Masochistic and Sadistic Ego States

Abstract

A theory describing the development of alternating, dissociated, victim/masochistic and perpetrator/sadistic ego states in persons who grew up with abusive primary caretakers will be proposed and a paradigm for treatment will be derived from the theory. Alternating ego states can be observed throughout the spectrum of dissociative disorders, from Borderline Personality to Dissociative Identity Disorder. Dependence on an abusive caretaker creates a series of relational dilemmas for the child. To maintain attachment, abuse must be dissociated, but to protect the self from abuse, need for attachment must be disavowed. Disorganized attachment may result. Incompatible internal working models, using parallel masochistic and sadistic defensive strategies, may be developed and elaborated into ego states. Masochistic and sadistic defenses are ultimately maladaptive, because they require dissociation of need for either self-protection or attachment. Each defensive attempt at resolving a relational dilemma leads to another impasse, a change in defensive strategy, and perhaps a shift in ego state. When alternating ego states are understood as evolving from defensive schemas developed to negotiate the dilemmas of attachment to an abuser, the following therapeutic techniques can be derived: (1) identifying adaptive needs and maladaptive defenses, (2) interpreting ego state switches as attempts to resolve relational dilemmas, (3) gradually bridging dissociation between states, (4) using transference and countertransference to understand relational patterns, and (5) cultivating more adaptive interpersonal skills within the therapeutic relationship.     

Surviving the Bad Object

ABSTRACT

A case study of a pivotal crisis in the treatment of a woman with Dissociative Identity Disorder illustrates attachment dilemmas and strategies as they are re-enacted within the treatment. Attachment theory has been applied to the development of dissociative disorders by Barach (1991) and Blizard (1997). The case crisis under study demonstrates how the resolution of an attachment conflict, expressed by two alters in regard to the transference, facilitated significant integration.     

Evidence for a Dissociative Subtype of Post-Traumatic Stress Disorder Among Help-Seeking Childhood Sexual Abuse Survivors

ABSTRACT

This study examined evidence for a dissociative subtype of post-traumatic stress disorder (PTSD) among women seeking psychotherapy for childhood sexual abuse (CSA). One hundred and twenty-two women seeking treatment for CSA completed a battery of questionnaires assessing PTSD, dissociative symptoms, and child maltreatment. Using signal detection analysis, we identified high and low dissociation PTSD subgroups. A constellation of three PTSD symptoms-hypervigilance, sense of foreshortened future, and sleep difficulties–discriminated between these two subgroups (OR = 8.15). Further evidence was provided by the finding of a nonlinear relationship between severity of childhood maltreatment and dissociation in the women with PTSD. These results provide support for a dissociative subtype of PTSD that may stem from more severe childhood experiences of neglect and abuse.     

Trauma and anxious attachment influence the relationship between suggestibility and dissociation: a moderated-moderation analysis

Introduction: Hypnotic suggestibility is elevated in the dissociative disorders but the relationship between dissociative tendencies and suggestibility in the general population seems to be constrained by additional factors. The diathesis-stress (DS) model stipulates that suggestibility interacts with trauma exposure to augment the propensity for dissociative states whereas the dual pathway to suggestibility (DPS) model proposes two developmental routes involving either dissociation preceded by trauma, or a healthy cognitive profile characterised by superior imagination.

Methods: This study sought to discriminate between these partially competing accounts and further considered the moderating role of anxious attachment. 209 participants completed psychometric measures of dissociative tendencies, trauma, and attachment, and a behavioural measure of suggestibility.

Results: In support of the DS model, trauma moderated the relationship between suggestibility and dissociation and, as predicted by the DPS model, dissociation moderated the relationship between trauma and suggestibility. Anxious attachment additionally moderated both effects. Model comparisons indicated that the DS model consistently provided a superior fit to the data. Further analyses showed that secure attachment independently predicted suggestibility, thereby supporting the non-dissociative pathway in the DPS model.

Conclusions: These results suggest that high suggestibility confers vulnerability to dissociative states in individuals exposed to trauma and displaying an anxious attachment style.     

