Prof. Joseph Levine

Conversation 75: Dissociation in the Light of Our Newly Developed Self Model

By Prof. Levine & Dr. Salganik

Hello to our readers,

As a rule, dissociation is a complex mental mechanism that includes biological and psychological brain processes. Many studies are trying to clarify the mechanisms involved in this phenomenon. Below is a detailed explanation of the various mechanisms with reference to brain, biological and psychological processes, plus an up-to-date list of references.

The biological-brain mechanisms of dissociation

Biological factors that could contribute to dissociative disorders might include:

1. Genetic Predisposition: A family history of mental health issues might increase vulnerability.
2. Neurobiological Factors: Abnormalities in brain areas involved in memory, identity, and emotion regulation, like the hippocampus and amygdala.
3. Neurochemical Imbalances: Imbalances in neurotransmitters that affect mood and stress responses.
4. Hormonal Influences: Chronic stress can alter cortisol levels, potentially impacting brain function related to dissociation.

These factors can interact with psychological and social influences, creating a complex picture.

Dysfunction of the amygdala and hippocampus: These two regions are directly involved in emotional processing and memory. Dissociation has been linked to changes in amygdala function, particularly reduced or increased responses to extreme stress, as well as to disruptions in hippocampal activity that affect memory formation.

Amygdala: Dissociation has been linked to altered amygdala reactivity, leading to impaired or disconnected emotional processing in response to trauma (Lanius et al., 2010).

Hippocampus: Decreased hippocampal volume has been observed in individuals with a history of repeated trauma associated with dissociative symptoms (Vermetten et al., 2006).

Prefrontal Cortex Changes: The prefrontal cortex is responsible for emotional regulation, attention, and self-control. Studies have shown reduced activity in this region during dissociative states, leading to a reduced ability to regulate emotional experience (Brand et al., 2012).

Hypothalamic-pituitary-adrenal (HPA) axis: Disruption of this system, which manages stress responses, may lead to chronic dissociation following repeated exposure to trauma or chronic stress, due to dysregulation of the hormone cortisol (Schalinski et al., 2015).

Brain Connectivity Patterns: Functional magnetic resonance imaging (fMRI) studies have demonstrated changes in brain network connectivity, particularly in the Default Mode Network (DMN), which is responsible for the sense of self and awareness (Daniels et al., 2015).

In dissociative states, a disruption occurs in the integration of these brain networks.

The Psychological Mechanisms of Dissociation

Dissociation as a Defense Mechanism: According to psychodynamic theory, dissociation is a defense mechanism designed to protect the psyche from mental pain or trauma, especially when there is no other way to physically or emotionally escape the traumatic situation (Putnam, 1989).

The "Escape from Self" Hypothesis: Dissociation is viewed as a cognitive coping strategy of "escape from self" – a situation in which a person disconnects from their sense of self in order to avoid confrontation with painful emotions or threatening memories (Baumeister, 1990).

Trauma and mental fragmentation model: According to this model, severe trauma or extreme experience leads to a mental fragmentation of memories, feelings and perceptions, resulting in dissociation. The person has difficulty integrating different experiences into a single coherent identity (Van der Hart et al., 2006).

Dissociative disorders

Dissociative disorders refer to a group of psychological conditions in which there are processes of disconnection (dissociation) between parts of consciousness, memory and identity.

Below is a detailed discussion of two major conditions in this area: dissociative identity disorder (sometimes called "dissociative personality disorder") and dissociative fugue state.

Dissociative Identity Disorder (DID)

Dissociative identity disorder is characterized by the presence of two or more distinct identities or states of mind, each with its own characteristics, memories, and behaviors.

The disorder manifests itself in the person experiencing disconnections in consciousness and memory – often without the ability to remember events that occurred at a time when another identity was activated.

Main characteristics:

The appearance of multiple identities:

The person displays different "states of mind", with each identity being able to express itself differently, relate to the environment and social reactions differently.

Memory weaknesses:

There are episodes in which the person does not remember what happened during actions performed by another identity, which leads to gaps in everyday memory.

Trauma-related:

Many cases are associated with a history of trauma, especially in childhood, when dissociation served as a psychological defense against intense emotional pain.

Effects on daily life:

The difficulty in integrating the different identities can cause difficulties in relationships, work, and daily functioning.

Diagnosis and treatment:

Diagnosis is made by mental health professionals using clinical tools and a comprehensive mental history. Treatment usually involves long-term psychotherapy, often using techniques aimed at unifying different identities and helping to cope with past traumas.

