Understanding Dissociation

Dissociation, from daydreaming to severe identity disorders, can be challenging to work with clinically. This article explores this complex psychological phenomenon.  

Related articles: Understanding Adverse Childhood Experiences (ACEs), Epigenetics and Intergenerational Trauma, Is Your Client Mentally Ill or Just Having a Tough Time?

Introduction

Dissociation is a complex psychological phenomenon often encountered in clinical practice. It can present in various forms, ranging from mild detachment from immediate surroundings to more severe disconnection from reality, affecting a person’s sense of identity, memory, and consciousness. This article aims to provide mental health professionals with an understanding of dissociation, including its definitions, aetiology, relationship with mental health disorders, clinical management strategies, and psychoeducation approaches for clients experiencing dissociation.

Definitions of dissociation

Dissociation is defined as a disruption or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour. This definition encompasses a wide range of experiences, from everyday dissociative events, such as daydreaming, to more severe dissociative disorders.

Types of dissociation

1. Depersonalisation/Derealisation Disorder: Persistent or recurrent experiences of feeling detached from one’s mind, self, or body (depersonalisation) or from surroundings (derealisation).
2. Dissociative Amnesia: Inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
3. Dissociative Identity Disorder (DID): Presence of two or more distinct personality states or an experience of possession, along with recurrent episodes of amnesia.
4. Other Specified Dissociative Disorder (OSDD): Dissociative symptoms that do not fully meet the criteria for any specific dissociative disorder.

Aetiology of dissociation

The aetiology of dissociation is multifaceted, involving biological, psychological, and social factors. Research indicates that dissociation often stems from traumatic experiences, particularly those occurring in childhood (e.g. Adverse Childhood Experiences or ACEs). Contributing factors include:

1. Trauma: Chronic and severe trauma, especially during developmental years, is strongly linked to dissociative disorders. This includes physical, emotional, and sexual abuse, as well as neglect.
2. Attachment and development: Disruptions in early attachment relationships and inadequate caregiving can predispose individuals to dissociative responses as a coping mechanism.
3. Neurobiological factors: Abnormalities in brain areas involved in memory and emotion regulation, such as the amygdala and hippocampus, have been implicated in dissociation.
4. Genetic and environmental factors: There is evidence suggesting a genetic predisposition to dissociation, along with environmental factors like stress and lack of social support.

Dissociation and mental health disorders

Dissociation is commonly associated with various mental health disorders. Understanding these associations is crucial for accurate diagnosis and effective treatment planning. Mental health disorders commonly associated with dissociation include:

1. Post-Traumatic Stress Disorder (PTSD): Dissociation is a prominent feature in PTSD, where individuals may experience flashbacks, emotional numbing, and out-of-body experiences.
2. Borderline Personality Disorder (BPD): Dissociative symptoms are frequent in BPD, often triggered by stress or interpersonal conflicts.
3. Anxiety and Mood Disorders: High levels of dissociation can occur in individuals with anxiety and mood disorders (e.g. Depression), particularly in those with a history of trauma.
4. Psychotic Disorders: While less common, dissociation can sometimes be mistaken for psychotic symptoms, necessitating careful differential diagnosis.

Clinical strategies for managing dissociation

Effective management of dissociation involves a combination of therapeutic approaches tailored to the individual’s needs and can include grounding techniques.

Therapeutic approaches

1. Trauma-Focused Therapy: Techniques such as Eye Movement Desensitisation and Reprocessing (EMDR) and Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) are effective in addressing underlying traumatic memories.
2. Dialectical Behaviour Therapy (DBT): Particularly useful for individuals with BPD, Dialectical Behaviour Therapy helps in developing emotion regulation, distress tolerance, and interpersonal effectiveness skills. For a curated collection of DBT-related courses, articles and resources, visit this page.
3. Cognitive Behavioural Therapy (CBT): CBT can be adapted to address dissociative symptoms, focusing on grounding techniques and cognitive restructuring.
4. Pharmacotherapy: While no specific medications are approved for dissociative disorders, pharmacotherapy can be used to treat comorbid conditions such as depression and anxiety.

Grounding techniques

• Sensory Grounding: Using the five senses to anchor oneself in the present moment (e.g., holding an ice cube, listening to loud music).
• Cognitive Grounding: Engaging the mind with challenging tasks (e.g., counting backward, reciting a poem).
• Physical Grounding: Focusing on physical sensations (e.g., stomping feet, stretching).

Psychoeducation strategies to help clients manage dissociation

Psychoeducation is a critical component of treatment, helping clients to understand their experiences and develop effective coping strategies. Psychoeducation components include:

1. Understanding dissociation: Explaining the nature of dissociation, its causes, and its role as a coping mechanism for dealing with trauma.
2. Normalising the experience: Helping clients understand that dissociation is a common response to trauma and not a sign of weakness or insanity.
3. Identifying triggers: Assisting clients in recognising situations, thoughts, or feelings that trigger dissociative episodes.
4. Developing coping strategies: Teaching clients various grounding techniques, mindfulness practices, and self-soothing activities to manage dissociative symptoms.
5. Building a support system: Encouraging clients to seek support from trusted individuals and to communicate openly about their experiences with dissociation.

Conclusion

Dissociation is a complex and multifaceted phenomenon that can significantly impact an individual’s mental health and daily functioning. Understanding the definitions, aetiology, and associations with other mental health disorders is crucial for accurate diagnosis and effective treatment. Clinical strategies should be tailored to the individual’s specific needs, incorporating trauma-focused therapy, grounding techniques, and psychoeducation. By providing clients with the knowledge and tools to manage their symptoms, mental health professionals can help them lead more integrated and fulfilling lives.

Key takeaways

• Dissociation involves disruptions in consciousness, memory, identity, and perception, ranging from mild to severe, and is often linked to trauma, especially in early childhood.
• Dissociation is commonly associated with PTSD, BPD, anxiety, mood disorders, and sometimes psychotic disorders.
• Effective management includes trauma-focused therapy, DBT, CBT, grounding techniques, and, when necessary, pharmacotherapy.
• Psychoeducation is essential for helping clients understand dissociation, identify triggers, and develop coping strategies.

References

• American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th edition, Text Revision.). Arlington, VA: American Psychiatric Publishing.
• Van der Kolk, B. A. (2015). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York, NY: Penguin Books.
• Nijenhuis, E. R. S., van der Hart, O., & Steele, K. (2017). Trauma-related structural dissociation of the personality. Activitas Nervosa Superior, Vol 52, pp 1-23. Available from Springer Link: https://link.springer.com/article/10.1007/BF03379560            
• Liotti, G. (2006). A model of dissociation based on attachment theory and research. Journal of Trauma & Dissociation, 7(4), 55-73.
• Spiegel, D., & Cardeña, E. (1991). Disintegrated experience: The dissociative disorders revisited. Journal of Abnormal Psychology, 100(3), 366-378.
• Lanius, R. A., Vermetten, E., & Pain, C. (Eds.). (2010). The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Cambridge University Press.