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Section 26
Trauma, Dissociation, and Boundaries

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Dissociation refers to a compartmentalization of experience: elements of the experience are not integrated into a unitary whole, but are stored in memory as isolated fragments consisting of sensory perceptions or affective states. However, the word dissociation is currently used to describe four distinct, but interrelated phenomena: (1) the sensory and emotional fragmentation of experience, as measured by the Traumatic Memory Inventory (see below); (2) depersonalization and derealization at the moment of the trauma (peritraumatic dissociation), as measured by the Peritraumatic Dissociation Experiences Questionnaire (PDEQ); (3) ongoing depersonalization and "spacing out" in everyday life, as measured by the Dissociative Experiences Scale; and t4) containing the traumatic memories within distinct ego-states (dissociative disorder), as measured by the Dissociative Disorders Interview Scale or the SCID-D. The precise interrelationships among these various phenomena remain to be spelled out. Not all people who have vivid sensory intrusions of traumatic events also experience depersonalization, whereas only a small proportion of people who have both of these experiences will go on to chronically dissociate, or to develop a full-blown dissociative disorder.

The British psychiatrist C. S. Meyers described the issue of dissociation in traumatized soldiers as follows: "The recent emotional experiences of the individual have the upper hand and determine his conduct: the normal has been replaced by what we may call the 'emotional' personality. Gradually or suddenly an 'apparently normal' personality returns-normal save for the lack of all memory of events directly connected with the shock , normal save for the manifestation of other ('somatic') hysteric disorders indicative of mental dissociation" (p. 67). Contemporary research has shown that "spacing out" at the moment of the trauma (peritraumatic dissociation) is a significant long-term predictor for the ultimate development of PTSD. Bremner et al. found that Vietnam veterans with PTSD reported having experienced higher levels of dissociative symptoms during combat than men who did not develop PTSD. Koopman, Classen, and Spiegel found that dissociative symptoms early in the course of a natural disaster predicted PTSD symptoms 7 months later. A prospective study of 51 injured trauma survivors in Israel found that peritraumatic dissociation was the strongest predictor of PTSD at 6-month follow-up, explaining 30% of the variance in PTSD symptoms over and above the effects of gender, education, age, event severity, and the intrusion, avoidance, anxiety, and depression symptoms that followed the event.

Christianson has described how, when people feel threatened, they experience a significant narrowing of consciousness, and remain focused on the central perceptual details. As people are being traumatized, this narrowing of consciousness sometimes evolves into amnesia for parts of the event, or for the entire experience. Students of traumatized individuals have repeatedly noted that during conditions of high arousal, explicit memory may fail. The individual is left in a state of speechless terror in which he or she lacks words to describe what has happened. However, whereas traumatized individuals may be unable to give a coherent narrative of the incident, there may be no interference with implicit memory; they may "know" the emotional valence of a stimulus and be aware of associated perceptions, without being able to articulate the reasons for feeling or behaving in a particular way.

More than 80 years ago, Janet observed: "Forgetting the event which precipitated the emotion . . . has frequently been found to accompany intense emotional experiences in the form of continuous and retrograde (p. 1607). He claimed that when people experience intense emotions, memories cannot be transformed into a neutral narrative: a person is "unable to make the recital which we call narrative memory, and yet he remains confronted by [the] difficult situation" (p.660). This results in "a phobia of memory" (p. 661) that prevents the integration ("synthesis") of traumatic events and splits off the traumatic memories from ordinary consciousness. Janet claimed that the memory traces of the trauma linger as what he called "unconscious fixed ideas" that cannot be "liquidated" as long as they have not been translated into a personal narrative. Failure to organize the memory into a narrative leads to the intrusion of elements of the trauma into consciousness as terrifying perceptions, obsessional preoccupations, and as somatic reexperiences, such as anxiety reactions.

Similar observations have been made by other clinicians treating traumatized individuals. For example, in 1945 Grinker and Spiegel noted that some combat soldiers developed excessive emotionality under stress, which they thought to be responsible for the development of a permanent disorder: "Fear and anger in small doses are stimulating and alert the ego, increasing efficacy. But, when stimulated by repeated psychological trauma the intensity of the emotion heightens until a point is reached at which the ego loses its effectiveness and may become altogether crippled." (p. 82). Grinker and Spiegel described traumatic amnesias in these soldiers, which were accompanied by: confusion, mutism, and stupor. Kardiner, in The Traumatic Neuroses of War, noted: that when patients develop amnesia for the trauma, it tends to generalize to a large variety of symptomatic expressions: "[the] subject acts as if the original traumatic situation were still in existence and engages in protective devices which failed on the original occasion" (p. 82). Kardiner noted that fixation occurs in dissociative fugue states. Triggered by a sensory stimulus, a patient might lash out, employing language suggestive of his trying to defend himself during a military assault. He noted that many such patients, while riding a subway train that entered a tunnel, had flashbacks to being: back in the trenches. Kardiner also viewed panic attacks and hysterical paralyses as the reexperiencing of fragments of the trauma. Piaget claimed that dissociation occurs when an active failure of semantic memory leads to the organization of memory on somatosensory or iconic levels. He pointed out: "It is precisely because there is no immediate accommodation that there is complete dissociation of the inner activity from the external world. As the external world is solely represented by images, it is assimilated without resistance (i.e., unattached to other memories) to the unconscious ego".

The realization of the role of dissociation in the processing of traumatic memories was revived for contemporary psychiatry when Horowitz described an "acute catastrophic stress reaction" in civilian trauma victims, which was characterized by panic,. cognitive disorganization, disorientation, and dissociation. Such dissociative processing of traumatic experience complicates the capacity to communicate about the trauma. In some people the memories of trauma may have no verbal (explicit) component at all; the memory may be entirely organized on an implict or perceptual level, without an accompanying narrative about what happened. Recent symptom-provocation neuro-; imaging studies of people with PTSD support that clinical observation. During the provocation of traumatic memories there was decreased activation of Broca's area, the part of the CNS most centrally involved in the transformation of subjective experience into speech. Simultaneously, the areas in the right hemisphere that are thought to process intense emotions and visual images had significantly increased activation.

People who have learned to cope with trauma by dissociating are vulnerable to continuing to do so in response to minor stresses. The repeated use of dissociation as a way of coping with stress interferes with the capacity to fully attend to life's challenges. The severity of ongoing dissociative processes (often measured with the Dissociative Experiences Scale JDESJ) has been correlated with a large variety of psychopathological conditions that are thought to be associated with histories of trauma and neglect: V severity of sexual abuse in adolescents, somatization, bulimia, self-mutilation, and borderline personality disorder. The most extreme example of this ongoing dissociation occurs in people who suffer from dissociative identity disorder (multiple personality disorder), who have the highest DES scores of all populations studied and in whom separate identities seem to contain the memories related to different traumatic incidents.
- Appelbaum, Paul, Uyehara, Lisa, & Mark Elin, Trauma and Memory: Clinical and Legal Controversies, Oxford University Press: New York, 1997.

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Personal Reflection Exercise #12
The preceding section contained information about trauma and dissociation. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 26
How can memories of the trauma have no verbal explicit component at all? Record the letter of the correct answer the Answer Booklet.