understanding dissociation and its relationship to self-injury and childhood trauma

Dissociation is an adaptive response to traumatic situations such as childhood sexual abuse, in which a person feels psychologically threatened. But training in understanding dissociation is a scarce commodity, says Jan Sutton

'[Dissociation]... begins with the child's self-hypnotic assertion "I am not here; this is not happening to me; I am not in this body."'
Phil Mollon (1996, p.15)¹

RESEARCH suggests that some children repeatedly exposed to severe trauma - for example, sexual, physical and/or emotional abuse - develop the gift of 'dissociation' (a creative survival strategy that enables children to switch off psychologically from the traumatic experience). Over time, however, dissociation can develop into a conditioned response to any stressful situation. Thus what served effectively as a problem-solving strategy in childhood can become a debilitating condition that may seriously impede healthy adult functioning.

What exactly is dissociation?
According to the international version of the Diagnostic and Statistical Manual of Mental Disorders,² 'the essential feature of the Dissociative Disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment'. Put simply, dissociation is a psychological mechanism that allows the mind or body to split off or compartmentalise traumatic memories or disquieting thoughts from normal consciousness.

DSM-IV2 lists five dissociative disorders:

1. Dissociative Amnesia - distinguished by a persistent loss of memory of significant personal information, typically of a traumatic or stressful nature, that is too all-embracing to be explained by normal absent-mindedness.

2. Dissociative Fugue - defined by an abrupt, non-scheduled journey away from one's home or usual place of work, accompanied by a loss of memory of one's past, confusion over one's identity, or assuming a new identity.

3. Dissociative Identity Disorder (DID - formerly Multiple Personality Disorder) is the most extreme form of dissociation. It is characterised by two or more separate identities or personality states that recurrently take control of the individual's behaviour, accompanied by a loss of memory of significant personal information that is too all-embracing to be explained by normal absent-mindedness.

4. Depersonalisation Disorder - defined by an unrelenting or frequent feeling of disconnection/detachment from oneself (mind-body split), during which reality testing remains intact. Depersonalisation is sometimes accompanied by derealisation (a sense that the external world feels strange or unreal).

5. Dissociative Disorder Not Otherwise Specified (DDNOS). This term is used to classify disorders where dissociative symptoms are a predominant feature but do not meet the criteria for any specific Dissociative Disorder. Paraphrased from APA criteria (pp. 489-503)

Etzel Cardeña gives this concise definition of dissociation:³ 'In its broadest sense, 'dissociation' (Janet's désagrégation) simply means that two or more mental processes or contents are not associated or integrated.'

Dissociation in relation to self-injury
It is becoming increasingly recognised that dissociative processes - particularly dissociative amnesia, depersonalisation, and derealisation can underpin self-injury (for example, self-cutting or burning). People who experience depersonalisation 'have disconcerting feelings of being detached from their bodies and mental processes'. (Favazza, 1996, p. 247)⁴ Indeed, many self-injurers report, (1) feeling 'emotionally numb', 'detached from themselves' or 'dead inside' prior to the act; (2) feeling little or no physical pain during the act, and (3) feeling more alive, more real, and more grounded following the act. Looking at self-injury in this light, we can see that it serves an important role in terminating dissociative episodes - which by all accounts are very unpleasant and frightening. Judith Herman, in her landmark book Trauma and Recovery (1994),⁵ whilst discussing dissociation and self-injury within the framework of major childhood trauma, identifies the sequence described:

'Survivors who self-mutilate consistently describe a profound dissociative state preceding the act. Depersonalisation, derealisation, and anesthesia are accompanied by a feeling of unbearable agitation and a compulsion to attack the body. The initial injuries often produce no pain at all.' (p.109)

Rachael, a participant in my current research into self-injury, gave this response when invited to explain how she felt prior to her most recent episode of self-injury:

'I am not exactly sure how I felt specifically this time. I do know that during previous times, I have felt spacey, not part of myself, and detached... this feeling is hard for me to explain. It is almost as if it is not "me'... it feels like something else has taken over and I no longer control it... it feels as if "I' am not really present during the time.'

For purposes of clarity, probably one of the best explanations of the relationship between dissociation and self-injury comes from Ruta Mazelis (1998)⁶ author of The Cutting Edge: A Newsletter for People Living with Self-Inflicted Violence:

'Whereas SIV [self-inflicted violence] is used as a coping mechanism to manage excruciating emotional states, it can also serve to alter feelings of profound numbness or deadness... SIV seems to be an effective tool for managing dissociation in both directions - to facilitate it when emotions are overwhelming, as well as to diminish it when one feels too disconnected from oneself and the world.'

For further insight into the role of dissociation in the process of self-injury, see the information below: Two Common Pathways to Self-Injury.