Dissociative Fugue

Dissociative fugue is characterized by a sudden and surprising disappearance of the person from their familiar surroundings, accompanied by confusion or a change in identity.

In this state, the person may set off without prior preparation, sometimes at a considerable distance from where they live, and their memories of the past may be erased or distorted.

During a dissociative fugue, a person may adopt a new identity, often with little or no memory of their previous life. This new identity can involve changes in name, personality, and even background story. Reference groups often change as well, because the individual distances themselves from their past connections to avoid the stress or conflict that triggered the fugue state. So, it's a total reboot, often involving a new social circle.

Identity shifting in dissociative fugue is often tied to the individual's attempt to escape distressing situations or internal conflicts. The new identity and reference group provide a mental refuge, allowing the person to avoid distressing memories or stressors associated with their previous identity. It's like pressing a psychological reset button, often unconsciously. The choice of identity and reference group usually reflects the person's desires, fears, or unresolved issues.

Research into why a specific identity is chosen during a dissociative fugue suggests that these new identities may be shaped by the individual's desires, cultural influences, or subconscious efforts to avoid stressful memories. Sometimes, these identities fulfill a need for safety, power, or acceptance that the person feels is lacking in their current life. The new identity can be a projection of an ideal self or a refuge from pain.

In dissociative fugue, the new identity can be entirely fictitious or loosely based on real-life figures. It's typically crafted from the person's imagination, desires, or subconscious, rather than being a direct copy of an existing person. The mind invents these identities to fulfill specific needs or to provide an escape, often leading to rich and detailed backstories. It's a complex creation process, highlighting the mind's capacity to construct alternate realities.

Dissociative fugue can indeed recur, especially if underlying stressors or unresolved trauma persist. Each episode can be triggered by new stress or traumatic events. However, with proper treatment and coping strategies, the risk of relapse can be reduced. It's a complex interplay between the mind's defense mechanisms and the individual's environment.

Key features:

Abrupt withdrawal:

The person leaves where they live or work without a clear explanation, and sometimes loses their sense of personal identity.

Confusion and re-identification:

During a relapse, the person may assume a new identity or be confused about who they are and what they are doing. Sometimes they may invent a new story about their past.

Memory changes:

There is difficulty remembering events that occurred before or during the remission. Personal memory may disappear or become distorted.

Difficulty integrating:

Upon returning to their previous life, the person may have difficulty understanding the course of events and coping with gaps in memory.

Diagnosis and Treatment:

Dissociative fugue states are usually diagnosed by mental health professionals, focusing on a history of trauma and symptoms related to personal identification and memory. Treatment primarily involves psychotherapy, with medical support sometimes needed in severe or high-risk cases.

Conclusions

Both disorders are part of the spectrum of dissociative phenomena, both embodying complex mechanisms of psychological defense against trauma or difficult situations.

While dissociative identity disorder focuses on the splitting of identity and the emergence of separate mental states, a state of remission is characterized by a sudden disappearance from identity and familiar surroundings.

Correct and early treatment can improve the quality of life of patients and help them integrate into society in the best possible way.

References:

Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 97(1), 90-113. https://doi.org/10.1037/0033-295X.97.1.90

Brand, B. L., Lanius, R. A., Vermetten, E., Loewenstein, R. J., & Spiegel, D. (2012). Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. Journal of Trauma & Dissociation, 13(1), 9-31. https://doi.org/10.1080/15299732.2011.620687

Daniels, J. K., Frewen, P., Theberge, J., & Lanius, R. A. (2015). Structural brain abnormalities in PTSD and dissociative disorders. In U. F. Lanius, S. L. Paulsen, & F. M. Corrigan (Eds.), Neurobiology and treatment of traumatic dissociation: Towards an embodied self (pp. 217-230). Springer.

Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J. D., & Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167(6), 640-647. https://doi.org/10.1176/appi.ajp.2009.09081168

Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. Guilford Press.

Schalinski, I., Elbert, T., Steudte-Schmiedgen, S., & Kirschbaum, C. (2015). The cortisol paradox of trauma-related disorders: Lower phasic responses but higher tonic levels of cortisol are associated with sexual abuse in childhood. PLoS ONE, 10(8), e0136921. https://doi.org/10.1371/journal.pone.0136921

Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. W. W. Norton & Company.