Narcissism,a Relational Aspect of Dissociation

ABSTRACT

Pathological narcissism is an inevitable result of trauma-generated dissociation. It is also a relational aspect of dissociation, for in dissociative psychopathology the mutuality of relationships, both interpersonal and intrapsychic, has collapsed in significant ways. Dissociation of both aggression and dependency characterizes the “closed system.” While an open system allows interaction with the outside and transformation of the individual through interactive interchange with another, a closed system precludes transformation and intersubjectivity. Grandiose, domineering self-states may be understood as procedural, somatoform, dyadic enactments. These working models of attachment are at the core of much of the narcissistic entitlement, grandiosity, domination, and self-sufficiency that are so often found in dissociative disorders and in narcissism. It is possible to have a real impact on the closed system of narcissistic psychopathology by providing a safe attachment within the therapeutic relationship, and empathizing with the expression of self-protective aggression while containing its destructiveness. As a safe attachment figure with expertise, the therapist has the opportunity to facilitate positive transformation.     

Phase-Oriented Treatment of Structural Dissociation in Complex Traumatization: Overcoming Trauma-Related Phobias

ABSTRACT

The theory of structural dissociation of the personality proposes that patients with complex trauma-related disorders are characterized by a division of their personality into different prototypical parts, each with its own psychobiological underpinnings. As one or more “apparently normal” parts (ANPs), patients have a propensity toward engaging in evolutionary prepared action systems for adaptation to daily living to guide their actions. Two or more “emotional” parts (EPs) are fixated in traumatic experience. As EPs, patients predominantly engage action systems related to physical defense and attachment cry. ANP and EP are insufficiently integrated, but interact and share a number of dispositions of the personality (e.g., speaking). All parts are stuck in maladaptive action tendencies that maintain dissociation, including a range of phobias, which is a major focus of this article. Phase-oriented treatment helps patients gradually develop adaptive mental and behavioral actions, thus overcoming their phobias and structural dissociation. Phase 1, “symptom reduction and stabilization,” is geared toward overcoming phobias of mental contents, dissociative parts, and attachment and attachment loss with the therapist. Phase 2, “treatment of traumatic memories,” is directed toward overcoming the phobia of traumatic memories, and phobias related to insecure attachment to the perpetrator(s), particularly in EPs. In Phase 3, “integration and rehabilitation,” treatment is focused on overcoming phobias of normal life, healthy risk-taking and change, and intimacy. To the degree that the theory of structural dissociation serves as an integrative heuristic for treatment, it should be compatible with other theories that guide effective treatment of patients with complex dissociative disorders.     

Attachment insecurity as a mediator of the relationship between childhood trauma and adult dissociation

This study aimed to investigate whether attachment insecurity mediates the relationship between childhood trauma and adult dissociation, specifically with regard to individual forms of childhood maltreatment. Psychiatric outpatients who visited a specialized trauma clinic (n = 115) participated in the study. Data were collected via the Childhood Trauma Questionnaire, Revised Adult Attachment Scale, and Dissociative Experience Scale. Structural equation modeling and path analysis were performed to analyze the mediating effects of attachment insecurity on the relationship between childhood trauma and adult dissociation. Greater childhood trauma was associated with higher dissociation, and the relationship between them was fully mediated by attachment anxiety. In path analysis of trauma subtypes, the effects of emotional abuse, physical abuse, and physical neglect as a child on adult dissociation were found to be fully mediated by attachment anxiety. The effect of sexual abuse on dissociation was mediated by a synergistic effect from both attachment anxiety and attachment avoidance. Regarding emotional neglect, a countervailing interaction was discovered between the direct and indirect effects thereof on dissociation; the indirect effect of emotional neglect on dissociation was partially mediated by attachment insecurity. Specific aspects of attachment insecurity may help explain the relationships between individual forms of childhood trauma and adult dissociative symptoms. Tailored treatments based on affected areas of attachment insecurity may improve outcomes among patients with dissociative symptoms and a history of childhood trauma.     

