The term dissociation refers to the (partial to complete) disassociation of mental functions that are normally related. Affected by dissociative splitting are usually the areas of perception, consciousness, memory, identity and motor function, but sometimes also bodily sensations (such as pain and hunger).
Examples include dissociative movement disorders, amnesia, sensory disturbances, seizures, personality disorders, and others.
It is about symptoms, backgrounds and new therapy approaches.
Three stories
A like Anna
A staff member rushed excitedly into my doctor's office. "Come quickly, there is something very strange". When I quickly followed her into the treatment cabin, everything seemed to be in order at first glance. A woman about 40 years old - we will call her Anna - was sitting on a treatment couch and was handling the examination equipment that was in the cabin. She seemed to be playing with it. When I approached her, I understood what had so irritated my co-worker. The woman spoke in the voice of a little girl. "Anna wants to play. Do you have any more toys? They're not pretty." The patient had been completely inconspicuous until a few minutes ago, acting controlled and adult. They had talked about everyday things. Then, during one of the examinations, she touched the patient's neck lightly. The patient froze, breathed heavily and was as if changed. All at once she began to speak in a squeaky voice and behaved like a small child.
B like Bettina
We introduced a round of about 10 patients to various therapy procedures. The hour was almost over when Bettina, one of the patients, slumped in her chair. Various possibilities from stroke to heart attack flashed through my mind. But the patient had already told me about this slump. She sat on the chair and seemed to be paralyzed. But she did not fall to the floor. With surprisingly little support, I was able to transport her to a couch. There I tried to make contact with her. But she remained unresponsive. Only her hand moved very slightly. I took hold of it and asked her to squeeze my hand if she could hear me. After a short delay, a light handshake followed. After we had agreed on a code (one squeeze = yes, two squeezes = no) we were thus able to have a short "conversation" in which she told me that she hoped to come out of the state in a moment. Such conditions had been plaguing Bettina for 8 years; at times she was bedridden for weeks.
C like Claudia
When I called on the thirty-year-old translator, Claudia, in the waiting room, I thought she would fall immediately. She was clearly no longer in control of her arms and legs. Her arms jerked wildly back and forth, her legs seemed to spasm, and even her upper body bent forward once jerkily and then overstretched backward again. In between, she smiled at me and tried to tell her back story. "A Huntington's chorea, St. Vitus' dance," I immediately thought. But then she informed me, under intermittent breath, that the symptomatology had begun only a few weeks ago.
What are dissociative disorders?
Neither conceited nor hysterical
Anna, Bettina and Claudia had highly different symptoms, all belonging to the same diagnostic group: Dissociative Disorders. It is one of the most puzzling psychological complaints in medicine, which have raised astonishment, questions or skepticism since time immemorial. Time and again, the suggestion that it is "faked," "fake," "imaginary," or "hysterical" surfaces.
In fact, dissociative disorders were counted as hysteria until the 20th century. The term comes from Greek hystera = womb. Since it was mainly women who suffered from it, the symptoms were associated with the uterus and possibly with unsatisfied sexuality. This is of course nonsense and since then the view has clearly differentiated.
What are dissociative disorders?
"Dissociation" means first of all the falling apart of parts that actually belong together. We all live in a space-time continuum and usually know when and where we got up today, what our name is, what we did during the day and what happened around us. Time, space and personal identity form a unity, everything is connected (= associated). But sometimes short gaps appear in this continuum even in healthy people. We are driving to work, are in thought or are talking. Suddenly we register, "Oh, already there!" Parts of the drive seem to fade out. Or: We step onto the road after a moving movie. We are still completely in the movie reality and have to shake ourselves to arrive at everyday life. Or: We read an exciting book and completely forget about time and the environment around us. Finally: Computer gamers intentionally put us into a suspended reality for hours. Reality falls apart (= dissociates).
Protection against excessive demands
Digressing into another world can also be used as protection in a situation that is difficult to bear or unbearable. This can be useful, even necessary. An athlete, while climbing a steep wall, does not feel that he has scraped himself and is bleeding. A patient had a traffic accident, there were injured. He behaved in an exemplary manner, helped the accident victims, took care of the flowing traffic, cleared away broken glass. But it was only an hour later that he discovered his broken ankle.
Forms
Today we distinguish different forms of dissociative disorders.
- Anna showed dissociative identity disorder, often known as multiple personality
- Bettina had a dissociative seizure
- Claudia suffered from a dissociative movement disorder
In addition, there are numerous other forms of dissociation:
- Memory lapses (amnesia)
- Fugue (wandering, traveling without memory)
- Trance
- Sensory disturbances and others.
Background information
Solution for extreme situations
Dissociative symptoms are often triggered in extreme situations. Probably they have old tribal roots. In some animals, a dead-leg reflex occurs in hopeless situations. This startle reflex can be life-saving when a hunter reacts primarily to the movement of a prey animal.
If children get into unbearable situations (violence, abuse), the memory of the experience can be completely split off (= dissociated). If there have been worst experiences of violence and humiliation in a family, then continuing to live in this environment would actually be unbearable. But a child usually has no choice but to stay. By segregating the memory into another area of the person, it can continue to function in everyday life.
