagnostic, mechanistic role that dissociation plays in regard to other mental health outcomes (e.g., does dissociation mediate the relationship between trauma and suicidal ideation?). As evident from the literature, these relationships are far from simple and likely bidirectional (Farina et al., 2019). Longitudinal studies may clarify this picture.

Measuring Betrayal Blindness Future research should focus on operationalizing and measuring the type of dissociation at the center of betrayal blindness, given its key role in betrayal trauma and other related theories. By definition, betrayal blindness is difficult to measure because it is a process of unawareness. However, Zounlome and colleagues (in press) have initially validated the Rotating Betrayal Blindness Questionnaire on young adults of Color. This retrospective questionnaire includes three measures of betrayal blindness: 1) at the time of the traumatic event, 2) currently, and 3) rotating (Noll & Gómez, 2013), in which betrayal blindness vacillates with awareness. Aspects of betrayal blindness related to trauma may include saliency/​intrusion, denial, memory, and significance (Gómez et al., in press). Future research undertakings should also prioritize the role of institutional and cultural contexts, thus promoting further understanding of how culture, context, and marginalization impact the experience of trauma and trauma-​related dissociation. However, this research requires sensitivity, nuance, and depth (Krüger, 2020) in order to avoid problematic between-​g roup comparisons (Cole & Stewart, 2001) that centralize white Americans’ lives as evidence of the default human experience (Heinrich et al., 2010). From a CBTT perspective (Gómez & Gobin, 2020), measures such as the Cultural Betrayal Trauma Multidimensional Inventory for Black American Young Adults (CBMI-​BAYA) can be adapted and utilized within marginalized populations of interest to ensure cultural sensitivity and relevancy (Gómez & Johnson, in preparation). Mixed methods approaches in which qualitative work contributes to the direction of research may also

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be particularly useful (Krüger, 2020). In addition, work that deliberately incorporates the complexities of interpersonal and institutional relationships, multiple intersecting oppressions (intersectionality; Crenshaw, 1989), and various central marginalized and privileged identities (Sellers et al., 1998) that vary in salience by context is the next frontier. Introductory work is developing in this domain that examines how hypodescent (Ho et al., 2011) and (intra)cultural trust affect the meaning and impact of cultural betrayal trauma in Black multiracial young adults (Marzette & Gómez, 2021). Other scholars are embarking upon work that delineates how multiple cultural betrayals, such as those related to marginalized race, gender, and sexuality, may compound dissociation and other outcomes (Wiggins et al., 2021). Within these domains, additional research should be conducted on how we can prevent betrayal trauma to begin with, as well as identifying means to buffer against its noxious effects. As evidence for the deleterious nature of betrayal accumulates, active confrontation of betrayal at multiple levels of society is needed. One strategy for confronting institutional betrayal has already been proposed –​institutional courage (Freyd, 2018; Freyd & Smidt, 2019). Broadly, institutional courage comprises conscious institutional actions centering on transparency, accountability, and justice that seek to prevent and/​or remedy institutional betrayal. As proposed, courage could serve as a possible “antidote” to betrayal (Freyd, 2018).

Conclusion BTT underscores the larger contexts in which trauma occurs. It makes specific predictions regarding the adaptive nature of trauma-​induced dissociation as a short-​term protective strategy to navigate the competing demands existing within a person who is harmed (i.e., to remain attached to a person, institutional or group who betrays). Although the bulk of the literature on betrayal has focused on interpersonal betrayal trauma, modern descendants of betrayal trauma theory –​ institutional betrayal and cultural betrayal trauma theory –​have begun to pave the way for a more comprehensive, inclusive understanding of betrayal and trauma-​related dissociation. Future research that continues to unpack contextual influences on trauma will aid the field in understanding traumatic dissociation in our families, communities, and societies. The complex and reciprocal nature of dissociation as a risk factor and outcome means that the ways in which dissociation manifests and has meaning for particular people can be different in different social contexts. Considering all three frameworks –​ interpersonal, institutional, and cultural –​is important to promote equality and to combat inequality (Adams-​Clark et al., 2020a). Such an expansive view can promote healing through recognizing and addressing meaning in dissociation.

Acknowledgments This chapter was based on earlier work by M. Rose Barlow and Jennifer J. Freyd. Correspondence concerning this chapter should be addressed to [email protected].

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Blihar, D., Delgado, E., Buryak, M., Gonzalez, M., & Waechter, R. (2020). A systematic review of the neuroanatomy of dissociative identity disorder. European Journal of Trauma & Dissociation, 4, 100148. Bowlby, J. (1969). Attachment and Loss, Vol. 1: Loss. New York: Basic Books. Briere, J., Kaltman, S., & Green, B. L. (2008). Accumulated childhood trauma and symptom complexity. Journal of Traumatic Stress, 21, 223–​226. Brown, L. S., & Freyd, J. J. (2008). PTSD Criterion A and betrayal trauma: A modest proposal for a new look at what constitutes danger to self. Trauma Psychology Newsletter, 3(1), 11–​15. Calati, R., Bensassi, I., & Courtet, P. (2017). The link between dissociation and both suicide attempts and non-​suicidal self-​ injury: Meta-​a nalyses. Psychiatry Research, 251, 103–​114. Carlson, E. B., Dalenberg, C., & McDade-​Montez, E. (2012). Dissociation in posttraumatic stress disorder part I: Definitions and review of research. 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Goldsmith, R. E., Chesney, S. A., Heath, N. M., & Barlow, M. R. (2013). Emotion regulation difficulties mediate associations between betrayal trauma and symptoms of posttraumatic stress, depression, and anxiety. Journal of Traumatic Stress, 26, 376–​384. Goldsmith, R. E., Freyd, J. J., & DePrince, A. P. (2012). Betrayal trauma: Associations with psychological and physical symptoms in young adults. Journal of Interpersonal Violence, 27, 547–​567. Gómez, J. M. (2012). Cultural betrayal trauma theory: The impact of culture on the effects of trauma. In Blind to Betrayal. https://​ Sites.Goo​g le.Com/​Site/ ​Betra​yalb​ook/ ​Betra​yal-​Resea​rch-​News/​Cultu​ral-​Betra​yal Gómez, J. M. (2017). Does ethno-​cultural betrayal in trauma affect Asian American/​Pacific Islander college students’ mental health outcomes? An exploratory study. Journal of American College Health, 65, 432–​436. Gómez, J. M. (2019a). Group dynamics as a predictor of dissociation for Black victims of violence: An exploratory study of cultural betrayal trauma theory. Transcultural Psychiatry, 56, 878– ​894. Gómez, J. M. (2019b). Isn’t it all about victimization? (Intra)cultural pressure and cultural betrayal trauma in ethnic minority college women. Violence Against Women, 25, 1211–​1225. Gómez, J. M. (2019c). What’s in a betrayal? Trauma, dissociation, and hallucinations among high-​functioning ethnic minority emerging adults. Journal of Aggression, Maltreatment & Trauma, 28, 1181–​1198. Gómez, J. M. (2019d). What’s the harm? Internalized prejudice and cultural betrayal trauma in ethnic minorities. American Journal of Orthopsychiatry, 89, 237–​247. Gómez, J. M. (2021a). Cultural betrayal as a dimension of traumatic harm: Violence & PTSS among ethnic minority emerging adults. Journal of Child & Adolescent Trauma. 14(3), 347–356. https://​10.1007/​s40​653– ​020– ​0 0314– ​0 Gómez, J. M. (2021b). Gendered sexual violence: Betrayal trauma, dissociation, & PTSD in diverse college students. Journal of Aggression, Maltreatment, & Trauma 30(5), 625–640. https://​10.1080/​10926​771.2020.1783​737 Gómez, J. M. (2020c). It hurts when you’re close: The roles of high betrayal sexual trauma and dissociation in suicidal ideation in young adults. Violence & Victims, 35, 712–​723. Gómez, J. M. (2021). Does gender matter? An exploratory study of cultural betrayal trauma and hallucinations in Latino undergraduates at a predominantly White university. Journal of Interpersonal Violence, 36(3–​4), NP1375–​1390NP. Gómez, J. M., & Freyd, J. J. (2017). High betrayal child sexual abuse and hallucinations: A test of an indirect effect of dissociation. Journal of Child Sexual Abuse, 26, 507–​518. Gómez, J. M., & Freyd, J. J. (2018). Psychological outcomes of within-​g roup sexual violence: Evidence of cultural betrayal. Journal of Immigrant and Minority Health, 20, 1458–​1467. Gómez, J. M., & Gobin, R. L. (2020). Black women and girls & #MeToo: Rape, cultural betrayal, & healing. Sex Roles, 82(1–​ 2), 1–​12. Gómez, J. M., & Johnson, L. (in preparation). Assessing “friendly fire”: The development and validation of the Cultural Betrayal Multidimensional for Black American Young Adults (CBMI-​BAYA). Gómez, J. M., Kaehler, L. A., & Freyd, J. J. (2014). Are hallucinations related to betrayal trauma exposure? A three-​study exploration. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 675–​682. Gómez, J. M., Lewis, J. K., Noll, L. K., Smidt, A. M., & Birrell, P. J. (2016). Shifting the focus: Nonpathologizing approaches to healing from betrayal trauma through an emphasis on relational care. Journal of Trauma & Dissociation, 17, 165–​185. Gómez, J. M., Zounlome, N. O. O., & Noll, L. K. (in press). Development and initialvalidation of the Betrayal Blindness Questionnaires (BBQs): Past memory, current memory, and rotating betrayal blindness questionnaires. Heinrich, J., Heine, S. J., & Norenzayan, A. (2010). Most people are not WEIRD. Nature, 466(7302), 29–​29. Herzog, S., D’Andrea, W., & DePierro, J. (2019). Zoning out: Automatic and conscious attention biases are differentially related to dissociative and post-​t raumatic symptoms. Psychiatry Research, 272, 304–​310. Ho, A. K., Sidanius, J., Levin, D. T., & Banaji, M. R. (2011). Evidence for hypodescent and racial hierarchy in the categorization and perception of biracial individuals. Journal of Personality and Social Psychology, 100, 492–​506. Hulette, A. C., Kaehler, L. A., & Freyd, J. J. (2011). Intergenerational associations between trauma and dissociation. Journal of Family Violence, 26, 217–​225. Kaehler, L. A., & Freyd, J. J. (2009). Borderline personality characteristics: A betrayal trauma approach. Psychological Trauma: Theory, Research, Practice, and Policy, 1, 261–​268. Kelley, L. P., Weathers, F. W., Mason, E. A., & Pruneau, G. M. (2012). 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8 DISSOCIATIVE MULTIPLICITY AND PSYCHOANALYSIS John A. O’Neil

‘Dissociation’ is a label which has come to be applied to a wide range of different phenomena. This chapter specifically concerns dissociative multiplicity, with related phenomena only of ancillary interest.

Dissociative Multiplicity In brief, dissociative multiplicity has to do with somebody having more than one center of consciousness, more than one ‘I.’ Diagnostically, this restricts the meaning to full or partial Dissociative Identity Disorder (DID) as defined by DSM-​5 (2013) or ICD-​11 (2022) –​what was called multiple personality disorder (MPD). Some extend this meaning to what may, by analogy, be called ‘normal multiplicity’ –​the idea that we all encompass a multiplicity of states of self. This is an example of the general difficulty in reconciling dimensional views, on a continuum, with categorical ones: at what point does a certain change of degree result in something qualitatively different? This has led to a dynamic between two poles regarding consciousness: one end arguing for just one; the other arguing for many. MPD was considered a kind of dissociative hysteria, in contrast to conversion hysteria, which gave rise to the other major interpretation of the word ‘conversion,’ wherein conditions which appeared to be neurological were judged to be psychogenic. MPD is the penultimate label; Chapter 1 in this book (Van der Hart & Dorahy) surveys the many turns of phrase, especially in France, but extending to the UK, the USA and Germany, which have been put forward to capture this condition of there being many within the one.

Psychoanalysis Once patients are officially diagnosed (or not), and are in treatment, it becomes useful to have a systematic way not only to characterize them descriptively, but also to interpret the essentially unobservable: what they are up to –​their intentionality or conation (wishes, drives, appetites, desires, beliefs, motives); what they do to cope with these and with the human and nonhuman environment (defense mechanisms and other coping strategies), including how they interact with the clinician (transference/​countertransference, etc.), and what underlying unconscious phantasies1 bring coherence to all the foregoing. Thus, clinicians all engage in various issues that are of central concern to psychoanalysis, whether they intend to or not. Formal diagnosis, generally based on history and mental state exam (signs and symptoms) needn’t involve psychoanalysis, nor any other clinical interpretive discipline. Again, as in the first edition of this chapter, I address more traditional psychoanalytic concepts in greater depth, and cover more recent perspectives somewhat selectively, and especially outside the relatively recent school of relational psychoanalysis, as the latter has produced an abundance of literature already well discussed by others2 (see Howell & Itzkowitz, Chapter 45, this volume).

DOI: 10.4324/9781003057314-10

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I reverse history somewhat in discussing dissociation vs splitting prior to discussing dissociation vs repression, as this makes more conceptual sense to me. Having dealt with these ‘two-​body problems,’ I then discuss ‘three-​body problems’ as reflected in various psychoanalytic triads, followed by a briefer discussion of theories which allow for ‘many-​bodies’: object relations theory, attachment theory and ego state theory. I conclude with a summary view and reflection on what still needs to occur for dissociation to be reintegrated into psychoanalysis.

Scientific Challenges Methodology I have offered critiques of the early twentieth-​century philosophy of science called logical positivism, and of operational definition as introduced into physics and derivatively into psychology and DSM-​III (1980; O’Neil, 1993, 2001, 2009, Chapter 21, this volume). Operational definition was thought to allow for theory-​free observation. I prefer the philosophy of Karl Popper, who credited himself with precipitating the death of logical positivism (1972/​1992). In the process, he demonstrated that operational definitions immediately mire one in contradiction. While operational definitions have prompted diagnostic criteria with higher interrater reliability, they mustn’t tempt us with the fantasy that high interrater reliability demonstrates the criteria to be theory-​free, or that the entities described are real. Other remnants of positivism appear in some interpretations of  ‘Evidence-​Based Medicine’ (EBM) or its subset, ‘Evidence-​Based Psychiatry’ (EBP). The actual logic is intact, but the wording often prompts accompanying rhetoric which implies the entirely erroneous belief that theories and treatments can be “based on evidence.” When originally and properly defined, “Evidence-​based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). EBP, then, applies to one’s clinical judgment –​not to the truth or validity of theories or treatments themselves. In practice, EBP methodology convincingly separates out worthy hypotheses from mistaken ones on the basis of evidence, but also may tempt us to erroneously conclude that the surviving psychiatric ‘truths’ are themselves based on evidence. The specific logical error involved is the Fallacy of Affirming the Consequent 3 (O’Neil, 2001). Regardless of the current ubiquity of adducing so-​called evidence-​based theories and treatments (including a number in the present volume), if one wishes to avoid manifesting mild formal thought disorder, one ought to try neither to invoke, nor imply, the Fallacy of Affirming the Consequent: one ought not to claim that any theory or treatment is itself “based on evidence.” Strictly speaking, there are no evidence-​based theories; there are no evidence-​based treatments. One’s judgments regarding the care of individual patients may be “evidence-​based” in that one may judiciously assess the record of empirical tests of available theories and treatments. Following Popper, it is well to recall that attribution of scientific truth is based on two inabilities: 1. the inability to refute the hypothesis on the basis of evidence (no matter how hard we try), while its competing hypotheses have all been so refuted, and 2. the inability to conceive of another hypothesis against which to test it. Scientific truth is thus always relative to refuted alternatives, and never relative to evidence per se.

Talking About Ourselves As If Talking About Something Else Psychology manifests a number of self-​referential knots. This is owing to the fact that the subject matter is ourselves, including ourselves as the source of all accounts of the psyche. I may have an account of your psyche, but if you hear about it, you may argue with me. Psychology is the only discipline whose subject matter talks back. Behaviorism is one refuge: dealing only with observed behavior shields one against back talk. And it can’t be applied to the behavior of the behaviorist. Otherwise, the behavior of expounding behaviorism becomes a behavior calling for explanation, rather than a potentially truthful claim. There is no escape from back-​talk in any psychotherapy, or any psychology with a derivative psychotherapy, where one is in dialogic relation with a patient-​client-​analysand. Therapy is unavoidably interpersonal in this regard. In practice, underlying any manifest psychotherapeutic theory are latent statements I can make to my client/​patient which is intended to foster their universe of freedom (by liberating islands of growth from restraint by impossibility, inability, poverty, transience, deprivation, neglect, trauma, loss, prohibition, punishment, etc.). To that extent, method and treatment ought to trump theory.

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The mindset of the therapist engaging with the client/​patient is different from the mindset of the therapist theorizing though, ideally, we can achieve a mixed mode when communicating to peers, trying to be theoretically clear, though motivated by an ideal of caring for and individually addressing the audience. We are aware of this implicitly when reading any clinical or theoretical paper, where the theory counts, but the extent to which it is ‘therapeutic’ to the reader-​a s-​therapist counts for more. If the writer seems not to care about being understood, nor to care about how one might care for another, nothing rings true. An important implication of the discontinuity between theory and therapy is that in the hands of a therapist, what most counts is whether their interpretive schema works for them. Regardless of the ‘truth’ of any theory, it is more likely to be therapeutic if it is convincing to the therapist –​if the therapist adopts it as their own. At the same time, some theories seem to work optimally only in the hands of their originators.

Biology vs Analogies From Artefacts Another way around the problem of self-​reference is to translate the psyche into something we understand already: something we have made on purpose and whose operating is thus transparent to us. This inevitably trips up and turns what tries too hard to be scientific into something which is scientistic.4 Human mentation has been interpreted by analogy to a variety of human artifacts, from Aristotle’s ceramics, to Hobbes’ mechanics (1651), to Descartes’ pineal gland bathed in the cerebrospinal fluid (1649), to Mesmer’s magnetized fluids (Ellenberger, 1970), to Freud’s direct-​c urrent or hydraulics model,5 to cybernetics’ cognitivism (O’Neil, 2009). The last item, cognitivism, merits some repetition here, as it remains current. Cognitivism is the application of principles of artificial intelligence to the brain. Computers are said to process information. By cognitivist extension to psychology, we have come to talk about our brains processing information, perception, conflict, trauma, etc. But the ‘processing’ analogy is astonishingly recent. The OED (1991) finds that the expression ‘data processing’ was adopted from ‘food processing’ in 1960, then generalized to ‘information processing.’ The metaphor was extended to brains only in 1968. My own brain, consequently, could be said to have begun to process information when I was 19 years old, as the processing metaphor didn’t exist before then. If you wonder what my brain could possibly have been described as doing from ages 0–​18, other than processing information, testifies to the uncritical generalization of the cybernetic metaphor. We reinterpret the past through the lens of the present. But the drift from biology, the study of real life, to cybernetics, the study of human computational artefacts, has its limits. The late Gerald Edelman, Nobel Prize Lauriat and neuroscientist, claimed: The brain in this view is a kind of computer. … The acceptance of this view or version of it is widespread in psychology, linguistics, computer science, and artificial intelligence. It is one of the most remarkable misunderstandings in the history of science. Indeed, not only is it not in accord with the known facts of human biology and brain science, but it constitutes a major category error as well. … [T]‌he majority of those working in cognitive psychology hold to the views I attack here. … [S]omeday the more vocal practitioners of cognitive psychology and the frequently smug empiricists of neuroscience will understand that they have unknowingly subjected themselves to an intellectual swindle. Edelman, 1992, pp. 228–​229 In brief, while computers are better at many mental tasks than we are (though hopelessly inept at others), they are the first artefacts that seem to ‘think.’ We have projected psychological categories into computer systems, such as ‘memory’ and ‘cognition,’ then forgotten the projection, and then reintrojected the meaning back into ourselves, so that we now talk about brains functioning as if they were computers. Edelman’s point is that brains don’t function that way, don’t mediate behavior the way computers process information. At the same time, metaphors from any familiar artefact (bowl, pressure cooker, automobile, filing cabinet, thermostat, computer) may be useful in therapy. I often find computer metaphors helpful with patients even if I am persuaded by Edelman that brains don’t process information per se.

Defining Psychoanalysis as a Psychology (i.e., an Account of the Psyche) The special peculiarities of translating an interpersonal encounter into theory are more evident in psychoanalysis than in other psychotherapies.

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Freud’s Definition: Method, Treatment, Theory Psychoanalysis is the name (1) of a procedure for the investigation of mental processes which are almost inaccessible in any other way, (2) of a method (based upon that investigation) for the treatment of neurotic disorders and (3) of a collection of psychological information obtained along those lines, which is gradually being accumulated into a new scientific discipline. S. Freud, 1923b Freud’s definition may be shorthanded by saying that psychoanalysis is (1) a method of psychological investigation, (2) a psychotherapy, or treatment of some, but not all, mental disorders and (3) a scientific theory (though worded in mistaken inductivist-​empiricist terms). The sequence, method-​psychotherapy-​psychology, implies that method informs the treatment, and the results of treatment inform the theory. By this reading, psychoanalytic treatment is not an application of psychoanalytic theory, but rather the theory is derived from the treatment. This claim is in keeping with Freud’s wrong-​headed inductivist-​empiricist aspirations, and side-​steps the enormous importation of nonclinical theory into therapy as first heralded by his Project (1895). This, then, is really Freud’s metatheory: his metatheory that method and treatment lead to psychoanalytic theory. In any case, dynamic tension among these three facets has been the motor of change and differentiation in psychoanalysis over the years. In any psychoanalytic debate, the method and treatment generally take precedence over the theory, according to the metatheory. The idea is that as long as we can profitably talk to ourselves, all is fine; but when we can no longer profitably talk to ourselves, then we need to talk to someone else. Within the boundaries of regular timed encounters (sessions), and other understandings that constitute the therapeutic frame (confidentiality, a nonjudgmental attitude, etc.), two people encounter each other with the understanding that one, the analysand, is there to achieve self understanding, mastery, autonomy, etc.; and another, the analyst, is there to assist in this project. The analysand talks about what they don’t know, until they know what they are talking about. One human being gradually reveals themself6 to another in communications which are equivocal, ambiguous or analogical; they will be motivated, and affect-​laden; there will be gaps in flow and coherence. The therapeutic relationship is enfolded within motive, desire, affect and communication, what we call transference and countertransference. The radical asymmetry of the encounter replays the original mother-​ infant dyad. The analysand is not an infant, however, and so the work is inescapably collaborative: diagnosis and cure occur simultaneously, to some extent, because a ‘diagnosis’ or interpretation is legitimated by the analysand accepting it, and this accepting making a difference in the analysand’s psyche.

Freedom and Determinism in the Method In theory, method informs treatment whose outcome informs theory. In practice, all three contend with each other. The essence of the method is freedom: free association for the analysand, and freely hovering attention for the analyst. Constraint is the essence of the theory: psychic determinism. Freedom transcending constraint is the essence of the treatment: “Where id was, there ego shall be” (Freud, 1933, p. 80). The method of investigation, free association and freely hovering attention, informs the treatment, theoretically yielding psychic truth. Theory describes what renders people unfree, and therapy directs how to free them. Thus, freedom figures prominently in the method and barely appears in the theory. True psychic freedom doesn’t warrant analysis, and attaining it is a signal to set the date for termination. So freedom tends to act as a telos, goal or ideal, but is rarely directly talked about. Psychoanalytic theory rather focuses on the psychic determinism7 which blocks freedom: unconscious memories and wishes and feelings; mechanisms of defense that operate to keep things unconscious, which are themselves unconscious; unconscious repetitive patterns of perception and behavior and interpersonal relationship; psychic deficits that impoverish, etc. When we invite analysands to freely associate, to put into words whatever comes to mind or body as they recline on the couch, without censorship, we are really inviting them to act as if already ‘cured.’ Analysts interpret how the associations are not free: dwelling on a single theme at the expense of everything else, or else ranging over everything except for some missing theme. Failing to freely associate is thus always a doing: concerning oneself with something, or avoiding doing so, and enacting this doing in what one does, including but not limited to what one says, to the analyst. In this way, failing to free associate, acting out (in the descriptive, and not pejorative, sense), and transference are all different facets of the same phenomenon. The analyst’s corresponding self-​instruction, called “freely hovering attention,” means paying even attention to everything the patient says and does. You can’t tell how a patient’s associations are unfree unless you have a telos of freedom of which these associations fall short.

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Just as for empirical science, however, nothing works in practice the way it is supposed to in theory. Freely hovering attention is an unnatural ability that needs cultivation. Every item of theory (i.e., everything that one believes to be the case) constrains freely hovering attention, which is why technique recommends certain ‘lists’: speaking freely ought to result in a mix of past, present and future; of love and hate; of love and work and play; of creation and judgment; of daydreams and nightdreams and resignation to necessity; of hopes and fears; of mother, father, siblings, superiors, peers and inferiors; and so on. Such lists are somewhat contrived, however, compared to the ideal: unbiased listening is something of a not-​doing rather than a doing, akin to what Keats called ‘negative capability’ (Leavy, 1970). Similarly, Bion (1970) recommends approaching each session ‘without memory or desire.’ The reader can judge whether what’s being recommended are technical rules of thumb, or altered states of consciousness in the analyst. In any case, the method is designed to allow everything to come to light, and to be put into words: to be narrated. When all is consciously utterable, the sphere of conscious control and mastery –​the realm of freedom –​expands. Dissociative multiplicity is a prime illustration of how the method backfires. Let us assume it to be a ‘real’ phenomenon with a significant prevalence world-​w ide.8 The psychoanalytic method of investigation ought to identify cases at some regular frequency wherever it is practiced. This hasn’t been the case. To the extent that DID is a pathology of hiddenness, people with DID hide very well. Certainly almost all of those with DID who have reclined for hundreds of hours on psychoanalytic couches have largely succeeded in remaining hidden. In short, while theory is supposed to come from method and treatment, theory may cripple method and treatment. Psychoanalysts, just like everyone else, only see what they look for, and theory tells them what to look for. Bias-​free methods don’t exist, nor can they.

Clean and Dirty Starts: Abandoning Hypnosis Freud was not alone in seeking a method free of bias. The natural sciences still seek such a method. The mythical clean start was one reason that Freud abandoned hypnosis as a method of investigation and treatment. This abandonment was fatal with respect to dissociative disorders, to the extent that they are autohypnotic. Some hypnotic vestiges remain. Freud used the couch for hypnosis. Then he abandoned hypnosis, but kept the couch. Reclining on the couch and staring at the ceiling gives body and mind as little to do as possible; and the instruction to free association invites a state of reverie –​a mild altered state of consciousness in the analysand that borders on hypnotic trance. There were two phases in Freud’s use of hypnosis. The first brief hypnotic phase (Freud, 1914a) was inspired by the Nancy School of Liébault and Bernheim, with a focus on treatment –​the elimination of symptoms through mendacious hypnotic suggestion (e.g., suggesting that some traumatic event didn’t in fact happen). Freud was averse to lying to patients, but also found that it failed therapeutically –​it didn’t work. The second brief hypnotic phase derives from Breuer’s celebrated treatment of Anna O (Bertha Pappenheim, who clearly had DID; Breuer & Freud, 1895), which eschews therapeutic suggestion and uses hypnosis to investigate the origins of symptoms in the so-​called cathartic method. This preserves truth and permits treatment. Freud abandoned the hypnosis, but retained the catharsis through free association. Why? Because Freud was not very good at hypnosis (S. Freud, 1910). Since Freud abandoned hypnosis, psychoanalytic conceptualizations of it have tended to be consistently wrong-​headed, no doubt because of acculturation to Freudian opinion, and to lack of exposure to hypnosis and to how it has evolved over the past century.9 The historical rupture between hypnosis and psychoanalysis is ongoing, and regrettable, depriving both traditions of essential insights concerning how the human mind functions, and fails to function, and how to treat these failings (Kluft, 1987b, 2018).

Scientific Hypotheses Vs Hermeneutics The irreducible dialectic of freedom and determinism invites interpreting psychoanalysis as other than a natural science. The question of clean and dirty starts mirrors the passage from Husserl’s ‘clean’ phenomenology to ‘dirty’ hermeneutics. Husserl tried to do philosophy in the manner of his fellow mathematician, Descartes, from a clean start, and spent his life having to start over and over again. The futility of his phenomenology spurred the ascent of hermeneutics, which makes no pretense to a clean start, but contents itself with whatever dirt (error, wishful thought, prejudice, myth) is already around.10 Paul Ricœur (1970) interprets Freud from a hermeneutic viewpoint. This starts from the idea that Descartes’ Cogito ergo sum (‘I think, therefore I am’) is a “certitude devoid of truth,” to use Ricœur’s provocative phrase: in effect, true, but so what? –​a truth with no issue. For Ricœur, there is no privileged beginning, no best way, no clean way, to begin. Meanings are always already there in every culture, and the task is to interpret them –​a messy, ambiguous task with no sterile procedure.

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This agrees with and complements Popper’s (1935) contention that all scientific theories derive from prior theories, and ultimately from myths, rather than from data, so that meaning comes from prior meaning, and ultimately from wishful thinking, exemplified in the triumphant ‘eureka’ of a new scientific hypothesis experienced as a ‘discovery.’ However, data can only refute (surprise, disappoint). In brief, hermeneutics may be interpreted as “the hypothetico-​ deductive method applied to meaningful material” (Føllesdal, 2001, p. 376). It is also clear to Ricœur that psychoanalysis must be more than a hermeneutic, a discourse, which mixes meaning and force into a ‘semantics of desire.’ The meaning part is the hermeneutics; the force part recognizes that what is to be interpreted is a real living human being, and not just a text, requiring recourse to explanatory (rather than interpretive) models such as those used in natural science –​thus, the need for something like Aristotle’s potter, Hobbes’s strings, or Freud’s Q, or the cybernetic metaphors of cognitivism. The point here is that while these ‘force’ dimensions are mistaken, they cannot simply be dumped, but need to be updated: tinkered with or replaced. There remains the ongoing promise of testable theories in the biological and social sciences, in place of analogies to artefacts. Human beings remain terrestrial biological-​social organisms, after all.11 Hermeneutics, curiously, is closer than phenomenology to biology. The baby is not born with a tabula rasa, but with an enormous array of expectations and quirks which have arisen by chance (random mutation) and which have not yet proven to be lethal over hundreds of millions of years (natural selection). I word it this way so as to avoid the overvaluation of survival and adaptation, which are not causes in the drama, but results. Survival is a non-​event: the non-​ occurrence of premature death. The baby starts dirty rather than clean, utterly unlike a virgin hard drive. Some of the baby’s earliest and seemingly most primitive behaviors, ontogenetically, are structurally ‘late’ and sophisticated phylogenetically. We might like to think that relating is primary, whether it be object relating or attachment or interpersonal rapport, just as Freud thought that sucking at the breast was primary and earlier than biting. But teeth have been around since the fish, and breasts only since the mammals. Biting and copulating are very much prior to sucking at the breast.

The Reification of Freud’s ‘Ich,’ and the Other Psychoanalysis is inevitably self-​referential in that we talk about ourselves. Self-​reference is logically fatal for any scientific theory, however, so it is interesting to reflect on how psychoanalysis evades the issue. This immediately arises in how psychoanalytic concepts ‘interfere’ with certain basic elements of speech (e.g., pronouns). There are two senses of ‘I’ in Freud. Freud’s ‘das Ich,’ while deriving from the common pronoun, is from the outset a technical one: the subject or agent of any verb that might follow, which he then promoted to a central position in his structural theory to be ‘the Ego’ of that celebrated trio, das Es, das Ich, das Über-​Ich: the It, the I, the Over-​I; the Id, the Ego, the Superego (S. Freud, 1923a). I judge myself to speak directly in uttering ‘I,’ whereas others describe my thinking and speaking as acts of my ‘the I,’ and different from what I might judge myself. ‘The Ego,’ being in Latin, facilitates its divorce from ‘I.’ This split resonates with Buber’s (1937) view of the world as twofold, depending on his two primary words, ‘I-​Thou’ and ‘I-​ It’: “The I of man is also twofold. For the I of the primary word I-​T hou is a different I from that of the primary word I-​It” (p. 15). Applying this to psychoanalysis, the I of the therapy is the I of I-​T hou, whereas the Ego of theory is the I of I-​It: two universes of discourse in perpetual interaction and conflict.

I as Subject; Subjectivity The I as subject warrants some reflection. When attempting to study something, we invoke subjects and objects (e.g., calling the object of study the subject matter). The relationship between these two ‘throwns’ or ‘jects’ (‘ject’ being the Latin root past participle of ‘to throw’) is that one is thrown under (sub) and the other is thrown in the way (ob). So we stumble over the object thrown in our way, and wonder about the underlying subject. The relationship between surface object and underlying subject has animated millennia of philosophical and scientific debate. It is formulated in our grammar: a sentence is a subject followed by a predicate, which itself is often a verb-​object combination. Predication itself (i.e., predicating something of a subject, of somebody) cannot be taken for granted. Donald Davidson’s (2005) last book, published posthumously, is 163 pages about that very subject. ‘Subject’ has traditionally been granted priority of place over ‘object,’ as deeper, more real, truer, and fewer. Fewer is key: a subject is a unity underlying some diversity of objects. Plato’s deep forms are what things really are, underlying all their surface details or predications or appearances or phainomena. One could have true knowledge (epistémé) of the subject, but only opinion (doxa) about the object, where the most one can hope for is to come up with an account (logos) which ‘saves the appearances,’ that is, isn’t contradicted by them. Science has evolved with a neat compromise between knowledge and opinion: it routinely hypothesizes deep structures to ‘save the appearances,’ and these structures

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are routinely more unitary, and carry more conviction of reality, than the appearances they purport to save or explain. Science remains covertly Platonic. It is not a coincidence that ‘subject’ connotes the actor or agent of a sentence; and the human being as agent, conscious or unconscious; and the unity underlying surface multiplicity. The conscious human being takes itself as a model for being: for what it thinks of whatever. Projection is ubiquitous. I am conscious of the unity of my consciousness. This is my body, all that I perceive are my perceptions, all that I do are my acts, and so on. Consciousness itself is the model of a unitary subject underlying surface multiplicity. I project this subjectivity onto all other entities. The universe becomes alive or, as Thales (ca. 600–​545 bce) said, “everything is full of gods.” So the world starts pantheist and polytheist. Thales is remembered, however, for that other thing he said: “The One is Water,” a projection of subjectivity to the cosmos as a whole. This was the inaugural proposition of western philosophy: an answer to the question of the One and the Many (Copleston, 1946/​1962), for which Thales has been deemed the ‘first’ philosopher. So the central problem of dissociative multiplicity is very ancient: How is what seems to be many, really be one? How can what is one manifest as many? Just what is it that there are many of, and what is it that remains one throughout? We have whittled consciousness down over time and eliminated the ‘gods’ (soul, psyche, spirit) from almost everything except ourselves and kindred metazoa, possibly; and demoted soul to mind or intentional agency. We have also turned the tables on subject and object by reinterpreting subjectivity as something arising from that very complex organization of objects known as a brain. And so subject (the mind) is reduced to object (the brain) even if the latter is an intentional object of the former (to the extent that it is knowable). While human subjectivity may not be as unitary as we once thought, its unity remains the source of that very concept of unity of which we subsequently deem it to fall short. Consequently, claims that the unity of consciousness is merely an illusion are greatly exaggerated.

The Other: The Psychoanalytic ‘Object’ Objects are so called because they were originally regarded as objects of a given drive (e.g., the breast as the object of hunger). While objects eventually expand into whole others, the term is retained, so that object relations means one’s relations with others. More precisely, one’s perception of an other (or an aspect of an other) is called an object representation, and the inner relationship between one’s self representation and a given object representation is what is intended by ‘object relations.’

Dissociative Multiplicity: How Many of What? Faced with somebody who is simultaneously both one and many, of what are there more than one, exactly, and of what does there remain just one, despite the multiplicity? Terminology continues to evolve over the past two centuries.

Body, Psyche, Mind Body and psyche escape the controversy and remain as one per human being. The Anglo-​Saxon body, whose current meaning is well known, and applies even to a dead body, had an originally broader meaning, connoting a whole live somebody, a meaning obviously implicit in that very word, and exemplified in a set of common English words: somebody, anybody, everybody, nobody. If we are wondering of what there remains one, despite any multiplicity, we may at least count on the one body, even if some self-​states of our patients don’t agree with us. A recent article underscores Italian research specifically linking continuity of consciousness with the ongoing experience of one’s heart, lungs and gut (Monti, 2021). The Greek psyche is sufficiently remote and impersonal that it is generally considered as one per human being. But even psyche has an experience-​near, concrete origin. As Julian Jaynes points out from the language of Homer’s Iliad: The word psyche, which later means soul or conscious mind, is in most instances life-​substances, such as blood or breath: a dying warrior bleeds out his psyche onto the ground or breathes it out in his last gasp. Jaynes, 1976 Remarkably, then, Homer anticipates Mesmer’s magnetic fluid and Freud’s Q error, of thought as a conservable fluid quantity. Some ideas, old enough, become cultural idées fixes. The Anglo-​Saxon mind is not far behind, though the expression “I’m of two minds about that” argues for multiplicity. The central conceptual issue comes back to ontology: the old dichotomy between deep and surface, reality and appearance, noumenon and phenomenon.

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Multiplication and Division Indecision regarding multiplication and division has origins in our common tongue. Multiplication and division are both present in the double meanings of both split and double. German Spaltung becomes English splitting and French clivage (Laplanche & Pontalis, 1967/​1973). ‘Cleave’ is equivocal, meaning both “hew, cut asunder, split” and “stick fast, adhere” (Onions, 1966, pp. 180–​181), and cleavage, need it be said, occurs between two whole breasts in close proximity. Similarly, the common French-​English word ‘double’ (Robert, 1994) means two-​fold, from Latin duplus, which itself has two roots, duos (two) and plicare (fold). When you fold something in two, you double the layers and halve the size. So ‘double’ has a double meaning: both division and multiplication. Multiplication prevailed, as ‘double’ generally connotes twice as much, and a second layer of clothing became a doublure or jacket lining, or doublet (Larousse, 1990). The French verb dédoubler and its cognate noun, dédoublement, reverse the process: you dedouble a cloth when you unfold it or open it up, thereby doubling the size; you dedouble a jacket when you remove its doublure or lining, in other words, when the doublure emerges from within. But a doublure is also one’s double in the sense of understudy, stand-​in or stuntman. So dédoublement de la personnalité may be taken to connote both alter creation and switching, when one’s understudy ‘comes out’ in one’s place. Repeated dédoublements in the creative sense would produce multiplicity: a multiplicity of wholes, or whole others, or alters (alter is Latin for ‘other’). This sense invites one to think of the human being as a group, “myself and my others,” of somebody (literally, some body) as a vehicle for a number of someones. The language of division is more restrictive. Désagrégation, splitting (Spaltung), and dissociation itself all connote a fragmenting process whose sum adds up to one whole at most. Dissociation is a verbal contraction of dis-​a ssociation, and derives from the wrong-​headed associationist psychology of the nineteenth century. The idea of a psychic division in somebody is at odds with ‘individual,’ which means indivisible, just as ‘atom’ means unsplittable. But we now know that atoms can be split. Whole atoms don’t split into parts of atoms, but rather into different whole atoms. Similarly, when somebody ‘divides’ into ‘parts,’ what results is a plurality of someones, not of parts of a someone. The anatomic parts of a human being are not themselves little human beings; and parts of the mind, such as perception, smelling, motor functions, are not themselves little minds. Exceptionally, in DID the plurality of someones are within the same one human being, and so each is a part of that human being. Thus, being a whole and a part at the same time. Just as for split, cleave and double, part has this double meaning. Faculty dissociation presents no ‘numerical’ or ‘ontological’ difficulties, as any number of faculties, functions, states or behaviors can be predicated of a single body, psyche, mind, I, ego, self, subject, person, whatever. Dissociative multiplicity, on the other hand, opens the question: how many of what?

When ‘the Ego’ Becomes ‘the Nos’ –​the We What happens when ‘I’ becomes ‘we,’ presenting as a series of distinct ‘I’s? Psychoanalytically, can there be more than one Ego? People with DID commonly use we, us, our, ours; and a given ‘alter’ (i.e., other) will commonly use ‘I’ in the restricted sense. If there can just be one Ego, the semantic link between ‘I’ and ‘the I’ is ruptured. One way is by demoting ‘I’ to a superficial conscious manifestation of ‘the I,’ such that ‘the I’ is the special structure that, among other things, gives rise to plural ‘I’s. Another way is to call the various ‘I’s something less. Following Janet, we might call them consciousnesses, personages, personalities, existences, etc., or in more modern parlance, ego states, self-​states, self-​ representations, personalities, alters, parts, identities, etc.

Self; Self-​representation Does there remain a single self, or are there a multiplicity of selves? Representations are clearly objects (thoughts) rather than subjects (thinkers); and this goes for self-​representations. Representations clearly don’t act. The self ‘itself,’ of which one might have a representation, has an ambiguous status as an element of intrapsychic structure. ‘Self ’ as one of my objects is clearly privileged by me (or ought to be), and so is vaguely both subjective and objective, or reflexive.12 This ambiguity has led to a gradual drift from ego to self (with the bonus of drifting from Latin to Anglo-​Saxon), and from ego state to self state. However, self remains in the objective case whereas I (ego) am in the subjective. Self is what I appropriate as myself (literally –​my self ). But self is not the I that does the appropriating. In any case, self is also a word in common spoken English. An alter is permitted to say, “Well, that may be true of [host], but it doesn’t apply to myself.” So one may opt for a plurality of selves, or its downgraded cognate, self-​states.

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Personality Personality has proven to be contentious in recent decades. Like cleave (see above) it has two contrasting meanings: deep and surface. The former term for DID, MPD, clearly implies multiple personalities –​the surface meaning. The deep meaning permits only one per human being, regardless of DID. Personality comes from personal which comes from person, whose history also spans surface and depth. The original word, Latin persona, was the Roman attempt to translate the Greek word for person –​prosopon –​into Latin. The Greek word intends moving towards (pros) the eyes (opas) –​putting on a mask. The Latin intends speaking (sona) through (per) the mask. So “I prosopon my mask, then I person it” =​“I put on my mask, then I speak through it.” This is the meaning behind the dramatis personæ listed at the start of any traditional play –​the list of masks or roles that will be played. Even today, we think of ‘person’ as the ‘really real’ human being (deep essential nature), and ‘persona’ as a role played (superficial, put on, acted, feigned). So if ‘person’ can flipflop between contrary meanings, it isn’t surprising that ‘personality’ can also flipflop. ‘Person’ started as surface (mask) and became deep (a real human being), ‘personality’ started as deep and became surface –​the current default meaning. The Encyclopædia Brittanica13 opens with a definition referring uniquely to surface personality: ways of thinking, feeling, behaving; moods, attitudes, opinions; behavioral characteristics, etc. And then introduces a dichotomy: …as a psychological concept two main meanings have evolved. The first pertains to the consistent differences that exist between people: … relatively stable human psychological characteristics [surface]. The second meaning emphasizes those qualities that make all people alike and that distinguish psychological man from other species [deep]; … no definition of personality has found universal acceptance within the field. The American Psychological Association14 defines personality as “individual differences in characteristic patterns of thinking, feeling and behaving; traits that define the way a person’s behavior is perceived” involving “individual differences in particular personality characteristics, such as sociability or irritability.” The focus on descriptive characteristics or traits has to do with appearances (surface). However, it goes on to say that it may also involve “how the various parts of a person come together as a whole.” This is an entirely distinct meaning, having to do with underlying structure (deep). Any theory of personality that is concerned with traits intends ‘personality’ in the surface sense.15 The online Merriam Webster16 lists three essential meanings, all surface. The expanded meanings add one further sense, a deep one. The semantics determine how we choose to talk about people with dissociative multiplicity. For anybody (literally) with dissociative multiplicity, choosing the ‘deep’ interpretation means that there is only one personality, regardless; choosing the surface interpretation means that there may be as many personalities as there are alters, self-​states, etc. The Theory of Structural Dissociation of the Personality (TSDP; see Van der Hart & Steele, Chapter 15, & Nijenhuis, Chapter 38, this volume) elects to restrict the word to the deep sense, attributing this restriction to Pierre Janet and Gordon W. Allport. This terminological choice permits the TSDP to interpret Janet in this way. But it is clearly not the case that Janet ever made such a claim. Any reading of L’automatisme psychologique ( Janet, 1889) reveals that what we would today call the alters or self-​states of somebody Janet called consciousnesses, personages, personalities, entities, etc. Janet used both connotations freely. Allport poses an even deeper conundrum. He is known as a trait theorist. In someone with DID, however, while there may be one ‘entity’ which organizes the system [deep], there are a plurality of sets of characteristic behaviors, traits and thoughts [surface]. And so Allport’s definition, both deep and surface, only applies to someone who is without dissociative multiplicity. This is the supreme irony in the idiosyncratic semantic restriction of ‘personality’ to its deep sense by the authors of the TSDP. Another major difficulty has to do with the DSM and ICD. The ‘personality’ of ‘personality disorder,’ in both the DSM and ICD, intends the surface meaning. Consequently, the TSDP has nothing whatever to say about DSM or ICD personality disorders, just as the DSM section on personality disorders has nothing whatever to say about dissociative disorders. Personality disorders used to be called ‘character disorders’ to distinguish them from ‘neurotic disorders’ because of their persistence over time. ‘Character’ comes from the Greek word for ‘carved’ –​the ‘characters’ which are letters carved into the surface of a rock, such as granite or limestone. Characters are ‘carved in stone,’ and so quite persistent, stable, inflexible, etc. –​those adjectives the DSM-​5 has in its diagnostic criteria for General Personality Disorder –​but still clearly superficial: carved into a surface. So if the granite or limestone is the ‘person,’ then personality would be what characters are carved into it: what one might predicate of it: smooth or rough or red or green or grey or clean or

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dirty or encrusted with moss; or paranoid, schizoid, histrionic, antisocial, narcissistic, borderline, obsessive-​compulsive, avoidant, etc. The TSDP is anomalous in that it arbitrarily restricts itself to the deep meaning. As a semantic choice which divorces one from Janet, MPD, DSM, ICD, and popular culture, I neither endorse nor recommend it. Any given human being may have any number of personalities in the surface sense. Consequently, when an alter says to me, “Well, we may be co-​conscious a lot of the time, but she and I have almost opposite personalities!” I don’t correct her use of the word ‘personality.’ Similarly, Myers (1940) talked of the Emotional and Apparently Normal Personalities, the EP and the ANP, clearly intending two personalities. The TSDP lengthens these to Emotional and Apparently Normal PARTS of the Personality. While I regard this as cumbersome, the TSDP applies EPP and ANPP to make an elegant bridge between PTSD and DID, and a useful heuristic for further speculation and theorizing. It is also useful in helping patients bring some order to their internal multitude. A patient of mine stated: “I’m obviously an ANP, because I function so well compared to the others. But I started off as an EP, and I know I have some past shit to still work through. But Phoebe was an ANP from the start. She was created to pass high school math.”

Full-​blown Dissociative Multiplicity: What Needs to be Accounted For A theory is as robust as the empirical tests it can survive. Dissociative disorders constitute severe tests for any psychological theory, such as psychoanalytic theory, and full-​blown DID constitutes the most severe test. DID also constitutes the most severe test for any philosophy of mind. So it is worth rehearsing the general features of a ‘worst case.’ There are many texts, both classic and more recent, regarding the basic facts of DID, about which there can be little debate (e.g., Chefetz, 2015; Chu, 2011; Dell, 2009a; Howell, 2011; Kluft, 1987a, 1988; Loewenstein & Ross, 1992; Putnam, 1989; Ross, 1997, Steele, Boone & Van der Hart, 2017). The essence of dissociative multiplicity is the presence of more than one self-​a scribing center of consciousness, more than one intentional agent, each of whose ‘I’ is distinct. These other centers of consciousness are variously called personalities, alters, alter egos, ego states, self-​states, parts, etc. ‘Alter’ is Latin for ‘other’; it evolved into French ‘autre.’ For simplicity, I opt for ‘host’ for the default center of consciousness over a given time period, and ‘alter’ for their ‘others.’ The alters may be few or many, of various ages, including older than the ‘body,’ same-​or cross-​gendered, hetero-​ or homosexual, alive or ‘dead,’ with either or both coconsciousness and copresence to varying degrees, which may not be commutative (i.e., may be one-​way), communicating not at all, or through hallucinations, or through ‘direct thought transfer,’ manifesting different physiological signs in the body when ‘out,’ clustered in various arrays of dyads, subgrouping, layers, purposes, etc. Subhuman, animal, alien or imaginary alters are not uncommon, with likely links to children’s fantasy. When ‘out,’ a given host or alter may appear globally to be mentally and behaviorally whole and ‘normal’ or an exaggerated caricature or a single-​function agent, etc., but not necessarily congruent with the age and gender of the body.

Inner, Internal and Third Worlds: The Inscape As summarized by Meissner (1972), Hartmann and Rapaport distinguished between the inner world, a map or schema of one’s external world (including oneself in it), and the internal world, “the organization and integration of intrapsychic structures that compose the psychic apparatus,” such as the id, the ego, the superego. He concludes that the inner world is representational, whereas the internal world is structural. The inner-​internal distinction bears on a major difference between Ego psychology and the Kleinian school. Ego psychology regards one’s objects as object representations in the inner world, whereas Kleinians regard one’s objects as structural entities in the internal world, akin to Freud’s superego, about which one may then have secondary representations in one’s inner world (Hinshelwood, 1991). This has a bearing on splitting and schemata. With DID, we have a multiplicity of inner realities, as each alter has its own subjective take on reality, leading Kluft (1991) to complement MPD with the felicitous term Multiple Reality Disorder. But there is often a common internal reality or landscape or ‘inscape’17 inhabited by the distinct phantom bodies18 of host and alters (O’Neil, 1997), which is likely ‘group autohypnotic,’ as a common inscape may be prompted on purpose through clinical hypnosis (see Fraser, 1991, 2003). Even if no one agrees with another on the external world, all generally agree on the inscape itself and on their respective appearances in it. The inscape is experienced by whoever is ‘out,’ or, in contemporary parlance, ‘fronting,’ as distinct from external reality, dream, fantasy, or posttraumatic hallucinatory flashback, and is thus clearly distinct from Meissner’s inner and internal worlds. Each alter has a distinct phantom body in a common phantom

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landscape that demonstrates continuity over time, and in which ‘historical’ events can take place with repercussions, just as for ‘real’ reality.19 Despite this multiplicity of the ego, however, and of corresponding internal bodies, the inscape also constitutes a single psychic context of unity underlying the multiplicity. The inscape does for the internal world what the single physical body does for the external. An interesting question is whether this common inscape is simply epiphenomenal to having arisen from a single brain, or rather created and managed by some underlying common agency (e.g., a Kantian transcendental ego, or ‘the Ego’ in a psychoanalytic sense), deeper than any ‘I,’ but perhaps more of a ‘something’ than a ‘someone.’

Dissociation and Psychoanalysis: The Literature In the first edition of this chapter (O’Neil, 2009) I cited the International Dictionary of Psychoanalysis (de Mijolla, 2005). The current PEP Consolidated Psychoanalytic Glossary20 (2016) is a very significant improvement, consolidating six major works, the most recent being Auchincloss and Samberg (2012). There are entries for Breuer (but not Janet), hysteria (state and conversion hysteria, specifically in Freud, Lacan, Fairbairn); conversion; dissociation; depersonalization; etc. The current entry for Dissociation makes a number of claims, some dated, some very current (my brief comments are in square parentheses): 1. It defines dissociation as a disruption in the continuity of mental experience for the purpose of defense, thus opting for Freud’s defense over Janet’s weakness. It includes disruptions of the various mental faculties, including the sense of identity, as in DID, which is associated with trauma [yes]. 2. Claims that defensive dissociation overlaps with Kleinian splitting, invoking Kernberg’s definition of splitting as “mutually dissociated ego states” [I don’t endorse Kernberg’s definition for reasons outlined below]. 3. Attributes the term dissociation especially to Janet as the “dual consciousness” of hysteria, originally adopted by Breuer and Freud [ Janet preferred ‘désagrégation,’ but the point is accurate otherwise]. 4. Suggests that Freud then conceptualized dissociation as the result of conflict/​repression, and not owing to constitutional incapacity for synthesis, as Janet had proposed [a partisan, though accurate interpretation, and the crux of what I call the primal category mistake of psychoanalysis, see below]. 5. Equates dissociation with Freud’s ‘splitting of the ego,’ involving contradictory views of reality [a conflation I would not endorse –​see below]. 6. Cites Ira Brenner’s dissociative character type as using dissociation as a defense in coping with severe trauma [this corrects the Primal Category Mistake]. 7. Cites Davies and Frawley regarding dissociation from the relational point of view [a welcome update]. 8. Cites the Psychoanalytic Diagnostic Manual of 2006 equating dissociative personality disorder with DID/​M PD [the 2nd edition (Lingiardi & McWilliams, 2017) came out the following year, and underscores how DID is not a personality disorder]. 9. Cites how dissociation was used over the years by various authors (e.g. Nunberg, Glover, Sterba, Vaillant) [welcome]. 10. Notes dissociation in interpersonal and relational psychoanalysis, with an accent on Sullivan, Stern and Bromberg [very welcome]. 11. Links the relational view of dissociation to the vertical split in Kohut’s self psychology, with coexisting contradictory self-​states [ambiguous –​see below]. 12. Addresses Fairbairn’s view that repression is the dissociation of unpleasant mental content, and that dissociation underlies the multiplicity of internalized ego-​object interactions central to his endopsychic theory [welcome –​see below]. This update is welcome. That being said, dissociative multiplicity remains a rarity in the psychoanalytic mainstream. As various histories relate (Dell, 2009b; Ellenberger, 1970; Van der Hart & Dorahy, Chapter 1, this volume), dissociation is present in the very early Freud, but then he abandoned it soon after. The great majority of his followers (e.g. Klein, object relations theory, Bowlby and attachment theory, Lacan, and self psychology) followed suit. When dissociation has been invoked, it is usually in the context of a prepsychoanalytic historical curiosity or mistake, or in the informal sense of something that isn’t associated, making for little difference in theory, and none in practice. Ronald Fairbairn was an exception (see below). Contemporary exceptions who are IPA 21 members include Richard Kluft (2000; see Chapter 43, this volume), Ira Brenner (2002), and Alex Tarnopolsky (2003), but they remain exceptions. Faced with such a history, the reincorporation of dissociation within IPA psychoanalysis is a major challenge. There have been more attempts to explain it away than attempts to come to terms with it.

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A very recent attempt to explain dissociation away is a paper by Harold Blum (2013)22, which gives a remarkably clear and condensed précis of dissociation. Blum grants that dissociation has been a peripheral concept in psychoanalysis; interprets dissociation as both defensive and adaptive; and relates dissociation to (auto)hypnosis. He highlights the contributions of Kluft, Brenner and Howell, but cites them very narrowly. Historically, he reiterates the distinction between Janet’s constitutional weakness and Freud’s active defense; singles out Ferenczi’s paper (1933), which underscores the reality of trauma and identification with the aggressor as defensive; cites Fairbairn’s formulation of endopsychic structures; etc. While depicting Anna O as clearly having DID, he declines to say so, and invokes auto-​ hypnosis, splitting and denial to account for her condition. He waters down dissociation by applying it to all possible meanings of altered state of consciousness, including all normal altered states, and to altered states in other conditions –​ one of his clinical examples is of a patient with clear bipolar disorder, which he interprets using dissociative language. Blum also conflates dissociation with Freud’s Splitting of the ego (1940); equates dissociation with character disorder; links dissociation with Winnicott’s true/​false self; reiterates Kernberg’s conflation of dissociation and polar splitting; and reduces dissociation to a mix of denial, splitting, repression, regression and isolation. Much of what he claims is directly at odds with Kluft, Brenner and Howell, despite having cited them. In the past few decades, only the interpersonal-​relational school of psychoanalysis (this includes Howell), with roots outside the IPA, has embraced dissociation as mainstream. It would seem that proximity to the IPA is inversely proportional to ability to think about, or recognize, hypnoid defenses and dissociation.

Dissociation and Splitting The usual discussion would be chronological, beginning with Freud’s replacement of hypnoid hysteria with defensive repression, and then proceed onto other psychoanalytic concepts. There is conceptual merit, however, in first dealing with splitting in its various meanings, as splitting in its most common sense, the one developed by Klein and elaborated by Kernberg, is generally understood to occur before the onset of repression ontogenetically, and to be central to borderline character structure –​the differential diagnosis of DID and Borderline Personality Disorder (BPD) is a subject of ongoing debate.

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Kinds of Splitting Splitting is a common word, and so has taken on a variety of meanings. Brook (1992) identifies three meanings in Freud which emerged in sequence: the dissociative splitting of consciousness into hypnoid states [dissociative states]; the splitting of representations of self, object (other) and affect into good and bad; and the splitting of one’s attitude to some aspect of reality. Early on, Freud rejected the first sense, dissociative splitting, in favor of repression. Melanie Klein and the British object relations school developed and deepened the second sense, and this has become the ‘default’ meaning of splitting today, nosologically associated especially with BPD. The third kind is best exemplified by Freud’s ‘Splitting of the ego in the process of defence’ (1940), which Freud applied to sexual perversion and psychosis (see ‘Perverse-​ psychotic splitting’ below).

Good-​bad Splitting of Representations Freud briefly discussed the polar (good-​bad) splitting of representations of self and object only three times (Brook, 1992). In fact, this kind of representational splitting in the inner world Klein would later regard as a later and more superficial sort of splitting than the structural splitting in the internal world that she had in mind. An early example of polar splitting shows up in Aristotle’s account of the Pythagoreans: There are ten principles which they arrange in two columns of cognates –​limit and unlimited, odd and even, one and plurality, right and left, male and female, resting and moving, straight and curved, light and darkness, good and bad, square and oblong. Aristotle 1941, Metaphysics A, 986a, p. 698 This splitting consists of 1. a multitude of polar opposites, 2. all grouped into a single overarching polarity, a single table of opposites. The Pythagoreans could comfortably conceive of one good limited right light resting straight square male. This grouping would effectively defend them against the alarming alternative: the many bad dark unlimited moving curved oblong females. The Pythagorean table of opposites is, inter alia, a misogynist defense against unfettered lust. This early attempt at systematizing the world is preambivalent: everything is simply good or bad, light or dark. This

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is not to say that all Pythagoreans were borderlines functioning in the paranoid-​schizoid position. It may just be that their theory hadn’t caught up with their practice (hardly a surprise, as neither has ours). They likely showed relative stability and adherence to the ‘male’ pole in their waking-​working hours (though perhaps exploring the other pole in their daydreams and night dreams). Can the splitting of representations explain multiplicity? Not at all, for two reasons.23 First, a split is into two, not many. The splitting of self and object representations manifest polarity: self–​object, good–​bad, male–​female, friend–​foe, etc., whereas alters generally don’t (though they may). Second, self-​states are intentional subjects or agents, entities capable of uttering “I.” A given ‘I’ has intentional objects which are its respective self and object representations. In other words, a split representation, even of the self, is an object of thought, not a thinker, not a subject or agent or ‘I.’ Split representations are the basis of virtually all categorical thinking about anything: good-​bad, day-​n ight, edible-​inedible, love-​hate, friend-​foe, birth-​death, male-​female, truth-​l ie, hot-​cold, wet-​d ry, in-​out, young-​old, deep-​shallow, positive-​ negative, rational-​irrational, real-​imaginary, past-​future, sacred-​profane, infinite-​fi nite, faithful-​infidel, etc. The advance from splitting to ambivalence happened when one set of contraries and another were made into an orthogonal grid, for example when Empedocles played dry-​wet against hot-​cold giving rise to the 2x2 grid that explained the four ‘elements’: earth (cold dry), air (hot wet), fire (hot dry) and water (cold wet). Philosophically, this grid thinking largely supplanted Pythagorean splitting. It was now possible to conceive of the odd good enlightened curved female, about whom one might feel so-​so, at least. And to recognize that men could be dark and crooked. But ambivalence can’t do away with splitting. Splitting remains necessary to resolve ambivalence. Once all the pros and cons are evaluated, one must make a choice, and this choice is necessarily ‘unreasonable’ because it collapses one’s ambivalence back into yes or no. The alternative is obsessive paralysis. We move from low-​level splitting to ambivalence, and resolve ambivalence with a higher-​level splitting. And so echoes of Pythagorean splitting remain with us today, not only in various religions, philosophies and ethical systems, but in mathematics and the sciences, and in all effective decision making.

Kleinian Splitting Proper Good-​bad Structural Splitting As noted above, Klein would interpret Pythagorean splitting of representations as the surface result in the adult of a prior and deeper splitting of more ‘concrete’ internal objects in the child. Complementing Laplanche and Pontalis’s (1967/​1973) exegesis of the Freudian œuvre, Hinshelwood’s Dictionary of Kleinian Thought (1991), is a convenient digest of Kleinian thinking. ‘Dissociation’ is not an entry; nor is ‘multiplicity.’ Internal object “denotes an unconscious experience or phantasy of a concrete object physically located internal to the ego (body) which has its own motives and intentions towards the ego and to other objects” (p. 68). In this conceptualization, such internal objects are introjected from experience with real objects; some are identified with, and become ego nuclei; selves and objects inhabit a phantasized internal world and may be creatively visualized; in acting out, such introjects are externalized. Freud’s punishing superego becomes just another introjected and internal object, while the ego ideal would be another. This underscores how Kleinian metapsychology reduces Freud’s structural theory to a special case. Instead of everybody having a Freud-​prescribed id-​ego-​superego, somebody might now have an idiosyncratic internal structure that reflects their own psychic history. To the punishing superego Klein adds helpful internal objects or ‘good objects’ which may be “in various degrees of synthesis and separateness in different contexts and at different times” (ibid., p. 71). Such internal objects are experienced (consciously or unconsciously) as real, rather than as representations; they may be experienced as ‘mine’ or ‘not mine,’ as ego syntonic or ego alien. Can Kleinian splitting explain multiplicity? Certainly far better than the splitting of representations. It appears that the internal others (objects) are experienced as real, and with their own intentions; the ‘set’ of split selves and objects in a phantasized internal landscape constitutes psychic structure; there is ambiguity as to what is more ‘self-​like’ and what is more ‘object-​like,’ as both are constituted by identification; helper alters are there; different degrees of proximity and difference are there. And so internal objects (and split parts of self ) look like dissociative alters. None of this is possible in a psychic structure where id, ego and superego hold a monopoly.

Splitting Leading to Fragmentation Klein also used the term splitting to refer to what she took to be a more pathological grade of splitting, the nonpolar splitting of the internal object into multiple fragments (Hinshelwood, 1991), which would imply a concomitant fragmentation of the self. This conceptualization, while multiple, does not serve our purposes, however, as Klein applied it to the mind of the schizophrenic, the psychotic.

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Can Splitting Explain Dissociation? Kleinian splitting, invoking fairly concrete internal objects with motives and intentions located within somebody, appears to accommodate dissociative multiplicity. But this remains a phantasy of a concrete internal object with motives and intentions, rather than an internal object which in fact has motives and intentions. There remains a single Kleinian ego, however concrete may be that ego’s phantasies of its own splits. Imagine a patient manifesting apparent borderline pathology. It is interesting to wonder whether a given manifestation of splitting is the appearance of a single ego’s transient identification with one of its phantasized part-​selves or part-​objects as it enacts the appropriate script of the object relation implied or, on the other hand, the appearance of a dissociative switch from ego-​1 to ego-​2, perhaps complicated by the fact that ego-​2 is similar to one of ego-​1’s internal objects, as both are identifications with the same real person. The crucial difference is that ego-​2 is independently endowed with its own subjectivity. Klein’s conceptualization of the splitting of internal objects thus brings us to the doorstep of frank dissociative multiplicity, but doesn’t quite cross the threshold. Does this suggest what happens in fact? If somebody reacts to trauma through Kleinian splitting, might they react to further or worse trauma by crossing that threshold into frank dissociative multiplicity? In brief, can an internal object or introject somehow become secondarily imbued with subjectivity –​with agency? My own view is that at this juncture, Kleinian splitting encounters the same obstacle as the splitting of representations. There are good reasons for assuming that primary proliferative dissociation predates Kleinian splitting. The dédoublement occurs because the baby or child is not yet capable of effective splitting, and the resulting multiplicity pre-​empts the need to split. Alternatively, if somebody has achieved a certain level of mental maturity, relative to the trauma suffered, then splitting without dédoublement becomes an option. The first child will grow up with DID. The second will grow up with BPD. Mixed presentations are common, of course, as once splitting becomes an option, the host or any of the alters may then, individually, split defensively. Multiples whose hosts have borderline traits are more challenging to treat than those who haven’t. But certainly the hosts of many multiples are without borderline traits. And many borderlines, including the very severe ones, may split without switching. So I would conclude that the Kleinians and British object-​relations theorists interpret preambivalent splitting in everybody, which is appropriate to the extent that it is present, and this enables them to treat analysands at the sicker end of the spectrum who engage primarily in preambivalent structural splitting. Their analysands include some who have DID, and who also split, of course, but not all of whom may primarily split, whose multiplicity remains unseen, whose internal subjects (alters) are misinterpreted as internal objects. We only find what we are looking for. There are British object-​relations theorists who are not dissociation-​blind. Alex Tarnopolsky (2003) has no difficulty crossing the threshold, but does so through a general recategorization. He regroups dissociative multiplicity, borderline splitting, perverse splitting and neurotic repression under a single catchphrase of Freud: “keeping things apart.” But while Freud’s user-​friendly expression may well capture what these various mechanisms have in common, it fails to adequately explain how they are different. Indeed, if they are all aspects of the same thing, then the terminological choice –​dissociation, repression or splitting –​becomes a matter of taste, and what then counts is how it helps a given therapist conduct effective therapy.

Can Dissociation Explain Splitting? If, as I suggest, dédoublement predates splitting, then perhaps we ought to cross the threshold in the other direction, beginning with dissociative multiplicity and having it explain the structural splitting of internal objects. Certainly, an alter created by dédoublement may have the character of a victim, in conformity with Ferenczi’s (1933/​1949) concept of identification with the aggressor,24 or with the concept of the EP, the Emotional Personality (Steele et al., 2009; Van der Hart, Nijenhuis, & Steele, 2006); or, less commonly, identify with an admired or envied figure. My view is that patients who appear to have BPD, where their defensive style and apparent psychic structure are dominated by splitting, may well be covertly multiple. Howell and Blizard (2009) advance strong arguments in support of the view that splitting and projective identification are both manifestations of dissociation. They interpret the spectrum of 1) frank DID, 2) BPD with dissociative symptoms, and 3) BPD without dissociative symptoms as indicating that splitting is fundamentally dissociative. But the spectrum may equally be interpreted as indicating the opposite: that the two are distinct. Of course, if dissociative multiplicity predates Kleinian splitting, then perhaps the dédoublement occurs first, and then partial integration reunites the ego but leaves ‘traces’ of its history as phantasies of concrete internal part selves and part objects. This is theoretically possible, though perhaps not possible to test empirically, as the research subjects would need to be traumatized babies and toddlers; and retrospective constructions from adults are open to all the usual methodological hazards.

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I have certainly assessed patients identified as having BPD who prove to have DID; and others where I do not detect DID, which may be a reflection of my diagnostic limitations. But the interpretation of all splitting as dissociative in the same sense leads to a conceptual conundrum. Imagine a patient with DID who has an alter who splits (e.g. an alter with borderline traits), alongside others who may have obsessional or histrionic traits, say. When the apparently borderline alter splits, becoming a good-​bad pair, in close but polar reverberation with each other, this pair clearly wouldn’t be alters in the same sense as the other alters are alters. And if either of the pair seemed to split, this would entail a possible infinite regress which could only be avoided by rejecting splitting as necessarily dissociative –​at least in the sense of dédoublement.

Perverse-​psychotic Splitting We now turn to Freud’s ‘Splitting of the ego in the process of defence’ (1940), which he applied to sexual perversion and psychosis. While this work was very late in Freud’s life, perversion had long occupied an important position in his thought as “neuroses are, so to say, the negative of perversions” (1905, p. 165). This is because what is hidden or repressed in the neurotic is manifest in the pervert. For “classical” psychoanalysts or Ego Psychologists of the USA, the repertoire of available concepts to explain dissociative multiplicity is quite limited: hypnoid hysteria is dismissed as prepsychoanalytic, the topography is eclipsed by the structural theory, and the splitting of representations is ‘tarnished’ by its Kleinian elaboration. That leaves perverse splitting as a remaining recourse. Perverse splitting of the Ego is of the fetishist’s contradictory attitude to reality as a whole (Brook, 1992; PEP, 2016). One attitude is realistic: women have no penises, castration has taken place, and so one’s penis is in danger. The other attitude is based on wishful thinking: women have penises, so castration has not taken place, and thus one’s penis is safe; and, in any case, even if women don’t have penises, at least they have high-​heeled shoes –​thus, the fetish. Displacing the penis onto the high heel (or the whole shoe) allows for a perversion that saves the man from psychosis: the outright denial of the reality of woman without a penis. Such attitudinal splitting has cleavage, in the sense of just two contradictory attitudes in close juxtaposition: the real and the perverse. Such splitting, therefore, begins as a splitting of reality, of one’s attitude to reality, engendering a splitting of the Ego which results in perversion or, if sufficiently extreme, in psychosis.

Brenner: Reducing Dissociative Multiplicity to Perverse Splitting In the Freud Encyclopedia (Erwin, 2002), Ira Brenner’s entry, Dissociation (2002), summarizes views he states elsewhere (2001). He interprets the Janet/​Freud dispute as one over passive/​active, with dissociation being passive, and repression being active. In such standoffs, activity always prevails. He clarifies that dissociation can be interpreted as active defense as well, and so rescues Janet’s stance to some degree. He describes psychoanalysis as having developed into ego psychology, self-​psychology and object relations theory, all having splitting in common. Repression and splitting are given explanatory precedence, so that dissociation “augments repression or primitive splitting of ego,” a view echoed by Dell (2009b). Finally, Brenner reduces multiple personality to a “dissociative character,” and, with another bow to orthodoxy, claims that the respective ego states are “aggressively and libidinally derived self and object representations”; there is no mention of alter creation precipitated by external trauma. I favor dissociation being interpreted as an active defense, and this will be discussed below under repression. Otherwise, there are serious difficulties with Brenner’s formulation. First of all, lumping together ego psychology, self-​psychology and object relations theory under ‘splitting’ conflates perverse, narcissistic and preambivalent (Kleinian) splitting. Second, does dissociation really augment repression or primitive splitting of ego? Or does this put the cart before the horse? Dissociation, clinically, tends to be prerepressive, and certainly prior to perverse splitting, which is itself subsequent to Kleinian splitting. In my view, it is early major defensive dissociation which may subsequently be augmented by splitting and then by either repression or its ‘negative’ (perverse splitting). Third, the reduction of multiple personality to a “dissociative character” suffers from the weakness of the ‘character’ construct (see above). Finally, the attempt to ‘promote’ self or object representations, whether these be aggressively or libidinally derived or not, to the status of alternate subjects is certainly more of a stretch than promoting Kleinian internal objects to subjects. Ultimately, I read Brenner’s formulation as a defensive maneuver, a compromise formation, between ego psychological orthodoxy and dissociative multiplicity. One category mistake in this conceptualization is that alters are necessarily aggressive or libidinal, whereas clinically we confront alters which are neither. The second category mistake is that alters derive from representations. With respect to dédoublement of the ego, representations are beside the point. On the other hand, a host or alter may be perverse, and perverse dynamics are commonly found in multiples. One may be curious about whether the perversion is simply an activation of innate perversion, especially of sado-​m asochism, along “classical” lines, or whether it is rather an identification with, or introjection of, the perversion of the perpetrator,

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or whatever, but in any case to that extent this sort of perverse ego splitting remains a serviceable concept in the treatment of dissociative patients, and helps me explain and deal with the special perverse characteristics of a given alter, or perverse dynamics in the transference-​countertransference. This sort of splitting can apply to a given alter, but cloven attitudes can hardly explain the genesis of alters each of whom utters a distinct “I.” Putnam (2016) addresses “secret lives” which perhaps better clarifies the difference between perverse splitting and dissociative multiplicity –​see below.

Fostering Attitudinal Splitting in Therapy At the healthy end of this spectrum, splitting of one’s attitude to reality, so as to hold, concurrently, two incompatible versions of reality, may be understood as a therapeutic goal that one hopes to achieve with each alter. Take the example of an alter exhibiting so-​called “Rip van Winkle Syndrome.”25 She insists that she is 5 years old, and that this is 1983. We hope to induce “splitting of the ego in the process of defence” so that she can know, at one and the same time, that she experiences herself as if 5 years old in 1983, but that she is really 44 years old in 2022. Another example would be for a host or alter to know, at one and the same time, that she is sitting in a chair in a trance in her therapist’s office, and also sitting in a special chair in a work room in the presence of her alters projecting images on a screen that all can see (except for her therapist).

Dissociation and Repression So much for polar splitting. We now return to Freud’s first use of the word splitting, the splitting of hypnoid hysteria, as that historically led directly to his repression, even if the latter was subsequently interpreted to be developmentally later than other sorts of splitting (of internal objects and of attitudes) discussed above. So it is of interest to understand a little about what allows for the progression from Kleinian splitting to repression.

The Shift from Splitting to Repression: Klein’s Positions, Bowlby’s Phases, Kübler-​Ross’s Stages Klein distinguished her model of development from Freud’s by replacing his term, ‘phase’ (e.g., oral phase), with ‘position’: “a constellation of anxieties, defences, object-​relations and impulses” (Hinshelwood, 1991). She settled on two major positions, the paranoid-​schizoid and the depressive, as representing the major move from borderline pathology, dominated by persecutory anxiety, splitting and projective identification, to normal-​neurotic pathology, dominated by ambivalence and repression. The hoped-​for goal of mental health is rarely advertised as repression, depression and ambivalence, however. Clifford Scott26 (unpublished) added a position of postdepressive zest to the picture. This is perhaps best anticipated by Klein’s concept of reparation (Hinshelwood, 1991). John Bowlby (1980) expanded Klein’s positions to four phases of mourning: 1. Numbness, 2. Yearning & protest, 3. Disorganization and despair, 4. Reorganization. The first is roughly schizoid, the second roughly paranoid, the third depressive, and his fourth can be construed as somewhat less optimistic zest. A parallel has also been drawn between Klein’s positions and Kübler-​Ross’s five stages of death and dying (Burch, 1989), a parallel which many find more ‘user-​friendly.’ Kübler-​Ross’s (1969) first two stages, denial and anger, would correspond to Klein’s paranoid-​schizoid and to Bowlby’s first two phases; her last two, despair and acceptance, would correspond to Klein’s depressive position and to Bowlby’s last two phases. Kübler-​Ross adds her third stage, bargaining, between paranoia-​protest-​anger and depression-​despair. This would correspond to an obsessive-​compulsive interlude between Klein’s positions. Earlier on, Klein referred to an ‘obsessional position,’ but later on folded this into her paranoid-​schizoid defenses against the depressive position (Spillius et al., 2011). These parallels underscore the general applicability of this progression to somebody’s reaction not just to loss or death, but to any dysphoric event, and also to dramatically different concurrent time frames: an entire lifetime; child development; a response to and recovery from a major loss, trauma or life challenge; the response of a patient to a therapist’s vacation or other frame distortion; the overall course of a therapy; the sequence within a single therapeutic session, etc. And so our discussion moves on to repression.

Freud’s Primal Category Mistake: Rejecting Hypnoid Hysteria in Favor of Defense Dissociative multiplicity predated psychoanalysis, under various names such as grand hysteria, hypnoid hysteria, dédoublement de la personnalité, désagrégation mentale, état second, existences successives, etc. The early Freud often

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references Jean-​M artin Charcot and Pierre Janet. At the time, dissociation and hypnosis were complementary concerns, and overt trauma was considered the primary etiology. These items all figure centrally and undisguised in what has been dubbed the primal book of psychoanalysis (Grubrich- ​Simitis, 1997), the Studies on Hysteria (Breuer & Freud, 1895): The splitting 27 of consciousness which is so striking in the well-​k nown classical cases under the form of ‘double conscience’ [‘dual consciousness’] is present to a rudimentary degree in every hysteria, and … a tendency to such a dissociation, and with it the emergence of abnormal states of consciousness (which we shall bring together under the term ‘hypnoid’) is the basic phenomenon of this neurosis. In these views we concur with Binet and the two Janets [Pierre and Jules]. p. 12 The passage is striking in a number of respects: there is confusion between division (splitting) and multiplication (doubling); multiplicity is regarded as primary, and functional dissociation as secondary, so that any ‘somatoform’ symptoms are subsumed under more global altered states of consciousness.28 Another telling citation is from Freud’s Neuro-​Psychoses of Defence (1894). Freud distinguished four accounts of hysteria, which I have labelled 0–​1–​2 –​3 so as to accord with Freud’s naming of them, as he immediately discarded the first [0]‌: … the syndrome of hysteria … justifies the assumption of there being a splitting of consciousness. … [0]‌According to Janet … it is based on an innate weakness of the capacity for psychical synthesis, … evidence of the degeneracy of hysterical individuals. … [1] According to [Breuer], “the basis and sine qua non of hysteria” is the occurrence of peculiar dream-​like state of consciousness with a restricted capacity for association, for which he proposes the name ‘hypnoid states.’ In that case, the splitting of consciousness is secondary and acquired. … [There are] two other extreme forms of hysteria in which it is impossible to regard the splitting of consciousness as primary in Janet’s sense. … [2]‌the splitting of consciousness is the result of an act of will on the part of the patient; … initiated by an effort of will whose motive can be specified. … [3] the splitting of consciousness play an insignificant part, or perhaps none at all. … [T]he reaction to traumatic stimuli has failed to occur. … [T]hese are the pure ‘retention hysterias.’ pp. 45–​47 Again, hysterical symptoms imply an underlying splitting of consciousness. Then apples and oranges muddy the waters. Is Janetian splitting of consciousness different from Breuerian oneiric or hypnoid states? Are Janetian “weakness of the capacity for psychical synthesis” and Breuerian “restricted capacity for association” essentially different? Are Janetian splits in consciousness congenital rather than acquired? Is an act of the will necessarily incapable of inducing a splitting of consciousness or hypnoid state? Does the presence of motive preclude an altered state of consciousness? The implied ‘Freudian’ answer to all these questions would be “Yes”; in my view, the correct answer to all of them is “No.” In any case, Freud discards Janet’s sense and calls the three remaining kinds 1. hypnoid, 2. defense and 3. retention hysteria (which he subsequently abandoned). Freud’s dismissal of Janet may have been polemically mutual, as any text referencing Janet in Freud is more noise than signal, and ascribes more noise than signal to what Janet has to say about psychoanalysis (Dell, 2009b). For example, Freud criticized Janet for blaming genetic or innate predisposition, while he was concurrently (1896) attributing ‘choice of neurosis’ to constitutional (hereditary) liability –​a theme which persisted throughout his life (Grubrich-​Simitis, 1988). And in the quote above, Freud neglects to mention ‘traumatic stimulus’ as an etiological agent for either hypnoid or defense hysteria, as if it were not central to all authors concerned ( Janet, Breuer and Freud). My reading of the original texts and of various excellent treatments on this complex topic (Bromberg, 1998; Dell, 2009b; Grubrich-​Simitis, 1997; Howell, 2005; Van der Hart & Dorahy, Chapter 1, this volume) is that Janet, Breuer and the early Freud had views which were essentially equivalent: both constitution and trauma were necessary etiological factors; splitting of consciousness, or oneiric or hypnoid states, resulted; which then manifested themselves through various hysterical symptoms. Freud exaggerated the differences as he was associated with Breuer [hysteria-​1] and wished to distance himself from Janet [hysteria-​0]. Freud then adds the interpretation that the subject’s reaction to trauma is on purpose: for defense. The primal book of psychoanalysis, then, features what I (O’Neil, 2009, 2018) have dubbed Freud’s primal category mistake: the confounding of defense and repression. This comes through in statu nascendi later in the text: “I willingly adhere to this hypothesis of there being a hypnoid hysteria” (Breuer & Freud, 1895). But the import of this is immediately undercut:

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Strangely enough, I have never in my own experience met with a genuine hypnoid hysteria. Any that I took in hand has turned into a defence hysteria. … I was able to show afterwards that the so-​called hypnoid state owed its separation to the act that in it a psychical group had come into effect which had previously been split off by defence. … I am unable to suppress a suspicion that somewhere or other the roots of hypnoid and defence hysteria come together, and that there the primary factor is defence. But I can say nothing about this. … [A]‌t the basis of retention hysteria, too, an element of defence is to be found. … It is to be hoped that fresh observations will soon decide whether I am running the risk of falling into one-​sidedness and error in thus favouring an extension of the concept of defence to the whole of hysteria. p. 286 The tension is palpable. Freud ‘willingly adheres’ to hypnoid hysteria, but is ‘unable to suppress a suspicion’; he says a great deal about what he ‘can say nothing’; he wonders if he is falling into error by making a risky hypothesis: defense characterizes the whole of hysteria. We can agree with Freud that the primary factor is defense, and we can disagree with him that only repression can defend. The mistake persisted, and emerges again roughly 30 years later: Breuer supposed that the pathogenic ideas produced their traumatic effect because they arose during ‘hypnoid states,’ in which mental functioning was subject to special limitations. [I]‌rejected this explanation and inclined to the belief that an idea became pathogenic if its content was in opposition to the predominant trend of the subject’s mental life so that it provoked him into ‘defence.’ ( Janet had attributed to hysterical patients a constitutional incapacity for holding together the contents of their minds; and it was at this point that his path diverged from that of Breuer and Freud.). S. Freud, 1923b, p. 237 Freud again dismisses Janet parenthetically in the last sentence. The initial two sentences confuse resultant state (hypnoid state) with rationale or purpose (defense). In between are mechanisms, such as dissociation or repression. Why can the rationale for dissociation not be defense? The autohypnotic nature of hypnoid states was clear from the beginning to all concerned. Why was Freud unable to conceive of such an act of autohypnosis as unconsciously motivated or intended? The solution staring him in the face was that (imperfect defensive) dissociation results in hypnoid states, and (imperfect defensive) repression results in conversion. By 1923, Freud is still so muddled that he cites trauma as an effect rather than a cause: pathogenic ideas in the presence of hypnoid states produces trauma as an effect. Freud was trapped in his own Pythagorean table of opposites. One side of the table would be bad, Janet/​Breuer, heredity, degeneracy, trauma, splitting of consciousness, hypnoid hysteria, dissociation. The other side would be good, Freud, drive, defense, repression, conversion. He was unable to advance to an Empedoclean grid, which would have allowed for defensive dissociative induction of hypnoid states, a move which would have allowed him to distinguish dissociation from repression without dismissing it, and forego the subsequent general psychoanalytic marginalization and abandonment of that significant (dissociative) patient population represented by a number of cases in his own Studies on Hysteria (Breuer & Freud, 1895). And so the latter is not only the primal book of psychoanalysis, but also the primal book of the psychoanalytic misinterpretation of major posttraumatic pathology. In this regard, I have some sympathy for Josef Breuer, who stated: “Freud is a man given to absolute and exclusive formulations: this is a psychical need which, in my opinion, leads to excessive generalization. There may in addition be a desire d’épater le bourgeois [to shock middle-​class attitudes]. … The case of Anna O., which was the germ-​cell of the whole of psycho-​analysis, proves that a fairly severe case of hysteria can develop, flourish, and be resolved without having a sexual basis. I confess that the plunging into sexuality in theory and practice is not to my taste. But what have my taste and my feeling about what is seemly and what is unseemly to do with the question of what is true? … I still regard Freud’s work as magnificent: built up on the most laborious study in his private practice and of the greatest importance –​even though no small part of its structure will doubtless crumble away again.” Josef Breuer, quoted by Cranefield, 1958, p. 320 The quotation is poignant: Breuer accurately identifies Freud’s excessive generalization, then denies the very significant sexuality in the case of Anna O,29 then admits to a distaste for the sexuality that he just claimed wasn’t there, then grants magnificent truth to Freud, then predicts that science will no doubt refute that magnificence.

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Freud’s absolute and exclusive formulation was to conflate repression and defense. This underscores the two meanings of repression in the literature. The early meaning is equivalent to defense, a blanket term for all conceivable defense mechanisms. The late meaning is as just one of the potential set of defense mechanisms. His daughter Anna Freud (1966), for example, listed ten, the other nine being: regression, reaction formation, isolation, undoing, projection, introjection, turning against the self, and sublimation. This doesn’t include Freud’s own perverse splitting, nor the Kleinian defenses, such as splitting, introjection, assimilation, disparagement, control, idealization, identification and projective identification. Freud clarified this in 1926: (c) Repression and Defence… I have revived a … term, of which I made exclusive use thirty year ago … ‘defensive process.’ I afterwards replaced it by the word ‘repression.’ … It will be an undoubted advantage … to revert to … ‘defence,’ provided we employ it explicitly as a general designation for all the techniques which the ego makes use of in conflicts which may lead to a neurosis, while we retain the word ‘repression’ for the special method of defence which the line of approach taken by our investigations made us better acquainted with in the first instance. S. Freud, 1926a, p. 163 Alas, despite disentangling defense and repression, Freud was still unable to recognize that his early cases included different kinds of resultant psychopathology, and thus invited the hypothesis that more than one kind of defense was involved. While undoing was now in the wider defensive repertoire, Freud was unable to undo his break with Breuer. In any case, Breuer’s comments focus more on sex, Freud’s second major shift in excessive generalization: in place of all psychopathology based on childhood sexual trauma, all psychopathology was now based on repressed sexual wishes. Freud’s “dissociative period” was thus short-​lived (coming to an end even prior to the publication of the Studies), and clearly designated as ‘pre-​psychoanalytic’ by Freud himself, and most psychoanalysts have dutifully followed his path. The abandonment of hypnoid hysteria was not just psychoanalytic, of course. By the early twentieth century, hysteria had slipped from fashion as a diagnosis, and Eugen Bleuler (1911/​1950) lumped some hysterics (i.e. patients with multiple personality) in with Kraepelin’s Dementia Præcox, which he renamed Schizophrenia [schizo =​split; phren =​mind], a misnomer which has fostered a century of diagnostic obfuscation and popular confusion. While the word hysteria continued on the books as both dissociative and conversion types (e.g., up to DSM-​II and ICD-​9), the diagnosis still fell into disuse. The shift from hypnoid to defense hysteria was thus a shift from dissociation to repression, from trauma to drive, from hypnosis to free association. There were obviously positive byproducts to such a shift: psychoanalysis went on to clarify the understanding of ‘normal-​neurotic’ psychopathology and its treatment. The Kleinians went on to develop a convincing understanding of (Pythagorean) splitting, and gave birth to the object relations tradition in psychoanalysis (though not independently). And Kohut went on to clarify narcissistic pathology, and so on. But psychoanalysis has had to venture into the more serious psychopathologies burdened with an obstinate and even ‘sanctimonious’ ignorance of trauma, dissociation and hypnosis. And so hysteria underwent a split in meaning when Freud shifted from dissociation to repression, followed by two relatively independent streams of development of hysteria and conversion, the dissociative stream outside of psychoanalysis, and the repressive stream within psychoanalysis.

Dissociation, Repression and Conversion Within Psychoanalysis: Conversion and Repression In hysteria, the incompatible idea is rendered innocuous by its sum of excitation being transformed into something somatic. For this I should like to propose the name of conversion. S. Freud, 1894, p. 49 This early quote coined the word. Note that it is directly tied to Freud’s Q (sum of excitation) and thus part of his wrong-​headed economic point of view, and for that reason frankly neurological at the time (though as the neurology in question was refuted, it became pseudoneurological). Originally, the ‘sum of excitation’ was due to external trauma; then to both external trauma and internal drive; and finally, primarily (though not exclusively), to internal drive. It rapidly became the paradigmatic compromise formation between drive (urge, intent, wish, motive) and defense (repression), and only secondarily between trauma and defense; and a paradigmatic example of primary gain: better to suffer the symptom than to be conscious of the wish or impulse.

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Conversion in Psychiatric Nosology Despite the Freudian origin of the word, conversion entered into official psychiatric nosology. In essence, any symptom appearing to be neurological but judged to be psychogenic is considered a conversion symptom, whereas a psychoanalyst would qualify it as a surface phenomenon of some more specific underlying dynamic –​repressed drive (See O’Neil, Chapter 21, this volume, for a more complete story). Hysteria disappeared from DSM-​III, then from ICD-​10. Conversion disappears in ICD-​11, now called Dissociative Neurological Symptom Disorder, while DSM-​5 retains conversion, but with the alternative title Functional Neurological Symptom Disorder. In sum, hysteria is gone, and conversion is on the way out.

Conversion in Dissociative Disorders In the dissociative disorders realm, conversion slips to subset status. Van der Hart et al. (2006) reflect psychiatric tradition by promoting dissociation to replace the umbrella term, hysteria, and then by qualifying the two types as psychoform and somatoform dissociation, a persistent pairing which is also in keeping with that high comorbidity which even the DSM-​5 grants. But somatoform dissociation is broader than repressed drive, and thus broader than psychoanalytic conversion. Indeed, the most common somatoform symptoms in dissociative disorders are partial posttraumatic revivifications, rather than repressed wishes, and so it is not entirely clear whether psychoanalytic conversion warrants being considered as dissociative at all. When faced with a somatoform symptom, then, one first rules out a neurological condition. One may then wonder whether it is a partial posttraumatic revivification (or the blunting of same), a repressed wish, or neither. So if somebody wakes up with pain and stiffness in the neck and shoulders, psychiatrically one wants to figure out, say, whether this is a tactile flashback of having struggled against being pinned down and strangled 30 years ago; or, on the other hand, whether while visiting mother last night she said something grossly unempathic and demeaning, and the immediate reaction was the impulse to strangle her. While confessing this impulse in therapy, if the patient holds out her arms and hands as if strangling mother, fury on her face, and then perplexity, and then moves her arms up and down in slow wave-​like fashion, and says, astonished, “The pain and stiffness are all gone –​I can’t even feel as if I just had it!” then better to have pain and stiffness in the muscle groups needed to strangle mother than to recall what she said or, indeed, that one wanted to strangle her. If somebody presents with blindness, one wants to clarify whether this is, say, a posttraumatic revivification of having been imprisoned in the pitch-​black cellar at three years old or, rather, the somatic expression of the wish not to see oneself in the mirror, motivated by self-​loathing, having recently discovered that one’s alter had sexually abused a child last autumn. If the latter, then better to be blind than to look at the face of a child molester, oneself, in the mirror. Revivifications may also be of one’s dissociative state at the time of the trauma, and so have the quality of ‘negative’ PTSD symptoms (e.g., local anesthesia or analgesia, oneiric state, etc.). For example, while working in an eating disorders in-​patient unit, I had a patient who was anesthetic from umbilicus to mid-​thigh. She manifested curious surprise when I informed her that most women had sensation “down there” (la belle indifférence is not passée). The distinction between revivification and conversion proper is independent of the question of  ‘source’ of the symptom. In general, the source needs to be ascertained before such a distinction can be clarified. Is the symptom coming from the one before me in the office, or is it an intrusion from one of their alters? In the case of multiplicity, the most common somatoform symptoms are intrusions from an alter, and so that is where one must go to determine whether they are partial posttraumatic revivifications or conversion symptoms. In such cases, true conversion symptoms (as incompletely repressed impulses) are rare enough that they come as a surprise. Intrusion phenomena are more commonly partial and undisguised revivifications from a traumatized child alter (e.g., oneself being strangled 30 years ago, or oneself in the cellar at three), so that psychoanalytic interpretation of symbolic significance may then be in the service of denial rather than insight –​a “fallacy of misplaced abstraction.”30 For example, if a patient feels “as if I’m being fucked in the head” this may be interpreted as symbolic of some sophisticated interpersonal manipulation enacted through verbal communications from a mate or boss, obscuring the more concrete possibility of having endured forced fellatio as a child. Combinations may also occur. A partial somatic (primarily posttraumatic) symptom may have secondary symbolic elaboration, as a compromise formation expressive of a wish-​defence conflict. It is also important not to needlessly multiply entities. If my neck and shoulders are stiff because I want to strangle my mother, I don’t need to have an alter of whose stiffness I am the recipient. Where the alter is the child being strangled, and whose struggle I experience as an intrusion, that child alter may well have repressed the experience as well, and have the symptom instead of the memory. An infinite regress looms if that alter requires a subalter to hold the experience. And so a dissociated traumatized child alter may herself engage in the repression of the trauma. And if this is called dissociation, then it has nothing whatever to do with the dissociation that leads to the alter having the experience instead of the host. So better to retain the concept, repression.

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Developmentally, I assume that dissociation of trauma predates its repression. In other words, one’s defensive elaboration of an alter who suffers the overt trauma, in order for oneself to avoid such an experience, predates the subsequent repression of that trauma in the alter concerned. That alter may no longer experience the trauma, and have no memory of it, but may alternate between periods of blissful ignorance and excruciating flashbacks, on the pattern of an alternation between the criterion sets B and C for PTSD. And such criterion B symptoms may not manifest in the ‘host’ for decades, until some untoward event in later adulthood overwhelms the fragile dissociative defenses and the alter’s revivification intrudes into the host’s sensorium and occasions a trip to the clinic. So then classic Freudian ‘repression’ remains a serviceable concept especially in the most flagrant cases of DID. Without it, two entirely separate kinds of dissociation need to be invoked: the dissociation into an alter of a given trauma; and the ‘dissociation’ (=​repression) of that trauma in a given alter. In practice, I accept the classic Freudian concept of repression not only as the repression of a wish that gains somatic expression in a compromise formation (conversion proper), but also as the repression of a trauma, in a given host or alter, that gains somatic expression in a partial post-​traumatic flashback (body memory). It is worth noting that this second sort of conversion was Freud’s initial idea, which he then largely replaced by the first sort. Historically, trauma preceded wish. And then wish replaced trauma. And now we have the return of the repressed: trauma trumps wish. But both survive. This is not to imply that partial posttraumatic revivification and repressed wishes exhaust the somatoform dissociative repertoire. Depersonalization, that perplexing whole-​body somatoform symptom, is a third type. And then there are complex enactments which involve the simultaneous play of real reality and the inscape, and conflict between the phantom realities of different alters. Examples follow. A patient walks through the toy section of a department store heading for adult female clothing; her left hand reaches out and grabs a little doll in the bin and shoves it into her left pocket; the patient can’t budge her left hand, and must reach over with her right hand to remove the doll to put it back. It is hardly pertinent to label the inability to move the left hand as pseudoneurological paralysis. It does make sense to assume that her 5-​year-​old alter was copresent in the eyes (she had to see the doll), and intruded her executive control into the left hand. A patient is talking and relating to me normally, except that her fingers are ‘clawed’ at the interphalangeal joints. I point this out. She denies it, and says they are normal. I hold a pencil by both ends, and sweep it down her palm. It catches on the clawed fingers and pulls her hand. “How did you do that?!” she responds in amazement. Her legs are crossed but she thinks they aren’t. She perceives her left foot as somewhere it isn’t. With her permission, I hold her left foot as, from her point of view, I’m holding nothing. I pull, and she is pulled in her chair. She looks behind her to see who pushed her. She wonders if she’s on Candid Camera. Later, I ‘speak through’ and ask who is in the hands and foot. More astonishment. She says a male child is in the hands, and he’s laughing; an adolescent is in the foot, and he’s more surly. So in this case, we have a pseudoneurological symptom that most resembles phantom limb, except that no limb has been amputated. Rather, the patient’s phantom body has overridden the real one so that she can’t perceive the ‘local presence’ of her alters in the hands and foot. This is clearly neither posttraumatic revivification (though the claws per se would be for the child alter) nor conversion.

Repression Reinterpreted: Zero Process Joseph Fernando’s The Processes of Defense (2009) has been regarded as the first major overall update on defense mechanisms since Anna Freud’s (1966) classic, The Ego and the Mechanisms of Defense. Fernando makes an addition to Freud’s concepts of the primary and secondary process by coining the ‘zero process,’ more primitive than the primary. The primary process operates in timeless fantasies, dreams, wishful thinking, poetry (metaphor, metonymy), etc., and the secondary process in logical sequential propositional thought. Fernando’s zero process is the posttraumatic mode of mentation, with its own set of defense mechanisms: denial (different from primary process denial), temporal shifting (different from primary process timelessness: as if the trauma has not yet happened, but may happen at any moment), turning passive into active (motivating repetition), etc., but which may also include ‘splitting of the identity’ which leads to DID. Fernando compares the ‘bits and pieces’ of zero process traumatic memory with Bion’s (1962) ‘beta elements,’ but underscores these bits and pieces as caused by trauma, while Bion stresses the failure of mother to integrate the infant’s endogenous bits and pieces of mental distress. The temporal shifting accounts for posttraumatic avoidance of the experience of the trauma, while its failure brings the future into the lived present: a posttraumatic flashback; when paired with alter generation, this temporal shifting accounts for the common occurrence of happy ‘pretraumatized’ child alters. Fernando is exceptional in dealing with trauma and multiplicity using very ‘orthodox’ psychoanalytic terminology, while at the same time daring to make very specific corrections and additions to it.

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Repression Reinterpreted: Unformulated Experience Stern (1997, 2009, Chapter 20, this volume) advances another interesting alternative to repression which bridges repression and dissociation. He defines dissociation as the refusal to formulate experience so that it never enters consciousness. Thus, instead of there being something conscious that needs to be rendered unconscious by repression, dissociation blocks it from becoming conscious in the first place. By this view, dissociation is earlier and more basic than repression. It involves a refusal to be curious, to engage in imagination. Becoming conscious requires curious, imaginative, effortful formulation, and refusing to do so is dissociation. This hypothesis adds another dimension to the difference between partial posttraumatic revivification and repressed wish (conversion). Returning to our posttraumatic example of somebody waking up with pain and stiffness in the neck and shoulders, having struggled against being pinned down and strangled 30 years ago, is this because the event was formulated in consciousness and then repressed, only to be discovered later in therapy; or, on the other hand, was it never fully formulated, and thus not fully conscious, at the time, and instead was registered as a ‘somatic memory,’ until finally formulated in therapy for the first time? If, on the other hand, the pain and stiffness reflects the wish to have strangled mother last night, was the wish conscious last night and then repressed? Or was it never conscious, but rather unformulated from the outset, and made conscious for the first time in therapy through an unconscious decision to belatedly formulate it? These are interesting alternatives, and difficult to test. It strikes me as very likely that unformulated experience results especially when the trauma is in excess of somebody’s ability to formulate, and thus more likely for more severe trauma, and younger victims. It would also better explain those amorphous symptoms and vague interpersonal conundrums for which there seems to be no words. It also matches the demographics of DID. And so if we grant an early inability to formulate, it is hardly a stretch to suppose a subsequent refusal to formulate. The former would be closer to Janet, the latter would be a bridge between Janet and Freud. But that is not to say that all repression is really unformulated experience. It is common for DID patients to suddenly remember something, consciously, and then to remember that they once remembered it, and that they forgot it for an interval, during which time they both forgot it and forgot they forgot, prior to remembering it ‘today.’ This is more in keeping with classic dissociation or repression of previously formulated experience.31 A middle-​ aged patient complains of an itchy torso. She switches to a 4-​ year-​ old child alter, who tearfully explains: “Daddy’s peepee is hurting him; he tries to make it feel better by rubbing it, but that only makes it worse; you can see it in his face; then his peepee gets really sick and suddenly throws up; daddy is sorry it threw up on me, and he tries to clean me off, but instead just seems to spread the throw-​up all over me; poor daddy.” Switch to a disdainful teen: “The idiot kid can’t figure out he was just jerking off over her! She makes excuses for him all the time! What a loser.” Switch to the sobbing adult: feeling betrayed and outraged –​but the itch is gone. So in the same patient we have two formulations, at different ages, expressed on the same day, but they seem to have a prior history. And while the child’s formulation is faulty, there is no lack of imagination, including mentalization: what the 4-​year-​old thought was going through daddy’s head at the time.

Dissociation and Assorted Triads Dédoublement produces two from one, but we wish to know if there is a route to multiplicity other than through successive dédoublements. Obvious alternatives consist in various triadic conceptualizations that predated Freud, which Freud invoked, and that have continued with other authors.

Dissociation and the Œdipal Triangle Returning to Breuer’s comments cited above, which focus more on sex, the switch from dissociation to repression was also the switch from the so-​called ‘seduction theory’ to the Œdipus Complex. Freud came to doubt some of the trauma stories that emerged, and wondered if they were due to suggestion. There is some irony in this, as the kind of hypnosis he engaged in at the time was essentially suggestive. In any case, this major shift in his thinking (Laplanche & Pontalis, 1967/​1973) has been, at one extreme, hailed as the founding moment of psychoanalysis, the discovery of the Unconscious and, at the other extreme, condemned as a defensive, conformist fabrication (Masson, 1984). Subsequent scholarship (Blum, 1996) clarifies the mythic character of both extremes, finding fault with Freud, but also finding fault with tendentious misreadings of him. The core œdipal triangle is the child faced with the parents, wishing for an exclusive relationship with one, jealous and wishing to be rid of the other for that reason. Variations on œdipal dynamics accommodate age, gender, hetero-​and

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homosexuality, identification, love and hate, and libido and aggression, and so may be viewed as a general schema underlying all triadic conflicts, as opposed to dyadic ones. Two’s company, three’s a crowd. Jealousy requires a trio. The first triad in a child’s life is with its parents. Leaving etiology aside, dissociative patients, host and alters, have triadic conflicts, and thus manifest œdipal dynamics. By the same token, such a universal dynamic is unable to account for the genesis of alters per se. In the manifestly traumatized, the œdipal triangle may be richly and ably complemented by various adaptations of Karpman’s (1968) drama triangle, whose shifting roles among rescuer, persecutor and victim have been best explained by Davies and Frawley (1994). Various dyads may be drawn from this triangle illuminating what is typically enacted in the transference and countertransference with adult survivors of childhood sexual abuse (e.g., neglected victim confronting sadistic abuser under the blindly indifferent gaze of the uninvolved nonabusing parent). This reconfiguration implies not only the bad things that shouldn’t have happened (sadistic abuser), but the lack of good things that should have happened (uninvolved parent).

Dissociation and the Topography: Cs, Pcs and Ucs When Freud replaces dissociation with repression, the vertical dissociative split rotates to become the horizontal repressive split of the topography between the Preconscious (Pcs) and the Unconscious (Ucs) (S. Freud, 1915a). There is also the minor horizontal split between Pcs and Conscious (Cs), caused by inattention.32 The idea is that repression is a dynamic forgetting, and so needs work (working-​through) to be undone (S. Freud, 1914b), whereas inattention just needs a reminder. This all remains clinically useful. The connection to multiplicity is complicated. Freud does claim that “The content of the Ucs may be compared to an aboriginal population in the mind” (S. Freud, 1915b), but this proves to be strictly metaphoric. No actual population is intended. The remark rather anticipates his later theory of the Id, apart from whatever mental contents are rendered unconscious by repression. As noted above, the difficulty with this triad is that a given alter will commonly have its own ‘repressed contents,’ but Freud would be unlikely to condone a plurality of Unconsciouses. This puzzle carries over to the structural theory.

Dissociation and the Structural Theory: Id, Ego and Superego The ‘classic’ sense of structural splitting is the split between the Id, Ego and Superego (S. Freud, 1923a). In the prior topography, the ego (small ‘e’) is in the Pcs-​Cs and, among other things, was responsible for defense mechanisms. But defenses are also dynamically unconscious. That is to say, one needs to work to get people to recognize not only what they repress, but that and how they repress. So ego defenses seem to belong in the Ucs, not the Pcs-​Cs. Freud also interpreted dynamically unconscious guilt in some of his analysands, and so needed to put some of the conscience into the Ucs. Freud solves this problem by giving the Ucs two levels. The sub-​basement he calls the Id, which remains the source of impulses (the ‘aboriginal population’). Above that he partitions the Ucs into unconscious Ego (defenses and repressed contents) and unconscious Superego (the source of unconscious guilt), then allows this new division to carry up through the old systems Pcs-​Cs, so that Ego and Superego are side by side at each level (despite the word ‘superego’ which literally means “above the ego”). This division is mostly functional: various mental faculties are allocated to various structures. But it is personal as well: the Ego, of course, must remain ‘I’ –​the subject of the verb, as opposed to ‘me’ or ‘self ’ or ‘myself ’ or any object of the verb. The Superego, in turn, is something like the little angel telling the Ego to be good, over one shoulder, while the devilish (aboriginal) Id tells the Ego to be bad, over the other, much like Plato’s charioteer with the rational white and lusty black horses. What happens when such a conceptual structure encounters multiplicity? The division might indeed seem to apply if the alters of a given patient happened to be exactly two and functionally distinct in just the right way (e.g., pure impulse vs. pure morality/​g uilt, etc). As we noted above, however, working even with the average multiple generally requires dealing with different ‘I’s, each of whom requires working through of their own unconscious defenses against unconscious mental contents, their own impulses, defensive style, cognitive ability and moral code. Thus, a given alter has its own Id, Ego and Superego, regardless of how muted, exaggerated or perverse these might be. This suffices to reject structural splitting as a viable explanation for alter generation or for relations between alters. Freud’s double layering of the Ucs invites a third layering between the Id and the unconscious ego of the one facing you in the therapy room: a deeper and singular unconscious ego, above which would be the various unconscious egos (and superegos) of host and alters. Some clinicians insist that such an ego can be met in every patient. That hasn’t been my experience. But there are reasons to assume this underlying ‘commonality.’ There is presumably some ‘agency’ that

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decides who is to be out when. There is also the remarkable internal third reality or ‘inscape’ inhabited by the distinct phantom bodies of host and alters, and as noted earlier, even if no one agrees with another on anything else, they generally agree on the inscape itself and on the respective appearances of their phantom bodies. All the same, whether this is simply epiphenomenal to having arisen from the same brain, or rather directed by some underlying common agency, the therapeutic goal is to achieve integration, such that Freud’s structural theory can play a teleological role: we intend that the patient eventually become such that the id-​ego-​superego model applies. In passing, the enormous psychoanalytic structural literature regarding the Superego may apply to intra-​a lter, alter-​ alter and alter-​therapist dynamics that feature conflict among impulses, defenses, prohibition, punishment and guilt. More particularly, just as is the case for internal object representations, a “harsh superego” may indicate the presence of an alter defensively identifying with an aggressor, or authority figure, in which case psychoanalytic literature on the harsh superego may be found to apply (Howell, 1997, 2011), even if it does not suffice.

Fairbairn’s Triad The theorizing of Ronald Fairbairn promises more to the clinician of dissociation than the work of any other classic author. Some of the headings of his (1944) paper on endopsychic structure hint at a return to nineteenth-​century multiplicity: ‘Back to hysteria,’ ‘A multiplicity of egos,’ ‘… the central ego and the subsidiary egos,’ and so on. There are a number of excellent summary discussions of this challenging author (Greenberg & Mitchell, 1983; Howell, 2011; Rubens, 1994, 1996). Freud is ‘corrected.’ The economic theory is jettisoned: no psychic energy comes from the Id –​psychic structures have their own energies. The topographic theory is jettisoned: repression is a mere subset of dissociation: the dissociation of the unpleasant; and a rather late arrival, requiring some degree of higher mental functioning. Drive theory is jettisoned: libido is object-​seeking, not pleasure-​seeking, and pleasure is a by-​product of successful object-​seeking. Hedonism, or the seeking for pure pleasure, is reinterpreted as the result of a failure of object-​relatedness. As a damning corollary, classical drive theory is reinterpreted as a symptom of conversion hysteria in the theorist-​analyst, focusing on erotogenic zones and missing how they are somatic displacements from interpersonal longing. Classical narcissism is jettisoned: newborn infants are not narcissistic but primordially object-​seeking, a view which anticipates attachment theory and interpersonal/​relational psychoanalysis. Klein is also ‘corrected.’ The ‘good breast’ and ‘bad breast’ are not in-​born templates, but the result of internalization of a real disappointing mother-​breast, and the split reinterpreted as the exciting and rejecting aspects of an ungratifying real mother. Splitting is not so much into good-​bad self-​object relations, as into a primary triad. The ‘original’ ego confronts the ungratifying mother, and becomes the ‘central ego’ by maintaining her as an ideal object. This it does by introjecting her ungratifying aspect as a split into the exciting and rejecting mother. The split mother has comparable split-​off parts of the ego: the two ‘subsidiary’ egos, libidinal and antilibidinal. Then the libidinal ego with its exciting mother and the antilibidinal ego with its rejecting mother are all repressed (or dissociated) into unconsciousness. This leaves the central ego free to have an ‘ideal’ relationship with an ‘ideal’ mother and to carry on ‘normally’ with the real world, similar to the clinical reality of a host with its alters, and unlike Kleinian splitting, which produces polar opposites but has no remaining center or core, no intervening third option. The repressed (or dissociated) ego-​object pairs fight it out with each other, and intrude into the real world. Indeed, Fairbairn had previously called the antilibidinal ego the ‘internal saboteur’ –​a wording which resonates clearly with troublesome alters in therapy. For Fairbairn, this is universal psychopathology –​‘normal’ psychopathology. From the perspective of a clinician treating DID, Fairbairn seems to be engaged in three separate lines of thought which he confounds. One is the introjection of a real object and the concomitant dissociation of a related part of the self into an unconscious subsidiary ego. This could be understood as his interpretation of the genesis of a dissociated alter personality, and it works quite well, but only to a point. It stops working when the patient switches and we discover that the subsidiary ego is quite conscious and has been conscious of the central ego (host) all along, even if the central ego has not been conscious of it. The second line of thought is that the introjected object is necessarily split in a Kleinian sense (i.e., into polar opposites) with exciting and rejecting internal objects. Related to these objects are the unconscious subsidiary libidinal and antilibidinal egos. This formulation requires that all alters show up in polar pairs. In practice, a significant portion of DID alters may be paired, such as contrasting child alters of the same age, or ‘twins,’ or child-​adult combinations such that the traumatized child is disguised as the traumatizing adult, etc., but certainly not all alters arrive in pairs. This difficulty was addressed long ago by Young (1988). The third line of thought is that all patients may be understood through this triadic schema. If so, then the triad would indeed apply to a host, but would also apply to each of the alters as they showed in therapy. We arrive at the same

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conundrum as we did with Freud’s structural theory. So the extent that such triadic dynamics are universally applicable, they can’t at the same time explain the genesis of DID and how it is different from universal normal neurosis. At the same time, a Fairbairnian analyst who ‘gets’ dissociative multiplicity, would likely be able to profitably reinterpret Fairbairn’s approach for the successful treatment of a given patient, just as Brenner does with Freud, or Tarnopolsky with Klein.

Kohut’s Triad: Dissociation and Self Psychology Another tempting conceptualization is Kohut’s self psychology. Kohut contrasted Freud’s horizontal split between preconscious above and unconscious below with his own vertical split between different aspects of self, which would then be side-​by-​side rather than at different depths. Can Kohutian vertical splitting accommodate dissociation? The limiting feature, as with Fairbairn, is that Kohut delimits three specific kinds of self defect, reflected in the three typical self-​object transferences that would emerge in analysis: the mirroring, alter-​ego, and idealizing self-​object deficits (Kohut, 1984). Self-​object mirroring is the earliest, and happens between mother and baby, wherein baby looks into mother’s eyes to discover what mother thinks of baby, and thus what baby thinks of itself –​the relational origin of basic self-​esteem, good, bad, or indifferent. Self-​object idealizing happens later, as child contemplates parent in the world beyond the home, serving as a concrete example of what the child might hope to become in life –​the relational origin of hope, admiration, emulation, optimism, idealism, etc. The alter-​ego dynamic mediates between mirroring (how wonderful I am) and idealizing (how much more wonderful I can hope to be) by showing how: having a peer just a little more advanced than oneself who can show you the ropes, who can help you realize your raw talent, your potential, in the real world.33 So Kohut is to some extent more old wine in new skins. Mirroring recycles the oral phase and the id: primarily with mother, but focusing on the eyes instead of the mouth, needing the satisfaction of an adoring, benevolent, tolerant gaze. The alter-​ego dynamic recycles the anal phase, latency and the ego: concerned with how-​to, competence, sibling relationships, group identity, mediating between the mirror and the ideal, just as the ego mediates between id and superego. Idealizing recycles the phallic phase, and the superego: concerned with wanting to become like another (instead of wanting another), and emphasizing the parental imago as ideal more than punishing. So Kohut makes a break from Freud, emphasizing the narcissistic side of both conflict and structure, but then dresses up the result in refitted Freudian clothing so that in succeeding to fit universally, it fails to fit dissociation in particular.

Triadic Conclusion Triadic theories, which interpret psychic structure into three components, are all challenged by dissociative multiplicity as the triads don’t apply to the dissociative structure itself, which has no particular preference for ‘three.’ All call for major reconceptualization in the presence of more than one center of consciousness. However, these triadic structural theories of Freud (id/​ego/​superego), Fairbairn (central/​libidinal/​antilibidinal egos) and Kohut (mirror/​a lter-​ego/​ ideal), are interpretive schemas universally applicable to any given ‘I,’ any given center of consciousness, any alter, any dissociative part.

Dissociation and Schemata in General Object Relations Theory Object relations theory has been implicit in the discussions involving splitting, the structural theory, and especially Fairbairn. As noted, ego psychology regards one’s objects as representations of objects in the inner world, while the superego and Klein’s internal objects are structural entities in the internal world, about which one may then have secondary representations in one’s inner world. In this regard, object relations theorists (e.g., Fairbairn, Winnicott, Balint, Guntrip, Bion) reflect Klein’s interpretation (Hinshelwood, 1991). An object relations theory that abandons forced dyads and triads and embraces a general multiplicity of internal objects gets around one problem of accounting for multiplicity, but is left with another: since object relations theory help us understand the interpersonal schemata operative in any patient, underlying their attitude to others in the world, and especially to us in the transference, the theory helps us understand the interpersonal schemata operative in any given host or alter, underlying their attitude to others in the world and to their alters, and especially to us in the transference. I’ve never met a host or alter in whom I was unable to interpret an internal world of object relations distinct from the world that would represent the host and alters as a whole, concretely manifest in the inscape. So in the true multiple, there are two very distinct levels of internal object relations, and the theory itself would need to explain that difference.

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Attachment Theory Attachment theory also invokes internalized object relations schemata under the label of Internal Working Models (IWMs). John Bowlby’s conceptualizations derive from a number of different sources (Sigmund and Anna Freud, Klein, ethology, systems theory, direct observation of parents and children, etc.), and so the resultant system has not been assimilated by any one psychoanalytic school without difficulty. Bowlby’s work has been interpreted as enriching many areas of psychoanalysis (Fonagy, 2001), and, to the contrary, of being essentially nonpsychoanalytic (Zepf, 2006). At one extreme, it may be seen as rescuing psychoanalysis from scientific error by bringing in elements of an updated natural science (ethology), and at the other extreme of being irrelevant because it doesn’t all derive “from the couch.” Peter Barach (1991) first proposed interpreting MPD as an attachment disorder. The late Giovanni Liotti (1999, 2004, 2009) made major advances, with further advances by Adriano Schimmenti (Chapter 10, this volume). The journal of The Bowlby Centre in London, Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, is a major source of publications bringing together attachment, dissociation, and relational psychoanalysis. The emphasis shifts from trauma to neglect, from the abuser to the uninvolved parent: not so much the bad things that happened to the child, but the good things the child did not get from the nonabusing parent –​the absence of a secure base. The literature on attachment and dissociation is enormously bolstered by the very large literature on attachment and allied concerns (e.g., child development, mental state theory, early trauma and deprivation, PTSD, personality disorders -​especially borderline, the interface with the neurosciences, etc). There seems little doubt that psychoanalysts who are able to incorporate attachment theory in all its complexity would be better able not only to critically evaluate a host of psychoanalytic theories, but also to reincorporate hypnoid hysteria: dissociative multiplicity. Hypnoid hysteria now tends to be called ego-​state theory or self-​state theory, and these theories have cross-​fertilized with attachment theory for a number of years. For further reading on this topic, please refer to the excellent chapters that discuss attachment and dissociation elsewhere in this book (e.g., Linde-​K rieger, Yates, & Carlson, Chapter 9; Schimmenti, Chapter 10; Schore, Chapter 11).

Dissociation and States of Mind Back to Breuer’s Hypnoid Hysteria We are returned to Breuer’s hypnoid hysteria as the earliest psychoanalytic example of a ‘state of mind.’ The concept has only recently begun to recover since Freud made his primal category mistake. It is interesting to wonder how psychoanalysis might have evolved if Freud had been able to go beyond Janet, and conceive of the induction of hypnoid states as defensive, and not merely as a fragmented effect of constitutional weakness. And then, of course, also adding defensive repression as well. A good example of how psychoanalysis might have evolved is represented by Richard Kluft, an IPA psychoanalyst who has been a leading figure in the dissociation field for the past 45 years in all its aspects (Kluft, 2003): diagnosis, treatment, teaching, research, publication, editing, etc. While remaining a psychoanalyst, he also mastered hypnosis to the point of rising to the forefront of that field,34 a trajectory which has led him to publish very widely outside the ‘psychoanalytic literature’ with just two notable exceptions (Kluft, 1999, 2000). Kluft’s eclectic theoretical origins and his seamless incorporation of formal and informal hypnosis into the process of treatment makes it difficult to discuss Kluft’s ‘psychoanalysis of dissociation,’ but then his work (see 2009, Chapter 43, this volume) clearly speaks for itself.

Federn’s Ego States and the Watkins’ Ego-​State Therapy It is curious that Paul Federn was dubbed “Apostle Paul” by his colleagues for his religious devotion to Freud and the psychoanalytic movement (Accerboni, undated). Federn analysed Edoardo Weiss, who founded the Italian psychoanalytic society before emigrating to Chicago, where he analysed the late Jack Watkins.35 It was through this route that Federn’s (1952) seminal ‘heresy’ regarding ‘ego states’ took root, sprouted and flowered into ‘ego state therapy’ (Watkins & Watkins, 1997),36 familiar to virtually everyone in the dissociation world. Watkins, a psychologist non-​physician, was not permitted to join the American Psychoanalytic Association (APsaA). This is perhaps fortuitous, as close affiliation with the APsaA may have precluded his subsequent theorizing and hypnoanalytic innovations, and constrained him to ego psychological orthodoxy. The Watkins’ book (1997) is a welcome summary of their contributions over the previous four decades, and elevates Federn’s ‘ego state’ construct to a general interpretive schema. This schema well describes and instructs the therapy of

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the most severe dissociative patients. But it is also an interpretation of normal-​neurotic patients generally as suffering from symptoms understood as dissociative. That is to say, in patients who are not manifestly dissociative in the diagnostic sense, the Watkins, in using hypnosis as a general therapeutic adjunct, are able to have patients encounter the ego states which ‘hold’ whatever symptom, affect, conflict, deficit, whatever, is in question, or in relation to whom the ‘host’ is in conflict. This amounts to interpreting all psychopathology as subclinical multiplicity. Like Fairbairn’s theorizing, it eclipses Freud’s drive theory, topography, and structural theory in favor of an expanded interpretation of Federn’s concept of ego state, and accords very well with Fairbairn’s idea of subsidiary egos, though without being hamstrung by his libidinal-​antilibidinal splitting. This general applicability exemplifies what they call the differentiation-​d issociation continuum. There is little question about the approach being faster than traditional psychoanalysis. Jack Watkins’ perennial complaint about psychoanalysis was how slow and time-​consuming it was (personal communications). The approach invites a variety of questions. Assuming that DID is real, then there is no question about the ‘reality’ of alters. But those who don’t have DID, and in whom ego states may be ‘discovered’ under hypnosis, an interesting research question is whether these ego states are pre-​existent, or rather hypnotically created at the time of ‘discovery.’ ‘Truth’ and therapeutic efficacy are independent, of course, so positive therapeutic outcome can’t decide the matter. Nor would the creation be a contrived artefact of the treatment, to the extent that it appropriately ‘packaged’ the pathology into a subjective ego structure and rendered it capable of speedy resolution. The issue is one which will likely be debated for years. And while ego state theory may best describe multiplicity, which is not to say that it explains it. The Watkins retained a number of classic psychoanalytic constructs in their explanations: energy economics of the self, self and object cathexis and decathexis, object relation, abreaction, adaptation, etc. As with Klein, the problem has to do with explaining the difference between subjects and objects. Federn conceived of there being a variety of mental objects, comparable to Kleinian internal selves and objects, and these could then be invested with more or less ego energy or cathexis.37 But “energy” is also a mental object, in the mind of the theorist, and calling it “ego energy” (in whatever language) hardly explains its character as subjective agency. We don’t generally converse with energy. Ego-​state theory thus tries to recycle Freud’s Q: his energic or economic viewpoint, his pseudoscientific fairy tale. Updated versions of the metaphor invoke information-​processing, but also miss the point: while information can be thought, it cannot think. Information can, however, be duplicated or proliferated, so that information-​processing at least provides a metaphor for alter genesis other than splitting.

Putnam: Discrete Behavioral States Independent of psychoanalysis, Frank Putnam, who authored the premier classic text on MPD (1989), has since drawn on research into infant behavioral states especially as described by Wolff (1987), and proposes a “Discrete Behavioral States” (DBS) model to describe and explain the derivation of normality, ego or self-​state disorders, and frank DID from infant behavioral states (Putnam, 1997; see Loewenstein & Putnam, Chapter 16, this volume). He has since generalized his interest in states of mind with a remarkable recent book (2016) concerning the origin of states of mind generally and the role they play in memory, identity, personality, and various psychopathologies. This approach promises to clarify the Breuer-​Freud split by beginning at the heart of the matter. The DBS model has already yielded a very detailed elaboration even for the perfectly normally developing child, an elaboration which clearly sets the stage for speculating about pathological development. To explain DID, with its multiplicity of self-​states, evident most often in adulthood, and with a supposed early childhood origin, Putnam begins with the finite set of well-​described infant states of mind, very closely related to attachment theory; state switches, not just in MPD/​DID, but also in panic attacks, catatonia, and manic-​depression; state-​dependent memory, especially autobiographical memory, and how this affects identity; the contribution of mental states to personality traits, but also how such theories fall short of explaining “secret lives”: people who have two distinct self-​states with dramatically different sets of personality traits. Putnam ably deals with what I had regarded as a difficulty with the theory when applied to DID: the question as to whether some ‘quantum leap’ is required to explain how I can have a whole set of states of mind, but apparently can manifest another whole set of states of mind which seem to be as if another’s whole set of states of mind. He describes the evolution of such clusters of states of mind, seen to some extent in all humans, but most dramatically in DID, when the clustering becomes more complexly and hierarchically nested. Between the normal multiplicity of states of mind, and cases of DID, Putnam’s treatment of “secret lives,” highlighting religious zealots and politicians, is perhaps the most interesting, clearly eclipsing any personality disorder explanation, but also different from DID. In my view, his “secret lives” resonates most with Freud’s Splitting of the ego in the process of defense (1940; see above under Brenner: Reducing dissociative multiplicity to perverse splitting).

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Interpersonal and Relational Psychoanalysis As I noted above, the interpersonal and relational schools of psychoanalysis have produced the most significant and voluminous contributions to dissociation in the psychoanalytic literature, and so I refer the reader to the appropriate chapters (see Bromberg, 2009; Howell & Itzkowitz, Chapter 45, & Stern, Chapter 20, this volume). Especially significant in this development is the smooth incorporation of attachment theory which has proven to be not only a link between psychoanalysis and empirical research in general, but also a link between American and British ‘heresies.’ Interpersonal and relational paradigms may in part be an unintended but welcome side effect of the prior exclusion of nonphysicians from the American Psychoanalytic Association 38 (APsaA), which gave rise to a variety of societies with otherwise perfectly ‘orthodox’ roots but which, by virtue of that very exclusion, were freed from the constraints of ongoing APsaA oversight, and able to evolve independently. A key historical event was ending the APsaA monopoly in 1989, allowing for non-​A PsaA societies to have direct membership in the International Psychoanalytic Association. A PEPWeb search for “multiple personality” or “dissociative identity disorder” by decade yields an average of only eight publications per decade for the period 1900–​1970; this increases to 26 for the 1970s; to 65 for the 1980s; and then jumps to an average of 235 per decade for the 1990s to 2020. This is all cause for optimism as the twenty-​fi rst-​century rediscovers, reappropriates and broadens knowledge and insight from the late 1800s.

Needed Research Researchers have little time to spend in prolonged empathic immersion with a given patient. And depth psychotherapists of whatever stripe have little time to spend in prolonged research design and data analysis. I am a psychotherapist and so my comments are more conceptual and clinical than research-​oriented. Hypotheses need to be formulated before they can be tested. There is no privileged source of scientific hypotheses, which is why both psychiatry (concerned with the diagnosis and treatment of the mentally ill), and psychoanalysis (concerned with the psychotherapeutic through open-​ended regular empathic immersion in the mind of another), after being filtered through colleagues and after arriving at some degree of consensus, can be so fertile for the generation of various hypotheses and even of elaborate diagnostic and explanatory systems about the human mind. But while such clinical experience can give rise to bumper cash crops, it can also result in a luxuriant overgrowth of weeds. The primary vocation of research is to do the weeding. Clinical experience comes up with bright ideas, and research shoots down the faulty ones. This relationship is irreducibly dialectical, and there is no way around it. ‘True’ theories are not so much evidence-​based as evidence-​v ulnerable. There is also no way around the self-​reference implicit in any psychology, and especially in any psychotherapy. This self-​reference is intrinsic to the problem of consciousness, and to any interpretive discipline regarding human intentionality. Psychoanalytic theories need to be tested against evidence, of course, but psychoanalysis also needs to be free to analyze proponents of those who hide behind scientistic methodologies in order to protect themselves from real encounters with life, and distasteful truths. Guile is core in the behavior of all metazoans, and raised to an exquisite art form in the human species, and psychoanalysis must remain free to circumvent it. That being said, it also seems to me that psychoanalysis has suffered from a century-​old selective blindness inherited from Sigmund Freud with regard to severe repetitive trauma happening during early development and the kind of psychopathology that results in the adult. The blindness includes willful ignorance about hypnosis. Solving the theoretical issues among the various camps requires first and foremost communication. Technical jargons differ. Resolution of interpretive questions would be helped by the following: 1. Dissociative multiplicity be considered part of the routine differential diagnosis in psychiatric, psychoanalytic and psychotherapeutic clinics. 2. Psychoanalysts include ‘hypnoid hysteria,’ states of consciousness, dissociation, multiplicity, body memories, the inscape, etc., in what they routinely look for in treating analysands. These modest recommendations are asking a great deal from some traditions. But until multiplicity is widely recognized and treated with eyes open, without apology, its psychotherapeutic treatment will be unpredictably compromised by selection bias in the patient sample and those inevitable blinders that all therapists wear, whether they know it or not.

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A Summary View Dédoublement One of the most primitive defenses available to the child is the hypnoid (hypnosis-​l ike) defense of auto-​duplication. I say auto-​duplication rather than self-​duplication so as not to imply that it is the child’s self, as one of its intentional objects, that is duplicated. The duplication is rather of subjective agency: of the ‘I’ rather than of the ‘me’ or ‘self ’; of the Ich or Ego; of ‘le je’ and not ‘le moi.’ From among various historical designations, dédoublement (doubling) would be closest to what I intend, as the action is essentially multiplicative rather than divisive. Dédoublement may occur if 1. the child has the capacity to do so –​this is most likely hypnotizability (Dell, Chapter 14, this volume); 2. the trauma is some combination of sufficiently early, severe and repeated; 3. There is no one available to appropriately rescue, soothe and comfort the child. Naturally, 2 and 3 are related, as if there were someone available to appropriately soothe the child, then the trauma would tend not to be repeated. Thus hypnotizability, trauma and disordered attachment are prerequisites for dédoublement.

Weakness vs Defense In this formulation, I opt, structurally, for Breuer’s hypnoid hysteria over Freud’s repression and, dynamically, for Freud’s active defense over Janet’s fragmentation due to weakness. This circumvents what I dubbed as Freud’s primal category mistake of assuming that the hypnoid state could not be the result of an active defense. At the same time, the formulation does allow for a little of Janet’s weakness in the age of onset –​early childhood –​with the implication that the elements of multiplicity in the adult must have been there from early childhood. But this weakness does not reflect constitutional deficit. If anything, it may reflect constitutional propensity to dissociate as a specific ability, and this may be identical to auto-​hypnotizability, especially in the young child. The active and creative aspect of the defense of dédoublement is consonant with a ‘remorselessly Darwinian’ view of mentation, to the extent that all mental contents and structures can be interpreted as being internally generated and acted upon selectively (never instructively) by environmental signals. To that extent, metaphors that connote instruction, such as induction, internalization, incorporation, introjection, intromission, alien haunting, etc., mislead, to the extent that they imply that something literally gets in from the outside. Other metaphors such as imitation and identification do not mislead in that sense.

Full Adult DID The paradigm case of dédoublement is somebody with full DID in whom the creative defense has been used repeatedly and become something of the default defense. Such a patient will have amnesia or lost time due to switching without co-​consciousness. We may erroneously claim that they experience themself as having distinct identitites, when this claim pertains more to the clinician: the patient may honestly deny experiencing themself that way –​at which point the clinician may wish that they experienced themself the same way the clinician experienced them. This remains the ‘hard case’ which psychoanalysis needs to accommodate.

Repression as a Defense In opting for hypnoid states as the result of an active defense, I do not replace or supplant Freud’s repression as a defense. Indeed, the attempt to reduce repression to dissociation leads to an infinite regress. In any frank multiple, it is common for distinct alters to have body memories of a repressed traumatic event (or series of events), and, less commonly, classic conversion symptoms (somatized wishes). When a host has amnesia for an event, it may well be that repression is not in play, because the event is ‘located’ in a dissociated alter. In that circumstance, explaining the amnesia by repression is an error. But the alter may likewise have amnesia for the event because it is repressed in the alter itself. Thus, defensive dissociation and defensive repression both operate and can be distinguished. They can most clearly be distinguished when they co-​occur in the same patient. A separate question is whether one is dealing with a traumatic event or a forbidden wish. A somatic symptom is commonly both dissociated from the host (say) and repressed in the alter concerned. What is repressed is commonly a traumatic event, so that the symptom is not, strictly speaking, a conversion symptom at all, but rather a partial posttraumatic revivification of the event, or what are succinctly called ‘body memories’ in the dissociation and trauma fields.

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However, it may be a classic conversion symptom: not a body memory, but rather a somatoform compromise formation between a wish and a defense.

Polar Splitting of Self and Object Representations In opting for dédoublement, a multiplicative rather than divisive concept, I do not supplant the classic Freudian or Kleinian polar splitting of self and object. Splitting and dissociation cannot account for each other. Splitting is a primitive style of mental categorization which predates ambivalence. No adult is entirely incapable of either splitting or ambivalence, and no measure of dissociative multiplicity is required for either. Anyone may have a greater propensity to split or to be ambivalent; the former tends to be labelled borderline and the latter normal neurotic. Dissociative multiplicity predates polar splitting, and the child who is able to effectively split needn’t engage in dédoublement. Similarly, both splitting and ambivalence are ‘available’ as defensive styles to host and alters.

Id, Ego, Superego, and Other Triads Freud’s most concrete evocation of a variety of multiplicity is his structural theory of Id, Ego and Superego. Of the three, only the Ego is really a subject, however, a role betrayed by its name, Ego, I, the subject of the verb (or of the defense mechanism). The Id is on the border of biology and mentation; and the Superego is the personification of one’s conscience. There is merit in considering whether someone’s Superego is rather a dissociated self-​state or alter personality. This ought to enter routinely into the ‘differential diagnosis’ of anyone with a Superego which seems to go beyond the ‘norm,’ such as being too harsh, or arbitrary, or idiosyncratic in one way or another. But the Superego, in general, cannot be reduced to a dissociated self-​state. That is because any patient with DID will have alters who themselves are not devoid of consciences, and some who will have relatively well-​delineated and personified consciences (i.e., Superegos), just as they may have lively internal object representations. Postulating two levels of Superego: 1. an alter who poses as the host’s conscience, and 2. the set of subordinate Superegos variably personifying the individual consciences of host and alters, including of the alter posing as the Superego, generates an infinite regress, and so must be avoided. An apparent Superego may prove to be an alter; but not all consciences are alters; especially as alters commonly have consciences.

Internal Object Relations, Attachment, IWMS, Templates, Schemas These approaches get beyond the triadic limit. The absence of someone to soothe the child can best be understood in terms of attachment pathology, and lends credence to the claim that dissociative multiplicity is essentially a result of disturbed attachment. The attachment paradigm works primarily from the stance of the external observer. This is what renders it so amenable to empirical test. The internal working model (IWM) of attachment theory has a counterpart in object relations theory: the internal object relation, which is a representation of the relation between a self-​representation and an object-​representation. What all such schemata have in common is a patterning of self-​other relationships. A case can always be made that one’s alters are simply one’s internal objects which have somehow become subjects, using such ideas as cathexis by ego energy, or whatever. But all such explanations are a way of hypothesizing subjectivity as a kind of conservable fluid that can flow into this or that internal object to endow it with subjectivity: covert translations of the mistaken ‘hydraulics’ of Freud’s Project. The internal-​object-​become-​subject poses another conundrum. Alters may function as relatively full psychological subjects. Consequently, their mentation is similarly interpretable in terms of their own repertoires of internal object relations, or IWMs, or templates, or schemata, some of which may overlap or coincide with those of the host or other alters, and some of which may prove to be unique. So we would then need two levels of object relation, a supraordinate one constituting the field of host and alters, and a set of subordinates ones variably characterizing the individual repertoires of the host and alters.

States Multiplicity is unquestionably a disorder of mental states, as has been conceptualized in that way from the beginning. There are two challenges facing any mental state theory: 1. to account for the difference between self-​states that define the alters of somebody with DID, and the various self-​states of any given alter; 2. To answer the original Janet-​Freud question: to what extent is the appearance of an alter due to a failure to integrate self-​states, and to what extent is it a

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purposive creative act of defense? Putnam (2016) has gone a long way to explain the complexity of hierarchical nesting of self-​states in DID.

Technique There is no consensus about altering ‘classical’ technique for DID analysands. Relational psychoanalysis is the current major alternative, but also with variable use of the couch, variable use of adjunctive techniques, such as hypnosis and EMDR, variable mixing of paradigms, with approaches borrowed from CBT and ego-​state therapy, a tendency toward fewer but longer sessions per week, variable use of techniques from child analysis (especially for child alters), etc.

Psychoanalysis and Multiplicity: Recent Developments In the first edition of this chapter (O’Neil, 2009) I interpreted the major ongoing obstacle to the smooth re-​adoption of multiplicity by psychoanalysis to have been Freud’s personal rejection of hypnoid hysteria and hypnosis at the dawn of psychoanalysis itself. While this rejection manifested a category mistake with suspect motives, psychoanalysis, like any other interpretive discipline (e.g., any psychotherapy) is formulated so as to be able to interpret anything and everything, shielding it from refutation. This goes for the various flavors of psychoanalysis; it also goes for the general construct of dissociative multiplicity, as is clear from the ego-​state therapy tradition. I had wondered whether interest in dissociative multiplicity would achieve critical mass: a sufficient number of IPA analysts who would be prepared to look for it, recognize it, and undertake to treat it. Would the psychoanalytic treatment (with or without so-​called parameters) of dissociative multiplicity approach the ‘average expectable’ range of case reports, etc., effectively reincorporating ‘hypnoid hysteria’ back into psychoanalysis? There have been some notable contributions in the past decade, which do not skirt the issue. As expected, most come from relational psychoanalysis (which includes the Bowlby Centre’s Attachment journal). To name just a few examples, Rothschild (2009) has a significant DID case report concerning integration; Baker (2010) presents a DID case describing the emergence of a cohesive sense of self out of eight self-​states; Epstein (2011) presents a DID patient with anorexia and a history of ritual abuse, in therapy for five years, with a focus on her achieving the leap “from object use to intersubjective relatedness”; Wolk, Savoy and Frederick (2012) present an fMRI study of switching in a DID case, and discuss how this might also apply to the vertical splitting described by Kohut; Sachs (2013) has a case illustrating the interrelationship of attachment, ongoing abuse, and DID; MacIntosh (2013) compares the trauma model with a relational psychoanalytic model for the understanding and treatment of dissociation, with proposals for their integration; Shahar (2016) focuses on relational body psychotherapy in addressing ‘disembodiment’ and ‘bodily homelessness,’ with the curious absence of any reference to depersonalization. Declining to correct Freud’s primal category mistake commonly requires imbuing mental objects with subjectivity. An implicit side effect of this contrivance is some sort of infinite regress. Important sources of clarification and correction will continue to be biological, ethological and social scientific, and also broad social developments beyond the sciences. Attachment theory has interdisciplinary roots which link psychoanalysis to biology, animal behavior and neuroscience. Neuroscience itself will continue to accelerate. Social movements, instrumental in changing ideas about women, then homosexuality, and currently transgender and related issues, now also include multiplicity, with websites providing information, online support groups, discussion groups, etc., with the usual admixture of signal and noise. The key to further psychoanalytic progress in this field is thus the same as in the psychiatric field: the need for dissociation to be become generally recognized as a predictable portion of the average expectable psychopathology one would encounter in any clinic.

Notes 1 In psychoanalysis, fantasies are conscious, while phantasies are unconscious. 2 See, e.g., Bromberg (1998), Davies (1998), and Howell (2005, 2011). 3 Very briefly, the Fallacy of Affirming the Consequent (FAC): [(H ⊃ P).P] ⊃ H. Hypothesis H implies prediction P, the consequent, and P is affirmed (found to be true), which we mistakenly take to imply the truth of H. The language has eroded over time. Logical positivists invoked ‘verification,’ which connoted implication of truth, and since this never occurs, it was serially downgraded to ‘confirmation,’ then to ‘corroboration,’ and now to ‘support,’ which still means nothing at all, except “not refuted when it might have been.” The FAC is obtained by tampering with one of two tautologies: Modus Ponens (tautology of affirming the antecedent) or Modus Tollens (tautology of denying the consequent). 4 From scientism =​excessive belief in the power of scientific knowledge and techniques.

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5 The most straight-​forward refutation of this is Swanson, 1977. 6 To avoid confusion, I use ‘themself ’ when the subject ‘they’ is intended to be nonbinary singular. 7 Strictly speaking, the doctrine of ‘psychic determinism’ is self-​refuting. If all mental phenomena are causally determined, then so are all mental products, including all doctrines, such as the doctrine of psychic determinism, at which point no doctrine can maintain any claim to truth but rather reduces to just another bit of behaviour warranting a causal explanation in the psychic determinism governing the one making the claim. Psychoanalytic psychic determinism and behaviourism have this in common. 8 The current ‘official’ figure is 1.5% of the general population, according to DSM-​5 (2013), as per Johnson et al. (2006). 9 Notable past exceptions are Lawrence Kubie (Silverstein & Silverstein, 1990) and Merton Gill (Hoffman, 1985). 10 My shamelessly free interpretation of the essential difference between phenomenology and hermeneutics. 11 Merton Gill (1988) succinctly summarize various sides to this conundrum up to 1988. 12 French verbes pronominaux (pronominal verbs) are a good example of self reflexivity, where the object is the subject, as in je me lave les mains =​I wash me the hands, rather than I wash my hands. 13 www.bri​t ann​ica.com/​topic/​pers​onal​ity 14 See www.apa.org/​top​ics/​pers​onal ​ity 15 E.g. Hippocrates, Galton, Allport, Cattell, Guilford, and the ‘Big Five.’ 16 www.merr ​iam-​webs​ter.com/​d ic​t ion​a ry/​pers​onal​ity 17 The oral tradition seems to have borrowed ‘inscape’ directly from the visual arts as intending an ‘internal landscape,’ rather than from Gerard Manley Hopkins who independently coined the term earlier, but gave it an unrelated meaning. 18 These bodies may be considered the body schemata of the respective alters, akin to virtual bodies in virtual reality. I prefer ‘phantom’ body to relate it to the older concept of phantom limb. 19 An excellent published autobiographic example is detailed by Robert Oxnam (2005). 20 PEP –​Psychoanalytic Electronic Publishing: https://​pep-​web.org/​ 21 International Psychoanalytic Association, headquartered in London. 22 Blum’s paper, Dissociation and its disorders, cites Dell & O’Neil (2009) early on, so its title may be a sardonic nod to Dissociation and the Dissociative Disorders. 23 This argument borrows from Young (1988). 24 Identification with the aggressor is most often associated with Anna Freud (1966), but the concept originates with Sándor Ferenczi (Frankel, 2002). 25 Named after a short story by Washington Irving published in 1819. 26 W. C. M. Scott (1903–​1997), a Klein analysand, former co-​editor of the International Journal of Psychoanalysis (1947–​62), and one of the founders of the Canadian Psychoanalytic Society (Scott, 2001). 27 Spaltung, Freud’s first sense of the word, the splitting of consciousness, or dissociative multiplicity. 28 In agreement with Steele, Van der Hart, & Nijenhuis (2009). 29 Bertha Pappenheim, who had hypnoid hysteria, or DID. 30 As the negative of Alfred North Whitehead’s (1925) oft-​cited “fallacy of misplaced concreteness”: misinterpreting an abstract belief, opinion or concept as physically or ‘concretely’ real. 31 See Williams (1994) for a study reflecting just this pattern. 32 Freud used the letters rather than the words when intending to denote parts of the psychic system. 33 Such as is summed up in the medical training adage: “See one, do one, teach one.” 34 He has been President of the American Society of Clinical Hypnosis, and of the Society for Clinical and Experimental Hypnosis. 35 John Goodrich Watkins, 1913–​2012. 36 A work he coauthored with his late wife, equally celebrated, Helen Watkins (née Helyanthe Maria Wagner), 1921–​2002. 37 When translating Freud’s plain German “besetzung” into English, Strachey (1966) instead picked the Greek term cathexis, meaning “a holding in” or “that which is held fast.” The nearest English cognate is “beset,” so “that with which one is beset”; the French chose to translate the plain German into plain French, and came up with “investissement,” roughly, “investment,” meaning the quantity of whatever, in this case psychic energy, with which something is invested. 38 This was done by A. A. Brill, against Freud’s (1926b) very clear preferences to the contrary. Canada and Latin America, in contrast, followed the international model.

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Etiological and Developmental Considerations

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9 A DEVELOPMENTAL PATHWAYS MODEL OF DISSOCIATION Linnea B. Linde-​Krieger, Tuppett M. Yates, and Elizabeth A. Carlson

Dissociation is a phenomenon of long-​standing interest in the psychological sciences, one that is often (mis)characterized as a unilaterally pathological deviation from normative functioning. In fact, dissociative processes range along a continuum of severity from short, often situation-​dependent, normative episodes such as daydreaming, to prolonged or frequent episodes that interfere with individual functioning, to profound disturbances in the self and disintegration across biological, emotional, cognitive, and behavioral systems (American Psychiatric Association, 2013; Putnam, 1991). Dissociative phenomena reflect psychobiological processes that alter the accessibility of memory and knowledge, the integration of emotion, cognition, and behavior, and the sense of a coherent self. These processes may manifest as disturbances of affect regulation (e.g., depression, mood swings, feelings of isolation), identity disruptions (e.g., splitting, fragmentation), autohypnotic phenomena (e.g., trances, time distortions, psychogenic numbing), memory dysfunction (e.g., psychogenic amnesia, fugue), revivification of traumatic experience (e.g., flashbacks, hallucinations), and behavioral disturbances (e.g., inattention, poor impulse control, self-​harm; Hornstein & Putnam, 1992). Importantly, the expression, intensity, and adaptive significance of dissociative phenomena change across the developmental continuum. Thus, a developmental approach is integral to advancing dissociation research and clinical practice. In this chapter, we illustrate how the integrative framework of developmental psychopathology and the corresponding tenets of an organizational perspective on development can advance research on dissociation as well as applied efforts to prevent its pathological expression. First, we emphasize that dissociation is a normative expression of cognitive and regulatory patterns in early childhood which may or may not consolidate over time in ways that compromise adaptation. Second, we describe normative changes in the expression and adaptive significance of dissociative processes across development. Third, we distinguish factors that initiate pathological dissociative processes as potentially distinct from those that maintain or exacerbate their expression over time. Informed by these principles, we describe a developmental pathways model of dissociation as illustrated by new findings from our own research showing that both caregiving behavior and caregiver state of mind during early childhood predict atypical trajectories of dissociation across childhood. Finally, we identify promising directions for future research and applied efforts to mitigate the development of pathological dissociative processes.

A Developmental Psychopathology Perspective on Dissociation As the study of the origins and course of individual patterns of adaptation, developmental psychopathology provides a valuable framework for integrating diverse theoretical accounts of dissociative processes (e.g., Cicchetti & Dawson, 2002; Sameroff, 2000; Sroufe & Rutter, 1984). Importantly, developmental psychopathology encourages process-​level analyses of experiences that probabilistically initiate maladaptation, modify the expression of disorder, and account for the maintenance or desistance of maladaptive pathways and patterns over time (see Carlson & Ruiz, 2016; Cicchetti, & Tucker, 1994; Yates et al., 2011). Moreover, this integrative framework values multiple levels of analysis in recognition

DOI: 10.4324/9781003057314-12

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150  Linnea B. Linde-Krieger, Tuppett M. Yates, and Elizabeth A. Carlson

that all adaptive processes (including dissociation) encompass both internal and external influences on biological and psychological transformations and reorganizations over time (Cicchetti & Dawson, 2002). The organizational perspective on development incorporates core principles of developmental psychopathology within a theoretical model that yields testable hypotheses about the nature of both typical and atypical development (Labella & Cicchetti, 2017; Sroufe, 2009). In this view, development encompasses a series of qualitative reorganizations whereby earlier patterns of adaptation provide a framework for, and are transformed by, later adaptations. At all ages, the organizational perspective defines adaptation with respect to how the quality of integration among domains of functioning support or thwart the individual’s negotiation of salient developmental issues (Cicchetti & Dawson, 2002). Positive adaptation reflects the integration of biological, emotional, cognitive, and behavioral capacities in a way that promotes the flexible negotiation of concurrent and future developmental issues, whereas maladaptation reflects developmental deviations from typical patterns of adaptation that compromise or constrain subsequent development (Cicchetti & Toth, 2016; Sroufe, 2009). In this way, development is cumulative, and successive adaptations represent the combined influence of contemporaneous experience and development up to that point (Bowlby, 1973; Sroufe, 2005). The organizational perspective holds that individuals actively participate in the construction of experience, whether adaptive or maladaptive, by interpreting and selecting experiences that are consistent with their developmental history (Carlson et al., 2004; Sroufe, 2009). Across both competent and disordered patterns and pathways, relations among successive adaptations are probabilistic, rather than pre-​d etermined (Hollenstein, 2012; Smith & Thelen, 2003). Thus, a single developmental starting point may yield divergent outcomes (i.e., multifinality), while different patterns of early adaptation may converge on a single developmental endpoint (i.e., equifinality; Cicchetti & Rogosch, 1996). The focus of an organizational investigation rests on patterns of adaptation, rather than on continuities in manifest discrete behaviors over time (Sroufe, 2009); developmental coherence occurs at the level of adaptive meaning and function (Sameroff & Chandler, 1975; Wichstrøm et al., 2017). The same observable behavior (e.g., the child’s dependence on caregivers) may promote competence at one point in time or in one context, yet undermine it at another depending upon how the individual’s developing capacities interface with environmental resources and demands. In this way, the organizational perspective illustrates a central tenet of developmental psychopathology –​normal and atypical developmental patterns are mutually defining and informing (Labella & Cicchetti, 2017). Efforts to identify and understand pathological pathways of dissociation must begin by examining normative expressions and patterns of dissociation across development. In a developmental psychopathology framework, dissociation, like all psychopathology, represents a problematic elaboration of otherwise adaptive capabilities (Yates et al., 2011). As in adults, dissociative processes in children and adolescents include alterations in memory, identity, and perception that reflect and/​or precipitate disconnections across biological, emotional, cognitive, and behavioral systems (Putnam, 1997). However, some degree of dissociation, or experiential fractionation, is expected in early childhood (e.g., fantasy proneness, hypnotizability; Fischer & Ayoub, 1994; Putnam, 2000). Dissociative processes may be a natural expression of typical childhood cognitive structures and regulatory strategies prior to the child’s transition to new levels of integrative organization (Cole et al., 1996; Fischer & Ayoub, 1994). In this view, the young child’s mind is naturally fractionated prior to developing the ability to process and integrate complex or contradictory experiences (e.g., early compartmentalization of positive versus negative views of self and other, or of good versus bad experiences; Harter, 1998; Putnam, 1991). Fischer and colleagues refer to children’s natural tendency toward fractionation in advance of subsequent integration as “passive” dissociation, whereas, “active” dissociation is a motivated systemic response to dysregulating or traumatic experience. Processes of active dissociation make use of the child’s natural proclivity for compartmentalizing affect and experience in ways that stymie, rather than promote, subsequent integration (Fischer & Ayoub, 1994; Fischer & Pipp, 1984). Children, adolescents, and adults differ not only in their cognitive capacity to recognize discontinuities in their behavior or sense of awareness, but also in their subjective distress about perceived inconsistencies. Consequently, the expression of dissociative symptoms may not have the same meaning across development. Given that proto-​d issociative behaviors typically decline across childhood as children achieve increasing levels of organization and integration (Ogawa et al., 1997), maladaptive dissociative expressions in later development may reflect the absence of a typical decline in dissociative tendencies and/​or an atypical increase in dissociative processes. Moreover, whereas dissociative behaviors may be natural (and prevalent) in early childhood, the significance and complexity of dissociation as an indicator of psychopathology may increase with age and more advanced modes of thought (Putnam, 1997; Wieland, 2011). Benefitting from adaptive dissociation early on, typical development and self-​organization progress towards greater flexibility, complexity, and integration across diverse aspects of experience (Sroufe, 1996). In pathological dissociation, however, development progresses toward greater complexity without complementary integration (Carlson et al., 2009).

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A Developmental Pathways Model of Dissociation  151

The Etiology of Dissociation The organizational perspective on development holds that the origins of self-​regulation lie within early biological, emotional, cognitive, and behavioral experiences of co-​regulation in the primary caregiving relationship (e.g., emotional attunement, distress modulation; Labella & Cicchetti et al., 2017; Sroufe, 1996; see Schimmenti, Chapter 10, this volume & Schore, Chapter 11, this volume). Experiences within the caregiving environment may support or distort children’s emergent regulatory capacities, such that receipt of sensitive, responsive care promotes adaptive functioning, whereas inadequate or aversive care instantiates maladaptation (Bowlby, 1973). Responsive caregiving enables young children to maintain organization in the context of internal arousal and/​or external threat, which, in turn, supports their emergent confidence that their emotions (both positive and negative) can be understood and managed (Bowlby, 1969/​1982; Denham et al., 2015; Lieberman, 2017). A history of responsive care provides children with access to both affectively-​and cognitively-​generated information. Over time, these experiential dimensions are integrated with increasing complexity and flexibility to meet intra-​and interpersonal demands. In contrast, when a child’s emotions repeatedly fail to achieve their purpose, when they are persistently activated without resolution, or when their expression is blocked or punished, emotions may become segregated from important relationships and experiences. Thus, repeated experiences of contradictory or overwhelming emotional experience in childhood, particularly in the absence of a supportive caregiving relationship, may consolidate normative dissociative propensities into rigid patterns of pathological dissociation. Research demonstrates that major disturbances in care, particularly early-​occurring and chronic maltreatment, are salient etiologic factors in the development of pathological dissociation. Maltreatment is consistently associated with elevated levels of contemporaneous dissociation within childhood (Byun et al., 2016; Hebert et al., 2020; Macfie et al., 2001; Ogawa et al., 1997). Moreover, adult research suggests these relations extend over time with evident links between dissociation and childhood sexual abuse, physical abuse, and neglect in both nonclinical (e.g., Schimmenti, 2018; Selvi et al., 2012; Vonderlin et al., 2018) and clinical (e.g., Frewen et al., 2014; Kefeli et al., 2018; Zanarini et al., 2000) samples. In addition to robust evidence supporting the etiologic role of early childhood maltreatment in the development of dissociation, some research suggests that more subtle disturbances in the parent-​child relationship may lead to elevated levels of dissociation in later development. Experiences of insensitive or contradictory, though not overtly abusive, care can disrupt child development. In particular, experiences of intrusive care, in which the caregiver misreads or ignores the child’s cues in a way that communicates a lack of respect for the child as an individual, can undermine the child’s emergent capacities for regulation and integration (Carlson et al., 1995; Mortensen & Barnett, 2019; Rudd et al., 2017). Likewise, caregiving characterized by undue hostility or low support may instantiate or exacerbate developmental vulnerabilities within and/​or across time. Investigations exploring the role of family environmental factors in the development of dissociation suggest that neglectful parenting (Schimmenti, 2018), low parental warmth and support (Modestin et al., 2002), poor parent-​child relationship quality (Maaranen et al., 2004), and infant attachment disorganization (Carlson, 1998) are associated with later dissociation. These findings are consistent with the principles of attachment theory, which posits that children’s representational processes (i.e., internalized expectations of self, others, and self-​in-​relation-​to-​others) and their regulatory functions develop in the context of early caregiving exchanges (Bretherton & Munholland, 2008; Schore, 2013). Expectations and attitudes regarding the self and others emerge in coordination with emotion regulation strategies (Sameroff & Emde, 1989; Waters et al., 2010) in ways that bias children’s reactions to subsequent experience (Gresham & Gullone, 2012; Sroufe, 1996). Thus, when infants experience care that is inconsistent or threatening, they may develop dissociated or unintegrated internal working models of the primary caregiver and, by extension, of the self. In turn, these representations function as information processing heuristics that magnify the disintegrative potentialities of subsequent stressful or traumatic experiences (Liotti, 1999). Prospective investigations of attachment have examined the role of caregiver-​infant relationship quality in pathways toward dissociation. In a seminal study, Ogawa and colleagues (1997) found that disorganized attachment and psychological unavailability of the caregiver prior to age two were the strongest independent predictors of elevated dissociation in late adolescence. Of note, psychological unavailability of the caregiver held more predictive power (accounting for 19% of the variance in dissociation scores at age 19) than disorganized attachment (accounting for 6% of the variance), and physical and sexual abuse did not add significant predictive power to the model. Moreover, as a testament to the probabilistic, rather than deterministic, pattern of adaptation over time, Ogawa and colleagues (1997) also found that some infants who were not classified as disorganized nevertheless developed maladaptive dissociation in late adolescence.

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This finding is consistent with subsequent studies yielding mixed relations between attachment disorganization and maladaptive dissociation in later development (Haltigan & Roisman, 2015; Smeekens et al., 2009). In a second longitudinal study of attachment and later dissociation, Dutra and colleagues (2009) found that the quality of mother-​i nfant interaction in the first 18 months of life accounted for half the variance in dissociation scores at age 19. While disrupted mother-​i nfant communication significantly contributed to elevated dissociative symptoms in late adolescence, neither childhood maltreatment nor infant disorganized attachment independently predicted later dissociation. These findings are consistent with Liotti’s (1999) suggestion that attachment disorganization may be one mechanism by which traumatic experience in the caregiving environment yields adaptational vulnerabilities, such as dissociation. This view counters the belief that dissociation results from trauma alone and posits a diathesis-​stress model wherein attachment disorganization renders individuals more vulnerable to the consolidation of pathological dissociative processes in the wake of ongoing or subsequent trauma. It is particularly noteworthy that Dutra and colleagues (2009) found “quieter” caregiving disruptions, such as a lack of positive maternal affective involvement, disrupted mother-​child communication, and flat maternal affect, which is a construct similar to the psychological unavailability noted by Ogawa et al. (1997), predicted late adolescent dissociation scores, whereas, maternal hostility/​ negativity did not predict later dissociation. Taken together, previous prospective studies support multiple developmental pathways to dissociation and suggest that parent-​child relationship factors beyond infancy and beyond those associated with childhood maltreatment may be important predictors of problematic dissociation in later development. Thus, processes by which dissociative phenomena in childhood canalize into problematic dissociation depend upon features of the caregiving environment (e.g., qualities of caregiver-​child interaction, caregivers’ state of mind regarding the parent-​child relationship) and upon the developmental capacities of the child (e.g., capacities to self-​soothe, abilities to symbolize experience through play or language). Beyond infancy, children’s advancing capacities for representation and symbolization through language, play, and fantasy provide new tools for managing affective experience (Carlson & Sroufe, 1995). Through language and playful interaction, children develop increasingly cohesive personal narratives that support the integration of affect, cognition, and sensory information. In the context of supportive caregiving relationships, these adaptive capacities promote the child’s understanding (and thereby integration and tolerance) of disparate feelings, attitudes, and experiences (Lieberman, 2017). In the absence of emotional support and scaffolding, these same capacities may fuel further segregation of experience and the consolidation of dissociative regulatory patterns. Thus, we argue that a truly developmental model of dissociation must adopt a pathways perspective that considers the child’s developmental strengths and vulnerabilities as integrally connected to those of the caregiving milieu.

A Developmental Pathways Model of Dissociation Chronic and severe trauma in early development may disrupt emergent integrations across biological, cognitive, emotional, and behavioral systems in ways that consolidate normative dissociative tendencies in early childhood into pathological dissociative processes that endure over time, particularly if traumatic events are ongoing. However, as noted earlier, even in the absence of abject trauma, marked deviations in early caregiving quality can undermine the organization of children’s attachment system, and resultant attachment disorganization may function as a diathesis for later pathological dissociation. Malevolent or frightening caregiving dysregulates immature cognitive structures, thwarts emergent capacities for representation and adaptive experiential integration, and heightens the child’s vulnerability to the effects of subsequent trauma (Liotti, 1999). Although trauma and attachment disorganization are most often cited in the etiology of pathological dissociation, “quieter” caregiving insensitivities, including those extending beyond the period of infancy, may overwhelm the child’s abilities and/​or neglect their needs in ways that similarly disrupt the expected developmental progression toward greater integration amidst declining dissociative tendencies (Dutra et al., 2009; Lyons-​Ruth, 2003). In addition to direct experiences of caregiving, theory and recent empirical evidence highlight the potential for caregiver’s state of mind about their child and the parent-​child relationship to influence their child’s development and adaptation. Consistent with the tenets of attachment theory, children’s expectations and internalized representations of self, others, and self-​w ith-​others are carried forward to influence later relationships with peers, partners, and, ultimately, with one’s own child(ren) in the next generation (Bowlby, 1973; Bretherton & Munholland, 2008). Thus, a caregiver’s own beliefs and expectations about their child and the parent-​child relationship are largely informed by their prior experiences of receiving care. In turn, caregivers’ mental representations will influence the quality of care they provide to the next generation and shape the broader developmental context to which the child is exposed (e.g., family emotional climate, caregiver assessment of safety/danger for the child, partner selection, and relationship

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A Developmental Pathways Model of Dissociation  153

quality). Research suggests that a caregiver’s unresolved state of mind regarding their own attachment experiences in childhood is associated with a helpless state of mind with regard to parenting their child(ren), which, in turn, predicts problematic caregiving of the next generation (George & Solomon, 1999; Linde-​K rieger & Yates, 2018; Lyons-​Ruth et al., 2004). In sum, extant evidence points to individual and interactive contributions of trauma, attachment, and caregiver state of mind to children’s representational and regulatory development, including dissociative processes. Moreover, consistent with a developmental psychopathology perspective (Yates et al., 2011), these and other factors may differentially influence the onset of dissociation versus patterns of persistence or desistance in dissociation over time. Moving forward, a developmental pathways perspective on dissociation requires nuanced investigations of dissociative growth across time to document typical and atypical trajectories of dissociation and to elucidate factors that initiate, maintain, and/​or modify atypical dissociative processes. In a new study of 250 parent-​child dyads drawn from the community, we employed a pathways model of dissociation to evaluate if and how caregiving behaviors and caregiver states of mind beyond infancy influenced children’s trajectories of dissociative symptoms. Following previous research (e.g., Ogawa et al., 1997), we predicted that children’s dissociative symptoms would decline from early to middle childhood. However, we further expected that both the quality of caregiving with regard to “quieter” caregiving behaviors, such as intrusion, hostility, and support, and the caregiver’s state of mind with regard to perceived helplessness in the parenting role would influence children’s initial levels of dissociative behaviors in early childhood (i.e., intercept) and patterns of change in dissociation over time (i.e., slope) in potentially unique ways.

TABLE 9.1  Participant Demographics at Wave 1

Child sex  Male  Female Child ethnicity/​race  Latinx  Black  White  Multiracial Caregiver ethnicity/​race  Latinx  Black  White  Asian   Other/​Multiracial Caregiver relation to child   Biological mother   Foster/​adoptive mother   Grandmother/​other kin Caregiver education   Did not complete high school   High school diploma or equivalent   Some college or technical school coursework   Bachelor’s degree or higher Caregiver employment  Employed   Not employed Caregiver partner status  Married   Other committed relationship  Single Poverty status   Poverty (Income < 100% of the poverty line)   Near Poverty (Income < 130% of the poverty line)   No Poverty

%

N

50% 50%

125 125

46% 18% 11.2% 24.8%

115 45 28 62

55.6% 19.2% 19.6% 1.6% 4.0%

139 48 49 4 10

91.2% 3.6% 5.2%

228 9 13

19.6% 16% 51.2% 13.2%

49 40 128 33

55.6% 44.4%

139 111

61.6% 18.8% 19.6%

154 47 49

37.6% 9.2% 53.2%

94 23 133

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154  Linnea B. Linde-Krieger, Tuppett M. Yates, and Elizabeth A. Carlson TABLE 9.2  Description of Study Measures

CORE STUDY MEASURES Insensitive Caregiving: When children were 4-​years-​old, caregivers’ intrusive, hostile, and supportive behaviors were rated during a series of semi-​structured teaching tasks (Block & Block, 1980). Independent coders evaluated caregivers’ parenting quality during each task using 7-​point scales (Carlson et al., 1995; Egeland, 1982). Intrusiveness assessed the extent to which the caregiver lacked respect for the child as an individual and failed to recognize the child's efforts to gain autonomy with higher scores connoting greater levels of intrusiveness (M =​2.79, SD =​0.82; ICC =​0.75). Hostility was indicated by the caregiver’s expression of anger, discounting, or rejection of the child with higher scores ref lecting greater hostility (M =​1.47, SD =​0.49; ICC =​0.80). Supportive presence captured the extent to which the caregiver provided a secure base for the child and remained attentive to the child’s needs for the duration of each task (Egeland, 1982). Support was reverse-​scored so that a score of 7 indicated low support and a score of 1 indicated high support (M =​3.14, SD =​0.81; ICC =​0.81). Caregivers’ Helpless State of Mind: Caregivers self-​reported their state of mind regarding their relationship with the target child using the Caregiving Helplessness Questionnaire (CHQ; George & Solomon, 2011). Helpless state of mind was assessed for the first time at age 5 using the 6-​item “mother helpless” subscale (e.g., When I am with my child, I often feel out of control) with items rated on a 5-​point Likert scale from 1 (not at all characteristic) to 5 (very characteristic). The CHQ helpless subscale evidences discriminant validity with measures of parental stress and coping and convergent validity with interview ratings of maternal helplessness (George & Solomon, 2011; Huth-​Bocks et al., 2016; Vulliez-​Coady et al., 2013). The CHQ demonstrates good reliability in prior research (Lecompte & Moss, 2014) and in the current sample (α =​.88). Children’s Dissociation: Following the laboratory assessments when children were 5, 6, 7, and 8, teachers completed Achenbach’s Teacher Report Form (McConaughy & Achenbach, 2004). Twelve items ref lecting dissociative tendencies (e.g., sudden changes in mood or feelings; confused or seems to be in a fog) rated 0 (not true), 1 (somewhat or sometimes true), or 2 (very or often true) were composited based on their similarity to items on the Child Dissociative Checklist (Putnam et al., 1993). This dissociation composite evidenced acceptable reliability (average α across waves =​.82) and is consistent with prior research (Haltigan & Roisman, 2015; Ogawa et al., 1997; Smeekens et al., 2009). COVARIATES Early Childhood Maltreatment: Children’s early maltreatment was assessed at age 4 based on caregiver reports on the Early Trauma Inventory (Bremner et al., 2007). Two independent coders rated the severity of each maltreatment type using criteria set forth by McGee and colleagues (1995) on a 4-​point scale, including 0 (no maltreatment), 1 (mild), 2 (moderate), and 3 (severe). A composite of child physical abuse, sexual abuse, emotional/​verbal abuse, exposure to domestic violence, and neglect severity was used in these analyses. Child IQ: The Vocabulary and Block Design subtests from the Wechsler Preschool and Primary Scale of Intelligence-​III (WPPSI-​ III; Wechsler, 2002) assessed children’s cognitive skills at wave 1. Using the published scoring guidelines, a pro-​rated measure of full-​scale IQ was computed by averaging the child’s verbal and performance IQ scores (Sattler, 2008). Family Socioeconomic Status (SES): Family SES was measured at age 4 using Hollingshead’s (1975) Four-​Factor Index of Social Status based on caregivers’ education and occupation. Scores ranged from 9 (unemployed with a 10th grade education) to 66 (an attorney with a graduate degree) with higher scores connoting higher SES (M =​32.13, SD =​12.14, e.g., a licensed vocational nurse with a trade degree). Caregiver Psychopathology: The Brief Symptom Inventory (Derogatis & Spencer, 1993) evaluated caregiver’s psychopathology during the week preceding the wave 1 interview. Caregivers indicated how much 47 symptoms (e.g., “feeling lonely”) bothered them on a 5-​point scale from not at all 0 (not at all) to 4 (extremely). Analyses controlled for caregiver’s Global Severity Index t-​scores, which reflect the number of symptoms and intensity of perceived distress.

Study participants were diverse with respect to ethnicity/​race and socioeconomic status (see Table 9.1 for detailed participant demographics). Children (50% girls, 50% boys) were 4 years old when the study began, and most caregivers (91.2%) were biological mothers. Annually from ages 4 to 8, dyads completed a three-​hour laboratory assessment that included measures with the child, the caregiver, and the caregiver and child interacting. Children’s teachers provided additional reports on children’s adjustment following each laboratory visit. Using these data, we evaluated prospective relations of observational measures of caregiving when the children were 4 years old and caregiver reports related to a helpless state of mind when the children were 5 years old with teacher reports of child dissociation across ages 5, 6, 7, and 8. Table 9.2 provides a summary of the study measures. Caregivers’ intrusive, hostile, and supportive behaviors were coded during a series of semi-​structured teaching tasks, which were adapted from Block and Block (1980) to be just beyond the level of difficulty that the child could complete alone. Caregivers self-​reported their state of mind regarding their relationship with the participating child using the Caregiving Helplessness Questionnaire (George & Solomon, 2011). Teachers rated children’s dissociative symptoms using items selected from the Teacher Report Form (McConaughy & Achenbach, 2004) as in previous research (e.g., Ogawa et al., 1997; Smeekens et al., 2009). All analyses controlled for children’s exposure to prior maltreatment, child IQ, family socioeconomic status (SES), and caregiver psychopathology.

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A Developmental Pathways Model of Dissociation  155 TABLE 9.3  Descriptive Statistics and Bivariate Correlations

  1. Dissociation Age 5   2. Dissociation Age 6   3. Dissociation Age 7   4. Dissociation Age 8   5. Low Support  6.Intrusiveness   7. Hostility   8. Helpless State of Mind   9. Family SES 10. Child IQ 11. Caregiver Psychopathology

M (SD)

1

2

3

4

5

6

7

8

9

10

.329 (.415) .281 (.333) .261 (.315) .243 (.276) 3.145 (.800) 2.780 (.824) 1.540 (.628) 1.326 (.515) 32.13 (12.14) 95.174 (13.47) 48.250 (11.07)

-​-​-​ .677** .391** .597** .368** .312** .302** .135 -​.171 -​.257** -​.028

-​-​-​ -​-​-​ .677** .663** .313** .283** .302** .099 -​.225** -​.226** .114

-​-​-​ -​-​-​ -​-​-​ .735** .223* .310** .244** .000 -​.140 -​.244** .268*

-​-​-​ -​-​-​ -​-​-​ -​-​-​ .326** .194* .212* .198* -​.187* -​.324** .219*

-​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ .573** .543** -​.186** -​.181** -​.163** .089

-​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ .413** .077 -​.132* -​.070 .074

-​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ .155* -​.040 -​.079 .127*

-​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​.010 -​.038 .339**

-​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ .256** -​.016

-​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ -​-​-​ .029

Note: *p < .05, **p < .01

Descriptive and bivariate analyses (see Table 9.3) revealed that children’s mean levels of dissociation decreased from ages 5 to 8, and correlations among dissociation scores as reported by different teachers over time were moderately to highly stable. Ratings of caregivers’ low support, intrusiveness, and hostility were significantly correlated with children’s dissociation across time. A series of unconditional and conditional growth models evaluated our hypothesis that caregiving practices and caregivers’ state of mind would account for developmental patterns of dissociation across middle childhood. Unconditional models first evaluated within-​and between-​person variance in dissociation and change in children’s dissociative symptoms over time. We then tested conditional growth models to evaluate predictors of children’s initial levels of dissociation at age 5 (i.e., intercept) and changes in dissociation across ages 5 through 8 (i.e., slope). The unconditional means model revealed significant variability in children’s dissociation scores at age 5 (i.e., Ψ=​ .272, SE =​.020, p < .001), as well as significant within-​person variance ( Ψ=​.017, SE =​.005, p < 001) and significant between-​person variance ( Ψ=​.068, SE =​.008, p < .001) in children’s dissociation intercept. Unconditional growth models of dissociation across ages 5, 6, 7, and 8 indicated that a linear growth pattern was the best fit for the data (RMSEA =​.01 [.00, .09], SRMR =​.04, CFI =​1.00). Both the intercept at age 5 (b0 =​.307, p < .001) and the slope or growth of dissociation from ages 5 to 8 (b1 =​ -​.018, p =​.05) were significant, as were individual differences in dissociation intercept ( Ψ=​.094, SE =​.017, p < .001) and slope ( Ψ=​.004, SE =​.002, p =​.05). These findings indicate that, at the group level, there was a significant decline (negative linear slope) in dissociative symptoms across childhood, with significant variation in children’s initial levels at age 5 (i.e., intercept) and in their developmental pathways (i.e., slope) from ages 5 to 8. Further, the significant covariance between the intercept and slope ( Ψ=​-​.011, p < .05) indicated that higher levels of dissociation at age 5 were associated with greater declines in dissociation from ages 5 to 8. Consistent with a developmental pathways perspective, conditional growth models revealed distinct predictors of initial levels of dissociation at age 5 (i.e., intercept) as compared to changes in dissociation across ages 5 to 8 (i.e., slope) (see Figure 9.1). Caregiver intrusiveness, but not hostility or low support, predicted higher levels of dissociation at age 5 above and beyond children’s exposure to prior maltreatment and other covariates. Caregiver helpless state of mind, though not significantly related to initial levels of dissociation, emerged as a predictor of change in children’s dissociation scores across time, such that higher levels of helpless state of mind predicted slower declines in dissociation across childhood. Regarding covariates, boys evidenced higher initial levels of dissociation than girls, prior maltreatment predicted higher initial levels of dissociation at age 5 but not change over time, and caregiver psychopathology predicted less dissociation at age 5 and slower declines in dissociation scores from 5 to 8. Model fit for the conditional growth model was good (RMSEA =​.02 [.00, .06], SRMR =​.03, CFI =​.99). In sum, the conditional growth model indicated that caregiver intrusiveness, child maltreatment, and male sex were associated with higher levels of dissociation at age 5 (i.e., intercept), whereas caregivers’ helpless state of mind regarding the parent-​child relationship and caregiver psychopathology inhibited the normative decline of children’s dissociative symptoms from ages 5 through 8 (i.e., slope). Consistent with a developmental pathways perspective, these findings show that factors associated with dissociative onset may be distinct from those related to the course of dissociative symptomatology across time. Our results illustrate how a developmental pathways model of dissociation captures the dynamics of dissociative processes across development in a way that acknowledges the potential for multiple etiologic factors, including those that differentially influence the initiation versus expression of dissociation across time. Consistent with prior theory

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Caregiver Helpless SOM

.21 -.011

Caregiver Psychopathology

.29

-.18 Child Maltreatment Caregiver Intrusiveness

.20

Child Sex

.30

1

1 1

Dissociation Age 5

Dissociation Slope

Dissociation Intercept

.35

0 1

1

Dissociation Age 6

Dissociation Age 7

2

3

Dissociation Age 8

F I G U R E 9.1   Conditional

linear growth model of children’s dissociation from ages 5 to 8. Note: We analyzed growth curve data using the lavaan package in R. The Full Information Maximum Likelihood (FIML) method accounted for missing data; an MLR estimator addressed non-​normality and provided robust maximum likelihood estimates. All paths are significant at p < .05. Non-​significant paths not shown for clarity

(Putnam, 1997) and preliminary evidence (Ogawa et al., 1997), children’s dissociative tendencies declined from early to middle childhood. However, there were significant differences both in where children began (i.e., the intercept of dissociative symptoms at age 5) and how they changed over time (i.e., the slope of dissociative symptoms from ages 5 to 8). Consistent with the findings of Dutra and colleagues (2009), the current findings show that subtle or “quieter” parenting processes are significantly linked to potentially problematic dissociative patterns. Specifically, intrusive caregiving behavior, but not low support or hostility, predicted higher levels of dissociation at age 5. Our results suggest that caregiving behaviors that undermine children’s autonomy predict levels of dissociative symptoms above and beyond reports of child maltreatment and other covariates. Intrusive care may compromise children’s beliefs in their own worth and efficacy, which, in turn, stymies the flexible regulatory strategies and adaptive integration that such beliefs afford. While intrusive caregiving predicted initial levels of dissociation at age 5 in our sample, caregiver helpless state of mind was associated with disruptions in expected dissociative declines over time. This finding suggests that, beyond direct caregiving behavior, a caregiver’s feelings, beliefs, and representations about the child and the self-​a s-​parent (i.e., the caregiver’s internal working model) may influence the development of dissociation. A caregiver’s state of mind influences both caregiving practices and the broader family environment via effects on partner selection, assessment of safety/​d anger for the child, and the caregiver’s own capacity to model and scaffold successful regulation. Thus, caregiver state of mind may have ongoing and far-​reaching implications for children’s regulatory adaptation. Extending extant evidence that caregiver-​infant relationship qualities influence the development of dissociation (Dutra et al., 2009; Ogawa et al., 1997), our findings suggest that experiences in the caregiving milieu beyond infancy also shape the onset and course of atypical patterns of dissociation. Mixed findings regarding the influence of caregiving factors on dissociation in prior studies (e.g., Haltigan & Roisman, 2015; Smeekens et al., 2009) may reflect inadequate attention to a crucial principle of the organizational perspective, namely, that different conditions may initiate versus maintain (mal)adaptive pathways across time (Yates et al., 2011). Development reflects a cumulative and probabilistic series of reorganizations whereby early patterns of adaptation influence, and are transformed by, subsequent adaptations (Sroufe, 2005). Thus, experiences of chronic caregiving insensitivities beyond infancy and transactional processes in the caregiving environment (including the caregiver’s state of mind) may influence dissociative regulatory patterns during middle childhood and beyond.

