Institute Inbrief - 03/06/2015
Welcome to Edition 226 of Institute Inbrief! Have you ever seen a movie in which the main character wakes up in a strange hotel room, dressed weirdly, with no idea how she got there, and no relationship to the name she gave hotel staff upon check-in? Such drama is the stuff of Hollywood depictions of dissociative disorders. There are various dissociative disorders, all of which feature some form of dissociation. But what, exactly, is the phenomenon of dissociating about? This is what we explore in this edition’s featured article.
Also in this edition:
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- Wellness tips
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The Phenomenon of Dissociation
Have you ever seen a movie in which the main character wakes up in a strange hotel room, dressed weirdly, with no idea how she got there, and no relationship to the name she gave hotel staff upon check-in? Such drama is the stuff of Hollywood depictions of dissociative disorders.
Dissociative identity disorder (DID), known as multiple personality disorder (MPD) until renamed in the DSM-IV (American Psychiatric Association, 1994), has attracted a lot of attention in the mental health field due to the unusual features of its symptomatology and the various controversies surrounding it. While MPD did not appear as an official disorder until the publication of the DSM -III in 1980 (Coons, 1980), the growing recognition of psychiatric conditions resulting from traumatic influences has come to be seen as a significant mental health issue. Until recently, DID was considered a rare and mysterious psychiatric disorder.
However, DID and other dissociative disorders (DD) are now understood to be fairly common effects of severe and extreme trauma in early childhood when repeated physical, sexual and emotional abuse are part of the individual’s history. In fact, the placement of dissociative disorders in the DSM-5 is next to (but not part of) the chapter on trauma and stressor-related disorders, reflecting the close relationship between these diagnostic classes (APA, 2013).
There are various dissociative disorders, all of which feature some form of dissociation. But what, exactly, is the phenomenon of dissociating about?
The phenomenon of dissociation
“Dissociation” describes a state in which the integrated functioning of a person’s identity, including consciousness, memory, and awareness of surroundings, is disrupted or eliminated. Specifically, dissociation is a mechanism or specific mental strategy that allows the mind to separate certain memories or thoughts from normal consciousness. These memories are not erased, but are buried or compartmentalised and may resurface or come out of the compartment at a later time. Dissociation is often explained as being a type of self-hypnosis that takes on the form of a hypnotic trance involving a temporarily altered state of consciousness. Occurring along a continuum, dissociation is often a normal part of human experience in milder forms, while the more extreme forms can become markedly debilitating.
How did I get here? Everyday dissociation
An example of everyday, mild dissociation is when a person is driving for a long period of time – say, on the motorway – and takes several turns and exits without remembering any of them. When prompted the person may find it almost impossible to recollect driving through those specific areas at all, even though they know that they did, and know that they did so without running off the road or causing an accident. In this instance, the mind continued to focus on driving and all that was required to keep safe, but it did so at an automated, unconscious level in which the driving activity was held in the background (or the unconscious part) of the mind while thoughts or daydreams predominated in the foreground: the overtly conscious part of the mind. Memory finds it easier to recollect what has been attended to in the foreground rather than what was occurring in the background of the mind. Hence, the daydreaming is remembered more readily than the road travelled. The point at which conscious attention switches from the driving to the day dream – even though an unconscious focus on the driving is maintained – is the act of moving to a mild dissociated state while driving.
Pathological dissociation
In more severe forms of dissociation, an individual begins to experience a lack of awareness of important aspects of his or her own identity (Phelps, 2000), so rather than simply slipping out of conscious awareness when driving down the motorway, certain aspects of the person’s identity (that is, aspects such as how s/he would normally think, feel and behave) slip into the background and are forgotten. A very important factor to remember in the process of dissociation is that while the specific element of focus (e.g., driving a car or thinking, feeling and behaving in a certain way) may end up receding into the background of consciousness and being forgotten, it can still function or operate as if in full awareness. So while a person in a mild dissociative state can still drive proficiently down the motorway while daydreaming and not being fully aware that he or she is d riving, so too a person in a more severe dissociative state can end up functioning in clear expression of thought, feeling and behaviour without being fully aware of doing it.