Sensitivity,security and internal working models: Bridging the transmission gap

Abstract

Empirical studies and meta-analytical reviews have shown security of attachment to be predicted by: (1) caregivers' current representations of their own childhood attachment experiences; and (2) caregivers' sensitive responsivity to their infants' cues during the first year of life. However, despite the wealth of data on these topics, the reasons for these connections remain poorly understood. The aim of this paper is to present a new theoretical approach that may enable us to identify the mechanisms involved in the evolution and transmission of attachment security. Specifically, it is suggested that the concept of parental mind-mindedness (Meins, 1997) may help to explain the links between parents' mental representations of attachment experiences and infant—parent attachment security. This approach may also contribute to our understanding of certain consequences of attachment relationships, such as recent evidence for security-related differences in children's mentalizing abilities.     

Dissociation and Schizophrenia

Abstract

Comorbidity of psychotic and dissociative disorders often is not reported. This 38 year-old female with a history of schizophrenic symptoms displayed evidence of dissociative identity disorder (DID) during admission to an inpatient psychiatric unit. The case illustrates how the presence of a dissociative disorder may influence the presentation of a co-morbid psychosis. The historical association and differential diagnosis between DID and schizophrenia is described. Implications of various treatment approaches for patients exhibiting dissociation in the context of psychosis are discussed.     

Ganser Syndrome,Organic Dementia and Hypnosis–A Case Study

ABSTRACT

Ganser Syndrome is a rare and controversial disorder, a form of pseudodementia, which has often been associated with prison environments. It is classified under dissociative disorder, not otherwise specified in the DSM-IV, and as a dissociative disorder with its own code in the ICD-10. In the literature, it has also been described as a psychotic illness, a factitious disorder, a histrionic disorder, and an organic illness. Despite special interest in dissociative disorders, we have diagnosed only one case of Ganser Syndrome during six years in Mental Hospital for Prisoners (that houses) with about 300 treatment periods per year of 3,000 male prisoners from a base population of five million people. While dissociative symptoms were clear, the patient also suffered from progressing organic dementia. Antipsychotic medication had no beneficial effect, but hypnosis clearly ameliorated the patient's symptoms. We conclude that Ganser Syndrome is rare, and may co-occur with organic dementia. The positive effect of hypnosis, apparently here described for the first time, may confirm the dissociative nature of the syndrome.     

Contextual Treatment of Dissociative Identity Disorder

Abstract

Evidence for the effectiveness of contextual therapy, a new approach for treating adult survivors of prolonged child abuse (PCA), is provided via case studies of three women with Dissociative Identity Disorder (DID). Contextual therapy is based on the premise that it is not only traumatic experiences that account for PCA survivors' psychological difficulties. Even more fundamentally, many survivors grow up in an interpersonal context in which adequate resources for secure attachment and acquisition of adaptive living skills are not available. As a result, they are left with lasting deficits that undermine not only their current functioning, but also their ability to cope with reliving their traumatic memories in therapy. The primary focus of this treatment approach, therefore, is on developing capacities for feeling and functioning better in the present, rather than on extensive exploration and processing of the client's trauma history or, in the case of DID, of identity fragments. Treatment of the three cases presented ranged from eight months to two and one-half years' duration, and culminated in very positive outcomes. The women's reports of achievements, such as obtaining and maintaining gainful employment, greater self-sufficiency, and the establishment of more intimate and gratifying relationships, indicated marked improvements in daily functioning. Objective test data obtained at admission and discharge, and in one case, at follow-up, documented substantial reductions in dissociative, posttraumatic stress, depressive, and other symptoms.     

The Structure of Dissociative Fugue: A Case Report

ABSTRACT

Classically, when an episode of dissociative fugue resolves, there is enduring amnesia for the period of fugue, with normal pre- and post-fugue memory. The authors describe a case in which their treatment goal was to reverse the amnesia for the period of fugue. In the course of treatment, the authors learned that dissociative fugue has a complex internal structure, is often preceded by major depression, and can be difficult to differentiate from other dissociative disorders. There is often a history of childhood trauma. Rather than being a simple dissociative disorder, as the authors had believed, fugue is complex, structured, and often accompanied by depression.     

