THERAPEUTIC SUPPORT GROUPS
"There is no such entity as consciousness: we are from moment to moment differently conscious. "
Hughlings Jackson. 1931
Dissociation, the compartmentalization of experience, identity, memory, perception, and motor function, challenges many comfortable assumptions. Dissociative phenomena are often stark, extreme, and vivid. Memory for an entire period of time during which one was conscicous seems 1st. Identities shift between apparent opposites. Pain is ignored. Trauma victims transform the experience and report floating above their injured bodies. Are these arcane, dramatic, or even staged events, or does dissociation underlie some fundamental aspect of mental organization? Is it merely the product of a troubled mind, or a key to understanding the structure of consciousness and the mind-body relationship? Is dissociation normal and the everyday perception of mental unity the delusion?
These are hard questions. but dissociative phenomena are so interesting that they are heing asked and answered. Why is it that healing ceremonies around the world seem to involve alterations in consciousness with dissociative features? It has been observed in the anthropological literature that there are three basic parts to healing rituals. First, the person becomes aware of being in a state of disease and seeks help from a healer of some kind. Second, he or she goes to the healer and one or both enter an altered state of consciousness, sometimes with somatic conversion symptoms, sometimes becoming quiet and hyporesponsive. Battle is done with the illness, and the patient's understanding of the illness and of what effect it will have upon him or her is altered. Third, the patient leaves the healing ceremony with some new perspective about the disease and, hopefully, with an improvement in symptoms. This process occurs even in high-tech Western medicine, although the cultural rituals surrounding the mental transformations are quite different. Dissociative changes in mental state have been associated with changed cognition and somatic function for millennia. Highly hypnotizable individuals seem uniquely capable of altering somatic function using dissociative mechanisms. Dissociation may well have something to teach us about the association between mind and body. Scientific research about the mind-body problem in the twentieth century has been single-mindedly deterministic. We have taken the Aristotelian reductionist approach, which holds that mind is the product of its biology but does not influence it. To understand the mind-body problem, this line of thought holds, one must understand the body and the brain. Tremendous advances have been made in understanding brain neurochemistry through the study of neurotransmitters, psychopharmacology, brain imaging, and molecular genetics. Nonetheless, our advancing computational technology allows us to attack, with relative precision, problems of greater complexity and provides the possibility of examining the mind and brain in interaction with the body. This means treating the whole as greater than the sum of its parts.
Interest in the role of dissociative and hypnotic phenomena as mediators of the mind-body relationship led the John D. and Catherine T. MacArthur Foundation to convene a network of investigators to develop a collaborative research agenda. The problem posed to us by board member and Nobel Prize-winning physicist Murray Gell-Mann was, "Figure out how hypnosis cures warts." He saw that truly understanding this odd but well replicated observation could lead to a major advance in appreciating the interaction between mind and body. How does a change in mental state (hypnosis) coupled with content directed at eliminating warts (tingling, numbness, picturing them shrivel and drop off) result in this actually happening on the body in a substantial portion of cases?
Over 4 years, a research group was assembled, and it developed a plan of exploration of this and related phenomena. As of this time, it consists of J. Allan Hobson, M.D., sleep researcher at Harvard University; Steven Kosslyn, Ph.D., an experimental psychologist at Harvard interested in the brain mechanisms underlying imagery; Kenneth Hugdahl, Ph.D., an experimental neuropsychologist from the University of Bergen in Norway with special interests in brain laterality; Arthur Kleinman, M.D., Ph.D., a Harvard psychiatrist and anthropologist; Robert Rose, M.D., a psychiatrist at the MacArthur Foundation and Rush Medical School with expertise in the psychoendocrinology of stress; Mardi Horowitz, M.D., a research psychoanalyst at the University of California in San Francisco; and myself from Stanford, a research psychiatrist with interests in hypnosis, dissociation. and psychosocial effects on cancer progression.
Our group believed that a conference on dissociative phenomena spanning culture, mind, and body would facilitate our work. This belief led to a conference at the Center for Advanced Study in the Behavioral Sciences in Stanford, California, on October 17 -- 19, 1991, sponsored by the Research Network on Mind-Body Interactions of the John D. and Catherine T. MacArthur Foundation. Experts in cognitive psychology, dissociation, cultural anthropology, hypnosis, and psychophysiology convened to examine these issues. What follows are selected, carefully written papers given at the conference and then extensively revised. They thus reflect the hest thinking of the authors in response to interaction with other experts from diverse fields. They represent a sympathetic but critical examination of dissociation from social, cognitive, and neurophysiological perspectives and shed important light on the contribution of the phenomena to our understanding of culture, mind, and body.