Implications and Future Directions This developmental pathways investigation of dissociation has significant potential to inform applied efforts to prevent the development of problematic dissociation. Interventions targeting insensitive caregiving behavior may buffer young children against disorganized attachment and promote security in the caregiver-​child relationship (e.g., Attachment and Biobehavioral Catch-​up; Bernard et al., 2012). In addition to intervening on caregiving behavior, caregiver state of mind is an important port of therapeutic entry and change (Lyons-​Ruth et al., 2004; Sameroff et al., 2004; Sher- ​Censor

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& Yates, 2014). Caregivers’ mental representations of the parent-​child relationship underlie parenting practices and influence the broader developmental context to which children are exposed. However, because mental representations are flexible and may be modified through intervention (Van IJzendoorn, 1995), applied efforts to shift the caregiver’s state of mind regarding the caregiver-​child relationship may help them to address feelings of helplessness and develop more coherent and effective working models of the caregiver-​child relationship (Erickson et al., 1992; Sher- ​Censor & Yates, 2014). Attachment-​and mentalization-​based therapies that focus on both parenting behavior and caregiver representations of the parent-​child relationship (e.g., Minding the Baby, Slade et al., 2020; Mothering from the Inside Out, Suchman et al., 2013) may be particularly effective for preventing and/​or re-​d irecting children’s atypical trajectories of dissociation. Caregivers’ beliefs and expectations regarding their child(ren) are informed by their own experiences of receiving care during childhood (Bowlby, 1973). Some research suggests that caregivers with a history of maltreatment during their own childhoods may be at heightened risk for engaging in insensitive caregiving behaviors toward the next generation (Linde-​K rieger & Yates, 2021). With regard to child maltreatment, effects can carry across generations to influence parenting in ways that may not be abjectly abusive, but are nevertheless damaging to child adaptation (Chu & DePrince, 2006). Importantly, the novel findings presented in this chapter suggest that both child maltreatment and intrusive caregiving may instantiate problematic pathways toward dissociation. Moreover, we documented significant contributions of caregivers’ mental representations of the caregiver-​child relationship to patterns of dissociation in the next generation, even beyond contemporaneous caregiving practices. Some research has shown that a parent’s own history of trauma may contribute to dissociation in the next generation via distortions in their capacities to perceive threat to their child(ren) and enact protective strategies (Hulette et al., 2011). This study highlights the need for both basic and applied research to understand (and modify) transgenerational influences on the development of childhood dissociation. Guided by the integrative framework of developmental psychopathology and the tenets of an organizational perspective on development, we have illustrated that a developmental model of dissociation requires an appreciation of both normative and atypical development, that both subtle and substantial deviations in caregiving may influence pathways of dissociation, and that conditions that initiate atypical dissociative processes may be distinct from those that maintain or exacerbate their expression over time. Importantly, our findings also suggest that experiences within the caregiving milieu beyond infancy may contribute to the onset or course of atypical patterns of dissociation, and that caregiver states of mind (and their translation to caregiving practices) may be an important, yet understudied, factor in the etiology and course of maladaptive dissociation.

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10 THE RELATIONSHIP BETWEEN ATTACHMENT AND DISSOCIATION Theory, Research, and Clinical Implications Adriano Schimmenti

This chapter examines the relationship between attachment and dissociation, and illustrates how attachment theory and research may inform the understanding and treatment of dissociative disorders. A tenet of attachment theory (Bowlby, 1969/​1982; 1973; 1980; 1988; Duschinsky & White, 2019) is that human beings are endowed with an inborn disposition to attach to other human beings for seeking care, closeness, help, and comfort. Especially activated when one experiences physical and mental pain, or feels threatened, in danger, and vulnerable, this innate tendency allows the forming and maintaining of relational bonds with significant others, the attachment figures. Interactions with attachment figures during childhood (usually, the parents) give rise to the Internal Working Models (IWMs) of attachment. These cognitive and affective schemata include representations of self, others, and the relationship between self and others (Bowlby, 1973). Such schemata also constitute structures of memory and expectation (Bretherton & Munholland, 2016) that shape and individualize the expression of attachment disposition during life (Liotti, 2009). Thus, attachment represents a motivational system (Gilbert, 1989; Lichtenberg, 1989; Panksepp, 1998) that persists “from the cradle to the grave” (Bowlby, 1969/​82, p. 208), plays a significant role in every life, and orients our behaviors in relationships. In fact, infants need to maintain proximity with their primary caregivers to be protected from threat and danger, receive support, and increase their chance of survival. Over time, the IWM template created through the pattern of interactions with caregivers will be utilized for relationships and social exchanges outside the family, and later on the attachment system will combine together with other motivational systems (such as those related to cooperation, caregiving, and sexuality) for generating romantic and intimate relationships. The attachment system can be considered a part of the biological endowment of our species, which allows it to persist over time (Schimmenti et al., 2014).

Defensive Exclusion and Segregated Mental States For an attachment-​based understanding of dissociation, it is critical to observe that the attachment system not only coordinates the feelings and behaviors directed to the development and maintenance of relational bonds, it also organizes the structure of memories concerning these bonds –​starting from the memories concerning attachment relationships during infancy and childhood (Liotti, 2009). According to Bowlby (1973), these memories are coded into two systems: one is explicit (i.e., declarative), the other is implicit (i.e., procedural). Bowlby’s original insights about defensive exclusion (1962, 1980; Duschinsky & White, 2019) shed some light on how the organization of childhood memories is potentially linked to the development of dissociation. In his early work on the function and consequences of psychological defenses that follow a caregiver’s loss, Bowlby (1962) proposed that a selective exclusion of proprioceptive and exteroceptive information is an automatic, integral, and ubiquitous part of the action of the central nervous system, which favors concentration and flow of actions. However, Bowlby also evidenced that in some cases the selective exclusion is highly motivated, as it may serve to protect the ego from mental pain or, more exactly, from information that may be disturbing because it is “incompatible with what is there already” (p. 55).

DOI: 10.4324/9781003057314-13

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Individuals who had experienced prolonged separation, loss of attachment figures, relevant failures of care or maltreatment from caregivers during childhood may especially filter out specific information related to their attachment figures and relationships, as this information would be associated with mental pain. Bowlby explained that when deploying such defensive exclusion in response to attachment experiences that would otherwise be overwhelming, the mind can retain some conditional integration, though at the price of segregating certain kinds of environmental information (Reisz, Duschinsky, & Siegel, 2017). Indeed, defensive exclusion may lead to a split in the IWM: one existing set of schemas –​based on what was known about the relationship with the caregiver –​ remains intact, whilst a second set based on the traumatic experiences begins to grow. Notably, the first IWM set will remain accessible to declarative memory and awareness: this set would represent the caregiver as good and his or her relational failures as caused by the “badness” of the child. The other IWM set contains implicit memories associated with what the child has experienced but has defensively excluded from awareness, and will represent the disappointing or hated side of the caregiver (Bretherton, 1992). In this way, Bowlby anticipated the understanding of dissociation as a normal process of the mind that allows individuals to maintain a sense of integration by excluding distressing mental states that are inconsistent with the present moment, which may however become pathological if the mind is already organized according to intense and pervasive dissociative needs based on traumatic relationships with caregivers (Bromberg, 1998). Accordingly, Bowlby (1962) argued that “what characterizes a pathological condition is that exclusion acts in such a way that it creates not only the usual temporary barrier but a permanent one. Thereby psychic systems are segregated from one another as though by an iron curtain” (p. 44). In more recent work, Bowlby (1988) explained how a strong motivation for defensive exclusion may also occur within apparently non-​abusive attachment relationships, leading to prolonged avoidance of mental contents which may undermine integration and may ultimately lead to the development of segregated states of mind. He noted that three situations especially render children prone to engaging in defensive exclusion: (a) situations in which the child has done or thought about doing something for which they are deeply ashamed; (b) situations that parents do not wish the child to know about, even though the child witnessed them; and (c) situations in which the child finds the parents’ behavior too unbearable to think about. Bowlby argued that, especially in the latter cases, caregivers may wish to disconfirm the child’s observations of events, emotional responses, and even awareness of the parents’ personalities and behavior, to protect their own image and their worthiness in the eyes of the child. If the process of defensive exclusion remains active, either because the caregiver disconfirms the perception of the child or because the child wants to protect the internal image of the caregiver, “the individual grows up inhabited by two systems contrary to each other and independent of each other” (Bowlby, 1962, p. 55). In other words, the preexisting information or the information the caregiver made available will be retained in declarative memory, whereas the segregated information will often remain unprocessed and more prone to implicit retrieval in procedural forms. The development of segregated mental states in childhood, epitomizing the presence of conflicting and incompatible sets within the IWM, represents a “royal road” to dissociation. However, the relational events precipitating such a process may greatly differ among them: whereas some instances of parental failures are subtle and likely have a cumulative effect on the child’s developing mind, other events occurring in the attachment relationships might be so overwhelming that they have not only a disorganizing but also a disintegrating effect. In this respect, Farina and colleagues (2019) proposed a useful theoretical distinction between disintegrative and dissociative processes. Albeit strictly interrelated, these two processes are different because disintegration corresponds to the disruption mechanism that generates a collapse in the functioning of consciousness, whereas dissociation consists of the functional re-​organization of the mind following the disintegrative process (see also Farina & Meares, Chapter 3, this volume). Disorganized attachment likely represents the earliest evidence of the disintegrative mental processes resulting from severe attachment failures. Following disintegration with its flood of dysregulation, the child’s mind is forced to reorganize itself around defensive exclusion and segregation of unbearable mental states –​that is, around dissociation of attachment-​related information –​ to avoid further risks of disintegration.

Infant Disorganized Attachment and Dissociation Attachment patterns in infancy are assessed with the Strange Situation Procedure (SSP; Ainsworth, Blehar, Waters, & Wall, 1978), an experimental procedure whereby children (usually from 9 to 18 months) are exposed to brief episodes of separation from, and reunion with, the parent in an unfamiliar laboratory environment. The SSP was designed to use the cues of unfamiliarity and separation to elicit potential anxiety regarding the availability of the caregiver (Duschinsky, 2015).

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Three main organized patterns of attachment behavior have been observed in the SSP: secure (or Type B), insecure avoidant (or Type A), and insecure ambivalent/​resistant (or Type C). Children with a secure pattern (B) show clear-​cut protest (separation cry) when the parent leaves, and quick comfort upon reunion. Children with an insecure avoidant pattern (A) do not protest when the parent leaves, and ignore or actively avoid the parent upon reunion. Children with an insecure ambivalent/​resistant pattern (C) show distress even before separation, and are frustrated and difficult to comfort on the caregiver’s return, seeming to distrust the caregiver’s availability even when he or she is present (Ainsworth et al., 1978). The A and C patterns of behavior are organized, albeit insecurely. In fact, they could be considered as “conditional strategies” for optimizing the closeness with the caregiver (Main, 1979). In contrast to the direct proximity-​seeking of the B infant, downplaying displays of attachment behavior in the A pattern could represent an adaptation to a generally rebuffing caregiving environment, whereas maximizing displays of distress and anger in the C pattern could keep the attention of a caregiver experienced as not reliable. Based on observations of abused infants during the SSP, Main and Solomon (1986, 1990) identified a fourth group of children (Type D: Disorganized/​d isoriented attachment) who fail to organize the attachment behaviors according to any of the coherent patterns of attachment. In fact, these children show a series of behaviors indicating a disorganization of the attachment system during the SSP, such as sequential or simultaneous displays of contradictory attachment patterns, atypical movements (e.g., undirected, misdirected, incomplete, slowed, asymmetrical, mistimed, interrupted), freezing, anomalous postures, stereotypies, and severe apprehension regarding the parent. Estimates of disorganized attachment in childhood vary in different contexts and studies, but it can be observed in approximately 10–​15% of low-​r isk families, and in approximately 20% to 80% of high-​r isk families and at-​r isk samples (Lyons-​Ruth & Jacobvitz, 2008; Solomon & George, 2011; Van IJzendoorn, Schuengel, & Bakermans-​K ranenburg, 1999; Vasileva & Petermann, 2016). Main (1991) argued that attachment disorganization likely involves the presence in the infant’s mind of incoherent, multiple and disaggregated representations of the self and the caregiver, because of a parental attitude that is frightening to the child. As Hesse and Main (2000) put it, “disorganized/​d isoriented behavior is expectable whenever an infant is markedly frightened by its primary haven(s) of safety, i.e., the attachment figure(s)” (p. 1102). It is indeed a “fright without solution” (Hesse & Main, 1999, p. 484), where the child is exposed to the caregiver’s violence and/​or the caregiver’s attitude expresses fear in situations otherwise devoid of danger, that disorganizes the child’s mind: an unbearable conflict emerges between the desire to approach the frightening parent (motivated by the attachment system) and to flee from him or her (motivated by the need to protect oneself from danger). Even when devoid of overt violence or abuse, interactions characterized by a fright without solution are akin to a traumatic event (Liotti, 2006), because the caregiver simultaneously represents “the source and the solution of the infant’s alarm” (Main & Hesse, 1990, p. 163). In the context of frightening and frightened parenting, the attachment figure may become a “scaregiver” (Epstein, 2019), that is, a person who is expected to protect and help but, on the contrary, generates fear, disorientation, and confusion in the child. And as the paradox of the fright without solution cannot be resolved, it disorganizes the attachment system. Liotti (1992) originally suggested that multiple perceptions of incompatible information about the self and the caregiver in frightening interactions may exceed the integrative capacity of consciousness and may generate simultaneous and multiple representations of aspects of reality normally construed as unitary. Therefore, from Liotti’s (1999) perspective disorganized attachment is characterized by a single IWM that has multiple dissociated representations of the self, the caregiver, and the relationship between the self and the caregiver. Accordingly, Main and Morgan (1996) proposed that attachment disorganization can be conceived as an early dissociative process, where a disruption occurs in the organizing and integrating functions of consciousness. This conceptual framework is also consistent with Putnam’s (1997) observation that early relational trauma hinders the normal coalescence and unification of discrete behavioral states (i.e., the fundamental units of organization of consciousness; see also Putnam, 2016). Therefore, attachment disorganization in infancy actually constitutes a disintegrative, rather than a defensive, process. Attachment disorganization indicates that there is too much for the infant’s mind to tolerate (Schimmenti & Caretti, 2016), and thus the developing integrative functions of the mind fail and collapse. Behaviors frequently observed in disorganized infants during the SSP testify to a disruption in the functions of consciousness. For example, an infant with disorganized attachment shows an abrupt interruption of movements that previously appeared meaningful and aimed at interacting with the caregiver. Such an interruption lasts about 30 seconds, and is accompanied by a dazed, trance-​like expression, suggesting a sudden disruption of the previously intact perception of the environment. After the interruption, the original movement is resumed as if nothing had happened (Liotti, 2009). Other disorganized infants display contradictory behavioral patterns (e.g., approaching the parent while averting the head so as to avoid meeting their gaze), or they may even show confused, apparently involuntary, and deeply disturbing behaviors, indicating a dramatic

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failure in their attachment strategy and rapid shifting among different states, which resembles the identity shifting observed in severe dissociative disorders. For example, a child appears paralyzed looking at the wall. Then, he turns his head back looking frightened at his caregiver. Immediately after he closes his eyes and starts violently moving his head back-​and-​forth (Schimmenti & Caretti, 2016). The effects of the disintegrative process can also be observed in the disorganized infants’ lack of a coherent and consistent attentional strategy (Hesse & Main, 2000). As Main (2000) reported, during the SSP secure infants display a flexible attentional strategy easily shifting from the caregiver to the toys scattered in the room, avoidant infants are focused on the toys and inflexibly shift their attention away from the caregiver, and ambivalent/​resistant infants inflexibly attend to the caregiver. As observed before, in attachment disorganization there is no consistent attentional strategy toward either the caregiver or the surrounding environment. Notably, abrupt interruption or diversion of attention (suggesting an unwitting absorption in the inner world of feelings and memories) is also reported in the study of adults’ disorganized states of mind regarding attachment (Main, Goldwin, & Hesse, 1984–​2003). These phenomena in adulthood resemble the disintegrative processes observed in disorganized infants.

Frightening/​frightened Parental Behavior and Infant’s Attachment Disorganization There is strong empirical evidence linking attachment disorganization in infants to unresolved/​d isorganized states of mind with respect to loss and abuse in their parents: in fact, an unresolved/​d isorganized attachment classification in the parent predicts a disorganized/​d isoriented classification in his or her child, with a moderate effect size (Hesse et al., 2003; Madigan et al., 2006; Van IJzendoorn, 1995). For example, an interesting study (Schuengel, Bakermans-​K ranenburg, & Van IJzendoorn, 1999) examined home interactions between 85 middle-​class mothers who had experienced a significant loss and their infants: the study demonstrated a positive association between overtly aggressive behaviors in the mothers and disorganized behaviors in their offspring. Also, Madigan et al. (2006) reported meta-​analytic findings showing that infants whose parents display frightened, frightening, or dissociative behavior were 3.7 times more likely to be classified as “disorganized/​d isoriented” in the SSP. Therefore, the intergenerational transmission of attachment disorganization is more related with a parental failure to process early traumatic experiences than with the mere presence of traumatic experiences in the childhood of parents (Ainsworth & Eichberg, 1991). Also, behavioral genetic studies have certainly increased our understanding of the link between unresolved mental states in parents and attachment disorganization in their infants, implicating the 5-​HTTLPR (a serotonin transporter gene; see Spangler et al., 2009) and 7-​repeat allele of the DRD4 gene (a gene regulating postsynaptic dopamine receptors; see Lakatos et al., 2000; Van IJzendoorn & Bakerman-​K ranenburg, 2006). However, genetic studies did not suggest a major role for genetic influences in determining the infant attachment pattern (Bakermans-​K ranenburg & Van IJzendoorn, 2016). Thus, environmental factors remain crucial in determining attachment disorganization. Frightening and frightened behaviors of the parents could represent the most important link between their unresolved states of mind regarding attachment and the presence of attachment disorganization in their offspring. Main and Hesse (1990) suggested that intrusions in the caregivers’ consciousness of unresolved memories of traumatic interactions with their own attachment figures may lead to parental behaviors that are either directly (e.g., abusive, violent) or indirectly (e.g., confused, frightened, or eerie) frightening to their infants. These behaviors produce the paradox of the fright without solution in the communication between the child and the caregiver, as the fear is induced by the very person who cares for the infant’s fear and distress. Liotti (1999) proposed that the fright without solution of disorganized children can be conceptualized in terms of simultaneous activations of the attachment system and the defense system. Both these inborn systems have evolved to deal with environmental threats: the defense system organizes “fight or flight” sympathetic responses of the autonomous nervous system in the face of a threat, whereas the attachment system leads to seek the protective closeness of a member of the social group who may help protect against the threat. In the fright without solution, both these systems are simultaneously activated in a conflicting manner, motivating the child to flee, and at the same time to approach, the caregiver. According to Liotti (2009), this unbearable conflict between the two systems, both necessary for survival, exceeds the limited capacity of the infant’s mind for organizing coherent experiences and unitary memory structures. The conflict thus results in a collapse of the attempts at developing an organized strategy of attention and behavior. Empirical research also suggests that parental frightening and frightened behaviors are embedded in a broader context of disrupted affective communication, where the exchanges of contradictory affect cues between parent and infant, of a more subtle quality than an overtly aggressive or neglecting behavior, may be involved in mediating parents’ unresolved states of mind and infants’ disorganized attachment (Lyons-​Ruth, 2003). Furthermore, it is likely that specific

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behaviors of caregivers are discriminatively associated with different behaviors suggestive of disorganization, disorientation, or confusion in the child (Duschinsky, 2018). There are indeed many ways a caregiver can relate to the child that are subsumed under the rubric of frightening and/​or frightened behaviors, among which are: (1) entering into a dissociative state, (2) threatening behavior inexplicable in origin and/​or anomalous in form, (3) frightened behavior inexplicable in origin and/​or anomalous in form, (4) deferential (role-​inverting) behavior, (5) sexualized behavior, and (6) disorganized/​d isoriented behavior (Hesse & Main, 2003). These different behaviors likely have their counterparts in how the child responds to the caregiver. Accordingly, Hesse and Main (2006) distinguished between manifestly apprehensive behaviors and other behaviors that appear more overtly dissociative among disorganized children: “While many D behaviors identified as disorganized are unlikely dissociative, as hiding under the chair upon the entrance of a clearly frightening mother, some D behaviors (chiefly trance-​like behaviors and seemingly dissociated actions) do seem to fit a dissociative model” (p. 334). In this respect, Schimmenti and Caretti (2016) proposed that children exposed to a frightening or frightened caregiver may enter into an alarm-​dependent learning mode, in which the process of mentalizing (i.e., the capacity to interpret one’s own and others’ behaviors as an expression of mental states; see Fonagy et al., 2002) is abruptly interrupted, and the attention of children is suddenly redirected from the understanding of the relational experience to the regulation of the disorganizing flood of emotions deriving from the traumatic interaction. As a consequence, the subsequent efforts of these children will be aimed to prevent and eventually find ways to control and master the traumatic interactions with the caregiver without disrupting the attachment system. Children’s attempts to adapt to the caregiver’s disorganized mental states, however, hamper their ability to integrate the emotional and relational experiences into a cohesive structure of meaning, which might further consolidate state-​dependent responses of hypervigilance and avoidance with respect to attachment-​related information. According to this perspective, the disintegrative process resulting from unbearable interactions with the caregiver (especially during moments of fright without solution) is usually followed by a reorganization of the IWM in the child, based on a defensive exclusion of relevant information concerning the attachment relationship. Therefore, the higher the need for such defensive exclusion to protect the attachment system, the higher the risk that the child will organize his or her response to real or perceived threats around dissociation. This hypothesis has received some empirical support, with research showing that parental failures of care during childhood predict difficulties mentalizing and emotion dysregulation, which in turn increase the risk of heightened dissociative responses in adults (Schimmenti, 2017a). To summarize, dissociation is not necessarily the outcome of abusive and violent interactions between an adult and a child. Provided that activation of the attachment system is involved, parental communications that are frightening, frightened or confused may set dissociative mental processes into motion (Liotti, 2009).

Dissociation in the Childhood Sequelae of Infant Disorganization Longitudinal studies from infancy to age 9 show that most children who were disorganized during infancy progressively organize their behavior toward the caregivers around unitary themes of control. Indeed, when reaching their sixth year, the majority of these children achieve such an organization by exerting active control on the caregiver’s attention and behavior, either through caregiving or domineering-​punitive strategies (Bureau, Easlerbrooks, & Lyons-​Ruth, 2009; Hesse et al., 2003; Liotti, 2011; Main & Cassidy, 1988; Moss et al., 2011). The controlling–​caregiving strategy is characterized by strategically solicitous caring behavior directed toward the caregiver. Role-​reversal, concerns for the well-​being of the parent, inhibition of aggression, and an exaggerated sense of responsibility are the hallmark of this strategy. The controlling–​punitive strategy is characterized by anger and dominant attitudes toward the caregiver: harsh criticism and coercive, hostile, or humiliating behavior are enacted to punish and embarrass the parent. How this reorganization occurs is a matter of debate. As discussed in the previous section, the frightening parents may convey relational information that is incoherent and dramatically contradictory during daily interactions with the child. The child needs to receive help from caregivers for survival, but at the same time is terrorized by them. Thus, the child experiences the unbearable tension of an insoluble paradox between approaching or fleeing the caregiver. As research in hypnosis suggests, the presence of multiple, simultaneous, and reciprocally incompatible information can induce altered states of consciousness even in normal individuals (Erickson, 1964). On the basis of these considerations, Liotti (1992) proposed that the disruption of the infant’s consciousness during the frightening interactions with caregivers is followed by a remodeling of the early IWM, so that these disorienting and overwhelming experiences are disconnected from the other experiences and become (at least partially) inaccessible to conscious recall. Accordingly, the implicit representations of the self and the caregiver in the IWM will become multiple, contradictory, and reciprocally dissociated.

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Trying to capture the intrinsically multiple and dissociated feature of the disorganized IWM, Liotti (1999, 2002) elaborated on Karpman’s (1968) metaphor of the drama triangle, according to which the characters of the internal drama theatre shift between the reciprocal roles of rescuer, persecutor, and victim. This drama is excruciatingly enacted in the mind of disorganized children. On one side, the parent is negatively represented in the child’s IWM, as the cause of the fear and disorientation experienced by the self. In this case, the self is represented as the victim, and the parent constitutes the persecutor. On the other side, the parent is simultaneously represented positively, as a rescuer: in fact, even though he or she might be frightened by unresolved traumatic memories, the parent may willingly offer comfort to the child in other situations. Together with these two opposed representations of the attachment figure (the persecutor and the rescuer) meeting a vulnerable and helpless self (victim), the disorganized IWM also conveys a representation of a powerful and evil persecutor self, held responsible for the aggression and fear expressed by the attachment figure. Furthermore, the child might represent both the self and the parent as the helpless victims of a mysterious, invisible source of danger. Finally, since the parent may be comforted by the tender feelings evoked by contact with the child, the child’s IWM may also contain a representation of the self as the powerful rescuer of a fragile attachment figure. Notably, these representations in the disorganized IWM bear generic formal resemblance to three main identity states that alternate in dissociative identity disorder (DID), that is, persecutor, rescuer and victim states (Liotti, 1995, 1999). Therefore, controlling strategies may result from a dissociative reorganization of the mind around the traumatic interactions with the caregiver. In fact, controlling the caregiver allows previously disorganized children to exclude from awareness the dysregulation deriving from the fright without solution, and to simultaneously protect their attachment system. In doing this, however, the split within the IWM sets becomes crystallized and concrete: in fact, the controlling-​caregiving strategy is likely based on the IWM representation that portrays the self as a rescuer and the parent as a helpless victim; the controlling-​punitive strategy may result instead from an IWM in which the self is identified with the powerful persecutor role in the relationship with a parent, who deserves to be victimized. Controlling strategies do not only imply a traumatic counter-​identification with the caregiver, they also testify to the split within the IWM. In fact, there is evidence that controlling strategies may collapse –​and disorganization and disorientation may resurface –​when the attachment system of caregiving and punitive children is strongly activated. This was evident when such children were asked to respond to attachment-​related stimuli or imagine child-​parent separations ( Jacobsen & Hoffman, 1997). Based on previous attachment research, Solomon, George, and De Jong (1995) developed an experimental procedure in which children aged 6 enacted doll-​play stories about attachment-​related themes of separation and reunion. They found that doll-​play of controlling children was characterized by themes of catastrophe and helplessness or by complete inhibition of play, suggesting disorganization of representational processes. In addition, the narrative structure of the doll-​play stories was typically flooded and chaotic, and sometimes children enacted themes of disintegration. As Solomon and colleagues stressed, the stories of these children “demonstrate that fears about the caregiver or the self are out of control and potentially destructive” (p. 454). More generally, in test situations activating the attachment system and its related representations, controlling children may appear inhibited, frightened or disoriented, make contradictory statements without acknowledging the contradiction, use nonsense language, may engage in disturbing fantasies with catastrophic content, or even fall silent and space out as if they had entered a trance-​like state (Hesse, Main, Abrams, & Rif kin, 2003). These observations suggest that the flood of emotional dysregulation associated with attachment disorganization, albeit kept separated in the mind by the mechanism of defensive exclusion, remains close to consciousness and contingent upon the activation of the attachment system. Notably, the fear associated with the activation of the disorganized IWM may play an important role, throughout child development, in increasing the risk of reacting to trauma with chronic dissociation. From an evolutionary perspective, Liotti (2011) observed that the development of controlling strategies in children who were disorganized in infancy may be conceived as the result of defensive inhibition of the motivational system of attachment, with the purpose of protecting both the child and the relationship with parents from the unbearable and chaotic experience of disorganization. Motivational systems derive from evolutionary processes and represent universal and inborn dispositions aimed at pursuing each specific biosocial goal (Gilbert, 2005; see also Lichtenberg, Lachmann, & Fosshage, 2011, for a multidimensional approach to the motivational systems). Beside the attachment system, whose goal is care-​seeking, inborn motivational systems include the caregiving system, the sexual mating system, the competitive (or ranking) system aimed at achieving dominance through competitive behavior when the availability of resources is low, and the cooperative system aimed at maximizing the possibility of achieving results and accumulating resources (Gilbert, 1989). Usually, the prevailing motivational system active in a social exchange tends to inhibit the activities of other systems, even though there could be dynamic tensions between the different systems that may allow for simultaneous activation of two or more of them. However, in the context of traumatic interactions with caregivers a relative inhibition

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of the attachment system may be achieved through coopting another motivational system during daily interactions. Therefore, the activation of the caregiving system (Solomon & George, 1996) in the service of a defensive inhibition of the attachment system might yield controlling caregiving strategies in the child, whereas the activation of the competitive system with its dialectics of dominance and submission (Gilbert, 2005) might lie at the base of controlling punitive strategies. Liotti (2009) further hypothesized that controlling-​caregiving children resort to this strategy as a response to their interaction with vulnerable, frightened, confused parents who nevertheless are not directly maltreating or neglecting. In contrast, controlling-​punitive children could be the offspring of parents who display overtly neglecting, hostile, or abusive behavior (Hesse et al., 2003). However, research findings are inconclusive in this respect. Some insights can be derived from research by Moss, Cyr, and Dubois-​Comtois (2004), who followed the preschool to school-​age trajectories of 242 children, including 37 with disorganized attachment, and observed that controlling children had poorer mother-​child interactive patterns and more difficult family climates than secure or insecure-​organized children. The controlling-​punitive group showed increased externalizing behaviors and maternal reports of child-​related stress between preschool and school age; the controlling-​caregiving group showed increased internalizing symptoms and a greater likelihood of a significant loss of close family members. Another important longitudinal study on 44 mother-​ child dyads revealed that maternal withdrawal in infancy significantly predicted child’s caregiving behaviors (Bureau et al., 2009). However, maternal negative and intrusive behaviors alone did not predict child’s punitive behaviors; instead, the overall level of maternal disrupted communication in infancy predicted child’s punitive behavior at age 8. In sum, an inhibition of the attachment system and a reorganization around controlling strategies, aimed at protection from the painful experience of disorganization, may occur through the activation of either caregiving or competitive motivational systems mediating different aspects of human relatedness. Thus, formerly disorganized infants may gradually come to employ these strategies to reduce disorganization. It is noteworthy, however, that in both cases the reorganization of the behavioral approach to the frightening/​frightened parent implies at least a rudimentary defensive function of the mind, which allows the child to turn passive subjugation to relational trauma into an active and controlling response to trauma threats. According to psychoanalytic theory, the defense mechanism of turning passive into active plays an important role in managing developmental anxiety associated with feelings of helplessness and powerlessness (Corradi, 2007; Schimmenti, 2012, 2017b).

Dissociative Phenomena in the Study of Adult Attachment A number of instruments exist to assess adult attachment styles, representations, and/​or their related behavioral and relational features. Among them are interviews, Q-​sort assessments, projective tests, self-​reported measures (Ravitz et al., 2010; Crowell & Treboux, 1995). All these instruments were developed using ideas from attachment theory, and most of them have proven to be valid and reliable in worldwide research. However, for the purpose of this chapter it is useful to focus on the Adult Attachment Interview (AAI: Main, Goldwyn, & Hesse, 1984–​2003). The AAI is a semi-​structured interview assessing states of mind regarding attachment; thus, it is not solely focused on manifest attachment behaviors but examines the internal representations of attachment as they emerge from autobiographical narratives of attachment-​ related memories. Responses to the AAI are able to reflect both disintegrative and dissociative processes related to attachment trauma. In fact, the recollection of memories concerning traumatic losses of attachment figures or physical and sexual abuse suffered at the hands of caregivers is not a rare occurrence during the administration of the AAI. In some of these interviews, the AAI coder can observe specific indicators, such as lapses in the monitoring of reasoning and discourse, reports of disorganized or disoriented behavioral responses to loss or trauma, poor metacognitive monitoring, and notable incoherence in the narratives. High scores on these indicators, which leads to an “Unresolved/​d isorganized” (U/​d) classification at the AAI, suggest that the traumatic memories concerning attachment relationships continue to interfere with the individual’s narrative of his or her history, so that an integration of the emotional and cognitive information concerning these memories has not been achieved. Some examples of U/​d specific indicators (Main, Goldwin, & Hesse, 1984–​2003) are provided here in light of the likely distinction between disintegrative and dissociative processes. These indicators include disbelief that a person is dead (e.g., “It’s probably better that he is dead, because now he can go on with being dead and I can get on with raising a family”; disintegration), disorientation with respect to the time of a loss (dissociation), confusion between the dead person and the self (e.g., “I died when my father was 14”; disintegration), prolonged silence (disintegration), sudden changes of topic (dissociation), reports of extreme responses at the time of bereavement (disintegration), unsuccessful denial of abusive experiences (e.g., an interviewee said that their father was not harsh when punishing him, and a few minutes later reported that he got some scary bruises due to the father’s

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punishment; dissociation), feelings of deserving the abuse (when an IWM contains self-​representations in which the self is identified with the perpetrator and needs punishing; dissociation), disoriented and confused speech with visual and sensory intrusion (e.g., “And then, he came after me, and I’m running up the stairs, count ‘em…one, two, three, four, bang! Duck around the door just it hit the wall near my head”; disintegration), and even fears of being possessed by the abusive figures (e.g., “I’ve had therapy about my mother. And I’m afraid that she might make me do bad things, somehow. And I couldn’t stop her”; both disintegration and dissociation). Even more impressive illustrations of the relationship between states of mind regarding attachment and dissociation are offered by those rare types of AAI that are coded “Cannot Classify,” meaning they do not fit with any of the secure or insecure categories, regardless of potential instances of disorganization (Hesse, 1996; Hesse et al., 2003). “Cannot Classify” interviews are typically split in two parts, one of which would lead to an “Entangled” classification (indicating anxious-​a mbivalent states of mind regarding attachment), whereas the other would be coded “Dismissing” (avoidant states of mind regarding attachment). Usually, the responder is not aware of such a marked change of attitude, which sometimes implies a change in the tone of voice while reporting past traumas that had been apparently forgotten: this can be considered an instance of dissociation and appears quite similar to the switch between identity states clinically observable in DID. Not surprisingly, the AAI of patients suffering from dissociative disorders typically receive the “Cannot Classify” code together with the “Unresolved/​d isorganized” code (Steele, 2002; Steele & Steele, 2003). Consistent empirical findings support the view that adult attachment disorganization is linked with dissociative symptoms, whether they refer to disintegrative (e.g., depersonalization, derealization, internal confusion) or dissociative (e.g., amnesia, pathological absorption) processes. For example, Hesse and Van IJzendoorn (1999) found in a low-​r isk sample that participants who reported unresolved traumatic memories during the AAI rated high on a scale measuring the propensity toward absorption and self-​hypnotic states of consciousness. Schimmenti and colleagues (2012) observed in a group of 36 adults with problematic gaming that those classified as Unresolved/​d isorganized on the AAI reported significantly higher dissociative symptoms than other participants. Most of the disorganized participants screened positive for dissociative disorders. In a study on 53 professional and semiprofessional artists, Thomson and Jaque (2012) observed that artists who displayed disorganized states of mind regarding attachment reported increased symptoms of amnesia and depersonalization. They also found the majority of those who positively screened for dissociative disorders were classified as U/​d on the AAI. Barbasio and Granieri (2013) examined the relationship between attachment disorganization and dissociation in a sample of 40 women suffering from systemic lupus erythematosus, and found that the high prevalence of U/​d states of mind regarding attachment was associated with increased dissociation scores. In a physiological case-​controlled study conducted on a group of 13 patients with dissociative disorders who were administered the AAI, Farina and collaborators (2015) found significant increases in the low frequency/​h igh frequency ratio of heart rate variability after the AAI administration, which was interpreted as an effect of the emotion dysregulation linked to dissociative processes evoked by traumatic attachment memories. In an experience sampling study conducted with 45 adults exposed to traumatic experiences during childhood, Marcusson-​ Clavertz and colleagues (2017) found that the U/​d classification on the AAI was associated with poor attentional control and beliefs in anomalous mental phenomena. Notably, the findings confirming an association between attachment disorganization and dissociation in adults extend to adolescents. For example, West and colleagues (2001) found in a sample of 133 adolescents in psychiatric treatment that those who were U/​d reported increased dissociative scores. In addition to this, there is a wealth of empirical research using self-​report measures (which are however unable to capture the subtle phenomena of attachment disorganization) in clinical and nonclinical adolescent and adult samples. Findings of studies with self-report measures also converge to show that different features of insecure attachment styles (such as the preoccupation with relationships, a fearful approach to intimate relationships, and a dismissing attitude toward others) are positively associated with both childhood traumatic experience and increased dissociation. In addition, research on the U/​d classification on the AAI lends indirect empirical support to the theory of an intergenerational transmission of dissociative states resulting from failures of care and abuse in attachment relationships (Lyons-​Ruth & Jacobvitz, 2008). In the context of the activation of the attachment system, evoked by the AAI questions and likely reinforced by the parents’ experience of taking care of their children, the unresolved traumatic memories that have been dormant and remained in a dissociated state for years are brought to consciousness. It is possible to speculate that these unresolved memories of loss and abuse have exerted and continue to exert their dissociating power both on the parents’ state of mind and on the children’s developing IWM of attachment (Liotti, 2009; see also Fraiberg, Adelson, & Shapiro, 1975, for a psychoanalytic interpretation of this process). All these considerations indicate the global relevance of attachment theory for understanding dissociative phenomena.

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From Parental Lack of Care to Adult Dissociation: A Developmental Pathway Two longitudinal studies (Carlson, 1998; Ogawa et al., 1997) demonstrated the increased tendency to experience dissociative symptoms in adolescents and young adults who had been disorganized in their infancy. In both studies, strong evidence has been provided that attachment disorganization in infancy is linked to more severe dissociative symptoms at 19 years. However, these studies also pointed out that attachment disorganization combines with other developmental risk factors to generate dissociative symptoms. For example, in Carlson’s (1998) study, teacher-​reported scores of internalizing and externalizing problems in middle childhood and late adolescence, together with parent-​child relationship quality at 13 years, improved prediction of dissociation at age 19 over and above infant disorganization alone (see also Linde-​K rieger, Yates, & Carlson, Chapter 9, this volume). In the study by Ogawa and colleagues (1997), dissociation at 19 years was strongly predicted by psychological unavailability of the caregiver at 12–​18 months, and to a lesser extent by low thresholds of attention span and persistence of the infant at 3 months as perceived by the caregiver, together with disorganized attachment as observed during the SSP. Therefore, longitudinal findings suggest that attachment disorganization constitutes a critical developmental dimension for explaining dissociation, which is closely interwoven with other aspects of the child’s life. Thus, the origin of the most pathological forms of dissociation may reside in the person’s infancy where the precursors of attachment disorganization were likely generated. As Lyons-​Ruth (2003) stated, “the parent’s incapacity to acknowledge particular aspects of the child’s existence and experience, in the dialogue with the child, is a primary contributor to the child’s inability to recognize and integrate those same aspects of experience” (p. 901). In some cases –​and actually in most cases of severe dissociative disorders –​the caregivers’ incapability, unavailability, or unwillingness to accept their child’s mental states is present much before instances of attachment disorganization occur in the child. Attachment disorganization may paradoxically represent a normal and expected response to a frighteningly abnormal child-​caregiver relationship. Accordingly, Schimmenti and Caretti (2010, 2016) have stressed that in these circumstances the configuration of the relational field including the child and his or her caregivers is characterized by the absence of emotional reciprocity, so that the child’s emotional needs are subdued by parental demands, conflicts, fears, and projections. As further observed by Lyons-​Ruth and colleagues (2006), hostile (frightening and self-​referential) and helpless (fearful) parenting stances may represent alternate aspects of a single hostile/​helpless IWM of the attachment figure, which likely sets the basis for attachment disorganization and dissociative responses in the offspring, thus representing a critical mechanism for the intergenerational transmission of dissociation. Research by Dutra and colleagues (2009) seems to support this perspective. In 56 low-​income young adults followed from infancy to age 19 they found that early childhood maltreatment did not predict dissociative symptoms at age 19. Also, they did not find evidence that infant disorganized attachment predicted dissociation scores. They instead observed that the objectively assessed quality of early care in the first 18 months of life accounted for approximately half of the variability in dissociative symptoms: specifically, they found that maternal disrupted communication, lack of positive affective involvement, and flatness of affect, together with episodes of verbal abuse reported during the AAI, predicted dissociation scores at age 19. These findings call for a comprehensive attachment-​based understanding of dissociation, in which attachment disorganization is included in the wider context of the parent-​infant emotional dialogue –​which molds and actualizes the individual’s representations and forms of intersubjectivity –​and its ruptures (Lyons-​Ruth, 2003). As Putnam (1992) succinctly explained, dissociation represents “the escape when there is no escape” (p. 104). Accordingly, a maladaptive developmental cascade is often observed in the life of individuals who display severe dissociative symptoms and dissociative disorders as adults (Guérin-​Marion, Sezlik, & Bureau, 2020). As children they are exposed to traumatic interactions with caregivers that impair their developing capacity for mentalization and affect regulation (Schimmenti, 2017a). These interactions involve episodes of fright without solution that foster disintegrative processes in the mind and lead to a split within the IWM of attachment (Liotti, 1992). The disorganizing activation of the attachment system contingent upon relational trauma, insofar as it implies a dramatic, multiple, and nonintegrated representation of self-​w ith-​other, hampers the organizing functions of consciousness and identity, bringing on by itself a dissociative state of mind in these children that cumulates with the dissociating effects of trauma (Liotti, 2004). As a reorganization is necessary, the children activate the process of defensive exclusion, by which they segregate the attachment-​related information that are incompatible with the requests of the attachment motivational system to avoid unbearable mental pain (Bowlby, 1980). Then, they might start to repeatedly engage in autohypnotic distancing from intolerable circumstances, developing an overlearned, highly-​motivated, automatized pattern of dissociative self-​ protection (Dell, 2019; see also Dell, Chapter 14, this volume), which likely allow them to move their attention away from threatening relational cues. This is in keeping with Ogawa and colleagues’ (1997) findings related to maternal

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perception of reduced span and persistence of attention in infants at 3 months predicting dissociative symptoms after 19 years. Subsequently, these children develop controlling strategies in their interaction with the caregivers, aimed at avoiding further instances of attachment disorganization; however, these strategies are fragile and tend to collapse when the attachment system is excessively activated (Solomon, George, & DeJong, 1995). At this point, the need to avoid disorganization and its related flood of dysregulation becomes so high that the entire personality and mental life of these children become organized around the dissociative processes (Granieri et al., 2018), frequently without escape: dissociation will allow psychic survival, but at the price of jeopardizing psychological and behavioral functioning.

Internal Working Models of Attachment and Dissociated Multiplicity From childhood to adulthood, one feature of pathological dissociation is the coexistence of multiple, contradictory, and often reciprocally segregated states. In their most extreme form, these states alternate in controlling the individual’s attitudes, behaviors, and feelings, as observed in DID. A subclinical parallel to this feature of dissociation already exists in the IWM of infants with disorganized attachment, as it portrays plural, nonintegrated representations of self, of the attachment figure, and of the relationship between the self and the attachment figure (Liotti, 2009). Accordingly, the IWM of disorganized infants is incoherent, containing multiple self-​other relational representations (Main, 1991), and greatly differs from the IWM of organized children. In fact, secure infants develop a unified and coherent IWM, in which their relational experiences are consistently accompanied by memories of validating responses from caregivers; as adults, they will be more likely to display “Free/​autonomous” attachment representations, showing positive, defense-​free attitudes toward attachment needs and their expression in human life. Avoidant children also develop a unified IWM, based on withdrawal from the emotionally distant attachment figures and on the redirection of attention toward the environment; as adults, they will be “Dismissing” toward attachment relationships and will continue to negatively evaluate attachment emotions. A unified IWM is observed in ambivalent children too, but quite opposite to that of avoidant children: their uncertain evaluation of the meaning of attachment emotions in the presence of the caregiver’s inconsistent responses usually lead them to develop “Entangled” states of mind regarding attachment, characterized by a continuing preoccupation about the meaning and value of attachment experiences (Main, 1995; Main, Kaplan, & Cassidy, 1985; Main, Goldwin, & Hesse, 1984–​2003). Despite the obvious differences among them, all the three organized IWMs portray a singular representation of self, other, and relationship between self and other. In sharp contrast, the IWM of disorganized children is already structured as a template for responding with dissociation to later traumatic experiences. As observed in the previous section, there is an additive, cumulative, or at least interactive effect between abuse and failures of care in childhood, attachment disorganization, and the presence of clinically significant dissociative symptoms in adulthood (Carlson, 1998; Ogawa et al., 1997 see also Liotti, 2004). Liotti (1992) advanced the hypothesis that three developmental pathways may follow attachment disorganization in infancy. The first pathway is contingent upon the progressive integration of the caregiver’s traumatic memories, and the lack of further risk factors during development, which may lead to progressive integration of the initially multiple representations in the IWM. The second pathway, in which there is a moderate exposure to further risk factors (e.g., adverse genetic influences, exposure to single traumatic episodes), may lead to relatively mild types of pathological dissociation. The third pathway directly leads from infant attachment disorganization to DID, mainly because of prolonged exposure to sexual, physical, and emotional trauma during childhood. Empirical findings partially support this hypothesis. On one side, there is no doubt that childhood trauma may foster dissociation, because meta-​analytic findings indicate significant and positive associations, of moderate effect size, between trauma exposure and dissociation (Dalenberg et al., 2012). On the other side, research indicates that people who were exposed to early traumatic experiences are at increased risk of being exposed to further traumatization in later life, suggesting that a different and more problematic developmental pathway is expected for individuals who had been exposed to attachment trauma with respect to other individuals. In addition, a small group of individuals has been detected in research who endured severe relational trauma during childhood but do not show clinically significant symptoms of dissociation in adulthood (Schimmenti, 2018). What personal and environmental factors may protect individuals who were exposed to attachment trauma during childhood from psychopathology is a matter of debate, but some evidence suggests that high levels of emotional support from alternative support figures and psychotherapy in later life may play a critical role in reorganizing and resolving the traumatic mental states concerning attachment (Saunders et al., 2011). Apart from these considerations, it could be generally said that the exposure to repeated and prolonged trauma in childhood is expected to have deep and long-​lasting dissociative effects, especially when the perpetrators are also attachment figures. This is because the fright without solution that lies at the core of infant attachment disorganization

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is constantly reenacted, threatening the self with disintegration and continuously forcing the individual to compartmentalize the attachment representations in the IWM, which makes it almost impossible to integrate the self-​experiences into a unified meaning structure (Schimmenti & Caretti, 2016). Established and reinforced by such interactions, the intrinsically dissociated IWM of attachment disorganization also foster dissociative responses to later traumatic experiences, and every time a life stressor activates the attachment system, painful feelings of disorganization, disorientation, confusion, and fear may follow, based on the surfacing of implicit memories concerning past frightening interactions and on the unconscious expectation of their repetition (Liotti, 2009). Moreover, efforts to integrate these disturbing experiences will be accompanied by failures in mentalizing and a limited capacity for self-​regulation of affect, which constitute additional and dramatic outcomes of parental abuse and neglect (Schimmenti, 2017a). Such an unbearable condition will set again dissociative processes in motion, in a vicious cycle without an apparent end. To summarize, three intertwined phenomena constitute the core of a pathological dissociated multiplicity throughout the life span, according to attachment theory: (1) the significant failures in the parent-​infant dialogue (in their covert forms and/​or in the more overt forms of neglect and abuse) that hamper the integration of internal states into a coordinated self-​structure, generates a multiplicity within the IWM of attachment, and in the most extreme cases damage the capacity for intersubjectivity; (2) the disruption of consciousness deriving from fright without solution in the relationship with an unresolved caregiver; and (3) the reorganization of the mind around defensive exclusion and segregation of mental states, linked to controlling strategies which aim to prevent the return of disorganization with its flood of dysregulation. Symptoms that are commonly observed in patients suffering from dissociative disorders can be explained from this perspective. For example, amnesic episodes may derive from defensive exclusion and related segregation of attachment-​related information that may disrupt the attachment system (Schimmenti & Caretti, 2016). Conversely, traumatic flashbacks may be conceived as a failure of defensive exclusion and the subsequent surfacing of flashbulb memories of significant failures in emotional exchanges with the attachment figure. Depersonalization and derealization may indicate a fright without solution, replicating the unwitting absorption of attention to the internal experience observed in some disorganized children and suggesting the fear of feeling real in the here-​and-​now (Chefetz, 2015). Identity alteration and identity confusion may suggest that specific representations enclosed in the disorganized IWM have come into light, sometimes expressing themselves through “voices” manifesting the persecutory, rescuer, or victim aspects of the drama triangle that characterizes such an IWM (Liotti, 2009). Such attachment-​based understanding of dissociative symptoms, when refined and personalized to the actual patient, can help clinicians providing better treatment.

Implications for Treatment Further research is needed to better understand the complex relationship between attachment and dissociation. Physiological and neurobiological studies that investigate the typical and atypical responses to attachment cues among children, adolescents and adults are especially welcomed, as they might serve to generate a more integrated and comprehensive biopsychosocial framework for the conceptualization, assessment, and treatment of dissociation. Also, there is a lack of longitudinal studies developed from an attachment framework that employ gold-​standard clinical measures for the evaluation of dissociative disorders: notably, these studies would generate valid and reliable findings that might be used to develop both effective preventative actions and tailored clinical interventions with dissociated individuals. Moreover, distinguishing between disintegrative, dissociative and defensive processes emerging from failures of care in childhood is a novel theoretical proposal that might deserve further investigation. Despite the limitations of actual research, there are already a number of suggestions that can be derived from an attachment-​informed understanding of dissociative processes. In this respect, Schimmenti and Caretti (2016) proposed that multiple layers of disconnections, at mind and bodily levels, are phenomenologically involved in pathological dissociation deriving from attachment trauma, including disconnection: (a) with reality, because dissociation prevents the dissociated individuals from experiencing the world with a sense of self-​continuity and spontaneity; (b) in interpersonal relationships, because dissociation damages the capacity to enjoy positive intersubjective exchanges, with sudden phenomena of disembodiment and the surfacing of unresolved mental states, which make interactions in relationships unpredictable and sometimes unwanted; (c) in behaviors, because behaviors are procedurally tied to the detection and avoidance of potential threats, rather than being freely directed toward secure exploration of environments and relationships; (d) in the self, where there is limited dialogue and integration between different mental states; and (e) between different components of a single mental state, with little integration between the emotional domain of that state and its representation, and the alternation of competing responses to emotional stimuli testifying to the early disorganization of attachment.

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Rewiring and reconnecting what has been disconnected earlier may seem an impossible feat. However, clear evidence exists that it is possible. A number of treatment strategies are available today for adolescent and adult dissociative disorders, and some of them have also received empirical support from research. What attachment theory and research may add to these treatments? In line with early conceptualization of the most severe forms of dissociation as attachment disorders (Barach, 1991; Liotti, 1992; Blizard, 1997), attachment constitutes a key variable in the development and maintenance of dissociative disorders. The internal and relational disconnections that reinforce the presence of parallel-​d istinct structures in the internal world and in the external reality of dissociated individuals (Şar, 2017) are indeed linked to the implicit memories of relational failures in childhood attachment experiences. The defensive exclusion of traumatic attachment memories may lead the individual to develop a phobia of attachment (Schimmenti & Caretti, 2016; Steele, Van der Hart, & Nijenhuis, 2005) observed in the therapy of adolescents and adults suffering from severe dissociative disorders. In fact, these individuals may display dissociative manifestations in response to well-​meaning clinical interventions, and they may even re-​enact, in more or less symbolic forms, their past relational trauma in the consulting room. This might confuse and worry the therapist. However, attachment theory suggests that all these phenomena, especially when observed at early stages of therapy, should be correctly interpreted as paradoxical attempts to protect the mind from the potential dysregulation implied in the relationship with someone who could represent an attachment figure (i.e., the therapist) and who is expected to be as much frightening, frightened, unresponsive, rejecting, or even abusing as the parents of these patients were. Many years ago, Barach (1991) sensed that such overwhelming reactions in dissociative patients have at least one positive aspect: a minimal hope survived in them that the original trauma can be corrected in the therapeutic relationship, and that this time they will not be abandoned or abused. Accordingly, the therapist should act as a source of safety and as a secure base for these patients (Liotti, 2006), tolerating their dissociated states with all the accompanying fears of dysregulation. Testing the therapist’s tolerance for their dissociative responses represent a prerequisite for dissociative patients, and passing such tests allows them to eventually develop a sense of safety and security in the relationship, reducing their needs to dissociate. Attachment theory suggests other features concerning the therapist’s attitude that may help dissociated patients in the difficult process of integration. For example, dissociative patients could abruptly enact dissociated states in the consulting room, display disruptive behaviors, and even try to manipulate or seduce the therapist in order to control him or her. However, if protection of the therapeutic boundaries is a crucial aspect of any effective treatment, it is even more important for these patients. With dissociated patients, any violation of boundaries retraces the original inconsistency of parental behaviors, with its consequent disorganization, and carries with itself the risk of abuse and revictimization, and in the end confirms to them that no one can be trusted (Schimmenti & Caretti, 2016). Accordingly, the therapist should constantly inspect and monitor his or her responses and countertransference reactions to these patients (Dalenberg, 2000), also to avoid becoming an unwitting and unconscious character of the drama triangle of rescuer, persecutor, and victim that is enacted in the patients’ mind (Liotti, 1999). In doing this, the therapist should remain sensitive and responsive to the needs of the patients, and should use as much tact as possible when exploring their internal states –​either explicit or implicit –​to avoid the abrupt surfacing of disintegrative processes or the automatic activation of defensive exclusion. This attention to the patients’ needs will make them feel sufficiently confident about the therapist’s commitment to thinking about their potential for affect dysregulation and will allow them to engage in the threatening process of cognitively and affectively elaborating on their internal experience (Schimmenti & Caretti, 2016). One could contend that all these clinical recommendations are just old relational wine in a new bottle. However, this is a precious old wine that has been distilled from decades of research on attachment and dissociation. Perhaps, it has become even more priceless in a time when available manualized treatments have multiplied and specific therapeutic techniques have been developed to treat dissociative disorders, yet therapists continue to struggle with understanding how to better approach relationally their actual dissociative patients. If the foundation of mental integration lies in the possibility of sharing intersubjective experiences and providing affective and cognitive meaning to them, then how we relate with others, in therapy as in the whole of life, can really make the difference.

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Oxford: Oxford University Press. Putnam, F. W. (1992). Discussion: Are alter personalities fragments or figments? Psychoanalytic Inquiry, 12, 95–​111. Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental approach. New York, NY: Guilford. Putnam, F. W. (2016). The Way We Are: How States of Mind Influence Our Identities, Personality and Potential for Change. US: International Psychoanalytic Books. Ravitz, P., Maunder, R., Hunter, J., Sthankiya, B., & Lancee, W. (2010). Adult attachment measures: A 25-​year review. Journal of Psychosomatic Research, 69, 419–​432. Reisz, S., Duschinsky, R., & Siegel, D. J. (2017). Disorganized attachment and defense: Exploring John Bowlby’s unpublished reflections. Attachment & Human Development, 20, 107–​134. Şar, V. (2017). Parallel-​d istinct structures of internal world and external reality: disavowing and re-​claiming the self-​identity in the aftermath of trauma-​generated dissociation. Frontiers in Psychology, 8, 216. Saunders, R., Jacobvitz, D., Zaccagnino, M., Beverung, L. M., & Hazen, N. (2011). Pathways to earned-​security: The role of alternative support figures. Attachment & Human Development, 13, 403–​420. Schimmenti, A. (2012). Unveiling the hidden self: Developmental trauma and pathological shame. Psychodynamic Practice, 18, 195–​211. Schimmenti, A. (2017a). The developmental roots of dissociation: A multiple mediation analysis. Psychoanalytic Psychology, 34, 96–​105. Schimmenti, A. (2017b). Traumatic identification. Attachment, 11, 154–​171. Schimmenti, A. (2018). The trauma factor: Examining the relationships among different types of trauma, dissociation, and psychopathology. Journal of Trauma & Dissociation, 19, 552–​571. Schimmenti, A., & Caretti, V. (2010). Psychic retreats or psychic pits?: Unbearable states of mind and technological addiction. Psychoanalytic Psychology, 27, 115–​132. Schimmenti, A., & Caretti, V. (2016). Linking the overwhelming with the unbearable: Developmental trauma, dissociation, and the disconnected self. Psychoanalytic Psychology, 33, 106–​128 Schimmenti, A., Guglielmucci, F., Barbasio, C., & Granieri, A. (2012). Attachment disorganization and dissociation in virtual worlds: A study on problematic Internet use among players of online role-​playing games. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 9, 195–​202. Schimmenti, A., Passanisi, A., Pace, U., Manzella, S., Di Carlo, G., & Caretti, V. (2014). The Relationship Between Attachment and Psychopathy: A Study with a Sample of Violent Offenders. Current Psychology, 33, 256–​270. Schuengel, C., Bakermans-​K ranenburg, M. J., & Van IJzendoorn, M. H. (1999). Frightening maternal behavior linking unresolved loss and disorganized infant attachment. Journal of Consulting and Clinical Psychology, 67, 54–​63. Solomon, J., & George, C. (1996). Defining the caregiving system: Toward a theory of caregiving. Infant Mental Health Journal, 17, 183–​197. Solomon, J., & George, C. (2011). The disorganized attachment-​caregiving system: Dysregulation of adaptive processes at multiple levels. In J. Solomon & C. George (Eds.), Disorganized attachment and caregiving (pp. 3–​24). New York, NY: The Guilford Press. Solomon, J., George, C., & De Jong, A. D. (1995). Children classified as controlling at age six: Evidence of disorganized representational strategies and aggression at home and at school. Development and Psychopathology, 7, 447–​463. Spangler, G., Johann, M., Ronai, Z., & Zimmermann, P. (2009). Genetic and environmental influence on attachment disorganization. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 50, 952–​961. Steele, H. (2002). Multiple dissociation in the context of the Adult Attachment Interview: Observations from interviewing individuals with dissociative identity disorder. In V. Sinason (Ed.), Attachment, trauma and multiplicity (pp. 107–​21). London: Brunner/​ Routledge. Steele, H., & Steele, M. (2003). Clinical uses of the Adult Attachment Interview. In M. Cortina & M. Marrone (Eds.), Attachment theory and the psychoanalytic process (pp. 107–​126). London: Whurr. Steele, K., Van der Hart, O., & Nijenhuis, E. R. S. (2005). Phase-​oriented treatment of structural dissociation in complex traumatization: Overcoming trauma-​related phobias. Journal of Trauma & Dissociation, 6, 11–​53.

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Thomson, P., & Jaque, S. V. (2012). Dissociation and the Adult Attachment Interview in artists and performing artists. Attachment & Human Development, 14, 145–​160. van IJzendoorn, M. H. (1995). Adult attachment representations, parental responsiveness, and infant attachment: A meta-​a nalysis on the predictive validity of the Adult Attachment Interview. Psychological Bulletin, 117, 387–​403. Van Ijzendoorn, M. H., & Bakermans-​K ranenburg, M. J. (2006). DRD4 7-​repeat polymorphism moderates the association between maternal unresolved loss or trauma and infant disorganization. Attachment & Human Development, 8, 291–​307. Van IJzendoorn, M. H., Schuengel, C., & Bakermans-​K ranenburg, M. J. (1999). Disorganized attachment in early childhood: Meta-​ analysis of precursors, concomitants and sequela. Development and Psychopathology, 11, 225–​249. Vasileva, M., & Petermann, F. (2018). Attachment, Development, and Mental Health in Abused and Neglected Preschool Children in Foster Care: A Meta-​A nalysis. Trauma, Violence, & Abuse, 19, 443–​458. West, M., Adam, K., Spreng, S., & Rose, S. (2001). Attachment Disorganization and Dissociative Symptoms in Clinically Treated Adolescents. The Canadian Journal of Psychiatry, 46, 627–​631.

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11 ATTACHMENT TRAUMA AND THE DEVELOPING RIGHT BRAIN Origins of Pathological Dissociation and Some Implications for Psychotherapy Allan N. Schore

The concept of dissociation has a long history of bridging psychiatry, psychology, and neurology. Because dissociation is inextricably linked to trauma, theoretical and clinical models of dissociation have spanned the psychological and biological realms. Dissociative phenomena are now being viewed through an interdisciplinary lens. Although the relationship between childhood trauma and dissociation was noted at the end of the nineteenth century, not until the end of the twentieth century has a developmental perspective been used to understand dissociation’s etiological mechanisms. As Putnam (1995) noted, a developmental view of dissociation offers “potentially very rich models for understanding the ontogeny of environmentally produced psychiatric conditions” (p. 582). In particular, I suggest that regulation theory (Schore, 1994, 2003a, b, 2012, 2019a, b) can provide such models. Towards that end I will draw upon (1) research findings about infant behavior from developmental psychology, (2) current data on brain development from neuroscience, (3) updated basic research in biological psychiatry on stress mechanisms, and (4) new information from developmental psychobiology on the essential functions of the autonomic nervous system in order to construct a model of the etiology and underlying psychoneurobiological mechanisms of pathological dissociation. I will use posttraumatic stress disorder (PTSD) as a paradigm for dissociative disorder. I will discuss the earliest expression of dissociation in human infancy –​pediatric PTSD –​ and its enduring impact on the experience-​dependent maturation of the right brain, including the characterological use of dissociation at later points of interpersonal stress. The concept of dissociation can be directly traced to the work of Pierre Janet (1887, 1889), who considered (pathological) dissociation to be a phobia of memories expressed as excessive or inappropriate physical responses to thought or memories of old traumas (Van der Hart & Dorahy, Chapter 1, this volume). This dissociation of cognitive, sensory, and motor processes is adaptive in the context of overwhelming traumatic experience, and yet such unbearable emotional reactions result in an altered state of consciousness. Janet described an abaissement du niveau mental, a lowering of the mental level, a regression to a state that is constricted and disunified. Furthermore, Janet speculated that dissociation was the result of a deficiency of psychological energy. Due to early developmental factors, the quantity of psychological energy is lowered below a critical point, and thus individuals with characterological pathological dissociation are deficient in binding together all their mental functions into an organized unity under the control of the self. Summarizing the essentials of Janet’s model, Van der Kolk, Weisaeth, and Van der Hart (1996, p. 52) stated: Janet proposed that when people experience “vehement emotions,” their minds may become incapable of matching their frightening experiences with existing cognitive schemes. As a result the memories of the experience cannot be integrated into personal awareness; instead, they are split off [dissociated] from consciousness and voluntary control…extreme emotional arousal results in failure to integrate traumatic memories…The memory traces of the trauma linger as unconscious “fixed ideas” that cannot be “liquidated”… they continue to intrude as terrifying perceptions, obsessional preoccupations, and somatic reexperiences. In Janet’s (1911) view, traumatized individuals “seem to have lost their capacity to assimilate new experiences as well. It is…as if their personality development has stopped at a certain point, and cannot enlarge any more by the addition of DOI: 10.4324/9781003057314-14

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new elements” (p. 532). Indeed, at the dawn of modern psychiatry, many other major pioneers (e.g., Charcot, Hughlings Jackson) were also interested in the neurology of dissociation. At the beginning of this century Brown and Trimble (2000) argued that we must move beyond a purely descriptive approach: “The first goal must be to provide a precise definition of dissociation based on a conceptually coherent and empirically justified account of the processes underlying these phenomena” (p. 288; see also Prueter, Schultz-​Venrath, & Rimpau, 2002). In the middle of the last century Whitlock (1967) and Ludwig (1972) suggested that the primary pathophysiological mechanism of dissociative symptoms is an attentional dysfunction that results from an increase in the corticofugal inhibition of afferent stimulation. This inhibition impairs the processing of essential information, which subsequently fails to be integrated into awareness, and thereby generates dissociative symptoms. The neurobiology of dissociation has generated more interest in recent years (see Lanius & Corrigan, Chapter 37, & Nijenhuis, Chapter 38, this volume) and current neuroimaging research is also contributing new information about the structure-​function relationships of dissociation in mature brain systems (e.g., Lebois et al., 2021; Reinders et al., 2019). Several important observations about dissociation have been advanced. In psychological studies of adults, Loewenstein (2018) noted that “dissociation is a psychobiological state or trait that functions as a protective response to traumatic or overwhelming experiences” (p. 230). In neuropsychiatric studies of adult trauma patients, Bremner and colleagues (1999) demonstrated that (a) there are two subtypes of acute trauma response, hyperarousal and dissociation, (b) dissociation represents an effective short-​term strategy that is detrimental to long-​term functioning (Bremner & Brett, 1997), and (c) extreme stress invokes neural mechanisms that produce long-​term alterations of brain functioning ( J. Krystal et al., 1998). Finally, Meares concluded that dissociation, when first occurring, is the consequence of high arousal or ‘psychological shock’ (see Farina & Meares, Chapter 3, this volume). I will offer evidence that each of the above observations about dissociation in adults applies to infants as well. Developmental studies offer specific models of the process whereby early trauma alters the human ontogenetic trajectory and creates a predisposition for later pathological dissociation. These models, in turn, afford a deeper understanding of the neurobiological mechanisms of dissociation. I believe that attachment theory, “the dominant approach to understanding early socioemotional and personality development during the past quarter-​century of research” (Thompson, 2000, p. 145), best describes the interactions among development, trauma, and dissociation (see also Schimmenti, Chapter 10, this volume). Disorganized-​d isoriented insecure attachment, a primary risk factor for the development of psychiatric disorders (Main, 1996), has been specifically implicated in the etiology of the dissociative disorders (Bromberg, 2011; Chefetz, 2015; Liotti, 2004; Schore, 1997). Longitudinal attachment studies have demonstrated an association between traumatic childhood events and proneness to dissociation (e.g., Ogawa et al., 1997). Current neurobiological models of attachment focus on the formation of the implicit subjective self system, located in the early maturing right brain (Schore, 1994, 2001a, 2012, 2019a,b). Researchers assert that fearful arousal and the relational modulation of that arousal lie at the heart of attachment theory, and that what I have termed relational trauma (Schore, 2001b), a form of chronic attachment trauma that results from repeated and prolonged exposure to highly stressful early social and emotional experiences, triggers states of hyperarousal and dissociation in the developing brain. I will show that abuse and neglect elicit dissociative defenses in the developing infant. As such, they represent a deleterious influence during the critical growth period of cortical, limbic, brainstem, and autonomic centers in the early maturing right brain. From research over the last three decades there is now common acknowledgment that childhood trauma arrests right brain emotional development, and that trauma in adulthood produces a regression in affective development. The most significant consequence of early relational trauma is the child’s failure to develop the capacity for emotional self-​regulation (Schore, 1994, 2003a,b, 2012, 2019a,b). This is expressed clinically in an inability to regulate affective intensity and duration, especially under stress (Van der Kolk & Fisler, 1994). Another enduring deficit is a characterological impairment in interpersonal functions. This chapter contends that these established principles of early emotional development must be incorporated into an overarching model of dissociation.

The Interpersonal Neurobiology of Secure Attachment The essential task of the first year of human life is the creation of a secure attachment bond between the infant and his/​ her primary caregiver. Secure attachment depends upon the mother’s psychobiological attunement with the infant’s internal states of arousal. Very recent neuroscience research now demonstrates “an overall right hemispheric dominance for emotion, attention, and arousal” (Hartikainen, 2021, p. 1). Through right brain-​to-​r ight brain visual-​facial, gestural, and auditory-​prosodic emotional communication, caregiver and infant learn the rhythmic structure of the other and modify their behavior to fit that structure, thereby co-​creating a specifically fitted interaction. During the bodily-​based affective communications of mutual gaze, the attuned mother synchronizes the spatiotemporal patterning of her exogenous sensory stimulation with the infant’s spontaneous expressions of endogenous organismic rhythms.

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Via this contingent responsivity, the mother appraises the nonverbal expressions of her infant’s internal arousal and affective states, regulates them, and communicates them to the infant. The psychobiologically attuned mother down-​ regulates the infant’s negative affective states, such as fear, as well as up-​regulates positive affective states, such as joy. To accomplish this, the mother must successfully autoregulate nonoptimal high or nonoptimal low levels of stimulation which would induce supra-​heightened or extremely low levels of arousal in the infant. However, the mother is not always attuned. If attachment represents the interactive regulation of biological synchronicity between and within organisms, then attachment stress is an asynchrony in that interactional engagement. In optimal interpersonal contexts, following such stressful ruptures of the attachment bond, a period of re-​established synchrony allows the child to recover his/​her regulatory equilibrium. The interactive regulation of attachment ruptures is thus a generator of resilience, and thereby an indicator of attachment security. Furthermore, the long-​enduring regulatory effects of attachment are due to their impact on brain development. According to Ziabreva et al. (2003, p. 5334): [T]‌he mother functions as a regulator of the socio-​emotional environment during early stages of postnatal development…subtle emotional regulatory interactions, which obviously can transiently or permanently alter brain activity levels…may play a critical role during the establishment and maintenance of limbic system circuits. For three decades I have offered interdisciplinary evidence indicating that the dyadic attachment mechanism is embedded in infant-​caregiver face-​to-​face right-​hemisphere-​to-​r ight-​hemisphere affective transactions (Schore, 1994). Recent research indicates that infants process faces in the right and not left hemisphere (Otsuka, 2014), specifically in the right occipito-temporal cortex (de Heering & Rossion, 2015). Because (1) the human emotion processing limbic system myelinates in the first year-​and-​a-​half (Kinney et al., 1988) and (2) the early-​m aturing right hemisphere (e.g., Allman et al., 2005; Chiron et al. 1997; Gupta et al., 2005; Mento et al., 2010, Ratnarajah et al., 2013, Sun et al., 2005), which is deeply connected into the limbic system is undergoing a growth spurt at this time, attachment experiences specifically impact limbic and cortical areas of the developing right brain (Schore, 1994, 2003a,b, 2012, 2019a,b). In the most comprehensive experimental validation of these central tenets of affect regulation theory, Bosch-Bayard et al. (2022) and colleagues offer a recent study, “EEG effective connectivity during the first year of life mirrors brain synaptogenesis, myelination, and early right hemisphere predominance.” These authors document connections of different brain areas at 2-3, 5-8, and 8-12 months that show increases in only the right and not the left hemisphere. The authors conclude. The right hemisphere is predominant during the preverbal epoch in infants and lasts during the first three years of life (Chiron et al., 1997, Schore, 2000). The right hemisphere is understood as an executive regulatory system of the emotional brain involved in inhibitory control. In particular the right orbital prefrontal region acts as an executive control for the entire right brain (Schore, 2000). The right predominance starts shifting to the left hemisphere by the age of 3 years (pp. 7–8). Confirming this model of the critical importance of right brain-​to-​r ight brain attachment communications in the progressive social-​emotional experience–​dependent lateralization of the right brain, neuroscientists now document that the right hemisphere is dominant in human infants, that the strong and consistent predominance for the right hemisphere emerges postnatally, and that the mother’s right hemisphere is more involved than the left in emotional processing and mothering. Nishitani and colleagues report that “the right prefrontal cortex is involved in human maternal behavior concerning infant facial emotion discrimination” (2011, p. 183), and Killeen and Teti found “greater relative right frontal activation in response to seeing one’s own infant is related to maternal negative affect matching during times of infant distress, and greater perceived intensity of infant joy during times of joy” (2012, p. 18). Researchers are now agreeing that one measure of healthy development in infants is lateralized behavior (Hall, Neal, & Dean, 2008). Thus, over the course of the first and second years the development of lateralization of the infant’s right hemisphere, the emotional brain, is dependent upon the emotional interactions embedded in the co-​ created mother-​infant attachment system. Indeed, studying the brain of newborn infants at the beginning of the first year, neuroscientists concluded, In early life the right cerebral hemisphere could be better able to process . . . emotion (Schore, 2000). This idea appears consistent with our findings of rightward asymmetry in . . . limbic structures. . . These neural substrates function as hubs in the right hemisphere for emotion processes and mother and child interaction. Ratnarajah et al., 2013, p. 193, italics added Tronick and colleagues’ reported that 6-​month-​old infants use left-​sided gestures generated by the right hemisphere in order to cope with the stressful still-​f ace paradigm. They interpreted these data as being “consistent with Schore’s (2005) hypotheses of hemispheric right-​sided activation of emotions and their regulation during infant–​mother

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interactions” (Montirosso et al., 2012, p. 826). Using near-​infrared spectroscopy, Minagawa-​K awai and colleagues’ study of infant-​mother attachment at the end of the first year observed, “Our results are in agreement with that of Schore (2000) who addressed the importance of the right hemisphere in the attachment system” (2009, p. 289). Attachment experiences continue in the second year, a period of continued critical development of higher orbitofrontal and ventromedial areas of the right hemisphere. Internal representations of attachment experiences are imprinted in right-​lateralized implicit-​procedural memory as an unconscious internal working model that encodes strategies of affect regulation, including the bottom-​line defense against consciously reexperiencing early relational traumatic affective states, dissociation (Schore, 2003b, 2012, 2019a,b).

The Neurobiology of Relational Attachment Trauma Optimal attachment communications directly affect the maturation of (a) the central nervous system (CNS) and its connections into the limbic system that processes and regulates social-​emotional stimuli and (b) the autonomic nervous system (ANS) that generates the somatic aspects of emotion. It is important to stress that a growth-​facilitating emotional environment is required for a child to develop an internal system that can adaptively regulate arousal and other psychobiological states (and thereby affect, cognition, and behavior). In right brain-​to-​r ight brain communications the good-​enough mother offers her securely-​attached infant access to her after a separation; she tends to respond appropriately and promptly to his/​her emotional expressions. She also allows high levels of positive affect to be generated during co-​shared play states. Such events as these support an expansion of the child’s coping capacities and illustrate why secure attachment is the primary defense against trauma-​induced psychopathology. In contrast to caregivers who foster secure attachment, abusive caregivers not only play less, but also induce enduring negative affect in the child. Such caregivers provide little protection against other environmental impingements, including that of an abusive father. This caregiver is emotionally inaccessible, given to inappropriate and/​or rejecting responses to her infant’s expressions of emotions and stress, and provides minimal or unpredictable regulation of the infant’s states of overarousal. Instead, she induces extreme levels of stimulation and arousal (i.e., the very high stimulation of abuse and/​or the very low stimulation of neglect). And finally, because she provides no interactive repair, she leaves the infant to endure intense negative states for long periods of time. Less than optimal early experiences, including the “relational trauma” of abuse and neglect (Schore, 2001b), are imprinted into right cortical-​subcortical systems, encoding disorganized-​disoriented insecure internal working models that are nonconsciously accessed at later points of interpersonal emotional stress. Not only traumatic experiences but also the defense against overwhelming trauma, dissociation, is stored in right-​lateralized implicit-​procedural memory. A large body of research is now revealing the underlying psychobiological mechanisms of attachment trauma. The infant has two psychobiological response patterns to trauma: hyperarousal and dissociation (Perry et al., 1995; Schore, 1997). Beebe (2000) describes the disorganized infant-​mother attachment pair as co-​creating “mutually escalating overarousal” that amplifies the infant’s hyperarousal. In this initial stage of threat, the child’s alarm or startle reaction indicates activation of the infant’s right hemisphere (Bradley, Cuthbert, & Lang, 1996). This, in turn, evokes a sudden increase of ANS sympathetic activity, resulting in significantly elevated heart rate, blood pressure, and respiration. Distress is expressed in crying and then screaming. Crying represents an autonomic response to stress, whereby the nucleus ambiguous of the right vagus excites both the right side of the larynx and the sinoatrial node of the heart (Porges et al., 1994). The infant’s state of “frantic distress” (Beebe, 2000) or what Perry terms fear-​terror, is mediated by sympathetic hyperarousal that is expressed in increased secretion of corticotropin releasing factor (CRF) –​the brain’s major stress hormone. CRF regulates sympathetic catecholamine activity (Brown et al., 1982). Thus, brain adrenaline, noradrenaline, and dopamine levels are significantly elevated, creating a hypermetabolic state within the developing brain. In addition, there is increased secretion of vasopressin, a hypothalamic neuropeptide that is released when the environment is perceived to be unsafe and challenging (Kvetnansky et al., 1989, 1990). Hyperarousal is the infant’s first reaction to stress. Dissociation is a later reaction to trauma, wherein the child disengages from the stimuli of the external world. Traumatized infants are observed to be “staring off into space with a glazed look”: [W]‌hen infants’ attempts fail to repair the interaction infants often lose postural control, withdraw, and self-​comfort. The disengagement is profound even with this short disruption of the mutual regulatory process and break in intersubjectivity. The infant’s reaction is reminiscent of the withdrawal of Harlow’s isolated monkey or of the infants in institutions observed by Bowlby and Spitz. Tronick & Weinberg, 1997, p. 66

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Winnicott (1958) holds that a particular failure of the maternal holding environment causes a discontinuity in the baby’s need for “going-​on-​being.” Kestenberg (1985) refers to dead spots in the infant’s subjective experience, an operational definition of dissociation’s restriction of consciousness. The child’s dissociation in the midst of terror involves numbing, avoidance, compliance and restricted affect (the same pattern as adult PTSD). This parasympathetic-​dominant state of conservation-​w ithdrawal occurs in helpless and hopeless stressful situations in which the individual becomes inhibited and strives to avoid attention in order to become “unseen” (Schore, 1994, 2001b). This state of metabolic shutdown ( Janetian energy deficiency) is a primary regulatory process that is used throughout the life span. In conservation-​w ithdrawal, the stressed individual passively disengages in order “to conserve energies…to foster survival by the risky posture of feigning death, to allow healing of wounds and restitution of depleted resources by immobility” (Powles, 1992, p. 213). This parasympathetic mechanism mediates the “profound detachment” (Barach, 1991) of dissociation. If early trauma is experienced as “psychic catastrophe” (Bion, 1962), then dissociation is a “detachment from an unbearable situation” (Mollon, 1996), “the escape when there is no escape” (Putnam, 1997), “a last resort defensive strategy” (Dixon, 1998). The neurobiology of dissociative hypoarousal is appreciably different from that of hyperarousal (see Schiavone & Lanius, Chapter 39, this volume). If dopamine and noradrenaline are reduced, serotonin levels are increased (see Tops et al., 2009, on serotonin as a modulator of a drive to withdraw). In this passive state of pain-​numbing and pain-​blunting, endogenous opiates (Fanselow, 1986) are elevated. The dorsal vagal complex in the brainstem medulla is activated, which decreases blood pressure, metabolic activity, and heart rate. This elevated parasympathetic arousal is a survival strategy that allows the infant to maintain homeostasis in the face of the internal state of sympathetic hyperarousal. It is seldom acknowledged that (1) parasympathetic energy-​conserving hypoarousal and (2) sympathetic energy-​expending hyperarousal are both states of intensely low or intensely high “extreme emotional arousal,” respectively. Although vagal tone is defined as “the amount of inhibitory influence on the heart by the parasympathetic nervous system” (Field, Picken, Fox, Nawrocki & Gonzalez, 1995), it is now known that there are two parasympathetic vagal systems. The late-​developing “mammalian” or “smart” ventral vagal system in the nucleus ambiguus enables contingent social interactions via the ability to communicate with facial expressions, vocalizations, and gestures. The early-​ developing “reptilian” or “vegetative” system in the dorsal motor nucleus of the vagus shuts down metabolic activity during immobilization, death feigning, and hiding behaviors (Porges, 1997, 2011). As opposed to the mammalian ventral vagal complex that can rapidly regulate cardiac output to foster engagement and disengagement with the social environment, the reptilian dorsal vagal complex “contributes to severe emotional states and may be related to emotional states of ‘immobilization’ such as extreme terror” (Porges, 1997, p. 75). There is now agreement that sympathetic nervous system activity manifests in tight engagement with the external environment and high levels of energy mobilization and utilization, while the parasympathetic component drives disengagement from the external environment and utilizes low levels of internal energy (Recordati, 2003). Perry’s (1997) description of the traumatized infant’s sudden switch from high energy sympathetic hyperarousal to low energy parasympathetic dissociation is reflected in Porges’ characterization of …the sudden and rapid transition from an unsuccessful strategy of struggling requiring massive sympathetic activation to the metabolically conservative immobilized state mimicking death associated with the dorsal vagal complex. p. 75 Whereas the nucleus ambiguus exhibits rapid and transitory patterns (associated with perceptive pain and unpleasantness), the dorsal vagal nucleus exhibits an involuntary and prolonged pattern of vagal outflow. This prolonged dorsal vagal parasympathetic activation explains the lengthy “void” states that are associated with pathological dissociative detachment (Allen, Console, & Lewis, 1999).

Developmental Psychology of Dissociation How are the trauma-​induced alterations of the developing right brain expressed in the socioemotional behavior of a traumatized toddler? Main and Solomon’s (1986) classic study of attachment in traumatized infants revealed a new attachment category, Type D, an insecure-​d isorganized/​d isoriented pattern that occurs in 80% of maltreated infants (Carlson et al., 1989). Type D attachment is also associated with pre-​and/​or postnatal maternal alcohol or cocaine-​use (Espinosa et al., 2001; O’Connor, Sigman, & Brill, 1987). Main and Solomon (1986) concluded that Type D infants have low stress tolerance and that their disorganization and disorientation indicate that the infant is alarmed by the

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parent. Because infants inevitably seek the parent when alarmed, Main and Solomon concluded that frightening parents placed infants in an irresolvable bind wherein they could neither approach their parents, shift their attention, nor flee. These infants are utterly unable to generate a coherent way to cope with their frightening parents. Hesse and Main (1999) noted that Type D disorganization and disorientation is phenotypically similar to dissociative states. Main and Solomon detailed the uniquely bizarre behaviors of 12-​month-​old Type D infants in the Strange Situation procedure. These infants displayed brief (frequently only 10–​30 seconds) but significant interruptions of organized behavior. At such times, Type D infants may exhibit a contradictory behavior pattern such as “backing” towards the parent rather than approaching face-​to-​face. The impression in each case was that approach movements were continually being inhibited and held back through simultaneous activation of avoidant tendencies. In most cases, however, proximity-​seeking sufficiently “over-​rode” avoidance to permit the increase in physical proximity. Thus, contradictory patterns were activated but were not mutually inhibited. Main & Solomon, 1986, p. 117 Notice the simultaneous activation of the energy-​expending sympathetic and energy-​conserving parasympathetic components of the ANS. Furthermore, maltreated infants exhibit apprehension, confusion, and very rapid shifts of state during the Strange Situation. Main and Solomon describe the child’s entrance into a dissociated state: One infant hunched her upper body and shoulders at hearing her mother’s call, then broke into extravagant laugh-​ like screeches with an excited forward movement. Her braying laughter became a cry and distress-​face without a new intake of breath as the infant hunched forward. Then suddenly she became silent, blank and dazed. 1986, p. 119 These behaviors are not restricted to the infant’s interactions with the mother; and so the intensity of the baby’s dysregulated affective state is often heightened when the infant is exposed to the added stress of an unfamiliar person. At a stranger’s entrance, two infants moved away from both mother and stranger to face the wall; another looked back with apparent terror after leaning their forehead against the wall for several seconds. Such infants exhibit “behavioral stilling” –​that is, “dazed” behavior and depressed affect. These are behavioral manifestations of dissociation. One infant “became for a moment excessively still, staring into space as though completely out of contact with self, environment, and parent” (Main and Solomon, 1986, p. 120). Another “fell face-​down on the floor in a depressed posture prior to separation, stilling all body movements” (p. 120). Guedeney and Fermanian (2001) have developed an alarm distress scale that assesses the sustained withdrawal that is associated with disorganized attachment; it assesses frozen, absent facial expression; total avoidance of eye contact; immobility; absence of vocalization; absence of relating to others; and the impression that the child is beyond reach. Dissociation in infants has also been studied with the still-​face procedure, an experimental paradigm of traumatic neglect. In the still-​face procedure, the infant is exposed to a severe relational stressor; the mother maintains eye contact with the infant, but she suddenly inhibits all vocalization and suspends all emotionally-​expressive facial expressions and gestures. This triggers an initial increase of interactive behavior and arousal in the infant. According to Tronick (2004), the infant’s confusion and fearfulness at the break in connection is accompanied by the idea that “this is threatening.” This is rapidly followed by bodily collapse, loss of postural control, withdrawal, gaze aversion, sad facial expression, and self-​comforting behavior. Most interestingly, this behavior is accompanied by a dissipation of the infant’s state of consciousness and a diminishment of self-​organizing abilities that reflect disorganization of many of the lower level psychobiological states, such as metabolic systems (Tronick, 2004). Recall that dissociation, a hypometabolic state, has been defined as a disruption in the usually integrated functions of consciousness, and described as “a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma” (Loewenstein, 1996, p. 312). Tronick (2004) suggests that infants who have a history of chronic breaks of connections exhibit an “extremely pathological state” of emotional apathy. Such infants ultimately adopt a communication style of “stay away, don’t connect.” This defensive stance is a very early forming, yet already chronic, pathological dissociation that is associated with loss of ventral vagal activation and dominance of dorsal vagal parasympathetic states. The Still-​face induction of initial hyperarousal then dissociation occurs face-​to-​face with the mother. The mother’s face is the most potent visual stimulus in the child’s world; it is well-​k nown that direct gaze can mediate not only loving, but aggressive messages (Hesse & Main, 1999). During a highly stressful experience of relational trauma, the infant is

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presented with an aggressive expression on the mother’s face. Both the image of this aggressive face and the associated alterations in the infant’s bodily state are indelibly imprinted into limbic circuits; they are stored in the imagistic procedural memory of the visuospatial right hemisphere, the locus of implicit (Hugdahl, 1995) and autobiographical (Botzung et al., 2010; Markowitsch et al., 2000; Markowitsch & Stanilou, 2011) memory. In classic research Main and Solomon (1986) noted that Type D infants often encounter a second kind of disturbing maternal behavior: A maternal expression of fear-​terror. This occurs when the mother withdraws from the infant as though the infant were frightening; such mothers of Type D infants exhibit dissociated, trance-​like, and fearful behavior. Other early studies showed a link between frightening maternal behavior, dissociation, and disorganized infant attachment (Schuengel, Bakersmans-​K ranenburg, & Van IJzendoorn, 1999). Hesse and Main observed that when the mother enters a dissociative state, a fear alarm state is triggered in the infant. The caregiver’s entrance into the dissociative state is expressed as “parent suddenly completely ‘freezes’ with eyes unmoving, half-​lidded, despite nearby movement; parent addresses infant in an ‘altered’ tone with simultaneous voicing and devoicing” (2006, p. 320). In describing the mother as she submits to the freeze state, they note: Here the parent appears to have become completely unresponsive to, or even aware of, the external surround, including the physical and verbal behavior of their infant…[W]‌e observed one mother who remained seated in an immobilized and uncomfortable position with her hand in the air, blankly staring into space for 50 sec. p. 321 During these episodes the disorganized infant is matching the rhythmic structures of the mother’s dysregulated states, and that this synchronization of escalating hyperarousal is registered in the firing patterns of the stress-​sensitive corticolimbic regions of the infant’s brain, especially in the right brain which is in a critical period of growth. Because many mothers suffer from unresolved trauma, their chaotic and dysregulated alterations of state become imprinted into the developing right brain of the child. An EEG study of 5-​month-​old infants observed increased theta activity over the right posterior temporal area while the infants were looking at a blank face (Bazhenova et al., 2007). At 6 months, the still-​face elicits right lateralization (Montirosso et al., 2012), and withdrawal behavior is associated with elevated cortisol and extreme right frontal electroencephalographic activity (Buss et al., 2003). Infants designated as “very fearful” at 7 months show larger evoked response potentials (ERPs) over the right hemisphere when viewing fearful facial expressions (de Haan et al., 2004). Indeed, it has been established that maternal care influences both the infant’s reactivity (Menard et al., 2004) and the infant’s defensive responses to threat, and that these “serve as the basis for the transmission of individual differences in stress responses from mother to offspring” (Weaver et al., 2004, p. 847). Indeed, in my own writings on relational trauma I have described the intergenerational transmission not only of the overwhelming intense emotional distress of relational trauma but also of the defensive response of characterological dissociation (Schore 2001a,b, 2003a, 2009, 2012, 2019a,b). In my work I cite the developmental studies of Beebe and her colleagues (2010) of mothers of 4-​month-​old infants who later show disorganized attachment. They documented that these caregivers show intrusive touch, as well as engage in dysregulating “mother-​chase-​infant-​dodge” and “mother positive/​surprised while infant depressed” (p. 355). These researchers observed that the mothers of these infants are overwhelmed with their own unresolved abuse or trauma and therefore cannot bear to intersubjectively engage with their infants’ distress. Because these mothers are unable to regulate their own distress, they cannot regulate the distress of their infants. This type of mother is unable to allow herself to be emotionally affected by the dysregulated state of her infant, thus she shuts down emotionally and closes her face, looking away from the infant’s face and failing to coordinate with the infant’s emotional state. Beebe interprets this fearful maternal behavior as a defensive dissociation, a strategy that protects the mother from the facial and visual intimacy that would come from joining the infant’s distressed moments. This type of mother thus shows disrupted and contradictory forms of affective communication (abuse-​intrusiveness-​ hyperarousal and neglect-​d isengagement-​hypoarousal), especially around the infant’s need for comfort when distressed. More recent research by Beebe et al. (2012) on the dyadic origins of disorganized attachment highlighted not only the 4-​month-​old infant’s unresolved fear linked to the mother’s fear-​arousing behaviors, but also the mother’s defensive emotional withdrawal in response to the infant’s distress. These authors described maternal emotional withdrawal in response to infant distress: Clinically we observed that this maternal ‘closing up’ of her face often occurred at moments of infant distress, as if mother is ‘going blank.’ To remain empathic to infant distress might re-​invoke mother’s own original traumatized state (p. 99). . .We conjecture that future D mothers cannot process emotional information in the moment because they are flooded by their experiences of the infant’s distress, which may re-​evoke earlier traumatic states of their

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own. They may shut down their own emotional processing and be unable to use the infant’s distress behaviors as communications, in a momentary dissociative process. For example, as one of the future disorganized infants sharply vocalized distress and turned his head abruptly away with a pre-​cry face, the mother’s head jerked back, as if ‘hit’ by the infant’s distress; she then looked down with a ‘closed-​up’ face. p. 102, italics added These observations fit well with my interpersonal neurobiological model of the intergenerational transmission of both trauma and the dissociative defenses against overwhelming and dysregulating affective states. The chronic psychobiological stress associated with attachment trauma not only impairs the development of the right brain but also sets the stage for the characterological use of the right brain defense of pathological dissociation when encountering later socioemotional stressors. In the developmental psychological literature, Dutra and colleagues observed that maternal disrupted affective communications and lack of involvement in the regulation of stressful arousal are associated with the child’s use of dissociation, “one of the few available means for achieving a modicum of relief from fearful arousal.” This in turn leads the child “not to acknowledge pain and distress within a set of caregiving relationships that are vital for survival” (2009, p. 388). Relational trauma-​triggered dissociation thus induces an emotional disconnection within the self, as well as between self and other.

Right Brain Processes and Dissociation Early traumatic attachment takes place when infants and toddlers repeatedly encounter massive misattunement from caregivers who trigger (and do not repair) long-​lasting intensely dysregulated states in the child. The growth-​inhibiting environment of relational attachment trauma generates dense and prolonged levels of negative affect associated with extremely stressful states of hyper-​and hypoarousal. In ‘self-​defense’ the child severely restricts overt expression of attachment need and significantly reduces the output of its emotion-​processing, limbic-​centered, attachment system. When the child is stressed, defensive functions are rapidly initiated that quickly shift the brain from interactive regulatory modes into long-​enduring, less complex autoregulatory modes. These patterns are primitive strategies for survival that remain on-​line for long intervals of time, periods in which the developing brain is in a hypometabolic state that is detrimental to the substantial amounts of energy required for critical period biosynthetic processes (Schore, 1994). This hypometabolic brain state ( Janetian deficiency of psychological energy) causes dissociative “encoding failures” (Allen et al., 1999) in the autobiographical memory of the developing self. Attachment trauma thus sets the stage for characterological use of primitive autoregulation –​that is, pathological dissociation during subsequent stages of development. In accord with this model, (1) severe early maternal dysfunction is associated with high dissociation in psychiatric patients (Draijer & Langeland, 1999); (2) physical abuse and parental dysfunction by the mother –​not the father –​is associated with somatoform dissociative symptoms (Roelofs et al., 2002); and (3) individuals with Type D attachment utilize dissociative behaviors in later stages of life (Van IJzendoorn et al., 1999). Allen and Coyne describe the characterological use of dissociation: Although initially they may have used dissociation to cope with traumatic events, they subsequently dissociate to defend against a broad range of daily stressors, including their own posttraumatic symptoms, pervasively undermining the continuity of their experience. 1995, p. 620 This psychic-​deadening defense is maladaptive not only because the individual resorts to dissociation at low levels of stress, but also finds it difficult to exit this state of conservation-​w ithdrawal. During these episodes, the person is impermeable to attachment communications and interactive regulation. This deprives the person of input that is vital to emotional development. Dissociative detachment (Allen et al., 1999) thus becomes an attractor state whereby social intimacy is habitually deemed to be dangerous (because such intimacy has always been a potential trigger of “vehement emotions”). The avoidance of emotional connections, especially those that contain novel and complex affective information, prevents emotional learning; this, in turn, precludes advances in the personality trait of right brain emotional intelligence (Schore, 2001a) or what Janet (1889) called “enlargement” of personality development. The dissociative defense against relational trauma blocks the learning of new social experiences and further development of the emotional right brain. A fundamental question that must be addressed in any developmental model of the origins of pathological dissociation is how does relational trauma of the early developing right brain impact the later behavior of the subjective self

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system as it develops at further stages of the life cycle? During the first years of life when the right brain is in a growth spurt (Trevarthen, 1996) and dominant (Chiron et al., 1997) adverse influences on brain development particularly impact the right brain (Schore, 1994, 2009, 2012, 2013; 2014a, 2017). Indeed, traumatic attachment experiences are “affectively burnt in” (Stuss & Alexander, 1999) limbic-​autonomic circuits of the cortical and subcortical components of the right brain during its critical period of growth. Classic basic research in neuroscience and neuropsychiatry indicated that “early adverse developmental experiences may leave behind a permanent physiological reactivity in limbic areas of the brain” (Post, Weiss, & Leverich, 1994, p. 800), that “the overwhelming stress of maltreatment in childhood is associated with adverse influences on brain development” (De Bellis et al., 1999, p. 1281), and that “increased sensitivity to the effects of stress later in life … render an individual vulnerable to stress-​related psychiatric disorders” (Graham et al., 1999, p. 545). Other studies revealed that maltreated children diagnosed with PTSD manifest right-​lateralized metabolic limbic abnormalities (De Bellis et al., 2000), and that adults severely abused in childhood (Raine et al., 2001) and diagnosed with PTSD (Galletly et al., 2001) show reduced right hemisphere activation during a working memory task. This research supports earlier assertions that the symptoms of PTSD fundamentally reflect an impairment of the right brain (Schore, 1997; Van de Kolk, 1996), and that the right hemisphere is paramount in the perceptual processing, and regulation of biological responses in PTSD patients (Spivak et al., 1998). The principle that individuals with severe right brain attachment pathology frequently cope with Janetian “vehement emotions” via primitive modes of autoregulation can be translated into the clinical tenet that in PTSD and other early-​forming severe pathologies of the self, the individual is cut off (dis-​a ssociated) from experiencing intense affective states. In the clinical literature, Kalsched (2005) described operations of defensive dissociative processes used by the child during traumatic experience by which “Affect in the body is severed from its corresponding images in the mind and thereby an unbearably painful meaning is obliterated” (p. 174). Lane and his colleagues (1997) described the defensive function of dissociation in later stages: “Traumatic stress in childhood could lead to self-​modulation of painful affect by directing attention away from internal emotional states” (p. 840). The right hemisphere is dominant not only for attachment regulation of affects, but also for attention (Raz, 2004; Spagna, Kim, Wu, & Fan, 2020) and pain processing (Symonds et al., 2006). Thus, the right brain strategy of dissociation represents the ultimate defense for blocking emotional bodily-​based pain. Both developmental (Perry et al., 1995; Schore, 1997) and adult (Bremner, 1999) studies support the proposition that there are two subtypes of acute trauma response in PTSD, hyperarousal and dissociative. I suggest that, in all stages of life, dissociation is a consequence of a ‘psychological shock’ or high arousal (Meares, 1999) and that at extremely high levels of arousal the coherent integration of sensory information breaks down and dissociative symptoms emerge. According to Gadea et al. (2005) mild to moderate negative affective experiences activate the right hemisphere, but an intense experience “might interfere with right hemisphere processing, with eventual damage if some critical point is reached” (p. 136). This damage is specifically hyperarousal-​induced apoptotic cell death in the hypermetabolic right brain. Thus, via a switch into a hypoarousal, a hypometabolic state allows for cell survival at times of intense stress (Schore, 2003a, 2012). A body of research indicates that both hyperarousal and dissociative responses are essentially driven by right brain processes. Metzger et al. (2004) report “PTSD arousal symptoms are associated with increased right-​sided parietal activation” (p. 324). Bonne et al. (2003) note that “regional blood flow in right precentral, superior temporal, and fusiform gyri in PTSD was higher than in healthy controls” (p. 1077), a finding that “may represent continuous preparatory motor activation, reflecting an increased basal level of anxiety and arousal.” They suggest that “this may reflect a component common to all survivors of trauma” (p. 1081). Similarly, Rabe et al. (2006) found that PTSD patients show a pattern of right hemisphere activation associated with anxious arousal during processing of trauma-​specific information. In perhaps the most extensive investigation, Lanius et al. (2004) observe that PTSD patients (as opposed to traumatized patients without PTSD) who experience traumatic memories with heart rate increases (i.e., hyperarousal), show a pattern of right brain connectivity: activation of the right posterior cingulate, right caudate, right occipital and right parietal lobe. They deduced that this right-​lateralized pattern may explain why traumatic memory is often nonverbal in nature in PTSD participants and cited other studies showing right hemisphere dominance during memory recall in individuals experiencing early trauma. Dissociation in PTSD is also centered in right brain processes. Research utilizing fMRI in PTSD patients while in a dissociative state (as reflected in a lack of increase in heart rate when exposed to their traumatic script) revealed “… activation effects in the superior and middle temporal gyrus, anterior cingulate, medial parietal lobe, and medial frontal gyres … were lateralized to the right side” (Lanius et al., 2002, p. 309). These authors concluded that dissociative responses in PTSD are underpinned by prefrontal and limbic structures, and stated that activation of the right superior and middle temporal gyri in dissociated PTSD patients is consistent with a corticolimbic model of dissociation. In a follow-​up study, Lanius et al. (2005) observed predominantly right-​hemispheric frontal and insula activation in

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PTSD patients while they are dissociating, and concluded that patients dissociate in order to escape the overwhelming emotions associated with the traumatic memory, and that dissociation can be interpreted as representing a nonverbal response to the traumatic memory (for further discussion, see Schiavone & Lanius, Chapter 39, this volume). Gundel et al. (2004) noted that dissociating patients struggle to integrate certain aspects of neuropsychological functions, like feelings and memories into current awareness, and proposed that the right anterior cingulate “may represent the structural, neuroanatomical correlate of an active inhibitory system causing a down regulation of emotional processing during the…expressive aspects of emotion” (p. 138). This right-​lateralization is confirmed in brain laterality research. In an early transcranial magnetic stimulation study Spitzer et al. (2004) reported, [D]‌issociation may involve a functional superiority of the left hemisphere over the right hemisphere or, alternatively a lack of integration in the right hemisphere. This corresponds with the idea that the right hemisphere has a distinct role in establishing, maintaining, and processing personally relevant aspects of an individual’s world. Thus a right hemispheric dysfunction might result in an altered sense of personally relevant familiarity, which resembles phenomenologically the dissociative symptoms of depersonalization and derealization…trauma-​related conditions, which themselves are closely-​associated with dissociative psychopathology, lack right hemispheric integration. p. 167 These authors concluded, “In dissociation-​prone individuals a trauma that is processed by the right hemisphere will lead to a disruption in the usually integrated function of consciousness” (p, 168). Further support for this model is offered by Enriquez and Bernabeu (2008) who documented that “dissociation is associated with dysfunctional changes in the right hemisphere which impair its characteristic dominance over emotional processing” (pp. 272–​273). These researchers observed that although high dissociators retain an ability for processing left-​hemispheric verbal stimuli, they show deficits in right-​hemispheric perception of the emotional tone of voice (prosody). Note that while dissociating the right hemisphere is dis-​integrating and directing attention away from anticipated emotional pain, left hemisphere functions may continue to operate in a “state of detachment.” Thus, in moments when the right brain is deflecting attention away from emotional states and from the external environment, left-​lateralized verbal output may continue, but in a detached tone (loss of right-​hemispheric prosody). This also means that while the individual is dissociating, he or she cannot read the emotional tone of the other’s voice. Helton, Dorahy, and Russell (2011) observed that high dissociators have difficulty coordinating activity within the right hemisphere, and that such deficits become evident when this hemisphere is …loaded with the combined effects of a sustained attention task and negative emotional stimuli…Thus, the integration of experience, which rely heavily on right hemispheric activation (e.g., negative emotion, sense of self with reference to the experience) may be compromised in high dissociators leading to dissociative (non-​integrated) memory encoding, and therefore later intrusive dissociative phenomena. p. 700 Most currently Şar’s laboratory offered an MRI study of dissociation in adolescents with a history of sexual abuse diagnosed as PTSD (Mutluer et al., 2018). Citing my right brain metabolic shutdown model, they report a right hemispheric primary “inflammation” trauma response reflected in lifetime re-​experiencing and lifetime hyperarousal associated with a larger right anterior cingulate, and a right hemispheric secondary “trauma illness” associated with a smaller right amygdala and lifetime avoidance, but a tertiary response of “alienation” associated with left hemisphere activation, which “may have a neuro-​protective effect” (p. 12). They suggest this may represent diminished callosal connectivity between the “Emotional Brain” and the “Rational Brain,” which “may be part of the ‘protective’ response among traumatized adolescents to ‘quarantine’ left hemisphere while right hemisphere was operating in ‘frontline’ ” (p. 121).

Dysregulation of Right-​lateralized Limbic-​autonomic Circuits and Dissociation The previously cited studies reflect the ontogenetic development of an early dysregulated system, and provide further evidence that prefrontal cortical and limbic areas, particularly of the right hemisphere, are central to the dissociative response. More so than the left, the right hemisphere is densely interconnected with limbic regions and subcortical areas that generate

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the physiological aspect of emotions, including fear-​terror (Borod, 2000; Gainotti, 2000; Tucker, 1992). In a classic study, Hecaen and Albert (1978) described the much overlooked importance of hierarchical vertical cortico-​subcortical functional systems: Cortical neural mechanisms of one hemisphere would be responsible for a particular performance, and subcortical structures connected to these cortical zones would participate in the realization of the performance, creating a complex, cortico-​subcortical functional system specific to each hemisphere. p. 414 In parallel writings, Barbas et al. (2003) report, Neural processing of emotions engages diverse structures from the highest to the lowest levels of the neuraxis. On the one hand, high-​order association areas are necessary to understand the significance of an emotional situation, and on the other hand, low level structures must be activated to express the emotion through changes in the rhythm of peripheral organs. p. 2 This hierarchical model of cortical-​subcortical circuits directly applies to the right hemisphere, “the emotional brain.” These vertical circuits also account for the fact that the right hemisphere contains the major circuitry of emotion-​ regulation (Cerqueira, Almeida, & Sousa, 2008; Porges, Doussard-​Roosevelt, & Maiti, 1994; Schore, 1994; Stevenson et al., 2008; Sullivan & Dufresne, 2006; Wang et al., 2005). I suggest that dissociation, a primitive coping strategy of affect regulation, is best understood as a loss of vertical connectivity between cortical and subcortical limbic areas within the right hemisphere. J. Krystal et al. (1998) emphasize changes in interhemispheric processing and “cortical disconnectivity” between higher frontal and limbic structures. Ontogenetically, however, dissociation appears well before the frontal areas of the cerebral cortex are myelinated and before callosal connections are functional (Bergman, Linley, & Fawcus, 2004; Schore, 2001a). Thus, models of early dissociative defense against organismic threat must move down the neuraxis into the brainstem that generates states of arousal. In a congruent model, Scaer (2001) postulates that dissociation “is elicited by internal and external cue-​specific stimuli, but because the threat itself has not been resolved, internal cues persist without inhibition from external messages of safety, and kindling is triggered in the cortical, limbic, and brainstem centers” (p. 84). Notice that Scaer’s reference to brainstem centers and external and internal cues clearly implies both top-​down and bottom-​up processing. Pathological dissociative detachment is a defensive state, driven by fear-​terror, in which the stressed individual copes by pervasively and diffusely disengaging attention “ from both the outer and inner worlds” (Allen et al., 1999, p. 164, italics added). In a similar conceptualization, Putnam (1997) describes dissociation between an observing and experiencing ego. Such terms (i.e., “inner world,” “experiencing ego”), however, have not been clearly defined by the dissociation literature. I have suggested that the ‘inner world,” the source of “internal cues,” is the realm of bodily processes, the somatic components of emotional states (Schore, 1994). According to Allen and his colleagues, “dissociatively detached individuals are not only detached from the environment, but also from the self -​their body, their own actions, and their sense of identity” (1999, p. 165). Thus dissociation represents disrupted integration in various functions including bodily movement, affect and behavior. With regard to body functions, research on the autonomic nervous system, or what Jackson (1931) called the “physiological bottom of the mind,” are vital to understanding the mind-​body alterations of trauma and the mechanism of dissociation (Schore, 2001b, 2002). Indeed, the higher regulatory systems of the right hemisphere form extensive reciprocal connections with the limbic, sympathetic, and parasympathetic branches of the ANS (Spence, Shapiro, & Zaidel, 1996; Tucker, 1992; Yoon et al., 1997). These control the somatic components of many emotional responses, especially autonomic physiological responses to social stimuli. Adaptive right brain emotion-​processing depends upon an integration of the activities of the CNS and the ANS (Hagemann, Waldstein, & Thayer, 2003), which is lost in the dissociative state. According to Porges at al. (1994, 2011), the lower right side of the brainstem that controls the ANS is innervated by the amygdala and unnamed higher limbic structures, and provide the primary central regulation of homeostasis and physiological reactivity. Porges’ model emphasizes the lower structures of a vertical system. Although he details the brainstem components, he refers to the higher structures as the “cortex” that processes information from the social environment. And yet, his model clearly implies a bidirectional system in which both top-​down and bottom-​up processes are responsible for generating adaptive regulatory functioning.

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Benarroch (1997) describes such CNS-​A NS limbic-​autonomic circuits in his model of a central autonomic network (CAN) –​an internal regulation system through which the brain controls visceromotor, neuroendocrine, and behavioral responses. Like Porges’ model, Benarroch’s CAN is a bidirectional hierarchical system. Benarroch, however, focuses more on higher limbic structures than lower brainstem structures. The CAN is composed of (a) limbic areas in the ventromedial (orbital) prefrontal cortex, anterior cingulate, insula, and amygdala, (b) diencephalic areas in the hypothalamus, (c) brainstem structures in the periaqueductal grey matter, and (d) the nucleus of the solitary tract and nucleus ambiguus in the medulla. Hagemann, Waldstein, and Thayer (2003) characterize the CAN as a network of neural structures that generate, receive, and integrate internal and external information in the service of goal-​d irected behavior and organism adaptability…These structures are reciprocally interconnected such that information flows in both directions –​top-​down and bottom-​up. The primary output of the CAN is mediated through the preganglionic sympathetic and parasympathetic neurons. These neurons innervate the heart via the stellate ganglia and the vagus nerve. pp. 83–​84 When this network is either completely uncoupled or rigidly coupled, the individual is less able to dynamically and adaptively assemble the components of the network to meet an environmental challenge, thereby displaying deficits in emotional expression and affect regulation (Demaree et al., 2004). Dissociation, which impairs these same adaptive affective capacities, represents a cortical-​subcortical disconnect in this hierarchical limbic circuit, a lack of synaptic connectivity between “higher,” “vertical” limbic structures and “lower” brainstem and autonomic structures. This finding leads back to the problem of psychopathogenesis –​what events could be responsible for such structural and functional deficits? Authors are now describing the developmental process of “cerebral maturation in the vertical dimension” (Luu & Tucker, 1996). Both the ANS and the CNS continue to develop postnatally (Schore, 2021). Importantly, the assembly of these limbic-​autonomic circuits (Rinaman, Levitt, & Card, 2000) is experience-​dependent (Schore, 1994, 2001a). These experiences are provided by attachment transactions of the first and second year, during which the primary caregiver provides complex interpersonal stimuli and interactive regulation of the infant’s core systems of central and autonomic arousal. Optimal environments promote secure attachments that facilitate the organization of limbic-​autonomic circuits and a right hemispheric limbic-​modulated ventral vagal parasympathetic circuit of emotion regulation that mediates both emotion and communication processes (Porges et al., 1994, 2011). Under stress, this complex system manifests itself as a flexible coping pattern in which homeostatic increases in activity in one ANS division are associated with decreases in the other. An autonomic mode of coupled reciprocal sympathetic-​ parasympathetic control is evident when an organism responds alertly and adaptively to a personally meaningful (especially social) stressor, yet promptly returns to the relaxed state of autonomic balance as soon as the context is appraised as safe. Thus, the ANS is not only sensitive to environmental demands and perceived stresses and threats, but will also, in a predictable order, rapidly reorganize to different neural-​mediated states (Porges, 2001). In contrast to this healthy developmental scenario, traumatizing primary caregivers amplify the infant’s states of hyperarousal and/​or dissociative hypoarousal. This relational intersubjective context inhibits the experience-​dependent maturation of CNS-​A NS links (which are more extensive on the right side of the brain). In this manner, dysregulation of the developing right brain is associated in the short-​term with traumatic attachment and in the long-​term with the psychopathogenesis of characterological dissociation. During a critical period an extensive apoptotic parcellation of vertical circuits in the developing right brain would lead to an inefficient regulation of the ANS by higher centers in the CNS, functionally expressed as a dissociation of central regulation of sympathetic and hypothalamic-​pituitary-​adrenal systems (Schore, 1994, 2014a, 2017, 2019a). This model of dissociation as a stress-​induced disconnect between right brain CNS and ANS systems directly applies to the etiology and psychobiological mechanism of “somatoform dissociation,” which is an outcome of early onset traumatization, often involving physical abuse and threat to life by another person. In somatoform dissociation there is a lack of integration of sensorimotor experiences, reactions, and functions of the individual and his/​her self-​representation (see Nijenhuis, Chapter 33, this volume). Since sensorimotor operations evolve from the operations of the ANS, the dissociation between the CNS and ANS creates a separation between the bodily-​based sensorimotor and self functions of the right-​lateralized corporeal self. Psychopathological regulatory systems associated with dissociation thus contain poorly evolved CNS-​A NS limbic-​ autonomic switching mechanisms that are inefficient or incapable of uncoupling and recoupling the sympathetic and parasympathetic components of the ANS in response to changing environmental circumstances. This nonreciprocal

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mode of autonomic control (Berntson et al., 1991) is unable to adapt to stress. In fact, the coping limitations of pathological dissociation are essentially defined by these systems’ overly rigid and continuing inhibition of certain other internal systems. In other words, dissociation reflects the inability of the right brain cortical-​subcortical system to (1) recognize and co-​process exteroceptive information from the relational environment and (2) on a moment-​to-​moment basis integrate this information with interoceptive information from the body. Neuroscience writers now refer to “a dissociation between the emotional evaluation of an event and the physiological reaction to that event, with the process being dependent on intact right hemisphere function” (Crucian et al., 2000, p. 643), implying that pathological dissociation is associated with a loss of intact coherent function of the right brain. An immature right brain circuit of emotion-​regulation would show deficits in “intense emotional-​homeostatic processes” (Porges et al., 1994), that is, it would too easily default from fast-​acting ventral vagal to slow-​acting dorsal vagal systems in moments of “vehement emotions” and, thereby, be unable to flexibly shift internal states and overt behavior in response to stressful external demands. Indeed, the ventral vagal complex is known to be defective in PTSD patients (Sahar, Shalev, & Porges, 2001), and this may account for the basal hyperarousal and high heart rates of these patients (Sack, Hopper, & Lamprecht, 2004). I suggest that under high stress an unstable ventral vagal system could be rapidly displaced by a dorsal vagal system; this would account for the low heart rate of dissociative hypoarousal. The disassociation of higher corticolimbic areas of the CAN internal regulation system and Porges’ right brain circuit of emotion regulation precludes (1) efficient top-​down control of lower brainstem and autonomic functions and (2) adaptive integration of CNS exteroceptive and ANS interoceptive information processing. This disinhibition releases lower control structures in the right amygdala via a mechanism that Hughlings Jackson (1958) called dissolution, a process whereby the higher nervous arrangements inhibit (or control) the lower, and thus, when the higher are suddenly rendered functionless, the lower rise in activity. Regarding higher control systems, as previously mentioned, the highest level of regulatory control of intense emotion in the human brain is located in frontolimbic systems of the right hemisphere. Note that the neuroanatomy of the right brain allows for a reciprocal connection between the highest level of the limbic system (the orbitofrontal and medial frontal cortices) and the brainstem medullary vagal systems that regulate parasympathetic hypoarousal and dissociation. A similar model is proposed by Phillips et al. (2003), who described a “ventral” regulation system, including orbitofrontal cortex, insula, anterior cingulate, and amygdala. As opposed to a nonlimbic “dorsal” effortful regulation system in the dorsolateral cortex, hippocampus, and other structures involved in explicit processing of the verbal aspects of emotional stimuli, this ventral system is important for the implicit identification of the emotional significance of environmental stimuli, and is central to the “automatic regulation and mediation of autonomic responses to emotional stimuli and contexts that accompany the production of affective states” (p. 510). I have described a model of right-​lateralized limbic-​autonomic circuits, a hierarchical sequence of interconnected limbic areas in the orbitofrontal cortex, insular cortex, anterior cingulate, and amygdala (Schore, 1994, 1996). Each component of this “rostral limbic system” interconnects with the other and with brainstem bioaminergic arousal and neuromodulatory systems, including vagal nuclei in the medulla and hypothalamic neuroendocrine nuclei that regulate the sympathetic and parasympathetic nervous systems (Schore, 1994, 2003a, b). Of particular importance are the highest levels of this vertical cortical-​subcortical system, especially the orbitofrontal-​ventromedial cortex, which monitors and controls responses initiated by other brain regions and is involved in the selection and active inhibition of neural circuits associated with emotional responses (Rule, Shimamura, & Knight, 2002). This prefrontal system performs a “hot’ ” executive function –​regulating affect and motivation via control of basic limbic system functions (Zelazo & Muller, 2002). According to Barbas and her colleagues (2003), Axons from orbitofrontal and medial prefrontal cortices converge in the hypothalamus with neurons projecting to brainstem and spinal autonomic centers, linking the highest with the lowest levels of the neuraxis…Descending pathways from orbitofrontal and medial prefrontal cortices [anterior cingulate], which are linked with the amygdala, provide the means for speedy influence of the prefrontal cortex on the autonomic system, in processes underlying appreciation and expression of emotions…Repetitive activation of the remarkably specific and bidirectional pathways linking the amygdala with the orbitofrontal cortex may be necessary for conscious appreciation of the emotional significance of events. This top-​down influence can either be excitatory or inhibitory; the latter expressed in the documented activation of the orbitofrontal cortex during defensive responses (Roberts et al., 2001). Recall Lanius et al.’s (2002) conclusion that prefrontal and limbic structures underlie dissociative responses in PTSD, and Gundel et al.’s (2004) proposal that the right anterior cingulate can act as an inhibitory system that down-​regulates emotional processing, resulting in dissociation (i.e., an inability to integrate feelings into conscious awareness).

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Indeed, this limbic-​autonomic circuit is right-​lateralized. The right orbitofrontal cortex, the hierarchical apex of the limbic system, exercises executive control over the entire right brain. Right orbitofrontal areas are more critical to emotional functions than left orbitofrontal areas (Tranel, Bechara, & Denburg, 2002). Within the orbitofrontal cortex, the lateral orbital prefrontal areas are specialized for regulating positive emotional states, while medial orbitofrontal areas are specialized for processing negative emotional states (Northoff et al., 2000; Schore, 2001a). The functioning of these two limbic-​autonomic circuits, one capped by the lateral orbitofrontal cortex and the other by the medial orbitofrontal cortex are organized by the attachment experiences of the first and second year. Optimal maturation of this prefrontolimbic system allows for the highest level of integration of exteroceptive and interoceptive information. The right orbitofrontal cortex, in conjunction with the right anterior insula, supports a representation of visceral responses accessible to awareness, and provides a substrate for subjective feeling states and emotional depth (Craig, 2004; Critchley et al., 2004), as well as the subjective experience of body-​ownership (Tsakiris, 2010). In contrast, pathological dissociation reflects a loss of awareness of memory, identity, immediate sensations, emotion, and control of body movements. Just as secure attachment constrains trauma and dissociation, so does optimal functioning of the orbitofrontal system oppose somatoform dissociation. Furthermore, the right prefrontal cortex, the senior executive of limbic arousal ( Joseph, 1996), is most directly linked to stress-​regulatory systems (Brake et al., 2000) and, therefore, is essential for the regulation of the hyperaroused and hypoaroused states that accompany traumatic stress. During the acquisition of conditioned fear (Fischer et al., 2002), the right prefrontal brain is activated. This cortical-​subcortical regulatory mechanism allows for orbitofrontal modulation of the right amygdala that is specialized for fear conditioning (Baker & Kim, 2004; Moses et al., 2007) and processing frightening faces (Whalen et al., 1998). The right amygdala directly projects to the brainstem startle center (Bradley, Cuthbert, & Lang, 1996) and to the dorsal motor vagal nucleus (Schwaber et al., 1982), and the amygdala’s connections with the dorsolateral periaqueductal gray in the brainstem mediate the defensive freeze response (Oliveira et al., 2004; Vianna et al., 2001). In this manner, the right orbitofrontal cortex “organizes the appropriate cortical and autonomic response based on the implications of …sensory information for survival. The orbitofrontal cortex therefore functions as a master regulator for organization of the brain’s response to threat” (Scarr, 2001, p. 78). These data strongly suggest that an individual with an impaired or developmentally immature orbitofrontal system resulting from early relational trauma will be vulnerable to pathological dissociation under stress. Without orbital prefrontal feedback regarding the level of threat, the organism remains in an amygdala-​d riven state (of hyperarousal or defensive dissociative hypoarousal) longer than necessary (Morgan & LeDoux, 1995). In humans, conditioned fear acquisition and extinction are associated with right-​hemisphere-​dominant amygdala function (La Bar et al., 1998). Such amygdala-​d riven startle and fear-​freeze responses are intense because they are totally unregulated by the orbitofrontal (and medial frontal) cortex. Indeed, dysfunction of the right frontal lobe is involved in PTSD symptomatology (Freeman & Kimbrell, 2001) and dissociative flashbacks (Berthier et al., 2001). In support of earlier proposals (Schore, 1994), it is now well established that human prefrontal functions emerge around the end of the first year (Happeney, Zelazo, & Stuss, 2004), and that conditions which modify early maternal variability in infancy produce “significant differences in right but not left adult prefrontal volumes, with experience-​ dependent asymmetric variation most clearly expressed in ventral medial cortex” (Lyons et al., 2002, p. 51). During these critical periods extensive hypometabolic states preclude optimal organization and optimal functional capacity of the highest frontolimbic levels of the early developing right brain. Pathological dissociation reflects an impairment of the affect regulatory functions of the higher centers in the orbitofrontal cortex. Through its connections with the ANS the orbitofrontal system is implicated in “the representation of emotional information and the regulation of emotional processes” (Roberts et al., 2004, p. 307) and the conscious awareness and importance of the emotional significance of autobiographical events (Barbas et al., 2003). In the dorsal vagal parasympathetic-​dominant state of dissociation, however, the individual is cut off (dis-​a ssociated) from both the external and the internal environment and, therefore, emotions are not consciously experienced. Although triggered by subcortical mechanisms, dissociation is regulated by higher corticolimbic centers. Pathological dissociation is the product of an inefficient frontolimbic system that cannot regulate the onset and offset of the dissociative response. Instead, for long periods of time, disinhibited lower subcortical centers, (especially the right amygdala) drive the dissociative response; this reflects a Janetian regression to a constricted and disunified state (Moskowitz & Van der Hart, 2020). Adequate orbitofrontal activity is needed to integrate information from the external world and the internal world (especially “messages of safety”); “such integration might provide a way whereby incoming information may be associated with motivational and emotional states to subserve processes such as selective attention and memory formation and retrieval” (Pandya & Yeterian, 1985, p. 51). Loss of orbitofrontal functions that maintain “the integration of past, present, and future experiences, enabling adequate performance in behavioral tasks, social situation, or situations involving survival” (Lipton

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et al., 1999, p. 356) is reflected in pathological dissociation (i.e., in the integration disruptions associated with emotion, consciousness, memory, identity, or perception of the environment). Indeed, patients with perhaps the most severe form of pathological dissociation –​dissociative identity disorder –​characterized by severe alterations of consciousness and loss of identity, show significant reduction of blood flow and therefore hypoactivation of the orbitofrontal cortices (Şar et al., 2007). In total, a body of studies now indicates that the right orbitofrontal system plays a fundamental role in not only the processing of emotion-​evoking stimuli without conscious awareness and controlling the allocation of attention to possible contents of consciousness, but also in the homeostatic regulation of body and motivational states via its monitoring and regulation of the duration, frequency, and intensity of conscious and unconscious dissociated affective states (Schore, 2012). Northoff and his colleagues (2007) assert that the orbitofrontal cortex is centrally involved in constituting a more mature and cognitively guided defense, and that dysfunction in this region makes the constitution of higher defense mechanisms impossible.

Further Proposals on the Biological Mechanisms Underlying Dissociation With a call for an understanding of dissociative symptoms using pathophysiologic and neurobiological mechanisms (Prueter et al., 2002), I have used regulation theory to offer a model of the earliest psychobiological expression of dissociation in human development. I argued that dissociation is a basic survival mechanism for coping with intense states of energy-​expending hyperarousal by shifting into an energy-​conserving hypometabolic state. This regulation strategy of hypoarousal, which is reflected in heart-​rate deceleration in response to stress, remains unchanged over the life span. This model is based in part on (1) Main’s observations (Main & Solomon, 1986; Main & Hesse, 1999, 2006) that the disorganization and disorientation of type “D” attachment phenotypically resembles dissociative states, and (2) Tronick’s (Tronick & Weinberg, 1997; Tronick, 2004) still-​face procedure –​a threatening interpersonal context that triggers “massive disengagement.” I have suggested these paradigms refer to the same state of dissociation that clinicians have described as “profound detachment” (Barach, 1991), “detachment from an unbearable situation” (Mollon, 1996), and “dissociative detachment” (Allen et al., 1999). At all points in the life span, the functional aspects of Janetian “extreme emotional arousal” and dissociation reflect a structural alteration in arousal systems in the brainstem associated with a loss of ventral vagal, and dominance of dorsal vagal, parasympathetic states. In this section I will offer further speculations about the basic biological mechanisms that underlie dissociation. Under stress, Type “D” infants show a dazed facial appearance, a stilling of all body movement, and at times a freezing of limbs, which had been in motion (Main & Solomon, 1986). Experiences of traumatic freezing are encoded in enduring implicit-​procedural memory, representing what Janet termed unconscious “fixed ideas” that cannot be “liquidated.” Indeed, the relationship between freeze behavior and dissociation has been noted by authors from various disciplines. In psychophysiological research, Porges (1997) described a trauma-​induced “immobilized state” associated with the dorsal vagal complex. In one of the most important psychiatric texts on trauma written in the last century, Henry Krystal (1988) described a traumatic “catatonoid” affective reaction to “the perception of fatal helplessness in the face of destructive danger” and equates this “pattern of surrender” with the “cataleptic immobility” of animals (pp. 114–​ 115). In the trauma literature, I have described (a) the “frozen watchfulness” of the abused child who waits warily for parental demands, responds quickly and compliantly, and then returns to her previous vigilant state, and (b) the “frozen state” of speechless terror seen in adult PTSD patients (Schore, 2001a). In neurological writings, Scaer (2001) postulates that dissociation “is initiated by a failed attempt at defensive/​escape efforts at the moment of a life threat, and is perpetuated if spontaneous recovery of the resulting freeze response is blocked or truncated” (p. 84): If deterrence of the threat through defense or fight fails, the animal enters a state of helplessness, associated by a marked increase in dorsal vagal complex tone, initiating the freeze/​immobility response…The extremes of vagal parasympathetic tone as manifested in the state of dorsal vagal activation, therefore, contribute greatly to the generation of severe emotions, especially those of terror and helplessness. Although freeze/​i mmobility states…may be useful for short-​term survival, prolongation or repeated activation of that state clearly has serious implications for health and long-​term survival. Scaer, 2001, p. 81 Several studies indicate that the freeze response is right-​lateralized. Freezing in primate infants, which is elicited by eye contact, correlates with extreme right frontal EEG activity and high basal cortisol levels (Kalin et al., 1998). Right

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parietal lesions in rats are associated with a conditioned freezing deficit (Hogg, Sanger, & Moser, 1998). In human catatonia, a basic somatic defense mechanism associated with “immobilization of anxieties,” there is a right lower prefronto-​ parietal cortical dysfunction (Northoff et al., 2000). Tronick’s (2004) developmental work describes not freeze behavior but a collapsed state of “profound disengagement.” He observed both a suspension of spontaneous emotional expression and gesture, and a marked reduction in the baby’s consciousness that is associated with disorganization of many lower level psychobiological systems, including metabolic systems. How does this relate to freezing? Keep in mind that the full manifestation of the fear-​f reeze response is a late-​occurring behavior; in human infants, it occurs in the second half of the first year. But the hypometabolic state of dissociation is seen in the hypoxic human fetus (Reed et al., 1999) and soon after birth (Bergman et al., 2004). Again, clues come from studies in basic biology and neuroscience. Citing this literature, Scaer asserts that freeze behavior is a state of alert immobility in the presence of a predator. He points out that a freeze may be succeeded by flight or, if attacked and captured by a predator, by a “deeper state of freeze –​one associated with apparent unresponsiveness and with marked changes in basal autonomic state” (2001, p. 76). This state of helplessness lasts for up to 30 minutes, and is accompanied by marked bradycardia (heart rate deceleration) and a pronounced state of “deep” parasympathetic vagal tone. Recall that Porges (1995) described an “involuntary and often prolonged characteristic pattern of vagal outflow from the dorsal vagal nucleus” (1995, p. 228). I equate this with a deep altered state of consciousness, which, if prolonged and chronic, is the psychobiological engine of pathological dissociation. Studies in basic biology offer further information about the psychobiological mechanism of this deeper state of freeze. Gabrielsen and Smith (1985) have explored the physiological responses that underlie basic defenses (i.e., “threat-​ induced behavior”) in all animals. In reaction to an environmental threat (a predator), an organism can respond in various ways: the organism may fight or flee in fear. Both responses are associated with tachycardia and increased activity, reflective of sympathetic hyperarousal. Aside from these two active defenses, Gabrielson and Smith describe two passive defenses (i.e., freezing and paralysis). The passive, immobile defenses differ; freezing occurs in response to visual or auditory stimuli of a predator’s approach, whereas paralysis occurs in response to strong tactile stimulation by the predator. Intriguingly, the organism is alert during a freeze, but “unconscious” during paralysis; parasympathetic heart-​rate deceleration, which they term “emotional bradycardia,” occurs in both. Biologists call this “fear bradycardia” or “alarm bradycardia” ( Jacobsen, 1979). I suggest that the differentiation of freeze vs. paralysis is the same difference as (1) Scarr’s freeze vs. deeper state of freeze, and (2) Main’s type “D” freezing when the infant is “alarmed by the parent” vs. Tronick’s still-​face collapse, loss of postural control, and “dissipation of consciousness.” Because high levels of dorsal vagal activation are associated with dangerous bradycardia, these data strongly suggest that the mother’s failure to repair infant dissociative states of deep freeze would be a potent generator of psychopathogenesis. Recall Bremner and Brett’s (1997) caution: “dissociation represents an effective short-​term strategy that is detrimental to long-​term functioning.” Gabrielsen and Smith (1985) discussed another term for the deep freeze state –​”feigned death” –​a defense mechanism that is utilized by a number of vertebrates, amphibians, reptiles, birds, and mammals (including humans). A mild threat (the face of a human in their study) to the American opossum elicited freezing and a 12% decrease in heart rate. A more severe threat (vigorous tactile shaking), however, induced death feigning and a stunning 46% decrease of heart rate deceleration. In a conception that is congruent with the neurobiological model of dissociation outlined in this chapter, Gabrielsen and Smith (1985) have postulated that (1) the sudden depression in heart-​rate and respiration strongly indicates that higher CNS structures are directly controlling the parasympathetic cardiovascular ‘centres’ in the medulla and (2) this alteration reflects a severe decrease in oxygen consumption and body temperature. I propose: (1) the freeze response is a dorsal vagal parasympathetic energy-​conserving state that is coupled with, but dominant over, a weaker state of energy-​expending sympathetic arousal; and (2) during the collapsed state of death feigning, the two ANS components are uncoupled. Thus, in the deep freeze there is no sympathetic activity (low levels of vasopressin, catecholamines, cortisol) and pure dorsal vagal activation that produces massive bradycardia (Cheng et al., 1999) and a hypometabolic state. This decrease in oxygen consumption during dissociative death feigning is congruent with the role of the dorsal vagal system in hypoxic responses (Porges, 2001; Potter & McCloskey, 1986) and with the reptilian diving reflex, an energy conservation strategy of heart rate deceleration that acts as a “metabolic defense” (Boutiler, 2001; Guppy & Withers, 1999). Metabolic defense explicitly describes an altered metabolic state in brain mitochondria, the generator of ATP, biological energy in the brain that is associated with changes in physiological arousal level. This shift is from an hypermetabolic aerobic to hypometabolic anaerobic metabolism in right-​lateralized limbic circuits. Parasympathetic vagal tone also increases “during entrance in hibernation, a long lasting disengagement from the external environment characterized by decreases in heart rate, breathing frequency, and metabolic rate” (Recordati, 2003, p. 4). The hypometabolic changes in brain plasticity (von der Ohe et al., 2006) and in mitochondrial energy

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generation (Eddy et al., 2006) during the hibernation state of torpor (apathy, low responsivesness) may thus be directly related to the neurobiological mechanism of dissociation. This shift into hypoxia also mediates “suspended animation” in developing systems (Padilla & Roth, 2001; Teodoro & O’Farrell, 2003). These data support my model of dissociation as a hypometabolic state (Schore, 2001b), a Janetian deficiency of psychological energy. Confirming this idea a recent study by Efrati al. (2018) cites this hibernation model and concludes, …dissociation could be interpreted from the biological perspective as a hypometabolic state and from the psychological perspective as a deficiency of psychological energy…this hypometabolic state at the cellular level (minimal energy potential for cell survival) … may correlate with apathy and low responsiveness (Schore, 2009, p. 5, italics added). Note the similarity of this “emotional bradycardia” to (1) the earlier psychoneurobiological portraits of the infant’s parasympathetic-​d riven heart rate deceleration and dissociative response to attachment trauma, (2) Kestenberg’s (1985) dead spots in the infant’s subjective experience, and (3) Powles (1992) state of conservation-​w ithdrawal in which the stressed individual passively disengages by “the risky posture of feigning death.” The clinical literature refers to dissociation as “a last resort defensive strategy” (Dixon, 1998) and “a submission and resignation to the inevitability of overwhelming, even psychically deadening danger” (Davies & Frawley, 1994, p. 65).

Right Brain Cortical and Subcortical Emotional Structures and Dissociation Classically the clinical manifestations of dissociation include amnesia for autobiographical information and derealization, phenomena that reflect a heavy emphasis on cognition. However, psychiatry, psychology, and neuroscience are now emphasizing the primacy of affect and affect regulation. This convergence suggests that emotion is a central aspect of dissociation. The contemporary revitalization of the work of Janet (Nemiah, 1989; Putnam, 1989; Van der Hart, Nijenhuis, & Steele, 2006) clearly implies a return to a model of dissociation in which “vehement emotions” and “extreme emotional arousal” are central, rather than secondary to cognition. A large body of converging clinical and experimental research suggests that severe affect dysregulation lies at the core of the dis-​integration that occurs in the dissociative response to overwhelming traumatic experience. The original Janetian concept of dissociation implies that the trigger for dis-​integration is an unbearable emotional reaction and an appraisal that the experience is overwhelming. What is dis-​a ssociated is a structural system that rapidly detects, processes, and copes with subjectively intense emotional information and overwhelming survival threat. This characterization applies to the right brain, which is dominant for the reception (Borod et al., 1998; George et al., 1996; Nakamura et al., 1999) and expression (Mandal & Ambady, 2004) of emotion, as well as responding to preattentive negative emotional stimuli (Kimura et al., 2004), coping with negative affects (Davidson et al., 1990; Silberman & Weingartner, 1986), and controlling vital functions that support survival and enable the organism to cope with stressors (Wittling & Schweiger, 1993; Schore, 2012, 2019a,b). The human threat detection system is located in the subcortical areas of the right brain, especially in the right amygdala, which is specialized for detecting, at unconscious levels, “unseen fear” (Morris et al., 1999), for fear conditioning (Fischer et al., 2002), for stress and emotionally related processes (Scicli et al., 2004), and for the expression of memory of aversively motivated experiences (Coleman-​Mesches & McGaugh, 1995). Neuroscience now demonstrates that throughout all stages of development, “the right amygdala may subserve a high-​speed detection role for unconscious stimuli” (Costafreda et al., 2008, p. 66) and for processing “unconscious emotional learning” (Morris, Ohman, & Dolan, 1998). In a study of predator-​related stress-​activation of the right amygdala and periaqueductal gray, Adamaec, Blundell, and Burton (2003) reported findings that “implicate neuroplasticity in right hemispheric limbic circuitry in mediating long-​lasting changes in negative affect following brief but severe stress” (p. 1264). The right amygdala is regulated by the right insula, right anterior cingulate, and right orbitofrontal cortex; this prefrontal hierarchical apex of the limbic system is activated in situations where survival is threatened (Lipton et al., 1999) and functions as a key regulator for coordinating the response to threat in the brain (Scaer, 2001). Indeed, “the right ventral medial prefrontal cortex plays a primary role in optimizing cautious and adaptive behavior in potentially threatening situations” (Sullivan & Gratton, 2002, p. 69). Earlier in this chapter, I showed that secure attachment experiences allow for optimal maturation of the right orbitofrontal cortex. Indeed, an adaptive right orbital frontal system represents the anatomical locus of the attachment control system and the most complex affect and stress regulating mechanisms, allowing the right brain to act as an integrative self-​regulating system (Schore, 2000). Accordingly, the psychological principle that secure attachment is the primary defense against trauma-​induced psychopathology is directly related to the developmental neurobiological tenet

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that healthy attachment experiences facilitate the experience-​dependent maturation of a right-​lateralized affect regulatory system that can efficiently modulate extreme emotional arousal and intense emotion. The capacity to consciously experience regulated negative (and positive) emotional states is profoundly adaptive. Affects provide an internal evaluation of our encounters with the environment, and allow for actual or expected changes in events that are important to the individual. In contrast, the relational context of a disorganized-​d isoriented insecure attachment acts as a growth-​inhibiting environment that generates immature and inefficient orbitofrontal systems, thereby precluding higher complex forms of affect regulation. Under stress, these immature prefrontal corticolimbic systems rapidly disorganize, disinhibiting lower subcortical systems that activate either states of hyperarousal or the primitive defense of dissociation that counterbalances these states. When dissociated from “top-​down” orbitofrontal influences, an “exaggerated amygdala” response to masked facially expressed fearful reminders of traumatic events occurs in PTSD patients (Rauch et al., 2000). Characterological use of this “last-​resort defensive strategy” precludes the capacity to consciously experience and integrate their affective states, thereby forfeiting their adaptive use in interpersonal and intraorganismic functioning and further emotional development. The symptomatology of dissociation reflects a structural impairment of a right brain regulatory system and its accompanying deficiencies of affect regulation. The clinical principle that dissociation is detrimental to long-​term functioning (Bremner & Brett, 1997) is directly related to the developmental observations that early-​ forming yet enduring disorganized insecure attachment associated with dissociative states is a primary risk factor for the development of mental disorders (Hesse & Main, 1999; Main, 1996), and to the neuropsychiatric observations that affect dysregulation and right hemisphere dysfunction play a prominent role in all psychiatric disorders (Cutting, 1992; Schore, 2003a,b). It is important to note that efficient orbitofrontal function is essential for consciously appraising an events’ personal emotional significance (Barbas et al., 2003). In normal participants, the right orbitofrontal cortex shows “an enhanced response to consciously perceived, as opposed to neglected fearful faces” (Winston, Vuillemer, & Dolan, 2003, p. 1827). In contrast, in PTSD patients that exhibit dissociative flashbacks, their right frontal lobe is dysfunctional (Berthier et al., 2001). The right orbitofrontal system is also critical for processing cognitive-​emotional interactions (Barbas, 1995). This “thinking part of the emotional brain” (Goleman, 1995) functions as an “internal reflecting and organizing agency” (Kaplan-​Solms & Solms, 1996) that is involved in emotion-​a ssociated learning (Rolls, Hornak, Wade, & McGrath, 1994). Acting at levels beneath conscious awareness the orbitofrontal cortex is able to “integrate and assign emotional-​ motivational significance to cognitive impressions; the association of emotion with ideas and thoughts” ( Joseph, 1996, italics added) and represents an important point of contact between emotional or affective information and mechanisms of action selection (Rogers et al., 1999). These data suggest that maladaptive characterological pathological dissociation and its deficient integrative and affect regulatory functions are located in an inefficient right orbitofrontal structure and its cortical and subcortical connections. In 1994, I described the unique neuroanatomical interconnectivity of the right hemisphere: This hemisphere, and its dense reciprocal interconnections with limbic and subcortical structures is specialized to regulate arousal (Levy, Heller, Banich, & Burton, 1983) and to integrate perceptual processes (Semmes, 1968)… It contains larger cortical areas than the left of intermodal associative zones that integrate processing of the three main sensory modalities (Goldberg & Costa, 1981)…This right hemisphere, more so than the left, is structurally specialized for greater cross-​modal integration (Tucker, 1992), perhaps due to the facts that it contains more myelinated fibers that optimize transfer across regions than the left (Gur et al., 1980), and that it is specialized to represent multiple information channels in parallel. Schore, 1994, p. 308, italics added Studies demonstrate that when the intracortical connections within this hemisphere are functioning in an optimal manner, the right hemisphere adaptively integrates cross-​sensory information and thereby subserves the integration of different representational information systems (Calvert et al., 2001). However, under the extreme stress of both hyperarousal and hypoarousal, the right cortical hemisphere loses it capacity to integrate posterior cortical sensory processing, thus causing the disruption in the integration of perceptual information. Moreover, under these intensely stressful periods, the right brain also loses it capacity to act as an integrated vertical cortical-​subcortical system. When this happens, limbic-​autonomic information is processed only at the lowest right amygdala level and blocked from access to higher right anterior cingulate and orbitofrontal areas. Such “partially processed” information (Whitlock, 1967; Ludwig, 1972) cannot be integrated into awareness as a conscious, subjectively experienced emotion. Instead, such “partially processed” somatic information is expressed as what Janet termed “excessive or inappropriate physical responses”

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and Freud (1893) described as “bizarre physical symptoms.” In short, dissociation refers to the loss of the integrative capacity of the hierarchical vertically-​organized emotional right brain.

The Right Brain Emotional-​Corporeal Self and Somatic Dissociation Recall, dissociation is associated with a loss of “identity.” The contemporary traumatology literature, along with all clinical and scientific disciplines now prefers to use the term self (Schore, 1994, 2003a,b, 2012, 2019a,b). For example, Van der Kolk (1996) suggests that dissociation refers to a compartmentalization of experience, and that elements of a trauma are not integrated into a unitary whole or an integrated sense of self. Similarly, in the psychoanalytic literature Kohut (1971) postulates that trauma survivors have a shattered self. H. Krystal (1988) states that the focus of treatment for trauma survivors is integration of the self. Developmentalists contend that traumatizing caregivers negatively impact the child’s attachment security, stress coping strategies, and sense of self (Crittenden & Ainsworth, 1989; Erickson, Egeland, & Pianta, 1989). The concept of self has also been absorbed into developmental neuroscience. Indeed, the self-​organization of the right brain and the origin of the self continue to be an essential theme of my own writings (Schore, 2012, 2019a,b). A central principle of my work dictates that “The self-​organization of the developing brain occurs in the context of a relationship with another self, another brain” (Schore, 1996, p. 60). Decety and Chaminade (2003) echo this: “The sense of self emerges from the activity of the brain in interaction with other selves” and conclude that “self-​awareness, empathy, identification with others, and more generally intersubjective processes, are largely dependent upon…right hemisphere resources, which are the first to develop” (p. 591). Indeed, the neuroscience literature is also very interested in the self. There is a growing consensus that “The self and personality, rather than consciousness, is the outstanding issue in neuroscience” (Davidson, 2002). Hence, the research and clinical study of dissociation should emphasize the construct of self in its investigations, at least to the same degree as, if not more than, left brain objective reflective consciousness. Rather, the right brain defensive strategy of dissociation represents a disruption of what Edelman (1989) called subjective “primary consciousness,” that relates visceral and emotional information pertaining to the biological self to stored information processing pertaining to outside reality, and which is specifically located in the right brain. It is currently thought that there are dual representations of self, one in each hemisphere (Schore, 2012, 2019a,b). Verbal self-​description is mainly a linguistic process associated with a left hemisphere advantage, while self-​description in terms of affective tone is associated with a right hemisphere advantage (Faust, Kravetz, & Nativ-​Safrai, 2004). This dual model is echoed in LeDoux’s statement that the existence of explicit and implicit aspects of the self is not a particularly novel idea. “It is closely related to Freud’s partition of the mind into conscious, preconscious (accessible but not currently accessed), and unconscious (inaccessible) levels” (2002, p. 28). This dichotomy reflects the link between the right hemisphere and nonconscious implicit processing, and the left with conscious explicit processing (Happaney et al., 2004). In recent research on “right hemispheric dominance in nonconscious processing” Chen and Hsiao (2014) demonstrate that the left hemisphere plays a greater role in processing explicit knowledge, whereas the right hemisphere has an advantage in shaping behavior with implicit information. In support of earlier theoretical proposals on the relationship between right hemispheric operations and the implicit self (Schore, 1994), a substantial amount of current research indicates that the right hemisphere is specialized for generating self-​awareness and self-​recognition, and for the processing of “self-​related material” (Decety & Chaminade, 2003; Kaplan et al., 2008; Keenan & Gorman, 2007; Morita et al., 2017; Perrin et al., 2005). According to Miller and his colleagues, “a nondominant frontal lobe process, one that connects the individual to emotionally salient experiences and memories underlying self-​schema, is the glue holding together a sense of self ” (2001, p. 821). Traumatic emotional experiences dissolve the right frontal “glue” that integrates the self. Similarly, Stuss and Alexander state that the right prefrontal cortex plays a central role in “the appreciation, integration, and modulation of affective and cognitive information” and serves as “a specific convergence site for all of the neural processes essential to affectively personalize higher order experience of self and to represent awareness of that experience” (1999, p. 223). Kuhl, Quirin, and Koole (2015) describe “the integrated self (that) is supported by parallel-​d istributed processing in the right anterior cortex,” and its adaptive right-​lateralized functions that are specifically expressed in “emotional connectedness, broad vigilance, utilization of felt feedback, unconscious processing, integration of negative experiences, extended resilience, and extended trust” (p. 115, italics added). The major debilitating impact of early attachment trauma is clearly on this right-​lateralized implicit system –​not the language functions of the left hemisphere. Devinsky (2000) argues that the right hemisphere plays an ontogenetic role in maintaining a coherent, continuous, and unified sense of self and in identifying a corporeal image of self. This concept of self is not just a mental one; it is a psychobiolgical, right-​lateralized bodily-​based process. Lou et al. (2004) report the parietal region of the right

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hemisphere has a role in representation of the physical self. Decety and Chaminade (2003) show that the right inferior parietal cortex is involved in somatic experience that is related to awareness and, therefore, participates in the sense of self. The rostral part of the posterior parietal cortex sends efferents to the insular cortex (Cavada & Goldman-​Rakic, 1989). As noted above, the right anterior insula and the right orbitofrontal cortex jointly generate a representation of visceral responses that is accessible to awareness; this provides a somatosensory substrate for subjective emotional states that are experienced by the corporeal self (Critchley et al., 2004). This right limbic structure is centrally involved in visceral and autonomic functions that mediate the generation of an image of one’s physiological state (Craig, 2004). Recall Crucian et al.’s (2000) description of a right hemisphere-​dependent dissociation between the emotional evaluation of an event and the physiological reaction to that event, and the observation of Spitzer et al. (2004) and Helton et al. (2011) that the dissociative symptoms of depersonalization reflect a lack of right hemispheric integration. Thus, the assertion that “impaired self-​awareness seems to be associated predominantly with right hemisphere dysfunction” (Andelman et al., 2004, p. 831) refers to a deficit in the right brain corporeal self during dissociative disruptions of identity. Scaer (2001) contends that the least appreciated manifestations of traumatic dissociation are perceptual alterations and somatic symptoms. In earlier work, I have offered a model by which attachment trauma alters the development of right-​lateralized limbic-​autonomic circuits that process visceral-​somatic information and set the stage for the characterological predisposition to somatoform dissociation (Schore, 2001b, 2002). This model also gives important clues for identifying psychobiological markers of somatoform dissociation. I have described the hypoarousal and heart-​rate deceleration of dissociating human infants and adults. In addition, I have also presented biological data to show that this passive defense mechanism is common to all vertebrates. In this “last resort defensive strategy” bradycardia occurs in response to survival threat. This rapid shift from a hypermetabolic state of hyperarousal into a hypometabolic state of hypoarousal reflects a significant homeostatic alteration of brain-​ cardiovascular interactions through higher CNS adjustments of the sympathetic and especially the medullary dorsal vagal parasympathetic energy-​conserving branches of the ANS. The activation of “the escape when there is no escape” (i.e., somatic dissociation), represents a disorganization of vertical circuits in the right hemisphere, which is dominant for cardiovascular (Yoon et al., 1997) and survival (Wittling & Schweiger, 1993) functions. In traumatizing contexts where active coping mechanisms are blocked or irrelevant, right-​ lateralized limbic-​ autonomic structures of the central autonomic network (ventromedial prefrontal cortex, anterior cingulate, insula, and amygdala) trigger an instantaneous re-​organization of the vagal circuit of emotion regulation on the right side of the brain (Porges et al., 1994) –​specifically, a shift in dominance from ventral vagal to dorsal vagal parasympathetic systems. Bradycardia is controlled by orbitofrontal, cingulate, and insula cortices (Buchanan, Powell, & Valentine, 1984; Hardy & Holmes, 1988). Tracing down this limbic-​autonomic vertical circuit, each of these cortical structures, like the central nucleus of the amygdala, regulates the periaqueductal gray and the lateral hypothalamus (Loewy,1991); the lateral hypothalamus modulates dorsal vagal complex neurons ( Jiang, Fogel, & Zhang, 2003); cardiac vagal motoneurons lateralized on right side of the medulla, down the right vagus, regulate the heart (Rentero et al., 2002); and ultimately parasympathetic efferent neurons that are primarily located in the right atrial ganglionated plexus (Stauss, 2003) trigger a hypometabolic response of “emotional bradycardia.” This pattern of dis-​organization is described by Porges (2000): [W]‌hen mobilization strategies (fight-​fl ight behaviors) are ineffective in removing the individual from the stressor and modulating stress, then the nervous system may degrade to a phylogenetically earlier level of organization… (This) may reflect a neural strategy associated with immobilization (e.g., passive avoidance, death feigning, dissociative states) that would require a reduction of energy resources. p. 15, italics added Recall that dissociation represents a hypometabolic state and a deficiency of psychological energy that allows for cell survival. I suggest that chronic parasympathetic emotional bradycardia is a psychobiological marker of pathological dissociation. Peritraumatic dissociation associated with low heart rate has been variously reported (Koopman et al., 2004; Lanius et al., 2002; Williams, Haines & Sale, 2003). In a clinical study, Schmahl and colleagues (2002) documented a heart-​rate decline while a PTSD patient with a history of childhood abuse was dissociating. Furthermore, the human right insula, a brain region involved in dissociation, is activated by perceptual awareness of threat (Critchley, Mathias, & Dolan, 2002), anticipation of emotionally aversive visual stimuli (Simmons et al., 2004) and harm avoidance (Paulus et al., 2003), all triggers of dissociation. In normal functioning, the right insula supports a representation of visceral responses accessible to self awareness (Critchley et al., 2004). On the other hand, relational trauma-​induced impairment of the right insula in infancy is associated with abnormal bradycardia (Seeck et al., 2003).

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Increased right insula activity is also found in adult subjects with bradycardia (Volkow et al., 2000). These studies suggest that across the life span the right insula, an essential component of the right-​lateralized self system, plays a key role in somatoform dissociation. In the introduction I cited Brown and Trimble’s (2000) call for a more precise definition of dissociation based on a conceptually coherent and empirically justified account of dissociative processes. In total this work suggests that such a definition must include a developmental neurobiological model of dissociative phenomena. The integration of this interdisciplinary data indicates that the developing right brain imprints not only the overwhelming affective states that lie at the core of attachment trauma, but also the early appearing primitive defense used against these affects –​the autoregulatory strategy of dissociation. The developmental principle that maltreatment in childhood is associated with adverse influences on brain development, specifically refers to an impairment of higher corticolimbic emotion regulation on the right side of the brain that generates the psychobiological defensive state of dissociation.

Attachment Trauma and Dissociation: Some Implications for Psychopathogenesis and Psychotherapy In this section I return to the problem of psychopathogenesis, especially as it’s encountered within the psychotherapeutic context. Over 30 years ago, Van der Kolk and Van der Hart (1989) citing the work of Janet, proposed that dissociation is a response to “overwhelming” emotional experience, particularly in childhood. A large body of research in the psychiatric and psychological literatures now supports the link between childhood trauma and pathological dissociation (see Dalenberg et al., 2012). Indeed, developmental psychologists have demonstrated a strong link between early attachment trauma and dissociation (e.g., Ogawa et al., 1997; Carlson, Yates, & Sroufe, 2009; Dutra, Bianchi, Lyons-​Ruth, & Siegel, 2009). That said, a fundamental understanding of the neurobiological mechanisms by which early trauma produces a later predisposition to pathological dissociation and exactly how early traumatic psychological experience generates deficits of later adaptive right brain emotional functioning is a central issue of both psychopathogenesis and psychotherapeutic treatment. My own work in developmental psychopathology integrates attachment theory, psychiatry, and developmental affective neuroscience in order to explore how attachment trauma alters the developmental trajectory of the right brain (Schore, 1994, 2003a, b, 2012, 2019a,b). From a developmental viewpoint, early abuse and neglect generate disorganized-​d isoriented insecure attachment patterns which endure into adolescence and adulthood, and act as a risk factor for later psychiatric disorders (Schore, 2001b). From a psychiatry viewpoint, “maltreatment-​related” (Beer & De Bellis, 2002) or “pediatric” (Carrion et al., 2001) PTSD is the short-​term negative effect; a predisposition to later psychiatric disorders is the negative long-​term effect. From a developmental neuroscience viewpoint, early abuse and neglect have immediate impact on the developing right brain during a critical growth period. This produces an immature, inflexible right brain that has a limited capacity to regulate intense affective states. These perspectives converge on a basic developmental principle: early relational attachment trauma is critical to the genesis of an enduring predisposition to pathological dissociation. For a more recent comprehensive overview of the last decade of my studies on attachment, relational trauma, and dissociation I refer the reader to a chapter in APA Handbook in Trauma Psychology (Schore, 2017). It is important to note that as a result of chronic relational trauma in infancy and toddlerhood, not only psychiatric disorders like PTSD, but a spectrum of early forming personality disorders shows a similar pattern of disorganized attachment psychopathogenesis, and do not attain an efficient right brain system of emotional communication and affect regulation. Indeed, individuals exhibiting right-​lateralized self pathology of borderline personality disorder lack internal affect regulatory mechanisms –​self-​soothing introjects that perform self-​consoling and regulatory functions during emotional upheaval. They also fail to develop a “reflective self ” that can take into account one’s own and others’ mental states, as well as affective empathy, achievements that are essential milestones in emotional development. Borderline personalities show right brain deficits in affect regulation and interpersonal relationships, as well as high levels of early relational trauma and the right brain affect blunting defense of dissociation. More specifically, early forming psychopathologies of the subjective self with a history of disorganized attachment automatically trigger right brain stress responses at low thresholds of relational stressors, frequently experience enduring states of high-​intensity negative affect, and defensively dissociate to threat or novelty at lower levels of arousal. In a social context, when under relational stress they characterologically access dissociation, a state of mind characterized by a break in the continuity of conscious experience, one associated with emotional blunting and detachment, as well as a loss of an adaptive ability for self-​monitoring. These fragile personalities use the affect-​deadening defense of dissociation in order to defend against an anticipated interpersonal context that can instantly trigger affective dysregulation. The characterological dissociative passive avoidance of relational threat and implicit deficit in processing interpersonal Janetian novelty occur at an unconscious level.

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In 2011 my colleagues and I published an event-​related potential study showing right hemispheric maturational failures in borderline personality disorder (Meares, Schore, & Melkonian, 2011). This work offered neurobiological evidence suggesting impeded maturation of right fronto-​medial regulatory systems due to a history of “traumatic attachments.” Applying these findings to the psychotherapeutic context, we suggested that a major role in treatment is played by a right brain-​to-​r ight brain engagement between therapist and patient that is expressed in the emotional, nonverbal, and analogical “language” of the right hemisphere. In a subsequent article in the journal Psychotherapy, I offered clinical and neurobiological research indicating the right hemisphere is dominant in psychotherapy (Schore, 2014b). On the matter of treatment –​in 1997 I applied the developmental construct of relational trauma to the therapeutic context. Over three decades I have offered research and clinical evidence to show that right brain-​to-​r ight brain nonverbal emotional communications are reciprocally expressed in the infant-​mother and patient-​therapist relationship. The patient’s dysregulated affect state, relational impairments, and symptomatology brings the individual with a history of attachment trauma into psychotherapy. Within the treatment in certain “heightened affective moments” of the session, interpersonal stressors within the transference-​countertransference relationship rupture the attachment bond between patient and therapist. This sudden shattering of the therapeutic alliance induces in the patient a chaotic altered state of consciousness associated with early traumatic experiences that are stored in right-​lateralized implicit-​procedural bodily-​based autobiographical memory. I further concluded, “This dialectical mechanism is especially prominent during stressful ruptures of the working alliance that occur during enactments” (Schore, 1997b, p. 48). This autobiographical memory of early relational trauma is not remembered but relived and reenacted in the therapeutic relationship, “beneath the words” of the patient and therapist. Shortly after Maroda (1998) stated that for the patient the enactment “is his or her chance to relive the past, from an affective standpoint, with a new opportunity for awareness and integration” (p. 520, my emphasis). Indeed it is now thought that reenactments of attachment trauma are not technical mistakes of the therapist or the patient’s acting out but that “the [clinician’s] sensitivity, or her right brain readiness to be fully attuned to nonverbal communication, is a necessary therapeutic skill. Becoming entangled in an enactment, although at first out of awareness, is a surprising facet of such sensitivity” (Ginot, 2007, p. 297). According to Ginot these unconscious affective interactions “bring to life and consequently alter implicit memories and attachment styles” (p. 317) and “generate interpersonal as well as internal processes eventually capable of promoting integration and growth” (pp. 317–​318, italics added). Subsequently in The Science of the Art of Psychotherapy I offered a chapter on “Therapeutic enactments: Working in right brain windows of affect tolerance,” wherein I discussed the importance of reenactments of early relational trauma and dissociation in clinical work with right brain disorganized attachment dynamics (Schore, 2012). Recently, clinical interest in psychotherapeutic enactments has grown substantially (see Howell & Itzkowitz, Chapter 45, this volume). Authors are now asserting that enactments are the only means of encountering dissociated aspects of the patient, that the repair of patient-​therapist enactment ruptures are not resolved by a technique or an interpretation but by an authentic intersubjective affective negotiation, and that interactively regulated enactments can facilitate the integration of the right brain (see Schore, 2019b). Indeed, in the field of relational psychoanalysis Aron and Atlas (2015) now warn that “Just as we may ‘get stuck’ in enactments, unable to work our way out of them so too we may inhibit or avoid entering into or surrendering to therapeutically generative enactments” (p. 322). Most recently, in one of my latest books, Right Brain Psychotherapy (2019b), I discuss working with dissociated affect in spontaneous reenactments of early right brain attachment trauma. In that work I further elaborate a therapeutic model of the critical role of transient synchronized mutual regressions of both the empathic therapist and patient from the rational left into the emotional right hemisphere, the locus of attachment, relational, and emotional functions and dysfunctions, as well as the defense of right brain dissociation. This synchronized mutual regression into an earlier stage of development can allow for therapeutic access to reenactments of early attachment trauma, and the right brain-​to-​r ight brain nonverbal communication and regulation of hyperaroused and hypoaroused dissociated negative affective self states within the therapeutic relationship (see Schore, 2019b for detailed clinical descriptions as well as relevant interdisciplinary research). Writing on the essential role of nonverbal physiological synchrony in psychotherapy Tschacher and Meier (2020) assert “Synchrony is generally defined as the social coupling of two (or more) individuals in the here-​and-​now of a communication context that emerges alongside, and in addition to, their verbal exchanges” (p. 558, italics added). This right-​lateralized nonverbal psychobiological system, operating beneath levels of conscious awareness, intersubjectively synchronizes with other “emotional” right brains that are tuned to receive these communications (2019b, 2021). This clearly implies that like the psychobiologically attuned mother who synchronizes with the child’s emotional state, the intuitive clinician, in “heightened affective moments” of the session, needs to transiently shift dominance from the left brain into the right brain, and thus direct access to the patient’s dysregulated attachment dynamics. I refer the reader to the earlier

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description of maternal-​infant disorganized attachment transactions described earlier by Beebe et al. (2010, 2012) in which the chronically misatttuned mother fails to coordinate and synchronize with the infant’s emotional state. These dynamics of a parent-​infant insecure attachment may be played out in the therapeutic alliance in a dyadic clinical reenactment. Furthermore, Koole and Tschacher (2016) argue interpersonal synchrony establishes interbrain coupling that provides “patient and therapist with access to another’s internal states, which facilitates common understanding and emotional sharing. Over time, these interpersonal exchanges may improve patients’ emotion-​regulatory capacities and therapeutic outcomes” (p. 1, italics added). Interpersonally synchronized right-​brain-​to-​r ight brain state sharing within the dynamic therapeutic relationship enables the therapist to enter into the patient’s changing feeling state, in order to “follow the affect,” and thereby to act as an implicit affect regulator of the patient’s dysregulated emotional states. This implicit affect regulatory function of the clinician is especially critical in stressful moments of stressful rupture and repair of the attachment bond embedded in the developing therapeutic alliance. It has long been established that stress is defined as an asynchrony in an interactional sequence, and thus “a period of synchrony, following the period of stress, provides a ‘recovery’ period” (Chapple, 1970, p. 631). This regulated synchronized coupling of the patient’s and therapist’s right brains allows for the nonverbal communication and regulation of not just conscious affects, but unconscious affects and the arousal dysregulation beneath the dissociative defense. Very recent neuroscience research describes a “specialization of the right hemisphere in the processing of emotional stimuli occuring outside the focus of awareness” (Ladavas & Bertini, 2021, p. 6). In an even more current article I apply regulation theory to group psychotherapy, including a detailed clinical analysis of the psychodynamics of a regression in a group enactment of dissociated attachment dynamics, focusing on shame (Schore, 2020). Although dissociation acts as a survival defense against intense overwhelming affective experiences entering into consciousness, characterological pathological dissociation represents a major counterforce to the emotional, relational, and motivational aspects of the change processes of psychotherapy. Overall, the clinical interpersonal neurobiological therapeutic principle for working with dissociation and mutual regressions in attachment reenactments of relational trauma dictates that the psychobiologically attuned empathic therapist facilitates the patient reexperiencing overwhelming affects in incrementally titrated, increasing affectively tolerable doses in the context of a safe and trusting environment, so that overwhelming traumatic feelings can be regulated, come into consciousness, and be adaptively integrated into the patient’s emotional life. Therapeutic mutual regressions that allow for regulated reenactments of attachment dynamics are triggered by an interpersonally synchronized transient loosening of the boundaries of the patient’s and therapist’s left and right hemispheres. That said, therapeutic boundaries between the patient and therapist must be firmly established and well-​structured before they can be loosened and become more fluid, permeable, and flexible. In addition to the symptom-​reduction of short-​term treatment, long-​term growth-​facilitating psychotherapy can establish a co-​created strong therapeutic alliance that increases safety and trust and reduces the dissociative defense. Over time this emergent function of the evolving therapeutic relationship can in turn promote the social-​emotional experience-​ dependent maturation of the patient’s more complexly interconnected right-​lateralized orbitofrontal-​cingulate-​insula-​ amygdala circuits, and thereby alter an insecure into a secure internal working model of attachment.

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12 ADVERSE CHILDHOOD EXPERIENCES AND DISSOCIATIVE DISORDERS A Causal Pathway Based on the Disruptive Impacts of Cumulative Childhood Adversity and Distress-​Related Dissociation Michael A. Quiñones

Adverse Childhood Experiences and Distress-​related Dissociation Adverse childhood experiences (ACEs) have become an increasingly relevant topic in the mainstream discussion on public health issues. Over two decades ago, Felitti and colleagues (1998) conducted a large-​scale investigation that identified 10 factors in an individual’s childhood that fell into three significant categories of adversity: abuse, neglect, and household dysfunction. These ACEs consisted of physical, sexual, and emotional abuse, emotional and physical neglect, and various forms of household dysfunction (i.e., household mental illness, parental separation, substance abusing family member, incarcerated family member, intimate partner violence). Felitti and colleagues found that various health-​related issues (e.g., obesity, heart disease, cancer, smoking and alcohol use, decreased life expectancy, depression, and anxiety) were strongly related to the number of ACEs an individual reported. In addition, the greater the number of ACEs reported, the greater risk of health-​related and psychological difficulties in adulthood, and the more impairments in functioning (Kendall-​Tackett, 2002; Tuscic, Flander, & Mateskovic, 2012). This pattern, described as a “dose-​response effect,” indicated that the total number of ACEs (“dose”) corresponds to increasingly severe impacts on physical and psychological well-​being (“response”). After further studies on the prevalence of ACEs, Felitti and colleagues established a simplified causal model summarizing the negative impacts associated with exposure to ACEs (Felitti et al., 1998). The model demonstrates that exposure to ACEs is the basis for a trajectory of disrupted childhood development with resultant difficulties throughout the lifespan that consists sequentially of, 1) negative impacts on neurological development, 2) social, emotional, and cognitive impairments, 3) adoption of health-​risk behaviors (e.g., substance use), 4) disease, disability, and social difficulties, and 5) decreased mortality. Since Felliti et al.’s 1998 study, there has been widespread research in the U.S. and internationally, providing ample evidence for a strong association between childhood abuse, household dysfunction, developmental deficits, and a range of psychological, trauma-​ related, and dissociative symptomology and disorders (Arata, Langhinrichsen-​Rohling, Bowers, & O’Farrill-​Swails, 2005; Briere & Elliott, 2003; Gardner, Thomas, & Erskine, 2019; Vonderlin et al., 2018). Research validates that increasing exposure to ACEs can negatively affect specific regions of the brain during development (Elbers, Rovnaghi, Golianu, & Anand, 2017), increase the likelihood of trauma-​related symptomology (Herzog & Schmahl, 2018), and potentiate psychological, behavioral, and interpersonal difficulties into adulthood (Kerker et al., 2015). Although there has been considerable growth in the knowledge base associated with ACEs, there are current limitations in the research regarding the causal relationship between ACEs and pathological forms of dissociation. There has been substantial research on the independent relationships among abuse and neglect, and the development of dissociative symptomology. However, there continues to be an opportunity for establishing the role of the ACEs framework in the development of dissociative symptoms and disorders. A review of the three categories of ACEs, and their constituent factors, will provide a foundation for conceptualizing a causal pathway between exposure to these types of childhood adversity and distress-​related dissociation. It will be shown how exposure to ACEs can increase the risk of developing pathological forms of dissociation in response to ACE-​related distress and ACEs’ disruptive impacts on development. DOI: 10.4324/9781003057314-15

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Childhood Physical Abuse Childhood physical abuse (CPA; e.g., punched, kicked, struck with objects, locked in small spaces) during childhood and adolescence constitutes a substantial form of adversity. Chronic exposure to CPA can range from sporadic, unexpected intense outbursts to more structured and systematic forms of physical abuse that occur in the home. Like other forms of maltreatment, CPA can instill a pervasive fearful hypervigilance in a family environment otherwise responsible for providing safety and security. Feelings of betrayal due to CPA by caregivers and family members perpetuates chronic distrust of others, negative expectancies in relationships, heightened fear of threat and harm, and increased vulnerability to violence and abuse in adulthood (Huh, Kim, Yu, & Chae, 2014; Ornduff, Kelsey, & O’Leary, 2001; Van der Kolk, 2005). CPA is associated with earlier onset and increased risk of trauma-​related and dissociative disorders (Carrion & Steiner, 2000; Diseth, 2005; Runyon, Deblinger, & Steer, 2014). CPA perpetuates chronic feelings of fear, hopelessness, anger, and shame (Bennett, Sullivan, & Lewis, 2005) and negatively impacts the development of self-​concept, self-​esteem, emotional expression, social skills, and independent functioning into adulthood (Cloitre, Miranda, Stovall-​ McClough, & Han, 2005; Elliott et al., 2005). CPA contributes to a constellation of negative impacts on development and functioning that instill a pervasive sense of distrust for caregivers as a potential source of threat, and potentiate the deprivation of supportive affection and attention. A child can be left with resultant psychological and emotional distress from the harm of physical abuse, lacking the soothing and interpersonal support needed to reduce distress, and left vulnerable to distress-​related dissociative reactions. Experiences of CPA can develop into chronic heightened sensitivity to anticipatory threat of harm and dissociative reactions in response to outbursts and abuse that underlie trauma-​related and dissociative symptomology. CPA is strongly associated with trauma-​related symptoms such as hyperarousal, avoidance behaviors, intrusive cognitions related to abuse, negative concept about self and others, and dissociative symptomology (i.e., depersonalization, derealization, and amnesia) (Carlson, Dalenberg, & McDade-​Montez, 2012; Kwon, & Lee, 2021; Twaite & Rodriguez-​ Srednicki, 2004). The severity and frequency of CPA are associated with more severe forms of PTSD and dissociative symptomology in adulthood (Mulder, Beautrais, Joyce, & Fergusson, 1998; Schalinski, 2016; Terock et al., 2016).

Childhood Sexual Abuse Childhood sexual abuse (CSA) is associated with a wide range of negative impacts on development and functioning. Exposure to sexual abuse in the family environment constitutes a severe threat to a child’s developing psychological, emotional, and bodily integrity. CSA can perpetuate pervasive distrust and confusion toward caregivers and instill feelings of fear, shame, and guilt about physical sensations and psychological and emotional needs (Lev-​Wiesel, 2008; Dorahy & Clearwater, 2012; Gartner, 2017). CSA perpetrated by a caregiver can cause a child to feel chronically unsafe, vulnerable and prone to feelings of fearfulness and hypervigilance. It also heightens the likelihood of risky sexual behaviors being engaged in during childhood and adolescence, early-​onset substance use, delinquency, and emotional and behavioral difficulties in interpersonal relationships (Homma, Wang, Saewyc, & Kishor, 2012; Sigfusdottir, Asgeirsdottir, Gudjonsson, & Sigurdsson, 2008; Shin, Hong, & Hazen, 2010). CSA can also lead to chronic avoidance and withdrawal due to fear of closeness and discomfort in interpersonal situations to hypersexual and otherwise inappropriate boundaries with adults and other children (Dimitrova et al., 2010; Merrick, Litrownik, Everson, & Cox, 2008; Schwartz & Galperin, 2002). Children, adolescents, and adult survivors of CSA report an increased likelihood of trauma-​related (i.e., hyperarousal, negative cognitions, emotional avoidance, or emotional distress) and dissociative (e.g., depersonalization, derealization, amnesia) symptomology occurring throughout their lifespan (Hébert, Langevin, & Oussaïd, 2018; McLean et al., 2014; Steine et al., 2017). Case studies and empirical research indicate a significant association among experiences of CSA and dissociative symptomology due to peritraumatic reactions, such as shock, confusion, and emotional distress during incidents of molestation (Leahy, Pretty, & Tenenbaum, 2003; Sugar & Ford, 2012). Both peritraumatic and posttraumatic dissociative reactions from CSA can increase the risk of developing trauma-​related disorders into adulthood (e.g., posttraumatic stress disorder, PTSD; borderline personality disorder, BPD; complex PTSD, C-​PTSD; dissociative disorders, including dissociative identity disorder, DID; Ford & Courtois, 2021; Ross & Ness, 2010; Ross, Ferrell, & Schroeder, 2014).

Childhood Emotional Abuse Childhood emotional abuse (CEA) can occur in several forms, from overt verbal abuse (e.g., yelling/​screaming, aggressive humiliation) to subtle and covert forms such as passive-​aggressive communication, persistent insults, and chronic invalidation of emotions and perceptions. Ongoing CEA can lead to a range of difficulties and functional

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impairments. Persistent CEA can create increased risk of developing emotional, cognitive, and behavioral difficulties (Berzenski, & Yates, 2010; Stoltenborgh, Bakermans-​K ranenburg, Alink, & Van Ijzendoorn, 2012), as well as resultant psychological symptoms and disorders (e.g., depression, anxiety, suicidality, PTSD, BPD; Banducci, Lejuez, Dougherty, & MacPherson, 2017; Mandelli, Petrelli, & Serretti, 2015; Zatti et al., 2017). Repeated experiences of CEA evoke intense emotional distress, impaired capacity for emotion regulation, and vulnerability to distress-​related dissociation and dissociative symptomology (King et al., 2020; Ó Laoide, Egan, & Osborn, 2018). CEA and the compounding effect of other forms of abuse exacerbate vulnerability to developing trauma-​related and dissociative symptomology (Hébert, Langevin, & Oussaïd, 2018). Indeed, studies support a causal relationship between childhood CEA and the presence of trauma-​related disorders and symptomology in both adolescence and adulthood (Hoeboer et al., 2021; Sullivan et al., 2006). Survivors of prolonged exposure to multiple forms of child abuse (i.e., including CEA) are likely to develop severe trauma-​related disorders and symptomology such as chronic PTSD, complex PTSD, depersonalization and derealization (DP/​DR), and DID (Gama et al., 2021).

Physical and Emotional Neglect Childhood neglect, the second category of ACEs, consists of the relative absence of beneficial influences in the provision of care. In ACEs research, neglect is the absence of having physical and emotional needs met that are necessary for adequate development. Physical neglect (CPN) can occur in multiple forms, such as not receiving adequate nutrition, clothing, safety, and physical attention. Emotional neglect (CEN) is an absence or general lack of love, affection, and positive engagement that are requisites for healthy emotional development and psychological functioning. The provision of adequate physical and emotional support provides children with the reinforcement needed to develop the capacities for adaptive adjustment to experiences of frustration and adversity. This provides the foundation for positive self-​concept and self-​esteem, and the capacity for interpersonal connection and relating, all of which contribute to a beneficial transition into and effective functioning in adulthood. Inadequate provision of these developmental necessities is associated with negative impacts on functioning and development. The health-​related impacts of neglect can negatively affect cognitive development, resulting in deficits in executive functioning, increased impulsivity, and emotional and behavioral difficulties (De Bellis, 2005; Hildyard & Wolfe, 2002). CPN and CEN can also increase the vulnerability to dissociative symptoms in adulthood (Schimmenti, 2017; Vonderlin et al., 2018), and when co-​occurring with other forms of childhood abuse, are a risk factor for an array of trauma-​related and dissociative symptomology (Horan & Widom, 2015; Raviv, Taussig, Culhane, & Garrido, 2010). Responsive caregiving and appropriate modeling contribute to the foundation for developing capacities related to emotion regulation, self-​soothing, effective communication, and cognitive forms of coping, all which counteract dissociation. Experiences of chronic neglect can effectively deprive a child of the necessary requisites for adequate development of those capacities, resulting in a childhood marked by prolonged experiences of distress, emotional constriction and blunting, and impaired capacity for relatedness to others. It is prudent to assume that a childhood marred by chronic neglect would cultivate the conditions for increased risk of dissociative reactions and less functional forms of coping to adapt to conditions of loneliness, distress, detachment, and interpersonal disconnection.