Factitious and Malingered Dissociative Identity Disorder

Abstract

This paper compares the clinical features of 18 persons given a diagnosis of factitious or malingered Dissociative Identity Disorder with those of 18 matched persons who were given a diagnosis of genuine Dissociative Identity Disorder, taken from a sample of 129 second opinion consultations. Clinical features suggesting a factitious diagnosis or malingering included having a score above 60 on the Dissociative Experiences Scale (DES), reporting dissociative symptoms inconsistent with the reporting on the DES, being able to tell a chronological life story and to sequence temporal events, using the first person over a range of affect, being able to express strong negative affect, bringing “proof of a dissociative diagnosis to the consultation, having told persons other than close confidants about the alleged abuse or alleged dissociative diagnosis, reporting alleged abuse that was inconsistent with the medical or psychiatric history or volunteering allegations of cult or ritualized abuse, telling of alleged abuse without accompanying shame, guilt, or suffering, having been involved in community self-help groups, not having symptoms of co-morbid posttraumatic stress disorder, and having obvious secondary gain in having a dissociative diagnosis. Given the potential legal ramifications of making afalse positive diagnosis of Dissociative Identity Disorder and recognizing that the treatment for persons with valid dissociative psychopathology differs from the treatment of factitious illness, it is prudent to be able to separate the two groups.     

Parental PTSD,adverse parenting and child attachment in a refugee sample

In contrast with traumatic experiences, there is a dearth of studies on the link between trauma symptoms, disconnected (frightened, threatening and dissociative) parenting behavior, extremely insensitive parenting behavior and child attachment. This study extends previous work on the impact of posttraumatic stress disorder (PTSD) on families by studying the unique contribution of disconnected and extremely insensitive parenting behavior on child attachment in a highly traumatized sample of 68 asylum seekers and refugees and their children (18–42 months). The results show that parental symptoms of PTSD are directly related to children’s insecure attachment and disorganized attachment. The greatest proportion of the risk could be attributed to factors related to the dyad and not the family. A mediation effect of adverse parenting behavior was not confirmed. On the one hand the results indicate the need for an effective treatment of PTSD symptomatology while on the other hand the results indicate the need for clinical attention to insecure attachment relationships.     

The Concept of Dissociation in Early Psychoanalytic Writers

ABSTRACT

The concept of dissociation in early psychoanalytic writing is examined in order to show the intimate connection between old and new theories and how they have been transformed through time and different models. Contemporary work on trauma and dissociation may be seen as an illustration of, and developing from, early psychoanalytic formulations on the organization of the personality. These pioneering ideas constitute an encompassing theory of the personality from which treatment of trauma is easily deduced. Psychoanalysis in the United States, which remained loyal to Freudian models, is contrasted with the British Object Relations School. The term, “dissociation,” has a variety of connotations: (1) observable clinical phenomena, i.e., symptoms; (2) a general principle of psychic organization; (3) loosely, several defense mechanisms; (4) a synonym for splitting, mainly within British Object Relations; and (5) the clinical presentation and psychodynamic understanding of multiple personality or dissociative identity disorder. This plurality of concepts may conspire against scientific integration, perpetuating a confusion between the differing uses. Alternatively, it can enrich our theories, provided we do not loose sight of the models that make terms meaningful. The various senses of the word, and the relevant theoretical frameworks, are illustrated with a case example.     

Combat-Induced Dissociative Amnesia

Abstract

Dissociative amnesia following combat trauma in various wars has been extensively documented. In this article, we describe theoretical constructs related to dissociative amnesia, and integrate them with clinical practice through the presentation of a case. Although there is ample documentation of this condition in combat soldiers, in actual clinical practice such dissociative amnesia is probably underdiagnosed and undertreated. This may be detrimental to therapeutic progress, given the fact that ongoing memory deficits constitute one of the core symptoms of chronic PTSD in combat veterans. As illustrated in our case example of combat-induced generalized dissociative amnesia, combat-induced amnesia may also reflect previously existing dissociated traumatic memories that become reactivated during trauma. In this case, intensive treatment using hypnosis within a larger therapeutic milieu involved both the uncovering and processing of recent dissociated traumatic experiences, and, by necessity, other traumas of the past.     