Matthew Erdelyi, Ph.D., a noted memory researcher and integrator of cognitive and psychodynamic theory (Erdelyi 1985), first intrigues us with a historical overview of the resiliency of the concept of dissociation. He notes that one can find traces of the idea at least as far back as the ancient Greek pnilosophers and that even though it may he abandoned (or dissociated) for long periods of our cultural history, it keeps reappearing, for good reason. He describes it as presenting a challenge to our comfortable Western assumption of mental unity and individual identity. He makes the bold and well-defended claim that indeed dissociation is a necessary part of complex mental functioning and may subsume the notion of the unconscious itself. He then presents experimental evidence from perception and memory research to illustrate that dissociation is a ubiquitous, necessary, and normal mental structure.
Kenneth Bowers, Ph.D., a highly regarded cognitive psychologist, provides a novel view of the phenomena underlying hypnosis, a form of structured dissociation coupled with highly focused attention and extreme sensitivity to social cues. He reviews data suggesting that hypnotic reduction of pain, for example, may proceed via two rather different pathways. On the one hand, some highly hypnotizable individuals achieve analgesia by focusing on and becoming absorbed in an image that carries with it an intense experience of relief -- putting the injured hand into a bucket of ice chips, for example. In hypnosis, the image is so vivid that it is felt as well as thought of, and it produces substantial analgesia. But Dr. Bowers notes that some hypnotized individuals do just as well or better by simply turning off sensation in the injured hand and thinking about something else, as though they were tapping some automatic subroutine. This use of hypnosis seems to provide access to low-level control systems that are not usually accessed in consciousness.
Eve B. Carison, Ph.D., who is the first author of the most widely used scale of dissociation, The Dissociative Experiences Scale (DES), summarizes its reliability, validity, factor structure, and relationship to hypnotizability. The three main factors include amnesia, absorption, and depersonalization and derealization.
Dr. Carlson notes that certain somatic disorders have been found to be associated with higher scores on the DES. These include the luteal phase of premenstrual syndrome and bulimia, suggesting a possible interactive effect. Although she emphasizes that the endocrine and eating disorders may underlie dissociative symptomatology, there may also be a dissociative component to the emotional disturbance. Some bulimic patients, for example, report feeling in a dissociative state when engaged in their compulsive eating behavior (Pettinati 1985). She notes that there is little evidence suggesting a link between seizure disorders and dissociation but does find several studies that show that patients with a history of physical and sexual abuse obtain substantially higher scores on the DES. In addition, such patients show a higher ability to tolerate pain in the laboratory. Thus this body of research suggests that dissociation may be elicited by, and may in turn represent an adaptation to, somatic distress, especially that involving pain, endocrine function, and eating behavior.
Interestingly, disorders of the nervous system, which seem to be a prime candidate, have in recent research not been shown to be associated with dissociative symptoms. However, the issue of the co-occurrence of certain kinds of seizure disorders, such as complex partial seizures, and dissociative symptoms needs further exploration (Spiegel 1991). It may well be that there is a dissociative syndrome associated with certain kinds of temporal lobe epilepsy that is phenomenologically similar to classical dissociative disorders but historically distinct. That is, these individuals may have dissociative amnesia, fugue, depersonalization, derealization, and other symptoms but may not have the history of sexual and physical trauma that is so typical of dissociative disorder patients. Thus it is unlikely that one explains the other, but it may well be that there are certain common mechanisms. In any event, the data reviewed in this chapter suggest that certain endocrine and gastrointestinal disorders are associated with higher prevalence of dissociative symptoms.
Dissociation can be measured as a normal phenomenon, as Dr. Carlson has done it, potentially occurring throughout the population. On the other hand, dissociative disorders are florid but rarer illnesses that occur among psychiatric patients. They can be understood as more extreme and uncontrolled eruptions of these normal phenomena, often elicited in the face of traumatic stress.
Marlene Steinberg, M.D., a Yale psychiatrist, has developed the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). It provides a reliable and valid means of establishing the presence or absence of such disorders. She describes the major components of these disorders as affecting memory, identity, and perception of the body and the surrounding environment. Thus dissociative phenomena may underlie both the organization and the pathological disorganization of mental and physical function.
Laurence Kirmayer, M.D., F.R.C.P.C., a psychiatrist and expert on crosscultural psychiatry and somatization, describes cultural influences on the manifestations of dissociation. Social forces may serve to make the most of underlying hypnotic and dissociative abilities. Trance dancing in Bali is often taught "body-up," the teacher moving the student's compliant body rather than explaining or demonstrating the movements. He notes that dissociative phenomena in the West often involve disruptions of identity, such as dissociative identity disorder (formerly called multiple personality disorder). This may underscore the Western preoccupation with the individual and illustrate that identity is in many ways a nonunitary social construct, an idea more congenial in the Orient.