In a clinical setting, depersonalisation may be described in terms of 'looking down or in on oneself', 'standing beside oneself', 'outside oneself', 'blank spells', or as a 'floaty, foggy, dazed out, phased out, zoned out, or trance-like feeling.' In some cases, the 'I' may be dissociated - for example 'she is not me'.

In derealisation the environment may be experienced as two-dimensional, strange, unreal, or 'The individual may perceive an uncanny alteration in the size and shape of objects'. (DSM-IV, p. 500)² In this context self-injury can serve as an extreme grounding technique to bring oneself back to the here-and-now ('I do exist', 'I am alive/real').

Amnesia, self-injury and DID
Some individuals who engage in self-injury are amnesic during the act, reporting that they feel shocked when they realise they have injured themselves, or describing how they wake up in a pool of blood without knowing they have hurt themselves. In the case of self-injurers with Dissociative Identity Disorder (DID), one hypothesis is that a persecutory 'alter' personality may punish the 'host' personality or another 'alter' in the system (for example, if the 'host' or an 'alter' discloses abuse to a therapist during the course of treatment).

Jessica, a research participant diagnosed with dissociative identity disorder, describes the process of amnesia during the act, due to an 'alter' personality taking control:

'I have DID and there is an alter... Sometimes when I consciously self-injure she will come out and take over and finish the job. I will not know what damage has been done until I wake up the next day. I become so detached that it is like I become in a trance-like state and it is like I am watching someone else doing the cutting.'

Interestingly, Ross (1997, p.151)⁷ argues that, 'the persecutor's underlying motivation is actually positive'. This is a view I share and if we return to the example given above, one positive scenario might be that the persecutory 'alter' believes she/he is acting in the 'host's' best interests. In other words, she/he is trying to prevent the truth coming out about the abuse for fear of 'not being believed' or other possible dire consequences (for example, the 'system' being emotionally overwhelmed or flooded with memories, mental disintegration, or rejection and abandonment by significant others).

Ross goes on to explain that, 'Most often, the persecutor is a misguided protector whose behaviour makes sense within her own world view: The first challenge to the therapist is to understand the persecutor's universe, and the laws that govern it.' (p. 151). I agree with this.

Discussion
From the foregoing, we can see that dissociation is an adaptive response to traumatic situations where a person feels psychologically threatened. It enables people to maintain integrity of the mind. Working alongside dissociative individuals on their healing pathway can be a rewarding, yet arduous journey at times, and training in understanding dissociation and self-injury is a scarce commodity. However, bearing in mind the ever-increasing number of survivors and self-injurers who appear to be stepping out of the shadows and seeking help, don't we owe it to them to provide the best service possible?

For information on training opportunities and guidelines for treatment, see resources below.

References

1. Mollon P. Multiple Selves, Multiple Voices: Working with Trauma, Violation and Dissociation, Chichester: John Wiley & Sons Ltd. 1996
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, International Version, Washington, DC. 1995
3. Cardeña E. The Domain of Dissociation. In Dissociation: Clinical and theoretical perspectives, Lynn S J, & Rhue J W (eds.), New York: The Guilford Press (p.15). 1994
4. Favazza A R. Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry, 2nd ed., Baltimore: The Johns Hopkins University Press. 1996
5. Herman J L. Trauma and Recovery: From Domestic Abuse to Political Terror, (Pandora edition), 1994.
6. Mazelis R. The Cutting Edge, A Newsletter for Women Living With Self-Inflicted Violence, Volume 9, Issue 3 (35) 1998
7. Ross C A. Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality. 2nd ed., New York: John Wiley & Sons, Inc. 1997
8. Steinberg M. Interviewers Guide to the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Washington, DC, American Psychiatric Press 1994
9. Nijenhuis E R S, Spinhoven P, Van Dyck R, Van der Hart O, & Vanderlinden J. 'The development and the psychometric characteristics of the Somatoform Dissociation Questionnaire (SDQ-20).' Journal of Nervous and Mental Disease, 184, pp. 688-694. 1996

Two Common Pathways to Self-Injury

Childhood Trauma (for example, abuse, neglect, loss, bullying, chronic invalidation)

Melting pot of unexpressed emotions/emotional pain (anger, rage, frustration, fear, sadness, guilt, self-hate)

Emotional Overload

Emotions become:
'Too real'
'Out of control'
'Overwhelming'

Person feels:
'Unable to cope'
'About to explode/disintegrate'

Person self-injures
Goal:
To shift the focus from internal to external, re-establish a sense of emotional balance, and induce dissociation

Consequences:
Temporary relief from the overwhelming emotions

Person feels:
'Better'
'More in control'
'More able to cope and function'

Vacillation

Traumatised person may waver/swing from one extreme to the other - between feeling emotionally overwhelmed to feeling emotionally numb (dissociated). This process can happen almost instinctively and the person may not be consciously aware of the process.