The Language of Dissociation

ABSTRACT

Three case studies of inner-city elementary school children illustrate the connection between speech-language disorders and dissociative disorders in children who have known or suspected trauma histories. The role of speech language pathologists in identifying and responding to dissociative symptoms in children is explored. Lack of adequate training concerning the impact of trauma and scarce literature on the communication profiles of dissociative children contributes and greatly impacts the diagnosis, referral, and treatment of these children. The case studies demonstrate how unusual speech and language symptoms and awareness of dissociative features may aid in identifying trauma-related problems and instituting effective treatment. Grounding techniques and specific language interventions can assist children in acquiring the vocabulary needed for communicating both their daily experiences and traumatic histories. The nature of the relationship between dissociation and communication disorders is explored, and the importance of future research, interdisciplinary collaboration, and trauma training in the speech-language curriculum is emphasized.     

Dissociative Symptoms and Cortisol Responses to Recounting Traumatic Experiences Among Childhood Sexual Abuse Survivors with PTSD

ABSTRACT

This study examined dissociative symptoms in relation to changes in evening salivary cortisol levels after recounting traumatic experiences among 49 women with PTSD for child sexual abuse (CSA). Each woman was interviewed to describe her sexual abuse and was assessed on acute dissociative symptoms in response to a recent stressful event in the previous month. Salivary cortisol was assessed during the interview using saliva samples taken immediately before and after the interview. Changes in cortisol levels were measured at one hour, 24 hours, and 48 hours after the interview. Acute dissociative symptoms were related to salivary cortisol levels 24 hours after the interview, with high dissociators showing elevated levels compared to low dissociators. These results suggest that dissociative symptoms in response to recent life stress are associated with cortisol dysregulation among women with PTSD for CSA.     

The Treatment of Dissociative Identity Disorder with Cognitive Analytic Therapy: Experimental Evidence of Sudden Gains

ABSTRACT

The central aim of this study was to assess the effectiveness of cognitive analytic therapy (CAT) with a patient presenting with DID. The methodology employed an A/B single case experimental design with six-months continuous follow-up in seven experimental measures. A and B represent the assessment of seven dissociative experimental variables under two conditions: baseline (A) and treatment (B). Treatment consisted of 24 sessions of CAT with four follow-up sessions, which is standard within the CAT model for personality disorder patients. A battery of measures of general psychological functioning was also completed at assessment, termination, and follow-up. During treatment the intensity of a range of dissociative symptoms was observed to be reduced, with sudden gains evident due to specific CAT interventions in specific dissociative symptoms. The long-term effectiveness of the intervention was established by the illustration of either continued stability or continued improvement in experimental variables across the follow-up period. Analysis of the general measures illustrates clinically significant change across a variety of robust psychometric measures. The study illustrates the utility of single-case approaches with dissociative disorders and the potential for utilizing CAT generally with such presentations.     

Direct and indirect relations between parent–child attachments,peer acceptance,and self-esteem for preschool children

ABSTRACT

The present study aims to test Bowlby’s suggestions concerning relations between the child’s attachment quality with parents and subsequently constructed models of self-worth during early childhood. In most research on this question, attachment with mothers is considered in relation to self-worth but the child’s attachment with fathers is not. Neither has the peer group been studied as an influence on child self-esteem, in the context of attachment research. This study addresses these relatively unstudied influences on child self-esteem. Attachment security to mother and father was measured by the Attachment Behavior Q-Set at two and half years of age. At five years of age social acceptance was measured using two sociometric techniques, and the self-esteem with the California Child Q-Sort. Our analyses indicated that security of the attachment to father and peer acceptance are both unique, significant predictors of the childrens’ self-esteem. The security of the attachment to mother was also related to child self-esteem but did not emerge as a uniquely significant predictor. Peer acceptance appeared to moderate of the effect of the security of the attachment to father on the self-esteem of children. Our results extend the relatively sparse literature relating early attachments to self-esteem during early childhood.