Contextualising the full scope of how dissociation can manifest, Braun (1988) suggests that the dissociative spectrum can extend from normal dissociation to a poly-fragmented dissociative identity disorder (DID). Dissociative identity disorder is at the extreme end of dissociative spectrum disorders and is a disturbance of identity in which two or more separate and distinct personality states, or identities, control the individual’s behaviour at different times (Loewenstein, 2005) and alternate between the foreground and background of conscious awareness.
The phrase “dissociative identity disorder” replaced “multiple personality disorder” because the new name emphasises the disruption of a person’s identity that characterises the disorder, while the term dissociation draws attention to the actual mental process taking place. When under the control of one identity, (i.e. when those aspects of self are in the conscious foreground), the person is usually unable to remember some of the events that occurred while other personalities were in control. The different identities, referred to as alters, can develop so independently of one another that they exhibit differences in speech, mannerisms, attitudes, thoughts, and gender orientation. The alters may differ in “physical” properties such as allergies, right-or-left handedness, or even the need for eye glass prescriptions. The differences are distinct and can often be quite striking to the observer (Haddock, 2001).
Dissociation is typically used to escape stressful or harmful situations by creating another place for the mind to go (such as when a person daydreams) while leaving some aspect of the self in the stressful or harmful environment to automatically function in it (Haddock, 2001). Thus the aetiology of DID is predominantly trauma-based. Symptoms develop as a result of dissociating from extreme traumatic events and then continue through ongoing habitual dissociation in survivor attempts to distance themselves from the traumatic memories (Kluft, 1996). Dissociation is therefore most likely to occur at the exact time a traumatic event is being experienced and when the horrific emotional distress that accompanies it is coupled with a strong sense of powerlessness to stop it or escape from it. Finding a place for the mind – a place for the self to hide – while being subjected to a traumatic event, is the only way the individual sees to cope (Holstrom, 1988).
Logically then, DID can happen to victims of any form of abuse. When the abuse is severe, dissociation or “splitting” might be the only means of escape. For example, when a person is completely overpowered and any form of resistance could lead to their death, splitting allows the individual to hold one aspect of themselves in the trauma to deal with it – albeit in an automated, emotionally detached way – while taking other aspects of the self away from the trauma and into the mind: into the daydream.
Subjective and objective reality: the development of alters
Those who have been subjected to trauma on an ongoing basis often report that the inside world of the ‘daydream’ feels more real than the objective events that occur outside, and that they prefer the world of the daydream to the objective reality of whatever is going on around them. Some client accounts of being in the daydream have been described as feeling like being inside one world (the daydream world that is very real to them) while looking out to a world that they don’t know (the objective reality of real-life experience).
If this process of ‘moving into the world of the mind’s dream’ occurs on a regular basis as a primary way of dealing with ongoing trauma, it can eventually bring on the development of other personalities: the alters that are created to help the individual survive the abuse. Alters constellate when dissociated individuals only allow certain aspects of their personality to the foreground at certain times (e.g., while being subjected to horrific abuse) while keeping other aspects of their personality in the daydream world. The more this occurs, the more the individual will switch between alternate states of consciousness in order to alter which parts of their personality stay in objective reality and which parts go for safety by moving back into the daydream.
As the dissociating individual continues with ever-greater frequency and intensity to alternate states of consciousness, the distinct qualities of each alter are reinforced. Consequently over time, rather than developing an integrated mindfulness of a whole, stable self, the dissociating person develops a personality that is split and in a continual state of flux, moving from one aspect of personality to another and from the objective reality of the tangible world to the subjective reality of the daydream world. Some parts of the personality may never enter the daydream while other parts of the personality may never enter the objective world.
The alters become increasingly distinct from one another, with very different characteristics, cognitive processes, memory, and physiology. They are experienced by the client as being different people. In many instances the altered states are not aware that they share one body (Kunzman, 1990) while in other instances they may consider themselves as separate people while accepting they share the same body.