Quotes by self-injurers about dissociative experiences prior to self-injury

'I assure you, it is a most unpleasant experience and an incentive to self-injure as soon as possible.' [Rev. Dianna - male]

'It usually feels like someone else has taken over or like a dazed out feeling.' [Crystal]

'...it's like a trance. Like I'm in a fog, or high on drugs-dreamy feeling. I make myself go into this state before I cut, it helps make the whole world go away and all the thoughts and worries and fears and anger and sadness while I'm cutting. This is the best part of it to me, besides watching the blood.' [Alexa]

Emotional Shutdown

Numbing, dissociation
(episodes of depersonalisation or derealisation). Coping strategies used to ward off overwhelming emotions (may be an automatic response to feeling unable to cope)

Person feels:
'Unreal'
'Disconnected'
'Dead inside'

Person self-injures
Goal: To terminate intense dissociative episodes (depersonalisation, derealisation, emotional numbness)

Consequences:
Proof of existence

Person thinks/feels:
'I do exist'
'I am alive/real'
'Grounded in reality'
(the here-and-now)

Dissociation screening and diagnostic tools

The following screening and diagnostic instruments are widely used by clinicians working in the field of dissociation to measure dissociative symptoms or diagnose disorders. A word of caution. They are included here for educational purposes and should not be administered without adequate training or guidance from an experienced practitioner. The websites listed were accessible at the date of writing (1 March 2004).

The Dissociative Experiences Scale (DES)
A widely used 28-item self-report questionnaire developed by Eve Bernstein Carlson, Ph.D. and Frank W. Putnam, M.D (1986) measures the frequency of dissociative experiences and is available in over 20 languages. The DES is quick to complete and easy to score.

Further information about the DES is available on Dr Colin Ross's site www.rossinst.com/des.htm

Adolescent Dissociative Experiences Scale (A-DES)
A version of the DES developed specifically for use with adolescents (approximate age 10-1) by Judith Armstrong, Frank W. Putnam, and Eve Bernstein Carlson - currently available in English only.

The DES and A-DES are available from The Sidran Institute
www.sidran.org/catalog/des.html

The Dissociative Disorders Interview Schedule (DDIS) DSM-IV Version
132-item highly structured interview, developed by Dr Colin Ross, which takes approximately 30-45 minutes to administer. It evaluates DSM-IV diagnoses of somatisation disorder, borderline personality disorder, and major depressive disorder, as well as all the dissociative disorders.

The DDIS is available on Dr Ross's website (with permission to copy) www.rossinst.com/dddquest.htm

It is also included in: Ross, C. A. (1997). Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality. 2nd Ed. New York: John Wiley & Sons, Inc. (pp. 383-402).⁷

The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D)
A semi-structured diagnostic interview designed and developed by Marlene Steinberg, M.D.⁸ Enables a trained clinician to assess the severity of the dissociative disorders based on DSM-IV criteria - dissociative amnesia, dissociative fugue, depersonalisation disorder, dissociative identity disorder and dissociative disorder not otherwise specified (DDNOS) (see references).

Steinberg Depersonalisation Questionnaire
A 15-item questionnaire that identifies symptoms of depersonalisation (mild, moderate or severe). Available online with scoring facility. Reprinted from The Stranger in the Mirror - Dissociation: The Hidden Epidemic, by Marlene Steinberg and Maxine Schnall (HarperCollins, 2000).
www.strangerinthemirror.com/questionnaire.html

Somatoform Questionnaire (SDQ-20 and SDQ-5)
The 20-item Somatoform Dissociation Questionnaire (SDQ-20; Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1996)⁹ evaluates the severity of somatoform dissociation. The five item SDQ-5 is a screening instrument for DSM-IV dissociative disorders. For further information, see webpage: www.enijenhuis.nl/index.html

Useful Internet Resources on Dissociation and Self-Injury Dissociation: Guidelines for treatment

Available from The International Society for the Study of Dissociation

Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents (February 2003). Available in pdf format from ISSD (with permission to reproduce).

Guidelines for Treating Dissociative Identity Disorder (Multiple Personality Disorder) in Adults (1997). Available from ISSD (with permission to reproduce). www.issd.org/indexpage/isdguide.htm

United Kingdom Society for the Study of Dissociation (UKSSD). UKSSD is a Component Society of the International Society for the Study of Dissociation (ISSD). Promotes research and training in the identification and treatment of dissociative disorders, provides professional and public education about dissociative disorders, supports national communication and cooperation among clinicians and investigators working in the field of dissociation, and promotes the development of local groups for study, education, and referral. www.ukssd.org

Self-Injury and Related Issues (SIARI). Information and support for self-injurers and their supporters. Includes creative works of self-injurers, message board for self-injurers, moderated online support group for helpers, bookstore, articles, and extensive list of resources on self-injury and related issues (self-harm, abuse, eating disorders, ptsd, bpd, dissociative disorders, counselling, and therapy). www.siari.co.uk

First Person Plural. A UK paper-based quarterly newsletter for dissociators and their allies. www.firstpersonplural.org.uk