Household Dysfunction The third category of ACEs research, household dysfunction, is comprised of: parental separation or divorce, violence against the maternal figure in the home, parental substance use, household mental illness and/​suicidality, and having an incarcerated family member. Household dysfunction can occur in many forms, with each of them providing a substantive impact on the well-​being and functioning of members of a household. Parental separation or divorce can disrupt household stability and familial relationships, disturb a child’s expectations of household functioning, and introduce additional distress and uncertainty to a child’s relationship with their caregivers. Parental substance use models maladaptive coping skills, exacerbates emotional volatility and interpersonal conflicts in the household, and disrupts consistent caregiving and responsiveness to a child’s needs. Household violence is associated with an increased risk of emotional and behavioral disturbances, interpersonal difficulties, and co-​occurring mental health issues (Vetere, 2011; Wolak & Finkelhor, 1998). Parental mental illness, especially when untreated, can lead to potential disruptions in the home, such as increased instability of caregivers, disruptions to the consistency and quality of caregiving, and vulnerability to emotionally disruptive and volatile situations in the home. Households with an incarcerated family member can also add undue stress with increased economic strain and hardship, increased emotional and psychological problems, and emotional, behavioral, and interpersonal difficulties for children growing up in the home (Zeman, Dallaire, Folk, & Thrash, 2018; Turney & Goodsell, 2018).

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Household dysfunction also heightens susceptibility to trauma-​ related and dissociative symptomology. The disruptions to parental responsiveness increase the frequency and severity of a child’s emotional distress while cultivating an atmosphere of hyperarousal, heightening vulnerability to being overwhelmed by life-stressors and other forms of adversity. Inadequate safety and support from chronic disruptions in caregiving can exacerbate these vulnerabilities and leave a child with limited strategies to cope effectively (beyond dissociative reactions) to mitigate emotional and psychological distress. These collective impacts from household dysfunction can increase the risk of and vulnerability to distress-​related dissociative reactions during childhood that may become a habitual and problematic pattern throughout adolescence and adulthood. Additionally, trauma-​related and dissociative symptoms that develop from childhood abuse and neglect are likely to proliferate in a developmental environment marred by severe household dysfunction. The following sections describe, 1) how ACEs, especially cumulative exposure to them, convey their detrimental effects through developmental and traumatic stress, 2) how ACEs severely disrupt adaptive development and potentiate the negative impacts associated with pathological dissociation, and 3) a pathway conceptualizing the causal relationship between ACEs and distress-​related dissociation through the lens of three phenomenological factors: attachment dynamics, an atmosphere of threat and deprivation, and performance and skills deficits.

Adverse Childhood Experiences and Dissociation: Distress, Disruption, and Disconnection ACEs are a source of both developmental stress and traumatic stress, which are principal factors in conceptualizing the relationship among ACEs, their collective impact on developing capacities and functioning, and pathological forms of dissociation. For example, ACEs related to abuse and certain forms of household dysfunction can be sources of traumatic stress, as can exposure to and witnessing severe forms of abuse, domestic violence, and household substance abuse. As exposure to one form of ACEs can increase the risk of exposure to others (Dong et al., 2004), so does the increased risk of traumatization. Although it is sensible to consider each form of ACEs as a significant source of distress, this does not necessarily mean they result in a traumatic form of distress. CPA, CSA, and CEA are well studied (independently and per ACEs research) and associated with childhood and adolescent traumatic stress. Increasingly frequent and severe forms of abuse can induce traumatic and overwhelming distress in children, resulting in peritraumatic and posttraumatic dissociation. Traumatization and dissociation from chronic abuse contribute to severe distress (psychological, emotional, and physiological), disruption in developing capacities and domains of functioning, and disconnection from supportive relationships and the experiential environment. The co-​occurrence of neglect and household dysfunction constitute significant stressors, but not necessarily ones that are traumatic. However, they do impede the opportunity for adequate caregiving and deprive a child of the attention, responsiveness, and modeling needed to develop adaptive forms of coping. In this way, neglect and household dysfunction are likely to increase the vulnerability to traumatization and heighten the negative impacts of exposure to abuse. An environment of abuse, neglect, and dysfunction leaves a child constrained and limited in their capacity to avoid sources of persistent distress and result in being subject to dissociative reactions that originate from exposure to overwhelming stressors. These dissociative reactions are likely to become more prevalent if the disruptions from ACEs impede the development of more adaptive strategies for mitigating psychological and emotional distress. Chronic developmental and traumatic stress can impede the development of emotion regulation, cognitive capacities for coping, help-​seeking behaviors, and interpersonal connection that are needed to manage and effectively reduce ACEs-​related distress (see Corrigan, Lanius, & Kaschor, Chapter 37, this volume). These forms of stress can strain the capacities, skills, and interpersonal support needed to manage overwhelming distress. Developmental and traumatic stress increase vulnerability to emotion dysregulation and impairments in cognitive functioning that underlie distress-​related dissociation (e.g., depersonalization, derealization, and amnesia) and trauma-​related symptomology (e.g., hyperarousal, negative cognitions, avoidance behaviors). Peritraumatic dissociation related to exposure to abuse-​related ACEs can increase the risk of trauma-​related disorders and co-​occurring dissociative symptomology (Marshall & Schell, 2002; McCanlies et al., 2017). Studies support peritraumatic dissociation as a risk factor for negative self-​concept, negative expectancies related to threat, and negative emotional states (McDonald et al., 2013; Thompson-​Hollands, Jun, & Sloan, 2017; Vásquez et al., 2012). Chronic exposure to traumatic and overwhelming stressors during childhood conveys a greater risk of developing more severe forms of PTSD and dissociative disorders in adulthood (Diseth, 2005; Dye, 2018; Frewen et al., 2019; Kalmakis et al., 2020). Research continues to support the association between increasing exposure to ACEs and the occurrence of trauma-​related disorders and dissociative symptomology (Frewen, Zhu, & Lanius, 2019). ACEs increase the likelihood of experiential distress in psychological, emotional, and physiological domains of functioning, disruption of beneficial developmental and caregiving experiences, and experiential disconnection from dissociative reactions and deprivation of supportive interactions. There are two important considerations for conceptualizing

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the pathway from exposure to ACEs and pathological forms of dissociation: 1) how traumatic and developmental stress from exposure to ACEs disrupt and impede developmental capacities that give rise to trauma-​related and dissociative symptomology and disorders, and 2) what factors support a pathway between ACEs-​related distress, disruptions in beneficial development, and experiential disconnection from distress-​related dissociation, and pathological forms of dissociation during development. The following sections review three specific factors strongly associated with the negative impacts from ACEs: attachment dynamics, experiences of threat and deprivation, and performance and skills deficits.

Attachment Dynamics, Threat and Deprivation, and Performance versus Skills Deficits Attachment dynamics play a critical role in early childhood and carry a significant resonance throughout development and the lifespan. ACEs can negatively impact healthy attachment characteristics and disrupt the development of attachment-​ related capacities such as emotion regulation, self-​concept clarity, relatedness to others and the world, and psychological development (Doyle & Cicchetti, 2017). ACEs also exert a two-​pronged detrimental impact on development in the form of threat and deprivation. Experiences of threat occur from various forms of abuse and more explicitly disruptive forms of household dysfunction. Deprivation occurs from chronic experiences of physical and emotional neglect, lack of or limited responsiveness to developmental needs, and a generally inadequate upbringing. ACEs negatively impact performance in several domains of functioning (i.e., interpersonal, behavioral, emotional, and psychological) due to developmental and traumatic stress while disrupting the development of skills necessary for adequate growth and functioning (i.e., adaptive behaviors, cognitive and social skills, and emotion regulation skills). The ACEs-​related impacts on each of these three causal factors, and their relationship to distress-​related dissociation, support a conceptual pathway linking ACEs to pathological forms of dissociation.

Attachment Dynamics: ACEs-​related Impacts and Vulnerability to Dissociation Attachment dynamics refers to a range of caregiving and interpersonal functions that consistently or intermittently occur between a caregiver and a child. These attachment-​related functions serve various purposes that facilitate adequate and adaptive development throughout childhood, adolescence, and adulthood. Being responded to with attention, warmth, and affection provide a foundation for the stability and consistency of beneficial responsiveness that nurtures early development and the capacity to engage in more advanced forms of attachment-​related caregiving. As a child grows, so does their need for age-​appropriate responsiveness in the caregiving they receive. From an initial dependency on responsiveness to infantile needs (e.g., hygiene, adequate nutrition, affectionate engagement, play), early childhood requires more elaborate psychological, emotional, behavioral, and interpersonal engagement between child and caregiver. Attachment-​related capacities such as attunement and reflective functioning become necessary requisites for a child’s adaptive growth and development and the quality of attachment with their caregivers (Fonagy & Target, 2005; Kelly, Slade, & Grienenberger, 2005). Attunement is nuanced, sensitive, and involves careful observation and responsiveness to a child in the early stages of their development. Attunement and adequate responsiveness are the primary means by which a caregiver nurtures increased bonding in infancy and early childhood. Attunement also serves as the pathway through which a caregiver can utilize the attachment-​related capacity of reflective functioning. An implicit aspect of attunement is the caregiver’s capacity to adequately understand the needs of a young child as expressed by them through limited forms of verbal and non-​ verbal communication (i.e., crying, smiling, laughter, eye contact or facial expressions, limited verbal responses, head and body movement). Reflective functioning refers to a caregiver’s utilization of their mental (and emotional) state and underlying capacities to understand and respond effectively to the child’s limited forms of communication especially in early years (Kelly, Slade, & Grienenberger, 2005). A caregiver ideally interprets these forms of developing communication in a way that accurately and adequately reflects and responds to what the child is trying to express. Caregivers utilize their emotional, behavioral, psychological, and interpersonal awareness to respond effectively to the child. The complexity and nuance of parental caregiving and attachment dynamics underlie the bi-​d irectional relationship between the array of capacities and functioning utilized by a caregiver and the development of those qualities in the child. The past few decades of research have firmly established the role of attachment dynamics in patterns of parental caregiving and childhood functioning and development. Attachment-​related research utilizes a heuristic known as “attachment-​style” that describes a constellation of emotional, psychological, behavioral, and interpersonal functioning exhibited during childhood primarily attributed to the caregiver-​child interaction. Attachment-​based research has developed a typology of attachment styles that originate from a combination of genetic and environmental factors, most notably the developing relationship between caregiver and child (Ravitz et al., 2010). There are variations in

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the terminology used to describe attachment styles; however, they are generally described as one of four types in adulthood: secure, anxious-​ preoccupied, dismissive-​ avoidant, and fearful-​ avoidant/​ d isorganized (Bartholomew & Horowitz, 1991). Secure attachment represents a range of adaptive behaviors developed throughout childhood to achieve awareness, connection, safety and soothing, and positive interactions with a caregiver (Van Buren & Cooley, 2002). When the provision of adequate caregiving and resources is lacking, there is a greater likelihood that a child will exhibit characteristics associated with varying types of insecure attachment (Bartholomew & Horowitz, 1991). A child may develop an increasingly severe form of insecure or disorganized attachment style depending on the frequency and quality (e.g., duration and intensity) of maladaptive experiences during childhood (e.g., see Schimmenti, Chapter 10, and Schore, Chapter 11, this volume). Anxious-​ preoccupied attachment generally refers to chronic uncertainty about interpersonal relationships, dependency-​ related difficulties, fear of abandonment, and impaired self-​ esteem and self-​ concept. Children with anxious-​preoccupied attachment are more likely to experience inconsistent caregiving and responsiveness, resulting in intermittent and chronic anxiety about receiving support. They may exhibit heightened distress when separated from their caregiver while having increased difficulty being soothed and returning to a baseline state of functioning during periods of emotional distress. Children with dismissive-​avoidant attachment show a pattern of distancing themselves and (or) disregarding their caregivers. Children with this attachment style are likely to remain to themselves, exhibit a lack of emotional responsiveness and expressiveness, and view others with distrust and uncertainty when their caregivers are not present. Fearful-​avoidant attachment, a form of disorganized attachment, is an extremely disturbed style of interaction that occurs from frequent exposure to severe forms of childhood abuse and household dysfunction. A “disorganized” state occurs in reaction to psychological and emotional distress composed of fearfulness towards caregivers, severe withdrawal in social situations, and dissociative reactions (e.g., disorientation, confusion, or non-​responsive). Fearful-​Disorganized attachment exemplifies the severe consequences of chronic exposure to ACEs and the impacts of persistent developmental and traumatic distress, disruption, and disconnection on a child’s attachment style. Attachment-​related capacities such as the way in which the concept of self-​and-​other is formulated, expectancies about relationships, and regulating emotional distress, co-​develop with a child’s psychological, emotional, behavioral, and interpersonal functioning. Attachment dynamics share an inextricable connection with the various ACEs to which a child can be exposed. For example, childhood experiences of abuse can potentiate profound disruptions in the development of the functions and capacities related to secure attachment (Baer & Martinez, 2006; Ensink et al., 2020; Unger & De Luca, 2014). Abuse-​related ACEs can instill an intense sense of fear, shame, confusion, and physical and emotional pain about a child’s relationship with their caregiver while disrupting the physical and emotional safety and security necessary for developing a secure attachment. Chronic experiences of ACEs-​related abuse perpetuate severe psychological and emotional distress and disrupt development of attachment-​related capacities for adaptive functioning. These types of ACEs create a pervasive sense of distrust and betrayal, feelings of guilt, shame and loneliness, while promoting disconnection from unmet emotional needs necessary to mitigate the negative impacts from these types of abuse (Gay et al., 2013; Ensink et al., 2020). The combination of ACEs-​related distress and disruptions in the requisites needed for development of secure attachment lowers the threshold at which a child can become emotionally overwhelmed and prone to unmitigated distress-​related dissociative reactions. Increasing exposure to these forms of abuse and their negative impacts on functioning, heightens a child’s vulnerability to, and frequency of, distress-​related dissociative reactions while potentiating experiential disconnection among the child and their environment. Chronic physical and emotional neglect is associated with an increased risk of insecure and disorganized forms of attachment (Müller et al., 2019). Patterns of anxious and avoidant behaviors attributed to insecure attachment types are likely to appear as a consequence of CPN and CEN. In more severe cases, chronic and pervasive neglect (and child maltreatment in general) are associated with disorganized attachment (Hildyard & Wolfe, 2002). Household dysfunction perpetuates a disruptive and chaotic atmosphere with inconsistent responsiveness (e.g., from parental separation, substance use, parental mental illness), emotional outbursts from caregivers (e.g., intimate partner violence), maladaptive modeling of emotional communication (e.g., aggressive outbursts) and problematic strategies for coping with distress (e.g., substance use, violent behavior). As a result, children experience inconsistent and inadequate responsiveness from caregivers, fear associated with an unsafe and unpredictable family environment, and a lack of emotional and physical support to cope with distress. Household dysfunction contributes to the disruption of the development of secure attachment while cultivating the adverse conditions associated with insecure attachment. When children are chronically subjected to these forms of household dysfunction, it erodes the opportunity for safety and security, and perpetuates chronic and debilitating distress which is left unmitigated by an otherwise dysfunctional environment. ACEs cultivate experiences of fearfulness,

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anxiety, and disconnection that underlie the development of negative concepts for self/​others, impaired capacities for tolerating and modulating distress, and anxious and avoidant coping strategies. Exploring the relationship between ACEs and their consequential impact on attachment provides further insight toward conceptualizing the pathway between ACEs and dissociative symptoms and disorders. Distress, disruption, and disconnection are prevailing themes that underlie the ACEs-​related impacts on attachment dynamics. Attachment processes are fundamentally concerned with providing safety and security to mitigate developmental distress and facilitate beneficial interpersonal connection. ACEs convey a substantial negative impact on attachment-​related processes because they independently and collectively contribute to 1) increased psychological and emotional distress, 2) disruption of processes contingent on the development of secure attachment, and 3) the promotion of psychological, emotional, and interpersonal disconnection that underlie distress-​related dissociation. ACEs-​related abuse exposes a child to physical threats and harm that increases psychological and emotional distress, while disrupting beneficial caregiving and associating caregivers with potential threat of harm. This exposes a child to traumatic and developmental stressors that can result in experiential disconnection from distress-​related dissociation. CPN and CEN further deprive a child of the conditions needed for the development of secure attachment, disrupt development of capacities needed for emotional regulation and support, and further increase vulnerability to distress-​related dissociation. Household dysfunction generates a maladaptive context for parental caregiving, imposing additional distress on both child and caregivers, and compounding risks for dissociative reactions. Therefore, each category of ACEs can be a source of traumatic and developmental stress that disrupts the possibility for the beneficial conditions and consistent caregiving needed to develop secure attachment. Simultaneously, ACEs potentiate the development of insecure attachment and vulnerability to distress-​related dissociative reactions. Pathological forms of dissociative symptomology in DP/​DR, DID, C-​PTSD, and the dissociative subtype of PTSD, are strongly associated with chronic exposure to child maltreatment and insecure/​d isorganized attachment styles (Byun, Brumariu, & Lyons-​Ruth, 2016; Kong et al., 2018). The conceptual link among ACEs, attachment dynamics, and distress-​related dissociation provides further support for the causal relationship between ACEs and pathological forms of dissociation. Two other domains substantively contribute to understanding this conceptual framework: threat and deprivation, and performance and skills deficits. The following sections will explore these domains and elaborate on their relationship to ACEs, attachment dynamics, and their causal contribution to pathological forms of dissociation.

Threat and Deprivation: Conditions for Distress, Disruption, and Disconnection Studies in the past decade have conceptualized and delineated the impact of ACEs through the lens of threat and deprivation (Lambert, King, Monahan, & McLaughlin, 2017; Miller et al., 2018; Sheridan & McLaughlin, 2014). Exposure to multiple forms of abuse and dysfunction are sources of threat and actual harm to a child’s physical and emotional sense of being. Anticipatory anxiety, negative expectancies, hypervigilance, avoidance behaviors, and dissociative reactions are common responses to the threat of harm and abuse. Deprivation, on the other hand, results from the lack of adequate resources and provisions necessary for adaptive and beneficial development. Household dysfunction and neglect limit the possibility that caregivers will be in a position to provide beneficial developmental resources and experiences. Attention, affection, and being responded to effectively and appropriately are just a modicum of the functions necessary for caregivers to care for and adequately raise a child. Household dysfunction strains a caregiver’s internal resources and capacities needed to respond to a child adequately. These forms of dysfunction result in greater instability in the family environment, impaired caregiver functioning, and may promote and then perpetuate chronic CPN and CEN. Neglect disrupts and restricts the adequate provision of even the most basic developmental needs of a child, such as sufficient nutrition, access to educational experiences, modeling of adaptive behaviors, and nurturing communication and positive human interactions. Chronic distress and disruption perpetuated by ACEs have meaningful impacts related to experiences of persistent threat, deprivation, and disconnection from the necessary supportive relationships and nurturance needed in childhood. Experiences of threat from abuse (directly and/​or witnessed within the household) increase physiological, psychological, and emotional distress that can disrupt and chronically overwhelm a child’s developing capacities for experiential presence, comfort-​seeking and self-​soothing, and positive concept of self/​other. Heightened distress and hypervigilance from exposure to ACEs increase the likelihood of dissociative reactions and trauma-​related symptomology that negatively impact various domains of functioning (Carpenter & Stacks, 2009; Dye, 2018). Chronic feelings of fear and hypervigilance heighten vulnerability to emotional distress and strain internal resources otherwise devoted to developing capacities for soothing, emotion regulation, and self-​awareness. Exposure to threats and abuse heightens the likelihood

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of emotion dysregulation, cognitive distress, and anxious-​avoidant behaviors associated with dissociative reactions such as “spacing out” and more severe dissociative reactions (i.e., depersonalization/​derealization, and dissociative amnesia). Children may exhibit these behaviors during and after experiences of abuse with non-​responsiveness, feeling numb or disconnected from their bodies, and absorption into an internal experience separate from that of the abuse (i.e., dissociative absorption/​fantasy proneness). These types of dissociative reactions personify the distress, detachment, and compartmentalization associated with traumatic stress. Deprivation leaves a child ill-​equipped to tolerate the psychological and emotional toll of exposure to abuse and dysfunction. Deprivation has a two-​fold impact on 1) the attention, responsiveness, and modeling needed for a child to develop internal resources for tolerating and coping with stress and adversity, and 2) prolonging the experience and strain of psychological and emotional distress from ACEs. Deprivation results in restricted resources and capacities to cope with greater vulnerability to the negative consequences of ACEs. The responsiveness of caregivers is the primary means by which children experience reduction and modulation of distress. Neglect and severe deprivation during early development can predispose a child to engage more frequently in distress-​related dissociative reactions that are primarily reflexive, autonomic processes activated in response to overwhelming stress (Perry, 2005; Guérin-​Marion, Sezlik, & Bureau, 2020). These dissociative reactions may continue during childhood due to developmental divergence from a more adaptive functional trajectory, facilitating secondary responses such as avoidance behaviors, isolation from others, impaired concentration/​attention, and emotional detachment. The causal link between ACEs and pathological forms of dissociation becomes increasingly distinct when conceptualized through the lens of threat and deprivation. Children are more vulnerable to distress, restricted in their capacities and resources to effectively cope, and risk developing trauma-​related symptoms and distress-​related dissociative reactions. The causal link shared amongst these factors (i.e., ACEs and their correspondence to threat and deprivation) support a framework where a) the dose-​response effect of ACEs are b) proportional to the severity of threat and deprivation they incur within the context of a child’s development and c) increase the vulnerability to, and risk of, traumatic stress and dissociative reactions in the absence of more adaptive regulatory strategies. The following section explores how ACEs-​related performance and skills deficits also contribute as a causal link in the framework describing the relationship between ACEs and dissociative disorders and symptomology.

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Performance and Skills Deficits The previous sections reviewed how ACEs can potentiate distress-​related dissociation through various forms of developmental and traumatic stress, disrupt attachment dynamics, impair development of capacities associated with secure attachment, and heighten experiences of threat and deprivation. The far-​reaching impacts associated with ACEs can also result in performance and skills deficits. Performance deficits are restrictions in functioning (i.e., psychological, emotional, behavioral, and interpersonal) that underlie the capacity to carry out functional skills such as cognitive and emotion regulation skills, social skills, and adaptive behaviors. Skills deficits describe the impairment in skill-​based capacities necessary for adequate functioning in various domains of life (e.g., interpersonal and social functioning, effective communication, capacity for learning, and developing adaptive skills and behaviors). For example, the capacities to carry out cognitive and social-​related functions (e.g., focus and attention, listening, learning and memory, verbal expression, and critical thinking) are directly related to the performance of psychological, emotional, and interpersonal functioning. Impairments in the development and utilization of cognitive and social skills correspond to deficits in psychological and emotional functioning (e.g., low frustration tolerance, hyperarousal, negative expectancies, and disruptive rumination). Performance-​related deficits in functioning increase vulnerability to emotional distress and disruption in cognition requisite for effective use of skills-​based capacities. The relationship between performance and skills deficits can also be conceptualized as bidirectional. Difficulty developing and utilizing effective skills can lead to chronic experiences of frustration, distress, and ineffectiveness that lead to maladaptive behaviors and modes of functioning (e.g., externalizing behaviors, avoidance, isolation, maladaptive coping; Gold, 2020; Gold, Chapter 18, this volume). Continued difficulties during childhood would likely exacerbate performance deficits and skills deficits leading to a pattern of maladaptive behaviors and coping strategies, negative experiences, and impaired developmental potential. ACEs are associated with impairments in the performance of various domains of functioning and utilization of skills-​ based capacities. These are most notably present due to trauma-​related and dissociative symptomology from exposure to ACEs. Trauma-​related and dissociative symptomology are strongly associated with impairments to psychological, emotional, behavioral, and interpersonal functioning (Aupperle, Melrose, Stein, & Paulus, 2012; Cloitre, Miranda, Stovall-​ McClough, & Han, 2005). Performance deficits in these domains of functioning can give rise to skills deficits associated with impairments to learning and memory, emotional expression and communication, and executive functioning,

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which are also associated with trauma-​related and dissociative symptomology (Aupperle, Melrose, Stein, & Paulus, 2012; Ford, 2017). Traumatic stress from abuse-​related ACEs can induce symptoms such as hypervigilance, hyperarousal, and emotional numbing, that can impair more adaptive performance in psychological, emotional, cognitive, and interpersonal functioning. Persistent trauma-​related symptomology can result in performance deficits in e­ motional and cognitive functioning, such as increased vulnerability to distress, impaired emotional expression, emotional volatility, and impaired reasoning and judgment. Performance deficits from trauma-​related symptoms in emotional functioning can exacerbate skills-​based deficits in cognitive, communication, and social skills. For example, children and adolescents exposed to one or multiple forms of abuse are more likely to exhibit performance and skills deficits such as emotion dysregulation, aggression, behavioral difficulties, low academic achievement, impulsivity, and maladaptive social skills (Helton, Lightfoot, Fu, & Bruhn, 2019; Kaplan, Pelcovitz, & Labruna, 1999). Neglect and household dysfunction can also perpetuate performance and skills deficits from deprivation of adequate care, modeling, and nurturing of healthy functions and capacities. Physical and emotional neglect by caregivers and disruptions from household dysfunction deprives a child of the communication, support, and modeling needed to develop the skills associated with socializing, critical thinking and judgment, and communicating effectively (Gold, 2020). Children enduring these circumstances are at risk of developing skills deficits in self-​control, emotion regulation, and cognitive flexibility that would otherwise contribute to beneficial development (Meldrum et al., 2020; Shahab & Taklavi, 2019). Performance deficits in psychological, emotional, and interpersonal functioning can impair the development and utilization of skills used to effectively communicate distress, seek soothing and reassurance, seek comforting distractions, or otherwise cope effectively to manage distress. As such, skills deficits can prolong 1) the duration of psychological and emotional distress, 2) feelings of helplessness in mitigating and reducing distress. Both these factors increase the likelihood of distress-​related dissociative reactions. Skills deficits also heighten vulnerability to being overwhelmed by both ACEs-​related stressors and resulting trauma-​related and dissociative symptomology. Feelings of inefficacy in managing distress and finding sufficient social and emotional support can further exacerbate symptoms of avoidance, hypervigilance, negative self-​concept, and negative expectancies of others. Thus, skills deficits can bi-​d irectionally exacerbate performance deficits and further compound psychological and emotional distress, disruption in developing adaptive forms of coping, and vulnerability to distress-​related dissociation. As a result, distress-​related dissociation becomes a “default” modality for responding to developmental and traumatic stress due to a developmental environment laden with adversity, restricted resources to develop resilience for tolerating and managing distress, and limited development of adaptive forms of coping. Performance deficits lower the threshold for, and heighten the likelihood of, dissociative reactions under adverse or traumatic circumstances. Corresponding skills deficits compound the risk for developing dissociative reactions in response to ACEs. Impaired development of emotion regulation, self-​control, and cognitive skills furthers susceptibility to being chronically overwhelmed by ACEs-​ related stressors and increasing the likelihood of dissociative reactions. ACEs-​related stressors and neglect can also impair executive functions that underlie cognitive skills and coping strategies (DePrince, Weinzierl, & Combs, 2009; Spann et al., 2012). Deficient and ineffective functioning and forms of coping can result in cognitive schemata associated with negative concepts of self/​other, negative expectancies about relationships, and low self-​esteem and self-​efficacy. Deficits in emotion regulation, and cognitive and interpersonal skills, further exacerbate negative emotional states, heighten sensitivity to loss and threat, and increase vulnerability to emotional distress and distress-​related dissociative reactions. Along with attachment dynamics and experiences of threat and deprivation, performance and skills deficits are another formative link in the pathway between ACEs, distress-​related dissociation, and dissociative symptoms and disorders. These factors are causal links in the conceptual pathway from ACEs to dissociative symptoms and disorders. Increasing exposure to ACEs impairs the development of secure attachment, increases the likelihood of traumatization, and heightens vulnerability to traumatic stress and dissociative reactions. The following section proposes a conceptual pathway based on distress, disruption, and disconnection that delineates the causal relationship between ACEs and dissociative symptoms and disorders.

ACEs and Distress-​related Dissociation: A Pathway for Vulnerability to Developing Dissociative Symptoms and Disorders The three causal factors reviewed above –​attachment dynamics, experiences of threat and deprivation, and performance and skills deficits –​constitute a conceptual pathway from ACEs to distress-​related dissociation. The relationship between ACEs and these causal factors is conceptualized through the lens of developmental and trauma-​related distress, disruptions in the requisites needed for adequate development, and experiential disconnection. Increasing exposure to ACEs results in chronic experiences of overwhelming distress with the potential for severe disruption of the development

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of 1) secure attachment, 2) a supportive and nurturing environment, and 3) adaptive and enriching learning experiences and interpersonal connection. ACEs-​related distress and disruption of a beneficial caregiving environment increase vulnerability to distress-​related dissociative reactions and experiential disconnection throughout development. Disconnection becomes more prevalent in reaction to 1) chronic stress and disruption of supportive caregiving and a safe environment, 2) increased vulnerability to distress from disruption in the functional capacities and skills needed for adequate development, and 3) increased vulnerability to and risk of dissociative reactions due to traumatic and developmental distress from exposure to ACEs. A developing child exposed to multiple ACEs faces daunting conditions that promote the likelihood of developmental and traumatic distress, harmful effects from exposure to threats and abuse, deprivation from neglect and household dysfunction, and increased vulnerabilities from an inadequate and debilitating environment. The dose-​response relationship between ACEs and more severe outcomes is a key mechanism of action. It supports the premise that 1) the distress, disruption, and disconnection are proportional to the presence and frequency of one or multiple ACEs, and 2) ACEs-​related distress, disruption, and disconnection have a cumulative effect on the causal factors (i.e., attachment dynamics, threat and deprivation, performance and skills deficits) related to dissociative reactions and symptomology. The collective impact of these causal factors supports a conceptual pathway between ACEs and their link to dissociative symptoms and disorders. Increasing exposure to one or multiple ACEs initiates a cascade of distress, disruptions, and disconnection into the child’s experiential environment impairing adequate growth and development. The degree to which experiences of ACEs-​related distress and disruption intrude upon attachment dynamics determine the likelihood that various types of insecure attachment will develop and experiential disconnection (e.g., dissociation) will occur. This is most vivid in the case of disorganized attachment, which is likely to intensify over time in response to chronic exposure to severe forms of abuse, neglect, and household dysfunction. Performance and skills deficits, and the magnitude of threat and deprivation cultivated in the family environment, are also proportional to the cumulative exposure from one or more ACEs. Increasing exposure to ACEs negatively affects development in necessary domains of functioning (i.e., psychological, emotional, behavioral, and interpersonal) and the capacities to utilize them effectively (i.e., performance and skills deficits), which in turn heightens dissociation. The pathway supporting this framework is based on a cascade of negative impacts initiated by the cumulative exposure to ACEs. Exposure to one or multiple ACEs compounds the potential for this cascade of negative effects that potentiate experiences of distress, disruption, and disconnection that impinge upon requisite developmental processes needed for adequate growth. The detrimental impact of ACEs-​related developmental and traumatic stress, disruptions in beneficial and adaptive forms of development, and experiential disconnection in the form of distress-​related dissociation, are causally related via attachment dynamics, threat and deprivation, and performance and skills deficits, forming a pathway proceeding from ACEs exposure to dissociative symptoms and disorders.

Conclusion Exposure to ACEs is associated with a wide range of detrimental impacts related to health and psychological well-​being. Research in the past two decades supports a substantial relationship between ACEs and dissociative symptomology. This chapter presents a framework that delineates a causal relationship between ACEs and dissociative symptoms and disorders which incorporates three causal factors: attachment dynamics, experiences of threat and deprivation, and performance and skills deficits. ACEs-​related experiences of traumatic and developmental distress, disruption, and disconnection underlie the debilitating consequences related to these causal factors. Throughout this pathway, the collective effects of ACEs potentiate the risk of developing both trauma-​related and dissociative symptoms and disorders that are almost certain to persist throughout the lifespan. Future research is warranted to more explicitly identify how the causal factors described in this pathway (individually and collectively) mediate and moderate the relationship among ACEs and dissociative symptomology. Research validating the framework proposed by this pathway can support treatment approaches that address both 1) ACEs-​related impacts associated with chronic developmental experiences of distress, disruption, and disconnection, and 2) the causal factors that facilitate increased vulnerability to, and risk for, dissociative symptoms and disorders. Doing so can highlight the relevance of dissociative symptomology as a key feature associated with ACEs and inform therapeutic approaches addressing dissociative symptoms and disorders.

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13 BEYOND DEATH: ENDURING INCEST The Fusion of Father with Daughter Warwick Middleton

Historical Foundations It has only been in very recent times that the phenomena of ongoing incest into adulthood have become the subject of systematic scientific study. Yet, this form of extreme trauma has been repeatedly reported in the lay press for one and a half centuries. For example, a press report dating from 1871 states: Joel W. Perkins, of Cornwall, Connecticut, has been on trial for incest with his six daughters and murder of some of their offspring, the eldest having five children by him. The girls stated that they submitted to him upon threat of death for refusal or divulgement. He says that his daughters invited him and his wife encouraged him, and that he did not know there was any law against such practices. The Latter-​Day saints’ Millennial Star, 1871, p. 319 Case reports or anecdotal references to such abuse had periodically appeared in scientific publications, including a report on five cases of “incest in the post-​adolescent period of life” identified in the one community within a space of five years (Sloane & Karpinski, 1942, p. 666). Three of the cases involved father-​d aughter incest,1 the other two, involved a brother and sister. A proneness to judge the victim perhaps reflects earlier prejudices about the assumed mendacity of “hysterical” females. For example, in their paper Sloane and Karpinski (1942) note, “It is evident, however, that the girl was more or less compliant, despite her protestations of innocence, since sexual relations took place at frequent intervals over long periods” (p. 671). Although the eroticization of young children wasn’t noted in Herman’s seminal 1981 text on father-​d aughter incest, an important and much neglected paper by Yates was published in the American Journal of Psychiatry the following year (1982) detailing the effects of being prematurely eroticized as a young child. She observed, In my experience, many incestuous children are uncommonly erotic. They are easily aroused, highly motivated and readily orgasmic. The degree of eroticization seems closely related to the intensity and duration of the incestuous union. The original mode (e.g., heterosexual or homosexual, oral-​genital, extra-​genital) remains highly cathected. These observations are consistent with the observation that sexual responsiveness is learned behaviour. The process of eroticization can occur at any age. p. 482 In the first multi-​author text devoted to the treatment of Multiple Personality Disorder (MPD) (Braun, 1986), Kluft tangentially touches on the problems of ongoing abuse in adult MPD patients, observing that,

DOI: 10.4324/9781003057314-16

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When patients’ current external life circumstances are difficult and/​or patients remain enmeshed with their abusers, their treatment becomes singularly difficult because they rarely can tolerate the discontinuing of their dividedness and dissociative defenses. p. 55 In her book, Healing the Incest Wound, Courtois (1988) identified the problem in the first page of her introduction, when describing her work at a campus rape crisis center: Some of these callers confided that they had been assaulted not by strangers on the street but by men they knew and by family members, including fathers, brothers, uncles, grandfathers and cousins. And for some of them, the assaults had never stopped –​they were still caught in the situation. p. xiii Courtois described such an individual, a young woman who presented with the words ‘HELP ME’ carved on her arm. She described the woman’s family as “solidly upper middle-​class and appearing to be well-​functioning to the outside community” (p. xiv). Courtois’ published the second edition of her book, Healing the Incest Wound in 2010. This comprehensive text is largely predicated on incest being past tense with extensive coverage of the “aftermath” of incest and its “aftereffects” and secondary elaborations. Courtois gave no estimate as to how often incest extended into adulthood, though the language she used tended to imply that this was not that common. “If the incest goes undiscovered or attempts at disclosure or intervention are ineffective, the incest begun in the child’s toddler years may well continue into adolescence and sometimes even into adulthood” (pp. 115–​116). Prevalence estimates, presented later in the chapter, suggest otherwise. Issues surrounding the chronically incestuously abused adult patient is not fully addressed by Putnam in his classic 1989 text, Diagnosis and Treatment of Multiple Personality Disorder, though there is a brief reference to the fact that “actual abuse of adult MPD patients by family members does occur and can touch off devastating crises” (p. 296). Also in 1989 Ross published his substantive text, Multiple Personality Disorder: Diagnosis, Clinical Features and Treatment. While not explored in detail, he did note that the reason for one patient not making expected therapeutic progress “…became clear when ongoing sexual abuse was finally disclosed. One should suspect ongoing trauma in a patient who isn’t getting better at the expected pace” (p. 307). In 1995 Kluft published an analysis of six patients with Dissociative Identity Disorder (DID) who he was treating and who had completed suicide. Though no particular emphasis is placed on it, Kluft states that four of the six had been incestuously abused as adults and that two patients, and intermittently a third, remained enmeshed with her abusers. In 2009, Kluft provides a case study in which the potential for additional incestuous abuse at the hands of a past abuser is canvassed in therapy. Clearly Kluft demonstrated a very acute awareness that his patient with DID remained at substantial risk of re-​abuse, despite the passage of many years. In 2011 the International Society for the Study of Trauma and Dissociation (ISSTD) revised the treatment guidelines for DID with this author involved in that revision. More than had been the case with previous guidelines or with the general thrust of the scientific literature in the dissociative disorders/​incest fields, there was an explicit acknowledgment that some adult patients with DID are still being incestuously abused at the time of presentation for treatment and that for others a sudden deterioration in their ability to function may signal the renewed involvement of a prior incestuous abuser. The guidelines also noted that long-​term incestuous abuse frequently merges with some form of organized abuse. Despite these cursory comments regarding ongoing incestuous abuse, there had been no attempt up till this point to collect a representative series of cases to define the general characteristics of such abuse, the nature of the attachment between the perpetrator and his victims, or to arrive at a rough estimation of how common such cases were. Cases that came to light in the popular literature along with the author’s own experience with such cases began to shine greater light on fathers sexually abusing their children (primarily daughters) into adulthood.

Current Perspectives Nearly a century and a half since the crimes of Joel W. Perkins were reported in the popular press, the extremes associated with the incestuous abuse of adults were being repeatedly brought into public consciousness, especially following the global attention focused on the case of Josef Fritzl. In 2008 he was discovered to have locked his daughter, Elisabeth, in a “dungeon” underneath his house for the preceding 24 years. During this period she gave birth to seven children, one of whom died, with Fritzl taking no action to seek medical attention for the ailing newborn infant (see

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Marsh & Pancevski, 2009; Middleton, 2013a, 2013c, 2014, 2015 & 2019a). Fritzl, despite being jailed for rape as a young man, was outwardly a successful engineer/​property developer/​landlord and family patriarch who lived in a large and renovated house. Moreover, he attracted positive acclaim for seemingly taking in infants abandoned on his porch by a mysterious wayward daughter who supposedly had left her family of origin to join a cult years before. Dr Heidi Kastner, the psychiatrist who assessed Fritzl reported, “He told me that he loved Elisabeth. He saw her as his wife, not his daughter. But most of all he saw her as his possession.” As for the incestuously fathered children? “The more subjects you have, the greater power, the greater realm,” stated Kastner (Saner, 2009). A contemporary Australian case involved a man from Moe, Victoria, who sexually abused his daughter for 30 years and fathered four children with her. The arresting detective encountered a man in his 60s whose responses exemplified the mindset necessary for such abuse to continue indefinitely. Detective Shaddock’s observed: He was in complete denial and showed no remorse whatsoever. I asked him specifically, “Have you ever had sex with your daughter,” and he said, “I’ve got no comment to that.” Katherine X & Smethurst, 2015, p. 136 Elsewhere, his daughter reflected on her unrelenting abuse incorporating violence and repeated death threats that eclipsed earlier attempts to escape: “Any sense of self I had was gone and I was completely under my father’s control. He behaved like a tribal leader, the chief who lorded it over the slaves” (Katherine X & Smethurst, 2015, p. 127). A psychiatric record associated with her father dating back to 1970 was quoted in her book: “The diagnosis was ‘explosive psychopathic personality disorder…grossly self-​centered, impulsive and unable to tolerate responsibility” (ibid, p. 227). The sentencing judge could identify no real level of remorse. In the limited number of biographical accounts published as books concerning particular examples of ongoing incest during adulthood, extremes of control and sadism on the part of the abusing father are the norm (e.g., Artley, 1993; Darke, 2007; Katherine X & Smethurst, 2015). Josef Fritzl used guns, handcuffs, the threat of electrocution and gassing to help ensure compliance and force his imprisoned daughter to re-​enact scenes from the pornography he was obsessed with. The psychiatric assessment leaked to the press described Fritzl as suffering with a severe personality disorder and a “deviant sexuality” and noted that he was highly likely to reoffend if given the opportunity (Marsh & Pancevski, 2009). Though the books on the crimes of fathers incestuously abusing their daughters in adulthood are not written from a clinical perspective, all include a lay person’s description of extreme and repeated dissociation. For example, Katherine X wrote, When he was having sex with me, I wasn’t there, my mind was somewhere else. I escaped into a different part of my brain, switched my mind off and let him do what he wanted to do. p. 137 She goes on, “I felt outside myself looking in. I wasn’t human anymore, I was virtually catatonic” (p. 146). She further notes, “I could take my body to another place and literally not feel a thing” (ibid., p. 149). Even in these lay accounts we see examples of the abuser’s awareness of his victim’s chronic dissociation. Artley (1993) describes the concluding moments of Tommy Thompson’s rapes of his daughter, June: No longer could June entirely float to the ceiling in detachment to separate her spirit and real being from the body below, because nowadays a sharp, hard blow from his fist on the side of her head always preceded the moment he could finally gain release. p. 204 Tommy Thompson’s wife was abused as cruelly as his daughters, but Tanjas Darke’s mother (Darke, 2007) and Katherine X’s physically abusive mother effectively abandoned their daughters to their fate. As Katherine X (2015) stated, I had told my mother what was going on, but, as expected, she didn’t believe a word I said. She told me outright I was a liar (p. 97). He started attacking me when she was home; he didn’t give a shit. My mother never lifted a finger, never said a word. I still struggle with this today. p. 132 Some cases of ongoing incest during adulthood reported in the international lay press have included references to multiple perpetrators and many cases have involved multiple victims. In an analysis of 54 cases of ongoing incestuous abuse during

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adulthood (Middleton, 2014), while there were three cases involving an adult child meeting up with an absent father after many years and commencing a sexual relationship, all other cases with the exception of John Phillips, seemingly involved violence and the threat of violence. In 40 of the 54 cases there were incestuously fathered children. Arcebio Alvarez of Columbia fathered no less than 11 incestuously fathered children and Armando Gomez of Argentina, fathered 10. Some abusers in this spectrum fathered large numbers of children to multiple women. Tim Colt (a pseudonym) fathered 17 children with two of his daughters. Additionally, he fathered two more children, one to another underage daughter and one to a granddaughter (Sutton, 2021). The U.S. Attorney’s Office stated Rodney Flucas had admitted to fathering at least 37 children by numerous women (Phillips, 2019). Goel Ratzon of Israel also fathered at least 37 children.

Systematic Research Efforts The reporting of alleged Satanic Ritual Abuse (SRA) in the 1980s and 1990s had proven to be highly polarizing for the emerging modern trauma and dissociation field (Ross, 1995; Putnam, 1997, Middleton, 2019b). Being very mindful of how things had panned out in that area, in reporting on ongoing incestuous abuse during adulthood, in 2019, I reflected, It seemed that the most effective way in which to unequivocally demonstrate that this form of abuse was widespread, was to establish a foundation that involved publishing in the first instance, a detailed analysis of the phenomena by drawing together mainstream news reports (based on court findings and police statements) which demonstrated common features of this form of abuse as well as its average duration [Middleton, 2013a]. Having done this, there was a strong reference point for then publishing a more detailed analysis of this form of abuse based around a clinical series (which incorporated considerable corroboration). Middleton, 2019b, p. 23 I pointed out then that, “Interestingly, to date, there has not, to my knowledge, been a single published criticism of the approach taken, or my reported findings” (ibid., p. 23). A review of 51 cases involving adult incest victims reported in the English language international press revealed the great majority of cases to have dynamics generally similar to the Fritzl case: extreme control, sadism, multiple pregnancies, and decades of sexual abuse where the victim(s) received little effective protection for a variety of reasons, from either their mother or their community (Middleton, 2013a, 2014). Press reports in the great majority of such cases were brief and focused on the sensational. Nevertheless, even these accounts frequently included the peripheral facts that the father was connected to some sort of abuse network and/​or that the mother continued to live in the house in which much of the ongoing abuse occurred. The average duration of such incestuous abuse, abruptly brought to a halt by police involvement, was approximately 20 years.2 The preponderance of cases of incestuous abuse of adults come to public awareness as a consequence of police action and subsequent incarceration of the offender. However, occasionally there are press reports of cases where the primary abuser was never prosecuted. For instance, Ashley, Iseult and Megan Manning of Dublin have described how their mother, Mary, was held like a slave for almost two decades by her stepfather Sean McDarby of Ballickmoyler, County Carlow. Mary was repeatedly raped from age 10 and became pregnant for the first time at age 16. McDarby was once arrested and admitted to fathering six children with Mary between 1981 and 1989, but stated he did not believe he had done anything wrong. A boy born in 1986 was adopted out and Mary never saw him again. DNA testing confirmed McDarby was the five other siblings’ father. Mary, who ultimately became a psychotherapist, reported McDarby to the police in 1994 but no charges were ever brought and a civil case collapsed because of Statute of Limitations issues. McDarby died in 2009 without ever facing justice (O’Reilly, 2019). Mary wrote a book meaningfully called Nobody Will Believe You (2015). In 2015, when asked if she believed her mother knew about the abuse, Mary poignantly responded, “I think she used drink to block everything out… She heard stories, she knew from the family dynamic. She knew” (Caden, 2015). Victims of ongoing incestuous abuse on occasions spectacularly enact extreme traumas on others. One such instance is the infamous British serial killer, Rose West (wife of serial killer Fred West) from “the House of Horrors,” Cromwell St, Gloucester (Middleton, 2013d). Rose’s father continued to be sexually involved with her, even after she had given birth to her fourth child and he was reported to have raped her husband’s daughter, Anne-​Marie (Burn, 2011). Fred West’s daughter and Rose’s stepdaughter, Anne Marie, who said she could not understand how of her parents could have treated her so badly, has also said that she still loved her stepmother and father despite what happened to her

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over the years (West & Hill, 1995). Anne Marie’s half-​sister Mae expressed similar sentiments regarding her sadistic serial killer father, “Despite everything, I still love him” (Woodrow, 2011, p. 267).

General Characteristics Of Ongoing Incestuous Abuse Of Adults Despite the lack of systematic clinical research focused on ongoing incest during adulthood but congruent with the “post-​Fritzl” increased press reporting of such cases, it had nevertheless been apparent that the phenomenon was far from rare. In reporting on a clinical series of 62 patients with DID, Middleton and Butler (1998) found that approximately 13% (n =​8) of adults with DID at the time of presentation reported incestuous abuse continuing into adult years and for some the abuse was still happening. In 2013 a clinical series of 10 such female incest victims was reported (Middleton, 2013b). All 10 women had been abused sexually by their father (as well as experiencing sexual abuse from others) for decades. The majority (80%) had also experienced sexual abuse by one or more of their grandparents. The great majority experienced some variation of multi-​generational/​extended family sexual abuse. For example, one reported being sexually abused by both grandfathers, by her father, by her mother, and by both brothers (one in association with her then husband on occasions). Sixty percent reported being sexually abused by an uncle and 40% by a sibling. Thus, for many, the sexual abuse was part of a trans-​generational pattern that went beyond the father and included grandparents, uncles and/​or brothers. Penetrative sexual abuse was on average reported to have started before four years of age. The mean duration of incestuous abuse was 31 years. The average estimated number of sexual abuse episodes was 3,320, a figure approximating the estimated number of abuse episodes that Elisabeth Fritzl experienced (Marsh & Pancevski, 2009). Reflecting their extreme sexual conditioning, typically (congruent with Yates’ 1982 findings), they became orgasmic at age five or six. It was apparent that manipulation of their sexual arousal assisted in conditioning an enduring sexualized attachment, while fear and shame were used as key components in achieving compliance and silence. Most of the fathers were also experienced as actively wanting their daughters to become pregnant to them. Ninety percent described experiencing severe physical abuse, with 70% reporting injuries that were so severe that surgery was required. Such women have high indices of self-​harm and suicidality and are initially at least, prone to place themselves in dangerous re-​enactment scenarios. The women described in the published case series (Middleton, 2013b & 2013c) experienced being “fused” to their father and generally did not feel that they had ownership of their own body. Despite a propensity to use or threaten violence to their daughters, the fathers were, or generally had been, productively employed, financially comfortable, and stably married, while half had close involvement with a church. Some abusers benefit from social security payments made to their daughters and some created another generation of child victims that they abused. Suicide and murder occurred within the first or second-​degree relatives of these women at a high frequency. All 10 had been sexually abused in an organized manner by various groupings of individuals connected to their fathers. Sexual abuse involving multiple perpetrators is typically more sadistic than that associated with a solo perpetrator (Salter, 2013). Ongoing incestuous abuse during adulthood requires a dynamic where both primary parental figures are actively involved in the sexual abuse of children in their care, or that at least, the primary abuser is passively supported by the other parental figure who never takes definitive action to protect her child/​children. While mothers at times vehemently deny that abuse has been and is taking place in their house, one virtually never encounters a victim of such abuse by the father where the mother is not described as at least clearly visualizing instances of the sexual abuse. More usually, the mother on occasions played a role as a co-​abuser, and in a minority of cases played a lead role as a sexual abuser of her child/​children. The mother is also frequently abused and dissociative herself. The mother may lamely claim, after decades of sexual abuse occurring under her own roof and multiple incestuously fathered children, that she had no idea what was happening in her house as in, for example, the case of Josef Fritzl) (Marsh & Pancevski, 2009), Detlef Spies (Daily Mail, 2011) and Katherine X (Katherine X & Smethurst, 2015). When incest continues into adulthood, the father’s extreme control very much limits the child making significant contact with anyone outside his abuse circle. Close contact with friends (e.g., attending sleep-​overs) is frequently thwarted. Any attempt to inform others (e.g., school teachers or police) typically ends badly, with the victim portrayed as a liar, trouble-​m aker or mentally disturbed. Afterward, a responsive escalation in the violence routinely occurs to reinforce the imperative not to tell. Some victims of ongoing incest, as adults, attempt, against the perpetrator’s opposition, to set up an independent living arrangement. One participant in my analysis reported that her father then burnt down her house. Characteristically the fathers sought to further psychologically subjugate their victim by forcing them to do sexual things to their own children. “Nerida” described how when her son was 18 months old her father wanted

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her to undo his nappy and touch him but she decided that to do so would make her like him. After a violent struggle it ended with her being anally raped. In many cases of ongoing incestuous abuse during adulthood interventions from child safety authorities and police are either ineffective or absent. The case of Detlef Spies laid bare the failure of neighbors and authorities to detect what was going on, with social workers having conducted interviews with the family, but with Spies present. “If you are a trained social worker, you are supposed to go there and interview the victims without the perpetrator being present, and not all together,” Spies’ stepson Bjoern was reported as observing (Sturdee, 2011).

Common Observations Clinical and media accounts do allow a few salient general observations to be made. When the pattern of ongoing incest is first recognized by an engaged heath professional the victim will most likely be a woman (but some male cases have been seen) in her early 30s with her father the principal abuser. Commonly victims come from a larger than usual sib-​ship and generally their siblings will also be subjected to sexual and other abuse within the family grouping. The victimized daughter may be particularly singled out for sexual abuse by the father who has a particular fixation on her. Often the other siblings resent her “specialness,” but usually if there are other female siblings they will have been subjected to similar abuse. They may however, be very avoidant in discussing it, to the point of joining in a family pattern of projecting all blame onto a sister. Abusive fathers invoking the notion of “specialness” is not limited to singling out a particular child for more abuse than siblings. It is frequently also used by such fathers in a further manifestation of a “divide and rule dynamic” in the creation of particular alters. For example, one of “Harriet’s” alters wrote in a child-​like script, “I am 9. I came cos Daddy said I was his slave girl who did things that other parts are not allowed to know about. He doesn’t do this stuff with the others. I am special.” In terms of sadism, duration of abuse, number and type of sexual abuse acts, and the propensity for such cases to feature abusers who use weapons and who on occasion kill victims, the clinical cases focused on in my research, very closely resemble those proven cases featured internationally in many news and court reports (Middleton, 2013a & 2014). Many individuals, such as those described in my 2013 case series, carry the medically documented internal injuries and external scars associated with their abuse. In some cases the injuries are extreme. A number have produced photographs indicating past and ongoing abuse, others have close relatives who corroborated the abuse, while a substantial number have been, or are, associated with police investigations involving prominent abusers. On occasions very substantial corroboration of abuse is obtained where one has the opportunity to interview siblings, children or spouses. At least four of these abused individuals in my series gave evidence in closed sessions of the Australian Royal Commission into institutional responses to child sexual abuse. Most victims of ongoing incest during adulthood are at particular risk of premature death via 1) suicide or via drug-​ related or other misadventure, 2) medical conditions directly or indirectly caused by their abuse, or 3) murder (frequently enacted via pressures to suicide). Repeatedly victims of this sort of extreme abuse reflect that without therapy which recognizes what was actually going on and provides an alternative, they would be dead. For some the entry point for initial recognition of what had already been decades of incestuous abuse, was a failed suicide attempt. Most daughters are aware of their father having been subjected to serious or even extreme childhood abuse himself, with such abuse incorporated into the rationale for her own abuse. Many are aware that their father is highly dissociative himself. “Leanne,” for example, felt it “very likely” that her father himself had DID. “There’s such big differences in his behavior… There’s abuse in the networks with other men, there’s violent abuse with just him and there’s gentle abuse.” In each scenario her father seemed to be a different person. She thought it likely that her father had dissociative parts that did not remember abusing her. Statements of ownership and extreme sexual objectification by such abusers are endless (e.g., “He’s always told us he owns us” (“Leanne”); “You’ve got a c-​-​t. What else do you expect” (“Bonnie”)?). For “Susan,” her father’s ownership of her body meant “That I would do what he said, that I’d respond how he wanted, that he was with me all the time. Even if not there he could still see me. He knew -​anything that came out of my mouth, he’d know. He said, he could even read my thoughts.” Characteristically, the fathers committing the abuse are heavily involved with pornography and obsessed with control. They are, in fact, frequently extremely sadistic, and as they age and rage mounts at life’s infirmities, waning physical powers or chronic illnesses, their long-​term victims become the primary focus of vengeful projections and murderous rage. The impact of such control does not end with death. Such fathers frequently portray themselves to their victims as omnipotent. Before dying, and as a final act of control, some fathers will encourage their victim to also die, by actively pressuring them to attempt suicide. Alternatively, when there has been uncomfortable attention on the part of

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authorities to the reality of ongoing abuse, an expedient “suicide” will put an end to any investigation as well as provide definitive proof of how “mentally unwell,” and thus factually unreliable, their daughter really was. An alternative tactic spontaneously devised by such abusers and reported to this author on more than one occasion is for the principal abuser to instruct his victim to seduce her therapist, as this would provide a mechanism to nullify his ability to support his patient. Like many others “Leanne” described her father as using particular code words or names to induce switching her into compliant parts. She was aware that her father targeted shame, and that shame in turn became a barrier to her co-​consciousness. She hates her body. Her father has “always” said he owns her body and has said this to “lots of us.” Another, “Queenie” repeatedly experienced her father telling her, “You’re weak and you’re worthless!” She frequently hears her father’s voice saying, “Don’t betray the family!” Molly stated, “I believe some parts will do everything for Dad.” When the fathers associated with this sort of extreme abuse face the justice system their defense characteristically is to take on victim status and blame their daughter, a dynamic very much in keeping with Jennifer Freyd’s concept of DARVO, (an acronym for “deny, attack, and reverse victim and offender”) (Freyd, 1997). As Freyd noted, the offender rapidly creates the impression that the abuser is the wronged one, while the victim or concerned observer is the offender. The attitude displayed by Joel W. Perkins (The Latter-​Day saints’ Millennial Star, 1871, p. 319) or Josef Fritzl, who even in prison for his offences, was still writing to his daughter, pressuring her for money so he could “study to be a lawyer so I can defend myself ” (The Scotsman, 2010). Henri Michelle Piette, jailed in 2019, kidnapped his stepdaughter Rosalyn when she was eleven or twelve, subjected her to extreme abuse and fathered nine children to her. Despite being found guilty of kidnapping and traveling with intent to engage in a sexual act with a juvenile, Piette maintained his innocence and stated that most of the claims against him were “lies.” “Ninety-​n ine percent of them are lies. I’m telling the truth” (Burke, 2019). Piette had spoken out about the case after Rosalyn had fled from him, accusing her of lying, and claiming they were “married” and in love (Shadwell, 2019). The enduring attachment to violent parents in individuals who have never known an abuse-​free existence is profound. “Susan” stated wish is poignant and typical -​“I so miss my dad. I wish you could understand that and why I want to be with him.” Another, “Nerida,” wrote a letter to her father following his death. It began, “Well you finally went and died.” It recounted sexual abuse that began at age four and which incorporated descriptions of violent multi-​ perpetrator victimization. The letter poignantly tries to ask for an explanation as to why she was treated so sadistically and then incorporated both the issues of powerlessness and enduring attachment to a violent man who threatened her life, discredited her and took dramatic steps to stop her individuation when she sought to distance herself from him, “Dad I am sorry I wasn’t there for you in the last few years… I am sorry for all the pain that I caused you, all the heartbreak of losing your family… I love you dad and I did still care.” The fusion of the victim with their traumatizing abuser is implicit in statements such as, “I don’t know where I ended and father started” (“Mary”), or “You become so enmeshed, you almost become one person (Claire).” Typically the victims, all of whom had developed DID, had multiple alters that represented some aspect of their abuse by their primary abuser (including their attachment to him), with the number of alters and the complication of their alter system overall frequently approximating polyfragmented DID (Kluft, 1991). Usually a number of other alters incorporate aspects of other abusers –​including mothers or associates of the primary abuser.

Discussion: Implications of the Patterns Observed The patterns that commonly occur in the ongoing incestuous abuse of adult victims, have major implications. I organized these in the form of questions and answers that arise from the existence of this form of abuse. The extremity and bizarreness of the long-​term sexual abuse of adults challenges conventional views of the nature of human society while informing our understanding of dissociation and attachment.

Why Was Any Systematic Examination of the Phenomena Of Ongoing Incestuous Abuse In Adulthood So Long In Coming? The issue of incest has been an ageless and defining challenge for society, but a public issue from 1896 when Freud challenged his colleagues with his “seduction” theory on the etiology of hysteria. Freud (1896/​2001) postulated that the cause of hysteria was sexual abuse beginning before age 8, based upon “grave sexual injuries” perpetrated by “close relatives.” The actual naming of fathers as abusers was only mentioned in letters to Wilhelm Fliess. Fliess was Freud’s closest confidant at the time, and a man whose son Robert (who became a psychoanalyst) described as having

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“ambulatory psychosis.” The concept of “ambulatory psychosis,” introduced by Robert Fliess, described a person who appeared normal in public, yet who in private was anything but, being highly sexualized, violent and sadistic. R. Fliess (1956, p. xvii). wrote, When one is able to diagnose it, one sees relatively few families of one’s patients that are entirely free of it… The child of such a parent becomes the object of substantially defused aggression (maltreated and beaten almost to within an inch of his life), and of a perverse sexuality that hardly knows an incest barrier (is seduced in the most bizarre ways by the parent and, at his instigation, by others). Fliess’ description would in broad terms be very similar to the description of abusive fathers given by the patients I have quoted in this chapter (see Middleton, 2019a). Robert Fliess strongly implied in his writings that he had been sexually abused by his father, Wilhelm (Middleton, 2016). By September of 1897 Freud was already in his correspondence with his friend, Robert Fliess’ father, distancing himself from his “seduction” theory. The die was cast for it to be replaced with a theory emphasizing “Oedipal fantasy.” Florence Rush (1977, 1980) and Judith Herman (1981), writing from feminist perspectives, penned critical accounts of how Freud revised his earlier theory to argue that his patients’ descriptions of incestuous abuse were fantasy rather than fact. In 1977 Rush referred to “the Freudian cover-​up.” Herman observed that Freud, in concluding that his patients’ numerous reports of sexual abuse were untrue, did not rely on any new evidence from his patients coming to light, “but rather on [his] own growing unwillingness to believe that licentious behavior on the part of fathers could be so widespread.” Herman also notes that “his correspondence of the period reveals that he was particularly troubled by awareness of his own incestuous wishes toward his daughter, and by suspicions of his father, who had recently died (Herman, 1981, p. 10).” Rather than being the victims of incest, daughters came to be characterized by Freud as the source of incestuous wishes, portrayed in the guise of Oedipal fantasies. “To incriminate daughters rather than fathers was an immense relief to [Freud], even though it entailed a public admission that he had been mistaken” (ibid., p. 10). Despite at times demonstrating prodigious feats of intellect and productivity, many early analysts were psychologically troubled individuals who “were sucked into the vortex of a host of major boundary transgressions” (Gabbard & Lester, 1996, p. 69) (see Middleton, 2016). Those few analysts over the years who challenged Freud’s renunciation of his seduction theory, Sandor Ferenczi, Robert Fliess, and Jeffrey Masson, suffered the opprobrium of the psychoanalytic movement (Masson, 1984; Middleton & McMaugh, 2020a&b). Bennett Simon, a psychoanalyst, set out to do a scholarly demolition of Masson’s thesis by performing a close reading of the analytic literature on Oedipal fantasy. But he arrived at the conclusion that, neither Freud, nor, to my knowledge, any other analyst, [has] published a case wherein a woman, not psychotic, told of an incestuous relationship with the father and then in the course of treatment it turned out to be a fantasy! 1992, pp. 968–​969 The story of the last century and a quarter has been a stepwise, mostly forward, but not infrequently backward, journey toward identifying the sorts and extents of traumas which humans inflict on each other. Beyond Freud’s replacement of the seduction theory with the claimed universality of Oedipal fantasy, Eugen Bleuler’s construct of “schizophrenia” (1911) effectively subsumed, and in doing so adeptly obscured, the constructs of DID and “hysterical psychosis.” Despite studies such as that of Landis (1940), which pointed to the true extent of child sexual abuse, as late as 1980 the 2,357 page Comprehensive Textbook of Psychiatry, Third Edition devoted less than two pages to the discussion of incest and perpetuated the falsehood that incest affected one in one million adults in the general population (Henderson, 1980). Similarly, Henderson (1975) alleged that “Oedipal guilt may play a role in [the] reluctance to accuse the father. If an accusation is made, it is often a desire for revenge evoked by a perceived withdrawal of the father’s affection” (p. 1807). We know that the younger the age of the child at which sexual abuse commences, the more troubling are the consequences (Cole & Putnam, 1992). With ongoing incestuous abuse extending into adulthood, we have the worst of two worlds –​characteristically the incest starts at a very young age, and unless the perpetrator(s) die, it will still be happening decades later. There are various factors that routinely bring childhood incest to an end. These include some concerned adult (e.g., the mother) intervening; the abuser becoming concerned about causing a pregnancy; the victim having enough contact with peers that she can make a decision to end the abuse; or the victim doing something dramatic that brings attention to her plight or she extricates herself, such as by overdosing or running away (see Rodriguez-​Srednicki, & Twaite, 2006; Courtois, 2010). When incest persists into adulthood, the father continues to exert extreme control and very much limits his child making contact with anyone outside his abuse circle.

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To some degree the prolonged silence regarding the true extent of ongoing incest during adulthood represents reflexive caution on the part of the complex trauma/​d issociative disorders field. Although considerable numbers of individuals had claimed to have been satanically ritually abused, investigations of these reports proved to be hugely polarizing. Yet documenting ongoing incest during adulthood has been a very different phenomenon. As noted earlier, accounts have repeatedly surfaced in the lay press for over a century with no claims of international conspiracies, no substantial professional polarizations (such as the so-​called “Memory Wars”), and essentially no accusations of “mass hysteria” or “moral panic (Cohen, 1972). As with a societal recognition of incest, child sexual abuse in general, or the prevalence of DID, a critical mass of widespread reporting of such cases had to be achieved, and reporting in the international lay press had to synergize with congruent systematic scientific investigation. I suspect that one of the reasons that for so long there was no attempt at significant systematic research into ongoing incestuous abuse during adulthood, was that the trauma and dissociation field was itself traumatized and understandably cautious about engaging openly with another spectrum of reported extreme trauma (Middleton, 2019b).

What Has Allowed for the Emergence of a Societal Awareness About The Extent Of Ongoing Incest During Adulthood? After two world wars and dalliances with constructs such as “shell shock” and “battle fatigue,” we seem to have found a more secure resting place in the construct of PTSD. Nearly a century of substantial denial of the reality of incestuous abuse by mainstream psychoanalysis has been supplanted by undeniable statistics. Multiple studies demonstrate that around two thirds of mental health inpatients and outpatients come with a history of childhood sexual and/​or physical abuse (Read et al., 2004). And of course, the case of Josef Fritzl forced the world to belatedly confront anew the reality that there were many similar abusers in the world and that the great majority managed to abuse and impregnate victims long-​term without digging a dungeon for that purpose. Such fathers, arrested by police in many different countries and sentenced in high profile court cases, resulted in various legislatures calling for enquiries as to why their child protection and policing systems had failed so badly.

How Does Ongoing Incest During Adulthood Inform The Etiology of DID? As noted, we found 13% of our 62 DID participants reported ongoing incest during adulthood (Middleton & Butler, 1998). In the admittedly small number of population prevalence studies of DID, the median finding was that approximately 1.1% of the adult population meets diagnostic criteria for DID (Şar et al., 2007). If approximately one in eight DID patients experienced ongoing incest during adulthood, this yields a rough estimate that approximately one in every 700 adults in the general population is in this category. Given the high indexes of suicidality of such patients, it is likely that many such patients are never identified due to early death by suicide, among other factors (e.g., abuse victims who never come forward and never escape). Dell (2019) notes that both the dissociative disorders and hypnosis fields rejected the theory that the dissociative disorders arise out of attempts to escape trauma-​related distress through autohypnosis. The dismissal of this model, he proposes, largely resulted from a number of correlational studies which found hypnotizability and dissociation to be minimally related. Dell also notes that dissociative patients are highly hypnotizable and proposes that only highly hypnotizable individuals can develop a dissociative disorder (see Dell, Chapter 14, this volume), arguing the methodology of correlational studies of hypnotizability and dissociation in random clinical and community samples would necessarily be constitutively unable to detect that association, and statistically unable to reflect, that fact. He argues that the autohypnotic model of dissociation necessarily implies that only 15% of the general population possess the ability to develop a dissociative disorder and that most highly hypnotizable individuals (who constitute around 15% of the population) will not develop a dissociative disorder –​because their relatively positive life circumstances do not motivate them to dissociate. There are issues relating to the existence of individuals experiencing ongoing incestuous abuse during adulthood that challenge Dell’s assertions. While clinically one will encounter many individuals who have suffered incestuous abuse during childhood who have clinical conditions that fall short of reaching full diagnostic criteria for DID, we do not see this sort of spectrum existing when the incestuous abuse is as extreme and prolonged as it is for those where incest has continued into adulthood. Here DID is ubiquitous. In order for Dell’s model to hold in respect to those subjected to ongoing incestuous abuse during adulthood, we would have to assume that the only individuals who are unable to escape incestuous abuse before adulthood are those who are in the approximate 15% of the population who are highly hypnotizable individuals. Alternatively, approximately 85% of those heading towards ongoing incest during adulthood (who are not

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highly hypnotizable) are already dead, by early suicide or misadventure, and are thus never clinically encountered. Neither position inherently seems to be likely. It is clear, given what we have seen, that many in the ongoing incestuous abuse spectrum have a past history of very serious suicide attempts and indeed attempts by abusers to kill them, and thus that being very dissociative is not a reliable guarantee of survivability. For example, one of the ten analyzed in my study of ongoing incestuous abuse during adulthood had physically survived two separate jumps from a multi-​story car park that normally would have been expected to be fatal (Middleton 2013b). Another was first seen in the context of a deliberate suicide attempt, a third had had over 100 mental-​health admissions when first seen and had survived a very serious overdose (that she had not been expected to survive). The great majority had made serious suicide attempts. As noted, of Kluft’s (1995) six individuals who suicided whilst in therapy, four had experienced their abuse continuing into adulthood. Debate about the etiological ingredients of DID challenges us to ask whether being highly dissociative represents for those subjected long-​term to ongoing abuse, a survival mechanism? After dissociative abilities have been drawn upon, does the high index of dissociation allied with an enduring strong attachment to the father, also represent something of a trap, as the abuser manipulates 1) the attachment dynamics, 2) the very limited self hood of the victim, and 3) their proneness to generate compliant alters? Does this then create a life-​t ime victim conditioned to never effectively report the abuse, and where the enduring attachment to their primary abusers by some identities, makes it difficult to ever leave? Extrapolating from the particular cases of ongoing incest during adulthood, one is led to the conclusion that the intensity and duration of trauma is a major factor in the development of DID no matter what one’s hypnotizability, and that the enduring attachment to the perpetrator (which he highly manipulates) is seemingly only possible by the creation of multiple dissociative identity states, a number of which are based around various aspects of the primary abuser. One simply does not encounter adult individuals, incestuously abused since early childhood, who do not have complex forms of DID and where diminishing the attachment to the father (alive or dead) is not a major issue in therapy.

How do Perpetrators Of Enduring Incest Establish Enduring Control? One suspects that dissociation can be, like so many defense mechanisms, both an unconscious survival strategy and a trap. This ‘dissociation trap’ is akin to resorting to drugs or alcohol which may represent a self-​medicating coping mechanism but one that also brings with it a whole range of additional problems). There may be no general category of trauma victims who are more dissociative on average than those living with ongoing incestuous abuse during adulthood. The average Dissociative Experiences Scale score of the 10 individuals described in my 2013 series, was 62, considerably higher than the mean or median DES score of any published series of general DID patients. Based on my clinical observations, it is clear that the abusive (violent) fathers, while not usually versed in the scientific literature of dissociation, usually pick up on the dissociative switching of their victim(s) and frequently mold identity states to fulfill a number of purposes associated with entrenching their power and control, and fulfilling their sexual desires. Thus, utilizing attachment dynamics, alters are formed that may act as an early warning system, where the victim contacts the abusive father, if for example she becomes aware that police have been informed and are planning a visit. Conditioned alters may be created to fulfill sexual desires, for example, in childlike states to initiate sex with their abuser. Central messages from the abuser emphasize power, omnipotence and a claim that they will somehow be around forever. The daughters will often describe their father calling out particular alters by name. Dissociation may compartmentalize the trauma of the victim (in some cases to the point of them subjectively being amnestic for substantial components of their trauma) and thus at some level allows them to survive. Yet, it generally does not protect them long-​term from serious physical assaults, or major self-​harming and suicide attempts. It may even provide a ready key for their principal abuser and associates with which to access a compliant, but fearful and shame-​ filled victim who has many reasons to maintain secrets. Even when in a switched state, the unprotected adult victim of ongoing abuse makes some attempt to disclose the trauma to someone in authority, it rarely achieves validation or safety (Salter, 2017). It can prove to be extraordinarily challenging for an individual with little self hood (and essentially no experience with safe and consistent boundaries) to loosen their attachment to an incestuous father, who himself may be dissociative and trans-​generationally sexually attached to a parent. So conditioned and dissociative are such victims, that the act of actually marrying a partner, almost never brings the incestuous abuse to an end. I can also think of no incestuous abuser who spontaneously decided to cease abusing his daughter when this abuse has gone into adulthood. In some instances, despite regular contact with a therapist, individuals continue to be sexually, physically and emotionally abused by a highly controlling abuser (who uses sadism in conditioning the orgasmic response of his life-​long victim).

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Given the general sadism of the abusive father, and the sexual conditioning such fathers impose on their victim from an early age, pain, sexual arousal and orgasm become inextricably mixed. In separating from their primary abuser, via his death or via beginning to build safety, it not uncommon that in a switched state, the daughter will seek out abusive men who will then be directed to reenact some aspect of the (absent) father’s abuse. While some, years after affecting separation from their primary abuser, will achieve a settled relationship with a partner, for others trying to achieve an engaged sexual relationship, is either too triggering, or is not attempted.

How Do Perpetrators’ Exploit Attachment and Identity Dynamics? While there is growing evidence that DID is usually amenable to psychotherapy utilizing a Three Phase Approach (Brand et al., 2013; Dorahy et al., 2014), Sachs (2017) points to a minority group of those with DID where this treatment method fails to lead to improvement. She makes a distinction between what she calls “Stable DID” and “Active DID” and points out that “Active DID” applies to those cases where the person is still actively involved in a life of abuse, which they are unable to stop, though this may not be initially apparent. In a commentary on my 2013 case series outline above, Sachs noted that within the families I described (2013b) generally the incest was practiced openly (e.g., 30% witnessed first-​hand their father being sexually involved with their grandfather). She (Sachs, 2013, p. 578) suggested that the relationship between dissociative disorders and ongoing incest during adulthood was cyclical: A child who grows up with severe abuse is at high risk of developing a Dissociative Disorder, so as to disown his or her abuse experiences. And a child in a social context in which cruelty and incest are not only deemed normal but are the most powerful way to engage the attachment figure will develop an abnormal attachment language. Both dissociation and … attachment increase the child’s vulnerability to further abuse, thus perpetuating the cycle. In a response I observed, that all such abusers/​attachment figures will be internally represented by identity states, and these were formed at times when it was necessary to incorporate the limited attachment objects available, as the other choice was the all too real option of abandonment and certain death: If indeed the only attachment option is a pair of sadistic serial killers, it will be taken. The sort of damage that comes with having to exercise such extreme choices is a highly dissociative, self-​hating, and frequently suicidal individual, fused to her primary abusers and with a highly conditioned sexuality that incorporates re-​enactments focused around the primary abusers. Middleton, 2013c, p. 582 Yates, in her classic paper, made the point that “the incestuous union may be the only available source of nurturance in an emotionally barren family” (p. 482). One comes across reports where DID is seen as a multi-​generational phenomena (e.g., Braun, 1985), or where incest is proven in up to five consecutive generations and the genetic issues are very apparent. For example, this is evident in Sutton’s (2021) description of the “Colt” family: “Some have low slung ears or misaligned eyes as a result of inbreeding and they look decades older than their calendar age.” Attachment to the perpetrator, a particular focus of Ross and Halpern’s, 2009 text, is closely related to the lack of developed self hood in the victims of this form of abuse. Self hood encompasses a substantial number of parameters but central issues include affective stability, being able to remember one’s life, being able to live for oneself rather than through or for others, a capacity for emotional intimacy, having and maintaining self-​esteem, having clear personal boundaries, being able to commit oneself to an objective or relationship, having an appropriate sense of entitlement, being able to remain grounded in current objective reality, and having a stably evolving sense of identity (Middleton, 2012). Overwhelmingly, the victims of ongoing incestuous abuse during adulthood demonstrate so little self hood that characteristically they feel fused with their primary abuser (alive or dead) and do not feel they own their own body. This extremely rudimentary sense of self appears to characterize these victims whether they are encountered while the abuse continues, after the death of the primary abuser, or while it continues to be perpetrated by one or more of his associates. The victims experience internalization of their primary abuser in the form of frequently hearing his characteristic commentary via one or more of their alters.

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Even when the abusive father is as disturbed as a serial killer, victims’ ambivalence is commonly reflected in the divergent attitudes expressed toward the perpetrator by various ego states (e.g., West & Hill, 1995). Over a century ago Freud wrestled with the challenge posed by the “ambivalently-​loved object.” Developed self hood, based as it is on healthy introjects and affective stability, has similar parameters to those that define psychological resilience, something neatly defined by Wilson and Agaibi (2006). They listed the factors that distinguish highly resilient trauma survivors, these being: 1) Sufficient childhood environments for general competence, 2) Secure attachment relationships in childhood, 3) Good affect modulation/​positive emotions, 4) Ability to see the “big picture” of situations, 5) Spring-​back personality factors (e.g., autonomy, hardiness, esteem, assertiveness), 6) Lack of personalizing bad events/​experiences, 7) Continuity in identity, 8) Mature ego-​defenses (e.g., altruism, sublimation), and 9) Healthy self-​d isclosure. In looking at these factors it is essentially self-​evident why those who are living through ongoing incest during adulthood have so many psychological challenges and so little in reserve with which to meet them. The typical victim of ongoing incestuous abuse would not be significantly covered by even one of these nine factors.

Where Does Ongoing Incest During Adulthood Fit Into the Spectrum of Forms of Abuse for Which There is Emerging Recognition? We live in a world where the widespread abuses associated with schools, sporting organizations, orphanages, juvenile detention centers, churches, politicians, the scouting movement, cults, internet pedophile groupings, the military, not to mention the family, have been verified many times over. A world where the #MeToo and Black Lives Matter movements have traction, and where we contemplate the reality of the trafficking of children/​youth for sexual purposes by a man who was friends with not one, but two American presidents, not to mention a beleaguered member of the British Royal Family. There is no shortage of groups motivated to coverup the sexual, and other abuse, of children and adults. Ongoing incestuous abuse is a clearly-​ defined form of trauma, where there have been numerous arrests and convictions in multiple countries. It is a form of extreme trauma where shame about the ongoing abuse, the nature of the attachments and the paternity of incestuously-​fathered children, combined with extreme dissociation and the other components of trauma-​spectrum symptomatology, make it hard for fearful and untrusting victims with limited self hood to share details of their painful predicament. Given the many verified cases of this form of extreme abuse, it adds to the validity of DID. If those that live with this form of abuse do not develop DID and related trauma-​spectrum conditions, what alternative psychological response could conceivably be experienced instead? This is the sort of question, on which the critics of the construct of DID are silent.

Treatment Issues The complex treatment issues entailed in therapy with survivors of ongoing incest in adulthood require detailed discussion. Here I only note some overarching points particularly worth emphasizing when treating this population. When working with adult victims of paternal and maternal incest, one needs to be mindful that one is encountering a deeply traumatized individual with very limited self hood, with marked shame and intense self-​d irected hate, who is nevertheless very attached to one or more individuals who subject her to essentially unending abuse (Middleton, 2017). Treatment invariably means attempting to reshape the life landscape, effecting separation from father and other abusers, as well as dealing with the multiple forms of damage that such abuse has inflicted on marital relationships and the paternity of children, while remaining mindful of issues which in time are likely to be investigated by police. Establishing basic safety is frequently a two steps forward, one step back routine, yet an emphasis on it has to remain constant. It is self-​evident that one cannot process past trauma while being subjected to ongoing trauma in the present. It is entirely unhelpful, when it becomes apparent that one’s adult patient is still being abused, to simply insist that as a condition of ongoing treatment the abuse cease forthwith. There can logically be no short-​term resolution of the effects of severe abuse that has frequently already spanned much more than half a life-​t ime, and persisted throughout an individual’s formative years. Obviously, therapists need to be well-​informed about all mandatory reporting provisions of the relevant local legislation that applies to their practice. What is concerning in reading international press reporting of such abuse is the frequency with which members of the local community were aware of the abuse without taking significant action. In addition, the historic and at times current ineffectualness of child protection authorities and police, despite substantive evidence of ongoing incest, including the recurrent births of children with suspicious paternity (some with genetic defects), underscores how difficult it is for those in the surrounding community to summon the determination to intervene. A related issue is often that local legislation makes it difficult to prosecute an abuser when his victim is an adult who may not be cooperative with a prosecution.

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Such patients have an enormous need for acceptance and empathic connection, but many have been conditioned to subdue emotional responses and to not trust anyone, particularly when so many have been sexually abused by a previous therapist. Therapists need to be able to genuinely convey a sense that they are comfortable with discussing things that the patient frequently has thus far never disclosed in any detail with any human being. This includes the way in which sexual arousal, orgasm, sexual contact with other young children etc. was conditioned from an early age while their abuser shamed them for the very responses they had themselves orchestrated. As a personal observation, factors associated with positive long-​term outcomes for individuals in this spectrum, in no particular order, have included: early evidence of rebelliousness, the absence of psychotic tendencies, having a reasonable partner, being willing to attempt work, having a sense of humor and empathy for others, having personal creativity, having a strong motivation to protect their own children, being likeable, and possessing a willingness to work towards taking charge of their life (i.e., being able to get to a place where, as unfair and traumatizing as life has been, they take on board the imperative to play the hand they have been dealt).

Concluding Observations The existence of ongoing incestuous abuse during adulthood as a relatively widespread phenomena, represents something of a bookmark for the conceptualization of DID. At one end of the DID spectrum there are those individuals where the manifestations of DID can be subtle or where the dissociative phenomena merges with a condition that does not fully fulfil diagnostic criteria for DID (e.g., someone who switches between identity states but where there is insufficient evidence of amnesia; i.e, Other Specified Dissociative Disorder –​­example 1). At the other end we have those adults who are still being incestuously and sadistically abused as adults, who have complex forms of DID with numerous alters, who score extremely highly on measures of dissociation, and where their ongoing abuse almost invariably incorporates elements of some version of organized abuse. Their primary abuser is often an abuse victim himself and may be dissociative (as is often the case with his wife). He is sadistic, obsessed with pornography, and will continue the abuse, even if his victim marries. His wife usually is at least an enabler and frequently a co-​abuser. Generally, he views the incestuously fathered progeny of his victim(s) as an extension of his power. Such children are also at grave risk of abuse. He maintains the submission and silence of his daughter via a combination of threat, conditioning and the manipulation of shame. His daughter has limited self hood (e.g., not feeling she owns her own body) and despite the ongoing abuse will often manifest a tenacious attachment to the abusive father to whom she is psychologically fused. He in turn will manipulate her dissociation and not infrequently actively create alters, an activity that speaks to the capacity for the psychologically uninformed to observe dissociation on the part of victims (perhaps because they know it first hand from their own experience) and in turn foster and manipulate its creation. Abusers of the type outlined this chapter typically remain hidden in plain sight. Eleanor Fliess in 1974 noted this about her father-​in-​law, Wilhelm Fliess, observing him as a man “who however charming to patients and acquaintances was a tyrant at home” (Fliess, p. 10). Like the apparently well-​functioning community members who were parents of the young woman that Courtois described in 1988, such abusers successfully camouflage themselves against detection as they go about life outside their home.

Notes 1 Since perpetrators of ongoing incestuous abuse are commonly either fathers or step-​fathers, in the remainder of this chapter the term “father” can be assumed to refer to either a father or step-​f ather. Whilst the described victim in this chapter is nominated as being female and the principal abuser male, there are occasions where the victim is male and occasions where the principal abuser is female. Where individual patients are quoted, pseudonyms are used. 2 The longest recorded duration of incest extending into adulthood involved Gottfried Wagner of Germany where the abuse, until uncovered, went on for 41 years (Middleton, 2014).

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Middleton, W. (2017). Extreme adaptations in extreme and chronic circumstances; The application of ‘weaponized sex’ to those exposed to ongoing incestuous abuse. Special (double) Issue, Journal of Trauma and Dissociation, 18, 284–​303. Middleton, W. (2019a). Trauma-​informed care and incest that continues into adult life. In: R. Benjamin, J. Haliburn, J. & S. King (Eds.), Humanising Mental Health Care in Australia: Introducing a trauma-​informed approach (pp. 122–​132). London: Routledge. Middleton, W. (2019b). Understanding Reports of Satanic Ritual Abuse. Frontiers in the Psychotherapy of Trauma & Dissociation, 3(1), 21–​28. Middleton, W. & Butler, J. (1998). Dissociative identity disorder: An Australian series. Australian and New Zealand Journal of Psychiatry, 32, 794–​804. Middleton, W. & McMaugh, K. (2020a). An interview with Jeffrey Masson –​Part 1 –​ISSTD News, March, https://​news.isst-​d.org/​ an-​i nterv​iew-​w ith-​jeff​rey-​m as​son-​part-​i/​ Middleton, W. & McMaugh, K. (2020b). An interview with Jeffrey Masson –​Part 2 –​ISSTD News, April, https://​news.isst-​d.org/​ an-​i nterv​iew-​w ith-​jeff​rey-​m as​son-​part-​2 -​w rit​i ng-​the-​a ssa​u lt-​on-​t ruth/​ O’Reilly, A. (2019, September 22). Fathered by evil: Three sisters born as result of rape brand evil dad the ‘Irish Joseph Fritzl’ and reveal no one helped their desperate mum. The Sun. Retrieved from https://​t iny ​u rl.com/​y743e​l9a Phillips, R. (2019, February 12). Former Stockton teacher Rodney Flucas sentenced to life in sex case. Recordnet.com Retrieved from https://​t iny ​u rl.com/​y 9cr2​4qk Putnam, F. W. (1989). Diagnosis and Treatment of Multiple Personality Disorder. New York: Guilford. Putnam F. W. (1997). Dissociation in Children and Adolescents: A developmental perspective. New York: Guilford. Read, J., Goodman, L., Morrison, A, Ross, C. & Aderhold, V. (2004). Childhood trauma, loss and stress. In J. Read, L. Mosher & R. Bentall (Eds.), Models of Madness: psychological, social and biological approaches to schizophrenia (pp. 223–​252). Hove: Brunner-​Routledge. Ross, C. A. (1989). Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment. New York: Wiley. Ross, C. A. (1995). Satanic Ritual Abuse: Principles of treatment. Toronto: University of Toronto Press. Ross, C. A. & Halpern, N. (2009). Trauma Model Therapy. A treatment approach for trauma, dissociation, and complex comorbidity. Richardson, TX: Manitou Communications. Rush, F. (1977). The Freudian cover-​up. Chrysalis, 1, 31–​45. Rush, F. (1980). The Best Kept Secret: Sexual abuse of children. Englewood Cliffs, NJ: Prentice-​Hall. Rodriguez-​Srednicki, O. & Twaite, J. (2006). Understanding, Assessing, and Treating Victims of Childhood Abuse. New York: Jason Aronson. Sachs, A. (2013). Commentary on “Parent–​child Incest that extends Into adulthood: A survey of international press reports, 2007–​ 2011” and “Ongoing incestuous abuse during adulthood” (Middleton). Journal of Trauma and Dissociation, 14, 576–​579. Sachs, A. (2017). Through the lens of attachment relationship: Stable DID, active DID and other trauma-​based mental disorders. Journal of Trauma and Dissociation, 18, 319–​339. Salter, M. (2013). Organised Sexual Abuse. Oxfordshire: Routledge. Salter, M. (2017). Organised abuse in adulthood: Survivor and professional perspectives. Journal of Trauma and Dissociation, 18, 441–​453. Saner, E. (2009, March 21). Interview: “Do I feel sorry for Josef Fritzl? A small part of me does.” The Guardian. Retrieved from https://​t iny ​u rl.com/​y 9dc5​r2b Şar, V., Akyüz, G. & Doğan, O. (2007). Prevalence of dissociative disorders among women in the general population. Psychiatry Research, 149, 169–​76. Simon, B. (1992). Incest –​see under Oedipus complex: The history of an error in psychoanalysis. Journal of the American Psychoanalytic Association, 40, 955–​988. Shadwell, T. (2019, 19th November). Woman kidnapped by stepdad aged 11 and forced to have his 9 kids reveals how she escaped. Mirror. Retrieved from https://​t iny ​u rl.com/​s2n7n​e9h Sloane, P., & Karpinski, E. (1942). Effects of incest on the participants. American Journal of Orthopsychiatry, 12, 666– ​673. Sturdee, S. (2011, 23rd March). German ‘incest trucker’ jailed. Retrieved from https://​t iny​u rl.com/​y vdkx​r ve Sutton, C. (2021, April 25). Family monster: How depraved incest patriarch raped daughters and fathered their children. Retrieved from https://​t iny​u rl.com/​d rw95​ye8 The Latter-​Day Saints’ Millenial Star (1871, May 16), p. 319. The Scotsman. (2010). Josef Fritzl begs daughter for cash. Retrieved from https://​t iny ​u rl.com/​23wnd​jka West, A. M. & Hill, V. (1995). Out of the Shadows: Fred West’s daughter tells her harrowing story of survival. London, England: Hodder & Stroughton. Wilson, J. P. & Agaibi, C. (2006). The resilient trauma survivor. In J. P. Wilson (Ed.), The Posttraumatic Self: Restoring meaning and wholeness to personality (pp. 369–​398). New York: Routledge. Woodrow, J. C. (2011). Rose West: The making of a monster. London, England: Hodder & Stroughton. Yates, A. (1982). Children eroticized by incest. American Journal of Psychiatry, 139, 482–​485.

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14 CLARIFYING THE ETIOLOGY OF THE DISSOCIATIVE DISORDERS It’s Not All About Trauma Paul F. Dell

American police used to claim that marijuana is the “gateway drug” to drug addiction. They used that ‘fact’ to justify harsh marijuana laws. The origin of the gateway drug belief was the fact that so many drug addicts began their ‘careers’ by smoking marijuana. This idea –​that marijuana causes drug addiction –​is false; it is based on a highly-​biased sample (i.e., drug addicts). Proper testing of this hypothesis requires that drug addicts be compared to marijuana smokers; that comparison shows that most marijuana smokers do not become addicted to cocaine, heroin, or methamphetamine. This chapter argues that the dissociative disorders field has two ‘gateway drug fallacies’ that are based on a highly-​biased sample (i.e., dissociative disorder patients): (1) trauma causes dissociation, and (2) structural dissociation is caused by an inability to integrate traumatic events. I think both of these hypotheses are wrong. Proper testing of these hypotheses requires that dissociative disorder patients be compared to: (1) individuals who have been exposed to major stressors, and (2) individuals who are unable to integrate stressful events. I predict that those comparisons would show that (1) few trauma survivors develop a dissociative disorder; and (2) few people with an impaired ability to integrate stressful events develop structural dissociation.

Trauma and the Dissociative Disorders In 1986, Putnam, Guroff, Silberman, Barban, and Post reported that 97% of 100 cases of multiple personality disorder reported an extensive history of childhood trauma. Since then, every study of trauma in dissociative identity disorder (DID) or major dissociative disorder patients has replicated that finding (e.g., Boon & Draijer, 1993; Coons, Bowman, & Milstein, 1988; Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006; Middleton & Butler, 1998; Ross et al., 1990; Ross, Norton, & Wozney, 1989). For the last 40 years, the informal consensus of the dissociative disorders field has been that trauma causes DID. Van der Hart and colleagues have emphasized that this is what Janet (1889; 1920/​1965) meant when he described dissociation as the consequence of a person’s inability to psychologically integrate traumatic events (Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011; Van der Hart & Dorahy, Chapter 1, this volume; Van der Hart, Nijenhuis & Steele, 2006; Van der Hart & Rydberg, 2019). Today’s neo-​Janetian theory (Moskowitz & Van der Hart, 2020) –​i.e., the theory of structural dissociation of the personality –​is one of the principal models in the dissociative disorders field (Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011; Nijenhuis, Van der Hart & Steele, 2002; Van der Hart et al., 2006). There is, a problem with the theory of structural dissociation (and with all trauma models of dissociation): the correlation between trauma and dissociation is only 0.32 (Dalenberg et al., 2012; see also Carlson et al., 2012; Briere, 2006). This surprisingly-​low correlation (that is barely medium in its effect size) does not change the fact that severely dissociative patients routinely report an extensive history of trauma and abuse, but it does indicate that trauma cannot be the sole determinant –​or even the primary determinant? –​of dissociation (Dell, 2019, 2021). What is going on here?

DOI: 10.4324/9781003057314-17

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High Hypnotizability: The Road Not Taken Individuals with high hypnotizability can produce a second personality (Braid, 1855/​1970; Cox & Barnier, 2013; Dell, 2021; Harriman, 1943; Janet, 1886; Kampman, 1976; Leavitt, 1947; Richet, 1883). Janet was well-​aware of this fact, but he gave no credence to its potential implications because he believed that hypnotic suggestibility is a pathological trait that can be cured by therapy! Why did Janet believe this? Probably because his patients with severe hysteria –​especially those with multiple personalities –​were extremely hypnotizable. Their high suggestibility seemed to Janet to be an essential aspect of their hysterical pathology: Hysteria is before everything else a mental disease consisting chiefly in an exaggeration of suggestibility [i.e., high hypnotizability]. Janet, 1920/​1965, p. xiii [I]‌t is only among hysterical patients that this hypnotism is to be found in a marked degree. Janet, 1920/​1965, p. 5

Suggestion [i.e., high hypnotizability] … depends on a lack of synthesis, on a weakening of consciousness. … It requires as its essential condition a malady of the personality. … A tendency to suggestion and subconscious acts is the sign of mental disease, but it is, above all, the sign of hysteria. Janet, 1920/​1965, pp. 288–​289, italics added Van der Hart and colleagues have said little about Janet’s many statements that hysterics (i.e., dissociative patients) are highly hypnotizable. They do, however, accept Janet’s report that hypnosis of normal individuals can produce a dissociation of the personality (i.e., a second, dissociated personality). Van der Hart and colleagues’ response to these two assertions by Janet has significantly shaped their structural theory of dissociation. In particular, like Janet, Van der Hart and colleagues appear to have given little thought to the implications of dissociative patients’ hypnotizability (Moskowitz & Van der Hart, 2020; Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011; Van der Hart et al., 2006; Van der Hart & Rydberg, 2019). Thus, in an article, partially titled “Dissociation in Trauma,” they declared that: Our definition of dissociation pertains [solely] to a division of the personality in the context of trauma. We are aware that this division may also occur in hypnosis and mediumship.” Nijenhuis & Van der Hart, 2011, p. 441, italics and bracketed content added Their unambiguous exclusion of hypnosis from their field of interest led Cardeña (2011), an authority on hypnosis, to criticize the structural model of dissociation on the grounds that it tied clinical dissociation solely to trauma. Perhaps in response to this, Nijenhuis amended the name of their theory, calling it, “the theory of (trauma-​related) structural dissociation of the personality” (Nijenhuis, 2015, p. 5). Still, Cardeña’s criticism is valid; the theory of (trauma-​related) structural dissociation focuses only on (1) trauma, (2) inability to synthesize that trauma, and (3) subsequent dissociation of the personality. The theory of structural dissociation says nothing about the high hypnotizability of dissociative patients. This amounts to a declaration that hypnotizability is irrelevant to trauma-​related dissociation. I disagree –​as does Cardeña (personal communication 1-​11-​21). This, I believe, is the fatal shortcoming in both Janet’s model of dissociation and Van der Hart and colleagues’ neo-​Janetian model of structural dissociation. Janet had a reason –​albeit erroneous –​to exclude hypnotizability from his study of hypnosis and dissociation; he considered suggestibility to be a major component of hysterical pathology. Today’s neo-​Janetians (Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011; Nijenhuis et al., 2002; Van der Hart et al., 2006), however, do not have a valid reason for their disinterest in the high hypnotizability of dissociative patients –​just the historical precedent of Janet’s (erroneous) beliefs about hypnotizability. In fairness, neo-​Janetians do have some justification for considering hypnotizability to be largely irrelevant. Twentieth-​ century research on the relationship between hypnotizability and dissociation was suspended in the 1990s by both the dissociative disorders field and the hypnosis field. Two reviews of the relationship between hypnotizability and dissociative experiences –​one from the hypnosis field (Whalen & Nash, 1996) and one from the dissociative disorders field (Putnam & Carlson, 1998) –​concluded that the relationship between hypnotizability and dissociation is vanishingly small (r =​0.12). Thus, since the 1990s, hypnotizability has been ‘the road not taken’ in the dissociative disorders field.

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But not entirely. First, there is an inconvenient fact: DID patients are significantly more hypnotizable than those with any other mental disorder (Bliss, 1983, 1986; Butler, Duran, Jasiukaitas, Koopman, & Spiegel, 1996; Dell, 2017a; Frischholz, Lipman, Braun & Sachs, 1992). This is not a trivial finding. Second, several publications have marshalled evidence and reasoned lucidly that high hypnotizability is essential to the dissociative disorders (Butler et al., 1996; Dell, 2009, 2017a, 2017b, 2019, 2021). Third, and most importantly, Dell (2019) showed that the 0.12 correlation between hypnotizability and dissociative experiences in unselected community and clinical samples is misleading because data from unselected samples (85% of whom are not highly hypnotizable) can shed no light on the etiological relationship between high hypnotizability and dissociative-​d isordered patients (see Dell, 2017a, 2019, 2021). In summary, Janet wrongly attributed hysterics’ high hypnotizability to their pathology. For the last quarter-​century, the dissociation field (and the hypnosis field) have wrongly believed that there was no meaningful, empirical relationship between hypnotizability and dissociation. The bottom line about hypnotizability and dissociation is that (1) Janet’s hysterics were extremely hypnotizable, and (2) today’s DID cases are significantly more hypnotizable than cases with any other mental disorder. It is an error for the trauma model of dissociation to dismiss that fact; it is an error to exclude that fact from the theory of structural dissociation.

The Road Taken: An Inability to Synthesize Trauma According to Janet (1889, 1920/​1965), dissociation of the personality is a two-​step sequence: (1) the person lacks the ability to integrate the biopsychosocial sequellae of stressful events, and (2) the person subsequently (spontaneously?) synthesizes those unintegrated traumatic sequellae and ideas into a second personality. In my opinion, the causal link between these two steps is the most underdeveloped aspect of Janet’s writings on hysteria (i.e., the dissociative disorders). In fact, Janet never proposed a causal theory of dissociation (see below). I also think that Janet’s two-​step account of dissociation is the weakest and most undeveloped aspect of the modern theory of structural dissociation of the personality (Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011; Nijenhuis et al., 2002; Van der Hart et al., 2006). Janet’s description of dissociation is a passive, bottom-​up, deficit model (Dell, 2009; Liotti & Liotti, 2019; Perry & Laurence, 1984): that is, Janet says that dissociation is preceded by the person’s mental or psychological inability to integrate certain ideas and events. In contrast, Freud (1914) proposed that unacceptable events and ideas are ‘pushed’ out of conscious memory by the active, motivated, top-​down defense of repression (Dell, 2009; Liotti & Liotti, 2019; Perry & Laurence, 1984). Freud mocked Janet’s deficit model: Janet’s hysterical patient reminds one of a feeble woman who has gone out shopping and is now returning home laden with a multitude of parcels and boxes. She cannot contain the whole heap of them with her two arms and ten fingers. So first … one object slips from her grasp; and when she stoops to pick it up, another one escapes her … and so on. Freud, 1910, pp. 21–​22 I do not quote Freud because I think that Freud was right and Janet was wrong. I reference Freud because I want to heighten the reader’s awareness of the distinction between a passive weakness or deficit (i.e., Janet’s descriptive account of dissociation) and an active, motivated process of will (i.e., Freud’s theory of repression). According to Freud, repression actively ‘pushes away’ and ‘splits-​off’ unacceptable contents of the mind, and forcibly confines them in the unconscious (Freud, 1914). I take from Freud not the psychoanalytic concept of repression, but instead his emphasis on an active, motivated, top-​down, defense. Evolution has built into every living organism a passive, bottom-​up, physiologically-​motivated, set of avoidance and defensive responses. Like other living organisms, humans exhibit bottom-​up, motivated actions of avoidance and defense. Crucially, however, humans also employ top-​down, motivated, willful actions of avoidance and defense when they are endangered, hurt, or even upset/​uncomfortable. Mitchell (1921), an expert on dissociation, was similarly dissatisfied with Janet’s passive, deficit-​d riven view of dissociation. Mitchell said that: [ Janet] seems to emphasize unduly the purely cognitive aspect of consciousness and to neglect the part played by the emotions and the will. Dissociation is for Janet a curtailment of capacity, passively submitted to by an enfeebled consciousness –​a catastrophe in which the emotions and the will take no active part. Mitchell, 1921, pp. 40–​41, italics added

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Although Janet and modern Janetians accept the existence of psychological or mental defenses, they flatly reject the idea that structural dissociation is a defense (Nijenhuis, 2015; Van der Hart et al., 2006; Van der Hart & Rydberg, 2019). Structural dissociation, they insist, stems from a deficit –​the individual’s mental or psychological inability to synthesize/​ integrate traumatic events.

The Autohypnotic Model of the Dissociative Disorders I have proposed that a dissociative disorder arises when individuals with high hypnotic ability repeatedly use that ability to mentally distance themselves from emotional and physical pain (Dell, 2009, 2019, 2021). On the other hand, individuals with low hypnotic ability –​no matter how hurt or traumatized they may be –​cannot develop a dissociative disorder (Dell, 2009, 2019). Thus, in this instance, I am claiming that both Freud and Janet are wrong. Both gave serious, but fleeting consideration to the hypnotizability of hysterics; ultimately, both rejected its etiological relevance (Breuer & Freud, 1895; Janet, 1889, 1920/​1965). In one isolated paragraph of his doctoral thesis, Janet proposed that: It is not hysteria which constitutes terrain favorable to hypnotism, but it is hypnotic sensibility that constitutes favorable terrain for hysteria and other illnesses. Janet, 1889, pp. 451–​452 This would have been a major insight, but Janet promptly abandoned it. He spent most of the remainder of his life insisting that high hypnotizability is a pathological symptom of hysteria –​a ‘symptom’ that is cured when the person receives successful treatment for his or her hysteria: Suggestion [i.e., high hypnotizability] is a … relatively rare phenomenon; it presents itself experimentally or accidentally only with hystericals. Janet, 1920/​1965, p. 292, italics added

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When Janet discussed the etiological role of suggestibility [i.e., high hypnotizability] in hysteria, he could not accept (or even see) what his own words proposed –​i.e., an ‘autohypnotic’ genesis of hysteria and the dissociative disorders: [T]‌h is psychological fact [i.e., the suggestibility of hysterics] plays a great role in the formation of their disease … Janet, 1920/​1965, p. 292, italics added Freud’s endorsement of the hypnotic etiology of hysteria was similarly short-​lived. In 1893, Freud joined with Breuer in declaring that: [T]‌he basis and sine qua non of hysteria is the existence of hypnoid states. These hypnoid states share with one another and with hypnosis … one common feature: the ideas which emerge in them are very intense but are cut off from associative communication with the rest of the content of consciousness. Breuer & Freud, 1893, p. 12, italics in original In these views we concur with Binet and the two Janets … Breuer & Freud, 1893, p. 12 Within a year, Freud rejected Janet’s theory of dissociation and Breuer’s theory of hypnoid states. In their place, Freud proposed a new theory of hysteria –​motivated, mental defenses: Janet … assigns too great an importance to the splitting of consciousness in his characterization of hysteria. Freud, 1894, p. 51 I was repeatedly able to show that the splitting of the content of consciousness is the result of an act of will on the part of the patient; that is to say, it is initiated by an effort of will whose motive can be specified. By this I do not, of course, mean that the patient intends to bring about a splitting of consciousness. His intention is a different one; but, instead of attaining its aim, it produces a splitting of consciousness. Freud, 1894, pp. 46–​47, italics added

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This last quotation of Freud is quite similar to the ‘autohypnotic’ model of the dissociative disorders (Dell, 2019, 2021). But, Freud was not interested in dissociation, and he was certainly no longer interested in hypnosis (Kluft, 2018). In the two quotations above, Freud is rationalizing his abandonment of Breuer’s hypnoid-​state model of hysteria –​a model that was based on Breuer’s treatment of Anna O (a woman with multiple personalities; Breuer & Freud, 1895). In his own chapters of their 1895 book, Freud openly abandoned Breuer’s theory of hypnoid states: Strangely enough, I have never in my own experience met with a genuine hypnoid hysteria. Any that I took in hand has turned into a defence hysteria. Breuer & Freud, 1895, p. 286, italics added In Freud’s subsequent writings, he had nothing positive to say about hypnosis, hypnoid states, Janet’s theory of dissociation, or even Janet himself (whom he deemed an intellectual thief ). Breuer was still convinced of the validity of his hypnoid-​states model of hysteria. In his own chapters of their book, Breuer tried to make peace with Freud’s new theory of defenses by suggesting that hypnoid states occur in major defense-​ hysteria (i.e., dissociative disorders such as multiple personalities), but not minor defense-​hysteria (i.e., simple sensory-​ motor ‘conversion’ symptoms). Breuer said: I am still of the opinion that hypnoid states are the cause and necessary condition of many, indeed of most, major and complex hysterias. (Breuer & Freud, 1895, p. 216, italics added) Freud’s observations and analyses show that the splitting of the mind can also be caused by “defence,” by the deliberate deflection of consciousness from the distressing ideas … I only venture to suggest that the assistance of the hypnoid state is necessary if defence is to result not merely in single converted ideas being made into unconscious ones, but in a genuine splitting of the mind. Breuer & Freud, 1895, pp. 235–​236, italics added I agree with Breuer’s final sentence, but I attribute defensive acts of dissociation to the abilities of highly-​hypnotizable individuals –​abilities that do not need the presence of ‘trance’ or a hypnoid state in order to operate (Dell, 2019, 2021). Thus, Breuer is the historical progenitor of the autohypnotic model of the dissociative disorders. Unfortunately, Breuer did not further develop his ideas. A quarter of a century later, Mitchell (1921) picked up the thread of autohypnotic dissociation. Mitchell (1) brought together high hypnotizability and the dissociative symptoms of hysteria, and, importantly, (2) challenged Janet’s erroneous belief that high hypnotizability is a pathological trait: We may suppose that some special capacity for dissociation is the one qualification necessary for both the occurrence of hysterical symptoms and for the induction of hypnosis. A person who can be hypnotized is a person who may under appropriate circumstances, become an hysteric [i.e., develop a dissociative disorder], but who need not already have suffered from any manifest hysterical ability [i.e., somatic dissociative symptoms]. Mitchell, 1921, p. 32, italics added The autohypnotic model lay fallow for the next half-​century until Herbert Spiegel’s (1974) important article, “The Grade 5 Syndrome,” shone a bright light on individuals who are highly hypnotizable. Spiegel said that highly hypnotizable individuals were often “victims of their own profound trance capacity” (H. Spiegel & Spiegel, 1978, p. 322) because they are prone to “spontaneously dissociate and develop hysterical, conversion, or dissociative symptoms under stress” (Butler et al., 1996, p. 53). The next important step for the autohypnotic model of the dissociative disorders came from David Spiegel’s research team at Stanford in 1996. Butler et al. (1996) documented –​symptom by symptom –​the correspondence between dissociative symptoms and the hypnotic responses of highly hypnotizable individuals. Butler and colleagues explicitly proposed an autohypnotic model of dissociation: [P]‌athological dissociation may result from a diathesis-​stress interaction of innate hypnotizability and traumatic experience. Dissociation, therefore, may be understood as an autohypnotic phenomenon. Butler et al., 1996, p. 43 Little attention was paid to this remarkable paper, probably because (1) both the hypnosis field (Whalen & Nash, 1996) and the dissociative disorders field (Putnam & Carlson, 1998) had concluded that there was no meaningful relationship

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between hypnotizability and dissociation, and (2) the dissociative disorders field had reached a consensus that dissociative disorders were caused by trauma. In 2009 (in the first edition of the present volume), I proposed a version of the autohypnotic model of the dissociative disorders. That model challenged the etiological primacy of trauma: High hypnotizability is both a sine qua non of MPD [multiple personality disorder] and the fundamental mechanism of clinical dissociation. When sufficiently motivated by recurrent trauma and pain, children with high hypnotizability will eventually utilize their hypnotic capacities in order to escape from, and to encapsulate or compartmentalize, the traumatic material. On the other hand, no amount of trauma can produce MPD unless the child is highly hypnotizable. Dell, 2009, p. 741, italics added This challenge to the trauma paradigm evoked little reaction from the dissociative disorder field. Ten years later (Dell, 2019), I refined my thinking about trauma, and described three important differences between the trauma model and the ‘autohypnotic’ model. First, pain and distress are necessary to develop a dissociative disorder, but ‘trauma’ per se is not necessary. Second, even when trauma has undeniably occurred, trauma is not sufficient to produce a dissociative disorder. Third, a dissociative disorder cannot occur unless the individual is highly hypnotizable. The ‘autohypnotic’ model of the dissociative disorders also differs radically from the structural model of dissociation. The ‘autohypnotic’ model is founded on a hypnotic ability (that enables motivated, defensive, mental-​d istancing from physical and emotional pain), whereas the structural model is founded on a cognitive/​emotional weakness or inability to integrate trauma. [T]‌he autohypnotic model leaves behind the generally accepted idea that dissociative disorders require a history of trauma. Recurring pain, distress, and suffering from nontraumatic mistreatment (especially, chronic emotional abuse) may be quite sufficient to motivate repeated acts of autohypnotic distancing. … [T ]he autohypnotic model is inconsistent with the idea that trauma has the ability to somehow “cause” dissociation (e.g., “making” or “splitting off” an alter personality or a “part”). Trauma does not have that ability, but some individuals do (i.e., those who are highly hypnotizable). … [A]utohypnotic distancing from pain/​suffering is always a motivated, mental effort to find some way, any way, to get away from the circumstances that are causing that pain. Dell, 2019, p. 65, italics in original The bottom line here is that the ‘autohypnotic’ model is radically different from the trauma model: the cause of the dissociative disorders lies solely in high hypnotizability; trauma is not causal –​it is motivational. Chronic usage of high hypnotizables’ dissociative ability is motivated by pain/​d istress/​trauma, but that pain/​d istress/​trauma can never cause a dissociative disorder. Never.

Janet Did Not Propose an Etiological Theory of Dissociation Van der Hart and colleagues (2006) adopted Janet’s psychology of action to describe the functioning of individuals with a dissociative disorder and to conceptualize their therapy. Additionally, they embraced Myers’ (1940) Janetian understanding of the dissociative symptoms of war-​trauma (i.e., “shell shock”) –​namely, that the ‘shell-​shocked’ soldier’s mind is divided into an apparently normal personality (ANP) and an emotional personality (EP). Van der Hart and colleagues have placed Myers’ model at the center of their conceptualization of the daily functioning and the therapy of individuals with DID. Their elaboration of Myers’ model (Van der Hart et al., 2006) is enormously rich; it gives clinicians a much-​needed understanding of their DID patients. More recently, Van der Hart and Rydberg (2019) have drawn upon Janet’s writings about vehement emotions. Vehement emotions occur when a person’s ability to cope is overwhelmed. Van der Hart and Rydberg use vehement emotions to better explicate the “integrative failure that involves a disaggregation or dissociation of the personality” (p. 191). In particular, Van der Hart and Rydberg (2019) draw upon Janet and Raymond’s (1898) account of vehement emotions in their two-​volume publication, Névroses et idées fixes: The main characteristic of vehement emotions is that they have a disintegrative power; they deteriorate the individual’s integrative capacity. La synthèse mentale; Raymond & Janet, 1898b, p. 254 [Vehement emotions] are gifted with a power of dissociation. Janet & Raymond, 1898, p. 476

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Van der Hart and colleagues’ theory of structural dissociation is compelling up to a point. Ultimately, however, their model of vehement emotions and the deterioration of the individual’s ability to engage in mental synthesis (la synthèse mentale) has a fatal shortcoming: neither Janet’s original accounts of dissociation, nor his later psychology of action –​nor Van der Hart and colleagues’ model of structural dissociation –​provides an explanation of how (or why) an inability to synthesize traumatic events would produce a second personality. Remember, trauma does not always lead to structural dissociation; the correlation between major stressors and dissociation is only 0.32. Thus, the critical issue is why some individuals respond to stressors by developing a dissociative disorder, and why most individuals do not (Briere, 2006). This lacuna in the etiological explanation of the dissociative disorders began with Janet. Now, a century later, the etiology of DID is still unexplained by the structural model of dissociation –​or by any other trauma model.

Trauma Models of the Dissociative Disorders All trauma models of the dissociative disorders propose the same explanatory formula: Traumatic stressor +​being overwhelmed →pathological dissociation. In no case do any of the trauma models provide a rigorous explanation of “→ pathological dissociation.” Each just says “→ pathological dissociation.” But, “→ pathological dissociation” must be explained. So far, only the autohypnotic model of the dissociative disorders has proposed a causal explanation of “→ a dissociative disorder.” The autohypnotic model proposes that highly hypnotizable individuals have a superior ability to make major alterations in their experience (e.g., turning off pain, ‘going up to the ceiling,’ ‘going into the wall,’ retreating into a fantasy world, creating an internal friend, creating alters, etc.). Thus: Recurrent/​inescapable pain/​distress strongly motivates avoidance +​high hypnotizability →‘hypnotic’/​dissociative distancing ​maneuvers. When repeated over time, these highly-​motivated, mental-​d istancing maneuvers evolve into a procedural/​conditioned, reflexively-​f unctioning dissociative disorder (Dell, 2019, 2021).

Janet’s Refusal to Theorize Curiously, there is a more basic reason why Janet’s model of hysteria lacks an etiological explanation of the dissociation of the personality: Janet refused to theorize. He insisted that he only reported what he observed. Janet’s anti-​theory ethic was characteristic of nineteenth-​century French science (Dell, 2009; Robinson, 1977). The following quotations illustrate Janet’s refusal to theorize about the cause(s) of hysteria and dissociation: [M]‌y old studies … simply endeavored to throw light upon, describe and classify, certain phenomena of pathological psychology. Janet, 1907/​1910, pp. 53–​54, italics added I intentionally avoid discussing theories … I simply remind myself that I have something quite different to do. Janet, 1907/​1910, p. 62, italics added [W]‌e have got other psychologic and clinical problems to resolve concerning the subconscious without embarrassing ourselves with … [theoretical] speculations. Janet, 1907/​1910, p. 65, italics and bracketed word added “[D]‌oubling” … of consciousness … is not a philosophical explanation; it is a simple clinical observation. Janet, 1907/​1910, p. 67, italics added Janet observed that severe hysterics (1) had a low level of emotional and cognitive functioning, (2) did not consciously integrate or synthesize the biopsychosocial sequellae of traumatic events, (3) were highly suggestible, and (4) exhibited a second consciousness that knew and did things that the primary consciousness did not know or do ( Janet, 1889, 1920/​ 1965). Janet’s observations do not constitute an etiological theory of dissociation –​but Van der Hart and colleagues imply that they do: Structural dissociation occurs when an individual’s mental efficiency and mental energy … are too low to fully integrate what happened. Van der Hart et al., 2006, p. 26

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Janet (1907, p. 332) noted that, when the capacity to integrate the experience is insufficient, a dissociation of the survivor’s personality in two or more “systems of ideas and functions” is bound to follow. Nijenhuis, 2015, p. 33, italics added [V]‌ehement emotions … entail an integrative failure that involves a disaggregation or dissociation of the personality, especially as part of traumatic experiences. This involves a division of the personality into different subsystems, each with its own sense of self and first-​person perspective … Van der Hart & Rydberg, p. 191, italics added Van der Hart and colleagues’ descriptions of “→ structural dissociation” are always a bit oblique. They never say explicitly that the inability to synthesize trauma causes structural dissociation. On the other hand, Van der Hart and colleagues (Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011; Van der Hart et al., 2006) have never stated that their theory is not a causal theory of structural dissociation. This leads me to suspect that they are discomfited by the murkiness of the causal relationship between (1) an inability to synthesize overly-​stressful events, and (2) the appearance of a second personality. I am tempted to construe Nijenhuis’ (2015) book as an extended effort to articulate the as-​yet-​unexplained, causal gap between inability-​to-​synthesize and development-​of-​a-​d issociative-​structure. Finally, several authors have recently drawn an important distinction between the disintegrative effects of traumatic experience and the dissociative process that subsequently organizes that which has been disrupted/​disintegrated into dissociative structures (Farina, Liotti & Imperatori, 2019; Meares & Barral, 2019; Şar, 2017; See Farina & Meares, Chapter 3, this volume). This is a sorely-​needed distinction because the disintegrative effects of trauma and the organization of that unintegrated material into a dissociative structure are not the same, and –​more importantly –​there is little evidence that these two processes are causally-​related.

So, What Is the Relationship Between Trauma and Dissociative Divisions of the Personality? In 2011, Nijenhuis and Van der Hart proposed “a precise definition of dissociation in trauma” (p. 416). Their definition surprised me because it makes the concepts of (1) trauma, (2) inability to synthesize, and (3) dissociative division of the personality interdependent, mutually explanatory, and dynamically inseparable from one another: Dissociation in trauma entails a division of an individual’s personality. … This division of personality constitutes a core feature of trauma. It evolves when the individual lacks the capacity to integrate adverse experiences … Nijenhuis & Van der Hart, 2011, p. 418, italics added Nijenhuis (2015) and Moskowitz and Van der Hart (2020) have reasserted this claim: Dissociation in trauma involves a division of the personality … into two or more conscious and self-​conscious subsystems or dissociative parts during or following traumatic/​traumatizing events. This division is a core feature of trauma. Nijenhuis, 205, p. 273, italics added Trauma-​related dissociation involves … a division of an individual’s personality … This division of the personality constitutes a core feature of trauma. Moskowitz & Van der Hart, 2020, p. 3, italics added This thrice-​a sserted claim –​that ‘the division of personality constitutes a core feature of trauma’ –​says that trauma has two components: (1) the individual’s inability to integrate it, and (2) the individual’s division of his/​her personality into parts. Thus: “No division of the personality =​no trauma;” and “No trauma =​no division of the personality.” In short, Van der Hart and colleagues seem to equate trauma with a structural division of the individual’s personality: Following Nijenhuis (2015), we would define trauma as a “biopsychosocial injury … (whose) formal cause is a lack of integration of particular experiences/​events … (which) manifests itself as a particular dissociation of the personality.” (Nijenhuis, 2015, p. 271); Moskowitz, Heinimaa & Van der Hart, 2019, p. 18, italics added [T]‌rauma-​related dissociation initially occurs because the traumatized individual does not have sufficient integrative capacity … Moskowitz & Van der Hart, 2020, p. 8, italics added

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For a similar point of view about trauma and dissociation, see Howell (2005, 2011). The title of Nijenhuis’ (2015) exegesis of trauma, The Trinity of Trauma: Ignorance, Fragility, and Control, equates trauma with the division of the personality –​that is, division into ANPs (who live in ignorance of the trauma) and EPs (who are either fragile or controlling). Then, unexpectedly, Nijenhuis declares that trauma and dissociation-​in-​t rauma are “not the same thing”: Dissociation in trauma and trauma are not the same thing –​they are not synonyms. Dissociation in trauma involves a particular division of personality, whereas trauma pertains to the complete gamut of biopsychosocial phenomena that make up traumatic experiences … Nijenhuis, 2015, p. 273, italics added “Dissociation in trauma and trauma are not the same thing.” This makes excellent sense to me, but as noted, the title of Nijenhuis’ book contradicts this assertion –​as does the text of the book. On page 273, Nijenhuis (2015) claims that, (1) “Dissociation in trauma and trauma are not the same thing,” and (2) “This division [of personality] is a core feature of trauma.” These two assertions negate one another; they cannot both be true. Nijenhuis’ contention –​that ‘division of the personality is the core of trauma’ –​is probably incorrect. Why? Because trauma most often consists of a “gamut of biopsychosocial phenomena” that do not include a division of the personality. We know this as clinicians (because most of our ‘traumatized’ patients do not have a dissociative disorder) and we know this as researchers (because the correlation between trauma and dissociation is only 0.32). Thus, dissociation of the personality cannot be the core feature of trauma. Nijenhuis’ (2015) book provides many clarifying insights about trauma, but my judgement is that the book does not explain the etiology of the dissociative disorders. To me, it seems impossible to explain the etiology of the dissociative disorders solely on the basis of (1) trauma, and (2) the inability to synthesize trauma. No matter how Nijenhuis defines them, these two variables do not explain why some traumatized individuals develop a dissociative disorder and other traumatized individuals do not. Another variable is needed.

The Theory of Structural Dissociation Needs to Incorporate High Hypnotizability The structural model of dissociation implies that dissociative disorders are caused by an inability to synthesize trauma. This implication must be incorrect (or, at least, incomplete) because far more people have an impaired ability to synthesize stressful events (i.e., they suffer various, nondissociative, and/or nonstructural traumatic sequellae) than have structural dissociation. An additional factor is needed to explain why only some traumatized people develop a dissociative disorder. As stated above, I propose that high hypnotizability is that factor. Before proceeding, I want to acknowledge the clinical value and descriptive/​conceptual usefulness of Myers (1940) and Van der Hart and colleagues’ (2006) ANPs and EPs. The structural model is at its very best in (1) its conceptualization of the psychological dynamics of ANPs and EPs, and (2) its psychology-​of-​action blueprint for treating dissociative patients. The clinical utility of Van der Hart and colleagues’ structural model has not been significantly undermined by excluding high hypnotizability from its field of interest. I do, however, doubt the clinical helpfulness of their insistence that posttraumatic stress disorder is always a form of structural dissociation (Dell, 2009, 2019). In order to fully assimilate the high hypnotizability of dissociative patients into their theory of structural dissociation, Van der Hart and colleagues would need to adjust their stance on four issues: (1) ability, (2) defense, (3) inability to integrate particular events and experiences, and (4) trauma. Their theory’s formulation of these matters has, I think, gone astray via misapprehensions that Van der Hart and colleagues inherited from Janet. Janet acknowledged two kinds of structural dissociation: (1) hypnotically-​induced divisions of the personality, and (2) trauma-​induced divisions of the personality. Van der Hart and colleagues agree with Janet about this. And –​to their disadvantage, I think –​Van der Hart and colleagues follow Janet in two crucial regards: (1) they pay no attention to high hypnotisability, and (2) they restrict their interest solely to trauma-​induced dissociation (Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011; Van der Hart et al., 2006). Van der Hart and Dorahy (Chapter 1, this volume) insist that hypnotic divisions of the personality are transient: when the ‘hypnotic state’ is terminated, the division of the personality promptly ceases. They portray hypnosis as belonging to the domain of normal, healthy individuals –​thereby implying that such hypnotic division of the personality is irrelevant to pathological, trauma-​related, structural dissociation. DID, however, is almost certainly the living proof that high hypnotizability enables abused/​betrayed children to self-​induce a division of the personality (Dell, 2009, 2017b, 2019, 2021) –​thereby producing a part that is not transient.

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Van der Hart and Dorahy suggest that a medium best exemplifies normal, self-​induced dissociation of the personality. However, they do not mention two important features of mediums (and other healthy individuals who self-​induce a hypnotic division of the personality). First, unlike individuals with a dissociative disorder, mediums are not impaired in their ability to synthesize events. Second –​and most importantly –​like individuals with a dissociative disorder, healthy individuals who self-​induce a division of their personality are highly hypnotizable. Thus, once again, this fundamental similarity (between structural dissociation and hypnotically-​induced division of the personality) goes unmentioned.

Ability I keep saying that Van der Hart and colleagues should embrace high hypnotizability. But, why should they? Why should they discard Janet’s inability-​to-​synthesize-​trauma as the fundamental cause of structural dissociation? There are eight reasons why. First, research has shown that Janet was wrong about hypnotizability. Hypnotizability is not pathological; it is a normal trait that has a bell-​curve distribution in the general population (Hilgard, 1965). Second, individuals with DID are significantly more hypnotizable than those with any other mental disorder (Dell, 2017a). Janet knew this –​but his insistence that high suggestibility is the defining symptom of hysteria (i.e., the dissociative disorders) led him to discount the possibility that high suggestibility is a nonpathological trait that enables/causes hysteria (i.e., dissociative disorders). Third, Janet was quite aware of two facts; (1) healthy individuals who are highly hypnotizable can easily produce a division of the personality, and (2) dissociative hysterics are highly hypnotizable. Janet should have concluded that high hypnotizability is the essential factor-​in-​common for division of the personality (in hysteria and in hypnosis). He did not. Janet’s conviction that high hypnotizability is a pathological trait deprived him of that insight. Fourth, high hypnotizability is associated with dissociative symptoms in seven mental disorders (i.e., phobias, bulimia, PTSD, acute stress disorder, ‘conversion’ disorder, somatization disorder, and DID; Dell, 2017a). This finding and other evidence led (some) modern researchers to conclude that high hypnotizability is a sine qua non for the development of a severe dissociative disorder (Butler et al., 1996; Dell, 2009, 2017a, 2019, 2021). Fifth, Butler and colleagues (1996) have shown that the phenomena of high hypnotizability corresponds isomorphically –​hypnotic phenomenon by hypnotic phenomenon –​with the symptoms of a dissociative disorder. Sixth, Janet never provided a causal theory of hysteria. Instead, he elaborated hysterics’ inability to synthesize certain events into a comprehensive analysis of human functioning (i.e., his psychology of action). Notably, however, Janet’s psychology of action considers hysterics to be just one of many diagnostic groups with poor mental efficiency, low mental energy, and a weakened ability to integrate stressful events. Seventh, Nijenhuis has already acknowledged that ability is an important component of the dissociative disorders: In our view, dissociative ability involves an individual’s ability to divide the personality in two or more insufficiently integrated, hence dissociated, parts, each with, at a minimum, his or her own first-​person perspective. Nijenhuis & Van der Hart, 2011, p, 436, italics added Dissociation of the personality involves the capacity to organize and reorganize the personality into two or more dissociative parts of the personality. Nijenhuis, 2015, p. 353, italics added The maintenance of dissociation is related to the ability to keep two or more parts of the personality and the associated actions and mental contents relatively divided from each other. Nijenhuis, 2015, p. 353, italics added Eighth, Nijenhuis and his colleagues have repeatedly identified phobias as the motivator for accomplishing and maintaining these dissociative divisions. But a phobia is not an ability. Phobias provide a motivation to avoid, but they do not explain (or provide) the remarkable mental ability to create and maintain alters. The bottom line here is that (1) Janet was wrong about high hypnotizability being a pathological trait, (2) and hence wrong about high hypnotizability being a symptom of hysteria, and (3) Nijenhuis (2015) already thinks that dissociation is enabled and maintained by an ability. Conversely, Janet never claimed that hysteria is caused by a lack of ability to synthesize trauma; Janet said that an inadequate capacity to synthesize events is found in many kinds of mental disorder (Crabtree, 1993; Janet, 1889). Nijenhuis agrees:

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Many forms of psychopathology involve a certain lack of integration, but it is not helpful to regard all integrative problems as manifestations of dissociation. Nijenhuis, 2015, p. 548 Accordingly, it would make good sense for Van der Hart and colleagues (1) not to repeat Janet’s error about high hypnotizability, and (2) not to claim –​or even imply –​that an inability to synthesize causes a dissociative disorder.

Defense Van der Hart and colleagues have taken up Janet’s mantle in the feud with Freud (Nijenhuis & Van der Hart, 2011; Van der Hart & Dorahy, this volume). Van der Hart and colleagues: inability to synthesize! Freud: defenses! Janet and Freud were two great psychologists; each elaborated a comprehensive clinical psychology. Each used their own fledgling psychology to explain hysteria. Janet insisted that severe hysterics (i.e., DID patients) had an inability to synthesize and integrate traumatic events; Freud insisted that hysteria was a defense against unacceptable ideas and urges. Janet: passive, nonmotivated inability to integrate. Freud: active, motivated defense. The debate continues today: Dissociation as a defence in psychoanalytic thinking can be distinguished from dissociation as insufficient psychological capacity for integrated functioning (e.g., Liotti, 2009) [italics in original]. In the latter Janetian sense, dissociation may come to have a secondary defensive value. However … Janet’s dissociation does not occur for the primary purpose of psychic defence (i.e., ego-​derived expulsion or ‘splitting off’ of noxious internal experience). Van der Hart & Dorahy, Chapter 1, this volume, p. ?? italics added They further note: “… [A]‌ny defensive purpose [that] this failed integration has is secondary to it rather than teleological of it.” (Van der Hart & Dorahy, Chapter 1, this volume, p.??) Defense and inability-​to-​synthesize are two very-​different conceptions of the same clinical phenomena –​one is an intentional action; the other is a deficit –​ an inability. All individuals defend against events and ideas that they find to be unacceptable or intolerable; they defensively refuse to tolerate and integrate them. They avoid them. The more that those events and ideas are unacceptable, (1) the more unwilling the person is to tolerate and integrate them, and, therefore, (2) the more the person avoids those events and ideas, and ‘pushes’ them away. In contrast, Janet claims that hysterics are unable to integrate particular events. The difference, of course, is that Freud focuses on motivation and will, whereas Janet focuses on cognitive/​emotional inability to synthesize and integrate (Liotti & Liotti, 2019). Their respective frames of reference turned Freud’s attention to the defensive functioning of the ego, and turned Janet’s attention to (what Freud and ego psychologists would call) the limitations of a weak ego (i.e., an insufficient capacity for integrative functioning). Irony abounds. The problem with the model of structural dissociation –​in fact, the problem with all trauma models of dissociation –​is that they focus too much on trauma (and fail to take heed of the many, painful/​d istressing experiences that fall short of frank trauma). As noted earlier in this chapter, all trauma models espouse the same causal formula: Traumatic stressor +​being overwhelmed →pathological dissociation; traumatic stressor +​being overwhelmed →structural dissociation. My point here is that trauma models of dissociation are almost inherently Janetian: trauma (i.e., ‘being-​traumatically-​overwhelmed’) is easily equated with ‘being-​unable-​to-​synthesize-​those-​events’: [T]‌his notion of trauma as a breaking-​point highlights the inability to integrate the implications of an event into the existing conceptions of one’s self and the world, recapitulating the historical linking of trauma and dissociation. … As such, the concept of trauma is intimately connected with the concept of dissociation … Moskowitz et al., 2019, p. 18, italics added This sentiment, of course, is held in common by all trauma models of dissociation: “trauma is intimately connected with dissociation.” What is wrong with that? Hasn’t the dissociation field espoused the trauma model of dissociation since the 1980s? Yes, it has, but … The problem with the trauma model is “trauma.” Van der Hart and colleagues’ model of trauma-​related structural dissociation contains two dubious claims: (1) structural dissociation requires “trauma”; and (2) avoidance and defense do not cause structural dissociation: “[B]‌eing overwhelmed” implies an insufficient integrative capacity for the task at hand. … If dissociation is a defense … then it would seem that he or she is not overwhelmed, i.e., overcome, submerged, crushed, inundated. … [D]uring a

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traumatizing event … the individual is indeed overwhelmed. … [I]ntegrative capacity is lowered, rendering the client unable to integrate experience precisely because defenses have failed. Van der Hart & Rydberg, 2019, p. 192, italics added Yes, indeed. During trauma, a person’s defenses and coping skills are truly overwhelmed; his or her defenses have failed. Nevertheless, I think that Van der Hart and colleagues are wrong about these matters. I think they are wrong to assume that trauma-​related structural dissociation requires being overwhelmed by trauma; I think they are wrong to insist that motivated, defensive dissociation cannot occur. Like all theories, their claims about trauma and defensive dissociation are hypotheses; they are not empirical facts. My hypothesis is that chronic dissociation is a motivated, high-​hypnotizability-​enabled avoidance of pain and distress –​that is, dissociation is not about “trauma” per se (Dell, 2019). Structural dissociation is initially generated either long before, or shortly after, a person is traumatically overwhelmed (Dell, 2019, 2021).

After Trauma Charcot (1889/​1991) and Israeli researchers of terrorist attacks (Yovell, Bennet & Shalev, 2003) have reported that the onset of hysterical symptoms and dissociative amnesia, respectively, do not occur at the time of the “trauma.” Instead, their onset is delayed. They observed that functional sensory-​motor disorders and dissociative amnesia arose only subsequent to the trauma, “after a period of incubation” (Charcot, 1889/​1991, p. 385, italics added). Breuer and Freud (1893) said the same. Neither Charcot nor Yovell and colleagues explain why this delay occurs; they simply report their repeated observation of the delay.

Before Trauma In childhood, I think that defensive/​d issociative avoidance/​d istancing from pain and distress most often takes place before a person is overwhelmed (Dell, 2019, 2021). As noted above, evolution has shaped every living organism to promptly avoid or to withdraw from any source of pain and distress –​in order to prevent the organism from being ‘traumatized’ and dying. All children who are mistreated by their parents find ways to avoid or defend themselves from their pain and distress. All of them. But only a small percentage of them defend themselves with pathological dissociation (i.e., those who are highly hypnotizable). That is the central message of this chapter: only a small percentage of children –​no matter how mistreated or traumatized they are –​have the ability to spontaneously deploy the mental defense of dissociative-​distancing (Dell, 2019; see especially, Dell, 2021). The essential developmental point here is this: when a highly hypnotizable child is repeatedly mistreated, she will probably enact various motivated, mental (i.e., ‘hypnotic’/​dissociative) distancing-​maneuvers (Dell, 2009, 2019, 2021) –​long before she encounters frank trauma. Dysfunctional parents may (or may not) traumatically-​overwhelm their children, but inflicting frank trauma is an infrequent aspect of most dysfunctional parenting. Dysfunctional parenting and frequent mistreatment –​short of trauma –​is more than sufficient to motivate pathological dissociation. Thus, I propose that frank trauma is not needed; trauma is not the necessary and sufficient gateway to structural dissociation. Finally, there is another irony about Van der Hart and colleagues’ theory of trauma-​related, structural dissociation. Despite their insistence that structural dissociation is not a defense (as Freud insists), Van der Hart and colleagues’ descriptions and explanations of dissociation are pervasively focused on defense: Chronically traumatized individuals … mentally avoid their unresolved and painful past and present. Van der Hart et al., 2006, p. 1, italics added [S]‌urvivors can become anxious and avoidant of any mental action, such as having particular feelings, sensations, and thoughts that are consciously or unconsciously associated with the original traumatic experience(s). Van der Hart et al., 2006, p. 14, italics added Integration is prevented when an individual avoids traumatic memories, suppresses thoughts about the traumatic experience, and has a negative interpretation of intrusive trauma-​related memories. Van der Hart et al., 2006, p. 26, italics added

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Once reactivated, EP … has a tendency to engage in defensive behavioral reactions such as running from danger, warding off attack, or freezing. Van der Hart et al., 2006, p. 52, italics added Dissociative parts of the personality often contain various mental defensive action tendencies, so-​called psychological defenses, which range from normal to quite primitive and pathological. Van der Hart et al., 2006, p. 65, italics added We endlessly desire and strive to get the good things of life, and we wish and struggle on end to evade or get rid of the bad things. Nijenhuis, 2015, p. 69, italics added The final cause of traumatic experience is the will to defend and find safety. Nijenhuis, 2015, p. 260, italics added Note, by the way, that these quotations apply equally well to children who experience dysfunctional parenting and repeated mistreatment that falls short of frank trauma (which is probably the vast majority of childhood mistreatment). Frank trauma is not necessary to ‘push’ or motivate mistreated children to create dissociated parts. Mistreated children are all about avoidance and defensive behavior. They don’t need frank trauma to motivate their mental efforts to get away from what is happening. I discuss the nature of trauma below. Finally, I want to return to Van der Hart and Rydberg’s rejection of defensive dissociation: If dissociation is a defense … then it would seem that he or she is not overwhelmed, i.e., overcome, submerged, crushed, inundated. Van der Hart & Rydberg, 2019, p. 192, italics added This is exactly my point. Structural dissociation (and other dissociative defenses) are mental efforts that can first occur only when a person is not in a traumatic state. Later in time –​after the dissociative child has developed an automatized set of dissociative defenses –​he or she may reflexively switch to another alter or create a new alter in the midst of being genuinely traumatized. Finally, all mistreated children –​of whatever hypnotic ability –​engage in acts of physical and mental avoidance whenever they can. But highly hypnotizable children can do it differently. Their superior ability to alter their experience makes their mental acts of avoidance enormously effective; those mental acts take the child far ‘away’ from her painful circumstances (e.g., by ‘turning off the pain,’ ‘going away,’ ‘going into the wall,’ ‘going up to the ceiling’ and watching the little girl ‘down there,’ etc.). See Dell (2019, 2021). I want to clarify two points. First, from my perspective, none of the immediately-​forgoing examples of dissociative/​mental avoidance involve structural dissociation. Second, the-​l ittle-​g irl-​going-​up-​to-​t he-​ceiling is not a symptom of depersonalization (such as feeling like your body is not yours, feeling disconnected from your body, etc.). The-​little-​g irl-​on-​the-​ceiling is also different from depersonalization-​derealization breakdown phenomena (see “Disruption of the Framework of Perceptual Organization” below). The-​little-​g irl-​on-​the-​ceiling adds a great deal to depersonalized disconnection from one’s body. I consider it to be an unusual feat, typical of ‘hypnotic’ phenomena (Dell, 2019).

Inability to Integrate Particular Events and Experiences Janet first applied his fledgling psychology of action to what was at that time called ‘hysteria.’ He concluded that hysterics have a weak ability to integrate their traumatic experiences and subsequently manifested diverse simultaneous existences (diverses existences simultanées). This ability/​inability to integrate life experiences became the conceptual centerpiece of Janet’s psychology of action. In the full flower of his psychology of action, however, it was apparent to Janet that a weak ability to integrate experiences was certainly not unique to trauma, structural dissociation, or the dissociative disorders. Van der Hart and colleagues agree: Integration is on a continuum, with everyone having some degree of integrative imperfection in life. However, not all integrative failure results in structural dissociation. Van der Hart et al., 2006, p. 143, italics added

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Many forms of psychopathology involve a certain lack of integration, but it is not helpful to regard all integrative problems as manifestations of dissociation. Nijenhuis, 2015, p. 548, italics added My point here is that one’s ability to integrate life experiences really has nothing to do with the origin of dissociative structures. On the other hand, Janet’s analysis of the ability/​inability to synthesize and integrate (i.e., his psychology of action) does provide Van der Hart and colleagues with an excellent, generalized “theoretical basis for clinical assessment and treatment of chronically traumatized patients” (Van der Hart et al., 2006, p. 131): Mental health is characterized by a high capacity for integration. Van der Hart et al., 2006, p. 133 [T]‌he difficulty of coping with and integrating adverse experiences … relates to factors that limit the exposed individual’s integrative capacity. Nijenhuis, 2015, p. 77 Accordingly, Van der Hart and colleagues (2006) use Janet’s psychology of action to inform a rich set of (Phase 1) interventions (International Society for the Study of Trauma and Dissociation, 2011) that enable dissociative individuals to increase their capacity for integration –​so that they become increasingly able to integrate their traumatic experiences and, eventually, their dissociative parts. These interventions make excellent clinical and practical sense. But they do not explain the etiology of structural dissociation. Van der Hart and colleagues need to look elsewhere than Janet’s psychology of action to find a rigorous explanation of what causes structural dissociation.

Trauma The term, trauma, is used broadly and, mostly, inaccurately. When therapists and lay people speak of “traumas,” “traumatic events,” and “being traumatized,” their use of those terms tends to be colloquial and metaphorical. The DSM’s discussion of “trauma” is more empirically-​g rounded (APA, 1980, 1994, 2013), but not much better. DSM-​5 obscures its inability to define trauma by using a broad, inclusive term, “Trauma-​and Stressor-​Related Disorders” (a regrouping that it borrowed from ICD-​10 [1992]).

What is Trauma? When we avoid our unmindful, colloquial use of the term, we seem to know what trauma is. Krystal (1988), Herman (1992a, 1992b), Kluft (1984), and Van der Kolk (1996) have uniformly described trauma in terms of “unbearable and inescapable threatening … experiences … in the face of which a person is powerless” (Farina et al., 2019, p. 4). Nijenhuis (2015) says that traumatic experiences are “phenomenally overwhelming and injurious” (p. 254). Moskowitz et al. (2019) invoke the concept of breaking point: “one can conceptualize trauma as an individual’s ‘breaking point’ when faced with events that are, for him or her, personally overwhelming” (p. 18). These descriptions of psychological trauma “ring true”; they conceptualize the subjective essence of (what we consider to be) trauma. They also show that our everyday use of the words “trauma” and “traumatic” is usually an exaggeration. Most everyday references to “traumatic events” refer to events that are not actually traumatic; instead, these events are adverse, unpleasant, distasteful, and even emotionally painful. Rarely, however, are they events that leave the person “completely and decisively defeated” (Nijenhuis, 2015, p. 255). Alright, that is clear enough, but there is still a problem. Many not-​fully-​traumatic stressors leave a lasting impact –​especially when they are repeated. Does that lasting impact constitute a “trauma”? This is where the matter gets murky. Proponents of the concepts of cumulative developmental trauma (Cloitre et al., 2009; Van der Kolk, 2005), attachment trauma (Farina et al., 2019; Isobel et al., 2017), or complex PTSD (Ford, 2015; Herman, 1992a; Roth, Newman, Pelcovitz, Van der Kolk, & Mandel, 1997; Şar, 2011) would probably say, “Yes.” It is worth taking a closer look at these concepts.

Chronic Relational Trauma The symptoms of cumulative developmental trauma, attachment trauma, and complex PTSD are personality traits: dysfunctional beliefs and expectations, relational problems, cutting off from friends and family, tendency to revictimization,

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mistrust of self and others, helplessness, despair, a feeling of permanent damage, feelings of worthlessness, shame, and guilt (see also Briere, 2000). These traits are, I think, best understood to be manifestations of attachment trauma: The pathogenetic model based on Attachment Trauma … link[s]‌early relational trauma, through … later traumas suffered at the hand of attachment figures, to the psychopathological processes … of Cumulative Developmental Trauma. Farina et al., 2019, p. 5 The essential manifestations of cumulative/​attachment/​complex trauma pertain to one’s personality and self. They are not the symptoms of simple PTSD; they are not the result of a single traumatic event. They are the inevitable, deeply-​ human responses to chronic misattunement, insensitivity, mistreatment, and betrayal by parents and other attachment ­figures –​including the world at large. These individuals are very deeply wounded –​the original meaning of the word trauma. And some of them were, indeed, pushed beyond their breaking point so that they were completely and decisively defeated. Some of these deeply wounded individuals have a dissociative disorder, but most do not. Why? Because a person’s inability to integrate this kind of mistreatment cannot –​by itself –​generate structural dissociation. Structural dissociation requires a particular ability.

Why is the Dissociation of the Dissociative Disorders Different from All Other Dissociation? Many mechanisms and processes produce so-​called “dissociative” experiences (Cardeña, 1994; Dell, 2009; Laddis, Dell, & Korzekwa, 2017). The central thesis of this chapter is that only the ‘mechanism’ of high hypnotizability can produce the kind of dissociation that occurs in the dissociative disorders. The mechanisms of all other “dissociative” symptoms are different –​and they are incapable of creating a dissociative disorder.

Disruption of the Framework of Perceptual Organization Most episodes of depersonalization or derealization are temporary disruptions or breakdowns of normal, neurocognitive and perceptual functioning. These incidents occur (1) infrequently in normal individuals, (2) frequently in persons with Borderline Personality Disorder (BPD), (3) incident-​ specifically during highly-​ unexpected (Beere, 2009) or highly-​ stressful moments (e.g., peritraumatic “dissociation”), (4) as a consequence of neural disruption/​toxicity secondary to drug ingestion, and (5) chronically in persons with Depersonalization-​Derealization Disorder. None of these alterations of consciousness are caused by high hypnotizability or by structural dissociation (Dell, 2009, 2019; Rodewald, Dell, Gößling, & Gast, 2011; Steele, Dorahy, Van der Hart & Nijenhuis, 2009). Beere (2009; Chapter 17, this volume) would characterize all of the above episodes of depersonalization and derealization as disruptions of the framework of perceptual organization. Such disruptions are especially common in BPD due to their neurodevelopmental failures of integration that are associated with an unstable sense of self, oversensitivity to interactions with others, susceptibility to cognitive-​emotional misprocessing, inability to regulate their emotional reactivity, and impulsive behavior. BPD incidents of depersonalization and derealization are not defensive; they are breakdown phenomena that are spontaneous, unbidden, and maladaptive. I am not saying that BPD patients never develop a comorbid dissociative disorder (i.e., structural dissociation). Some do (Korzekwa & Dell, Chapter 31, this volume); but the dissociative symptoms of structural dissociation are not an aspect of their BPD pathology. When a person with BPD has a comorbid dissociative disorder, that dissociative disorder arose in exactly the same way –​and for the same ‘reasons’ –​as it does in individuals who are not borderline: it arose as a hypnotizability-​enabled defense against repeated pain and distress. So, the bottom line about dissociation in BPD is that dissociation-​like breakdown-​phenomena (i.e., depersonalization, derealization, and nonreversible ‘amnesia’) seem to be inherent to many cases of BPD pathology. This means that BPD is not a dissociative disorder (see also Brand et al., 2016). Conversely, a subset of highly-​hypnotizable BPD persons may encounter repeated pain/​d istress and develop a comorbid, structural, dissociative disorder. They may also develop a minor (nonstructural) dissociative disorder (see below).

Hypnotizability-​Enabled Dissociative Defenses According to the theory of structural dissociation, only the activity of dissociative structures can produce ‘genuine’ dissociative phenomena (Steele et al., 2009); all other dissociation-​like phenomena are nondissociative alterations of

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consciousness (e.g., Steele et al., Chapter 4, this volume). The autohypnotic model of the dissociative disorders defines a somewhat broader domain of dissociation. The autohypnotic model’s domain of the dissociative disorders consists of all hypnotizability-​enabled, automatic/​proceduralized, dissociative symptoms –​regardless of whether those symptoms are generated by a dissociative structure (Dell, 2021). Thus, in contrast to the structural model of dissociation, the autohypnotic model identifies several, minor (i.e., nonstructural) dissociative disorders: (1) chronic, proceduralized (i.e., automatic) blocking of pain, (2) out-​of-​ body experiences that occur spontaneously during pain, abuse, or extreme threat (3) spontaneous, out-​of-​control, self-​protective episodes of extreme, dissociative detachment (Allen et al., 1999, 2002), (4) spontaneous retreats into fantasy in the midst of pain/​distress, and (5) reversible amnesias that do not involve a personified, or non-​personified, dissociative part. These minor dissociative disorders do not require the presence of a dissociative structure: they are motivated, hypnotizability-​enabled actions of self-​defense and self-​care that have become proceduralized and automatic (Dell, 2021). They are also common auxiliary defenses in DID patients. It is of great importance to realize that the chronic, dissociative symptoms of an adult always originated (usually in childhood) as active, intentional, mental efforts to escape or distance from pain and distress. I suspect that the success of the child’s mental efforts to get away from the pain was unexpected –​in fact, so unexpected that the child does not realize that she made it happen. If the painful circumstances continue –​as is inevitable with dysfunctional or abusive parents –​these hypnotizability-​enabled, mental acts of defense become organized into a reflexive, proceduralized pattern of distancing-​ maneuvers that constitutes a dissociative disorder (Dell, 2019, 2021). This procedural automatization of ‘autohypnotic’/​ d issociative defenses has two important consequences. First, whether minor (i.e., nonstructural) or major (i.e., structural), dissociative disorders tend to be unremittingly chronic because they are sustained by negative reinforcement (Dell, 2019, 2021). Second, by the time that a dissociative patient encounters a therapist (or researcher), the long-​since-​established automaticity of the patient’s dissociative symptoms ‘obscures’ their motivated/​defensive origins.

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Crucial Remaining Issues About High Hypnotizability The Hypnotizability of Dissociative Patients Although there is little doubt that DID patients are more hypnotizable than other mental disorders (Bliss, 1986; Butler et al., 1996; Dell, 2017a, Frischholz, 1985; Janet, 1920/​1965; Myers, 1940), the empirical demonstrations of that fact are still sparse (Bliss, 1983, 1986; Frischholz, Lipman, Braun & Sachs, 1992). This is probably due to the loss of interest in the relationship between hypnotizability and dissociation that took hold a quarter-​century ago (Putnam & Carlson, 1998; Whelan & Nash, 1996). More research on the hypnotizability of DID and other dissociative disorder patients is needed. In particular, researchers should study the hypnotizability of trauma patients who report episodes of extreme dissociative detachment (Allen et al., 1999, 2002).

The Question of Whether Trauma Causes High Hypnotizability In the last quarter of the twentieth century, some investigators claimed that trauma increases hypnotizability. This notion was first raised by J. Hilgard (1970, 1974). She described two pathways to high hypnotizability: (1) a strong liking for fantasy and reading, and (2) harsh punishment during childhood. Hilgard’s (1974) evidence for these two pathways was statistically significant, but of small-​medium magnitude (i.e., r =​~.30). A few years later, Nash and colleagues raised the issue anew. They presented evidence (Nash & Lynn, 1985–​1986; Nash et al., 1984) that the high hypnotizability and high dissociativity of dissociative individuals might have “a common traumatogenic etiology” (Whalen & Nash, 1996, p. 193). Subsequent research, however, led Nash and colleagues to conclude that their earlier findings had been spurious (see Putnam & Carlson, 1998). Similarly, in a study with highly-​ rigorous methodology, Putnam, Helmers, Horowitz, and Trickett (1995) found no difference in the hypnotizability of sexually abused girls and matched controls. The general form of this hypothesis (i.e., that early trauma increases hypnotizability) is the proposal that there is a sensitive period (Knudsen, 2004) in early childhood for skill acquisition. Experts in music or sports –​like adults with a dissociative disorder –​often started their musical or athletic training early in childhood. Accordingly, some have proposed that adult expertise in music or sports was boosted by practice during an early sensitive period (e.g., Baharloo,

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Johnston, Service, Gitschier & Freimer, 1998; Schlaug, Jancke, Huang, Staiger & Steinmetz, 1995). Recent research, however, indicates that adult musical expertise is fully explained by genetic aptitude –​rather than by practice during a sensitive period (Wesseldijk, Mosing & Ullén, 2021). Informal discussions at conferences have shown me that some experts on the dissociative disorders still suspect that repeated trauma during childhood increases hypnotizability. In my experience, this belief is especially prevalent among proponents of the structural model of dissociation –​for two reasons, I think. First, the two progenitors of the structural model of dissociation –​Janet and Myers –​explicitly claimed that trauma increases suggestibility. Janet said that trauma brought about a retraction of the field of consciousness and a sharp increase in suggestibility. Myers, who was deeply grounded in Janetian psychology, wrote that shell shock immediately produced a “disordered personality” that was “characterized by amnesia, fission of personality, and suggestibility” (Myers, 1940, p. 75). Van der Hart and Rydberg (2019) recently said that vehement emotions during trauma generate a pervasive sense of powerlessness, a lowered level of consciousness, and a narrowed field of consciousness –​all of which leads to mental disaggregation: Janet adds that after this “complete dissociation” –​involving the actual disaggregation or dissociation of mental systems –​ consciousness weakly reappears, with heightened suggestibility, and … the idée fixe. This is a whole set of experiences dominating consciousness and functions as a malignant hypnotic condition in which the dissociative part of the personality present during the trauma remains fixated … Van der Hart & Rydberg, 2019, p. 195, italics added Second, if trauma causes high hypnotizability, then high hypnotizability is just another posttraumatic symptom. In short, Janet’s and Myers’ claims –​that trauma and dissociation cause extreme suggestibility –​have freed the proponents of structural dissociation from the need to consider the possibility that high hypnotizability causes structural dissociation.

Temporary Increases of Hypnotizability Certain circumstances may temporarily increase hypnotizability: pregnancy, impending surgery, and severe injury. A version of this idea was first proposed by Charcot (1889/​1991); he said that traumatic shock might temporarily produce a hypnotic state that was susceptible to autohypnotic suggestion: [I]‌t may be inquired whether the mental condition occasioned by the Nervous Shock experienced at the moment of the accident [i.e., the traumatic event] and for some time after, is not equivalent in a certain measure … to the cerebral condition which is determined in “hysterics” by hypnotism. Charcot, 1889/​1991, p. 305 Such increases in responsiveness to hypnotic suggestion are not lasting. There is an extensive literature on stress-​related, opioid and non-​opioid hormonal mechanisms of anesthesia (e.g., Lichtman & Fanselow, 1991; Van der Kolk, Greenberg, Boyd & Krystal, 1985; Watkins & Maier, 1986). These hormonal mechanisms are unrelated to the hypnotizability-​enabled pain-​reduction (Spiegel, Bierre & Rootenberg, 1989). Importantly, hypnotically-​induced anesthesia is not neutralized by naloxone (Goldstein & Hilgard, 1975; Spiegel & Albert, 1983) –​whereas opioid-​hormonal, stress-​related anesthesia is neutralized by naloxone. Finally, stress-​related anesthesia is temporary, not permanent.

Impending Surgery In 1846, Esdaile reported that 80% of his patients achieved hypnotic anesthesia prior to surgical amputations. Esdaile did not demonstrate that this presurgical intervention produced greater hypnotic responsiveness than their everyday responsiveness to hypnosis, but, logically, that would seem to be the case. Bejenke (2007) has reported that trance and suggestibility increase substantially in immediately-​presurgical patients –​even with patients who are typically not hypnotizable. This responsiveness, Bejenke reports, lasts until the patient recovers. An impressive series of modern studies has demonstrated that presurgical hypnotic interventions produce a significant reduction in the use of propofol and lidocaine; reduced pain, nausea, fatigue, and discomfort; and produced cost savings due to shorter times in the operating room (Lang et al., 2000; Lang & Joyce, 1996; Lang & Rosen, 2002: Montgomery et al., 2007).

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Pregnancy Two studies have documented an increase in hypnotic responsiveness during pregnancy (Alexander, Turnbull, & Cyna, 2009; Tiba, 1990). Tiba (1990) administered the 12-​item Harvard Group Scale of Hypnotic Susceptibility (Shor & Orne, 1962) to 180 pregnant women in Hungary. The Hungarian population-​mean Harvard score is 5.15, but Tiba’s sample of second-​and third-​trimester pregnant women obtained a mean score of 8.12. Women in their first pregnancy obtained a mean Harvard score of 9.0! Alexandra et al. (2009) administered the Creative Imagination Scale (CIS; Barber & Wilson, 1979) to 37 third-​ trimester pregnant women in Australia (mean CIS score =​23.5, SD =​6.9) and administered it again, 14 to 24 months after delivery (mean CIS score =​18.7, SD =​6.6; p < .001). The effect size of this mean difference was 0.84, “suggesting that the hypnotizability change was both statistically significant and clinically meaningful” (p. 13).

Severe Injury There is no evidence that trauma causes a permanent increase in hypnotizability, but life-​threatening events may produce a time-​limited increase in a person’s ability to alter their experience of pain and emotion. We know, for example, that human beings have biological “animal defenses” that spontaneously alter their perceptions in ways that increase their ability to survive in moments that threaten imminent death (for detailed accounts of these evolution-​prepared defenses, see Bolles & Fanselow, 1980; and Dell, 2009). Hypnosis reduces most patients’ postsurgical pain, reduces their postsurgical emotional distress, and speeds their recuperation (Esdaile, 1846; Montgomery, David, Winkel, Silverstein, & Bovbjerg, 2002; Montgomery, DuHamel & Redd, 2000; Montgomery, Schnur & David, 2011). The largest meta-​analysis of the literature on hypnotic pain-​reduction (3,632 participants in 85 studies) found that direct analgesic suggestions reduced pain by 42% in high hypnotizables, 29% in medium hypnotizables, and 17% in low hypnotizables (Thompson et al., 2019). Thus, most patients, with the exception of low hypnotizables, respond well to hypnotic suggestions for reduced pain. There is little research, however, on the question of whether humans undergo a spontaneous, temporary increase in their ability to manage pain (1) during moments of severe injury and imminent threat to life, and (2) during recuperation from injury. We know that evolution has selected for a set of spontaneously-​occurring, biological alterations that facilitate recuperation after injury (Bolles & Fanselow, 1980), but we do not know whether there are comparable increases in the ability to alter experience (Dell, 2021) that seems to underlie responsiveness to suggestions for pain reduction. Madeo, Castellani, Chiara and Santarcangelo (2015) have presented evidence which suggests that Gray’s Behavioral Inhibition System (Gray, 1990; Gray & McNaughton, 2000) may manage negative affect and pain so completely during recuperation that a person’s hypnotizability makes no additional contribution to managing that pain and emotion. I have argued that evolution has not selected for the trait of hypnotizability (Dell, 2021). If natural selection had been brought to bear on hypnotizability, then most people would be highly hypnotizable. On the other hand, it makes more sense to hypothesize that evolution has selected for a temporary increase in the ability to alter one’s experience of pain (i.e., ‘autohypnotic’ ability; see Dell, 2021) in circumstances with high relevance to survival –​pregnancy, severe injury, and immediately-​ impending severe injury and pain (i.e., amputation, surgery). From an evolutionary perspective, such an ability to successfully manage or alter our experience, during circumstances that potentially endanger survival, should be prevalent in the general population (and it should not be constrained by one’s everyday level of hypnotizability).

Humans Have a Natural, Biological Ability to Alter Experience There seems to be a natural, biological, human ability to alter one’s experience that exists and operates independently of any hypnotic induction (Dell, 2021). Individual differences in this ability range from low to high and are largely commensurate with the person’s assessed hypnotizability. More importantly, these preexisting, individual differences in the ability to alter experience seem to be the ‘substrate’ that enables each individual’s response to so-​called hypnotic suggestions. Since the late 1700s, Western culture has discussed and used a Western concept (i.e., hypnosis) and various Western techniques (i.e., hypnotic inductions, suggestions) in order to bring about impressive alterations in hypnotic subjects’ experience (e.g., arm so heavy it cannot be lifted, forgetting the number “4,” not seeing objects or people directly in front of the subject, not smelling ammonia, etc.). I have argued that the concept and techniques of hypnosis are a Western, culture-​bound entity that are enabled by a natural, biological, human ability to alter experience –​an ability that is little acknowledged in Western culture (Dell, 2021). Because Western culture seldom acknowledges the existence of this natural human ability to alter experience, Westerners seldom use this ability unless they cross paths with a hypnotist. There are, however, at least two important

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exceptions to this generalization. First, individuals who enjoy fantasizing may unknowingly use their ability to amplify and enrich their fantasies. Some of these individuals become fantasy-​prone personalities (Wilson & Barber, 1981, 1983) or maladaptive daydreamers (Somer, Chapter 35, this volume). Second, children who are repeatedly subjected to inescapable pain and discomfort will make mental efforts to escape from their circumstances and, unwittingly/​ unknowingly, access their latent ability to alter their experience (by blocking pain, ‘going away,’ ‘going’ to a fantasy world, ‘going up to the ceiling’ and ‘watching the little girl down there,’ making another alter, etc.). Repeated use of these mental ‘escapes’ generates a proceduralized, autonomously-​functioning, dissociative disorder (Dell, 2019, 2021). Finally, Dienes et al. (2020) have suggested that this same ability –​which they call “phenomenological control” –​plays a role in subjects’ responding to the demand characteristics of experimental studies (Orne, 1962), the vicarious experience of another’s pain, mirror touch synesthesia, and even the rubber hand illusion.

Summary and Conclusions For the last 40 years, the trauma model has provided the dissociative disorders field with a guiding paradigm. The extensive trauma-​h istories of severely dissociative patients have made the trauma model compelling. Nevertheless, most “trauma survivors” do not have a dissociative disorder. The trauma model needs to identify the factors that determine why only some “trauma survivors” develop a dissociative disorder. For the last 15 years, the dominant trauma model has been Van der Hart and colleagues’ (2006) model of structural dissociation of the personality. The structural model follows the writings of Janet and Myers. Van der Hart and colleagues have used Janet’s psychology of action to great advantage in conceptualizing the motivational dynamics of dissociative parts and formulating their treatment. Janet’s understanding of high hypnotizability (i.e., suggestibility) and its relation to hysteria and the dissociative disorders was wrong. He was erroneously convinced that the high hypnotizability of these patients is a pathological feature of their mental disorder. Accordingly, he rejected the possibility that high hypnotizability was a crucial –​in fact the crucial –​etiological factor in these disorders. Van der Hart and colleagues’ theory of structural dissociation of the personality has followed Janet’s example; they, too, reject the etiological importance of high hypnotizability for the dissociative disorders.

The Bottom Line The ‘autohypnotic’ model of the dissociative disorders rejects all current versions of the trauma model. Trauma has no capacity to cause a dissociative disorder. Only high hypnotizability can do that. Yes, pain/​d istress/​t rauma is regularly associated with pathological dissociation, but trauma is a motivator of dissociation –​not its cause. Only highly hypnotizable individuals have the mental ability to ‘go away,’ ‘go into the wall,’ block pain, ‘go up to the ceiling’ and ‘watch the little girl down there,’ forget that it happened, make alters, and so on. These are ability-​enabled ‘hypnotic’ phenomena, not posttraumatic symptoms.

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PART 3

Theoretical Approaches

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15 THE THEORY OF TRAUMA-​RELATED STRUCTURAL DISSOCIATION OF THE PERSONALITY Onno van der Hart and Kathy Steele

The theory of structural dissociation of the personality is founded upon the historical idea that components of the personality may become divided from each other under extreme stress and may manifest as different psychobiological conditions (e.g., Butler et al., 1996; Crabtree, 1993; Janet, 1889/2022a,b 1907, 1909a; Van der Hart & Dorahy, Chapter 1, this volume). The theory seeks to integrate this definition of dissociation with research and contemporary theories about reactions to overwhelming events (Nijenhuis, 2004, 2015, 2017; Nijenhuis, Van der Hart, & Steele, 2002, 2004; Steele, Boon, & Van der Hart, 2017; Steele, Van der Hart, & Nijenhuis, 2005; Van der Hart, Nijenhuis, & Steele, 2005, 2006; Van der Hart, Nijenhuis, Steele, & Brown, 2004). Following Allport (1961), we define personality as a biopsychosocial system that determines an individual’s characteristic mental and behavioral actions (Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011, p. 420). This definition highlights the fact that personality includes percption and emotion; that perception, emotion, and thought involve mental actions, including decision making, and that behavior involves combined mental and motor action. Personality constitutes a whole system that has an ongoing tendency towards “good enough” integration, that is, binding and differentiation of various components of experiences as well as experiences across time (Edelman & Tonnoni, 2000; Van der Hart et al., 2006). We propose that trauma-​related dissociation refers to the existence of at least two self-​organizing subsystems of biopsychosocial states. These dissociative subsystems are parts of the personality as a whole system, each with its own first-​person perspective that are insufficiently integrated with one another (Nijenhuis, 2015; Nijenhuis & Van der Hart, 2011). However, they share some underlying implicit and explicit functions and mental contents. We maintain that trauma-​related dissociation is primarily based on a diminished integrative capacity that results in a dissociative disorganization and reorganization of the personality that we have called structural dissociation of the personality. Only secondarily is dissociation a psychological defense. Dissociation is maintained by specific factors, first and foremost, a lowering of integrative capacity that results in lower-​order, that is, less adaptive integrations. Structural dissociation manifests in dissociative symptoms that can be categorized as positive or negative, psychoform or somatoform. These symptoms can, but need not, include particular alterations of consciousness, such as absorption. However, we differentiate structural dissociation from other alterations in consciousness (often referred to as “normal dissociation”) that can range from normal in non-​clinical populations to pathological in many clinical populations (cf. Steele, Dorahy, & Van der Hart, Chapter 4, this volume).

The Conceptual Origins of Structural Dissociation of the Personality We developed the theory of trauma-​related structural dissociation in reaction to several issues. First, we have emphasized that dissociation, as it was orginally understood, pertained to a relatively rigid division of the personality or multiplication of parts of the personality, unlike contemporary definitions that include symptoms of absorption and spacing out that do not necessarily involve structural dissociation of the personality. There is disagreement in the literature about which symptoms are dissociative, and the underlying dynamics that create them (cf., Brunet et al., 2001; Cardeña, 1994; Marshall, Spitzer, & Leibowitz, 1999; Nijenhuis, 2015; Van der Hart & Dorahy, Chapter 1, this volume). More general

DOI: 10.4324/9781003057314-19

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and nonspecific alterations in consciousness (i.e., absorption, daydreaming, imaginative involvement, etc.) should be distinguished from symptoms related to structural dissociation as they have quite different underlying dynamics (Steele et al., Chapter 4, this volume). Even though these two categories of symptoms generally occur together ( Janet, 1907), they require quite different treatment interventions. The term “structural” implies a systemic organization of the personality as a whole, not just attention and cognition. The dissociative organization involves undue separations among mental and behavioral actions and sense/​idea of self (first-​person perspective). The theory of structural dissociation expands upon Janet’s original definition of dissociation as a division of personality so that a more coherent and cohesive organization becomes more compartmentalized. Pure alterations in consciousness do not involve dissociation of the personality. When there are different parts of the personality that are dissociated, they do not completely share the same episodic and semantic memories, as in the case in mere alterations in consciousness. Alterations in consciousness may involve a failure to create episodic and semantic memories in any part of the personality (Brown, 2006; Butler et al., 1996; Holmes et al., 2005; Janet, 1907; Myers, 1940; Van der Hart et al., 2000, 2006). Thus, many individuals who experience alterations in consciousness do not have structural dissociation, but all individuals who have developed structural dissociation also have alterations in consciousness. Second, we sought to distinguish between structural dissociation and what are sometimes referred to as “normal” symptoms such as absorption, as we believe the underlying dynamics are different and they require different treatment approaches. Third, our clinical work repeatedly showed us that patients handle different functions of defense and daily life via various dissociative parts. Fourth, we sought a theory that could explain all dissociative symptoms. Finally, we sought a theory that would pinpoint and explain discrepant findings in that literature. The theory of structural dissociation of the personality addresses these issues and integrates (1) the authors’ collective clinical experience with trauma and dissociation and (2) the clinical literature of the late nineteenth and early twentieth centuries (e.g., Jackson, 1931/​32; Janet, 1889/2022a,b, 1907, 1919/​25; McDougall, 1926; Myers, 1940), and more recent literature (e.g., Chu, 2011; Howell, 2006, 2011; Kluft & Fine, 1993; Lanius, Paulsen, & Corrigan, 2014; Putnam, 1997; Ross, 1997). The theory also seeks to integrate neurobiology (e.g., Frewen & Lanius, 2015; Nijenhuis, 2015, Chapter 38, this volume; Porges, 2004, 2011; Schore, 2002, 2019; Siegel, 2020; Teicher, Andersen, Polcari, Anderson, & Navalta, 2002); learning theory (e.g., Fanselow & Lester, 1988); motivational systems theory (e.g., Cortina & Liotti, 2014; Davis & Panksepp, 2018; Lichtenberg, Lachmann, & Fosshage, 2010; Liotti, 2017; Panksepp, 1998; Panksepp & Biven, 2012; Steele, 2018, in press; Toates, 1986); attachment theory (e.g., Bowlby, 1969/​1982; Cassidy & Shaver, 2018; Liotti, 1995, 1999a,b, 2006, 2017; Main & Morgan, 1996); psychoanalytic and psychodynamic theory (e.g., Bromberg, 2001, 2011; Chefetz, 2015; Howell, 2006, 2011; Kluft, 2000; Steele, Boon, & Van der Hart, 2017); and empirical findings regarding the effects of exposure to adverse events (e.g., Dutra et al., 2009; Ogawa et al., 1997), including studies of peritraumatic dissociation (e.g., Lensvelt-​Mulders et al., 2008).

Deficits in Integrative Capacity as a Foundation for Structural Dissociation of the Personality Mental health is characterized by the ongoing capacity to integrate significant past and present experiences into a relatively coherent and cohesive personality that allows for efficient adaptive functioning ( Jackson, 1931/​32; Janet, 1889/2022a,b, 1919/​25; Meares, 1999; Nijenhuis et al., 2002; Van der Hart et al., 2006). Janet (1889/2022a,b) stated that integrative activity “reunites more or less numerous given phenomena into a new phenomenon different from its elements” (p. 483) and that these elements are “necessary to maintain the organism in equilibrium with the changes of the surroundings” (p. 487). In other words, the capacity for integration has high adaptive value. Integration is grounded in two essential actions: (1) synthesis and (2) realization. Synthesis involves the clustering of different components of experiences and functions into personally meaningful wholes, and is based on two aspects: (1) synthesis of components of experiences (sensations, perceptions, affects, movements) and at least a basic first-​person perspective (Nijenhuis, 2015) within a given episode of time that fits the achievement of a particular goal (Ciompi, 1991; Siegel, 2020), and (2) synthesis of experiences, knowledge, and functions across time (Ciompi, 1991; Siegel, 2020) into the personality as a whole biopsychosocial system. Janet maintained that efficient goal-​oriented behavior depends upon one’s capacity to create personally meaningful syntheses of sensations, affects, behaviors, and perceptions of the environment within a given moment and across time. Thus, dealing effectively with extremely stressful events requires the capacity to synthesize one’s sensory, emotional, cognitive, and behavioral actions within a coherent and cohesive organization. The synthesis should be goal-​oriented, ensuring that actions should be effective and efficient, maximally adaptive and creative in the present. Realization consists of two complex mental actions: Personification and presentification (Van der Hart et al., 2006). Personification is the mental action by which an individual endows experience with a personal sense of ownership ( Janet,

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1903): “That happened to me, and I think and feel thus and so about it.” Personification also denotes the mental action by which one endows one’s actions with a sense of agency: “I move (agency) my arm (ownership).” Presentification is the mental action of integrating one’s past, present, and future, and brings that integration to bear on one’s actions in the moment ( Janet, 1928; Van der Hart & Steele, 1997). In presentification, the individual accords the present with the highest degree of reality. At the same time, the proximate past and future (e.g., yesterday and last week, or tomorrow and next week) are considered to be more real than the distant past and future (e.g., 30 years ago or 30 years in the future). Thus, although the person realizes that past events affect who one is and how one acts, the present is accorded a higher reality. When needed, presentification allows us to address the present situation in a reflective, mindful, and adaptive or creative manner. Trauma-​related disorders are considered to be “syndromes of non-​realization” ( Janet, 1935; Van der Hart et al., 2006; Steele et al., 2017), with non-​realization being the core of dissociation, which occurs on a continuum, from factual accounts without emotion, to partial amnesia, to complete amnesia. Generally, the more severe the amnesia, the greater the degree of phobic avoidance of realization. Thus, a traumatized individual may say: “I know my life was threatened, but it feels as if it happened to someone else, or as if it were a dream.” Another might say, “I know I was abused, but don’t know when it started or stopped –​my memory has holes in it.” Yet another may deny any awareness of trauma despite evidence to the contrary. Non-​realization can have a major impact on sense of self. Semantic memory involves declarative knowledge. One knows something to be a fact, but that fact has no link to one’s autobiographical sense and conception of self. Thus, when personification fails and memories remain semantic, one’s coherent sense of personal existence is compromised. A person engaged in successful personification produces episodic memories that are, as much as possible, integrated into a relatively context-​independent sense of self. Eventually, realization involves becoming consciously aware of the implications of events and experiences for one’s life and making them part of one’s autobiography ( Janet, 1928; Van der Hart et al., 2006; Van der Hart, Steele, Boon, & Brown, 1993). Sustained, high levels of integrative capacity are needed to realize and integrate extremely stressful events. If a person’s integrative capacity is too low, it may drop further during stressful events, falling below a critical level. The tendency towards stress-​related disintegration or disorganization may, in part, be mediated neurobiologically via stress hormones and stress-​related alterations of the hippocampus and the prefrontal cortex, and related over-​or under-​regulation (e.g., Frewen & Lanius, 2015; Nijenhuis & Den Boer, 2009; Nijenhuis et al., 2002; Nijenhuis, 2015, Chapter 38 this volume; Tsai, Condie, Wu, & Chang, 1999; Van Dijke et al., 2010).

Prototypes in Structural Dissociation of the Personality Traumatized individuals may re-​experience traumatizing events, but also engage in emotional numbing or avoidance of reminders of trauma. These quite different states may coexist or alternate. This pattern, which has been observed for over a century (e.g., Breuer & Freud, 1893; Janet, 1889/2022a,b, 1904, 1911; Kardiner, 1941; Myers, 1940), is the foundation for the diagnosis of posttraumatic stress disorder (PTSD). In fact, the parallel activation of, or the alternation between, experiencing “too much” and “too little” seems to be a hallmark of trauma-​related disorders. We propose that the biopsychosocial differences between experiencing too much (i.e., intrusion, vehement emotions) and experiencing too little (i.e., avoidance, numbing, amnesia, functional motor losses) characterize dissociative parts of the personality (Van der Hart et al., 2006). One or more dissociative parts become fixated in traumatic memory and experience too much of the past. They live in “trauma-​t ime” (Van der Hart, Nijenhuis, & Solomon, 2010), and do not have enough realization of the present, thus remaining embedded in non-​realization. Another type of dissociative part focuses on daily life, phobically avoiding traumatic memories or having flashbacks that prevent full realization. This kind of part realizes too little of the past, having a different manifestation of non-​realization. The idea that the personality of traumatized individuals is divided is not new. Many theorists have proposed their own terminology for the results of such divisions (cf. Van der Hart & Dorahy, Chapter 1, this volume). We have adopted the terminology of British army psychiatrist and psychologist, Charles Samuel Myers (1940), whose observations of World War I “shell-​shocked” combat soldiers are the cornerstone of our understanding of trauma-​related structural dissociation of the personality (cf., Nijenhuis & Van der Hart, 1999; Nijenhuis et al., 2002; Van der Hart et al., 2006; Van der Hart, Van Dijke, Van Son, & Steele, 2000). Myers (1940) postulated that a structural dissociation occurred between a so-​called “emotional” personality (EP) and an “apparently normal” personality (ANP) in acutely traumatized soldiers. These soldiers recurrently suffered from vivid sensorimotor experiences and painful affects that subjectively mirrored the original trauma in “emotional personality” subsystems. EPs are mostly stuck in “trauma-​time,” that is, in traumatic re-​ experiencing that they do not resolve into a narrative memory, with its accompanying personification and presentification.

