What is dissociation when it comes to trauma
I am pleased that I am able to give this lecture on the subject of “Dissociative Disorders” today, as I would like to make a contribution to making these special forms of mental illness, which are often associated with a lot of suffering for those affected, a little better known.
Even among experts, the topic of "dissociative disorders" and, above all, the possibilities of treating them is still largely unknown, so it is not surprising that many patients are often treated for years due to misdiagnosis without any significant improvement in their symptoms.
The fact that the topic has received so little attention in Germany so far is possibly due to a taboo that has been upheld in Germany for a long time:
This is the so-called “trauma taboo”, namely the idea that there were no traumatized people in Germany for a long time and consequently no people who suffered from the consequences of previous traumatization existed.
This taboo has resulted in the fact that to this day it has been largely denied that there are thousands of trauma victims in the generation of our fathers and grandfathers - people who have never really come to terms with their war experiences - as well as the many victims of sexual abuse and domestic violence who are still always have to fight to be believed, even if their symptoms speak a language very clearly.
Fortunately, events such as the train accident in Eschede and the rampage of a schoolboy in Erfurt are slowly dissolving this taboo. Perhaps these events will eventually lead to the recognition that about 1/3 of the people at some point in their lives have experienced major trauma, i. That is, they live through a situation with an experience of near death and only two thirds of these people manage to have this experience without a lasting psychological experience
To survive damage. Perhaps these events lead to the fact that the interest in “dissociative disorders” as one of the most important sequelae of traumatic experiences may perhaps increase somewhat.
Psychotraumatology as a new research area gives reason to hope for positive developments.
As a therapist, I have been focusing on dissociative disorders, especially as a result of sexual abuse in childhood, for about 10 years. It is mainly women who come to my practice and I would like to preface my statements about "dissociation" and about forms of treatment "dissociative disorders" with some typical statements from clients that already contain clear indications of the presence of such a disorder:
When asked about her childhood, a client reports:
“I can't remember my childhood at all. There are photos from that time, but I have the feeling that I wasn't there. "
Another client describes the relationship to her body:
“My body is like an appendage or something that doesn't belong to me. I look down on myself and have zero relationship with myself. During sex I have the feeling that I am not there. "
And another example:
“Whenever I smell the beer, I panic. I am paralyzed and can no longer do anything. "
What do these examples, which deal with the loss of memories, then the loss of physical feelings and finally the fear that is triggered by a smell, have to do with "dissociation"?
First of all, a definition that highlights what all dissociative disorders have in common:
“The general characteristic of dissociative disorders is the partial or complete loss of the normal integration of memories of the past, of the sense of identity, of the immediate sensations, as well as the control of body movements.
To put it simply, dissociation is another word for splitting or falling apart. The opposite is association.
Dissociation is a process in which something that actually belongs together falls apart. A related psychological process breaks down into individual parts (that has nothing
to do with splitting in schizophrenia). Something has gotten out of the overall experience and is no longer fully conscious.
How does this psychic process come about? What is dissociation for?
Dissociation is to be understood as a coping mechanism that serves to make traumatic experiences, insoluble or unbearable conflicts bearable. It is about experiences that are so stressful that they cannot be integrated into a person's everyday consciousness. ("I can't stand it in my head!")
Dissociation is a psychological coping mechanism - one can also speak of a defense mechanism - which serves to split off unbearable feelings, body sensations, memories, perceptual contents in order to make a situation bearable in this way, i.e. H. to be able to survive
Although clinical studies have now found that dissociation also leads to physiological changes (medicine - new research area), dissociation is primarily a disturbance of consciousness.
By the way, all people dissociate more or less strongly. A healthy form of dissociation is the everyday "fading out" of perceptions or feelings that make us uncomfortable.
Dissociation as a disorder begins where the splits restrict a person's ability to function in daily life. (E.g. loss of body sensations - often after sexual abuse).
Let us take a closer look at the process of dissociation:
With the exception of organic brain changes and substance abuse, the disorder is always closely related to the experience of a very stressful, i.e. traumatic, situation, a situation that is perceived as hopeless or unsolvable.
The predominant feeling in such situations is the feeling of fear (in the case of severe trauma - the fear of annihilation) and it is precisely this fear that must be made bearable.
Such “stressful situations” usually put the organism into an active state of action in which fighting and flight tendencies alternate. Both tendencies aim to cope with the external problem situation.
The special thing about a traumatic situation, in which the psychological mechanism of dissociation then sets in, is that there is neither the possibility of escape nor of fighting.
What happens now is as creative as it is interesting:
The person affected by traumatic stress undertakes a flight in perception, in which he z. B.
- steps out of his body
- feels like an outside observer of what is happening
- as if floating above things
- Parts of his body are not experienced as belonging to him
- creates another person who experiences the trauma instead (pain reduction)
What the dissociation causes is that the unbearable fear or unbearable body sensations (pain) are converted into tolerable ones, which means salvation for the moment, but creates a pathological situation in the long term.
What can develop are symptoms that are classified under the umbrella term "post-traumatic stress disorder".