Prevalence and Incidence
While the true prevalence of the disorder is hard to determine due to its undetectable nature, DID has been found in a wide range of cultures throughout the world. For example, while one study reported that 4% of Turkish outpatients could qualify for a diagnosis of DID (Levy & Swanson, 2008), it is generally reported in less than 1% of the population, with it being three to nine times more prevalent in adult women than adult men (Levy & Swanson, 2008). It has also been found that 15% of clients experiencing substance dependency may also be dealing with DID (Ross, 1997 cited in Levy & Swanson, 2008).
There has been a sharp rise in reported cases of dissociative identity disorder in recent years and this finding has been subject to different interpretations. One possibility is that greater awareness of the disorder among mental health professionals has resulted in easier identification of cases that were previously undiagnosed. Conversely, the syndrome may be over-diagnosed due to being induced in individuals who are highly suggestible.
References:
American Psychiatric Association, (2000). Diagnostic and Statistical Manual of Mental Disorders. (4th ed.). Text Revision. Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, D.C.: American Psychiatric Association.
Braun, B. (1985). The development of multiple personality disorder, predisposing, precipitating and perpetuating factors. ln R. Kluft (Ed). Childhood Antecedents of Multiple Personality. Washington. D.C.: American Psychiatric Press.
Haddock, D.B. (2001). The dissociative identity disorder resource book, New York, NY: McGraw-Hill.
Levy, B., & Swanson, J.E. (2008). Clinical assessment of dissociative identity disorder among college couselling clients. Journal of College Couselling, 11, 73-86.
Loewestein, R.J. (2005). Psychopharmacologic treatments for dissociative identity disorder. Psychiatric Annals, 35, 666-673.
Kluft, R. (1985). Childhood Antecedents of Multiple Personality. Washington D.C., American Psychiatric Press.
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How to overcome anxiety
The CEO of the fast-expanding organisation looked at me, despair seeping through a veneer of confidence. With three growing children, a loving husband, and work at the top of the corporate ladder, her life ticked all the boxes. “I’m coping OK,” she confided, “but I’ve been better.” “Better” was before she came to be afflicted with one of the most common mental conditions in Australia and worldwide: anxiety.
What is anxiety?
Anxiety means feeling distress or uneasiness about what might happen. Some feelings of apprehension – like when we psyche up for a test, competition or job interview – can be helpful, but for many the anxious feelings are severe and damaging. Affecting about 14% of the population (some 3.2 million Australians), anxiety can have people feeling anxious for so long that they fail to recognise its characteristics. There are psychological symptoms such as feeling frequently worried, tired, irritable, and weepy, with difficulty concentrating. The physical symptoms include rapid breathing, rising blood pressure and pounding heart, a sense of restlessness or feeling on edge, muscle tension, sleep disturbance, and nausea/sickness with an urgent need to go to the toilet.
You may be familiar with some types of anxiety: panic disorder (“attacks” in public places); social anxiety disorder (difficulty socialising even with acquaintances); or specific phobias, such as fear of flying, spiders, or heights. The CEO I have mentioned suffers from generalised anxiety disorder which involves persistent worry about all types of things that could go wrong. In her case, she worried about health, family safety and finances – and the worries were worsened by concerns about not coping with the worries.
Anxiety isn’t your fault
There is no single cause for anxiety, but several factors contribute to its development.
Brain chemistry. Medication works well to reduce anxiety, which suggests that brain chemical imbalances can create anxiety. The two chemical messengers most strongly implicated are the neurotransmitters serotonin and dopamine, which regulate thought and feeling. An imbalance between these two makes people feel depressed and anxious.
Heredity. Anxiety disorders run in families. If parents have an anxiety disorder, children are at higher risk of developing one. If caregivers show fear and anxiety on a daily basis, this, too, can affect the children, as the brain and its learned behaviour are inherited.
Life experiences. A life of abuse, poverty, or violence is fertile ground for the development of anxiety.
