Psychiatric Annals

From the Guest Editor 

This Issue: Dissociative Disorders

Richard A. Chefetz, MD

Abstract

Dissociative disorders have been found to be present in 5% to 15% of psychiatric inpatients,1,2 and 6% of a general population sample had “high levels of dissociative symptoms” in a random sample of 1,028 people.3 A recent search of PubMed shows similar data from the United States, Canada, Germany, Netherlands, Italy, Turkey, and elsewhere. Infant attachment research and multi-generational longitudinal studies confirm intergenerational transmission of a dissociative “phenotype,” but no study has yet been done to confirm the incidence of dissociative disorders in this group of cohorts.4–7

In consideration of this, what is your experience with patients and their dissociative experiences? Do you know how to ask about these experiences? How are dissociative experiences related to the disorders you are trying to treat in your offices, clinics, and inpatient units? If you have not recognized anyone with a dissociative disorder, why not? The studies above are only a fraction of the quality work being done on this subject all over the world. Might it be time to take a look to see what's new?

Where has postgraduate education about the dissociative disorders been? If you didn't learn about dissociation, then why was that? The unfortunate hype about multiple personality disorder in the 1990s obscured what is otherwise a radical change in the view of what it means to have a mind that is conceptually different from the psychoanalytic mind of id–ego–superego, or the cognitive perspective of mind focused on event, meaning, belief, action. The problem we have faced as clinicians all along has been to explain behavior that seemed predicated upon a person's “state of mind.” This “state” issue is visible in our patients, but it is also a basic part of being human. Who has never said: “I'm so sorry I did that. I don't know what got into me! It's not like me to say such a thing! I'm just not myself today. Please forgive me.”

What is the speaker talking about? If it wasn't like them to say what they said, then who said it? Yes, it's a figure of speech, but it has meaning in regard to the extent that the speaker was willing to “own” their ill will. Yes, this is denial or disavowal. However, in some situations, it may also be dissociative process: the tendency to isolate elements of experience that are so outside a person's world view that the experience can neither be assimilated into existing self-views, nor can the self-view accommodate any change that could encompass the new view without destroying the basic view of self.

For example, in complicated bereavement, the depressed person often is bereft over the loss of a loved one, and typically there are unconscious, isolated affects of anger and betrayal for the deceased person that are incompatible with a grieving person's view of themselves and how they are “allowed” to feel toward their dead loved one. Isolated affect is an old concept related to obsessional neurosis, denial and undoing, but “isolated” could also be spelled d-i-s-s-o-c-i-a-t-i-o-n. The alternate identity of dissociative disorders could also be termed “isolated subjectivity.”8

Dissociation may be defined as the separation of normally associated psychological elements with loss of recognition of their relatedness. The person with an eating disorder tells you that they don't know why they eat, or don't eat; it's like they don't have control over what they are doing. The person with a drug addiction tells you that they knew better than to go to the bar to meet their friends; it's like they just couldn't keep that thought in their mind when they were feeling lonely. Dissociated thought? Isolated…

Dissociative disorders have been found to be present in 5% to 15% of psychiatric inpatients,1,2 and 6% of a general population sample had “high levels of dissociative symptoms” in a random sample of 1,028 people.3 A recent search of PubMed shows similar data from the United States, Canada, Germany, Netherlands, Italy, Turkey, and elsewhere. Infant attachment research and multi-generational longitudinal studies confirm intergenerational transmission of a dissociative “phenotype,” but no study has yet been done to confirm the incidence of dissociative disorders in this group of cohorts.4–7

In consideration of this, what is your experience with patients and their dissociative experiences? Do you know how to ask about these experiences? How are dissociative experiences related to the disorders you are trying to treat in your offices, clinics, and inpatient units? If you have not recognized anyone with a dissociative disorder, why not? The studies above are only a fraction of the quality work being done on this subject all over the world. Might it be time to take a look to see what's new?