Typical features are:
- repeated experience of the trauma in flashbacks or dreams
- Feelings of numbness, indifference to other people
- Avoidance behavior
- acute bursts of fear, panic, occasionally aggression
- States of vegetative overexcitation, excessive anxiety
- often depression / suicidal ideation
It is not uncommon for permanent personality changes to occur after extreme stress.
Typical for this are
- a hostile and suspicious attitude towards the world
- social withdrawal
- Feelings of emptiness / hopelessness
- chronic feelings of nervousness
- Feelings of alienation
What precedes the development of such symptoms, i.e. H. What happens in a person physically when the so-called “dissociative reaction” occurs has only been known for a few years - since medicine and brain research became interested in the subject of “trauma”.
One of the most important results of this research is the realization that the human brain works differently under extreme stress - and a traumatic experience always means extreme stress for the person concerned - than in situations with normal stress levels.
Normally, two memory systems work together in the brain stem - the so-called hippocampus system and the amygdala system - which are particularly important for dealing with stress.
Together they store memories in such a way that a person knows what happened in the past, can also classify it in time and tell it.
It is different with experiences with a traumatic stress level. Here the hippocampus system switches itself off, which is primarily responsible for the temporal classification, the connections between an experience and the networking with language, and the amygdala system continues to work independently or largely independently.
This system, which can be thought of as a kind of fire department, only deals with the parts of the experience that are most burning. These are the moments that generate the most intense fear, the most intense pain and the most unpleasant emotional reactions
And it is precisely these that are stored by the amygdala system, along with the associated feelings, without any connection and without any connection with a person's language center.
And here is the explanation why people who are traumatized often do not remember or only remember partially.
This explains why people who have experienced a trauma repeatedly experience that certain smells, noises, images, the sound of a voice or anything else have the most violent fear reactions and body memories (palpitations, shortness of breath, nausea, dizziness, cramps, pain sensations) trigger.
Emotionally, they relive the traumatic experience over and over again, as if it were happening right now.
What is missing is any temporal and spatial context as well as the relational context of the traumatic situation. If these connections existed, it would be clear that it is a memory of an event far back in the past, which has ended and which no longer poses a threat.
Unfortunately, these split off trauma parts are like "frozen" in the memory. They do not change, but are triggered again and again by external and internal stimuli that remind the person of the dream event in some form.
It is important to mention that even one-time traumatic experiences can lead to dissociative disorders. People who have been traumatized particularly early in their life or over a longer period of time and who have repeatedly saved themselves in their distress through dissociation, usually also use this protection option in later life, even in less threatening situations where it is not necessary at all would.
Small children dissociate particularly well and particularly often. This is due to the fact that the hippocampus system is only fully functional from the age of 12.
If one looks at these relationships, it is not surprising that “dissociative disorders” are often not recognized and that misdiagnoses are often made.
The most common misdiagnoses are:
- Psychosomatoses (physical disorders)
- Anxiety / Panic Disorders
- Mini psychoses
- Personality disorders (borderline disorder and histrionic personality disorder)
Most patients often go long treatment paths before a dissociative disorder is recognized and then perhaps treated.
There are some indications that doctors and psychotherapists should always think about the possible presence of a "dissociative disorder":
- Amnesias / gaps in memory
- Trance states
- Disturbances of movement and sensation without an organic cause
- Sensory and sensory disturbances
- Disorders of self-perception or self-experience (standing next to oneself)
- Unexplained seizures
- Body awareness disorders
- Existence of two or more personalities in one person (dissociative identity disorder - most severe form of dissociative disorder)
(These disorders are classified in detail in the ICD 10 diagnostic manual for mental disorders.)
The connection between traumatic experience and dissociation is clearly proven by many studies not only in the USA, but also in Europe.
The connection between the severity of a trauma and the extent of memory gaps has also been proven.
The more severe the trauma is for the person concerned, the greater the memory gaps that can be expected.
There is also a relationship between dissociation and age.
Childhood trauma leads to more frequent and more severe dissociative disorders than trauma in later life.
These connections are particularly impressively confirmed in the most severe form of dissociative disorders, the "multiple personality disorder" or "dissociative identity disorder" by a study by Brown from 1985.
Of 1,000 patients diagnosed with DID, 96.8% reported experiencing physical violence (over 80%), sexual violence (almost 90%), and neglect (over 50%).
Question: What about the remaining 3.2%?
There was an interesting explanation here:
2% of these people had not experienced trauma from their parents or their surroundings, but rather woke up as children during operations because the anesthesia was insufficient. It was here that these children experienced their first division and in this way were able to save themselves from unbearable pain and fear.
Through a kind of deep trance, the real events were banned behind an amnestic barrier, i. h .: There was a split between the normal state of consciousness and the memory of the traumatic situation (amygdala reaction).
For the moment this was an extremely helpful and creative solution, but it subsequently created a situation that is all too familiar to people with dissociative disorders:
There is no memory of the traumatic experience - it is kept and locked up in a split-off fragment of the personality - but this fragment can certainly be washed into consciousness again and again by certain triggers.