Roberto Lewis-Fernandez, M.D., a research fellow and psychiatrist at Harvard, pursues this theme in detail, examining the effect of cultural differences on the configuration of two dissociative disorders: Puerto Rican ataque de nervios and Indian "possession syndrome."
Dr. Lewis-Fernandez notes that there are both important commonalities and differences in the way dissociative phenomena emerge across cultures. Both seem to afflict disadvantaged individuals in their cultures, those of lower socioeconomic status with some history of life disadvantage or trauma, and family disruptions such as divorce or death, and yet there are important differences. Possession syndrome involves the transformation of identity. The possessed individual enters a trance-like state and feels that his or her personal identity is superseded by that of an invading, outside force. On the other hand, patients with ataque de nervios suffer a variety of experiential and somatic changes and worry about them but show no disruption in their sense of personal identity. Dr. Lewis-Fernandez attributes this difference in part to social definitions of identity and preoccupations with spirituality. The very malleability of individuals prone to dissociation can make them a kind of cultural barometer, prone to exhibit symptoms along cultural fault lines that may reflect either important points of cultural stress, contradiction or conflict, or areas of considerable cultural attention and importance.
In "Dissociation and Physical Illness," Colin Ross, M.D., provides a theoretical model in which a history of physical and sexual abuse produces the mental effect of dissociation and the physical effect of somatization. Thus these two co-occur but are not seen as causing one another. Dr. Ross refers to evidence that patients with extreme dissociative disorders, such as dissociative identity, show unusual somatic symptoms as well. He postulates a more generic model in which somatic disorders involving genitourinary functioning are natural consequences of sexual abuse. In addition, he provides evidence from his own research that disorders of the gastrointestinal tract, such as irritable bowel syndrome, are associated with a history of trauma. This is interesting in view of Whorewell's (1984) controlled study showing that hypnosis can be effective in treating irritable bowel syndrome. Coupled with Dr. Garison's finding of a link between dissociation and luteal phase and eating disorders, it may be that disruption of certain somatic systems such as the gastrointestinal and endocrine system may be associated with a greater use of dissociative defenses.
Dr. Ross also summarizes his Dissociative Disorders Interview Schedule designed to yield a DSM-III-R diagnosis and examines its relationship to measures of somatization. He calls for further research on the relationship between dissociation and somatization.
In our article, "Physiological Correlates of Hypnosis and Dissociation," I and Eric Vermutten, M.D., review data on mind-brain and mind-body control evidenced during hypnotic and dissociative phenomena. Highly hypnotizable individuals seem to have an unusual capacity to control both mental functions, such as perception, memory, and attention, and somatic functions, especially in certain systems available to awareness (i.e., the gastrointestinal system, nervous systems involving motor function, and the skin). The changes highly hypnotizable people can produce are disciplined and reversible. They seem to reflect not so much being in or out of the trance state, per se, as they do the task undertaken within the trance state. For example, in highly hypnotizable individuals taught to obstruct perception of a stimulus using hypnotic hallucination, changes can be observed in brain electrophysiological response to those stimuli. Highly hypnotizable individuals can learn to increase or decrease the flow of gastric acid, the presence of irritable bowel symptoms, and pain. Thus hypnosis and the less structured dissociative phenomena seem to provide enhanced access to control systems that interconnect mind and body. By demonstrating the limits of our ability to modulate these control systems, we may learn more not only about how mind and body interact but how cultural, social, and mental phenomena may adversely or therapeutically influence the health of the body.
In this book you will find not so much complete agreement as a thoughtful examination of intersecting issues and, hopefully, a useful integration of the related cultural, mental, and physical aspects of dissociation.
Erdelyi MH: Psychoanalysis: Freud's Cognitive Psychology. New York, WH Freeman, 1985
Pettinati HM, Horne RL, Staats JM: Hypnotizability in patients with anorexia nervosa and bulimia. Arch Gen Psychiatry 42:1014 -- 1016, 1985
Spiegel D: Neurophysiological correlates of hypnosis and dissociation. Journal of Neuropsychiatry 3:440 -- 445, 1991
Whorewell PJ, Prior A, Faragher EB: Controlled trial of hypnotherapy in the treatment of severe refractory irritable bowel syndrome. Lancet 1:1232 -- 1234, 1984
© Copyright 1994 American Psychiatric Press, Inc. Reprinted with permission