By David Joel Miller.
Does Dissociation really happen? What cause it?
Personally I think there is more misunderstanding around this condition than most other mental health issues. First off Dissociation is way more common than most people realize. It comes in varying intensities; much of it is mild and goes unrecognized, denied and undiagnosed.
Dissociation, particularly Dissociative Identity Disorder has so much stigma around it that when we see it in clinical practice, I believe most clinicians call it something else more acceptable, like stress or Posttraumatic Stress Disorder, and let it go at that. This leaves people with more severe cases of dissociation with less than adequate treatment.
My view is that milder forms of dissociation are a normal protective behavior for most vertebrates, humans included. Under stress the brain stem engages the “F’s” and takes over the functions of the brain to ensure survival.
Dissociation in its milder forms is, as I understand it, a functional survival mechanism. It is a close cousin to daydreaming and alcoholic blackouts.
Some simple examples of Dissociation.
I am driving along, I am thinking about something I need to do tonight. In my mind I am picturing a set of slides that I want to create for the power point. I realize all of a sudden that I am miles past my freeway exit and I have no memory of driving this way. My mind has blanked out.
At this point I turn around, drive as fast as I can and reach my destination. Do I tell everyone about my “zoning out?” Not a chance. I make some lame excuse about traffic and getting off work late.
Next example, more severe
A woman who was gang raped in the past is walking around downtown. She sees some men who are wearing gang colors and look kind of like the men that assaulted her. She becomes frightened and crosses the street, she begins walking fast to get away. A few minutes later she slows down. Her panic is subsiding. She looks around and finds she is walking through a neighborhood and she has no idea where she is or how she got here.
So now we can see a mechanism by which someone who is upset might do actions like run away and be functioning essentially on autopilot. High levels of stress, like high levels of alcohol in blackouts, might shut off the connection between current functioning and memory.
Does that mean this woman has some form of Dissociative Disorder?
Maybe, maybe not. The new DSM-5 lists five major kinds of dissociative Disorders plus some specifiers and or sub-types.
This woman, now upset because this past problem, memories of the rape, is messing up her life and also a lot worried because she ended up in a strange neighborhood with no memory of how she got there comes to see a therapist.
She begins to talk about her experience. She had an experience that brought back memories of her rape (Intrusive thoughts.) She tried to avoid things, ran away (avoidance, yes.) She has been anxious for several nights since and has lost sleep over this. Maybe even had a nightmare and this has been affecting her home life and her relationship.
At this point she gets assessed, a treatment plan created and treatment begins.
She was embarrassed so she left out the part about walking for a while and having no memory how she got there.
Her diagnosis – it’s likely to be Posttraumatic Stress Disorder.
In clinical settings the stress related disorders get diagnosed a lot more than the dissociative disorders. Sometimes it is a judgment call. Which disorder is this woman’s symptoms more like? But I think we professionals may be overlooking a lot of dissociative symptoms. The result may be that in outpatient settings we are under-diagnosing Dissociative Disorder and over diagnosing PTSD.
In carefully controlled research the prevalence of Dissociative Disorders of all 5 types exceeded 5% of the population. That makes dissociation up to 17 times more common than Schizophrenia.
Dissociative Disorders are the next chapter over in the DSM-5 from stress related disorders. We see a huge overlap between those two groups. There is also an overlap with Borderline Personality Disorder another misunderstood condition.
If we think of all these conditions as reasonable responses to stress given the persons biology and experiences we can see how some of the things that occur to a person with dissociation make sense.
Dissociative Disorders are most commonly found in the aftermath of traumatic events. Some of the symptoms of dissociation are embarrassment, confusion and a desire to hide the existence of your symptoms. If you are the victim of trauma and let on how much the trauma affected you, this might put you at risk to be revictimized.
People under stress will have gaps in their memory. People with dissociation may also not know they have those gaps until someone asks about something they can’t remember. This is referred to in the literature as “amnesia about the amnesia.”
Dissociative Disorders, all 5 of them according to the DSM-5, include both positive and negative symptoms. In the past the only other disorder that I remember being described that way was Schizophrenia, but as I think about them other disorders have both also.
Positive and negative symptoms do not mean they are good and bad. What this means is that people with a disorder lose the ability to do some things others can do. This loss is called negative symptoms.
They also develop symptoms that others do not have. These added symptoms are called positive symptoms.
Since I believe people can and do recover I think that these areas of altered functioning can vary in intensity and can get better or worse depending on time, traumas, conditions and treatment. More on negative and positive symptoms in future posts.
Another area of concern in talking about dissociation is something called state or trait theory. Trait would imply that once you got it you always got it. So if you dissociate then you are a goner and who wants to believe that. But if dissociation is a state then you can move into and out of it.
One other cause of Dissociative symptoms is efforts to reprogram or expose someone to “thought reform.” This mental reprogramming, like brain washing, results in a brain that at some level believes two contradictory things. Can you see how that brain could pop in and out of contact with others?
Last, despite all the press about extreme cases of dissociation and the recurrent belief that this is something that only happens to women, the research tells me it is in fact more common among men that women. I have some theories about why that might be but that like the rest of this needs to wait till another post.
Dissociative disorders vary from person to person and time to time. Nothing I can say will fit everyone and there is a lot to be said for listening to the “lived experience” of those who have these disorders. More to come on this topic, but in the meantime what do all of you think about this?
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