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On the other hand, ANP subsystems are generally related to functioning in daily life. While the individual may appear normal and function on the surface, there remains significant avoidance of integrating traumatic memories. When shell-​ shocked soldiers were operating in an ANP subsystem, they engaged in avoidance, detachment, numbing, and partial or complete amnesia to avoid traumatic memories. We made a small but significant change in Myers’ terminology. In our opinion, he overstated his case when he used the term personality (e.g., emotional personality), particularly in relation to acutely traumatized individuals. We prefer the term “dissociative parts of the personality” (cf., Moskowitz & Van der Hart, 2020), indicating that no matter how autonomous they may appear, they are still part of a single personality, a single human being. Although we use the terms ANP and EP, it is important to note that neither type always presents as clear-​cut “alternate identities” or “personality states” (American Psychiatric Association, 2013). In fact, the theory of structural dissociation does not support undue reification of separate “identities” or “personality states.” Dissociative parts are not completely separate because they tend to share at least some mental and behavioral actions and contents, and, of course, one body, regardless of the subjective sense of separateness the individual may experience. We rather observe that dissociative parts are unduly rather than completely divided, falling short of an adaptive integration of the personality as a whole (Van der Hart & Rydberg, 2019). While they should not be reified, dissociative parts –​with their own first-​ person perspective –​should be distinguished for treatment purposes from normal “ego states,” or “self-​states,” which belong to a single sense of self and personality (cf. Moskowitz & Van der Hart, 2020). Much more conflict and rigid defenses against realization and integration are typically found in dissociative parts as opposed to ego states. To be clear, ANPs and EPs are prototypical dissociative parts that have innumerable variations, so clinicians should not be overly concerned if they are unable to determine whether a specific part is functioning as ANP or EP, as there is occasionally significant overlap. The main point to understand is the basic dissociative division among functions of daily life and fixation in trauma time. Depending on how much division has occurred, a traumatized person may have anywhere from a single EP and a single ANP, to numerous EPs and several ANPs. ANPs and EPs routinely differ from one another on a large variety of variables: intrusion and avoidance of trauma-​ related cues, affect regulation, mentalizing capacities, psychological defenses, insight, perception of and response to stimuli, body movements, behavior, cognitive schemas, attention, attachment styles, sense of self, self-​destructiveness, suicidality, and flexibility and adaptability in daily life. But overall, systemic defenses and resistances serve to maintain dissociation (and thus, non-​realization) through a series of trauma-​related phobias (which are discussed below), even when some parts appear fully cooperative and motivated to engage in treatment. ANPs and EPs also tend to have at least some features in common. For example, most have some desires, preferences, emotions, thoughts, images, behaviors, etc. in common. They each resist full realization of the trauma and of the present to varying degrees. The patient displays significant dissociative symptoms stemming from dissociative parts, regardless of which part is in executive control. Since dissociative disorders such as DID are chronic, the theory of structural dissociation holds that all parts are chronically dissociated from each other all the time rather than the patient moving in and out of dissociation. Even when a patient appears fully present, there still remain divisions within the personality among dissociative parts until integration takes place. In most cases, structural dissociation has overt manifestations that can be assessed with careful clinical interviews and with instruments such as the Structured Interview for DSM-​I V Dissociative Disorders (Steinberg, 1994, not yet updated to the DSM 5), the Dissociative Disorders Interview Schedule (DDIS; Ross et al., 1989, now updated to the DSM 5), or the Multidimensional Inventory of Dissociation (Dell, 2006). Covert manifestations have been documented in neuroimaging research (see Nijenhuis, 2015, Chapter 38; Lebois, Kaplan, Palermo, Pan and Kaufman, Chapter 24, this volume).

The “Apparently Normal” Part of Personality One subtype of ANP typically phobically avoids emotions in general and reminders of traumatic experience in particular, and also may strenuously avoid dissociative parts. This is a common presentation in highly avoidant dissociative patients. If the patient as ANP speaks of the traumatic experience at all, he or she tends to be devoid of emotion, without a sense of personal ownership and agency (i.e., with insufficient personification). Such ANPs often manifest a range of negative dissociative symptoms (Nijenhuis & Van der Hart, 1999; Van der Hart et al., 2000, 2006) such as partial or complete amnesia for the traumatizing event, sensory anesthesia, restricted emotion, numbness, and depersonalization. When a higher-​functioning ANP is dominant, the patient may appear on the surface to be “normal,” as the term ANP suggests. For example, the patient may be able to function at work, raise children and be social. For such patients symptoms are often private, without observable impact on social and occupational functioning, but cause no less

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suffering. And the patient may minimize, dismiss, or dissimulate symptoms (Kluft, 1987b). Generally, on closer examination, the patient as ANP typically has significant symptoms and may suffer from anhedonia, depression, anxiety, sleep and eating problems, as well as amnestic episodes and other functional losses and intrusion. As Myers noted, “no one can have a normal self so long as part of the activities of that self…are pathologically inhibited” (1916, p. 189). Thus, the ANP has not been able to (fully) realize the traumatic past, but this also implies that the patient as ANP also cannot fully realize the present. Research indicates significant structural brain changes in both PTSD and DID (cf., Nijenhuis, Chapter 38, this volume). A second subtype of ANP is generally highly hyper-​a roused and chronically dysregulated. Such patients as ANP may have limited emotion-​regulation skills in general, and some may be overly focused on trying to remember in great detail, further activating themselves, or may be activated by intruding EPs that are re-​experiencing traumatic memories. They often have serious challenges in experiencing positive emotions for a variety of reasons, and thus are chronically distressed. ANPs are generally the “major shareholder[s]‌” (Fraser, 1987, p. 24) of the personality and are in evidence most of the time in the average dissociative patient. ANPs are analogous to Laufer’s (1988) “adaptive self;” Wang et al.’s (1996) “normal personality functioning mode;” the adult part of the Holocaust survivor’s “compound” personality (Tauber, 1996); the dissociative “coping part” in borderline personality disorder (BPD; Golynkina & Ryle, 1999); the “host personality” and other alter identities that function in daily life in DID (Kluft, 1984; Putnam, 1989); and identities associated with verbally accessible memories of general autobiographical experience and of some elements of traumatizing events (VAM, Brewin et al., 1996; Brewin, 2001, 2003).

The “Emotional” Part of the Personality EPs are not emotional in the sense of having a normal range of affects. Instead, the patient as EP experiences “vehement” emotions (e.g., intense fear, helplessness, horror, anger, and shame) that are overwhelming and outside the window of tolerance ( Janet, 1909b). The impulsive and reactive behaviors involved in vehement emotions are inefficient substitutes for higher level (i.e. more efficient mental and behavioral) actions ( Janet, 1909b; Van der Hart & Rydberg, 2019). EPs can take many forms, but typically have at least some disorientation to time and place in the sense that they live in a traumatic phenomenal world more than they are rooted in the present time, place, and identity. Their lack of realization involves not knowing the past is over and not experiencing the present as fully real. There are several subtypes of EPs that are relatively common. One type has the tendency to vividly re-​enact traumatic experiences in a hyper-​ aroused, emotional and sensorimotor fashion. These parts more or less completely live in “trauma-​time,” and often experience themselves as a traumatized child. Another subtype of EP appears collapsed, listless or unresponsive, a condition related to the animal defense of faint (dorsal vagal shutdown) (see below). A third subtype of EP involves parts that seem almost entirely devoid of feeling. They are often depersonalized, observing traumatizing events from a distance. A fourth subtype involves aggression. Aggressive EPs may be fixed in the animal defense of fight, in competitive aggression to get needs met, or in rage at perceived attachment loss (Steele, 2018, in press). A specific subtype of aggressive EPs is modeled on the perpetrator, which we have called “perpetrator-​imitating” parts. These parts believe they are the actual perpetrator, which distinguishes them from other aggressive parts. They have significant narcissistic defenses, are so dissociated that they often believe the body does not belong to them, and some have sadistic tendencies. EPs are usually associated with a specific image of the body and have a separate phenomenal self that is typically derived from traumatic memories (McDougall, 1926). These dissociative parts vary in complexity. EPs in PTSD are relatively simple; they primarily manifest in symptoms of reexperiencing accompanied by some degree of loss of touch with present reality. At least some EPs in severe dissociative disorders are more elaborated and autonomous. They also tend to be more numerous in these disorders. We have noted that EPs are found in all trauma-​related disorders, from PTSD to DID. They are analogous to Simmel’s (1918) “Feeling-​toned complex of ideas;” Laufer’s (1988) “war self;” Wang et al.’s (1996) “survivor mode”; the child part of the Holocaust survivor’s “compound” personality (Tauber, 1996); the dissociative parts that embody abuser rage, victim rage, and passivity, or zombie parts in trauma-​related BPD (Golynkina & Ryle, 1999); certain “alter identities” in DID, such as the “frozen in time” child and perpetrator-​imitating parts (Kluft, 1984; Kluft & Fine, 1993; Nijenhuis, 2017; Putnam, 1989; Putnam et al., 1986; Van der Hart et al., 2006); and identities associated with situationally accessible memories related to trauma (SAM; Brewin et al., 1996; Brewin, 2001, 2003). Because they are so fixed in ‘immediate’ reactions to the past, and live so much in trauma-​time, EPs are not typically very functional in present day circumstances, with some exeptions. For example, Donna was a highly functional woman who had an EP that

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functioned in limited social situations in the “role” of a tough, rather aggressive teenager. When this EP was dominate, Donna boasted, told bawdy jokes, flirted, and “showed off” to get attention, but also to defend herself against vulnerability. While not entirely appropriate and certainly not consistent with Donna’s more usual modest presentation, these behaviors were still directed to the current situation, so the EP was not completely stuck in trauma time. The traumatic memories of EPs are very different from normal autobiographical memories (i.e., integrated narratives of traumatic experiences; Brewin, 2003; Janet, 1889/2022a,b, 1904, 1919/​25, 1928; Van der Hart, Bolt, & Van der Kolk, 2005; Van der Kolk & Van der Hart, 1991). Normal memories convey a narrative to the listener, with stories told and retold, that are changeable over time, and adapted to an audience. Whereas narrative memories are verbal, time-​ condensed, social, and reconstructive in nature, traumatic memories are often experienced as if the overwhelming event were happening right now and involve significant re-​experiencing of elements of traumatic experiences in the present. These repetitions are often subjectively characterized by a sense of timelessness and immutability (Modell, 1990; Spiegel, Frischholz, & Spira, 1993; Van der Hart & Steele, 1997). Therefore, Janet (1925) states that, “[s]‌trictly speaking, then, one who retains a fixed idea of a happening cannot be said to have a “memory” of the happening. It is only for convenience that we speak of it as a ‘traumatic memory’ ” (p. 663). Unintegrated traumatic memories that are re-​activated tend to simultaneously block access to many other neutral or positive memories. Thus, when patients are activated as one or more EPs, they typically lose access to many memories that are readily available to them as ANP.

Action Systems Mediate ANP and EP We have proposed that the fault lines between dissociative parts are mediated by evolutionary prepared, psychobiological systems (Panksepp, 1998; Panksepp & Biven, 2012; Toates, 1986). These systems have been referred to as motivational (e.g., Toates, 1986), behavioral (e.g., Bowlby, 1969/​1982; Cassidy, 2018), functional (Fanselow & Lester, 1988), emotional operating systems (Panksepp, 1998), emotional action systems (Panksepp & Biven, 2012), or action systems (Nijenhuis, 2015; Van der Hart et al., 2006). Their purpose is to generate actions that help animals and humans to (1) determine whether an event is biologically useful or harmful, and (2) evoke efficient ways of dealing with current life circumstances. They provide us with a readiness and ability to act (Arnold, 1960; Frijda, 1986; Panksepp & Biven, 2012). However, they do not compel an individual to act in a fixed way; rather, they influence and shape action through action tendencies. Each action system seems to be associated with particular patterns of neural activation. Action systems manifest as patterns of activation in sensory awareness, perceptual bias, emotional tone, emotional regulation, memory processes, mental models, behavioral response patterns (Siegel, 2020), and a sense of self and first-​person perspective. There are two broad categories of action systems: (1) those that promote functioning in daily life, including in the prosocial realm, and (2) those that serve survival of the individual by promoting defense in the face of perceived danger or life threat. Ideally, development involves a degree of synthesis among action systems. Action systems that are functionally related (e.g., attachment and cooperation) may be synthesized more readily than those that involve quite different functions, such as attachment and fight, or freeze and sexual actions. Metaphorically speaking, there are natural fault lines between action systems of daily life and those of defense. Under threat, action systems of daily life will be inhibited; in the absence of perceived threat, defense systems will be inhibited. The core conflict in abused children is the dilemma between attaching to a caregiver (involving prosocial action systems of daily life) and defending against the same caregiver who is perceived to be dangerous or life threatening (action systems of defense) (Liotti, 1999a, 2006, Nijenhuis, 2015; Steele et al., 2017; Van der Hart et al., 2006). These systems of prosocial actions and defensive actions are incompatible. This is the foundation of disorganized/​d isoriented attachment. Thus, the most natural fault line of dissociation is the division between the inborn tendency toward attachment and the inborn tendency to defend against perceived threat. In trauma-​related structural dissociation of the personality, the coordination and coherence of action systems and action tendencies involving different motivations, needs and goals seem to be disrupted. Because the prosocial action systems of daily life and action systems of defense naturally inhibit one another, traumatic stress will more readily derail their mutual coordination. We thus propose that a conflict-​d riven dissociative division between prosocial action systems of daily life and action systems of defense substantially accounts for the prototypical organizations of ANPs and EPs. Action systems that guide prosocial functions in daily life tend to be activated in the patient as ANP as a general rule. Of course, ANP has the capability of engaging in defense in the present, but this function is often relegated to EPs, resulting in a switch between ANP and EP. The needs and desires of the patient as ANP may include exploration (including work, study, and therapy), play, attachment, cooperation, sexuality, competition, and care taking (e.g., Cassidy, 2018; Liotti, 2017; Panksepp, 1998 Panksepp & Biven, 2012; Steele, 2018, 2021).

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The patient as EP is fixated in traumatic memories, lives in trauma-​time, needs to defend, and is grounded in the action systems of defense: flight, fight, freeze and faint; or in substitutes for attachment (e.g., sexual or caregiving [codependent] behaviors), since attachment is not experienced as safe. Some EPs may be fixed in the attachment (or separation) cry, the young animal’s or child’s distressed vocalization when separated from a caretaker. This involves frantic seeking of care and comfort and is accompanied by disorganizing panic. Parts of the patient may also engage in dominance or appeasing strategies from the ranking action system, or from excessive caretaking from the caretaking system, or from the sexuality system, using sex to attain a pseudo-​sense of connection without true attachment.

Psychological Defense in ANP and EP Dissociation is often understood as a psychological defense (as defined in psychodynamic terms) against the affects and experiences of trauma that an individual cannot tolerate, including those related to major conflicts such as simultaneously loving and hating the perpetrator (e.g., Briere, 1992; Cardeña, 1994; Chu, 2011; Freyd, 1996; Putnam, 1985; Spiegel, 1990, Steele et al., 2017). However, it is often overlooked that dissociation may first and foremost be a deficit, implying that in treatment building the patient’s capacities must come before the erosion of the defense. Psychological defense is compatible with our proposal that dissociation includes a lack of coordination among different action systems, including those of physical defense. We are sentient, social beings with different goals and needs, especially in the realms of attachment and sociability. Complex, and sometimes contradictory, social behaviors and attitudes are required to maintain an acceptable social status within the family and within society. Accordingly, we need psychological defenses as well as physical ones. Both ANPs and EPs utilize psychological defenses that serve their specific action tendencies. For example, various parts of the personality may disown affect or project, devalue, and deny. ANPs effectively “use” EPs for psychological protection; EPs “contain” emotions, thoughts, sensations, and so on that the ANPs deem unbearable. Other mental actions and related contents that are unacceptable to ANPs, such as thoughts, ideas, fantasies, wishes, and needs are usually found in the EPs. For example, EPs that have dependency needs and extreme attachment insecurity are often seen in patients whose ANP is ashamed and even phobic of dependence and attachment (Steele, 2018; Steele et al., 2017; Steele, Van der Hart, & Nijenhuis, 2001).

Developmental Pathways to Structural Dissociation Overwhelming events may more easily precipitate lower order, substitute integrative actions for several reasons in children (Van der Hart & Rydberg, 2019). First, brain regions that have major integrative functions, such as the prefrontal cortices and the hippocampus, have not yet fully matured in children (e.g., Benes, 1998), making more complex integration extremely difficult. Second, extremely stressful events compromise integrative functioning of the brain in general, but particularly in children (for reviews see Bremner, 1999a, 2003; Siegel, 2020). Finally, the integrative capacity of children is limited due to a relative absence of experience-​derived templates that serve as “attractors” (Siegel, 2020) to integrate new and/​or emotionally charged experiences. Thus, the personality may be poorly integrated from the beginning in some patients who have been traumatized early in life. While this means that there is not a sufficient level of coordination and integration needed for adult functioning, it does not necessarily mean these individuals have dissociation of the personality. Not all integrative failures involve dissociation. For example, they could, instead, take the path of personality disorders without an accompanying dissociative disorder (Mosquera & Steele, 2017). Nevertheless, young children are more vulnerable to structural dissociation because of the limited integration and developmental capacities available to them. The earliest developmental pathways to structural dissociation of the personality probably involve the hindrance of the natural, socially-​mediated integration of action systems and “discrete behavioral states” (Putnam, 1997; Siegel, 1999). In the infant, the sense of self is still highly state-​dependent (Putnam, 1997; Wolff, 1987). Abuse and neglect can alter the mind and the brain of young children in ways that promote state-​dependent or personality-​dependent functioning. Their rudimentary motivational states (that are influenced by different action systems) can become easily dissociated. As is clinically observed, research indicates that severely disrupted attachment in traumatized children appears to be a significant cause of chronic dissociation (Carlson, 1998; Draijer, & Langeland, 1999; Dutra, Bureau, Holes, Lyubchik, & Lyons-​Ruth, 2009; Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997; Van IJzendoorn, Schuengel, & Bakersman-​ Kranenberg, 1999). Early, chronic trauma and neglect often induce disorganized/​d isoriented attachment (D-​attachment, Liotti, 1992; 1995; 1999a, b; 2006; Lyons-​Ruth, 2003; Main, 1991; Main & Hesse, 1990; Main & Morgan, 1996; Schore, 2002). In our view, D-​attachment is not actually disorganized, nor does it necessarily involve disorientation. Instead,

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we propose that Type D attachment involves concurrent or rapid successive activations of prosocial action systems and defense action systems in a child who simultaneously approaches and defends against a scary caregiver. This insoluble approach-​avoidance dilemma can promote a basic division of the personality in an ANP and an EP. Disorganized attachment can, in fact, be understood as a dissociative problem (Van der Hart et al., 2006). For example, a child as ANP who is loyal and connected to the dangerous caretaker(s) either through attachment, competition, or caretaking action systems, may have dissociated from the EP that holds memories of abuse/​neglect and represents the defensive system. Some patients have a second type of EP that represents the attachment cry. Attachment-​ related EPs have two common forms: (1) a child-​like part of the personality that yearns for and is intensely loyal to the perpetrating caregiver, and (2) the part of the personality that seeks attachment to a “stronger and wiser” therapist or other perceived “caregiver” in the present. The dissociative parts of the personality that avoid awareness of attachment needs typically have a phobia of attachment: avoidance of contact, pseudo-​independence, and disconnection from basic self needs. Parts of the personality that are dedicated to attachment display a phobia of emotional loss: fear of abandonment, emotional clinging, intolerance of aloneness, and maladaptive dependency (Steele et al., 2001, 2017).

Maintenance of Structural Dissociation Many factors perpetuate structural dissociation. These include conditioned learning and phobic avoidance of inner experience, pervasive emotion dysregulation, difficulties mentalizing, unresolved internal conflicts and fantasies, and characterological defenses that are embedded in the personality of the individual. A lack of social support and therapeutic mistakes can also lead to persistence of structural dissociation. All of these result in ongoing non-​realization and must be addressed from the beginning of treatment. The lack of adequate capacities to manage emotions in many chronically traumatized individuals leads to defenses against acknowledging and coping with emotions adaptively. Limitations in mentalizing lead to chronic relational misunderstandings and misattunements that are difficult to repair. Patients (or parts of the patient) may engage in chronic attachment avoidance or seek “perfect” relationships, resulting in chronic disappointment. Such patients may lack the ability to understand their own inner experience and find it frightening, overwhelming and shameful, leading to further phobic avoidance of inner experience. In addition, classical conditioning plays an essential role in all trauma-​related mental disorders (Coupland, 2000; Nijenhuis et al., 2002; Van der Hart et al., 2005, 2006). For example, once children learn that their caretaker’s anger signals the likelihood of physical abuse, that anger serves as a conditioned stimulus that reactivates memory of the abuse. This memory will subsequently tend to activate the child’s defensive system whether or not the caretaker becomes abusive. As a result of generalization learning, anyone’s anger will tend to activate the child’s defensive system. In children who are structurally dissociated, this defensive response may include a reactivation of an EP and an inhibition of ANP. Intermittent success in the apparent ability to prevent anger in a caregiver via cetain behaviors (e.g., appeasing, caretaking, sexual, or aggressive behaviors) will lead the child to reinforce those behaviors. However, this is often more fantasy than reality, with the child reinforcing their own omnipotent fantasies of control even when their behaviors have not resulted in changing the caregiver’s behavior. Because the EP represents the traumatizing event/​s, the ANP develops a classically conditioned fear or shame of the EP. Over time, this fear /​shame becomes generalized and the patient needs to develop ever more complex and extensive defenses against EP and related experiences. A key concept in the theory of structural dissociation is that a series of inner directed phobias maintain dissociation and these should be addressed systematically in treatment. These phobias include (1) an over-​arching phobia of inner experience (emotions, thoughts, wishes, needs, sensations, etc.); (2) the phobia of dissociative parts; (3) the phobia of attachment and attachment loss (abandonment and rejection); (4) the phobia of traumatic memory; and (5) the phobia of adaptive risk and change. These phobias are not only fear-​based, but often have a foundation of chronic shame: Both emotions must be persistently addressed to resolve dissociation. Treatment focuses first on helping patients develop capacities to identify, tolerate and accept inner experience in a step-​w ise manner, gradually addressing the more specific phobias. We refer to phobic efforts to maintain dissociation as part of lower-​level or substitute integrative actions (cf. Van der Hart & Rydberg, 2019). Dissociative parts typically resist higher-​level integrative tendencies (i.e., those that move the individual toward more realization and a coherent and cohesive sense of self and personality, and thus toward more adaptive actions in the present). Thus, the overarching phobic avoidance of general inner experience is much more broad than the more commonly discussed problem of affect phobia (McCullough, Kuhn, Andrews, Kaplan, Wolf, & Hurley, 2003). Some (or even all) parts of the patient strenuously avoid certain emotions, thoughts, wishes, needs, fantasies and dreams, and body sensations. Fear and shame and sometimes anger toward inner experience in trauma-​related phobias

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serve as inhibitory emotions that prevent realization of other inner experiences. This leads to the additional phobias of dissociative parts, attachment and attachment loss, traumatic memory, and adaptive risk-​taking and change, each of which prevents more complete realization and integration. Active mental actions to avoid conditioned fear stimuli include thought suppression, diversion of attention, and engagement in incompatible mental activities. A patient with depersonalization disorder engaged in involuntary subvocal singing and switched off almost all emotions and body sensations when reactivation of a traumatized state was imminent. A patient with complex PTSD “switched” from ANP to EP when exposed to traumatic memories in therapy. After he learned to prevent this involuntary transition, he could still only perceive the trauma from a third-​person perspective. Most patients experience this dissociation as involuntary and automatic. However, data suggest that mental avoidance of trauma and the EP may involve preconscious mental efforts (Hermans, Nijenhuis, Van Honk, Huntjens, & Van der Hart 2006; Schlumpf et al., 2013). Passive mental avoidance prevents encounters with cues of threat via mental withdrawal or shutdown (dorsal vagal collapse). Structural dissociation also can be partially maintained by poor social support and lack of restorative experiences following trauma. Social support buffers negative effects in the aftermath of trauma ( Joseph, Yule, Williams, & Andrews, 1993; Runtz & Schallow, 1997; Solomon, Mikulincer, & Avitzur, 1988). Lack of support enhances dissociative tendencies (Freyd, 1996) because it deprives the person of the relational sustenance and regulation that are necessary for integration of extremely difficult experiences (Freyd, DePrince, & Zurbriggen, 2001; King, King, Fairbank, Keane, & Adams, 1998; Kluft, 1984; Laub & Auerhahn, 1989; Vanderlinden, Van Dyck, Vandereycken, & Vertommen, 1993). Social support in the present has often become limited and complicated due to the patient’s struggle to mentalize adequately and to chronic relational re-​enactments. Finally, therapeutic mistakes can lead to further entrenchment of structural dissociation. These include: reification of parts and fascination with differences among them ( Janet, 1889/2022a,b; Kluft, 1993); treating parts individuallly without a systemic focus (see Kluft, Chapter 43, this volume); lack of awareness of and focus on significant conflicts and psychological defenses (Steele et al., 2017); mismanagment of boundaries and dependency issues (Steele et al., 2017); and premature or exclusive focus on traumatic memories.

Degrees of Structural Dissociation and Diagnosis We have come to understand the theory of structural dissociation as a transdiagnostic conceptualization. Some experts in the trauma field have criticized the classification of trauma-​related disorders in DSM-​IV and ICD-​10; they have proposed a spectrum of trauma-​related symptoms (e.g., Allen, 2001; Van der Kolk et al., 1996) and trauma-​related disorders (Bremner, 1999b; Bremner, Vermetten, Southwick, Krystal, & Charney, 1998; Moreau & Zisook, 2002). It has been noted that the “one central element that all these [posttraumatic] conditions have in common is the high prevalence of dissociation” (McFarlane & Van der Kolk, 1996, p. 570). Although DSM-​5 separates the dissociative disorders from the classic trauma-​related disorders (ASD & PTSD), many authors have noted that DID is the most complex form of PTSD (e.g., Dell, 1998; Lœwenstein, 1991; Spiegel, 1984, 1986, 1993), and that PTSD should be considered a dissociative disorder (e.g., Chu, Frey, Ganzel, & Matthews, 1999; Spiegel & Cardeña, 1991; Van der Hart et al., 1998). We propose that structural dissociation is evident across all trauma related disorders, including ASD, PTSD, Complex PTSD and most Dissociative Disorders.

Primary Structural Dissociation The theory of structural dissociation views PTSD as the quintessential disorder of trauma. PTSD may result in the classic alternation between numbing/​detachment/​avoidance, and intrusions that are the hallmarks of a rudimentary ANP and EP (Dorahy & Van der Hart, 2015; Nijenhuis, 2014, 2015; Van der Hart et al., 2006). Thus, PTSD represents structural dissociation of the personality into two biopsychosocial systems, which has been termed primary structural dissociation (Nijenhuis, 2015; Nijenhuis & Van der Hart, 1999; Van der Hart et al., 2006). In primary structural dissociation, there is a single EP (associated with re-​experiencing the trauma) and a single ANP (that has been unable or unwilling to integrate the traumatic experience, and that handles daily life). Consequently, not only is the so-​called dissociative subtype of PTSD dissociative, with its emphasis on depersonalization and derealization (Lanius et al., 2012), but classic PTSD can also involve symptoms of depersonalization and derealization. Cases of pure dissociative amnesia may involve a single ANP and a single EP. More simple (i.e., primary) structural dissociation is most likely to be seen in ASD, PTSD, and dissociative amnesia. There are always exceptions, but this is the general rule according to clinical observation.

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Secondary Structural Dissociation When the severity and/​or duration of traumatization is great, occurs at a younger age, or when the individual has a fairly limited integrative capacity to begin with, further division of the EP may occur, with a single ANP remaining intact. We have called this secondary structural dissociation. It is usually based on a lack of integration of different animal-​ defense-​l ike subsystems. Thus, one EP may be mediated by flight (as in dissociative fugue), another EP in freeze, and still others in fight, in total submission, or in faint. Some EPs can be mediated by sexuality or competition or other defensive strategies that involve more prosocial defensive strategies. The division among two or more EPs can also involve a lack of integration of psychoform (cognitive/​a ffective) or somatoform (sensorimotor) components of traumatic experiences. For example, one EP may be associated with sexual arousal during rape, another with an extremely physically painful phase of the experience, and still another with the moment of near death. But again, there may be exceptions. Generally, the autonomy and elaboration of these parts is less than in cases of DID. Despite being rejected for inclusion in both DSM-​I V (APA, 200) and DSM 5 (APA, 2013), Complex PTSD has now been included in the ICD-​11 (WHO, 2020), and has gained respect as a clinical entity (Courtois & Ford, 2015; Ford, Stockton, Kaltman, & Green, 2006). Dissociation was a core criterion in the initial formulations of Complex PTSD (Dickinson, DeGruy, Dickinson, & Candib, 1998; Herman, 1993; Pelcovitz et al., 1997; Roth et al., 1997; Van der Hart et al., 2005), and is a feature in the newly accepted diagnosis in ICD-​11 (Hyland, Shevlin, Fyvie, Cloitre, & Karatzias, 2020; WHO, 2020). Research has found that BPD is also strongly associated with trauma-​related dissociation (Anderson, Yasenik, & Ross, 1993; Chu & Dill, 1991; Gershuny & Thayer, 1999; Korzekwa, Dell, Links, Thabane, & Fougere, 2009; Stiglmayr, 2001; Zanarini, Ruser, Frankenburg, & Hennen, 2000). In one study, approximately one quarter of the BPD sample met additional criteria for OSDD, and another quarter met full criteria for DID, so approximately half of BPD patients in this study had a co-​occuring dissociative disorder (Korzekwa et al., 2009; see Korzekwa & Dell, Chapter 31, this volume). Many patients with BPD seem to manifest secondary structural dissociation.

Tertiary Structural Dissociation In tertiary structural dissociation the personality is divided into more than one EP and further divisions occur in the ANP along the lines of daily life actions systems (e.g., the worker, the mother, the student). Multiple ANPs typically result when aspects of daily life are inescapably associated with trauma or when there is little motivation or capacity to deal with the vicissitudes of everyday life. Tertiary structural dissociation –​more than one EP and more than one ANP –​seems to best characterize the more complex cases of DID.

Symptoms of Structural Dissociation Structural dissociation of the personality generates a spectrum of mental and physical symptoms that extend far beyond the cognitive and attentional symptoms of alterations in consciousness. Dissociative symptoms may be understood as positive (i.e., intrusions) or negative (i.e., losses of functional capacities); they also may be understood as psychoform (cognitive/​affective) dissociative symptoms, or somatoform (sensorimotor) dissociative symptoms (Nijenhuis, 1999/​ 2004, 2015; Nijenhuis et al., 1996; Steele et al., 2017; Van der Hart et al., 2000, 2006). Psychoform and somatoform dissociation are highly correlated phenomena (Dell, 2002; El-​Hage et al., 2002; Nijenhuis, 2015, Chapter 38, this volume; Nijenhuis et al., 1996; Sar et al., 2000; Waller et al., 2001). It is often quite difficult in practice to clearly discern dissociative symptoms from non-​d issociative ones. There are numerous symptoms, which are not typically dissociative in appearance that can have a dissociative dynamic in dissociative patients. For example, trauma-​related symptoms of general psychopathology (e.g., depression, suicidality, eating disorders, substance use, self-​harm, and promiscuity) may be dissociative whenever they are manifestations of the actions of a particular dissociative part of the personality (Şar, 2011; Van der Hart et al., 2006). This is in keeping with our definition of dissociative symptoms: A symptom can be said to be indicative of structural dissociative if and only if two conditions are fulfilled: (a) there is clear evidence of dissociative parts of the personality, and (b) the symptom is found in one or some parts of the personality, but not in others. This definition implies that endorsement of items of self-​report questionnaires should not be used as the sole indication of symptoms of structural dissociation of the personality. Structural dissociation cannot adequately be diagnosed in the absence of careful clinical questioning and observation over time except in highly florid cases. Time is often needed to determine whether apparently dissociative symptoms are due to (1) structural dissociation, or (b) alterations in consciousness, or (c) both.

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Negative Psychoform Dissociative Symptoms Negative psychoform dissociative symptoms include losses: of memory (i.e., amnesia); of affect (i.e., numbing); of critical functions (i.e., impaired thinking; previously available skills); and of needs, wishes, and fantasies (Van der Hart et al., 2006). Negative symptoms are characteristic of ANPs, but some occur in EPs (e.g., the emotional anesthesia that accompanies the defensive reaction of fainting).

Negative Somatoform Dissociative Symptoms Early clinical sources (e.g., Charcot, 1887; Janet, 1889/2022a,b; McDougall, 1926; Myers, 1940; Nemiah, 1991; Van der Hart et al., 2000) and modern empirical studies (El-​Hage et al., 2002; Nijenhuis et al., 1996, 1999; Nijenhuis & Van Duyl, 2001; Şar et al., 2000; Waller et al., 2001) both indicate that structural dissociation of the personality generates somatoform (sensorimotor) symptoms such as loss of motor functions, loss of movement, and loss of sensations that should be present or available (i.e., anesthesia, analgesia, loss of vision, smell, taste, or hearing). Negative somatoform symptoms mostly occur in ANPs, but freezing and fainting (collapse) occurs in some EPs.

Positive Psychoform Dissociative Symptoms Positive psychoform dissociative symptoms are intrusive symptoms. They occur in all posttraumatic disorders. They reflect the partial intrusions of EPs into ANPs, and full alternations among ANPs and EPs (i.e., ‘switching’). Mental intrusions of one dissociative part into another part are often interpreted as Schneiderian first-​rank symptoms of schizophrenia (Boon & Draijer, 1993; Ellason & Ross, 1995; Kluft, 1987a; Ross & Joshi, 1992). The voices arguing, voices commenting, thought insertion, thought withdrawal, and so on that occur in dissociative patients, including those with dissociative psychosis (Van der Hart & Witztum, 2019), should be distinguished from the first-​ranked symptoms that occur in schizophrenic patients. For example, dissociative auditory voices can be distinguished from psychotic voices by a number of phenomenological characteristics (Dorahy et al., 2009). To illustrate, voices in DID typically occur before the age of ten; are heard regularly or constantly; involve more than one voice; include voices of people in the past and child voices; and can generally be directly engaged in dialogue by the client and the therapist. These characteristics are not generally found in schizophrenic auditory hallucinations.

Positive Somatoform Dissociative Symptoms Positive somatoform dissociative symptoms are the behaviors and physical experiences of specific dissociative parts of the personality; they occur in some parts, but not in others ( Janet, 1907; Butler et al., 1996; Van der Hart et al., 2000). These symptoms include pain without organic cause; nonvolitional behavior; repetitive, uncontrollable movements such as tics, tremors, and palsy; and sensory perceptions (i.e., vision, physical sensation, hearing, taste, and smell) that may or may not be distorted. Some positive somatoform symptoms –​the experience of feeling one’s body is influenced by something or someone else –​is a first-​rank Schneiderian symptom (Kluft, 1987a).

Treatment Implications of the Theory of Structural Dissociation Depending on the degree of persistent dissociation and the particular trauma-​related disorder, treatment may follow a relatively rapid and straightforward course (in ASD and simple PTSD) to more moderate or long-​term courses of treatment (in Complex PTSD, OSDD, DID and trauma-​related disorders complicated by significant comorbidity, especially personality disorders). Complex cases, as a rule, need phase-​oriented treatment, in which three phases are distinguished: (1) stabilization, symptom reduction, and skills training; (2) treatment of traumatic memories; and (3) personality integration and rehabilitation (ISSTD, 2011; Nijenhuis, 2017; Steele et al., 2017; Van der Hart et al., 2006). Most patients with a signficant dissociative disorder require at least a modicum of skills-​building to increase emotion regulation and mentalizing functions and decrease maladaptive strategies such as substance use, self-​harm, and chronic suicidality. They often need support in learning how to stay present and be mindful, to structure their time, and to have adaptive relational strategies. Many require quite intensive and long periods of stabilization, often needing significant support to reach the capacity to integrate traumatic memories and dissociative parts. Early in treatment phobic avoidance should be assessed by determining the particular defenses of the patient as a whole and the significant non-​realizations that are present. Each dissociative part plays a role in maintaining the status

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quo of non-​realization, and the particular defenses and strategies of each part should be understood in the context of the whole person, with mutually shared treatment goals in focus (Steele et al., 2017). Thus, work with parts always considers the systemic function of each part and addresses avoidance of parts of each other. Parts are not treated as individuals, but rather as subsystems within a whole system, each with functions that maintain dissociation, making the systemic addressing of trauma-​related phobias essential for increasing integration. Thus, in every therapy session, to the degree possible, the therapist focuses on helping all parts be engaged in the therapeutic work, mostly working through the ANP. However, at times it is necessary to work with two or more parts to establish communication and cooperation, and then immediately return to the system as a whole, or to work with a single part to establish inner communication and cooperation, again moving back to the whole system as soon as possible. The theory of structural dissociation proposes that work should be done first with either a single ANP or among multiple ANPs in a given patient. This is typically –​though not always –​considered to be the “adult self ” of the patient, a foundation for the work of therapy (Gonzalez & Mosquera, 2012; Steele, et al., 2017). The first goal is to ensure that the patient –​at least as ANP –​can engage in treatment in a functional manner, coming and going on time and in a functional state, and being available to discuss issues with the therapist. The second goal is to increase cooperation and collaboration among parts in daily life so that the patient’s daily experience is improved. Once the patient as ANP(s) is more stable, work can commence with parts that remain fixed in trauma. Challenges occur when the patient as ANP(s) is highly defensive, avoiding emotion and dissociative parts, rendering the work slow to move forward. Work with more defensive parts generally precedes work with more vulnerable parts, whenever possible. The trauma-​related phobias and related defensive strategies, fantasies, and schemas of each part should be identified, particularly the conflicts that maintain dissociation. For example, some parts of the patient want connection with the therapist, while others detest the therapist; some parts are loyal to the perpetrator while others want to cut all ties; some parts want to remember what happened, while others are entirely opposed to remembering; some parts want to get better, while others are terrified of what that may mean and thus sabotage all efforts at improvement. These are not uncommon conflicts, but when they involve dissociation they are more difficult to access. It is also helpful to understand the action systems that motivate each dissociative part, as this can help the therapist understand the function and strategies of each part (Liotti, 2017; Steele, 2021; Steele et al., 2017; Van der Hart et al., 2006). For example, parts mediated primarly by competition will use dominant and/​or submissive strategies to subsitute for attachment, while parts mediated by the sexuality system may use seductive behaviors to attempt to gain power, to appease, or to substitute for connection. The therapist can shift interventions according to the dominant motivation system. For example, parts that are competitively aggressive do best when their need is acknowledged and some negotiation occurs, rather than attempting to use attachment-​focused work. Likewise, parts that are aggressive because they feel threatened respond best to provision of safety and having the therapist back off a bit instead of reassuring that connection is safe. Once dissociative parts are more communicative and cooperative, and defenses have been eroded sufficiently, treatment of traumatic memory may commence, typically with more titrated work, a bit at a time to maintain integrative capacity across all parts (Gonzalez & Mosquera, 2012; Kluft, 2013; Mosquera, 2019; Steele et al., 2017; Van der Hart et al., 2006). Our understanding of the adaptive personality and self as a developmental achievement that is a dyanmic, coherent and cohesive system implies that the ideal outcome is integration of all parts into a single personality and sense of self that is adaptive across time and contexts.

Conclusion The theory of structural dissociation of the personality is an attempt to define dissociation more rigorously. The theory offers a unifying perspective on the symptoms and processes that occur across trauma-​related disorders. Our overview of dissociative symptoms is precise; it includes some dissociative symptoms (e.g., positive and somatoform dissociative symptoms) that other recent views of dissociation have omitted, and omits some symptoms (e.g., those reflective of alterations in consciousness) that others class as dissociation. We have highlighted the pattern of avoidance and fixation in trauma that we consider to be a sine qua non of trauma-​related disorders. Because this pattern has often been set aside by nosologists, the fundamental commonality among the trauma-​related disorders has been obscured or lost. The dichotomy of ANP and EP may appear to be unduly reductionistic, but we wish to emphasize five points: (1) ANPs and EPs are prototypes of the phenomena of structural dissociation of the personality and can have significant variance; (2) dissociative structures take somewhat different forms across different degrees of dissociative complexity; (3) we distinguish many different, occasionally overlapping, functions of ANPs and EPs; (4) we recognize that more complex dissociative patients

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may have parts that manifest a mixture of the characteristics of ANPs and EPs; and (5) the sum of these dissociative structures do not comprise the personality entire: personality is a superordinate system within which these parts function with limited integration and coordination. The theory provides both an integrative understanding of the maladaptive mental and behavioral actions of traumatized individuals and a blueprint for more efficient ones. For example, the theory guides treatment by specifying which parts of the personality should first be strengthened (ANP) and which should first be contained (EP). The theory provides interventions and a specific rationale for gradually raising the integrative level of the patient.

Acknowledgment We wish to thank Ellert Nijenhuis for his essential collaboration on the first edition of this chapter in 2009, and for his helpful comments on this version.

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16 DISCRETE BEHAVIORAL STATES THEORY Richard J. Loewenstein and Frank W. Putnam

Discrete Behavioral States Theory (DBST) developed by Frank W. Putnam is a transtheoretical, translational theory of human consciousness. This chapter focuses on DBST particularly as it relates to psychological trauma, dissociation and posttraumatic and dissociative disorders (DD). For a complete discussion of DBST see Putnam’s book, The Way We Are: How States of Mind Influence Our Identities, Personality, and Potential for Change (2016).1 DBST elucidates human experience and behavior across myriad normal and pathological domains. Discrete states of being (SoB) are so pervasive and ubiquitous as to be essentially invisible, unless they shift in dramatic, unexpected ways, and, even then, we usually do not conceptualize these changes in terms of behavioral states –​although we use the word “state” frequently. The “atheoretical” DSM-​5 (American Psychiatric Association, 2013) uses the term “state/​states” over 100 times in describing psychiatric symptoms and disorders. DID diagnostic criteria are founded on the constructs of “identity state” and “personality state,” in the DSM-​IV-​TR and DSM-​5 (and DSM-​III-​R), respectively. The term “state” appears frequently in writings about the DD, especially dissociative identity disorder (DID). DBST is not a “perfect” theory. There are many areas that need to be refined, and it may not explain all aspects of human consciousness. However, the power of DBST is based in substantial support from numerous domains of research, including human development, neurobiology, chronobiology, psychopathology, and many others –​from subcellular to social systems.

Discrete Behavioral States/​States of Being A discrete SoB is defined as a repeating pattern of mind, body, and brain variables/​dimensions that for a finite period is correlated with and/​or influences how a person thinks, feels, and acts. Each distinct SoB uniquely (state-​dependently) influences perception, cognition, memory, emotion, motivation, values, psychophysiology, and interpersonal interactions. The construct of SoB describes human states of consciousness as a subset of the broader construct of discrete behavioral states (DBS). As such, one could argue that these terms are isomorphic (see below). Table 16.1 enumerates state-​dependent variables that may vary and/​or vary together in patterning states of being. Phylogenetically, DBS (e.g., chronobiological states) can be mapped across myriad species from jellyfish to mammals. Although controversial, some conceptualize bacterial and plant behavior in terms of DBS (Calvo et al., 2020). DBST is an organizing framework to understand human personality, identity, and, self, and self-​systems. It is a paradigm that cuts across diagnostic labels with a potentially unifying conceptualization of many psychiatric disorders as “state-​change” disorders (e.g., bipolar disorder/​mood disorders, PTSD, panic disorder, DID, impulse control disorders, addictive disorders). In other psychiatric disorders, symptom fluctuations and/​or decompensations can be understood as related to state changes (e.g., psychotic disorders, developmental disorders). DBST can help conceptualize aspects of process and change in psychiatric treatment and psychotherapy (Horowitz, 1979). Table 16.2 illustrates the potential scope of DBST and its translational and unifying potential across human experience.

DOI: 10.4324/9781003057314-20

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282  Richard J. Loewenstein and Frank W. Putnam TABLE 16.1  Variables That “Dimensionalize” State-​Space to Map Discrete States of Being

Emotional, Sensory, Attentional, Temporal, and/​or Subjective Awareness •  Level of alertness, energy, posture, dexterity and coordination (motor performance) •  Attention, concentration •  Pain tolerance •  Sensory perception •  Time perception •  Level of response to external and internal stimuli •  Emotional reactions to relevant or noxious stimuli •  Sense of self (state/​context-​dependent identities) Memory Pattern •  Access to general and specific domains of knowledge •  Access to autobiographical memories •  Patterns of cognitive associations and implicit assumptions Motor Patterns •  Body activity •  Eye movements •  Qualities of voice •  Facial expression •  Breathing pattern Psychobiological changes •  Neuroendocrine patterns •  Brain activation patterns Regulatory and stress physiology •  Heart rate •  Blood flow •  Blood pressure •  Muscle tone •  Skin conductance •  Breathing rate

The Ubiquity of States of Being Becoming aware of one’s discrete states of being is reminiscent of the literature student who suddenly realized that she was “speaking prose.” We use many terms to describe our everyday experience that can be more rigorously understood using the states concept (e.g., “mode,” “mood,” “feeling,” etc.). Notice how commonly we refer to states and state changes in everyday parlance: “I’m sorry, I got out on the wrong side of bed today;” “I’m locked in! I’m in the zone!” “I’m stressed out! What a terrible day! The boss was in one of his moods! I need a drink!”; “This hangover sucks bigtime.” Whilst suffering from several days of nausea and vomiting with a severe gastro-​intestinal disorder, one has trouble remembering what it was like to not be in this state. When the illness passes, it is difficult to put oneself back experientially into the nauseous/​vomiting state; it feels far away and distant. The latter illustrates another state-​based phenomenon: state-​dependent learning and memory (SDLM). Autobiographical memory is most affected by SDLM. Commonly, pregnant women describe a series of compellingly different SoB throughout pregnancy. Melancholically depressed patients deny that they could have ever experienced a different state. SDLM is common in dissociative and trauma-​and-​stressor-​related disorders. For example, in DID, dissociative amnesia (DA) manifests when some self-​states recount experiences as first-​hand autobiographical memory whilst others deny recall of these events and may insist, they did not occur. Other self-​states describe derealized memory: they “know about” these life events, but do not experience them as their personal autobiography. There is a motivated, defensive aspect to difficulty recalling painful states: one does not want to recall them.

Repeating State Cycles Larger blocks of behavior are often composed of repeating state cycles. Adult sleep consists of the repeated cycling of the sleep stages (states) I-​I V and REM sleep. These, and their transitions, are associated with specific neuronal firing

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Discrete Behavioral States Theory  283 TABLE 16.2  DBST Domains –​A Theory of Consciousness

This table includes state changes in the natural world to indicate the ubiquity of state-​based phenomena •  Chronobiological Phenomena: Biological clock phenomena found in cells, organs, and in all species from bacteria to mammals    •  Circadian rhythms (Approximately 24-​hour biological rhythm)    • Temperature    •  Cortisol and other neuroendocrine    •  Cell division in different organs    • Others    •  Ultradian rhythms (less than a day, longer than an hour), e.g., sleep-​wake    •  Sleep has stages (states) within the ultradian rhythm, e.g., REM-​n REM sleep    •  Sleep has different neuro-​endocrinological patterns than waking, etc.    •  Sleep-​wake stages/​states found in organisms as primitive as jellyfish    • Infradian rhythms (longer than a day): e.g., Menstrual cycle (circatrigintan or circalunar rhythm: 21–​35 days)    • Pregnancy    • Menopause    •  Circannual rhythms    •  Seasonal Affective Disorder and other seasonal mood state changes    •  Anniversary reactions    •  Human behavioral changes with seasons    • Changes in behavior, biology in migratory birds and other migratory species; reproductive cycles; hibernation cycles •  State Changes in Infant and Later Development    •  All developmental stages involve different states of being •  Attachment-​based shared states in child development:    • Attunement    •  Attachment Types and Disorders    •  Trauma and Attachment •  State Dependent Learning and Memory •  Brain States    •  Micro-​states    •  Default Network Mode (State)    •  Salience Network Mode (State)    •  Other Brain Networks    • Stupor    • Coma    •  Persistent Vegetative State    •  Brain death    • Other •  “Ordinary” States    •  Self-​states    •  Identity States    •  Giving Birth    • Daydreaming    • Reading    •  Watching movies, TV, etc.    •  Private states, e.g., bathing, going to the bathroom, etc.    •  Sexual states –​individual and shared (continued)

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284  Richard J. Loewenstein and Frank W. Putnam Table 16.2 Cont.

•  Creative States –​Artist and Audience –​individual, shared, group    •  Visual arts    • Music    • Dance    •  Creative Writing    • Athletics •  Religious and Spiritual States   • Prayer    •  Spiritual experiences    • Possession    •  Shared Religious/​Spiritual States    •  Worshipping Together    •  Shared Grief/​L oss    •  Shared Trance states    •  Shared Religious Music    •  Spirit-​Possession (the Holy Ghost in Pentecostal Churches)    • Glossolalia •  Emotional States (not exhaustive)    •  Shame/​Humiliation    •  Envy/​Jealousy    • Guilt    •  Fear/​Terror    •  Anger/​R age    •  Distress/​A nguish    • Grieving    •  Disgust/​Dissmell    •  Surprise/​Startle    •  Interest and Excitement    •  Enjoyment/​Joy    • Pride    • Dignity •  Emergency States    •  Fight-​F light    •  Peritraumatic Dissociation    •  Freeze, Shut Down, Feign Death •  Exceptional States    •  Peak Experiences    •  Extreme Sports and other Athletic States    •  Martial Arts    •  Hypnotic States: auto-​, hetero-​, self-​hypnosis    •  Meditative States    • Yoga

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•  Personality States    •  Normal Aspects of Personality Shifts    •  Pathological Personality States    •  Secret Lives •  Psychopathological States/​State-​Change Disorders/​State Change in Relapse/​Remission/​Behavioral Patterns    •  Bipolar and other Mood Disorders    •  Panic Disorder and Generalized Anxiety Disorder    •  Schizophrenia: Acute or Exacerbation    •  Delusional Disorder(s)    •  Schizo-​A ffective Disorder    •  Brief Psychotic Disorder    • Catatonia    •  Trauma and Stressor-​Related Disorders    •  Dissociative Disorders    •  Conversion Disorder, esp. Dissociative/​Psychogenic Non-​Epileptic Seizures    •  Other Somatic Symptom Disorders, e.g., Pain Disorder    •  Borderline Personality Disorder    •  Bulimia Nervosa, Binge-​eating Disorder, Anorexia Nervosa, other Feeding-​eating disorders    •  Impulse Control Disorders: Intermittent Explosive Disorder, Oppositional Defiant Disorder, Pyromania, Kleptomania    •  Attention-​Deficit Hyperactivity Disorder    •  Sexual Disorders    •  Sleep-​Wake Disorders and Parasomnias    • Delirium    •  Developmental Disorders    • Paraphilias    •  Some Factitious Disorders, including Factitious Disorder Imposed on Others –​both as Perpetrator and Victim •  Self-​Destructive States    •  Suicidal States    •  Non-​Suicidal Self Injury    •  Reckless Driving    •  High-​R isk Sexual Behavior    • Other •  Addictive States    •  Substance Related    • Gambling    • Sexual    •  Internet Related •  States and Psychotherapy    •  Tracking States in Psychotherapy –​in the Patient and Therapist    •  Shared States Between Therapist/​Patient –​Physical Mirroring    •  Free Association    •  Free-​F loating Attention of the Therapist    •  Disruptions in States in Therapy (continued)

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286  Richard J. Loewenstein and Frank W. Putnam Table 16.2 Cont.

   •  Group Therapy States    •  Couples and Family States •  Group and Mass States    •  Groups at Musical Events    •  Groups at Sporting Events    • Protests    •  Mob Behavior    •  “Mass Hysteria” •  Medical States Disease states cause myriad different states of being (not an exhaustive list)    •  Epileptic States    •  Concussion And Brain Injury    •  Pain States: Acute, Chronic    •  Infectious Diseases    •  Gastro-​Intestinal Diseases: Nausea/​Vomiting    •  Upper Respiratory Infections/​F lu/​Covid-​19, etc.    •  State-​based Worsening of Movement Disorders, e.g., Tourette’s and other Tic Disorders    •  Chronic Disease States    •  Surgical anesthesia: local, regional (spinal, epidural), monitored anesthesia care (conscious sedation), general anesthesia    • Chemotherapy    • Other •  Criminal Activity –​Alone or in Groups    •  Robbery/​Burglary    •  Dangerousness to Others    • Aggression    • Violence    • Homicide    •  Sexual crimes    •  Child Maltreatment    •  Organized Abuse    •  Financial Crimes    • Other

patterns in specific brain regions that underlie these state switches. EEG and Magnetoencephalography (MEG) have demonstrated “micro-​switches” underlying brain electrical activity. Alpha waves are made up of a small number of repeating microstates in distinct neural networks that turn on and off. States of mind consist of the repeating pattern of a few microstates (e.g., four specific repeating microstates underlie daydreaming). These microstates have been called “atoms of thought” (Putnam, 2016, p. 72), as they may constitute much of our thinking and perceiving. SoB can be simultaneously conceptualized at many levels of mind-​brain-​body phenomena (i.e., as isomorphs). The isomorphism of states may lead to a more fundamental translational understanding of relationships from molecules to organisms, and even ways that behavioral states affect human beings in dyads, families and socio-​cultural groups. For example, sleep-​related state changes have been studied hierarchically and cybernetically at the neurochemical, sub-​cellar, and cellular levels, as well as with regard to interactions of specific brain regions and neurotransmitters, and in the sequence of normal, adult sleep states. Sleep studies have described synchronization of sleep states in couples (Drews et al., 2020).

State Switches and Shifts All states are transient. Even people in “permanent” vegetative states show alternating sleep-​wake cycles and brain activation patterns. We are continually moving, gliding, shifting, switching through different states. We may experience

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different states in conflict, as well as overlapping, interfering, intruding, and influencing states. We may shift and/​or switch among many everyday (hopefully) adaptive self/​identity states, typically related to our differing professional, personal, parental, and other roles. Switches to another state may be immediate, (e.g., a sudden, rapid, acute, disorganizing switch into the fast-​t rack emotion of shame/​humiliation). Other state changes occur more gradually, (e.g., steadily going deeper into a meditative state). Adaptive functioning requires coordination, integration, and control functions to allow relatively smooth transitions among states, to get the “right” state configuration to the “right” place, at the “right” time, and maintain that state as necessary. We need to be able to shift out of maladapted states, or, as in the instance of a shame storm, survive through it until it can (hopefully) be gradually managed later.

Characteristics of Switching Psychobiological markers of state switching/​shifting are enumerated in Table 16.3. Specific aspects of state switching may dominate, for example, the marked change in mood (state) with a sudden switch from depression into mania in patients with rapidly cycling bipolar disorder. In the bipolar switch, other variables change as well: motor activity, behavioral activation, level of consciousness, sense of self, access to memory, cognitive set, reality testing, observing ego, etc. State switches are briefer than states before and after the switch. Within the same individual, different types of switches may occur between the same pair of states. One may feel rapidly alert awakening from sleep; or one awakens slowly, groggily, perhaps alternating between waking and a dream state. Switches between any given pair of states are typically asymmetrical (e.g., a panic attack has a rapid onset followed by a slow, often irregular, decline). Less disjunct state changes may be better characterized as state “shifting” (e.g., briefly answering a personal call at work with a transition from the “work” state to the “personal” state and back). Clinically in DID, state shifting is more common than state switching, and more adaptive to overall functioning. Sudden, more discrete DID state changes may be problematic (e.g., an air traffic controller at work who suddenly switched to a child self-​state). However, the core phenomenology of DID is characterized by the state of multiple, simultaneous states. There may be conflict, overlap, interference, intrusion, and influence, as well as coordination, cooperation, and collaboration among states that generate the moment-​to-​moment state of the DID individual (Loewenstein, 2020). In DID, some switches are rapid; some characterized by a “chaotic” disorganization-​reorganization of variables into a different state. Classically, DID switching is accompanied by a brief loss of awareness, a trance state, or an intermediate sleep state. In these cases, switching is recognized retrospectively; although there may be variable, state-​dependent dissociative amnesia among DID self-​states for some or all of what occurred. A DID individual may alternate among all these switching patterns, and/​or experience “order effects”: some self-​states emerge only in a particular sequence.

Infant States Form the Core of All Human States In the 1960s–​1970s, a time when researchers were attempting to rigorously study hypnotic and drug-​induced altered states of consciousness, an eclectic group of developmentally-​oriented researchers engaged in an intensive, ethological, observational study of the behavioral states of human infants (Prechtl & O’Brian, 1982; Wolff, 1987). Known as the “Baby Watchers,” they observed and measured infant behaviors in natural settings over long periods. They discovered that healthy, full-​term, newborns have a basic set of behavioral states that probabilistically switch, one to another in two–​three-​hour cycles.

TABLE 16.3  Markers of Switches in State5

• Rapid changes in mood/​a ffect (e.g., panic attacks, mood swings, flashbacks, fear, shame, explosive anger, etc). • Changes in activity level, coordination, posture, agility, and mobility (e.g., psychomotor agitation/​retardation, catatonia). • Shifts in level of consciousness/​a lertness/​awareness (e.g., intoxication, sleep/​wake, drowsy, lucid dreaming, stupor, coma, permanent vegetative state). • Alterations in attentional, cognitive, affective functions (e.g., trance, creative, “peak” states). • Changes in associations/​responses to stimuli (e.g., PTSD or other memory cues) • Changes in cognition, state-​dependent learning and memory (e.g., availability of autobiographical memories). • Changes in sense of self, aspects of identity (e.g., moral values). • Changes in metacognition (e.g., variability in self-​reflective [observing ego] functions, executive function, reality testing).

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F I G U R E 16 .1   Behavioral

Cycles in One Month Old Infant in 3-​Dimensional State-​Space  

These cycles could be altered or reset by environmental, caretaker, and/​or internal input (e.g., a mother assisting the infant out of a “fussy” state, and into an alert state, avoiding the cry state). Some state variables are dichotomous (e.g., eyes open/​closed); others are dimensional (e.g., heart rate). These states included: 1. regular (quiet) sleep; 2. irregular (restless) sleep; 3. alert inactivity (bright and shiny eyes); 4. waking activity (fussiness); 5. cry. Figure 16.1 illustrates a model of 3-​dimensional state space including measurement of motor activity, respiratory, and heart rates. The overall state space defines the baby’s range of behavior. Brief transitions (i.e., switches) bridge between different states, linking together the infant’s behavioral cycles. Switches are characterized by brief episodes of dysregulation of heart rate, breathing, and changes in alertness and movement. As infants develop, additional states come online (e.g., an “alert active” state develops around age 3 months). As time goes on, more SoB are added to the infant’s repertoire leading to more complex pathways between states and shifting directional probabilities of state cycles. The baby now has more starting points, more states to enter, and more different directions to go in state space. By the end of the first year of life, there are so many states that it becomes impossible to map them (See Figure 16.2).

The Role of Early Caretaking Attunement Attunement is the ongoing, moment-​to-​moment process that reflects the quality and sensitivity of the mother/​caregiver (henceforth, mother) to the infant. Attunement represents the mother’s capacity to match the inner states of the child and gently guide these states into mutually harmonious connections. Also, attunement involves the, partly culturally defined, ways that mothers modulate the rhythm and intensity of interactions with the baby (e.g., gazing-​ towards alternating with gazing-​away). There are data on infant and maternal biological variables (e.g., heart rate) showing that attunement is characterized by close biological mirroring of the rising and falling curves of these psychophysiological variables in the baby.

Attachment Attachment, the most critical process in child development, begins during the first year of life. Attachment is shaped by the psychobiological bond between infant and mother; and by the qualities of the mother-​infant attunement. Healthy attachments result in a markedly greater capacity for the child to self-​regulate emotional states, manage social interactions, and to withstand stress. Damaged or disrupted attachments predict more emotional problems, difficulties with relationships, and mental and physical illness. There is no specific, absolute synchrony between mother

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F I G U R E 16 . 2   Increasing

complexity of SoB during the 1st year of life

and infant; rather, a dynamic capacity to make modifications to one’s own state to accommodate the other’s state. It is the infant/​toddler’s experience recognizing the mother’s state and making adjustments or reparations to the maternal states that assist with the infant’s development of a sense of self that has the coherence, continuity and agency necessary to develop secure and stable relationships with others.

Self-​Modulation Over the course of development, positive attachment experiences result in the child’s increasing capacity to self-​ modulate and adapt to the emergence of new states in new circumstances (e.g., friends, socialization, school, play). The child develops increased self-​control/​regulation over state modulation. The child learns to match states to the appropriate situation; maintain an appropriate state in the face of distraction and intrusion and recover from state disruptions.

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As development proceeds, the child acquires an increased attention span, task orientation, and ability to recognize and resist incongruent, dysfunctional states. The child begins to develop improved metacognitive, executive, observing ego capacities. This improves the integration of self, identity, behavior, and information across states of being. Improvement in metacognitive capacity expands more generalized access to autobiographical memory, and to general knowledge and skills; improved “cause-​and-​effect” thinking and understanding; more deliberative integration of behavior; centrality and continuity of identity, and greater integration of self.

Personality, Identity, Self, Self-​System The definitions and conceptualization of self, identity, and personality have been debated at length within different schools of thought in the psychological, sociological, anthropological, and philosophical literatures.2 These terms are often used interchangeably or defined tautologically. The concepts of self, identity, and personality have fuzzy conceptual boundaries, and have numerous definitions based in specific conceptual paradigms (e.g., behaviorist vs. psychoanalytic). The state model defines personality, not as traits, but as “…[T]‌he integration of a person’s [self/​identities], emotional, cognitive and other relevant states of being weighted by the history of their recurrent interactions with the person’s inner and outer worlds integrated over time” (Putnam, 2016, p. 160). As a metaphor, our personality represents broad-​brush state domains, partially delimited by genetic factors, “where” self and identity states organize themselves, and provides boundaries, tolerances, and strata within which the latter can be scaffolded. Human temperament may subsume part of the “trait” level of human personality (Zwir et al, 2020), as it is both genetically and environmentally determined. The self can be defined as psychobiological states related to moment-​to-​moment subjective consciousness of “I” and “me” in relation to inner and outer reality, including information processing, body image, thoughts, emotions, awareness of the self in the past, and anticipation of the self in the future. The self has the capacity for decisions, agency, and action. It has a capacity to observe and judge “itself.” The self is the subjective “who” we experience as ourselves on a moment-​to-​moment basis. Identity overlaps with the self, as it has both a subjective aspect and an observable one. One can think of identity as “what” we are. Aspects of identity may represent longer-​term zones of our being (e.g., gender identity, ethnicity). Yet, other identity states, like self-​states, are hidden or are in conflict. As there are self-​state systems, so too there are identity-​state systems. At times, even when self and identity states are relatively integrated, these states may be in conflict –​sometimes observably; in extreme inner conflict, the tolerances of the personality state-​system may be stretched to its adaptive limits. Identity can be a political and socio-​cultural process through which groups define themselves positively, but also to demonize, marginalize, and attempt to control other groups. The latter may have their socio-​cultural identity shaped in compliance, internalization, opposition, resistance, and/​or rebellion. Genocide is an extreme outcome of negative, objectifying, views of the “other,” who, stripped of all humanity, becomes an objectified identity: the hated cause of woe who must be eradicated. Similarly, in abusive families, children may take on violence-​based, variably internalized family roles (self-​identities).

The Self-​System The self-​system was originally defined by Sullivan (1953), as the child’s internalization of different subjective senses of self in response to parenting. In a broader sense, the self-​system describes a range of more-​or-​less organized self-​states that emerge during development (see Beere, Chapter 17, this volume). Across the life cycle, some self-​states may no longer appear (e.g., states related to prior developmental epochs). Typically, adults have a range of self-​states organized around many variables. These include professional and personal roles, emotions (e.g., ashamed self-​states, frightened self-​states), etc. Some self-​states (e.g., an angry state) may appear suddenly, interfering with other states (e.g., a work-​ related self-​state). In the complex grieving state, the grieving self-​state(s) emerge when they are not adaptive (e.g., they “hit” during the workday). Many of our SoB are complex admixtures of different self-​states and identity-​states that emerge around a host of everyday and/​or stressful human situations. Under substantial stress, any of us can regress to less differentiated and inflexible SoB making it harder to utilize adaptive resources.

Discrete Behavioral States and Psychopathology The DBST model of psychopathology creates a translational framework for understanding, treating, and researching many disorders. The first level is that of the pathological states themselves (e.g., DID self-​states, depersonalization/​

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derealization). The second results from inability to self-​modulate, regulate, manage, or integrate these dysfunctional states resulting in additional symptoms and maladaptive behavior. The third level results from symptomatic compensatory self-​modulation/​regulation strategies to block or manage these pathological states (e.g., substance abuse, non-​ suicidal self-​injury).

Trauma, Posttraumatic Responding, Dissociation Acute and Posttraumatic Stress Disorders (ASD & PTSD) Acute trauma, chronic trauma, and posttraumatic and dissociative disorders can be paradigmatically conceptualized in terms of changes in discrete behavioral states (e.g., the acute switch to fight-​fl ight-​freeze states in the face of danger, that, in posttraumatic disorders maladaptively persist in various forms after the dangers have passed). Peritraumatic responses are characterized by numerous markers of state change: psychobiological, physiological, consciousness, perceptual, behavioral, affective, cognitive, etc. Virtually all ASD/​PTSD symptoms can be conceptualized as state based (e.g., dissociative flashbacks, numbing, hypervigilance, startle, disordered sleep, depersonalization/​derealization, and dissociative amnesia). PTSD state changes have been studied in terms of psychobiological, somatosensory, behavioral, cognitive, memory, self-​state, and affective changes. ASD/​PTSD state changes involve switching of varying rapidity. ASD/​PTSD patients commonly attempt to use external means to modify posttraumatic states: social withdrawal, substance use, reckless behavior, dangerousness to self/​others, etc.

Dissociation3 In DBST, dissociation is conceptualized as a key part of the psychobiology of the response to life-​threatening danger. In acute dissociative trauma responses, an altered state of consciousness develops associated with changes in physiology, perception, pain sensation, time sense, sense of self, depersonalization/​derealization, etc. Trauma-​related memories and affects are encoded during these altered states. Afterwards, due to SDLM, the person has less access to the dissociated experiences, with amnesia for at least aspects of the traumatic event. The dissociated memories and affects can manifest nonverbally in posttraumatic nightmares, reenactments, intrusive imagery, and somatoform symptoms. In addition to limited access to autobiographical trauma memory, the person dissociates alterations of basic meaning systems: beliefs about the self, relationships, other people, and the nature of the world.

Dissociative Disorders (DD) The DBS model of dissociation conceptualizes DD in terms of pathological states of being, with the development of distinct states of consciousness (being) altering the individual’s sense of self, experiences of the body, access to explicit and implicit memory representations, as well autobiographical experiences, and psychophysiological reactivity, etc. Disturbances of self-​systems are the nucleus around which dissociative states organize, just as mood disruptions organize the SoB of the bipolar patient. Dissociative disturbances of memory are extreme examples of state-​dependent learning, storage, and retrieval. Major autobiographical memory dysfunction has significant impact on our sense of self and identity (Conway & Pleydell-​Pearce, 2000). Alterations in psychophysiological sensitivity in dissociative disorders reflect state-​dependent changes in autonomic nervous system and neuroendocrine function. All current models for dissociation and the DD, for example, structural dissociation theory (SDT; See Van der Hart & Steele, Chapter 15, this volume), the autohypnotic model (See Dell, Chapter 14, this volume), the “4-​f actor theory” (Kluft, 1985), and the 4-​D theory (Frewen & Lanius, 2015; See Frewen, Wong, & Lanius, Chapter 19, this volume) are fundamentally based on discrete behavioral states (e.g., the apparently normal and emotional “personalities” of SDT; altered states of consciousness in the autohypnotic model, etc.). DBST etiological models of DD are based in studies of child development, and not –​as are other models –​developed retrospectively from observations of adults with DD, PTSD, and other disorders. For example, SDT uses the SoB developmental model as the origin of DID self-​states, but then re-​conceptualizes subsequent development (e.g., type-​D attachment), in terms of an oversimplified, adult-​based model of alternations between specific types of self-​states (e.g., the emotional personality and the apparently normal personality). Most neurobiological research on DD involves state-​based phenomena (e.g., Reinders et al., 2016). Neurobiological studies on DD literally have the term “states” in their text, if not found in their title.

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Depersonalization/​derealization Disorder (DDD) DDD can be understood as a persistent disconnection of the self/​self-​observation from memory, emotions, mind, body, other people, and/​or the world. DDD patients describe highly distressing, continuous or relapsing/​remitting SoB involving alienation from perceptual, cognitive, and affective processes. Self-​observation typically results in an anhedonic, dysphoric, often frightening state of disconnection, but little actual insight. DDD patients typically describe limited ability to moderate or modulate the depersonalization/​derealization states of alienation and disconnection. Some DDD patients manifest dominant SoB of numbness and detachment. Others respond with states of agitation and desperation about the altered states, especially numbness and detachment. Depersonalization/​derealization states are a normal part of dissociative responses to trauma and life-​threat, often permitting survival-​based down-​regulation of autonomic functions (e.g., heart rate, blood pressure, rate of breathing, and of the HPA axis; Loewenstein et al., 2017). In DDD, these states become persistent, autonomous, and disconnected from their survival functions. Preliminary studies of DDD neurobiology are consistent with this, demonstrating autonomic blunting and diminished HPA axis sensitivity, along with alteration of parietal integrative functions, and frontal down-​regulation of amygdala and insula. The trauma history of the DDD patient is characterized by childhood emotional/​verbal abuse and/​or repeated, helpless, frozen witnessing of violent or dangerous situations (Simeon et al., 2001), although some of these patients may also describe physical abuse and/​or episodes of childhood sexual abuse, typically in the context of bizarrely detached parental responses to the child’s distress. For example, a latency age child was repeatedly left behind by her father and brothers to stay with her violent, frightening, medication-​refusing schizophrenic mother while awaiting the arrival of emergency services. The terrorized patient felt compelled to follow her mother through the house –​despite mother’s brandishing a large kitchen knife, threatening invisible tormentors –​fearful that the mother would hurt herself, if not the patient. Often, DDD patients describe initial depersonalization/​derealization states during these terrifying early life events, that later return and persist.

Dissociative Amnesia (DA) The most common form of DA is localized amnesia for past events, usually of a stressful or traumatic nature, for example, a rape (Dell, 2013). Repeated, cumulative adverse childhood experiences (ACEs) before age 18, particularly sexual and/​ or physical abuse, results in a graded increase in prevalence of childhood autobiographical memory disturbance (CAMD) (Brown et al., 2007), where memory is impaired not only for trauma, but for substantial segments of everyday events as well (Edwards et al., 2001). Clinically, this results in an individual with autobiographical memory experienced as SoB with gaps and/​or jumbled, fragmented recollection for life history. Individuals with DA often have a limited range of available SoB, and appear emotionally rigid, constricted and brittle. Those with more jumbled, fragmented forms of DA may experience SoB that feel disconnected and chaotic. Both can occur in a single individual. Metacognitive integrative capacities are impaired, as those with DA cannot connect their SoB to past events (e.g., a highly successful physician who is puzzled that he feels phobic of intimate contact with others, has superficial friendships, and says, “I don’t remember that much about growing up. Maybe that’s because nothing important happened”). Generalized Dissociative Amnesia Generalized dissociative amnesia (GDA) is a rare DA presentation. (For an extensive review of GDA, see Loewenstein, et al., 2017). The person comes to clinical attention with a sudden loss of most or all memory for life history. In its most severe form, GDA presents as a SoB with lack of memory for identity, and even for procedural memory, and/​or anterograde DA, an inability to form new memories. In some cases, the patient presents with GDA after an episode of dissociative fugue (DF) (Staniloiu & Markowitsch, 2014). GDA is accompanied by major alterations in the self, as well as information about identity (e.g., marital status). The presenting self/​identity states in GDA are often emotionally constricted, perplexed, and confused –​either with a distress about the state, or surprising lack of distress. Some appear in a more child-​like state, suggesting a DID diagnosis. In the authors’ experience with GDA, over 90 percent of these patients ultimately will meet diagnostic criteria for DID, with formation of a “new” amnestic self-​state typically as an alternative to suicide while in a state of extreme, acute trauma and/​or profound seemingly insoluble self/​identity state conflict (e.g., a militantly “pro-​life” Christian woman who became pregnant after being savagely raped by her brother, and desperately wanted to terminate the pregnancy). Many patients with GDA have a chronic course (Staniloiu & Markowitsch, 2014). These individuals typically

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are disabled, and exist in highly anxious, but psychologically constricted, empty SoB. As one of these patients said, “When I lost my memory, I lost my life.” Betrayal Trauma, Attachment Pathology and Dissociative Amnesia During development, the caretaker’s and child’s states of being continually interact. The child tries to reflect the caretaker’s states in any way that shrinks the state-​space between them. With abusive parenting, the child’s need to maintain attachment overrides other needs. The child assumes whatever state seems the least likely to provoke the caretaker –​often a passive (proto-​d issociative) withdrawal into an inner world. There are data supporting caregiver betrayal as an important factor in DA related to childhood sexual abuse (Wager, 2011). From a DBS perspective, to maintain attachment, the maltreated child creates self-​states that are relatively betrayal-​blind, to maintain connection with the dangerous caregiver, and mitigate fear generated by the caregiver’s frightening and/​or frightened behavioral states. Trauma involving betrayal may be processed differently from other autobiographical experiences, compounding state-​ dependent memory deficits. These data are consistent with the literature on Type-​D attachment patterns, and the relationship of Type-​D attachment to later dissociation and psychopathology (see Schimmenti, Chapter 10, this volume). Betrayal trauma theory can be viewed as isomorphic with type-​D attachment: describing the cognitive processes that exist within type-​D attachment. Maternal dissociation, not maternal maltreatment history per se, predicts the multi-​generational transmission of maltreatment (Kim et al., 2010). With regard to the ACE studies on CAMD, one can hypothesize that the generation of child behavioral states in response to betrayal and maternal dissociation may moderate the extent of retrospective DA in adults with a history of childhood maltreatment as autobiographical details are distributed in different DBS.

Dissociative Identity Disorder DID is the paradigmatic dissociative developmental state-​change disorder. DID is understood as a developmental failure by a traumatized child –​younger than age 5–​6 to establish a unified sense of self across states and contexts. Repeated severe traumatic experiences, primarily at the hands of caregivers, disrupt unification of self through the creation of extreme states. Further, these caregivers, at best, provide unpredictable comfort or mitigation for these extreme states. Secondarily, the child experiences SoB to attempt to mitigate, modulate, and regulate states that overwhelm other capacities for assuaging the impact of trauma. Typically, the DID child also experiences repeated parental betrayals, and type-​D disturbances of caretaker-​child attachment. DID patients’ maltreatment begins before the development of the capacity for cognitive constancy. The dissociative child may experience the nighttime rapist daddy as literally a different daddy from the daddy at breakfast –​with self-​states congruent with the “different” parents (Putnam, 1997). These different attachment dynamics may become more complex with DID parents. The DID child develops self-​states aligned with specific parental self-​states (e.g., multiple rapist fathers). These factors disrupt the development of normal metacognitive processes involved in the elaboration and consolidation of a unified sense of self. The child fails to integrate the different experiences of self that normally occur across different contexts (e.g., with parents, peers, and others, as well as internal states). This results in an individual with multiple, relatively concretized, quasi-​independent senses of self, often in psychological conflict. The secondary structuring of these self-​states due to a variety of developmental pressures and intrapsychic needs may result in the concrete elaboration of the self-​state identities with names, personal descriptors, and variable ways of presenting themselves to others. These secondary elaborations are not the core aspect of the disorder. In addition, the DID child develops self-​ state systems with many adaptive and unifying elements. Because of metacognitive deficits across the self-​state systems, there may be maladaptive, rigid, and stereotyped responding to developmental and other challenges, primarily due to posttraumatic reactivity overriding more adaptive capacities. Switch Processes, Psychopathology, and DID In The Way We Are, Putnam (2016) describes his experience at NIMH studying rapid-​c ycling bipolar disorder patients. When severely depressed, after 24 hours of complete sleep deprivation, these patients may suddenly switch to euthymia, or, more problematically, acute mania. If they fall to sleep even momentarily, they may awaken again in the depressed state. Studies of state-​switching and the switch process in mood disorders led to Putnam’s groundbreaking research on DID as a state-​change disorder.

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DID, State-​Switching, and Neurobiology DID state switching can result in sudden, notable changes in many psychobiological variables. These include muscle tone and posture, heartbeat rhythms, pulse (e.g., 50 percent decrease with a switch), blood pressure, blood glucose, skin conductance, visual evoked potential, handedness, 16-​lead EEG patterns, vocal chamber resonance, visual acuity, eye-​ muscle balance, pupillary size, allergic responses, handwriting, coordination and balance, and many others. During the state transition (i.e., switching), Putnam observed a disorganization of muscle tone and posture, but also rapid, wide, oscillating swings in psychophysiological variables, (e.g., heart rate) until a new, different rhythm stabilized. Control subjects who created “imaginary personalities” could not duplicate any of these phenomena. Controls who used hypnosis or deep relaxation showed distinct psychophysiological states, but these differed significantly from those of the DID subjects. Consistent with the DBS theory of DID, the psychobiological disorganization between DID state switches is similar to those observed in transitions between infant states. DID patients may show impaired control and integrative functions across different SoB, and possible persistence of early childhood forms of state transition. Art productions show a clear developmental trajectory from early childhood into adolescence. In both a simulated and hypnotic age regression, DID patients manifested SoB with multiple developmental-​age-​congruent states when compared to controls, interpreted as failure of developmental self-​integration (Fuhrman et al., 1990). Neurobiological Studies of Brain Activation in DID Reinders et al. (2016), compared DID patients either as a Traumatized Personality State (TPS) or as a Neutral Personality State (NPS).4 In response to personal trauma scripts, DID subjects showed state-​dependent autobiographical memory accompanied by state-​dependent brain activation patterns. TPS reported specific trauma memories as autobiographical. NPS denied this. Autonomic function also significantly differed with TPS showing significantly elevated pulse and systolic blood pressure, and NPS displaying significantly higher heart rate variability. Brain activation/​autonomic states were homologous to those found between subjects with the dissociative subtype of PTSD compared with non-​ dissociative PTSD patients (Reinders et al., 2014). Control subjects could not duplicate these findings. A prior study, without use of personal trauma scripts, did not find significant differences between specific self-​states on SPECT scintigraphy (Şar et al., 2007). The State of Multiple States Putnam and colleagues’ studies on the psychobiology of DID led to the conceptualization of DID as the “state of multiple, simultaneous, overlapping states.” The historical view of DID was that individual self-​states were distinguished by stable, recurrently observable traits over time. Across studies, there was significantly more variability in the DID subjects compared with simulating controls. DID subjects were unable to maintain stable states without state-​shifting. They described intrusion/​i nterference with self-​states “coming out” and/​or overlapping during study protocols. This state of multiple states is consistent with the phenomenology of childhood DID. In clinical case series of DID children, DID does not typically present with frequent state switching. The DID child’s self-​state system is experienced as relatively autonomous, imaginary-​companion-​like entities that overlap and interfere, leading to conflicting states of being often with dissociated actions. Clinically, DID individuals experience SoB where attitudes, emotions, and behaviors –​even one’s body –​are experiences as “not mine,” and/​or can suddenly change in ways that are “not under my control” (Laddis & Dell, 2012). Complex, ongoing forms of SDLM in DID include the state-​dependency of skills, habits, and areas of knowledge that may inexplicably appear, disappear, and/​or be experienced as “not mine” (Dell, 2013). There may be state-​dependent use of substances (e.g., nicotine, alcohol, caffeine) and state-​dependent differences in response to drugs and medications (e.g., a DID patient appears severely intoxicated in one state, and shifts to a state that appears to have no impairment; Loewenstein, 1991). We tend to view DA in DID from the perspective of self-​states that report the DA, or the perplexing experiences of overlap/​interference/​intrusion/​influence (e.g., we say that the patient experienced “out of awareness behavior,” or perplexing “not-​m ine” experiences). From the perspective of the self-​states that engage in “dissociated” behaviors, these are typically “in awareness,” and/​or from the perspective of self-​states experienced as impinging/​intruding, usually they are aware of their “own” perspectives, skills, habits, knowledge, etc. In DID, these characteristic complex states of being must be evaluated from multiple perspectives. Clinically (see Loewenstein, Chapter 47, this volume), this supports the

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idea that successful treatment of DID requires continual empathic attention to the self-​states that appear to take over, intrude, overlap, influence, etc., and are often aware of what they are doing and why.

Conclusion DBST is a powerful translational, transtheoretical, integrative theory, conceptualizing human consciousness from molecules to social systems. DBST describes isomorphisms across psychopathological states and diagnoses as state-​change disorders. The SoB model of trauma-​related dissociation and dissociative disorders, as well as trauma-​and-​stressor-​related disorders is based in data from numerous research domains including alternate states of consciousness, sleep studies, SDLM, and prospective studies on normal and pathological child development, including studies of gene-​environment interactions. These comprise studies of discrete SoB in infants and children, and the relationship of child SoBs and child-​ caregiver interactions. In studies of maltreated and neglected children, type-​D attachment, as well as earlier, repeated, and more severe maltreatment predicts later dissociation in adolescents and young adults. Maternal dissociation itself predicts multigenerational transmission of maltreatment. In addition to these factors, repeated –​typically sadistic –​ unpredictable maltreatment by attachment figures before the age of five to six predicts the core psychopathology in DID: a failure to develop a unified sense of self across states and contexts. All other models of the etiology of DD are conceptualized in terms of disordered SoB but are primarily retrospectively based on studies of traumatized adults. DBST can inspire translational conceptualization and research on the interrelationship, diagnosis, and treatment of many disorders. Mood disorders, stressor-​and-​trauma-​related disorders, dissociative disorders, substance-​related and addictive disorders, suicidal behavior, and non-​suicidal self-​injury are all linked as trauma outcomes. Research using the SoB framework may allow discovery of underlying commonalities, even endophenotypes, among these conditions. This type of research might resolve many issues, including the ongoing argument of whether PTSD is “fundamentally” dissociative or dissociation in PTSD is primarily indicative of a sub-​t ype or component of PTSD (Dalenberg & Carlson, 2012; see Winkler, Burback, Bremault-​Phillips, & Vermetten, Chapter 29, this volume). Finally, DBST raises questions about switch processes themselves as critical variables in the neurobiology of state-​change disorders (Rubinow, 2021), rather than focusing solely on post-​switch states (e.g., mania, depression, self-​state shift, etc.) For example, study of micro-​states and switch processes during treatment of post-​partum depression with a 60-​hour infusion of brexanolone (Meltzer-​Brody et al., 2018) may allow a long enough state-​change “window” to acquire generalizable findings for treatment of all state-​change disorders, including the DD.

Notes 1 In the interest of conciseness, we are not including many technical references. We refer you to the relevant sections of Putnam (2016) for more in-​depth discussion. 2 This brief chapter is not the place to debate these concepts. The DBST model of self, identity and personality does not “explain” everything about these constructs. It does show that state theory can organize disparate data across paradigms to think in a more unified way about terms that are generally used imprecisely and interchangeably. 3 There are data that pathological dissociation may result from a combination of trauma type and timing (earlier and more severe) and genetic factors, (e.g., specific haplotypes of the FKBP5 gene that regulate aspects of HPA functioning). See Becker-​Blease et al., 2004 and Yaylaci et al., 2016. 4 In some studies, Reinders and her colleagues use the DSM-​I V-​T R-​based term “identity state.” 5 Many of these vary together during state changing, e.g., intoxication

References American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders DSM-​5 (5 ed.). American Psychiatric Press. Becker-​Blease, K. A., Deater-​Deckard, K., Eley, T., Freyd, J. J., Stevenson, J., & Plomin, R. (2004). A genetic analysis of individual differences in dissociative behaviors in childhood and adolescence. Journal of Child Psychology and Psychiatry and Allied Disciplines, 45, 522–​532. Brown, D. W., Anda, R. F., Edwards, V. J., Felitti, V. J., Dube, S. R., & Giles, W. H. (2007). Adverse childhood experiences and childhood autobiographical memory disturbance. Child Abuse and Neglect, 31, 961–​969. Calvo, P., Gagliano, M., Souza, G. M., & Trewavas, A. (2020). Plants are intelligent, here’s how. Annals of Botany, 125(1), 11–​28. Conway, M. A., & Pleydell-​Pierce, C. W. (2000). The construction of autobiographical memories in the self memory system. Psychological Review, 107, 261–​288.

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Dalenberg, C., & Carlson, E. B. (2012). Dissociation in Posttraumatic Stress Disorder Part II: How theoretical models fit the empirical evidence and recommendations for modifying the diagnostic criteria for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 4(6), 551–​559. Dell, P. F. (2013). Three dimensions of dissociative amnesia. Journal of Trauma and Dissociation, 14, 25–​39. Drews, H. J., Wallot, S., Brysch, P., Berger-​Johannsen, H., Weinhold, S. L., Mitkidis, P., Baier, P. C., Lechinger, J., Roepstorff, A., & Göder, R. (2020). Bed-​sharing in couples is associated with increased and stabilized REM sleep and sleep-​stage synchronization. Frontiers in Psychiatry, 11(583). Edwards, V. J., Fivush, R., Anda, R. F., Felitti, V. J., & Nordenberg, D. F. (2001). Autobiographical memory disturbances in childhood abuse survivors. Journal of Aggression, Maltreatment & Trauma, 4(2), 247–​263. Fuhrman, N. L., Zingaro, J. C., & Kokenes, B. (1990). A preliminary comparative study of drawings produced under hypnosis and in a simulated state by both MPD and non-​M PD adults. Dissociation, 3, 107–​112. Horowitz, M. J. (1979). States of Mind: Analysis of Change in Psychotherapy. Plenum. Kim, K., Trickett, P. K., & Putnam, F. W. (2010). Childhood experiences of sexual abuse and later parenting practices among non-​ offending mothers of sexually abused and comparison girls. Child Abuse and Neglect, 34, 610–​622. Kluft, R. P. (1985). The natural history of multiple personality disorder. In R. P. Kluft (Ed.), Childhood Antecedents of Multiple Personality (pp. 197–​238). American Psychiatric Press. Laddis, A., & Dell, P. F. (2012). Dissociation and psychosis in dissociative identity disorder and schizophrenia. Journal of Trauma and Dissociation, 13, 397–​413. Frewen, P. & Lanius, R. (2015). Healing the Traumatized Self: Consciousness, Neuroscience Treatment. Norton. Loewenstein, R. J. (1991). Rational psychopharmacology for multiple personality disorder. Psychiatric Clinics of North America, 14, 721–​740. Loewenstein, R. J. (2020). Firebug! Dissociative identity disorder? Malingering? Or …? An intensive case study of an arsonist. Psychological Injury and Law, 13, 187–​224. Loewenstein, R. J., Frewen, P. A., & Lewis-​Fernández R. (2017). Dissociative Disorders. In B. J. Sadock, V. A. Sadock, & P. Ruiz (Eds.), Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (10th ed., Vol. 1, pp. 1866–​1952). Wolters Kluwer/​Lippincott Williams & Wilkens. Meltzer-​Brody, S., Colquhoun, S., Riesenberg, R., Epperson, C. N., Dligiannidis, K. M., Rubinow, D. R., Li, H., Sankoh, A. J., Clemson, C., Schacterle, A., Jonas, J., & Kanes, S. (2018). Brexanolone injection in post-​partum depression: two multicentre, double-​blind, randomised, placebo-​controlled, phase 3 trials. The Lancet, 392(10152), 1058–​1070. Prechtl, H. F. R., & O’Brian, M. J. (1982). Behavioral states of the full-​term newborn. The emergence of a concept. In P. Stratton (Ed.), Psychobiology of the Human Newborn (pp. 53–​74). John Wiley & Sons. Putnam, F. W. (1997). Dissociation in Children and Adolescents: A Developmental Model. Guilford. Putnam, F. W. (2016). The Way We Are: How States of Mind Influence Our Identities, Personality, and Potential for Change. IUP. Reinders, A. A., Willemsen, A. T., den Boer, J. A., Vos, H. P., Veltman, D. J., & Loewenstein, R. J. (2014). Opposite brain emotion-​regulation patterns in identity states of dissociative identity disorder: a PET study and neurobiological model. Psychiatry Research: Neuroimaging Section, 223(3), 236–​243. Reinders, A. A., Willemsen, A. T., Vissia, E. M., Vos, H. P., den Boer, J. A., & Nijenhuis, E. R. (2016). The psychobiology of authentic and simulated dissociative personality states: The full monty. Journal of Nervous and Mental Disease, 204, 445–​457. Rubinow, D. R. (2021). One small step for PMDD, one large step for affective disorders. American Journal of Psychiatry, 178(3), 215–​217. Şar, V., Unal, S. N., & Ozturk, E. (2007). Frontal and occipital perfusion changes in dissociative identity disorder. Psychiatry Research, 156, 217–​223. Simeon, D., Guralnik, O., Schmeidler, J., Sirof, B., & Knutelska, M. (2001). The role of childhood interpersonal trauma in depersonalization disorder. American Journal of Psychiatry, 158, 1027–​1033. Staniloiu, A., & Markowitsch, H. J. (2014). Dissociative amnesia. The Lancet Psychiatry, 1, 226–​241. Sullivan, H. S. (1953). The Interpersonal Theory of Psychiatry. Norton. Wager, N. M. (2011). Psychogenic amnesia for childhood sexual abuse and risk for sexual revictimisation in both adolescence and adulthood. Sex Education, 12(3), 1–​19. Wolff, P. H. (1987). The Development of Behavioral States and the Expression of Emotion in Early Infancy. University of Chicago Press. Yaylaci, F. T., Cicchetti, D., Rogosch, F. A., Bulut, O., & Hetzel, S. R. (2016). The interactive effects of child maltreatment and the FK506 binding protein 5 gene (FKBP5) on dissociative symptoms in adolescence. Development and Psychopathology, 29(3), 1105–​1117. Zwir, I., Arnedo, J., Del-​Val, C., Pulkki-​R aback, L., Konte, B., Yang, S. S., Romero-​Zaliz, R., Hintsanen, M., Cloninger, K. M., Garcia, D., Svrakic, D. M., Rozsa, S., Martinez, M., Lyytikainen, L. P., Giegling, I., Kahonen, M., Hernandez-​Cuervo, H., Seppala, I., Raitoharju, E., . . . Cloninger, C. R. (2020). Uncovering the complex genetics of human temperament. Molecular Psychiatry, 25(10), 2275–​2294.

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17 THE PERCEPTUAL THEORY OF DISSOCIATION Donald B. Beere

The Perceptual Theory of Dissociation (PTD; Beere, 1995a; Beere, 2009a; Beere, 2009b) emerges from the philosophical world-​v iew of phenomenology (Husserl, 1931/​1962) and combined with the Self System theory (Sullivan, 1956) is used to explain the dissociative disorders. The phenomenological approach is to “go to the experience” and, when applied to dissociation, shows that perceptual changes distinguish different kinds of dissociation. A phenomenological analysis (Husserl, 1931/​1962; Giorgi, 1985) educed a model that explains how dissociation occurs. The analysis revealed that perceptual components of the background (i.e., identity, mind, body, world, time) were automatically blocked out and, as a result, not integrated into current perception, which leads to dissociation. The concept of the background derives from the perceptual phenomenology of Merleau-​Ponty (1962) and its components map isomorphically onto dissociative phenomena. The PTD model for how dissociation occurs predicted new dissociative phenomena and generated hypotheses supported by empirical tests. Perceptual experiments supported the fundamental hypothesis of the theory that individuals with dissociative traits are less influenced by the background. When applied to psychotherapy the PTD creates a new and effective clinical intervention called “Personification.”

The Explanatory Mechanisms of Dissociation: The Perceptual Theory The most elemental Gestalt principle is organizing perception into figure and ground: The figure is what is perceived, and the ground surrounds yet recedes ‘behind’ the figure, for instance looking at a computer (figure) surrounded by books, stationary, and papers (ground). Perceiving figure-​in-​g round is both dissociative and associative. The figure is dissociated from the ground and the figure becomes the figure via association. For example, looking out a window there is an overlapping group of eight trees. First, the trees appear as a unit or group, and then a single tree separates from the group and becomes the figure, while the other trees become the ground, receding behind the single tree. Consciousness brings the “group of trees” together via association as a cohesive grouping. Consciousness associates the visual stimuli into the “single tree” and the tree separates, dis-​a ssociates, from the other trees which then become the ground behind and around the single tree. Although this conceptualization does not explain dissociative reactions, Beere (1995a & 1995b) has shown that dissociative symptoms are perceptual experiences and has provided an explanation for how dissociative reactions arise from trauma. Perception should be a foundational concept in understanding dissociation, and Fine (1988), for example, asserted that the cognitions and affects of persons with Dissociative Identity Disorder (DID) stem from a dysfunctional perceptual organization. The essential diagnostic criteria for DID are: two or more distinct dissociative identities; amnesia for important events and daily life; distressed about or having difficulty with current functioning; the individual’s functioning is inconsistent with their culture or religion; and the disruptions are not the result of substances or a medical condition (American Psychiatric Association, 2013). An individual’s single identity can be construed as a perceptual construct, and, therefore, multiple identities reflect a deviation in normative perception. Amnesia can be understood

DOI: 10.4324/9781003057314-21

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as remembered experiences that cannot be integrated into a particular personality’s lived-​world and are therefore inaccessible. In Phenomenology of Perception, Merleau-​Ponty (1962) proposed five essential components of experience. First, there is always an “I” or “identity” who “perceives” the “figure” in a “ground.” Second, the “I” is always in a “mind.” Wherever there is a mind, there is an associated “body;” and wherever there is an embodied person, there is an associated mind. Thus, third, “I” am in a body. Fourth, my embodiment is in the world. The “world” is not an objective reality; it is subjective, meaning-​fi lled and designated the lived-​world. Fifth, all perception occurs in and over time: The present moment comes from a past which leads to a future. These five components (I, Mind, Body, World, Time) comprise a background framework for all perceptual experience; we take this underlying organization of perceptual experience (i.e., figure-​ ground-​background) for granted. The term background, as distinct from ground, defines these ever-​present and essential components of the perceptual framework. Experience generally presents itself whole and has this basic perceptual structure: I, having this mind, in this body, in this world, all of which are in time, perceive this figure in this ground. Everyday experience is a constant flow of different figure/​g round/​background perceptions. Yet, even though perception flits continually across a myriad of foci, from a thought to a sensation in the foot and then a creak from behind followed by the sight of words on a computer screen, experience flows largely uninterrupted and complete; a unified whole. Thought, sound, sight, smell, touch, movement and proprioception are seamlessly brought together. This captures what in phenomenology is called “the constituting character of consciousness,” namely that all experience is “constituted” in, through and as consciousness. Consciousness organizes this whole and each figure (a specific perception) occurs with time, world, body, mind, and identity in the background.

Dissociation and its Domain Recognizing the background in perception clarifies what happens during dissociation –​the background is lost or loses constancy. The lived-​integration, the association, of figure-​g round-​background makes up meaningful lived-​experience; during dissociation, this meaningful lived-​integration is ruptured. When dissociation occurs, the association (or integration) between domains (time, world, body, mind, identity) is dis-​associated (or dis-​i ntegrated). Consequently, everyday experience, what most would call reality, is profoundly altered and disturbed in its alignment with the background element affected. Examples of possible dissociative experiences that might occur in these domains include identity shifting locations and the person seeing the body from above; not feeling like themselves; feeling robotic, distant or unconnected. Mind seems unreal or empty; and thoughts are slowed, quickened, or experienced as not-​m ine. Body seems distant, acting on its own, disappearing, feeling larger, smaller, or numb. World is unreal, dream-​like, more distant, larger, smaller, mechanical, in a tunnel, blurry, shiny, or fuzzy. Time might stop, slow down or speed up. Dissociative experiences can occur from a variety of causes: drugs, neurological problems, trance inducing practices, meditation, psychological difficulties, or trauma. The previous paragraph describes the domain of dissociative experiences. Dissociative reactions are dissociative experiences arising during, and in response to, a specific situation. Thus, experiencing one’s body as unreal during an earthquake is a dissociative reaction. Dissociative symptoms are enduring or repeated dissociative experiences that continue to occur when no apparent external situation is occurring. So, recurrent experience of one’s body as unreal (when there are no current precipitating situations) is a dissociative symptom –​and often evokes an unsettling, emotional reaction, experienced as unreal, weird, uncanny, eerie, bizarre, or strange. Dissociative symptoms and reactions map isomorphically onto components of the background (see Table 17.1). Identity, for example, maps to fugue and dissociative identity disorder. Mind maps to depersonalization. Body maps to depersonalization. World maps to derealization. Amnesia, a post hoc “symptom,” is not a perceptual phenomenon and will be explained in a later section devoted to the Dissociative Disorders. Dissociative reactions will now be examined. TABLE 17.1  Relationship between loss of or change in the specific component of the

perceptual background and dissociative symptoms and disorders 1 Component lost or changed

Dissociative Disorder

“I” or Identity Mind Body World Time

Fugue; Multiple Personality Disorder Depersonalization; Amnesia Depersonalization (Disembodiment) Derealization Changes in experienced time (Detemporalization)

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The Experiential Structure of a Dissociative Perceptual Reaction During Threat During trauma (Beere, 1995a), a person focuses on the threat so completely that perception of the background components are blocked, evoking a dissociative experience. Dissociation occurs because the figure becomes the exclusive focus of attention; when this occurs, the background fades, changes, or is lost. This narrowing of perception can be called a hyperfocus.

A Percept “of Determining Significance” Hyperfocusing occurs when the percept has determining significance. This section provides an explanation for a concept not amenable to succinct definition. Beere (1995a) used an eidetic reduction (a type of phenomenological analysis) to understand dissociating during a threat for the first time. The results indicated that attention hyperfocuses and, as a result, background domains drop out or degrade. The hyperfocus is on “a percept of determining significance,” an idea for which there is no English equivalent. Some adjectives, such as significant, meaningful, important, emotional, powerful, or impactful might fit the situation although they do not capture the concept explaining hyperfocusing. What might lead an individual to hyperfocus? The focus of attention (the object, feeling, sound, or event) must be “of determining significance,” namely, an experience (a percept) whose meaning determines how an individual constitutes identity, mind, body, world or time. The “determining percept” might threaten, deconstruct or enhance/​extend/​elaborate the meaning of an individual’s existence. Using more colloquial language, the reason perception hyperfocuses is that the percept is personally significant (of determining significance) –​but the words “personally significant” do not capture the essential meaning from a PTD perspective. One might say that the hyperfocus could reveal to the individual an underlying facet of the person’s existence-​a s-​constituted, part of its underlying meaningful structure. For example, a gun has determining significance since death would undo the target’s existence. The gun acquired that significance during the pointing. One way to understand “determining significance” is that the percept in hyperfocus has a determining role in the constitution of an individual’s existence –​the way in which identity, mind, body, world and time are constituted. Hyperfocusing on the gun (World) would lead to depersonalization (blocking Mind or Body). A second example. The author lived in Minneapolis and frequently crossed one of the bridges. A few years after he moved, it collapsed while traffic was driving over it, dropping cars into the river and killing people. He briefly depersonalized on learning about this. That bridge was a solid reality; its collapse temporarily deconstructed the way he had constituted the world. In subsequent sections, research will be described in which dissociative perception is expanded to situations that are positive and personally significant.

General Principles Involved in Dissociation Traumatic situations that evoke dissociation need not be physically painful, ‘objectively’ intense, or sudden. To elicit a dissociative reaction, a threat needs to be of sufficient importance (the precise phrase is “of determining significance” –​see below) that it so focuses perception that background components are lost. In a traumatic situation, when the locus of threat is in one domain of the background, that domain is not dissociated. Conversely, the background domains that do not contain threats are likely to evince dissociative reactions. For example, if the body is under threat during a trauma, Mind, World and Time may be blocked or distorted (i.e. dealt with dissociatively) leading to depersonalization (blocked Mind), derealization (blocked World) or time alterations (blocked Time). Dissociation occurs spontaneously as an artifact of the hyperfocus and is not under conscious control.

A Continuum of Dissociative Complexity Dissociative phenomena vary in their complexity. For example, a dissociative identity is a complex dissociative phenomenon that probably could not result from a single trauma; dissociative identities require substantial preparatory experience and psychological mediation. An alteration in perceived time involves changes in the perception of sequences of events as they occur; this immediate response requires less complex psychological processing than that required for the creation of a dissociative identity. These two dissociative reactions lie at the opposite extremes of a continuum of psychological complexity.

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Research Supporting the Perceptual Theory Frequency and Complexity of Dissociative Reactions Based on the PTD, the author hypothesized that dissociative reactions which are more psychologically complex will occur less frequently, and that dissociative reactions which are less psychologically complex will occur more frequently (Beere, 1995a). For example, changes in body-​experience during trauma should occur less frequently than changes related to the world and mind. The theory predicts this because the body is a stable and consistent source of perceptual input; as a perceptual “constant,” the body is resistant to change. To experience a change in the size or shape of the body requires a marked alteration in perceptual processing and requires greater “force” than to change perception of the world or mind. World-​linked perception involves the continuous processing of incongruities (e.g., inconstancies of size and color). Distant objects stimulate small areas of the retina in contrast to similar, closer objects, which stimulate larger areas, yet both are perceived equal in size. The world as a percept is less “constant” or “stable” relative to the body and, as a result, should require less “force” to alter. Finally, the “mind” has no external stimuli that can provide stability, constancy, or consistency. The theory predicted that mind-​related perception should be easiest to alter. In keeping with this principle of complexity, the responses of 189 participants showed that the percentages reporting 15 specific dissociative reactions during trauma were consistent with predictions based on the PTD (Beere, 1992 & 2009a). The frequency of trauma-​evoked changes in perception of the body (e.g., body numb or not-​m ine; 12%) was lower than changes in perception of the world (e.g., objects appeared larger or smaller; 24%); which in turn was lower than changes in the experience of the mind (e.g., feel unreal or not like myself; 36%). These results support a continuum of dissociative complexity. The dissociative reactions that are least frequent require more “force” to create. As a result, more severe and more frequent traumas create the least frequently occurring dissociative reactions: Changes in identity (development of dissociative identities) would require the most number of and most severe traumas while changes in the experience of time would require the least number of and least severe traumas. Yet, actual traumatic situations seldom affect just the body, or just the world, or just the mind. Traumatic situations and their evoked dissociative reactions usually affect several domains of the background simultaneously.

The Relationship of Dissociative Reactions to the Focus of Perception Beere (1995b) tested the relationships between perceptual focus during a traumatic event and the ensuing dissociative reaction. College students reported (1) how often they had been traumatized, (2) whether they had experienced specific dissociative reactions during those traumas (e.g., time slowing, objects appearing far away, changes in body size, feeling as if in a dream), and (3) the background domain of the traumas. They also indicated whether they had ever experienced the same list of dissociative reactions when they were not experiencing a trauma. Reports of dissociative reactions by students who experienced only one trauma were compared with the reports of students who reported no traumas. Data from these non-​t raumatized students provide a baseline for the frequency of non-​traumatic dissociative reactions. The author emphasizes that individuals reporting no trauma did report dissociative experiences. This finding recurs several times in subsequent pages and raises significant issues for understanding dissociation since it occurs in non-​t raumatic contexts. Findings supported the PTD and lead to three conclusions: (1) as predicted, when perception of the background is lost or altered during trauma a dissociative reaction occurs; (2) specific, perceptual dissociative reactions occur in domains (body, world, mind, identity) in which the trauma did not occur; and (3) some trauma-​evoked dissociative reactions do not appear to be defensive; instead, they simply reflect an artifact of a perceptual hyperfocus on the traumatic threat.

Temperamental Traits and Blocking Out the Background Beere and Pica (1995) tested the hypothesis that specific temperamental traits are associated with blocking out the background, which might make dissociative reactions more likely in those with such traits. Three hypotheses about temperament were proposed: (1) distractibility correlates with dissociativity; (2) the ability to pay attention does not correlate with dissociativity; and (3) Flexibility/​R igidity correlates with dissociativity. The correlation between Flexibility/​ Rigidity and the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986) showed that high dissociators were unresponsive to changes in the environment; they persisted in their prior mode of response. In this regard, they are less adaptive and less flexible than non-​d issociators. In addition, high dissociators did not have regular daily habits (i.e., responses to tiredness, hunger, or need to toilet), probably from blocking out bodily cues. Finally, distractibility and attention are closely related (in order to attend one must inhibit distractions), but blocking out the background was a different perceptual process than inhibiting distractions, suggesting that dissociativity derives from a different perceptual process than being distractible. Overall, results support the basic view that dissociators block out background stimuli.

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Dissociation in Significant Situations Beere, Cooper, Pica, and Maurer (1997) tested the hypothesis that individuals will hyperfocus in situations that are personally significant to them, making dissociation more likely. Consistent with this idea, a significantly higher percentage of intrinsically religious college students (i.e., those who experience their religion as personally meaningful) reported more prayer-​related dissociative experiences than did extrinsically religious individuals (i.e., those who engage in religious activities for ulterior motives). Participants who did and did not report prayer-​related dissociative experiences did not differ in general on their dissociation scores. This result supports the PTD’s contention that dissociation occurs during hyperfocusing of attention and need not be traumatic. Furthermore, as hypothesized by the theory, dissociation is a byproduct of this hyperfocus and not inherently a defense or coping mechanism.

Dissociation in Positive Situations Based on the PTD, Beere (1995a) hypothesized that dissociation would occur during positive and non-​traumatic situations. Two studies, extensively discussed in Beere (2009a), substantiated this. In the first study (Pica & Beere, 1995) both low and high dissociators reported dissociating during positive situations, such as sports, sexual encounters, or being in nature (37%). If dissociation is traumatically-​induced, no subject should have reported dissociation in such situations. In addition, participants wrote a description of dissociating during their positive experience. Phenomenological methods (Giorgi, 1985) educed the experiential structure of the dissociative experience. In keeping with Beere’s (1995a) PTD, positive dissociative experiences occur during an intense, lived-​situation of considerable personal significance. At this time, perception narrows to just those aspects of the lived-​situation which carry its meaning for the person –​and the person dissociates. This finding provides additional validation for the psychological mechanism leading to dissociation. The second study (Beere, Pica & Greba, 1996) replicated the prior one and found as predicted that a significantly higher percentage of participants (76%) reported dissociation in at least one positive experience. Moreover, 52% reported dissociation in two or more positive experiences. Participants in the first study, relying on recall, wrote down a list of situations in which they had dissociated while participants in the second study selected from a list, developed by the researchers, of many situations in which dissociation might have occurred. These findings strongly support (a) the occurrence of dissociative experiences during positive events and (b) Pica and Beere’s (1995) assertion that dissociation is “a more widely occurring phenomenon than an adaptive or defensive response to trauma” (p. 244).

Perceptual Experiments The previous sections examined the psychological mechanism leading to a dissociative reaction as hypothesized by the PTD. Does this same mechanism characterize individuals who possess a dissociative trait? If so, then individuals with dissociative symptoms should have an even stronger capacity not to notice the background. Beere, Pica, Maurer and Fuller (1996) conducted three experiments to test this fundamental assumption that dissociators block out the background. The theory posits that, even in the absence of hyperfocusing, high dissociators more readily block out background influences than low dissociators. An extensive presentation of these findings can be found in the original papers or in Beere (2009a). Only two of these studies will be summarized here. The Embedded Figures Test (EFT) The EFT (Witkin, Oltman, Raskin, & Karp, 1971) involves finding a geometric figure (e.g., rectangles, polygons, and diamonds) in a complex, colored design made of multiple, overlapping geometric figures. The EFT measures psychological differentiation assessed by whether a person is more field independent (more easily ignores influences from the overall gestalt when finding a hidden figure) or field dependent (has difficulty ignoring influences from the overall gestalt when finding a hidden figure). Each trial lasts no more than 180 seconds; the time recorded to find the designated figure is the individual’s score for that task. The faster that the participant performs, the more field-​independent; the slower the participant performs, the more field-​dependent. The EFT should accurately measure a participant’s capacity to block out irrelevant and confounding cues, and, therefore, the background. On first considering this task, the reader might see no connection with blocking out the background. The explanation derives from the test’s development. The EFT is an easily administered substitute for the Rod-​and-​Frame Test which overtly assesses the influence of the background. In Witkin’s perceptual experiment (Witkin & Asch, 1948), the participant sat in a chair tilted to the right or left in a darkened room. The only visual input was a lighted rod centered in

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a lighted frame, both of which were tilted (in other words not vertical). The participant’s task was to align the rod with the gravitational vertical. The participant had the following sensory input: kinesthetic and vestibular (the tilted chair) and visual (the tilted frame). The tilted frame and chair provided confounding input. The Rod-​and-​Frame Test assesses the influence of the background: figure [rod], ground [frame], and background [vestibular sense; i.e., body]. Since the EFT was developed to substitute for the tilted Rod-​and-​Frame Test, it should provide a measure of a participant’s ability to block out the background. Consequently, the author predicted that high dissociators would block out the background more effectively than low dissociators and obtain a significantly faster score. The EFT was administered to 69 college students, and the results supported this prediction.

The Necker Cube (NC) The NC is a reversible figure that shows the outer edges of a cube. As an individual looks at the figure, it periodically reverses perspective so that different faces are in front. Participants tap a pencil on the table each time the figure reverses perspective. Necker cubes with 3/​4 inch sides were drawn in the center of two 5-​inch-​square cards with the sides of the cube parallel to the edges of the card. In the diamond or perceptually unstable condition, the card was rotated 90 degrees. The task matches the theory being tested: the cube face is the figure, the rest of the cube is the ground, and the card outline is the background. Supporting the hypothesis non-​clinical high dissociators (N=​14) reported significantly fewer reversals in both the stable (square) and the unstable (diamond) conditions than low dissociators (N=​31). High dissociators did not significantly change their number of reversals from the square to the diamond conditions, but the low dissociators did. In other words, the high dissociators were less influenced by the cube’s reversals and less influenced by the unstable background –​they blocked out the background. Conclusions from the Perceptual Experiments These experiments yielded significant differences between high and low dissociators as predicted by the theory. Overall, these results strongly support the extension of the psychological mechanism for dissociation to individuals with dissociative traits: Dissociators, when not hyperfocusing, block out background stimuli. As well, these results can be extended to individuals with dissociative symptoms who should also block out background stimuli.

Summary This section began with the philosophical foundation of the PTD which demonstrates that dissociation is perceptual in nature. All perception is organized into figure-​g round-​background where background includes the following ever-​present features –​identity, mind, body, world and time. A phenomenological analysis revealed a psychological mechanism that produces dissociation during threat: Attention hyperfocuses on a percept of determining significance for the individual which leads to a blocking out of background domains and the experience of dissociation occurs. The mechanism explains why dissociation is both spontaneous and involuntary. This model of dissociation yielded a series of hypotheses supported by empirical tests. The complexity and frequencies of dissociative reactions in different domains of the background (i.e., body, world, and mind) were predicted and explained by the theory. As predicted, the background domain of focus during the trauma inversely connects with the kind of dissociation that arises in the other background locations. Dissociation is specific and not global. The theory predicted and confirmed that dissociation occurs in personally significant situations regardless of emotional tone. Providing additional validation for the psychological mechanism, a phenomenological analysis of descriptions of dissociation in positive situations yielded the identical psychological mechanism as originally presented in the trauma-​ related theory. Research supported the extension of the psychological mechanism for dissociation where individuals with dissociative traits blocked out background stimuli more effectively. The research garnered to date that support the PTD and the psychological mechanism leading to dissociation allow the following conclusion: During dissociative perception, the individual hyperfocuses on a situation of determining significance for the individual and dissociation arises in the non-​focused and blocked out background domains. For example, an external threat such as an attacker or hurtling automobile (a percept in the World background domain) would lead to depersonalization (a loss or degrading of the Mind or Body background domains).

The Perceptual Theory of Dissociative Disorders The previous section emphasized research examining the psychological mechanism proposed by the PTD that leads to dissociation. In this section, the overarching conceptual structure of experience, used in the previous section as a

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framework to explain dissociative perception, will be used to account for dissociative disorders. This will involve a shift from a detailed focus on dissociative perception to theoretical issues such as identity and world-​v iew, depersonalization, derealization, amnesia, and dissociative identities.

The Dissociative Disorders: The Self System as Mechanism The PTD proposed that the domain of dissociative pathology has three foci: depersonalization and derealization, amnesia, and dissociative identities. The following presents a theoretical explanation of these phenomena using concepts derived from the PTD and from ideas in phenomenological philosophy. Sullivan’s (1956) concept of the Self System dovetails with essential concepts in phenomenology and will be extrapolated to explain dissociative pathology. How phenomenological philosophy (Husserl, 1931/​1962) conceptualizes consciousness subsumes the Self System. All experience –​identity, the world and its constituents (i.e., inanimate objects and living beings), my body, my mind, and the experience of time –​are created in consciousness, from consciousness, and through consciousness (Merleau-​Ponty, 1962; See Figure 17.1). To emphasize this point, my identity –​who I am –​is not created by me. Rather, I, as I know myself, am constituted in, through and as consciousness. Sullivan (1956) approximates the constitution of identity in consciousness with the Self System which creates the “I,” the “other,” and the relationship between them. Though not an aspect of his theory, the Self System, as conceptualized here, also constitutes all aspects of the background. Taking a different conceptual standpoint, from a neuropsychological perspective, everything we experience must be “created” in the brain. All neurological input must be integrated into the various details we experience, whether they consist of external objects, our bodies, our minds, or our identities. The next section explains how dissociative reactions can become dissociative disorders.

Depersonalization/​Derealization Disorder as a Conditioned Dissociative Reaction Can dissociative perception, blocking out the background by focusing solely on one critical aspect of the situation, occur in the absence of environmental situations of determining significance? Yes. Such a dissociative perception would have an earlier origin in trauma when a reactive perceptual dissociation occurred. Those specific perceptual dissociative experiences (i.e., the world looking foggy; objects appearing larger or smaller; time speeding up or slowing down; experiencing one’s body as distant, not mine, or mechanical) were conditioned to specific cues in that traumatic situation. Subsequent encounters with those cues evoke the linked dissociative perceptual experiences. When dissociative perceptual experiences occur in this context, they are dissociative symptoms, rather than dissociative experiences. Specific dissociative symptoms, therefore, are often learned perceptions evoked by specific cues. This conclusion derives also from the author’s clinical experience. Besides the above external cue-​linked explanation of dissociative symptoms, there is also a state-​linked explanation. When an individual re-​experiences a state in which a dissociative experience previously occurred, that state evokes the same dissociative experience –​which is now properly considered a dissociative symptom. The trigger could be an emotion, a motivation or a somatic state, such as hope, exhaustion, sexual arousal, or starvation. As an example of cue-​linked derealization, a client discussed losing his job and felt more and more derealized. This sense of personal distance and unreality originated during the original experience of being fired. Discussing the experience in session re-​presented, as memories, the cues in the original situation linked to the dissociative state which, in turn, evoked in the present the dissociation of distance and unreality he had experienced. In hyperfocusing on the thoughts and emotions he had about being fired (Mind and Body), he blocked access to the background feature of the World and derealization ensued. Notice that dissociation takes place spontaneously and involuntarily. Although clients might say they are chronically depersonalized or derealized, in the author’s clinical experience these dissociative symptoms come and go. Clients notice the dissociative symptoms, but rarely notice their variability. After

Inherent action of consciousness

Essential structures of perception

CONSCIOUSNESS constitutes

IDENTITY MIND BODY WORLD

in and over TIME

FIGURE 17.1  The essential structures of all perception according to the PTD Source: see Merleau-​Ponty, 1962

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tracking symptoms, clients begin to realize that specific stimuli or contexts precede the dissociation. These stimuli need not be external. Thinking about the car accident or hearing sirens might evoke the dissociative symptom. Similarly, physical states, such as anxiety, over-​caffeination, or a startle might evoke the symptom. Some clients have such extensive trauma histories that they seem to encounter almost continual triggers. Alternatively, non-​pathological dissociative experiences can arise for meditators who have learned to focus perception such that dissociation occurs.

Depersonalization/​Derealization Disorder and the Self System This section introduces the concept of the Self System, an expansion of Sullivan’s (1956) concept, as a structuring of consciousness that provides a different explanation from the previous section on depersonalization/​derealization disorder. Depersonalization and derealization can result from a Self System that excludes specific experiences. According to Sullivan (1956), the Self System is the inner structuring of awareness that establishes me-​you relationships to maintain security, self-​esteem and reduce anxiety. There are good and bad aspects of the “me” that reciprocally interrelate with good and bad “you’s” such that there are various me-​you relationships. Certain experiences fall outside the boundaries of what has been incorporated into the Self System and are deemed “not-​me.” When a not-​me experience arises, one might say “That just wasn’t me” and feel what Sullivan called “uncanny emotion” –​for example, awe or horror. Symptoms of depersonalization and derealization can be reactions to not-​me experiences. When dissociative symptoms occur, they are experienced as bizarre or weird because they fall outside the set of experiences associated with the Self System. Using Sullivanian terminology, these experiences have not been integrated into this person’s Self System. Not-​me experiences fall outside the Self System. Phenomenologically, consciousness constitutes all experience in, through and as consciousness (Beere, 1995a; Merleau-​Ponty, 1962). Thus, identity, mind, body, world, and time are constituted in, through and as consciousness. Merleau-​Ponty’s comprehensive model of experience subsumes all Sullivanian concepts. The Self System, as conceived within the PTD, structures how I view myself and others, my body, world events, and what will and can happen over time. Stated differently, my beliefs about who I am, how others are, the nature of reality, my religious beliefs, what is possible for me individually, in relationships or in my work are all contained by, and constituted within, this Self System. Note that, within consciousness, there can be multiple Self Systems, a topic addressed in a later section. Cognitions and attitudes are clearly Mind or I domain experiences. Beliefs, anticipations, and expectations are ostensibly the same since these are mental phenomena. Consider, however, religious beliefs. For many people, they structure how they view other people, how they participate in social groups and how they understand the natural world. Consider, as well, anticipation. Going to an excellent restaurant most anticipate that a host will greet and then seat them after which they will enjoy a great meal. Though the anticipation of these events is supposedly cognitive, it structures how the individual experiences entering the restaurant, awaiting the welcome, the trip to the table and then the meal. The anticipation suffuses almost all aspects of the experience. And, finally, consider expectations. A student has the expectation of going to college and then working at a job. This expectation stretches out in his or her experienced horizon of time. The lived-​world is organized in terms of this expectation. The point in this set of observations has to do with the difficulty in consistently specifying the background domain of how the Self System organizes experience. A Self System limits what ought to be experienced. This limitation defines this specific individual who relates in particular ways to others, has these specific beliefs and attitudes, engages in particular actions, and feels a range and variety of emotions. Being born at a particular time in history or to a specific ethnic group also limits who and how an individual will become. These limitations define an individual’s existence as this and not that. Consciousness is more all-​encompassing than the Self System and includes more than what becomes a limited and particular person. The limits of consciousness in Figure 17.2 are drawn in an amoeba-​l ike fashion to show its boundaries (e.g., range of perceivable light, sound, kinds of tactile input, or beliefs and opinions). This represents the scope of what is possible for, in, and through consciousness. Consciousness has its own boundaries and limitations. For example, sight and hearing work only within certain limits. Consider, a person’s beliefs, opinions or conclusions about anything at all. Many options exist, but most individuals only espouse one and will defend it vehemently. Figure 17.2 represents the Self System with an ellipse enclosing identity-​m ind-​body-​world and represents the experiential limitations inherent with the Self System. The Self System establishes what is of determining significance for the individual. Using different words, core beliefs about identity, mind, body, world and time determine (define or establish) an individual’s existence-​a s-​constituted. Experiences of determining significance connect to those core beliefs and when they coincide with hyperfocusing are likely to evoke dissociative perceptual experiences. In the context of the PTD, “not-​me” should more accurately be labelled “not-​included-​in-​existence-​as-​constituted” but that is awkward phrasing. As a result, not-​me will be used in its place. In elaborating the significance of the not-​me,

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F I G U R E 17. 2   The

essential structures of all perception according to the PTD

Source: see Merleau-​Ponty, 1962

experiences in this region are so discrepant from how the Self System has been organized that, from its perspective, they cannot exist. In this regard, not-​me experiences possess a powerful significance such that they undermine the essential organizing structures of the Self System. Following are a few examples outside a person’s Self System and therefore, not-​me. A pacifist experiences murderous rage, an emotion (Body and Mind). A person witnesses someone hacked to death (World). A person sees a skyscraper crumble to the ground (World). A person suddenly discovers they despise a relative (Mind). A person wants to do something taboo (I). In this regard, then, not-​me experiences have a determining significance that negates aspects of the Self System; in the present context, then, they have a negating determining significance. What happens when an individual has experiences outside the limits of his or her Self System? Unlike consciousness that limits what is possible to experience, the Self System limits what ought to be experienced. When experiences lie outside the boundaries of the Self System depersonalization or derealization ensue. From the perspective of the Self System, these experiences are not-​me and elicit uncanny emotion due to a hyperfocusing on that not-​me experience. If the not-​ me experience is internal, about me, my thoughts, my emotions, then derealization occurs. If the not-​me experience is external, in the world, then depersonalization occurs. Notice that the dissociation is spontaneous and involuntary.

Example My client was an accountant: Logical, organized, and hard-​working. This established the limits of his Self System. He referred himself for treatment because of depersonalization. From his point of view, he had done everything required to get promoted, even if it seemed unfair or, to my ears, hostile and undercutting. He tried to be unflaggingly upbeat. When an action by his supervisor would have evoked anger from almost anyone, he felt no anger. As homework, I asked him to record his experience of dissociation. When did it occur? Where and how did it come and go? What was the dissociative experience? Before doing this assignment, he claimed that the depersonalization was constant. Several weeks later, however, he had discovered that his level of dissociation varied from situation to situation, and he had become less dissociated at home. His depersonalization was associated with conflictual situations at the office, where he was treated unfairly and undermined. In session, I accepted and reflected back to him his work environment. He began to notice what was negative if not assaultive; details he had previously not perceived based on his Self System. In successive weeks, he reported irritation and anger, emotions associated with his new perception of the work environment; concomitantly the intensity of his depersonalization diminished and, at times, remitted. As he integrated negative emotion into his Self System, his dissociation diminished. Then he was passed over for promotion, which exacerbated his depersonalization and activated derealization. At this moment, the boundaries of his Self System quickly became more apparent. The changes he had made prepared him to “see” his situation more clearly and to have more intense emotions. This logical, “good,” and fair-​m inded man was confronted by rage (Body, Mind), an emotion discrepant from how he was constituted. Simultaneously, he was confronted by his lived-​belief in fair and just treatment, his lived-​belief that hard and good work has a just reward, and his lived-​belief that being assertive and angry are counterproductive (World). He did not like having emotions; they were not just disconcerting, but difficult to experience. He was beset by both depersonalization and derealization since his not-​me experiences occurred in a variety of domains. As he integrated these new experiences into his understanding of himself (good work does not always pay off ), others (people will not always be fair), and the world ( justice does not always occur), his depersonalization and derealization diminished and he felt consistently real.

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Amnestic Disorders and Abreactions What happens when amnesia lifts, especially when reliving a previously amnestic trauma, opens a window to a theoretical understanding that is outlined in this section. Amnesia for a trauma comes about because its representation has not been integrated into the person’s Self System. As a result amnesia is always associated with dissociative identities, where there are separate Self Systems in operation. Thus, understanding amnesia and abreactions will link to the subsequent discussion of DID. The following clinical example introduces several concepts discussed below. Early in therapy, my client re-​lived a violent rape, perceiving my office as a field and seeing the rapists as present. Though she responded to my words during the reliving, I later discovered that my words had become “included” as part of the re-​experienced rape. After the reliving ended, she had no memory for the reliving nor the rape from her past, and claimed that during the reliving she had gone on a walk and then returned to the office. On later occasions, she again relived the rape triggered by recollections of specific rape-​preceding details. Still later, after working through the rape, she recalled it as a past event, did not relive it, and could discuss it. Notice that this trauma, as well as most others, is multisensory and involves identity, mind, body and world. If dissociation occurs, it would be almost impossible to specify dissociative reactions. Based on such clinical material, characteristics of relived traumas disclose themselves. Relived traumas transform present-​time perception, repeat identically as a series of past events experienced as taking place “now,” do not lead to change unless recalled as past events, occur without conscious choice, and are triggered by trauma-​linked cues occurring in a precipitating context. Finally, traumas that are relived remain amnestic until they are psychologically ‘metabolized’ and resolved. These conclusions are not new; they closely track conclusions first drawn by Janet (Van der Hart & Friedman, 2019) over a century ago. As a prelude to examining the mechanisms of traumatic reliving, let us first examine some basic mechanisms of perception. In perception, a stimulus-​array impinges on the sensory system. To be perceived, the array must be combined (associated) into a meaningful, perceptual figure (see Burton, 1990a & 1990b). To accomplish this, the received sensory array is automatically compared, outside of conscious awareness, to other arrays stored in memory until a match is found. When that match is found, the array is then “perceived” as “that particular percept.” Context guides this automatic, non-​conscious matching. For example, while viewing abstract art, one might ask “What is it?” One might be aware of an inner search for known or familiar percepts. “It’s like the side of a building” might come to awareness and the abstract painting transforms into the side of a building. Thenceforth, recreating the previous bewildering view of the art is difficult since it will now appear as the side of a building. The unconscious, automatic search for a matching percept brings up “side of a building.” Using this model as a guide, the same mechanism precipitates traumatic reliving (Beere, 2001, 2002, 2009b). A stimulus starts an automatic, non-​conscious search to find a match and retrieves a non-​conscious memory of an amnestic trauma while not retrieving a match that would lead to a present-​t ime percept. Traumas are amnestic because they were subjectively overwhelming and unmanageable, and, therefore, cannot be included in the Self System. When an amnestic trauma is elicited via the automatic search mechanisms, the memory floods conscious awareness with the overwhelming, unmanageable emotions and sensations that occurred at that prior time. Perception apprehends the present environment as if it were the past. Once activated, the relived trauma unfolds, as if it were a present-​time experience, eventually stopping on its own. One might critique the use of perception as an explanatory paradigm by asserting that the relived trauma is a learned response to triggering cues. A learned response cannot explain what happens when a trauma is relived. A “learned response” cannot explain the temporal unfolding of a long series of past events, experienced as happening now. A learning paradigm can explain neither the fullness of the re-​experiencing nor its power to change the person’s perception of the current environment. Why does an experience become amnestic? In terms of the Self System, why is an experience excluded? Consider what occurs when an amnestic episode surfaces as an abreaction. Summarizing what happens clinically, an abreaction has these elements: intolerable impulses, choices or actions (e.g., injuring, killing, eating, copulating, or verbalizing); intense negative emotion (e.g., terror, horror, revulsion, mortification); intense physical sensations (e.g., pain, sexual arousal, asphyxiation, unbearable noise, taste or smell); perceiving other people in intolerable ways (violent and violating, rapists, murderers, or torturers). The individual might feel or wish the following: To stop what is overwhelming and unmanageable; to reduce the intense negative emotions and possibly physical pain; to avoid knowing reprehensible choices, impulses and actions; to not see and know what others are doing, often to other people but also to this person as victim; to stop what is happening; or to stop time. This list is not exhaustive. Obviously, not all amnestic traumas have these elements but must include aspects that are sufficiently extreme they cannot be integrated into the Self System

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and thus remain in the not-​me. The amnesia, the exclusion of memory, is neither intended nor purposeful but rather an artifact of its being irreconcilable with the individual’s existence-​a s-​constituted. Amnesia, from the PTD perspective, does not serve a defensive function. In other words, amnesia is not denial or repression or dissociation but occurs as an outcome of the Self Systems inability to integrate it. A trauma is resolved when it is available to conscious awareness and memory, and is assimilable by the Self System, so when remembered, it does not evoke overwhelming emotions. Exposure is one treatment of choice for PTSD, with the client repeatedly experiencing the traumatic emotion with no negative consequences. The treatment rationale is that the fear will eventually extinguish. The reliving experience seems to be precisely what exposure attempts to activate –​the full sensory and emotional experience. When reliving occurs spontaneously, however, the re-​exposure does not lead to resolution. Why? Because conscious recall of the trauma continues to be unavailable; the trauma is a not-​me experience, outside the Self System. The individual ‘remembers’ the trauma, but as a re-​experiencing rather than as a conscious memory. Note that no other recall of a memory emerges this way: swamping the present, distorting present awareness, and unfolding from start to finish as if happening now. An abreaction occurs spontaneously and involuntarily. One explanation of abreaction is that the trauma has not been filed in a way that allows for its resolution and for its being recalled as a ‘normal’ memory. To phrase this in terms of the PTD, an amnestic trauma has been resolved when it has been included in the Self System. This explanation posits that there are different memory systems (i.e., conscious and non-​conscious) and different retrieval processes (i.e., conscious memory retrieval and automatic, non-​conscious search). There is a distinction between narrative and procedural memory and between explicit and implicit memory retrieval. Narrative memories with their explicit retrieval are available to conscious recall, but procedural memories with their implicit retrieval are not. ‘Memory’ for relived trauma seems to be different from both types of memory. Brewin (2003) draws a similar distinction, positing a situationally accessible memory system. Perhaps there is a different dichotomy among memory systems than is reflected by narrative/​procedural, and so on; one that includes, (1) memory that preserves an event as an on-​going first person experience; and (2) memory that is non-​immediate, psychologically distant, and accompanied by a conviction that the experience is over, even if emotionally distressing. Reliving an amnesic trauma is a different order of experience since it evokes overwhelming, intense and painful emotion, displaces present time perception so it seems to be happening in the moment, proceeds in what appears to be the identical sequence, and subsequently cannot be remembered. I propose that relived memories have been filed as ongoing or unfinished. Successful treatment allows that experience to be stored as the second, non-​i mmediate type of memory, a memory of experience that is known to be ‘over’. The individual can then remember without being thrown into the experience; the person can remember and know that the trauma is in the past. In short, a trauma is amnestic because it cannot be integrated into the person’s existence-​a s-​constituted or Self System. Using Sullivanian language, these traumatic experiences remain not-​me. Using more phenomenological language, these traumatic experiences are excluded by the me-​you-​world structure or existence-​a s-​constituted; the experience is outside the limits of “the person’s reality.” An amnestic disorder, therefore, would imply a Self System that excludes distressing, probably traumatic events, incommensurate with its existence-​a s-​constituted.

Dissociative Identity Disorder Dissociative identities always involve amnesia because the experience contained in one Self System is not integrated into other existing Self Systems. In a qualitative study of switching from one dissociative identity to another, Beere (1996a, 1996b) showed that the rigidity of the Self System generates the amnestic barriers between alters. The experiential structure of switching provides a model for DID. Some discussion of rigid Self Systems might be clarifying. The Self System is a linguistic device used to make accessible philosophical ideas whose languaging tends to be abstruse if not opaque. The Self System is an explanatory concept that encompasses all human experience, the non-​pathological and pathological. Not-​me experiences are outside the limits or boundaries of the Self System. Figures 17.2 and 17.3 symbolize this. In this context, rigid refers to a clear and overt exclusion of experience that lies outside the Self System boundary. Of course, there is no actual boundary though it can be a useful way to describe what happens. Consider an individual with three identities: the first is logical and experiences no emotion; the second experiences and expresses irritation; and the third feels and enacts murderous rage. In this situation, both the second and third identities could experience irritation. If, however, that increases to anger only the third identity would have that experience. The first would experience no emotion. Figure 17.3 depicts two identities who have nothing in common and are amnestic for each other, each being in the not-​me zone of the other Self System. As a Self System changes so does existence-​a s-​constituted which means that what can be experienced as an

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I, as a mind, as a body, as the world, or as time changes. Usually the changes are holistic since the various domains are interconnected. As a result of these changes new experiences emerge for the individual. A few of the possibilities might be finding changes in self-​control, perceiving and understanding in new ways, retrieving previously unrecalled memories, having more differentiated or new emotions, or seeing previously hidden future possibilities.

Switching The context for switching needs to satisfy several conditions. First, within this person’s experienced-​totality, there are at least two dissociative identities who can assume control of the body. Second, the lived-​world presents a lived-​ situation that energizes the identity who is not in control of the body. This lived-​situation can lead to the enactment of an energized need, impulse or emotion. Third, the identity in current executive control has been constituted to exclude this specific energized need, impulse, or emotion which is activating the second identity. Conversely, the Self System of the second identity who is not currently in control includes the expression of this specific need, impulse, or action which possess significance for this identity’s being-​in-​the-​world. Switching occurs when the identity not currently in control believes that events will proceed toward a specific outcome that will allow for the enactment of the energized need, impulse or emotion within their Self System. The identity engages in psychological activities, unbeknown to the other identity, designed to minimize feared realities and to actualize desired lived-​realities. The non-​controlling identity’s Self System includes accepting, expressing, and enacting these specific energized needs, impulses or emotions, and takes control of the body when the intense state overwhelms the identity who had been in executive control. The switch to the second identity occurs because a lived-​possibility could, in fact, become a reality. Said differently, as the experience intensifies and becomes less distant, the identity’s ability to maintain executive control lessens until the energized, other identity takes over. The new identity’s being-​in-​ the-​world re-​presents itself as a unique lived-​body in a unique lived-​world. In the preceding paragraphs, Self System refers to identity-​m ind-​body-​world-​time constituted into a meaningful whole. Since the entire scope of a person-​in-​the-​world is encompassed, the phenomenological term existence-​as-​constituted could also be used. In this description of switching, multiple existences-​a s-​constituted co-​exist within a single consciousness (See Figure 17.3). Beere’s (1996a, 1996b) research showed that intensity of experience was a necessary precondition for switching –​not fear, pain, or stress. Switching required the identity in executive control to have a rigid Self System which excluded that intensity of experience, but where the intensity of experience is included in the Self System of another identity. Switching always involved taking control of the body; bodily control makes action in the world possible. The assumption of bodily control follows intensification associated with a realizable possibility. In switching, the “new” identity seeks to actualize a potential and significant lived-​possibility. This analysis yields the following conclusion: Self-​control is bounded by the way that the Self System is constituted in consciousness; an identity can control only those experiences that occur within its boundaries. Importantly, however, non-​executive identities can, without the awareness or choice of the current executive identity, perceive worldly events, anticipate possibilities, plan future actions, and influence the executive identity. One might conceptualize dissociative identities as Self Systems “trapped” in past trauma or Self Systems reflecting adaptations to past trauma. When a current context resonates with one of those traumas, the associated Self System can readily be activated by trauma-​a ssociated cues. Interestingly, in most trauma-​cue-​elicited switches, a dissociative identity ‘comes out,’ but the associated trauma does not surface as a full re-​experiencing. This clinical datum suggests that the cues activated

F I G U R E 17. 3   Existence-as-constituted

within the limits of consciousness

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a dissociative identity with a Self System equipped for adapting to trauma, so such switching continues to insulate consciousness from reliving the trauma. From the point of view of a dissociative identity, experiences outside its scope do not exist; if the identity had such discrepant experiences, it could no longer be as it is. Such experiences are not-​me; they are outside the identity’s Self System. When identity-​d iscrepant experiences become too likely, there will be a switch to another identity whose scope can manage those experiences. In situations such as this, the avoided experience has a negating determining significance to the identity who ‘goes away;’ an encounter with that experience would undermine that identity’s existence-​a s-​constituted. In short, because that experience would undo the identity’s existence (as he or she knows it), the potential for that experience evokes a constriction of the identity’s perception to what is already known in that identity’s Self System. Thus, the experience is excluded, avoided, or denied. This is an extreme example of what Sullivan (1956) called selective inattention. How does a dissociative identity get created? According to the PTD, the new identity must assume agency. This is distinct from a dissociative reaction which arises in response to what is usually an external event and not chosen by the individual. Dissociative reactions are spontaneous and involuntary. By contrast, assuming agency means that the identity intends, chooses, and acts. The act of agency (the intention, choice, or action) must be discrepant from the prior identity, in other words, be in the not-​me region. Repeated traumatic abuse in early childhood would probably create a dissociative identity but a single abuse incident is, at the very least, highly unlikely to create one. Some examples, unfortunately gruesome, might clarify. Consider a child who is forced to initiate sex with a significant other and forced to say specific positive words. Consider that same child as an adolescent who is forced to torture their best friend to death as punishment for telling them about the abuse. Both sets of experiences entail acting in Self System discrepant ways such that a new dissociative identity needs to be constituted in order to initiate, choose and do what cannot be avoided in those abusive situations. Before adolescence the Self System has not consolidated and is therefore more malleable and open to the development of DID. Thus, there is an age limit for its creation. In the context of the PTD, an adult would have a Self System sufficiently solidified that consciousness could not constitute an alternative, dissociative Self System. Theoretical and clinical work notes a link between disorganized attachment and later DID (Lyons-​Ruth & Jacobite, 1999; Liotti, 2004). How might we understand this in the context of the PTD? When there is disorganized attachment, the young child is unable to have clarity about how the parenting-​one is acting. As a result, the connection with the parenting-​one is lost or inconsistent. Furthermore, in addition to good-​parent and bad-​parent there might be frightening-​parent and absent-​parent. According to Sullivan’s conceptualization, the me-​you constructs might multiply into terrified me-​frightening parent and rejected me-​absent parent. Considering this range of relational experiences, alternative identities become solutions that reduce anxiety and maintain the relationship with the parenting-​one.

Presentification: The Perceptual Theory Applied to Psychotherapy Theoretical and Empirical Foundation When the background (I, mind, body, world or time) has degraded such that it leads to a dissociative experience, how does someone de-​d issociate? To phrase this in the context of the PTD, how does one reintegrate a blocked or absent background? Smell, sight and sound present the world at a distance. Sensation and movement (kinesthesis) present the world and the body more closely. The mind presents itself as cognitive contents and the “I” arises as the observer, knower or agent. How might one bring them together? Action in the world is crucial to the development of visual and spatial perception. This conclusion derives from a variety of experimental results. For example, Held and Hein (1963) put two kittens in a carousel. One was harnessed so it could walk, moving the carousel. The second was harnessed so it could only have its feet dragged, could not move the carousel and was moved passively. Both kittens had the same changing visual experience but just one acted to create that experience. Only the active kitten developed spatial and depth perception. Action in the world is a prerequisite to developing the perception of space and depth. The author hypothesizes that action and movement in the world are the origins of vision and perception as a whole. When a client becomes overwhelmed or dissociated, a typical intervention is to “ground” the client by asking them to feel the arm of their seat, gripping it firmly to create a solid connection with reality. Such interventions were marginally effective and alternatives derived from the PTD developed. Consider, in this context, that most psychotherapies rely on words and not actions or movement. In the context of ameliorating dissociation, therefore, action in and interaction with the world is crucial. The new interventions based on the PTD help the client perceive lost background components. The specific and simple interventions developed from this point of view require action from the client vis

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à vis the world. When successful, the client “comes into” the present, thus the name “Presentification,” a term others have also used from their own theoretical perspective (e.g., Van der Hart, Nijenhuis & Steele, 2006).

Presentification: Overview During episodes of dissociation in therapy, clients cannot accurately perceive what is happening and therefore cannot describe it. Interventions that allow connection with lost, blocked or degraded background elements and thereby re-​ establish presentification can effectively re-​engage the dissociative client. Two tasks have the greatest impact: balancing and feeling a wall. Both consolidate the body-​in-​space or, in the theory’s context, presentifies the body here and now. Yet, when the client does these and other tasks, how does the therapist know the client is perceiving what is present? The solution: the client engages in simple tasks that require perceptual discrimination –​tasks done in experimental psychology. If the client provides the correct answer, then the therapist can “know” they and the client, at that moment, are experiencing a shared reality. Silly and non-​threatening tasks, with the client’s permission, perhaps framed as the therapist’s simple-​m inded requests, can quickly re-​engage lost backgrounds. For example, the therapist might hold up their left hand and ask the client to “Point to which hand I have up.” Notice that this response requires an action, pointing or indicating with the body, usually a finger. The therapist can then add a slightly more involved action by holding up four fingers saying, “With your hand, show me how many fingers I have up.” To engage in these tasks requires hearing, understanding spoken words, cognitive processing, seeing, and physical action, all of which involve background components of I, mind, body and world in time. The therapist who does not wear a hat might ask, “Do you like my hat?” This requires the client to perceive the top of the therapist’s head and note that they wear no hat. The question also requires looking just above the therapist’s face, possibly bringing their appearance into clearer focus. The question also has a twist since it asks about “liking” a non-​existent hat. That is slightly jarring since it makes little sense and requires processing the words, thinking about the words, seeing the present situation, and then articulating an answer, so it draws on identity, mind, body and world. Sometimes, to help the client focus more clearly on the therapist’s face, they might ask about the therapist’s sunglasses (presuming they have none on), or whether they have specific facial hair or lip color. Sometimes, even though the client has responded, he or she remains immobile or dissociated. The next step is making sensory distinctions and establishing body boundaries. The therapist can ask the following kind of questions, pausing between each question for an answer. “Rub your hands on your legs. Now rub them on the chair next to your legs. Are the sensations the same or different? Is one smoother? Are they the same temperature? When you rub your legs can you distinguish the feelings in your hands from the feelings in your legs? When you rub the chair, can you feel the difference between your hands and the surface of the chair?” The therapist can also ask the person to shift around on the seating and sense their body’s back and the seat itself. The next request can have a strong impact since it quickly brings a dissociative identity into present-​t ime reality. The task establishes the body-​in-​space. “Please stand. Thank you. Slowly shift your weight from foot to foot a few times. Now, slowly lift one foot so you are balancing on the other.” It is best for the therapist to engage in these tasks as well to reduce any shame or embarrassment associated with ‘performing’ for the therapist. Where there are concerns about the client’s balance ask them to stand next to a chair to regain balance should they begin to fall. The client can then be asked to balance on the other foot. Clients frequently stop, overtly frightened. It can be inferred that the client expects what was traumatic in the past to reoccur in the present; if I am real, then I am unprotected and vulnerable to attack. This can be explored once the client is reoriented and grounded. Once the client has balanced, they can be invited to explore the office visually. “Please point to a plant.” The therapist should always validate the response. “Yes. That’s a plant. And please point to a chair. That’s right! There are pictures hanging on the wall. Please point to one. Excellent.” Sometimes the therapist can ask the person to denote or even describe objects in the office before standing. The therapist can next ask the client to walk around and explore the office by feeling objects and to observe differences or distinctions. “Please slide your hand (or fingers) along the glass of the picture. Now slide it along the wall. What do you notice?” Most important theoretically is the experience of surfaces since those establish boundaries between background elements, for example, the distinction between the wall (world) and the hand (body). “Please slide your hand along the wall. Can you feel the wall and your hand as different sensations? Is the corner different from the wall?” Though one might consider the hand separate from the body, to move to the wall and to slide a hand along the wall entails using the whole body. The client can be asked questions about whatever (non-​confidential) objects they stumble upon. From the theory’s perspective, moving around the office to look at what is there requires the “I” to choose and to act and to observe, the mind to cognitively process the objects and differences, the body to interact with the space and the objects, and the world to be

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represented by the office and objects in it. For some traumatized clients, freely exploring triggers fear. If that happens, the therapist can ask the client to look carefully about the office and find what is frightening. Then, together, they can check whether there is a threat. The exploration should be benign and non-​threatening and, as a result, create a memory of a safe place. A transition to perceiving time begins by asking how old the client was during the traumatic experience this identity had been processing. “Please estimate how tall that child was?” The therapist can then ask the client to place a post-​it note on the wall at that height. Next, the client can be asked to place a note on the wall at their current height. The client writes the current year on that note, and, then writes on the child’s note the year the trauma happened. Sometimes a series of childhood events arise and the client places several dated post-​it notes at various heights. This task often generates reactions that can be explored. The last step locates the present in the stream of time. The therapist can gather documents with printed dates, such as magazines, newspapers, receipts. “Please read the date aloud.” Frequently, the dissociative identity is incredulous about the present date. “How many years is that from when the trauma happened?” “How old was the perpetrator then?” “And how old would that person be now?” Other questions can assist the client in understanding the unlikely possibility of a current attack by the former perpetrator. These steps should not be slavishly followed but creatively decided along the way. Nonetheless, the sequence outlined is good to at least initially follow since it gradually allows the client to presentify comprehensively. The therapist can stop at any point in the sequence when the client indicates so as not to force or attempt to coerce the client. When a client needs to stop, usually the past has intruded. For example, the initial stages of presentfying, where the client is focusing on the therapist, the therapist’s presence can trigger fear of being hurt: “If I am present, then I am vulnerable.” With succeeding presentification attempts, the identity typically proceeds further through the sequence.

Conclusions and Implications The PTD provides a comprehensive understanding of dissociation and the dissociative disorders, beginning with a substantiated psychological mechanism that produces dissociation, developing a model that explains dissociative psychopathology, and creating effective intervention strategies. Merleau-​Ponty’s (1962) phenomenology of perception demonstrated that there are ever-​present perceptual constants, called the “background”: identity, mind, body, world and time. When dissociating, attention hyperfocuses on a percept of determining significance and elements of the background are lost or blocked out. Counterintuitively, dissociation does not occur in the domain of a perceived threat. The theory also explains that dissociation is spontaneous and involuntary because dissociation is an indirect result of hyperfocusing and, as a result, neither intended nor expected when it arises. The theory implies and research supports the idea that dissociation lies along a continuum of psychological complexity; severe and repeated trauma will evoke the most complex dissociative reactions. The frequencies of dissociative reactions in different domains of the background (e.g., body, world, mind) are predicted and explained by the theory. The background domain of the trauma inversely interlocks with the background domain of dissociation, so if a trauma is in the world, depersonalization (blocking of I, Mind, possibly Body) occurs. Dissociative reactions are specific (not global) and connect to the focus of perception. Actual traumatic situations usually occur in many domains, leading to what appears to be a global dissociative reaction. Dissociation is not always a defense, a coping strategy, a response to trauma, or a way to manage overwhelming experience, but it does result from hyperfocusing. This does not imply that dissociation cannot be defensive. The research question is “In what circumstances and how does dissociation become a defense?” Evidence showed that dissociation occurs in non-​t raumatic situations. The theory predicted and confirmed that dissociation would occur in significant situations, including non-​traumatic situations that are personally meaningful and positive. A phenomenological analysis of descriptions of dissociating in positive situations yielded the identical experiential structure as articulated in the original PTD that focused on traumatic situations. A set of perceptual experiments confirmed that individuals with dissociative traits block out the background while not hyperfocusing. This body of research provides support for the PTD and the psychological mechanism leading to dissociation. The phenomenological foundation of the PTD provided a conceptual framework to explain the dissociative disorders. The background constants map isomorphically to most of the dissociative disorders: Identity with DID, Mind and Body with depersonalization, World with derealization, and there are frequent distortions in experienced-​time. Deepening this explanatory account, by using the Sullivanian concept of the Self System as a substitute for the phenomenological concept of consciousness, all of the dissociative disorders can be explained.

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Derealization and depersonalization were accounted for with two models. The first explanation is a learned response to internal or external cues associated with an earlier dissociative reaction. The second explanation entailed the intrusion of not-​me experiences from outside the Self System. Similarly, amnesia results from experience being outside the Self System, and abreactions provided a window into amnesia and amnestic disorders. To experience a “percept” requires a non-​conscious automatic search for a context-​relevant, unconscious memory that crystalizes into “this” percept. In abreaction, the traumatic memory has not been filed as “past” but as “present.” The memory is not available to conscious recall. The traumatic memory is a not-​me experience and, though an aspect of consciousness, cannot be accommodated by the Self System. When retrieved, an abreaction ensues spontaneously and involuntarily. DID is understandable as multiple Self Systems within a single consciousness. Beere’s (1996a, 1996b) phenomenological analysis of switching demonstrated that a rigid Self System cannot integrate specific experiences of determining significance (thoughts, impulses, emotions, and perceptions in the not-​me region). A different Self System, that included those experiences, can respond to events in the world such that these not-​me experiences could be actualized. When the intensity of those experiences reaches a threshold, there is an automatic switch from one dissociative identity to another. The PTD clarifies the connection between disorganized attachment and later DID since the child must create multiple Self Systems to manage an inconsistent parenting-​one. Applying the PTD to psychotherapy affords clinical validation. When dissociated, action-​in-​the-​world is an effective means to reintegrate the background, to reduce dissociation and produce Presentification. The PTD explains how such simple activities would have this unanticipated yet powerful effect. Using methods adapted from experimental psychology, clients progress through tasks that re-​engage the perceptual background and require them to interact bodily with the world. After completing the Presentification sequence, the client “comes into” the present, perceiving current reality, knowing that the past is over.

References American Psychiatric Association (2013). DSM-​5. Diagnostic and Statistical Manual of Mental Disorders (5th ed). Washington, DC: Author. Beere, D. B. (1992). Dissociative symptoms and characteristics of trauma: A test of hypotheses derived from a perceptual theory of dissociation. Paper presented at the Ninth International Conference on Multiple Personality and Dissociative States, Chicago. Beere, D. B. (1995a). Loss of “Background”: A perceptual theory of dissociation. Dissociation, 8, 166–​174. Beere, D. B. (1995b). Dissociative reactions and characteristics of the trauma: Preliminary tests of a perceptual theory of dissociation. Dissociation, 8, 175–​202. Beere, D. B. (1996a). Switching: Part I –​An investigation using experimental phenomenology. Dissociation, 9, 49–​60. Beere, D. B. (1996b). Switching: Part II –​Theoretical implications of an investigation using experimental phenomenology. Dissociation, 9, 61–​68. Beere, D. B. (2001). Abreaction: Internal context, theoretical implications, and treatment options. 18th Annual Meeting of the International Society for the Study of Dissociation, New Orleans, LA. Dec. 2001. Beere, D. B. (2002). A perceptual view of dissociation. In P. Dell (chair), What the heck is dissociation anyway? 19th Annual International Conference of the International Society for the Study of Dissociation, Baltimore, MD, Nov. 2002. Beere, D. B. (2009a). Dissociative Perceptual Reactions: The Perceptual Theory of Dissociation. In P. Dell & J. O’Neil (Ed.s), Dissociation and the Dissociative Disorders: DSM-​V and Beyond (pp. 209–​222). New York: Routledge. Beere, D. B. (2009b). The Self-​system as “Mechanism” for the Dissociative Disorders: An Extension of the Perceptual Theory of Dissociation. In P. Dell & J. O’Neil (Ed.s), Dissociation and the Dissociative Disorders: DSM-​V and Beyond (pp. 277–​285). New York: Routledge. Beere, D. B., Cooper, N., Pica, M., & Maurer, L. (1997). Prayer and the perceptual theory of dissociation. In D. Beere (Chair), The perceptual theory of dissociation: An overview and discussion. Symposium conducted at the meeting of the American Psychological Association, Aug. 1997, Chicago IL. Beere, D. B., & Pica, M. (1995). The predisposition to dissociate: The temperamental traits of flexibility/​rigidity, daily rhythm, emotionality and interactional speed. Dissociation, 8, 236–​240. Beere, D. B., Pica, M., & Greba, J. (1996). Dissociation in positive situations: A replication and extension. Presented at the 104th Annual Convention of the American Psychological Association, Aug. 1996, Toronto ON. Beere, D. B., Pica, M., Maurer, L, & Fuller, G. (1996). Dissociation and loss of background: A test of the perceptual theory of dissociation. In D. Beere (Chair), Psychological research on dissociation. Symposium conducted at the meeting of the International Society for the Study of Dissociation, Nov. 1996, San Francisco CA. Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–​735. Brewin, C. R. (2003). Posttraumatic Stress Disorder: Malady or Myth? New Haven, CT: Yale University Press. Burton, P. (1990a). A search for explanation of the brain and learning: Elements of the psychonomic interface between psychology and neurophysiology. I. A cognitive approach to early learning. Psychobiology, 18, 119–​161.

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Burton, P. (1990b). A search for explanation of the brain and learning: Elements of the psychonomic interface between psychology and neurophysiology. II. Early behavior and its control, the origin of consciousness, and the rise of symbolic thought. Psychobiology, 18, 162–​194. Fine, C. (1988). Thoughts on the cognitive perceptual substrate of multiple personality disorder. Dissociation, 1, 5–​10. Giorgi, A. (Ed.). (1985). Phenomenology and psychological research. Pittsburgh: Duquesne University Press. Held, R., & Heine, A. (1963). Movement-​produced stimulation in the development of visually guided behavior. Journal of Comparative and Physiological Psychology, 56, 872–​876. Husserl, E. (1931/​1962). Ideas: General introduction to pure phenomenology. (W. R. Boyce Gibson, trans.) New York: Collier Books (Macmillan Publishing Co.). Liotti, G. (2004.) Trauma, Dissociation, and Disorganized Attachment: Three Strands of a Single Braid. Psychotherapy: Theory, research, practice, training Vol. 41, 472–​486. Lyons-​Ruth, K. & Jacobite, D. (1999.) Attachment Disorganization: Unresolved Loss, Relational Violence and Lapses in Behavioral and Attentional Strategies. In Handbook of Attachment Theory and Research. (Cassidy J, Shaver, ed.) New York, NY: Guilford Press, 520–​554. Merleau-​Ponty, M. (1962). Phenomenology of perception. (Trans. C. Smith). New York: The Humanities Press, Routledge & Kegan Paul. Pica, M., & Beere, D. B. (1995). Dissociation during positive situations. Dissociation, 8, 241–​246. Sullivan, H. S. (1956). The collected works of Harry Stack Sullivan, Vols. I & II. New York: Norton. Van der Hart, O., & Friedman, B. (2019). A reader’s guide to Pierre Janet on dissociation: A neglected intellectual heritage. In G. Craparo, F. Ortu, F., & O. Van der Hart. (Eds.), Rediscovering Pierre Janet: Trauma, dissociation, and a new context for psychoanalysis (pp. 4–​27). London & New York: Routledge. (Originally published in 1989: Dissociation, 2, 3–​16.) Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: Norton & Co. Witkin, H. A., & Asch, S. E. (1948). Studies in space orientation: IV. Further experiments on perception of the upright with displaced visual fields. Journal of Experimental Psychology, 38, 762–​782. Witkin, H. A., Oltman, P. K., Raskin, E., & Karp, S. A. (1971). A manual for the Embedded Figures Tests. Palo Alto, CA: Consulting Psychologists Press, Inc.

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18 CONTEXTUAL DISSOCIATION THEORY The Dual Impact of Trauma and Developmental Deprivation Steven N. Gold

The Nature and Causes of Dissociation As reflected in various chapters in this volume, experts disagree about what dissociation is, the scope of phenomena that it encompasses, its root causes, and even whether it is primarily a form of dysfunction (e.g., Nijenhuis’s ecology/​ structural dissociation chapter [Chapter 38]) or includes adaptive variants (e.g., Dalenberg, Katz, Thompson & Paulson [Chapter 5]). Within the conceptual framework of Contextual Trauma Theory (CTT), dissociation is viewed as a basic aspect of human functioning that has adaptive variants, rather than exclusively representing exotic and disruptive forms of pathology. CTT proposes that dissociation assumes a range of manifestations that can be either adaptive (i.e., functional) or problematic (i.e., pathological). It understands problematic dissociation that is related to an extensive history of child maltreatment (i.e., complex dissociation) as not only being a result of traumatization, but also as the consequence of developmental deprivation. In conceptualizing complex dissociation as the expression of developmental deprivation, CTT views it as reflecting a skills deficit largely grounded in a restricted ability to modulate and sustain attention that in turn constricts the scope and attributes of conscious awareness. Contextual Trauma Therapy (CTTx) helps clients with complex dissociation recognize, anticipate, decondition, and learn to modulate their dissociative responses, episodes, and states, working to expand their capacity for awareness so that maladaptive functioning wanes, developmental limitations are remediated and effective responding is qualitatively enhanced. Ultimately, this process consists of repeated engagement in practices that progressively foster greater psychological development by helping the complex dissociative client acquire the capacities to reduce distress, sustain attention, enhance awareness, promote functional integration, and engage in flexible (i.e., modulated) responding (see Gold, 2000; Gold, 2020; Gold & Quiñones, 2020).

Dissociation Related to a History of Trauma Very often Prolonged Childhood Abuse (PCA) survivors’ insufficiencies in development, socialization, and adaptive living skills are attributed to the traumatic effects of abusive treatment itself. Undoubtedly, the disruptive effects of PCA and other forms of trauma do contribute to dissociative states and other problems in adjustment (Briere & Runtz, 1988; Chu, Frey, Ganzel, & Matthews 1999; Dalenberg et al., 2012; Irwin, 1996; Putnam, 1997; Putnam, Guroff, Silberman, Barban, & Post, 1986; Stein & Kendall, 2004; Ullah, Khalily, Ahmad, & Hallahan, 2018). However, some studies have raised questions about the putative direct and exclusive causal relationship between trauma and dissociation (Briere, 2006; Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997). Briere (2006) concluded that the relationship between trauma and dissociation is complex. Although he found that most persons with significant dissociative symptoms did report a history of trauma, the converse was not true: the majority of people with a background of trauma did not report significant dissociative symptoms. Additional risk factors on the pathway between trauma and dissociation included impaired affect-​regulation (Briere, 2006; Briere & Runtz, 2015).

DOI: 10.4324/9781003057314-22

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Ogawa et al. (1997) also concluded that the relationship between trauma and dissociation is multi-​faceted. They reported that the chronicity, severity, and age of onset of trauma correlated highly with dissociation. Importantly, however, they also found that both disorganized and avoidant patterns of attachment strongly predicted dissociative symptoms. Further support for an intricate relation between trauma and dissociation was provided by Waller, Putnam, and Carlson (1996), who found that trauma is a necessary condition for the development of dissociation, but that it is not sufficient. In a similar vein Dell (Chapter 14, this volume) notes, specifically in regard to dissociative identity disorder (DID), that trauma only accounts for a relatively small proportion of the variance associated with the disorder. He argues that this extreme form of dissociation only occurs in response to trauma among highly hypnotizable individuals.

Dissociation Related to Insecure Attachment A growing consensus has emerged that insecure attachment is related to the emergence of maladaptive dissociative behaviors (See Schimmenti, Chapter 10 & Schore, Chapter 11, this volume). Barach (1991) was the first to explicitly note that there were striking similarities between the behavior of insecurely attached infants and that of dissociative individuals. He stressed the concordance between the detachment of insecurely attached children and the disordered attachment of dissociative patients: “My reading of Bowlby’s work is that the detachment he describes is actually a type of dissociation” (Barach, 1991, p. 118). Soon after, Liotti (1992) arrived at a similar conclusion, proposing that dissociation was specifically linked to a disorganized/​d isoriented attachment style, referred to as unresolved attachment in adults (also known as U/​d, i.e., unresolved/​d isorganized, attachment). The U/​d attachment style results not from parental detachment in general, but specifically from a parent’s ongoing frightened and/​or frightening behavior (Main & Hesse, 1990; Main & Solomon, 1986). Since 1991, the conceptual work of Barach and Liotti has been supported (and augmented) by empirical research. Calamari and Pini (2003) reported that insecure adolescent females, especially those with ambivalent attachment, obtained higher scores on the Dissociative Experiences Scale (DES) than adolescents with other attachment styles. Carlson (1998) found a significant correlation between disorganized attachment in infancy and dissociation at age 19. Paetzold, Rholes, and Andrus, (2017) confirmed a relationship between disorganized attachment and dissociation. Hesse and Van IJzendoorn (1999) reported that individuals who described unresolved trauma memories in response to the Adult Attachment Interview (AAI; Hesse, 1999) obtained high scores on a measure of dissociation. Hesse’s (1999) data point to a link between attachment-​related difficulties and dissociation, as does a study of adolescent mothers, in which elevations in dissociation were found to be related to unresolved attachment (Bailey, Moran & Pederson, 2007). In an experience-​sampling study in which the Adult Attachment Interview and the Berkeley-​Leiden Adult Attachment Questionnaire were administered to adults with a history of childhood trauma, Marcusson-​Clavertz, Gušić, Bengtsson, Jacobsen, and Cardeña (2017) reported that the latter measure identified a relationship between unresolved attachment and dissociation. Moreover, both instruments yielded an association between unresolved attachment and impaired attentional control.1 Ogawa et al. (1997) found dissociation to be related not only to disorganized attachment, which is related to frightening parenting, but also avoidant attachment. Similarly, Calamari and Pini (2003) reported a relationship between dissociation and ambivalent attachment. In general, insecure attachment, regardless of the particular form or style it assumes, evolves out of a lack of adequate parental attunement and responsiveness to the individuals’ developmental needs.

Beyond Trauma and Attachment: Psychological Development In keeping with the research cited in the previous section, CTT recognizes that insecure attachment comprises a foundation for dissociative forms of functioning. However, CTT views insecure attachment as just one component out of a constellation of factors, albeit a central one, commonly exhibited by adults with a PCA history that is both a deviation from optimal development and in turn a contributor to further gaps and distortions in development, socialization, and adaptive living skills. What can be lost in an overly exclusive focus on attachment is awareness of how other aspects of development are also adversely affected by the types of interpersonal environments from which the various forms of insecure attachment are forged. There is more (or, more literally, less) to the broader parental and familial atmosphere in which PCA is almost inevitably embedded than a dearth of opportunities for secure attachment. For example, Dutra, Bureau, Holmes, Lyubchik, and Lyons-​Ruth (2009) conducted a prospective longitudinal study in which the quality of care received by participants in infancy was observed, rated and related to scores obtained at age 19 on the DES. They

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not only found that dissociation was predicted by lack of parental responsiveness, but also that verbal abuse was the only form of trauma that further augmented the prediction of dissociation. The CTT conceptual framework subsumes and builds upon the trauma-​related and attachment-​focused explanatory models of dissociation. Dissociative pathology has been widely documented among survivors of child abuse (Briere & Runtz, 1988; Chu & Dill, 1990; Irwin, 1996), but other forms of trauma, especially ones occurring later in life, are less strongly associated with chronic dissociative symptoms (Kirby, Chu, & Dill, 1993; Zlotnick, Shea, Pearlstein, Begin, Simpson, & Costello, 1996). Even among survivors of child abuse, dissociative syndromes are most strongly linked to maltreatment that was prolonged and severe (Brand & Alexander, 2003; Briere, 2006; Lipschitz, Kaplan, Sorkenn, Chorney, & Asnis, 1996). These findings suggest that dissociation is not exclusively linked to trauma per se; rather, dissociation is most robustly linked to (1) abuse that (2) occurs in early childhood, (3) is relatively severe, and (4) of lengthy duration. While parental responsiveness is unquestionably a major factor in the attainment of secure attachment, the facets of psychological development that are contingent on it extend well beyond attachment. Attuned interaction with parents in infancy, and increasingly with adults beyond the immediate family as one proceeds through the life cycle, stimulates brain development, fostering a broad array of capacities that in many ways are grounded in, but extend well beyond, secure attachment. These include but are by no means limited to, modulation of attention, sensory awareness, motor coordination, emotional acuity and expression, impulse control, cognitive complexity, and social competency (Siegel, 2020). CTT proposes that the PCA which underlies Complex PTSD (C-​PTSD; Briere & Rickards, 2007; Cloitre, Scarvalone, & Difide, 1997; Powers, Fani, Carter, Cross, Cloitre, & Bradley, 2017; Wamser-​Nanney, & Vandenberg, 2013) and is a major source of the most disruptive forms of dissociative difficulties almost inevitably occurs within an encompassing background, or context (the C in CTT), of developmental deprivation (Gold, 2000, 2020). Rather than putting the bulk of etiological weight on traumatic experiences, CTT emphasizes that many of the psychological problems exhibited by PCA survivors, including complex dissociation, are more broadly a consequence of having been reared in ineffective family environments that failed to foster adequate psychological development (Berenbaum & James, 1994; Brown, Schrag, & Trimble, 2005; Narang & Contreras, 2005; Nash, Hulsey, Sexton, Harralson, & Lambert, 1993). PCA clients with an extensive child abuse history describe having come from chaotic families with high levels of control and interpersonal conflict and little consistent affection and emotional responsiveness (Gold, 2000, 2020). These reports are consistent with empirical research which shows that these qualities are prevalent in the families of survivors of PCA (Benedict & Zautra, 1993; Rudd & Herzberger, 2000; Seibel, 2004). More specifically, these are households that have been found to be characterized by low levels of a sense of belonging, cohesion, and emotional expressiveness, and elevated levels of interpersonal conflict and control (Fassler, Amodeo, Griffin, Clay, & Ellis, 2005; Gold, Hyman, & Andres-​Hyman, 2004; Griffin & Amodeo, 2010; Mollerstrom, Patchner, & Milner, 1992; Yama, Tovey, Fogas, & Teegarden, 1992). The atmosphere of such families is consistent with the attachment difficulties of highly dissociative clients (Ogawa et al., 1997). Certainly, families with these characteristics are highly likely to foster insecure attachment. Although one might understandably assume that these features characterize abusive and incestuous families, research indicates that they also typify the families of child abuse survivors whose perpetrators were not family members (Benedict & Zautra, 1993; Gold, Hyman, & Andres-​Hyman, 2004; Jackson, & Townsley, 1991; Ray, Jackson, & Townsley, 1991; Rudd & Herzberger, 1999). Empirical findings suggest that this is the case whether abusive behavior is perpetrated by someone within or outside the child’s immediate family (Gold, Hyman, & Andres-​Hyman, 2004; Ray, Jackson, & Townsley, 1991; Yama, Tovey, & Fogas, 1993). It is not surprising that families with deficient affection, consistency, predictability, and autonomy would render children vulnerable to victimization. Children from such families are desperate for attention, starved for interpersonal contact, inadequately equipped to assert themselves, and lack a strong sense of appropriate boundaries and personal rights, all qualities sought out by perpetrators (Gold, 2000. 2020).

Dissociation as Disconnection: A Unitary Substrate for Divergent Manifestations Dissociative symptoms are so disparate in appearance that they do not readily disclose to an observer what they have in common. What could possibly tie together the diverse phenomena of feeling oneself to be unreal (depersonalization) or experiencing one’s surroundings as unreal (derealization), the various forms of memory difficulty encompassed by the term dissociative amnesia, and an uncertain (identity confusion) or shifting sense of self (identity fragmentation, typified by DID)? CTT proposes that all aspects of dissociation reflect the same set of fundamental psychological processes –​ones such as attention, memory, awareness, and attachment –​that underlie both adaptive and pathological functioning. It suggests that the answer to the question of what the common element is in these seemingly divergent experiences lies

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in the literal meaning of the word dissociation: disconnection. The model views dissociative phenomena as reflecting various forms of disconnection or distancing from immediate experiential awareness that can occur in respect to one or more of three spheres: the personal, the interpersonal, and the environmental. Disconnection in the personal realm manifests as a relative lack of awareness or clarity and vibrancy of modes such as sensation, perception, emotion, and cognition. In the interpersonal realm it corresponds to a sense of estrangement, alienation, and lack of affinity with others. In the environmental realm it manifests as a foggy or diminished awareness of one’s surroundings. The experience of dissociative disconnection can be framed as occurring across a range of levels of intensity of experiential distance from a mild sense of detachment to a complete lack of awareness. Conversely, it is important to note that an increasing capacity for connection –​to other people, to one’s own subjective experience, and to one’s surroundings –​is a fundamental aspect of human development which is reflected in the growing complexity of interconnections between neuronal networks (Siegel, 2020; Elman, Bates, Johnson, Karmiloff-​ Smith, Parisi, & Plunkett, 1997). Accordingly, contextual theory posits that problematic dissociation is inversely related to development, which is in large part a function of increased capacities for attention and corresponding expanding awareness that fuels intensification of the experience of connection. However, this principle is not as simple as the proposition that disconnection wanes with the progression of psychological development and connection inverses increases. From a CTT perspective, disconnection is not exclusively a detrimental phenomenon. It is also a capacity which can be employed in adaptive ways. Sustained, focal concentration on an activity, for example, requires that one be able to disconnect from surrounding stimuli that could serve as potential distractions from the task at hand. Advances in development are not equivalent to the elimination of disconnected states of consciousness. They are characterized, rather, by the increasing ability to engage in attentive, aware, connected modes of experience and to modulate between detached and engaged mental states. Many aspects of development –​secure attachment, immediate subjective awareness of emotions and sensations, emotional regulation, the capacity for abstract and critical thinking, perspective-​t aking, and the capacity for empathy –​ contribute to (or are expressions of ) the general facility for connection. CTT stresses, therefore, that therapy aimed at diminishing dissociation needs to transmit and foster these essential developmental capacities. Defective or weak capacities for connection promote the experience of problematic dissociative phenomena. For example, disconnection from one’s surroundings may generate experiences of amnesia or derealization. Disconnection from inner experience can foster depersonalization. Disconnection from other people manifests as interpersonal detachment and a limited capacity for intimacy. Much of development occurs via interpersonal transmission (Siegel, 2020), since it is through experiential connection in our interactions with others that brain development is stimulated. Therefore, interpersonal disconnection is not only a result of inadequate parental attentiveness and responsiveness, but also constitutes a causal impediment to subsequent development. Unless the individual who has grown up with insufficient parental responsiveness is fortunate enough to encounter others who become especially invested in and attentive to them despite their restricted capacity for interpersonal connectedness, there will be a substantial limit to the evolution of the ability to sustain focused attention and expanded awareness that are at the core of psychological development. A diminished capacity to feel connected to other people therefore constitutes a powerful inhibitor of further development. This is a pivotal reason why the quality of the therapeutic relationship is especially essential for reversing dissociation. The practitioner needs to be devoted to maintaining a high degree of attentiveness to the complexly dissociative client to provide them with a clear “signal” to which they can orient and in response to which they can evolve an increasing capacity for the experience of connection (Gold, 2000, 2020).

A Key Distinction Between “Simple” and Complex Dissociation Consider the implications of the CTT model for distinguishing between dissociative experiences related to a circumscribed or single event trauma occurring in adulthood (e.g., in PTSD) and the more severe and extensive manifestations of complex dissociation exhibited by PCA survivors (e.g., in C-​PTSD and DID). In the former instance, problematic dissociative reactions would be primarily, in most instances exclusively, attributable to the interference of intrusion, avoidance and hyperarousal trauma symptoms with attentiveness to and therefore awareness of the immediate present. Of course, due to the impact of traumatization, dissociative episodes would also occur via these same PTSD-​related mechanisms among complex trauma survivors. However, CTT points to an additional source of dissociation in the latter group, one which would be related not to the episodic quality of dissociative reactions, but to an enduring state or orientation characteristic of the more severe forms of dissociation, such as identity confusion, identity fragmentation, and extensive amnesia for long stretches of

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personal history. This complex dissociative orientation would be an expression not of lapsing into discrete periods of disconnection, but to a degree of disconnection that is constant. In addition to the interference of trauma-​related symptoms with attention and awareness, individuals with a complex trauma history will almost inevitably exhibit a range of gaps and warps in psychological development stemming from limited capacities for attention and awareness that sustain a constant level of dissociative absence and disconnection. Particular varieties of developmental lacunae undergirding the persistent dissociative mental status of those with complex traumatization can vary considerably from one individual to another based in the varying forms and extents of deprivation in their histories. The two major groups of impairment constituting C-​PTSD closely correspond to the distinction pointed to by CTT between trauma-​related disruptions in functioning and developmental limitations. In addition to the trauma-​ related symptoms comprising single-​event, “classic,” or “simple” PTSD as outlined in the DSM-​5 (American Psychiatric Association, 2013), C-​PTSD as it is delineated in the ICD-​11 (World Health Organization, 2020) consists of a separate set of difficulties, collectively referred to as disturbances in self-​organization (DSO). The ICD-​11 identifies the DSO as consisting of three components: affective dysregulation, disturbances in relationships, and negative self-​image. In contrast to the symptomatic nature of the criteria comprising PTSD, the DSO are three aspects of psychological functioning. CTT construes the areas of functional impairment that constitute DSO as manifestations of gaps and warps in development. This perspective is supported by the findings of McLaughlin (2017) who, with her colleagues (McLaughlin & Sheridan, 2016; McLaughlin, Sheridan & Lambert, 2014; McLaughlin, Sheridan & Nelson, 2017; Sheridan & McLaughlin, 2014) executed a program of research examining the differential consequences of childhood abuse and childhood neglect.2 They found that child abuse trauma –​which they refer to as “experiences of threat” –​engender the hypervigilance and proclivity to perceive danger, even when it is not present, that is emblematic of PTSD. They concluded, on the other hand, that “experiences of deprivation” in childhood were associated with impaired social and cognitive development. This finding is consistent with the conceptualization of the DSO component of C-​PTSD, which is comprised of facets of social and cognitive functioning, as primarily reflecting the impact of developmental deprivation. Complex traumatization as codified in the two major divisions in the ICD-​11 criteria for diagnosing C-​ PTSD, therefore –​PTSD symptoms and DSO areas of dysfunction –​corresponds to the dichotomy proposed by CTT between trauma-​related difficulties and impairments linked to restricted psychological development.

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Revealing a Broader Terrain of Dissociative Manifestations via a Developmental Perspective Dissociation is widely defined as a lack of integration between aspects of experience that are normally integrated. When dissociation is conceptualized primarily or exclusively as a response to trauma, this description can be taken to mean that an initial state of integration has been disrupted by the impact of trauma, or that experiential disconnection (whether reflexive and automatic or volitional) is a form of defense. Thinking of dissociation from the perspective of psychological development introduces an appreciably different additional possibility: that the integration of various aspects of experience and functioning were never fully or stably established. CTT emphasizes that in PCA survivors, who can be expected to exhibit both the PTSD and DSO facets of complex traumatization, both forms of dissociation (i.e., disruption after initial integration; failed initial integration) are likely to be exhibited. As opposed to dissociation that is exclusively a reaction to trauma, manifestations of complex dissociation related to truncated development can be expected to be continuous rather than episodic. This is because integration, rather than having been disrupted during a traumatic event or temporarily unsettled by trauma-​related cues, was never fully and achieved. Clients with dissociative difficulties that are developmental in nature, therefore, are prone to report that these dissociative phenomena have always been a characteristic feature of their experience. They cannot identify a time when this was not the case. Since they have always been pervasive features of their phenomenological world, they may presume that these developmentally based (rather than trauma-​related) dissociative experiences are normative and therefore consistent with everyone else’s mode of experiencing. Obviously, if clinicians are not cognizant of these phenomena, they are unlikely to detect their presence, just as practitioners not trained in dissociation are prone to fail to recognize its manifestations when they encounter them. When the sustained dissociative state of consciousness exhibited by survivors of complex trauma is construed as reflecting integration that has never taken place due to developmental deprivation, it becomes easier to recognize a range of phenomena that interfere with effective functioning, which otherwise are rarely noticed by practitioners working with complexly dissociative clients. These phenomena are not commonly thought of as dissociative because they are not subsumed under the classic dissociative “symptoms” as described, for example, in the DSM. The more extreme and severe the complex dissociative presentation, however, the more likely they are to be present, and to be identifiable through careful questioning.