Vermetten, E., Schmahl, C., Lindner, S., Loewenstein, R. J., & Bremner, J. D. (2006). Hippocampal and amygdalar volumes in dissociative identity disorder. American Journal of Psychiatry, 163(4), 630-636. https://doi.org/10.1176/appi.ajp.163.4.630

The phenomenon of dissociation in the light of the self model we develop

The phenomenon of mental dissociation, as mentioned, is manifested in the separation or disconnection of parts of consciousness, memory, or self-perceptions, and can develop in situations of emotional stress or trauma.

According to the model we are developing [see previous discussions], in which the self is divided into basic components (the "primary self") and superstructures built from the infrastructure of the primary self – [primordial nuclei] which are secondary internalized structures (referred to as secondary selves such as the "board of internalized figures", the "enemies’ group" and "the self-representation group")—it is possible to explain how the dissociation process manifests itself as a result of a possible split both in the primary self [which is expressed, among other things, in the splitting of cognitive, emotional, and behavioral processes.] and in the characters’ board and self-representations [which serve as a kind of container into which information flows from the internalized characters’ board].

The individual's self-identity stems from the current self-representation to which there is a flow of information mainly from the internalized figures board but in certain situations, usually of mental disorder, also from the enemy group. And if it is a question of identity change or multiple identities in dissociative disorders, then it is a question of different or other self-representations, etc.

Illustration of the model of the self that we are developing [see previous articles]

Psychic dissociation – process and development

According to the model, the self begins with an innate biological nucleus – the primary self – which also includes cognitive and instinctive processes that change throughout life depending on events, traumas and external influences. As mentioned, these processes lead to the development of various internalized secondary structures, with integration and dialogue between them.

When a significant disruption occurs in these processes – as a result, for example, of a traumatic event or emotional overload that cannot be processed within the framework of these mechanisms – the integration and dialogue between and within the structures described above, mainly in the board of internalized figures and consequently in the representations of the self, go awry and dissociative states of detachment may develop.

A simple example is a change in the internalized character board in which a subgroup detaches from the character board and functions as if it is now the acting and influencing board itself, creating a self-representation that now expresses the person who often does not remember and has no access to the previous, larger character board unless they have undergone appropriate psychotherapy.

Dissociative fugue

Let's explore Dissociative Fugue (DF) through the lens of Reference Group Focus Therapy (RGFT):

1. Reference Group Influence: RGFT suggests that reference groups—like family or societal norms—play a crucial role in shaping identity. In DF, the inability to reconcile conflicting pressures from these groups may lead to dissociative episodes.

2. Triggering Fugue States: The intense conflict between different reference group expectations can trigger fugue states. Individuals might escape or flee from their current identity, leading to temporary amnesia and travel away from home.

3. RGFT's Role: In therapy, RGFT focuses on identifying and addressing these conflicting reference groups. By reshaping perceptions of these groups, individuals can work towards a more stable identity.

4. Identity Reintegration: Through RGFT, individuals aim to reintegrate their identities, reducing the need to dissociate and flee.

In short, RGFT seeks to understand and address the underlying identity conflicts that lead to dissociative fugue.

Reference groups provide a framework for identity, values, and behavior standards. When an individual undergoes extreme stress or identity conflict, especially when it clashes with the norms of their reference groups, their response can lead to a dissociative fugue. The origins might be rooted in a need to escape overwhelming stress, avoid painful memories, or reconcile conflicting identities. It's a drastic, subconscious self-protection mechanism.

According to the model, dissociative fugue manifests itself in the emergence of a separate subsystem within the internalized character board. When faced with a traumatic event or strong emotional stress, the character board mechanisms may fail to provide a holistic response to the flow of internal information.

The event can lead to the creation of a powerful enemy figure or figures who will be able to penetrate the board of directors, which will probably lead, as a form of defense, to a split in the board of directors in which a certain subsystem will dominate and will now express the board of characters and influence the representation of a new self.

This split leads to the disconnection of parts of the memories and attitudes [of previous dominant figures in the board of characters whose representations of their attitudes, feelings, and behaviors are in the primary self] that were previously connected to the integrative whole.

In the process of defense, parts of the personal identity (e.g., representations of the self in the normative normal state related to social roles or previous experiences) may be rejected and separated from the system of the whole.

This process creates a situation in which the person is now represented by a subgroup on the board of directors that operates a new self representation that manifests itself in a state of journey or wandering (characterizing the dissociative fugue), while the rest of the system remains "frozen" to prevent a possible conflictual situation.

Dissociative fugue is characterized by the temporary disappearance of some memories or past identities, indicating that information related to the ongoing functioning of the current self-representation is not accessible to conscious awareness. This condition is seen as a defense mechanism – designed to protect the individual from unbearable emotional overload – but at the same time impairs the continuity and unity of identity.

