Dissociation

Dissociation, a group of phenomena long recognized as commonly exhibited by traumatized individuals, is a topic that is frequently misunderstood or entirely overlooked. On one hand, it has been identified as a phenomenon of central importance in the field of psychology for over a century and is much more prevalent than is generally recognized. On the other, it rarely receives the attention it deserves.

One reason for this state of affairs is that dissociation is a phenomenon that is difficult to grasp conceptually. It covers a wide range of manifestations that do not have an obvious common denominator. For example, depersonalization, feeling unreal or detached from one's own experience; psychogenic amnesia, memory difficulties because of psychological factors that are not within the range of ordinary forgetting; and identity fragmentation, an appreciable shift in sense of self from one situation to another are all considered dissociative phenomena. This source of confusion can be resolved by remembering that dissociation literally means disconnection. What [Page 214]the divergent manifestations of dissociation share is that they all represent forms of detachment, whether from the external environment (e.g., derealization), from one's own experience (e.g., identify fragmentation) or from other people (e.g., disorganized attachment).

A second major reason that dissociation is not as widely recognized as its prevalence warrants is that in the minds of many, both professionals and laypeople, it is often equated almost exclusively with dissociative identity disorder (DID, previously known as multiple personality disorder). Conventional wisdom has been that DID is so rare that most practitioners will be unlikely to encounter a single case of it in their entire careers. This is not the case. Research suggests that the prevalence of DID in the general population is somewhere between 1% and 3%, a rate commensurate with that of obsessive-compulsive disorder. Moreover, the prevalence of DID is unquestionably outstripped by that of other dissociative disorders.

There are a number of interrelationships between trauma and dissociation. Dissociative pathology has long been associated with a history of exposure to traumatic events. An extensive body of empirical research provides support for this relationship in a variety of different types of trauma. However, more recent proposals that impaired attachment is a pathway to dissociative difficulties have also been borne out by research. The numbing symptoms that have been recognized as a defining feature of posttrau-matic stress disorder (PTSD) since its inclusion in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) are generally understood to compose a major dissociative component of this disorder. In fact, dissociative symptoms are sufficiently prominent in PTSD that some have proposed that it would be more accurately classified as a dissociative disorder than among the anxiety disorders, where it has been classified since it first appeared in the publication of the third edition of the DSM in 1980.

Although trauma appears to often be a precursor to later dissociation, it has generally been believed that when dissociation accompanies a traumatic event (referred to as peritraumatic dissociation) this increases the likelihood of developing PTSD. However, research has not decisively supported this contention. Two recent studies may help explain this ambiguity. An examination of the latent structure of the Peritraumatic Dissociative Experiences Questionnaire suggested that there may be two components of peritraumatic dissociation: “altered awareness” because of truncated encoding of the traumatic experience, and “depersonalization,” a distorted sense of reality that seems to be related to attempts to distance oneself from the traumatic experience. It appeared that it was only the latter component that was related to the occurrence of PTSD. In a study comparing war veterans with immediate onset and delayed onset (PTSD), it was found that peritraumatic dissociation was more prevalent in immediate onset PTSD. Peritraumatic dissociation, therefore, may be specifically related to delayed onset PTSD, especially in those instances where it is prominently characterized by depersonalization. However, the findings of at least one study raise the possibility that PTSD may be more strongly related to a persistent pattern of dissociation than to the temporary dissociative state that may occur at the time of the trauma represented by peritraumatic dissociation.

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