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The following is a list of such phenomena –​forms of incomplete development that are dissociative in nature. All of them have been reported in therapy by complex trauma survivors presenting with a dissociative clinical picture to have been a lifelong constituent of their experience, rather than episodic: •

•

•

•

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•

•

•

A relative lack of bilateral integration: difficulty coordinating movement between the right and left sides of the body, with the experience of the right and left sides of the body as markedly more distinct, separate, and independent than is commonly the case. The sense of separateness is likely to be accompanied by a functional and experiential weakness of sensory integration and physical coordination between the right and left sides of the body. It is sometimes accompanied by an unsteady gait and general difficulties with maintaining balance. Similarly, since it is a function of bilateral integration, poor visual coordination: the experience of vision as two rather than three dimensional due to a lack of muscular coordination between the right and left eyes. As a consequence, the “external” world is perceived as “flat” and lacking depth. This is a good example of a mode of experience that may not be recognized as anomalous by the dissociative individual because it never occurred to them that there is an alternative type of vision. The visceral experience of oneself as two dimensional (i.e., physically “flat”), as opposed to three dimensional: a lack of a stable sense of one’s body as having depth and dimension. It is as if the visual sense of flatness is analogously how one’s physical being is experienced. The absence of a stable sense of emotional object constancy, which reflects the experience that another person still exists and continues to be a source of care even when they are not physically present. Emotional object constancy is highlighted in Margaret Mahler’s separation-​individuation theory (Blum, 2020; Mahler, Pine, & Bergman, 1975), a good example of the correspondence between attachment and other facets of development. Insecurity surrounding emotional object constancy is likely to be encountered with some regularity among practitioners who treat dissociative clients. It commonly finds expression in comments indicating uncertainty about whether the therapist is still “there” between sessions or when out of town, and a general insecurity about the clinician’s degree of caring and reliability. Emotional object constancy is a very good example of one facet of the lack of attainment of secure attachment that may lie outside characteristics that are commonly associated with attachment styles. From a CTT perspective, it is one indicator of a relative inability to experience interpersonal connection, so that when another person is not physically present, there is no sense of relationship to them. Alexithymia, a substantial deficit in emotional awareness that is associated with difficulty identifying the presence of emotion, the relative absence of intensely felt affect, considerable difficulty differentiating emotions from each other, and limitations in the ability to verbalize emotions has been found to be related to dissociation (Serrano-​Sevillano, González-​Ordi, Corbí-​Gran, & Vallejo-​Pareja, 2017; Zorzella, Muller, Cribbie, Bambrah, & Classen, 2020). CTT proposes that the ability to discern the presence of emotions, distinguish shades of emotion, and express them is a function of attentive, responsive parenting, and therefore likely to be appreciably adversely affected in emotionally unresponsive families. Özsoy and Taşcı (2021) found alexithymia, dissociation, and a history of emotional abuse and neglect to be elevated in patients with chronic migraine headaches. It is not unusual for dissociative clients to report a notable degree of poor awareness of affect or its intensity, even when their overt behavior appears strikingly emotionally reactive. The relative absence of the experience of feeling connected to other people (i.e., of emotional intimacy), including friends, romantic partners/​spouses, and one’s own children: This may include a lack of emotional object constancy, but it is distinct from it. It pertains more to the absence of a sense of connectedness one experiences with others, as opposed to the inability to retain an implicit and confident sense that others exist and continue to care about oneself. As with the other phenomena that CTT views as being more closely attributable to deficient development rather than to the impact of trauma, the sense of distance from others is not seen as a form of defense, but rather as a weak or missing capacity. CTT proposes that when one grows up around people who are not caring and attentive, the “receptors” for these experiences are not firmly established. Facilitating this attainment through consistent, clearly discernable attentiveness and responsiveness is a central function of the therapist in treating survivors with complex dissociation. A persistent and pervasive sense of self as disembodied: often a corresponding experience of seeing things from a vantage point outside one’s body rather than through one’s eyes, this mode of experience is essentially chronic depersonalization. In this respect, among the phenomena described here it comes closest to a widely recognized variant of dissociation. Like the other developmental forms of dissociation, what distinguishes it from depersonalization as it is commonly construed is that it has been a lifelong characteristic, reported to be without a point of onset, as always having been the case. The experience is continuous, without breaks, not episodic or even waxing

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and waning in intensity. There is no alternate mode of self-​experience to compare it to, and some may report that they always assumed that this mode of experience –​being outside the body and seeing from a point external to the body rather than through one’s eyes –​was the norm for people in general. Some of the items in these bullet points may be construed as forms of somatoform dissociation, and that is literally the case. However, CTT considers them as being a function of constricted development rather than solely of traumatization. Although most of them, such as incomplete coordination between the right and left sides of the body, are indicative of a lack of integration, they are clearly distinguishable from identity disintegration/​fragmentation and other widely recognized dissociative symptoms. There is no reason to assume that this conglomeration of qualities of experience that can be understood as reflecting both developmental deficits and dissociatively disconnected qualities of experience is exhaustive. It is meant to be suggestive of a broad spectrum of types of experience that are dissociative in nature but not routinely recognized as such. A perspective grounded in the principle that development is in large part a process of increasing capacities for attention, awareness, connection, and neuropsychological integration points to the dissociative nature of these experiential phenomena among PCA survivors –​people who, according to CTT, grew up with developmental deprivation as well as ongoing trauma.

Integration of the Sense of Self The discussion up to this point has mostly addressed forms of dissociation other than the most extreme dissociative diagnosis, identity fragmentation/​DID. This section addresses the question of how a developmental model of dissociation such as CTT conceptualizes DID.

Integration of Self as a Developmental Process Most contemporary conceptualizations consider a lack of integration of the sense of self as the core and quintessential mechanism of dissociation, like the theory of structural dissociation of the personality (see Nijenhuis, Chapter 38 & Van der Hart & Steele, Chapter 15, this volume). For many experts in the field of dissociation, the integration of a sense of identity is itself a developmental achievement. For instance, Richard Kluft (1994), a leading pioneer in the modern study of dissociation, writes The unity of the self is a subjective illusion, and it cannot be assumed that humans are born with a sense of unity. In fact there is every reason to believe that the infant begins without a sense of continuity and this is achieved gradually. p. 23 Similarly, David Spiegel (1993) observes Unity of consciousness is an achievement, not a given. From this point of view, dissociative phenomena are not an oddity but rather a central problem in the study of psychopathology. The issue is no longer why dissociative symptoms occur; it becomes rather why they do not occur more often. p. ix What both Kluft and Spiegel are emphasizing here is that integrated functioning and a cohesive sense of self are not inborn characteristics of human beings, but rather attainments that are only reached gradually over time. The implication of these statements is that the relative absence of integration is the normative starting point of human development. In other words, dissociation in its most extreme form –​identity fragmentation –​is a fundamental and universal feature of the earliest stages of development.

Human Development, Interpersonal Connection, and the Integration of Sense of Self Daniel Siegel (1999), in his book, The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are, assembles extensive empirical evidence that effective neuropsychological functioning is directly dependent on interrelations with other human beings. He writes:

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In… psychiatry, the tremendous expansion of neuroscientific research seems to have been interpreted in the extreme by some as a call to “biological determinism” –​that is, to a view of psychiatric disorders as a result of biochemical processes, most of which are genetically determined and little influenced by experience…. What is ironic, and what up until now has not been well known, is that recent findings of neural science in fact point to just the opposite: Interactions with the environment, especially relationships with other people, directly shape the development of the brain’s structure and function. p. xii Siegel’s point is particularly relevant to the topic of dissociation because he explicitly relates the influence of the interpersonal environment not only to the development of the various components of psychological functioning –​such as attention, memory, and emotion –​but to the attainment of an integrated sense of self: The capacity for self-​integration, like the processes of the mind itself, is continually created by an interaction of internal neurophysiological processes and interpersonal relationships. Resilience and emotional well-​being are fundamental mental processes that emerge as the mind integrates the flow of energy and information across time and between minds. 1999, p. 314; italics in the original In other words, the connections between aspects of mental functioning, including a cohesive and enduring sense of self, evolve largely out of connections and interactions with other human beings; the capacities for internal connection among subjective experiences and connection with the external environment emerge from the impact of interpersonal connection on the structure and functioning of the individual’s nervous system. Development itself, therefore, is to a considerable extent a journey from disconnectedness toward an evolving capacity for connection. Moreover, the development of “inner” connectedness emerges from the availability of reliable and responsive interpersonal connections, most critically in the earliest phases of development. To help concretize this fairly abstract perspective it is helpful to imagine how the types of family environments –​ ones that are often chaotic and emotionally neglectful –​fail to provide the conditions described by Siegel that foster a cohesive and consistent sense of self. Living in the midst of a chaotic interpersonal atmosphere, the developing child has no means of predicting from moment to moment the reactions of those around them generally and towards themself specifically, and therefore has no basis for arriving at a sense of self that is coherent and enduring over time. Alternately, to the degree that there is an experiential vacuum created by a failure on the part of caretakers to accurately recognize and appropriately respond to what the child is experiencing, the developing child may lack a substantial sense of self all together. Clients from these types of backgrounds say that they have always felt invisible, as if they did not exist, and empty, that is, as lacking a sense of self. Descriptions of this form of self-​experience are ones that clinicians who work with complex dissociation frequently encounter. Paradoxically, clients with complex dissociation may both present as if they have multiple senses of self while indicating that they lack a sense of self all together. This is consistent with the general notion of DID where the multiple identities add up to less than one self (See Spiegel, Chapter 49, this volume).

Clinical Implications Theoretical understanding is not an end unto itself. It is a guide to practical applications. The CTT conceptual model aims to elucidate principles that can serve to guide general approaches to treatment. It also helps to identify novel targets for intervention and suggests specific methods of intervention. This section explores some of the practical clinical implications of the CTT framework.

Performance Deficits Versus Skills Deficits A key clinical implication of the distinction in CTT between trauma-​related forms of impairment and those associated with developmental deprivation is that these two forces promote qualitatively divergent types of adversity. Abuse trauma primarily fosters performance deficits, psychological processes that are compromised even though the affected individual has acquired those capacities required for adaptive functioning. Consider, for example, an adult who was functioning well previously but who, in response to a traumatic event, say some form of violent attack such as a mugging, now vigorously avoids many social situations. Even though before the assault they might have displayed a high degree of social competence and were entirely comfortable around other people, as an expression

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of the avoidance component of PTSD their social adjustment is now seriously restricted to the point of being deficient. They still possess the capacity to be effective and at ease in social settings, but their ability to execute behavior (i.e., perform it) is hindered or blocked by trauma-​related avoidance. In contrast, developmental deprivation results in skills deficits. A skills deficit is one that is due to the absence of the requisite ability. These are the types of capacities that are represented in part by the DSO component of C-​P TSD. Trauma-​related difficulties consist of performance deficits: when the restrictions created by the effects of trauma are resolved and subside, already extant capacities that were obstructed by them become accessible. In contrast, limitations in functioning stemming from restricted development represent skills deficits: abilities that the PCA survivor never acquired due to having been reared with limited interpersonal guidance, stimulation, and support. The ability of the clinician to distinguish these two forms of impairment is a key factor in treatment outcome because they require different forms of intervention to effectively alleviate the impairments created by each of them. Trauma-​focused interventions cannot “restore” capacities that never developed in the first place. Resolution of trauma-​related difficulties can accurately be considered a process of recovery. Skills deficits, however, are not resolved, but rather remediated, a process of discovery (Gold, 2020). The impact of these two distinct forces –​abuse trauma that promotes performance deficits and developmental deprivation that results in skills deficits –​can in some instances be challenging to distinguish because they sometimes converge to contribute to the emergence of the same difficulty. Consider two extremely common examples of the joint effect of PCA trauma and the failure of caretakers to provide the resources needed for adequate psychological development: interpersonal mistrust and negative self-​concept. An ongoing pattern of maltreatment –​whether it be verbal, physical, or sexual in nature –​is likely to lead to each of these difficulties. The child is prone to become wary and mistrustful not only of both their abuse perpetrator(s) and people in general, but also to absorb pervasively critical attitudes toward themself. At the same time, even in the absence of abusive parental behavior, growing up in a household lacking the consistent attentiveness and demonstrations of affection that are essential for promoting resilient psychological development not only severely constrain the child’s sense of comfort and trust in others, but leave them with the conviction of being detestable and unlovable; “If my own family doesn’t care about me,” the child implicitly concludes, “I’m not worth caring about, and can’t expect anyone else to care about me. If my family, does not see me as worthy, then there is no way I can see myself as being worthwhile.” In other instances, however, abuse trauma and deficient developmental stimulation have decidedly different effects. Flashbacks, for instance, are obviously an unambiguously direct consequence of abuse trauma, and almost entirely unrelated to psychological development. In contrast, CTT suggests that other characteristics frequently displayed by PCA survivors, such as a restricted ability to be aware of, fully experience, distinguish between, and label emotions, is predominantly traceable to having grown up in the absence of attentiveness and responsiveness to feelings by the child’s caretakers. The major practical implication of CTT, therefore, is that the psychological impediments associated with each of these two types of adversity require decidedly different intervention strategies. The recognition of the role of skills deficits in the problems in adaptation of survivors of complex traumatization helps clarify the observation, dating back at least to Herman (1992), and, according to her account, much earlier to Janet (1889), that an initial phase of “stabilization” is necessary prior to extensive and intensive processing of traumatic events (see Stavropoulos & Elliott, Chapter 44, this volume). For individuals who suffer from both the presence of prolonged trauma and the absence of adequate developmental supports and resources, and who due to pervasive skills deficits are regularly overwhelmed by the routine demands of daily living, confronting the most nightmarish moments of their past is almost certain to be seriously debilitating. Therefore, CTT asserts that prior to intensive trauma-​focused work what is required is not merely stabilization, but remediation of developmental capacities that render coping with both the “ordinary” stressors of daily living and the extraordinary stressor of unresolved trauma manageable.

Concluding Thoughts The CTT view of dissociation and method of treating it differs in certain important respects from other contemporary approaches. It considers dissociation to be a central aspect of psychological functioning grounded in fundamental, universal psychological processes, such as attention, memory, awareness, and emotion regulation. It views dissociation, especially complex dissociation, as resulting from a confluence of a childhood history of extensive abuse along with inadequate attentiveness and responsiveness in the child’s interpersonal household environment (for further discussion, see Quiñones, Chapter 12, this volume). Under favorable circumstances, with developmental progression, the proclivity toward complex dissociation decreases as the capacity for focal attention and awareness expands. A guiding principle in

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CTT-​oriented therapy, therefore, is to identify developmental anomalies and rectify them by fostering the acquisition of capacities that were not adequately nurtured in the person’s family of origin environment. Despite the differences in emphasis of the CTT perspective from some other contemporary approaches to understanding and treating dissociation, there are points of agreement with those whom Cotsell (2005) refers to as the “dissociationists” of late nineteenth and early twentieth century Europe and North America. This cadre included such influential figures as Pierre Janet, Alfred Binet, William James, and Morton Prince, among others. A key force in the work of these investigators was that several of them viewed dissociation as central to understanding the entire realm of psychopathology (e.g., Janet) or even of all of psychology, both abnormal and normal. Assuming the latter position, Prince (1906) wrote that The principle of dissociation of the mind is very important. Only by thoroughly grasping it can one understand multiple personality and other phenomena of abnormal psychology. It underlies the great psychosis hysteria, as well as many manifestations of normal life, like absent-​mindedness, hypnosis, sleep, dreams, visions, etc. p. 92 A second major principle of CTT shared by many turn-​of-​the-​century dissociationists was that dissociation is understood in terms of psychological development. In an overview of Janet’s approach to psychotherapy, Bühler and Heim (2001) observe that he “calls neuroses developmental illnesses….” that can be “traced back to functional disorders [e.g., traumatization] or to an arrest in patients [sic] development” (pp. 84–​85). CTT suggests that complex dissociation emerges from a convergence of both these forces. It further proposes that central to the limitations in development displayed in complex dissociation is impairment in the capacities for sustaining attention and awareness that render the ability to stay focally aware of the present moment tenuous. This ability is essentially what Pierre Janet referred to by the term “ ‘présentification’ (the ability to be present)” (Cotsell, 2005, p. 45, italics in the original). The term “présentification” is reminiscent of the term commonly used interchangeably with “mindfulness” (i.e., “being present”). All of these designations are considered by CTT to essentially be equivalent to each other, and to the capacity for experiential connection, the converse of dissociation. Normal developmental processes and successful psychotherapy both increase the capability for connectedness, but this does not mean that the ability to disconnect is lost. Nor would this be desirable. According to CTT there is nothing inherently maladaptive about experiential disconnection; there are many times when “turning off” awareness is functional. The objective, therefore, is not to eliminate dissociative responding all together, but to equip the person to be able to modulate their level of dissociation versus connectedness, absence versus presence, distractedness versus mindfulness, as needed. Accordingly, CTTx does not aim to eliminate a person’s capacity for disconnection. Instead, its aim is to render dissociative disconnection less habitual and less unintentional by identifying and remediating areas of deficient psychological development. In doing so, CTTx aims to provide the freedom to choose to direct attention and awareness to connect or disconnect as the situation warrants.

Acknowledgments I gratefully acknowledge the contribution of Michael A. Quiñones, who through the course of many engaging discussions has helped sharpen my thinking about the perspective presented here, and the valuable suggestions of Martin Dorahy for refining this chapter.

Notes 1 This finding is especially relevant to the perspective delineated here, because CTT posits an impaired ability to modulate attention to be a key factor underlying pathological dissociation. 2 For reasons discussed elsewhere in detail (Gold, 2020), childhood neglect is referred to here as developmental deprivation, a designation also employed in McLaughlin and colleagues’ empirical investigations.

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Paetzold, R. L., Rholes, W. S., & Andrus, J. L. (2017). A bayesian analysis of the link between adult disorganized attachment and dissociative symptoms. Personality and Individual Differences, 107, 17–​22. Powers, A., Fani, N., Carter, S., Cross, D., Cloitre, M., & Bradley, B. (2017). Differential predictors of DSM-​5 PTSD and ICD-​11 complex PTSD among african american women. European Journal of Psychotraumatology, 8(1), 11. Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York: Guilford Press. Putnam, F. W., Guroff, J. J., Silberman, E. K., Barban, L., & Post, R. M. (1986). The clinical phenomenology of multiple personality disorder: Review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285–​293. Ray, K. C., Jackson, J. L., & Townsley, R. M. (1991). Family environments of victims of intrafamilial and extrafamilial child sexual abuse. Journal of Family Violence, 6, 365–​374. Rudd, J. M., & Herzberger, S. D. (1999). 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19 THE FOUR-​DIMENSIONAL (4-​D) MODEL AS A FRAMEWORK FOR UNDERSTANDING TRAUMA-​RELATED DISSOCIATION Paul Frewen, Serena Wong, and Ruth A. Lanius

This chapter summarizes our clinical-​theoretical perspective on dissociative experiences referring to time, thought, body, and emotional dimensions formalized as the Four-​Dimensional (4-​D) Model of Trauma-​related Dissociation (hereafter, “the 4-​D model”) in the text Healing the Traumatized Self (hereafter, “Healing”; Frewen & Lanius, 2015). We also provide a brief literature review of the empirical studies undertaken so far to evaluate the model and reference some recent literature investigating the brain bases of some of these dimensions of posttraumatic experience. We also consider the clinical significance of the 4-​D model for assessment, diagnosis, and treatment of trauma-​related dissociation.

Prior Theoretical Bases for the 4-​D model Other chapters in this second edition of Dissociation and the Dissociative Disorders (hereafter, “the text”) document continuing progress in our understanding of dissociative experiences over the decade interim since publication of the first volume of the text. Our own theorizing about dissociative experiences, culminating in the 4-​D Model of Trauma-​ related Dissociation (Frewen & Lanius, 2015), was much informed by and took some influence from, scholarly work that tried to provide clear and pragmatic definitions of dissociation (i.e., Holmes et al., 2005; Steele, Dorahy, Van der Hart, & Nijenhuis, 2009). We were also deeply influenced by the discerning treatises authored by Dell (2009a, 2009b). Calling for increased conceptual clarity for the field, these authors’ earlier works recognized the value of differentiating the phenomenological construct of dissociative experiences into at least two factors, thus “dissociating” one form of dissociative experience from another. All of these prior works explicitly recognized alterations in consciousness (ASC). Steele et al. (2009), distinguish ASC from dissociation, while seeing them as closely related. Holmes et al. (2005) refer to ASC as one form of dissociation labelled “detachment.” Dell (2009a, 2009b) further differentiates ASC into various phenomena including those of “derealization” and “depersonalization,” that are definitive of the dissociative subtype of PTSD (e.g., Lanius et al., 2012). Reference to “detachment” and “depersonalization” emphasizes ASC as an experience of disconnection or disengagement, which also speaks to the theorizing of other authors, such as Cardeña. In highlighting their ASC characteristics, he describes dissociative experiences as “qualitative departures from one’s ordinary modes of experiencing, wherein an unusual disconnection or disengagement from the self and/​or the surroundings occurs as a central aspect of the experience” (Cardeña, 1994, p. 23), and as “a sense of experiential disconnectedness that may include perceptual distortions about the self or the environment” (Cardeña & Carlson, 2011, p. 252). Thus, these writings described ASC as involving changes from one’s usual way of experiencing oneself and the world, in other words, from normal waking consciousness (NWC). Further, such changes were described as often (although not always) presenting in the form of an experienced “detachment,” “disconnection,” or “disengagement” from that norm. Arguably a limitation of these definitions of dissociative experiences as ASC, however, is that they do not start first by characterizing the “ordinary modes of experiencing,” that is, the qualities of NWC that ASC qualitatively depart from. Instead, these prior descriptions generally take as a given readers’ familiarity with what NWC “is like,” in other words,

DOI: 10.4324/9781003057314-23

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that the phenomenology of “one’s ordinary modes of experiencing” requires no further explanation. In effect, these descriptions define ASC as being qualitatively different from NWC, but are silent regarding exactly how they differ. Moreover, although dissociative experiences defined by ASC refer to phenomenology, they offer no explanation of the psychological processes or mechanisms by which these ASC come to pass. Prior theoretical models also recognized compartmentalization of psychological functions as a dissociative experience that is different from ASC. We resonate with Spiegel and colleagues’ description of compartmentalization as the plainest definition we have so far come across: “aspects of psychological functioning that should be associated, coordinated, and/​ or linked are not” (Spiegel et al., 2011, p. 826). Notice that whereas ASC are defined by phenomenology, compartmentalization describes dissociation mechanistically: a hypothesized psychological process is elucidated through which various symptoms arise. In this case, however, these symptomatic experiences are defined extremely broadly when it comes to phenomenology. Generally, experiences of compartmentalization are described as unwanted or intrusive, and as either positive or negative symptoms (drawing on terms that have been applied in the psychosis literature), for example: (a) a loss of continuity in subjective experience with accompanying involuntary and unwanted intrusions into awareness and behavior (so-​called positive dissociation); and/​or (b) an inability to access information or control mental functions or behaviors, manifested as symptoms such as gaps in awareness, memory, or self-​identification, that are normally amenable to such access/​control (so-​called negative dissociation). Cardeña & Carlson, 2011, p. 251 Beyond these general descriptors, the phenomenological domain of dissociation defined by compartmentalization is highly open. For example, as articulated by Dell: “the domain of dissociative psychopathology is all of human experience” (Dell, 2009a, p. 228, italics original), and he explicitly notes that dissociation “can (and often does) affect seeing, hearing, smelling, tasting, touching, emoting, wanting, dreaming, intending, expecting, knowing, believing, recognizing, remembering, and so on” (Dell, 2009a, p. 228, italics original). Thus, from the perspective of compartmentalization, the phenomenology of dissociative experiences is an open field; just about any experience seems potentially to qualify as a product of compartmentalization. Particularly insofar as psychological processes cannot be observed directly but can only be inferred through self-​reports, behavioral observations, and psychophysiological (including neurobiological) measurements, we believe this non-​descriptive phenomenology has led to some confusion as to what constitutes a dissociative experience. In particular, when the exemplars are defined as broadly as this, the boundaries of the category become so fluid that the category itself becomes difficult to grasp. Certain authors go further than just the notion of compartmentalization of psychological functions to account for so-​ called positive and negative dissociative experiences by positing that the key function that may be compartmentalized in the person with a dissociative disorder may be that of self-​referential processing (SRP) (e.g., Nijenhuis & Van der Hart, 2011; see Van der Hart & Steele, Chapter 15, this volume). This family of models are commonly known as “structural” theories in the literature, and refer specifically to a dissociation within the sense of self hood, that is, different senses of self within different egos-​personalities-​identities, that manifest in other psychological functions such as learning, memory, attention, executive functions, emotions, bodily experience, etc. We prefer using the term SRP as its name simply implies psychological processing of stimuli in reference to a self-​construct, that is, a summative concept of the person. Here, normally it is assumed that an individual has a singular (if complex) self-​construct. In comparison, the person with a dissociative disorder is described as internalizing multiple self-​constructs, each of which may be the acting conscious subject of experience, that is, operating in the agentic role of first-​person perspective (1PP), even as other senses of self are processing the same stimuli subconsciously, in parallel. From this point of view, intrusions are posited as the result of the currently conscious subject (1PP) experiencing the responses of alternate subconscious self-​constructs (i.e., other 1PP). The structural theories also emphasize the processes by which dissociative experiences may come about more than they emphasize the phenomenological qualities of dissociative experiences. For example, Steele et al. (2009) wrote: “in theory it is simple to distinguish between the symptoms of structural dissociation and pathological fields and levels of conscious awareness: the former involves a division of the personality and the latter does not” (p. 160). It is important to point out here that Steele and colleagues therefore do not take the presence of ASC to be a definite marker of structural dissociation of the personality. Rather, in their stated clinical experience, while most if not all of those persons who are experiencing structural dissociation will endorse ASC, it does not necessarily go both ways: they note that those who experience ASC do not necessarily exhibit prominent signs of structural dissociation of the personality and multiple 1PPs. Such observations further serve to differentiate ASC from both compartmentalization and structural dissociation as a distinct kind or model of dissociative experiences. Further, it should also be noted that the symptomatic effects of

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structural dissociation, as noted above for compartmentalization, are also posited to be broad. For example, Nijenhuis and Van der Hart (2011, p. 418) indicated that: “Phenomenologically, this division of the personality manifests in dissociative symptoms that can be categorized as negative (functional losses such as amnesia and paralysis) or positive (intrusions such as flashbacks or voices) and psychoform (symptoms such as amnesia, hearing voices) or somatoform (symptoms such as anesthesia or tics).” Besides the aforementioned distinction between positive and negative dissociative experiences, this framework makes an additional interesting primary distinction between psychological and somatic dissociative experiences. This natural boundary between psychological and somatic senses is taken up later in our discussion of the consciousness of SRP more generally (Frewen et al., 2020). In summary, prior writings emphasized the importance of distinguishing between at least two different kinds or ways of defining dissociative experiences: those defined phenomenologically as ASC, and those defined either by the psychological mechanism of compartmentalization generally, or by the structural division of the personality more specifically. We now turn to explicating the 4-​D model as a successor of these important theoretical perspectives.

The 4-​D Model as a Phenomenological Framework for Understanding Dissociative Experiences as ASC The 4-​D model has mostly been evaluated in its phenomenological format, where it is clearly aligned with the ASC perspective on dissociative experience. However, where we feel the 4-​D model goes beyond prior definitions of ASC is that it attempts to first make clear its phenomenological model for defining NWC and how, in turn, ASC represent a violation of these defining characteristics of NWC. Thus, the 4-​D model does not simply hold that NWC and ASC are different, as seemingly have some prior writings, but describes specifically how or in what specific ways NWC and ASC differ. Moreover, rather than only referring to a sense of “detachment” from an “ordinary” or “normal” way in which one experiences oneself and the world, the 4-​D model refers to four specific phenomenological domains of experience in their NWC vs. ASC forms: our sense of time, thought, body, and emotion. This list thus also respects an important distinction between psychoform and somatoform dissociation (e.g., Nijenhuis & Van der Hart, 2011), and has also been accorded with differing positive (time, thought) and negative (body, emotion) experiences of dissociative experience. Here we will first explicate each of the four phenomenological dimensions in the form of NWC, and describe PTSD symptoms that appear not to violate these definitions of NWC for each dimension. Subsequently, ASC are described for each dimension, and dissociative experiences are noted that appear to fit as a violation of the given NWC definitions. Indeed, we have recently acknowledged that it falls on us to articulate what constitutes the case of NWC for each of the four phenomenological dimensions, and in turn how dissociative experiences violate these identifying features of NWC (Frewen, MacPhail, Schielke, Lanius, & Brand, 2022). We took up this responsibility and offered a thorough explication in the original writing (Frewen & Lanius, 2015), but have perhaps neglected this in subsequent empirical work. Here we hope to make clearer that our process of differentiating between psychopathological symptoms involving ASC and those that do not is anything but arbitrary. Table 19.1 outlines the symptoms we attribute to NWC versus ASC, with reference to survey items of the PTSD Checklist for DSM-​5 (PCL-​5; Blevins et al., 2015) as measures of NWC and various face valid items we articulated ourselves (Frewen, Brown & Lanius, 2017) as measures of Trauma-​ Related ASC (TRASC). In the appendix we also include a 10-​item questionnaire we now routinely administer in our studies of dissociative experiences as an addendum to the 20-​item PCL-​5, that is, as items 21–​30 and using the PCL-​5 item anchors and scoring from “Not at all” to “Extremely” as 0 to 4; these face valid items cover assessment of the 4-​D model dimensions of ASC as well as other items referring to the presence of structural dissociation. Clinical researchers are free to use these survey items in their own assessments as they please.

Normal Waking Vs. Altered States of Consciousness of Time Referring to the phenomenological dimension of time, we have suggested that our NWC of time, first and foremost, involves accurately differentiating between past and present, in other words, that the past and present are known as such. From this straightforward definition it then follows that those experiences involving a confusion of past versus present are constitutive of an ASC of time. In this case, the 4-​D model highlights the importance of distinguishing between the PTSD symptoms of intrusive memories and reminders of distress, on the one hand, and flashbacks, on the other. Here we are suggesting that only with flashbacks is there a misapprehending of the past for the present, that is, an ASC of our experience of time. Comparably, distress experienced when recalling a traumatic event that happened in the past is held to be qualitatively different from reliving a trauma as if it is occurring in the here and now. In effect what we are suggesting is that it falls within the domain

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330  Paul Frewen, Serena Wong, and Ruth A. Lanius TABLE 19.1  Brief definition and face-​valid symptom measurement of the 4-​D Model Dimensions

Dimension

NWC Definition

NWC-​D istress Symptom(s)

Time

Accurately differentiating between past and present.

Response to each of the two following Mistakenly PCL-​5 items is summed and then differentiating divided by two: (a) “Repeated, between past disturbing, and unwanted memories of and present a stressful experience.” and (b) “Feeling (e.g., past very upset when something reminded regarded as you of a stressful experience.” present).

Thought

Self-​referential thought transpires in 1PP.

Body

Experience Is embodied.

Response to each of the two following Self-​referential PCL-​5 items is summed and then thought does divided by two: (a) “Having strong not transpire negative beliefs about yourself, in 1PP (e.g., other people, or the world (e.g., transpires in having thoughts such as: I am bad, 2PP). there is something seriously wrong with me, no one can be trusted, the world is completely dangerous).” and (b) “Blaming yourself or someone else strongly for a stressful experience or what happened after it.” “Having a strong physical reaction when Experience is something reminded you of the stressful not embodied experience (e.g., heart pounding, (i.e., is trouble breathing, sweating).” disembodied).

Emotion

A range of emotional feelings can and are experienced.

“Having strong negative feelings such as fear, horror, anger, guilt, or shame.”

TRASC Definition

TRASC Symptom(s) “Flashbacks of a Traumatic Event: Acting or feeling as if a traumatic event that you have experienced in the past is happening in the present. Having the sense that you are actually ‘reliving’ the event in the present, rather than only remembering the event as it happened in the past.” “Hearing Voices Inside Your Head: Hearing voices inside your head that seem to be different from your own voice and/​or different from your own thoughts.”

Response to each of the two following TRASC-​ Q items is summed and then divided by two: (a) “Out of Body Experience -​Feeling detached or separated from your body, for example, feeling like you are looking down on yourself from above, or like you are an outside observer of your own body.” and (b) “Feeling like a Part of Your Body is Not Your Own -​For example, like your hands or feet are strange, unfamiliar, disconnected, not there, or that they do not belong to you.” A range of “Marked Loss emotional of Emotional feelings cannot Feeling: Feeling be experienced. completely numb, hollow, and lifeless inside, as if you are already dead.”

Note. PCL-​5 =​PTSD Checklist for DSM-​5. NWC-​Distress symptoms are measured by items from the PCL-​5, while TRASC symptoms are measured by the Trauma-​related Altered States of Consciousness Questionnaire (TRASC-​Q; Frewen, Brown, & Lanius, 2017)

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of NWC to intrusively recall and become upset by past traumatic stressors in so far as these recollections nevertheless entail the clear recognition that the stressors occurred in the past. Comparably, when we respond as if the past trauma is actually occurring in the present, we hold that our ordinary sense of time has been altered. In summary, stated plainly, we have PTSD symptoms that do not violate the strict definition we have given for the NWC of time (i.e., intrusive memories and reminder distress), while we also have a PTSD symptom that violates the definition (i.e., flashbacks). These PTSD symptoms are thus held to be qualitatively different in phenomenology, with only the latter described as a dissociative experience involving ASC. For an elaborated treatise on dissociative experiences of the consciousness of time, including alterations of the pacing of the experience of time (e.g., time seeming to move slower or faster than usual, i.e., as in NWC) please see Correa, Rodriguez, and Bortolaso (2022).

Normal Waking Vs. Altered States of Consciousness of Thought Turning to the dimension of thought, the 4-​D model defines the NWC of self-​referential thought to be that which transpires in 1PP. This is to say that ordinarily we experience the world as if it is happening to an agentic “ego” that is referenced in 1PP, in other words, as “I” rather than “you” (2PP) or “the” (3PP). Further, a sense of ownership is often experienced in reference to the internal voice of thoughts that are “heard” in 1PP, a sense often absent in thoughts experienced in 2PP or 3PP. For example, consider picking up an apple. If the internal verbal experience of doing so would read something like “I am picking up an apple,” one is having the experience of 1PP, here defined as the NWC of thought about said action. In this case, it seems likely that the person will experience the thought as their own thought, that is, they will experience a sense of ownership over the thought. Comparably, notice that if we would have the thought “You are picking up an apple” (2PP) or “The apple is being picked up” (3PP), the agent who is picking up the apple is comparably deidentified with (from a 1PP), and the thought itself may be disowned as not mine. In each of the latter cases, there is a more than subtle differentiation between the sense of self that is picking up the apple and the sense of self that has the corresponding thought. This works the same way with negative self-​referential thoughts, wherein the 4-​D model holds that voice hearing represents self-​referential thought occurring in 2PP instead of the normal 1PP, thereby constituting an ASC of thought. The 4-​D model describes experiencing negative self-​referential thoughts in 1PP as frequently symptomatic of PTSD (e.g., the item “I am a weak person” that is included in the Posttraumatic Cognitions Inventory) to be different from hearing a voice inside one’s head saying something similar but in 2PP (e.g., “You are a weak person”), particularly in so far as the individual would believe that the thought is not their own, but rather, the voice of someone else. In brief, the former experience does not violate our defining criterion for the NWC of thought (i.e., as occurring in 1PP) whereas the latter does. Voice hearing is therefore described as an ASC of self-​referential thought (i.e., a dissociative manifestation of thought).

Normal Waking Vs. Altered States of Consciousness of the Body Coming to the dimension of the body, the 4-​D model describes the NWC of the body as embodied. This is to say that NWC entails a bodily felt consciousness and an experience in which we find ourselves to be spatially located within our physical body, further entailing a felt ownership over the body (i.e., that this is “my” body) not unlike the felt ownership over thoughts experienced in 1PP described earlier. Following this definition, the 4-​D model considers somatically-​referenced and “owned” feelings of distress (e.g., the feeling that “my heart is racing”) to be different from responses to distress that involve a sense of disembodiment (e.g., depersonalization, out of body experiences). These latter experiences characteristically involve a felt disidentification with and lack of ownership over the physical body, experienced from the perspective of a spatial separation between the body and an alternately located representation for the ego or agentic self, be it within another body or not. Given that such experiences violate the definition given for the NWC of the body as embodied, these experiences are described as ASC of the body.

Normal Waking Vs. Altered States of Consciousness of Emotion Finally, referring to our NWC of emotion, the 4-​D model simply draws attention to the fact that ordinarily our affective life comprises a range of different emotional experiences. For example, feeling fear, sadness, anger, guilt, and shame may all be experienced in time, particularly if one has been unfortunate enough to repeatedly encounter traumatic events and be involved in multiple abusive relationships, especially from a young age.

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Against this description of a deeply felt experience of different painful emotions, the 4-​D model holds that the experience of marked emotional numbing is necessarily considered an ASC of emotionality in so far as a marked emotional numbness replaces the normal affective range definitive of NWC. Notably, we have asserted that marked emotional numbing is itself a feeling, but one defined by the lack altogether of any other affective feeling (Frewen et al., 2012), for example, characterized as the feeling of being “completely numb, hollow, and lifeless inside, even as if one is already dead” (Frewen, Brown, & Lanius, 2017). In effect, we are suggesting that NWC of emotion merely requires that one affectively feel something; accordingly, the various pervasive negative affective states often accompanying PTSD (e.g., fear, sadness, anger, guilt, and shame) are not described as an ASC of emotion within the 4-​D model. Comparably, if instead one feels nothing (marked emotionally numbing), one violates the definition we have given for the NWC of emotion, and one must be said to be experiencing an ASC (i.e., a dissociative experience) of emotion.

Section summary In summary, the 4-​D model articulates a set of straightforward and clearly defined phenomenological criteria for the NWC of four dimensions: those governing our ordinary experience of time, thought, our body, and emotions. Then, PTSD symptoms are recognized for each phenomenological dimension that do not violate these defining criteria, which we have collectively labelled symptoms of normal waking conscious distress (NWC-​d istress). Different dissociative experiences were also recognized for each dimension in so far as these experiences violate the defining characteristics of NWC, thereby constituting ASC of our experience of time, thought, body or emotion. With reference to prior conceptual literature that recognizes ASC as dissociative experiences (e.g., Holmes et al., 2005; Spiegel et al., 2011), the 4-​D model thus distinguishes trauma-​related symptoms into phenomenally distinguishable forms: those that do not entail an alteration of the defining characteristics of NWC, and those that do (ASC). In so far as the latter come about post-​t raumatically, we further refer to these ASC as trauma-​related ASC (i.e., TRASC).

Empirical Tests of Four Hypotheses of the 4-​D Model Beyond articulating a set of defining phenomenological criteria for NWC and providing a corresponding list of symptoms that do versus do not violate such criteria, the 4-​D model makes four testable hypotheses that, if empirically supported, would further validate that the distinctions we make between these two sets of symptoms are real and important. In brief, these four hypotheses refer to the frequency of symptom endorsements, the co-​frequency of endorsements, the co-​frequency of symptom endorsements with other measures that are either recognized or not as measures of dissociative experiences, and the specificity with which symptom endorsements are made in persons with childhood trauma histories. We explicate the conceptual basis by which we make each prediction in turn, and the reader may refer to Table 19.2 for a brief systematic review of the results we have so far observed across several previous studies. Here we submit that the 4-​D model goes further than prior theoretical frameworks that defined dissociative experiences as ASC in that, rather than only providing a definition, the 4-​D model gives a number of falsifiable predictions by which it can either be supported or refuted.

Hypothesis 1: Frequency of Symptom Occurrences As noted, the first hypothesis of the 4-​D model refers to the mean frequency of symptom endorsements, wherein NWC symptoms are predicted to be endorsed more frequently than TRASC symptoms. This pattern of results is theoretically expected on the basis that, if we have the symptoms sorted correctly into their respective NWC vs. ASC categories, the symptom that accords with the defining characteristics of NWC must be experienced more frequently than ASC; in other words, this occurs by definition. This is the case simply because what is the “normal” case comes to be as a result of being the most frequent way things are; the more frequent something is the case, the more ordinary, expected, or “normal” we will refer to future recurrences. As the reader can see in Table 19.2, the majority of our prior studies have found that the symptoms we labelled as TRASC were less often endorsed than the symptoms we labelled as indicative of NWC-​d istress, although results varied somewhat by the dimension of consciousness that was evaluated. Specifically, of the nine studies we have so far conducted, TRASC of time (flashbacks) were endorsed less frequently than NWC-​d istress of time (intrusive memories, reminder distress) in all nine studies, while TRASC of thought, body and emotion were endorsed less

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Understanding Trauma-Related Dissociation  333 TABLE 19.2  Systematic Review of the Results of the 4 Hypotheses of the 4-​D Model up to 2021 Dimension

Study

Time

Thought

Body

Emotion

Temporality (sense of time and memory)

Narrative (the story-​like quality of thought)

Embodiment (the sense of having and consciously belonging to a body)

Affect

Supported

Supported

Supported

Supported

H1: Yes H 2: No H 3: Yes H4: Partial

H1: Yes H 2: No H 3: Yes H4: Partial

H1: Yes H 2: No H 3: Yes H4: Partial

H1: Yes H 2: No H 3: Yes H4: Yes

H1: Yes H 2: Yes H 3: Mostly H4: Partial

H1: Yes H 2: Yes H 3: Mostly H4: Partial

H1: Yes H 2: Yes H 3: Mostly H4: Partial

H1: Yes H 2: Yes H 3: Mostly H4: Partial

H1: Yes H 2: Yes H 3: Yes H4: Yes H1: Yes H 2: Yes H 3: Not Evaluated H4: Not Evaluated

H1: Yes H 2: Yes H 3: Yes H4: No H1: Yes H 2: Yes H 3: Not Evaluated H4: Not Evaluated

H1: Yes H 2: Yes H 3: Yes H4: No H1: Yes H 2: Yes H 3: Not Evaluated H4: Not Evaluated

H1: Yes H 2: No H 3: Partial H4: Partial

H1: Yes H 2: No H 3: Partial H4: Partial

H1: Yes H 2: No H 3: Partial H4: Partial

H1: Yes H 2: No H 3: Partial H4: Partial

H1: Yes H 2: Yes H 3: No H4: No

H1: Yes H 2: Yes H 3: Yes H4: No

H1: Yes H 2: Yes H 3: Partial H4: No

H1: Yes H 2: Yes H 3: Partial H4: No

H1: Yes H 2: Yes H 3: Mostly H4: Partial

H1: Yes H 2: Yes H 3: Mostly H4: Partial

H1: Yes H 2: Partial H 3: Mostly H4: Partial

H1: Yes H 2: Partial H 3: Mostly H4: Partial

H1: Yes H 2: Partial H 3: No H4: No

H1: Yes H 2: Partial H 3: No H4: No

H1: Yes H 2: Partial H 3: Yes H4: No

H1: Yes H 2: Yes H 3: No H4: No

H1: Yes H 2: No H 3: No H4: Not Evaluated

H1: No H 2: Partial H 3: No H4: Not Evaluated

H1: No H 2: No H 3: Partial H4: Not Evaluated

H1: No H 2: Partial H 3: No H4: Not Evaluated

Bækkelund et al., 2018 N =​142 Norwegian PTSD outpatients, with (n =​46) and without (n =​96) comorbid dissociative disorders Brown & Frewen, 2017 N =​288 undergraduates with psychological symptoms and histories of childhood trauma Frewen & Lanius, 2014 N =​74 women with PTSD primarily from childhood trauma

H1: Yes H 2: Yes N =​504 undergraduate students, majority H 3: Yes H4: No non- ​clinical H1: Yes H 2: Yes H 3: Not Evaluated H4: Not Evaluated Frewen et al., 2014 N =​258 women with borderline personality disorder with (n =​126) and without (n =​132) PTSD Frewen et al., 2015 N =​180 acutely traumatized adults

Frewen et al., 2017 N =​2478 MTurk sample

Tzannidakis & Frewen, 2015 N =​556 MTurk sample

Frewen et al. (in press) N =​111 participants with dissociative disorders participating in the TOP-​DD-​ Internet trial

Notes. In traumatized persons, compared with normal waking consciousness (NWC), symptoms of TRASC will be: H1: observed less frequently H 2: less intercorrelated, especially as measured as moment-​to-​moment states H 3: observed more frequently in people with high dissociative symptomatology as measured independently H4: observed more often in people who have experienced repeated traumatization, particularly early developmental trauma H 3 and H4 were evaluated only in some but not all studies as indicated.

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frequently than NWC-​d istress of the same dimensions in eight of the nine studies. The exception was the most recent study by Frewen et al. (2022).

Hypothesis 2: Frequency of Symptom Co-​occurrences The second hypothesis tested by the 4-​D model regards the frequency of symptom co-​occurrences. This hypothesis has its theoretical basis in the notion of compartmentalization described earlier. Simply stated, NWC-​d istress symptom endorsements are predicted to be more highly intercorrelated than reports of TRASC because, if dissociative experiences are held to be compartmentalized in experience, they should be less “associated, coordinated, and/​ or linked,” to use again the convenient phrasing of Spiegel et al. (2011). Thus, even if one endorses one dimension of altered experience, one may not endorse the other, because the two dimensions of experience do not go together as frequently as is normally expected. If the experiences are compartmentalized or disintegrated in conscious experience, they will be less correlated, implying that one may be more likely to be present in the absence of the other than is normally the case (see also Briere et al., 2005). The prediction of varying symptom co-​occurrences has also been confirmed in the majority of prior studies, although results have again varied somewhat by the dimension of consciousness that was evaluated. Specifically, the prediction was confirmed at least in part in six of nine studies of the TRASC of time and body, and seven of nine studies of the TRASC of thought and emotion, as summarized in Table 19.2. Regarding partial sources of support we refer to statistical results that were not entirely unambiguous; please see the original referenced reports cited in Table 19.2 for elaboration on this point.

Hypothesis 3: Frequency of Symptom Occurrences With Other Measures of Dissociative Experiences The third hypothesis of the 4-​D model considers the co-​occurrence of ASC with other markers of dissociative experience. This hypothesis has essentially involved evaluations of convergent validity: if TRASC are indeed measures of dissociative experiences they should be more highly correlated with other measures of dissociative experiences as compared with measures of PTSD and distress symptoms that are not normally considered dissociative experiences. The majority of the eight studies that have evaluated this hypothesis have supported it to date, albeit results again vary by the phenomenological dimension being evaluated. Specifically, if one accepts partial sources of support, the hypothesis was confirmed in five studies of the TRASC of time, six studies of the TRASC of thought and emotion, and all eight studies of the TRASC of body.

Hypothesis 4: Specificity of Symptom Occurrences in Persons With Childhood Trauma Histories Finally, the fourth hypothesis of the 4-​D model addresses the co-​occurrence of ASC with childhood traumatization. This hypothesis is the one most relevant to describing ASC as a trauma-​related ASC (i.e., TRASC). The hypothesis was put forth based on the notion that early trauma exposure would likely play a particularly disruptive role when compared with later trauma exposure in the normal development of reality orientation and sense of self, that is, NWC. As originally articulated by Frewen and Lanius (2015), the hypothesis is that TRASC will be more specifically identified in persons with developmental (childhood) trauma histories such as severe emotional, physical, and sexual abuse. Unfortunately, however, the hypothesis has rarely been evaluated by measures of specificity (c.f., Frewen, Brown, & Lanius, 2017), and instead mostly only correlational analyses have been conducted, which do not differentiate between measures of sensitivity versus specificity. Acknowledging this limitation in the statistical methods conducted to date, the basic essence of the prediction was evaluated at least in comparing correlation coefficients in seven studies. As shown in Table 19.2, the hypothesis was supported or partially supported in four studies for the TRASC of time, body, and emotion, and in five studies for the TRASC of thought.

Section Summary Taken together we conclude that research conducted to date seems to suggest that compared with symptoms that the 4-​ D model considers not to violate the defining criteria of NWC, the symptoms it considers to be dissociative experiences of ASC tend to occur less frequently (hypothesis 1), co-​occur less frequently (hypothesis 2), co-​occur more often with other measures of dissociative experiences (hypothesis 3), and co-​occur more specifically with measures of childhood maltreatment (hypothesis 4). The results did vary somewhat by which of the four dimensions of TRASC (time, thought,

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Understanding Trauma-Related Dissociation  335

body, or emotion) one is evaluating. Yet, overall these results tend to validate that there is a difference between the two sets of symptoms in Table 19.1, and that our sorting of these symptoms into their respective categories is not arbitrary. As we see it, some of these symptoms do not violate the defining criteria of NWC, while others do, and so must thereby be called ASC. Further, to the extent that the underlying etiology of these ASC can be traced to the occurrence of traumatic life events, we may refer to them as TRASC.

Neurophenomenology and the 4-​D Model: A Focus on Neuroimaging Studies of the Consciousness of Self Just as the aforementioned four hypotheses have been tested as a means of differentiating between various symptoms by self-​report, the 4-​D model was also born out of our knowledge of functional neuroimaging studies that tended to support distinguishing these dimensions of ASC from symptoms of distress that did not violate our definitions of NWC. The primary text for the 4-​D model thus reviewed hundreds of neuroimaging studies including meta-​analytic reviews that tended to support the distinction between NWC and ASC in respect to our consciousness of time, thought, body, and emotion (see Frewen & Lanius, 2015). Rather than repeating reference to this now older literature, we take the liberty of reviewing some studies published since, and consider a recent integrative framework for summarizing the neuroimaging literature that was published after the 4-​D model (Frewen et al., 2020). Much of the earlier cited and more recent literature has emphasized certain neural networks as partly underlying our NWC of time, thought, body, and emotion. Most notably, responses in the so-​called cortical midline structures and insula cortex are described as forming a primary basis for the consciousness of self into two aspects: one that is verbally mediated (conceptual, psychological) and accessible via introspection, and one that is non-​ verbally mediated (bodily, somatic) and accessible via interoception (Frewen et al., 2020). The review suggests that these verbal versus non-​verbal forms of SRP may be mediated by differing neural networks, that is, the left inferior parietal cortex in the verbal case and the right inferior parietal cortex and insula in the non-​verbal case. Moreover, the review identifies possible convergence zones where the two representations are integrated to form higher-​order representations in the cortical midline, within the parietal lobe (posterior cingulate, precuneus) and the frontal lobe (medial prefrontal cortex), the latter further differentiated on the vertical axis based on the emotional salience of SRP and differing by whether SRP is taking place via 1PP versus 3PP. Interestingly, these neural networks underlying SRP also appear to be implicated in dissociative experiences as evidenced in recent studies. For example, referring to the notion of multiple 1PPs, an interesting case report was published describing acute onset of a transient dissociative identity disorder typified by the assumption of abusive persons experienced in the workplace. The patient was an elderly man without any history of childhood trauma in whom computed tomography scan identified an acute left parietal haematoma (an older lacunar infarct in the right frontal lobe was also identified in this patient; Sreenivasa & Mayur, 2019). Consistent with the haematoma, the notion that the left (inferior) parietal cortex partly mediates the verbal narrative sense of self is well specified in the review by Frewen et al. (2020). Comparably, the prior work emphasized right inferior parietal involvement in bodily self-​consciousness, although a recent case study has further suggested that the same can be invoked by a tumor exercised from the right posterior cingulate cortex in the case of an adult female, interpreted as an effect that may relate to functional connectivity with the right inferior parietal lobe in so far as the posterior cingulate cortex is a highly interconnected brain region (Hiromitsu, Shinoura, Yamada, & Midorikawa, 2020). Further, in broad keeping with the influence of the cortical midline structures in providing a neurobiological basis for dissociative experiences, Lebois et al. (2021) showed that within and especially between network connectivity of the default-​mode and frontoparietal control networks is altered in persons self-​reporting a high severity of pathological dissociation. Nevertheless, some of our neuroimaging studies show that the origins of alterations in these higher-​level cortical networks often lie deeper in subcortical and brainstem regions and a whole-​brain approach will continue to be necessary if we are to fully understand the neurophenomenology of TRASC (e.g., Harricharan, McKinnon, & Lanius, 2021).

The 4-​D Model as a Compartmental-​Structural Theory for Understanding Dissociative Experiences While the 4-​D model has mostly been evaluated as a phenomenology for understanding dissociative experiences aligned with the ASC perspective, it also explicitly accounts for the role of compartmentalization of psychological functions and structural dissociation of the personality in two ways. First, as has already been mentioned, the 4-​D model makes the prediction that the co-​occurrence (correlation in endorsement rates) of state symptoms across the four phenomenological dimensions should be lower in the case of ASC (dissociative experiences) than NWC (non-​d issociative experiences).

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This is a prediction it derived directly from the notion of compartmentalization. Recall Spiegel and colleagues’ (2011) description that with dissociation “aspects of psychological functioning [such as the 4 experiential dimensions of time, thought, body and emotion] that should be associated, coordinated, and/​or linked are not” (Spiegel et al., 2011, p. 826). From this it follows that while NWC-​d istress symptoms may be highly “associated, coordinated, and linked,” dissociative experiences should be significantly reduced in association, coordination, and linkage. It is important to emphasize however that this applies to state measures of dissociative experiences (i.e., assessments referring to current experience, what a person is experiencing right now) rather than trait measures (e.g., assessments referring to longer time scales, such as the frequency of symptoms over the course of a full day, week, month, etc). While we have evaluated the prediction in several studies, unfortunately we have only done so with assessments referring to long time scales. The results of these tests have already been summarized previously in the chapter. Beyond that, lesser known is that the 4-​D model also includes a process description of how ASC, compartmentalization, and structural dissociation may come about, which we originally titled a “(non)-​self-​referential processing model” (N-​SRP model; Frewen & Lanius, 2015). The N-​SRP model has much in common with structural theories of dissociation, but differentiates how ASC can arise not only in the presence but also in the absence of formation of multiple 1PPs, which we take as the basis for differentiating between structural dissociation of the personality versus compartmentalization alone, respectively. In short, the N-​SRP model describes NWC as occurring in 1PP, thus stimuli are encoded in such a way that it feels like whatever is happening is happening to a “me.” Further, the N-​SRP model takes the assumption that NWC is motivated by self-​preservation, meaning that, whenever possible, stressors will be responded to with active coping to increase pleasure and decrease pain, such as fight or flight responses. However, when active coping is not possible, behaviorally passive coping may be the only recourse, for example, seeking to suppress the feeling of, distract oneself from, repress the memory of, or emotionally decenter from, the inescapable stressor. The N-​SRP model describes each of these emotion regulation strategies as having in common an attempt at non-​ self-​referential processing, that is, at diminishing the self-​referential salience of what is happening. We have considered that these coping skills may be tantamount to altering the experience of events from 1PP to third person perspective (3PP). For example, “He is beating me up” is processed as something akin to “Someone is beating someone up”; the personal relevance of the matter is reduced. We conceive of this transfer of processing from 1PP to 3PP as effecting a compartmentalization of the self-​referentiality of the experience from its other phenomenological dimensions, making it somehow now less urgent (in time), relevant (in thought), somatically experienced (in body), and affectively felt (in emotion). Nevertheless, this transfer of 1PP to 3PP in our view does not appear to require “other-​referential processing,” and so we refer to the process as involving merely compartmentalization and not necessarily structural dissociation of the personality (i.e., multiple 1PPs). In contrast, while the N-​SRP model describes 3PP processing of traumatic stressors as a mechanism limited to the notion of compartmentalization, it describes a structural dissociation of the personality as transpiring when events are responded to as if they are happening to another person, that is, with “other-​referential processing” (ORP) instead of self-​referential processing (SRP). Here, one cognitively reappraises events as something that is happening to someone other than the self, that is, another 1PP. Nevertheless, while doing so, the person also maintains ongoing SRP in parallel, that is, a 1PP with which they self-​identify. Taken together, the N-​SRP model holds that one is engaging in a structural dissociation of the personality when one simultaneously responds to events with at least one form of SRP (one 1PP) and one form of ORP (another 1PP). In this case, “He is beating me up” (SRP in 1PP) is also independently processed as something like: “He is beating her up; it is not me that is being beaten up, it is someone else, she is being beaten up, not me” (ORP, or, a second 1PP). In this way, the traumatized individual invokes the formation of another self (1PP) to be the victim of the abuse, thereby saving herself in a psychological form of escape when physical escape was not possible.

The 4-​D Model, Dissociative Disorders, and the Dissociative Subtype of PTSD The 4-​D model was written not long after the acceptance of a dissociative subtype of PTSD (D-​PTSD) into the nomenclature of psychiatry within the DSM-​5 (American Psychiatric Association, 2013). D-​PTSD is diagnosed when a person with PTSD also endorses at least one of two dissociative experiences of derealization and depersonalization. Comparably, the revised description of depersonalization disorder under DSM-​5 expanded the construct of depersonalization so that various temporal, emotional, and perceptual disturbances also potentially qualified as symptomatic of the disorder (Spiegel et al., 2011, 2013).

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The 4-​D model agrees with each of these revisions to our understanding of pathological dissociative experiences under DSM-​5. Regarding the specification of a D-​PTSD subtype that differentiates persons with PTSD who do versus who do not report prominent dissociative experiences, the 4-​D model is predicated on the notion that some persons with PTSD present with prominent dissociative experiences (TRASC) whereas for other persons with PTSD, their symptomatic presentation is limited to experiences of distress that fall within the phenomenological boundaries of NWC. Moreover, the 4-​D model agrees with the phenomenological expansion of the construct of trauma-​related dissociative experiences that should be routinely assessed in traumatized persons beyond only depersonalization and derealization. Specifically, the 4-​D model describes at least four dissociative experiences that should be routinely assessed in traumatized persons: flashbacks (TRASC of time), voice hearing (TRASC of thought), depersonalization (TRASC of body), and marked emotional numbing (TRASC of emotion). Each of these dimensions is broadly in agreement with the symptomatic descriptions of dissociative disorders in DSM-​5, including the expanded diagnostic criteria for depersonalization disorder. Additional signs and symptoms of a dissociative disorder are also recommended for routine assessment using the brief survey appended, including derealization, time elongation, amnesia, and a divided sense of self (i.e., structural dissociation of the personality). The reader may note that these dissociative experiences too can be described as ASC. For example, in the case of derealization, we may say that NWC is defined by a form of reality orientation toward the external world characterized by the perception of external events as real; when this is not the case, we have an ASC (e.g., the world appearing dreamlike and insubstantial). Similarly, in the case of amnesia, we may say that NWC is defined as a continuous stream of experience; when the stream of consciousness is markedly discontinuous, we have an ASC, as when we experience ourselves “coming to” after periods of “blackouts” and the like, having no memory for periods of minutes, hours, or even longer. This all seems straightforward enough, although these symptoms have not been included in our previous tests of the 4-​D model insofar as there appears to be no comparable PTSD symptoms within NWC to which these ASC may be compared. In any case, clearly various ASC can be specified beyond only those included in Table 19.1, and the further specification of the domain of ASC as distinguishable from NWC in psychology and psychiatry remains an important endeavor for future clinician researchers, and the study of dissociative disorders, especially in comparison to other clinical presentations.

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Treating Trauma-​Related Altered States of Consciousness We have proposed that direct interventions to reduce TRASC and increase integration across the four dimensions of consciousness may be required to treat trauma-​related dissociative disorders as well as D-​PTSD (Frewen & Lanius, 2015). Whereas we noted that experienced safety within the therapeutic alliance may partially decrease the need for coping with distress via TRASC, specific therapeutic tasks or exercises are likely also required to directly reduce TRASC presenting in the form of flashbacks, voice hearing, depersonalization, and marked emotional numbing. This is important because in a recent study of a combined in-​person psychotherapy with online psychoeducational program (the TOP-​DD-​Internet study), TRASC were found to be reduced less significantly than were PTSD symptoms associated with NWC-​Distress, evidenced by a less steep slope in symptom reduction over the course of the year-​long intervention for TRASC as compared with NWC-​Distress (Frewen et al., in press). At this time there is also an increasing interest in examining medicine augmented psychotherapies (MAPs) for treating trauma-​related disorders, and it will be important to determine whether these therapies are differentially effective for symptoms of NWC-​Distress versus TRASC. Notably, different medicines may be indicated for the two sets of trauma-​ related symptoms, and this should be researched carefully. It is interesting to consider that different medicines actually seem to act via modulating consciousness either seemingly within the boundaries of NWC (e.g., when administering the so-​called “empathogen” medicines) such as with MDMA treatment for PTSD (e.g., Mitchell et al., 2021) or beyond NWC into ASC with traditional psychedelics (sometimes referred to as “enactogens”), such as with psilocybin treatment of treatment-​resistant depression (e.g., Carhart-​Harris et al., 2016; Davis et al., 2021). Research is thus now considering the application of ASC in treatment through the use of the MAPs approach, as compared with attempts at modulating consciousness therapeutically through psychological means alone (e.g., hypnosis, meditation). It will be important to determine the benefits vs. risks of using either approach as well as their combination in treating persons with differing clinical presentations, for example, those endorsing symptoms limited to the domain of NWC-​Distress versus those also experiencing TRASC and other dissociative experiences. Further evaluation of other non-​pharmacological approaches to conducting neuroscience-​informed treatments for PTSD and TRASC (e.g., neurofeedback, non-​invasive brain stimulation) will also be an area of interest in future studies (e.g., Lanius, Frewen, Nicholson, & MacKinnon, 2021).

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Conclusion In this chapter we overviewed the theoretical background to the 4-​D model of trauma-​related dissociation, which considers dissociative experiences that occur in four domains of experience: time, thought, body, and emotion. The 4-​D model is primarily aligned with phenomenological frameworks that regard dissociative experiences as ASC, but it also articulates a perspective that is consistent with, while differentiating between, compartmentalization and structural theories of dissociation. We also reviewed the theoretical basis for four predictions associated with the 4-​D model, and the empirical support for each based on a systematic review of the extant literature. Beyond that, we made brief reference to recent neuroimaging studies of dissociation that provide a basis for a neurophenomenological account of dissociative experiences. In addition, we considered the consistency that seems to be evident between the 4-​D model and how dissociative disorders and the D-​PTSD subtype are recommended to be diagnosed under DSM-​5. Finally, we explored some of the treatment implications for the 4-​D model not only for traditional psychotherapy but also for augmenting psychotherapy by neuroscience-​informed treatments. To conclude, the 4-​D model provides one testable account of part of the greater domain of pathological dissociation, focusing on trauma-​related alterations in persons’ experiences of time, thought, their bodies, and emotion. Firmly rooted in a neurophenomenological analysis, the 4-​D model clearly articulates the basis by which it differentiates posttraumatic experiences into those bounded within the domain of NWC, and those qualitatively separated from that domain and constituting dissociative experiences of TRASC. We submit that differentiating trauma-​related responses into those that are cardinally dissociative versus those that are not is not only theoretically justified but by now empirically supported given our systematic review of the nine studies published to date. Further, we believe that differentiating trauma-​related responses as such is also clinically significant for assessment, differential diagnosis, and maybe even treatment. However, given the nascent stage of the literature, further research will be required to ascertain whether these early impressions are substantiated in subsequent studies.

References American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders DSM-​5 (5 ed.). Arlington, VA: American Psychiatric Press. Bækkelund, H., Frewen, P., Lanius, R., Ottesen Berg, A., & Arnevik, E. A. (2018). Trauma-​related altered states of consciousness in post-​traumatic stress disorder patients with or without comorbid dissociative disorders. European Journal of Psychotraumatology, 9(1), 1544025–​11. Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The posttraumatic stress disorder checklist for DSM-​5 (PCL-​5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28, 489–​498. Briere, J., Scott, C., & Weathers, F. (2005). Peritraumatic and persistent dissociation in the presumed etiology of PTSD. The American Journal of Psychiatry, 162, 2295–​2301. Brown, M. F. D., & Frewen, P. A. (2017). Trauma-​related altered states of consciousness in undergraduate students. Traumatology, 23, 282–​293. Cardeña, E. (1994). The domain of dissociation. In S. J. Lynn & J. W. Rhue (Eds.), Dissociation: Clinical and theoretical perspectives (pp. 15–​31). New York: The Guilford Press. Cardeña, E., & Carlson, E. (2011). Acute stress disorder revisited. Annual Review of Clinical Psychology, 7(1), 245–​267. Carhart-​Harris, R. L., Bolstridge, M., Rucker, J., Day, C. M., Erritzoe, D., Kaelen, M., Bloomfield, M., Rickard, J. A., Forbes, B., Feilding, A., Taylor, D., Pilling, S., Curran, V. H., & Nutt, D. J. (2016). Psilocybin with psychological support for treatment-​ resistant depression: An open-​label feasibility study. Lancet Psychiatry, 3, 619–​627. Correa, R., Rodriguez, N., & Bortolaso, M. (2022). What is the nature of the alteration of temporality in Trauma-​Related Altered States of Consciousness? A neuro-​phenomenological analysis. European Journal of Trauma and Dissociation, 6(2), 100227. Davis, A. K., Barrett, F. S., May, D. G., Cosimano, M. P., Sepeda, N. D., Johnson, M. W., Finan, P. H., & Griffiths, R. R. (2021). Effects of psilocybin-​a ssisted therapy on major depressive disorder: A randomized clinical trial. JAMA Psychiatry, 78, 481–​489. Dell, P. F. (2009a). The phenomenology of pathological dissociation. In P. F. Dell and J. A. O’Neil (Eds.) Dissociation and the dissociative disorders (pp. 225–​238). New York: Routledge/​Taylor & Francis Group. Dell, P. F. (2009b). Understanding dissociation. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-​V and beyond (pp. 709–​825). New York: Routledge/​Taylor & Francis Group. Frewen, P., Brand, B. L., Schielke, H. J., McPhail, I. V., & Lanius, R. (2022). Examining the 4-​D Model in Persons Enrolled in the TOP DD Internet Intervention. Journal of Trauma and Dissociation. DOI: 10.1080/15299732.2022.2079794 Frewen, P. A., Brown, M. F. D., & Lanius, R. A. (2017). Trauma-​related altered states of consciousness (TRASC) in an online community sample: Further support for the 4-​D model of trauma-​related dissociation. Psychology of Consciousness, 4(1), 92–​114. Frewen P. A., Dozois D. J. A., Neufeld R.W. J., Lane R. D., Densmore M., Stevens T. K., Lanius R. A. (2012). Emotional numbing in posttraumatic stress disorder: A functional magnetic resonance imaging study. Journal of Clinical Psychiatry, 73, 431–​436. Frewen, P., Hegadoren, K., Coupland, N. J., Rowe, B. H., Neufeld, R. W. J., & Lanius, R. (2015). Trauma-​related altered states of consciousness (TRASC) and functional impairment I: Prospective study in acutely traumatized persons. Journal of Trauma & Dissociation, 16, 500–​519.

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Frewen, P., Kleindienst, N., Lanius, R., & Schmahl, C. (2014). Trauma-​related altered states of consciousness in women with BPD with or without co-​occurring PTSD. European Journal of Psychotraumatology, 5(1), 24863–​10. Frewen, P., & Lanius, R. A. (2015). Healing the traumatized self: consciousness, neuroscience, treatment (First edition.). New York: W. W Norton & Company. Frewen, P. A., & Lanius, R. A. (2014). Trauma-​related altered states of consciousness: Exploring the 4-​D model. Journal of Trauma & Dissociation, 15, 436–​456. Frewen, P., Schroeter, M. L., Riva, G., Cipresso, P., Fairfield, B., Padulo, C., Kemp, A. H., Palaniyappan, L., Owolabi, M., Kusi-​ Mensah, K., Polyakova, M., Fehertoi, N., D’Andrea, W., Lowe, L., & Northoff, G. (2020). Neuroimaging the consciousness of self: Review, and conceptual-​methodological framework. Neuroscience and Biobehavioral Reviews, 112, 164–​212. Harricharan, S., McKinnon, M. C., & Lanius, R. A. (2021). How processing of sensory information from the internal and external worlds shape the perception and engagement with the world in the aftermath of trauma: implications for PTSD. Frontiers in Neuroscience, 15, 625490– ​625490. Hiromitsu, K., Shinoura, N., Yamada, R., & Midorikawa, A. (2020). Dissociation of the subjective and objective bodies: Out-​of-​ body experiences following the development of a posterior cingulate lesion. Journal of Neuropsychology, 14, 183–​192. Holmes, E. A., Brown, R. J., Mansell, W., Fearon, R. P., Hunter, E. C., Frasquilho, F., & Oakley, D. A. (2005). Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical Psychology Review, 25(1), 1–​23. Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D. (2012). The dissociative subtype of posttraumatic stress disorder: Rationale, clinical, and neurobiological evidence, and implications. Depression and Anxiety, 29, 701–​708. Lanius, R. A., Frewen, P. A., Nicholson, A. N., & McKinnon, M. C. (2021). Restoring large scale brain networks in the aftermath of trauma: implications for neuroscientifically-​informed treatments. European Journal of Psychotraumatology, 12(sup1), 1866410. https://​doi.org/​10.1080/​20008​198.2020.1866​410. Lebois, L. A., Li, M., Baker, J. T., Wolff, J. D., Wang, D., Lambros, A. M., … Kaufman, M. L. (2021). Large-​Scale Functional Brain Network Architecture Changes Associated With Trauma-​Related Dissociation. American Journal of Psychiatry, 178, 165–​173. Mitchell, J. M., Bogenschutz, M., Lilienstein, A., Harrison, C., Kleiman, S., Parker-​Guilbert, K.,… Doblin, R. (2021). MDMA-​ assisted therapy for severe PTSD: a randomized, double-​blind, placebo-​controlled phase 3 study. Nature Medicine, 27, 1025–​1033. Nijenhuis, E. R. S., & Van der Hart, O. (2011). Dissociation in trauma: A new definition and comparison with previous formulations. Journal of Trauma & Dissociation, 12, 416–​4 45. Spiegel, D., Lewis-​Fernández, R., Lanius, R. Vermetten, E., Simeon, D., & Friedman, M. (2013). Dissociative disorders in DSM-​5. Annual Review of Clinical Psychology, 9, 299–​326. Spiegel, D., Loewenstein, R. J., Lewis-​Fernández, R., Sar, V., Simeon, D., Vermetten, E., Cardeña, E., & Dell, P. F. (2011). Dissociative disorders in DSM-​5. Depression and Anxiety, 28, 824–​852. Sreenivasa, V., & Mayur, P. (2019). Dissociation of identity following left parietal haematoma –​a single case report. Australasian Psychiatry: Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 27, 462–​464. Steele, K., Dorahy, M. J., Van der Hart, O., & Nijenhuis, E. R. S. (2009). Dissociation versus alterations in consciousness: Related but different concepts. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-​V and beyond (pp. 155–​169). New York: Routledge/​Taylor & Francis Group. Tzannidakis, N. C. A., & Frewen, P. (2015). Trauma-​related altered states of consciousness (TRASC) and functional impairment II: Perceived causal relationships in an online sample. Journal of Trauma & Dissociation, 16, 520–​540.

Appendix Trauma-​ related Altered States of Consciousness (TRASC) Questionnaire -​ -​ -​Administered as an Addendum to PCL-​ 5 (as items 21–​30) Below is a list of problems and complaints that people sometimes have in response to traumatic life events. Please read each one carefully, and then circle to indicate how much you have been bothered by that problem in the past month. In the past month, how much were you bothered by:

Not At All A Little Bit Mode​rately Quite A Bit Extre​mely

1. Flashbacks of a Traumatic Event -​Feeling as if a traumatic event from the past is happening in the present. Feeling like you are RELIVING the event, rather than only remembering it. 2. Altered Sense of Time -​Having little sense of the passage of time, or feeling like time has slowed down, speeded up, or seems like it is stopped or standing still. 3. Marked Loss of Emotional Feeling -​Feeling completely numb, hollow, and lifeless inside, as if you are already dead. 4. Feeling like What You are Experiencing is Not Real -​A change in the way you perceive or experience the world or other people, so that things seem dreamlike, strange or unreal.

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5. Out of Body Experience -​Feeling detached or separated from your body, for example, feeling like you are looking down on yourself from above, or like you are an outside observer of your own body. 6. Feeling like a Part of Your Body is Not Your Own -​For example, like your hands or feet are strange, unfamiliar, disconnected, not there, or that they do not belong to you. 7. Identity Confusion -​Having an extremely unstable sense of self; feeling like you don’t know who you are.   8. Divided or Multiple Senses of Self -​Feeling like your sense of self is divided into different parts, that who you are seems to change across time, or feeling like you are made up of two or more different people.   9. Losing time for periods of at least 10 minutes, so that you have very little (if any) awareness or memory for what happened during the missing periods of time. 10. Hearing voices inside your head that seem different from your own voice, and different from your own thoughts.

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20 DISSOCIATION AND UNFORMULATED EXPERIENCE A Psychoanalytic Model of Mind Donnel B. Stern

While dissociation is conceived in many ways in the trauma literature, theories of dissociation tend to center around the idea of a self-​protective process that takes place when the events of life are beyond tolerance. We leave ourselves, so to speak; psychically, we turn away. In the particular way I use the term, these meanings are preserved, but expanded. Dissociation is not only a fallback position. It is also part of a psychoanalytic understanding of the nature of experiencing, a means of understanding both the unconscious and the defensive processes, on the one hand, and consciousness on the other. Thus, dissociation is one of the most significant components of a psychoanalytic model of mind. When I first presented my ideas (Stern, 1983), my inspirations were both psychoanalytic (Levenson, 1972/​2005, 1983/​2005, 1991/​2016, 2017; Schafer, 1976, 1983, 1992; Schachtel, 1959; Spence, 1982; Sullivan, 1940, 1953) and philosophical (Fingarette, 1969; Gadamer, 1965/​2004, 1966; James, 1890; Merleau-​Ponty, 1945/​1962, 1964; Taylor, 2016). I have sought to develop a relational perspective on mind that is at once clinically useful, hermeneutically grounded, and phenomenologically recognizable. I came to dissociation via the influence of Harry Stack Sullivan (1940, 1953). Sullivan differed from the classical analysts of his day in seeing the origin of “problems in living” (a term he preferred to “psychopathology”) not in the clash of drive and defense, as was the dominant view in his time, but in what had actually happened in relationships with significant others. Relationships and the need for them replaced drive and defense as the stuff of life. For Sullivan, dissociation, not repression, was the primary defensive maneuver, because he understood the primary danger to be the revival of intolerable experience, not the breakthrough of primitive endogenous fantasy. (Sullivan’s conception is distinguished from Freud’s theory of repression in the following section.) From a modern perspective, we could say that, for Sullivan, the great threat was retraumatization. Eventually, Sullivan’s views formed the basis for what became interpersonal psychoanalysis (see Lionells, et al, 1995; Stern, et al., 1995, Stern & Hirsch, 2017a, b); and Sullivan and interpersonal thinking then became one of the primary springboards for relational psychoanalysis (e.g., Mitchell, 1988, 1993, 1997, 2000; Mitchell & Aron, 1999). For the most part, I will be able to credit in this short account only the most immediate sources of my views. The brevity necessary in a summary chapter such as this one precludes several subject matters I would like to be able to include, but cannot. The first is clinical illustration. This I particularly regret, because the ideas were created in the attempt to make a clinical contribution (see my work in the reference list which contain many clinical illustrations). The second is the body of work that has been devoted to the dissociation of self-​states from one another, pioneered especially by Bromberg (1998, 2006, 2011) (see Howell & Itzkowitz, Chapter 45, this volume). I have often written about dissociation and mutual enactment in the treatment situation as the defensively motivated separation of self-​states. While that view is easily integrated with the views I present here, and has been (Stern, 2010, 2015), I will only be able to consider it in passing. This subject deserves a chapter of its own. In recent years, I have been particularly interested in the comparison and contrast of the theory of unformulated experience, in which dissociation plays a prominent role, with Bionian field theory (e.g., Ferro, 2009; Ferro & Civitarese, 2016; see also Stern, 2015, Chapters 3 & 4), and also with theories in which, as in the theory of unformulated experience,

DOI: 10.4324/9781003057314-24

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states of mind are inaccessible not because they are repressed but because they cannot be given psychic representation at all (Bion, 1962/​1977; Green, 1975, 1999; Laplanche, 1999, 2011; Botella & Botella, 2005; Levine, Reed & Scarfone, 2013; McGleughlin, 2015, 2020). I must be satisfied in this chapter merely to make reference to the many links between this material and the phenomena and theory of dissociation and unformulated experience.

Assumptions Underlying the Repression Model In order to contextualize dissociation as a defensive process, I begin by outlining the ideas from which I depart. I start with certain assumptions underlying the repression-​based classical psychoanalytic model of mind, and then contrast that perspective with a dissociation-​based view. I do not intend my description of repression and the primary and secondary processes to be an authoritative account; rather, this description of the primary elements of the traditional psychoanalytic theory of mind serves as a foil against the background of which I clarify my own views and highlight major differences in emphasis of the two ways of thinking. Mental representations due to be repressed, wrote Freud (1915a), are both repulsed by consciousness and attracted by previous repressed contents in the unconscious. Once repressed, representations can be cognized only via the primary process, Freud’s (1895, 1900, 1915b) term for the means by which he believed the unconscious (or later in his work, the id) continuously sought to reinstate the perceptions associated with the original satisfactions of drive. The primary process seeks hallucinatory wish fulfillment. Except for certain nonlinguistic functions (such as the use of words as simple labels), language appears in the primary process only in a regressed and primitive form.1 But Freud also believed that, for those aspects of subjectivity that could be represented in language, consciousness was the natural state. These aspects of mental functioning, the secondary process, had been traditionally described in the psychology of the day: Waking thought, attention, judgment, reasoning, and controlled (consciously chosen) action. On one hand, the secondary process regulates the primary process, inhibiting hallucinatory wish fulfillment (at least during waking life) and heedless observance of the pleasure principle (which would bring even greater unpleasure in its wake). It might also be said, though, that the secondary process is merely an indirect route to drive satisfaction, one shaped by a respect for the complexities of reality (Freud, 1895, 1900, 1915b). In Freud’s thinking, there is an insistent pressure for drive to be represented in awareness. All repressed representations, in the form of what Freud (1915a, b) called “derivatives” of the repressed or the unconscious, press for expression; derivatives “want” to be released, to be satisfied, just as drive itself does. And so we have the doctrine of the return of the repressed, the continuous pressure toward consciousness exerted by contents that have been repressed (Freud, 1915a). In turn, this urgent pressure is the origin of the necessity for the development by the ego of unconscious defenses: Because the sudden appearance of certain drive-​related material in consciousness would arouse intolerable anxiety (that is, in the end there would be more unpleasure than pleasure), there come to be processes in the mind that, when unconsciously deployed, prevent that kind of sudden eruption. Although the repressed does continuously come back in the form of “a compromise between the repressed ideas and the repressing ones” (Freud, 1896, p. 170; italics in the original), the ego turns out to be a worthy adversary. Despite being the prize over which the battle between drive and defense is fought, however, that part of the ego which we know as consciousness is itself a fairly passive aspect of the mind in Freud’s scheme. The contents of consciousness are not specifically selected. Rather, they are what can be tolerated by the defenses, what remains when the smoke of battle has cleared, the outcome, an epiphenomenon, a byproduct, of the clash of drive and defense. Consciousness is not the main event; it is what remains after the great events have taken place. Just as symptoms or dreams are the effects of parts of the mind beyond themselves (i.e., the unconscious), and passive in that sense, consciousness, too, is a passive record in Freud’s work. In Freud’s terms, we can imagine consciousness as the most superficial layer of an archeological dig –​a fascinating, essential record we must study if we want to appreciate the events that, in disguised fashion, are sedimented in it –​but the record of a compromise nevertheless. Like other writers of his day, Freud accepted without reservation the idea that the mind –​and therefore, the unconscious –​is composed of fully formed contents. This unconsidered belief derives from the deep and culture-​ wide assumption, explicitly accepted by Freud (Schimek, 1975), that perception is a sensory given, and that experience is therefore rooted in mental elements that come to us already fully formed. Freud’s era took place long before the development of the “New Look” in perception research (Bruner & Klein, 1960; Bruner & Postman, 1949), in which perception was reconceptualized in constructivist terms. Even today, and especially in everyday life, we are seldom aware that we construct our own experience. We are much more likely to feel as if everything we experience was already there, fully formed, merely awaiting our registration of it. The view I present later directly contradicts this view.

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Following in the wake of the assumption that perception is merely a matter of registering fully formed sensory stimuli is an equally crucial corollary just as unconsidered and widely accepted in psychoanalysis today as the first point was in Freud’s era: If we are unaware of some aspect of experience, it is because we have made ourselves unaware. That is, because the elements of thought are always already present in our minds, defense is necessarily a matter of unconsciously refusing to acknowledge fully formed and pre-​existing mental content. Lack of awareness is unconsciously purposeful. Most psychoanalysts still accept these postulates about consciousness and the unconscious in an unquestioning way –​-​that is, without considering that they represent only one of the alternatives. Later in this chapter I will champion one of those neglected alternatives. These points, of course, amount to Freud’s hypothesis of repression, the foundation for virtually every model of unconscious defensive processes since Freud. In the terms of repression, to keep contents unconscious requires effort, what Laplanche and Pontalis (1973) call “a complex interplay of decathexes, recathexes and anticathexes [of ] the instinctual representatives” (p. 394). These “instinctual representatives” are not “bound,” as is the secondary process, and so it is their inclination to occupy the entire mind. In this “barbarians-​at-​the-​g ates” sense, consciousness is part of their “natural” domain, a land they would overrun immediately without the intervention of defense. It would probably be more accurate, actually, to say that the id is continuously trying to convert the rest of subjectivity into a version of itself, a land run by the rules of the primary process. In the imagery of a less military metaphor, it is as if the repressed were a beach ball we are trying to keep underwater by sitting on it. Unless we balance ourselves with the greatest care, expending a good deal of energy in the process (and even then we may be unsuccessful), the beach ball explodes out from under us and shoots up to the surface. And so, in this view, unless defense interrupts the process, understanding ourselves and the world around us ought to be natural and effortless. In Freud’s view, we already contain the knowing we need. It is there inside us, formed and ready: “…the essence of repression lies simply in turning something away, and keeping it at a distance, from the conscious” (1915a, p. 147; italics in the original). Except when we are genuinely ignorant, the thoughts and feelings we need in order to make sense of our lives would come into our minds if we would but allow them to do so. It seems that understanding should arise by itself; the process of coming to understand does not seem to require any particular explanation. Misunderstanding, on the other hand, is an anomaly, misunderstanding is the event we need to explain. We can misunderstand out of ignorance, of course. But with that single exception, misunderstanding is anomalous in the perspective associated with the repression hypothesis: When we do not understand, it can only be because the natural unfolding of comprehension has been interrupted by unconscious defensive processes. Notice that this view implies yet another assumption, one much more open to question now than even 30 or 40 years ago, and still taken for granted in many quarters: If we accept that the truth impresses itself upon us, then we are (usually without realizing it) taking the position that truth is singular and objectively verifiable. In this view, the unconscious is made up of the truths we will not accept –​fully formed feelings, thoughts and mental “objects” that have the kind of invisible, objective existence of a stage set behind a curtain. The goodness or fullness of our understanding is judged by reference to whether we accept the truth, which, in turn, is defined as the mental representation of objective reality. The question, then, is whether what we understand corresponds to objective reality. For this reason, the position I am describing often has been described as the “correspondence” view of truth: We judge that we have reached the truth when our understanding “matches” or “corresponds to” the supposedly objective reality that we are trying to grasp. One might think that the respect for psychic reality (i.e., inner reality, the mind’s own reality) in classical psychoanalytic views is inconsistent with the correspondence view. After all, in Freud’s theory and the theories of those who followed him, psychic reality is the entirely subjective foundation of motivation, and therefore of psychic life. You cannot understand someone else’s motives without first understanding the subjectively-​based intrapsychic fantasies that underlie them. In this sense, it is true that psychic reality is hardly an objective phenomenon. However, this subjectivity can still be understood in objective terms. As non-​rational as it is, psychic reality can still be seen as a singular, predetermined phenomenon that allows only one objective understanding. In most cases, classical analysts do write, as a matter of fact, as if the proper psychoanalytic understanding of psychic reality is an objective understanding, as if the nature of subjectivity (psychic reality) is objectively verifiable. Nor does the existence of multiple subjective truths about the same mental contents necessarily contradict the correspondence view, because each of these multiple truths can still be understood to have an objective existence. Note that the correspondence view implies that any influence on understanding besides objective reality must be misleading; this implication leads directly to our usual definition of bias or prejudice as a predisposition or preconception that distorts knowing by reducing our capacity to allow reality simply to register itself. (We shall find a different view in hermeneutics and the dissociation view associated with it). From the correspondence perspective, understanding is absolute and noncontextual: The nature of truth in one circumstance is the same as it is in another. These points

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uniformly underline the correspondence view’s tendency to portray understanding as passive and unidirectional, a straightforward inscription of world on mind. The only effort required by the process of knowing is expended in the removal of impediments to a natural unfolding. Thus, we understand by clearing away the obstacles that prevent mind from following its inclination to shape itself in reality’s image. But what if things are otherwise?

Unformulated Experience: A Dissociation-​Based Psychoanalytic Model of Mind In point of fact, almost everyone these days agrees that things are otherwise. Almost no one accepts the correspondence view anymore –​neither psychologists, psychoanalysts, philosophers, nor cognitive neuroscientists. Virtually no one would argue today, at least not in the most traditional way, that truth is defined simply by objective observation. Knowing and understanding are constructed, not merely registered. And yet many classical psychoanalysts still accept a modified version of the older view. Lawrence Friedman (2000), for instance, one of the most influential of Freudian theorists, champions objectivity as an ideal, describing objective observation as a construction built up from many small observations, each of which, in and of itself, may be subjective. The particular dissociation-​based view I am describing, rooted in the concept of unformulated experience, grew from the same soil that nurtured the move away from correspondence theory, and so it contradicts many of the assumptions underlying the repression-​based view. I address these differences in the same order I presented the assumptions discussed above. Perception is not a sensory given in the dissociation model; instead, perception is constructed from a less fully formulated state: There is an ongoing process of emergence in perception, thought, and feeling, from vagueness to clarity. Mental contents therefore are not necessarily fully formed, especially unconscious contents. Instead, they are unformulated, less clearly actualized than they will be when they are formulated. The unconscious is composed of potential experience, contents that do not yet have an explicit, knowable shape, and that may take any one of several or many possible shapes when eventually they are formulated. To begin with, my position was that the formulation of meaning takes place exclusively in language (e.g., Stern, 1983, 1997). I took that position because my purpose at that time was limited to charting the path of experience from its unformulated beginnings to the explicitly meaningful shape it takes in reflective awareness. I believed that only when experience is formulated in verbal language could it be consciously, explicitly reflected on; and of course the creation of a capacity to reflect in areas of our lives in which we could not reflect before has always been a hallmark of psychoanalysis. I have not changed my view about the nature of explicit reflection, although I do now consider therapeutic action to be less a matter of reflection, or understanding, than of greater freedom in the interpersonal field (which then allows greater understanding). Recently, I have expanded the theory of unformulated experience to include formulated nonverbal meaning (Stern, 2018). In keeping with that expanded purpose, I now believe we should recognize two varieties of unformulated experience. Some unformulated experience, when its potential is formulated, tends toward articulation as verbal-​reflective meaning; this is the kind of formulation I have described before, the kind of formulation that allows explicit reflection. But a second kind of unformulated experience, when its potential is formulated, tends toward realization as nonverbal meaning. Some nonverbal meanings, once they are realized, can then be articulated as verbal-​reflective meaning and enter explicit, reflective awareness. But many nonverbal meanings –​procedural meanings are a good ­example –​are not necessarily amenable to articulation in verbal language, and therefore cannot be reflected on. These latter meanings do participate in the creation of living, but in their nonverbal form, not in a verbally articulated one. Let me offer a brief, simple example of what I mean by realized nonverbal meaning. Let us say that a particular (fictional) patient is highly anxious about sexual arousal, so anxious that he can allow himself only a very pale version of the sensory pleasure of sex. The unformulated experience of a sexual encounter contains myriad affective and sensory possibilities, only some of which are realized in anyone’s experience. In the case of our fictional patient, the possibilities that are realized –​the nonverbal sensory and affective meanings that he derives from the sexual experience –​are notably muted. The man can reflect on these muted realizations, but only to a certain extent. Because language is not an adequate means of symbolizing the nuances of sensory experience, our patient can reflect on only a portion of even that part of his unformulated sexual experience that has been realized as nonverbal meaning. Perhaps the most significant role played by realized nonverbal meaning is its part in ongoing relatedness. Imagine my fictional patient in a social situation in which flirtation is a possibility. Flirtation, we shall say, has been infected by the patient’s anxiety about sexuality. My patient is therefore hobbled in such a context. He is unlikely to have access to the experience that he would need in order to make ongoing, intuitive sense of the other person’s flirting, or to participate

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in a natural way in the flirting himself. He is overcome with anxiety, both because of what he does grasp (again, nonverbally) about this kind of relatedness, and because of what his anxiety prevents him from comprehending. All of us bring with us into each moment an unformulated “way of being” from which we unconsciously select and develop the meanings that become our verbal and nonverbal experience of that moment. The parts of our ways of being that we cannot tolerate are not selected; we can say that these possibilities are dissociated, verbal and nonverbal alike. The parts of our ways of being that we can tolerate, on the other hand, are either articulated (in verbal-​reflective meaning) or realized (in nonverbal meaning). We are able to use the articulated and realized parts of experience in the ongoing negotiation of relatedness with others. But to the extent that we do not articulate or realize our ways of being in any particular moment, our flexibility and freedom to relate to the other in that moment are compromised. In the case of both verbal-​reflective articulations and nonverbal realizations, then, consciousness is not a passive outcome, but a creation, an achievement that demands the expenditure of effort. We understand only what we formulate, and that process of construction requires mental work. If experience has a “natural” state, it is neither articulation nor realization, but lack of formulation. Without the application of attention and effort, unformulated experience stays just as it is. The contents of consciousness are therefore not merely what is left over after an internal battle. They are specifically and actively selected according to our (conscious and unconscious) interests and values, in interaction with the contexts in which the formulation of our experience takes place. The metaphor of the beach ball hurtling up from the depths as soon as it is no longer held down is replaced by a symbol of effort, perhaps something like a heavy adjustable lens that must be pointed in a particular direction and then wrested to a new setting in order to bring an unconsciously chosen view into clarity. Consciousness is an active creation, an accomplishment, not a leftover. If unconscious mental contents are unformulated, it no longer makes sense to conceive of defense as a refusal to acknowledge a truth that already exists in parts of our minds to which we have no access. Instead, defense becomes the prevention of the formulation of unformulated experience –​the prevention of the very existence of articulations and realizations. If we define dissociation as the inability or unconscious unwillingness to formulate experience in symbolic form (and most of us do define it that way), it follows that to prevent experience from being shaped into verbal-​reflective or nonverbal meaning is to dissociate.2 The primary defense is therefore dissociation. In this way of thinking, it is not fully formed mental contents that must be controlled (because they are not “there” to be controlled). What must be controlled by defense is instead the effort that we would need to expend in order to formulate the unformulated. The willingness to make this effort, to try to open ourselves to what is questionable, and therefore to what it is possible to formulate, is what I refer to as “curiosity.” In this frame of reference, defense, or dissociation, can be defined either as the unconscious refusal to formulate experience or as the unconsciously motivated refusal to be curious. Remember that in the repression model, understanding is the natural state of affairs, interrupted only by the distortions of defense. It is probably clear by now that this cannot be true of the dissociation model I am presenting. If understanding always remains to be constructed, then it is not the presence of understanding, but its absence that is the natural state of affairs. Understanding does not happen “by itself ”; it is an outcome of some kind of effort. Lack of understanding is what happens “by itself.” And therefore the mystery that surrounds not-​k nowing in the repression model is transferred to the process of understanding –​that is, to the process by which meaning is formulated.

What is Understanding? I have already said that dissociation is the unconscious refusal to be curious; I have also said that curiosity is what makes understanding possible; and finally, I have said that understanding, not the absence of understanding, is now the mysterious event requiring explanation. And so, if we are to understand dissociation, we must understand the nature of understanding itself. What process is it that dissociation interrupts? How should we understand understanding? According to hermemeutic philosopher Hans-​ G eorg Gadamer (1965/​2 004, 1976), we can never perceive reality itself; that is, we can never perceive reality in any absolute or unmediated sense. 3 Instead, we construct reality according to the various traditions sedimented in our languages and cultures. Reality is mediated to us by the meanings that have currency in our time and place. Language and culture are the lens through which our understanding of the world and ourselves comes into being. And so in Gadamer’s work we have a view that is neither objectivist nor relativist, but that charts a course between the two (Bernstein, 1983; Sass, 1988). On the one hand, truth is constrained by reality; but on the other, each of our formulations is only one of the possibilities, potentiated by its context. Reality is manifold; truth is multiple. Gadamer redefines “bias” and “prejudice,” arguing that our “preconceptions,” the meanings that our cultures predispose us to find, are what make it possible for us to make any meaning at all. We depend on bias and prejudice. They are crucial: “It is not so much our judgments as our prejudgments that constitute our being” (Gadamer, quoted by

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Linge, 1976, p. xvii). Elsewhere Gadamer (1966) says, “Prejudices are biases of our openness to the world. They are simply conditions whereby we experience something –​whereby what we encounter says something to us” (p. 8). And yet, Gadamer (1965/​2004) also tells us that learning something new is a matter of transcending these prejudices: “Every experience worthy of the name runs counter to our expectation…Insight is more than the knowledge of this or that situation. It always involves an escape from something that had deceived us and held us captive” (pp. 319–​320). Prejudices are both the ground on which we can experience anything at all and the blinders we must manage to reflect on and disconfirm if we are to experience anything new. For hermeneuticists, including Gadamer, the process by which we bring our prejudices into play and then disconfirm them is the hermeneutic circle. The idea arises from a paradox. We can understand only those communications that we can locate in their proper contexts. Unless an utterance can be placed in the appropriate configuration of tradition, its meaning remains obscure. Imagine trying to understand certain passages in Freud without knowing that he was taking issue with Jung; or trying to understand a dream without knowing the events of the day preceding it, or the patient’s associations to it; or trying to understand a patient’s barely supportable characterization of a co-​worker as greedy without knowing that the patient himself is terribly afraid of being greedy. We comprehend by means of continuously projecting complete understandings into communications from the other, communications we actually understand only partially. We extrapolate complete understandings on the basis of the partial understandings we already have. And where do the partial understandings come from? They are in turn stimulated by the complete understandings we project. Thus is the circle closed. But of course, something else must happen, or else comprehension would be nothing more than self-​reference. All comprehension is a process of projecting partial understandings into fully rounded ones, and then modifying these projections on the basis of what we actually come into contact with in conversation with the other person.4 In other words, when we have understood, we have been able to treat our projections like hypotheses; and when we have not understood, we have not managed to adopt this degree of uncertainty. The problem is clear: How do we avoid seeing nothing more than we expect to see? Under what circumstances can projections be hypotheses rather than givens? Dissociation is the condition under which we see what we expect to see. Novelty does not speak to us; we are ruled by our preconceptions, which remain invisible to us. We are not able to be curious about what faces us and instead are satisfied, even insistent upon, limiting ourselves to what is familiar. Curiosity is the active attitude of openness that allows us to disconfirm our preconceptions and substitute new meanings for them. In emphasizing curiosity as an active attitude of openness, I mean to be going far beyond the everyday meaning of the word. I intend to refer to an openness to what is unbidden in life, to what comes to us if we are able to allow ourselves to accept the uncertainty of the experience we will have in the next moment. Curiosity is not the asking of questions, or at least not merely the asking of questions. Because it is a kind of acceptance (to be differentiated from approval) of whatever arrives in one’s mind, a surrender to one’s own capacity to construct the unexpected, curiosity may, in fact, appear to be a passive state of being. But if it is passive, it is a very actively maintained kind of passivity. Unfettered curiosity is the polar opposite of dissociation. Perhaps the greatest divergence of Gadamer’s hermeneutic view from correspondence theory is Gadamer’s insistence that truth is always accomplished in dialogue. It can never be created in isolation. Uncertainty about preconceptions, and the consequent possibilities for the perception of novelty, can be created only when one’s own projections are met by the attempt of the other to speak (or act) back, to converse. Truth is a mutual creation forged in dialogue. In these points Gadamer unwittingly shares a view that has developed over many decades in interpersonal and relational psychoanalysis: The most important context in the creation of understanding or meaning is the interpersonal context, or the interpersonal field. Harry Stack Sullivan (1940) wrote that, “Situations call out motivations” (p. 191), reversing the usual polarity. He means that any particular moment’s experience is heavily influenced by the people with whom we are relating at the time (by “people,” I mean both real, flesh-​and-​blood beings in the outer world and the internal objects of the inner world). The contents of consciousness are a function of one’s predispositions, in interaction with the nature of the interpersonal field. And so we come to the conclusion, very different from the conclusion of early Freudian psychoanalysts, that what is true depends, within the significant constraints provided by reality, on the interpersonal situation in which that truth is formulated. The interpersonal field determines, to a large extent, the explicit shape taken by unformulated experience, or even whether it will take any shape at all. The interpersonal field is the single most significant of the contexts that continuously participate in the creation of experience and the decision about what is true. To insist (unconsciously) on keeping experience unformulated is to dissociate; to be open to formulating it, and to grasping the preconceptions that help give it shape, is to be curious. Therefore, dissociation, too, exists relative to the interpersonal field. In fact, any particular interpersonal field can be said to be defined by the particular relationship of curiosity

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and dissociation within it. Think of it this way: The explicit experience it is possible to formulate (be curious about) in one field (that is, in the presence of one particular person, or a particular internal object) differs from the experience that can be formulated in another. And reciprocally, the experience that cannot be formulated (is dissociated, outside the range of curiosity) in one field also differs from the experience that cannot be formulated in another. Dissociation and curiosity define one another; each gains its meaning only in the context of the other. Curiosity is the absence of dissociation; dissociation is the absence of curiosity.

The Role of Language The capacity to make new meaning, either linguistically or nonverbally, is one way to describe the process of effective curiosity, the absence of dissociation. Dissociation is an insistence on the creation of familiar experience, conventional forms that cannot contain novelty and that signify, as Mallarmé puts it, only as “the worn coin placed silently in my hand” (cited by Merleau-​Ponty, 1964, p. 44). Conventionalization, of course, obscures novelty, which disappears into the familiar. We hardly notice what is being signified. Gadamer’s work is part of the linguistic turn in philosophy that began, in different ways, with Heidegger and Wittgenstein. Language is not a tool that we use as we please, as if words were clothing for meanings that exist independent of them. Instead, to the extent that we allow language to give us all it can, it controls us. In fact, it constitutes us. Language is the sum total of a culture’s traditions; and tradition is the culture’s collection of the prejudices and preconceptions that we must have if we are to make any meaning at all. Language does not simply label meanings, it creates their very possibility. Language has a life of its own, an unruly and generative life that Merleau-​Ponty (e.g., 1964, 1968, 1973) has described particularly well. Here is an interesting and significant conclusion suggested by this view of language: Meanings made possible by language are not limited to those in the verbal-​reflective mode. Among the possibilities created by language are the possibilities we have for nonverbal meaning –​even the kind of nonverbal realizations that are not necessarily amenable to verbal-​reflective articulation! This point is perfectly consistent with Gadamer’s thought, because for Gadamer, as for his mentor Heidegger before him, it is language that creates the architecture of experience, and it is that architecture that makes any meaning possible. Therefore, and ironically enough, especially for those who think of the verbal and the nonverbal as independent modes of representation, the hermeneutic perspective holds that language plays a significant role in defining the possibilities for nonverbal meaning.5 If we give ourselves over to the “wild-​flowering mind” (Merleau-​Ponty, 1964, p. 181), we frequently experience ourselves as conduits for the meanings that arise in us. Despite feeling that meanings arrive in our minds unbidden at such times, we are liable to feel that it is just this experience that is most our own, and that it is in just such moments that we are most ourselves. We are at our best as conversational partners: It is at these times that we can most fully create in our own minds the world of the other, and thereby grasp what the other is conveying to us. It is at these times that novelty reveals itself to us. And because we give ourselves over to curiosity and the world of the other in the same instant that we give ourselves over to language, it is also at such moments that we are most fully imaginative and least dissociated.

Two Varieties of Dissociation Experience is a narrative process. We are attached to the stories we tell ourselves about our lives. We are so attached, as a matter of fact, that myriad possibilities in life remain unformulated simply because we experience in habitual ways, insistently telling our particular stories. We continuously burn bridges to meanings we might otherwise have formulated. These unconsidered alternatives are not necessarily meanings we would actively turn away from if we knew them; we miss the opportunity to actualize them only because of our focus elsewhere. This very common kind of dissociation I refer to as passive dissociation, or dissociation in the weak sense (Stern, 1997, Chapter 6; 2010). We can often be helped to see some of these meanings simply by having our attention drawn to their possibility. But there are also meanings, of course, that we actively avoid, that we turn away from with unconscious purpose. This is experience that we maintain in an unformulated (unconscious) state for defensive reasons. The pain such experience would create in us is simply more than we will bear. The worst of such pain is caused when we are unable to avoid the formulation of experience that we cannot even acknowledge belongs to us; such experience is what Harry Stack Sullivan calls “not-​me,” and it feels as if it exists outside the bounds of what we can accept as “self.” Trauma, of course, falls in this category. If we are to maintain an acceptable degree of comfort and psychic equilibrium, not-​me must be maintained as unformulated experience. We develop a quite specific unconscious refusal to articulate or realize these aspects of our subjectivity. This defensive process I refer to as active dissociation or dissociation in the strong sense (Stern, 1997, Chapter 7; Stern, 2010).

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Now let me go back a step: Remember that the contents of consciousness are heavily influenced by the nature of the interpersonal field. To make this claim, it turns out, is to arrive at the very same theory of dissociated self-​states that has become highly influential in relational psychoanalysis in recent years (e.g., Davies and Frawley, 1994; Mitchell, 1993; Bromberg, 1998, 2006, 2011; Pizer, 1998; Stern, 1997, 2010; 2015). One merely has to reverse the lens and, instead of looking at the self-​state (i.e., the current configuration of the interpersonal field) as a significant part of the context that determines the shape of the experience to be formulated, look at the particular selection of experience that can be formulated as what defines a self-​state. A self-​state, if we think about it this way, is defined by the experience that can be formulated within it. And therefore, dissociation in the strong sense (the unconscious refusal to formulate certain content) is synonymous with the dissociation of self-​states from one another. Unconsciously refusing to formulate certain mental content, that is, is equivalent to unconsciously enforcing the defensive isolation of the self-​state in which this content could be known (Stern, 2010, 2015).

From Dissociation to Imagination: the Question of Psychopathology But I am not suggesting that dissociation in the strong sense is necessarily pathological. Every me is accompanied by a not-​me, and all of us, therefore, dissociate in the strong sense, at least sometimes. The differentiation of “normal” and pathological dissociation is more complicated than that (for definitions and descriptions of “expectable” and “pathological” dissociation, see Bromberg, 1998). It is usually taken for granted that the aspects of psychic functioning most affected by dissociation are those we think of as the building blocks of experience: Affect, thought, perception, and memory. In the largest sense, though, dissociation is not fully described as a failure of any of these functions. Dissociation is a failure to allow one’s imagination free play. In many instances one can think of the failure of imagination as the collapse of transitional space (Winnicott, 1971) into deadness or literalness. Merleau-​Ponty (1964, 1968, 1973), who has captured the sense of what I mean by imagination as well as anyone, writes that “speech takes flight from where it rolls in the wave of speechless communication” (p. 165). He tells us that creative speech, which is the domain of imagination, “tears out or tears apart meanings in the undivided whole of the nameable, as our gestures do in that of the perceptible” (1964, p. 17). Imagination is our capacity to allow meanings of both kinds, what Merleau-​Ponty refers to as the nameable and the perceptible, and what I have described as the verbal and the nonverbal, to come to fruition within us as they will. If we wish to do so, we can use Lacan’s terms here: Imagination takes place in the realm of the Symbolic, dissociation in the Imaginary. Just as in the Imaginary, dissociation is the insistence on denying that life is in continuous, unpredictable flux. In order to prevent the eruption of not-​me, the next moment must be completely (and falsely) predictable, at least in certain important respects. Experience must be forced into conventional, stereotyped shapes that are not necessarily the best fit for it. Experience should not be categorized as simply “present” or “absent,” formulated or unformulated. That way of thinking would be a simpleminded dualism. I have already defined the absence of dissociation as (relatively) unfettered curiosity. I can now expand that point: Experience ranges from highly imagined to highly dissociated, with all the implied variations in between. It is by now a clinical truism that experience dissociated in the strong sense –​dissociated with unconscious defensive purpose –​does not simply disappear into some untended part of the mind, but is instead repetitively externalized, unconsciously enacted in relationship (Davies, 1996, 1997, 1998, 1999; Davies & Frawley, 1994; Bromberg, 1998, 2006, 2011; Stern, 1997, 2010, 2015, 2018; Pizer, 1998). Enactments are more or less stereotyped, rigid, constricted, and highly selective ways of behaving and experiencing. They require a dampening of curiosity and imagination. During an enactment, what one does not understand is precisely the dissociated meanings one is simultaneously bringing into play in the relationship. It follows logically, and turns out to make good clinical sense, too, that therapeutic action is a matter of breaching these enactments (Stern, 2010), thereby creating more “relational freedom” (Stern, 2015). When that happens, which requires the recognition, by either the patient or the analyst, (either may be “first”) of the dissociative constriction, the field shifts in a way that allows greater freedom of thought in both minds. New understanding arises at such moments; but the new understanding is more a signpost or landmark of the really significant change –​the shift in the field that created the new freedom in the first place –​than it is the primary engine of therapeutic action. One conclusion that all this leads to is that there is no particular intrinsic variety of dissociation that we should define as pathological. We all dissociate in the same way for defensive purposes, and we all unconsciously enact the dissociated meanings. On the other hand, the degree of people’s insistence on maintaining a dissociative enactment, and the degree of their difficulty in thinking about (understanding, interpreting) the enactments in which they are involved, varies considerably. The more inaccessible the dissociation is to interpersonal negotiation, the more rigid and unyielding is its enactment. In the case of particularly rigid enactments, one’s capacity to be curious about them is severely curtailed. On

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the basis of this way of thinking, pathological dissociation should be defined according to the frequency and thoroughness of impairment in the capacity for imagination. The fact that pathological dissociation must be identified contextually and not absolutely means that, in this scheme, there can be no objective determination of abnormality. Selecting the point on the continuum between dissociation and imagination that separates normal and pathological dissociation is a contextual, clinical matter; and therefore the problems that bring people for treatment are better understood, as I suggested in the beginning of this chapter, as what Sullivan (1940) referred to as “problems in living” than as psychopathology.

Concluding Remarks I have addressed throughout my work the matter of working clinically with unformulated experience, dissociation, and enactment. I have only been able to gesture in the direction of that work here. I recommend the interested reader to Bromberg’s and Davies’s work on the topic, as well as my own (see reference list). The field of trauma and the field of psychoanalysis have grown closer in recent years (Bromberg and Chefetz, 2004; Chefetz, 2015; Howell, 2006, 2020; Howell & Itzkowitz, 2016). In closing, I want to express my hope that the psychoanalytic model of mind I have described, in which dissociation plays such a central role, contributes to this rapprochement.

Notes 1 But see Loewald’s (1978) brilliant reformulation of the theory of the primary and secondary processes, in which language can partake of the primary process without being schizophrenic, as in poetry or free association. In fact, for Loewald language is not really alive unless it is in contact with the primary process. Freud’s account of the primary process and secondary process changed and developed over his lifetime. Gill (1967), though, feels that in the end Freud offered “nothing like a comprehensive metapsychological treatment” (p. 265) of these ideas. Interested readers should consult Gill’s (1967) careful study. 2 The “inability” to formulate experience is a consequence of massive psychic trauma, and is not my primary subject. I address primarily the “unconscious unwillingness” to formulate in this chapter, a defensive process. But I do mention both inability and unwillingness in this sentence. I make that choice because I want to emphasize that most of us, as I say in the text, define dissociation of any kind as the prevention of symbolic representation. 3 In addition to Gadamer’s (1965/​2004) magnum opus, Truth and Method, a collection of his seminal papers is presented in Gadamer (1976), which is accompanied by a useful introduction to his work (Linge, 1976). Numerous secondary sources are also available (e.g., Bernstein, 1983; Warnke, 1987; Weinsheimer, 1985; Scheibler, 2000). 4 Gadamer applies his conception of understanding most often to the grasp of the meanings of cultural products such as art, drama, and literature. But he does also write about the kind of understanding that goes on between two people. I am limiting my discussion here to the attempt of two people to understand one another. 5 Space restrictions do not allow me to make this argument in the detail it deserves. Elsewhere (Stern, 2018) I have made a more complete presentation.

References Bernstein, R. J. (1983). Beyond objectivism and relativism: Science, hermeneutics, and praxis. Philadelphia: University of Pennsylvania Press. Bion, W. R. (1962/​1977). Learning from experience. In: Seven Servants: Four Works by Wilfred R. Bion (pp. 1–​111). New York: Jason Aronson. Botella, C. & Botella, S. (2005). The work of psychic figurability: Mental states without representation. New York: Routledge. Bromberg, P. M. (1998). Standing in the spaces: essays on clinical process, Trauma, and dissociation Hillsdale, NJ: The Analytic Press. Bromberg, P. M. (2006). Awakening the dreamer: Clinical journeys. Hillsdale, NJ: The Analytic Press. Bromberg, P. M. (2011). The shadow of the tsunami: And the growth of the relational mind. New York: Routledge. Bromberg, P. M. & Chefetz, R. A. (2004). Talking with “me” and “not-​me”: A dialogue. Contemporary Psychoanalysis, 40, 409–​464. Bruner, J. S. & Klein, G. S. (1960). The function of perceiving: New Look retrospect. In S. Wapner & B. Kaplan (Eds.), Perspectives in Psychological Theory. New York: International Universities Press. Bruner, J. S. & Postman, L. (1949). Perception, cognition, and personality. Journal of Personality, 18, 14–​31. Chefetz, R. (2015). Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. New York: Norton. Davies, J. M. & Frawley, M. G. (1994), Treating the Adult Survivor of Childhood Sexual Abuse. New York: Basic Books. Davies, J. M. (1996). Linking the pre-​a nalytic with the postclassical: Integration, dissociation, and the multiplicity of unconscious processes. Contemporary Psychoanalysis, 32, 553–​576. Davies, J. M. (1997), Dissociation and therapeutic enactment. Gender and Psychoanalysis, 2, 241–​257. Davies, J. M. (1998). The multiple aspects of multiplicity: Symposium on clinical choices in psychoanalysis. Psychoanalytic Dialogues, 8, 195–​206. Davies, J. M. (1999). Getting cold feet defining “safe-​enough” borders: Dissociation, multiplicity, and integration in the analyst’s experience. Psychoanalytic Quarterly, 78, 184–​208.

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Ferro, A. (2009). Transformations in dreaming and characters in the psychoanalytic field. International Journal of Psychoanalysis, 90, 209–​230. Ferro, A. & Civitarese, G. (2016). Psychoanalysis and the analytic field. In A. Elliot (Ed.), The Routledge Handbook of Psychoanalysis in the Humanities and the Social Sciences (pp. 132–​148). New York: Routledge. Fingarette, H. (1969). Self-​deception. London: Routledge and Kegan Paul. Freud, S. (1895). Project for a scientific psychology. Standard Edition, 1, 295–​387. Freud, S. (1896). Further remarks on the neuro-​psychoses of defence. Standard Edition, 3, 162–​185. Freud, S. (1900). The interpretation of dreams. Standard Edition, 4–​5. Freud, S. (1915a). Repression. Standard Edition, 14, 146–​58. Freud, S. (1915b). The unconscious. Standard Edition, 14, 166–​204. Friedman, L. (2000). Are minds objects or dramas? In D. K. Silverman & D. L. Wolitzky (Eds.), Changing Conceptions of Psychoanalysis: The Legacy of Merton Gill (pp. 146–​170). Hillsdale, NJ: The Analytic Press. Gadamer, H.-​G. (1965/​2004). Truth and Method. Revised translation, by J. Weinsheimer & D. G. Marshall, from the 2nd edition in German. London: Continuum. Gadamer, H.-​G. (1966). The universality of the hermeneutical problem. In D. E. Linge (Ed.) Philosophical Hermeneutics (pp. 3–​17). Berkeley, CA: University of California Press, 1976. Gadamer, H.-​G. (1976) Philosophical hermeneutics, trans. & ed. D. E. Linge. Berkeley, CA: University of California Press. Gill, M. M. (1967). The primary process. In R. R. Holt (Ed.), Motives and thought. Psychoanalytic essays in honor of David Rapaport. Psychological Issues, Vol. 18–​19. New York: International Universities Press, pp. 260–​298. Green, A. (1975). The analyst, symbolization, and absence in the analytic setting. International Journal of Psychoanalysis, 56, 1–​22. Green, A. (1999). The Work of the Negative. Trans. A. Weller. London: Free Association Books. Howell, E. F. (2006). The dissociative mind. New York: Routledge. Howell, E. F. & Itzkowitz, S., eds. (2016). The dissociative mind and psychoanalysis: Understanding and working with trauma. New York: Routledge. Howell, E. F. (2020). Trauma and dissociation-​informed psychotherapy: relational healing and the therapeutic connection. New York: Routledge. James, W. (1890). Principles of Psychology. New York: Henry Holt and Co., 1899. Laplanche, J. (1999). Essays on Otherness. New York: Routledge. Laplanche, J. (2011). Freud and the Sexual: Essays 2000–​2006. New York: International Psychoanalysis Books. Laplanche, J. & J.-​P. Pontalis (1973). The Language of psycho-​analysis. Trans. D. Nicholson-​Smith. New York: Norton. Levenson, E. A. (1972/​ 2005). The Fallacy of Understanding. In: The Fallacy of Understanding & The Ambiguity of Change. New York: Routledge. Levenson, E. A. (1983/​2005). The Ambiguity of Change. The Fallacy of Understanding. In: The Fallacy of Understanding & The Ambiguity of Change. New York: Routledge. Levenson, E. A. (1991/​2016). The Purloined Self: The Interpersonal Perspective in Psychoanalysis. (A. Slomowitz, Ed.). New York: Routledge. Levenson, E. A. (2017). Interpersonal psychoanalysis and the enigma of consciousness. (A. Slomowitz, Ed.). New York: Routledge. Levine, H. B., Reed, G. S. & Scarfone, D. (Eds.) (2013). Unrepresented states and the construction of meaning: Clinical and theoretical contributions. London: Karnac. Linge, D. E. (1976). Editor’s introduction. In D. E. Linge (ed.), Philosophical hermeneutics (pp. xi-​lviii). Berkeley, CA: University of California Press. Lionells, M., Fiscalini, J., Mann, C. M. & Stern, D. B. (Eds.) (1995). The handbook of interpersonal psychoanalysis. New York: Routledge. Loewald, H. W. (1978). Primary process, secondary process, and language. In Papers on psychoanalysis (pp. 178–​206). New Haven & London: Yale University Press, 1980. McGleughlin, J. (2015). Do we find or lose ourselves in the negative? Psychoanalytic Dialogues, 25, 214–​236. McGleughlin, J. (2020). The analyst’s necessary nonsovereignty and the generative power of the negative. Psychoanalytic Dialogues, 30, 123–​138. Merleau-​Ponty, M. (1945/​1962). The Phenomenology of perception. (C Smith, trans). New York: Routledge & Kegan Paul. Merleau-​Ponty, M. (1964). Signs. Trans. Richard McCleary. Evanston, IL: Northwestern University Press, pp. 3–​35. Merleau-​Ponty, M. (1968). The visible and the invisible. (C. Lefort, trans). A. Lingis. Evanston, IL: Northwestern University Press. Merleau-​Ponty, M. (1973). The prose of the world. (C. Lefort, Ed., J. O’Neill, trans). Evanston, IL: Northwestern University Press. Mitchell, S. A. (1988). Relational concepts in psychoanalysis. Cambridge, MA: Harvard University Press. Mitchell, S. A. (1993). Hope and dread in psychoanalysis. New York: Basic Books. Mitchell, S. A. (1997). Influence and autonomy in psychoanalysis. Hillsdale, NJ: The Analytic Press. Mitchell, S. A. (2000). Relationality. Hillsdale, NJ: The Analytic Press. Mitchell, S. A. & Aron, L. (Eds) (1999). Relational psychoanalysis: The emergence of a tradition. Hillsdale, NJ: The Analytic Press. Pizer, S. (1998). Building bridges: The negotiation of paradox in psychoanalysis. Hillsdale, New Jersey: The Analytic Press. Sass, L. A. (1988). Humanism, hermeneutics, and humanistic psychoanalysis: Differing conceptions of subjectivity. Psychoanalysis and Contemporary Thought, 12, 433–​504. Schachtel, E. (1959). Metamorphosis. New York: Basic Books. Schafer, R. (1976). A new language for psychoanalysis. New Haven: Yale University Press. Schafer, R. (1983). The analytic attitude. New York: Basic Books. Schafer, R. (1992). Retelling a life. New York: Basic Books. Scheibler, I. (2000). Gadamer: Between Heidegger and Habermas. Lanham, MD: Rowman & Littlefield

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Schimek, J. G. (1975). A critical re-​examination of Freud’s concept of unconscious mental representations. International Journal of Psycho-​Analysis, 2, 171–​187. Spence, D. P. (1982). Narrative truth and historical truth: Meaning and interpretation in psychoanalysis. New York: Norton. Stern, D. B. (1983). Unformulated experience. Contemporary Psychoanalysis, 19, 71–​99. Stern, D. B. (1997). Unformulated experience: From dissociation to imagination in psychoanalysis. Hillsdale, NJ: The Analytic Press. Stern, D. B. (2010). Partners in thought: Working with unformulated experience, dissociation, and enactment. New York: Routledge. Stern, D. B. (2015). Relational freedom: Emergent properties of the interpersonal field. New York: Routledge. Stern, D. B. (2018). The infinity of the unsaid: Unformulated experience, language, and the nonverbal. New York: Routledge. Stern, D. B, & Hirsch, I., Eds. (2017a). The Interpersonal Perspective in Psychoanalysis, 1960s–​1990s: Rethinking Transference and Countertransference. New York: Routledge. Stern, D. B. & Hirsch, I. (Eds.) (2017b), Further Developments in Contemporary Interpersonal Psychoanalysis, 1980s–​2010s: Evolving Interest in the Analyst’s Subjectivity. New York: Routledge. Stern, D. B., Mann, C., Kantor, S. & Schlesinger, G. (Eds.) (1995). Pioneers of Interpersonal Psychoanalysis. New York: Routledge. Sullivan, H. S. (1940). Conceptions of modern psychiatry. New York: Norton, 1953. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: Norton. Taylor, C. (2016). The language animal: The full shape of the human linguistic capacity. Cambridge, MA: Harvard University Press. Warnke, G. (1987). Gadamer: Hermeutics, tradition and reason. Stanford, CA: Stanford University Press. Weinsheimer, J. C. (1985). Gadamer’s hermeneutics: A reading of truth and method. New Haven, CT: Yale University Press. Winnicott, D. W. (1971). Playing and reality. London: Tavistock.

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PART 4

The Dissociative Disorders

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21 DISSOCIATION IN THE ICDs AND DSMs John A. O’Neil

Official Nosologies: the ICD and DSM This chapter is devoted to explaining the position of dissociation and the dissociative disorders in the two most important nosologies1 in official use, and their interactions over time. These are the International Classification of Diseases (ICD), which covers ‘everything,’ and the American Diagnostic and Statistical Manual of Mental Disorders (DSM), which covers psychiatry. As official systems of classification, they are the products of both scientific research and ‘political’ forces, the latter being a reflection of academic and cultural fashions operative at the time of formulation, and in the geographical areas concerned. The ICD evolved principally in Europe, while the DSM derived from autonomous American sources; they briefly coincided in DSM-​II/​ICD-​7-​8 -​9, then rediverged, though continuing to interact with each other. These are briefly introduced here, to trace the appearance and evolution of dissociation through the various editions of these official nosologies.

The ICD The ICD is published by the World Health Organization (WHO) based in Geneva, Switzerland. It has undergone a number of different publishers and name changes over the past 122 years. France published The International List of Causes of Death in 1900, subsequently reinterpreted as ICD-​1. France published ICD-​1-​2 -​3; the League of Nations published ICD-​4 -​5; the WHO took over from ICD-​6 (1948). WHO Nomenclature Regulations (1967) stipulate that Member States use the most current ICD revision for national and international mortality and morbidity statistics. Consequently, it is the official classification of diseases worldwide, covering virtually all topics of relevance to medicine and all its disciplines, and to issues of public health, making it global and massive in scope. The original list was limited to mortality, including death by war, homicide, accident and suicide. Over the years, it was greatly extended by adding morbidity, including injury and poisoning from all sources; and then medical and surgical interventions. ICD-​8 added examinations and investigations; ICD-​9 added personal histories of prior and current psycho-​social conditions; ICD-​10 added signs, symptoms and abnormal findings; ICD-​11 expands on all these categories with a huge increase in available codes (see below). An extremely small part of ICD-​11 (2022) is its 6th section (of 26), entitled Mental, behavioural or neurodevelopmental disorders.

The DSM The DSM is the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. DSM-​I appeared in 1952; the current version, DSM-​5, has been in use since 2013. DSM-​5 -​TR (text revision) is currently being edited for publication. Psychiatry is the only medical specialty with its own Manual in parallel with the ICD, defining the “current official text” regarding psychiatric diagnosis in the USA, but also largely adopted worldwide for psychiatric research as it has generally been more scientifically advanced than the ICD since DSM-​III (1980). Other medical specialties evolve through decentralized research, publication, training, conferencing, etc., with the ICD

DOI: 10.4324/9781003057314-26

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playing nosological and statistical catchup. In contrast, the American Psychiatric Association’s (APA) DSM has taken on more of a leading role both academically and legally.

ICD and DSM History – Overview ICD History: From Bertillon to ICD-​9 In 1899, Jacques Bertillon published the Bertillon Classification of Causes of Death (English translation: see American Public Health Association, 1899), a simple list of just 44 items. It was the basis for ICD-​1 (1900), translated from French into various other languages, and called the International Classification of Causes of Death, with an expansion of Bertillon’s 44 items to 190. Bertillon remained the editor until ICD-​3 (Bertillon, 1920). ICD-​6 (1948, under the WHO) has an expanded title: International Statistical Classification of Diseases, Injuries and Causes of Death. It introduces the familiar code structure of three digits, followed by a decimal point, subsequently adopted by DSM-​II-​III-​I V. Its mental disorders section begins to resemble what we are familiar with today. It has three diagnostic clusters: Psychoses, Psychoneurotic Disorders, and Disorders of character, behaviour, and intelligence. ICD-​7 (1957) and ICD-​8 (1965) recategorize diseases, whenever possible, by etiology rather than by anatomical location. In the USA, ICDA-​8a becomes the American version of ICD-​8, and its mental health subsection becomes DSM-​II. ICD-​9 is a relatively minor update.

American Nosology Prior to DSM-​I According to the APA (1952), a forerunner to DSM-​I was the Statistical Manual for the Use of Hospitals for Mental Diseases in 1917, an effort to harmonize nomenclature. By the late 1920s, however, each major teaching center still employed its own nomenclature, compromising communication and statistics. In 1933, the Statistical Manual was updated and incorporated into the American general medical Standard Classified Nomenclature of Diseases, which itself had evolved independent of the ICD, as a chapter awkwardly entitled Diseases of the Psychobiologic Unit. Early in World War II, Armed Forces psychiatrists found the Standard Nomenclature inadequate for 90% of cases seen: it still concentrated on death, and psychiatric cases were among the living. In 1945, the American Armed Forces adopted a new nomenclature, revised and endorsed by the Veterans Administration in 1946, the same year that Congress established the NIMH, whose Biometrics Branch took over statistical reporting, leaving the APA free to focus on general principles and procedures. But there were still three major active nosologies in use: the old Standard, the Armed Forces’, and the VA's, all different from each other and from ICD-​6. In 1950, the APA proposed a revision and, following significant feedback from its membership, issued a second revision updating the Diseases of the Psychobiologic Unit of the Standard Nomenclature. Finally, that updated section was published independently as the Diagnostic and Statistical Manual –​Mental Disorders, now called DSM-​I (1952).

DSM-​I (1952) DSM-​I terminology adopted the preferred term ‘reaction’ from Dr Adolf Meyer, the first psychiatrist-​in-​chief of Johns Hopkins. Consequently, there is Dissociative reaction: depersonalization, dissociated personality, stupor, fugue, amnesia, dream state, somnambulism; and Conversion reaction: anesthesia, paralysis, dyskinesis. Note that ‘hysteria’ is not mentioned, and that depersonalization is considered a symptom of Dissociative reaction.

DSM-​II (1968) and ICD-​7-​8-​9 The DSM-​II and ICD-​7-​8 -​9 will be discussed as a unit, in the interests of space, because DSM-​II (1968) adopted the ICD-​8 (1965) and so these are virtually identical. ICD-​9 (1979) has more extended text, and for mental disorders it borrows the text of DSM-​II (1968), making them not only structurally but textually comparable (Moriyama et al., 2011). Hysterical neurosis (300.1) is part of the Neuroses (300), with conversion type and dissociative type. The conversion type includes blindness, deafness, anosmia, anesthesias, paresthesias, paralyses, ataxias, akinesias, and dyskinesias. The dissociative type includes amnesia, somnambulism, fugue, and multiple personality. Depersonalization is missing, because it remains its own standalone neurosis: 300.6 –​Depersonalization Neurosis. The DSMs and ICDs at the time had at most descriptive paragraphs for each disorder, and sometimes just for a class of disorders, leaving considerable room for clinical judgment as to whether the description fits the person being assessed. Note that dissociation and conversion are two types of the same thing –​hysteria –​and that depersonalization is something else entirely.

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DSM-​III (1980) DSM-​III (1980) introduces a wealth of major innovations. The most important was a borrowing from a physicist, Percy W. Bridgman (1927), who had proposed ‘operational definitions’ for physics concepts, to replace semantic definitions with descriptions of the operation of measurement. Curiously, operational definitions didn’t last in the basic sciences –​they were almost immediately mired in irremediable contradiction 2 –​but the idea took hold in the social sciences3 in an effort to be more ‘scientific,’ and has lingered there because the subject matter is so complex that it isn’t obvious that operationalism is conceptually flawed. What was hoped to be scientific proved to be scientistic. In any case, wishful thinking about theory-​free observations through operational definition did inspire diagnostic criteria which improve interrater reliability –​a worthy objective. The temptation, however, is then to misconstrue high interrater reliability with ‘theory-​free observation’ and other conceptual conceits. Each diagnosis includes a very extended text, including essential features, associated features, age at onset, course, impairment, complications, predisposing factors, prevalence, sex ratio, familial pattern, and differential diagnosis. The enormous increase in text elevated the DSM into a form of diagnostic textbook, which DSM-​I-​II and ICD-​1-​9 never were. Another major DSM-​III innovation is the introduction of the familiar 5 Axes. Axis IV is of etiological interest: Severity of Psychosocial Stressors, with a long list of typical developmental challenges and traumas, and inviting systematic attention to predisposing, precipitating, perpetuating and protective factors in the biological, psychological, and social spheres –​ good systematic preparation for a global clinical discussion. Axis V –​Highest Level of Adaptive Functioning in the Past Year: a simple 5-​point scale, from superior to poor functioning in social relations, occupational functioning, and use of leisure time, with purported prognostic significance. DSM-​III also includes an ‘Atypical’ presentation for each diagnostic grouping, largely derived from DSM-​II’s ‘other’ and ‘unspecified’ diagnoses, which it had in common with ICD-​7-​8 -​9. Terminologically, DSM-​III reverts to some elements of DSM-​I, performing a ‘complete hysterectomy’ by abandoning hysterical neurosis, and renaming hysterical personality as histrionic. Hysterical Neurosis, dissociative type, is moved to the newly-​m inted Dissociative Disorders, which includes Psychogenic Amnesia, Psychogenic Fugue, and Multiple Personality. Depersonalization Neurosis is also reinterpreted as a Dissociative Disorder, as it had been in DSM-​I, now called Depersonalization Disorder. Hysterical Neurosis, conversion type, is renamed Conversion Disorder, and moves to the newly-​m inted Somatoform Disorders, grouped with Somatization Disorder, Psychogenic Pain Disorder, and Hypochrondriasis. In essence, the primary ‘dissociative’ changes are the clear separation of dissociation and conversion into two distinct categories, and the reinterpretation of depersonalization as dissociative.

DSM-​III-​R (1987) In DSM-​III-​R, the now-​familiar “Specify if…” is appended to some diagnoses. The concluding “Atypical” diagnosis for each diagnostic category is replaced by the now-​familiar ‘Not Otherwise Specified’ or NOS addendum. This wording is used even if followed by highly otherwise specified examples; thus, Atypical Dissociative Disorder becomes DDNOS with four highly otherwise specified examples, but not limited to these.

ICD-​10 (1992) ICD-​10 represents a major revision of the ICD, with a number of significant departures from ICD-​6 -​9, and some major borrowings from DSM-​III. First of all, alleviating ICD-​9 ‘code exhaustion,’ to accommodate new entities, the 1000 possible main codes (000-​999) are expanded to 2600 by replacing the initial number by a letter (A00-​Z99). Mental Disorders are allocated ‘F’ (F00-​F99), increasing its possible main diagnoses from 30 to 100. ICD-​10’s ‘blue book’ (1992), entitled Clinical descriptions and diagnostic guidelines, is stylistically close to ICD-​7-​8 -​9/​ DSM-​II and meant primarily for clinicians in practice; its expanded text for each diagnosis remains considerably less than for DSM-​III. The ‘green book’ (1993), entitled Diagnostic criteria for research, echoes DSM-​III’s specific diagnostic criteria, and is primarily for researchers. Mental disorders are Fxx., and ICD-​9’s ‘Other’ and ‘Unspecified’ diagnoses become numerically embodied as Fxx.8 for ‘Other’ and Fxx.9 for ‘Unspecified.’ While alluding to ‘Neurosis’ in the major heading of Neurotic, stress-​related and somatoform disorders, ICD-​10 follows DSM-​III in scattering its former components among new groupings. The most striking involves the creation of a subgroup: Reaction to severe stress, and adjustment disorders. This includes its own newly-​m inted diagnoses, Acute stress reaction and Post-​traumatic stress disorder, borrowed from DSM-​III, though removing it from DSM-​III’s Anxiety Disorders.

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Especially new is the inclusion within this group of Adjustment disorders (a separate DSM-​III grouping) thereby consolidating all ‘event-​related’ diagnoses under one heading. OCD is likewise promoted to its own subgroup, also removing it from anxiety disorders. Not new is the treatment of dissociative and conversion pathologies. Dissociative [conversion] disorders (D[C]‌D) constitute more of a name change than an innovation, being essentially equivalent to Hysterical Neurosis, dissociative and conversion types, though now elaborated into 12 specific diagnoses. The D[C]Ds strain even ICD-​10’s new coding system, as specific conversion disorders quickly exhaust its primary list, forcing it to have specific subdiagnoses within its “Other” heading –​the only ICD-​10 diagnostic grouping to do so –​and that is where one finally finds F44.81 –​Multiple personality disorder (MPD). F48.1 –​Depersonalization-​derealization syndrome continues to be listed separately, again following ICD-​9, and declining to follow DSM-​III’s reinterpretation. Within the Personality Disorders, ICD-​10’s major innovation is the formulation of F60 –​General criteria for personality disorder; indeed, the ‘A’ criterion for each specific personality disorder (1993, pp. 123–​129) is “The general criteria for personality disorder (F60) must be met.” In summary, ICD-​10 follows ICD-​9 in keeping dissociation and conversion together, and depersonalization distinct.

DSM-​IV/​IV-​TR –​ 1994/​2000 DSM-​I V (1994) and DSM-​I V-​TR (2000) represent significant developments of DSM-​III, though, unaccountably, borrowing almost nothing from ICD-​10. DSM-​I V continues the limited ICD-​9 codes throughout, though Appendix H (DSM-​I V, p. 829; DSM-​I V-​TR, p. 883) features DSM-​IV Classification with ICD-​10 Codes, freely available since 1992. The five diagnostic ‘Axes’ are maintained, but Axes IV Severity of psychosocial stressors, becomes Psychosocial and Environmental Problems –​a mere laundry list of immediate current complicating factors, leading to a dumbing down of diagnosis. Axis V becomes the GAF: the Global Assessment of Functioning Scale. The GAF reflects overall current state, lacks prognostic significance, and condenses into a single user-​hostile page an amalgam of psychosocial functioning, symptom severity, thought disorder, and suicidality, into a single 1-​100 scale, guaranteeing miserable interrater reliability. Most diagnoses now routinely require “clinically significant distress or impairment in functioning,” largely absent throughout DSM-​III. Remarkably, DID still requires no clinically significant distress or impairment in functioning.

…Not Otherwise Specified Despite still falling short of ICD-​10’s distinction between ‘Other’ and ‘Unspecified’ diagnoses, ‘NOS’ diagnoses are now defined as falling into four specific categories. These include insufficient or conflicting data collection; etiological uncertainty; presentations with diagnostic criteria provided in Appendix B –​Criteria Sets and Axes Provided for Further Study, for example, DDNOS-​4 –​Dissociative Trance Disorder, with text and specific ‘Research criteria’ (p. 727); and the familiar subclinical or atypical presentations of specific diagnoses of a given group, for example, DDNOS-​1 (subthreshold DID) and DDNOS-​2 (derealization without depersonalization). No NOS diagnosis designates a condition which one might ‘have,’ as every NOS diagnosis without further specification, ambiguously signals something about the diagnosing clinician (insufficient information, indecision), or else about the patient. There are no diagnostic criteria, per se, for an NOS diagnosis, apart from tentative ‘Research criteria,’ for examples in Appendix B. Thus, no NOS diagnosis ‘names’ a ‘disorder’ per se, but rather, at best, implies a temporary list of diagnostic possibilities. I treat this at some length, as the APA assumes that their various lists of specific diagnoses will cover the majority of cases, with the corresponding NOS designations added on to accommodate atypical ‘leftovers’ –​statistical outliers –​ that don’t quite fit the specific diagnoses. DDNOS ­example 1 (subthreshold DID), however, becomes the single most common diagnosis among clinicians making dissociative diagnoses.

Personality Disorders DSM-​I V makes two major innovations: it introduces General diagnostic criteria for a Personality Disorder, whose existence, structure and wording are clearly borrowed from ICD-​10. Actual criteria for each specific personality disorder, however, fail to begin with something akin to “General diagnostic criteria for a Personality Disorder must be met,” allowing for these general criteria to be routinely disregarded in both practice and research.

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DSM-​IV-​TR (2000) DSM-​IV-​TR represents a very minor emendation of DSM-​IV, and again borrows nothing from ICD-​10. Within Personality Disorders, there is an added paragraph, “Dimensional Models for Personality Disorders” (p. 589), which would herald a major, though unadopted, 21-​page addition to DSM-​5.

DSM-​5 (2013) Catching up with 1992 DSM-​5 is most marked by finally adopting developments introduced by ICD-​10, 21 years after the fact. DSM-​5 maintains ICD-​9 codes for 2013, and finally adopts ICD-​10 codes for 2014, increasing its main psychiatric codes from 30 to 100. DSM-​5 replaces all ‘NOS’ diagnoses by ‘Other Specified’ (OS) and ‘Unspecified’ (US) diagnoses. Curiously, ‘Other Specified’ does not specify the 4 specified kinds of ‘Not Otherwise Specified’ of DSM-​I V (see above), and leaves the distinction between ‘OS’ and ‘US’ to clinical judgment: if the clinician has anything to add beyond identifying the diagnostic group, then OS applies; if the clinician has nothing to add, then US applies. The transitions from ‘NOS’ to the ‘OS/​US’ distinction, and from ICD-​9 to ICD-​10 codes, comes with a number of glitches. Unlike ICD-​10, OS examples persist in DSM-​5, despite the coding opportunity to ‘promote’ them to diagnoses in their own right. DSM-​5 has a number of codes, entirely absent from ICD-​10, which are frankly oxymoronic, in the form Fxx.89, indicating that they are simultaneously Other Specified (8) and Unspecified (9). These include F80.89, F31.89, F40.298, F44.89, F60.89, and F65.89. Regrettably, one oxymoronic code is OSDD –​Other Specified Dissociative Disorder –​miscoded as F44.89 rather than F44.88. Obsessive-​Compulsive Disorder (OCD) is promoted to its own grouping: Obsessive-​Compulsive and Related Disorders, with subdiagnoses. PTSD and acute stress disorder (ASD) are promoted to their own grouping: Trauma-​ and Stressor-​Related Disorders, which now includes Adjustment Disorders, again consolidating all ‘event-​related’ diagnoses under one heading. Abandoning the ‘Axes’ DSM-​5 abandons Axes I-​V, now simply listing all diagnoses, both psychiatric and medical. While Axis IV is gone, the list of Other Conditions that may be a focus of clinical interest expands from 23 to 133, clinically daunting and awkward, though possibly useful for researchers and statisticians. Of particular interest to dissociative disorders clinicians would be: Z62.810-​Z62.812, which cover Personal/​past history in childhood of physical abuse; …of sexual abuse; …of neglect; …of psychological abuse. Other Features Somatoform Disorders are now called Somatic Symptom and Related Disorders; Conversion Disorder remains there, but with Functional Neurological Symptom Disorder (FNSD) added in parentheses, which I assume will become the sole title in DSM’s next iteration. ‘Hysterical’ became ‘Psychogenic’ and now becomes ‘Functional,’ a more acceptable term for the idea that everything mental is ultimately linked to the organic brain, while simultaneously allowing a euphemism for ‘all in the head.’ It underscores what the symptom is not: not related to any identifiable organic lesion. Personality Disorders Within the main text, DSM-​5 Personality Disorders are identical to DSM-​IV. But Section III –​Emerging Measures and Models includes Alternative DSM-​5 Model for Personality Disorders (pp. 761-​781), heralded by that single paragraph in DSM-​IV-​TR, “Dimensional Models for Personality Disorders” (see above). Following General Criteria for Personality Disorder, types of personality disorder are reduced from 10 to 6: Antisocial, Avoidant, Borderline, Narcissistic, Obsessive-​Compulsive, and Schizotypal. This is followed by a lengthy, and markedly user-​hostile, section on personality traits. I have always suspected that clinicians and researchers couldn’t agree on an elegant final product, justifying the central Task Force’s rejection.

ICD-​11 (2018/​2022) As noted above, ICD-​11 (first released 2018, and officially 2022) is a second complete redoing of the ICD. Just as ICD-​10 completely revises ICD-​7-​8 -​9, ICD-​11 completely revises ICD-​10. This includes a second revision of codes, allowing

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for an enormous increase which should prove to be sufficient for the foreseeable future. Codes are expanded to four characters before the decimal point, best represented as CLCC, where L =​A-​Z (apart from I and O =​24 possible characters); and where C =​0-​9, followed by A-​Z (apart from I and O =​10+​24 =​34 possible characters). Thus, CLCC yields 34x24x34x34 =​943,296 possible main diagnoses, 363 times more than for ICD-​10, and 943 times more than for ICD-​9. The 6th section of ICD-​11 is Mental, behavioural or neurodevelopmental disorders, and so its codes run from 6A00 to 6ZZZ, or 1x24x34x34 =​27,744 possible main diagnoses, though it currently limits itself to a modest 960 (6A00–​ 6E8Z) –​not all these possibilities are exploited. ‘Other’ and ‘Unspecified’ diagnoses, signaled in ICD-​10 by a terminal ‘8’ and ‘9’ respectively, are now signaled by a terminal ‘Y’ and ‘Z.’ 6B6x. –​ Dissociative Disorders –​drops the word ‘conversion’ from ICD-​10’s Dissociative [conversion] disorders, but hugely expands to 22 specific subdiagnoses (double ICD-​10’s 11, and DSM-​5’s 3), of which fully 15 are specific subtypes of 6B60. –​ Dissociative neurological symptom disorder. DNSD is the ICD-​11 counterpart to DSM-​5’s FNSD (conversion disorder). The specific use of ‘dissociative’ goes beyond DSM-​5’s noncommittal ‘functional’ and proclaims what the symptom is: dissociative. Thus, dissociation and conversion remain together, just as in DSM-​II/​ICD-​7-​8 -​9-​10. 6B64. –​ Dissociative Identity Disorder finally renames MPD as DID, and promotes ICD-​10’s F44.81 –​Multiple personality disorder, which had been a mere subdiagnosis of ‘Other dissociative [conversion] disorders,’ to its own ‘1st rank’ diagnosis. More remarkably, it creates 6B65. –​Partial Dissociative Identity Disorder, promoting sub-​threshold DID to a fully-​fledged diagnosis, on an equal footing with DID. This finally corrects the long-​standing scandal of DDNOS-​1 and OSDD-​1 having been mere examples. Equally remarkably, ICD-​11 creates 6B41. –​Complex post traumatic stress disorder, a significant advance on DSM-​5, and satisfying a decades-​long wish for an official CPTSD (or DTD –​Developmental trauma Disorder, or DESNOS –​ Disorder of Extreme Stress NOS). 6B66 –​ Depersonalization-​derealization disorder is now one of the Dissociative disorders, representing a break from ICD-​7-​ 8-​9-​10, and belatedly following DSM-​III-​I V-​5’s lead in this regard. Within the Personality Disorders, ICD-​11 makes a global innovation, new to ICD and, at first glance, new to DSM, although borrowing heavily from DSM-​5’s Alternative Model (see above), dividing severity and type into two different diagnostic groupings. There are just two root diagnoses: Personality Disorder, and QE50.7 –​Personality difficulty; which are of mild, moderate or severe degree. One then may specify 6D11.x –​Prominent personality traits or pattern, of which there are six (not ten) types: Negative affectivity; Detachment; Dissociality; Disinhibition; Anankastia; Borderline. The terms Negative affectivity, Detachment and Disinhibition are lifted directly from DSM-​5’s Section III –​Emerging Measure and Models –​Alternative Model for Personality Disorders (p. 770ff ). The Borderline description is a single paragraph encompassing all DSM-​5’s criteria. This concludes a brief introduction to the development of the ICDs and DSMs overall.

Dissociation in General Dissociation: Evolution of the Definition The original signifier is hysteria. This term appears in Bertillon’s classification (1899), not in ICD-​1 (1900). It reappears in ICD-​2 -​3 (1909/​1920), but grouped with neuralgia, sciatica, neuritis, etc. It is absent again in ICD-​4 -​5 (1929/​1938). In ICD-​6 (1948), dissociation is implied by Hysterical reaction without mention of anxiety reaction. Somatoform disorders are implied by Psychoneurosis with somatic symptoms. Depersonalization is standalone, where it will remain until ICD-​11. DSM-​I (1952) adopts dissociative and conversion reactions, the former including depersonalization; ‘hysteria’ is not invoked. A dissociative reaction is a neurotic personality disorganization, wherein “The repressed impulse giving rise to the anxiety may be discharged by, or deflected into, various symptomatic expressions, such as depersonalization, dissociated personality, stupor, fugue, amnesia, dream state, somnambulism, etc.” (p. 32). In conversion reactions, impulses causing anxiety were “converted” into functional symptoms in organs or parts of the body usually under voluntary (vs. autonomic and visceral) control, thereby lessening conscious anxiety, a clear reference to primary gain. The DSM-​II/​ICD-​8 congruence remains a key node in the general history of dissociation. The chief characteristic of Neuroses is anxiety, either felt and expressed directly, or altered by psychological mechanisms such as conversion or displacement. Hysterical Neurosis “is characterized by an involuntary psychogenic loss or disorder of function. Symptoms … are symbolic of the underlying conflicts. Often they can be modified by suggestion alone” (p. 39). The dissociative type includes alterations in consciousness and identity, for which amnesia, somnambulism, fugue, and multiple personality are considered symptoms. Depersonalization is missing, because it remains its own standalone neurosis: Depersonalization Neurosis: feelings of unreality and of estrangement from the self, body, or surroundings.

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The conversion type affects the senses or the voluntary nervous system, for which blindness, deafness, anosmia, anesthesias, paresthesias, paralyses, ataxias, akinesias, and dyskinesias are symptoms. DSM-​I’s allusion to primary gain is reiterated in reference to la belle indifférence, though mislabelled as secondary gain. DSM-​III mints Dissociative Disorders and Somatoform Disorders which allows it to promote Hysterical Neurosis, dissociative type, into the various Dissociative Disorders, and to shuffle Hysterical Neurosis, conversion type, off to Somatoform Disorders. As noted above, ‘Dissociative Disorders’ now also includes what was Depersonalization Neurosis, reinstating the DSM-​I interpretation. DSM-​III describes the essential feature of dissociation as a “sudden, temporary alteration in the normally integrative functions of consciousness, identity, or motor behavior” (p. 253). This triad is misleadingly simple-​m inded, linking amnesia to consciousness, multiplicity and depersonalization to identity, and fugue to motor behavior, whereas alterations of consciousness, and alterations of motor behavior and depersonalization, are all most common in alterations of identity. DSM-​III-​R (1987) edits the usually integrated functions to “identity, memory or consciousness” (p. 253), adding memory and dropping motor behavior, likely preferring the latter to remain with somatoform disorders. DSM-​I V expands the usually integrated functions to “consciousness, memory, identity, or perception of the environment” (p. 477). The addition of perception of the environment is interesting, and hints at derealization, but, once again, alterations of consciousness, memory and perception of the environment are all most common in alterations of identity. DSM-​IV-​TR shortens the usually integrated functions to “consciousness, memory, identity, or perception” (p. 519). Dropping “of the environment” allows for depersonalization. DSM-​5 brings a significant elaboration: “a disruption of and/​or discontinuity in the normal integration of consciousness, memory, identity, … perception” but with the notable addition of “emotion, … body representation, motor control, and behavior” (p. 291). Emotion allows especially for both blunting and intrusions; body representation and behavior are generally most marked with dissociative identity; reinstating ‘motor control,’ which rewords DSM-​III’s ‘motor behavior,’ oddly reopens the door to FNSD (conversion), though this remains in the Somatic Symptom orbit. Dissociative symptoms are described as positive (intrusions) or negative (inabilities), but this is not helpful, as the identity of the one experiencing is not addressed, and this is generally the central matter. ICD-​ 11 defines dissociation as involving “involuntary disruption or discontinuity in the normal integration of…: identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, or behaviour.” Relative to DSM-​5’s definition, ICD-​11 drops consciousness and body representation; and adds thoughts and sensations. ‘Sensations’ and ‘bodily movements’ underlie the persistent grouping of DNSDs (Dissociative neurological symptom disorder –​conversion) with dissociation.

Specific Kinds of Dissociation The inadequate definitions of the ICDs and DSMs are attempts to throw a complex group of interrelated phenomena into a grab bag. The various kinds of ‘dissociation’ fall into a small number of relatively distinct groups, spread among specific diagnoses and their related NOS/​OS depictions. This section attempts to clarify the ICD/​DSM history of each group. Regrettably, the discussion is largely limited to diagnostic criteria rather than extended text, given limitations of chapter length: 1. Dissociative multiplicity: this includes Multiple Personality, Multiple Personality Disorder, Dissociative Identity Disorder, and the various sub-​threshold DIDs. 2. Dissociation of memory: this includes Psychogenic/​Dissociative Amnesia and Fugue. 3. Depersonalization and derealization. 4. Sensorimotor dissociation: Conversion Disorder and Functional/​Dissociative Neurological Symptom Disorder. 5. Residual kinds of dissociation: this includes Dissociative Trance Disorder.

1.  Dissociative Multiplicity I use this term to express the key feature of MPD/​DID, which requires the presence of more than one center of consciousness. ‘Identity’ remains an ambiguous term for two reasons: 1. dissociated identity may apply to both identity diffusion and identity alteration; this section concerns identity alteration, and not diffusion; 2. the question of who is designating identity: it may be the diagnosing clinician making a claim about a patient having more than one identity, or, alternatively, it may be a claim made by a patient about their own experienced identity, whether diffuse or alternating.

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Prevalence This epidemiological ‘prelude’ applies most to dissociative multiplicity but, to a less extent, to all the dissociative disorders. One may only describe cases that show up, and current estimates of prevalence in the general population are a few orders of magnitude higher than both earlier estimates, and than cases that come to clinical attention even today. The various nosologies (DSMs and ICDs) describe cases that tended to show up clinically at the time and place in question. Regarding time, we would expect increasingly subtle presentations of dissociative multiplicity to be identified over time, paralleling similar patterns for other psychiatric diagnoses (borderline, autistic spectrum, gender dysphoria, etc.). Patterns of case identification may be dissimilar, as a reflection of the differing cultures, of both patients presenting and clinicians diagnosing, in different parts of the world. DSM-​II/​ICD-​8 offer no prevalence for Hysterical neurosis, dissociative type –​multiple personality. DSM-​III (1980) states “The disorder is apparently extremely rare” (p.258). DSM-​III-​R (1987) states “Recent reports suggest that this disorder is not nearly so rare as it has commonly been thought to be” (p. 271). ICD-​10’s (1992) opening sentence states: “This disorder is rare, and controversy exists about the extent to which it is iatrogenic or culture-​specific” (p. 160). DSM-​I V (1994, p. 486) and DSM-​I V-​TR (2000, p. 528) give no estimate at all, while commenting: “The sharp rise in reported cases of Dissociative Identity Disorder in the United States in recent years has been subject to very different interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been overdiagnosed in individuals who are highly suggestible (p. 528).” DSM-​5 (2013) is definitively on the side of the first explanation: that the sharp rise in reported cases of DID reflects identification of cases that were previously undiagnosed. The DSM-​5 prevalence becomes very precise: “The 12-​month prevalence of dissociative identity disorder among adults in a small US community study was 1.5%. … 1.6% for males and 1.4% for females” (p. 294). The source of these estimates is Johnson et al. (2006). The figure in this study for DDNOS (from the text, a mix of DDNOS-​1-​2, at least) was 5.5%, possibly increasing the prevalence of dissociative multiplicity to ~5%. ICD-​11 (2022), perhaps wisely, declines to give an estimate, as 1.5% is very far from rare. In the USA, the Rare Diseases Act of 2002 defines a rare disease as one affecting fewer than 200,000 Americans, or, according to the US population that year (287.6 million), < 0.07% of the population. Simple math indicated that DID is now estimated to be ~21 times more prevalent than diseases officially considered rare; and DID/​OSDD-​1 perhaps ~70 times more prevalent than diseases officially considered rare. It is often the case that dramatic presentations of whatever (both medical and psychiatric) come to attention first; and then with clinical experience, clinicians learn what to look for, and become able to notice more subtle cases. This means that over time the number of discerning clinicians increases, so that the number of identified cases increases. But at the same time the ‘average expectable’ presentation also becomes less dramatic, more nuanced, widening the range of detected illness expression. Thus, DSM-​III MPD is very dramatic, and extremely rare. DSM-​5 DID is far less dramatic, and astonishingly common.

DSM-​III: 300.14 –​Multiple Personality As noted, DSM-​II/​ICD-​9 limits itself to merely listing multiple personality as a possible expression of Hysterical neurosis, dissociative type. DSM-​III retains ‘multiple personality’ (without the ‘disorder’) and provides the first extended text and diagnostic criteria which require “A. The existence within the individual of two or more distinct personalities, each of which is dominant at a particular time; B. The personality that is dominant at any particular time determines the individual’s behavior; and C. Each individual personality is complex and integrated with its own unique behavior patterns and social relationships” (p. 259). Essentially, DSM-​III diagnostic criteria require multiplicity with switching, amnesia optional. Through today’s lens, the criteria are major exaggerations, which we now might mitigate as: “…two or more distinct personalities, of varying complexity and integration, some of which are dominant at particular times, determining the individual’s behavior; personalities have identifiable behavior patterns and, if they become dominant, may have their own social relationships.” DSM-​III has no added routine criteria requiring distress or impairment, nor exclusion criteria, so there are none for any dissociative disorder.

DSM-​III-​R: 300.14 –​Multiple Personality Disorder DSM-​III-​R diagnostic criteria for MPD collapse DSM-​III’s A and C criteria into one: “A. The existence within the individual of two or more distinct personalities or personality states (each with its own relatively enduring pattern of

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perceiving, relating to, and thinking about the environment and self )” and then reformulates DSM-​III’s B criterion: “B. At least two of these personalities or personality states recurrently take full control of the person’s behavior” (p. 272). DSM-​III-​R continues to require multiplicity with switching, amnesia optional, but the personalities need only display relatively enduring personality traits, more or less distinct from each other, and not all are required to take full control for some periods of time.

DSM-​III-​R: 300.15 –​ DDNOS-​2 Sub-​threshold MPD isn’t mentioned in DSM-​III’s Atypical Dissociative Disorder. Subthreshold MPD becomes DDNOS-​2, which obtains when there is overt switching, but the personality states are insufficiently distinct; or else when they are sufficiently distinct, but don’t assume complete executive control. There is no clear cutoff for ‘distinctness.’ The absence of full switching is clearer. Amnesia for switches is not mentioned.

ICD-​10: F44.81 –​Multiple Personality Disorder MPD barely makes it into the fully restructured ICD-​10, as is evident in the ‘8’ code: Other dissociative [conversion] disorders, where it takes second place to F44.80 –​Ganser’s syndrome! Combining the Blue and Green Book accounts, ICD-​10 is noncommittal about MPD’s existence; there are two or more distinct and complete personalities, each with their own memories, preferences, and behavior patterns; each of whom recurrently takes full control, so that only one is evident at a given time; switching is sudden and usually triggered by traumatic events (though subsequent switching may occur in therapy); the “common form” involves two personalities who are unaware of each other, and who share no memories. To DSM-​III’s multiplicity with switching, then, ICD-​10 adds amnesia as an “inability to recall important personal information which is too extensive to be explained by ordinary forgetfulness,” and an exclusion criterion. Subclinical MPD has no specific existence in ICD-​10. Basically, any case of dissociative multiplicity would be covered by the F44.81 code. In summary, ICD-​10 repeats some of DSM-​III’s errors, but adds a few more. In fact, MPD does exist; just two personalities are not at all common; copresence and intrusion phenomena are far more common than overt switches; not every personality is complete; some personalities never come out; etc. However, ICD-​10 does refer to amnesia, though with the misleading impression that it is similar to very extensive forgetfulness, whereas amnestic episodes in MPD are memory blanks having nothing whatever to do with forgetfulness, ordinary or otherwise.

DSM-​IV: 300.14 –​Dissociative Identity Disorder DSM-​I V updates MPD to DID, so as to allow for inclusion of the word ‘dissociative.’ This also involves dropping both ‘multiple’ and ‘personality,’ inviting a semantic shift at the turn-​of-​the-​century that would see some schools of thought abandon ‘multiple personalities’ in favor of ‘division of the (one) personality into parts.’ The first meaning generally refers to the particular set of personality traits of a given host or alter; the second has more do to with the underlying mental structure –​two different meanings of ‘personality’ that have nothing to do with each other, generating major confusion regarding the word, which persists today. DSM-​I V (1994, p. 487) and DSM-​I V-​TR (2000, p. 529) are identical regarding DID. In general, the A and B criteria reiterate DSM-​III-​R’s; the C criterion adopts ICD-​10’s amnesia criterion –​“Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness”; a new D criterion is an exclusion criterion regarding substances and other medical condition, and, for children, “imaginary playmates or other fantasy play.” Differences from DSM-​III are fairly subtle. ‘Existence’ becomes ‘presence’ (see above); ‘personalities’ become ‘personality states,’ equated with ‘identities’; ‘complexity’ and ‘dominance’ of each personality are dropped; ‘each of which’ becomes ‘at least two’; “individual’s behavior … behavior patterns and social relationships” becomes “enduring pattern of perceiving, relating to, and thinking about the environment and self.” Adding amnesia is perhaps essential, though it persists with the misleading impression that dissociative amnesia has something to do with forgetfulness (just as for ICD-​10). An added note: the ‘Diagnostic Features’ section claims that DID “reflects a failure to integrate various aspects of identity, memory, and consciousness” (p. 484). This goes beyond diagnostic features to etiology: the hypothesis that the absence of integration is caused by a failure to integrate. This is a testable causal hypothesis that has no place in the DSM, as long as the DSM pretends to be etiologically agnostic. If psychoanalytic causality is excluded, then this causality also ought to have been excluded.

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Essentially, then, DID in DSM-​I V requires a multiplicity of more or less distinct personalities, displaying relatively enduring personality traits, some of whom switch; with some degree of amnesia. Overall, the shift is from what is grossly observable in those rare dramatic cases to what is happening ‘inside’ in those more common and less dramatic cases. Remarkably, there is still no criterion requiring distress or impairment, despite such a criterion now being universally present throughout DSM-​I V, including for the other three dissociative disorders.

DSM-​IV/​IV-​TR: 300.15 –​ DDNOS-​1 For subthreshold DID, DSM-​III-​R’s DDNOS-​2 becomes DSM-​IV’s DDNOS-​1. DDNOS-​2 was for a) switching with indistinct personalities, or else b) distinct personalities without switching. This was clear. DSM-​IV is less clear. DDNOS-​1 is now for cases where “a) there are not two or more distinct personality states, or b) amnesia for important personal information does not occur” (p. 490). This informal description, which mustn’t be confused with diagnostic criteria per se, is lamentably equivocal. Would ‘a’ apply to presentations where there is just one distinct personality state? or just two personality states which are insufficiently distinct? and what is the cutoff for ‘distinctness’? Would ‘b’ apply to someone who has full access to all important personal information, despite experiencing regular amnestic episodes? Full personal information –​knowing what happened –​doesn’t require memory of having experienced it. Despite these reservations, in clinical settings that diagnose dissociative disorders at all, DDNOS-​1 would become a very major dissociative disorder, to the extent that the ‘-​1’ was routinely dropped, and DDNOS recorded as a diagnosis, even though it was a differential diagnostic label, and never a diagnosis per se.

DSM-​5: F44.81 –​Dissociative Identity Disorder DSM-​5 diagnostic criteria for DID bring a number of major changes, which warrant direct quotation (p. 292): A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/​or sensory-​motor functioning. These signs and symptoms may be observed by others or reported by the individual. B. Recurrent gaps in the recall of everyday events, important personal information, and/​or traumatic events that are inconsistent with ordinary forgetting. D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play. C & E. [pro forma distress/​impairment and substance/​medical exclusion clauses]. Criterion A involves a shift from the mere ‘existence’ or ‘presence’ of distinct identities to the ‘disruption of identity’ arising from distinct personality states; this effectively blends DSM-​I V Criteria A (multiplicity) and B (switching) which subsumes ‘recurrently take control’ under ‘disruption of identity.’ The criterion also grants that in some cultures this disruption of identity may be interpreted as pathological possession.4 DSM-​5 adds that signs and symptoms may be observed by others (e.g., family members) or reported by the individual. Criterion B updates DSM-​IV Criterion C’s “Inability to recall important personal information” with “Recurrent gaps in the recall of everyday events, important personal information, and/​or traumatic events” –​‘recurrent gaps’ comes much closer to implying amnestic episodes, more successfully distancing it from forgetfulness. Criterion C adds the long-​awaited distress/​i mpairment criterion to the diagnosis, bringing it into line with virtually all other DSM diagnoses for the first time. A stickler for the ‘letter of the law’ might then quip that in 2013 all of those people diagnosed with DID, who had convincingly denied both distress and impairment, abruptly ceased to have DID, any multiplicity or benign switching notwithstanding. Curiously, this may also parallel the arrival of the self-​declared nonpathological ‘plurals’ in social media. Criterion C is anticipated in Criterion A: ‘disruption of identity’ occasioned by multiplicity implies some degree of distress or impairment. Criteria D adds culture and religion to the “imaginary playmates or other fantasy play” of childhood.

DSM-​5: F44.885 –​OSDD-​1: Chronic and Recurrent Syndromes of Mixed Dissociative Symptoms This example now has a specific title, as noted. It includes “… identity disturbance … with less-​than-​m arked discontinuities in sense of self and agency, or alterations of identity or episodes of possession … [with] no dissociative amnesia”

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(p.306). This effectively covers cases of multiplicity without full switching, though, again, the cutoff for ‘marked discontinuity’ is unclear.

ICD-​11: 6B64 –​Dissociative Identity Disorder The description is largely borrowed from DSM-​5, with similar choice of words (e.g. “disruption of identity”). A significant improvement is in depicting DSM-​5’s “recurrent gaps” in memory to “episodes of amnesia,” the most accurate wording so far among all the DSMs and ICDs.

ICD-​11: 6B65 –​Partial Dissociative Identity Disorder The major news is ICD-​11’s promotion of subthreshold DID to its own full specific diagnosis as ‘6B65 Partial Dissociative Identity Disorder’ (PDID). What had been a mere example of DDNOS or of OSDD in the DSMs achieves full diagnostic equality with DID itself. The first two sentences are identical to those for DID. Then, …One personality state is dominant and normally functions in daily life, but is intruded upon by one or more non-​dominant personality states (dissociative intrusions). These intrusions may be cognitive, affective, perceptual, motor, or behavioral. They are experienced as interfering with the functioning of the dominant personality state and are typically aversive. The non-​dominant personality states do not recurrently take executive control of the individual’s consciousness and functioning, but there may be occasional, limited and transient episodes in which a distinct personality state assumes executive control to engage in circumscribed behaviours, such as in response to extreme emotional states or during episodes of self-​harm or the reenactment of traumatic memories. … This is followed by pro forma exclusion/​impairment clauses. This description underscores intrusions, but these apply equally to full DID, and also allows for rare full switches, without specifying amnesia, which until then had been pathognomonic of full DID; and with no clear cutoff regarding frequency. The description also overstates the negative, as intrusions often facilitate, rather than interfere with, functioning and may be welcome. This reflects the critical role of sample bias as discussed above, as patients are more likely to present for interfering intrusions, rather than facilitating ones. The word ‘partial’ is anomalous for a diagnosis per se. ICD-​11 could have followed its own precedent for ‘6B60 –​ Dissociative neurological symptom disorder,’ which expands to 19 different subdiagnoses. DID and PDID could have been subdiagnoses of a common grouping, such as ‘Dissociative multiplicity,’ as cases of DID often evolve into PDID, and cases initially diagnosed as PDID are often ‘promoted’ to DID as the patient becomes better known. It would also have better allowed for a more varied iteration of both full and subthreshold DID. There are a number of relatively independent variables in DID/​PDID: switching, intrusions (bidden and unbidden, positive and negative), co-​consciousness, co-​presence, amnesia (e.g., foggy, oneiric, or after-​the-​fact), and ‘hostship’ (there may be no single dominant or default personality state, migrating hostship, etc.). In future versions of the DSM and ICD, other subdiagnoses may emerge.

2.  Dissociation of Memory DSM-​III/​III-​R: 300.12 –​Psychogenic Amnesia and 300.13 –​Psychogenic Fugue As noted, DSM-​II/​ICD-​9 limits itself to merely listing amnesia and fugue as possible expressions of 300.1 –​Hysterical neurosis, dissociative type. DSM-​III (1980) criteria for Psychogenic Amnesia call simply for a “Sudden inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness” (p. 255), followed by the usual exclusion criterion. As usual, this confuses information with lived memory (see discussion above regarding amnesia in DID). Criteria for Psychogenic Fugue call simply for “Sudden unexpected travel away from one’s home or customary place of work, with inability to recall one’s past,” and “Assumption of a new identity (partial or complete)” (p. 257). There is no DSM-​ III “Atypical DD” that relates to amnesia. DSM-​ III-​ R’s DDNOS-​ 6, however, allows for Psychogenic Fugue’s amnesia for one’s entire past, but without assumption of a new identity.

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ICD-​10 (1992): F44.0 –​Dissociative Amnesia and F44.1 –​Dissociative Fugue ICD-​10’s Dissociative amnesia calls for “amnesia, either partial or complete, for recent events that are of a traumatic or stressful nature,” where the amnesia is “too extensive and persistent to be explained by ordinary forgetfulness” (p. 154); together with pro forma clauses. Dissociative fugue calls for “An unexpected yet normally organized journey away from home or the ordinary places of work and social activities, during which self-​care is largely maintained” (p. 155); with amnesia for the journey compatible with Dissociative Amnesia, together with pro forma clauses.

DSM-​IV/​IV-​TR: 300.12 –​Dissociative Amnesia and 300.13 –​Dissociative Fugue DSM-​I V (1994, pp. 478-​484) renames Psychogenic Amnesia and Fugue as Dissociative Amnesia and Fugue, following ICD-​10’s lead; perhaps because ‘psychogenic’ may suggest ‘all in the mind.’ Criterion A again mistakenly implies that dissociative amnesia has something to do with severe forgetfulness, though adds “usually of a traumatic or stressful nature”; followed by exclusion/​impairment criteria. Criteria for Dissociative Fugue are virtually identical to DSM-​III’s, though confusion about one’s identity is added as an alternative to assumption of a new identity.

DSM-​5: F44.0 –​Dissociative Amnesia (F44.1 if with Dissociative Fugue) DSM-​5’s (2013) A criterion calls for “An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting,” changing ‘forgetfulness’ to ‘forgetting,’ then adding “most often … of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history” (p. 298). The A criterion continues to confuse information with lived memory, and while “localized or selective amnesia for a specific event or events” better connotes an amnestic episode, “generalized amnesia for identity and life history” is what used to be Dissociative Fugue. That leaves the “With dissociative fugue” specifier with just “apparently purposeful travel or bewildered wandering” –​a curiously contrasting pair –​ together with amnesia for identity. In any case, the extreme rarity of complete amnesia for one’s past and assumption of a new identity accounts for its being downgraded to a mere specifier.

ICD-​11: 6B61 –​Dissociative Amnesia (± Dissociative Fugue) Remarkably, ICD-​11 (2022) follows DSM-​5 in folding dissociative fugue into dissociative amnesia. The description is copied from DSM-​5 almost word for word. DSM-​5’s fugue specifier is promoted to two subdiagnoses: 6B61.0 Dissociative amnesia with dissociative fugue, and 6B61.1 Dissociative amnesia without dissociative fugue. There is a major gap in this entire fugue discussion: minifugues (or fuguettes) where one finds oneself in a place, disoriented to time, sometimes to place, never to person, but with amnesia for the ‘trip’ –​amnesia for how one came to be there. These are extremely common in Dissociative amnesia, DID, and PDID (OSDD-​1).

3.  Depersonalization and Derealization DSM-​II/​ICD-​9: 300.6 –​ Depersonalization Neurosis In DSM-​II/​ICD-​9, the standalone Depersonalization Neurosis, or syndrome, was “dominated by a feeling of unreality and of estrangement from the self, body, or surroundings” (p. 41). The word ‘derealization’ is not mentioned.

DSM-​III/​III-​R: 300.60 –​ Depersonalization Disorder As noted, DSM-​III (1980), having dissolved all the Neuroses, incorporates depersonalization into its new category, Dissociative Disorders. Its A criterion is overly concise: “One or more episodes of depersonalization sufficient to produce significant impairment in social or occupational functioning” (p. 260); no signs or symptoms are mentioned. The preliminary text, however, adequately describes both depersonalization and derealization. Atypical Dissociative Disorder (300.15) includes derealization without depersonalization in its sole paragraph.

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DSM-​III-​R (1987) expands the criteria to define depersonalization: “feeling detached from, and as if one is an outside observer of, one’s mental processes or body” or “feeling like an automaton or as if in a dream.” This is followed by intact reality testing and the usual distress/​exclusion clauses. Its DDNOS-​4 is “derealization unaccompanied by depersonalization.”

ICD-​10: F48.1 –​Depersonalization-​Derealization Syndrome ICD-​10’s (1992) standalone Depersonalization-​derealization syndrome puts depersonalization and derealization on an equal footing: one may have either, or both; together with intact insight (reality testing) and clear sensorium. The differential diagnosis section includes the erroneous claim that it differs from a dissociative disorder “where awareness of change is lacking” –​in fact, patients with DID are commonly aware of when they have or don’t have DP/​DR.

DSM-​IV/​IV-​TR: 300.6 Depersonalization Disorder, and DDNOS-​2 Diagnostic criteria for Depersonalization Disorder are the same in DSM-​I V (1994) and DSM-​I V-​TR (2000), and differ from DSM-​III-​R by only a few words. DSM-​III’s DDNOS-​4 becomes DDNOS-​2, as “Derealization unaccompanied by depersonalization in adults.”

DSM-​5: F48.1 –​Depersonalization/​Derealization Disorder (DP/​DRD) DSM-​5 (2013) finally follows ICD-​10 (21 years later) in absorbing DDNOS-​2 into the main diagnosis, as is reflected in the expanded name. Criteria now allow for either depersonalization or derealization, or both; with the same pro forma clauses.

ICD-​11: 6B66 –​Depersonalization-​Derealization Disorder The major event here is ICD-​11’s (2022) inclusion of DP/​DRD under its Dissociative Disorders heading –​the first ICD to interpret DP/​DR as dissociative. Criteria are almost identical to those of ICD-​10 and DSM-​5.

4.  Sensorimotor Dissociation Overview Hysteria in DSM-​II/​ICD-​9 was a mental disorder in which “motives, of which the patient seems unaware, produce either a restriction of the field of consciousness or disturbances of motor or sensory function. … In the conversion form the chief or only symptoms consist of psychogenic disturbance of function in some part of the body, e.g., paralysis, tremor, blindness, deafness, seizures.” Despite conversion having migrated to DSM-​III’s Somatoform Disorders, the “disturbance of motor or sensory function” continues to peek through DSM-​5’s definition of dissociation with regard to faulty integration of “consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.” It remains clustered within dissociative disorders in ICD-​10-​11. Categorically speaking, no DSM conversion is dissociative, whereas all ICD conversion is dissociative. I regard both claims as overstated. The word ‘conversion’ will likely disappear completely, as DSM now also calls it Functional Neurological Symptom Disorder (FNSD) and ICD-​11 now calls it simply Dissociative Neurological Symptom Disorder (DNSD). In my view, FNSD is more vague but more accurate, as some FNSD (or DNSD) is neither dissociative, nor a conversion symptom. ICD-​11’s DNSD now account for 15 of the 22 specific dissociative disorders, and committing itself to interpreting as dissociative all that had formerly been called conversion, psychogenic, pseudoneurological or functional.

DSM-​I: Conversion Reaction DSM-​I (1952) hypothesizes an impulse causing anxiety to be ‘converted’ into functional symptoms under voluntary control, instead of being experienced consciously. That “symptoms serve to lessen conscious (felt) anxiety” implies primary gain, while “[symptoms] ordinarily are symbolic of the underlying mental conflict” reflects a psychoanalytic interpretation of how a conversion symptom may simultaneously hide and betray a covert conflict. Specific symptoms are sensory, motor, or dyskinetic. Psychogenic stupor/​coma and seizures are not mentioned.

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DSM-​II/​ICD-​9: 300.1 Hysterical Neurosis, Conversion Type The text for DSM-​II/​ICD-​9’s Hysterical neurosis, conversion type is something of a downgrade from the DSM-​I depiction. Symptoms are sensory or voluntary motor/​dyskinetic; there is often la belle indifférence; secondary gain is also highlighted. Psychogenic stupor/​coma and seizures still aren’t referenced.

DSM-​III/​III-​R: 300.11 Conversion Disorder As noted, DSM-​III (1980) renames Hysterical Neurosis, conversion type as Conversion Disorder and subsumes it under its new grouping, Somatoform Disorders. DSM-​III diagnostic criteria call for “…loss of or alteration in physical functioning suggesting a physical disorder”; Psychological factors are judged to be etiologically involved in the symptom [because of ] … an environmental stimulus that is apparently related to a psychological conflict or need … [or] the symptom enables the individual to avoid some activity that is noxious to him or her … [or] the symptom enables the individual to get support from the environment that otherwise might not be forthcoming” (p. 247). In brief, the symptoms are not physical, but psychogenic, and express a psychological conflict or need (correctly discussed in the text as primary gain), or are generated for the purpose of secondary gain. La belle indifférence is cited, though minimized as probative. The text allows for the usual sensory, motor and dyskinetic symptoms, but seizures are added; some autonomic or endocrine or visceral symptoms are permitted (e.g., some vomiting, pseudocyesis). Stupor/​coma remains neglected. Psychogenic Pain Disorder and Psychosexual Dysfunctions are excluded. DSM-​III-​R (1987) diagnostic criteria maintain the primary gain clause and drop the secondary gain clauses; they add that “the symptom is not a culturally sanctioned response pattern.”

ICD-​10: F44 –​Dissociative [Conversion] Disorders ICD-​10 (1992) essentially relabels Hysterical Neurosis, dissociative and conversion types, as Dissociative [conversion] disorders, maintaining both words, but subordinating conversion to dissociation. The specific ICD-​10 disorders that are more ‘conversion’ than ‘dissociation’: stupor; motor disorders; convulsions; anæsthesia and sensory loss.

DSM-​IV/​IV-​TR: 300.11 –​Conversion Disorder and DDNOS-​5 DSM-​I V/​I V-​TR (1994/​2000) diagnostic criteria are identical, and with only minor edits to those of DSM-​III. ICD-​10’s four specific diagnoses are somewhat reproduced in the Specifier which provides for four types: With Motor Symptom or Deficit; With Sensory Symptom or Deficit; With Seizures or Convulsions; With Mixed Presentation. ICD-​10’s dissociative stupor seems to be missing, but in fact can be found as an abandoned remnant of conversion’s former link to dissociation, as DDNOS-​5: “Loss of consciousness, stupor or coma not attributable to a general medical condition.” It is perplexing that this condition failed to successfully migrate to the somatoform-​conversion disorders. Meanwhile, under Somatoform Disorders NOS, SDNOS-​1 is Pseudocyesis –​hysterical pregnancy. This would be a good example of a psychogenic neuroendocrine condition clearly related to a psychological conflict or deficit or desire, which crosses the ‘voluntary nervous system’ line of demarcation, and is consequently difficult to classify.