Drug use. Does one too many morning coffees make your heart pound? Anxiety can be triggered by drugs such as caffeine and amphetamines (the stimulant drugs). Prolonged amphetamine use can cause feelings of panic and anxiety which last for years after the drug is stopped. Exhaustion and certain medications can also trigger anxiety.
Getting past anxiety – and why you should
Experiments with mice have shown that long-term exposure to stress hormones causes depression and anxiety. Having ongoing anxious feelings can cause major issues in your life: from seeing potential threats where they don’t exist (because you’re literally “wired” by your hormones) to relational, health, and work issues. Recent research showed that highly anxious subjects made poorer decisions than non-anxious subjects; “burned” by past errors, the anxious people did not take on new information and their decision-making was skewed. Anxiety is serious.
So what can you do about anxiety?
Self-awareness is key. Learn to identify the symptoms quickly. Ask yourself: “What is making me feel this way?” Sometimes you can change the anxiety-making circumstance, but even if you can’t, you can still deal with it better if you acknowledge it.
Interpret it positively. Anxious about a big decision? You’re encountering something “new and important”! Got a job interview? How “exciting” (as opposed to “threatening”). Positive interpretation helps reduce the anxious reactions to a more manageable level.
A little is a good thing. Too much anxiety can be damaging but too little can mean you might not perform to your best ability. View anxiety as a resource you can manage to keep you “in the zone”: not too much or too little.
Optimise your gut flora with diet. Weird but true: it’s as if we have two brains. One is in our skull and the other is in our gut. The gut “brain” (the “enteric nervous system”) gets out of balance with sugars, processed foods, starchy foods, and processed vegetable oils. Research has shown that nourishing the gut flora by avoiding the above foods and adding in omega-3 fats, caused a 20% reduction in anxiety among medical students. Studies of certain probiotics (which, along with fermented vegetables nourish the gut) found the probiotics lowered the stress-induced hormone corticosterone, reducing anxious behaviours.
Exercise. In addition to creating new neurons which release calming neurotransmitter GABA, exercise boosts levels of potent brain chemicals like serotonin, dopamine, and norepinephrine, which may help buffer some of the effects of stress and reduce anxiety.
Relaxation and meditation programs work wonders. Regular stillness reduces stress, anxiety, and depression. No teacher around? Jump online, where resources abound.
Therapy. Emotional Freedom Technique and Cognitive-behavioural therapies have been shown to be effective at re-programming psychological and physical reactions to life’s inevitable stressors. These therapies should be conducted by experienced therapists who can help their patients re-program irrational, unhelpful thinking.
Finally, if you are caring for someone with anxiety, you must look after yourself too (the above suggestions are just as helpful for you). As the case of our CEO demonstrates, your life may tick many – or even all of – the boxes but this doesn’t mean you will be immune to anxiety. Anxiety is rife in our increasingly stressful modern world, but you can always take steps to reduce anxiety either for yourself or someone that you care for.
References:
Cole, S. (2015). How anxiety affects your decision-making skills. Fast company. Retrieved on 14 May, 2015, from: hyperlink.
Living with anxiety.com. (2015). Anxiety causes. LivingWithAnxiety.com. Retrieved on 11 May, 2015, from: hyperlink.
Mercola (2013). What anxiety can do to your brain and what you can do about it. Mercola.com. Retrieved on 14 May, 2015, from: hyperlink.
Helping and Stress Management
Stress is any pressure, demand, or threat placed on an organism (say, a human being) that causes a need to re-establish balance or “equilibrium”. The Oxford Dictionary online adds that stress is “a state of mental or emotional strain or tension resulting from adverse or demanding circumstances.” In this article, we look at stress management from the perspective of a helper: that is, anyone who is currently providing emotional or psychological support to a friend, client or loved one. Hence, the concepts outlined apply to therapists as well as people without any specific counselling or mental health training.
Hard-wired to connect: Mirror neurons and empathy
Many people have suspected for a long time that we human beings are designed to be able to experience things happening for another person: in good times or in bad. So we see a stranger clumsily bump their head on a low-hanging branch at the park, and we flinch, too. We hear that a friend has gotten some good news about a medical diagnosis, and we are genuinely happier. Yet although we have suspected this – and even have words, such as empathy and clairsentience, to describe it – it was not until 1992 that science could demonstrate how it happens, and even then it was a serendipitous discovery.
