How we walk with the broken speaks louder than how we sit with the great.

― Bill Bennot

Dissociative disorders are made up of complex systems within the brain and are usually related to different types of trauma. Derealisation and Depersonalisation are subtypes of PTSD and structural dissociation is often present following complex trauma and is associated with further diagnosis such as Borderline personality disorder. There are multiple changes which occur in the brain that lead to internal systems not opperating in the way they would if one has not experienced trauma. Neuroscience, attachment, trauma and the Autonomic Nervous system all need attention to heal from Dissociation.

Ocean waves crashing on rocks

THE PRIMARY DISSOCIATION OF THE PERSONALITY

There are three different categorised stages of structural dissociation.

PTSD - (Primary dissociation of the personality)

C-PTSD -  (Secondary dissociation of the personality) 

Type III- (Tertiary dissociation of the personality) 

Structural dissociation 

However there are two PTSD subtypes of Dissociation which are

  • Derealisation

  • Depersonalisation

Clients suffering from simple PTSD (primary dissociation of the personality). consists of little more than the traumatic memory, successful reprocessing of the traumatic memory automatically involves the fusion of apparently normal part(s) of the personality (ANP; Myers, 1940). 

ANP and Emotional Personality (EP)—that is, their respective memory networks integrate completely. However, even in some cases of simple post-traumatic stress disorder (PTSD), the EP may also be characterised by some secondary elaboration, that is, have a slightly wider repertoire of (dys)functional actions in addition to re-enacting traumatic experiences. When secondary elaboration exists, some more work is probably needed on the relationship between ANP and EP than only the integration of traumatic memory. 

An example pertains to a 52-year-old woman, characterized by primary dissociation of the personality, with whom the therapist was working on her memory of a five-days hospital stay at the age of 5 years, most of the time without the parents’ presence because doctors would only allow short visits. During the session, she was focusing on the image of herself at night, in the hospital, being afraid, and feeling “I am not safe.” 

Believing that the client was not really connected with her traumatic memories and the part containing them, the therapist asked her to look at the child’s eyes. The client responded, “The little child  is turning back, she is afraid of me.” 

This little child seemed to be an EP with a rudimentary first-person perspective. The therapist helped the client as ANP to communicate with the child EP, using, among other things, Knipe’s (2007) loving eyes procedure. The client as ANP was able to look at the child part’s eyes, subsequently sharing in, and thus processing, the fear that this EP had kept for so long and which was previously inaccessible for the ANP. In this way, ANP and the single EP were able to integrate. 

This is a similar, yet basic strategy and is reasonably successful with people with primary dissociation. However when people have structural dissociation, attachment disorders combined with emotion dysregulation, it requires a slower integration of all aspects to restore consistent ANP. 

Dissociation involves disruptions of usually integrated functions of consciousness, perception, memory, identity, and affect (e.g., depersonalization, derealization, numbing, amnesia, and analgesia). While the precise neurobiological underpinnings of dissociation remain elusive, neuroimaging studies in disorders, characterised by high dissociation (e.g., depersonalization/derealisation disorder (DDD), dissociative identity disorder (DID), dissociative subtype of post traumatic stress disorder (D-PTSD)), have provided valuable insight into brain alterations possibly underlying dissociation. Neuroimaging studies in borderline personality disorder (BPD), investigating links between altered brain function/ structure and dissociation, are still relatively rare. In this article, we provide an overview of neurobiological models of dissociation, primarily based on research in DDD, DID, and D-PTSD. Based on this background, we review recent neuroimaging studies on associations between dissociation and altered brain function and structure in BPD.