DSM-​5: F44.4-​7 –​Conversion Disorder (Functional Neurological Symptom Disorder) The title is interesting in that earlier versions of the DSM would put the prior label in parentheses, whereas here it appears that the future label is in parentheses. Since the demise of hysteria, conversion is likely the next to go. ICD-​11 has already eliminated it. DSM-​5 (2013) is able to attach a number of ICD-​10 codes to its specifiers, which have increased in number, so that now there are F44.4 –​with weakness or paralysis; with abnormal movement; with swallowing symptoms; with speech symptoms; F44.5 –​with attacks or seizures; F44.6 –​with anesthesia or sensory loss; with special sensory symptoms; F44.7 –​with mixed symptoms. Dissociative stupor remains conspicuously absent, and DSM-​IV’s DDNOS-​5: “Loss of consciousness, stupor or coma…” which might have become DSM-​5’s OSDD-​6 (as per p. 292), is lost in the shuffle.

ICD-​11: 6B60 –​Dissociative Neurological Symptom Disorder ICD-​11 (2022) completes the process of consolidating everything under the ‘dissociative’ label with this renaming of ‘conversion disorder.’ Its description is interesting, in that it now includes “motor, sensory, or cognitive symptoms that

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imply an involuntary discontinuity in the normal integration of motor, sensory, or cognitive functions” –​the word ‘cognitive’ is new to the formulation, and may seem out of place, being more ‘psychoform’ than ‘somatoform.’ The 15 specific DNSDs include four for sensory symptoms; one each for non-​epileptic seizures, speech disturbance, paresis, and gait disturbance; six specific movement disturbances; and one with cognitive symptoms. The latter is for “impaired cognitive performance in memory, language or other cognitive domains that is internally inconsistent and not consistent with … etc.” I imagine that the border between this diagnosis and dissociative amnesia would be a challenge to formulate. The key words may be “internally inconsistent.”

Concluding Comment Whether a (pseudo-​)neurological symptom be called hysterical, psychogenic, functional or dissociative doesn’t matter to neurologists, as long as it justifies referring the case to psychiatry: whatever it is, it’s definitely non-​neurological –​unless some patient subsequently proves to have some neurological condition after all. Within psychiatry, however, the diagnostic challenge is just beginning. Psychiatrically-​speaking, each presentation of dissociative amnesia, DP/​DR or F/​DNSD prompts the following questions: 1. does the symptom originate in the apparent patient before me, or is it an intrusion from or withdrawal by another self state? Is there any dissociative multiplicity present? 2. if from another self state, is it inadvertent or motivated? Is it a ‘spillover’ from that state, or a willful intrusion, an attempt by that state to get our attention, or to punish? 3. is the symptom itself, whatever the source, a tactile or sensorimotor posttraumatic flashback? –​these are common, as in PTSD Criterion B. 4. is the symptom, whatever the source, the somatic expression of a psychological conflict or repressed (forbidden) impulse? –​these are less common, in my clinical experience, but would also be the original meaning of ‘conversion’ –​ no other expression really warrants the word ‘conversion.’ The questioning can go on from there, but these are good starting points, and go well beyond DSM-​5 or ICD-​11, requiring not only neurological, but also psychiatric, diagnostic competence.

5.  Remaining Kinds of Dissociation Dissociative Trance Disorder ‘Trance’ doesn’t appear in any DSM or ICD prior to 1980. DSM-​III (1980) cites “trance-​like states” in its Atypical Dissociative Disorder paragraph. DSM-​III-​R (1987) designates trance states as its DDNOS-​3. ICD-​10 (1992) promotes trance to its own formal diagnosis: F44.3 –​Trance and possession disorders, involving a temporary loss of personal identity, “as if taken over by another personality, spirit, deity, or ‘force’ ” (p. 156) and narrowed awareness of surroundings, often with limited and repeated movements, postures, and utterances. Excluded are voluntary trance states, including those that are part of religious or cultural rituals. DSM-​I V/​I V-​T R (1994/​2 000) designate trance states as their DDNOS-​4, but there is also a full text with ‘research criteria’ for Dissociative Trance Disorder in Appendix B. This seemed a step toward promoting Dissociative Trance Disorder to its own full diagnosis, following ICD-​10’s lead, but DSM-​5 disappointed. The condition calls for single or episodic disturbances in consciousness, identity, or memory indigenous to particular locations and cultures, with narrowing of awareness of surroundings, or subjectively involuntary stereotypic behaviors or movements. Alternatively, possession trance involves replacement of one’s personal identity by a new one, attributed to a spirit, power, deity, or other person, with stereotypic behaviors or movements which may be culturally determined, but are not accepted as part of normal cultural or religious practice. Named examples are given, together with their geographic regions. DSM-​5 (2013) demotes ‘Dissociative trance’: while continuing to designate it as its OSDD-​4, with an abbreviated description, it no longer appears in Appendix B. On the other hand, DSM-​5’s DID Criterion A allows for “disruption of identity … which may be described in some cultures as an experience of possession” (p. 307), absorbing one component of trance disorder into DID itself, and perhaps justifying its abolition as a potential diagnosis in its own right. ICD-​11 (2022) separates out ICD-​10’s Trance and possession disorders into two specific disorders: 6B62 –​Trance disorder, and 6B63 –​Possession trance disorder. Following the usual description, in Trance disorder there is no experience of being replaced by an alternate identity, whereas in Possession trance disorder, one’s customary identity is replaced by a ‘possessing’ identity who is experienced as controlling behavior or movement.

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Ganser’s Syndrome Ganser’s syndrome is the giving of “approximate answers” to questions. DSM-​III (1980) cites it as an instance of 300.16 Factitious Disorder with Psychological Symptoms. DSM-​III-​R (1987) ‘redeems’ it by listing it as DDNOS-​1. ICD-​10 (1992) promotes it to a specific full diagnosis: F44.80 Ganser’s syndrome. DSM-​I V/​I V-​TR (1994/​2000) demotes it by listing it as DDNOS-​6. DSM-​5 (2013) demonstrates ambivalence: on p. 292, it is the last of the seven examples of OSDD; on p. 306, OSDD has just four examples, and Ganser’s is not one of them. Ganser’s demise parallels that of Dissociative loss of consciousness, stupor, or coma (see DDNOS-​5 above under DSM-​I V/​TR Conversion Disorder). ICD-​11 (2022) also fails to mention Ganser’s syndrome, mirroring DSM-​5’s omission. And so Ganser’s syndrome no longer officially exists, either through intent or editing accident.

OSDD-​2: Brainwashing, Thought Reform, and Indoctrination DSM-​III (1980), in its Atypical Dissociative Disorder paragraph, cites “people who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought reform, and indoctrination while the captive of terrorists or cultists” (p. 260). DSM-​III-​R (1987) promotes this to its DDNOS-​5. DSM-​I V/​I V-​TR (1994/​2000) lists it as their DDNOS-​3. DSM-​5 (2013) lists it as its OSDD-​2. It doesn’t appear in ICD-​10-​11.

OSDD-​3: Acute Dissociative Reactions to Stressful Events In my opinion, this entity is misplaced, and constitutes a variant of Acute Stress Disorder. In any case, according to the DSM-​5 text (p. 292), it was originally to have been two OSDDs, the second one with the added complication of psychotic symptoms. But when you arrive on p. 306, that second acute dissociative reaction is missing, as are Ganser’s and Loss of consciousness, stupor or coma, which have somehow ‘evaporated.’

Dissociation Beyond the Dissociative Disorders Apart from sections devoted to dissociative disorders themselves, where else in the current ICD and DSM does dissociation appear? The ICD-​11 is simple: outside of the dissociative disorders, ‘dissociation’ occurs only once, in the description of the borderline pattern of personality traits: “Transient dissociative symptoms or psychotic-​like features in situations of high affective arousal.” Being a rewording of DSM-​I V’s Criterion 9 for BPD, there is nothing new here. DSM-​5 is more interesting, though with some incoherence.

Trauma-​and Stressor-​Related Disorders These disorders are the most directly linked to dissociation. PTSD Criterion B equates flashbacks with ‘dissociative reactions’; Criterion D refers to ‘dissociative amnesia,’ but upon arriving at the Specify whether –​With Dissociative symptoms, we are limited to depersonalization and derealization; dissociative flashbacks and amnesia, even if present, no longer count as dissociative. In short, a patient may have dissociative flashbacks and dissociative amnesia and simultaneously be without dissociative symptoms. In brief, DSM-​5 PTSD diagnostic criteria contradict themselves regarding what is dissociative. It would appear that the Trauma-​and Stressor-​Related Disorders Work Group never came to a consensus about what dissociation is, and what it is not.

Personality Disorders These are also interesting. DSM-​IV (following ICD-​10’s lead) introduced six General diagnostic criteria for a personality disorder (p. 633) that most clinicians and researchers routinely ignore. DSM-​IV also added Criterion 9 to the polythetic criteria for Borderline Personality Disorder (of which someone with BPD must have at least five of the nine): “transient, stress-​related paranoid ideation or severe dissociative symptoms” –​the text that ICD-​11 rewords. The expanded text provides a single example of a severe dissociative symptom: depersonalization. One might well wonder, especially given the very high level of misdiagnosis of cases of DID as BPD, what the Personality Disorders chapter of the DSM as a whole thinks about the other kinds of dissociation: dissociative amnesia, dissociative multiplicity, functional dissociation, etc. It doesn’t think about them at all. There is no other reference to dissociation in the entire PD section. This brings us back to General diagnostic criteria. These require a single enduring pattern of inner experience and behavior which is inflexible and pervasive, stable and of long duration. However, no patient with DID has any single pattern which is inflexible, pervasive, stable, and of long duration. Consequently, anyone with DID, according to these criteria, cannot simultaneously have any personality disorder. This

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state of affairs is anomalous, given the fact that most patients with DID have self states, or alters, which manifest sometimes exaggerated personality disorder traits, and commonly these different self states have dramatically contrasting personality traits. The Alternative DSM-​5 Model for Personality Disorders (p. 761) provides no remedy. One Criterion for BPD involves Identity, which includes “dissociative states under stress,” but this is strictly limited to identity diffusion. Identity alteration is not mentioned. Dissociation is also listed as an expression of psychoticism (p. 770). While the General Criteria now require impairments in personality functioning which are now only relatively inflexible and pervasive, and relatively stable across time, there is still no possibility of accommodating DID/​OSDD-​1/​PDID.

Differential Diagnosis in DSM-​5 This topic concerns a central issue regarding the coherence of the DSM-​5 as a whole. In assessing a patient, you may well have an initial diagnostic impression, but then you consider the differential diagnosis: the diagnoses suggested by some sign, symptom or finding. You then evaluate the case further to rule out some of these options, so as to narrow down the diagnosis and eventually arrive at a final diagnosis. It is tacitly (and logically) understood that if condition-​B is in the standard Differential Diagnosis for condition-​ A, then condition-​A would be in the standard Differential Diagnosis for condition-​B. It is interesting to see to what extent the DSM-​5 as a whole satisfies this tacit (and logically compelling) assumption. For example, diagnoses within Schizophrenia Spectrum and Other Psychotic Disorders, those within Bipolar and Related Disorders, and those within Depressive Disorders routinely list each other in their differential diagnosis sections, as would be expected. It would also be expected, then, that diagnoses listed in the differential diagnosis sections of Dissociative Disorders (DDs) would routinely list those dissociative disorders in their own differential diagnosis sections. We would expect this to occur especially with those diagnoses which traditionally tend to cluster with DDs historically, etiologically, or symptomatically, for example, FNSD; stress-​related disorders (ASD, PTSD); and personality disorders, especially BPD. Differential diagnosis for DID runs close to two full pages. The following are discussed: OSDD-​1, major depressive disorder, bipolar disorders (especially bipolar II), PTSD, psychotic disorders, substance/​medication-​induced disorders, personality disorders, FNSD, seizure disorders, factitious disorder, and malingering. Criterion D for Dissociative Amnesia specifically states, “not better explained by DID, PTSD, ASD, Somatic Symptom Disorder, or major or mild Neurocognitive Disorder” (p. 298). Its differential diagnosis text adds substance-​related disorders, posttraumatic amnesia due to brain injury, seizure disorders, catatonic stupor, factitious disorder, malingering, and normal and age-​related changes in memory. Criterion E for Depersonalization/​Derealization Disorder (DP/​DRD) specifically states “not better explained by … schizophrenia, panic disorder, major depressive disorder, ASD, PTSD, or another dissociative disorder” (p. 302). Its differential diagnosis text adds illness anxiety disorder, obsessive-​compulsive disorder, and anxiety disorders. So the following disorders are listed by dissociative disorders among its differential diagnoses: psychotic disorders, schizophrenia, catatonic stupor, bipolar disorders (especially bipolar II), major depressive disorder, anxiety disorders, panic disorder, obsessive-​compulsive disorder, PTSD, ASD, illness anxiety disorder, somatic symptom disorder, FNSD, substance/​medication-​induced disorders, personality disorders, neurocognitive disorder, normal and age-​related changes in memory, posttraumatic amnesia due to brain injury, seizure disorder, factitious disorder, and malingering. Conditions which appear in the differential diagnosis for these DDs ought to include those DDs in their own differential diagnosis. Anything else would indicate deficient editing of the DSM-​5 as a whole. So which of these diagnoses successfully list DDs in their Differential Diagnosis sections? Not surprisingly, Trauma-​and Stressor-​Related disorders and Somatic Symptom and Related Disorders rise to the challenge. Differential diagnosis for PTSD discusses all three major dissociative disorders; differential diagnosis for ASD discusses all but DID; FNSD states that dissociative symptoms are common, and so comorbid DDs are likely. No other diagnosis discusses a dissociative disorder. Consequently, the following diagnoses erroneously fail to mention dissociative disorders in their exclusion criteria or differential diagnosis sections, or both: psychotic disorders, schizophrenia, catatonic stupor, bipolar disorders (especially bipolar II), major depressive disorder, anxiety disorders, panic disorder, obsessive-​compulsive disorder, substance/​medication-​induced disorders, personality disorders, neurocognitive disorder, normal and age-​related changes in memory, posttraumatic amnesia due to brain injury, seizure disorder, factitious disorder, and malingering. This glaring incongruity guarantees that all those diagnoses, by erroneously failing to list dissociative disorders in their differential diagnosis, generate a certain degree of false positives for all those diagnoses. This implies a comparable degree of false negatives for dissociative disorders. There is no exit from this damning conclusion.

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‘Thumbnail’ Summary Prior to the Nosologies ‘Hysteria’ dates from ancient times. ‘Neurosis’ dates from the eighteenth century. Labels were extremely varied in the nineteenth century (see Van der Hart & Dorahy, Chapter 1, this volume), especially for MPD/​DID. Bertillon (1899; see American Public Health Association, 1899) listed hysteria, amnesia, paramnesia, and somnambulism.

ICD-​I-​5 (1900–​1938): Hysteria appears only in ICD-​2 -​3, where it is grouped with frankly neurological conditions (neuritis, neuralgia, sciatica).

DSM-​I (1952): Most diagnoses are ‘reactions,’ giving it the allure of a pan-​posttraumatic nosology. Dissociative reaction includes depersonalization and dissociated personality. The word hysteria is not used. There is no Hysterical PD.

DSM-​II /​ ICD-​7-​9 (1968): These coincide, though they are much closer to the ICD tradition than to DSM-​I. Hysteria is a central concept. Neuroses include Hysterical Neurosis and Depersonalization Neurosis. Hysterical Neurosis divides into ‘dissociative type’ (which lists multiple personality as an example) and ‘conversion type.’ One of the personality disorders is ‘Hysterical PD.’

DSM-​III/​III-​R (1980; 1987): A major departure from DSM-​II and ICD-​7-​9, with the introduction of the 5 Axes, and of ‘Operational Diagnostic Criteria.’ New categories of disorder are created: Anxiety, Somatoform, Dissociative, Psychosexual, Factitious, etc. ‘Neurosis’ and ‘hysteria’ are eliminated. ‘Hysterical Neurosis, dissociative type,’ and ‘Depersonalization Neurosis’ combine under a new heading, ‘Dissociative Disorders’ (one of which is MPD), while ‘Hysterical Neurosis, conversion type,’ becomes one of the newly-​m inted ‘Somatoform Disorders.’ ‘Hysterical PD’ is rebranded ‘Histrionic PD.’ DSM-​III-​R (1987) introduces ‘Specify if…’ and ‘NOS.’

ICD-​10 (1992): Entirely new coding allows for more possible disorders. ‘NOS’ expands to ‘OS’ and ‘US.’ The ‘Green Book’ of ‘Diagnostic criteria for research’ is modeled after the diagnostic criteria of DSM-​III. ‘Neurosis’ is expanded to ‘Neurotic, stress-​related and somatoform disorders.’ OCD is removed from Anxiety Disorders and elevated to its own category. ‘Reaction to severe stress, and adjustment disorders,’ removes ASD and PTSD from the Anxiety Disorders, and joins them with Adjustment Disorders. ‘Dissociative [conversion] disorders’ maintains the link between dissociation and conversion; ‘Depersonalization-​derealization syndrome’ remains apart as an ‘Other neurotic disorder.’

DSM-​IV/​IV-​TR (1994; 2000): MPD becomes DID. No ICD-​10 innovation is adopted.

DSM-​5 (2013): Belated adoption of many ICD-​10 innovations: replacing NOS by OS and US; elevation of OCD to its own category; grouping of PTSD and ASD with Adjustment Disorders; eventual adoption of ICD-​10 codes. The five Axes are eliminated. Conversion Disorder is also named Functional Neurological Symptom Disorder.

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ICD-​11 (2022): Another entirely new coding allows for an enormous increase in possible specific codes for disorders. DP/​DRD is finally recognized as a dissociative disorder. Partial DID and Complex PTSD are created as specific disorders (and not as mere examples of an OS diagnosis). Conversion disorder becomes Dissociative neurological symptom disorder, with an enormously expanded list of specific diagnoses.

Discussion The ICDs and DSMs remain scientific (and cultural/​political) works in progress –​the ICDs for extraordinary global breadth, and the DSMs for narrow psychiatric depth. The ICD-​DSM interchange over the decades reminds us that the major players in this drama are culture, finance, and science –​ultimately politics. As for the huge majority of scientific literature, the most current ICD or DSM will always be out of date, while at the same time performing the onerous task of officially “raising the lowest common denominator” as regards diagnosis, and sanctioning a likely current best common language for the conditions involved –​tidying up the past more than charting the future, in order to keep it clear for further advance. There are more sinister interpretations (e.g., Horwitz, 2021) but that would be another chapter entirely. Dissociation is an especially thorny issue because there is no general agreement about what it means. Historically, it arose in relation to nineteenth-​century associationism, and to that extent is a misnomer, just as hypnosis is, relative to sleep. ICD regards DNSD as dissociative, whereas DSM regards FNSD as somatoform. ICD is only now agreeing to DP/​DRD being dissociative, whereas DSM first regarded it as dissociative in 1952. DSM-​5 PTSD contradicts itself within its own diagnostic criteria. And so on. We might believe that ICD finally caving to DSM regarding DP/​DRD being dissociative is the end of it, but then recent research (Holmes et al., 2015; Butler et al., 2019) divides dissociation into two kinds: detachment and compartmentalization. Detachment pertains especially to depersonalization. Compartmentalization pertains especially to amnesia, sensorimotor dissociation, and multiplicity. This distinction is identical to the DSM-​II/​ICD-​7-​9 divide between Depersonalization and Hysterical Neuroses. In this regard, ‘compartmentalization’ is simply what used to be called ‘hysteria.’ In my view, the question of dissociative multiplicity is equally fundamental. I am in sympathy with the Theory of Structural Dissociation of the Personality (TSDP; e.g., Van der Hart et al., 2006) which makes a clear divide between dissociative multiplicity and alterations in the field and level of consciousness. As a follow up to my prior comments, a given patient may have putative dissociative symptoms such as DP/​DR, amnesia, or sensorimotor dissociation; but such a patient may also have dissociative identities who have separate sets of DP/​DR, amnesia, or sensorimotor symptoms, elevating multiplicity over DP/​DR, amnesia, and sensorimotor dissociation. TSDP regards depersonalization as frankly nondissociative (in agreement with the ‘compartmentalists’), and only dissociative multiplicity truly dissociative, in welcome resonance with my prior comment. But then TSDP runs into difficulty with amnesia and sensorimotor dissociation: TSDP regards these as truly dissociative only if occurring in the context of dissociative multiplicity. But then, what does one do with amnesia and sensorimotor dissociation in a nonmultiple? And so debate continues. Future ICDs and DSMs cannot be expected to lead the way –​that is not their function, nor can it be, but their treatment of dissociation will continue to document some latest “official expert opinion” regarding dissociation and the dissociative disorders. In the meantime, efforts ought to be made to remove blatant contradictions and deficits from the DSM regarding what dissociation is, and especially regarding differential diagnosis. Other questions remain open. Will depersonalization remain dissociative? Will dissociative multiplicity be promoted to a group category? Will the varied etiologies of sensorimotor dissociation lead to diagnostic distinctions? I think it fitting to conclude this chapter with these questions.

Notes 1 Nosology, from νόσος (nosos), disease, and λογος (logos), word, account. 2 E.g. This arises immediately through definitional circularity even for utterly basic measurements such as length and temperature: you need to specify temperature to reliably measure length (temperature affects the length of the measuring rod), and to specify length to reliably measure temperature (e.g. the height of the column of mercury in the thermometer) –​see Popper (1963, p. 62). ‘Length’ is especially important, as its ‘nonoperationality’ compromises the ‘operational definitional integrity’ of every graph purportedly displaying data regarding whatever.

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3 According to an editorial in the British Journal of Psychiatry (Turner, 2003, although see also Cooper & Blashfield, 2018), Bridgman’s proposal came to psychology, and to DSM-​III, via Carl Gustav Hempel’s Fundamentals of Taxomony (1959) regarding mental disorders, where Hempel, discussing conversion disorder, allows for theoretically assumed psychodynamic factors having meaning only in the context of psychodynamic theory. The DSM committee set aside this implied support for psychodynamic theory and instead attempted to limit itself to ‘theory-​independent observables’ and reject theory-​dependent interpretables. 4 And this may have contributed to the demise of ‘Dissociative Trance Disorder’ –​see below. 5 Corrected from the ‘official’ but lamentably oxymoronic F44.89, which simultaneously signals ‘other specified’ (8) and ‘unspecified’ (9).

References American Psychiatric Association (1952). DSM-​I –​Diagnostic and Statistical Manual –​Mental Disorders. Washington DC: Author. American Psychiatric Association (1968). DSM-​II –​Diagnostic and Statistical Manual of Mental Disorders, Second edition. Washington, DC: Author. American Psychiatric Association (1980). DSM-​III –​Diagnostic and Statistical Manual of Mental Disorders, Third edition. Washington, DC: Author. American Psychiatric Association (1987). DSM-​III-​R –​Diagnostic and Statistical Manual of Mental Disorders, Third edition, Revised. Washington, DC: Author. American Psychiatric Association (1994). DSM-​I V –​Diagnostic and Statistical Manual of Mental Disorders, Fourth edition. Washington, DC: Author. American Psychiatric Association (2000). DSM-​IV-​T R –​Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: Author. American Psychiatric Association (2013). DSM-​5 –​Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: Author. American Public Health Association (1899). The Bertillon Classification of Causes of Death. Lansing: Robert Smith Printing Co. https://​i iif.lib.harv​a rd.edu/​m anife​sts/​v iew/​d rs:6736​548$1i Bertillon, J. (1920) International list of causes of death. The Lancet, 196(5068), P807. Bridgman, P. W. (1927). The logic of modern physics. New York: Macmillan. Butler, C., Dorahy, M. J., Middleton, W. (2019). The Detachment and Compartmentalization Inventory (DCI): An assessment tool for two potentially distinct forms of dissociation. Journal of Trauma & Dissociation, 20, 526–​547. Cooper, R., & Blashfield, R. (2018). The myth of Hempel and the DSM-​III. Studies in History and Philosophy of Biological and Biomedical Sciences, 70, 10–​19. Hempel, C. G. (1959). Fundamentals of taxonomy. In C. G. Hempel (Ed.), Aspects of scientific explanation & other essays in the philosophy of science (pp. 137–​154). New York: The Free Press. Holmes, E., Brown, R., et al. (2005). Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical Psychology Review, 25, 1–​23. Horwitz, A. V. (2021). DSM –​A History of Psychiatry’s Bible. Baltimore, MD: John Hopkins University Press. ICD-​1. (1900). International List of Causes of Death. Johnson, J. G., Cohen, P., Kasen, S., Brook, J. S. (2006). Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. Journal of Psychiatric Research, 40, 131–​140. Moriyama, I. M., Loy, R. M., Robb-​Smith, A. H. T., edited and updated by H. M. Rosenberg & D. L. Hoyert. (2011). History of the statistical classification of diseases and causes of death. Hyattsville MD: National Center for Health Statistics. Popper, K. R. (1963). Conjectures and refutations: the growth of scientific knowledge. New York: Basic Books. Turner, M. A. (2003). Psychiatry and the human sciences. British Journal of Psychiatry, 182, 472–​474. World Health Organization (1948). ICD-​6 –​Manual of the International Statistical Classification of Diseases, injuries, and Causes of Death –​Sixth Revision. Geneva: author. World Health Organization. (1957). International classification of diseases –​7th Revision. Geneva: WHO. World Health Organization. (1965). International classification of diseases –​8th Revision. Geneva: WHO. World Health Organization. (1979). International classification of disease –​9th Revision. Geneva: WHO. World Health Organization (1992). ICD-​10 –​The ICD-​10 Classification of Mental and Behavioural Disorders –​Clinical descriptions and diagnostic guidelines [“Blue Book”]. Geneva: author. World Health Organization (1993). ICD-​10 –​The ICD-​10 Classification of Mental and Behavioural Disorders –​Diagnostic criteria for research [“Green Book”]. Geneva: author. World Health Organization (2019/​2022). ICD-​11 –​The International Classification of Diseases, Eleventh Revision. Geneva: author. See: https://​icd.who.int/​brows​e11/​l-​m /​en; also see https://​icd.who.int/​dev11/​l-​m /​en Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York, NY: Norton.

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22 DISSOCIATIVE AMNESIA AND DISSOCIATIVE FUGUE Colin A. Ross

Compared to the large literature on dissociative identity disorder (DID), the literature on dissociative amnesia and dissociative fugue is sparse. What does exist has been reviewed by Coons (1999; 2000), Ford (1989), Kenny (1986), Kilhstrom, Tataryn and Hoyt (1984) Brandt and Van Gorp (2006) and Loewenstein (1991; 1993; 1995; 1996). More recent reviews include those by Loewenstein and Putnam (2004), Spiegel, Loewenstein, Lewis-​Fernandez, et al. (2011), Wolf and Nochakski (2013), Markowitsch and Staniliou (2013; 2016), Thomas-​A nterion (2017), Harrison, Johnston, Corno, et al. (2017), Yoshimasu, Yasuda and Kurihara (2018) and Langer (2019). Occasional cases of dissociative fugue have been published since 1990 (MacDonald & MacDonald, 2009; Ross, 1994; Ross & Howley, 2003) but these are very rare, much like the disorder itself. In clinical practice, dissociative amnesia is rarely seen as a separate disorder but it does occur commonly as a component of other disorders such as posttraumatic stress disorder (PTSD) and DID. Dissociative symptoms, including amnesia, can occur across the entire domain of psychopathology, for instance, during a psychotic episode, mood disorder, anxiety disorder, eating disorder or substance abuse disorder. Dissociative symptoms are included among the diagnostic criteria for acute stress disorder, PTSD, somatic symptom disorder, borderline personality disorder, schizotypal personality disorder, and, of course, the dissociative disorders. Although dissociative amnesia and dissociative fugue can occur as a circumscribed disorder, both are most commonly seen as a part of a more complex dissociative disorder, especially DID and other specified dissociative disorder (OSDD). The clinical case literatures on dissociative amnesia and dissociative fugue overlap and are comprised mostly of papers that are half a century old (Abeles & Schilder, 1935; Akhtar and Brenner, 1979; Berrington, Liddell & Foulds, 1956; Fisher, 1945; 1947; Fisher & Joseph, 1949; Stengel & Vienna, 1941). Given the small volume and slow evolution of these literatures, there are no data-​based reasons to modify the DSM-​5 (American Psychiatric Association, 2013) diagnostic criteria for amnesia and fugue (but see discussion of changes made in DSM-​5 below). There are some problematic issues, however, that may warrant modification of the next DSM text about dissociative amnesia and dissociative fugue. For a skeptical viewpoint on the existence of dissociative amnesia, the reader is referred to Otgaar, Howe, Patihis, et al. (2019), who proffer the same arguments and opinions they have been expressing since the 1990s. Dalenberg et al. (2020) provide a review with supporting empirical evidence for dissociative amnesia; for a classic paper documenting amnesia in adulthood for verified childhood sexual abuse, see Williams (1994).

Definitions of Dissociation, Dissociative Amnesia and Dissociative Fugue There are four meanings of the word dissociation (Ross, 1999; 2000) referring to four different but to some degree overlapping phenomena. First, there is a general systems meaning of dissociation: the opposite of association, a disconnection or lack of interaction between two variables. There are dissociation constants in physical chemistry, for instance. Second, dissociation is a technical term in experimental cognitive psychology. In cognitive psychology, dissociation is often a normal property of cognitive functioning. For example, countless studies have demonstrated the dissociation between procedural and declarative memory (Cohen & Eichenbaum, 1993). Such dissociation is normal in that it does not entail any special operations or exceptional properties of the mind. Third, dissociation is a phenomenological term in clinical psychology and psychiatry that has been operationalized by various measures. In this sense, dissociation is what is measured by the items on questionnaires and structured interviews assessing dissociative experiences and symptoms, like the Dissociative

DOI: 10.4324/9781003057314-27

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Experiences Scale (DES; Bernstein and Putnam, 1986) and the Dissociative Disorders Interview Schedule (DDIS; Ross, 1997). Fourth, dissociation is an intrapsychic defense mechanism. Confusion arises when these different meanings of the word dissociation have not been specified. For instance, lack of experimental evidence for dissociation as an intrapsychic defense mechanism is not relevant to (1) the scientific status of dissociation in cognitive psychology, or (2) the psychometric properties, of measures of dissociation. In this chapter I will deal primarily with the phenomena of dissociation as operationalized by structured interviews and self-​report measures of dissociation. Approximately 10,000 individuals with dissociative disorders have been admitted to my Trauma Program in the Dallas, Texas area in the last 30 years. During this time, to the best of my recollection, I have encountered fewer than 10 individuals with pure dissociative amnesia or pure dissociative fugue. On the other hand, symptoms of amnesia and fugue were common in those 10,000 dissociative patients; they did not warrant a separate diagnosis because they were part of either OSDD or DID. This does not imply that dissociative amnesia as a separate disorder is rare in the general population, only that it does not require inpatient treatment. In DSM-​5, dissociative amnesia is defined as, “inability to recall important personal information, particularly of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness” (American Psychiatric Association, 2013, p. 298). The amnesia cannot be due to substances use or a medical condition and cannot be better understood as an element of another disorder. Dissociative fugue is a subtype of dissociative amnesia accompanied by “sudden unexpected travel away from your home or customary place of work, with inability to recall your past” and a positive response to the question, “During this period did you experience confusion about your identity or assume a partial or complete new identity?”

Problems with the DSM-​5 Rules for Dissociative Amnesia and Dissociative Fugue One of the problems with the DSM-​5 rules for dissociative amnesia and dissociative fugue is illustrated by a case example. In response to an accumulation of non-​catastrophic stressors, a man awoke one morning with complete amnesia for his past life. Subsequently, he gradually developed a new identity, but did not travel away from home. He therefore met DSM-​5 criteria for dissociative amnesia, however, the man had created a new identity, therefore he had more than a simple amnesia. I might have diagnosed dissociative fugue but, since he had not traveled, I could not do so. Given the options afforded by DSM-​5, I could render a diagnosis of OSDD, even though he would, in fact, be a classical case of fugue if he had traveled away from home. Placing him in the category of OSDD seems unsatisfactory but DSM-​5 does not offer another option. Since such cases are rare, this is likely more of a theoretical than a practical problem, however it does illustrate the difficulties of imposing distinct categorical diagnoses on nature. There are cases that do not fit into the DSM-​5 dissociative disorder categories very well. At present, these are mostly placed in OSDD or unspecified dissociative disorder (UDD), but UDD is an undefined residual category so does not provide much illumination of the patient. There is another problem with the DSM-​ 5 distinction between dissociative amnesia and dissociative fugue. Dissociative fugues typically resolve into dissociative amnesias; that is, these persons emerge from the fugue and regain both their memory and their identity –​but then they have amnesia for the period of fugue. It does not quite make sense to say that dissociative amnesia with travel resolves into dissociative amnesia for the period of travel. This sounds a bit like saying that dissociative amnesia goes away and becomes dissociative amnesia. This is an unresolved problem with the DSM-​5 terminology, and with its clinical description of the natural history of dissociative fugue. To further complicate matters, it is also possible to reconceptualize dissociative fugue as a variant of DID. I interviewed the case described above during the fugue episode. In other words, I was able to interview the person’s new identity. This identity did not differ from the alter personalities that occur in DID –​except that the identity had been created quite recently. The new “person” was like an alter personality that was characterized by (1) complete two-​way amnesia for the host personality and (2) a full-​blown delusion of separateness. He believed that the pre-​f ugue identity had a separate physical body. He was prepared to become physically violent with the pre-​fugue identity if it tried to come back and take over. Thus, the new identity exhibited the trance logic that is so typical of alter personalities in DID. From this perspective, some cases of dissociative fugue are an adult-​onset form of dual personality in which the “host personality” is suppressed (during the period of fugue), and then re-​emerges. If an “alter personality” was created during the period of fugue, it is suppressed after the host emerges from the fugue and resumes executive control. Clinicians and researchers have not yet addressed the question of whether a fugue “alter personality” continues to exist after the return of the host. Viewed in this way, amnesia for the period of fugue occurs because the original identity and the fugue identity have not been integrated. Integration would produce continuity of memory –​and also an integration of the hopes, dreams, attitudes and feelings that were not possessed by (i.e., were unavailable to) the original pre-​fugue personality (but which are part of the larger self ). Clinicians tend not to think this way because cases of fugue are rare and because

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they seldom encounter the case until the fugue is over. Consequently, clinicians very rarely have an opportunity to speak with the “alter personality” that existed during the fugue. The DSM-​6 Dissociative Disorders Committee should discuss (1) the degree of separateness between dissociative amnesia and dissociative fugue, (2) the possibility that fugue is a variant of DID, and (3) whether the core feature of fugue is travel, identity change or amnesia. In addition, the complex internal structure of fugue episodes should be more clearly delineated (Howley & Ross, 2003). A fugue is not an undifferentiated period of time; a fugue is divided into two sub-​stages, each with its own form of amnesia: (1) the stage of flight, and (2) the stage in the new location (that is characterized by amnesia for the period of flight). For now, in DSM-​5, there is no separate diagnosis of dissociative fugue; fugue is a subtype of dissociative amnesia. However, there are many remaining uncertainties about how the DSM-​5 classifies dissociative amnesia and fugue that require further study and research. The main problem with making progress in this regard is the rarity of fugue states, other than those occurring in OSDD and DID.

Problems with the DSM-​5 Rules for Other Specified Dissociative Disorder In earlier versions of the DSM (American Psychiatric Association, 1980), DDNOS was called atypical dissociative disorder. The NOS diagnosis in DSM-​I V still carried that connotation –​atypical –​as does the OSDD diagnosis in DSM-​5. Yet, OSDD is definitely not atypical, at least in terms of prevalence. In fact, OSDD/​DDNOS is usually found to be the most common dissociative disorder (Akyuz, Dogan, Sar, Yargic & Tutkun, 1999; Ross, 1991; 1997; Ross, Duffy, & Ellason, 2002). The DSM-​6 should find a better way to diagnose cases of OSDD. It doesn’t make sense that an ‘atypical’ dissociative disorder is the most common dissociative disorder. This problem was not solved by changing the terminology to DDNOS and then to OSDD.

Persons with Dissociative Amnesia do not Appear to be in the Dissociative Taxon I have carefully interviewed individuals with previously undiagnosed dissociative amnesia (Ross, Duffy & Ellason, 2002). These are the only cases of pure dissociative amnesia that I have encountered. Unlike persons with OSDD and DID, these individuals did not seem to be members of the dissociative taxon, a collection of eight items on the DES that assess pathological dissociation and are known as the DES-​T (Waller, Putnam & Carlson, 1996; Waller & Ross, 1997). These dissociative amnesia patients had low scores on the DES and were not experiencing part-​self intrusions (i.e., ongoing Schneiderian symptoms, amnesias, or depersonalization). They had experienced one to three past episodes of amnesia in response to specific events; the durations of these episodes of amnesia ranged from hours to a few days. These individuals constitute a type of dissociative disorder that is quite different from members of the dissociative taxon (such as persons with OSDD or DID). The DSM-​6 Dissociative Disorders Committee should consider whether the issue of taxon membership deserves comment in the DSM-​6 texts about dissociative amnesia and dissociative fugue. For more detailed discussion of the dissociative taxon as defined by the DES-​T see Ross (2021).

Severity of Trauma in Dissociative Amnesia and Dissociative Fugue I endorse the trauma model of pathological dissociation (Ross, 1994; 1997; 1999; 2000; 2004). Typically, however, the stressors that precede dissociative fugue and dissociative amnesia are milder, simpler, briefer, and less numerous than those that precede DID and OSDD. This conclusion, however, is based on limited clinical experience with dissociative amnesia and dissociative fugue; there are no large published case series of amnesia and fugue that comprehensively enumerate their trauma histories. The empirical literature on dissociative fugue emphasizes trauma during adulthood, especially military combat, but also frequently mentions traumatic and abusive childhoods (Howley & Ross, 2003). Similarly, the literature on dissociative amnesia emphasizes a single, antecedent event (or set of stressful circumstances). Future research should include a focus on characterizing the trauma that precedes dissociative amnesia and dissociative fugue.

Empirical Strengths and Weaknesses of Dissociative Fugue and Dissociative Amnesia The clinical literature on dissociative amnesia and dissociative fugue dates back to the nineteenth century (Langer, 2019; Ross, 1997; Ross & Howley, 2004). As described since then dissociative fugue often involves a more abrupt and radical dissociation of memory and identity than is typically the case in DID. Dissociative amnesia is a rigorously demonstrated phenomenon in cognitive psychology and is validated by the common experience of having something on the tip of

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your tongue for a period of time before remembering it. Everyone has had the experience of not being able to remember a name, details of an encounter or other information without repeated recall effort or a triggering cue. The major weakness of the empirical literature on fugue and amnesia is the lack of large modern case series that report psychometric data. In particular, we lack sufficient cases of dissociative fugue to study the similarities and differences between the amnesia in the two disorders, and the existence of dissociated identities in the two disorders.

Needed Research The reliability and validity of dissociative amnesia and dissociative fugue need to be demonstrated with modern measures of dissociation. Because cases of dissociative fugue are rare in the clinical and research caseloads of experts in dissociation, a registry of some sort would be beneficial. A central bank could accumulate data on a sizable series of fugue cases by sending self-​report measures to reporting clinicians. The central bank could also assist clinicians to administer structured diagnostic interviews to these cases. The International Society for the Study of Dissociation (ISSTD) would be the logical candidate to set up and administer this databank. ISSTD members could be requested to report fugue cases that they encounter in their practices, as well as cases reported in their local media. A sizable series of dissociative amnesia cases could be identified by screening clinical populations with the 12-​item Memory Problems Scale of the Multidimensional Inventory of Dissociation (MID). Respondents who scored above a cutoff would then be administered the DDIS (Ross, 1997), Structured Clinical Interview for DSM-​IV-​Dissociative Disorders (Steinberg, 1995) or a specially-​designed structured interview for dissociative amnesia. Such research should also assess comorbid disorders and antecedent stressors. Recent studies have involved case series of dissociative amnesia (Harrison, Johnston, Corno et al., 2017; Stanisliou, Markowitsch & Kordon, 2018). This is a welcome development but future studies should be based on standardized measures of dissociation and dissociative disorders, and involve larger numbers of cases. Future research should take account of Dell’s (2013) study using the MID, which identified three types of amnesia: discovering dissociated actions; lapses of recent memories and skills; and gaps in remote memory.

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References Abeles, M. & Schilder, P. (1935). Psychogenic loss of personal identity. Amnesia. Archives of Neurology and Psychiatry, 34, 587–​604. Akhtar, S., & Brenner, I. (1979). Differential diagnoses of fugue-​like states. Journal of Clinical Psychology, 40, 381–​385. Akyuz, G., Dogan, O., Sar, V., Yargic, I., & Tutkun, H. (1999). Frequency of dissociative identity disorder in the general population in Turkey. Comprehensive Psychiatry, 40, 151–​159. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders, third edition. Washington, DC: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: American Psychiatric Association. Berington, W. P., Liddell, D. W., & Foulds, G. A. (1956). A re-​evaluation of the fugue. Journal of Mental Science, 102, 280–​286. Bernstein, E. M., Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–​735. Brandt, J., & Van Gorp, W. G. (2006). Functional (“psychogenic”) amnesia. Seminars in Neurology, 26, 331–​340. Cohen, N. J. & Eichenbaum, H. (1993). Memory, amnesia, and the hippocampal system. Cambridge: MIT Press. Coons, P. M. (1999). Psychogenic or dissociative fugue: A clinical investigation of five cases. Psychological Reports, 84, 881–​886. Coons, P. M. (2000). Dissociative fugue. In B. J. Sadock & V. Sadock (Eds.), Comprehensive textbook of psychiatry (7th ed.) (pp. 1549–​ 1552). New York: Lippincott, Williams, & Wilkins. Dalenberg, C. J., Brand, B. L., Loewenstein, R. J., Frewen, P. A., & Spiegel, D. (2020). Inviting Scientific Discourse on Traumatic Dissociation: Progress Made and Obstacles to Further Resolution. Psychological Injury and Law, 13, 135–​154. Dell, P. F. (2013). Three dimensions of dissociative amnesia. Journal of Trauma and Dissociation, 14, 25–​39. Fisher, C. (1945). Amnestic states in war neuroses: The psychogenesis of fugues. Psychoanalytic Quarterly, 14, 437–​468. Fisher, C. (1947). The psychogenesis of fugue states. American Journal of Psychotherapy, 1, 211–​221. Fisher, C. & Joseph, E. D. (1949). Fugue with loss of personal identity. Psychoanalytic Quarterly, 18, 480–​493. Ford, C. V. (1989). Psychogenic fugue. In T. B. Karasu (Ed.), Treatments of psychiatric disorders, vol. 3 (pp 2190–​2196). Washington, DC: American Psychiatric Press. Harrison, N. A., Johnston, K., Corno, F., Casey, S. J., Friedner, K., Humphreys, K., Jaldow, E. J., Pitkanen, M., & Kopelman, M. D. (2017). Psychogenic amnesia: Syndromes, outcome, and patterns of retrograde amnesia. Brain, 140, 2498–​2510. Howley, J., & Ross, C. A. (2003). The structure of dissociative fugue: A case report. Journal of Trauma and Dissociation, 4, 109–​124. Kenny, M. G. (1986). The passion of Ansel Bourne. Washington, DC: Smithsonian Institution Press.

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Kihlstrom, J. F., Tataryn, D. J., & Hoyt, I. (1984). Dissociative disorders. In P. B. Sutker, & H. E. Adams (Eds.), Comprehensive handbook of psychopathology (pp. 203–​234). New York: Plenum Press. Langer, K. G. (2019). Early history of amnesia. Frontiers in Neurology and Neuroscience Research, 44, 64–​74. Loewenstein, R. J. (1991). Psychogenic amnesia and psychogenic fugue: a comprehensive review. In A. Tasman & S. M. Goldfinger (Eds.), American Psychiatric Press Review of Psychiatry (pp. 189–​221). Washington, DC: American Psychiatric Press. Loewenstein, R. J. (1993). Psychogenic amnesia and psychogenic fugue: A comprehensive review. In D. Spiegel (Ed.), Dissociative disorders, a clinical review (pp. 45–​77). Lutherville, MD: Sidran Press. Loewenstein, R. J. (1995). Dissociative amnesia and dissociative fugue. In G.O. Gabbard (Ed.), Treatments of psychiatric disorders, vol. 2 (pp. 1569–​1597). Washington, DC: American Psychiatric Press. Loewenstein, R. J. (1996). Dissociative amnesia and dissociative fugue. In L. K. Michelson, & W. J. Ray (Eds.), Handbook of dissociation: Theoretical, empirical and clinical perspectives (pp. 307–​336). New York: Plenum Press. Loewenstein, R. J., & Putnam, F. W. (2004). Dissociative disorders. In B. J. Sadock, & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (pp. 1844–​1901). Philadelphia, PA: Lippincott, Williams & Wilkins. MacDonald, K., & MacDonald, T. (2009). Peas, please: A case reports and neuroscientific review of dissociative amnesia and fugue. Journal of Trauma and Dissociation, 10, 420–​435. Markowitsch, H. J., & Staniliou, A. (2013). The impairment of recollection in functional amnesic states. Cortex, 49, 1494–​1510. Markowitsch, H. J., & Staniloiu, A. (2016). Functional (dissociative) retrograde amnesia. Handbook of Clinical Neurology, 139, 419–​455. Otgaar, H., Howe, M. L., Patihis, L., Merckelbach, H., Lynn, S. J., Lilienfeld, S. O., & Loftus, E. F. (2019). The return of the repressed: the persistent and problematic claims of long-​forgotten trauma. Perspectives on Psychological Science, 14, 1072–​1095. Ross, C. A. (1991). Epidemiology of multiple personality disorder and dissociation. Psychiatric Clinics of North America, 14, 503–​517. Ross, C. A. (1994). The Osiris Complex: Case studies in multiple personality disorder. Toronto, OT: University of Toronto Press. Ross, C. A. (1997). Dissociative identity disorder. Diagnosis, clinical features, and treatment of multiple personality. (2nd Ed.). New York: John Wiley & Sons. Ross, C. A. (1999). The dissociative disorders. In T. Million, P. P. Blaney, & R. Davis, (Eds.), Oxford textbook of psychopathology (pp. 466–​481). New York: Oxford University Press. Ross, C. A. (2000). The trauma model: A solution to the problem of comorbidity in psychiatry. Richardson, TX: Manitou Communications. Ross, C. A. (2004). Schizophrenia: Innovations in Diagnosis and Treatment. New York: Haworth Press. Ross, C. A. (2021). The dissociative taxon and dissociative identity disorder. Journal of Trauma and Dissociation, 22, 555–​562. Ross, C. A., Duffy, C. M. M., & Ellason, J. W. (2002). Prevalence, reliability and validity of dissociative disorders in an inpatient setting. Journal of Trauma and Dissociation, 3, 7–​17. Spiegel, D., Loewenstein, R. J., Lewis-​Fernandez, R., Sar, V., Simeon, D., Vermetten, E., Cardena, E., Brown, R. J., & Dell, P. F. (2011). Dissociative disorders in DSM-​5. Depression and Anxiety, 28, E17–​45. Staniliou, A., Markowitsch, J. J., & Kordon, A. (2018). Psychological causes of autobiographical amnesia: A study of 28 cases. Neuropsychologia, 110, 134–​147. Steinberg, M. (1995). Handbook for the assessment of dissociation. A clinical guide. Washington, DC: American Psychiatric Press. Stengel, E., & Vienna, M. D. (1941). On the aetiology of the fugue states. Journal of Mental Science, 87, 572–​599. Thomas-​A nterion, C. (2017). Dissociative amnesia: disproportionate retrograde amnesia, stressful experiences and neurological circumstances. Revue Neurologique, 173, 516–​520. Yoshimasu, H., Yasuda, T., & Kurihara, A. (2018). Psychogenic retrograde and anterograde amnesia. Journal of Brain and Nerve, 70, 803–​812. Waller, N. G., Putnam, F. W., & Carlson, E. B. (1996). The types of dissociation and dissociative types: A taxometric analysis of dissociative experiences. Psychological Methods, 1, 300–​321. Waller, N. G., & Ross, C. A. (1997). The prevalence and taxometric structure of pathological dissociation in the general population: Taxometric structure and behavior genetic findings. Journal of Abnormal Psychology, 106, 499–​510. Williams, L. M. (1994). Recall of childhood trauma: A prospective study of women’s memories of child sexual abuse. Journal of Consulting and Clinical Psychology, 67, 1167–​1176. Wolf, M. R., & Nochajski, T. (2013). Child abuse survivors with dissociative amnesia. Journal of Child Sexual Abuse, 22, 462–​480.

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23 DEPERSONALIZATION/​DEREALIZATION DISORDER Matthias Michal

The Symptoms of Depersonalization-​Derealization Disorder Depersonalization (DP) describes a disrupted integration of self-​perceptions with the sense of self so that individuals experiencing depersonalization are in a subjective state of feeling estranged, detached, or disconnected from their own being. The following are common descriptions of depersonalization experiences (Sierra & Berrios, 2000): feeling strange, as if not real or as if being cut off from the world; feeling as if parts of one’s own body do not belong to oneself; having the feeling of being a ‘detached observer’ of oneself, including the feeling of being outside of one’s body or watching oneself from a distance; perceiving the body as very light, as if floating on air; perceiving one’s own voice as remote and unreal; feeling detached from autobiographical memories as if not having been involved in them; not feeling any affection towards family or close friends; feeling as if not in charge of movements, as if moving automatically or like a robot; perceiving one’s own image in the mirror as strange and unreal; feeling the need to touch oneself to make sure that one’s body is real and exists; feeling disconnected from one’s own thoughts and feelings. Depersonalization is frequently accompanied by derealization (DR) –​a sense of unfamiliarity, alteration or detachment from one’s own surroundings, other people, and objects. The following are common descriptions of DR: seeing the surrounding as ‘flat’ or ‘lifeless’ as if looking at a picture; feeling detached from surroundings or perceiving them as unreal, as if there is a veil between the person and the outside world; impression that objects seem to look smaller or further away; experience of familiar places looking unfamiliar, as never seen before (Sierra & Berrios, 2000). Notably, all the above experiences are “as if ” experiences, meaning that an individual with DP/​DR has intact reality testing; this point is crucial to the differentiation from psychosis.

The Occurrence of DP/​DR Symptoms Depersonalization-​derealization disorder (DDD) is characterized by persistent symptoms of DP/​DR. However, DP/​ DR symptoms are among the diagnostic criteria of many mental disorders (e.g., anxiety disorders, posttraumatic stress disorder), or they may be related to neurological diseases (e.g., symptoms of seizures, concussion, sleep apnea) or are caused by drug intoxication or withdrawal (e.g., marijuana, hallucinogens, ketamine intoxication; benzodiazepine withdrawal). The symptoms may also occur in healthy people temporarily and briefly in reaction to substantial changes in the environment, jetlag, or even academic exam stress (Hunter, Charlton, & David, 2017; Jacobson, 1959; Schweden, Wolfradt, Jahnke, & Hoyer, 2018). In the alternative DSM-​5 model for personality disorders, DP/​DR represent perceptual dysregulation symptoms and belong to the trait domain of psychoticism versus lucidity (APA, 2013). DP/​DR are considered the most frequent symptoms after anxiety and depression in patients with mental disorders (Stewart, 1964). However, the symptoms are often overlooked because they are not the focus of systematic inquiry. In the general population, around 1 in 10 people endorse being impaired by these symptoms in the last six months (Michal, Wiltink, Subic-​Wrana, et al., 2009). A representative survey of students aged 12–​18 years found that 47% were bothered by DP/​DR symptoms at least once in the previous two weeks (Michal et al., 2015). A majority of mental health care outpatients and inpatients reveal, in response to specific questions, the occurrence of at least transient and mild

DOI: 10.4324/9781003057314-28

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symptoms of DP and DR over the last month (Hunter, Sierra, & David, 2004; Michal, Sann, Grabhorn, Overbeck, & Röder, 2005; Michal, Wiltink, Zwerenz, et al., 2009).

History of Depersonalization-​Derealization Disorder In 1845, more than 50 years before the terms depersonalization and derealization were introduced in psychiatry, the German psychiatrist Wilhelm Griesinger (1817–​1868) described in one of the first psychiatry textbooks the symptoms of DP and DR as features of melancholia in a chapter on anesthesia. Griesinger quoted a patient with the following words: “I see, I hear, I feel, but the objects no longer reach me, I cannot absorb the sensations, it is as if there is a wall between me and the outside world” (Griesinger, 1845, p. 67, translation M. Michal [MM]). Moreover, in a very contemporary fashion, Griesinger described the horrific consequences for the individual: “… the outside world, alive or inanimate, suddenly seems to us to have become cold and strange, it is as if our favorite objects no longer belong to us, and by no longer receiving a lively impression of anything, we find ourselves even more destined to be alienated from the world around us and to be isolated within” (Griesinger 1845, p. 68, translation MM). The first scientific case study of patients with DDD was published in 1873 by the Hungarian ear-​nose-​throat specialist Krishaber (1836–​1883). He described 38 patients with psychophysiological stress symptoms, like anxiety, fatigue, dizziness, and pervasive DP/​DR. Krishaber outlined the case of a 43-​year-​old army officer who suddenly developed a pervasive state of depersonalization and derealization that lasted several years: “… One day he suddenly felt a pulling pain in the heart area and had the feeling of being choked. He could hardly hold back his tears. From hour to hour, he got worse, it was as if something wanted to wrap itself around him and slide between him and the outside world. “It was like a barrier between me and the world.” When he spoke, his voice seemed strange to him, he recognized it but did not consider his voice as his own. He could not turn his attention to what he was told. Doubts about his existence grew in him. He no longer believed himself to be himself. At times he was even sure not to exist. At the same time, he had lost consciousness of the reality of the outside world and felt as if he had sunk into a deep dream.” cited by Störring, 1933, p. 463–​465, translation MM

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It is important to note that even today, many patients with DDD tend to assume an underlying physical cause initially (e.g., brain damage due to drug intoxication or a tumor, or an eye disease because of distorted vision). Therefore, many patients first consult an eye, ear-​nose-​throat (e.g., a physician like Krishaber), neurology, or internal medicine specialist before seeking help from a mental health care professional (Michal, 2021; Simeon & Abugel, 2006). In 1898, the French Psychiatrist Ludovic Dugas (1876–​1914) introduced the term depersonalization to psychiatry in his paper “Un cas de depersonnalisation.” He derived the term from the belles-​lettres. The Swiss philosopher Amiel described in his diary his disrupted perception: “Everything is strange to me, I can be outside of my body, of myself as an individual, I am depersonalized, detached, away” (cited by Dugas, Sierra, & Berrios, 1996, p. 452).

The Diagnosis and Clinical Picture of DDD DDD has been included in all versions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Mental and Behavioral Disorders. The diagnostic criteria for DDD, according to the DSM-​5, comprise the presence of persistent or recurrent experiences of depersonalization, derealization, or both, intact reality testing, and functional impairment or distress by the symptoms. Further, the symptoms may not be caused by medical conditions or better explained by another mental disorder. The new ICD-​11 criteria are identical to the DSM-​5. Although neither DSM-​5 nor ICD-​11 has a criterion for the duration of the DP/​DR symptoms, experts say that the symptoms should be present for a significant portion of each day over a period of at least one, or more stringently, three months (Simeon, 2014). The symptoms’ duration and persistence are the most essential criterion for differential diagnosis since transient and fleeting symptoms, as noted above, are quite common and do not amount to a clinical disorder.

Prevalence of DDD In the general population, the point-​prevalence of DDD is approximately 1% (Hunter et al., 2004; Johnson, Cohen, Kasen, & Brook, 2006; Lee, Kwok, Hunter, Richards, & David, 2012). However, due to many clinicians’ low awareness and unfamiliarity with the diagnostic criteria, the diagnosis is made extremely rarely. Usually, it takes several years from the first consultation with a mental health care professional until the final diagnosis is made (Hunter, Phillips, Chalder, Sierra, & David, 2003). The analysis of administrative diagnoses in 1.567 million insured people in a statutory health

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insurance fund in Germany in 2006 revealed a one-​year prevalence of only 0.007% for DDD (Michal, Beutel, & Grobe, 2010). This low prevalence rate would give DDD the status of a rare and orphan disease. However, as shown by surveys, DDD is not rare, and thus might be conceptualized as quite common in prevalence but orphaned in terms of professional awareness.

Typical Clinical Presentation of DDD Patients The mean age of DDD onset is around 16 years (Simeon, Knutelska, Nelson, & Guralnik, 2003). Some patients report onset during primary school, but usually, DDD starts in adolescence. In only 20% of cases is the onset after the age of 20 (Simeon et al., 2003). Both sexes are equally affected, with a slight preponderance of men according to two large case series (Baker et al., 2003; Michal et al., 2016). The onset can be sudden, especially when associated with a panic attack, a “bad trip” caused by cannabis or hallucinogens, or triggered by an emotionally stressful situation. When DDD starts with panic attacks, patients typically report that the frequency of panic attacks decreases over time as the duration and intensity of DP/​DR symptoms increase. The onset can be more insidious when associated with a depressive episode. In these cases, patients often report that while the severity of depression diminished over time, the intensity of DP/​DR increases and becomes the main complaint. Many patients report frustrating treatment experiences: They did not feel understood; they were misdiagnosed as only anxious or depressed, or even only “stressed”; were misdiagnosed as psychotic and treated with antipsychotics; or health care professionals did not provide adequate education about the symptoms, with patients receiving enlightenment only through their own internet searches (Michal, Tavlaridou, Subic-​Wrana, & Beutel, 2012; Simeon & Abugel, 2006). In interviews with mental health care professionals, patients often say they have difficulty putting the symptoms into words. Many patients fear that the presence of DP/​DR symptoms means they are going “crazy” or are considered “crazy” by others. In addition to the disrupted perceptions, patients often complain of stress symptoms such as head fullness, tingling, lightheadedness, and an altered sense of time (time passing too slow or too fast), or difficulties recalling memories vividly. The past medical history often includes tinnitus, migraine headaches, vertigo syndromes, or non-​ specific heart rhythm disturbances (Baker et al., 2003; Michal, Beutel, et al., 2010). These somatic symptoms are suspected psychophysiological correlates of anxiety and low affect-​tolerance (Abbass, 2015). Typically, patients tend to ruminate obsessively about the symptoms and are constantly checking their perceptions to avoid loss of control. Most patients experience the symptoms of DDD as highly distressing. However, these patients’ detached demeanor masks the immense anxiety and pain that is being isolated and disconnected from observable behavior, risking underestimation of their burden, functional impairment, and the severity of the disorder (APA, 2013). Patients typically complain of impairment of interpersonal functioning from being detached and emotionally unresponsive. Occupational impairment might be further related to subjective difficulty in focusing attention and retaining information (APA, 2013). However, patients with DDD do not differ from healthy persons in routine neuropsychological tests comprising full-​scale, verbal, and performance intelligence assessment, working memory, or selective attention (Guralnik, Giesbrecht, Knutelska, Sirroff, & Simeon, 2007). Some patients may be able to perform quite well occupationally, despite severe DDD.

The Course of DDD The course of the disorder tends to be chronic and persistent. It is common for patients to complain of unremitting DDD for several years or even decades. Symptoms are often unresponsive to various treatments. Less frequently, patients report an episodic course with bouts lasting for weeks to months to years, interspersed by symptom-​free intervals. However, information about the course of DDD is built on retrospective case series. In these retrospective case series, DDD’s mean duration from onset to assessment ranged from 7.6 to 13.9 years (Baker et al., 2003; Michal et al., 2016; Simeon et al., 2003). A rough idea of DDD’s prospective course is provided by a cohort study of 290 patients with a primary diagnosis of borderline personality disorder (BPD) over a 20-​year follow-​up period (Shah, Temes, Frankenburg, Fitzmaurice, & Zanarini, 2020). A subgroup of 140 of these 290 patients completed a questionnaire that included typical DP/​DR symptoms (“feeling unreal,” “feeling like people and things are not real,” “feel completely numb”). In general, the severity of DP/​DR symptoms decreased over the two decades. Patients free of BPD 20 years later had significantly lower DP/​DR severity at study intake. Patients who recovered from the personality disorder 20 years later were also free of DP/​DR symptoms. Although this study was not designed for DDD, it confirms firstly that DP/​DR symptoms are important for prognosis, and secondly, that improvement and even remission is possible.

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Differential Diagnosis As patients with DDD typically fulfill diagnostic criteria for two or more mental disorders (Baker et al., 2003; Michal et al., 2016; Simeon et al., 2003), differential diagnostic considerations are essential. The most common comorbidities are depressive disorders, anxiety disorders (especially social phobia, agoraphobia, panic disorder), obsessive-​compulsive disorder, illness anxiety disorder, body dysmorphic disorder, and personality disorders. Very often, there is a past history of substance-​abuse related disorders. Most patients, however, stop substance abuse when DDD starts because of their fear of worsening the symptoms. Patients experiencing alleviation of symptoms by alcohol, benzodiazepines, or illicit drug intake are in danger of developing substance addiction. The most crucial differential diagnostic criterion is the persistence and duration of the DP/​DR symptoms. Symptoms that occur all day long for months without dissociative amnesia are highly suggestible of a DDD diagnosis. Another important consideration heightening the likelihood of a patient suffering from DDD is DP/​DR symptoms not directly covarying with comorbid disorders. Specific and common comorbid and associated disorders are now examined to assist differential diagnosis. Anxiety disorders: DP/​DR are common symptoms of anxiety. In panic disorder, there is an abrupt surge of intense fear that reaches a peak within minutes. DP/​DR symptoms occur only for a short time during the panic attack. In DDD, however, the symptoms clearly persist outside the panic attack (e.g., for much of the day over a few months). In phobic anxiety disorders (social anxiety, specific phobia, agoraphobia), DP/​DR symptoms may occur if anxiety increases in reaction to the phobic stimulus (Čolić et al., 2020; Michal, Kauf hold et al., 2005). In generalized anxiety disorder (GAD), DP/​DR symptoms may occur temporarily during a massive increase in anxiety, but if they persist for much of the day and for months, they can be considered to reflect DDD. Depressive Disorders: Depressive disorders are a frequent comorbidity of patients with DDD. DP/​DR symptoms are not listed as symptoms of depressive disorders in current diagnostic manuals (Kendler, 2016). Yet, in ancient psychiatric textbooks, symptoms of DP/​DR were common features of major depression and melancholia (Kendler, 2017). Complaints about anhedonia, loss of feeling, or feeling dead are common in patients with depressive disorders. However, depressive disorders, as defined by current diagnostic criteria, lack the complex picture of perceptual dysregulation. Other dissociative disorders: DP/​DR symptoms that occur along with dissociative symptoms such as amnesia and identity change suggest a dissociative disorder other than DDD. Although in the DSM-​5 and ICD-​11, DDD is listed among the dissociative disorders (APA, 2013; WHO, 2020), there are apparent phenomenological differences between DDD and the other dissociative disorders (dissociative amnesia, dissociative neurological symptom disorder). These distinctions are conceptualized in the dichotomy between “detachment” and “compartmentalization” (Brown, 2006; Holmes et al., 2005). Detachment refers to an altered state of consciousness characterized by a sense of distance (or detachment) from mental and bodily processes or the external world as seen in DDD. Compartmentalization captures pseudo-​neurological symptoms such as dissociative amnesia, conversion paralysis, sensory loss, and pseudo-​seizures. TABLE 23.1  Detachment versus compartmentalization regarding different psychosomatic functions

Memory

Consciousness

Body

Sensory Organs

DDD as a disorder of detachment

The other dissociative disorders as disorders of compartmentalization

Feeling detached from personal memories as if not having being involved in them. The individual has access to the facts but no access to the emotions, which give personal meaning to the memory. Feeling like living in a dream without disrupted wakefulness and general intact awareness and normal responsiveness.

Dissociative amnesia, i.e., no access to encoded information with observable deficits in the ability to remember past experiences or personal information.

Dissociative stupor and pseudo-​seizures with a significant reduction of consciousness and responsiveness; in extreme cases being unconscious and unresponsive. Dissociative pseudoneurological symptoms like paralysis and anesthesia.

Feeling disconnected from the body; the body feels light as if floating; parts of the body feel larger or smaller without significant impairment of bodily functions. Perceiving actual familiar voices as remote, Dissociative pseudoneurological symptoms like strange, and unreal; seeing like through a veil or deafness and blindness. glass bell, seeing objects look smaller or further away.

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Table 23.1 shows how these two distinct mechanisms affect mental and bodily functions differently in DDD and the other dissociative disorders. It is critical in clinical communications to specify the type of dissociative phenomenon, as the clinical picture differs significantly. Posttraumatic stress disorder (PTSD): The dissociative subtype of PTSD is now included in the DSM-​5 and is determined by persistent or recurrent symptoms of DP/​DR. In contrast to DDD, PTSD is characterized by the core diagnostic criteria of PTSD (exposure to a traumatic event, intrusive symptoms, avoidance, negative alteration in mood and cognition, and hyperarousal), and these are needed in conjunction with DP/​DR to be diagnosed with the dissociative subtype. PTSD is a rare comorbid diagnosis in patients with DDD. Schizophrenia: DP/​DR symptoms are not among the diagnostic criteria of schizophrenia. In DDD, reality testing is intact. Schizophrenia is a common misdiagnosis of patients with DDD. DP/​DR symptoms are relatively common in patients with schizophrenia but rarely reach the intensity of DDD (Gonzalez-​Torres et al., 2010). Substance-​related disorders: If DP/​DR occurs only in reaction to intoxication (e.g., cannabis, hallucinogens) or withdrawal (e.g., benzodiazepines), no diagnosis of DDD is made. If the symptoms persist for weeks or months after drug intake, the symptoms are not attributable to the drug. Personality disorders: In the alternative DSM-​5 model, personality disorders are diagnosed if there are at least moderate difficulties in two or more areas of personality functioning regarding identity, self-​d irection, empathy, and intimacy accompanied by pathological traits. The trait factor “psychoticism” includes DP/​DR as typical symptoms of perceptual dysregulation. All types of personality disorders, especially personality disorders from the fearful-​avoidant cluster, are common comorbid diagnoses of DDD patients (Simeon et al., 2003). Brain diseases: Brief transient episodes of DP/​DR may occur in epileptic or paraepileptic seizures, migraines, and mild traumatic brain injury (Van Gils et al., 2020). DP/​DR are quite common after concussions but typically resolve over three months and do not become chronic. Organic and somatoform vertigo are often associated with DP/​DR (Michal, Beutel, et al., 2010; Sang, Jáuregui-​Renaud, Green, Bronstein, & Gresty, 2006; Tschan, Wiltink, Adler, Beutel, & Michal, 2013). There are usually other neurological abnormalities in persons with structural brain damage (e.g., brain tumor; Lambert, Sierra, Phillips, & David, 2002). If DP/​DR symptoms occur in an episodic-​remitting manner with neurological abnormalities, a thorough medical evaluation is necessary. The onset, accompanying symptoms, and duration of the symptoms allow the determination of the correct diagnosis.

Measurement and Diagnostics In the mental status examination, DP and DR symptoms belong to disorders of perception. The mental health care professional should ask actively about the occurrence of these symptoms and determine their duration, persistence, and the individual’s awareness of fluctuations of the intensity of the symptoms, as these findings provide valuable diagnostic information. For example, as noted above, in a panic attack, the symptoms occur only for minutes to a few hours and do not last the whole day for weeks or months, as in the case in DDD. Several semistructured diagnostic interviews identify the presence and severity of DP/​ DR, including: The Depersonalization Severity Scale (Simeon, Guralnik, & Schmeidler, 2001), the Structured Clinical Interview for DSM-​ IV Dissociative Disorders (Steinberg, 1994), and the subscales of the Clinician-​Administered PTSD Scale for DSM-​5 (CAPS-​5) (Weathers et al., 2018).

TABLE 23.2  The 2-​item version of the Cambridge Depersonalization Scale

Over the last two weeks, how often have you been bothered by the following problems?

Not at all

1. Your surroundings feel detached or unreal, as if there were 0 a veil between you and the outside world. 2. Out of the blue, you feel strange, as if you were not real or 0 as if you were cut off from the world.

Several days

More than half the days

Nearly every day

1

2

3

1

2

3

The CDS-​2 score is the sum of items 1 and 2. The sum score correlates strongly with the severity of DP/​DR. The cut-​off score for the detection of clinically relevant DP/​DR is 3 or above. DDD patients have mean scores of 4.9 (Michal et al., 2016). The response format of the CDS-​2 is taken from the depression module of the patient health questionnaire (PHQ-​9), enabling the integration of the CDS-​2 into the PHQ-​9.

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The most common questionnaires for the assessment of DP/​DR symptoms are the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986) and the Cambridge Depersonalization Scale (Sierra & Berrios, 2000). The DES has 28 items measuring the lifetime severity of the broad spectrum of dissociative experiences, including six items assessing DP/​DR (Michal, Sann, Niebecker, Lazanowski, et al., 2004; Simeon et al., 1998). The CDS measures the duration and frequency of 29 DP/​DR symptoms. Standard time frames are six months and six weeks. Also available is a short version of the CDS with nine (Michal, Sann, Niebecker, Lazanowsky, et al., 2004) and one with two items that measures only frequency (Table 23.2; Michal, Zwerenz, et al., 2010), and a state version with 22 items (Medford et al., 2003). The Personality Inventory for DSM-​5 (PID-​5) (Krueger, Derringer, Markon, Watson, & Skodol, 2012) includes several items in the subscale “Perceptual Dysregulation” that capture DP/​DR symptoms (e.g., “have periods in which I feel disconnected from the world or from myself ”).

Risk Factors for Developing DDD In the biopsychosocial framework, several risk factors are proposed to be associated with the development of DDD. Harm-​avoidance is considered a predisposing temperamental factor for DDD (Simeon, Guralnik, Knutelska, & Schmeidler, 2002). Harm-​avoidance, as defined by Cloninger (1987, p 575, italics added), is “a heritable tendency to respond intensely to signals of aversive stimuli, thereby learning to inhibit behavior to avoid punishment…(Cloninger, 1987).” Harm-​avoidance is also a risk factor for major depression and anxiety disorders, especially social anxiety (Absher & Cloutier, 2016; Kampman, Viikki, Järventausta, & Leinonen, 2014). The role of harm-​avoidance and, respectively, the increased sensitivity to fearful stimuli for the development of DDD is also supported by a prospective cohort study that found that teacher-​estimated childhood anxiety (presumably connected with harm-​avoidance) was the strongest predictor for the later development of severe adult depersonalization (Lee et al., 2012). Thus, harm-​avoidance, a genetic disposition for increased sensitivity to fearful stimuli (Cloninger, Cloninger, Zwir, & Keltikangas-​Järvinen, 2019), might constitute an unspecific risk factor for developing DDD. One small study examined genetic polymorphisms for the dissociative subtype of PTSD using a genome-​w ide approach. The authors identified several single-​ nucleotide polymorphisms associated with fear conditioning and memory consolidation as putative risk factors (Wolf et al., 2014). Another small study reported a gene-​environment interaction of the oxytocin receptor gene polymorphism (rs53576) and unresolved attachment status, predicting the severity of DP/​DR symptoms. The carriers of the GG-​a llele, which is usually associated with higher general sociality and self-​esteem, turned to a risk factor for DP/​DR if the person was exposed to attachment trauma and was still in an unresolved attachment status (Reiner, Frieling, Beutel, & Michal, 2016). However, overall, the current evidence on biological risk factors is weak. Concerning socio-​cultural risk factors, DP/​DR symptoms seem to occur more often in individualistic than collectivist cultures (Sierra-​Siegert & David, 2007; Sierra et al., 2006). In individualistic societies, there is a trend to lower social cohesion. The individual is expected to care for himself and his immediate relatives. In collectivistic cultures, such as Latin American or Asian countries, there are more close and firm bonds in the extended family. This provides the individual with an implicit protective sense of social support (Sierra, 2009). The lack of social support plays a significant role in DDD patients, usually expressed by the fear of not being understood or the fear of losing control and going crazy (Michal, 2021). The exploration of the later catastrophizing cognition regularly reveals that this fear reflects the expectation of getting into a situation where the individual is isolated without any hope of overcoming the disconnection from other people (Michal, 2021). Similarly, the fear of not being understood reflects the early attachment trauma as reenacted in the transference (Michal, 2021). Childhood adversity is the single biggest risk factor for DDD, like for most mental disorders. However, it is essential to note that while DP/​DR are typical reactions to distress or traumatic events, DDD is not specifically associated with a history of severe childhood trauma (Lee et al., 2012; Michal et al., 2016; Simeon, Guralnik, Schmeidler, Sirof, & Knutelska, 2001). A large case series of n =​223 DDD patients reported that DDD outpatients as compared to depressed outpatients without severe DP/​DR had lower levels of self-​rated traumatic childhood experiences and current psychosocial stressors (Michal et al., 2016). In DDD patients, the mean level of traumatic childhood experiences was in the minimal to low range. Based on the critical cut-​points, DDD patients reported the following rates of clinically significant traumatization (Michal et al., 2016): Emotional abuse 44.7%, emotional neglect 35.8%, physical abuse 12.3%, physical neglect 15.1%, and sexual abuse 6.1%. In total, 42.2% reported no significant traumatic childhood experience. In DDD patients, the severity of childhood traumatic experiences did not correlate with the severity of DP/​DR. However, DDD patients reported a high family history of anxiety disorders in their parents, which is a risk factor for insecure attachment.

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In summary, it can be stated that unlike severe dissociative disorders (e.g., dissociative identity disorder), DDD is not specifically associated with a history of childhood trauma. We assume that a genetic vulnerability manifest as the temperamental construct of harm-​avoidance in combination with early adverse childhood experiences predisposes the individual to developing DDD. A recent study showed that especially a history of emotional abuse and neglect combined with attachment-​related anxiety and a negative attitude towards emotions predicted severe DP/​DR symptoms (Laoide, Egan, & Osborn, 2018). Although there is a lack of empirical studies of DDD, based on clinical experience, there is always some kind of early attachment trauma in DDD patients, usually characterized by a lack of adaptive emotional responsiveness in the caregivers to the former attachment needs of the patient (Michal, 2021).

Psychological Models of DDD Below, we first provide a brief overview of cognitive-​behavioral and psychodynamic concepts for symptom formation. Second, we present a viable integrative model for understanding DP/​DR that can easily inform and guide psychotherapeutic interventions. Cognitive-​behavioral models have only recently addressed the phenomena of DP/​DR, with an initial conceptualization suggesting that DDD is caused by a vicious cycle like that operating in panic disorder development, where catastrophic misinterpretation of perceptual disruptions drive the distress. If DP/​DR symptoms are catastrophically misinterpreted as signs of incipient mental or terminal illness, a vicious circle of increasing anxiety/​fear and DP/​DR will result. Safety behaviors and cognitive biases maintain the disorder by increasing hypochondriacal observations of the symptoms and escalating the perceived threat (Hunter, Baker, Phillips, Sierra, & David, 2005; Hunter et al., 2003; Hunter, Salkovskis, & David, 2014). The treatment principles derived from this conceptualization operate to decatastrophize attitudes towards the symptoms (cognitive restructuring), reduce symptom-​checking (e.g., by grounding techniques), as well as avoidance behaviors. Exercises to decrease attention to the symptoms have been found to alleviate the symptoms quickly (e.g., mental arithmetic, dichotic listening), while focusing attention on the symptoms immediately increases their intensity (Hunter et al., 2014). The “third wave” of the development of cognitive-​behavioral therapies incorporated concepts such as mindfulness and tended to give more emphasis to the importance of emotions and relationships (Hayes & Hofmann, 2017). Mindfulness is the practice of deliberately staying present without judgment, becoming aware of, and connected with, the present moment (e.g., bodily sensations, feelings, etc.). Therefore, mindfulness can be viewed as the antithesis to DP/​DR (Allen, 2008; Michal et al., 2007; Nestler, Sierra, Jay, & David, 2015; Zerubavel & Messman-​Moore, 2015). It has been shown that mindfulness meditation can instantly reduce the intensity of DP/​DR for the exercise duration (Michal et al., 2013). However, mindfulness exercises are very strenuous for DDD patients, especially for beginners. This is particularly so because, during mindfulness meditation, patients usually experience a lot of anxiety symptoms (chest tightness, shortness of breath, dizziness, nausea, heart racing, sometimes even paranoid ideation) and witness the extent to which they are prone to catastrophic ruminations and thought racing (Michal, 2021). In contrast to cognitive-​behavioral models, psychodynamic theory has a long history of attempting to conceptualize DP/​DR, starting with Sigmund Freud (1856–​1939) analyzing his own experience of derealization while visiting the Acropolis in a letter to his friend Romain Rolland (1866–​1944). He considered DP/​DR as a defense against conflictual emotions and related thoughts. In his case, Freud (1964) concluded that his DP/​DR resulted from unprocessed feelings towards his father, leading to a kind of denial of his perception that he was actually on the Acropolis, something his father could never achieve in his life. In line with the cognitive-​behavioral approach, early psychodynamic clinicians highlighted the importance of symptom-​checking for the disorder’s maintenance. However, as Otto Fenichel (1897–​1947) and Paul Schilder (1886–​ 1940) explained, the function of obsessive self-​observation and symptom checking is to ward off conflictual emotional experiences because they evoke too much anxiety and overwhelm the system leading to DP/​DR (Fenichel, 1945; Michal, 2021). As Fenichel (1945, cited by Jacobson 1959, p. 585) stated: “The experiences of estrangement and depersonalization are due to a special type of defense, namely, to a countercathexis against one’s own feelings.” Depersonalization was also described as an “emergency defense against the threatened eruption into consciousness of a massive complex of feelings of deprivation, rage and anxiety” (Blank, 1954, p. 36). In support of this, early case studies reported remission of DP/​DR as soon as the conflictual emotions were fully experienced (Ballard, Mohan, & Handy, 1992). Edith Jacobson (1897–​1978) expanded the psychoanalytic literature on depersonalization by drawing on conflicting self-​representations and the defense of splitting the ego into “a detached, intact part of the ego observing the other -​emotionally or physically dead -​unacceptable part” ( Jacobson, 1959, p. 608). Jacobson (1959, p. 589) also put the evolutionary function of depersonalization very clearly into words:

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“The defensive function of the emotional detachment was clearly evident and very successful… in as much as anxiety and other undesirable emotions had disappeared, and a high level of ego functioning could be maintained with control and direction of aggression into the proper channels of organized thinking and behavior.” Harry Guntrip (1901–​1975), like Jacobson, was a contributor to psychoanalytic object relations theory. He considered DP/​DR to be one of the core symptoms of the schizoid condition (in a psychoanalytic, not psychiatric-​classificatory, sense), together with clinical features of introversion, a narcissistic sense of self-​sufficiency and superiority, loss of affect, loneliness, and being overwhelmed by the external world (Guntrip, 1952). Leon Wurmser (1931–​2020) considered shame-​anxiety (i.e., a “self ” represented as worthless, and the associated projective anxiety of being devaluated and attacked by others) to be central to depersonalization. The symptom itself becomes the motor of a vicious cycle when the individual takes the symptoms as a representation and stigma of one’s worthlessness, generating more shame and more DP/​DR (Wurmser, 1994). Henry Krystal (1925–​2015), holocaust survivor and trauma expert, added another critical piece to the understanding of DP/​DR, the significance of affect-​tolerance: “If the individual’s affect tolerance is exceeded, he may have to ward off the affect by becoming depersonalized, i.e., by developing a massive »numbing« through isolation of affect. Under these circumstances, the person experiences the event as an observer, as if it was happening to someone else.” Krystal, 1971, p. 17 Summarizing the above clinical findings and experiences, DP/​DR symptoms represent a specific defense against intolerable conflicting feelings when the individual’s affect tolerance is exceeded. Low affect tolerance is symptomatic of significant impairment of personality functioning. A healthy personality functioning is characterized by the capability “of experiencing, tolerating, and regulating a full range of emotions” (APA 2013, p. 775). Indeed, many DDD patients score high on alexithymia scales and have difficulty identifying their feelings (Simeon, Giesbrecht, Knutelska, Smith, & Smith, 2009). Impaired personality functioning is also reflected in the predominance of immature defenses such as splitting, projection, and denial (Simeon et al., 2002). Typically, DDD patients experience themselves as helpless, hopeless, isolated, and worthless, and others as bad and disappointing, and thus tend to avoid intimacy and reality (Michal, Kauf hold, Overbeck, & Grabhorn, 2006; Sierra, 2009).

Understanding DP/​DR with the Triangles of Conflict and Persons Modern psychodynamic affect-​focused approaches such as Intensive Short-​Term Dynamic Psychotherapy (Abbass, 2015; Davanloo, 2000), Affect-​Phobia-​Therapy (McCullough, 2003), and Accelerated Experiential Dynamic Psychotherapy (Fosha, 2000), use the triangles of conflict and persons (Malan, 2013) for understanding symptom formations and structuring psychotherapeutic interventions. These psychotherapeutic approaches consider unprocessed complex emotions from attachment trauma as the core of mental disorders. Emotions are the central innate force for motivation, development of identity, and relationships (Demos, 2019). The symptoms are caused by the anxiety of and defensive mechanisms against conflictual emotions. Emotions are mobilized in interpersonal relationships, trigger anxiety, and activate defenses, which form the symptoms (► Figure 23.1). For example, feeling down and worthless may result from turning anger (critic, devaluation, hate) against the self. In the triangle of conflict, DP/​DR symptoms are both a defense against conflictual emotions and a symptom of anxiety. The defensive function of DP/​DR consists of warding off the conflictual feelings, thereby detaching from reality, which creates the perception of alienation. At the same time, DP/​ DR symptoms also represent anxiety symptoms. Anxiety can manifest in different somatic pathways (e.g., muscular tension, sweating, trembling) (Davanloo, 2000). If the anxiety is overwhelming, it can disrupt thought and perceptual processes (Abbass, 2015; Grecucci et al., 2020). In this regard, DP/​DR symptoms represent perceptual disturbances due to flooding anxiety, indicating that the individual’s affect tolerance has been exceeded (Abbass, 2015; APA, 2013). These symptoms, therefore, indicate an impairment of personality functioning (ego or structural deficit) that is manifested specifically in reaction to certain conflictual emotions or globally in reaction to almost all emotions in patients with DDD. Harm-​avoidance might represent a genetic contributor to this structural deficit of diminished affect-​tolerance. From the perspective of the triangles of persons (Malan, 2013), there is usually a history of early attachment trauma before age six in DDD patients. Attachment trauma occurs when the infant’s bond with its primary caregiver is disrupted by inappropriate responses to the infant’s emotions, abusive behaviors, conflicting messages (e.g., fearful responses), or the caregiver’s absence. The infant reacts to the disruptions with a range of complex and painful feelings (fear, anger, sadness). These disruptions are particularly harmful if nobody is available to help the infant regulate its emotions

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388  Matthias Michal Triangle of Conflict

Defense

Triangle of Persons

Anxiety

Therapist

Current Person

D

A

T

C

F/I

P

Feeling/Impulse

Past Persons

F I G U R E 2 3 .1   The

Triangles of Person and Conflict

(Abbass, 2015). The consequence is the development of defensive strategies to cope with distress and maintain a crucial relationship with the caregiver. In the aftermath, emotions that endanger the relationship with caregivers automatically provoke anxiety and activate unconscious defensive mechanisms (Grecucci et al., 2020). Further, the unconscious anger becomes the source of a punitive superego. The remaining unprocessed complex feelings lead to anxiety, avoidance of emotions, difficulties with intimacy, and various symptom formations (Abbass, 2015). In DDD patients, the symptoms are typically triggered in close relationships. The symptomatology thus also represents a kind of compromise formation, in such a manner that the individual can be in a relationship with the other on the one hand and absent at the same time. This compromise formation reflects the defensive reaction of the individual to the attachment trauma and represents a significant resistance to change as Guntrip has formulated (Guntrip, 1952, p. 17): “The psychotherapist must be greatly concerned with those states of mind in which patients become inaccessible emotionally, when the patient seems to be bodily present but mentally absent.” It implies from the preceding that focusing on emotional closeness, emotional experiencing and anxiety regulation is crucial for the treatment of DDD.

Conclusion DP/​DR symptoms represent a kind of perceptual disruption caused by overwhelming anxiety, and also specific defenses against conflictual emotions. The symptoms can occur with many mental disorders, define subtypes of mental disorders (e.g., the dissociative subtype of PTSD), or characterize the whole clinical picture, as in DDD. Concerning psychiatric classification, it is quite conceivable that similar subtyping based on the presence of DP/​DR symptoms that has been adopted for PTSD may also apply to other mental disorders such as major depression or obsessive-​compulsive disorder. Something similar is already emerging in the alternative model of personality disorders, where DP/​DR symptoms represent experiences of the personality trait domain of perceptual dysregulation. A classification approach that looks more at mechanisms and the level of personality functioning seems to be more consistent with the patients’ reality than the current psychiatric classification with its comorbidity problem. Concerning DDD treatment, psychotherapy is the first-​line treatment according to the clinical practice guideline on the diagnosis and treatment of DDD from the Association of the Scientific Medical Societies in Germany (AWMF/​051-​030, 2014). However, there is an urgent need for funded trials on psychotherapeutic and medication interventions.

Acknowledgment I thank Daphne Simeon for her critical review of the manuscript.

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24 A GROUNDED THEORY OF DISSOCIATIVE IDENTITY DISORDER Placing DID in Mind, Brain, and Body Lauren A. M. Lebois, Chloe S. Kaplan, Cori A. Palermo, Xi Pan, and Milissa L. Kaufman

In some ways, dissociative identity disorder (DID) is paradoxical (Loewenstein, 2020). It is both a psychiatric disorder and a marker of effective early developmental adaptation to overwhelming traumatic stress and confounding attachment dilemmas (Putnam, 1997; 2016). Historical controversies surrounding DID, and, at times, this paradoxical perspective, have impeded its empirical study and obscured the validity of existing findings. However, a burgeoning body of research has linked DID to a particular causal environment and to a variety of biological manifestations. Here we provide an innovative theory of DID that translates the phenomenology using modern models of cognition and neuroscience, and grounds DID in environmental experience, the brain and body.

What is DID? DID is a posttraumatic psychobiological syndrome that develops in childhood to help the child survive overwhelming experiences (Putnam, 1997). It is demarcated by experiences of identity alteration and dissociative amnesia (APA, 2013). The timing of traumatic experience during childhood for individuals with DID disrupts typical identity development (Putnam, 2016). In typical development, children gradually coalesce a coherent sense of self that is perceived as stable across time, as well as emotional and behavioral contexts (Harter, 2015). Individuals with DID instead go down an alternative developmental pathway. Consequently, they experience behavioral and emotional states that subjectively feel discrete and remain unintegrated in adulthood (Putnam, 2016). These seemingly discrete mental states are termed “personality states” or “identity states” in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (APA, 2013) or sometimes called “alters” or “parts” in the literature. However, the term “self-​states” acknowledges the subjectively discrete experience of these states without reifying them as actual “people” that inhabit the mind of someone with DID (Kluft, 1988). Furthermore, the term self-​state permits a straightforward mapping of this experience in DID to current theories of cognition, and the existing empirical biological research on DID. To aid in our novel synthesis, we use the term self-​states moving forward.

What is a Self-​state? To begin our discussion, it is important to note that all people have self-​states –​not just those with DID. A self-​state is the subjective experience of a particular “way of being you” (Chefetz, 2015, p. 66). A self-​state is a metaphor with “umph,” a subjective experience in a living being, grounded in cognition that conceptually expands to include embodiment. Following theories of grounded cognition1 (Barsalou, 2008), self-​state as metaphor is grounded in the experience of the body and five senses in the world. In this section, we explain how the metaphor of the self-​state is an actual embodied, dynamic construction used to help us predict how to act and be in the world. Then, by reflecting the language of DID self-​states within our understanding of modern cognitive psychology and neuroscience, we hope to demystify and destigmatize the experience of identity alteration in DID. Self-​states manifest and operate the way they do because that is just the way human minds and brains work according to the science of grounded cognition. We are all a collection of self-​states, some collections more integrated and some more dissociative than others.

DOI: 10.4324/9781003057314-29

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Our ability to create a variety of self-​states is perhaps infinite. Indeed, we have aspects of subjective experience that may feel, for example, enthusiastic, inspired, nervous, attentive, determined, hungry, angry, ashamed, creative, loving, tense or some marvellous, messy combination thereof. A self-​state is a dynamic construction that develops in memory over time. As such, it can change over time –​it is not static. Given this, both learning and our unique experiences in the world play fundamental roles in the development and elaboration of self-​states over time. Furthermore, our self-​ states can adapt to the context at hand (see Barsalou, 2010; Lebois et al., 2019 for examples of learning and context-​ dependence in emotion and conceptual knowledge). Importantly, self-​states are actually a dynamic network of brain activity. This brain activity is a collection of perceptions (e.g., vision), actions (e.g., proprioception), and internal states (e.g., affect) associated with that particular self-​state based on our past experience (Barsalou, 2008). Given this, your subjective experience in a particular self-​state might include what it feels like in your body, what you look like, attributes or skills you have, and how you feel about yourself in a particular context (and the brain activity associated with all of these perceptions, actions and internal states). For example, in a specific self-​state you might feel yourself breathing smoothly with a sense of ease in your body. You have the perception that you look solidly present and calm. You are aware of your ability to be a sensitive, listening presence. You feel a warm curiosity and sense that you are good. In another self-​state, you might feel an adrenaline rush that sends tingles through your arms. You have the perception that you look calm on the outside but feel excited anticipation inside. You are aware of your ability to speak competently in front of an audience, and you feel a sense of mastery as you start talking. Critically, when you are experiencing a particular self-​state or even just thinking about that state, you are, to a certain extent, reactivating brain activity (memories) associated with past experiences linked to that state. This brain activity includes perceptions, actions, and internal states that are stored in memory (i.e., simulation, Barsalou, 2008). Having a mind and brain that works this way helps us predict what might happen in the environment and prepares our body to interact with the environment (Barsalou, 2020). A self-​state in DID, just like other self-​states, is a constellation of perceptions, actions and internal states based on past experience stored in memory. In the same vein, the neural correlates of a self-​state in DID are also a dynamic, distributed network of brain activity. To a certain extent, brain activity associated with past experience while in that self-​state is reactivated when someone with DID is currently in that state or thinking about that self-​state. Importantly, this reactivation is context-​dependent, just like self-​states experienced by someone without DID. However, a self-​state in DID is unique as compared to a self-​state in someone without DID. In DID, one experiences shifts in subjectivity and agency such that the one self-​state may become an observer while another aspect of self, another self-​state, takes control of the “wheel” and drives on (R. Oxnam, personal communication, February 2016). Furthermore, in DID, self-​states often feel non-​autobiographical or ego-​a lien, that is, they feel distinctly separate as if they do not belong to the person, and often as if they belong to someone else (Brenner, 2001; Chefetz & Bromberg, 2004). This ego-​a lien experience of one’s sense of self is also termed a “not-​me” experience (Sullivan, 2013). For example, a progression along this “not-​me” continuum may include: 1. feeling like you are watching a self-​state from above that belongs to you but simultaneously is somewhat separate; 2. feeling like a markedly different self-​state that does not belong to you; and 3. feeling a complete loss of experiential awareness while in a different self-​state (Brenner, 2001). Often self-​states in DID are dominated by a particular affect, set of memories, and behaviors (Kluft, 1988). A self-​ state in DID may also have a particular mental image or experience of the body associated with it (Loewenstein, 2020). In a particular self-​state, you might feel numb and detached. For example, you perceive yourself to look like an adult woman (as you are), but your body does not feel real below the neck and your emotions seem far away or absent. In another self-​state, you might feel like an angry young boy. In this self-​state you feel that your body is smaller, like a child’s, you perceive yourself to be physically strong and male (despite being an adult woman), and you feel a generalized sense that you are angry and somehow bad. In yet another self-​state, you might feel even more separate, realizing only later that you went to work and competently made an important presentation in front of a large group of colleagues, leaving you confused as to how someone as anxious as you could perform in such a professional manner. Importantly, while DID self-​states may have statistical regularities in their associated affect, memories and behaviors, they are not static, stable states –​they are dynamic ( just like any other self-​state). The mind of an individual with DID is a collection of self-​states or a dynamic, “self-​state system” (Loewenstein, 2020).

Other Dissociative Symptoms Experienced in DID Having a mind made up of a dynamic, self-​state system is commonly associated with a number of related discontinuities and alterations in experience. These discontinuities and alterations disrupt executive functioning and one’s sense of self

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in a variety of ways, and span a range of experiences including general memory problems, depersonalization, derealization, posttraumatic flashbacks, somatoform symptoms, trance, voice hearing, speech/​thought insertion or withdrawal, “made” experiences (i.e., feelings, emotions, impulses, actions), temporary loss of knowledge, and amnesia (Dell, 2009). Dell hypothesizes that, in DID, these experiences are actually dissociative intrusions in which a self-​state intrudes into the conscious experience of another self-​state. Often individuals with DID are aware of these symptoms (e.g., depersonalization, made emotions). However, some occur outside awareness (e.g., amnesia). Importantly, these experiences largely occur internally, not overtly (Dell, 2009). Below we describe three dissociative experiences that are characteristic of DID, including depersonalization, “made” experiences, and amnesia (see Dell, 2009 for a complete review). These features are further explored in the empirical biological sections of this review. Depersonalization is the experience of detachment or disconnection from one’s sense of self or body (Dell, 2009). In DID, depersonalization experiences include prototypical examples such as feeling like you are watching yourself from outside your body or that parts of your body feel unreal (Steinberg, 1994). However, in DID depersonalization becomes so severe that it intersects with identity alteration. For example, individuals may experience a loss of agency where it feels as if their emotions, thoughts, and behaviors emerge without their control (i.e., “made” or intrusive feelings, emotions, impulses, actions; APA, 2013; Dell 2006b). As described in the previous section, sometimes this experience is coupled with a feeling that emotions, thoughts, behaviors and/​or their body are not their own, and at times that they belong to someone else (APA, 2013). Importantly, individuals with DID logically understand these experiences must be their own even though they feel alien (Dell, 2009). Overall, depersonalization functions adaptively to provide distance from overwhelming affect by creating the illusion of, for example, physical distance or “not-​me-​ness” (Brenner, 2001). Dissociative amnesia includes gaps in memory for autobiographical information or experiences (APA, 2013). It can be either persistent or recurrent and the content traumatic or nontraumatic in nature. The amnesia can be generalized to one’s life and identity (e.g., a fugue in which someone does not remember who they are or their personal history), localized to the details of a specific time period (e.g., ages 6–​10 are ‘missing’) and/​or selective for only some details during a period of time (e.g., Sunday visits to my grandparents in childhood are just blank; Steinberg, 1994). In DID, dissociative amnesia functions adaptively to preserve attachment bonds by compartmentalizing highly conflicted thoughts and feelings about abusive caregivers (Liotti, 1992).

Observable Manifestations of Self-​states The self-​state and associated dissociative intrusions reviewed so far are experienced largely internally, as subjective qualities of experience in someone with DID (Dell, 2009). This makes it challenging to find ways of confirming that someone is experiencing these symptoms beyond relying solely on their self-​report. Brain and body-​based measures of these experiences, however, can augment subjective self-​reports. Research in DID is beginning to develop paradigms to capture the objectively observable manifestations of self-​states and dissociative intrusions in biology and performance on various tasks. The rest of this review is dedicated to a novel synthesis of this empirical work –​grounding DID in experience in the world and body.

Grounding DID in Environmental Risk Factors Like other psychiatric disorders, the etiology of DID includes a combination of genetic and environmental factors. Genetic variation moderates the association between environmental risk factors and psychiatric disorders (Caspi & Moffitt, 2006). For example, an individual with a low genetic loading for DID might not develop this disorder despite chronic, severe childhood trauma. In contrast, someone with a high genetic loading for DID might develop this disorder with a less severe childhood trauma load. In this way, there could be different pathways to the development of DID. This gene by environment interaction is understudied in psychiatry, let alone in DID specifically; however, patterns are beginning to emerge for DID and pathological dissociation more generally. Given that there are currently no DID-​ specific molecular genetic studies, here we focus on grounding DID in common environmental risk factors.

Overwhelming Childhood Experiences, Trauma, and Abuse Clinical reports, empirical work, epidemiological studies, and meta-​analyses support a moderate relationship between trauma and dissociation, and trauma and dissociative disorders, especially DID (Dalenberg et al., 2012). This work has

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been conducted in both children and adults in the general population, clinical, and DID-​samples across several countries (Dorahy et al., 2014). Research specific to DID has found high rates of many different maltreatment types (Dalenberg et al., 2012), and often individuals with DID have been found to have a higher trauma load than any other psychiatric group (Loewenstein, 2020). Given ethical constraints, the work examining the relationship between trauma and dissociation, and trauma and DID, is necessarily correlational. However, prospective, longitudinal evidence following individuals in the direct aftermath of an acute trauma has demonstrated the link between trauma and dissociation (Carlson et al., 2016; Daniels et al., 2012), further supporting the strength of this relationship and the probability that trauma is causally linked to the occurrence of dissociation and DID (cf., Dell, Chapter 14, this volume). In addition, a history of childhood trauma in individuals with DID has been verified using hospital, police, and child protection agency records, providing additional support for the direct link between trauma and DID (e.g., Chu et al., 1999; Coons, 1994). In light of this evidence, the field has largely moved beyond simply documenting the association between maltreatment, dissociation, and/​or DID to instead identifying the distinct aspects of maltreatment leading to the development of DID specifically. In particular, a pattern of severe, chronic childhood trauma has emerged in almost all systematic studies of DID (Dorahy et al., 2014). Typically, this trauma is relational and occurs between the child and an attachment figure (Liotti, 1992; Ross, Norton, & Wozney, 1989). The abuse is often physical or sexual in nature. For example, rates of childhood physical abuse were around 84% and rates of sexual abuse ranged from 74% to 90% in a sample of individuals with DID (Ross & Ness, 2010). While the relationship between DID and childhood physical/​sexual abuse is often emphasized, data also suggests verbal abuse, emotional abuse, and emotional neglect are also strongly associated with adulthood dissociative symptoms (e.g., Teicher, Samson, Polcari & McGreenery, 2006; Şar, Dorahy, & Krüger, 2017). Of the different maltreatment types, emotional maltreatment may be among the strongest predictors of dissociative symptoms (King et al., 2020). For example, in a sample of psychiatric patients, childhood emotional neglect by immediate family members had the strongest association with an adult dissociative disorder diagnosis (Krüger & Fletcher, 2017). While the majority of research has associated the environmental etiology of DID with severe, chronic childhood relational abuse by caregivers, two variations are of note. First, chaotic family dynamics characterized by frequent mood swings, uncontrollable anger, dissociation, paranoid ideation, and subclinical features of borderline personality disorder may also contribute, and in some cases, may be sufficient environmental circumstances for the development of DID (Ozturk & Şar, 2006). Second, chronic, painful, traumatic medical procedures performed by caregivers with non-​m alicious intent during developmentally sensitive time periods in childhood have also been associated with dissociative symptomatology in adults (Diseth, 2006), though this association has not yet been tested in DID specifically.

Disorganized Attachment In addition to overwhelming childhood experiences, researchers theorize that the etiology of DID includes a disorganized attachment style (Barach, 1991; Blizard, 2003; Liotti, 1992; 1999). Disorganized attachment is marked by inconsistent and conflicting attachment behaviors (also known as Disoriented or Type D attachment; Main & Solomon, 1986). Infants with this attachment style display early dissociative processes such as trance-​l ike or contradictory behavior (Main & Hesse, 1990; Main & Solomon, 1986). For example, in the strange situation paradigm where children are briefly separated and then reunited with caregivers, the child may approach their parent and simultaneously freeze in greeting them, even if they had been screaming during their separation. Disorganized attachment is frequently observed in children who have been abused or neglected, or whose early caregiver was unavailable, inconsistent, or insensitive (Barach, 1991; Blizard, 2003; Carlson, 1998; Carlson et al., 1989; Lyons-​Ruth et al., 2006). Longitudinal research has demonstrated that disorganized attachment in infancy predicts dissociation in adulthood, and a combination of disorganized attachment and trauma predicts elevated levels of dissociation in clinical and non-​clinical populations (Carlson, 1998; Coe et al., 1995; Dutra et al., 2009; Ogawa et al., 1997). It is hypothesized that disorganized attachment may contribute specifically to the etiology of DID by facilitating the development and elaboration of self-​states that feel subjectively separate (Liotti, 1992; 2004). Furthermore, it is posited that the more confounding the early attachment relationship, the higher the likelihood that the child will later develop a more severe case of DID (Blizard, 1997). If there had been secure and consistent early attachments, it is thought that later trauma would not produce self-​states (Liotti, 1992, 1999; McFadden, 2011).

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Although the connection between trauma, disorganized attachment and dissociation in adulthood has been established, to date, no systematic empirical developmental research has focused specifically on DID samples and the hypothesized etiological contributions of disorganized attachment. This is a critical direction for future research.

Grounding DID in Biological Patterns Foundational work has grounded DID in biology and begun to map out the biological mechanisms that underpin the experience of DID. Both neuroimaging and psychophysiological methodologies highlight that the symptoms of DID are associated with observable biological patterns (for recent systematic reviews see Lotifina, Soorgi, Mertens & Daniels, 2020; Roydeva & Reinders, 2020; See also Nijenhuis, Chapter 38, this volume). Here we review brain activity, anatomy, and peripheral physiology associated with DID.

Neurobiology of DID Neurobiological research in DID has focused largely on differentiating self-​states on the basis of activity in the brain. This body of work has shown observable differences between self-​states across various paradigms. In addition, preliminary work has examined the neural correlates of switching between states and the process of self-​state integration. Furthermore, DID brain structure and activity has been compared to nonpsychiatric controls and to controls pretending to have DID. Emerging patterns place DID on a continuum with PTSD and add to the body of literature supporting DID as a trauma-​spectrum disorder, not a disorder of role-​playing or fantasy involvement. More recent work points toward a fingerprint of DID in brain structure and function.

Common Methodologies Common neuroimaging modalities used in DID research span direct and indirect measures of brain activity. Direct measures of brain electrical activity include electroencephalogram (EEG) and a derivative of EEG, called event-​related potentials (ERP), that ties activity to a stimulus presentation. Indirect measures of brain activity track metabolism in the brain by leveraging blood flow, blood oxygen levels, blood water protons, or exogenous tracers injected into the bloodstream. Techniques that indirectly measure brain activity through metabolism include functional magnetic resonance imaging (fMRI), arterial spin labelling, positron emission tomography (PET), and single-​photon emission computerized tomography (SPECT). EEG and ERP, as direct measures of brain activity, have strong temporal resolution, but poorer spatial resolution, that is, they can better pinpoint the timing of brain activity as opposed to the specific location of that activity. In contrast, techniques like fMRI and PET imaging have high spatial resolution, but poorer temporal resolution, meaning they can better pinpoint the location of brain activity as opposed to the timing of when that activity occurred. These methodological strengths and weaknesses should be kept in mind when interpreting the findings that follow.

Neural Correlates of Self-​states Self-​states have Different Activity Most of the neurobiological work in DID has focused on testing whether different self-​states exhibit distinct patterns of brain activity. The majority of evidence demonstrates that there is differential brain activity across self-​states. This has been observed across several task paradigms and while the participant is at “rest” with no task or experimenter-​d irected external stimulus (e.g., Reinders et al., 2003; 2006; Schlumpf et al., 2014). It has also been detected using a range of imaging methodologies including EEG, ERP, SPECT, PET, arterial spin labelling fMRI, and fMRI. Only a handful of exceptions have reported no differences between self-​states in at least some experimental conditions (Coons et al., 1982; Cocores, Bender & McBride, 1984; Şar et al., 2001). We will discuss why this is not problematic at the end of this section. The pattern of differential brain activity across self-​states depends on the experimental context. Contexts studied to date range from intentionally emotionally provocative tasks to more mundane tasks, to no task (i.e., resting-​state). The pattern is also influenced by brain imaging modality. For example, during a masked angry and neutral face fMRI paradigm, differential activity between self-​states occurred in the parahippocampal gyrus (Schlumpf et al., 2013), whereas in a PET study, listening to trauma scripts elicited differential self-​state activity across the brain in cortical (e.g., lateral and medial prefrontal cortex, cingulate, superior/​inferior parietal lobule, occipital regions) and subcortical areas (e.g.,

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parietal operculum, insula, amygdala, caudate, globus pallidus; Reinders et al., 2003; 2006). Two memory-​related tasks demonstrated different EEG alpha coherence (Hopper et al., 2002), and different P300 ERP amplitudes across self-​states (Allen & Movius, 2000). Several early studies flashed different light intensities to compare signal changes in the brain across self-​states (Braun, 1983; Coons et al., 1982; Larmore, Ludwig, & Cain, 1977; Ludwig, Brandsma, Wilbur et al., 1972; Putnam, 1984). Most reported qualitatively-​a ssessed differences distributed across the brain, although one study demonstrated quantified latency and amplitude differences (Larmore et al., 1977), and another showed differences across delta, beta, and theta frequency bands when comparing self-​states (Coons et al., 1982). Most differences occurred in parietal and temporal regions. Resting-​state studies also report self-​state differences distributed across alpha, beta, theta, and delta frequency bands that occur most consistently in the temporal lobe region, though some studies demonstrate differences in frontal, parietal, and occipital regions (Coons et al., 1982; Flor-​Henry et al., 1990; Hughes, Kuhlman, Fichtner, & Gruenfeld, 1990; Lapointe, Crayton, Devito et al., 2006; Ludwig et al., 1972; Thigpen & Cleckley, 1954; Morselli, 1953). One arterial spin labelling resting-​state fMRI study localized differences in self-​state brain activity to the dorsomedial prefrontal cortex, somatosensorimotor, superior parietal, middle temporal regions and thalamus (Schlumpf et al., 2014). Altogether this work demonstrates brain-​based self-​state activity is identifiable across emotion, memory, perception, and resting-​ state tasks with neural correlate patterns that vary with the experimental context.

Switching between Self-​states The process of transitioning between self-​states has also received some neurobiological attention. Two fMRI case studies have begun to identify brain activity implicated in this transition, also colloquially termed “switching.” One study identified differential activity in the hippocampus, parahippocampal gyrus, medial temporal regions, substantia nigra, and globus pallidus, depending on which state the individual was transitioning to (Tsai, Condie, Wu, & Chang, 1999). In another case, researchers implicated pre and postcentral gyrus, nucleus accumbens, and lateral prefrontal cortex in the switching process (Savoy, Frederick, Keuroghlian, Wolk, 2012; Wolk, Savoy, & Frederick, 2012).

Self-​state Integration Recovery from DID is associated with no longer experiencing self-​states that feel distinctly separate and feel as if they do not belong to the person or seem to belong to someone else. A small body of case study work has begun to examine this process by looking at brain function at various levels of integration. For example, topographic maps of two individuals with DID pre-​integration looked different compared to post integration EEG maps (Braun, 1983). Another case study demonstrated cerebral blood flow patterns were different pre versus post integration (Mathew, Jack & West, 1985). The blood flow pattern was relatively stable across experimental sessions for the individual with DID post integration –​similar to stability demonstrated by nonpsychiatric controls. Two individuals with higher levels of integration demonstrated a neural marker of memory recognition (i.e., a higher P300 amplitude) for words learned by a different self-​state, whereas two individuals with lower levels of integration did not demonstrate this neural marker for words learned in a different self-​state (Allen & Movius, 2000). Finally, one study examined structural brain differences between individuals with DID and those who have recovered from DID. Recovered individuals had significantly larger hippocampal volume compared to individuals with current DID (Ehling, Nijenhuis & Krikke, 2008).

Summary The research reviewed here suggests that self-​states in DID are dynamic, distributed networks of brain activity and specific differences or similarities between states in any moment are context-​dependent. Previous work has hypothesized that self-​states have different neural correlates because they are associated with a different moods, emotional states, levels of arousal, or senses of ownership over memories. Likely all of these contribute to differential neural activity between self-​states. Following theories of grounded cognition (Barsalou, 2008), the reason for this is that a self-​state is made up of a constellation of perceptions, actions and internal states stored in memory and supported by a dynamic network of brain activity. A historical critique of this work argued that if brain differences were not observed between self-​states –​or if differences observed could be attributed to fluctuations in mood or arousal –​then this would delegitimize DID. Of course, this logic is flawed. Because self-​states are embodied, dynamic constructions grounded in perception, action, and introspection based on past experience, they will be paired with different perceptions, actions, internal states, and thus, different levels of valence and arousal.

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Along the same lines, states may not differ in all contexts, at least at the level discernible by current technologies. Accordingly, differential brain activity related to mood or arousal does not suggest that self-​states are not “real.” Furthermore, failure to show differences between states in a particular task also does not suggest that self-​states are not “real.” A more nuanced question is what neural activity may be unique to DID self-​states? For example, someone without DID will show different neural activity in the same task if they complete it once while feeling angry, and again while feeling fearful or numb. How does self-​state activity in DID look different from this? The collection of results reviewed so far does not answer this question.

DID Versus Nonpsychiatric Controls and People Simulating DID A body of work that does start to answer the question of what is neurobiologically unique to DID contrasts both brain structure and function to nonpsychiatric controls. A subset of this work also contrasts DID self-​state activity to brain activity of individuals, often hired actors, pretending to experience DID self-​states. While the experimental practice of comparing individuals with DID to DID-​simulating controls does shed some light on what may be neurobiologically unique to DID, this paradigm has largely been used to test alternative theories of DID that attribute this disorder to fantasy proneness, suggestibility, and factitiousness. We review each set of studies in turn.

Nonpsychiatric Controls Brain structure. Most brain anatomy work comparing DID and control samples have focused on the hippocampus. The hippocampus is centrally involved in learning and memory processing (Squire & Zola-​Morgan, 1991), and is sensitive to the neurotoxic effects of chronically activated stress hormones (Conrad, 2008). The majority of studies find that the hippocampus is smaller and abnormally shaped in DID groups compared to nonpsychiatric control groups (Chalavi et al., 2015a; Chalavi et al., 2015b; Ehling et al., 2008; Irle, Lange, Sachsse, & Weniger, 2009; Tsai et al., 1999; Vermetten, Schmahl, Lindner, Loewenstein & Bremner, 2006). In addition to group level comparisons, some work has also demonstrated a negative correlation between hippocampal size and dissociative symptom severity in DID samples or mixed samples that include some individuals with DID (Chalavi et al., 2015b; Ehling et al., 2008; Stein, Koverola, Hanna, Torchia & McClarty, 1997). There is also evidence of structural differences in other brain regions in DID samples. For example, some studies show DID groups have smaller amygdala, smaller parahippocampal gyrus, and larger pallidum volumes compared to controls (Chalavi et al., 2015a; Ehling et al., 2008; Vermetten et al., 2006). One exception to the hippocampal and amygdala patterns was shown in a mixed DID /​Dissociative Amnesia group without comorbid PTSD (Weniger, Lange, Sachsse & Irle, 2008). This sample had no difference in hippocampal or amygdala volume compared to nonpsychiatric controls. Brain Function Most work comparing DID to nonpsychiatric control brain activity has focused on resting-​state activity, attention, memory, and spatial tasks. This work is split between studies that compare self-​states and those that do not. Studies without self-​state comparisons typically demonstrate differences in brain activity related to working memory, spatial navigation, and memory recognition for individuals with DID. For example, a mixed DID and dissociative disorder not otherwise specified (DDNOS, milder presentation of DID) group outperformed nonpsychiatric controls on difficult trials in a verbal working memory fMRI task and had more brain activity in typical working memory brain regions compared to controls (e.g., lateral PFC, parietal cortex; Elzinga et al., 2007). Similarly, a mixed DID/​Dissociative amnesia sample performed comparably to controls in an fMRI virtual maze navigation (Weniger et al., 2013). Brain activity looked similar across groups, except the dissociative disorder sample had less activity in the postcentral gyrus, inferior parietal lobule, insula, superior temporal gyrus, cingulate, caudate and thalamus compared to controls. A series of SPECT studies at rest demonstrated increased regional cerebral blood flow in the temporal lobes (Şar et al, 2001), prefrontal cortex and occipital lobes, and decreased orbitofrontal cortex cerebral blood flow in a DID sample compared to controls (Şar, Unal, & Ozturk, 2007). Finally, a cohort including some individuals with DID had less EEG connectivity compared to controls after adult attachment interview provocation (Farina et al., 2014). Studies that incorporated different self-​states into the design have demonstrated differential activity related to verbal, spatial, and memory tasks, and rest conditions. For example, a DID sample showed a smaller ERP P300 amplitude, a marker of memory recognition, compared to a control group in a memory assessment (Allen & Movius, 2000). In

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addition, several studies found contrasting results related to signal variability across tasks and rest. One found that brain activity in a DID group showed less variability across verbal and spatial tasks compared to control activity as measured by EEG (Flor-​Henry et al., 1990). In contrast, DID self-​states exhibited more EEG signal and regional cerebral blood flow variability at rest compared to controls across different sessions, but less variability than comparing controls to one another (Mathew et al., 1985; Lapointe et al., 2006).

Simulating Controls Across numerous experimental designs and imaging methodologies no DID-​simulating control groups have reproduced the differences in brain activity between self-​states demonstrated by DID groups (Coons et al., 1982; Hopper et al., 2002; Hughes et al., 1990; Putnam, 1984; Reinders et al, 2014; Schlumpf et al., 2013; Schlumpf et al., 2014). Activity between groups was different even when controls were prone to deep involvement in fantasy (Reinders et al., 2016; Reinders, Willemsen, Vos, den Boer & Nijenhuis, 2012). Importantly, the simulating controls did demonstrate differences in neural activity when they were in different states, but these patterns did not correspond to the patterns observed in DID samples.

Summary Altogether, studies comparing DID participants to controls suggest that the neural correlates of DID involve a dynamic, distributed network of brain activity and that specific differences between DID and nonpsychiatric controls are task-​ dependent. To date, the strongest structural evidence is for hippocampal abnormalities in DID. Additionally, there are two emerging patterns to highlight in brain function. 1) There is some evidence that under some working and spatial memory task conditions dissociative disorder samples match or outperform control performance, but exhibit different brain activity (Elzinga et al., 2007; Weniger et al., 2013). This suggests executive and visuospatial functioning may be conserved under these circumstances and differential DID versus control brain activity may either represent a compensatory mechanism or unique processing style. However, these studies employed mixed dissociative disorders samples. It is yet unclear if a DID-​only sample would replicate these results. 2) Control groups simulating DID have not replicated self-​state patterns exhibited by individuals with DID, suggesting DID is not a disorder of role-​playing, fantasy proneness, suggestibility, fabrication, and/​or factitiousness. This collection of results also begins to answer the question of what is unique to DID and self-​state activity (in comparison to simulation of these states). It does not, however, fully tease out how differential self-​state activity is distinct from the differential brain activity someone without DID would display when completing a task multiple times in different states (e.g., feeling angry, fearful, or numb). More targeted studies eliciting and isolating the felt sense that feelings, thoughts, and memories are nonautobiographical would further contribute to understanding the neural correlates of DID. Moreover, a limitation of the findings discussed here is that they do not demonstrate what is specific to DID versus general psychopathology. Further insight into the neural correlates specific to DID requires psychiatric control groups.

Placing DID on a Continuum with PTSD Neurobiology –​Evidence of a Posttraumatic Adaptation Perhaps unsurprisingly, given DID is a trauma-​spectrum disorder, research is beginning to show that the neural correlates of DID overlap with the neurobiological underpinnings of PTSD. The research paradigm demonstrating this overlap is termed “symptom provocation.” In these studies, participants often listen to recordings of their own trauma narratives while brain activity is being measured indirectly using fMRI or PET imaging. Listening to a trauma narrative presumably activates a participant’s PTSD symptoms. Brain activity during the trauma narrative is then compared to activity that occurs when participants are listening to a non-​t rauma or “neutral” narrative. This approach allows researchers to isolate neural activity related to posttraumatic stress symptoms. Symptom provocation studies show that a key neurobiological mechanism of dissociation in PTSD and DID is an excess of corticolimbic inhibition (Lanius et al., 2002; 2006; Reinders et al., 2014). For example, on average, individuals with frequent depersonalization/​derealization experiences and PTSD, that is, the dissociative subtype of PTSD, exhibit hyperactivity in cortical areas of the brain involved in emotion and arousal regulation (e.g., ventromedial prefrontal cortex, rostral anterior cingulate cortex). In contrast, limbic regions are often hypoactive (e.g., amygdala, insula; Lanius et al., 2002; 2006; see Schiavone & Lanius, Chapter 39, this volume). This pattern, in part, underpins the experience of numbness and detachment individuals with this PTSD subtype report.

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Several resting-​state functional connectivity studies support these findings. They reveal entrenched patterns of emotion and arousal over-​regulation in the way brain areas communicate in individuals with significant trauma-​related dissociative symptoms –​even while the individual is at rest with no engagement in a task (e.g., Harricharan et al., 2016; Nicholson et al., 2015). In contrast, on average, individuals with classic PTSD, that is, no/​very few or infrequent depersonalization/​derealization symptoms, exhibit a pattern of failed corticolimbic inhibition in these situations (Lanius et al., 2001; 2002; 2006). They have hyperactivity in limbic areas of the brain involved in relevance detection (amygdala) and bodily experience (insula), but hypoactivity in cortical regions involved in regulating the limbic activity (e.g., ventromedial prefrontal cortex, rostral anterior cingulate cortex). This pattern, in part, underpins the experience of hyperarousal and emotion under-​regulation in PTSD. Studies of DID using the symptom provocation paradigm mirror these contrasting PTSD findings. Specifically, when individuals with DID are in a hyperaroused self-​state (also termed “trauma identity/​personality state” or “emotional part”), brain patterns resemble failed corticolimbic inhibition patterns in classic PTSD (Reinders et al., 2014; Reinders et al., 2016). In contrast, when individuals with DID are in a numb, detached self-​state (also termed “neutral identity/​ personality state” or “apparently normal part”), brain patterns resemble excessive corticolimbic inhibition patterns in the dissociative subtype of PTSD (Reinders et al., 2014; Reinders et al., 2016). These findings suggest that individuals with DID oscillate between common PTSD brain patterns when thinking about and re-​experiencing their own traumatic events. SPECT-​based work supports these conclusions when an individual with DID is at rest. Şar and colleagues (2007) found increased activity in medial and lateral prefrontal areas for individuals with DID compared to control participants.

Structural Findings In addition to brain function, several studies have demonstrated similar brain structure in DID and PTSD, with some distinguishing patterns that may be specific to DID symptomatology. Structural hippocampal findings have been central to neurobiologically connecting PTSD and DID. One of the largest neuroimaging studies of PTSD to date definitively demonstrated smaller hippocampal volume in PTSD versus trauma exposed controls (Logue et al., 2018). As discussed earlier, smaller hippocampal volume has also been demonstrated in DID and dissociative disorder cohorts (Chalavi et al., 2015a; Chalavi et al., 2015b; Ehling et al., 2008; Irle et al., 2009; Tsai et al., 1999; Vermetten et al., 2006; however, c.f., Weniger et al., 2008 for contrasting evidence). Furthermore, hippocampal volume was negatively associated with the severity of trauma history (Chalavi et al., 2015a; Chalavi et al., 2015b). When brain structure was directly compared between DID and PTSD cohorts, both had smaller whole brain, frontal, temporal, and insular gray matter volume compared to nonpsychiatric controls (Chalavi et al., 2015a). In addition, the DID group had larger putamen and pallidum compared to the PTSD group, and the volume of these structures was positively associated with dissociative symptom severity (Chalavi et al., 2015a). Furthermore, some hippocampal subfields, CA4-​dentate gyrus and subiculum, were smaller in DID compared to PTSD (Chalavi et al., 2015b).

Summary Taken together, this functional and structural brain imaging work continues to highlight DID as a posttraumatic developmental adaptation, and it has begun to place DID on a continuum with PTSD. Corticolimbic inhibition has emerged as a mechanism of depersonalization and derealization in both PTSD and DID, and individuals with DID display either an excess or failure of corticolimbic inhibition depending on the experimental conditions and self-​state. Future work is needed to identify the neural correlates specific to other forms of dissociation experienced by individuals with DID. Furthermore, the basal ganglia are emerging as key regions that may distinguish PTSD and DID given structural findings related to the putamen and pallidum (Chalavi et al., 2015a), differential brain activity between self-​states in the caudate and pallidum (Reinders et al., 2006), and activity in the nucleus accumbens and substantia nigra while transitioning between self-​states (Savoy et al., 2012; Wolk et al., 2012; Tsai et al., 1999). The basal ganglia have been implicated in diverse functions including habit, skill, and reward learning, working memory, motor control, planning, reasoning, problem solving, language, and processing emotional stimuli (Packard & Knowlton, 2002; Stocco, Lebiere, & Anderson, 2010; Pierce & Péron, 2020). Overall, they may serve to gate and perhaps select or coordinate diverse, competing response patterns across cognitive, affective and motoric domains (Pierce & Péron, 2020; Stocco et al., 2010). Thus, we hypothesize that these structures may be critical to the experience of a mind made up of a self-​state system with many competing and conflicting thoughts and feelings.

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On a final note, while there are several studies directly comparing DID to PTSD groups in brain structure, there are currently no studies that directly make this group comparison with brain activity or connectivity. This is a major gap in the data needed to distinguish overlapping versus unique patterns between PTSD and DID.

A Neurobiological Fingerprint of DID? Case studies aside, the work reviewed so far tells us about average patterns of brain structure and function in DID. However, this does not mean that any one individual with DID would necessarily approximate this average pattern given the substantial variability in brain structure and function across individuals. It is still an open question whether it is possible to look at an individual’s brain and determine whether or not they have DID. However, recent machine learning-​based work has begun to answer this question. Machine learning is a type of artificial intelligence in which computer algorithms build a model based on a set of data and use that model to make predictions. Importantly, these predictions are not explicitly programmed by the experimenter. Using only data about brain structure, pattern classifiers could distinguish between DID and nonpsychiatric control brains with relatively high sensitivity and specificity (Reinders et al., 2018). Both DID-​related increases and decreases in gray and white matter volume distributed across the brain drove the prediction in this model. Similarly, a recent study demonstrated an individual’s overall pathological dissociation score, a marker of DID symptom severity (Dell, 2006a), could be estimated using only brain functional network connectivity (Lebois et al., 2021). Two networks that emerged as central to the results were the default mode and frontoparietal control network. The default mode network is implicated in internally-​focused attention often related to self-​related processing (Raichle, 2015), whereas the frontoparietal control network is involved in executive functioning like problem solving and working memory (Menon, 2011). These networks are coactive during internally-​focused problem solving or planning (Spreng, Stevens, Chamberlain, Gilmore, & Schacter, 2010). A pattern of hyperconnectivity between the default mode network and frontoparietal control network emerged as the most predictive of DID pathology. This indicates that brain activity in these networks is synchronized in DID. Furthermore, this pattern was measured across conditions of rest, a challenging attention task, and an emotional faces paradigm, indicating synchronicity between default mode and frontoparietal control networks may be a task-​independent biomarker of pathological dissociation. In aggregate, these two studies move us closer to identifying a structural and functional “fingerprint” of DID in the brain that could be used to reliably identify someone with DID on an individual basis.

Peripheral Psychophysiology of DID A small body of work has begun to ground DID in peripheral psychophysiology. Depending on the experimental context and self-​state, individuals with DID fluctuate between patterns reflective of hyper and hypoarousal in their peripheral physiology. Furthermore, psychophysiological markers demonstrate that self-​states sometimes display similar or disparate patterns depending on the emotional content of the stimuli.

Common Methodologies Most psychophysiological work in DID focuses on electrodermal activity, that is, changes in electrical activity of the skin. Increased skin conductance reflects increased arousal. Other common recordings include heart rate, heart rate variability and blood pressure. Increased heart rate variability demonstrates flexibility in autonomic response, which is typically thought to be adaptive, whereas decreased variability implies a rigid response despite changes in context. Changes in heart rate cause blood pressure to rise or fall, for example, as the heart beats more times per minute, blood pressure rises as blood vessels expand to allow more blood to flow more efficiently. Some studies also leverage electromyography (EMG) to measure electrical activity produced by muscles in various paradigms. In particular, EMG has been used to measure muscle movement near the eye when an individual startles (i.e., eye blink startle response).

Psychophysiology of Self-​states Like the neurobiological work, most peripheral psychophysiological research has focused on demonstrating different patterns across self-​states within an individual with DID. All studies conducted to date have demonstrated different patterns across self-​states in the peripheral psychophysiology; however, the pattern depends on the experimental

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context. For example, two case studies demonstrated skin conductance response differences across states when reading emotionally provocative words (Ludwig et al., 1972; Prince & Peterson, 1908). The increased skin conductance response was only present when the words were identified as personally meaningful in a specific self-​state. All states, however, had an increased skin conductance response in a conditioning task regardless of the state in which the conditioning originally occurred (Ludwig et al., 1972). Several other case studies conceptually replicated and extended these findings. Specifically, changes in respiration, heart rate, and skin conductance response were observed across different states (Bahnson & Smith, 1975). Changes in light intensity elicited a different pattern across self-​states in heart rate, skin conductance, blood pressure, and in particular, EMG (Larmore et al., 1977). In addition, skin conductance response changed across self-​states, and the pattern was different depending on whether the participant was attempting to control versus express emotions (Brende, 1984). This case study work is bolstered by two group-​based studies that also demonstrated, across self-​states, different heart rate and respiration patterns in a rest and habituation paradigm (Putnam, Zahn, & Post, 1990), and different blood pressure, heart rate and heart rate variability in a symptom provocation paradigm (Reinders et al., 2006).

Simulating Controls Some work compared self-​states in DID to those generated by controls simulating DID. Across rest, a habituation paradigm, and a symptom provocation paradigm, no simulating controls have replicated peripheral psychophysiological patterns demonstrated across DID self-​states in heart rate, heart rate variability, respiration, skin conductance, or blood pressure, even when those controls were prone to involvement in fantasy (Putnam et al., 1990; Reinders et al., 2014; Reinders et al., 2016; Reinders et al., 2012). Importantly, as in the neurobiological studies, the simulating controls often did demonstrate differences in peripheral psychophysiology when simulating different states; it just was not the same pattern as the DID samples.

Summary Studies on the self-​state psychophysiology of DID, taken together with neurobiological studies, demonstrate that self-​ states are dynamic, distributed networks of brain activity that prepare the body to interact with the world in a particular way. Given this, self-​states are “visible” in both the central and peripheral nervous system and differences across states are context-​dependent. An emerging pattern based on this work suggests that differences in self-​states may be more readily discernible in more emotionally provocative contexts (e.g., Ludwig et al., 1972; Reinders et al., 2006). Additionally, the fact that controls simulating DID could not replicate DID self-​state patterns again suggests DID is not a disorder of role-​playing, fantasy proneness, suggestibility, fabrication, and/​or factitiousness.

Placing DID on a Continuum with PTSD Psychophysiology –​Evidence of a Posttraumatic Adaptation Much like the neurobiological work on DID demonstrating overlap with PTSD, the peripheral psychophysiology is beginning to show a parallel overlap. As described earlier, the research paradigm with the strongest evidence for this overlap is symptom provocation. These studies show that an excess of corticolimbic inhibition during depersonalization and derealization is visible in the peripheral nervous system in both PTSD and DID (Lanius et al., 2002; 2006; Reinders et al., 2014). For example, on average, individuals with the dissociative subtype of PTSD show no change or a decrease in heart rate while listening to trauma narratives (Lanius et al., 2002). In contrast, on average, individuals with classic PTSD (i.e., no or infrequent depersonalization/​derealization symptoms), show an increased heart rate during these conditions compared to control participants (e.g., Lanius et al., 2001). These contrasting PTSD results are mirrored in DID using the symptom provocation paradigm (Reinders et al., 2006; Reinders et al., 2012; Reinders et al., 2014; Reinders et al., 2016). When individuals with DID are in a hyperaroused self-​state, peripheral psychophysiology patterns resemble failed corticolimbic inhibition patterns in classic PTSD. Specifically, individuals with DID demonstrate higher heart rate frequency and systolic blood pressure and decreased average heart rate variability while listening to trauma narratives. In contrast, when individuals with DID are in a numb, detached self-​state, peripheral psychophysiology patterns resemble excessive corticolimbic inhibition patterns in the dissociative subtype of PTSD. Specifically, individuals with DID demonstrate lower heart rate, systolic blood pressure, and more heart rate variability. A symptom provocation case study supports these conclusions, demonstrating a decrease in heart rate during a trauma narrative when the participant with DID was experiencing depersonalization (Williams, Haines & Sale, 2003). This suggests that individuals with DID oscillate between common PTSD patterns in the autonomic nervous system when thinking about and re-​experiencing their own traumatic events.

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Two studies have also demonstrated reduced or a trend toward reduced habituation in DID groups (Dale et al., 2008; Putnam, Zahn, & Post, 1990). For example, individuals with DID maintained a startle response in EMG signal to auditory stimuli, whereas control participants no longer startled after some time in the task (Dale et al., 2008). This reduced habituation pattern is typically found in PTSD samples during conditioning paradigms and reflects a failure of extinction and inhibitory learning (Lebois et al., 2019).

Summary In aggregate, peripheral psychophysiology work continues to highlight DID as a posttraumatic developmental adaptation, and like the neurobiological work, it has begun to place DID on a continuum with PTSD. Corticolimbic inhibition is not only measurable in brain activity, but also visible in the peripheral physiology as a mechanism of depersonalization and derealization in both PTSD and DID. Individuals with DID display either an excess or failure of corticolimbic inhibition depending on the experimental conditions and self-​state. Notably, no studies have directly compared DID and PTSD within one study to more definitively determine overlap versus physiological correlates that may be unique to DID. This is a key direction for future work.

Digging Deeper: DID Research Moving Forward Conclusions In this review, we have grounded DID in modern theories of cognition, and experience in the world and body. Research suggests that self-​states are dynamic, distributed networks of brain activity that prepare the body to interact with the world in a particular way. This distributed network of brain activity represents a constellation of perceptions (e.g., vision), actions (e.g., movement) and internal states (e.g., affect) stored in memory based on past experience. To a certain extent, brain activity associated with past experience while in a specific self-​state is reactivated when someone is currently in that state or thinking about that self-​state, and this reactivation is context-​dependent. Using this grounded cognition framework demystifies seemingly contradictory evidence in biological studies of DID and self-​ states in which different states do not always show consistent patterns across experimental conditions. These findings are not actually conflicting –​one would anticipate situation-​specific manifestations given this conceptualization of self-​ states. Similarly, given this theory, valence, levels of arousal, emotion, or felt sense of ownership over memories could all or at various times contribute to different patterns seen across self-​states in neuroimaging and psychophysiological paradigms. This helps to sharpen predictions in future work examining self-​states in DID. Work to date shows that DID is associated with childhood trauma, severely dysfunctional family dynamics, and in theory, disorganized attachment. These environmental circumstances interact with a genetic predisposition for the capacity to dissociate. An important implication of this work is that these environmental circumstances and experiences must occur during an early developmental window for DID to manifest –​an acute onset adult trauma in the absence of early childhood trauma does not produce DID. In a related line of thinking, given gene by environmental interactions in other psychiatric disorders, even these environmental circumstances will likely not always produce DID if the person does not have a genetic predisposition towards dissociation or their genetic loading for DID is very low. Finally, research demonstrates that DID is grounded in unique biological patterns. Self-​states have differential brain activity and peripheral physiology across various paradigms and levels of integration. DID has distinguishable patterns in brain structure, function, and peripheral psychophysiology compared to nonpsychiatric controls and people simulating DID. Additionally, corticolimbic inhibition is a key mechanism of depersonalization and derealization in DID. Lastly, cutting edge machine learning work suggests DID and pathological dissociation can be identified in the brain on an individual basis–​an early proof of concept demonstration moving us one step closer to having a neurobiological fingerprint of DID that could be used to identify someone with these experiences just by looking at their neurobiology. Altogether, this work is beginning to build a body of evidence demonstrating what many clinicians and people with lived experience have long known–​DID is a valid disorder and a developmental posttraumatic adaptation.

Remaining Questions Notwithstanding the reviewed seminal work, many gaps remain in our understanding of DID. For example, the literature linking DID with disorganized attachment and the development of self-​states is currently theoretical. There are no genetic or epigenetic studies of DID, and no brain function or psychophysiological studies directly comparing DID and PTSD cohorts. Also, differing levels of self-​state integration are large sources of unaccounted for variance in

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research findings to date. Furthermore, while brain differences between DID and control cohorts have been identified, a remaining question is whether these differences in brain structure and function are pre-​existing vulnerabilities that increase the likelihood of developing DID following severe childhood trauma or if they are changes that develop as adaptations to severe childhood trauma –​or some combination thereof. These gaps point toward exciting opportunities for new research. In light of this synthesis, we have several recommendations for future work grounding DID in world and bodily experience. First, an overwhelming amount of evidence supports DID as a valid diagnosis with strong content, criterion and construct validity (Dorahy et al., 2014). Given this pivotal work, we may be at a juncture in the field where we can move beyond research efforts whose central focus is to prove or disprove the “reality” of DID. In a similar vein, it will be helpful to diversify comparison groups beyond those that simulate DID to controls that allow us to pinpoint even more nuanced psychobiological mechanisms in DID. For example, nonpsychiatric controls in altered states of consciousness (e.g., hypnosis) or experiencing perceptual illusions (e.g., rubber hand illusions) may be fruitful comparisons. Likewise, psychiatric controls will allow us to identify mechanisms that are unique to DID as opposed to more general psychopathology. In particular, comparison to the different subtypes of PTSD will further elucidate common and unique characteristics of DID as a trauma-​spectrum disorder, and comparison to bipolar disorder may shed light on shared versus unique correlates of mental state shifts. Several topics that remain understudied in DID include state versus trait dissociation, self-​related processing, basic science models, developmental trajectories, treatment studies and individual variability in DID presentation. For example, we have yet to identify reliable markers of state-​based fluctuations in dissociation. Robust biomarkers are critical for future clinical trials of trauma and dissociation-​related treatment. Likewise, nascent attempts at basic science models of dissociation have recently emerged (Meloni et al., 2016; Vesuna et al., 2020), and more work in this area may also help identify novel treatment targets down the line. Additionally, few studies exist that systematically or longitudinally document child manifestations of DID and early intervention, and none that we are aware of measure biological mechanisms. Not only would this inform treatment modalities and developmental trajectories in DID, but it would also inform yet to be identified mechanisms of typical identity development in comparison. Lastly, like PTSD, DID is a heterogeneous disorder (Kluft, 1999; Ross, 1997). Biological studies may help us distinguish between different DID subtypes and stratify cohorts for future clinical trials. The field is currently standing on fertile ground for future research and greater insight into DID.

Acknowledgments We are grateful to Richard Chefetz, MD for feedback on this chapter and our research participants who have taught us so much about lived experience with trauma and DID. Funding Sources: The work was supported by National Institute of Mental Health K01MH118467 to LAML, and the National Institute of Mental Health R01MH119227, McLean Hospital Trauma Scholars Fund, the Barlow Family Foundation Fund, and the Julia Kasparian Fund for Neuroscience Research to MLK.

Note 1 Traditional theories of cognition suggest knowledge is stored in memory separate from the brain’s systems for perception (e.g., olfaction), action (e.g., movement), and introspection (e.g., mental states). Backed by neuroscience, grounded cognition instead proposes these systems underly cognition.

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Fragmentation and Beyond Considering the mind as an integrated system, which strives to maintain the biopsychosocial “homeostasis” of the individual, any psychotic condition, per this definition, implies some type of “disintegration” of this functional unity. Such disintegration may affect one or more mental processes, with a particular emphasis on thinking, because psychosis is characterized by difficulties determining what is real and what is not. Thus, loss of cognitive insight may occur. Such disintegration may lead to lack of motivation, emotional difficulties, social withdrawal, difficulties carrying out daily activities, sleep problems, incoherent speech, and behavior inappropriate to the situation. Psychosis may be associated with a variety of syndromes. Among them are schizophrenia, bipolar disorder, acute and chronic organic mental disorders, and many other psychiatric conditions, which increase proneness to, or may be complicated by, psychosis. Psychosis may be acute and transient or chronic and life-​long. From an etiological point of view in general psychiatry, psychotic disorders have been considered as either “reactive” (trauma-​or stress-​related) or “endogenous” (constitutional, neurobiological), or “exogenous” (directly related to the effects of toxic substances or of medically diagnosable bodily illness). Dissociation is defined in DSM-​5 (American Psychiatric Association [APA], 2013) as a disruption in the usually integrated functions of consciousness, memory, identity, sensori-​motor abilities, or perception of the environment, and therefore also constitutes a type of disintegration (Scalabrini et al., 2020; see Farina & Meares, Chapter 3, this volume). From another perspective, which is still related to mental fragmentation, the construct of dissociation can be conceptualized as estrangement or detachment from one’s subjective experience, or “depersonalization” in its broader sense (Şar, 2017; Şar, Alioğlu, & Akyüz, 2017a; Şar and Öztürk, 2009). Interestingly, as well as being common in dissociative disorders, some types of depersonalization and/​or derealization also occur in psychotic disorders (Graux, Lemoine, El Hage, & Camus, 2012). Depersonalization/​derealization were found to be associated with mistrustful beliefs in dissociative identity disorder (DID) but not in schizophrenia (Martinez et al., 2021), while in this latter group they predict auditory hallucinations (e.g., Perona- ​Garcelán et al., 2012). Nevertheless, this difference does not necessarily point to distinct psychopathogenetic roots of depersonalization/​derealization in the two conditions (e.g., the difference may represent the severity of mental fragmentation). Depersonalization connotes an impairment in the sense of ownership of mental phenomena which Jaspers (1913) called “personalization” –​the experience that all psychological faculties (perception, body perception, memory retrieval, imagination, thought, feeling, etc.) belong to oneself (Ataria, 2015). Janet (1919/​1925, cited by Van der Hart, Steele, Boon, & Brown, 1993), when describing disturbed “realization” of one’s traumatic past, also referred to the role of diminished  “personalization”  in dissociative disorders, as occurring alongside a deficiency in “presentification,” the ability to differentiate past, present, and future. Disconnection from the present moment, common in dissociation, is captured by detemporalization (Bailey, Boyer & Brand, 2019). Beere (1995), from the perspective of perceptual theory, underlined the role of “loss of background” in the development of dissociation, a mechanism which he attributed to psychological trauma (see Beere, Chapter 17, this volume). The “perceptual background” of an experience is proposed to be composed of five components: (1) I, (2) having this mind, (3) in this body, (4) in this world, (5) all of which are in time. Erikson (1950 /​1963) emphasized the significance of “mutuality” in his theory of human development, a concept which mainly reflects the effect of generations on each other, especially among families, and particularly between parents and children and grandchildren, as well as between the developing “psychosocial mutuality” child and the

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caretaker from early on. While describing psychosocial mutuality as a prerequisite of healthy psychological development, he stated that, the bizarreness and withdrawal in the behavior of many very sick individuals hides an attempt to recover social mutuality by a testing of the borderlines between senses and physical reality and between words and social meanings. p. 248 To describe a relatively general model of dissociation covering a disturbance of psychosocial mutuality, Şar (2017) proposed “parallel-​d istinct structures” of the internal and external world, which may be de-​syncronized in the aftermath of psychological trauma.

Psychosis as a Transdiagnostic Phenomenon The American Psychiatric Glossary (Stone, 1988) defines psychosis as: a major mental disorder of organic or emotional origin in which a person’s ability to think, respond emotionally, remember, communicate, interpret reality, and behave appropriately is sufficiently impaired so as to interfere grossly with the capacity to meet the ordinary demands of life. This term is applicable to conditions having a wide range of severity and duration, including schizophrenic, mood, and organic mental disorders. p. 139 However, several psychiatric disorders which were considered as belonging to the “non-​psychotic” domain may also manifest symptoms which typically occur in psychotic disorders (e.g., transient hallucinations or disorganized behavior in PTSD or paranoid ideation during transient crises in BPD) or loss of cognitive insight (e.g., obsessive-​compulsive disorder) which is a further typical criterion of psychosis. Thus, psychosis may also be defined as a transdiagnostic concept. As such, some patients with both acute and chronic dissociative disorders may also show various features of psychosis. In addition to the possibility of loss of cognitive insight after a particular level of severity (e.g. delusional belief about separateness of alternate personality states which may end up by suicide in the way of “internal homicide,” Putnam, 1989), dissociative disorders may lead to incapacitation at a psychotic level, particularly during an acute crisis situation (Tutkun, Yargıç, & Şar, 1996).

The Concept of Reactive Psychosis Spiegel and Spiegel (1978) noted that patients with a previously good level of functioning may respond to severe environmental stress with rapid psychotic decompensation. They may be delusional and have ideas of reference, loose associations, and affect disturbance that may range from bland indifference or flatness to intense agitation. They frequently garner tremendous attention and anxiety from their social network. These patients often recompensate rapidly, especially when an appropriate intervention is made in their environment. From a general psychiatric perspective, brief psychoses are poorly understood; they probably are a heterogenous group of psychotic disorders that have long created diagnostic dilemmas for psychiatry (Susser, Fennig, Jandorf, Amador & Bromet, 1995). The relationship of these cases to schizophrenic disorder and mood disorders remains uncertain (Susser & Wanderling, 1994; Susser, Varma, Malhotra, Conover & Amador, 1995).

Psychogenic Psychosis Psychogenic psychosis is usually considered as reactive to an “external” event (i.e., trauma-​or stress-​related) or a consequence of intrapsychic conflicts or other possible “psychological” dynamism (e.g., defense mechanism). This contrasts with schizophrenia and bipolar disorder, which have been considered “endogenous” (i.e., conditions with an unknown, but supposedly biological, origin; Strömgren, 1986) at least among psychiatrists who subscribe to a “medical model” of psychiatry. Scandinavian psychiatrists adopted Jasper’s distinction between process schizophrenia (presumed to be organically based) and reactive psychoses, with a better prognosis for the latter (Gelder, Gath, Mayou & Cowen, 1996). In Denmark and Norway, the terms “reactive psychosis” or “psychogenic psychosis” are commonly applied to conditions which appear to be precipitated by stress, consist of symptoms that are to some extent understandable, and have a

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good prognosis (Strömgren, 1974, 1986). In France, the term “bouffée délirante polymorphe aigüe” (literally, “acute polymorphous delusional puff”) is used for a sudden-​onset syndrome of good prognosis (Pichot, 1982, 1984). In Germany, Leonhard (1957/​1979) published a classification which distinguishes schizophrenia from the cycloid psychoses, a group of non-​a ffective psychoses with a good outcome. The concept of a psychogenic psychosis distinct from schizophrenia has persisted in most of Europe throughout the twentieth century (Faergeman, 1963; Strömgren, 1974). The mainstream of North American psychiatry and the Bleulerian tradition place these conditions at the psychogenic pole of a broad schizophrenic spectrum. European psychiatry and the Kræpelinian tradition, with their narrower definition of schizophrenia, kept a niche for acute reactive dissociative psychosis (ARDP) and DID cases in the psychogenic psychosis category without an overt intention to do so. For example, Turkish psychiatry has recognized the existence of an ARDP (i.e., hysterical psychosis) distinct from schizophrenia or any other “endogenous” psychosis for many decades (Ozturk & Göğüs, 1973). This notion provided a firm ground for the discovery of DID in the 1990s (Şar, Yargıç, & Tutkun, 1996), which had remained unrecognized for decades. The first cases of DID were identified among psychiatric inpatients who were thought to have an acute ARDP rather than schizophrenia, as shown by their improvement and lack of schizoptypal sequelae during follow-​up (Tutkun, Yargıç, & Şar, 1996). Their seemingly acute condition was a transient crisis episode superposed on an unrecognized chronic dissociative process. Langness (1965) considers the bena bena syndrome in the New Guinea highlands as a dissociative psychosis which he saw as not limited to certain cultures (Langness, 1967). Many conditions which were previously categorized as culture-​ bound or exotic syndromes (Meth, 1974) may have dissociative quality. These include amok (Indonesia), bebainan (Indonesia), latah (Malaysia), and pibloktoq (Arctic).

Reality Testing According to the American Psychiatric Glossary (Stone, 1988 p.143) reality testing is “the ability to evaluate the external world objectively and to differentiate adequately between it and the internal world.” On the other hand, impaired reality testing is considered one of the central features of psychosis. Patients with DID or related types of other specified dissociative disorder (OSDD) usually have insight into their illness. Their reality testing is intact except during ARDP episodes. The dissociative patient’s claim of containing in them the existence of another person or of having more than one personality seems to be the reflection of an experience rather than a primary disturbance of thought –​the actual experience of the “other inside” as “not me” (Sullivan, 1953). Among dissociative subjects, external reality and the internal world are not confused either permanently or pervasively. When this confusion does occur, it does so only in a time-​ limited manner or it may be restricted to an alternate personality state. A minority of patients with DID may claim separateness of alternate personality states to a degree that reflects a circumscribed form of diminished insight.

“Borderline” Conditions Some prodromal cases of schizophrenia were historically labeled pseudo-​neurotic schizophrenia or borderline schizophrenia (Hoch & Polatin, 1949). After a period of debate about its relationship to schizophrenic and affective disorders (Akiskal, 1981; McGlashan, 1983), the borderline syndrome was formally classified as Borderline Personality Disorder (BPD) and included on Axis-​II in DSM-​III (American Psychiatric Association, 1980). These cases were considered psychosis-​prone (Volkan, 1987). The psychoanalytic notion of “borderline personality organization” was taken as a conceptual basis for defining borderline conditions as a personality disorder (Kernberg, 1967). In fact, the psychoanalytic concept identified a broader spectrum than the DSM diagnosis of BPD. While the diagnostic criteria of the latter identified a group of individuals reliably, the validity of this construct as a personality disorder remained questionable in consideration of its high comorbidity with other psychiatric disorders (Akiskal, 1981; Gunderson, 1984), dissociative disorders among them (Şar et al., 2003, 2006). Research concerning paranoid ideation and depersonalization/​derealization among patients with BPD (Zanarini, Gunderson, Frankenburg & Chauncey, 1990) led to the introduction of the ninth diagnostic criterion of BPD in DSM-​I V, which states: “during periods of extreme stress, transient paranoid ideation or dissociative symptoms may occur, but these are generally of insufficient severity or duration to warrant an additional diagnosis” (APA, 2013, p. 664). While the combination of dissociative symptoms and paranoid ideation in the same criterion may be problematic, studies report a high frequency of dissociative symptoms among patients with BPD (Brodsky, Cloitre & Dulit, 1995; Zanarini, Ruser, Frankenburg & Hennen, 2000). Roughly two thirds of patients with DSM-​III-​R BPD (i.e., without

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the ninth criterion) and three quarters of subjects with DSM-​5 BPD have symptoms which are not simply stress-​related or transient, and which call for a separate diagnosis (Şar et al., 2003, 2006). Among the most frequently observed dissociative symptoms are chronic or repeated depersonalization-​derealization, dissociative amnesia, and symptoms associated with DID; that is, identity confusion and alteration (Şar et al., 2014; 2017a, 2017b; See Korzekwa & Dell, Chapter 31, this volume). Consequently, the dissociative psychopathology seen in these putative BPD patients extends far beyond the boundaries of BPD’s ninth diagnostic criterion. In one of the earliest papers distinguishing BPD from neurotic disorders, Stern and Stern (1938) reported 75% of individuals with BPD had early childhood histories marked by lack of spontaneous maternal affection, many parental quarrels, including temper outbursts directed at the child, early divorce and separation or desertion, and actual cruelty, neglect, and brutality by the parents over many years. Although later etiological theories seemed to almost entirely overlook the role of what today would be considered adverse childhood experiences in fostering BPD, modern empirical studies revived this earlier insight; that is, high rates of childhood abuse and/​or neglect have been reported as central to BPD (Herman, Perry & Van der Kolk, 1989) and dissociative disorders (Chu & Dill, 1990). Chu and Dill (1990) and Meares (2012) argued that BPD is a type of post-​traumatic syndrome involving the mechanism of dissociation. Kernberg regarded “splitting” (following Melanie Klein) as the main defense mechanism in BPD, whereas some current authors (e.g., Ross, 1997) would reinterpret splitting as dissociation. Alternation between dissociated self-​states may account for the identity disturbance, affective instability, and idealizing and devaluing relationships characteristic of BPD (Blizard, 2003).

Crisis and Process Psychotic symptoms may occur not only in chronic but also in acute dissociative disorders. While chronic dissociative disorders such as DID and its partial forms should be differentiated from schizophrenic disorder, acute types of dissociation require differentiation from a brief psychotic disorder. A dissociative condition may cause subjective distress or interfere with daily functioning to a certain extent, but may not lead to a collapse of overall social adjustment for a prolonged period. For example, there may be some occupational and intimacy problems, difficulties in school, fluctuating suicidal tendencies, or depressive mood. Despite this suffering, a chronic dissociative disorder may remain dormant for a long time (Kluft, 1985). Most subjects with a chronic dissoiative disorder enter the mental health system in response to acute stress created by a crisis situation which they are unable to resolve with their own psychological resources. For example, a patient with DID may enter an unstable phase characterized by rapid switching of personality states, severe anxiety and depression, fear due to hallucinations, etc. Such a condition may even lead to hospitalization. Outside these crisis moments, there are transient conditions which interfere with the normal activities of daily living but last no longer than a few hours. These episodic behavioral disturbances include functional (dissociative) neurological symptoms (e.g., pseudoseizures), flashbacks, self-​mutilation, suicide attempts, or micro-​psychotic episodes. Thus, such acute conditions should raise suspicion about an underlying chronic dissociative disorder, particularly if the seemingly acute condition tends to be persistent or repetitive (Şar, Akyüz, Kundakçi, Kızıltan & Doğan, 2004).

Psychotic Symptoms in Dissociative Disorders Dissociative disorders and schizophrenia share a number of symptomatological similarities, such as auditory hallucinations, paranoid ideas and Schneiderian first-​rank symptoms, such as “made” behaviors, thoughts, and feelings (i.e., the experience of one’s mental activities being generated, owned, and/​or controlled by an agent other than oneself (Kluft, 1987; Ross et al., 1990a; Şar & Öztürk, 2019).

Hallucinations A recent meta-​analysis reported a robust link between dissociation and hallucinations distinct from flashbacks (Longden et al., 2020). Moreover, dissociation mediates the relationship between childhood trauma and hallucination-​proneness (Varese, Barkus, & Bentall, 2012) and subclinical psychosis (Cole, Newman-​Taylor & Kennedy, 2016). Among patients with DID, 80–​90% report auditory hallucinations (Loewenstein, 1991; Ross et al., 1990a). The voices may be talking, commenting, arguing, or screaming. They may be pejorative and critical or supportive. The “voices” usually have the capacity to enter into a dialogue with the clinician (Putnam, 1989). Such “voices” originate typically from dissociative identities talking and they typically disappear following fusion of the related personality states with the host personality. In dissociative disorders, visual hallucinations are also frequently reported (Putnam, 1989). They may have a dramatic

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quality such as seeing a person, an animal, or an unidentifiable creature or they also may have an elementary quality such as perceiving a light. Hallucinations may also be perceived as belonging to a “foreign entity” localized within the person, to an imaginary companion, or to an external source influencing them (i.e., possession). Due to a lack of awareness about the nature of the condition, many patients do not recognize the hallucinatory internal dialogues as dissociative identities communicating with each other. Where these voices begin in the early years of life, the patient may get used to them to believe that they are ordinary experiences common to everyone (Dorahy et al., 2009). Other types of hallucinations in DID are related to secondary fixed symptoms as reported by Janet. They do not represent voices or images of another dissociative identity and unlike other voices, a dialogue cannot be started with these voices. Hostile dissociative identities may also generate hallucinations with the intention to frighten and punish the host personality. The source of these visual and/​or acoustic experiences may be difficult to identify as these experiences may also come from an alter trying to overcome the host personality’s amnesia or denial of associated traumatic experiences (Sakarya et al., 2012). These intrusions are characterized by strong sensory, motor and perceptual representations (Brewin, 2001). Compared to psychotic disorders, hallucinations experienced as having an internal locus (“voices inside the head,” as opposed to voices seemingly emanating from external sources) are considered more typical of dissociative disorders (Stephne et al., 2003). However, there are also findings which challenge this notion (Dorahy et al., 2009; Honig et al., 1998). Compared to those with schizophrenia, patients with DID tend to report having started to hear voices before 18 years of age, hearing more than two voices, including hearing both child and adult voices (Dorahy et al., 2009). Laddis and Dell (2012) reported that compared to those with schizophrenia, DID patients had higher scores for hearing child, angry, persecutory, and commenting voices.

Schneiderian Symptoms Schneiderian symptoms consist of certain types of auditory hallucinations, passive-​influence (i.e., made) experiences, delusional perceptions, and experiences of diffusion of self. They can typically include voices talking about the patient, commenting on their thoughts, or as repeating them (Schneider, 1946/​1976). Experiences of thought withdrawal, thought insertion, thought broadcasting, audible thoughts, and having thoughts different from the patient’s own, point to a subjective feeling of alienation from self. Made thoughts, feelings, and impulsive actions are also commonly experienced in DID. Schneider’s originally proposed that these symptoms were pathognomonic for schizophrenia. However, they have been consistently observed in DID patients as well (Kluft, 1987; Ross et al., 1990b). In a series with DID, 89% of patients reported three or more Schneiderian symptoms on average (Ross et al., 1990a). In comparison with schizophrenic disorder, DID patients have even higher scores of passive influence symptoms (Laddis & Dell, 2012) such as the experience of their bodies being controlled by an outside force, or thought withdrawal. In a study of women in the general population, those with a dissociative disorder had 2.4 Schneiderian symptoms on average; this rate was 0.3 for non-​d issociative participants (Şar et al., 2007). Patients with DID report hallucinations and passive influence symptoms commonly, however, they rarely express thought diffusion, thought projection, or delusional perception (Kluft, 1987). Patients with schizophrenic disorder have higher delusion scores than those with DID (Laddis & Dell, 2012). In DID, passive influence experiences can be related to dissociative identity activities. In many schizophrenia cases, however, the “delusional perception” comes first and an interpretation of the environment in a new way follows this (i.e., in a manner consistent with that delusional perceptual framework, Schneider, 1946/​1976). A subgroup of patients with DID (mostly adolescents) may report that their mind is read by other individuals. This phenomenon may reflect the expression of a hidden personality state carrying a perspective from very early childhood (e.g., representing a limited theory of mind) or even a consequence of perceived and/​or ongoing intrusive attitudes (“mind control”) by caretakers (Şar, 2020).

Loss of Insight As previously noted, reality testing is intact in patients with dissociative disorders except during ARDP episodes. The “internal world” is rarely confused with “external reality” which is commonly the case in psychosis. When reality testing is impaired in DID, it is only in a time-​limited and/​or circumscribed fashion. A core aspect of the cognition of DID is the so-​called “trance-​logic.” This relates to the tolerance and/​or rationalization of logical inconsistency while being in a hypnotic state. The patient with trance logic can conform to the expectations of “normal” daily life while maintaining beliefs which do not fit the external reality. The same mechanism also allows co-​existence of mutually

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inconsistent thoughts. Bleuler (1911) had similar observations of the patients with schizophrenia which he called “double bookkeeping” without mentioning dissociation. Accordingly, Kluft (2003) referred to “alternating reality states,” Şar (2017) mentions “parallel-​d istinct structures” of the mind. Dissociative trance-​logic is the mechanism which allows the patient to maintain the belief that dissociative identities are separate. This may have important behavioral consequences. The patient may consider dissociative identities as friends in the real world. It is possible that the “murderous” hostility of a “persecutory” personality state against the “host” personality may lead to a suicide attempt or completed suicide as the patient may not comprehend that both personality state share the same body. This is what Putnam (1989) has called as “internal homicide.” Another example occurs when a persecutory personality state is projected onto a person in the environment. An experience which creates similar consequences happens when a persecutory state is experienced as a hallucination in the outside world. Namely, these phenomena may resemble a paranoid condition unless the association of the symptoms with the projection of dissociative identities is considered. Dissociative patients are usually aware of the pathological quality of these phenomena, whereas those with schizophrenia usually lose insight about the abnormal nature of their symptoms. In a comparative clinical study, cognitive insight of patients with DID or OSDD was better than patients with a schizophrenic disorder (Şar et al., 2012). Dissociative patients did not significantly differ from obsessive-​compulsive disorder or major depression groups on cognitive insight scores. Interestingy, different than the latter two non-​psychotic groups and similar to the schizophrenic group, dissociative patients had heightened “self-​certainty” (i.e., rigidity of thought in terms of certainty about one’s beliefs and conclusions. However, their capacity for “self-​reflection” (i.e., objectivity, reflectiveness, and openness to feedback) was better than those with schizophrenia, so their overall cognitive insight remained still in the non-​ psychotic range.

Grossly Disorganized Behavior Patients with a dissociative disorder may exhibit grossly abnormal behavior when under intense stress which differs from their relatively good adjustment to functions of daily life. States of stupor, episodic amnesias with or without fugue, flashback episodes, nonepileptic seizures and/​or other sensorimotor symptoms are examples. Child personality states may cause grossly abnormal behavior which may look like “regressive” (e.g., playing like a child). Rapid switching between personality states may generate unexpected changes in behavior or disruptive shifts in self-​presentation. Self-​mutilative impulses driven by a persecutory personality state, or an overall breakdown of dissociative defenses can also create abnormal behavior.

Formal Thought Disorder Formal thought disorder is characterized by disturbances in thought flow which typically occurs in patients with schizophrenia or organic mental disorder. Among these disturbances are loosening of associations, blocking, circumstantiality, tangentiality, verbal stereotypy, and neologisms. Dissociative patients have no formal thought disorder. However, switching between dissociative identities or micro-​amnesias may resemble a blocking in thought flow which is more typical in schizophrenic disorder (Putnam, 1989). Thus, severe crisis episodes may temporarily make the differentiation difficult.

Acute Reactive Dissociative Psychosis Acute dissociative reaction to a stressful event has been introduced as one of the OSDDs in DSM-​5 (APA, 2013). Such episodes are expected to have less than one-​month duration. This category primarily covers non-​psychotic conditions, but a psychotic form of this reaction is mentioned in the text (p. 292). In fact, acute reactive dissociative psychosis (ARDP) is a contemporary equivalent of the term “hysterical psychosis” (Hollender & Hirsch, 1964). Overall, an ARDP may resemble a schizophrenic, manic, and/​or organic mental disorder. Dissociative symptoms may be difficult to identify in the mixture of positive (e.g., Schneiderian) symptoms. Lack of affective flatness, a good premorbid psychosocial functionality, unexpected and sudden onset (often leading to emergency psychiatric admission) and abrupt improvement, as well as the dramatic nature of the hallucinations (e.g., hallucinating figures which are heard and seen) differentiate such dissociative episodes from other psychotic disorders. In ARDP, organic mental disorder (delirium) ought to be ruled out immediately, as this might imply a medical emergency. Suicidal and homicidal tendencies should be carefully evaluated, as any dissociative patient is at increased risk to

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act on these impulses during an ARDP. Admission to a closed unit is advised until the accurate diagnosis is established. Hospitalization itself may have a therapeutic effect, as patients may need to be removed from the stressors of their social environments for a certain time prior to returning to their premorbid levels of functioning.

Symptomatology Visual and auditory hallucinations, and disorganized or grossly unusual behavior, are predominant symptoms of ARDP. Thought form may appear discontinuous, and reality testing may be impaired. Child-​like behavior, trying to escape from home or even from the hospital room, catatonia, unorganized, or animal-​like behavior may be observed. Non-​ epileptic seizures and other sensorimotor (conversion, functional neurological) symptoms may also occur. There may be flashback experiences that may give the impression of hallucinations. The patient’s overall behavior and level of cooperation may fluctuate to periodically appear as improved and compliant. The patient appears affectively labile, typically cycling rapidly through a wide range of inappropriate emotions that may be misperceived as indicators of bipolar disorder. Due to rapid switching between mental states, the patient may exhibit extreme ambivalence, doing and undoing some act in a psychotic or perseverative fashion (Putnam, 1989). Occasionally, amnesia for the episode may persist.

Overlap between DID and ARDP ARDP and DID have rarely been studies in conjunction with each other. For example, Van der Hart and Spiegel (1993) consider both ARDP and DID as trauma-​induced severe dissociative disorders; however, they do not mention a possible overlap between the two. Yet Tutkun et al. (1996), evaluating Turkish patients for both conditions over a set time period, demonstrated a link between ARDP and DID. They concluded that ARDP might be a transient manifestation of a more chronic and complex dissociative disorder (DID or OSDD). In a patient with DID where the host identity is in control most of the time (with the alter identities being suppressed), accurately diagnosing the disorder may be extremely difficult. However, if a stressful event occurs, this equilibrium may disappear, rendering the presence of DID easier to detect. Intense distress may re-​activate many suppressed dissociative identities. As the host no longer has the “mental energy” to stay dominant, activities of other identities (and the formation of new ones) may ensue, and severe dissociative symptoms and flashbacks may find expression in the form of an ARDP. An acutely stressful event or internal conflicts may lead to a struggle for both control and influence between dissociative identities who have frightening, fearful, aggressive or delusional features, some of which may have been long dormant (Tutkun et al., 1996). This condition has been called a “revolving door” (Putnam, 1989) or “co-​consciousness” crisis (Kluft, personal communication, May 12, 1995). The former refers to rapid switching between dissociative identities due to a struggle for control, while the latter refers to a transient collapse of amnestic barriers between the senses of self. In this way, ARDP may serve as a “diagnostic window” (Kluft, 1987) for DID; for some patients, their psychiatric symptomatology may be limited to dissociative crises that occur sporadically throughout their lives.

Dissociation and Psychosis: Continuity or Comorbidity The perspective of a relationship between dissociation and psychosis is important not only for theory and research, but also for differential diagnostic work as well as possible approaches to psychotherapeutic and pharmacological treatment in composite cases. Given the common symptoms between two conditions, a misdiagnosis of the predominant psychopathology is possible in daily practice which may lead to delay in appropriate treatment tailored for a particular patient. Thus, clinicians should be aware of not only psychotic presentations of dissociative disorders but also dissociative symptoms in other psychiatric disorders such as schizophrenic disorder, which may contribute to misdiagnosis if not considered by the attending mental health professional.

The Dissociative Subtype of Schizophrenic Disorder As a transdiagnostic phenomenon (see Dalenberg, Katz, Thompson & Paulson, Chapter 5, this volume), dissociation can be an essential component of both simple and complex PTSD, DID, and BPD (Şar, 2011), as well as of an entire set of psychiatric conditions, such as eating, mood, somatic symptom, depressive, and even schizophrenic disorders (Lyssenko et al., 2018; Şar & Ross, 2006). In support of a dissociative subtype of schizophrenia (Ross, 2004), a study utilizing cluster analysis identified two subgroups of schizophrenic patients with elevated dissociation and childhood trauma

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scores (Şar et al., 2010). These two groups exhibited distinct characteristics. Each subgroup reported equally elevated scores on childhood emotional and physical neglect as well as more Schneiderian symptoms compared to the non-​ dissociative psychotic patients (Şar et al., 2010). Those with a history of childhood emotional abuse were characterized by higher positive symptoms of schizophrenia and symptoms associated with DID. Those who additionally had histories of childhood sexual and physical abuse had a more severe clinical condition. This was characterized by high positive and negative symptoms of schizophrenia and more lifetime and current general psychiatric comorbidity (including more meeting BPD criteria) than the other traumatized, dissociative group. There are also patients who could be characterized as suffering from a “schizo-​d issociative” condition (Ross, 2004). These patients present with an almost equal mixture of dissociative and schizophrenia symptom. They have better clinical insight and less disturbed affectivity compared to those with a dissociative subtype of schizophrenia).

An “Interaction” (Duality) Model According to the continuity hypothesis, a non-​d issociative (standard) schizophrenia, a dissociative (subtype of ) schizophrenia, schizo-​d issociative disorder, and DID constitute a spectrum (Ross, 2004). In contrast to the neo-​K raepelinian assumption about the distinctiveness of diagnostic categories and that they are mutually exclusive, the continuity hypothesis may be considered a neo-​Bleulerian understanding of psychosis. To integrate both perspectives, the interaction (duality) model (Şar et al., 2010) tries to explain the complex comorbidity between two distinct but concurrent or serially occurring disorders. This duality model assumes that the interaction between the two psychopathologies implies that dissociation may be 1) a risk factor for, 2) a defense against, or 3) a response to, a schizophrenic disorder. The emergence of a schizophrenic disorder may be facilitated by childhood trauma (Morgan & Fisher, 2007) while the role of possible subsequent dissociation in the early years of life is not known yet. If considered a defense against the development of a schizophrenic disorder, the question remains whether this (dissociative) defense prevents the progression of, or encapsulates, schizophrenic psychopathology. Coping with the lifelong experience of having a chronic mental illness may evoke adaptive dissociative mechanism as well, such as denial of the disorder and social detachment. In cases in which both dissociative and psychotic pathology is suspected, treatment should take both aspects into consideration.

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Explanatory Mechanisms The Dissociative Quality To consider any psychotic features related to dissociative disorders, identification of the dissociative features is crucial. For example, Van der Hart, Witztum, & Friedman (1993) quoted Janet when describing the “dissociative quality” in ARDP: (a) the psychosis is embedded in dissociative phenomena; (b) the psychosis itself is seen as a dissociated state; (c) a splitting or doubling of the mind has occurred; (d) subconscious phenomena are observed; and (e) altered states of consciousness occur. Van der Hart et al. (1993) claim that, rather than brief duration, a dissociative foundation is essential to ADP. Steingard and Frankel (1985) proposed that certain highly hypnotizable persons are prone to experience transient but severe psychotic states. Spiegel and Fink (1979) stated that ARDP patients are highly hypnotizable and curable with psychotherapy, in contrast to those with a schizophrenic disorder. Hypnotizability has a bearing on the differential diagnosis of schizophrenia and ARDP (Van der Hart & Spiegel, 1993). Hypnosis can be used productively in psychotherapy with patients with ARDP (Van der Hart & Spiegel, 1993; Van der Hart et al., 1993). For example, in a case of post-​partum ARDP, hypnotherapeutic interventions with light trance were used to access the patient’s inner world to understand the meaning of the symptoms and gain a resolution of the trauma-​related dissociative parts involved in the expression of symptoms (Pietford-​Marin, 2020). In chronic conditions such as DID or OSDD-­​­example 1, the existence of a distinct personality state may be felt by the patient as the presence of another person in the environment, a presence which may be very real for some, but quite vague for others. In its mildest form, the subject complains of feeling as if “somebody is behind me,” accompanied by anxious expectation and worrying, particularly if the accompanying personality state is a persecutory one. This situation may mimic an idea of reference, and thus a paranoid psychosis. Most DID patients have “persecutory” personality states with hostile tendencies toward the “host” personality. In some cases, such a personality state seems to mimic a person in the environment of the patient (e.g., family member, spouse, close friend, neighbor). The patient may temporarily confuse the alter personality state (in the “internal world”) with the corresponding person in the external world. For example, the threats of a persecutory personality state may be attributed to the person in the real world. In this case, it may be difficult to distinguish this situation on a phenomenological basis from a paranoid psychosis unless the clinician suspects the presence of a dissociative disorder and explores this link. The observation of switching to the persecutory

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personality state or resolving the “persecutory delusions” following integration of this personality state with the host personality makes the distinction possible.

The Traumatic Background Most Schneiderian symptoms represent a diminished sense of self and agency. In fact, the imagined relationship with an omnipotent power resembles the type of relationships seen among victims of developmental trauma based on “attachment to the perpetrator” and a “locus of control shift” (Ross, 1997). This type of relationship is analogous to the dominance-​submission pattern of an abusive interpersonal situation. Indeed, Ross and Joshi (1992) documented a relationship between reports of childhood trauma and Schneiderian symptoms in the general population. Much social-​ psychological research is needed, especially regarding the role (e.g., scapegoat) assigned to the dissociative patient by the family. Many concepts proposed to account for schizophrenia which failed to be supported by research (e.g., schizophrenogenic mother, double bind, marital schism, pseudomutuality) may prove to have etiological relevance for dissociative psychopathology (Spiegel, 1986; Moskowitz & Montirosso, 2018). Some authors who try to explain the psychodynamics and precipitating environmental stresses accompanying ARDP suggest as etiological factors intrafamilial relationships (Richman & White, 1970), disturbed marriages (Martin, 1971), an unwelcome or wished-​ for but not forthcoming sexual advance (Cavenar, Sullivan & Maltbie, 1979), and “complacent overadjustment” (submission) to a restrictive/​oppressive family (Öztürk & Göğüs, 1973). In her detailed archival study on a 10-​year series of consecutive inpatients with dissociative disorders, İlknur Şar (1983) underlined the widespread presence of early maternal rejection (emotional/​hostile neglect) among female patients in particular.

Conclusion Psychotic presentations in dissociative disorders may remain at the level of symptoms or may even take the form of a psychotic episode as seen in ARDP. Both categorical and dimensional models lead to insights in the difficult psychiatric intersection between dissociative and psychotic phenomena. Beyond providing diagnostic challenges and questions for further research, this phenomenological overlap may have important implications for the treatment of both dissociative and psychotic disorders. As both dissociation and psychosis influence sense of self and agency, their intersection may also provide challenges across the broad domain of psychiatry, including in forensic settings that required exploration.

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26 THE OTHER IN THE SELF Possession, Trance, and Related Phenomena1 Etzel Cardeña, Yvonne Schaffler, and Marjolein van Duijl

The anthropologist and initiate into the Candomblé religion, Arnaud Halloy, noted the experiences, which are not necessarily bizarre or pathological, in which “something” or “someone” else takes control over one’s actions: “I cannot clearly discern when, during Ode’s songs, the surrounding scene started to vanish. I just know that Júnior was calling upon the name of my orixá very close to my head. Now it was as if each of his words was touching me inside my belly, as if each sound produced by his mouth was instantaneously translated into gut sensations. I know I began to swing my torso back and forth. I cannot say if this first movement was intentional or not: I just know it started and it felt good. It was like an overdose of energy, the sensation of a body being too small to contain such a force invading me from nowhere. I was scared and elated at the same time… From that moment on, memories remain extremely vague as if external forms and sounds lost their recognizable shape. I was not dancing: I was danced . . .” Halloy & Servais, 2014, pp. 490–​491 Even those of us who are not initiated into a religion in which dances enable devotees to become possessed by the gods or orixás, may find at times that a rhythm or an action appears to “take over” our self for a moment, whether in the midst of dancing or while “being inspired.” Depending on the time and the place, this “otherness” has been called or attributed to the Id, the muses, Platonic manias, unconscious forces, Apollo or enthusiasm (literally “being filled with the gods”), Jungian complexes, right hemisphere processes, or various types of spiritual forces (i.e., possession). From this angle, it is not surprising that in a review of 488 societies Erika Bourguignon found that 74% believed that spiritual forces can affect the personality and well-​being of individuals, and 52% maintained that the individual’s personality can be replaced by that of another being (Bourguignon, 1973, p. 31). In contrast with Halloy’s account, the experience of an alternate identity is sometimes associated with serious distress and conflict. Consider a case seen by the third author (MvD) in Uganda. For many years, a 33-​year-​old woman had experienced regular attacks during which she exhibited aggressive, unusual behaviors and spoke with other voices. These attacks occurred when the family prepared to go to church or pray. During the intake interview, the client held her hands like claws, made animal-​like noises, and spoke in a strange language and voice. Her sister explained this was the voice of an uncle who had died many years ago. This uncle had a conflict with her father as her father neglected traditional rituals due to his Christian belief. The patient had suffered because her father had not let her marry the Muslim man she loved. Because the attacks often occurred when religious activities were about to be performed, clinicians suspected that they expressed her suppressed anger against her father who had ruined her life because of his unyielding principles. The client agreed to attend counseling to learn to control her attacks and understand and deal with the underlying experiences. Medication assisted her to control the attacks when she felt anxiety was increasing. The second author (YS) encountered a person in the Dominican Republic whose uncontrolled possession episodes brought about many symptoms and negative evaluations. The woman in her mid-​t wenties experienced what a vodouist healer classified as spirit possession. During these episodes, she experienced herself as powerless and exposed to the whims of the spirits of Vodou that she felt were forcing her to do things she would not have done otherwise. Among the sensations she described was “a very strong force entering my body that I am unable to control.” The episodes started

DOI: 10.4324/9781003057314-31

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soon after her involuntary return from a work stay abroad. She was also in a conflict with her ex-​husband and about to lose custody of a child. She described her relationship with the spirits thus: They [the spirits] mount me whenever they want; I never foresee when they rise within me; I never invoke them. And Marta [a female spirit] throws me on the floor when she is angry with me because I do not do what she wants me to do. Unlike the case described by MvD, this one was resolved through emic (local vodouist) rather than counseling interventions. In short, it is crucial to differentiate between instances of possession that may benefit from clinical intervention (sometimes in combination with cultural or religious interventions) and those that have no deleterious consequences to the individual or community (APA, 2013; Cardeña, 1992). The experience of one’s identity being substituted by that of some entity from within or without challenges basic Western premises about the self. One of them is that we have a single, discrete identity or self that cannot be replaced by external influences, spiritual or otherwise. A related premise is that our conscious self owns and controls our body and mental life. A myriad of perspectives can be brought to bear on this issue –​from philosophical analyses of self hood and identity to neurocognitive explanations of agency. Here, we limit our analysis to the domain of possession/​trance phenomena (PTP) and to whether they can be characterized as dissociative. In doing so, we will describe features that distinguish pathological from non-​pathological PTP and will review the various explanations for it.