Emergency plans
As mentioned, there are numerous forms of dissociation. Dissociative identity disorder with two or more separate personality aspects, or dissociative forgetting, appears repeatedly in literature and Hollywood films (Dr. Jakyll and Mr. Hyde, Jason Bourne series). It seems incomprehensible; indeed, it seems "crazy." But at its core, the split originally served survival in a hopeless life situation.
For extreme situations, our brain apparently has a whole series of "emergency plans" at its disposal, as recent research with functional MRI has shown. There, significant changes in blood flow in individual brain sections are revealed and also show how connections between them are activated or even completely blocked.
There is still no overarching theory of dissociative disorders. But it seems obvious that the symptoms are each based on different aspects of distress reactions. Depending on the situation, it was better to freeze, to run away or simply not to perceive or feel anything at all. These behavioral patterns are each activated in different parts of the brain (limbic system, motor or sensory cortex).
Depending on the individual biography and the extent of the stress reaction, parts of behaviors are then activated that may have once been useful in the course of evolution or in the biographical context. The more severe the stresses are and the earlier they affect a person, the more likely dissociative behavior is chosen as a "solution."
Dissociative movement disorders
Dissociative seizures
Therapy
Psychotherapy
The therapy of dissociative identity disorder is usually protracted. Psychotherapy is the main focus. Often, a phase model is followed, which primarily provides security and stability in the first phase. In phases two and three, an attempt is now made to work through the trauma - as far as it can be remembered - and to gradually integrate the separated aspects.
Ride through hell
This may sound dry, but it means that during this process the person in question is exposed to the old painful or disturbing experiences that originally caused the split. It can become a ride through hell! In the therapeutic healing process, body-oriented methods can also be helpful. Here it can be experienced, especially sensually, that touch and physical contact do not have to be threatening. At the same time, confidence and self-confidence in one's own resources and abilities should be strengthened and consolidated.
Medication
There is no specific drug therapy for dissociation. That would also be difficult to imagine. However, medications, e.g. calming antidepressants, can be used in a supportive manner.
New therapeutic approaches
Rigidity of fear - freezing behaviour
In recent years, we found two more aspects that may be significant for therapy: Stress and respiration.
In the case of a pronounced threat, animals and also humans react with a slowing down of the respiration (our breath stops), the pulse becomes slower and a freezing behavior can occur. At the same time, stress hormones are produced, which, interestingly enough, cannot yet have their effect due to the slowed breathing. This freezing behavior resembles a shooter who remains motionless with a tense bow. Then suddenly the behavior changes, the respiration is strongly accelerated, the carbon dioxide content of the blood drops rapidly. All of a sudden, the body reacts to the previously produced stress hormones. The arrow speeds up! Flight or attack are the result.
Anna, Bettina and Claudia
Back to the three women. As different as the symptomatology was in all of them, we found similar breathing patterns. At the beginning of the dissociative state, their breathing changed. They breathed deeper, faster, and more into the chest. At first we thought this was a coincidence. But in Anna's case we could see this several times directly before the dissociation and in Claudia's case the movement disturbances could be observed completely regularly already after a few deep and fast breaths.
Therefore, in all three women we measured the concentration of CO2 in the blood and found low values. Within the next weeks we therefore tried to achieve a change with different methods of respiratory therapy.
With Anna, the success was the least. The therapy measures themselves - especially physical touch - repeatedly triggered dissociation. However, in the course of her several years of previous therapies, she had found a "trick" for convincing the traumatized child within her to return to the adult ego. All she had to do was look intently at her driver's license. There it was plainly written that she was definitely an adult. After half an hour, she usually calmed down and was able to return to the adult identity. Voice and behavior became age appropriate. The memory of the dissociation, however, remained mostly dim. In the following months, however, she took singing lessons and learned to control her breathing. The dissociative seizures did not disappear completely, but they diminished to such an extent that she was able to discontinue some of the medication she had previously been taking.
Bettina's progress was much faster. But she, too, had to practice for several months before her breathing habits changed. But in parallel with the increase in blood carbon dioxide levels, the dissociative seizures subsided. Recently, I heard from her. She had been symptom-free for a year.
Claudia's change was impressive. Already after one week the movements of arms and legs calmed down. After four weeks there was nothing more to be seen of the symptoms. I had the last contact about a year later. She was still symptom-free.
References
During the literature search, an important clue was then found: Australian pediatricians had found significantly altered breathing habits in children with dissociative seizures. The affected children and adolescents breathed too shallowly and quickly. Above all, the carbon dioxide content of their blood was lowered. It is now known that a high blood CO2 content dampens, calms and, in extreme cases, leads to anesthesia, while conversely low values have an excitatory effect and can even cause convulsions.
Conclusion
1-2% of the population suffers from dissociative symptomatology, which is to be understood as an emergency reaction of body, mind and soul. Partly acquired, partly innate old behavior patterns are activated. In addition to psychotherapy and body-oriented procedures, specific breathing therapy may also be able to make a helpful contribution.