Where has postgraduate education about the dissociative disorders been? If you didn't learn about dissociation, then why was that? The unfortunate hype about multiple personality disorder in the 1990s obscured what is otherwise a radical change in the view of what it means to have a mind that is conceptually different from the psychoanalytic mind of id–ego–superego, or the cognitive perspective of mind focused on event, meaning, belief, action. The problem we have faced as clinicians all along has been to explain behavior that seemed predicated upon a person's “state of mind.” This “state” issue is visible in our patients, but it is also a basic part of being human. Who has never said: “I'm so sorry I did that. I don't know what got into me! It's not like me to say such a thing! I'm just not myself today. Please forgive me.”

What is the speaker talking about? If it wasn't like them to say what they said, then who said it? Yes, it's a figure of speech, but it has meaning in regard to the extent that the speaker was willing to “own” their ill will. Yes, this is denial or disavowal. However, in some situations, it may also be dissociative process: the tendency to isolate elements of experience that are so outside a person's world view that the experience can neither be assimilated into existing self-views, nor can the self-view accommodate any change that could encompass the new view without destroying the basic view of self.

For example, in complicated bereavement, the depressed person often is bereft over the loss of a loved one, and typically there are unconscious, isolated affects of anger and betrayal for the deceased person that are incompatible with a grieving person's view of themselves and how they are “allowed” to feel toward their dead loved one. Isolated affect is an old concept related to obsessional neurosis, denial and undoing, but “isolated” could also be spelled d-i-s-s-o-c-i-a-t-i-o-n. The alternate identity of dissociative disorders could also be termed “isolated subjectivity.”8

Dissociation may be defined as the separation of normally associated psychological elements with loss of recognition of their relatedness. The person with an eating disorder tells you that they don't know why they eat, or don't eat; it's like they don't have control over what they are doing. The person with a drug addiction tells you that they knew better than to go to the bar to meet their friends; it's like they just couldn't keep that thought in their mind when they were feeling lonely. Dissociated thought? Isolated knowledge? Amnesia? State of mind?

The study of the dissociative process often is the study of affect dysregulation in people who have been so overwhelmed by their experiences that they ceased to function at some point. Every day, for many people with dissociative disorders, is Sophie's Choice:9 pain that is unbearable amid choices that feel impossible, shameful, or unacceptable. Is the knowledge of 15 years of incest bearable? How long can a child try to prompt a depressed, unresponsive parent before lapsing into unresponsiveness herself? How much humiliation can a child take from a drunken, shouting, violent parent who tells her she is worthless, and that's why bad things happen to her?

Dissociative processes include doing away with being able to know feelings: isolated affect. A person who is emotionally numb will often report that her body is without sensation, that she feels dead — as if carrying the body like a suitcase, with no use for it. This is the metaphorical statement of dissociative experience. For the clinician, part of the goal is to identify the associated affects, reconstruct a narrative of the missing part of the experience, put it all together, gently, and integrate a “lived” knowledge of the past with the present. This is tough work for everyone.

In This Issue

The articles in this issue were written by colleagues who are all seasoned clinicians. I asked them to write the articles so that people new to thinking about dissociative experience could learn with as little difficulty as possible. I also asked them to write about dissociative identity disorder (DID), rather than trying to write about all the dissociative disorders. Medical training often makes use of studying the “extreme” conditions as a way to understand the full range of possibilities about a disorder. We do that here.

Dr. Kluft has pulled together a wide variety of information into a coherent and encyclopedic article on diagnosis of DID. I don't know anybody who knows as much about dissociation as does Rick Kluft. Gleaves and Williams wrote a primer on trauma and memory, and I've tackled treatment issues, trying to use more traditional psychotherapy principles to inform the discussion rather than to focus on alternate identities and their management, often the focus of discussions of this disorder. I believe that for the uninitiated, talking about alternate identities in detail makes little sense, and that people new to thinking about dissociative disorders need to stay focused on what they have already learned about psychotherapy, and how to expand those views to include understanding dissociative experiences.