Possession/​Trance Phenomena and Dissociation In psychology, the term dissociation originated as the opposite of the “association” of psychological processes. Cardeña (1994) proposed two main descriptive senses for the term “dissociation.” One characterizes dissociation as an alteration in consciousness wherein disconnection/​d isengagement from the self or the environment is experienced (e.g., “out-​ of-​body” experiences, depersonalization, derealization). The other refers to dissociated or nonintegrated psychological processes or systems that should ordinarily be integrated (Holmes et al., 2005, presented this distinction as experiential detachment or psychological compartmentalization). The latter sense of the term is most germane to this chapter. This sense of “dissociation” can be further divided into three categories of phenomena: (1) lack of awareness of current or previous information that should ordinarily be integrated; (2) the coexistence of separate mental systems that are ordinarily integrated in consciousness, memory, or identity; and (3) ongoing behavior or perception that contradicts a sincere introspective verbal report. PTP mostly involves the first two categories: absence of reflective awareness of stimuli and behavior, and lack of integration of different identities and memories. Like other dissociative phenomena, PTP has non-​ pathological and pathological manifestations (Cardeña, 1994; Cardeña & Carlson, 2011). It is important to distinguish spirit possession from Eliade’s (1964) canonical shamanic experience of “magical flight.” The shamanic magical flight is a mostly imaginal experience in which the soul of the healer is purported to fly to other worlds or realities to seek spiritual assistance, retrieve the sick person’s soul, and so on. In contrast with this “disembodied” imaginal journey, spirit possession is characterized by a “radical alteration of embodied identity” (Cardeña, 1989, p. 2; see also Seligman, 2014, 2018), in which the identity of the individual is replaced –​typically by a spirit or an ancestor, or by an animal (Van Duijl et al., 2005). When the person recovers his/​her original identity, s/​he usually claims amnesia for what transpired during the possession. This distinction is similar to (a) Rouget’s (1985) classification of “ecstasy” (immobility, silence, recollection, imaginal events, etc.) and “trance” (movements, noise, crisis, amnesia, etc.), and to (b) proposed typologies of hypnotic virtuosos (Cardeña, 1996; Terhune & Cardeña, 2010). Although we focus in this chapter on PTP, it should be borne in mind that “spirit possession” and “magical flight” experiences can coexist in the same person or culture. For instance, the Chukchees engage in both types of religious practices (Lewis, 1989). Academic discourse about possession has shifted, from singling it out as an exotic event, to immersing it within personal and cultural notions of identity, relationships, and reality (Boddy, 1994; Swartz, 1998), and it has been described as a very common technique of ritual healing across cultures (Sax & Weinhold, 2010). An important distinction should be made between two senses of spirit possession: (1) possession as an attribution or explanation of events (e.g., illness), and (2) possession as an experience of one’s identity being replaced by that of an ancestor, spirit, or other entity (Bourguignon, 1976). Spirit possession as attribution connotes the belief that the person’s condition is caused by a spiritual influence. Note, however, that attributions of this type of influence can also occur when the patient evidences no alteration of consciousness. In both Western and non-​Western societies, individuals may use notions such as sickness caused by some type of spiritual interference (such as “sent sickness,” Keys et al., 2012) as an explanatory model or framework to understand psychiatric or medical conditions (Kleinman, 1988a; Khoury

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et al., 2012), but without any accompanying alterations of consciousness (such as narrowing of awareness, stereotyped movements, substitution of identities, amnesia for the event, etc.). Depending on the symptoms, these patients may be diagnosed as suffering from a medical, dissociative, psychotic, mood, somatoform, anxiety, or neurological disorder. In a study in Sri Lanka, Somasundaram and colleagues (2008) compared individuals manifesting “possession states” from three groups: psychiatric inpatients, general medical outpatients, and members of a group known to have frequent possession states. Among the psychiatric patients, 73% were diagnosed with schizophrenia, 10% with dissociative, and 13% with somatoform disorders. Common mental disorders were found among 40% of the possessed medical outpatients, and 20% of the individuals belonging to the community group. In an epidemiological study of youths and young adults (N =​1,113) in war-​a ffected regions of Northern Uganda, Neuner et al. (2012) divided the sample into High and Low groups based on the frequencies of spirit possession (SP) symptoms. SP was significantly associated with posttraumatic stress disorder (PTSD) and depression (e.g., 10% of Low and 44.5 % of the High SP met criteria for PTSD). The illness attributed to spirit possession may be medically unexplained, such as epidemics of psychogenic fainting among a group of Bhutanese refugees (Van Ommeren et al., 2001). This chapter does not address spirit possession as attribution but focuses on spirit possession as an experience. Bourguignon (1976) also drew a distinction between possession trance (PT) or an altered state of consciousness during which the individual’s identity is replaced by that of a spirit or entity, and trance, an alteration of consciousness not accompanied by such replacement. However, the term “trance” is polysemantic and vague, and there is little evidence that conditions called “trance” are homogeneous and vary from “possession trance” only in their causal attribution. An alternative to her classification is to delineate specific features of trance and PT. Cardeña (1992) defined “trance” as a temporary alteration of consciousness, identity, and/​or behavior evidenced by at least two of the following: (a) Marked alteration of consciousness or loss of the usual sense of identity without replacement by an alternate identity. (b) Narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on environmental stimuli. (c) Stereotyped behaviors or movements experienced as being beyond one’s control. He described spirit possession as a temporary alteration of consciousness, identity and/​or behavior, attributed to possession by a spiritual force or another person, and evidenced by at least two of the following: (a) Single or episodic replacement of the usual sense of identity by that attributed to the possessing force. (b) Stereotyped and culturally-​determined behaviors or movements attributed to the possessing identity. (c) Full or partial amnesia for the event. This classification, included in the DSM-​I V as experimental, has two merits: First, it seeks to define how “trance” is manifested, rather than using the term as a synonym for (any) alteration of consciousness. Second, it provides a distinction between “trance” and “possession trance” besides the causal attribution to spiritual forces. For instance, PT requires replacement by a new identity, whereas trance does not. This categorization can distinguish such “cultural concepts of distress” (CCD) as amok, latah, and extreme forms of Thai mindlessness, which include narrowing of attention and hypersuggestibility but not the adoption of a new identity (Cassaniti, 2019; Rhoades, 2005a) from possession. CCD were introduced in the DSM-​5 to better characterize the broad set of constructs identified in clinical and ethnographic research on cultural variations in distress, and replaces the term of culture-​bound syndromes (Lewis-​Fernández & Kirmayer, 2019). The distinction between trance and possession trance as outlined seems to be consistent with the neuroscientific research that differentiates between the experience of being in control and that of being the agent of an action (Hohwy & Frith, 2004), or of alterations in self-​experience or in identity (Cardeña & Alvarado, 2014). There is some empirical support for the definitions provided. Gaw and colleagues (1998) reported that Chinese possession inpatients manifested loss of control of actions, low awareness of surroundings and personal identity, perceived insensitivity to pain, changes in tone of voice, and problems distinguishing reality from fantasy. In a sample of Singaporean inpatients, Ng (2000) encountered similar manifestations: unusual vocalizations and movements including shaking, apparent immunity from pain, unfocused or fixed gaze, and assumption of a different identity. Kianpoor and Rhoades (2005) described a possession state in Iran (Djinnati) that involves unresponsiveness to external stimuli, glossolalia (“speaking in tongues,” typically in certain religious ceremonies), identity alteration, and subsequent amnesia. Case descriptions from India and other places are very similar (Cardeña et al., 1996). An analysis of 119 spirit possessed patients (Van Duijl et al., 2013, 2014) revealed three overlapping phases of symptoms: 1) medical complaints that did not heal after medical interventions;

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2) “passive dissociative experiences,” such as being unable to move, feeling something holding them and hearing voices; and 3) possession states including behavior representing the possessing entity. For 50% this state occurred spontaneously before seeing a traditional healer, for the others it was the healer who encouraged the angry spirits to manifest themselves during the healing sessions. The phases of uncontrolled passive dissociative experiences were generally experienced as very disturbing as their meaning was not clear. Once the spirits expressed their grievances a solution could be sought. Finer distinctions can be made for a possession event. Cardeña (1989) proposed three major types: (1) transitional states (e.g., saoulé or inebriation in Haitian Vodou; spiritual touch in Dominican Vodou, Schaffler et al., 2016; irradiación in Afro-​Brazilian religions, Frigerio, 1989; the hal dizziness state among the Hamadsha (Crapanzano, 1973), in which individuals are cognitively disorganized as they move from their usual state of consciousness to an alternate state or identity; (2) the canonical type of spirit possession, in which the person exhibits an alternative identity (e.g., a culturally recognized spirit or an ancestor; and (3) a transcendent, non-​ego state in which the person experiences a union with a spiritual entity (e.g., “Irresistibly it took possession of my mind and will… [the] progressive obliteration of space, time, sensation” Wulff, 2014, p. 372). Most authors use the term “spirit possession” to refer primarily to the second type, and we follow that practice in the rest of this chapter. Possession practitioners themselves differentiate between levels of the experience, and the extent of the accompanying amnesia varies from time to time and according to the context (Crapanzano, 2001; Espírito Santo, 2017; Friedson, 1996; Frigerio, 1989; Halperin, 1995; Maraldi et al., 2019; Schmidt, 2015), as can happen as well among Western psychic mediums (Troubridge, 1922). This implies that whether the usual identity of the individual is absent while possessed, or whether some co-​consciousness with the possessing entity occurs, varies across experiences. Even if we restrict our focus to the “alternate identity” type of possession, we find that its domain is quite large. It includes phenomena such as mediumship and channeling, glossolalia and non-​possession types of dissociative identity disorder (Cardeña & Alvarado, 2014). Like spirit possession that usually involves more physical (inter)action than mediumism, which can take place in a seated position, mediumistic experience is more or less shaped by cultural narrative references shared by a group. Comparing mediumism across cultures, Maraldi et al. (2019) found that experiences among Spiritist mediums in Brazil are more influenced by collective beliefs and less idiosyncratic than those in the UK.

What Distinguishes Non-​Pathological from Pathological PTP? When PTP causes chronic dysfunction and/​or distress, and is not part of a culturally accepted practice, it can be considered a disorder. The Fourth edition of the Diagnostic and Statistical Manual of Mental Disorders-​I V-​TR (APA, 2000; Cardeña et al., 1996) listed Dissociative Trance Disorder as a condition meriting further study. The next edition (DSM-​5, APA, 2013) split dysfunctional possession and trance into two different diagnoses: 1) possession as a type of Dissociative Identity Disorder (DID), and 2) trance as “other specified dissociative disorder.” DID is defined as a “disruption of identity characterized by two or more distinct personality states or an experience of possession,” including disruptions in the sense of self and agency, other alterations of consciousness, psychogenic amnesia, and clinical distress or impairment (APA, 2013, p. 292). The DSM-​5 also introduced a dissociative subtype of posttraumatic stress disorder (PTSD) with derealization and/​or depersonalization as its defining symptoms. In some cultures, the dissociative subtype of PTSD might cover possession phenomena (Şar et al., 2014). Another possibility to code possession experiences in the DSM-​5 is the new category of acute dissociative reaction to stress (duration of less than one month). As transient possession phenomena may not be classified as DID or DDNOS (for these diagnoses, the symptoms are required to be chronic), they may be classified as an acute dissociative reaction (Hecker et al., 2015). These changes partially followed recommendations advanced by one of the authors (Cardeña, 1992; Spiegel et al., 2011). The ICD-​10 (WHO, 1992, pp. 125–​126) includes Trance and Possession Disorders as a separate entity. Overall these are welcome changes considering that research in non-​Western cultures suggests that their most common dissociative disorders involve trance and possession. For instance, when asked to provide examples of dissociative identity disorder, Ugandan informants described local examples of spirit possession (Van Duijl et al., 2005), a similar presentation to that in India (Saxena & Prasad, 1989). In an era of increased multiculturalism, it is important to recognize the interaction of different cultural narratives in both the expression and resolution of individual possession cases (Gingrich, 2005; Rhoades, 2005b). Criticisms of the diagnostic validity of dysfunctional possession as a type of DID (e.g., Onchev, 1998) can be addressed if DID is differentiated from pathologies in which spirit possession is just an attribution or a symptom of a condition such as psychosis (WHO, 1992), but the clinician should realize that “first rank symptoms” such as hearing voices also occur in dissociation (Moskowitz et al., 2018). Many Westerners view spirit possession as malignant or demoniacal (from a religious perspective) or psychopathological (from a secular perspective). Cross-​cultural data, however, show a very different picture. For many non-​Christian

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religious traditions (e.g., African, Afro-​A merican, Asian), spirit possession is the central liturgical event. In Haiti the faithful interact with the Vodou lwas (spirits, universal forces) by inviting them to take over their identity and “ride” them (Desmangles & Cardeña, 1996). In the Philippines, the widespread occurrence of spirit possession renders it a bona fide social institution (Gingrich, 2005), whereas in Tibet the religious figure of the oracle becomes possessed when requested and for religious purposes (Crook, 1997). Within the Christian tradition, there is a long history among many groups (e.g., Pentecostalists, Shakers, and members of the Charismatic Church) of being taken over by the Holy Ghost, receiving the “gifts,” and so on (Garrett, 1987; Martínez-​Taboas, 1999; Sluhovsky, 2011). The fact that spiritual possession is culturally widespread does not mean that it is never psychopathological, but a careful differential diagnosis is in order, as a percentage of psychotic and less disturbed individuals attribute their condition to the devil (Goff et al., 1991; Pfeifer, 1999). In these cases, spirit belief or attribution is merely incidental to the pathology, as opposed to being a cardinal feature. Second, Lewis (1989) distinguished between central and peripheral possession. Central possession is culturally sanctioned and typically occurs only during a religious ritual that follows cultural prescriptions for when possessions occur, what is acceptable from the possessing entity, and so on. This type of possession is episodic, sought-​a fter, time-​limited, generally organized, and its practice follows culturally-​e stablished parameters. The general criteria for psychopathology (i.e., distress and/​or dysfunction) do not justify classifying it as pathological. Since not all followers of ecstatic religions become possessed, what distinguishes those who become possessed from those who do not? An early study (Ward & Beaubrun, 1981) examined possession in a religion that considered it to be a disorder (i.e., Pentecostalists from Trinidad). Those who experienced possession had higher scores on measures of neuroticism and ‘hysteria’ than did a control group. These findings agreed with case studies that showed a higher degree of somatization among the possessed. The authors cautioned, however, against arguing “that possession per se is pathological” (p. 296). In a study of Brazilian Candomblé practitioners, Seligman (2005) found that the tendency to somatize predicted who became possessed, although her statistical analyses are unclear and difficult to interpret. Several recent studies provide a clearer picture. Gingrich (2005) found no relation between a DID diagnosis and reports of being spirit possessed in a Philippine sample. Similarly, Spiritist mediums in Brazil, as compared with patients with DID, show significantly better health and psychological adjustment, and less early trauma, as indexed by a structured interview (Moreira de Almeida et al., 2008). Also in Brazil, Negro (2002) studied 110 Spiritists and found that controlled dissociation was positively related to training in mediumship, and that mediums reported good socialization and adaptation. In contrast, pathological forms of dissociation were associated with younger age, less control of mediumship activity, poorer social support and previous psychiatric history. The relation between controlled dissociation and formal training in mediumship was corroborated by Schaffler et al. (2016), who found that possessed Dominican Republic vodouists reported less currently experienced affliction due to unbidden or violent possession than they had in the past. Another study with Brazilian Spiritist mediums did not find a difference in their self-​a ssessed mental health and that of a comparison group (Bastos et al., 2020). Laria (1998) compared three groups of Cubans: spirit mediums, mental health patients, and a control group of non-​mediums/​non-​patients, and concluded that mediums reported higher levels of “normal” dissociative experiences, lower levels of psychopathology, fewer traumatic experiences, and exhibited less subjective distress than mental health patients, despite having endured more stressful events than the controls. Relatedly, practitioners of Western channeling/​mediumship and speaking in tongues are typically normal, psychologically healthy individuals (Hastings, 1991). Newberg and colleagues (2006) found that a sample of Christian women who regularly experienced glossolalia did not have neurological, medical, or psychiatric conditions. Cardeña et al. (2015) compared Western spiritual practitioners/​mediums with a closely matched healthy general population sample, finding no difference between the two groups. Nonetheless, they also found a subset of troubled individuals within those interested in paranormal or anomalous experiences who had a need to go into a long-​term spiritual retreat. In sum, overall participants in central possession groups are psychologically healthy, and training/​socialization into mediumship provides an organizing-​therapeutic function. Similarly, Boddy (1988) studied the zar cult in Sudan and concluded that possession, which was exhibited by almost 50% of women over 15 years of age, provides a form of communal bonding and insight therapy. Lewis’s (1989) second type, peripheral possession, occurs outside of a ritual setting, seems uncontrollable, is often chronic, and involves conflict between the individual and his/​her surrounding milieu. He treated this involuntary type of possession as a primary phase in the onset of possession that affects the unprepared novice, until the dynamics of the process are understood and controlled. The secondary phase starts when possession bouts become chronic and require treatment. A traditional healer may then conduct an exorcism and/​or introduce the person to a possession group where the afflicted may learn how to better control and organize their experiences (a good strategy, it would seem, judging by

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Negro’s results). Halloy (2012) describes how shared learning among practitioners of a possession cult in Brazil enables novices to identify and react to specific emotional states in accordance with cultural representations and expectations. For example, they may come to associate unusual body arousals to mythological images captured by the highly evocative content of songs, invocations, objects, and substances during ritual activity. A review of the literature supports the validity of a diagnosis of pathological forms of possession (During et al., 2011). A multiple correspondence analysis of 119 spirit-​possessed patients in Uganda revealed the presence of two symptom dimensions: 1) mainly “passive” or “negative” symptoms, such as amnesia/​changed consciousness, forgetfulness, feeling influenced, and isolating oneself, and 2) mainly “active” or “positive” symptoms, such as shaking of the body and talking in voices other than one’s normal voice, expressing the shift from the normal identity to the possessing agent (Van Duijl et al., 2013). A division into passive and active symptoms is also found in other mental disorders, such as schizophrenia and post-​t raumatic stress disorders (PTSD) with its avoidant and intrusive symptoms. Case studies from Sri Lanka (Chapin, 2008), Brazil (Delmonte et al., 2016) and the Dominican Republic (Cardeña & Schaffler, 2018) describe how specific cultural conditions can help change originally dysfunctional expressions of spirit possession into personally and socially beneficial ones. In these cases, unusual early behaviors and experiences during the first phase were associated with severe suffering and a lack of control, and did not have a “good fit” with the acceptable surrounding cultural roles. After frequent participation in rituals provided cognitive accommodation and assimilation (Luhrmann et al., 2010), some of the formerly afflicted could reidentify themselves as experts on ritual services and become respected members of their communities. Of the spirit possessed patients in Uganda (Van Duijl et al., 2014), 10% attributed their (uncontrolled) dissociative and preceding unexplained medical complaints to the call to become a traditional healer. Their complaints reduced after acquiring healing skills through apprenticeships with healers. Rhoades (2005b) noted that Hawaiian possession cases are often interpreted as being instances of “spiritual help” for a troubled person, and that lack of beneficence on the part of the possessing agent is often interpreted as indicating a false experience. Those with resistant, chronic conditions may be hospitalized (Gaw et al., 1998). Peripheral possessions may best be considered as a culturally-​shaped “idiom of distress” (Nichter, 1981) for a gamut of interpersonal conflicts, stressors, and chronic personal maladjustment (e.g., Gaw et al., 1998; Ward & Beabrun, 1981). In a study using logistic regression analyses, Ng and Chan (2004) found that conflicts over religious and cultural issues, prior exposure to “trance states,” and being a spiritual healer or his/​her assistant were significant predictors of a diagnosis of dissociative trance disorder in Singapore. In sum, these are common characteristics of pathological possession: (1) it is not part of a culturally accepted practice, (2) it is associated with individual dynamics, distress and maladjustment, or a psychiatric history, and, (3) the person has less training in ritual practices. Process variables, such as the ability to induce the onset of the possession where it is appropriate and the capacity to organize the experience in a personal and socially meaningful way, help distinguish non-​pathological from pathological possession.

Explanatory Frameworks of PTP Because the domain of spirit possession is complex, there are many explanations from different disciplines and at different levels of analysis. The reader should be aware, however, that comparing Western diagnostic categories with local concepts risks making a category fallacy, in which a Western construct may be imposed on a different culture without knowing whether it is valid in it (Kleinman, 1988b). Anthropology makes a similar distinction between emic (i.e., indigenous) and etic (universalizing) explanations. Bearing this in mind, we now turn to explanatory theories of PTP, but should mention that field studies of spirit possession (e.g., Stoller, 1989) and of past life experiences (Mills & Tucker, 2014) suggest that metaphysical explanation of possession should not be dismissed off hand.

Psychological/​Developmental Theories of PTP Any analysis of possession phenomena must address the unusual relation of the self towards its body. Even if we disagree with Cartesian dualism, we still experience ourselves as a core of consciousness, somewhere inside the center of the head, which controls its “vehicle,” the body. A sense of ownership of our bodily and mental events can be, however, compromised. Unbidden and sometimes surprising images, memories, and impulses are everyday occurrences (Klinger, 1978); our bodies “obey us” only so far, and a limb can suddenly become “restless.” And in dreams we may act atypically and seem to be characters in a play created by someone else. Psychology has documented how we are greatly affected by a myriad of biological, cognitive, social, and environmental variables. Indeed, our judgments of the probable causes of our behavior tend to be quite inaccurate (Nisbett

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& Wilson, 1977). So, perhaps the question should not be why some people experience being taken over by a foreign identity, but why we do not have that experience more often. One answer proposes that different aspects of the self cohere into a unified sense only after a number of developmental stages (Stern, 1985). During development, children in Western technological societies are led to cover experiential gaps and incomprehensible actions with a narrative of a single, impermeable subjective self (Kirmayer, 1994). Other cultures provide “local theories of the mind,” that include the influence of unseen, spiritual forces that manifest as “spirit possession” (Cardeña, 1991). Luhrmann (2020) found that experiencing the mind-​world boundary as permeable relates to near-​sensory experiences of invisible others. Swartz (1998) describes how some social scientists have moved from the idea of a single “unitary” subject to the idea that identity is fragmented and that reality is negotiable and questionable. The concept of dividual questions the Western notion of single entities (e.g., Pype, 2011), and there is an increasing interest in acknowledgment of voices and expressions of dissociated realities, including those of spiritual forces. Spirit possession has been analyzed according to the functionality it may have for expressing individual, cultural and sociopolitical conflicts. There is little explanation, however, of why some believers become possessed easily and others become possessed only with difficulty or not at all. The earlier assumption of individual psychopathology (typically “neurosis” or “hysteria”) clashes with more recent data on the psychological health of many if not most ritual practitioners. Seligman (2005) proposed that Candomblé mediums tend to somatize, but the statistical analyses have a confound with socioeconomic status (SES). A study that does not have that confound did find greater somatoform dissociation among Vodou devotees (n =​47) who experienced possession as compared with those who did not (n =​38; Schaffler et al., 2016). Possession has so many variations that it is improbable that any single theory or set of variables will explain them all. Nonetheless, following a model on the development of dissociation in general, we can propose two paths to possession. Central possession can be partly explained by a genetic predisposition to dissociate, which is then interpreted and shaped by sociocultural factors into the experience of controlled ritual possession and mediumship. Through these practices, individuals may “let themselves follow” their impulses and intuitions, and acquire a more authoritative voice and perhaps economic advantages in their community than they would have otherwise. Once the experience is over, they can go back to their usual sense of an identity. The process of socialization into these practices starts very early. For example, the first and second authors saw little children in Haiti and the Dominican Republic dance and imitate the possessed adults during Vodou ceremonies. In peripheral, dysfunctional possession, the predisposition to dissociate may be accompanied by a disturbed development that makes alterations of identity difficult to control or organize. The literature on pathological dissociation posits two risk factors: (1) early, severe trauma/​neglect interacting with an insecure form of attachment with the main caretaker (Cardeña & Schaffler, 2018; Moskowitz et al., 2018) and (2) an inherited diathesis to dissociate and be highly suggestible. In support of risk factor 1, in migrant teens the relation between traumatic events and dissociation was mediated by anxious attachment (Gušić et al., 2016), an American study found a relation between childhood trauma, dissociation, and delusions of possession among psychotic patients (Goff et al., 1991), and Bhutanese refugees exhibiting mass psychogenic illness (explained as spirit possession) had more recent and earlier trauma than a comparison group (Van Ommeren et al., 2001). History of severe trauma has been related to possession. Boddy (1988) described how zar possessed females in Sudan typically had undergone female genital mutilation. Spirit-​possessed patients of traditional healers in Uganda reported more traumatic events and had higher somatoform and psychoform dissociation than a healthy, matched control group (Van Duijl et al., 2010). Also in Uganda, extreme levels of trauma such as those experienced by abducted child soldiers related to dissociation and spirit possession phenomena (Neuner et al., 2012). Ugandan health workers and counselors considered that severe trauma and dissociative amnesia and depersonalization are related (Van Duijl et al., 2005). A literature review on trauma exposure and spirit possession in 14 low-​and middle-​income countries with 917 patients found a strong relation between trauma exposure and spirit possession with high prevalence rates found especially in postwar areas in African countries (Hecker et al., 2015). In Turkey, Şar et al. (2014) reported that among women in the general population spirit possession and other forms of dissociation were more prevalent among the more traumatized in a low SES sample. In the study comparing Vodou devotees who experienced possession with those who did not, the first group reported significantly greater exposure to mortal danger but did not differ in other types of trauma (Schaffler et al., 2016). Of particular interest to possession experiences is that among migrant teens from war zones, dissociative episodes were characterized as involving loss of mental control (Gušić et al., 2018). Nonetheless, it is appropriate to reiterate that what may start as a dysfunctional type of possession may become healthy later in life if the devotee learns from cultural experts how to control manifestations and frame them in positive terms.

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Cultural and Sociopolitical Theories of PTP Probably the most influential theory in anthropology is that spirit possession provides women and other underprivileged groups a medium to express their complaints in a context where they may be heard (Lewis, 1989). Seligman’s (2005) data clearly show that distress and perhaps pathology is related to a low SES status in Brazil, but do not clearly indicate that these factors affect who gets possessed by the spirits. On the other hand, in a few cultures, it is the elite rather than the underprivileged who become possessed (Behrend & Luig, 1999). Anthropologists have also described the emergence of new types of spirit possession and the shaping of their specific features by changing socio-​political circumstances, either to support or oppose them. Masquelier (1999) notes that new emerging Dodo spirits in Southern Niger remind people of traditional moral and social values, in contrast with the pollution and decline of values of modernity. Igreja (2003) describes how the Gamba spirits and healers who emerged after the war in Mozambique seemed to support the recovery process of war survivors from their psychosocial hurts. Likewise, drawing on findings based on observation in a postwar society, De Jong and Reis (2010) describe how individual experience born from a traumatic origin can develop into Kiyang-​yang, a possession and healing cult for marginalized, barren women, and how their experience can generalize into an idiom of distress that allows the expression of individual and collective stressors in southern Guinea-​Bissau. With reference to an urban-​ industrial societal context, Dawson (2011) points out that Brazilian Santo Daime’s recent progressive appeal to the urban middle-​classes has entailed a development towards a hybrid ritual repertoire and possession practice, and a typically modern preoccupation with self-​development. There is also a dramaturgical component to ritual spirit possession (Métraux, 1955). Not only are the characteristics of the possessing agent enacted, but full representations of historical and political dynamics take place. For a sophisticated analysis of perhaps the most famous case of possession in the West that included aspects of performance, suggestibility, and sociocultural tensions see De Certeau (1996).

Biological Theories and Correlates of PTP Biological explanations have been offered for specific findings such as the observation that possession tends to occur more often among women and those of low SES. Kehoe and Giletti (1981) proposed that the effect on the CNS of deficiencies of thiamine, tryptophan-​n iacin, calcium, and vitamin D may be interpreted and shaped as a manifestation of spirit possession. Although nutritional deficiencies may play a part in some cases, this theory cannot account for possession among well-​fed, middle class individuals. Kawai and collaborators (2001) compared Balinese dancers who exhibited trance behaviors (e.g., unfocused gaze, tremors, lack of facial expression) with those who did not. Trance-​d ancers had higher concentrations of noradrenaline, dopamine, and beta-​endorphin (a neuropeptide associated with analgesia), but whether these values preceded or followed the behaviors was not evaluated. There is also a probable biological predisposition to dissociate. Two studies found evidence for genetic and non-​ shared environmental contributions (Becker-​Blease et al., 2004; Jang et al., 1998), whereas an earlier one which used an adult dissociation scale with teens did not (Waller & Ross, 1997). Relatedly, absorption, the ability to fully deploy one’s attention toward internal or external stimuli, is a construct related to dissociation and hypnotizability, and it shows substantial heritability (Tellegen et al., 1988). Individuals with high levels of absorption, dissociation, and/​or hypnotizability tend to report unusual experiences, including reputed psychic phenomena and an openness to experiencing altered states (Cardeña et al., 2014). This is consistent with Laria’s (1998) finding that mediums had “thinner mental boundaries” (e.g., greater fluidity between states of consciousness). A clear neuropsychological profile of PTP has yet to emerge, but some evidence points to frontal cortical structures. A SPECT study of Christian glossolalists (Newberg et al., 2006) found decreased cerebral blood flow in the dorsolateral prefrontal cortices after glossolalia, in contrast with regular singing, consistent with participants’ reported experience of involuntariness while singing “in tongues.” The frontal lobes may also be implicated in the performance of stereotyped, culturally-​appropriate behaviors outside of awareness, as is evident from case studies of frontal lobe lesion patients (Lhermitte, 1986). This does not indicate that spirit possession is associated with frontal lobe dysfunction, but that it may relate to a decoupling of frontal lobe structures, as has been found with highly hypnotizable individuals (e.g., Jamieson & Woody, 2007). Research on the experience of not feeling in control suggests that attenuation of activity in the inferior parietal cortex, modulated by the anterior cingulate, the dorsolateral prefrontal cortex (including the supplementary motor area), the posterior/​i nferior parietal cortex, and insula may also be relevant to the experience of possession (David et al., 2008; Hohwy & Frith, 2004). Underlying cognitive and neural processes can be studied through, for instance, hypnotic suggestions for automatic writing (Deeley

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et al., 2013), or comparing brain activity of “automatic” and ordinary writing (Peres et al., 2012). A recent study found no difference on pineal gland and pituitary volumes or levels of urinary melatonin (6-​sulfatoxymelatonin) between female Spiritist mediums and a comparison group (Bastos et al., 2020).

Conclusions and Further Research Whether possession or trance are dysfunctional depends to a degree on their fit with cultural religious practices. Furthermore, what starts as dysfunctional can become adaptive with personal development and sociocultural support. Clinicians should evaluate pathological trance and possession states according to DSM-​5 and ICD-​10 criteria, but bear in mind cultural and developmental aspects. Exploring different explanatory models, including an ecological one with the patient and family is important to understand the background and implement culturally sensitive interventions for pathological trance and possession states as needed (Van Duijl et al., 2014). Another important task is to assess optimal diagnostic criteria for sensitivity and specificity. For instance, in a literature review During et al. (2011) found that hallucinations and somatic complaints are frequent symptoms of possession yet are not contemplated in current diagnostic criteria. On the basic research side, there is a need for greater psychological and cultural understanding of the vast panoply of alterations currently subsumed under trance and possession. This may follow a comparative phenomenology of the interactions between ways in which a local culture gives significance and meaning to mental or bodily sensation (“cultural invitation”), and the array of genetic and individual historical factors that shape people’s bodily responsiveness (“bodily physiology”) (Cassaniti & Luhrmann, 2014). Longitudinal studies of the development of PTP, whether functional or not, should be encouraged, to clarify risk and protective factors of pathology. Another area worth investigating is the efficacy of emic treatments, Western psychiatric ones, or an integration of both. Traditional healing processes of spirit possession can play a role in restoring connections with the supra-​, inter-​, intra-​, and extra-​human worlds. Healers can discuss with the possessing agents the underlying problems (e.g., ritual neglect, neglect of responsibilities, jealousy, or land disputes); then, the patients and their families are given advice to change their behavior so that relationships with the spiritual world, families, and communities, can be restored (Van Duijl et al., 2014). Igreja (2003) opined that Reassembling possession patients’ fragmented and unclear stories can lead to restored health, morality, justice, and reparation at a societal level (Igreja, 2003). Despite some greater understanding of related variables, we remain far from understanding all that PTP reveals about the human experience.

Note 1 This chapter is partly based on Cardeña, E., Van Duijl, M., Weiner, L., & Terhune, D. (2009). Possession/​t rance phenomena. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-​V and beyond (pp. 171–​181). Routledge.

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27 DISSOCIATIVE DISORDERS IN CHILDREN AND ADOLESCENTS Joyanna Silberg and Stephanie Dallam

There has been much advancement of the field of dissociation over these last 37 years since the first articles about child dissociation appeared in contemporary literature. Despite the fact that dissociation in childhood has much potential to reveal the origins and processes that evolve into adult manifestations of dissociation, many questions remain unanswered. This chapter summarizes developing knowledge in this still fledgling field.

A Brief History of the Field of Childhood Dissociation The contemporary literature on child and adolescent dissociative disorders began in 1984 with the contemporaneous publication of articles by Fagan and McMahan (1984) and Kluft (1984). Fagan and McMahon reported cases in children with histories of trauma who presented with identity alterations, apparent amnesia, and a constellation of self-​destructive behaviors. Their clinical presentations differed from those of dissociative adults and the children responded to treatment fairly rapidly. These early descriptions of child dissociation were soon followed by more fully described cases (e.g., Bowman, Blix & Coons, 1985; Malenbaum & Russell, 1987; Weiss, Sutton & Utecht, 1985). Preschool children with dissociative pathology were also reported ( Jones, 1986; Riley & Mead, 1988). Vincent and Pickering (1988) developed a symptom list from case descriptions in the literature and recommended that clinicians use screening questionnaires to detect dissociative cases in high-​r isk populations of children. In the 1990s, larger case series of dissociative children began to appear. Peterson (1991) reviewed the 25 cases from the literature and noted that fully elaborated personalities were uncommon in dissociative children. Hornstein and Putnam (1992) described 64 dissociative children whose symptoms included amnesia, trance states, hallucinations, self-​destructive behavior, and profound identity fluctuations or a sense of divided identity. They noted that dissociative children typically manifest an array of post-​traumatic and other comorbid symptoms. Other case series included 25 children (Coons, 1996), 11 adolescents with Multiple Personality Disorder (MPD; now termed Dissociative Identity Disorder [DID]; Dell & Eisenhower, 1990), and 17 dissociative inpatient children (Hornstein & Tyson, 1991). Numerous single case studies were also reported (e.g., Jacobsen, 1995; McElroy, 1992; Snow, White, Pilkington & Beckman, 1995; Zoroglu, Yargic, Tutkun, Ozturk & Şar, 1996). The publication of large case series prompted researchers to develop diagnostic tools. In 1993, Putnam, Helmers and Trickett devised the Child Dissociative Checklist (CDC), which has become the mostly widely used assessment tool for dissociation in children. The Children’s Perceptual Alteration Scale (CPAS; Evers-​Szostak & Sanders, 1992) was developed as a standardized, self-​report measure of children’s dissociative experiences. Several assessment tools for children were modeled after the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986), a measure of dissociation in adults. Stolbach (1997) developed the Children’s Dissociative Experiences Scale and Traumatic Stress Inventory to assess trauma symptoms and dissociation in children aged 7–​12 years old. The Adolescent Dissociative Experiences Scale (A-​DES; Armstrong, Putnam, Carlson, Libero & Smith, 1997; Smith & Carlson, 1996) was constructed to measure dissociative amnesia, absorption and imaginative involvement, and depersonalization and derealization. Three books on childhood dissociative disorders were published during the 1990s. Shirar’s (1996) Dissociative Children: Bridging the Inner and Outer Worlds described the in-​depth treatment of dissociative children with play therapy and Gestalt therapy techniques. Silberg (1996/​1998) edited The Dissociative Child: Diagnosis, Treatment and Management,

DOI: 10.4324/9781003057314-32

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which described clinical findings, diagnostic problems, and therapeutic techniques in evaluating and treating dissociative children. Frank Putnam’s (1997) Dissociation in Children and Adolescents: A Developmental Approach contributed an important theoretical advance by integrating the literature on childhood dissociative disorders with findings from developmental psychopathology. In addition, volume 5 of Child and Adolescent Psychiatric Clinics of North America (1996) was devoted to the epidemiology, assessment, and treatment of dissociative disorders in children. In the early 2000s, articles on dissociative psychopathology in children and adolescents were increasingly accepted in journals that focus on maltreatment (Haugaard, 2004; Silberg, 2000). Chapters on treatment of dissociative pathology in children were included in two psychopathology textbooks: Child and Adolescent Psychological Disorders (Wallach & Dollinger, 1999) and Handbook of Conceptualization and Treatment of Child Psychopathology (Silberg, 2001). In addition, a book was published that focused on neurobiological correlates of childhood trauma (Stien & Kendall, 2004). Dissociation was also addressed in the guidelines for the treatment of child abuse released by the National Crime Victims Research and Treatment Center (Saunders, Berliner & Hanson, 2004), and the International Society for the Study of Dissociation ([ISSD], 2004) released updated guidelines for the assessment and treatment of dissociative symptoms on children. Diagnostic tools to assess youth with dissociative disorders continued to be developed. An adolescent version of the Multidimensional Inventory for Dissociation (A-​MID) was produced (Ruths, Silberg, Dell & Jenkins, 2002) that is now routinely used clinically and in research. Sim et al. (2005) developed a 7-​item PTSD subscale, a 3-​item Dissociation subscale, and a 16-​item PTSD/​Dissociation subscale. These subscales were created using the Child Behavior Checklist (Achenbach, 1991) based on item ratings by clinical child psychology experts. Sim and colleagues found that sexually abused 4-​to 12-​year-​old children had significantly higher levels of dissociation and PTSD than a normative sample. The last 10 years have seen a significant increase in attention to child and adolescent dissociation. Innovations in treatment were described in a variety of new books, including Dissociation in Traumatized Children and Adolescents: Theory and Clinical Interventions (Wieland, 2011/​2 015). Wieland’s book contains a collection of international case studies which show that similar methodology has been developed cross-​c ulturally to deal with this difficult population. In 2013, Silberg published The Child Survivor: Healing Developmental Trauma and Dissociation, a book which reviewed existing literature and presented an organized treatment protocol for working with dissociative children (the second edition was released in 2021 [copyright 2022]). Frances Waters’ book, Healing the Fractured Child, followed in 2016 and provided a comprehensive compendium on the assessment and treatment of dissociation in youth. The Way We Are by Frank Putnam (2016) furthered our understanding of the developmental origins of dissociation. Treating Children with Dissociative Disorders: Attachment Trauma, Theory and Practice provides a comprehensive overview of research into dissociation in children (Sinason & Marks, 2022). The wider fields of clinical child psychology and trauma studies have begun to include chapters addressing child dissociation in texts. The latest edition of the American Psychological Association’s (APA) APA Handbook of Trauma Psychology contains a chapter on childhood dissociation (Silberg, 2018), as does the latest edition of Lewis and Rudolph’s Handbook of Developmental Psychopathology (Silberg, 2014). Ford and Courtois included a chapter on dissociation in their book Complex Trauma in Children and Adolescents (Wieland & Silberg, 2013). Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy treatment originally designed to alleviate the distress associated with traumatic memories in adults (Shapiro, 1989). Gomez (2012) adapted EMDR therapy for treating children with complex trauma, attachment problems and/​or dissociative tendencies. An attachment focus is increasingly stressed for work with dissociative symptoms and complex trauma (Gomez-​Perales, 2015). Struik (2014) discussed ways to assess a dissociative client’s readiness for trauma processing in Treating Chronically Traumatized Children –​ a book about treating complex PTSD and dissociation in children. Newer treatment protocols for traumatized children have begun to address dissociation, such as the Attachment, Regulation and Competency (ARC) Framework (Blaustein & Kinniburgh, 2010). Case studies have recognized the value of a number of adjunctive therapies with dissociation including the DIR/​Floortime Model (Silberg & Lapin, 2017) and creative arts therapy (Waters & Raven, 2016; Young, 2022).

Dissociation and its Relation to Trauma A growing body of research supports a consistent association between a variety of forms of early maltreatment and the presence of dissociative symptomatology in children, adolescents, and adults. A meta-​analysis of 65 studies found a robust relationship between childhood maltreatment (including neglect) and dissociation in adults (Vonderlin et al., 2018). Earlier age of onset of the abuse, longer duration of the abuse, and the parent as abuser predicted higher dissociation scores in adults.

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Burgeoning research documenting the effect of early trauma on brain development (e.g., Teicher, 2019) have made the global effects of early trauma more understandable to clinicians across many specialties and levels of expertise. In addition, the availability of standardized instruments has led to increasing research on symptomatic correlates of dissociation in numerous populations of children and adolescents. For example, research has found that dissociation is not only associated with maltreatment by caregivers. Teicher, Samson, Sheu, Polcari, and McGreenery (2010) found that substantial exposure to peer verbal abuse was associated with an over 10-​fold increase in dissociation, with a greater effect in females compared to males. Gušić, Cardeña, Bengtsson, and Søndergaard (2016) found that emotional abuse such as verbal harassment and bullying peers was predictive of dissociative symptoms, particularly in teenage girls. Deficits in caregiving are also associated with elevated levels of dissociation in children. Dissociative symptoms are associated with insecure attachment styles (Gušić et al., 2016), including the disorganized type and affect dysregulation (Hébert, Langevin & Charest, 2020). Longitudinal follow-​up studies have measured significant dissociation in children of parents who are psychologically insensitive and avoidant (Dutra, Bureau, Holmes, Lyubchik, & Lyons-​Ruth, 2009), neglectful (Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997) or punitive (Kim, Trickett, & Putnam, 2010). Severe dissociative symptoms such as hearing voices, collapsed immobility (Kozlowska, Walker, McLean, & Carrive, 2015) and extreme emotional dyscontrol have been found in children reporting organized abuse with multiple perpetrators (Silberg, 2022a). Silberg (2022b) documented dissociative symptoms in 70 young children who appeared to have been targeted by a particularly sadistic organized group of abusers in Israel. Some children described their abuse being videotaped and live-​streamed over the Internet. A study of a cohort of young adults abused by organized perpetrators engaged in the production of child sexual abuse images also reported significant dissociative symptoms (Canadian Centre for Child Protection, 2017).

Diagnostic Considerations in Children and Adolescents Early recognition and treatment of dissociation can avert a trajectory of maladaptive behavior and mental processes that can continue throughout the lifespan (Silberg, 2013/​2022a). Unfortunately, few children receive the early treatment they need. Children with dissociative disorders are frequently misdiagnosed based on co-​morbid symptomatology with a variety of conditions including: Attention Deficit/​Hyperactivity Disorder (ADHD), conduct disorder, oppositional defiant disorder, schizophrenia, various forms of epilepsy, affective disorders, eating disorders, and conversion or other somatoform disorders (Waters, 2016; Zoroğlu et al., 1996). The DSM-​5 does not contain a child-​specific diagnostic category for childhood dissociation, and childhood dissociative disorders are not adequately represented by adult criteria (Silberg, 2013/​2022a; Waters, 2016). Dissociation is defined in DSM-​5 as “a disruption of and/​or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (American Psychiatric Association [APA], 2013, p. 291). By referring to “normal integration,” this definition relates more to adults than children, as it describes “disruption,” rather than the process of development and integration. Children are not born with an integrated sense of self and do not start expressing an “idea of me” until toddlerhood when they begin to develop autobiographical memory (Ross, Martin, & Cunningham, 2016). Research indicates infants and toddlers slowly gain a sense of self through early developmental tasks accomplished in relation to attentive caregivers (Stern, 1985). In addition, DSM-​5 DID criteria require that, “Two or more distinct identities or personality states are present, each with its own relatively enduring pattern of perceiving, relating to and thinking about the environment and self ” (APA, 2013, p. 292). However, the manifestations of dissociation found in young children fall on a continuum of severity and the differing states the child may present do not always include an “enduring pattern,” as these manifestations may resemble normal developmental processes –​such as the phenomenon of vivid imaginary friends in young children. The DSM-​5, however, considers the presence of imaginary friends as an exclusion criterion for the diagnosis of a dissociative disorder in children. Yet, similarities between the imaginary friends of normal preschoolers and the hallucinated voices and dissociated identities of traumatized dissociative children have been noted. Silberg (2022a) indicates that the child’s apparent interaction with imaginary friends can be an early indicator of the development of dissociative self-​states in traumatized children and distinguishing between normal imaginary friends and dissociative manifestations is not easy for the inexperienced clinician. Imaginary friends found in traumatized children have been termed “transitional identities” (Silberg, 2022a). These are distinguished from the imaginary friends of normal children by their function to sequester traumatic content. A dissociative child is more likely to experience the imaginary figure as real, feel their behavior is outside of the child’s control, and perceive imaginary figures in conflict with each other (see below).

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The DSM-​5 provides an alternative designation that can be applied to children, Other Specified Dissociative Disorder, which pertains to cases that don’t fit criteria for DID, Dissociative Amnesia, or Depersonalization/​Derealization Disorder. This may be the choice most appropriate for older children and some adolescents who have significant dissociative symptoms which do not conform to standard adult criteria. In addition, the DSM-​5 does include a child-​specific diagnosis that does contribute to diagnostic clarity in young children –​Preschool Post-​Traumatic Stress Disorder. The description of this disorder provides clear markers of how young children manifest trauma in their behavior and includes dissociative reactions, like flashbacks, in its descriptive criteria, signifying an important development in the recognition of dissociative phenomena in children. Despite the lack of guidance in the DSM-​5, the ability to diagnose dissociative disorders in children is key to preventing a trajectory of significant risk and adversity. A study of 27,000 children in the Illinois child welfare system found that the presence of significant dissociation is a key predictor of psychiatric hospitalization, severe risk-​taking behaviors, and disruption of foster and adoptive placements (Kisiel, Torgersen, & McClelland, 2020).

Dissociative Symptomatology Preschool Children Young children from traumatic backgrounds may present with a variety of dissociative symptoms, such as trance-​like states, perplexing forgetfulness, behavioral and emotional fluctuations, hallucinatory phenomena, and somatic abnormalities (Silberg, 2013, 2022a). However, dissociated aspects of the self in young children do not tend to have a well elaborated sense of autonomy. Instead, feelings, thoughts, and impulses that the child experiences as foreign may be projected onto transitional objects such as dolls, fantasy playmates, cartoon characters or even animals that have a perceived reality far beyond the fantasy involvement of normal children. For instance, a dissociative child may talk to their toys, hear their answers, consult them for advice, insist that the toy be given a place at the dinner table, and insist on their reality as a sentient being. Young children may use their own body parts as transitional objects, which may be called “handy” or “footy,” that appear to the child to be autonomous. Silberg (2022a) coined the term “transitional identities” to describe the voices or internal identities of children showing the beginnings of a dissociative process. Like transitional objects, these transitional identities are projected elements of the self to which a child attributes living characteristics and with whom they develop relationships. Some transitional identities may be internalized attachment figures, which provide a cushion of protection against the chaotic relationships experienced with their real caregivers. Other transitional identities may be the personification of feelings like anger and fear, or the internalization of the characteristics of abusive people in their environment–setting the stage for perpetrating self-​states seen in older children and adults. Left untreated, Silberg (2013, 2022a) found that over time transitional identities can solidify into the discrete identity states in DID. Thus, transitional identities serve as a developmental transition between imaginary friends (or other normative fantasy phenomena) and dissociative self-​states. A number of factors differentiate the transitional identities found in dissociative children from the imaginary friends that appear in normal children. First, transitional identities are usually accompanied by intense post-​traumatic symptomatology such as fearfulness, night terrors, or intrusive traumatic thoughts. In addition, the child may be in conflict with a transitional identity and feel compelled to follow the directions of these transitional identities against their perceived will, believing they are “real.” Another difference between the experiences of dissociative and normal children is the emotion predominant when their imaginary friends “visit.” For normal children, the predominant emotion is happiness, whereas among dissociative children, the dominant emotion is usually anger (Silberg, 2022a). Children may have amnesia for actions influenced by transitional identities; however, unlike personality states in DID, these transitional identities do not present full separateness and do not yet have enduring patterns of relating to the world. While clear-​cut childhood DID is uncommon in preschool children, it does occur. In a well-​documented case, a three-​year-​old presented with two ‘personalities’ that represented adaptive reactions to two discrete environments (Riley & Mead, 1988). More commonly, children show dissociative manifestations without evidence of discrete identity fragmentation. Terr (1988) described trance-​like states in traumatized children during which they rigidly and compulsively re-​enact traumatic scenarios. During dissociative episodes, the child may have a look of non-​recognition in response to usually familiar people or places. Sometimes during these dissociative states, the children will appear to have a flashback in which they re-​enact traumatic scenarios with shouts of “no” and body movements simulating a violent assault (Cintron, Salloum, Blair-​A ndrews, & Storch, 2018). Amnesia may be present but may be viewed by the child’s caregivers as lying or forgetfulness (Silberg, 2013/​2022a). However, in some cases, the child may deny personal accomplishments that are praiseworthy (Hornstein, 1998). Further,

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young children in dissociative states may have trouble recognizing their caregivers (Silberg, 2022a; Waters, 2016; Young, 2022). Psychosomatic manifestations of dissociation span a range of presentations. Children may have enuresis and encopresis, which may relate, in part, to a desensitization of areas of the body involved in the trauma (Silberg, 2013/​2022a; Waters, 2015). Young children may suffer from headaches and stomachaches, have pain at the sites of previous injuries, be insensitive to pain, or have distortions in their sense of their body (derealization). Young dissociative children may also display shifting conversion symptoms with pains and disabilities, like an intermittent inability to walk (Silberg, 2013/​2022a). In young children, fluctuating behavior may include unpredictable eruptions into tantrums of surprising intensity, which appear out of context to what is going on around them (Cintron et al., 2018). Although regressive behavior is frequently present, it may be hard to detect unless the child is assessed over time. Dissociative preschool children may also display sleep disorders (Hébert, Langevin, Guidi, Bernard-​Bonnin, & Allard-​Dansereau, 2017). They may have difficulty sleeping alone; resist sleep; suffer from nightmares; have insomnia; talk, walk, or cry during sleep; wake frequently; and be constantly tired (Silberg, 2022a).

School-​Age Children With increasing age, the frequency of DID-​l ike symptoms also increases (Putnam, Hornstein & Peterson, 1996). School-​ age children may present with more differentiated dissociated identities; however, these identities may continue to be projected onto stuffed animals or toys (McElroy, 1992). Identity fluctuations may become more discernible because the regressive states become more developmentally aberrant. Some clinicians have documented wildly fluctuating variations in cognitive skill level, which can become very frustrating in school settings where the behavior may be interpreted as willful or avoidant (Yehuda, 2015). Amnestic symptoms may become apparent when children deny observed behavior and forget autobiographical information. Dissociative children often have difficulty remembering what they did while in states of rage. Children may also complain of changes in their sense of identity –​feeling like when they are angry or upset, it is not really them. Trance-​l ike behavior may become more intense and may span the range from vacant staring and blanking-​out to profound states of dissociative disconnection in which children are unresponsive to their external surroundings (Perry, Pollard, Blakely, Baker & Vigilante, 1995; Silberg, 2013, 2022a). These profound changes in awareness can be severe and last for several hours while the child seems lost in a trance and not easily aroused. Some dissociative children have particular difficulty upon awakening from sleep and may display aggressive behavior with little awareness or wake up in a regressed state (Silberg, 2013, 2022a).

Adolescents In adolescence, dissociative states tend to become more rigid and symptom patterns start to resemble more closely those of adults (Ruths et al., 2002). Dissociative adolescents often show shifting moods, dazed states, episodes of forgetfulness about recent events, sleepiness or sleeplessness, and may be plagued by self-​critical voices. A common presentation for DID in adolescents is amnesia for behavior that seems out of character, such as a sudden violent episode. Sudden onset of school problems (e.g., school anxiety and avoidance, academic regression, etc.) may signal dissociative conflict between self-​states. Comorbid, nondissociative symptoms tend to increase during adolescence and may frequently constitute the presenting complaint. Typical comorbid disorders and symptoms include conduct problems, sexual behavior problems, mood disorders, eating disorders, self-​mutilation, substance abuse, obsessive-​compulsive behaviors, and suicidal ideation/​attempts (Silberg, Stipic & Taghizadeh, 1997; Waters, 2016). Self-​i njury among teenagers is heavily correlated with dissociation (Cernis, Chan, & Cooper, 2019; Hoyos et al., 2019) and may serve a variety of functions such as identifying with abusive caregivers, self-​punishment, calling attention to their pain, and/​or releasing internal opioids (Ferentz, 2012). Sometimes children and teenagers use repetitive self-​h arming such as head-​banging to silence internal harassing perpetrators’ voices (Silberg, 2013/​2 022a). Self-​h arming behaviors may also occur during dissociated sleep states (Ratnamohan et al., 2018). Dissociative adolescents are also at risk for being misdiagnosed as psychotic, as auditory hallucinations appear to have an especially strong relation with dissociative processes (e.g., Altman, Collins & Mundy, 1997). Dissociative states may resemble seizures and many dissociative children are diagnosed with psychogenic non-​epileptic seizures (PNES) when EEGs fail to show abnormal brain wave activity (Bowman, 2006).

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Depersonalization and derealization symptoms, such as seeing oneself as if through a fog, are frequently found in teens with dissociative symptoms. The age of onset for Depersonalization/​Derealization Disorder is commonly 16, so careful assessment of this disorder in adolescents is essential (Simeon & Abugel, 2006). Carrion and Steiner (2000) found that 28% of juveniles on probation met criteria for a dissociative disorder, with depersonalization being the most commonly reported dissociative symptom. While an episode of illicit drug intoxication may precipitate depersonalization, the disorder is often related to a history of trauma. Treatment for depersonalization involves identification of the triggering traumatic thoughts and feelings that are precursors to the onset of the symptom, learning grounding techniques, and somato-​sensory interventions that help the teen learn to experience themselves and their environment with more heightened awareness. In summary, dissociation in childhood and adolescence presents with severe symptomatology of perplexing forgetfulness, shifts in identity, trance-​like states, unusual somatic experiences, and hallucinatory phenomena. Careful assessment and intervention is needed to prevent dissociative children and adolescents from progressing along a developmental trajectory that leads, with age, to much higher levels of morbidity and resistance to treatment.

Assessment of Dissociation The SCID-​D (Steinberg, 1993) is a structured interview that assesses dissociation using a semi-​structured interview based on DSM criteria. While developed for adults, this measure has been successfully used with adolescents (Carrion & Steiner, 2000; Goffinet & Beine, 2018; Şar, Onder, Kilincaslan, Zoroglu, & Alyanak, 2014). It examines five areas including symptoms of depersonalization, derealization, identity confusion, identity alteration, and amnesia. Since its development (Putnam et al., 1993), the CDC has become a standard tool for evaluating dissociative symptoms in young children. It assesses 20 key behaviors commonly found in dissociative children on a scale from 0 to 2, including items such as children referring to themselves with other names, having vivid imaginary friends, avoiding talking about known traumatic events, or denying observed behaviors. The CDC has good reliability and validity (Peterson & Putnam, 1994). The A-​DES, developed by Armstrong et al. (1997), is applicable to young people aged 11 and older. Dissociative experiences, such as feeling “there are walls in my mind,” “finding items that don’t belong to me,” and “feeling like there are different people inside me,” are scored on a scale ranging from 0 to 10 based on how frequently the adolescent experiences these phenomena. Scores of 4 or greater suggest pathological levels of dissociation, and further evaluation is warranted. The A-​DES is a reliable and valid instrument in adolescents (Farrington, Waller, Smerden, & Faupel, 2001; Smith & Carlson, 1996), and has been validated in a variety of languages and cultures (Goffinet & Beine, 2018; Nilsson & Svedin, 2006; Shin, Jeong, & Chung, 2009; Soukup, Papežová, Kuběna, & Mikolajová, 2010; Zoroğlu et al., 2002). The Brief Dissociative Experience Scale (DES-​B) is an emerging measure, developed by Dalenberg and Carlson (2010) for 11-​to 17-​year-​olds. The young person is asked to agree or disagree with eight sentences about eight different dissociative symptoms: staring into space, feeling the world is unreal, talking to oneself, ignoring pain, fluctuating behaviors, the world seeming to be in a fog, acting like different people, and fluctuating skills. (The measure is available at www.psy​chia​t ry.org/​psychi​atri​sts/​pract​ice/​d sm/​educ​atio​nal-​resour​ces/​a ss​essm​ent-​measu​res.) The adolescent version of the MID (Ruths et al., 2002) provides a comprehensive tool that has items relevant to an adolescent population. The adolescent rates 218-​items assessing 23 symptoms of dissociation on a scale of 0 to 10. Ruths et al. found that the pattern of dissociation in adolescents closely mirrors that of adults on this measure. Goffinet and Beine (2018) found 45% of consecutive adolescent inpatients had dissociative disorders based on the adolescent MID. (The measure is available at www.mid-​a ss​essm​ent.com​.) The Somatoform Dissociation Questionnaire (SDQ-​20) is a 20-​item measure assessing somatic manifestations of dissociation (Nijenhuis, 2004). Analgesia, motor disturbances, anesthesia, and conversion symptoms are assessed, all frequently found in dissociative adolescents. It appears to correlate with A-​DES psychoform dissociation (Pullin, Webster, & Hanstock, 2014) and with eating disorders in adolescents (Nilsson, Lejonclou, & Holmqvist, 2020). Indications of dissociation may also be picked up during traditional psychological testing. During testing, dissociative children often engage in staring episodes, odd movements, and display shifts in the developmental level of their language (Silberg, 1998). On projective testing dissociative children may draw or perceive multiple images, such as an individual with two heads, four eyes, or other multiple body parts. Children may also tell stories where sleeping, forgetting, or pretending are common themes, and perceive morbid images of death, blood, and destruction, a feature also found on the psychological testing of adults with dissociative disorders (Brand, Armstrong, & Loewenstein, 2006).

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While screening measures and psychological testing are helpful as an initial tool, it is through the clinical interview that the clinician gains entrance into the phenomenological world of the dissociative child. Guidelines for clinical interviewing have been developed by Silberg (2013, 2022a) and Waters (2016). Dissociative children and adolescents may display dramatic dissociative presentations, with children or adolescents changing their voices, carriage, and manner, and identifying themselves with different names. Cases in which clients perceptibly shift identities and amnesia is apparent are best diagnosed as DID. However, it is more common for child and adolescents to present with more subtle symptomatology (e.g., trance-​l ike episodes, arguing internal voices, sudden shifts in skills or developmental level) which is best characterized as Otherwise Specified Dissociative Disorder.

Theoretical Considerations There is no comprehensive theory that completely explains the symptoms, phenomenology, and developmental course of dissociation. However, a variety of theoretical viewpoints can help build insight into how dissociation may develop in severely traumatized children, with some being more relevant to child and adolescents, while others capture adult manifestations more adequately (Silberg, 2013, 2022a). Only the former will be examined here. Putnam’s (2016) Discrete Behavioral States theory of dissociation views the phenomenon from a developmentally sensitive viewpoint. Putnam based his theory on the infant observation studies of Peter Wolff (1987), who identified the basic states infants cycle through each day –​deep sleep, to REM sleep, to crying, to fussy, to alert. As the babies developed, Wolff observed increasing flexibility between states, facilitated by attentive parenting. Putnam theorized that the traumatized child develops states that are fear-​based, and which may be associated with unique state-​dependent memories. In chronically traumatized children, these states can become increasingly segregated over time and impervious to regulation. Putnam’s theory provides valuable insight as it recognizes that normal development involves a process of alternating and shifting states, and that flexibility and freedom to move within states is a hallmark of normal development. Liotti (2006) theorized that dissociation may be a consequence of disorganized attachment. Disorganized attachment is associated with an unpredictable or sometimes traumatizing parental caregiver, and is characterized by contradictory behavior patterns, asymmetrical movements, incomplete and interrupted movements, freezing and stilling, and indications of apprehension (Main & Solomon, 1990). Liotti (2009) theorized that caregivers who are fearful and frightening may elicit multiple, competing representations within an internal working model in the developing infant (see Schimmenti, Chapter 10 this volume). These competing schemas may be experienced simultaneously or in rapid succession, leading to confusion, impaired integration, and the “freezing” observed in young children with disorganized attachment. Waters (2016) integrates research on disrupted attachment into her STAR model of dissociation. The STAR model is represented by a 5-​pointed star that integrates aspects of attachment theory, dissociation theory, developmental theory, family systems theory, and neurobiology. Waters built on the insights of Barach (1991) who noted that Bowlby’s (1980, 1988) case studies on young children who experienced extended separation from their mothers may provide early descriptions of dissociation. Waters noted that symptoms Bowlby called “detachment,” are now typically associated with dissociation –​such as blank looks and apparent amnesia when an absent parent returns. Longitudinal research has shown that disorganized attachment in infancy is an important predictor of dissociative symptoms in late adolescence, particularly in combination with parenting deficits or traumatic experiences (Dutra et al., 2009; Lyons-​Ruth, 2003; Ogawa et al., 1997). A prospective study of preschool-​aged children found that disorganized attachment and emotion dysregulation mediated the association between CSA and dissociation (Hébert et al., 2020). Lyons-​Ruth (2020) found that early unavailability of consistent caregiving directly predicted dissociation and other maladaptive behavior patterns as children grow and is associated with brain anomalies as well. Cognitive theorists have developed the theory of “motivated forgetting” to explain amnesia for traumatic events. Motivated forgetting is based on the concept that people can block out traumatic memories when they are motivated to do so. Motivated forgetting is theorized to be an active process used as a coping strategy to avoid unpleasant affect. Numerous laboratory studies provide empirical support for this process. Subjects asked to memorize associations between words can be trained to selectively forget certain words through a variety of incentives introduced by the experimenter (Anderson & Huddleston, 2012). A similar process of selective memory, probably motivated by avoidance of shame and other painful affects, may occur in dissociative children for recent behaviors associated with traumatic events (Silberg, 2013/​2022a). Betrayal Trauma Theory (BTT) proposes that abused children develop amnesia for betrayal by caregivers in order to maintain attachment to the person on whom they are dependent for basic survival (Freyd, 1996; 1999). Research

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has confirmed several of the predictions of BTT. For instance, the presence of betrayal trauma before age 18 predicts pathological dissociation after age 18 (DePrince, 2005). Similarly, exposure to high betrayal type traumas correlate with increased dissociative symptoms (Freyd, Klest & Allard, 2005). Silberg’s (2013/​2022a) Affect Avoidance Theory of dissociation relies on Putnam’s (2016) Discrete Behavioral State model, insights from attachment theories, as well as Tomkin’s (1962, 1963) affect theory, to explain the automatic state shifts found in dissociative children and adolescents. According to Affect Avoidance Theory, affect scripts (collections of learned associations between emotions, what stimulated them, and behaviors that help regulate them) evolve to avoid the arousal of affects associated with trauma (terror, humiliation, disgust), and these painful affects are soon mistaken for the sources of trauma, and thus provoke avoidance scripts of their own. As these patterns of behavior are practiced, they become more rigid and automatic, and ultimately become self-​reinforcing as they shape the interpersonal environment around them. Based on Silberg’s model, treatment must focus on the transitional moments that trigger these automatic programs of response and the child must learn to identify, express, and regulate the affective responses that they are avoiding.

The Neurophysiology of Trauma and Dissociation Advances in neurobiology have led to new understanding of the biological substrates of dissociative symptoms in children and adolescents. Research suggests that trauma produces neurochemical, functional, and structural abnormalities in brain areas associated with the integrative process of cognition and memory (Bremner, 2005; Diseth, 2005). A review by McLaughlin, Weissman and Bitrán (2019) found that children experiencing harm or threat of harm had reduced amygdala, medial prefrontal cortex, and hippocampal volume and heightened amygdala activation to threat in a majority of studies. These neural differences are consistent with behavioral studies demonstrating enhanced threat processing in children exposed to violence (McLaughlin & Lambert, 2017). Children exposed to threat also have greater threat-​related activation in the anterior insula (McLaughlin et al., 2019), which regulates information flow across other large-​s cale brain networks involved in attentional processing and cognitive control (Sridharan, Levitin, & Menon, 2008). Childhood abuse is also associated with abnormalities in the corpus callosum (e.g., Teicher et al., 2004). The corpus callosum controls inter-​hemispheric communication of arousal, emotion, and higher cognitive abilities. A dysfunction of hemispheric interaction may predispose children to dissociative psychopathology (Spitzer et al., 2004). De Bellis et al. (1999) found a negative correlation between CDC scores and total corpus callosum area in maltreated children. The finding of an underdeveloped corpus callosum in maltreated children may suggest a potential neurological underpinning for the disconnections, flashbacks, and dissociative phenomena observed in traumatized children (Teicher et al., 2003). The underdeveloped corpus callosum may inhibit the ability to integrate visual information (right brain) with verbal encoding (left brain) which may help explain why PTSD patients tend to experience traumatic recall as flashbacks rather than as verbal narratives.

Treatment The consensus of experts is that complex trauma-​related disorders in adults –​including DID –​are most appropriately treated using a three-​stage model that includes: safety and stabilization; working through and reassessing traumatic memories; and reintegration and rehabilitation (International Society for the Study of Trauma and Dissociation [ISSTD], 2011). Strides are currently being made in validating treatments for adults with dissociative disorders. For example, a recent study examined the effect of phase-​oriented inpatient trauma treatment on neural networks in patients with complex PTSD and complex dissociative disorders. Following treatment, connectivity became normalized in networks comprising regions associated with cognitive control and memory (Schlumpf, Nijenhuis, Klein, Jäncke, & Bachmann, 2019). Brand et al. (2019) validated the efficacy of a psychoeducational and skills-​based intervention for the treatment of adults with dissociative disorders. The most severely dissociative clients improved the most, and improvement included better emotional regulation, higher adaptive capacity, and reduction in PTSD and dissociative symptoms. Currently, there are no similar empirically validated treatments for children and adolescents. However, there are clear indications that younger people often respond well to treatment. Generally, the younger the child is diagnosed and treated for dissociation, the swifter the recovery. Numerous case studies show good response to treatment in dissociative children with remission of symptoms and return to developmentally normal functioning (e.g., Silberg, 2013/​2022a; Waters, 2016; Wieland, 2015; Young, 2022). Without early therapeutic intervention, children’s early manifestations

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of dissociation may solidify into discrete identity states that are more resistant to treatment (Silberg, 2013/​2022a). Still, younger adults tend to respond to treatment better than older ones. A longitudinal study of dissociative disorder treatment outcome in adults aged 18–​30, found that compared to older participants, young adults were more impaired initially but improved at a more rapid pace (Myrick et al., 2012). While the normal developmental tasks of adolescence make it a challenging time for treatment (Kluft, 2000), successful treatment trajectories in adolescents have been documented (e.g., Baita, 2020; Ratnamohan et al., 2018; Silberg, 2013, 2022a; Waters, 2016; Wieland, 2011/​2015). Challenges include the frequency of self-​harming behaviors, self-​destructive acting out and unstable relationships, often in response to shifting environments (e.g., residential placements, foster homes). Even in a stable home, the dissociative adolescent’s shifting patterns of relatedness (e.g., alternating between dependence and mistrust) often produces chaos. When a clinician provides successful treatment to a child, they may not only prevent a lifetime of severe pathology but may provide significant economic benefit to society as well. Trauma-​related disorders cost society billions of dollars annually (Myrick, Webermann, Langeland, Putnam, & Brand, 2017). Studies show that the longer a client receives dissociation-​specific treatment, the lower the ultimate cost utilization for both outpatient and inpatient services (Langeland et al., 2020; Myrick et al., 2017). The ISSTD’s Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents, published in 2004 and now undergoing revision, reflected a consensus of the field regarding the treatment of children and adolescents with dissociative symptoms and disorders. Much of its content is still relevant today. Foremost, dissociative youngsters cannot be successfully treated unless they are in a safe environment. In cases with unstable families, the therapy may have more limited goals such as crisis intervention and promoting stability. Case descriptions dramatically illustrate the pitfalls in treatment when safety is not achieved (e.g., Baita, 2020; Waters; 2016). A sequential model moving from stabilization through processing and integration is stressed by expert therapists. Waters (2016) emphasizes a variety of stabilization strategies, such as imagery of safe places and internal safety contracts, to help children contain overwhelming affect in early treatment. Struik (2014) identifies key components in assessing whether it is time for traumatic processing: achieving external safety, adequate daily living skills, availability of attachment figures, skills in affect regulation, psychological safety in relation to the abuser, and the ability to safely acknowledge trauma. Silberg’s (2013, 2022a) recommends a sequential treatment path that follows the acronym EDUCATE, and initially starts with psychoeducation (E) and assesses the child’s motivations to maintain dissociation (D: dissociation motivation). The next group of interventions assists the child in (U) understanding the hidden parts of the self and (C) claiming and embracing affective experiences and memories. The A in EDUCATE stands for regulation of arousal, affect, and attachment. The crux of treatment is learning affect regulation techniques reinforced in the context of relationships with attachment figures. Trauma processing and understanding triggers is the “T” in the model. In the ending stage of therapy (E), the child embraces new developmental challenges, and learns to appreciate the ways their current life differs from their traumatic past. Psychoeducation involves teaching how individual parts contribute to a successful whole through metaphors and toys that illustrate the concept of parts working together (e.g., Silberg, 2013/​2022a; Waters, 2016). Children’s literature such as The Colors of Me (Gomez & Paulsen, 2016) can help children understand post-​traumatic stress and dissociation. Another important psychoeducational concept is helping children understand that internal voices are not the “real” perpetrators and can be viewed as “feelings” talking to them (Silberg, 2013). A major goal of treatment involves helping the child to learn to regulate affect, improve self-​soothing skills, and make internal connections that promote awareness of other states, affects, or identity shifts (Silberg 2013, 2022a; Waters, 2016; Wieland, 2015). In addition, therapy focuses on triggers and onset of dissociative episodes so the child can learn new ways to respond to traumatic reminders and interrupt automatic processes ( Johnson, 2002; Silberg, 2013). The clinician should also help the young person acknowledge how dissociation has helped them deal with overwhelming trauma, while recognizing its usefulness has passed (Silberg, 2013, 2022a). The therapist can help to break down dissociative barriers by modeling acceptance of all of the child’s contrasting feelings. Through creative arts, puppet shows, dramatization, and sand play, the client can illustrate hidden parts of self and learn the importance of owning all their feelings, no matter how foreign they seem. Detailed protocols of how to identify dissociated self-​states in children and teens, and work with them towards self-​acceptance of “sequestered” aspects of the self, have been described (e.g., Silberg, 2013, 2022a; Waters, 2016; Wieland, 2015; Young, 2022). Silberg (2013, 2022a) presents specific guidelines for assisting children with accessing dissociated autobiographical memory by focusing on precursors to the forgotten events and enhancing awareness of the affective experiences they are trying to avoid. The therapist is continuously encouraging the child towards a sense of efficacy and mastery (ISSD, 2004).

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Family work is extremely important because the relational impairments of dissociative children make the reciprocal relationship with a trustworthy adult a key component in the healing process (Gomez-​Perales, 2015; Silberg, 2013/​ 2022a; Struik, 2014; Waters, 2016). The ISSD (2004) Guidelines recommend family interventions that enhance reciprocity in communication, encourage direct expression of feeling, and avoid the reinforcement of regressive coping. To work on attachment issues, dyadic therapy with a safe parent and child together is often recommended (e.g., Gomez-​ Perales, 2015; Silberg & Lapin, 2016). Parental education helps caregivers gain tolerance for the expression of the child’s feelings and reframe the child’s problematic behavior (Gomez-​Perales, 2015; Waters, 1998). Caregivers should be helped to view dissociation as a coping tool that helped the child survive but should be cautioned against interacting with the child’s dissociative states as if they are literally separate from the child (ISSD, 2004). A number of adjunctive techniques may prove helpful in treatment. Gestalt-​like techniques and play therapy can help the child dramatize conflicting emotions and dissociated feeling states (e.g., Friedrich, 1991; Gil, 1991; Shirar, 1996). Art therapy (Sobol & Schneider, 1998; Waters & Raven, 2016) and DIR/​F loortime Therapy (Silberg & Lapin, 2017) may be useful adjunctive techniques. EMDR (Gomez, 2012) or hypnotic techniques may be useful when dealing with traumatic flashbacks (Wieland, 1998) or to guide the child towards mastery experiences (Friedrich, 1991; Williams & Velazquez, 1996). Mindfulness exercises which help children learn to observe and experience internal sensations and emotions without judgment (Forner, 2017), can improve affect tolerance, and the focus on the “here and now” combats dissociation. There are no controlled studies on medications to treat dissociative disorders in children (ISSD, 2004). Pharmacological treatment may be useful for co-​morbid disorders or managing symptoms such as anxiety, inattention, depression, insomnia or behavioral dyscontrol (ISSD, 2004, Nemzer, 1998; Silberg et al., 1997; Stierum & Waters, 2016). When medications are used, communication and teamwork between the therapist and the prescribing physician is essential (ISSD, 2004; Silberg, 2013, 2022a; Waters, 2016). Inpatient treatment may be necessary when the behavior of the child or adolescent is dangerous, self-​injurious, or destructive. Unfortunately, there is a dearth of appropriate inpatient services available for these children. Of those that are available, time and reimbursement constraints promote reliance on medications to control symptoms rather than addressing the underlying traumatic roots of the child’s behavioral problems. However, even long-​term inpatient stays are not without their problems. Extended stays in residential or hospital settings make it difficult to address the child’s ongoing attachment dilemmas with their caregivers (ISSD, 2004). Clinicians treating dissociative children should have training in child therapy, child development and a variety of treatment approaches for traumatized children (ISSD, 2004). Continuing education is available at the meetings of international trauma societies, such as the International Society for the Study of Trauma and Dissociation (ISST-​D.org). Specialized techniques for working with trauma and dissociation using bilateral stimulation to achieve more rapid processing are also taught by EMDR practitioners (see EMDRIA.org).

Where Do We Go from Here? Despite the changing and provisional nature of our knowledge on dissociative children, promising diagnostic tools and treatment strategies are available. Empirical validation of treatment success for dissociative children and adolescents will depend on the field converging on a clear diagnostic measure that can discriminate pathological dissociation from non-​ pathological behaviors. Such a measure should be able to discriminate between diagnostic categories and provide an indication of severity. As instruments become increasingly sophisticated to monitor change and growth in treatment, the field is ripe for research to validate that dissociation-​t argeted interventions can reverse dissociation and return children and adolescents to a developmentally appropriate trajectory. The field of neuroscience will continue to contribute theoretical and practical approaches for treating dissociation in children. There is already emerging data showing that functional neurological changes can be documented following treatment of complex trauma disorders in adults (e.g., Schlumpf et al., 2019) and neuroimaging has been used to determine which PTSD symptoms are most likely to respond to a specific intervention (e.g., Bryant et al., 2008). Similar studies in children could provide valuable information to help discern the best therapies for children based on their symptom profile. Although children with dissociative disorders currently remain under-​recognized and underserved, we anticipate that the study of dissociative disorders in children and adolescence will increasingly move into the mainstream. As this happens, we hope to see more emphasis on the early detection of emerging dissociative symptoms in young children and prompt treatment by clinicians skilled in addressing these children’s unique needs. The mental health of our children and the generations that follow depend on this progress.

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Dissociation as a Transdiagnostic Process Acute and Chronic

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28 PERITRAUMATIC DISSOCIATION AND CHRONIC POSTTRAUMATIC SYMPTOMATOLOGY Thirty Years and Counting Etzel Cardeña and Catherine C. Classen

Three decades ago, systematic research on possible acute and long-​term aftereffects of peritraumatic dissociation (PD) was partly spurred by the proposal of a Brief Reactive Dissociative Disorder (BRDD) and the associated literature reviews and analyses of datasets (Cardeña, Lewis-​Fernández, Beahr, Pakianathan & Spiegel, 1996; Cardeña et al., 1998; Spiegel & Cardeña, 1991). The goal was to “encourage greater clinical and research attention to the substantial number of people who may have severe and acute dissociative and anxiety reactions to trauma and bring the DSM nosology into greater accord with the ICD-​10 diagnosis of acute stress reaction” (Cardeña et al., 1996, p. 994). That proposal was discussed by the DSM-​IV Anxiety Disorders Work Force within the frame of what became the Acute Stress Disorder diagnosis. This chapter provides an introduction to the concepts of dissociation and peritraumatic dissociation (henceforth PD), and reviews measures of peritraumatic dissociation and related biological research. It then discusses PD within the context of Acute Stress Disorder (ASD) and its role as a predictor of PTSD or, more generally, of posttraumatic stress symptoms (PTSS), including research on potential mediators and moderators, before providing conclusions and recommendations for future research.

Dissociation In contrast with the minimalistic definition of dissociation in the DSM taxonomy as alterations in the subjective integration of behavior, memory, identity, consciousness, emotion, body representation, and motor control (American Psychiatric Press [APA], 2013), Cardeña and Carlson (2011, p. 252) offered a more comprehensive definition of dissociation: An experienced loss of information or control over mental processes that, under normal circumstances, are available to conscious awareness, self-​attribution, or control, in relation to the individual’s age and cognitive development. Symptoms are characterized by (a) a loss of continuity in subjective experience with accompanying involuntary and unwanted intrusions into awareness and behavior (so-​called positive dissociation); and/​or (b) an inability to access information or control mental functions or behaviors, manifested as symptoms such as gaps in awareness, memory, or self-​identification, that are normally amenable to such access/​control (so-​called negative dissociation); and/​or (c) a sense of experiential disconnectedness that may include perceptual distortions about the self or the environment. It is important to mention that dissociative phenomena are not necessarily indicative of pathology (Cardeña, 1997), although that is what we will concentrate on in this chapter. How these processes are experienced around the time of trauma may be discerned from a set of items endorsed by a significantly large group of respondents one week after a devastating earthquake, as compared with about four months later: Alterations in cognition (e.g., confusion, difficulty with new information, narrowing of attention, attention drawn automatically to stimuli), alterations in memory (intrusive recollections, reliving the trauma), alterations in time perception, derealization (e.g., perceiving the surroundings as unreal), and depersonalization (e.g., a sense of the self detaching from the body, numbing/​slowness) (Cardeña & Spiegel, 1993). To these should be added psychogenic amnesia for personal information, including experiences during

DOI: 10.4324/9781003057314-34

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a traumatic event, and the sense that one’s identity is fragmented/​compartmentalized. The theory of structural dissociation (e.g., Van der Hart, Nijenhuis, & Steele, 2006) emphasizes the last type of phenomena, which seem to be more related to early, chronic, intentionally-​caused, interpersonal trauma than to single instances of unintentional trauma such as disasters (cf. Terr, 1991, for a discussion of effects of different types of trauma).

Peritraumatic Dissociation The basic meaning of the term “peritraumatic dissociation” (PD) is simple: dissociation around the time of the trauma. Beyond it there is an important temporal question that remains muddy. By “around” do we mean only at the time of the traumatic event? Or, if also later, how much later? It turns out that this is a consequential question with important implications for the understanding of the relation between dissociative reactions and traumatic events. Let us take the simplest answer and define peritraumatic as at the time of trauma or shortly (hours or a few days at most) thereafter. Typically, a large percentage of people experience dissociative and related phenomena such as time expansion and the surroundings as unreal around the time of trauma, which decrease considerably over time once the person is safe (e.g., 51% and 40%, respectively, in a non-​clinical sample after an earthquake, falling to 19% and 12% four months later, Cardeña & Spiegel, 1993). Predictably, PD reactions are also far more prevalent than acute or long-​term diagnoses. In a study with survivors of motor vehicle accidents (MVA), 79% reported at least one PD symptom and 57% endorsed time distortion; 34% and 25% of respondents had a diagnosis of acute or chronic PTSD, much lower figures than those reporting at least one PD symptom (Ursano et al., 1999). Since the rate of short-​term dysfunction, as indexed by ASD, is much lower [less than 20% for non-​i nterpersonal trauma according to the DSM-​5 (APA, 2013)] than the percentage of people experiencing a dissociative response, the mere presence of a PD reaction at the time of trauma is clearly not specific enough to guide clinical decisions or theoretical conceptualizations. The intensity and number of PD reactions are better indicators than the presence of any single PD reaction. Furthermore, dissociative reactions that do not fade away after the traumatic event, known as lingering or persistent dissociation, may be a better or at least different predictor of chronic pathology (see below).

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Measures of Peritraumatic Dissociation Besides the Structured Clinical Interview for DSM-​5 (First, Williams, Karg, & Spitzer, 2015), which includes a section for ASD, various self-​report instruments assess peritraumatic dissociation in a reliable and valid way. There are dissociation items within larger PTSD measures (e.g., Briere & Runtz, 1989) as well as measures focused on PD and acute stress reactions. A widely used measure is the 8-​item Peritraumatic Dissociative Experiences Questionnaire (PDEQ; Marmar, Weiss & Metzler, 2004), which has been translated into French and Portuguese. A latent structure analysis reported that it has two factors: altered awareness and derealization (Brooks et al., 2009), a finding replicated by Sijbrandij and colleagues (2012). More comprehensive measures of reactions to acute stress including dissociation, arousal, and other symptoms have also been developed and often employed. They include the Acute Stress Disorder Scale (19 items; translated into German), the Acute Stress Disorder Interview (Bryant & Harvey, 2000) and the Stanford Acute Stress Reaction Questionnaire (SASRQ; Cardeña, Koopman, Classen, Waelde, & Spiegel, 2000), translated into nine other languages. A newer version of the SASRQ that follows DSM-​5 criteria for ASD has also been developed and translated into other languages (Cardeña et al., 2014). In addition to retrospective questionnaires and interviews, a promising recent development is the evaluation of people’s experiences as they occur, using probes that may be determined totally randomly or tied to an event or an interval. A study pioneered this strategy by having a sample of traumatic injury participants or their relatives respond to their experience of PTSD items (Carlson et al., 2016). The results were valid and reliable using multi-​level analyses, with strong correlations between PTSD and dissociation items. These techniques have also been employed to evaluate dissociation more generally, including a study comparing mind-​wandering among non-​clinical adult high-​and low dissociators, in which the former evidenced less sense of control and more negative affect (Cardeña & Marcusson-​Clavertz, 2016).

Physiological Correlates Research on the physiological correlates of PD is challenging. Its assessment is almost inevitably retrospective because usually it is logistically impossible to examine physiological correlates while trauma occurs or very shortly thereafter.

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We identified only one study that was able to do this (Delahanty et al., 2003). Most research designs can only indirectly assess the relation of physiological functions to PD.

Heart Rate Several studies have examined the relation between heart rate (HR) and PD, some within days of the traumatic event (Delahanty et al., 2003; Griffin, Resick & Mechanic, 1997; Kuhn, Blanchard, Fuse, Hickling, & Broderick, 2006) and others years later (Bichescu, Steyer, Steinert, Grieb & Tschöke, 2017; Hetzel-​R iggin, 2010; Kaufman et al., 2002; Pole et al., 2005). Delahanty and colleagues studied 99 MVA victims and found no relation whatsoever between PD and mean HR. This study is notable because heart rate was assessed within the first 20 minutes of admission to the hospital and PD was assessed a couple of days later. Given the definition of PD and the fact that MVA requiring hospitalization could be considered a more protracted trauma, it can be reasonably assumed that PD was assessed around the time of the traumatic experience. Their findings contrast with those of Kuhn and colleagues (2006), who also assessed HR among 50 MVA victims while in the emergency department, and found that it correlated positively with PD. However, in Kuhn’s study PD was assessed two weeks after the MVA. Griffin and colleagues (1997) evaluated 85 rape victims two weeks after rape and prompted participants to tell the story of the rape, and reported that those with high PD had lower HR than participants with low PD. Elsesser and colleagues (2008) examined reactions to startle stimuli among 51 participants who had experienced different types of traumatic events an average of 21 days before (range of 1 to 9 weeks) assessing both HR and PD and found no relation between them. Some differences between the Griffen et al. study and the others are that they studied sexual assault as opposed to MVA or a range of traumatic experiences, and they activated memories of the trauma, whereas the other studies did not. Although these studies had the advantage of assessing PD shortly after the trauma, they do not show consistent results. Studies of PD assessed years after the trauma and its relation to HR in response to reminders of trauma also fail to reveal a consistent pattern. Bichescu and colleagues (2017) studied 28 women with borderline personality disorder compared to 15 healthy controls. Women who retrospectively reported high levels of PD in relation to their most severe traumatic event had a lower HR when imagining their trauma while listening to a neutral voice describing it compared to those with low levels of PD or healthy controls. Hetzel-​R iggin (2010) studied 86 sexual assault victims, on average two years after their sexual assault, and found that those with high PD at the time of their assault had higher HR when listening to their personal scripts of a fear experience or their sexual assault than those with low PD. In addition, greater variation in HR over time was found for low PD compared to high PD. Kaufman and colleagues (2002) studied the physiological responses of Vietnam veterans with chronic PTSD who retrospectively reported either high (n =​256) or low (n =​118) PD at the time of their most stressful combat-​ related experiences. When exposed to trauma-​related stimuli, there were no differences in physiological measures including HR. Pole and colleagues (2005) studied 19 participants who had experienced trauma at least three years before; when comparing those reporting high versus low PD during the trauma they did not find a significant difference in HR. However, a post-​hoc analysis showed greater discordance between HR (elevated) and systolic blood pressure for high PD, along with greater negative emotion when talking about trauma compared to those with low PD.

Blood Pressure Research examining the relation between blood pressure and PD is even more limited. Kaufman and colleagues’ (2002) study of Vietnam veterans found no relation, whereas Pole et al. (2005) found that high PD was associated with low blood pressure prior to talking about trauma and that there was a greater discordance between HR and systolic blood pressure (SBP) for high PD participants when talking about their trauma. Delahanty and colleagues reported that in females (n =​25) PD was negatively correlated with systolic blood pressure.

Electroactivity of Skeletal Muscles and Associated Nerve Functions Elsesser and colleagues’ found startle reactions and PD to be negatively correlated. Ladwig and colleagues (2002) studied startle reactions to auditory stimuli in cardiac arrest patients comparing high (n =​32), low (n =​40), and no PD (n =​31) about three years after the event. They found a non-​significant heightened startle response among high PD patients and significant impairment in habituation, whereas Kaufman’s et al. (2002) study did not reveal differences in electromyograms across PD groups in response to personally relevant combat scripts.

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Skin Conductance Skin conductance, an indirect measure of the sympathetic autonomic response, has been investigated in a handful of studies. Griffin and colleagues (1997) found lower skin conductance among high PD sexual assault victims when talking about their rape and immediately afterwards, consistent with the hypothesis of PD as a coping strategy. In contrast, Hetzel-​R iggin’s study (2010) of sexual assault victims found elevated skin conductance among high PD participants while listening to nonpositive scripts of their experiences. Kaufman et al. (2002) did not find differences in skin conductance across PD group, whereas Ladwig and colleagues (2002) reported that high PD was associated with higher skin conductance.

Stress Hormones Delahanty and colleagues (2003) examined 15-​hour urine samples of MVA victims, which covered the period of the accident and the entire hospital experience. They found a negative correlation between PD and epinephrine and norepinephrine. PD in females was related to level of norepinephrine and in males to epinephrine. The relation in women was particularly strong. Kobayashi and Delahanty (2014) assessed urinary samples of 39 participants three weeks after a hospital stay due to traumatic injury. For those in the high PD group daytime cortisol levels were lower in those who developed PTSD than in those who did not. They did not mention whether there was a relation between PD and cortisol. Taylor and colleagues (2007) assessed salivary cortisol and dehydroepiandrosterone sulfate (DHEAS) in response to the survival training of 19 military men and did not find any association with PD.

Genetic Correlates The only study we found on genetic correlates is a brief report by Koenen and colleagues (2005). Their research on FKBP5, a gene involved in the regulation of the hypothalamic–​pituitary–​adrenal (HPA) axis, which is related to stress, found that two single nucleotide polymorphisms (SNPs) on the FKBP5 gene were associated with PD among medically injured children.

Summary In sum, the physiological findings related to PD are disparate and often inconsistent. However, if one looks past the noise of different physiological measures, traumatic experiences, and research design, there is some evidence that PD may dampen the physiological response to trauma and be protective that way. HR has received the most attention. Here there is some support for the theory that PD may be protective by lowering HR (Bichescu et al., 2017; Griffin et al., 1997), although other research found the opposite (Hetzel-​R iggin, 2010; Kuhn et al., 2006) and some, no relation at all (Delahanty et al., 2003; Elsesser et al., 2008). There is some evidence that PD may be associated with lower blood pressure (Delahanty et al., 2003; Pole et al., 2005). Research on skin conductance provides contradictory support for the hypothesis that PD is associated with a reduced sympathetic autonomic response to trauma, with one study supporting it (Griffin et al., 1997) and three others not (Hetzel-​R iggin, 2010; Kaufman et al., 2002; Ladwig et al., 2002). PD may impact stress hormones (Delahanty et al., 2003). It is important to point out that there are important differences between these studies including type of trauma, evaluation since trauma, whether memories of the trauma were activated, and the physiological variables under investigation. These methodological differences may have obscured a potential relation between PD and physiological responses to trauma. Also, analyses of potential non-linear relations should be conducted.

Acute Stress Disorder and Posttraumatic Stress Disorder in the DSM Taxonomy The criteria for ASD in the DSM-​I V included exposure to trauma; intense fear, helplessness, or horror in response to trauma; three or more dissociative symptoms; and an unspecified number of re-​experiencing, avoidance, and anxiety symptoms causing clinical distress or impairment, with symptoms lasting from two to 30 days (APA, 2000). Brewin and associates (1999, p. 364) reported “clear support for the specific complex of acute disorder symptoms proposed.” This was in contrast with the criticisms of Harvey and Bryant (2002), some justified and some not so much (see Cardeña & Carlson, 2011). The DSM-​5 (APA, 2013) made changes to the previous ASD criteria. It deleted the requirement of an intense emotional reaction, which is problematic to measure and runs counter to a numbing emotional response. ASD criteria

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now require exposure to actual or threatened death, serious injury or violation, and nine or more symptoms of intrusion (including intrusive memories), negative mood, dissociation (derealization and amnesia are listed), avoidance, and arousal, with symptoms lasting from three days to a month. When comparing the DSM-​5 criteria for ASD and for PTSD a lack of coherence becomes evident. For instance, amnesia is mentioned as a dissociative symptom in ASD, but as a negative alteration in cognition and mood in PTSD. A helpful change, in our view, is that PTSD now includes the specifier of “with dissociative symptoms,” although only depersonalization or derealization are mentioned, an issue we discuss in the following section. A study compared DSM-​I V and DSM-5 criteria, with the former producing fewer (8%) ASD diagnoses than the latter (14%), and similar percentages using either set of criteria predicting later PTSD; DSM-​5 criteria were a better predictor for other disorders such as depression and anxiety disorders (Bryant et al., 2015).

More than One Acute Stress Disorder, more than One Posttraumatic Stress Disorder Although sharing the same proposed causal variable, a potentially traumatizing event, it is evident that pathological reactions to trauma are multifarious when following DSM-​5 criteria. Galatzer-​Levy and Bryant (2013) estimated that there are an astonishing 636,120 combinations of symptoms that can give rise to a PTSD diagnosis. Before getting into the research on ASD, it is important to point out that most people recover well psychologically from most traumas (extreme prolonged traumas like repeated early abuse or having been a tortured POW is another matter, e.g., Engdahl, Dikel, Eberly, & Blank, 1997; reviewed in Cardeña & Carlson, 2011). For less severe traumas and losses, longitudinal research has found that most individuals show resilience, with smaller subgroups exhibiting recovery from threshold pathology, chronic dysfunction, or a delayed dysfunctional response to trauma (Bonanno, 2004). For instance, Pérez and colleagues (2016) evaluated women five times over the course of their cancer diagnosis, treatment, and follow-​up, finding four subgroups: recovery (44.5%), mild acute stress (41%), delayed recovery (12%), and chronic acute stress (3%). As mentioned, the DSM-​5 introduced the specifier of a dissociative subtype of PTSD, but the place of dissociative phenomena in such criteria remains incoherent. The subtype is defined by the presence of dissociative symptoms, of which only depersonalization and derealization are listed, while simultaneously psychogenic amnesia (under negative alterations in cognitions and mood) and “dissociative reactions” such as flashbacks (under intrusion symptoms) are subsumed under other categories, which thus muddies the role of dissociative phenomena in PTSD. Be that as it may, at least 16 publications using latent class analysis/​latent profile analysis (LCA/​LPA) have supported a type of PTSD involving depersonalizations/​derealization (Ellickson-​L arew, Escarfulleri, & Wolf, 2020). Nonetheless, some studies with both adults (e.g., Ross, Baník, Dědová, Mikulášková, & Armour, 2018) and adolescents (Cardeña et al., 2022) have shown that other types of dissociative phenomena such as gaps in awareness/​memory and mental partition/​compartmentalization should be considered part of the dissociative subtype. More generally, Schimmenti and Şar (2019) found in a network analysis of a dissociation questionnaire that amnesia items were important to various symptom intercorrelations. There is also research supporting a dissociative type of PTSD among youth. In retrospective research with detained youth, those with high depersonalization/​derealization (n =​20) had more PTSS and emotion dysregulation than those with low (n =​205); in addition, a mediation analysis suggested that PD contributed to lingering dissociation (Bennett, Modrowski, Kerig, & Chaplo, 2015). A large study with 3,081 trauma-​seeking adolescents reported five PTSS types based on symptomatology: dissociative subtype/​h igh PTSD, high PTSD symptoms only, anxious arousal, dysphoric arousal, and low symptoms, with an expanded model identifying a class featuring dissociative amnesia and detached arousal (i.e., a mixture of dissociative and dysphoric arousal symptoms; Choi et al., 2017). Another analysis on the same sample reported that the dissociative PTSD subtype was associated with more traumatizing events, maltreatment, and being female (Choi et al., 2019). Although there is not as much research on ASD as there is on PTSD, there is support, also using LPA, for a multi-​ symptomatic, dissociative type of ASD, as had been proposed earlier (e.g., Cardeña & Carlson, 2011; Isserlin, Zerach, & Solomon, 2008). Hansen et al. (2015) analyzed five different samples (N =​472), one of rape victims, the others of bank robberies (two samples), an earthquake, and work violence. The rates of ASD for rape were much higher than for the other samples (56% versus 15% or less), although the ASD means were very similar across samples. The LPA resulted in five classes of acute stress reactions: Class 1 (10%) was associated with low dissociation compared with the others, Class 2 (18%) with marked low levels of avoidance, Class 3 (33%) had lower symptomatology than the others except for intrusion, Class 4 (23%) had higher means of intrusion and arousal than the other classes except for Class 5 (17%) which was the most highly symptomatic overall, including dissociative reactions. Furthermore, for a sample assessed following a bank robbery, the highly symptomatic ASD type (Class 5) increased the probability of PTSD

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membership at six months, with negative cognitions about the self and neuroticism also being significant predictors (Hansen, Hyland, & Armour, 2016). A variety of factors can affect different aspects (or types) of ASD. In a study with 935 MVA survivors, PD and peritraumatic distress (negative emotions and physiological reactions related to the trauma, which correlates moderately to strongly with PD, Fikretoglu et al., 2006) had both common (being female, anxiety before the MVA, vehicle damage severity) and distinct (better physical health but worse mental health) risk factors for PD and (lower socioeconomic status) for peritraumatic distress (Lewis et al., 2014). A study of an international sample of children and adolescents (5–​18 years; N =​2,287) evaluated risk factors for degrees of severity of ASD and found that those with intermediate-​to-​ high levels of ASD tended to be female, younger, with parents who had not completed secondary school, and to have been exposed to an MVA or interpersonal violence (as compared with non-​intentional injury) (Lenferink et al., 2020).

Peritraumatic Dissociation as a Predictor of Posttraumatic Diagnoses A review of ASD as predictor of PTSD based on DSM-​I V criteria pointed out that the former predicted the latter reasonably well, but that there were many individuals who developed PTSD who did not originally have ASD (Bryant, 2011). This may be explained partly by different PTSD trajectories. Another aspect to bear in mind is that different factors seem to relate to immediate and delayed onset PTSD. In retrospective interviews with 142 war veterans, delayed onset related to less PD, anger, and shame, and having experienced an intense life stressor before the onset of PTSD as compared with immediate onset PTSD (Andrews, Brewin, Stewart, Philpott, & Hejdenberg, 2009). A large number of studies have evaluated specifically whether PD is associated with PTSS, including studies of veterans, survivors of catastrophes, emergency rescue workers, survivors of disasters, MVA, terrorist attacks, and receiving a cancer diagnosis (for earlier reviews see Bryant, 2011; Cardeña & Carlson, 2011). There have also been meta-​a nalyses that included PD as a predictor of PTSD symptomatology using DSM-​I V criteria. Ozer et al.’s (2003) meta-​a nalysis of 68 studies reported seven proximal and distal factors, with PD the most strongly associated with later PTSD (weighed r =​.35). Many assessed studies were retrospective and might reflect reporting bias, but a second meta-​ analysis calculated a separate effect size for 20 “quasi-​prospective” studies and was almost identical to the previous one (weighed r =​.34; Breh & Seidler, 2007). (Some authors use the term “quasi” to indicate that the initial evaluations typically take place shortly after trauma rather than before). Similarly, a meta-​a nalysis of 59 studies reported an overall r =​.40 between PD and PTSD, with prospective studies showing a stronger relation to PTSD than retrospective ones (Lensveldt-​Mulders et al., 2008). A more limited meta-​a nalysis of 17 studies (with additional inclusion requirements such as single traumatic events and controlling for mental health problems at the time of assessment) reported only six significant associations between PD and PTSD, and concluded that PD is not a strong independent predictor of later PTSD (Van der Velden & Wittmann, 2008). After those meta-​analyses, retrospective and prospective studies have continued to show that PD is a significant predictor of PTSS. This relation may be based more on subjective than objective indexes of trauma. In a retrospective study with 65 survivors of various types of injury, subjective rather than objective indicators of injury severity predicted PTSS, and PD moderated the impact of those indices at six-​week and three-​month follow-​ups, showing that for those who appraised their injuries as more severe, the more PD, the more PTSS (Gabert-​Quillen, Fallon, & Delahanty, 2011). We first present prospective studies, followed by retrospective ones.

Prospective Studies In a longitudinal study of 532 female students following a campus shooting, retrospective preshooting experiential avoidance was related to greater PD, intrusions and dysphoria, and PD was associated with PTSS at one-​month and at an eight-​month follow-​up (Kumpula, Orcutt, Bardeen, & Varkovitzky, 2011). In research with 111 victims of violent crime evaluated within 28 days of the assault, both PD and peritraumatic distress predicted PTSS two months after the crime regardless of participant gender (Demarble, Fortin, D’Antono, & Guay, 2018). In a sample of 129 lymphoma patients, at two-​weeks’ post diagnosis 49% of patients reported peritraumatic distress and 20% PD, and both, plus anxiety and mucositis, predicted PTSS at three months (Camille et al., 2020). In research with 128 parents of children unexpectedly admitted to an intensive care unit and evaluated three months later, PD was strongly associated with PTSS, anxiety, and depression (Bronner et al., 2009). PD may also mediate the relation between other symptoms and PTSS. For instance, in a study with 208 patients in trauma hospitals, derealization mediated the effect of peritraumatic panic reaction and PTSS at three months post-​injury (Bryant et al., 2011). Lastly, PD (and, independently, persistent dissociation) can predict medical outcomes such as mortality after a myocardial infarction (Ginzburg et al., 2016).

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Retrospective Studies A study of 200 survivors of a factory explosion evaluated two months later found that peritraumatic distress, PD, and ASD explained unique and substantial variance at six months (Birmes et al., 2005). In research with 71 participants with spinal cord injuries, PD partially mediated the relation between peritraumatic distress and PTSS, although peritraumatic distress led to PTSS irrespective of PD (Otis et al., 2012). In a study with 328 police officers, PD had a large relation with PTSS (β =​.65) and a weak one with depression (β =​.27), and PD’s relation to depression was moderated by previous trauma exposure (McCanlies, Sarkisian, Andrew, Burchfiel, & Violanti, 2017). In research with 49 victims of lightning strike, PD correlated weakly with measures of PTSS and depression, with posttraumatic distress also correlating significantly with PTSS (Yrondi et al., 2019). In contrast, in research with 685 post-​partum women, PD explained 24% of the variance in PTSS and had a moderate correlation (r = .​52) with a general measure of psychopathology, although it had a negative correlation with depression and other aspects of pathology when controlling for PTSS; PD was also related to assisted vaginal and unexpected Cesarean delivery (Thiel & Dekel, 2020). In a study with 101 earthquake survivors seeking treatment PD predicted PTSS and anxiety (Duncan, Dorahy, Hanna, Bagshaw, & Blampied, 2013). In a study with 287 flood victims, PD predicted PTSS and was a mediator between alexithymia, ongoing dissociation, and PTS (Craparo et al., 2014). A cross-​sectional evaluation of 212 police officers found that PD, negative affect, job duration, and number of critical incident exposures were associated with PTS, with PD and negative affect having a synergistic effect (Maia et al., 2011), and PD was also found to predict secondary traumatic stress in a study with 144 health care professionals (Samson & Shvartzman, 2018). This review has centered on the psychological aspects of dissociation rather than on somatic manifestations or “somatoform dissociation” (see Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1998), but a recent cross-​sectional study conflated them both. In a study of 308 Italian earthquake survivors, a factor labelled “somatoform dissociation,” but which actually included both psychological and somatic dissociative manifestations predicted all four PTSD DSM-​5 symptom clusters, as did a measure of mental defeat (Massazza, Joffe, Hyland, & Brewin, 2021).

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Studies with Non-​Western Samples A few studies with non-​Western samples have corroborated an association between PD and PTSS. Among 120 people exposed to army conflicts in the Democratic Republic of Congo using retrospective reports by those who had been directly brutalized, women and those with low education levels reported more PD, which in turn predicted PTSS (Duagani Masika et al., 2019). A retrospective study with 127 survivors of an earthquake in Iran reported that pre-​ earthquake variables including demographics, trauma, trait dissociation, PD, and severity of exposure to the earthquake all contributed unique variance to PTSS, with PD making the strongest contribution (Nobakht, Ojagh, & Dale, 2019).

PD and Lingering/​Persistent Dissociation With respect to lingering or persistent dissociation, Briere, Scott, and Weathers (2005) used two samples (N =​52,368) of trauma-​exposed participants and reported that ongoing dissociation was a better predictor of PTSD than PD, whose predictive power was no longer significant at the multivariate level. This study, as others arriving at the same conclusion (e.g., Panasetis & Bryant, 2003), was cross-​sectional and retrospective, which makes this conclusion questionable. In contrast, two prospective studies presented evidence for an effect of PD along with persistent dissociation on PTSS. In research with MVA in-​patient and out-​patient samples (ns =​27 and 176) ongoing dissociation and rumination at four weeks were stronger predictors of PTSS than PD measured within a couple of days after the accident, but the latter was also a significant predictor (Murray, Ehlers, & Mayou, 2002). Another prospective study, with 62 assault victims, both PD (measured on average 28.2 days after the assault) and persistent dissociation (measured 225 days after the assault) predicted PTSS at follow-​up (Werner & Griffin, 2012). An area that has barely received research attention is whether PD may be practically protective around the time of trauma. One study found that high dissociators were more likely to engage in dangerous behavior (Koopman, Classen, & Spiegel, 1996) while another had mixed results, with. PD being related to interference in social functioning but also to enacting protective actions (Koopman, Zarcone, Mann, Freinkel, & Spiegel, 1998).

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PD Studies with Teens and Children Most studies have focused on adults, but there is a similar pattern in youth samples. In a sample of 204 Latino youth using retrospective clinical interviews, PD was related to shame, lifetime number of traumatic events, and PTSD symptoms or diagnosis (Vásquez et al., 2012). Prospective research with 103 children (8–​15 years-​of-​age) found an association between peritraumatic distress, PDm and two measures of PTSS, but in a multivariate analysis only distress remained a significant predictor (Bui et al., 2010). A later meta-​analysis of peritraumatic risk factors for PTSD in children and adolescents reported subjective threat being the largest significant factor, with PD and processing (e.g., feeling confused during trauma) also being significant factors (Memarzia, Walker, & Meiser-​Stedman, 2021). It should be pointed out that the last factor might have also involved dissociation.

Mediators and Moderators of the Effect of PD on Psychopathology Few studies have focused on potential mechanisms underlying the relation between PD and PTSS. Peltonen, Kangaslampi, Saranpää, Qouta, and Punamäki (2017) reported that the effect of PD on PTSS was partially but not completely mediated by disorganized and inaccessible memories related to the trauma in a sample with 192 Palestinian children, supporting the importance of memory in the development of PTSS in general (for a general review see Brewin, 2018). In another investigation with 73 assault victims, initial peritraumatic cognitive processing (including dissociation during assault, data-​d riven processing, and self-​referent processing) led to disorganized memories and PTSD, with ongoing dissociation and negative appraisal perpetuating PTSS (Halligan, Michael, Clark, & Ehlers, 2003). In a study of 662 survivors of earthquakes or floods, peritraumatic distress, PD and positive or negative beliefs about memory predicted PTSS, and there was an interaction such that high peritraumatic distress and dissociation and high level of negative beliefs about memory produced the greatest dysfunction (Kannis-​D ymand, Carter, Lane, & Innes, 2019). In a cross-​sectional study, Gershuny, Cloitre, and Otto (2003) reported that fear of death and loss of control mediated the effect of PD on PTSD severity, but also mentioned that they could not ascertain whether PD was a cause or an effect of those cognitions. In another cross-​sectional design, panic mediated the relation between fear, helplessness, and horror, and PD (Fikretoglu et al., 2007). After controlling for symptom severity and current dissociation, negative beliefs about the self partly mediated the effect of PD on PTSD symptoms (Thompson-​Hollands, Jun, & Sloan, 2017). Younger age and prior major depression were associated with greater endorsement of PD among survivors of MVA (Fullerton et al., 2000). There is some research on other potential predictors and mediators/​moderators of PD. In a study with 372 women, the majority African American, who had suffered intimate partner violence, PD was predicted by child physical abuse, current injury, cognitive distortions about threat of harm, and disengagement coping; cognitive distortions and PD had an indirect effect on the relation between abuse/​injury and PTSD-​related dissociation (Fleming & Resick, 2016). In a sample of 1,503 college students with different types of trauma or loss, those reporting interpersonal violence, multiple traumas, and women reported more PD, PTS, and general psychopathology (Hetzel-​R iggin & Roby, 2013). Also, in a sample of 294 college students, coping strategies depended on the type of reported abuse, which had a differential effect on PTSS; PD as well as social control and punishment thought strategies used to control intrusive thoughts were found to mediate the relation between type of abuse and PTSS (Wilson & Scarpa, 2012). In a study of 243 respondents from trauma units, retrospective assessments of longer perceived warning and being female predicted PD (McDonald et al., 2013). Kupula and colleagues (2011) reported that pretrauma experiential avoidance was related to PD, but the 7-​item measure used (Bond et al., 2011) is questionable since some items (e.g., “I am afraid of my feelings,” “Emotions cause problems in my life”) seems to assess negative evaluations of feelings rather than actual avoidance (the same can be said of another study apparently using the same measure, Marx & Sloan, 2005). There have also been experiments inducing PD in the lab. In exposure to a painful cold pressor task, anxiety sensitivity measured nine months before the task as well as concurrent depressive symptoms and catastrophizing predicted dissociation induced by the task (Gómez-​Pérez, López-​M artínez, & Asmundson, 2013). Another study used a terrifying movie (the 2005 feature film The Descent) and found that out of a number of variables only PD and state anxiety predicted PTSS four months later (Carleton, Sikorski, & Asmundson, 2010). Similarly, the effect of PD on 99 students after watching an experimental 10-​m inute film depicting the aftermath of MVA was no longer significant after controlling for horror during the film (Hagenaars & Krans, 2011). A study also using a film on horrible MVA footage with 148 students found that PD predicted intrusive images but not intrusive thoughts (Măirean & Ceobanu, 2017).

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Given the research in which early trauma was related to PD, we should also briefly discuss a distal proposed mediator of dissociation in general, namely disorganized attachment, which may mediate or moderate PD. A child with disorganized attachment will exhibit simultaneous apparently contradictory sets of behaviors such as becoming “frozen” at the arrival of the caretaker. Disorganized attachment has been found in various studies to predict trait dissociation throughout adolescence and early adulthood (for a review see Liotti, 2009). However, a longitudinal study using a larger sample than previous studies did not replicate those results, although it found small correlations between infant avoidance and dissociation, but only when assessed by mothers and teachers rather than through self-​reports (Haltigan & Roisman, 2014). The authors acknowledged that previous studies had involved higher risk samples, with a likely greater exposure to traumatizing events than in their sample. Nonetheless, a study of adolescents reported that anxious attachment moderated the relation between trauma and dissociation (Gušić, Cardeña, Bengtsson, & Søndergaard, 2016). Adults who manifested an unresolved/​d isorganized type of attachment reported more negative content during mind-​wandering, poor attentional control, and belief in anomalous mental phenomena (Marcusson-​Clavertz, Gušić, Bengtsson, Jacobsen, & Cardeña, 2017); the first two of these characteristics might be mediators of cognitive deficits related to dysfunctional dissociation. Although beyond the scope of this chapter, developmental research shows potential mechanisms for the relation between parental care and later dissociation. For instance, “atypical maternal behavior” in interaction with the infant during the first 18 months of life explained half of the variance in later dissociation (Dutra et al., 2009). Such behavior could lead to lower mentalizing abilities, which have been proposed to mediate the association between early trauma and later dissociation (Huang, Fonagy, Feigenbaum, Montague, & Nolte, 2000).

Conclusions The research on acute reactions to trauma and their predictive power for chronic pathology has provided and continues to provide data and models that show the strengths and weaknesses of the initial criticisms of ASD. First, the evidence suggests that there is more than one type of both ASD and PTSD, with different predictors. As Bovin and Marx (2011) posit, how humans respond to traumatic events depends on a variety of resources (which may be based on distal factors) and idiosyncratic cognitive, emotional, physiological, and behavioral forms of reacting. It would be naïve to expect a single set of reactions to explain all or even most of the variance in the development of psychopathology. Second, research on different trajectories for acute versus chronic reactions suggest that only repeated longitudinal assessments can provide a comprehensive view. Third, it has remained the case that PD is an important component of some acute and chronic posttraumatic symptomatology, particularly of a more severe type of PTSD, although it is not the only important variable and it relates to other distal and proximal variables. Fourth, it seems that PD may be particularly important in the presence of more severe and/​or chronic types of trauma. In any event, the data continue to challenge proposals that there is “little, if any, value to be gained by using temporally proximal measures of peritraumatic dissociation as a marker of subsequent PTSD symptom severity” (Marshall & Schell, 2002, p. 633), or that the relation between PD and later pathology can be explained away through the vagaries of retrospective recollection (e.g., Candel & Merkelbach, 2004). Fifth, biological parameters have not been clearly associated with PD, but using an experimental trigger (e.g., a disturbing film or an induced recollection), may provide clearer findings, with the proviso that earlier, severe trauma may be an important mediator/​moderator of any relation. Much more research in this area is warranted. The development of research on posttraumatic conditions shows the importance of greater clarity and specificity in the research questions, diagnostic taxonomies, and evaluation and therapeutic strategies. For instance, which symptoms, dissociative and otherwise, predict which types of pathology can now be better addressed with techniques such as mapping different post-​t rauma trajectories, conducting network analyses, and employing experiential sampling procedures. Furthermore, given the finding of a highly symptomatic type of ASD and PTSD, it would be important to evaluate these groups within the framework of the general p factor proposed for youth with anxiety problems, and which refers to overarching processes in pathology such as poor emotion regulation (cf. Cervin et al., 2021). Both general dissociation measures and those geared specifically for PD have provided valuable information but have the disadvantage of constraining possible answers. Adding more mixed or purely qualitative research can expand our understanding of dissociation, for instance by pointing to the importance of a sense of lack of mental control (cf. Gušić et al., 2018). The purpose of this chapter is not to provide a theoretical discussion of why immediate dissociative reactions to traumatic events may contribute to pathology, but rather to review what the research suggests about whether they do. It seems to us that rather than trying to evaluate whether PD is an (imperfect) predictor of posttraumatic (and other) symptomatology, it will be more fruitful to look at the processes through which PD lingers on and how it may relate

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to other variables. To give but two examples, some of the studies reviewed reported an association between PD and memory processes. In addition, dissociation in general has been related to sleep difficulties (e.g., Van Heugten-​van der Kloet, Giesbrecht, & Merckelbach, 2015), which may trigger disturbed self-​states (Cardeña et al., 2021) (not necessarily reified into alternate parts) and prevent a healthy integration of posttraumatic memories and states. For all its limitations, the idea of dysfunctional PD has been, and continues to be, a source of important insights.

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Peritraumatic dissociation predicts posttraumatic stress disorder symptoms via dysfunctional trauma-​related memory among war-​a ffected children. European Journal of Psychotraumatology, 8(Suppl 3), 1–​8. Pérez, S., Conchado, A., Andreu, Y., Galdón, M. J., Cardeña, E., Ibáñez, E., & Durá, E. (2016). Acute stress trajectories 1 year after a breast cancer diagnosis. Supportive Care in Cancer, 24,1671–​1678. Pole, N., Cumberbatch, E., Taylor, W. M., Metzler, T. J., Marmar, C. R., & Neylan, T. C. (2005). Comparisons between high and low peritraumatic dissociators in cardiovascular and emotional activity while remembering trauma. Journal of Trauma & Dissociation, 6(4), 51–​67. Ross, J., Baník, G., Dědová, M., Mikulášková, G., & Armour, C. (2018). Assessing the structure and meaningfulness of the dissociative type of PTSD. Social Psychiatry and Psychiatric Epidemiology, 53(5), 87–​97. Samson, T., & Shvartzman, P. (2018). Secondary traumatization and proneness to dissociation among palliative care workers: A cross-​sectional study. Journal of Pain and Symptom Management, 56, 245–​251. Schimmenti, A., & Şar, V. (2019). A correlation network analysis of dissociative experiences. Journal of Trauma & Dissociation, 20, 402–​419. Sijbrandij, M., Engelhard, I. M., Opmeer, B. C., van de Schoot, R., Carlier, I. V. E., Gersons, B. P. R., & Olff, M. (2012). The structure of peritraumatic dissociation: A cross validation in clinical and nonclinical samples. Journal of Traumatic Stress, 25, 475–​479. Spiegel, D., & Cardeña, E. (1991). Disintegrated experience: The dissociative disorders revisited. Journal of Abnormal Psychology, 100, 366–​378. Taylor, M. K., Sausen, K. P., Potterat, E. G., Mujica-​Parodi, L. R., Reis, J. P., Markham, A. E., Padilla, G. A., & Taylor, D. L. (2007). Stressful military training: Endocrine reactivity, performance, and psychological impact. Aviation, Space, and Environmental Medicine, 78, 1143–​1149. Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148, 10–​20. Thiel, F., & Dekel, S. (2020). Peritraumatic dissociation in childbirth-​evoked posttraumatic stress and postpartum mental health. Archives of Women’s Mental Health, 23, 189–​197.

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Thompson-​ Hollands, J., Jun, J. J., & Sloan, D. M. (2017). The association between peritraumatic dissociation and PTSD symptoms: The mediating role of negative beliefs about the self. Journal of Traumatic Stress, 30, 190–​194. Ursano, R. J., Fullerton, C. S., Epstein, R. S., Crowley, B., Vance, K., Kao, T., C., & Baum, A. (1999). Peritraumatic dissociation and posttraumatic stress disorder following motor vehicle accidents. American Journal of Psychiatry, 156, 1808–​1810. Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: Norton. Van der Velden, P. G., & Wittmann, L. (2008). The independent predictive value of peritraumatic dissociation for PTSD symptomatology after type I trauma: A systematic review of prospective studies. Clinical Psychology Review, 28, 1009–​1020. Van Heugten-​van der Kloet, D, Giesbrecht, T., & Merckelbach, H. (2015). Sleep loss increases dissociation and affects memory for emotional stimuli. Journal of Behavioral Therapy and Experimental Psychiatry, 47, 9–​17. Vásquez, D. A., de Arellano, M. A., Reid-​Quiñones, K., Bridges, A. J., Rheingold, A. A., Stocker, R. P., & Danielson, C. K. (2012). Peritraumatic dissociation and peritraumatic emotional predictors of PTSD in Latino youths: Results from the Hispanic family study. Journal of Trauma & Dissociation, 13, 509–​525. Werner, K. B., & Griffin, M. G. (2012). Peritraumatic and persistent dissociation as predictors of PTSD symptoms in a female cohort. Journal of Traumatic Stress, 25, 401–​407. Wilson, L. C., & Scarpa, A. (2012). The mediating role of peritraumatic dissociation and thought control strategies on posttraumatic stress in women survivors of child sexual and physical abuse. Journal of Aggression, Maltreatment & Trauma, 21, 477–​494. Yrondi, A., DerKasbarian, R., Gallini, A., Max, V., Pauron, C., Joubin, A., … Birmes, P. (2019). Symptoms of depression and post-​ traumatic stress in a group of lightning strike victims. Journal of Psychosomatic Research, 120, 90–​95.

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29 DISSOCIATION AND TRAUMA Clinical and Research Intersections in PTSD Olga Winkler, Lisa Burback, Suzette Brémault-​Phillips, and Eric Vermetten

Significant steps have recently been taken to further scientific understandings in the area of dissociation and trauma, with increased willingness of mainstream researchers to acknowledge the importance of traumatic dissociation in psychopathology and investigate its underpinnings (Boyd et al., 2018 ; Herzog, Fogle, Harpaz-Rotem, Tsai, & Pietrzak, 2020 ; Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012 ; Ross, 2021 ; Stein et al., 2013). Advances in empirically-​ based investigation tools and methodologies (Carlson et al., 2018; Carlson & Putman, 1993; Eidhof, et al., 2019; Stein et al., 2013; Steuwe, Lanius & Frewen, 2012; Wolf et al., 2012) as well as neuroimaging technology are facilitating the growing understanding of dissociative processes (Lanius et al., 2012; Lanius et al., 2018; Lebois et al., 2021; Lyssenko, et al., 2018). Novel treatments have been created to address dissociation, both by developing specific treatment models and techniques and by adapting or refining existing models to fit the latent and manifest clinical content (Cloitre et al., 2010; Fisher, 2017; Harned, Korslund, Foa, & Linehan, 2012; Levine & Frederick, 1997; Ogden, Pain, & Fisher, 2006; Scalabrini, Mucci, Esposito, Damiani, & Northoff, 2020). Yet, dissociation is often poorly understood and neglected in routine clinical assessment and treatment of posttraumatic stress disorder (PTSD), despite years of groundbreaking work and important contributions by authors like David Spiegel (1991), Bessel van der Kolk (van der Kolk & Fisler, 1995), John Nemiah (1998), Frank Putnam (1997), and evidence linking dissociation to illness severity, suicidality, lower treatment response and worse functional outcomes (Loewenstein, 2018). A comprehensive understanding of dissociation in PTSD can contribute to a better appreciation of its role in other disorders where traumatic exposure was also a factor. This is particularly relevant given that exposure to traumatic events (e.g., adverse childhood events, physical abuse, family violence, combat and war, assaultive threats) remains a common aspect of the human experience, and can lead to a wide range of psychopathology (Bellis et al., 2019; Carr, Martins, Stingel, Lemgruber, & Juruena, 2013; Curran, Adamson, Rosato, De Cock, & Leavey, 2018; Kisely et al., 2018; Sacks & Murphey, 2018). In this chapter, we examine whether the current boundaries of how dissociation is defined in PTSD are reflective of the nature and phenomena of traumatic dissociation, with implications for future conceptualization of traumatic stress across a wider range of psychopathology.

Historical and Cultural Influences on the Conceptualization of Trauma and Dissociation For over a century, theorists have recognized the interplay between psychological trauma and dissociation. Pierre Janet (1889) believed that a person with insufficient ego strength to integrate an experience could “split off” ’ traumatic content, later reliving it through psychological and somatoform manifestations. Sigmund Freud (1895) argued that traumatic memories were repressed by the ego as a defense against untenable psychological conflict associated with unbearable emotional pain. American psychiatrist John C. Nemiah, at the end of the last century, theorized that both the Freudian conflict model and Janet’s ego-​deficit model were important mechanisms in a spectrum of dissociative processes underlying a range of psychological symptoms (Nemiah, 1977, 1992, 1998). Traumatic experiences of combat soldiers added significantly to an evolving understanding of trauma and dissociation. The first trauma response included in the DSM (published in 1952), referred to as a Gross Stress Reaction, was informed by observations of soldiers with “shell shock” returning from the battlefields during World Wars I and II (American Psychiatric Association [APA], 1952; Bremner, 1999). Dissociative and somatic components were integral to

DOI: 10.4324/9781003057314-35

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this diagnosis as many soldiers experienced amnesia for autobiographical information, significant confusion, compulsive repetitive movements, and depersonalization. These symptoms fit with the still prevailing psychodynamic influence at that time, including the theories of Janet and Freud. The stress response was described, however, as acute and temporary, and was only considered possible in the face of exposure to extreme traumatic events outside the range of normal experience. In the relative peace following the second World War, the revised manual, DSM-​II (APA, 1968), dropped the Gross Stress Reaction diagnosis altogether (Bremner, 1999). The post-​Vietnam war period later informed the introduction of PTSD in the DSM-​III (APA, 1980; Bremner, 1999), a diagnosis which de-​emphasized dissociation and somatic symptoms in PTSD. The DSM-​III also separated dissociative, somatic, and trauma spectrum disorders from each other. This marked a significant change, following which scholarly inquiry in the fields of dissociation, traumatology, and somatization began to develop more independently of each other. In the later 1950s and 1960s, dissociation was explored clinically in mainstream psychiatry via hypnosis, becoming a source of public curiosity with the marketing of films such as The Three Faces of Eve (Thigpen & Cleckley, 1957) and Sybil (Schreiber, 1976) which depicted what is now called dissociative identity disorder (DID). By 1990, chronic dissociation in psychiatry was subject to critique and skepticism, especially from advocates of false memory syndrome, which fueled a strong disinclination among funding sources to support research on dissociation (Loewenstein, 2018). In response, leading investigators of dissociation redirected their work towards conducting studies aimed at countering such allegations. By the late 1990s, dissociation research into newer and more effective treatments for the most severely traumatized populations with chronic dissociation was stifled (APA, 2000; Bremner, 1999). Recently, more rigorous investigation regarding assessment of dissociation has made the presence, prevalence, and dimensionality of trauma in dissociation again more apparent (Vermetten, Dorahy, & Spiegel, 2007). The development and use of validated dissociation assessment tools, such as the Dissociative Experiences Scale (DES), the Clinician Administered Dissociative States Scale (CADSS), and the Structured Clinical Interview for DSM Dissociative Disorders (SCID-​D), confirmed the presence of dissociative symptoms in PTSD across different cultures and socioeconomic boundaries (Stein et al., 2013), as well as across a range of other disorders (Carlson & Putman, 1993; Lyssenko et al., 2018). Neurobiological, phenomenological, and physiological studies of the dissociative nature of some peritraumatic responses and PTSD (Marmar, Weiss, & Metzler 1998; Thompson-​Hollands, Marx, Lee, & Sloan, 2021) have provided further evidence for dissociation in traumatized individuals (Lanius, Hopper, & Mennon, 2003; Lyssenko et al., 2018; Schiavone, Frewen, McKinnon, & Lanius, 2018; Stein et al., 2013; Terpou et al., 2019; see Schiavone & R. Lanius, Chapter 39, & Corrigan, U. Lanius & Kaschor, Chapter 37, this volume). The above influences and research findings coalesced into a recognition of the need to include dissociation more explicitly within the DSM’s conceptualization of trauma. Changes in the DSM-​5 (APA, 2013), such as reclassifying PTSD outside the anxiety disorder classification, introducing the heavily debated dissociative subtype of PTSD and adding reference to childhood adversity and its consequences of emotional dysregulation, unstable interpersonal relationships, and dissociative symptoms, were significant (APA, 2013). These changes also led to new assessment tools for dissociation (Eidhot et al., 2019; Guetta et al., 2019). Yet, the current classification and recognition of trauma and dissociation requires further revision; the section on ‘Trauma-​and Stressor-​related Disorders’ in DSM would benefit from recognition of dissociation as a core element of a traumatic response.

What is Dissociation in Trauma? The term dissociation, which has been reviewed widely in psychiatry, describes a failure of the (normal) integration of processes such as consciousness, perception, and memory. Dissociation can be non-​pathological (e.g., absorption, transient and brief amnesia, or daydreaming), or pathological (e.g. dissociative states), and can be observed in a range of disorders, such as anxiety, mood, and psychotic disorders, personality disorders (Vermetten & Spiegel, 2014), medical conditions such as partial complex epilepsy (Castillo, 1997; Krüger, 2020; Levin & Spei, 2004), and eating disorders (La Mela, Maglietta, Castellini, Amoroso, & Lucarelli, 2010; Vanderlinden, Vandereycken, Van Dyck, & Vertommen, 1993). At its core, dissociation creates a separation from both the world and from a coherent sense of Self, and is due to a failure to integrate an experience across a variety of possible domains. The dissociative disorders section of the DSM-​5 is comprehensive in the description of these dissociative domains, identifying them as consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior (APA, 2013). In certain cases, only one or several of these domains are affected while others remain relatively intact, whereas in other cases, all domains may be impacted. The degree to which this failure of integration occurs within each domain can also vary. Two main categories of dissociative symptoms result from a failure to integrate. First, dissociated information may become unavailable to be accessed or controlled (APA, 2013). One example of this is seen in amnestic memory gaps in

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Clinical and Research Intersections in PTSD  467 TABLE 29.1  Evolving features of dissociation across DSM editions

Disruption of and/​or discontinuity in the normal integration of:

DSM-​I II

DSM-​I II-​R

DSM-​IV-​T R

DSM-​5

Consciousness Memory Identity Emotion Perception Body representation Motor behavior

⧫

⧫ ⧫ ⧫

⧫ ⧫ ⧫

⧫ ⧫ ⧫ ⧫ ⧫ ⧫ ⧫

⧫ ⧫

⧫

PTSD, where certain aspects of past traumatic memories may be inaccessible to voluntary recall. Second, the sequestered information along the aforementioned domains may suddenly intrude upon awareness. A flagship example of intrusive dissociative phenomena is the experience of traumatic flashbacks, where pieces of dissociated memory, emotion, or perception may suddenly intrude upon awareness. The DSM, upon new research better delineating the various faces of dissociation (Carlson et al., 2018; Carlson & Putman, 1993; Lanius et al., 2010; Longo et al., 2019; Lyssenko et al., 2018), began to expand its conceptualization (APA, 1980, 1987, 2000, 2013). The DSM-​5 dissociative disorders section contains the most comprehensive definition and explanation of dissociative symptoms to date (see Table 29.1), reflecting the multiple domains across which pathological dissociation can occur, describing the features of inaccessibility and intrusiveness, and the absence of volitional control over its occurrence. However, outside of the dissociative disorders section, this comprehensive conceptualization is not applied consistently to other psychiatric disorders. This inconsistency is especially visible in the 5th edition’s description of PTSD.

Development of Pathological Dissociation During or in the immediate aftermath of acute trauma such as violent physical or sexual abuse, victims report various dissociative experiences. These can include feeling dazed, unaware of physical injury, or experiencing the trauma as if they were in a dream. Many rape victims report floating above their body, feeling sorry for the person being assaulted below them. Sexually or physically abused children often report seeking comfort from imaginary playmates or imagined protectors, or by imagining themselves absorbed in the pattern of the wallpaper (Spiegel & Cardeña, 1991). Some continue to feel detached and disintegrated for weeks, months or years after trauma. This can lead to a kind of ‘somatic estrangement’ with changes in bodily perceptions: feeling as if one’s entire body or a part of one’s body does not belong to oneself. This typical dissociative symptomatology can include affect compartmentalization, disrupted memory encoding, time distortion and fugue (Loewenstein, 1991). The disruption of a consistent stream of memory and associated personal identity has been thought of as serving a protective function, at least in response to acute stress. However, over time, these defenses may start to interfere with necessary cognitive and affective processing of traumatic experiences, and as a result, lead to failure of integration of episodic and autobiographical memory. The dissociative spectrum is complex: depersonalization and derealization can be seen as belonging to self-​monitoring and identity disturbances. Other domains and symptoms include but are not limited to disruptions in: emotion (withdrawal/​detachment), memory (amnesia, shifts in memory encoding), sensory perception (altered time, visual or contextual perception, proprioception, analgesia, changes in olfaction, taste) and cognition (constricted attention, neglect, confusion, altered associated capacities) (see also Table 29.2). Dissociative symptoms can be further characterized by: (a) unbidden and unpleasant intrusions into awareness and behavior, with an accompanying loss of continuity in subjective experience (i.e., ‘positive’ dissociative symptoms); and/​or an inability to access information or control mental functions that are normally amenable to such access or control (i.e., ‘negative’ dissociative symptoms; Frewen & Lanius, 2006). The more severe forms of dissociation include stupor, autobiographical memory gaps, or identity confusion (Vermetten & Spiegel, 2014). Dissociation is thought to occur in response to either overwhelming affect or psychological conflict (Schore, 2009). Psychological trauma can have devastating consequences on emotion regulatory capacities and lead to dissociative processes that provide subjective detachment from overwhelming emotional experience during and in the aftermath of trauma. In pathological dissociation, the intensity and duration of an experience that produces such reactions is enough to overwhelm the individual’s innate capacity to cope. In the case of affective overwhelm, where an individual is faced

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468  Olga Winkler et al. TABLE 29.2  Examples of dissociative symptoms in PTSD

Dissociative dimension

Symptoms of PTSD that fit with the named dissociative dimension

Consciousness

Involuntary and intrusive distressing memories. Confusion Constricted attention Involuntary and intrusive distressing memories (re-​experiencing) Dissociative reactions (flashbacks) Distressing dreams in which the content and/​or affect of the dream are related to the traumatic event Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia) Feelings of detachment or estrangement with others Depersonalization Hallucinations (referred to as Pseudohallucinations in the DSM) Physiological or psychological reactivity or distress, respectively to internal or external cues that symbolize or resemble the traumatic event Persistently inability to experience positive emotions Distressing dreams in which the content and/​or affect of the dream are related to the traumatic event Numbing, detachment, withdrawal Distressing dreams in which the content and/​or affect of the dream are related to the traumatic event Derealization Altered sensory perception, pain or analgesia Altered proprioception Altered time perception Depersonalization (absent) (absent)

Memory

Identity

Emotion

Perception

Body representation Motor control Behavior

with a threat to the integrity or existence of the Self, separating traumatic content from awareness may serve as a regulatory function of consciousness to reduce emotional or physical pain (Chung, Hensel, Schmidinger, Bekrater-​Bodmann, & Flor, 2020; Defrin, Schreiber & Ginzburg, 2015; Lanius et al., 2010). Indeed, the dissociative PTSD subtype has been associated with reduced limbic activity and the subjective absence of hyperarousal when exposed to traumatic cues (Lanius et al., 2010), and an increased pain threshold (Defrin et al., 2015). Conflict between trauma-​based affects, needs, and drives with those needed for daily functioning can also result in dissociation (Schore, Chapter 11, this volume; Liotti, 2017). Compartmentalization of trauma, keeping it away from consciousness, allows the individual to maintain day-​to-​d ay functioning, ensure survival, and potentially protect the Self from further harm (Liotti, 2017; Schimmenti & Caretti, 2016; Schore, 2009). For example, it may not be safe to express anger towards an abuser if one is reliant on them for food and shelter (Stein, 2012). When such conflicts arise, dissociation may function as a means to avoid and distract from the traumatic content at hand (Liotti, 2017; Morgan 3rd & Taylor, 2013). In cases of both overwhelm or conflict, separating off aspects of an experience may additionally allow the person to avoid untenable or prolonged hyperarousal, protecting the body from physiological overdrive and exhaustion (Griffin, Resick, & Mechanic, 1997). Critical to our understanding is that dissociation is not created by trauma, but rather that trauma disrupts the natural drive towards integration that occurs continuously throughout one’s lifespan (see Linde-​K rieger, Yates & Carlson, Chapter 9, this volume). The impact of trauma can be especially disruptive in childhood, a time of extensive brain development and integration of experience. Accordingly, the degree to which an individual may be affected by trauma must be contextualized within their developmental history. Parental verbal abuse may not feel overly traumatic or threatening to one’s existence when experienced by an adult, but a small child may be overwhelmed beyond capacity with such experiences, with less ability to integrate their experience and more global and severe consequences. Adverse childhood experiences (ACEs) are a strong risk factor for the later development of PTSD in the context of new trauma (Anda et al., 2006; Aronson et al., 2020; see Quiñones, Chapter 12, this volume). The link is especially prominent in the dissociative subtype, reflecting the importance of developmental contributors (Frewen, Zhu, & Lanius, 2019; Hansen, Ross, & Armour, 2017; Stein et al., 2013). ACE studies have shown that exposure to trauma

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and attachment disruptions early in life can result in long-​lasting and seemingly permanent changes in emotional regulation, hypothalamus–​pituitary–​adrenal (HPA) axis dysregulation, increased oxidative stress and inflammation, altered microbiome, varied gene expression, reduced telomere length, and structural and network connectivity brain changes (Ancelin et al., 2021; Anda et al., 2006; Cloitre et al., 2019; Dannlowski et al., 2012; Felitti et al., 1998; Hantsoo et al., 2019; Kliewer & Robins, 2021; Levine, Cole, Weir, & Crimmins, 2015; Renna et al., 2021; Schiweck et al., 2020). Further, those exposed to difficult upbringings have consistently been shown to be more prone to future psychiatric morbidities, including mood and anxiety disorders, trauma spectrum disorders, pathological dissociation, and suicidality, with overlapping neurobiology (APA, 2013; Carr et al., 2013; Copeland et al., 2018; Kiseley et al., 2018; Loewenstein, 2005). Not all pathological dissociation is created by trauma or adverse childhood experiences. Seemingly minor deficits in the home environment of a child, where secure attachment was not able to develop, can also predispose to dissociation. Building on attachment theory pioneered by Bowlby (1969) and Ainsworth (1978), it has been well established that humans need the containment and co-​regulation characteristics of safe and supportive attachment relationships to develop a sense of Self, learn to regulate affect and create coherent models of the world, themselves, and their relationship to others (Benoit, 2004; Fossati, Gratz, Somma, Maffei, & Borroni, 2016; Haywart, Hayward, Vartanian, Kwok, & Newby, 2020; Hébert, Langevin, & Charest, 2020). A caring and responsive environment allows a child to feel safe enough to explore the environment, learn from experience, and successfully integrate their perceptual systems. In the absence of a supportive caregiver who can help the child integrate his or her daily experiences and habituate to the inevitable life experiences that create intense affect, dissociation can become a child’s default response. Although the role of childhood adversity and its impact on emotional dysregulation and unstable interpersonal relationships is mentioned in the associated features of PTSD, explicit acknowledgement of the role of attachment and early development as contributors to more complex traumatic injury are not (APA, 2013). This needs to be remedied as these factors so often relate to dissociation.

Evolving Conceptualization of Dissociation in PTSD From DSM-​III through DSM IV-​TR, posttraumatic stress was viewed as an anxiety disorder that represented a fear response to direct exposures to severe traumas (APA, 1980, 1987, 2000). The emphasis in these prior editions was on active fight or flight defensive responses, such as anger or fear, and concomitant sympathetic hyperarousal (Schauer & Elbert, 2015). This downplayed the role of hypoaroused affective states in PTSD, in which dissociation, a parasympathetically driven shut down response, is prominent (Lanius et al., 2010; Schauer, & Elbert, 2015). In contrast, PTSD is now classified under the new Trauma and Stressor related disorders in the DSM-​5 with reduced emphasis on hyperarousal and increased recognition of hypoaroused affective states. In the new criteria, references to emotional and social detachment, low drive to engage in regular activities, and shame and related affect, allow for those with hypoaroused dissociative states, or fluctuations between hyperarousal and hypoarousal, to also be considered for a PTSD diagnosis. In essence, dissociative processes in PTSD are now much more visible in the DSM. The attention on dissociation in PTSD became especially more prominent with the introduction of a dissociative PTSD subtype, which, as we will see below, is not without controversy.

Dissociative Subtype The dissociative subtype of PTSD (PTSD+​DS) was introduced in the DSM-​5 as a response to the growing recognition of the importance of distinguishing those with more prominent traumatic dissociation in PTSD (Lanius et al., 2012; Lanius et al., 2018). Dissociative PTSD is more often marked by more severe core PTSD symptoms, higher suicidality, more comorbidities, and greater functional impairment (Hansen et al., 2017; Stein et al., 2013). Childhood trauma or trauma prior to the index trauma are more common in the dissociative subtype (Hansen et al., 2017; Lanius et al., 2012; Stein et al., 2013), which may be the result of compounded disruption in integration (Hayward et al., 2020), both during a vulnerable time of early brain development and later on in adulthood. Recent developments in neurobiology have clarified our understanding of a dissociative subtype of PTSD (see Schiavone & R. Lanius, Chapter 39, this volume). A landmark paper by Lanius et al. (2003) described the different PTSD responses of a husband and wife exposed to the same motor vehicle accident. Their very different brain responses, one dissociative and the other hyperarousal-​based, suggested there were two discrete trajectories of response in trauma. A series of subsequent papers (Brand, Lanius, Vermetten, Loewenstein, & Spiegel, 2012; Lanius et al., 2010; Steuwe et al., 2012; Wolf et al., 2012) elaborating on these subtypes contributed significantly to the inclusion of the dissociative

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subtype of PTSD in DSM-​5, which also necessitated the development of structured assessment instruments (Eidhof et al., 2019). PTSD brain imaging studies have found the dissociative PTSD subtype to be associated with specific brain regions (Lanius et al., 2010). Increased activity of the medial prefrontal cortex and anterior cingulate cortex, and decreased activity of the amygdala and anterior insula are found in response to trauma-​related cues. This pattern is opposite to non-​d issociative PTSD and hypothesized to represent over-​rather than under-​modulation of the limbic system and subsequent hyperarousal typical of non-​d issociative PTSD. This overmodulation is accompanied by activation of dissociative processes by the periaqueductal gray at the level of the brainstem, which suppresses sympathetic drive, alters pain sensitivity (numbness), reduces awareness through opioid release and causes immobility by blocking motor response (Lanius et al., 2018; Terpou et al., 2019; see Corrigan, U. Lanius & Kaschor, Chapter 37, this volume). These results have been explored as human correlates of animal models of dissociation (tonic immobility and flaccid paralysis), making dissociation understandable as an evolutionarily conserved response to imminent, inescapable threat or conflict (Lanius et al., 2018; Terpou et al., 2019). While depersonalization and derealization were identified as hallmark features of PTSD+​DS, subsequent research appears to question whether these truly distinguish dissociative from non-​d issociative PTSD (Műllerová, Hansen, Contractor, Elhai, & Armour, 2016). As the debate around the boundaries of dissociation in PTSD continues, it has been suggested that there may also be other dissociative symptoms that are part of a dissociative subtype such as disengagement, memory disturbance, identity dissociation, time loss, trance, loss of awareness, and psychogenic amnesia (Armour, Contractor, Palmieri, & Elhai, 2014; Frewen & Lanius, 2015; Krüger, 2020; Műllerová et al., 2016; Wolf et al., 2015).

Dissociation Debates in PTSD Several questions and differing opinions have been raised regarding the dissociative nature of PTSD. Given the intrinsic complexity of PTSD, two central questions persist: a) is PTSD inherently dissociative, regardless of subtype, and b) does the dissociative subtype, characterized by depersonalization and derealization, adequately encompass the nature of dissociation in this patient subgroup. As mentioned above, whether depersonalization and derealization truly epitomize PTSD+​DS is a matter of ongoing investigation. While introduction of the PTSD+​DS may implicitly suggest that all dissociative symptoms of PTSD are contained within this new subtype, core symptoms of PTSD such as flashbacks and amnestic gaps are explicitly attributed to dissociative processes (APA, 2013), suggesting that dissociation is inherent in all PTSD. Confusion around dissociative symptoms in PTSD is compounded by the fact that many other symptoms within PTSD criteria, though not explicitly labelled as such, are also dissociative. Core PTSD symptoms that possess a quality of involuntary intrusiveness or inaccessibility typical of dissociation, and which fall within the dissociative domains outlined in the dissociative disorders section of the DSM, have been central to many debates on the dissociative nature of PTSD (Berntsen & Rubin, 2014; Brewin, 2007). For example, inability to experience positive emotion, lack of interest, or detachment from others can be viewed as forms of disconnection from emotion and associated motivational drives (Spiegel, 1991, 1997). Intrusive dreams, where content and/​or affect related to sequestered trauma intrude upon sleep, can also be considered dissociative. More subtly, there are references to avoidance being attributed to a somatic “distressing” state, which implies excessive affective and perceptual intrusions of content related to dissociated trauma. Table 29.3 demonstrates how core PTSD symptoms

TABLE 29.3  Mapping dissociative dimensions against symptoms of PTSD

Dissociative dimensions

PTSD symptoms

Dissociative amnesia Inability to experience positive emotions Depersonalization Derealization Intrusive distressing memories Flashbacks Dreams related to the traumatic event

Consciousness

Memory Identity Emotion Perception

⧫

⧫

⧫ ⧫ ⧫

⧫ ⧫ ⧫

⧫

⧫ ⧫ ⧫ ⧫

⧫ ⧫ ⧫ ⧫

Body representation

⧫

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map against the different dimensions of dissociation in the DSM, whereas Table 29.2 provides examples of PTSD symptoms that can be understood as dissociative. As we begin to see that many core PTSD symptoms can be viewed as dissociative, further questions arise about the implication of dissociation in common associated features complicating PTSD. For example, it may be that for some individuals, reported loss of interest and alexithymia, which are typically attributed to depression, may represent dissociative freeze states wherein patients are disconnected from awareness of their emotions. Similarly, sudden surges of intense affect, as observed in panic attacks, may be conceptualized as dissociative intrusions. Further, it is possible that moral injury ( Jinkerson, 2016), due to “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009), sets up greater potential for dissociation by creating untenable psychological and existential conflict and inducing shame and guilt, prompting avoidance of emotion and a need to create distance from parts of Self (Griffin et al., 2019). While this pattern of response remains theoretical, it underscores the importance of understanding dissociative processes within and beyond trauma spectrum disorders.

Dissociation in PTSD: Case Examples To identify dissociative symptoms in PTSD, it is helpful to be reminded that dissociative phenomena are sequestered aspects of a past experience, which either become inaccessible or intrude upon awareness without volitional control. While keeping these principles in mind and recalling that dissociation occurs along the dissociative domains of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior, we can better recognize the multiform ways in which dissociation can manifest. Below, we present three brief cases that illustrate this point. Case 1 depicts the involuntary and intrusive nature of a dissociative flashback and its impact on the regulation of consciousness, even after seeming recovery from PTSD. Case 2 highlights distressing derealization symptoms. Case 3 showcases more complex dissociative phenomena, which can mimic psychotic symptoms and deeply impact sense of Self, challenging the boundaries of what we would typically consider as dissociative in PTSD. Vignette 1 During deployment in Bosnia, a 21-​year-​old serviceman saw a child being hit by a car. In his role as a medic, he stopped and picked up the child to assess if he could provide help. As he did so, a man rushed out of a car and took the child out of his arms, while pointing a gun at his head. In that moment, he wondered if the weapon had failed, recalling that it ‘clicked’ in his head. Immediately after the incident, he reported that it became dark and that he had no memory of returning to the base. He felt angry and upset in the subsequent days and did not connect his emotions with the memory of what had happened. Five years after his deployment, he recounted the event during an assessment that found he had recovered from PTSD and allowed him to continue a career in the military. However, when he was invited to speak about the event 25 years later for a student class, he suddenly stopped talking and froze for 2 minutes with a fixed eye gaze when recollecting the event. He was caught by surprise and felt ashamed, since he thought he had recovered from PTSD and learned to control his dissociative response. In the above vignette, the serviceman had recovered from PTSD but experienced dissociation with lack of awareness of his surroundings and an altered consciousness in response to a trauma related cue (talking about his experience). This stark dissociative state occurred outside the parameters of PTSD+​DS currently recognized in the DSM-​5, confirming the importance of dissociation beyond this confine. It is notable that during the original trauma, he experienced peritraumatic dissociation in the form of amnesia, which is a common risk factor for later dissociative symptoms and development of PTSD (see Cardeña & Classen, Chapter 28, this volume). In addition to inducing amnesia, altered states of consciousness can impact a person’s perception of incoming sensory information. This information can take the form of distorted or unusual experiences, which can be distressing, including altered visual perception of the shapes, sizes, brightness, or colors of external objects. Other senses may also be affected, including olfactory, gustatory or tactile perceptions (e.g., pain). Perceptions of body shape and size or the body’s relationship to the surrounding space can also change. An altered sense of time flowing more quickly or slowly may also arise, and contextual temporal relatedness of inner and outer experiences may be affected. Derealization, where the world does not feel real or is somehow removed from being directly experienced, is not uncommon in this context, as is paranoid ideation, hallucinations, and illusions. The next case below illustrates symptoms of derealization. Vignette 2 A 20-​year-​old man was admitted to psychiatry with suicidal thoughts due to feeling out of control after the sudden onset of derealization symptoms following a short course of trauma therapy for a recent family conflict. He noted halos around lights, periods

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of blurry vision, and feeling as if the floor underneath him was moving, as if he was standing on a ship. Furniture around him appeared further away, and surfaces he touched felt somehow unreal, making him question whether he still existed in the same world as he did before. At times, he felt he could see a vague shadowy figure out of the corner of his eye, but when he looked in that direction, the figure would be absent. During a week-​long stay in hospital, in which he attended groups and reconnected with his family, his symptoms gradually dissipated without the need for medications; as his derealization symptoms remitted, so did his suicidal thoughts. Despite the distress and overwhelm these symptoms caused, the individual in the above vignette did not experience disintegration of his identity. A more profound dissociative split is demonstrated in the vignette below, where multiple dissociative domains are affected, including that of identity. Vignette 3 A successful nurse in her 40s was recovering from a medically induced coma following a near-​death car accident caused by her best friend. As she was recovering in hospital, heavily medicated and unable to move, she began to experience visual hallucinations of frightening monsters violently torturing others around her, including the healthcare staff who cared for her. After discharge, she began to have nightmares of these same monsters, which disturbed her sleep as she frequently woke in a panic, drenched in sweat. During daytime, she began to have vague visions of the monsters and heard voices telling her to die. She became hypervigilant and anxious, and felt as if the monsters would somehow hurt her. She also became detached from her friends and easily irritable with her family. Despite pleas from her family and friends, she resisted seeking help because her physician practiced out of a hospital, and going there felt unbearable, as it reminded her of her hospitalization. When finally assessed, she was diagnosed with PTSD with dissociation, and referred for Eye Movement Desensitization and Reprocessing Therapy (EMDR). During the initial consultation for therapy, it was noted that she had endured severe, chronic, and recurrent childhood physical, emotional, and sexual abuse at the hands of her closest caregivers, in addition to the car accident and hospitalization. EMDR therapy targeting her car accident reduced her overall hypervigilance and frequency of nightmares, but her hallucinations of monsters and the voices persisted. A modified EMDR protocol targeting early childhood experiences was then used, during which she saw images of the same monsters rescuing her from her childhood abuse. With the new realization that the monsters’ function was to protect her, she gradually became less fearful of them and more curious about their role as protectors within herself. Six months into treatment, she expressed a firm belief that the monsters were an integral part of her and necessary to protect her from abuse or danger in the future. Soon after, her hallucinations and nightmares resolved, and she remained in complete remission from all other PTSD and dissociative symptoms at 6-​month follow-​up. The above vignette illustrates the sometimes layered complexity of dissociative symptoms that can occur when adult traumas are superimposed upon severe, repeated childhood interpersonal trauma. It also demonstrates how more complex presentations of PTSD can blur the boundary between PTSD and dissociative disorders. While both Vignettes 2 and 3 would likely qualify for a PTSD+​DS diagnosis, they differ with respect to severity, complexity, and phenomenology. In Vignette 3, flashbacks, nightmares, and hypervigilance more typical of PTSD were observed alongside hallucinations representing disavowed parts of the Self more reminiscent of a dissociative disorder. More severe dissociative divisions observed in PTSD do not fit well within the current diagnostic boundaries in the DSM; they occur along a continuum of degrees of separation from the Self, often involving multiple dissociation dimensions of identity, emotion, memory, perception, consciousness, and body representation. These can present in a variety of ways. For example, depersonalization can present as a sense of partial to complete disembodiment, conversion reactions, fugue, or a more severe dissociative division in personality. In severe cases, intrusions of dissociative hostile or shame-​based voices or other hallucinations may also be present (APA, 2013). Experienced subjectively, they can feel as if separate personality states are acting independently. The fragmented nature of how dissociated traumatic memories are stored and retrieved can cause amnestic gaps and intrusive re-​experiencing of aspects of the trauma. Memory intrusions may occur in the form of flashbacks or disturbing dreams and be experienced as fragments of memories or symbolic forms reflective of the trauma. In summary, dissociation in PTSD can manifest in many ways, including and apart from depersonalization and derealization attributed to the dissociative subtype, or flashbacks and dissociative amnesia described in core PTSD criteria. The emotional consequence of a trauma-​induced dissociative division is extremes of emotional reactivity ranging from detachment, emotional numbing, and alexithymia to anxiety, rage, or altered states of consciousness.

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Treatment Implications of Dissociation in PTSD Important treatment implications follow from the recognition of prominent dissociation, and the establishment of the dissociative subtype within PTSD. One major consideration is the potential for poorer treatment outcomes from traditional trauma-​focused treatments that prioritize quickly initiating emotional exposure to process past trauma (Bae, Kim, & Park, 2016; Murphy, Karatzias, Busuttil, Greenberg, & Shevlin, 2021). Exposure may be challenging for this population as trauma-​related cues may prompt dissociation and impair new learning (Ebner-​Priemer et al., 2009), deeming this therapy less effective for PTSD with more pronounced dissociative symptoms. In this context, it is not surprising that many clinicians are hesitant to use standard trauma therapy as the first line treatment option in this population. Expert opinion and clinical guidelines regarding treatment of dissociation or complex trauma generally recommends a more graduated approach, starting with stabilization, establishing safety, self-​care, and enhancing coping skills (Cloitre et al., 2012; Courtois & Ford, 2009; International Society for the Study of Trauma and Dissociation, 2011). However, this recommendation has not been without controversy, with some studies demonstrating no adverse impact of dissociation on psychotherapy outcomes (Hoeboer et al., 2020; See Stavropoulos & Elliott, Chapter 44, this volume). This highlights the need for further research to help clinicians better determine what works for whom, at what time, and importantly, at what point in their course of treatment. Various therapeutic tools exist which can be used to address dissociation in PTSD. Strategies based on cognitive or dialectical behavioral therapies can aid in acquisition of coping and self-​regulation skills (Boon, Steele, & Van der Hart, 2011; Cloitre et al., 2010). Graduated emotional exposure through trauma-​informed mindfulness or modified exposure is often a core component of many therapies (Cloitre et al., 2010; Forner, 2017). Newer approaches that are more body and movement oriented, such as somatic psychotherapies and trauma-​informed yoga, can help a person experience pleasant, resourceful bodily states, tolerate titrated experiences of bodily distress, and use attention, movement and body posture to shift emotional arousal and process traumatic memory (Emerson & Hopper, 2012; Levine & Frederick, 1997; Ogden et al., 2006). The more recently developed Multi-​Modal Motion-​a ssisted Memory Desensitization and Reconsolidation (3MDR) (Bisson et al., 2020; Jones et al., 2021; van Gelderen, Nijdam & Vermetten, 2018) –​a virtual reality supported, exposure-​based psychotherapy that incorporates treadmill walking as a critical element of trauma processing (Nijdam & Vermetten, 2018) –​is also demonstrating positive outcomes and much promise. With respect to pharmacologic treatments, there is a virtual vacuum of controlled research to guide treatment of dissociation, both for the dissociative subtype of PTSD and dissociative disorders. A recent meta-​analysis of pharmacotherapy for dissociative disorders revealed only seven randomized controlled trials (focusing on fluoxetine, paroxetine, lamotrigine, naltrexone and naloxone), which included treatments for depersonalization disorder, or dissociation in either borderline personality disorder (BPD) or chronic PTSD (Sutar & Sahu, 2019). Current PTSD treatment is predominantly focused on treating hyperarousal (e.g., anxiety, agitation, or anger) and intrusive symptoms (e.g., flashbacks or disturbing dreams) (Chu, 2011), whereas hypoarousal and dissociative symptoms are largely ignored. Expert opinion regarding medication treatment of complex dissociation is that treatment is off-​label and empirical, often has modest effectiveness, and is adjunctive to psychotherapy (Chu, 2011; Loewenstein, 2005). Further, at the present time, medications may at best “take the edge off” hyperarousal and smooth emotional dysregulation patterns, rather than fully ameliorate symptoms or attend to hypoarousal and dissociation. Given the very real risks of medication toxicity and sequelae of suboptimally treated illness, the research gap is surprising, especially considering that the topic of dissociation has one of the longest histories in psychiatry yet appears to be one of the least researched. Given the complexity of the trauma recovery process, there is a need for a personalized approach and flexibility on the part of the therapist and patient. Further, as short term, manualized treatments are unlikely to be sufficient, clinicians and patients alike need to recognize that learning new skills can be time-​consuming and treatment may be lengthy and require perseverance.

Trauma Spectrum Disorders –​Revisited Epidemiological, neurobiological, and physiological findings suggest that PTSD and PTSD+​DS may belong on a spectrum of trauma disorders characterized by a differential severity of dissociation, depending on the timing and cumulative effect of trauma (Kim et al., 2019; Schalinski et al., 2016; Stein et al., 2013; van Huijstee & Vermetten, 2017). More sequestered and disorganized dissociative symptoms point to earlier onset and/​or more chronic and severe traumatic or attachment injuries (Schimmenti, 2018). Following this logic, and in line with earlier ideas and concepts laid out by Bremner (1999), we aim to re-​propose that in the absence of an underlying medical condition, other disorders with

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dissociation as a feature are also part of a trauma spectrum (see Van der Hart & Steele, Chapter 15, this volume, for related ideas on a dissociative spectrum). DID shares etiological and neurobiological similarities with PTSD and could be considered part of the trauma spectrum; the prevalence of childhood abuse and neglect in those affected by DID is 90% (APA, 2013). Similar to the two PTSD subtypes, DID demonstrates differential brain and physiological responses when in traumatic or neutral identity states, with different states manifesting in physiological hyper-​or hypo-​arousal (Reinders et al., 2006; See Nijenhuis, Chapter 38, & Lebois et al., Chapter 24, this volume). Additionally, DES scores for PTSD are second highest among all psychiatric disorders, surpassed only by dissociative disorders (Carlson & Putman, 1993; Lyssenko et al., 2018). This is not surprising since many of the core PTSD symptoms are inherently dissociative in nature, and again highlights the close relationship between posttraumatic and dissociative disorders. It was in recognition of this close relationship that trauma spectrum and dissociative disorders are now placed next to each other in the DSM-​5 (APA, 2013). Another diagnosis that lies on the spectrum of trauma is BPD, which is often marked by derealization and depersonalization, similar to dissociative PTSD (Vermetten & Spiegel, 2014). BPD is additionally accompanied by severe emotional dysregulation and interpersonal difficulties, which are listed as associated features of PTSD in the DSM-​5. As with dissociative PTSD, childhood adversity is common in BPD, as is functional impairment, multiple comorbidities, and suicidality. The overlap suggests the two disorders may be part of a wider spectrum. Other psychiatric disorders also can present with dissociative symptoms, and have also been associated with a history of trauma (Gold, 2004; Luyten, et al., 2017; Read & Ross, 2003). Those with affective disorders, anxiety disorders, and schizophrenia score higher on the DES than normal controls, indicating dissociation in disorders that lie outside the trauma-​related or dissociative disorders sections in the DSM (Carlson & Putman, 1993, APA 2013). Alexithymia, or disconnection from emotion, is an inherently dissociative feature (Nemiah, 1977), yet is most frequently attributed to depression and not trauma. Panic attacks have previously been theorized as dissociative (Nemiah, 1992) and could be conceptualized as intrusions of disconnected affect upon awareness and a trauma response similar to a flashback experienced in PTSD. There is very limited research, however, that explores this hypothesis. The significance of recognizing that traumatic injury is at the core of many psychiatric disorders, and marked by dissociation, is of utmost importance. By dismissing or marginalizing the role of trauma in the generation of dissociative symptoms, and in turn the role of dissociation in many psychiatric presentations, patients are inadvertently invalidated. Adding to the injury is the fact that those with more severe dissociative symptoms are also the ones most likely to have been affected by disruptions in early attachment and childhood adversity, resulting in difficulties with interpersonal trust and ability to heal in a therapeutic setting. Encountering clinicians who deny or fail to recognize their traumatic injury while at their most vulnerable can often lead to further traumatization. As we have seen in this chapter, there are a number of interconnected factors that contribute to the development of pathological dissociation as part of a trauma response. It is therefore not surprising that pathological dissociation can present itself across a variety of psychiatric disorders. It is hoped that future DSM editions will revisit the idea of a trauma spectrum disorder or dimension, since current conceptualizations do not account for this complexity. Research must likewise take into consideration how trauma impacts various Research Domain Criteria (RDoC).

An RDoC Approach Linking PTSD and Dissociation Nearly five decades of PTSD research has resulted in substantial accumulation of knowledge on the pathobiology of this frequent and debilitating disorder. The National Institute of Mental Health recently launched the RDoC framework, which aims to leave diagnosis-​oriented psychiatric research behind and move toward use of research domains overarching the traditional diagnosis systems. RDoC is a dimensional approach that relies on dimensions ranging from normal to pathological. At the center of RDoC is a matrix of functional dimensions, grouped into domains such as systems for social processes and cognition. Each of these domains can be studied using different classes of variables (termed “units of analysis”) of which eight were hitherto specified: genes, molecules, cells, neural circuits, physiology, behaviors, self-​reports, and paradigms (National Institute of Mental Health, 2021). The utility of the RDoC system for PTSD and dissociation research, however, has not been systematically assessed. We reviewed core findings in neurobiological PTSD research and matched them to the RDoC research domains and units of analysis. Our synthesis revealed that several core findings in PTSD, such as amygdala overactivity, have been linked to RDoC domains without further specification of their distinct role in the pathophysiological pathways associated with these domains. This circumstance indicates that the elucidation of the cellular and molecular processes ultimately decisive for regulation of psychic processes and expression of psychopathological symptoms is still grossly incomplete. The same can be said about dissociation and dissociative disorders. A problem, as outlined in a critical

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research paper, is that the RDoC research domains may be useful but insufficient for PTSD research (Indelli, Landeira-​ Fernandez, & Mograbi, 2018). Hence, it was suggested to add two novel domains, namely (a) stress and emotional regulation, and (b) maintenance of consciousness (Schmidt & Vermetten, 2017). As both domains play a role in multiple, if not all psychiatric diseases, we judge them to be useful not only for PTSD and dissociation research but for psychiatric research in general.

Is There a Renewed Interest in Traumatic Dissociation? The time for re-​v isioning PTSD and trauma disorders appears to be ripe, as society, researchers, and patients are becoming more open to exploring the various properties of dissociation. We yet have much to learn, however, about the properties of dissociation both as a marker of pathology and as a potentially therapeutic tool. Numerous challenges and opportunities remain regarding the conceptualization, assessment and treatment of dissociation and PTSD. Defining and recognizing dissociation and its different manifestations, including within PTSD, has been one facet of the challenge in recognizing dissociation’s role in traumatic sequelae. Disruptions in integrated functions of consciousness, memory, perception or identity are dimensional and can manifest in a variety of ways, from normal to pathological, and state to trait. A better understanding of these phenomena, their underlying mechanisms, and neural correlates in PTSD is critically needed. Determination of the transdiagnostic value of assessing, measuring and treating dissociation, and clarifying the boundaries of dissociative PTSD from dissociative disorders would add much needed clarity to this field of study. In addition, a greater understanding of the underlying neurobiology of different types of dissociation would facilitate development of more effective treatment strategies for this population. After reviewing the current state of knowledge, research and practice, we feel that implementation of existing reliable, validated tools for assessment of these specific, overlapping populations would enable clinicians to better understand patients’ struggles and treatment response, and inform treatment planning. Yet, even with improved assessment tools, the paucity of psychopharmacological and non-​pharmacological evidence-​based interventions in the field of dissociation and trauma still leaves many challenges for patients and clinicians, especially within general psychiatric clinics with time demands and limited access to highly trained psychotherapists. As the field of PTSD is moving from cognitive to experiential-​based interventions, there is also an opportunity to extend this trend to the intersection of dissociation in PTSD. One cannot think one’s way out of PTSD; the real intervention for curative treatment may be revisiting core emotions and conflicts that give rise to dissociation. Momentum has been growing regarding the exploration of novel treatments and compounds that fundamentally address core aspects of trauma, targeting drives for chronicity in shame and fear-​based memories (e.g., MDMA, psilocybin) in the treatment of dissociation and PTSD. Several working models of corrective experiences utilizing psychedelic pharmaceuticals have been found to hold promise. The main approach here is “inner directed” psychotherapy which aims to follow the person’s internal process, and often involves acceptance of parts of the experiences and parts of Self that were previously shunned or dissociated. Phase 3 clinical research trials of MDMA-​a ssisted therapy currently underway to treat PTSD are nearing completion with promising results (Mitchell et al., 2021). It is hypothesized that psychedelics may change underlying neural networks, allowing for the introduction of ideas that effectively challenge feelings such as shame. Despite DSM-​5’s acknowledgement of dissociative phenomena as a feature of trauma by introducing a dissociative subtype of PTSD, the division between trauma and dissociation continues with the separation of trauma spectrum and dissociative disorders. We feel the negative consequences of this long-​standing separation have been profound. Current status is such that training, knowledge, education, and research in the field of traumatic dissociation is very limited, often leading to those experiencing chronic dissociative symptoms being misunderstood, not believed, or seen as difficult when seeking help. This results in polypharmacy, limited offerings of short-​term therapy, and revolving door hospital admissions, which are of questionable benefit.

Visioning Next Steps Future exploration and research on the intersections between trauma and dissociation may demonstrate an increasingly complex and interconnected link between attachment, personality, human development, and life events. Since the experience and consequences of trauma are as individual as the people who endured it, nosological classifications such as the DSM may become increasingly less relevant or useful. Following are several lines of research that we would like to underscore in order to address knowledge, practice and research gaps in order to better understand the connection between trauma and dissociation.

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• There is a dire need for an enhanced RDoC approach to incorporate dimensions of emotional regulation and maintenance of consciousness that extend beyond the classical model of PTSD in the DSM (Schmidt & Vermetten, 2017). • Improved curricula are needed to train new mental health professionals in the science and art of evidence-​based trauma care (Loewenstein, 2018) to better understand the link between trauma and dissociation. • Innovation and research on the treatment of dissociation is urgently needed, including pharmacological and psychotherapeutic interventions that encompass the many facets, and complex nature, of trauma and dissociation, such as differentiating dissociative compartmentalization and difficult-​to-​treat psychotic phenomena (Treise & Perez, 2021). • Novel trauma processing psychotherapies (e.g., EMDR, 3MDR, Sensorimotor psychotherapy, Somatic Experiencing Therapy, Psychodrama, or trauma-​informed equine therapy or yoga) that incorporate body movement and/​or body sensations need more systematic studies to improve treatment of traumatic dissociation. • Emotionally-​and relationally-​based approaches are needed to address non-​fear-​based aspects of trauma and dissociation, especially considering the link with ACEs and attachment injury in PTSD+​DS. This includes self-​forgiveness, self-​compassion, and other biopsychosocial-​spiritual practices that address shame, guilt, anger, regret and bitterness that accompanies violation of Self and one’s moral code (Brémault-​Phillips, Pike, Scarcella, & Cherwick, 2019; Vermetten, Jetly, Smith-​MacDonald, Jones, & Brémault-​Phillip, 2021) • Novel treatments and compounds (e.g., MDMA, psilocybin, naltrexone) may be promising for treatment of more complex trauma presentations and PTSD+​DS. Their mechanisms of actions, effectiveness for PTSD and dissociation, and safety profiles need investigation (Cameron et al., 2021). They serve as clinical illustrations of how deeply trauma and dissociation are connected. As we move forward, it is critical to the delivery of optimal clinical care, that the diverse needs of the widespread trauma cases be effectively assessed, addressed and optimally treated. To do so, current researchers must educate about how dissociation intersects with PTSD; future young researchers and therapists must take this knowledge, value its significance, and apply learnings to inform trauma care.

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30 COMPLEX PTSD AND EMOTION DYSREGULATION The Role of Dissociation Julian D. Ford

Complex Posttraumatic Stress Disorder (cPTSD) was originally proposed as an expansion of PTSD, with symptoms in seven domains: (1) emotion dysregulation, (2) altered schemas of self, (3) altered relationships, (4) altered systems of meaning (i.e., trauma-​related change in sustaining beliefs related to morality and spirituality), (5) somatization (i.e., bodily symptoms with no identifiable physical causation), (6) dissociation, and (7) altered perceptions of perpetrators (Herman, 1992; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997; van der Kolk et al., 1996; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). That formulation of cPTSD was proposed as a new diagnosis in the 4th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-​4; American Psychiatric Association, 1994), under the title Disorders of Extreme Stress Not Otherwise Specified (DESNOS). However, DESNOS was included in the DSM-​4 only as associated features of PTSD and not as a separate diagnosis or sub-​type of PTSD. DESNOS was entirely excluded from the DSM-​5 (American Psychiatric Association, 2013), with the developers opting for a broader conceptualization of PTSD that included several new symptoms similar to the DESNOS symptoms of emotion dysregulation, along with altered schemas, beliefs, and relationships. In the DSM-​5 dissociation is represented among the symptoms of PTSD by flashbacks (B3) and psychogenic amnesia (D1), and as an associated feature that may occur “following prolonged, repeated, and severe traumatic events (e.g., childhood abuse, torture)” (APA, 2013, p. 276). A new dissociative sub-​t ype of PTSD (PTSD-​D) is included, requiring the presence of symptoms of derealization or depersonalization (Lanius, 2015; Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012). However, none of the positive and negative psychoform (e.g., dissociative trance or identity fragmentation) and somatoform (e.g., conversion reactions such as analgesia or paralysis) dissociative symptoms that involve structural fragmentation of the self (Laddis, Dell, & Korzekwa, 2017; Nijenhuis & Van der Hart, 2011) were included in PTSD-​D. Structural dissociation is hypothesized to involve more than disorientation and memory gaps, relating specifically to a division of the self into partial personalities that are either superficially normal (“apparently normal personalities” [ANP]) or significantly disturbed (“emotional personalities” [EP]) (Nijenhuis & Van der Hart, 2011). Since the release of the DSM-​5, research aimed at streamlining complex PTSD for clinical efficiency led to the identification of three core features that now constitute a new formulation of complex PTSD (Brewin et al., 2017): emotion, relational, and self-​dysregulation. These new domains of symptoms in cPTSD are referred to as Disturbances of Self Organization (DSO) in order to highlight the fundamental adverse impact of traumatic stressors involving intentional acts that not only elicit fear and other distressing emotions that are features of PTSD in the DSM-​5, but also challenge the person’s core identity and trust in primary relationships. The resultant revised cPTSD formulation, DSO plus core PTSD symptoms (Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013; Cloitre et al., 2019; Hyland, Shevlin, Fyvie, & Karatzias, 2018), was adopted as a diagnosis in the 11th Revision of the World Health Organization’s International Classification of Diseases (ICD-​11). Based on confirmatory factor analysis studies with adults (Brewin et al., 2017), cPTSD in the ICD-​11 includes a streamlined version of PTSD (i.e., two symptoms from each of the three DSM-​IV criteria –​ intrusive re-​experiencing, avoidance of trauma reminders, hyperarousal), and two symptoms from each of the three DSO domains: (1) emotional dysregulation or numbing, (2) oneself perceived as a failure or worthless, and (3) emotional avoidance or detachment in relationships. Dissociation is not a symptom in ICD-​11’s cPTSD. The exclusion of dissociative symptoms from the DSO component of the ICD-​11 cPTSD diagnostic criteria is noteworthy, given the primary role pathological dissociation was viewed as playing in the earlier DESNOS formulation of

DOI: 10.4324/9781003057314-36

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cPTSD (van der Kolk et al., 1996). Empirical evidence was cited of dissociation not loading on factors derived from exploratory and confirmatory factor analyses done first with the DESNOS structured interview (Scoboria, Ford, Lin, & Frisman, 2008) and subsequently with omnibus measures of PTSD and DSO symptoms (Brewin et al., 2017). However, recent empirical findings suggest that pathological dissociation occurs for many individuals diagnosed with either cPTSD/​DSO or DESNOS. That research will be reviewed here, followed by a summary of research linking a core feature in both cPTSD and DESNOS (emotion dysregulation) with dissociation. Research will be summarized showing that traumatic disruption of attachment bonding with primary caregivers in childhood and its sequela, disorganized attachment, is a precursor to both emotion dysregulation and pathological dissociation. Subsequently, an alternative conceptualization of cPTSD based on a confluence of those factors will be presented: Developmental Trauma Disorder (DTD). Neuroimaging research on trauma-​ related dissociation will then be reviewed as a basis for proposing a dissociative sub-​t ype of cPTSD paralleling PTSD-​D in DSM-​5. Implications of a dissociative sub-​t ype of cPTSD for research and clinical practice will be discussed.

Dissociation in Complex PTSD Research on dissociation in ICD-​11’s formulation of cPTSD is at an early stage, but the emerging results suggest dissociation is often experienced by persons diagnosed with cPTSD. Adult mental health patients meeting criteria for cPTSD have been shown to have more severe dissociative symptoms than patients diagnosed with PTSD alone (Hyland, Shevlin, Fyvie, Cloitre, & Karatzias, 2020). In a representative population sample from Ireland, dissociative symptoms partially mediated the relationship of childhood trauma exposure with both PTSD and DSO symptoms, but fully mediated the relationship of adolescent and adult trauma exposure with DSO symptoms ( Jowett, Karatzias, Shevlin, & Hyland, 2021). In a study of adult survivors of childhood abuse, negative (depersonalization, derealization) and positive (flashbacks) dissociative symptoms were correlated with symptoms of cPTSD/​DSO, but also with symptoms of PTSD and borderline personality disorder (BPD) (Knefel, Tran, & Lueger-​Schuster, 2016). A study with foster children found that dissociation mediated the relationship between cumulative childhood trauma and cPTSD (Haselgruber, Knefel, Solva, & Lueger-​Schuster, 2021). Thus, in community and clinical adult samples, and child and adult at-​r isk samples, there is evidence that pathological dissociation is associated with cPTSD and potentially mediates the relationship of childhood trauma exposure with cPTSD. Although dissociation may be associated with the development of cPTSD in the aftermath of childhood trauma exposure, there is no evidence as yet that dissociative symptoms warrant inclusion as core cPTSD symptoms. Dissociation’s role in DESNOS has been somewhat more extensively investigated. Although dissociation did not emerge as a core component of DESNOS in factor analyses of data from clinical and at-​risk adult samples (Scoboria et al., 2008), in a cohort of adult psychiatric inpatients (Van Dijke, Ford, Frank, Van Son, & Van der Hart, 2013; Van Dijke et al., 2010; Van Dijke, Hopman, & Ford, 2018a), DESNOS was associated both with psychoform dissociation’s positive (i.e., flashbacks, identity fragmentation) and negative (i.e., derealization, depersonalization, fugue states) features and somatoform dissociation (i.e., physical conversion reactions) (Del Rio-​Casanova, Gonzalez, Paramo, Van Dijke, & Brenlla, 2016; Van Dijke, Ford, Frank, & Van der Hart, 2015; Van Dijke et al., 2012; Van Dijke, Hopman, & Ford, 2018b). Psychoform dissociation also partially mediated the relationship of childhood abuse with DESNOS (Van Dijke et al., 2015), independent of the effects of personality disorder symptoms, fears of abandonment and closeness, and emotion dysregulation (Van Dijke et al., 2018b). In other samples of adults in mental health treatment, DESNOS symptoms have been associated with heightened levels of dissociative symptoms (Dorahy et al., 2013; Dorahy et al., 2017), and these samples experienced levels of child abuse comparable to those found in patients diagnosed with dissociative disorders (DD) (Dorahy, Middleton, Seager, Williams, & Chambers, 2016). However, in the latter study, DD-​d iagnosed patients were more likely than DESNOS-​ diagnosed patients to have histories of childhood sexual abuse (CSA), and CSA was the sole predictor (with emotional abuse trending) of pathological dissociative symptoms. Other studies have found that DESNOS is associated with CSA primarily when it co-​occurs with Borderline Personality Disorder (BPD) (Ford & Courtois, 2021), which suggests that the well-​documented relationship between CSA and pathological dissociation (Gewirtz-​Meydan & Lahav, 2020) may occur in DESNOS mainly as a result of comorbidity between DESNOS and other disorders specifically defined by severe dissociation or severe emotion dysregulation (i.e., DDs or BPD).