Detached from the current situation, the traumatic experience or parts of this experience (fear, pain, disgust, feelings of anger) are relived over and over again.
It is particularly dramatic for those affected when, as a result of years of continued trauma, independent personalities with distinct memories, emotions, behaviors and skills have developed from the split-off fragments.
Since these personalities often have no contact with one another, but always take control of the body and the behavior of the person, there is constant experience of extreme time gaps and amnesias in everyday life, which lead to a variety of problems.
In addition, there are stimuli everywhere in everyday life that repeatedly revive the experienced - split off - traumatizations or require a change of personality in order to protect the person from being flooded.
The therapist realizes that this is an extremely creative and effective survival pattern at the latest when the individual personalities begin to report about the suffering they have experienced. The atrocities are usually far beyond our normal imagination.
If it weren't for the headaches, panic attacks, depression, self-harm, insomnia, sexual disorders, obsessive-compulsive phenomena, and inexplicable pain that the
For the most part to induce those affected to begin therapy, it would be a very gracious solution to leave those terrible memories behind the barriers the soul has built to protect them.
Unfortunately, this is not a permanent solution, as real healing can only take place if it is possible to integrate the split off parts (in the case of DIS personalities).
As long as dissociation and amnesia keep the fragments of experience separate from each other, a traumatic event cannot be seen, felt, physically felt and thought of as a whole story. However, this is a prerequisite for integration. In order to be able to turn an event into a “neutral” memory, our brain needs the known sequence and perceptual structure of “beginning-course-end” as well as information about the meaning of an event for learning.The trauma can only be processed when it is possible to put it back together like a broken mirror, the splinters of which no longer reveal what has happened, but only that something has happened , which I would like to introduce to you briefly at the end.
What has proven to be of little help in treating dissociative disorders in previous experience is not to talk about the trauma in therapy or only to talk about the trauma.
Therapy that is limited to talking about the trauma tends to have a retraumatising effect, just as simply "letting it out" of split-off feelings is not sufficient.
Relaxation procedures should be enjoyed with great caution (if so, then "progressive muscle relaxation according to Jacobsen"). Under no circumstances should respiratory therapy or autogenic training be tried.
What also does not help - except in absolute crisis situations - are medication.
Based on the experience that many common psychotherapy methods have resulted in patients with dissociative disorders often feeling worse, a special trauma therapy has been developed in recent years that takes the following knowledge into account:
With dissociative disorders we always have to do with two forms of memory / memory, namely an explicit memory, which is accessible to consciousness and linked to language, and an implicit memory, which is not accessible to consciousness, which is suddenly triggered by so-called “Triggers”, and the contents of which represent components of traumatic experience without any temporal connection.
In order to gain therapeutic access to this implicit memory (trauma awareness), the combination of analytical depth psychology and behavioral therapy methods with hypnotherapeutic methods and / or EMDR (Eye Movement Desensitization and Reprocessing) has proven to be particularly effective. Creative methods such as painting and music therapy and gentle body therapies can be used as support.
The absolute prerequisite for successful therapy is the establishment of a stable therapeutic relationship with clear boundaries, high reliability, regularity and clear rules.
Another prerequisite, which is not always given, especially in the case of sexual abuse, is that there is currently no trauma.
The stages of treatment are divided into one
- Stabilization phase
- Phase of distancing from trauma material
- Exposure trauma work-through phase
- Phase of integration, grief work and reconnection to a life without trauma
Before working on the actual trauma content, a lot of preparatory work is necessary to ensure that the trauma processing itself does not lead to further destabilization and regression.
In a mostly longer phase of stabilization, for which, in my experience, group therapy in particular can be of great benefit, among other things, around
- learning to care for yourself and for others (e.g. children) even in stressful situations
- the development of relationship and conflict management skills
- the development of a meaningful and satisfying everyday structure
- learning to control in situations in which feelings of fear threaten to overflow.
The learning of techniques to cope with fear (imaginative techniques such as “safe place”, “safe”, “screen technology”) lead to the phase of distancing from trauma material.
The actual integration work, the integration of the split off trauma memories into the “adult memory”, then takes place step by step in a very structured procedure with the help of so-called “screen technology” or with EMDR.
The point here is to relive the trauma again in every detail from beginning to end and then finally to close it. It is very impressive how often a single session leads to a clear experience of relief and liberation.
Other possible benefits of this work are that fears, body memories, psychosomatic phenomena, which can be traced back to trauma, completely dissolve or improve significantly.
After successful integration work, the affected person is no longer triggered and overwhelmed by the old images and trauma fragments that had them in their hands, so to speak, but he himself has the history and the associated experiences in his hand and can let them become the past as memories.
I would like to end with a quote from Pierre Janet, a contemporary of Freud, who over a hundred years ago was the first to write about the phenomenon of "dissociation and trauma":
“A trauma that is not realized has to be re-enacted over and over again. A trauma is realized - and thus true - when a person can talk about it without sinking into it emotionally. "
I would like to encourage one to face the wholesome process of remembering.
Lecture for the association ‘Schotterblume e.V.’ by Maria Heilmann (2003)
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