Dissociative identity disorder (DID)

Let's delve into Dissociative Identity Disorder (DID) through the theoretical lens of Reference Group Focused Therapy (RGFT):

1. Reference Groups in Identity Formation: RGFT posits that our identities are shaped by influential groups—family, peers, cultural norms. These reference groups set expectations and norms that can impact self-identity.

2. Conflict and Dissociation: In DID, severe conflicts between these identity-shaping groups may lead to dissociation. When individuals can't reconcile differing pressures or norms, they may develop alternate identities to manage these conflicts.

3. Role of RGFT: RGFT aims to identify and address these conflicting reference groups. By reshaping perceptions of these groups, individuals can integrate dissociated identities.

4. Identity Reintegration: Through therapy, individuals work to integrate their identities, reducing the need for dissociation to manage conflicting reference groups.

Essentially, RGFT views DID as a response to intense identity conflicts, with therapy focusing on reconciling these conflicts.

DID is manifested in an internal split in which several "self-representation" states exist, each functioning at different times and sometimes even competing with each other [unconsciously to the person] as to which one will appear.

According to our model, the phenomenon can occur when there is a deep separation between the internalized subsystems of the board of directors, often when the enemies group is dominantly activated following trauma or ongoing stress and its representatives even infiltrate the board of directors.

In this situation, an enemy character or characters infiltrate the board of characters and create an unbearable threat that leads to a split in the board of directors in which subgroups are created on the board, with each time another one being active and taking over, and this one influencing the creation of a certain self-representation – a separate entity in order to be replaced by another entity when another subgroup takes over the board of directors.

According to the model, when the dynamics of the board of directors are disrupted – for example, as mentioned, due to the invasion of enemy figures into the board of directors or due to the inability to integrate relational, perceptual, and behavioral positions – the possibility of a “dissociative identity disorder” exists, represented by a subgroup on the board of directors.

Such a subgroup can contain figures who were already on the board of directors or, more often than not, new virtual figures.

This process, which reflects the fragmentation between the subsystems in the board of directors, can serve as psychological protection in situations of extreme stress, but at the same time, of course, it harms the sense of unity and integrity of personal identity.

In both Dissociative Identity Disorder (DID) and Dissociative Fugue, intense identity conflicts can be triggered by reference group pressures. However, the difference lies in how the individual copes:

1. DID: Onset is usually in early childhood, often before age 6–9, but symptoms may not be recognized until late adolescence or adulthood. Symptoms begin early, but diagnosis is often delayed until ages 20–40, because dissociation can be hidden or misdiagnosed (e.g., as depression, schizophrenia, borderline personality disorder).

Patients may not become aware of alters or memory gaps until adulthood. DID almost always results from chronic, severe trauma during early childhood—usually abuse, neglect, or overwhelming attachment disruptions.

At this age, the child's sense of self is still forming, so they may compartmentalize experiences into separate identities (alters) as a coping mechanism.

In cases where reference group conflicts are so intense and contradictory, an individual might cope by developing multiple distinct identities. Each identity manages different aspects of the conflicting pressures, creating a fragmented sense of self.

2. Dissociative Fugue: Typical Age of Onset: Usually in late adolescence to mid-adulthood (ages 20–40). Rare in children or the elderly. Alternatively, some individuals respond to identity conflicts by fleeing from their identity entirely, leading to sudden travel and amnesia for personal history.

Fugue is often triggered by acute psychological stress—e.g., job loss, combat exposure, marital breakdown—usually after identity has formed, not during its development like DID, Fugue episodes can last hours to days, and rarely months. The person may assume a new identity temporarily and forget their previous life.

Dissociative Fugue focuses on amnesia and travel, often with a single alternate identity during the fugue. DID is more about chronic switching between distinct identities or personality states, often without travel. In some complex cases, a person with DID might also experience fugue states, and during those, different alters (identities) may take control.

The determining factor is how the individual navigates the pressure from reference groups: either by creating multiple identities to manage it (DID) or by temporarily abandoning their identity (Dissociative Fugue). It's all about how they respond to the internal and external pressures from these influential groups.

DID, or Dissociative Identity Disorder, also features identity shifts, but it's more complex than fugue. Multiple distinct identities or "alters" coexist and take turns controlling behavior. Each alter may have its own name, age, gender, and backstory, often serving different psychological functions. The formation of these identities is believed to be a response to early trauma, offering a way to compartmentalize and manage distress.