Emotion Dysregulation, Dissociation, and Complex PTSD Emotion dysregulation is a core feature in both cPTSD/​DSO and DESNOS, based on evidence that it is highly interrelated with the other components of complex PTSD, as well as with associated psychiatric comorbidity and

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behavioral health risks such as suicidality and addictions ( Jakovina, Crnkovic Batista, RaZic Pavicic, Zuric Jakovina, & Begovac, 2018; Liese, Kim, & Hodgins, 2020; Malik, Wells, & Wittkowski, 2015; Tatnell, Hasking, Newman, Taffe, & Martin, 2017; Theoret, Lapierre, Blais, & Hebert, 2020). Emotion dysregulation also has been shown to be related to pathological dissociation across the age range from early childhood through adulthood (Hebert, Langevin, & Oussaid, 2018; Henschel, Doba, & Nandrino, 2019; Mosquera, Gonzalez, & Leeds, 2014; Winter, 2016). Among adult psychiatric patients, pathological dissociation is associated with both under-​regulation of emotion (i.e., difficulty recovering from persistent intense distress co-​occurring with positive psychoform and somatoform dissociative symptoms), and over-​ regulation of emotion (i.e., blunting or numbing of emotions, co-​occurring with negative psychoform and somatoform dissociative symptoms) (Barnow et al., 2012; Del Rio-​Casanova et al., 2016; Van Dijke et al., 2015). Well before adulthood, adolescents with cumulative maltreatment histories and emotion regulation difficulties were found to have severe psychoform and somatoform dissociation (Henschel et al., 2019). In a study with school-​ age children who had experienced sexual abuse, emotion dysregulation and dissociation were intercorrelated and, both separately and together, mediated the relationship between past cumulative trauma and internalizing and externalizing behavior problems (Hebert et al., 2018). Similarly, a study with foster children found that dissociation and emotion regulation were inversely correlated, and that both mediated the relationship between cumulative childhood trauma and cPTSD (Haselgruber et al., 2021). Finally, among pre-​school age children, emotion dysregulation mediated the relationship between past sexual abuse and dissociative pathology at a one-​year follow-​ up (Hebert, Langevin, & Charest, 2020). Thus, not only are dissociation and emotion dysregulation interrelated, but they also provide a link between cumulative childhood trauma and cPTSD. Moreover, emotion dysregulation also may be a precursor to dissociative pathology. In addition to the adverse effects of exposure to interpersonal trauma in childhood, shown to be strongly related to cPTSD (Karatzias, Shevlin, Fyvie, et al., 2020; Karatzias, Shevlin, Hyland, et al., 2020; Van Dijke et al., 2018b), disruption of early life attachment bonding with primary caregivers has been linked with both emotion dysregulation and dissociation (Beeney et al., 2017; Bohlin, Eninger, Brocki, & Thorell, 2012; Groh, Roisman, Van Ijzendoorn, Bakermans-​ K ranenburg, & Fearon, 2012). When children experience traumatic victimization and fundamental problems in emotional bonding with primary caregivers they are at risk for a combination of dissociation and emotion dysregulation that can persist into adulthood (Decarli, Pierrehumbert, Schulz, Schaan, & Vogele, 2020; Liotti, 2017; Lyons-​Ruth, Pechtel, Yoon, Anderson, & Teicher, 2016; Van Hoof, Riem, Garrett, Pannekoek, et al., 2019; Van Hoof, Riem, Garrett, Van der Wee, et al., 2019). This combination of under-​and over-​regulation of emotion and dissociation has been described as disorganized attachment, and appears to result from a fundamental confusion about whether to seek, fear, or reject closeness in important relationships (Granqvist et al., 2017). Disorganized attachment has been found to be a precursor to pathological dissociation, beginning in early childhood (Byun, Brumariu, & Lyons-​Ruth, 2016; Marcusson-​Clavertz, Gusic, Bengtsson, Jacobsen, & Cardena, 2017; Mosquera et al., 2014) and extending into adulthood (Byun et al., 2016; Lyons-​Ruth et al., 2016; Marcusson-​Clavertz et al., 2017; Paetzold & Rholes, 2021; See Schimmenti, Chapter 10, this volume). A combination of disorganized attachment and emotion dysregulation was found to be common amongst sexually abused children –​and to be predictive of dissociation a year later (Hebert et al., 2020). Similarly, a combination of emotion dysregulation and disorganized attachment in young adulthood mediated the relationship between child abuse history and pathological dissociation as an adult (Byun et al., 2016). These findings suggest that disorganized attachment in the aftermath of childhood exposure to traumatic victimization and disrupted attachment bonding with primary caregivers may involve a combination of emotion dysregulation and dissociation –​and may lead to cPTSD in childhood that may persist into adulthood. Both the DESNOS and ICD-​11 formulations of cPTSD capture a portion of the features of disorganized attachment (i.e., relational and emotion dysregulation in cPTSD; dissociation and emotion dysregulation in DESNOS), but neither represent the full range of problems involved in disorganized attachment. An alternative formulation of complex PTSD for children, Developmental Trauma Disorder (DTD), may provide a more complete picture than cPTSD or DESNOS of how emotion dysregulation and dissociation are manifested in disorganized attachment and cPTSD.

An Alternative Approach to Inclusion of Dissociation: Developmental Trauma Disorder (DTD) DTD is a childhood syndrome formulated to complement and extend the PTSD diagnosis for children (Ford et al., 2013; Ford, Spinazzola, van der Kolk, & Grasso, 2018; Ford, Spinazzola, & van der Kolk, 2021; Ford, Spinnazola, van der Kolk, & Chan, 2022; Spinazzola, van der Kolk, & Ford, 2018, 2021; van der Kolk, Ford, & Spinazzola, 2019; van der Kolk, 2005). DTD involves 15 symptoms in three domains of dysregulation: emotional/​somatic, cognitive/​behavioral, and self/​relational (Table 30.1).

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484  Julian D. Ford TABLE 30.1  Developmental Trauma Disorder (DTD) Criteria

•  Criterion A: lifetime exposure to two types of stressors   • A1: interpersonal victimization: experienced or witnessed physical or sexual assault or abuse, or witnessed family or community violence;   • A2: disruption in attachment bonding to primary caregiver(s): loss of, prolonged separation from, or neglect by a primary caregiver. •  Criterion B (current emotion or somatic dysregulation, 4 items; 1 required for DTD)   •  B1: Emotion dysregulation (either B1.a. extreme emotional distress; or B1.b. impaired recovery from emotional distress)   • B2: Somatic dysregulation (either B2.a. aversion to touch; or B2.b. aversion to sounds; or B2.c. bodily dysfunction/​illness that cannot be medically explained/​resolved)   • B3: Impaired access to emotion or bodily feelings (either B3.a. inability to experience emotion; or B3.b. anaesthesia or paralysis that cannot be medically explained/​resolved)   • B4: Impaired expression of emotion or body states (either B4.a. alexithymia; or B4.b. inability to express bodily feelings/​states in words) •  Criterion C (current attentional or behavioral dysregulation, 5 items; 2 required for DTD)   • C1: Attention bias toward or away from threat (either C1.a. preoccupation with real/​perceived threats; or C1.b. impaired ability to recognize actual or potential danger)   • C2: Impaired self-​protection (either C2.a. extreme risk-​t aking or reckless or careless behavior; or, C2.b. intentional seeking of conflict or violence)   •  C3: Maladaptive self-​soothing (attempts to reduce emotional distress that are primitive and obsessional)   •  C4: Non-​suicidal self-​injury (self-​harm intended to reduce/​contain distress)   • C5: Impaired ability to initiate or sustain goal-​d irected behavior (consistent problems in independently starting and completing actions designed to achieve personal goals) •  Criterion D (current relational-​or self-​dysregulation, 5 items; 2 required for DTD)   •  D1: Self-​loathing (viewing self as irreparably damaged or defective)   • D2: Attachment insecurity and disorganization (either D2.a. parentified attempts to protect caregivers; or D2.b. difficulty engaging emotionally with primary caregiver(s) following separation)   • D3: Betrayal-​based beliefs about relationships (either D3.a. expectation of betrayal in relationships; or D3.b. oppositional-​ defiance based on expecting to be coerced or exploited in relationships)   • D4: Reactive verbal or physical aggression (including proactive aggression intended to prevent/​respond to harm/​injury)   • D5: Impaired psychological boundaries (either D.5a. promiscuous enmeshment –​seeking physical or emotional intimacy from any available source; or D5.b. consistently needing emotional reassurance in relationships)   • D6: Impaired interpersonal empathy (either D6.a. intolerant of others’ distress; or D6.b. excessive responsiveness to others’ emotional distress)

DTD includes several sequelae of exposure to victimization and attachment disruption that are not defined as symptoms in the ICD-​11’s cPTSD DSO. Although DSO includes emotion dysregulation symptoms of inability to recover from intense distress and emotional numbing (Haselgruber, Solva, & Lueger-​Schuster, 2020), it does not have any symptoms that reference somatic expressions of emotion dysregulation. DTD’s somatic dysregulation symptoms (B2, B3b, B4b) explicitly identify somatic forms of emotion dysregulation, consistent with the importance of somatic expressions of distress in child and adolescent PTSD (Zhang, Zhu, Du, & Zhang, 2015) and somatoform dissociation (Silberg, 2021). In the self-​dysregulation domain, DTD focuses on sense of self as damaged, as opposed to the emphasis on self as worthless or a failure in cPTSD. DTD also includes symptoms of maladaptive self-​soothing and non-​suicidal self-​injury, although these were found to be indicators of behavioral dysregulation rather than a disturbance of self-​perception per se (Ford et al., 2018). The DTD domain of attentional and behavioral dysregulation also includes several other symptoms that may be reflective of dissociation but are not specified in the ICD-​11 formulation of cPTSD: preoccupation with or disregard for potential threats, reckless or risky behavior, and impairment in goal-​d irected behavior. In the relational dysregulation domain, DTD has symptoms that extend beyond the cPTSD relationship symptoms, which focus mainly on emotion over-​regulation (i.e., relational avoidance and detachment). DTD does address over-​regulation in relationships with symptoms representing restricted capacity for empathy and the avoidant component of disorganized attachment. However DTD also includes manifestations of severe emotional under-​regulation in relationships, in the form of the insecurity component of attachment disorganization, as well as symptoms of self-​other boundary confusion, empathic enmeshment, and reactive aggression.

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Although DTD was initially formulated to identify symptoms consistent with childhood and adolescent developmental epochs, its proposed antecedents (i.e., traumatic victimization and disrupted attachment bonding with primary caregivers) are consistent with those proposed for the adult versions of complex PTSD, DESNOS (van der Kolk et al., 2005) and cPTSD (Cloitre et al., 2020) (i.e., severe and chronic interpersonal violence or victimization). The addition of attachment disruption as an antecedent for DTD aligns it with evidence cited above that disorganized attachment is a sequela of traumatic disruption of primary attachment bonding and both predictive of, and an ongoing contributor to, emotion dysregulation and pathological dissociation throughout childhood and into adulthood (See Schimmenti, Chapter 10, & Schore, Chapter 11, this volume). By explicitly including attachment disruption as well as traumatic interpersonal victimization, DTD thus more closely aligns its stressor criterion with the antecedents of pathological dissociation and emotion dysregulation, compared to the sole focus on trauma as the stressor criterion for both DESNOS and cPTSD. In terms of symptoms, DTD’s core domain, emotion dysregulation, mirrors the central feature of both DESNOS and cPTSD. However, rather than placing dissociative symptoms as a separate domain (as in DESNOS) or excluding them entirely (as in cPTSD), DTD incorporates both psychoform (B3, B4) and somatoform (B2, B3, B4) dissociation into the domain of emotion dysregulation symptoms (see Table 30.1). Negative dissociation symptoms (e.g., depersonalization, derealization, fugue) and positive dissociation symptoms (e.g., flashbacks, part-​selves) are not explicitly referenced in DTD due to the difficulty of distinguishing these phenomena from children’s normative experiences and reactions to stressors (Silberg, 2021). However, with the exception of a symptom explicitly referencing DID-​like part-​ selves, the psychoform dissociation symptoms could be assessed with DTD’s emotion dysregulation symptoms (i.e., under-​regulation characteristic of the EP and over-​regulation characteristic of the ANP). If adapted for adults, DTD could explicitly include depersonalization, derealization, and fugue states within the rubric of its emotion dysregulation symptoms. DTD’s somatic dysregulation symptoms (i.e., unawareness of or aversion to bodily sensations, and medically unexplained physical illness, pain, or disability) directly address the somatoform domain of pathological dissociation. Thus, with added clarification of how psychoform dissociation can contribute to DTD’s emotion dysregulation symptoms, both psychoform and somatoform dissociation could be accounted for as a core component of DTD, and this could be done without adding dissociation as a separate symptom domain. As noted above, DTD also provides opportunities for identifying dissociation as a contributor to attentional (i.e., unawareness of threats), behavioral (e.g., maladaptive self-​soothing, self-​harm, impaired goal-​d irected behavior), and relational (e.g., impaired empathy and boundaries, aggression, disorganized attachment) symptoms –​similar to, but extending beyond the potentially dissociation-​related symptoms that are included in DESNOS (e.g., maladaptive self-​soothing, self-​harm, severe anger). Unlike cPTSD, DTD thus includes a wide range of symptoms of dysregulation that potentially reflect the action of dissociation, with a fuller representation of disorganized attachment than in DESNOS. The parsimony of symptom domains in cPTSD is evident in DTD, with psychoform and somatoform dissociative symptoms incorporated in a single domain of emotion and somatic dysregulation, rather than as separate domains as DESNOS does for dissociation and somatization. DTD therefore could potentially increase both the diagnostic sensitivity and informativeness of the original DESNOS formulation of complex PTSD compared to ICD-​11’s cPTSD as a result of including dissociation (as is done currently on an implicit basis with psychoform dissociation and explicitly with somatoform dissociation), while potentially improving diagnostic specificity and efficiency compared to DESNOS by not requiring psychoform and somatoform dissociation to serve as separate criteria.

Another Alternative Approach to Including Dissociation: The Dissociative Sub-​type of PTSD Although there is evidence that children and adults diagnosed with cPTSD may be at risk for pathological dissociation, this may be best understood as dissociation serving as an associated feature or comorbidity rather than as a core feature of complex PTSD. However, the potentially important contribution of dissociation to DTD’s emotion/​somatic dysregulation symptoms suggests that, in some cases, dissociation may be a defining feature of cPTSD. One possible approach to including dissociation in cPTSD is the designation of a sub-​type of complex PTSD characterized by dissociative manifestations of the core symptoms of emotion dysregulation. There is a precedent for such a sub-​t ype: the dissociative sub-​type of PTSD (PTSD-​D) (Lanius et al., 2012). Neuroimaging findings for PTSD-​D can serve as a starting point for understanding the neural substrates that could comprise a dissociative sub-​type of complex PTSD. This potential approach is consistent with evidence that a majority of PTSD-​D patients meet criteria for other dissociative disorders, with no difference in depression, anxiety, or personality disorder symptoms between those with or without a comorbid dissociative disorder (Swart, Wildschut, Draijer, Langeland, & Smit, 2020). In addition, individuals “with dissociative identity disorder and with dissociative PTSD showed more overlap in brain activation than each of

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those two sub-​g roups showed with depersonalization/​derealization disorder” (Lotfinia, Soorgi, Mertens, & Daniels, 2020, p. 5). PTSD-​D and its dissociative symptoms (depersonalization, derealization) also have been found to be highly correlated (r =​0.63-​0.80) with cPTSD and its DSO symptoms (Frewen, Zhu, & Lanius, 2019). Although PTSD-​D includes only two of the many symptoms of pathological dissociation (and none of the positive psychoform nor either positive or negative somatoform dissociative symptoms), similarly to cPTSD, it has been found to be associated with childhood interpersonal traumas (e.g., maltreatment, family violence) (Frewen et al., 2019; Hill et al., 2020; Seng et al., 2018; Stein et al., 2013). Dissociative symptoms also have been found to be highly correlated with PTSD symptom severity among adults decades after having experienced childhood sexual abuse (CSA) (Murphy, Elklit, Murphy, Hyland, & Shevlin, 2017) and to be a predominant feature in a sub-​g roup of young children (i.e., age 3 to 6 years old) who had extensive histories of CSA (Hagan, Gentry, Ippen, & Lieberman, 2018). Findings from studies with trauma-​exposed military veterans (Wolf et al., 2017), adult accident survivors (Hansen, Hyland, Armour, & Andersen, 2019), and trauma-​exposed treatment-​seeking adolescents (Choi et al., 2019), however, suggest that it may be symptom severity rather than trauma history that differentiates PTSD-​D from PTSD alone. PTSD-​D thus may emerge when the core PTSD symptoms exceed the individual’s capacity for self-​regulation, either due to the severity of the PTSD symptoms or the severity of the psychological injury caused by trauma (e.g., CSA). The central role of emotion dysregulation in complex PTSD confers a high level of vulnerability to experiencing the breakdown of self-​regulation, and hence to the emergence of dissociation. Therefore, some (perhaps many) individuals diagnosed with PTSD-​D may be experiencing dissociation in the context of cPTSD and might be best diagnosed as dissociative sub-​t ype of cPTSD (cPTSD-​D). Neuroimaging studies with PTSD-​D offer insights regarding the potential neural basis for a dissociative sub-​type of complex PTSD. Two brain networks appear to play a key role in PTSD-​D: (1) the default mode network (DMN), which connects posterior and medial prefrontal cortex (PfC) areas involved in self-​referential processes, including spontaneous and intentional self-​awareness, recognizing self/​emotionally-​relevant stimuli and contexts, and autobiographical memory; and (2) the task positive network (TPN), which regulates cognition, emotion, and action via three sub-​networks that are responsible for attention (AN), salience/​stress reactivity (SN), and executive functions including cognitive appraisal and planning, working memory, and emotion regulation (EN) (Lanius et al., 2012). PTSD has been shown to involve a state of chronic hyperarousal and emotional under-​regulation (Lanius et al., 2018). This includes chronic hyperactivation of threat processing and related emotional reactivity (SN) (Harricharan et al., 2020; Nicholson et al., 2017; Nicholson et al., 2020; Tursich et al., 2015), and diminished resting state and threat-​related activation of the EN and its top-​down inhibition of the SN (Akiki, Averill, & Abdallah, 2017; Harricharan et al., 2020; Nicholson et al., 2019; Nicholson et al., 2017). PTSD also is associated with diminished goal-​d irected cognition as a result of reduced activation of the TPN (Fani et al., 2019; Neumeister et al., 2017; Wolf & Herringa, 2016), and diminished self-​awareness as a result of reduced activation of the DMN (Akiki et al., 2018; Patriat, Birn, Keding, & Herringa, 2016; Sripada et al., 2012). In contrast, dissociation (as manifested by depersonalization, derealization and emotional shut down) is associated with hypo-​a rousal and emotion over-​regulation (Lebois et al., 2020). Correspondingly, in PTSD-​D, heightened top-​down EN inhibition of the SN is increased to the point of over-​regulation, resulting in suppression of emotion awareness and defensive self-​protection, as well as a reduction in self-​awareness that is due to heightened connectivity between the SN and DMN (Nicholson et al., 2015; Nicholson et al., 2017). The increased activation of the orbital PfC (Nicholson et al., 2019) and reduced connectivity between the orbital PfC and the EN (Nicholson et al., 2020) in PTSD-​D also may lead to dissociative alterations in sense of self (consistent with a structural model of dissociation, see below), based on the orbital PfC’s role in integrating emotion regulation and consciousness. PTSD-​D also is associated with decreased connectivity within the DMN by an area (the precuneus) that is involved in self-​ referencing of emotion-​ relevant interpersonal stimuli, interoceptive/​ bodily self-​ awareness, first-​ person perspective-​t aking, imagery, and episodic memory retrieval (Nicholson et al., 2020). Further, PTSD-​D is associated with decreased activation and connectivity with the primary visual cortex of an area in the SN (the insula) involved in visceral arousal, self-​awareness, alertness, cognitive emotion processing, and autobiographical memory, which is consistent with the diminished awareness of and emotional responsiveness to both internal and external stimuli in pathological dissociation (Harricharan et al., 2020; Nicholson et al., 2020). Additional evidence of altered brain function related to bodily self-​awareness in PTSD-​D is provided by findings that connectivity between the EN and parietal cortex areas involved in vestibular integration of multi-​sensory information are reduced in PTSD-​D (Harricharan et al., 2017). PTSD-​D also involves heightened cortical activation and preconscious attention to negative valence emotional stimuli, along with diminished cortical activation and conscious attention to positive valence emotional stimuli (Klimova, Bryant, Williams, & Felmingham, 2013). Taken together, the

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neuroimaging findings suggest that PTSD-​D is associated with an increase in preconscious emotional reactivity and hypervigilance as well as a numbing and blunting of conscious awareness in three domains: emotion, emotionally salient self-​relevant multi-​sensory bodily states, and external visual and interpersonal stimuli and contexts. In short, depersonalization/​derealization in PTSD-​D seems to involve the shutdown of the mind and the body in reaction to threat that parallels the ultimate stage of the stress response –​tonic immobility –​and over-​regulation of the brain’s innate alarm (i.e., top-​down inhibition of amygdala and Periaqueductal Gray-​mediated arousal by the medial PfC) (Lanius et al., 2018; Lanius et al., 2017). The resultant dissociative symptoms could take the form of a decrease in conscious awareness of threat or threat-​related emotions as seen in PTSD-​D (Lanius et al., 2018), or of the dissociative states seen in borderline personality disorder (Krause-​Utz et al., 2018). Studies with adults diagnosed with depersonalization/​derealization disorder (DDD) who are engaged in emotion processing tasks have identified a pattern of increased activation of the dorsolateral PfC and anterior cingulate as well as the medial PfC, and decreased activation of the hypothalamus as well as the amygdala, in emotion processing tasks (Lotfinia et al., 2020). These patterns are consistent with clinical observations that DDD involves a combination of hypervigilance and emotional numbing (similar to PTSD-​D), and with research findings on the electrodermal correlates of emotion processing in depersonalization (Horn et al., 2020). Another study found that, when engaged in an emotionally neutral word recognition task, adults with DDD had lower levels of activation of areas of the brain involved in cognitive (memory/​information) integration (i.e., the precuneus and dorsolateral PfC) and emotion processing (medial PfC) compared to healthy controls (Lotfinia et al., 2020). DDD thus appears to involve brain activation patterns similar to those identified in PTSD-​D, consistent with a view of depersonalization/​derealization as the product of preconscious emotional reactivity and hypervigilance combined with conscious numbing of emotion awareness. This combination of mobilization of prefrontal inhibitory activation and suppression of limbic and physiological arousal in order to maintain the over-​regulation of emotional distress, will compete with and could diminish the activation of prefrontal and parietal (i.e., precuneus) brain areas necessary for conscious cognitive processing and integration of neutral memories and external information. Thus, in both DDD and PTSD-​D, the detachment and confusion involved in derealization and depersonalization can be understood as, at least in part, a byproduct of preconscious over-​regulation of emotion. In PTSD-​D these neural alterations appear to lead to a shift from under-​regulation to over-​regulation of distress-​ related arousal (Lanius et al., 2018). Emotion dysregulation in DESNOS (Van Dijke et al., 2015, 2018) and cPTSD (Brewin et al., 2017), in contrast, explicitly involves both under-​regulation (i.e., difficulty recovering from extreme distress) and over-​regulation (i.e., emotional numbing) consistent with concurrent or alternating states of hypo-​and hyperarousal.

Structural Dissociation in Complex PTSD In addition to the dissociative symptoms of depersonalization and derealization, there are other manifestations of pathological dissociation that involve a fragmentation and re-​d istribution of the sense of self into vertically split parts of the personality, or part-​selves. As described by the theory of structural dissociation of the personality (Moskowitz & Van der Hart, 2020), exposure to psychological trauma can lead to a split in the self between an “emotional part” (EP) that experiences and expresses distress versus an “apparently normal part” (ANP) that avoids or suppresses awareness of distress in order to maintain normal functioning. The division involves two or more insufficiently integrated dynamic but excessively stable subsystems. Each dissociative subsystem, that is, dissociative part of the personality, minimally includes its own, at least rudimentary, first-​person perspective. (Nijenhuis & Van der Hart, 2011, p. 418) Structural dissociation of the personality is hypothesized to involve, at a minimum, an alternation between a state of apparently well-​modulated emotion (the ANP, characterized by low levels of activation in both the TPN and DMN) and a state of extreme dysregulation (the EP). When faced with stressors (including but not limited to psychological traumas) that overwhelm the individual’s capacity to cope with emotion dysregulation, the self may fragment and an ANP and EP may emerge. In some cases of PTSD and PTSD-​D this can be seen in the contrast between maintaining some functionality in some areas of life while coping in a depersonalized/​derealized manner or by experiencing amnesia (ANP) versus episodes of flashback in PTSD or extreme emotional over-​regulation in PTSD-​D (EP). Although structural dissociation may occur as a result of the heightened under-​and over-​regulation of emotion in DESNOS, cPTSD, or DTD, there is evidence suggesting that a dissociative sub-​t ype of DESNOS can be differentiated from the most extreme form of structural dissociation, Dissociative Identity Disorder (DID). Therapists with expertise in treatment of DESNOS or DID who were surveyed identified several common features of these disorders (e.g., difficulty forming a therapeutic relationship, ongoing victimization, lack of motivation for recovery, social isolation,

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self-​harm, limited past experiences of positive attachment; Baars et al., 2011). However, other features were viewed by the therapists as principally characteristic of only DID (e.g., amnesia for ongoing abuse, conflict of part-​selves with one another and with therapist) or cPTSD (e.g., inability to trust, severe and persistent self-​blame). These observations suggest that cPTSD and DID both are characterized by the hallmarks of pathological dissociation: a combination of under-​and over-​regulation of emotion and related problems with chaos, abuse, conflict, or isolation in relationships. Where they differ is that cPTSD involves a sense of self as damaged but still intact, while in DID the self is experienced as multifaceted, shattered, and involuntarily shifting from one part-​self to another in reaction to the presence or absence of internal distress or external stressors. Neuroimaging studies with DID underscore its potential differentiation from cPTSD. DID has consistently been found to involve reductions in the cortical thickness, surface area, and volume of multiple sub-​cortical (e.g., insula, amygdala) and cortical (e.g., PfC, cingulate, fusiform gyri in the temporal lobe) areas (Blihar et al., 2021; Blihar, Delgado, Buryak, Gonzalez, & Waechter, 2020; Lotfinia et al., 2020; Reinders et al., 2019; see Nijenhuis, Chapter 38, & LeBois et al., Chapter 24, this volume). In a study comparing adults diagnosed with DID and actors simulating DID, those with authentic DID, in their EP mode, showed increased activation of the brainstem, primary motor cortex, and the fusiform gyrus (an area involved in face processing, visual imagery and cognitive emotion regulation) when processing neutral faces, but only activation of the primary motor cortex when processing angry faces (Schlumpf et al., 2013). Fusiform gyrus activation was especially pronounced when individuals with DID viewed pictures of their own face while in their EP mode. Those with authentic DID in their ANP mode, however, showed reduced activation across multiple brain areas. In addition, participants with authentic DID in their EP mode demonstrated increased activation of the dorsomedial prefrontal cortex, which is associated with sense of self, social judgments, empathy, and modulation or inhibition of distress, as well as increased activation of the primary somatosensory and motor cortices (Schlumpf et al., 2014). In addition to a combination of under-​and over-​regulation of emotion, DID thus appears to involve disorientation and heightened attempts to regain three core aspects of psychosocial functioning: awareness of self (interoceptively as well as psychologically), connection with other persons, and the ability to act with intention. In those respects, DID parallels cPTSD. However, the loss of a sense of a core self (including facial recognition and somatosensory awareness as well as the psychological experience of being divided into separate selves) is a distinctive feature of DID that distinguishes it from cPTSD. Whereas in cPTSD the self is experienced as damaged but still intact, in DID, in the words of William Butler Yeats, “Things fall apart, the centre cannot hold; anarchy is loosed upon the world.”

Conclusion Research findings suggest that dissociation is more common amongst individuals meeting criteria for cPTSD or DESNOS than generally among adults or children in psychiatric, at-​r isk, or community samples. Whether dissociation warrants inclusion in any or all of the variants of cPTSD, or on what basis (e.g., as a core symptom or criterion domain; as an associated feature or sub-​type indicator), remains uncertain. However, paralleling the addition of a dissociative sub-​t ype of PTSD, a dissociative sub-​t ype of DESNOS or cPTSD would provide a basis for identifying the individuals who are experiencing maladaptive dissociation along with the core cPTSD symptoms of emotion, relational, and self-​ dysregulation. Whether the full range of psychoform and somatofom dissociative symptoms would be included in such a cPTSD-​D, or only the more limited set of depersonalization/​derealization symptoms that are the dissociative indicators for PTSD-​D, is an important question for empirical research. Inclusion of dissociation as a modifier rather than a core symptom could provide a basis for identifying cPTSD cases where dissociation is an important part of the clinical formulation and treatment plan. However, the DTD formulation provides another alternative approach: in DTD dissociative reactions are included as potential manifestations of DTD’s core affect/​somatic dysregulation symptoms. The evidence that dissociation represents a manifestation of extreme emotion under-​and over-​regulation, and the centrality of those two forms of dysregulation as core features in DTD, was the basis for including dissociative reactions within DTD’s core symptoms as an expression of posttraumatic stress reactions that exceed the individual’s capacity to modulate intense emotional and bodily dysregulation. The somatization symptoms identified in DESNOS and DTD also provide a basis for identifying the bodily aspects of extreme dysregulation (i.e., somatoform dissociative symptoms), which are not referenced in the criteria for PTSD, PTSD-​D, or cPTSD/​DSO. Separate from its dissociative sub-​type, the DSM versions of PTSD include core symptoms that are distinctly dissociative reactions (i.e., flashbacks and psychogenic amnesia), which makes it possible for individuals who are experiencing trauma-​related dissociation to have these symptoms recognized for the purposes of treatment planning –​without requiring that all persons diagnosed with PTSD must have these

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dissociative symptoms. Similarly, DTD provides the possibility of identifying dissociative reactions as a manifestation of core emotion/​somatic dysregulation, without requiring that either dissociative symptoms must be present in order to meet criteria for the diagnosis (as is the case in DESNOS) or the other extreme of eliminating dissociation entirely (as is the case in cPTSD). Recognizing dissociation as an indicator of extreme under-​and over-​regulation of emotion provides a focus for therapeutic intervention with PTSD that complements and extends approaches currently in use that rely upon somatosensory grounding and enhancing mindfulness and bodily awareness. When severe structural dissociation is an additional complication for patients with complex trauma histories, trauma-​focused emotion regulation psychotherapies offer an alternative to the exposure-​focused cognitive behavioral therapies for PTSD (see Stavropoulos & Elliott, Chapter 44, this volume). This includes trauma memory processing that is therapist guided but under the control of the client and aimed at restoring emotion modulation and relational security (Ford, 2018), consistent with practice guidelines developed and clinically field tested for dissociative disorders (Brand et al., 2019). The addition of a cPTSD-​D for adults and a DTD for children with dissociative forms of its emotion/​somatic dysregulation symptoms, would provide clinicians and researchers with a systematic framework for identifying persons who might benefit from therapeutic assistance not only in processing trauma memories (as in PTSD-​D) but also in regaining the capacity to modulate emotional dysregulation and to achieve a sense of earned security in their primary relationships (Courtois & Ford, 2013).

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Attachment, Emotion Regulation, Childhood Abuse and Assault: Examining Predictors of NSSI Among Adolescents. Archives of Suicide Research, 21, 610–​620. Theoret, V., Lapierre, A., Blais, M., & Hebert, M. (2020). Can emotion dysregulation explain the association between attachment insecurities and teen dating violence perpetration? Journal of Interpersonal Violence, 886260520915547. Tursich, M., Ros, T., Frewen, P. A., Kluetsch, R. C., Calhoun, V. D., & Lanius, R. A. (2015). Distinct intrinsic network connectivity patterns of post-​t raumatic stress disorder symptom clusters. Acta Psychiatrica Scandinavica, 132, 29–​38. van der Kolk, B., Ford, J. D., & Spinazzola, J. (2019). Comorbidity of developmental trauma disorder (DTD) and post-​traumatic stress disorder: findings from the DTD field trial. European Journal of Psychotraumatology, 10(1), 1562841. van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35, 401–​408. van der Kolk, B. A., Pelcovitz, D., Roth, S., Mandel, F. S., McFarlane, A., & Herman, J. L. (1996). Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. American Journal of Psychiatry, 153(7 Suppl), 83–​93. van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18, 389–​399.

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Van Dijke, A., Ford, J. D., Frank, L., Van Son, M., & Van der Hart, O. (2013). Association of childhood trauma-​by-​primary-​ caregiver and affect dysregulation with borderline personality disorder symptoms in adulthood. Psychological Trauma: Theory, Research, Practice & Policy, 5, 217–​224. Van Dijke, A., Ford, J. D., Frank, L. E., & van der Hart, O. (2015). Association of childhood complex trauma and dissociation with complex posttraumatic stress disorder symptoms in adulthood. Journal of Trauma and Dissociation, 16, 428–​4 41. Van Dijke, A., Ford, J. D., van der Hart, O., van Son, M., van der Heijden, P., & Buhring, M. (2010). Affect dysregulation in borderline personality disorder and somatoform disorder: Differentiating under-​and over-​regulation. Journal of Personality Disorders, 24, 296–​311. Van Dijke, A., Ford, J. D., Van der Hart, O., Van Son, M., van der Heijden, P., & Bühring, M. (2012). Complex posttraumatic stress disorder in patients with borderline personality disorder and somatoform disorders Psychological Trauma: Theory, Research, Practice & Policy, 4, 162–​168. Van Dijke, A., Hopman, J. A. B., & Ford, J. D. (2018a). Affect dysregulation, adult attachment problems, and dissociation mediate the relationship between childhood trauma and Borderline Personality Disorder symptoms in adulthood. European Journal of Trauma and Dissociation, 2, 91–​99. Van Dijke, A., Hopman, J. A. B., & Ford, J. D. (2018b). Affect dysregulation, psychoform dissociation, and adult relational fears mediate the relationship between childhood trauma and complex posttraumatic stress disorder independent of the symptoms of borderline personality disorder. European Journal of Psychotraumatology, 9(1), 1400878. Van Hoof, M. J., Riem, M., Garrett, A., Pannekoek, N., van der Wee, N., van, I. M., & Vermeiren, R. (2019). Unresolved-​ disorganized attachment is associated with smaller hippocampus and increased functional connectivity beyond psychopathology. Journal of Traumatic Stress, 32, 742–​752. Van Hoof, M. J., Riem, M. M. E., Garrett, A. S., van der Wee, N. J. A., van, I. M. H., & Vermeiren, R. (2019). Unresolved-​ disorganized attachment adjusted for a general psychopathology factor associated with atypical amygdala resting-​state functional connectivity. European Journal of Psychotraumatology, 10(1), 1583525. Winter, D. (2016). Attention to emotional stimuli in borderline personality disorder -​a review of the influence of dissociation, self-​ reference, and psychotherapeutic interventions. Borderline Personality Disorder and Emotion Dysregulation, 3, 11. Wolf, E. J., Mitchell, K. S., Sadeh, N., Hein, C., Fuhrman, I., Pietrzak, R. H., & Miller, M. W. (2017). The Dissociative Subtype of PTSD Scale: Initial evaluation in a national sample of trauma-​exposed veterans. Assessment, 24, 503–​516. Wolf, R. C., & Herringa, R. J. (2016). Prefrontal-​A mygdala dysregulation to threat in pediatric Posttraumatic Stress Disorder. Neuropsychopharmacology, 41, 822–​831. Zhang, J., Zhu, S., Du, C., & Zhang, Y. (2015). Posttraumatic stress disorder and somatic symptoms among child and adolescent survivors following the Lushan earthquake in China: A six-​month longitudinal study. Journal of Psychosomatic Research, 79, 100–​106.

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31 IS DISSOCIATION AN INTEGRAL ASPECT OF BORDERLINE PERSONALITY DISORDER, OR IS IT A COMORBID DISORDER? Marilyn I. Korzekwa and Paul F. Dell

Dissociation in Borderline Personality Disorder (BPD) is a complex and contentious topic. Jaeger et al. (2017) query whether the relationship of dissociation to BPD is as “a part of the BPD pathology or as a co-​occurring separate disorder” (p. 73). Some BPD experts say that dissociative symptoms in BPD are common, but a less ​urgent concern than other BPD symptoms (Zanarini & Jager-​Hyman, 2009). Still, at 10-​year follow-​up, 16% of patients diagnosed with BPD show high levels of dissociation despite (most of them) being in therapy (Zanarini, Frankenburg, Jager-​Hyman, Reich, & Fitzmaurice, 2008). Conversely, dissociative disorder (DD) experts report that DD patients with comorbid BPD exhibit greater severity, more comorbidity, and poorer functioning than DD patients without BPD (Dell, 1998; Ross, Ferrell & Schroeder, 2014). In this chapter, we discuss the nature of dissociation in BPD, the interface between DDs and BPD, a comparison of risk factors for DDs and BPD, the treatment of dissociation in BPD, and our model of dissociative subgroups in BPD.

Dissociation and the Dissociative Disorders Many dissociative experiences are normal: daydreaming, “highway hypnosis,” time distortion, being so absorbed in activities that one is unaware of one’s immediate environment, and brief, infrequent, stress-​related feelings of unreality (i.e., derealization) or feeling detached/​d isconnected from oneself (i.e., depersonalization). On the other hand, depersonalization and derealization are judged to be “pathological” if they occur frequently, produce distress or dysfunction, and are not stress-​related (Steinberg, 1994). Other pathological dissociative symptoms include amnesia and identity alteration (e.g., experiencing internal images and voices of dissociated ego states, finding evidence of the activity of dissociated ego states, or feeling possessed or controlled). DSM-​5 lists three major Dissociative Disorders: (1) Dissociative Amnesia (DA), (2) Depersonalization/​Derealization Disorder (DP/​DRD), and (3) Dissociative Identity Disorder (DID). DID is the most complex and severe DD. Its diagnostic criteria require the presence of two or more distinct personality states, a disruption in identity involving “marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/​or other sensory-​motor functioning,” and dissociative amnesia (American Psychiatric Association [APA], 2013, p. 292). The most commonly-​d iagnosed DD is Example 1 of Other Specified Dissociative Disorder (OSDD-​ 1; Ross, Duffy & Ellason, 2002). OSDD-​1 is so common that when authors use the term “OSDD,” they usually mean OSDD-​1. OSDD-​1 (or Dissociative Disorder Not Otherwise Specified e­ xample 1 [DDNOS-​1] in DSM-​I V) presents with either (1) an identity disturbance with “less-​than-​m arked discontinuities in sense of self and agency,” or (2) identity alteration with no dissociative amnesia (APA, 2013, p. 306). People with OSDD-​1 usually display “dissociated ego states,” which are other ego states or self-​states that operate separately from the default conscious self-​state (i.e., the one considered as such by itself and outsiders). These other self-​states may generate intrusive experiences of disowned feelings, impulses, actions, and thoughts that are a source of distress or dysfunction (Dell, 2009a). Dissociation is most commonly measured with the Dissociative Experiences Scale (DES), a 28-​item self-​report questionnaire that rates the frequency (0–​100% of the time) of experiences such as absorption, depersonalization/​derealization, and amnesia (Carlson & Putnam, 1993). Normal adults score below 10; anxiety, affective and psychotic disorders

DOI: 10.4324/9781003057314-37

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between 10–​18; and Post-​Traumatic Stress Disorder (PTSD), DA, and DP/​DRD between 20–​30. Scores of 30 or higher may signify the presence of OSDD-​1 or DID.

Dissociation and Borderline Personality Disorder Diagnostic Issues John O’Neil (personal communication, March 19, 2021) is of the view that persons with DID cannot meet diagnostic criteria for General Personality Disorder because the DSM requires the presence of  “an enduring pattern of inner experiences and behavior that deviates markedly from the expectations of the individual’s culture” (criterion A), that is “inflexible and pervasive across a wide range of personal and social situations” (Criterion B), and that is “stable and of long duration” (Criterion D; APA, 2013, pp. 646–​647). O’Neil contends that switching in DID (from one identity to another) violates these criteria, so that a person with DID who switches cannot be diagnosed with any personality disorder (PD), despite having self-​states that may manifest as various PDs. Furthermore, he notes that Criterion E states that the “pattern of inner experiences and behavior” must not be “better explained as a manifestation or consequence of another mental disorder” (p. 647). The DSM-​5’s diagnostic guidance is made more opaque by the fact that the entire text on PDs says nothing about differential diagnosis vis-​à-​v is the dissociative disorders (pp. 645–​684). O’Neil concludes that, because the criteria for General PD are routinely ignored in both practice and research, DDs are underdiagnosed and BPD is overdiagnosed. We, too, believe that investigation of the comorbidity of BPD and DDs has been seriously undermined by inadequacies of the DSM. For example, the DSM-​IV-​TR (APA, 2000) section on BPD contains “no rules or guidelines for the differential diagnosis of dissociative disorders” (Ross, 2007, p. 79). Similarly, the BPD text of DSM-​5 states incorrectly (see literature review below) that depersonalization in BPD is “generally of insufficient severity or duration to warrant another diagnosis” (APA, 2013, p. 664). These shortcomings of the DSM discourage investigators of BPD from considering comorbid DD diagnoses. Such “omission of dissociative disorders in differential diagnosis confounds and weakens studies” (Şar & Ross, 2006, p. 138). When BPD researchers fail to screen for DDs, they virtually ensure that their sample will contain false positive cases of BPD. Indeed, Jaeger et al. (2017) question whether a considerable number of the participants in a study of dissociative subgroups in BPD might have an undiagnosed comorbid dissociative disorder. Although we doubt the trustworthiness of many DSM-​g uided diagnoses of BPD (and correspondingly-​infrequent diagnoses of DID), in this chapter we will not raise these doubts each time we discuss research on the comorbidity of BPD and DID.

Borderline Personality Disorder and the DES Most early research of dissociation in BPD used the DES. A recent meta-​analysis of 1705 BPD participants in 27 studies reported a mean DES score of 27.9; 1313 DID participants obtained a mean DES score of 48.7; 3073 mixed DDs obtained a mean score of 38.9; 2108 PTSD subjects obtained a score of 28.6; and 759 DP/​DRD participants obtained a score of 25.1 (Lyssenko et al., 2018). On the DES, BPD participants scored highest on the absorption subscale, while DID scored highest on the depersonalization/​derealization subscale. Other researchers reported that BPD participants obtained higher DES scores than (1) other personality disorders, and (2) general psychiatric patients (Ross, 2007; Scalabrini, Cavicchioli, Fossati, & Maffei, 2017; Zanarini, Ruser, Frankenburg, & Hennen, 2000a). BPD participants with high DES scores reported high levels of both normal and pathological dissociation (Goodman et al., 2003). BPD participants’ DES scores correlated significantly with the number of BPD features; comorbid schizotypal, obsessive-​compulsive, and antisocial personality disorders (Rodriguez-​Delgado et al., 2019); depression (Brodsky, Cloitre & Dulit, 1995; Russ et al., 1993; Wildgoose, Clarke, & Waller, 2000); internet addiction (Dalbudak, Evren, Aldemir, & Evren, 2014); reduced sense of body ownership (Löffler, Kleindienst, Cackowski, Schmidinger, & Bekrater-​ Bodmann, 2020); auditory verbal hallucinations (Cavelti et al., 2019); oligodipsia (reduced fluid intake; Hoeschel et al., 2008); global psychopathology (Brodsky, Cloitre, & Dulit, 1995; Wildgoose et al., 2000); and use of psychiatric services (Brodsky et al., 1995; Shearer, 1994). High scores on an eight-​item measure of pathological dissociation (i.e., the DES-​ Taxon scale; Waller, Putnam & Carlson, 1996) were associated with reduced functioning for every neuropsychological domain (Haaland & Landrø, 2009). Most importantly, dissociation in BPD patients is correlated with suicide attempts (Russ, Shearin, Clarkin, Harrison, & Hull, 1993; Vine, Victor, Mohr, Byrd, & Stepp, 2020), non-​suicidal self-​injury (NSSI; Cerutti, Presaghi, Gratz, & Manca, 2012; Shearer, 1994; Zlotnick et al., 1996; Zwieg-​Frank, Paris, & Guzder, 1994a & b), and analgesia for NSSI

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(Ludäscher et al., 2010). Two multivariate studies found that dissociation is not significantly related to NSSI in BPD (Zweig-​Frank et al., 1994a & b), but another study reported a significant relationship (Zlotnick et al., 1996). At 16-​year follow-​up of BPD patients, severe dissociation predicted suicide attempts (Wedig et al., 2012). Interestingly, however, dissociation did not predict completed suicide in BPD persons (McGirr, Paris, Lesage, Renaud, & Turecki, 2007). The relationship between dissociation and BPD may be best understood by looking at subgroups. For example, Zanarini et al. (2000a) divided 290 interview-​d iagnosed BPD inpatients into three subgroups: Low dissociation (32%; DES scores =​0–​9.9); Moderate dissociation (42%; DES scores =​10–​29.9); and High dissociation (26%; DES scores > 30). See below.

BPD Patients with a Comorbid Dissociative Disorder The prevalence of BPD in the two largest national epidemiological surveys was 1.1% and 5.9%, depending on how strictly the researchers applied the diagnostic rules for BPD (Grant et al., 2008; Ten Have et al., 2016). Based on structured interviews, the prevalence of BPD among general psychiatric inpatients was 40–​43% (Grilo et al., 1998). The prevalence of DDs and DID in the general population was about 8.5% and 1.5%, respectively ( Johnson, Cohen, Kasen, & Brook, 2006). The prevalence of DDs and DID among psychiatric inpatients was 16% and 4%, respectively (Ross et al., 2002). The comorbidity of BPD and DD in individuals diagnosed with BPD is best determined by instruments that are more comprehensive than the DES. Using the 218-​item Multidimensional Inventory of Dissociation (MID; Dell, 2006), Laddis and Dell (2002) divided 30 BPD participants into four subgroups: (1) BPD with no DD (30%) exhibited only some flashbacks; (2) BPD with dissociative symptoms (30%) experienced strong flashbacks, trance, angry dissociated ego states, and memory problems, but little frank amnesia; (3) BPD with DDNOS-​1 (13%) experienced strong flashbacks, “coming to” from amnesia, internal voices, and child and persecutor dissociated ego-​states; and (4) BPD with DID (27%) met DSM-​I V criteria for DID. Şar et al. (2003) administered the “gold standard” Structured Clinical Interview for DSM-​I V Dissociative Disorders (SCID-​D; Steinberg, 1994) to 25 BPD participants with high DES scores. The SCID-​D diagnosed 36% DDNOS (example not specified), 24% DID, and 4% DA. Subsequently, Şar, Akyüz, Kuğu, Öztürk, and Ertem-​Vehid (2006) administered the SCID-​D -​R interview to 80 university students with BPD; the SCID-​D -​R diagnosed 42.5% DDNOS (76% of whom had ­example 1); 12.5% DA, 10% DID, and 7.5% Depersonalization Disorder (DPD). Ross (2007) administered the Dissociative Disorders Interview Schedule (DDIS: Ross, Heber et al., 1989) to 93 BPD participants. The DDIS diagnosed 59% DDs (28% DA 22% DDNOS, 18% DID, and 12% DPD; Ross, 2007). We screened an entire outpatient psychiatric clinic (N =​360) to determine the cross-​sectional prevalence of BPD. Structured interview diagnosed 54 BPD patients (Korzekwa, Dell, Links, Thabane, & Webb, 2008), 21 of whom received a SCID-​D -​R interview with the following DSM-​IV diagnoses: DDNOS-​1 (23.8%), DID (23.8%), no DD (23.8%), DPD (19%), and DA (9.5%; Korzekwa, Dell, Links, Thabane, & Fougere, 2009). The BPD sample had a mean DES score of 26.9. The five BPD participants with no DD had a mean DES score of 11.7 and reported only a few dissociative symptoms such as depersonalization and memory problems. Applying Zanarini et al.’s (2000a) method, we divided the 21 BPD participants into three groups: Low Dissociation (14.3%; DES scores =​1–​9.9); Moderate Dissociation (52.4%; DES scores =​10–​29.9); and High Dissociation (33.3%; DES scores > 30). In summary, 24–​41% of people with BPD do not have a comorbid DD, 10–​24% have comorbid DID, and 35–​66% have a less severe, comorbid DD. Conversely, in participants with a DD, the frequency of BPD varies from 48% to 85% (Şar et al., 2003; Tutkun et al., 1998). In participants with DID, diagnosed on structured and semi-​structured interview, the frequency of BPD varies from 31% to 64% (Ellason, Ross, & Fuchs, 1996; Ross et al., 1990; Şar, Yargıç & Tutkun, 1996). Clinically, the bottom line is that (1) both BPD and DID are present in many patients presenting with either BPD or DID and (2) DID patients with comorbid BPD display increased severity, increased comorbidity, and lower functioning than other DID patients (Dell, 1998; Ross, Ferrell & Schroeder, 2014).

Five Disputed Issues about Dissociation and BPD 1.  Is Dissociation an Aspect of BPD Pathology or a Separate, Co-​occurring Disorder? A.  An aspect of BPD pathology? If dissociation was integral to BPD pathology, then all persons with BPD would dissociate. A quarter to a third of BPD persons have low levels of dissociative experiences. Moreover, these BPD participants with low dissociation are very

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different from BPD participants with high dissociation. The magnitude of this difference suggests that severely dissociative BPD patients have an additional, comorbid, non-​BPD, pathological process. If dissociation were integral to BPD pathology, then BPD treatments should substantially ameliorate that dissociation. Research shows that BPD treatment reduces, but does not resolve, dissociative symptoms (Braakmann et al., 2006; Harned, Jackson, Comtois, & Linehan, 2010; Zanarini et al., 2008). This is especially true of BPD individuals with severe dissociative symptoms.

B.  Co-​occurring separate disorders? Robins and Guze (1970) proposed a five-​component method for assessing the diagnostic validity of a psychiatric disorder: clinical description, laboratory study, exclusion of other disorders, family study, and follow-​up study. Using this method, they divided cases of schizophrenia into two groups (poor prognosis and good prognosis) and showed that the two groups represent different illnesses. Application of Robins and Guze’s method indicates that BPD and DID are separate disorders. Clinical Description There are many clinical similarities between BPD and DID: rapid mood swings, identity confusion, flashbacks, depersonalization experiences (Korzekwa et al., 2009), impulsive self-​destructive behavior, self-​injury, and suicidal behavior (APA, 2013). There are also differences. Compared to DID, BPD participants had less lifetime anxiety disorders, somatic symptoms, Schneiderian symptoms (Fink & Golinkoff, 1990), amnesia, identity confusion, identity alteration (Boon & Draijer, 1993), and schizoaffective disorder, and more substance abuse (Lauer, Black & Keen, 1993). Laddis and Dell (2002) reported many significant symptomatic and character differences between DID and BPD patients: BPD patients were more antisocial, aggressive-​sadistic, passive-​aggressive, distrusting, compulsive, alcohol-​and drug-​dependent, delusional, and attention-​seeking, but less depressed and less dissociative. Moreover, BPD patients do not manifest identity alteration; DID patients do.

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Laboratory Studies BPD and DID patients perform differently on the Rorschach test. DID participants manifest greater self-​reflection, introspection, logical thinking, reality testing, emotion regulation, and interest in others than do BPD participants (Brand, Armstrong, Loewenstein & McNary, 2009). The hormones and neurotransmitters that underlie emotional dysregulation in BPD (Ruocco & Carcone, 2016) are likely different from the hormones and neurotransmitters that underlie dissociation in BPD (Philipsen, Schmahl & Lieb, 2004). In BPD, the prefrontal cortex fails to suppress limbic structures, especially the amygdala (Schmahl & Bremner, 2006). This emotionally-​overactivated state in BPD has some features in common with the activated trauma-​state in DID (Brand et al., 2016; Reinders et al., 2014). Neuroimaging, however, reveals a unique pattern in DID. Specifically, DID patients manifest both a hyper-​aroused identity state that overmodulates emotion and activates the amygdala, insula, and the dorsal striatum, and a hypo-​aroused identity state that overmodulates emotion and activates the prefrontal cortex, cingulate, posterior association areas and parahippocampal gyri (Reinders et al., 2014; See Lebois et al., Chapter 24 & Nijenhuis, Chapter 38, this volume). Of even greater diagnostic significance, neuroimaging studies have repeatedly found major differences between BPD participants with high and low dissociation scores. Highly dissociative BPD patients exhibit the opposite pattern to that of most BPD patients. Highly dissociative BPD participants display a blunted (amygdala-​ mediated) startle-​response (Ebner-​Priemer et al., 2005), less activation of the amygdala in an emotional-​challenge paradigm (Hazlett et al., 2012), and more analgesia during NSSI with less brain activity (fMRI) in response to heat stimuli (i.e., greater cortical suppression of sensory information about pain; Schmahl et al., 2006). A second pattern of dissociation in BPD was found in a sample of severely-​abused women, most of whom had BPD and DP/​DRD. Lange, Kracht, Herholz, Sashsse & Irle (2005) found reduced metabolism in parietal somatosensory and temporal pole association areas. This is somewhat similar to the pattern in DP/​DRD (Simeon et al., 2000), namely functional abnormalities of the sensory cortex and areas responsible for integrated body schema. It is hypothesized that emotional numbing and perceptual detachment is produced by cortical inhibition of emotional processing, whereas feelings of disembodiment and absence of a sense of agency come from temporo-​parietal dysfunction (Sierra & David, 2011). Volumetric MRI distinguishes BPD from DID. In BPD participants, hippocampal and amygdalar volumes were smaller than normal (Niedtfeld et al., 2013). In DID participants, hippocampal volume was smaller than normal, but the putamen was larger and the amygdalæ were generally normal in volume. In DID-​w ith-​PTSD, the putamen volumes

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were larger than those of patients with only PTSD. Part of the dorsal striatum, the putamen is assumed to participate in the switching of states and the dominance of trauma-​related, procedural memory (Chalavi et al., 2015). Exclusion of Other Disorders The core features of BPD are affective instability, self-​harm, suicidality, impulsivity, and interpersonal relationships that are intense and unstable. BPD can be differentiated from schizophrenia, and its course differs from major depression (Pope, Jonas, Hudson, Cohen & Gunderson, 1993). “Complex” Axis I comorbidity (i.e., the presence of an affective or anxiety disorder, and a substance or eating disorder) distinguished BPD from other personality disorders (Zanarini et al., 1998). The core features of DID –​identity alteration (evidence of distinct personality states) and amnesia between states –​are unique among psychiatric disorders. Family Study The heritability of BPD in twin studies ranges from 37–​69% (Gunderson, Zanarini et al., 2011). There are no genetic studies of DID. Studies of pathological dissociation report widely conflicting heritabilities: 0% (Waller & Ross, 1997) and 55% ( Jang, Paris, Zweig-​Frank, & Livesley, 1998). DES scores have a heritability of 48% ( Jang et al., 1998). Depersonalization has a heritability of 34% ( Jang, Livesley, Vernon, & Jackson, 1996). Thus, both BPD and dissociation appear to be significantly heritable. Follow-​up Study BPD and DID have different prognoses. Even in DID-​specific treatment, about 20–​25% of DID patients have a poor prognosis (i.e., they have many hospitalizations and are unlikely to recover; Kluft, 1999, 2017). It is estimated that the 40–​45% of DID patients with the best prognosis require two to seven years of DID-​specific therapy (Kluft, 1999, 2017). Unlike DID, BPD prognosis has been assessed in major prospective studies. At 10-​year follow-​up, 85% of 111 patients (original cohort =​175) had remitted (≤ 2 BPD criteria; Gunderson, Stout, et al., 2011). In a longer study (original cohort =​290), 73.5% of 264 BPD participants had remitted (≤ 5 BPD criteria) after six years (Zanarini, Frankenburg, Hennen, & Silk, 2003); 88% of 249 BPD participants had remitted by 10 years; and 99% of 231 BPD participants had remitted by 16 years, with a suicide rate of 4.5% (Zanarini, Frankenburg, Reich, & Fitzmaurice, 2012). The longest BPD follow-​up study (original cohort =​165; 27-​year follow-​up) found that 92.2% of 64 BPD participants had remitted (Global Assessment of Functioning score of 63.3), with a suicide rate of 10.3% (Paris & Zweig-​Frank, 2001). The above-​described difference in prognosis of BPD and DID was highlighted by two notable facts: (1) DID is unlikely to remit without lengthy DID-​specific treatment; and (2) the remissions of BPD in the above-​cited studies were not necessarily due to treatment.

C. Summary question: Is dissociation an aspect of BPD pathology or is it a separate, co-​occurring disorder? Some BPD researchers think that dissociation is not a core feature of BPD (Scalabrini et al., 2017). Some attribute dissociation to the “temperamental endowment” of BPD; others attribute dissociation to a history of child abuse (Zanarini & Jager-​Hyman, 2009). We think that the answer to this question depends on the subgroup of BPD patients that is being examined. In the BPD subgroup with minimal to no dissociation, dissociation is clearly not a part of the BPD pathology. In the BPD subgroup with moderate dissociation, their dissociative experiences are probably secondary to their temperamental endowment –​hence, part of BPD pathology (albeit likely aggravated by abuse and compromised parenting). In the BPD subgroup with high dissociation, their dissociative experiences clearly reflect the presence of a comorbid dissociative disorder (i.e., DID or OSDD-​1).

2. Do the Dissociative Symptoms of Borderline Personality Disorder Differ from the Dissociative Symptoms of the Dissociative Disorders? Authors from the DDs field have offered three relevant conceptualizations of dissociation in BPD. Marmer and Fink (1994) have argued that BPD and DID are “two distinct conditions, with different process, structure and dynamic

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features” (p. 744). In BPD, dissociation is transient; in DID, dissociation is the defining element. In BPD, there is identity diffusion; in DID, there are multiple identities. Amnesia is a key diagnostic feature of DID, but not of BPD. BPD patients have a single self who does not know who or what it is; DID patients have several identities (created to manage trauma) who often are sure of who or what they are, but who often do not know each other. Splitting, as a defense in BPD, is seen as a failure to mature to the stage of whole objects. They split in order to prevent the good self and good object from being contaminated by the bad. In DID, splitting compartmentalizes memory and affect, thereby creating a barrier against overwhelming trauma. The DID ego/​identity is divided into parts, at the cost of disrupted memory. Howell and Blizard (2009) consider BPD to be a chronic relational-​t rauma disorder that has been generated by frightening behavior, severe misattunement, overt abuse, and/​or disorganized attachment in significant relationships. They propose that BPD patients have sudden alterations in mood, sense of self, and relationships because of partially-​or fully-​d issociated self-​states. With partial dissociation, there is “(1) continuity of identity, (2) superficial awareness of abrupt changes in affect or behavior, (3) minimal ability to link these states in consciousness, and (4) little acknowledgment of the significance of these shifting states” (Howell & Blizard, 2009, p. 498). According to Howell and Blizard, individuals with BPD lie on a dissociative spectrum. At the mild end, BPD patients experience alternating self-​states, without severe dissociation. BPD patients in the middle of the dissociation spectrum hear voices, have “made” actions, but have little amnesia. BPD patients at the severe end of the spectrum have DID (i.e., fully dissociated and personified self-​states and amnesia). Van der Hart, Nijenhuis and Steele (2006) have proposed a theory of Structural Dissociation of the Personality wherein the personality divides into Apparently Normal Parts (ANPs) that try to carry on normal life and Emotional Parts (EPs) that contain traumatic emotions and their associated memories. Mosquera, Gonzalez, and Van der Hart (2011) explain how BPD symptoms can reflect the actions of ANPs and EPs. Frantic efforts to avoid abandonment could be the actions of EPs activated by memories of traumatic attachment experiences. The unstable interpersonal relationships and affective instability of BPD patients may reflect a switch from the ANP to an EP. Identity disturbance, they suggest, reflects the fluctuating influences from different parts or an ANP not aware of the existence of EPs. Similarly, BPD feelings of emptiness may be caused by ANPs’ avoidance of internal emotions (i.e., EPs); alternatively, feelings of emptiness may be EP’s memories of abandonment or neglect. The impulsivity of substance abuse and eating disorders may be an ANP’s attempt to numb an EP. Impulsive risk-​t aking, sexuality, or purging may be the actions of EPs who have momentarily escaped the ANP’s control. Suicide attempts and self-​injury may be an ANP’s or an EP’s effort to reduce intolerable emotion. Inappropriate, intense anger could be a hyperactivated EP experiencing flashbacks of past mistreatment. Paranoid ideation could be an EP stuck in a trauma-​related defense. Finally, auditory hallucinations are an EP’s vocal intrusions into an ANP’s consciousness (Mosquera et al., 2011). BPD researchers have sought to characterize the dissociative experiences of BPD patients. Gunderson and colleagues concluded that depersonalization (30–​85%) or derealization (30–​92%) differentiated patients with BPD from other psychiatric groups, including other personality disorders (Gunderson, Zanarini & Kisiel, 1991). This research led to the addition of BPD diagnostic criterion 9 in DSM-​IV: “transient, stress-​related paranoid ideation or severe dissociative symptoms” (APA, 1994, p. 654). The DSM-​5 ancillary text for BPD defines dissociation (in criterion 9) only as depersonalization (p. 664). In practice, Criterion 9 has usually been understood as stress-​related depersonalization/​derealization (Zanarini & Jager-​Hyman, 2009). In 2010, Gunderson suggested that DSM-​5 criterion 9 be reworded to portray dissociation in BPD as more trait-​like: “dissociative states of mind (i.e., perceives self or the world as disconnected, unreal) with episodic stress-​related paranoid ideation” (Gunderson, 2010, p. 696). Stiglmayr, Shapiro, Stieglitz, Limberger, and Bohus (2001) reported that BPD participants experience psychological and somatic dissociative symptoms 20% of the time during a single day. In a second study, Stiglmayr et al. (2008) reported that BPD participants have higher state dissociation scores than do Axis I participants and healthy controls; this was true during all levels of perceived stress –​low, medium and high. Furthermore, the average maximum dissociation score of BPD participants routinely fell in the severe range (Stiglmayr et al., 2008). We conclude that the average BPD patient experiences a frequent (or constant) low level of dissociation that becomes severe during perceived stress. Finally, in a MID analysis of 34 BPD participants (Korzekwa & Dell, 2010), 50% or more reported dissociative symptoms that are typical of a severe dissociative disorder. They endorsed, at a clinically significant level; trance-​l ike states, hearing voices, depersonalization, amnesia for recent and remote events, large memory gaps, and doing or saying things when angry that they did not remember. Their flashbacks lasted for days, involved loss of contact with the present, and made them want to inflict pain on themselves or die. Importantly, they rated depersonalization as only “sometimes” stress-​related, occurring about three times per month, and lasting most of the day (Korzekwa, Dell & Links, 2011).

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Empirical Comparison Of Dissociative Experiences in DID and BPD Our latest research sheds light on the quality of dissociation in BPD (Laddis, Dell & Korzekwa, 2017). We compared 100 BPD patients from a community mental health setting with 75 DID outpatients from private practice settings. The Mean MID score for DID was 51.4; for BPD, it was 30.8. A minority of BPD patients (29%) obtained low MID scores (0–​15). The rate of DID in the BPD sample was estimated to be 24%. Strikingly, DID patients obtained significantly higher scores than BPD patients on all 13 primary dissociation scales of the MID, but BPD patients obtained significantly higher scores than DID patients on all five of the MID’s validity scales and the psychosis screen. A regression analysis of the validity scales on the Mean MID score showed that Cognitive Distraction scores predicted the mean MID scores of DID patients. In contrast, the mean MID scores of BPD patients was predicted by four scales: Cognitive Distraction, Rare Symptoms, Psychosis Screen, and Emotional Suffering. This suggests that different processes underlie the dissociative symptoms of BPD patients as compared to the dissociative symptoms of DID patients. Because Cognitive Distraction (everyday errors and lapses of attention) was a major predictor of MID scores in both diagnostic groups, we examined the predictors of Cognitive Distraction. In DID, Cognitive Distraction was predicted by Memory Problems and Ego-​A lien Experiences. In BPD, it was predicted by Emotional Suffering, Memory Problems, and Trance. These predictors suggest that cognitive distraction in DID is caused by different processes from those in BPD. In BPD, cognitive distraction likely reflects absorptive detachment (Allen, Console & Lewis, 1999) and the disorganizing effects of strong negative emotions on concentration and memory. Unlike normal absorption, the absorption of extreme detachment is often content-​less; sufferers say they feel spacey, unreal, or blank. They are so detached they do not register and store memories, leading to irreversible memory gaps. We found that BPD patients endorsed high DES Absorption scores even when their mean DES scores fell within the normal range (Korzekwa & Dell, 2016). The “dissociative core” of DID (i.e., the dissociative symptoms always present regardless of level of dissociation) reflected the activities of self-​state/​a lter identities, experiences of identity confusion, and memory problems (Table 31.1). The “dissociative core” of BPD emphasized flashbacks, experiences of identity confusion, and memory problems (Table 31.1). Regression analysis of Flashbacks scores on the MID’s validity and dissociation scales showed that 61% of the variance in BPD patients’ Flashbacks scores is unexplained (i.e., not measured by any MID scale). We speculated that flashbacks in BPD may be “more a consequence of their characterological and neurobiological reactivity” (Laddis et al., 2017, p. 162) than the flashbacks that occur in PTSD. Ego-​A lien Experiences, on regression analysis, predicted 61% of the variance in the Identity Confusion scores of DID participants. In contrast, Ego-​A lien Experiences, Emotional Suffering, and Experiences of Self-​A lteration predicted 75% of the variance in BPD patients’ Identity Confusion scores. These predictors of identity confusion in BPD may reflect their “longstanding neurodevelopmental deficits in affect regulation and self-​representation” (Laddis et al., 2017, p. 163). Finally, memory problems in DID were primarily predicted by dissociative intrusions from alters. In contrast, memory problems in BPD were predicted by Depersonalization and Cognitive Distraction. This latter finding is important; it strongly suggests that BPD memory problems are caused by disruptions of the perceptual frame of reference (Beere, 2009; See Beere, Chapter 17, this volume) and losses of

TABLE 31.1  The Dissociative Cores of DID and BPD

Dx.

Dissociative Core

Variance

Interpretation

DID

activities of self-​state/​a lter identities experiences of identity confusion memory problems flashbacks

∅

∅

experiences of identity confusion

75% Ego-​A lien Experiences, Emotional Suffering, Experiences of Self-​A lteration

memory problems

Depersonalization and Cognitive Distraction

BPD

BPD meta-​i nterpretation:

61% Ego-​A lien Experiences dissociative intrusions from alters 61% unexplained, ≠ PTSD

∅ ∅ characterological and neurobiological reactivity longstanding neurodevelopmental deficits in affect regulation and self-​representation disruptions of the perceptual frame of reference and losses of concentration Dissociative symptoms =​deficit-​or disintegration-​phenomena

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concentration. In other words, the “dissociative” symptoms of most BPD patients are deficit-​or disintegration-​phenomena (Dell, 2019, Chapter 14, this volume). Nevertheless, a quarter of BPD patients manifested the structural dissociation of a severe dissociative disorder. In conclusion, we consider dissociation in DID a defensive, developmental process that distances the person from pain and distress (Dell, 2019, 2021, Chapter 14, this volume). Conversely, we think that different subgroups of BPD manifest different mechanisms of dissociation. The dissociation of BPD patients with low to moderate dissociation scores is primarily a disruption phenomenon (Dell, 2019, Chapter 14, this volume). The dissociation of BPD patients with high dissociation scores is generated by the same defensive, developmental process as that of non-​BPD individuals with a severe dissociative disorder (Dell, 2019, Chapter 14, this volume).

BPD with Low Dissociation The functioning of BPD patients with low dissociation (DES scores =​0–​14) is minimally affected by their dissociation. They have some disruptions of perceptual organization and resulting depersonalization (Beere, 2009). About half of BPD patients with low dissociation experience alternating self-​states that leave them feeling as if their strong emotions or impulsive actions are not in their control. They have little reflective ability that could make sense of, or control, these “not-​me” experiences.

BPD with Moderate Dissociation BPD patients with moderate dissociation (DES scores =​15–​29) are quite heterogeneous; various mechanisms underlie their dissociative experiences. Amnesia experiences in this group of BPD patients may be either reversible (i.e., dissociative amnesia) or irreversible (i.e., failures to store information during [1]‌extreme absorptive detachment or [2] serious disruptions of regulated functioning). BPD patients with comorbid DP/​DRD probably experience a mixture of defensive depersonalization/​derealization, extreme absorptive detachment, and incidents of disrupted perceptual organization (Beere, 2009). Identity confusion in this middle group mostly stems from poorly-​integrated good vs. bad parts, rather than defensive, trauma-​centric, dissociative parts. Some cases of BPD with comorbid OSDD-​1 fall into this category; they manifest angry or self-​harming ego-​states (with some amnesia for the activity of these parts).

BPD with High Dissociation BPD participants with high dissociation (DES scores > 30) usually have a severe dissociative disorder (i.e., OSDD-​1 or DID). Their self-​states have a sense of personal identity; they usually have recurrent incidents of amnesia. Their depersonalization and derealization are typically either defensive or due to the partial intrusion of another part. Their dissociation profiles on the MID are virtually indistinguishable from those of DID patients without BPD. This is the group that O’Neil contends would fail to satisfy DSM-​I V/​DSM-​5 Criteria A, B, D, and E for General Personality Disorder, despite the claim of reliable BPD diagnosis by interview, indicating that either the BPD diagnostic tools are in error, or else the DSM Personality Disorder construct is flawed.

3. Are the Risk Factors for Dissociation in BPD Patients Different from the Risk Factors in Dissociative Disorder Patients? Risk Factors for the Dissociative Disorders The empirical literature suggests that there are two diatheses of pathological dissociation: dissociative ability and disorganized/​unresolved attachment. The ability to dissociate in general appears to be substantially genetic –​as much as 59% in a child and adolescent twin and adoption sample study (Becker-​Blease et al., 2004). Dell proposes that the capacity to dissociate is based upon high hypnotisability (Dell, 2009b, 2019, 2021), which is up to 63% heritable (Morgan, 1973). Disorganized/​unresolved attachment to the primary caregiving figure (Ogawa, Sroufe, Weinfeild, Carlson, & Egeland, 1997) develops when the parent’s behavior is “frightened or frightening,” often due to the parents’ unresolved grief or PTSD. The child reacts to the parent’s behavior with fear, which activates the attachment system, causing the child to approach the parent –​but the parent is frightening rather than comforting (Main & Hesse, 1990). This situation, when chronic, causes a breakdown of the child’s attachment strategy, leading to the development of disaggregated internal working models of self and others, which disrupts “the integrative power of consciousness” (p. 68), thus leading

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to pathological dissociation (Liotti, 2006). One of us (PD) is dubious about the etiological importance of the significant, but small, correlations between disorganized attachment and dissociation (r =​0.14 to 0.35; Ogawa et al., 1997); PD considers disorganized attachment to be caused by the same factors that cause dissociative symptoms. There are no large-​scale studies of attachment in DID, but Steele (2002) has administered the Adult Attachment Interview to patients with DID: “The resulting profiles are remarkably similar in that ... the interview elicits other voices, personalities or alters whose origin and viewpoint depends on a particular mode of experiencing and responding” (p. 108). Thus, Steele implies that disorganized-​unresolved attachment is almost ubiquitous in DID. A prospective study of infants found that two variables (i.e., disorganized attachment and psychologically-​unavailable care in infancy) correctly classified 75% of the sample –​as being either members or non-​members of the pathological dissociation taxon (Ogawa et al., 1997). A near-​consensus in the DD f ield is that trauma causes pathological dissociation (but see Dell, 2019, Chapter 14, this volume). The types of traumatic stress that are associated with the development of dissociation include sexual abuse (SA), abuse by multiple perpetrators, multiple forms of abuse, torture or pain, severe neglect, conf inement abuse, and situations that engender feelings of extreme helplessness or powerlessness. Dissociation is also more likely in females and younger children (Draijer & Langeland, 1999; Ogawa et al., 1997; Perry, Pollard, Blakely, Baker, & Vigilante, 1995). The rates of abuse in DID are extremely high. The largest DID case series reported an 88–​9 8% incidence of childhood abuse. Childhood SA was reported by 79–​9 2% of DID cases and childhood physical abuse (PA) was reported by 75–​9 0% (Ellason, Ross & Fuchs, 1996; Ross, Norton & Wozney, 1989; Schultz, Braun & Kluft, 1989). Dissociative Disorders are predicted by earlier onset and greater severity of reported childhood SA and PA than in BPD (Boon & Draijer, 1993).

Risk Factors for BPD Disparate genetic factors likely contribute to the heterogeneous forms of dissociation in BPD –​e.g., affect dysregulation (45% heritable; Jang et al., 1996), neurocognitive deficits in executive functioning (77% heritable; Judd, 2005), and hypnotizability (which correlates 0.26 with Borderline Personality style; Peter et al., 2015). The attachment status of BPD participants is routinely insecure: disorganized attachment (50–​89%) and anxious-​preoccupied attachment (23–​ 75%). Only 0–​8% of BPD participants have secure attachment (Agrawal, Gunderson, Holmes, & Lyons-​Ruth, 2004). We endorse Judd’s (2005) hypothesis that BPD is a neurodevelopmental disorder, with dissociation being a developmental outcome of interactions among cognitive vulnerabilities, disordered attachment, environment, and genetic factors. BPD individuals exhibit neuropsychological deficits in speed of processing, symbolization, and integration of auditory, visual, and sensory information. If faced with a misattuned caregiver, such children would have difficulty integrating information and regulating affect. Judd suggests that, even during low stress, individuals with BPD may feel mildly disconnected. As stress increases, information-​processing would be impaired, triggering feelings of depersonalization and derealization. Finally, during extreme stress, non-​reversible amnesia (i.e., a complete absence of cognitive processing of events) might occur ( Judd, 2012). Childhood abuse and trauma are extremely common in BPD. A multicenter study of 136 BPD participants found that 95.6% reported at least one serious childhood trauma: neglect 87.5%, Emotional Abuse (EA) 82.4%, PA 65%, and SA 43% (Sack, Sachsse, Overkamp, & Dulz, 2013). A study of 214 BPD outpatients found neglect in 90%, childhood SA in 44%, and any type of childhood abuse in 81% (Battle et al., 2004). Rates of childhood SA and multiple forms of abuse are greater in BPD than controls (Herman, Perry, & Van der Kolk, 1989; Links et al., 1988). Their abuse history predicts severity of symptoms, prognosis, chronicity, and dissociation (de Aquino Ferreira, Pereira, Benevides & Melo, 2018). However, a meta-​analysis reported that childhood SA is only moderately predictive (r =​0.28) of the BPD diagnosis (Fossati, Madeddu & Maffei, 1999). Extending our previous research (Korzekwa et al., 2009), we collected SCID-​D -​R data on 28 additional BPD patients (Total N =​49; Korzekwa & Dell, 2016). We divided the sample into four SCID-​D -​R subgroups: (1) No DD (28.6%); (2) mild DD (DA or DPD; 26.5%); (3) DDNOS-​1 (32.7%); and (4) DID (12.2%). BPD participants with comorbid DID had significantly higher scores on childhood EA, SA, Emotional Neglect (EN), and total Childhood Trauma Questionnaire (CTQ; Bernstein et al., 1994) scores than (1) BPD participants with no DD, and (2) BPD participants with a mild comorbid DD (Korzekwa & Dell, 2016). Correlational studies of BPD data, show that childhood abuse is significantly correlated with dissociation (Goodman et al., 2003; Herman et al., 1989; Van Den Bosch, Verheul, Langeland, & Van den Brink, 2003). About two-​thirds of multiple regression analyses (Kerig & Modrowski, 2018; Merza, Papp & Szabó, 2015; Shearer, 1994; Zanarini, Ruser, Frankenburg, Hennen, & Gunderson, 2000b) uphold the relation between childhood trauma and dissociation, but

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one-​third do not (Simeon, Nelson, Elias, Greenberg, & Hollander, 2003; Zweig-​Frank, Paris & Guzder, 1994c & 1994d). Overall, the literature suggests that there are two pathways to dissociation in BPD: (1) childhood trauma (i.e., abuse and neglect), and (2) a collection of other factors –​i.e., more subtle mistreatment (fearful attachment, inconsistent care, maternal dysfunction, witnessing of violence), genetics, neurocognitive vulnerabilities/​deficits, adult SA, or substance abuse ( Judd, 2012; Shearer, 1994; Simeon et al., 2003; Van Den Bosch et al., 2003; Zanarini et al., 2000b).

Comparing Risk Factors for the DDs and BPD Şar et al. (2006) found that childhood EA, SA and physical neglect correlated with a BPD diagnosis, whereas EN correlated with a DD diagnosis. Şar concluded that these disparate correlations contradict the contention that BPD and DID are actually the same disorder. We found that childhood EA, EN, and SA were significantly greater in BPD participants with DID than in BPD participants without a DD (Korzekwa & Dell, 2016). Likewise, Ross et al. (2014) found that BPD participants with comorbid DID had greater PA and/​or SA scores than did those without a comorbid DD.

Mosquera and Colleagues’ Subgroup Model Of Risk Factors Mosquera and colleagues (2011) conceptualize three subgroups of BPD patients: (1) Dissociative BPD, (2) Attachment-​ Based BPD, and (3) Biologically-​Based BPD. They contend that trauma, disordered attachment, and biological vulnerabilities play a role, to varying degrees, in all three subtypes of BPD. According to the Structural Model of Dissociation, complexity of dissociation is related to the early commencement, severity, frequency, and duration of trauma. This complexity manifests itself in the number and types of parts, and in the degree of dissociation among those parts.

Dissociative BPD In ‘Dissociative BPD,’ the trauma and dissociation are severe and complex. The dissociative parts of the personality have a “first-​person perspective” (i.e., the EPs feel like they have their own identity) and there is significant dissociation between parts. These Dissociative BPD cases usually receive a diagnosis of DID or OSDD-​1.

Attachment-​based BPD In ‘Attachment-​based BPD,’ attachment trauma is prominent, but their trauma history and dissociation are less severe. These BPD patients experience unexplained intrusions of emotions, thoughts, and actions; they usually receive a diagnosis of Complex PTSD.

Biologically-​based BPD In ‘Biologically-​based BPD,’ genetic traits interact with (traumatic) environmental factors. They typically have comorbid Axis I disorders (e.g., bipolar disorder, schizophrenia, Attention-​Deficit/​Hyperactivity Disorder).

Summary and Conclusions So, is BPD a trauma disorder? Sometimes yes and sometimes no. The population of individuals with BPD is notoriously heterogeneous (Lenzwenger, 2010). Not all BPD patients have been abused. Not all BPD patients dissociate. Not all BPD patients who dissociate have been abused. Not all BPD patients have a disorganized attachment status. The key factors in the development of dissociation in BPD are probably a mixture of biology, suboptimal parenting, trauma, disordered attachment, and a genetic capacity to dissociate. The relative influence of these factors seems to differ by subgroup. BPDs with low dissociation scores have little or no genetic capacity to dissociate. BPD patients with moderate dissociation scores can display a wide spectrum of dissociative symptoms due to two, very-​d ifferent mechanisms: (1) disruptions of the person’s perceptual frame of reference

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(depersonalization and derealization) that are caused by (a) neurodevelopmental vulnerabilities, and/​or (b) disordered attachment, interacting with (c) stress and trauma; and (2) a genetic capacity to dissociate whose use is motivated by pain/​d istress/​trauma. BPD individuals with high dissociation scores have a strong, genetic capacity to dissociate that is complicated by neurodevelopmental vulnerabilities and disordered attachment and is molded into its final form by environmental insults (e.g., abuse, invalidation/​betrayal).

4.  Does BPD Treatment Ameliorate Dissociative Symptoms? Standard BPD Treatment At 10-​year follow-​up, the DES scores of an index group of 290 inpatients diagnosed with BPD had fallen to normal levels –​from 21.8 to 8.5 (Zanarini et al., 2008). Seventy percent of these patients were still receiving unspecified therapy. The mean DES score for those with high dissociation had improved from 48.4 to 17.7; and the mean DES score for those with moderate dissociation had improved from 17.8 to 6.8. On the other hand, 14 of these BPD patients had a “new onset” of high dissociation; 18 had a “recurrence” of high dissociation; and 15 of them exhibited high dissociation throughout the 10 years. Thus, the bottom line is that 16% of Zanarini and colleagues’ (2008) BPD sample obtained DES profiles that suggest the presence of a serious, comorbid DD –​a DD that was not improved by ‘treatment as usual.’ At 20-​year follow-​up, a majority of this group was still receiving treatment. Those who had not recovered from BPD still reported moderate levels of depersonalization. These unrecovered BPD patients had higher baseline-​levels of depersonalization than did recovered BPD patients (Shah, Temes, Frankenburg, Fitzmaurice, & Zanarini, 2020). Two BPD treatments –​that do not target dissociation per se –​have reported significant improvement in DES scores: psychoanalytic transference-​focused psychotherapy and schema-​focused cognitive behavioral therapy (Kremers, Spinoven, Van der Does, & Van Dyck, 2006). Arntz, Stupar-​Rutenfrans, Bloo, Van Dyck, and Spinhoven (2015) reported that dissociation during therapy sessions mediated the effect of elevated baseline levels of dissociation on reduced recovery rates. That is, dissociating during sessions seemed to impair the effectiveness of treatment. Spitzer, Barnow, Freyberger and Grabe (2007) found that higher dissociation scores at baseline predicted non-​response to treatment (in a 4-​to 8-​week, inpatient, psychodynamic, group treatment program for severely disturbed BPD patients). In a 6-​month, inpatient eclectic treatment study, Digre and colleagues (2009) found that “severely disturbed internalizing” BPD patients (25% of their 77 BPD sample) exhibited high DES scores at baseline (mean DES =​44.5) that did not improve (post-​t reatment DES =​43.9).

Dissociation-​focused BPD Treatment Dialectical Behavior Therapy (DBT; Linehan, 1993) targets dissociation in BPD patient via chain analysis, emotion regulation and mindfulness skills and desensitization of triggers to past trauma. Two randomized controlled trials have shown that DBT effectively treats the dissociative symptoms of BPD patients (Koons et al., 2001; Bohus et al., 2004). Kleindienst and colleagues (2008) found that (1) the therapeutic gains of Bohus and colleagues’ (2004) 3-​month inpatient study were maintained at 24 months, and (2) high DES scores at baseline were associated with poor improvement. Braakmann et al. (2006) reported that BPD patients with high dissociation at baseline displayed greater general psychopathology at the end of treatment. Importantly, however, high dissociators made significant gains during treatment –​on general psychopathology, anxiety, depression, and psychosocial functioning. They even achieved the highest reduction in dissociation scores (Braakmann et al., 2006). In a 3-​month inpatient DBT study, Sleuwaegen et al. (2018) divided BPD patients into subtypes based on reactive and regulative temperament. The “emotional/​d isinhibited subtype” had higher dissociation scores at baseline than the other two groups. Their dissociation scores improved significantly, but their post-​t reatment dissociation scores were still higher than the baseline dissociation scores of the other two groups. Some DBT programs provide prolonged exposure (PE) PTSD treatment upon completion of standard DBT. With the exception of one study (Bohus et al., 2013), this staged treatment of BPD has decreased dissociation significantly (Harned, Korslund & Linehan, 2014; Steil et al., 2018). Notably, these BPD patients’ DES scores did not improve significantly until after the PE phase of treatment (Harned, Gallop & Valenstein-​Mah, 2018). Unfortunately, 18% (of a sample of 51 BPD patients completing the first year of standard DBT) were not eligible for the PE-​PTSD treatment because their DES-​Taxon scores were still above 20 (Harned et al., 2010) –​suggesting the presence of a comorbid DD. Cognitive analytic therapy targets dissociated states; it reduced DES scores in 19 BPD participants (Kellet, Bennett, Ryle, & Thake, 2013). A psychodynamically-​oriented, inpatient program that treats trauma produced greater reductions in dissociation than treatment as usual (Sachsse, Vogel & Leichsenring, 2006). Dynamic deconstructive psychotherapy

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seeks to increase the adaptive processing of emotional experiences; it was more effective in reducing DES scores than treatment as usual (Gregory et al., 2008). Three cases of DID with comorbid BPD, who were treated with dynamic deconstructive therapy, attained dramatic reductions in their DES scores (Chlebowski & Gregory, 2012). Mindfulness-​ Based Cognitive Therapy (MBCT) teaches mindful responding to emotions; MBCT reduced somatic dissociation, but did not reduce psychological dissociation (Sachse, Keville & Feigenbaum, 2011). Medications have not been shown to be effective for treating dissociation in BPD in randomized controlled studies. Nevertheless, a few studies of experimental treatments have reported interesting results. In a randomized double-​blind, cross-​over design study, Philipsen, Schmahl and Lieb (2004) found that placebo and naloxone (an opiate receptor antagonist) attained equal reductions of dissociation in nine BPD participants with NSSI with analgesia. A larger study (N =​25 BPD) of placebo and naloxone treatment in a double-​blind, placebo-​controlled, random crossover design, found that naloxone produced a nonsignificant reduction of dissociative symptoms (Schmahl et al., 2012). In another study, clonidine (α2 -​adrenergic receptor agonist) produced a significant reduction in the dissociative symptoms of 14 BPD patients (Philipsen, Richter et al., 2004).

Summary A subgroup-​approach to studying BPD makes the most sense. Evidence-​based treatments for BPD improve dissociation in BPD patients with low dissociation (and some cases of moderate dissociation). Treatments that teach emotion-​awareness and emotion-​regulation, and trauma-​cue desensitization seem to be more effective than treatment as usual. Most patients with moderate dissociation need treatments that target dissociation. Finally, most BPD patients with high levels of dissociation have: (1) a severe DD, (2) a poor prognosis, and (3) require a three-​phase treatment that targets dissociation and dissociated states.

5.  Research on Dissociation in BPD: Quo Vadis? The DSM’s discussion of dissociation in BPD is frankly problematic; it is incomplete and partially incorrect. The diagnostic criteria for General Personality Disorder and BPD should explicitly address the Dissociative Disorders –​either as comorbid or exclusionary. The DSM needs to clearly state that BPD patients should be screened for DDs, and that experiences of pathological dissociation (e.g., dissociative amnesia, identity alteration, frequent depersonalization or derealization that interferes with functioning) or high dissociation scores on screening instruments should be followed-​ up with DD diagnostic tools. If BPD researchers screen for DDs, then more-​homogenous subgroups can be identified and DDs misdiagnosed as BPD can be excluded from the subject sample, thereby strengthening results (Şar & Ross, 2006), and yielding more meaningful findings. The treatment literature on BPD is starting to recognize that dissociation interferes with information-​processing and hinders treatment. BPD treatment programs should (1) screen for dissociative symptoms and dissociative disorders, and (2) incorporate interventions for those symptoms. It would also be helpful for therapists to recognize the significant disorganizing effect of attachment disturbance, concomitant dissociative experiences, and dysregulation of opioid and oxytocin metabolism (Perez-​Rodriguez et al., 2018). The most promising neuroimaging studies challenge BPD participants with a trauma-​d issociation script to evoke a dissociative state while they are in the fMRI scanner. These challenge paradigms elicit dissociative experiences at levels that are three times higher than BPD participants’ ambient level of dissociative experiences when they come to the lab (Krause-​Utz, Frost, Winter, & Elzinga, 2017). Recently, a sample of BPD participants was divided into (1) those with a state dissociation induction, and (2) those who read a neutral script. Both groups were challenged with an emotional, working-​memory task. The BPD participants who received the dissociation induction showed reduced activity in areas associated with emotion processing, memory, and self-​referential processes (Krause-​Utz et al., 2018). Studies of functional connectivity are another promising avenue of research. Elevated dissociation scores are associated with alterations in resting-​state networks (Krause-​Utz et al., 2014; Wolf et al., 2011). Finally, Paret et al. (2016) improved amygdala-​prefrontal cortical connectivity by using biofeedback (of the fMRI signal from the right amygdala) to train BPD patients to reduce their amygdalar activation, thereby reducing their ‘lack of emotional awareness’ and their level of dissociative experiences.

Conclusions Dissociation is common in BPD, but it is not ubiquitous. Similarly, although BPD patients report significantly more childhood abuse than do non-​DD psychiatric clients, not all BPD patients have experienced child abuse. Thus, not all dissociation in BPD is trauma-​related.

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Despite some phenotypic, dissociation-​like similarities, we believe that BPD and severe dissociative disorder (i.e., DID and OSDD-​1) are separate pathological processes. We consider BPD and DID to be independent, but contemporaneous, developmental processes. One (BPD) has a biological substrate of neurocognitive vulnerabilities and the other (DID) has a biological substrate of high hypnotizability (Dell, 2009b, 2019, 2021, Chapter 14, this volume). In both cases, their diagnostically-​relevant, biological substrate is activated, aggravated, and energized by environmental insults such as trauma, mistreatment, and other parental failures. The dissociative experiences of BPD individuals are passive, breakdown-​phenomena; they reflect the episodic disruptions of the BPD individual’s vulnerable, poorly-​integrated, perceptual/​neurocognitive/​a ffective frame of reference (Beere, 2009; Dell, 2019, Chapter 14, this volume). The dissociative experiences of individuals with DID are active, motivated, high-​hypnotizability-​enabled, mental efforts to escape pain; with repetition, these defensive actions have become automatic. They have developed into the dissociative, procedural routines that constitute DID (Dell, 2019, 2021, Chapter 14, this volume). With this understanding in mind, we can say the following about dissociative experiences in BPD.

BPD with Normal Levels of Dissociative Experience Twenty-​four to 41% of BPD patients have dissociation scores in the normal range. They have experienced minimal abuse or neglect. Other factors (e.g., other Axis I genetics, neurocognitive vulnerabilities/​deficits, and other forms of childhood inconsistent or deprived care) are involved in the genesis of their BPD and any mild dissociative symptoms that they may have. Their attachment status is likely secure or insecure-​anxious. They probably have little genetic capacity for dissociation. Their amygdalar activity is excessive and is poorly inhibited by the prefrontal cortex. Their dissociation will likely improve with standard BPD treatments.

BPD with Moderate Levels of Dissociative Experience Forty to 63% of BPD patients have moderate dissociation scores. This is the most heterogeneous subgroup of BPD. They have some amnesia; frequent, lengthy, disruptions of perceptual/​neurocognitive/​affective frame of reference and/​or stress-​related episodes of depersonalization, and some dissociated ego states. Their attachment status is insecure or disorganized. Their history of trauma is mild to severe, and their genetic ability to dissociate is low to high. Non-​t rauma factors may play a role in their dissociation. Studies of their startle response (Ebner-​Priemer et al., 2005) and pain tolerance show cortical suppression of limbic emotional activity (Schmahl et al., 2006). They will likely improve with treatments that assess and treat dissociation as a symptom and teach emotion-​regulation. A subset of these BPD patients needs explicit trauma work.

BPD with High Levels of Dissociative Experience Ten to 24% of BPD patients have comorbid DID on structured or semi-​structured interview. These BPD-​DID cases have dissociative symptoms that are frequent, severe, and of long duration. These individuals with BPD/​DID have a high genetic capacity for dissociation, a disorganized-​unresolved attachment status, and severe histories of childhood trauma. Brain imaging of highly dissociative BPD individuals shows cortical inhibition of emotional processing and a lack of somatosensory integration. They are at high risk for NSSI, hospitalization, and suicide attempts. They require complex treatment.

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32 THE NATURE OF PSYCHOTIC SYMPTOMS Traumatic in Origin and Dissociative in Kind? Andrew Moskowitz, Eleanor Longden, Filippo Varese, Dolores Mosquera, and John Read

Introduction and Overview How can psychosis be understood? For many years, the prevailing opinion was that this question could not be answered. Karl Jaspers had argued more than 100 years ago that psychotic symptoms were psychologically irreducible, not understandable ( Jaspers, 1963/​1913), and his position continues to dominate thinking in the field today (as the terms disorganized thinking and disorganized behavior –​which imply the absence of any organization or meaning –​in the DSM and ICD diagnostic manuals demonstrate; APA, 2013; WHO, 1992, 2019). But over the last several decades, researchers and clinicians have come to question this received wisdom, arguing that –​not infrequently –​psychotic symptoms, even apparently bizarre ones, can be understood, specifically by linking them back to an individual’s life experiences and social context. Such a realization has led to important new models and theories and, in some cases, clinical breakthroughs (Moskowitz, Mosquera & Longden, 2017). This chapter takes its subtitle from the chapter in the first edition of this book, ‘Are psychotic symptoms traumatic in origin and dissociative in kind?’ (Moskowitz, Read, Farrelly, Rudegeair & Williams, 2009). In that chapter, it was argued that the traumatic histories of some individuals with psychotic symptoms were real but often obscured, with a possibly unconscious motivation, to keep traumatic memories at bay. And, in keeping with Jaspers (and Freud’s post-​1896) positions, reported traumas were often discounted by clinicians, sometimes leading to inappropriate diagnoses. As we noted then, [A]‌person’s diagnosis is partly dependent on whether the clinician knows the context in which the patient’s signs and symptoms make sense. If clinicians know the traumatic context, then they are likely to issue a posttraumatic diagnosis; if not, they will probably issue a psychotic diagnosis. Moskowitz et al., 2009, p. 528 Of the many risks of inaccurate diagnosis, ineffective and potentially dangerous treatments are among the most severe. Misdiagnosis remains a major concern, even as substantial work over the past decade has demonstrated that: 1) certain psychotic1 symptoms are common in many disorders, including posttraumatic stress disorder (PTSD) and dissociative identity disorder (DID), and largely indistinguishable from the same symptoms in psychotic disorders such as schizophrenia (Moskowitz et al., 2017) and 2) psychological treatment approaches developed in the trauma and dissociation fields have proven effective in treating many psychotic symptoms (De Bont, De Jongh & Van den Berg, 2019; Gonzalez, Mosquera & Leeds, 2019). These insights have led to the development of new approaches to psychosis, such as trauma-​ informed CBT (Morrison, 2013). The core of the earlier chapter lay in the evidence linking specific psychotic symptoms to dissociation. It was concluded that hallucinations, particularly auditory verbal hallucinations (AVH), were linked to dissociative processes, and that other psychotic symptoms might also be linked to dissociation. Now, more than ten years later, evidence supporting these positions has accrued, and will be reviewed here. In the interest of space, discussion will be largely limited to delusions (including so-​called passivity experiences, discussed below) and hallucinations, which have been most strongly emphasized in the diagnosis of schizophrenia for decades. This chapter begins with a developmental consideration of the impact of trauma on psychosis, and possible mechanisms through which early traumatic experiences in childhood may lead to psychotic symptoms later in life. The question

DOI: 10.4324/9781003057314-38

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of general vs. specific etiology will be noted (i.e., the extent to which childhood trauma specifically predicts psychosis above and beyond the heightened risk it creates for all mental disorders). The crucial role of dissociation as a mediator between childhood traumatic experiences and psychotic symptoms later in life will also be discussed, along with the manner by which attachment disturbances may impact the development of adult psychotic disorders. With this as background, the core of the chapter in the first edition will be updated; evidence that dissociation can be linked to delusions and hallucinations will be presented. Passive influence symptoms, sometimes referred to as delusions (experiences that one’s thoughts, feelings or actions are being influenced by an outside source) will be particularly emphasized, because of their substantial weighting in the DSM-​5 (APA, 2013) and ICD-​11 (WHO, 2019) diagnostic criteria for both psychotic and dissociative disorders. Following this, the prevalence and significance of classic dissociative symptoms in psychotic disorders, such as depersonalization, derealization and amnesia, will be briefly addressed. Issues of differential diagnosis will be considered. The chapter ends with relevant clinical and research implications.

A Developmental Perspective on Trauma and Psychotic Disorders Childhood trauma, or the somewhat broader category of childhood adversity (including also experiences such as neglect, witnessing violence between parents, parental death or loss, and poverty), is common and of etiological significance in a wide range of mental disorders. A recent meta-​analysis found that persons diagnosed with schizophrenia reported as much abuse and adversity in their childhood as persons diagnosed with affective psychosis, depression or personality disorders (Matheson, Shepherd, Pinchbeck, Laurens, & Carr, 2013). Persons diagnosed with anxiety disorders reported less childhood adversity, but those diagnosed with PTSD or dissociative disorders somewhat more. The prevalence of childhood adversity in persons with schizophrenia was more than 3.5 times that of the general population.

The Prevalence and Significance of Childhood Trauma in Psychotic Disorders Over the past three decades, a large amount of evidence has confirmed the existence of a robust relationship between exposure to childhood trauma and the risk of developing psychotic symptoms. For example, research confirmed that childhood trauma is highly prevalent among individuals regarded as ‘ultra-​h igh risk’ for developing psychotic disorders (i.e., individuals with low-​level or intermittent psychotic symptoms not meeting diagnostic thresholds for a psychotic disorder; Yung et al., 2005). Recent systematic reviews and meta-​analyses suggest that, on average, 86.8% of individuals at ultra-​h igh risk for psychosis report a history of childhood trauma; this level of trauma exposure is considerably higher than that observed in ‘healthy control’ samples (Kraan et al., 2015; Peh et al., 2019). One reason for this may be that childhood trauma produces neurodevelopmental brain changes that increase the risk for adulthood psychotic disorders (Read, Fosse, Moskowitz & Perry, 2014). Childhood trauma is also highly prevalent in people already diagnosed with a psychotic disorder. While prevalence rates for specific childhood traumas in this population vary, largely for methodological reasons, a recent conservative meta-​analysis found that, on average, approximately 34% of people with psychosis report a history of emotional abuse, 39% a history of physical abuse and 26% report experiences of sexual abuse (Bonoldi et al., 2013). Other reviews have reported even higher rates (i.e., Read, 2013). Meta-​analytic evidence has also confirmed that these and other childhood adversities (e.g., bullying and forms of emotional and physical neglect) significantly contribute to the risk of developing psychosis. Varese et al. (2012) reviewed 18 case-​control studies (2048 patients with psychosis, 1856 non-​ psychiatric controls), 10 prospective studies (41,803 participants), and eight population-​based cross-​sectional studies (35,546 participants) and found strong and well replicated associations between childhood trauma and increased risk of developing psychosis; the highest odds ratio was for emotional abuse (3.40), followed by physical abuse (2.95). The association between childhood trauma and psychosis often follows a ‘dose response’ pattern in both longitudinal studies and large-​scale population-​based investigations. Dose response relationships are considered a crucial marker of potential causal relationships in epidemiological data (i.e., the ‘Bradford-​H ill criteria’); their presence increases confidence that childhood trauma should be regarded as a central risk factor for developing psychosis (Bentall & Varese, 2012).

How Can the Relationship Between Childhood Trauma and Psychosis be Explained? Potential Mediating Variables Having established that childhood trauma is common in persons who develop psychosis, the question arises as to whether this relationship may be specific, and whether any mediating variables or factors could explain this relationship. These two issues are intrinsically related. Many meta-​analyses have linked childhood adversities to a wide range

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of mental health difficulties later in life (e.g., McKay et al., 2021). There is considerable support for the notion that overwhelming stress in childhood represents the starting point for developmental trajectories leading to various forms of psychological distress, not only psychosis. This generic risk could be explained by the non-​specific impact of early adversity on transdiagnostic processes implicated in most, if not all, forms of psychological distress (e.g., stress regulation). However, some more specificity may be found by examining psychological variables or processes related to childhood adversity that predict the development of psychotic symptoms, thus mediating the childhood trauma/​psychosis relationship (Bentall et al., 2014). In recent years, a growing number of empirical studies have looked for such mediators. The findings of three recent systematic reviews and meta-​analyses suggest that the relationship between childhood trauma and psychosis is complex and multi-​faceted, and that multiple trauma-​related processes may be involved in the development and maintenance of psychotic experiences (Alameda et al., 2020; Sideli et al., 2020; Williams et al., 2018). While some research has found specific genetic alleles, such as the BDNF Val66Met polymorphism (Alemany et al., 2011), to mediate between childhood trauma and adult psychotic symptoms, genetic variables were not supported as mediators in these three meta-​analyses. In the following sections, we explore two mediating factors identified as significant in the relationship between childhood trauma and psychosis: attachment patterns and dissociation or dissociative capacity. The purpose of these sections is to provide evidence that these two variables mediate between childhood trauma and psychosis. Later sections examine the specific nature of these relationships, and how they may explain certain psychotic symptoms.

Attachment Several authors argue for the relevance of attachment insecurity in the etiology of psychotic experiences (e.g., Bentall et al., 2014; Berry, Varese & Bucci, 2017; Read & Gumley, 2008). According to attachment theory, early interactions with primary caregivers result in the development of enduring ‘internal working models’ –​internal relational representations of self and others which influence relating styles and emotional regulation abilities across the lifespan (e.g., Bowlby, 1982). Early adversities, in particular those directly involving caregivers and/​or impacting the child-​caregiver relationship, can result in the development of various ‘insecure attachment styles’ which may have a long-​term effect on the individual’s psychosocial functioning. Meta-​analytic evidence confirms that attachment insecurity is common among children exposed to maltreatment (Baer & Martinez, 2006), and that these enduring insecure attachment styles are associated with various forms of adult psychopathology (Woodhouse, Ayers & Field, 2015). A meta-​analysis of 25 psychosis studies found that 78% of people with psychosis presented an insecure attachment style, and that attachment insecurity in psychosis was significantly more common than among non-​psychiatric controls (Carr, Hardy & Fornells-​A mbrojo, 2018). With a pooled prevalence rate of 38%, ‘fearful’ attachment (characterized by an inconsistent sense of self, ambivalence in seeking interpersonal closeness and emotional regulation difficulties), which is posited to correspond to a complex childhood attachment pattern knows as ‘disorganized’, was the most common insecure attachment style in people with psychosis. The next most prevalent was avoidant attachment (characterized by emotional over-​regulation/​suppression and avoidance of interpersonal closeness) at 23%, followed by anxious attachment (featuring heightened emotional expression, desire for interpersonal closeness and dependence on others) at 17%. This meta-​analysis also confirmed that anxious and avoidant attachment styles were significantly associated with heightened symptom severity; too few studies were available to consider fearful attachment in this regard. Three recent systematic reviews have corroborated that, in both clinical and non-​ clinical samples, insecure attachment represents a significant mediator of the relationship between early adversity and psychotic experiences (Alameda et al., 2020; Sideli et al., 2020; Williams et al., 2018). Recent mediation studies have found fearful attachment not only to be robustly associated with positive psychotic symptoms, but also to mediate the association between trauma exposure and specific psychotic experiences in clinical samples, including hallucinations and paranoia (Pearce et al., 2017). Developments in the assessment of fearful/​d isorganized attachment, in particular the integration of validated disorganized attachment subscales in widely used psychosis-​specific self-​report measures of attachment (Pollard et al., 2020), will provide opportunities to further explore the role of this specific attachment style in the etiology and maintenance of psychosis, and its interaction with other important mediators of the relationship between trauma and psychosis, most notably dissociation (Berry et al., 2017; Liotti, 2006).

Dissociation A large body of research has demonstrated a strong relationship between dissociative processes and symptoms of psychosis, along with the possibility that dissociation may mediate the relationship between childhood trauma and psychosis.

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Recent meta-​analyses suggest that dissociation is considerably more prevalent in people with a diagnoses of schizophrenia compared to non-​psychiatric controls (O’Driscoll, Laing & Mason, 2014), and that childhood trauma exposure is associated with higher levels of dissociative experiences in people with psychosis (Rafiq, Campodonico & Varese, 2018). Meta-​analytic findings (described in more detail in subsequent sections) also confirm large and well-​replicated associations between dissociative experiences and psychotic experiences, especially positive symptoms of psychosis, in both non-​clinical and clinical samples (Longden et al., 2020; Pilton, Varese, Berry & Bucci, 2015). Several systematic reviews and meta-​analyses have similarly corroborated that dissociation is a significant mediator of the relationship between childhood adversity and symptoms of psychosis (Alameda et al., 2020; Sideli et al., 2020; Williams et al., 2018). While the majority of these mediation studies have focused on vulnerability for experiencing hallucinations, more recent evidence suggests that dissociation represents a statistically robust mediator of the relationship between childhood adversity and other positive symptoms of psychosis, like paranoia (Pearce et al., 2017) and delusions (Cole, Newman-​ Taylor, & Kennedy, 2016; Sun et al., 2018), in both clinical and non-​clinical populations.

Summary The available evidence supports not only a central role for childhood trauma in the development of psychotic disorders, but also an important mediating role in this relationship for both insecure (particularly fearful) attachment styles and dissociation. The specific ways in which dissociation and attachment patterns may relate to delusions and hallucinations will be discussed below. It must be noted, however, that the relationships documented above cannot claim to be specific to psychosis, as particular attachment styles and dissociation clearly play a role in other disorders as well, most notably borderline personality disorder (BPD; Levy, 2005) and DID (Liotti, 1992).

Dissociation in Psychotic Disorders and Psychotic Symptoms in Dissociative Disorders: Hiding in Plain Sight? Shifting from a developmental to a phenomenological perspective, we now consider the prevalence of dissociative symptoms in psychotic disorders and psychotic symptoms in dissociative disorders (see also Şar, Chapter 25, this volume). Particularly with regard to the latter issue, the definition and conception of psychotic symptoms becomes crucial. For example, the question as to whether certain Schneiderian/​fi rst rank symptoms –​such as reports of thought insertion or withdrawal –​should be considered delusions or experiences is central to this issue but not resolved in the DSM-​5 or ICD-​ 11. The position that one takes when assessing the signs and symptoms an individual presents with is crucial in making this determination; the same symptoms will be conceptualized in very different ways based on the perspective of the interviewer and, as a consequence, certain aspects of her or his presentation will not be recognized or focused on, and potentially relevant lines of enquiry overlooked. The question in this section’s subtitle, ‘hiding in plain sight?’, references this problem. This section begins with a review of the most complex dissociative disorders, DID and Partial DID, focusing on the ways in which the division of a personality into dissociative parts can manifest as apparent psychotic symptoms. We then consider the role that dissociation plays in psychotic symptoms, particularly delusions and hallucinations, reviewing the evidence from studies of persons with psychotic disorders, as well as other disorders, along with persons without a clinical diagnosis. Finally, as a prelude to discussing differential diagnosis and hybrid diagnoses, we review the few studies that have assessed for classic dissociative symptoms (such as dissociative amnesia) in psychotic disorders.

Dissociative Disorders of Identity and Their Presentations The most severe form of dissociative disorder is DID. A common presentation of this disorder is a person who is high-​functioning in certain domains of his or her life, but is troubled by peculiar symptoms and memory losses in everyday life, which may be severe (Kluft, 2009). As a consequence of extensive childhood abuse, neglect or adversity (in the overwhelming majority of cases; Scott et al., 2019), parts of the person’s personality develop to serve different functions –​broadly categorized as mammalian defense (fight, flight, freeze, immobility –​manifested physically or psychologically) or daily life functioning (Van der Hart, Nijenhuis & Steele, 2006). In DID, these parts, which may be manifold, have a high level of complexity and independence, and their own unique first-​person perspective on themselves, other persons, and the world. Some parts (but not all) periodically or occasionally assume executive control (i.e., ‘take charge’ of the body). When this occurs, there often is a loss of memory from the perspective of one or more of the parts; other apparent memory losses (experienced by some, but not other, dissociative identities) relate to episodes from the past.

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In addition to DID, it has long been recognized that many people suffer from an apparently similar condition, with the difference that the organized dissociative parts do not assume executive control or experience episodes of amnesia (or only do so under very special circumstances, such as self-​harm). This condition is recognized as one form of Other Specified Dissociative Disorder in the DSM-​5, and is called Partial DID in the ICD-​11 (Moskowitz, Nijenhuis, Moreira-​ Almeida & Lewis-​Fernández, in press). Another proposed name for this disorder was Complex Dissociative Intrusions Disorder, to emphasize that persons with this condition primarily experience intrusions and withdrawals between different parts of the personality. The experience of intrusions phenomenologically appears as thoughts, feelings, images, emotions, apparent memories or even voices that enter consciousness but do not feel they belong to the part that is currently in executive control; in addition to the lack of a sense of ownership of the intrusive material, the content of the material may seem quite foreign. In contrast, withdrawals are phenomenologically experienced as the involuntary removal of such elements from consciousness. While such experiences are central to Partial DID, they also frequently occur in DID as well. As discussed below, many symptoms currently classified as psychotic may derive from a highly dissociative personality structure. For example, voice hearing and passive influence symptoms (such as ‘thought insertion’) may relate to the intrusions of one part of the personality into the part currently in executive control; disorganized thinking or behavior may result from the sudden switch between parts in DID where, for example, a terrified or even catatonic child part ‘takes over’. Even thought disorder could occur through the ‘rapid switching’ between parts, with each part speaking in a different manner or even language (Şar & Öztürk, 2019).

The Role of Dissociation in Psychotic Symptoms Psychotic symptoms have classically been considered to consist of delusions and hallucinations, along with certain disturbances of thinking and behavior. Despite such symptoms not having been emphasized in the original diagnosis of schizophrenia (Moskowitz & Heim, 2011), psychotic symptoms have been central to both the ICD and DSM diagnostic criteria for schizophrenia for more than 40 years. As noted above, apparently disorganized thinking (thought disorder) or disorganized behavior or catatonia may be the expression of a dissociative part or parts of the personality (dissociative identities); when this is not recognized, they may be seen as symptoms of a psychotic disorder instead of a dissociative disorder. These issues have been discussed in the previous version of this chapter (Moskowitz et al., 2009) and will not be further reviewed here. Of note, however, is that catatonia was expanded in the DSM-​5 from a subtype of schizophrenia to a qualifier for a number of different disorders (APA, 2013), and in the ICD-​11 to a diagnostic grouping of its own (WHO, 2019). This heightened visibility of catatonia as a qualifier or diagnosis makes it even more important that dissociative disorders be considered as a differential diagnosis –​a possibility which is not raised in the relevant sections of the DSM-​5 or ICD-​11. We now focus on the relation of dissociation to various forms of hallucinations and delusions, specifically: 1) AVH, 2) other hallucinations, 3) delusions of control (DSM-​5) or experiences of influence, passivity or control (ICD-​11) and 4) other delusions (paranoid, grandiose, delusions of reference, etc.). Interpretations or explanations of these symptoms from a dissociation perspective will be offered, where relevant.

Hallucinations Hallucinations are typically defined as sensory perceptions experienced as subjectively real in the absence of relevant external stimuli (APA, 2000). While they may occur in any sensory modality, AVH have for decades been particularly emphasized in the diagnostic criteria for schizophrenia. This is because of the influence of Kurt Schneider, who argued that certain so-​called first rank symptoms were particularly predictive of schizophrenia (Moskowitz & Heim, 2019). Among these first rank symptoms were experiences of voices conversing with each other or commenting on the person’s behavior (but not other forms of hallucinations) along with passive influence experiences (discussed below). Auditory Verbal Hallucinations/​Voice Hearing Since the seminal papers of Moskowitz and Corstens (2007) and Longden, Madill and Waterman (2012) linking auditory hallucinations to dissociation, extensive data has accrued supporting this relationship. The argument to consider voice hearing as dissociative can be formulated in the following way. First of all, the prevalence of voice hearing across multiple clinical and non-​clinical populations far exceeds that which would be expected if hallucinations were primarily a psychotic phenomenon (Waters & Fernyhough, 2017). Estimates from the general population vary widely according

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to methodology but have been reported in the region of 5–​40% among children and young adults (e.g., De Loore et al., 2011; Pearson et al., 2008) and 7–​15% for adults (e.g., Kråkvik et al., 2015; Sommer et al., 2010). Second, the phenomenology of voice hearing does not differ between various clinical and non-​clinical groups. Only 1 out of 21 aspects of voice hearing (age of onset, which was significantly later in schizophrenia) was significantly different between the groups experiencing hallucinations (persons diagnosed with 1) schizophrenia, 2) a range of other psychiatric disorders, 3) substance-​use related conditions, 4) medical and neurological conditions, or 5) non-​patients) in a systematic review of 43 studies (Waters & Fernyhough, 2017). Other features traditionally believed to be of clinical significance (e.g., location, frequency, perceptual vividness, negative content) were unreliable for defining what constitutes a ‘psychotic’ versus a ‘non-​psychotic’ hallucination (see also Longden et al., 2012). While some studies do show that patient, compared to non-​patient, voice hearers report more frequent voices which are more abusive, less controllable and more ego-​dystonic (Daalman et al., 2011; Larøi et al., 2012; Sorrell, Hayward, & Meddings, 2010), the bulk of evidence now suggests that voice hearing occurring in different populations is experienced quite similarly. Such similarities imply that a general factor may underlie the phenomenon of hallucinations ( Johns et al., 2014). Since Moskowitz and Corstens (2007) proposed that dissociation may be this factor, substantial research has demonstrated robust, positive associations between measures of dissociation and hallucinations (most commonly auditory) using varied samples and methodologies. A recent meta-​a nalysis reported strong summary effects for hallucinations generally (r =​.46) and auditory hallucinations specifically (r =​.50) across different populations (Longden et al., 2020; see also Pilton et al., 2015). Using another methodological approach, Laddis and Dell (2012) found voice hearing in persons diagnosed with schizophrenia to predict almost 92% of the variance in overall dissociation scores. In addition, the high levels of childhood trauma and adversity in most voice hearers is consistent with a dissociation-​voice hearing relationship, given the firmly established connection between trauma and dissociative symptoms and disorders (Dalenberg et al., 2012). Finally, the dissociation hypothesis is further supported by the extremely high level of voice hearing in DID, estimated at 80–​90% of all DID patients (Şar & Öztürk, 2019). The experience of voices in DID (and Partial DID), interpreted as intrusions from other parts of the personality, appears similar to voices in schizophrenia, on the basis of limited comparative studies. For example, Dorahy et al. (2009) found broad similarities in phenomenology between the groups, including in voice location and mood-​congruence, while Laddis and Dell (2012) found similar levels of ‘voices arguing’ between the groups. As in the Pilton et al. (2015) meta-​analysis, these studies found the onset of voices occurred later in schizophrenia than in DID (Dorahy et al., 2009; Laddis & Dell, 2012). In contrast to the meta-​analysis, however, Dorahy et al. (2009) found more voices in DID than in schizophrenia; they, along with Laddis and Dell (2012), also found considerably more child voices in DID than in schizophrenia (where they were almost non-​existent). Of potential use for differential diagnosis, Laddis and Dell (2012) found delusional interpretations of voices to be significantly more common in schizophrenia than in DID, and Tschoeke, Steinert, Flammer and Uhlmann (2014) found very few voices hearers with schizophrenia reported feeling ‘controlled’ by their voices, in comparison to more than half of those with BPD (which, in this study, were overwhelmingly diagnosed with a comorbid dissociative disorder). The evidence thus suggests that AVH are dissociative in nature; the differences seen between voice hearing in schizophrenia and in DID (child voices, age of onset, sense of control, and possibly number of voices) may be more a consequence of the higher levels of dissociation in DID than evidence for any essential group differences in voice hearing. Thus, when a person experiences voices they consider to be different from their own thoughts and inner speech, such voices may be best characterized as split-​off representations of the self (or self-​other relationships) that intrude into functioning parts of the personality (see also Dorahy & Palmer, 2016; Longden, Moskowitz, Dorahy & Perona-​ Garcelán, 2019; Moskowitz et al., 2017). Hallucinations in Other Sensory Modalities Other than AVH, hallucinations may occur in any sensory modality. Auditory hallucinations which are non-​verbal (i.e., sounds, but not voices) are not infrequent. These hallucinations, when trauma related, may involve dissociative parts trying to block memories or experiences (i.e., ‘white noise’) but may also be flashbacks. Flashbacks are the hallmark of PTSD and can be understood as dissociative intrusions of sensory/​perceptual aspects of a previous trauma; importantly, an individual may be unaware of the link between these experiences and past events (Nadel & Jacobs, 1996). Available evidence, though preliminary, suggests a significant relationship between dissociation and non-​auditory hallucinations. For example, Yamasaki et al. (2016) assessed correlates of auditory and visual hallucinations in more than 4000 Japanese adolescents and found hallucinatory experiences to be significantly associated with dissociation. Dissociation was also found to significantly mediate the relationship between peer victimization and hallucinations.

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Nesbit et al. (in press) found dissociation variables to significantly mediate between experiences of childhood trauma and non-​auditory hallucinations for persons diagnosed with DID and, to a lesser extent, those diagnosed with schizophrenia. While Longden et al.’s (2020) meta-​analysis identified only four studies for visual hallucinations, the overall effect size (r =​.48) was almost as strong as that detected for auditory experiences. Investigations into hallucinations in modalities other than auditory and visual are intriguing but limited. In one study of persons with first-​episode psychosis, most of whom reported non-​auditory hallucinations, a significant relationship between dissociation and visual, tactile, olfactory, and gustatory hallucinations was demonstrated (Longden, House & Waterman, 2016). This relationship remained significant even after controlling for exposure to adversity and psychological distress. Taken together, it may be the case that traumatic dissociation is associated with multi-​modal hallucinations, which in psychotic disorders may be interpreted delusionally, in a manner which we now discuss.

Delusions For many years, delusions had been conceptualized as ‘false beliefs’ held with ‘conviction’, and unaffected by ‘opposing evidence’. However, on the basis of numerous counterexamples, the framers of the DSM-​5 decided that delusions need not be false beliefs, derived from external reality, or based on faulty inference (as opposed to subjective experience with minimal inference) in order to be deemed clinically relevant (Bortolotti, 2013). Rather, the DSM-​5 (APA, 2013) defines delusions as ‘fixed beliefs that are not amenable to change in light of conflicting evidence’ (p. 87). Common delusions include paranoia, grandiosity, and delusions of reference (where everyday objects or events, such as newspaper headlines, are interpreted as having unique, personal meaning). Delusions which are characterized as ‘bizarre’, considered particularly relevant to schizophrenia, feature content not reflecting typical life experiences and which members of the person’s cultural group would deem implausible (APA, 2013). Many of Kurt Schneider’s first rank symptoms, such as passive influence symptoms involving experiences that one’s thoughts, feelings or actions are influenced by an outside force, are typically considered forms of bizarre delusion. Delusions of Control /​Passivity Experiences Kurt Schneider argued that certain symptoms, which he saw as deriving from a breakdown in the ego/​world boundary, were strongly predictive of schizophrenia, and called them first-​rank symptoms (Schneider, 1959/​1950). These first rank symptoms consisted of certain auditory hallucinations (multiple voices conversing with themselves, voices commenting on one’s behavior), thought disturbances (thoughts being inserted, withdrawn or broadcast), and passivity phenomena (feeling that one’s thoughts, actions, or emotions were controlled by another force; Moskowitz & Dorahy, 2021). First rank passivity symptoms are strongly emphasized in both the DSM-​5 (where they are called ‘delusions of control’) and the ICD-​11 diagnostic criteria for schizophrenia. In the latter, they are simply called ‘experiences of influence, passivity or control’ and not identified as delusions. According to the DSM-​5, passivity experiences are common in both schizophrenia and DID; indeed, the language used is almost identical: schizophrenia (‘feelings, impulses, thoughts or actions… experienced as… [not] under one’s own control’, APA, 2013, p. 289) and DID (‘a feeling that attitudes, emotions, and behaviors… are “not mine” and/​or “not under my control” ’, APA, 2013, p. 293). Indeed, a recent study found delusions of control to be expressed equally in both schizophrenia and DID patients (Martinez et al., 2020). Nonetheless, in both the DSM-​5 and ICD-​11, DID is not considered in the differential diagnosis of schizophrenia. However, available research suggests that passivity symptoms are not only common in DID (Şar, Akyüz, & Doğan, 2007), but are present at a considerably higher rates than in schizophrenia (Laddis & Dell, 2012; Ross et al., 1990). In DID (and Partial DID), such symptoms are the results of dissociative intrusions and withdrawals between different parts of the personality. The possibility that first-​rank symptoms could result from dissociative processes, rather than from a disturbance in the ego/​world boundary, was not envisioned by Schneider, partly because he did not accept the existence of dissociative disorders (Moskowitz & Heim, 2019). In addition, there is some evidence to suggest that passivity phenomena are related to dissociation in psychotic patients. For example, Goff, Brotman, Kindlon, Waites and Amico (1991) found psychotic patients with delusions of possession (which conceptually overlaps with experiences of passivity, influence or control) to have significantly higher dissociation scores than patients not endorsing such delusions. The former group also reported more auditory hallucinations, beliefs that their thoughts were being controlled, and childhood sexual abuse, than the comparison group. More recent research indicates that first-​rank symptoms are linked with measures of dissociation in patients with schizophrenia (Ross & Keyes, 2004; Şar et al., 2010), mixed-​d iagnosis psychiatric patients (Chiu et al., 2016; Ross & Browning, 2016), and mixed samples of community and clinical participants (Somer, Ross, Kirshberg, Bakri & Ismail, 2015).

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Importantly, the first rank symptom of thought-​broadcasting or thought projection, which Schneider added later, is rare in DID but common in schizophrenia (Ross et al., 1990). This symptom cannot be understood simply as a passive influence symptom, as it also includes a delusional belief; that is to say, thinking that one’s thoughts are public, not private, cannot be based only on a description of one’s internal experience (unlike, for example, thought insertion). In contrast, genuine passive influence symptoms may simply derive from the influence of one dissociative identity on another. Since some of Schneider’s symptoms can also clearly be due to a disturbance in the boundary between the self and the world (Sass, Pienkos, Nelson & Medford, 2013), diagnostic confusion can easily ensue. At the very least, the presence of passive influence symptoms, particularly in the absence of the negative symptoms of schizophrenia, should raise the possibility of DID or Partial DID.

Delusions of Reference, Paranoia, Grandiosity and Other Delusions But what of non-​bizarre delusions, such as paranoia or grandiosity? Might they also be related to dissociation? A recent meta-​analysis found evidence of this, after reviewing 30 effect sizes generated from a range of clinical and non-​clinical studies on the relation between delusional beliefs and dissociation (Longden et al., 2020). A moderate-​to-​large statistically heterogeneous relationship between delusions and dissociation was found: r =​0.42. There is also some empirical support for this position. For example, Černis et al. (2014) found links between depersonalization, as measured by the Cambridge Depersonalization Scale, paranoia and delusions in persons with persecutory delusions, and Sun et al. (2018) found that measures of dissociation (the DES-​II and SCID-​D -​R) were both significantly associated with PANSS-​rated delusions in 66 patients with first episode psychosis. Links between dissociation and non-​bizarre delusions, such as paranoia, grandiosity and delusions of reference, may be explained by different mechanisms than those underlying experiences of passivity/​delusions of control. While the latter may be directly based on a dissociative personality structure, non-​bizarre delusions can be seen as memory-​related; namely, explanations for anomalous experiences (Maher, 1988), which might be dissociated traumatic memories or implicit memories of early attachment experiences. Such early decontextualized memories would typically be associated with overwhelming affect (Garfield, 2009). As decontextualization relates to both traumatic memories (Nadel & Jacobs, 1996) and schizophrenia (Danion, Rizzo & Bruant, 1999), such delusions can be understood as deriving from sensory and emotional flashbacks that are so dissociated from their spatiotemporal context as to be unrecognizable as memories (Hardy, 2017; Moskowitz, Nadel, Watts & Jacobs, 2008). Importantly, the reemergence of implicit memories of early disorganized attachment experiences, which cannot be recalled as autobiographical memories, may provide the foundation for a wide range of delusions, including paranoia and grandiosity (Liotti & Gumley, 2019; Moskowitz & Montirosso, 2019). In addition, delusions may serve to maintain such powerful affective memories, either explicit or implicit (including ‘body’ memories), as dissociated structures. Delusional explanations for unrecognized memories could keep memories from becoming conscious by allowing for: 1) the expression of the affective, without the cognitive, component of the memory (notably, the development of delusions is associated with a reduction in anxiety or affective arousal; Cunningham Owens et al., 2005), and 2) the symbolic expressions of affect associated with the real life events (i.e., feeling fear and disgust at delusional snakes in one’s bed instead of at memories of sexual abuse episodes; Moskowitz & Montirosso, 2019). Such a coping mechanism, based on dissociated memories, may be required in individuals with limited dissociative capacity. That is to say, in highly dissociative individuals, such as those with DID or Partial DID, explicit traumatic or implicit attachment-​based memories may be compartmentalized in dissociated parts of the personality; in individuals with psychotic disorders, whose levels of dissociation are lower, the development of delusions may be a necessary alternative coping response. In this regard, it is noteworthy that non-​bizarre delusions are less common in DID than in schizophrenia (Laddis & Dell, 2012; Steinberg, 1995). Indeed, a recent study found such self-​referential delusions (including paranoid and grandiose delusions, as well as delusions of reference) to be substantially more common in persons diagnosed with schizophrenia than in persons diagnosed with DID (Martinez et al., 2020).

Summary of the Relation Between Dissociation, Delusions and Hallucinations In summary, AVH, or voice hearing, and delusions of control or passive influence symptoms, can both be conceptualized as the direct expression of dissociative identities, or dissociative parts of the personality. Both of these groups of symptoms (which include most of Schneider’s first rank symptoms of schizophrenia) may be best understood as dissociative intrusions from one dissociative part of the personality into another. In contrast, other forms of hallucinations and non-​bizarre

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delusions such as delusions of reference, paranoia and grandiosity, may represent traumatic flashbacks –​either directly, in the form of sensory flashbacks (hallucinations), or as interpretations of flashbacks (delusions, particularly when they consist primarily of strong emotions). Finally, such emotionally-​based flashbacks, which may underlie paranoia or grandiosity, could relate to early disorganized attachment experiences, for which no autobiographical memory is possible (Moskowitz & Montirosso, 2019).

The Prevalence and Significance of Dissociative Symptoms in Schizophrenia and Other Psychotic Disorders In the previous sections, it has been established that most forms of delusions and hallucinations can be linked to dissociation and are commonly found in dissociative disorders. It has been further argued that, for the most part, the dissociative basis for these symptoms applies not only to dissociative disorders but also to psychotic disorders (and, to some extent, non-​clinical populations). But what of the converse question –​are classic dissociative symptoms, namely, dissociative amnesia, dissociative identities or personality states, and depersonalization and derealization common in psychotic disorders? In considering this issue, the first challenge faced is that of differential diagnosis. For example, while there is a large body of literature that focusses on disturbances of self in schizophrenia which, as typically defined, overlaps considerably with depersonalization, almost none of these studies screen for dissociative disorders. This is a considerable problem, as a review of the few studies that did screen for DID, for example, in schizophrenia samples conservatively estimated the prevalence as 10% (Schäfer et al., 2019). Thus, the issue raised in this section has not yet been addressed by research. Nonetheless, a few comments can be made. With regard to dissociative identities, this would seem to be an issue of differential diagnosis. Given the prevalence of psychotic, particularly first-​rank, symptoms in dissociative disorders (see Şar, Chapter 25, this volume), the presence of dissociative identities in persons also experiencing psychotic symptoms should rule out schizophrenia or a primary psychotic disorder. Rather, DID or Partial DID, or perhaps a hybrid diagnosis not currently in the nomenclature, would seem to make the most sense. On the other hand, as noted above, symptoms of depersonalization and derealization are common in psychotic disorders; similarities and differences between such symptoms in psychotic disorders and dissociative disorders are just beginning to be explored (see Sass et al., 2013), but would seem to be a fruitful area for more work. Finally, dissociative amnesia seems to be rare in genuine psychotic disorders (Steinberg et al., 1994). Indeed, from clinical experience it appears that persons who have recovered from psychotic episodes often have very clear memories of their psychotic experiences, even when their current state of mind is non-​psychotic. This would seem to be a potentially important clue for differential diagnosis and is a crucial area for future research.

Discussion Having reviewed the prevalence of trauma in psychotic disorders, potential mediating factors between trauma and psychotic symptoms, and the dissociative underpinnings of psychotic symptoms, along with psychotic symptoms in dissociative disorders and dissociative symptoms in psychotic disorders, we now turn to the implications of our findings.

Differential Diagnosis and Novel or Hybrid Diagnoses The reliability and validity of psychiatric diagnoses has been challenged for decades (Read & Dillon, 2013). Many argue that psychiatric disorders in general, and psychotic disorders and symptoms in particular, are best conceptualized as lying on a continuum with normal (non-​clinical) experiences (Van Os et al., 2009), and that the effective treatment of symptoms does not require a diagnosis (Bentall, 2009). The diagnosis of schizophrenia also carries with it enormous stigma, which has led to numerous calls for it to be replaced. Nonetheless, the current dominant diagnostic systems continue to use it. If future research evidence supports a limited role for diagnosis in psychiatry and clinical psychology, perhaps at least the term schizophrenia can be replaced. As this review makes clear, the proper differential diagnosis between psychotic and dissociative disorders cannot rely on psychotic symptoms, as all of them can arise (some more frequently than others) through dissociative processes. Different issues arise, however, when considering depersonalization-​derealization disorder (DDD) or DID/​Partial DID in comparison to schizophrenia and other psychotic disorders. DDD shares with schizophrenia disturbances of self but lacks the fundamental disturbance in the ego/​world boundary that is common in the latter (Sass et al., 2013). In addition, delusional interpretations of derealization or depersonalization (or other psychotic symptoms) are rare in DDD, but

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common in schizophrenia (Hamilton & Simeon, 2019). However, while DID/​Partial DID, like DDD, also lack the ego/​ world boundary issues present in schizophrenia, psychotic symptoms, particularly voice hearing and other Schneiderian symptoms, are common. While there is preliminary evidence that certain psychotic symptoms may distinguish between the groups –​such as hearing child voices or delusions implying ego/​world confusion –​genuine dissociative symptoms such as dissociative amnesia and the presence of dissociative identities would seem to have more promise for differential diagnosis. Distinguishing between DID/​Partial DID and schizophrenia/​primary psychotic disorders is likely to remain highly problematic until: 1) the diagnostic criteria for schizophrenia are modified to de-​emphasize psychotic symptoms –​particularly voice hearing and passive influence experiences and 2) DID/​Partial DID (along with DDD) are highlighted as important differential diagnoses for schizophrenia/​primary psychotic disorders. We will likely have to wait for the DSM-​6 and ICD-​12 for this to occur but can only hope that the research evidence at that point will be too overwhelming to ignore. The possibility of a hybrid dissociation/​psychosis diagnosis, typically called dissociative psychosis, was proposed for both the DSM-​5 and ICD-​11 but rejected by the editors. Such a condition was well-​recognized early in the twentieth century as hysterical psychosis (Witztum & Van der Hart, 2019), but has been absent from the nomenclature since then. The need for such a diagnosis, however, in addition to existing dissociative disorder diagnoses, is debated; perhaps this question can only be resolved once the differential diagnosis issues outlined above are adequately addressed.

Clinical Implications In addition to the conceptual/​d iagnostic arguments for looking for dissociative disorders in persons currently diagnosed with schizophrenia or a psychotic disorder, there are clinical arguments as well. First, the term schizophrenia carries with it enormous stigma and prejudice, and profound feelings of hopelessness and helplessness in both the person diagnosed and their family. The term schizophrenia is strongly associated with notions of biogenetic causality (i.e., a ‘brain disease’), encouraging clinicians not to consider a history of trauma (Read & Dillon, 2013). Many clinicians are reluctant to ask about childhood trauma in persons diagnosed with schizophrenia, or to minimize the importance of such histories when they are documented or revealed. Yet the evidence is clear that asking about trauma histories is experienced as helpful (Toner, Daiches & Larkin, 2013), and can be the beginning of trauma-​based approaches that can relieve, or even eliminate, psychotic symptoms (Gonzales et al., 2019). In addition, evidence is accruing that psychotic symptoms, even in persons who appear to be properly diagnosed with schizophrenia or a psychotic disorder, can be worked with not only from a trauma perspective, but also from a dissociation perspective that treats the symptoms as representing parts of the personality (Moskowitz et al., 2017). Clearly, the recognition of important dissociation-​psychosis relationships should pave the way for further clinical breakthroughs in the treatment of psychotic symptoms, regardless of diagnosis.

Research Implications Because dissociation and dissociative disorders are almost never considered by schizophrenia and psychosis researchers (who overwhelmingly are biogenetic, not environmental-​t raumatic, in their orientation), and because of the frequency of psychotic symptoms in dissociative disorders, the prevalence of dissociative disorders in (apparently) psychotic populations remains unknown. Yet the limited research that has addressed this issue has found a substantial minority of dissociative disorders hidden within psychotic populations. This raises the possibility that much research on psychotic disorders is fundamentally flawed, as the samples could contain a substantial number of persons who, more properly, would be diagnosed with a dissociative (or another posttraumatic) disorder. Clearly, the differential diagnosis of psychotic and dissociative disorders carries major research implications. In addition, there are clearly important specific avenues for future research. Just a few will be raised here: 1) can all persons who hear voices be effectively treated with a dissociative (dialogical) approach? If not, why not? 2) How well do certain symptoms actually distinguish between diagnostic groups –​such as child voices, delusions of reference and paranoia, thought projection, ego-​d isturbances, etc?, 3) can certain psychotic symptoms be linked to early attachment experiences? And perhaps most importantly, if both psychotic and dissociative disorders have their genesis in early attachment and/​or traumatic experiences, how and when do they diverge? Are there different types of trauma, or a different degree of trauma experienced, or do certain persons have more of a dissociative ‘capacity’ –​whatever that might mean (see Dell, Chapter 14, this volume)? Attempts to address these questions would potentially reap significant clinical benefits.

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Conclusions The question embedded in our title is whether psychotic symptoms are traumatic in origin and dissociative in kind. When this question was first posed in 2009, the chapter ended with a ‘yes’ for voice hearing but was equivocal for the other psychotic symptoms. In the past decade, however, scores of research articles and reviews have moved the needle; it is now widely recognized that trauma is a major cause for psychotic symptoms, and that dissociation is related to many, if not most, psychotic symptoms. Indeed, the position that AVH be conceptualized as dissociative, instead of psychotic, first raised in 2007 (Moskowitz & Corstens, 2007) is gaining traction, and dissociation now appears to be linked to other forms of hallucinations and many, if not most, forms of delusions (Longden et al., 2020). The frequency with which dissociation also underpins thought disorder and catatonia/​d isorganized behavior, however, remains to be determined. The importance of this question cannot be overstated. Treating persons with a psychotic disorder from a trauma/​ dissociation perspective, and correctly identifying persons who more accurately should be diagnosed with a dissociative disorder, is of overwhelming importance. Thousands, if not hundreds of thousands, of persons would be spared the shame, stigma and inappropriate (as well as potentially dangerous) treatment associated with a biogenetic view of schizophrenia if they can be seen instead as suffering from a trauma-​based, and largely dissociative, condition. The rest of the psychiatric and psychological world must be convinced of the importance of this task if significant suffering is to be alleviated. Identifying the obstacles to changing the paradigm is a first step to creating the conditions for change; we hope that the existing research and clinical commitment from those who share our concerns will create the momentum to allow this to occur.

Note 1 A note about terminology: for historical continuity, and for ease of communication, we will continue to refer to hallucinations, delusions, and disorganized thinking and behavior as ‘psychotic’, even as our considerations lead us to suggest that some of them may be more accurately characterized as ‘dissociative’ than as ‘psychotic’.

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O., & Waterman, M. G. (2016). Associations between nonauditory hallucinations, dissociation, and childhood adversity in first-​episode psychosis. Journal of Trauma & Dissociation, 17, 545–​560. Longden, E., Madill, A., & Waterman, M. G. (2012). Dissociation, trauma, and the role of lived experience: Toward a new conceptualization of voice hearing. Psychological Bulletin, 138, 28–​76. Longden, E., Moskowitz, A., Dorahy, M., & Perona-​Garcelán, S. (2019). Auditory verbal hallucinations: Prevalence, phenomenology, and the dissociation hypothesis. In A. Moskowitz, M. J. Dorahy & I. Schäfer (Eds.). Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology (2nd ed., pp. 207–​222). Chichester, West Sussex: Wiley Blackwell.

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Maher, B. A. (1988). Anomalous experience and delusional thinking: The logic of explanations. In T. F. Oltmanns & B. A. Maher (Eds.). Delusional beliefs (pp. 15–​33). New York, NY: Wiley. Martinez, A. P., Dorahy, M. J., Nesbit, A., Palmer, R., & Middleton, W. (2020). Delusional beliefs and their characteristics: A comparative study between dissociative identity disorder and schizophrenia spectrum disorders. Journal of Psychiatric Research, 131, 263–​268. Matheson, S. L., Shepherd, A. M., Pinchbeck, R. M., Laurens, K. R., & Carr, V. J. (2013). Childhood adversity in schizophrenia: A systematic meta-​a nalysis. Psychological Medicine, 43, 225–​238. McKay, M.T., Cannon, M., Chambers, D., Conroy, R. M., Coughlan, H., Dodd, P., Healy, C., O’Donnell, L., & Clarke, M.C. (2021). Childhood trauma and adult mental disorder: A systematic review and meta-​a nalysis of longitudinal cohort studies. Acta Psychiatrica. Scandinavica, 143, 189–​205. Morrison, A. (2013). Cognitive therapy for people experiencing psychosis. In J. Read & J. Dillon (Eds.) Models of madness (2nd ed., pp 319–​335). London, UK: Routledge. Moskowitz, A., & Corstens, D. (2007). Auditory hallucinations: Psychotic symptom or dissociative experience? The Journal of Psychological Trauma, 6(2–​3), 35–​63. Moskowitz, A., & Dorahy, M. J. (2021). First rank symptoms, dissociation and dissociative disorders: A commentary on Humpston et al. (2020). Schizophrenia Research, 228, 460–​461. Moskowitz, A., & Heim, G. (2011). Eugen Bleuler’s Dementia Praecox or the Group of Schizophrenias (1911): A centenary appreciation and reconsideration. Schizophrenia Bulletin, 37, 471–​479. Moskowitz, A., & Heim, G. (2019). The role of dissociation in the historical concept of schizophrenia. In A. Moskowitz, M. J. Dorahy & I. Schäfer (Eds.). Psychosis, trauma and dissociation: Evolving perspectives on severe psychopathology (2nd ed., pp. 55–​67). Chichester, West Sussex: Wiley Blackwell. 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Dissociation as a mediator between child abuse and hallucinations: An exploratory investigation using clinical samples with dissociative identity disorder and schizophrenia spectrum disorders. Journal of Trauma and Dissociation. O’Driscoll, C., Laing, J., & Mason, O. (2014). Cognitive emotion regulation strategies, alexithymia and dissociation in schizophrenia: A review and meta-​a nalysis. Clinical Psychology Review, 34, 482–​495. Pearson, D., Smalley, M., Ainsworth, C., Cook, M., Boyle, J., & Flury, S. (2008). Auditory hallucinations in adolescent and adult students: Implications for continuums and adult pathology following child abuse. The Journal of Nervous and Mental Disease, 196, 634– ​638. Pearce, J., Simpson, J., Berry, K., Bucci, S., Moskowitz, A., & Varese, F. (2017). Attachment and dissociation as mediators of the link between childhood trauma and psychotic experiences. Clinical Psychology & Psychotherapy, 24, 1304–​1312. Peh, O. H., Rapisarda, A., & Lee, J. (2019). Childhood adversities in people at ultra-​h igh risk (UHR) for psychosis: A systematic review and meta-​a nalysis. Psychological Medicine, 49, 1089–​1101. Pilton, M., Varese, F., Berry, K., & Bucci, S. (2015). The relationship between dissociation and voices: A systematic literature review and meta-​a nalysis. Clinical Psychology Review, 40, 138–​155. Pollard, C., Bucci, S., MacBeth, A., & Berry, K. (2020). The revised Psychosis Attachment Measure: Measuring disorganized attachment. British Journal of Clinical Psychology, 59(3), e12249. Rafiq, S., Campodonico, C., & Varese, F. (2018). The relationship between childhood adversities and dissociation in severe mental illness: A meta-​a nalytic review. Acta Psychiatrica Scandinavica, 138, 509–​525. Read, J. (2013). Childhood adversity and psychosis: From heresy to certainty. In J. Read & J. Dillon (Eds.), Models of madness: Psychological, social and biological approaches to psychosis (pp. 249–​275). Routledge/​Taylor & Francis Group. 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33 SOMATOFORM DISSOCIATION, AGENCY, AND CONSCIOUSNESS Ellert R. S. Nijenhuis

Historically, dissociative (or what at the time were referred to as ‘hysterical’) symptoms encompassed sensory, motor, affective, cognitive and behavioral phenomena ( Janet, 1901, 1907). Some concerned losses (mental stigmata or negative symptoms) and others intrusions (mental accidents or positive symptoms). The somatoform losses included insensitivity to pain (analgesia), other sensory deficits (blindness, bodily numbness, other anesthesias), as well as paralyses. The somatoform intrusions pertained to phenomena such as (physically unexplained) pain, choking, smells, and sensations of being pushed or pulled, or touched, and involuntary movements and motor actions. The stigmata were invariant (an absence is an absence), and the accidents were far more variable (intrusions can take many forms and can have many ‘contents’). The symptoms were dissociative inasmuch as they were grounded in the existence of two or more insufficiently integrated “[sub]systems of ideas and functions” ( Janet, 1907, p. 332) of a biopsychosocial system that Janet referred to as the personality.1 Conducting the first empirical study of hysterical disorder, Briquet (1859) found it was associated with terrible life occurrences, particularly among women and children. These basic understandings of hysteria became largely lost until a renewal of interest in dissociative symptoms and disorders from the early 1980s. Yet, this development mostly excluded somatoform dissociative symptoms and disorders, although ICD-​10 (WHO, 1992) included dissociative disorders of movement and sensation. However, our recurrent clinical experiences and observations from the 1980s, as well as the literature on hysteria, suggested to my collegues and me the following hypotheses and formulations: H1. Sensory and motor (‘somatoform’) symptoms in dissociative disorders often reflect dissociative symptoms. H2. The involved symptoms are dissociative when they involve features of dissociative ‘parts’ or agents.2 H3. Some somatoform symptoms of dissociative disorders can be categorized as negative (absences) and others as positive (intrusions); H4. Somatoform dissociative symptoms are sensitive and specific to individuals with dissociative disorders. The disorders include, • ICD-​10 Dissociative Disorders of Movement and Sensation, described in DSM-​III, DSM-​IV and DSM-​5 as Conversion Disorder. • What in DSM-​IV was called Dissociative Disorder Not Otherwise Specified (DDNOS); many of these cases involve what will be called in ICD-​11 (WHO, 2019) Partial Dissociative Identity Disorder (Partial DID). • Dissociative Identity Disorder (DID). • Posttraumatic Stress Disorder (PTSD; APA, 2013) and Complex PTSD (WHO, 2019) that I regard, irrespective of its subtypes, as a relatively simple dissociative disorder (Nijenhuis, 2015b, 2017b). H5. The severity of somatoform dissociative symptoms is positively correlated with the complexity of the dissociative disorder. H6. Somatoform dissociative symptoms are in many cases highly co-​occurrent with cognitive-​emotional or ‘psychoform’ dissociative symptoms.

DOI: 10.4324/9781003057314-39

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H7. Somatoform dissociative symptoms are typically, although not exclusively, related to adverse life occurrences and major intrapersonal and interpersonal stress or conflicts. The review of empirical findings and reflections offered in this chapter are consonant with these hypotheses. I will also discuss that developing a clear, distinct and internally consistent nomenclature for and classification of the body-​related symptoms and disorders of present concern depends on solid theoretical formulations. A core question in this regard is what dissociative symptoms are symptoms of. H2 states that somatoform dissociative symptoms are manifestations of dissociative agents, of partly conscious subsystems of an organism-​environment or ecological system, discussed below. In this frame, somatoform phenomena that do not relate to dissociative agents are not considered dissociative.

What are Dissociative Symptoms Symptoms of? It cannot be said on the mere face of it if a sensory or motor phenomenon is dissociative. Like forgetting and hearing voices, low body awareness and intruding body sensations may be, but need not be, dissociative. To judge what applies as dissociative, we must first of all formulate what somatoform dissociative phenomena are symptoms of. This determination takes a clear, distinct and internally consistent definition of ‘dissociation.’ The Merriam-​Webster online dictionary states that ‘dissociation’ involves the act or process and result of dividing a whole into parts. Acts/​processes and results are two sides of a coin. For example, sensations, movements, and feelings result from the acts of sensing, moving, and feeling. If individuals are dissociated, they engage a dissociative act/​process, resulting in, for example, sensations that are dissociated from each other. Definitions of acts tend to refer to processes. For example, the Oxford English Dictionary’s main definition of act says that action stands for “the fact or process of doing something, typically to achieve an aim.” “Process” involves “a series of actions or steps taken in order to achieve a particular end.” The general definitions of “act” and “process,” thus, are circular. Since “process” can also stand for “a series of mechanical or chemical operations,” the former of which in particular is not ideally suited when theorizing about dissociation in psychology/​psychiatry, it is preferable to speak of dissociative acts or actions. As strivings to achieve an aim or goal (Greek: telos), organisms’ actions are essentially guided by their longings. Organisms long to get something that is useful to them, to avoid or get rid of something that is harmful to them, and to leave alone what is neither useful nor harmful to them. The act of dissociation, then, is teleological (Nijenhuis, 2015a,b, 2019). Defining dissociation as a structural and teleological division of a whole into subsystems would be overly general, as it would pertain to all sorts of subsystems (e.g., cells, groups of cells, and organs). Merriam-​Webster’s definition provides a clue to delimit dissociative divisions in psychology/​psychiatry to conscious subsystems. It states that in dissociation one part pertains to “mainstream conciousness,” implying the existence of at least a second conscious part. In keeping with this, I define dissociation as a division of a whole system into partly conscious subsystems, more specifically, subsystems enacting their own experience and idea of self, environment, and self as an intrinsic part of this environment (Nijenhuis, 2015a,b, 2017a, 2019; Nijenhuis & Van der Hart, 2011a,b).

The Somatoform Dissociation Questionnaire (SDQ-​20) To measure the presence and severity of somatoform dissociative symptoms, we developed the Somatoform Dissociation Questionnaire (SDQ-​20; Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1996; 1998b). As a first step, we sampled somatoform dissociative symptoms we had clinically observed. We defined somatoform dissociative phenomena as sensory and motor phenomena that existed for one or more but not all dissociative agents. For example, we regarded the inability to sense a body part as an instance of dissociative anesthesia if one or more but not all dissociative agents had it. We only regarded intruding somatoform sensations and movements as dissociative insofar as they involved sensations and movements of one or more dissociative agents that intruded on one or more other dissociative agents. Next, we asked clinicians with substantial experience in the assessment and treatment of complex dissociative disorders if they regarded our short symptom descriptions (77 items in total) as likely instances of dissociation. On this basis, two items were removed. We subsequently invited individuals with and without complex dissociative disorders to fill out the questionnaire and investigated which set of items best distinguished individuals with and without a DSM-​I V dissociative disorder. We found a set of 20 items (SDQ-​20) that basically converge with the major symptoms of hysteria as formulated by Janet. They include such negative symptoms as analgesia (“Sometimes my body, or a part of it, is insensitive to pain”), kinesthetic or visual anesthesia (“Sometimes it is as if my body, or a part of it, has disappeared”), and

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motor inhibitions (e.g., “Sometimes I am paralysed for a while”). The SDQ-​20 also includes such positive somatoform dissociative symptoms as pain (e.g., “Sometimes I have pain while urinating”). The instrument has excellent psychometric properties. Our psychometric findings in Dutch/​Flemish samples have been replicated in Turkey (Şar, Kundakçı, Kızıltan, Bakım, & Bozkurt, 2000), France (El-​Hage, Darves-​Bornoz, Allilaire, & Gaillard, 2002), Germany/​Switzerland (Mueller-​Pfeiffer et al., 2010), Poland (Pietkiewicz, Helka, & Tomalski, 2019), Portugal (Espirito-​Santo & Pio-​Abreu, 2007), Spain (Gónzalez-​Vázquez et al., 2017), and Sweden (Nilsson, Lejonclou, Jonsson, Svedin, & Holmqvist, 2015). In most SDQ-​20 studies somatoform dissociation was not or only weakly related to age (Maaranen et al., 2004; Şar et al., 2000). In some clinical studies, women had slightly higher scores than men (El-​Hage et al., 2002; González-​ Vásquez et al., 2017; Müller-​Pfeiffer et al., 2010; Nijenhuis, Van der Hart, & Kruger, 2002; Pietkiewicz et al. 2019), but men had slightly higher scores in a general population study (Maaranen et al., 2004).

Terminology and Classification Before we can consider the existence and severity of somatoform dissociation in various mental disorders, we must briefly consider existing terminological and classificatory diversity and confusion, as well as touch upon the problematic concept of ‘conversion.’

DSM The various editions of the DSM do not use the terms ‘somatoform dissociation’ or ‘somatoform dissociative disorders.’ For example, the DSM-​5 (APA, 2013) uses the terms ‘conversion symptoms’ and ‘conversion disorder (functional neurological symptom disorder).’ Starting with the DSM-​III there was an attempt to remove orientation-​ specific terms such as neurosis, but conversion, which is based on a psychoanalytic conceptualization of somatization, remains in the DSM. The various versions of the DSM do not explain what gets converted into what, and how this conversion would work. In the DSM-​5 chapter on dissociative disorders it is mentioned that DID includes disruptions of identity that can be accompanied “by alterations in sensory-​motor functioning” (p. 292). These are not described as conversion symptoms, although the text for ‘conversion disorder’ mentions that conversion symptoms involve “altered voluntary motor or sensory function” (p. 318). If the authors of the DSM-​5 had honored the principle of internal consistency, they should have included the term ‘conversion symptoms’ in the text on DID. Had they done so, empirical, conceptual, and classificatory problems would have come to light. As detailed below, empirical research shows that ‘conversion symptoms’ are as characteristic of complex dissociative disorders as psychoform dissociative symptoms. But the DSM-​5 does not classsify or regard complex dissociative disorders as conversion disorders. Conversion and dissociation are treated as different, where for example, it is stated that “[d]‌issociative symptoms are common in individuals with conversion disorder” (p. 321). It does not, however, indicate what the difference(s) would be between dissociative and conversion symptoms. If the authors of the DSM-​5 actually held that ‘conversion’ involves converting a mental problem into a physical symptom, and that ‘dissociation’ stands for lack of integration, then they should have said that complex dissociative disorders involve two different essential actions (‘conversion’ and ‘dissociation’), not one (i.e., ‘dissociation’). The point is that, as mentioned before, DSM-​5 ‘conversion’ symptoms are as characteristic of complex dissociative disorders as DSM-​5 ‘dissociative’ symptoms. But the DSM-​5 says that ‘conversion’ is comorbid, rather than fundamental to complex dissociative disorders. The DSM-​5 term for conversion disorder, ‘functional neurological symptom disorder,’ is not any less confusing. Disorders manifest in signs and symptoms, but there are no ‘symptom disorders.’ Further, the involved symptoms are not understood as symptoms of a neurological condition, but as symptoms of a mental process called ‘conversion.’

ICD ICD-​10 uses the general term ‘Dissociative (Conversion) Disorders,’ one of which is ‘Dissociative Disorders of Movement and Sensation’ (WHO, 1992). The latter disorders include ‘Dissociative Motor Disorders,’ ‘Dissociative Convulsions,’ and ‘Dissociative Anesthesia and Sensory Loss.’ This terminology is conceptually much clearer and sound. A group of experts invited to formulate proposals for ICD-​11 recommended the term ‘Dissociative Disorders of Movement, Sensation, and Cognition.’3 This suggestion was not accepted; for unclear and unexplained reasons ‘Dissociative Neurological Symptom Disorder’ was substituted instead. However, in striking inconsistency with this

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designation, it is stated that the disorder “is characterized by the presentation of motor, sensory, or cognitive symptoms that imply an involuntary discontinuity in the normal integration of motor, sensory, or cognitive functions …” which “are not consistent with a recognized disease of the nervous system.” To overcome the various confusions, I will use in this chapter the terms ‘somatoform’ or ‘sensory and motor’ dissociative symptoms, or, briefly ‘somatoform dissociation,’ as well as ‘somatoform dissociative disorders’ or ‘sensory and motor dissociative disorders.’ However, Tables 33.1 and 33.2 employ the names of the disorder(s) that were used in the referenced studies. As explained in Chapter 38 (this volume), I further take the position that the mind and the body do not cause each other, but are different attributes of one system. I thus reject the idea that something mental can get converted into something physical, or vice versa.4 The basic fact is that no one has any idea how the mind would cause the body, or the body the mind.

Somatoform Dissociation in Various Mental Disorders Particular mental disorders but not others are associated with high SDQ-​20 scores (Table 33.1). The minimum total SDQ-​20 score is 20 and the maximum 100. TABLE 33.1  Somatoform dissociation (SDQ-​2 0) in various populations

Groups

Study

M

SD

Statistically significant differences

51.8

12.6

Nijenhuis et al., 1998b Nijenhuis et al., 1999 Şar et al., 2000 Vissia et al., 2016

57.3 55.1 58.7 57.1

14.9 13.5 17.9 17.3

DID > Dissociative Disorder NOS (DDNOS)/​ Depersonalization Disorder (DP) > Healthy Controls (HC) DID > DDNOS > HC DID > DDNOS DID > other mental disorders /​HC DID > PTSD > HC

Dissociative Disorder NOS (DDNOS) (+​some with depersonalization disorder [DP]) Nijenhuis et al., 1996 Nijenhuis et al., 1998b Nijenhuis et al., 1999

43.8 44.6 43.0

 7.1 11.9 12.01

Şar et al., 2000

46.3

16.2

Van Duijl et al., 2010

39.4

 7.4

51.8

17.4

38.4

12.4

Dissociative Identity Disorder (DID) Nijenhuis et al., 1996

530

DDNOS/​DP > HC DDNOS > HC DDNOS > other, nondissociative mental disorders DDNOS > other mental disorders/​HC

Spirit Possession Disorder (PD) Mixed Dissociative Disorders (DD) DID and DDNOS with suicidal Ozturk & Şar, 2008 ideation DID and DDNOS without suicidal idem ideation

Mixed Dissociative Disorders excl. Somatoform Dissociative Disorder Dissociative Amnesia, Fugue, Espirito-​Santo & Pio-​Abreu, 39.3 Depersonalization Disorder, 2007 DDNOS Müller-​Pfeiffer et al., 2010 48.4 DSM-​I V dissociative disorders

12.0

DD > other mental disorders (nondissociative)

15.3

DD > other mental disorders (nondissociative) DD > Somatization Disorder, Anxiety and Depression Disorders, HC DD > other mental disorders (nondissociative) DD > other mental disorders (nondissociative) (continued)

Espirito-​Santo & Pio-​Abreu, 2008

39.0

11.7

Müller-​Pfeiffer et al., 2013

Median 39 40.5

11

González-​Vásquez et al., 2017

PD > HC

14.6

532

532  Ellert R. S. Nijenhuis Table 31.1 Cont.

Groups

Study

M

SD

Statistically significant differences

Simeon et al., 2008

28.3

 7.6

Depersonalization Disorder > HC

Nijenhuis et al., 1999

31.9

 9.4

Şar et al., 2004

58.8

12.4

CD, PD, SD > mixed nondissociative mental disorders CD+​> CD-​

idem

43.4

14.7

Şar, Islam, & Ozturk, 2009b

37.1

 9.0

idem

34.2

13.3

Roelofs et al., 2002

30.5

 8.5

Conversion Disorder (CD) Conversion Disorder (CD)

Steffen et al., 2015 Spinhoven et al., 2004

33.3 30.7

 9.5  8.2

Conversion Disorder (CD)

Espirito-​Santo & Pio-​Abreu, 2007 Espirito-​Santo & Pio-​Abreu, 2008 González-​Vásquez et al., 2017

39.8

10.2

39.5

14

37.2

 9.4

Pietkiewicz, et al., 2019 Demartini et al., 2016 Espirito-​Santo & Pio-​Abreu, 2009

40.3 44.9 31.8

 9.9  8.9  9.2

Kuyk et al., 1999 idem idem Spinhoven et al., 2004

29.8 24.3 25.6 28.8

 7.5  6.8  7.3  7.4

NS > epilepsy

Lawton, Baker, & Brown, 2008

16.1 11.5  9.4

NS > E

Depersonalization Disorder Somatoform Disorders (DSM-​I V) Conversion Disorder (CD), Pain Disorder (PD), Somatization Disorder (SD) Conversion Disorder (CD) with DSM-​I V dissociative disorder (CD+​) Conversion Disorder (CD) without DSM-​I V dissociative disorder (CD-​) Conversion Disorder with DSM-​I V dissociative disorder (CD+​) Conversion Disorder without DSM-​ IV dissociative disorder (CD-​) Conversion Disorder (CD)

Conversion Disorder (CD) Conversion Disorder (CD) Conversion Disorder (CD) Functional Motor Symptoms (FMS) Somatization Disorder (SD)

CD+​ =​ CD-​

CD > other mental disorders (nondissociative) CD > HC CD > other mental disorders (nondissociative) CD > other mental disorders (nondissociative) CD > HC CD > other mental disorders (nondissociative) CD > other mental disorders FMS > HC SD > HC SD < DD, PTSD SD =​Anxiety and Depression Disorders

Nonepileptic Seizures (NS) Temporal lobe epilepsy Non-​temporal lobe epilepsy

NS, chronic pelvic pain/​epileptic seizures > other mental disorders (nondissociative) NS > E, but not after controlling for anxiety and depression

Epilepsy (E)

idem

Epilepsy (E)

Lally et al., 2009 idem Demartini et al., 2016

Median 39 Median 29 41.2 30.0 23.3

Martino et al., 2018

27.3

10.3

Pick, Mellers & Goldstein, 2017

Median 34

 8

NS, HC < Functional Motor Symptoms NS > Mild-​Major Depressive Disorder NS > HC

Yücel et al., 2002 Kucukgoncu et al., 2014

32.6 31.0

10.4 10

CH =​Low Back Pain (LBP) M > HC

Pain Disorder Chronic headache (CH) Migraine (M)

532

53

Somatoform Dissociation, Agency, and Consciousness  533 Table 31.1 Cont.

Groups

Study

M

SD

Statistically significant differences

Tension headache (TH) Chronic low back pain Chronic pelvic pain

Kucukgoncu et al., 2014 Yücel et al., 2002 Nijenhuis et al., 2003; Spinhoven et al., 2004 Farina et al., 2011b

32.9 30.6 25.7

 8.7 10.9  9.3

TH > HC LBP =​CH CPP > other mental disorders (nondissociative)

Bohn et al., 2013 Chiu et al., 2017

31.7 34.2

10.5 11.2

idem

27.8

 5.4

IC/​BPS-​ =​ HC

idem 24.9 Ozen, Ozdemir, & Bestepe, 2018 27.1

 4.4  6.8

GPP/​PD>HC

Female orgasmic and sexual pain disorders Fibromyalgia Syndrome Interstitial cystitis/​Bladder Pain Syndrome (BPS; urogenital disease without known organic causes) with childhood traumatization by close others (IC/​BPS+​) IC/​BPS without childhood traumatization by close others (IC/​ BPS-​) Acute Cystitis (AC, organic disease) Genito-​pelvic pain/​penetration disorder

Posttraumatic Stress Disorder (PTSD) Espirito-​Santo & Pío-​Abreu, 2007 Müller-​Pfeiffer et al., 2010 Espirito-​Santo & Pio-​Abreu, 2008 Vissia et al., 2016 Kienle et al., 2017

532

ICD-​10 Dissociative Disorder of idem Movement/​Sensation (DDMS) and PTSD with one or more negative somatoform dissociative symptoms but without positive somatoform dissociative symptoms (DDMS+​ PSTD) DDMS without PTSD idem Pietkiewicz et al., 2019 Male Prisoners (Many with PTSD; strong correlation Öğülmüş et al., 2020 for SDQ-​20 and features of PTSD) Borderline Personality Disorder (BPD) Korzekwa et al. 2008 Pietkiewicz et al., 2019

31.0

38.7

11.7

35.0

14.7

39.0

11.8

32.7 Median 36.0 Median 36.5

13.4

Median 28.5 30.2

 8.3

40.9

16.9

28.0 29.7

 6.8  9.1

27.7 27.0 38.2 32.6 30.0 39.6 30.0 24.3

 8.8  7.6 14.8 –​ 10.6 14.0 10.6  5.7

IC/​BPS+​> Acute Cystitis (AC)/​ HC

PTSD > other mental disorders (nondissociative) PTSD > other mental disorders (nondissociative) PTSD > other mental disorders (nondissociative) PTSD > HC (PTSD =​DDMS+​PTSD) > DDMS-​PTSD/​HC

CD > PTSD

CD > BPD

Eating Disorders (ED) Anorexia nervosa, restrictive (RA) Anorexia nervosa, binge purge (BA) Bulimia nervosa (BN) RA BA BN Binge eating disorder (BED)

Nijenhuis et al., 1999 Waller et al., 2003 Idem Idem Palmisano et al., 2018 Idem Idem Idem

(ED=​HC) < DDNOS < DID RA < BA BA > BN BN > HC BA, RA, BN > BED, HC BA > all other groups BED =​HC (continued)

534

534  Ellert R. S. Nijenhuis Table 31.1 Cont.

Groups

Study

M

SD

Statistically significant differences

AN, BN, Unspecifed ED

Nilsson et al., 2019a

30.0

 9.2

(AN =​BN =​unspecified eating disorder) > HC

Adolescents and young adults with ED

Nilsson et al. 2015

Median 29

Şar et al., 2001 Espirito-​Santo & Pio-​Abreu, 2008 Müller-​Pfeiffer et al., 2010

26.8 28.8

 6.4  6.6

26.5

11.6

Şar et al., 2000 Nijenhuis et al., 1999 Şar et al., 2000 González-​Vásquez et al., 2017 Fung et al., 2019 Pullin, Webster, & Hanstock, 2014

27.1 21.6 22.7 27.3 28.3 28.4

 9.5  1.9  3.5  8.4  9.6  8.7

27.4 27.0 26.2 23.4 23.3 23.2 23.2

 8.2  4.7 10.6  4.8  6.1  5.0  4.0

Adults in Italy Adults in Italy Adults in Germany Adults in the UK

Şar et al., 2000 Van Duijl et al., 2010 Waller et al., 2003 Pietkiewicz et al., 2019 Maaranen et al., 2004 Näring & Nijenhuis, 2005 Espirito-​Santo & Pio-​Abreu, 2008 Demartini et al., 2016 Palmisano et al., 2018 Steffen et al., 2015 Pick et al., 2017

 6.9  4.2  1.7  2

Adults in Germany

Kienle et al., 2017

Students in The Netherlands Students in Italy Czech young adults (M=​18.6 years) Czech adolescents

Näring & Nijenhuis, 2005 Farina et al., 2011a Bob et al., 2013 Kukla et al., 2010

22.8 22.7 21.4 Median 21 Median 21 24.4 24.6 23.2 22.6

Adolescents in Sweden

Nilsson et al., 2015

Other mental disorders Anxiety Disorder (Turkey) Anxiety Disorder /​Depression (Portugal) Anxiety Disorder (Germany/​ Switzerland) Schizophrenia (Turkey) Bipolar Mood Disorder (Netherlands) Mixed (Turkey) Mixed (Spain) Mixed (Hong Kong) Mixed, adolescents (Australia) Nonclinical samples Adults in Turkey Adults in Uganda Adults in the UK Adults in Poland Adults in Finland Adults in The Netherlands Adults in Portugal

 4.4  5.5  4.4  2.9

534

Trauma Symptom Checklist-​ 40 (Briere, 1996) x SDQ-​ 20: r =​.43

Median 22

According to the Theory of Structural Dissociation of the Personality (TSDP; Van der Hart, Nijenhuis & Steele, 2006), there is a spectrum of dissociative disorders involving more or less complex systemic divisions of the personality (see Steele & Van der Hart, Chapter 15, this volume). Simple dissociative disorders include (classic) PTSD and simple somatoform dissociative disorders. More complex dissociative disorders include Complex PTSD (a proposed diagnosis for ICD-​11 (WHO, 2019), more complex somatoform dissociative disorders and, particularly, dissociative disorders with a structural complexity that approaches and includes DID. In DSM-​5, the condition approaching DID is referred to as ‘Other Specified Dissociative Disorder, type 1’ (formerly DDNOS, ­example 1). For ICD-​11, our working group proposed an explicit diagnosis rather than inclusion in an ‘other specified’ grouping for conditions that approach but do not involve the degree of structural complexity that characterizes DID. In keeping with the core phenomenology of the disorder, we named it ‘Complex Dissociative Intrusion Disorder.’ The diagnosis became accepted but the name the framers of the ICD-​11 have applied to the disorder is Partial DID.

53

534

Somatoform Dissociation, Agency, and Consciousness  535

This alternative name is problematic in that all dissociative disorders with a lesser degree of structural complexity than found in DID are partial forms of DID. According to the TSDP, the structural complexity of Partial DID is less than in DID, but typically more complex than in PTSD. Depersonalization Disorder would only be a dissociative disorder when it involves a structural division, and when it does, its structural complexity is rather simple. Consistent with the TSDP, Table 33.1 shows that the severity of somatoform dissociation as measured with the SDQ-​20 is associated with the structural complexity of dissociative disorders: DID > OSDD/​Partial DID > PTSD, somatoform dissociative disorders. For DID, the mean scores were beyond 50. Patients with DDNOS (OSDD)/​Partial DID had scores between 40 and 50, PTSD patients between approximately 32 and 41, and patients with somatoform dissociative disorders between 30 and 45. Also consistent with TSDP, somatoform dissociation in Depersonalization Disorder is rather low. Two studies found high somatoform dissociation for somatoform dissociative disorders, more specifically dissociative motor disorder (Demartini et al., 2016). Compared to healthy controls, patients with current or past PTSD reported higher levels of somatoform and psychoform dissociation, which were both strongly correlated with scores on the Clinician-​Administered PTSD Scale (CAPS; El-​Hage et al., 2002). Somatoform dissociation was also positively associated with symptoms of PTSD (Mueller-​ Pfeiffer et al., 2010; Ogulmus, Boysan, Fidan-​Acar, & Koca, 2020; Steffen-​K latt et al., 2019) and complex PTSD (Van Dijke, Ford, Frank & Van der Hart, 2015). Dissociative seizures were associated with low SDQ-​20 scores in one study (M =​23.3; Demartini et al., 2016). This result was unexpected. Individuals with dissociative seizures as a diagnosis may be expected to give the maximum score for the single item evaluating full loss of consciousness. If they do not endorse other SDQ-​20 items, their score would be 24. However, they typically also have at least some other sensorimotor dissociative symptoms as other studies and clinical experience suggest. Therefore, one would expect them to have an SDQ-​20 score higher than 24. Dissociative seizures were associated with marked scores in other studies (see Table 33.1), and a high score in Lawton et al. (2008). Kuyk, Spinhoven, Van Emde Boas, and Van Dyck (1999) documented higher SDQ-​20 scores for patients with dissociative seizures than for patients with temporal lobe epilepsy and non temporal lobe epilepsy that survived statistical correction for general psychopathology. In contrast, controlling for anxiety and depression, the different degrees of somatoform dissociation for dissociative seizures and epilepsy was lost in Lawton et al. (2008). Several other diagnoses were also associated with SDQ-​20 scores between, roughly, 30 and 40. In most studies, individuals with an eating disorder had SDQ-​20 scores between approximately 29 and 38. Somatoform dissociation was strongly linked to bulimic attitudes and certain bulimic features (i.e., excessive exercise, laxative abuse, diet pill abuse, diuretic abuse) in two studies (Palmisano et al., 2018; Waller et al., 2003). Nijenhuis et al. (1999) did not find a link between eating disorders and high somatoform dissociation, but patients with eating disorders reporting substantial adverse occurrences had higher SDQ-​20 scores. Patients with Pain Disorders had scores between approximately 25 (acute cystitis) and 34. Theoretically, my viewpoint is that BPD does not qualify as a dissociative disorder, because these patients experience insufficiently integrated modes of longing and striving, not dissociative agents (see Nijenhuis, Chapter 38, this volume). Consistent with this persepctive, BPD patients had a mean SDQ-​20 score just under 30. Also in line with TSDP, other ‘nondissociative’ mental disorders (e.g., anxiety disorders other than PTSD) were associated with low SDQ-​20 scores (i.e., scores of 29 or less). Mentally healthy adults, students and adolescents also had low scores. The SDQ-​20 discriminates among various diagnostic categories (Espirito-​Santo & Pio-​Abreu, 2007; González-​ Vásquez et al., 2017; Nijenhuis et al., 1999; Şar, Kundakçı, Kızıltan, Bakım, & Bozkurt, 2000). The discrimination remained after controlling for the influence of general psychopathology (Nijenhuis et al., 1999). Hence, the severity of somatoform dissociation across diagnostic groups is not explained by general psychopathology. Screening for dissociative disorders among psychiatric outpatients, sensitivity and specificity of the SDQ-​20 at cutoff rates of 29 (Nijenhuis et al., 1997) and 30 (Müller-​Pfeiffer et al., 2010) were .88 /​.94 and .83 /​.82, respectively. The positive and negative predictive values in the screening for Partial DID and DID were .39 and .96, respectively, using a cutoff of 33 and an estimated prevalence of 10% in the latter study. Nijenhuis et al. (1997) found a similar value for the negative predictive value (.97) and a somewhat higher positive predictive value (.62). The screening efficiency of the Dissociative Experiences Scale (DES, 28 items; Bernstein & Putnam, 1986), Multidimensional Inventory of Dissociation (MID, 218 items; Dell, 2006) and the SDQ-​20 were highly comparable. In all, the collective findings strongly suggest that 1. Dissociative disorders generally involve psychoform as well as somatoform dissociative symptoms (#H1); many cases of depersonalization disorder may be the exception in this regard.

536

536  Ellert R. S. Nijenhuis

2. Somatoform dissociation in these disorders typically includes negative and positive symptoms (#H3). 3. Somatoform dissociative symptoms are sensitive and specific for these disorders (#H4). 4. Somatoform dissociation severity generally matches the complexity of the dissociative disorder (#H5).

Somatoform and Psychoform Dissociation Somatoform dissociation and psychoform dissociation are highly correlated (see Nijenhuis 2017a). The relationship has been found in different populations. These included, among others, the general population (Farina et al., 2011b), adult psychiatric outpatients (Nijenhuis, Van der Hart, Krüger, & Steele, 2004), adult patients with DSM-​IV dissociative disorders and ICD-​10 dissociative disorders of movement and sensation (for review, see Nijenhuis, 2009), somatoform disorders (Van der Boom, Van den Hout, & Huntjens, 2010), and patients with orgasmic and sexual pain disorders (Farina et al., 2011a). The strong association between somatoform and psychoform dissociation also exists for adolescents. The samples examined include psychiatric outpatients (Pullin, Webster, & Hanstock, 2014) and inpatients (Soukup, Papezova, Kubena, & Mikolajova, 2010), nonclinical and clinical adolescents, young adults and students (Farina et al., 2011b; Soukup et al., 2010), and adolescents and young adults with eating disorders (Nilsson, Lejonclou, & Holmqvist, 2019a). A similar powerful association has been found in children and adolescents (Nilsson, Green, Svedin, & Dahlström, 2019b). In the study by Farina et al. (2011b), the association between somatoform and psychoform dissociation was strong for individuals with a moderate level of DES scores (O.R.=​7.0). However, it was much stronger for individuals with a high level of DES scores (O.R.=​18.9). A close link between somatoform and psychoform dissociation is further suggested by the finding that the 14 dimensions of the MID (Dell, 2002), including the somatoform dissociation dimension, loaded on one factor that accounted for 84% of the variance. Similarly, somatoform dissociation as measured with the Hebrew version of the MID correlated strongly with different measures of psychoform dissociation (r =​0.58, r =​0.73, and r =​0.77) in two Israeli studies (Somer & Dell, 2005). Peritraumatic somatoform and psychoform dissociation (i.e., dissociation that occurs during or immediately after a potentially traumatizing event) were correlated as well (Nijenhuis, Van Engen, Kusters, & Van der Hart, 2001). The correlational data are consonant with #H6. They fit the idea that somatoform and psychoform dissociation are both manifestations of the existence of dissociative agents.

Somatoform Dissociation, Adversity and Other Stressors The correlation between somatoform dissociation and symptoms of posttraumatic stress fits #H7, which states that somatoform dissociative symptoms are typically, although not exclusively, related to adverse life occurrences and major intrapersonal and interpersonal stress or conflicts. This hypothesis will now be explored more specifically. Moderate to strong associations between somatoform dissociative symptoms and reported adverse/​ stressful occurrences have been documented (Table 33.2). The studies included adult and adolescent/​young adult general population samples (Bob et al., 2013; Nilsson et al., 2015), students (Näring & Nijenhuis, 2005), as well as various psychiatric disorders (Nijenhuis, 2009). The relationship between somatoform dissociation and adverse/​stressful life occurrences was not mediated by absorption (Näring & Nijenhuis, 2005) or cultural beliefs: It was also found in Uganda, a country in which there is no cultural belief in an association between dissociative symptoms and adverse occurrences (Van Duijl et al., 2010). Mueller-​Pfeiffer et al. (2013) found the relationship does not seem to be mediated by anxiety and depression either. Childhood maltreatment was by far the best predictor of somatoform and psychoform dissociation in this study, and, like psychoform dissociation, somatoform dissociation was not correlated with gender, age, adult life stressors or early life stressors other than childhood maltreatment. Further, dissociative symptoms were more strongly correlated with early life stress than posttraumatic stress symptoms. The latter symptoms were associated with adult life stressors. Other studies documented a particularly marked relationship between somatoform dissociation and physical and sexual abuse in a general psychiatric population (e.g., El-​Hage et al., 2002: r =​.49). The correlation between somatoform dissociation and adverse life occurrences in another study (Fung et al., 2019) also became stronger when only childhood abuse and neglect were considered (r =​.30). In a retrospective study, delayed recall of childhood sexual abuse was associated with peritraumatic sensorimotor dissociation and the severity of this abuse (Nijenhuis et al., 2001).

536

537

536

Somatoform Dissociation, Agency, and Consciousness  537 TABLE 33.2  Correlations between adverse occurrences and dissociative symptoms

n

Nonclinical adults: Näring & Nijenhuis, 2005 Nonclinical students: Näring & Nijenhuis, 2005 General psychiatric patients: Waller et al., 2000 General psychiatric patients (test/​retest): Nijenhuis et al., 2002 General psychiatric patients: El-​Hage et al., 2002 General psychiatric patients: Fung et al., 2019 General psychiatric patients: Mueller-​Pfeiffer et al., 2013 Substance use disorder: Baars et al., 2001 Women with chronic pelvic pain: Nijenhuis et al., 2003 Fibromyalgia: Bohn et al., 2013 Somatoform disorders: Van der Boom et al., 2010 Eating disorders: Waller et al., 2003   Nonclinical controls   Restrictive anorexia nervosa   Binge-​purge anorexia nervosa   Bulimia nervosa Adolescents with eating disorders and nonclinical adolescents: Nilsson et al., 2015   Interpersonal adverse events   Noninterpersonal adverse events   Adverse childhood circumstances Spirit possession disorder and mentally healthy controls: Van Duijl et al., 2010 Chronic pelvic pain: Nijenhuis et al., 2003 Psychiatric outpatients: Nijenhuis et al., 2004   Total score***   Bodily threat/​intense pain   Emotional abuse/​neglect   Sexual abuse

147  73  72 155 140 202 287 229  52 117  86 n

SDQ-​20

DES /​ DIS-​Q*

r

p

r

p

.20** .27** .32 .57 /​.66 .41 .24 .44 .41 .69 .32 .28 r