Q&A with Toula Gordillo (Clinical Psychologist)
Q. I have heard that trauma can affect our clients’ brain but I don’t know how to explain it to my clients so that they understand without sounding too scientific and confusing them. How can I explain it so they will understand?
A. Neuroplasticity (the ability of a person’s brain to change) is a fascinating subject, and one in which your clients may be very interested. This is particularly true if they have endured some sort of trauma themselves, or they have a friend/family member who has. Discussions around brain trauma may be particularly relevant for clients who may be suffering posttraumatic stress disorder (PTSD) or dissociative disorders (severe isolated or repeated traumas may result in a person developing dissociative or posttraumatic stress disorders as well as a plethora of other comorbid disorders such as anxiety, depression etc).
Psychological/neurological terms can be quite challenging for clients to understand, particularly if they have endured trauma themselves and their cognitive functioning may be impaired. In such cases, one of the best ways to deliver the information is through a story... the story of their brain. To demonstrate the concept of neuroplasticity (the ability of a person’s brain to change), show the client images of a normal healthy brain, through pictures on a page, a 3D model or images on the computer screen. Discuss the story of their brain, referring back to the images, using the analogy of putty.
Help the client to visualise putty in their hands in the shape of their brain. Explain that the putty is always changing shape in response to their experiences. These changes mean that although the trauma might change the brain, we can help ourselves to heal our brains too. Our traumatic, as well as healing experiences, ensure our brains keep changing. Clients visualise moving the putty and putting it back again into the same or similar position.
Explain to your client that the putty in their hands has three levels – all of which can influence their thoughts, feelings or behaviour and can be affected by trauma. The reptilian brain (yes they can visualise the putty in the shape of a slow moving reptile) is the part of the brain which has the fewest neurons, is associated with instincts and survival responses. It learns very slowly but the effects of trauma on this part of the brain can be reversed, no matter how many neurons they may, or may not, have in this part of brain.
The brain also has four main structures that engage during a traumatic incident. Show the client where the brain stem is, the amygdala, hippocampus and pre-frontal cortex using the images. Help your client to see that how these four structures interact and function individually, influencing how they feel during or after the trauma. When they overact or underact, our thoughts, feelings and behaviour can be affected.
Lastly, help your client to see that chemicals are sent from the brain to the body, via the neck, to help the person fight, flight, freeze or rest and regain. Following trauma, chemicals such as cortisol may remain high, with severe effects on the brain. The client may be unable to create new memories or access old ones. Cortisol may lessen how effectively brain cells communicate (draw a picture of the brain cells talking) by interfering with the function of neurotransmitters and the way the cells send messages (draw a picture and talk about the old fashioned telephones connected by wires but some of the wires have been damaged).
What is most important for your client to know is that it is possible to reverse the changes of trauma and get each of the components back into alignment and working together again i.e., the damaged wires can be repaired, though perhaps not exactly the same as before, and the putty can be restored similar to its original position!
Toula Gordillo is a Clinical Psychologist, AIPC private assessor/tutor and regular contributor for Institute Inbrief. Toula has an extensive work history as a Clinical Psychologist, Teacher, and Guidance Officer. For more information, visit www.talktoteens.com.au.
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How to Gain Strength from Adversity
Most of us would have heard the saying, “what doesn’t kill us makes us stronger.” While the optimist in us will hope this saying holds true, it now seems there is some more veracity to this claim. Since the 1990s, there has been huge interest in the question of whether, after a trauma, we must succumb to post-traumatic stress, or whether we are able to instead experience post-traumatic growth.
The question isn’t new, as all of the world’s major religions have told us about the transformative power of suffering. But the new emphasis is more scientific, so we need to ask: what counts as trauma? What would growth look like? And what do we need to watch out for, post-trauma, to ensure we experience growth?
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