DID might develop when a person faces intense internal conflicts between different reference groups, leading to the formation of distinct identities to manage these conflicts. In contrast, Dissociative Fugue could arise when the pressure from conflicting reference groups leads to a temporary escape from one’s identity, resulting in amnesia and unplanned travel. It's like the mind's way of coping with overwhelming stress in different ways.

In Dissociative Identity Disorder, the personalities or "alters" can be entirely fictional, or they may be influenced by people the individual has encountered. Alters might represent real figures from the person’s life or embody characteristics they find appealing or threatening. These identities can manifest diverse traits, ages, and backgrounds, creating a complex internal world.

The difference in response could be influenced by various factors:

1. Individual Coping Mechanisms: People have unique ways of coping with stress. In some, the fragmentation of identity (leading to DID) might be a coping mechanism, while others might "flee" from their identity temporarily (Dissociative Fugue).
2. Severity of Conflict: The intensity and nature of the conflict within reference groups could determine the dissociative response. More severe or conflicting pressures might lead to DID, while less severe but still overwhelming conflicts could lead to fugue states.
3. Personal History: Past traumas or experiences might predispose someone to one disorder over the other.

Both conditions involve identity disturbance linked to trauma. DID features multiple distinct identities coexisting, while dissociative fugue involves a temporary, often single, identity shift. DID identities might be aware of each other, but in fugue, the new identity's unaware of the past. Both serve as coping mechanisms for intense psychological stress.

The difference likely stems from the distinct ways individuals respond to trauma. DID may develop from chronic, severe childhood trauma, where dissociation serves as a coping mechanism, resulting in multiple identities to compartmentalize trauma. Dissociative fugue, often tied to acute stress or conflict, results in a singular identity shift to escape immediate distress. It's the mind's way of protecting the self, but the approach varies based on the nature and timing of the trauma.

Ultimately, the development of these disorders is complex and unique to each individual, influenced by a mix of psychological, social, and possibly biological factors.

It is feasible that such individuals are more prone to dissociative reaction to stress (mostly due to activation of the threat channel) while some other person could react in the same situation with a depressive reaction or maybe even psychosis – all dependent on the intrinsic peculiarities of a specific primary self.

Patients with DID and dissociative fugue often have a higher capacity for dissociation, which can sometimes make them more susceptible to hypnosis. The dissociative tendencies inherent in these conditions might align with the focused, trance-like state induced by hypnosis.

And lastly, we would like to bring 2 clinical cases, one of a person suffering from DID and, another one, of a person suffering from the dissociative fugue followed by a description of their treatment using RGFT.

Case 1: RGFT Treatment of DID

Patient: Sarah, 35, housewife, diagnosed with Dissociative Identity Disorder (DID).

Symptoms: Recurrent amnesia and distinct identities, causing distress and functional impairment.

Treatment Approach:

1. Identification: Sarah, with her therapist, identified key reference groups influencing her identities, including family and societal expectations.
2. Self-Reflection: She reflected on how these groups contributed to her fragmented identity, recognizing conflicts and pressures.
3. Restructuring Perceptions: With the therapist's guidance, Sarah worked on restructuring her perceptions of these reference groups, aiming to diminish their negative influence.
4. Identity Reintegration: Through RGFT, Sarah began to integrate her dissociated identities, creating a more cohesive self-concept.

Outcome: Over 12 months of follow up, Sarah demonstrated reduced dissociative episodes and improved identity integration.

Case 2: RGFT Treatment of Dissociative Fugue

Patient: David, 40, dentist, experiencing episodes of fugue states, characterized by sudden, unexpected travel away from home with inability to recall one's past.

Symptoms: Amnesia regarding personal identity and history.

Treatment Approach:

1. Identification: David and his therapist identified key reference groups linked to his identity, focusing on those contributing to his dissociative episodes.
2. Self-Reflection: David engaged in self-reflection to understand the conflicts and pressures from these groups that triggered his fugue states.
3. Restructuring Perceptions: With RGFT, David worked on restructuring his perceptions of these reference groups, aiming to create a more stable sense of identity.
4. Identity Integration: As perceptions shifted, David began to reintegrate aspects of his identity, reducing the occurrence of fugue states.

Outcome: After 10 months of therapy, David experienced fewer fugue episodes and developed a more coherent sense of self.

These cases highlight the adaptability of RGFT in treating different dissociative disorders.

So far for now,

yours,

Dr. Igor Salganik and Prof. Joseph Levine