Dr. Loewenstein's article is one of the first reviews of the psychopharmacologic treatment of dissociative disorders in nearly 10 years. It was long overdue. His accumulated wisdom is always refreshing. Dr. Welzant focuses on stabilization of the dissociative patient, the centerpiece of initiating therapy. He is a clinician who was trained in the trenches and somehow managed to survive working in an inpatient and day hospital milieu for many years. Finally, Dr. Stolbach presents a beautiful, creative, and compassionate treatment of a child with dissociative adaptations to a burn injury. It is a testimony to his skill and compassion as a clinician.

Drs. Cox and Cohen did some extra work for us as a fitting statement of respect for the artwork that adorns the cover and accompanies these articles. All of the art in this issue was submitted by patients with dissociative disorders. There is art from the US, Germany, and the United Kingdom. Many thanks to the clinicians on DISSOC, a privately run dissociative disorder listserv, for facilitating their patients submitting their work for consideration.

References

  1. Saxe GN, van der Kolk BA, Berkowitz R, et al. Dissociative disorders in psychiatric inpatients. Am J Psychiatry. 1993; 150(7):1037–1042. doi:10.1176/ajp.150.7.1037 [CrossRef]8317573
  2. Tutkun H, Sar V, Yargic LI, et al. Frequency of dissociative disorders among psychiatric inpatients in a Turkish University Clinic. Am J Psychiatry. 1998; 155(6):800–805.9619153
  3. Mulder RT, Beautrais AL, Joyce PR, Fergusson DM. Relationship between dissociation, childhood sexual abuse, childhood physical abuse, and mental illness in a general population sample. Am J Psychiatry. 1998;155(6):806–811.9619154
  4. Main M, Hesse E. Parents' unresolved traumatic experiences are related to infant disorganized attachment status: is frightened and/or frightening parental behavior the linking mechanism? In: Greenberg MT, Ciccheti D, Cummings EM, ed. Attachment in the Preschool Years: Theory, Research, and Intervention. Chicago, IL: The University of Chicago; 1990:161–182.
  5. Ogawa JR, Sroufe LA, Weinfield NS, Carlson EA, Egelend B. Development and the fragmented self: longitudinal study of dissociative symptomatology in a nonclinical sample. Dev Psychopathol. 1997;9(4):855–879. doi:10.1017/S0954579497001478 [CrossRef]
  6. Lyons-Ruth K. Dissociation and the parent-infant dialogue: a longitudinal perspective from attachment research. J Am Psychoanal Assoc. 2003;51(3):883–911. doi:10.1177/00030651030510031501 [CrossRef]14596565
  7. van Ijzendoorn MH. Adult attachment representations, parental responsiveness, and infant attachment: a meta-analysis on the predictive validity of the Adult Attachment Interview. Psychol Bull. 1995; 117(3):387–403. doi:10.1037/0033-2909.117.3.387 [CrossRef]7777645
  8. Chefetz R, Bromberg P. Talking with “Me” and “Not-Me”: a dialogue. Contemp Psychoanal. 2004;40(3):409–464. doi:10.1080/00107530.2004.10745840 [CrossRef]
  9. Styron W. Sophie's Choice. New York, NY: Vintage; 1992.

About the Guest Editor

Richard A. Chefetz, MD, is a psychiatrist in private practice in Washington, DC. He also is a distinguished visiting lecturer at the William Alanson White Institute of Psychiatry, Psychoanalysis and Psychology, New York, NY, and on the faculty of the Advanced Psychotherapy Training Program of the Washington School of Psychiatry, and Institute of Contemporary Psychotherapy and Psychoanalysis. He is an interdisciplinary member of the Washington Psychoanalytic Society.

Dr. Chefetz is a diplomate of the American Boards of Psychiatry and Neurology, Medical Hypnosis, and Family Practice. He is a past president of the International Society for the Study of Dissociation and co-director of their Dissociative Disorders Psychotherapy Training Program. He is a certified consultant in hypnosis of the American Society of Clinical Hypnosis.

Dr. Chefetz has been involved in teaching psychotherapy for many years. His work in the dissociative disorders reflects an ongoing fascination with how a mind develops and maintains itself.

Authors

10.3928/00485713-20050801-02

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