THE THEORY OF STRUCTURAL DISSOCIATION OF THE PERSONALITY

The "emotional" part of the personality
The EP is a manifestation of a more or less complex mental system that essentially involves traumatic memories. When traumatised individuals remain as EP, these memories are autonoetic for the EP, but not for the ANP. The memories can represent [pathogenic] kernel aspects of the trauma (Van der Hart & Op den Velde, 1995), a complete overwhelming event, or series of such events, and are usually associated with a different image of the body and a rudimentary or more evolved separate sense of self (McDougall, 1926). Therefore the EP range in forms from re-experiencing unintegrated aspects of trauma in cases of acute and post traumatic stress disorder (PTSD), to traumatised dissociative parts of the personality in dissociative identity disorder (DID; APA, 1994).

Traumatic memories manifested in the EP are very different from processed narratives of trauma (Janet, 1889, 1904, 1919/25, 1928; Van der Kolk & Van der Hart, 1991). Normal memories convey a narrative to the listener, stories told and retold, changeable over time, and adapted to an audience. While narrative memories are verbal, time-condensed, social and reconstructive in nature, traumatic memories are often experienced as if the once overwhelming event were happening here and now. These hallucinatory, solitary, and involuntary experiences consist of visual images, sensations, and motor actions, which engross the entire perceptual field. They are at least subjectively characterised by a sense of timelessness and immutability (Modell, 1990; Spiegel, Frischholz, & Spira, 1993; Van der Hart & Steele, 1997), and they have no social function (Janet, 1928). Although the EP’s traumatic memories include reproductive elements, they are not exact replications of overwhelming events. 

Apart from the individual’s experience of the event, they may include his or her fantasy and misperceptions at the time, and exclude parts of the experience. For example, the traumatic memory of Charcot’s patient LeLog included the idea that he had been run over by a wagon (Charcot, 1889). In fact, before losing consciousness, he had seen the wheels approaching him, which impressed upon him the idea of being run over, though he was actually never hit. Also, elements of other (traumatic) experiences may become associated with the traumatic memory, and thus confound it

Another distinctive feature of traumatic memories is that upon their reactivation, access to many other memories is more or less obstructed. Thus, when the EP is activated, the patient in that state tends to lose access to a range of memories that are readily available for the ANP. The lost memories typically involve episodic memories (personified memories of personal experiences), but may also include semantic memories (fac- Activitas Nervosa Superior 2010;52:1,1-23 

(Van der Hart & Nijenhuis, 2001). Myers (1940, p. 46) gives an example of the alteration between the EP, stuck in combat trauma, and the ANP in a World War I soldier (cf. Van der Hart, Van Dijke, Van Son, & Steele, 2000). After being subjected to heavy bom- bardment, during which a shell burst close to him, this man was brought into the Aid Post because he could not be restrained from rushing over the parapet with bombs in broad daylight. At the Aid Post he could not give his name or regiment, and was only induced to go down to the Field Ambulance by a ruse. In bed, he developed complete mutism and an extremely restless condition, from time to time turning his eyes and head as if follow- ing an imaginary object, after which he would withdraw his head beneath the bed clothes in abject horror. Later, when out of bed, he began to have dissociative convul- sions, during which he would undoubtedly have hurt himself unless restrained, and following which he evi- dently visualized his terrifying experiences in the trenches. He called out during these attacks, but after- wards, returned from the EP into the ANP, he had no recollection of his attacks and his mutism persisted. Between attacks he seemed otherwise normal. 

As illustrated in this example, the EP typically displays defensive motor behaviors, in particular in response to "triggers" i.e. classically conditioned, trauma-related stimuli. For example, in this condition, the patient may curl up in her chair, and remain largely immobile and silent. She may also hide behind a chair or in a corner. However, when feeling relatively safe, she may be more verbal and mobile. Thus in cases of childhood abuse, the EP with the identity of a child can occasionally dis- play behaviors such as childlike playfulness (e.g. Put- nam, 1997; Van der Hart & Nijenhuis, 1998). 

Research and clinical observations support the hypothe- sis that traumatic memories strongly involve sensorimo- tor features. For example, Van der Kolk and Fisler (1995) found that traumatic memories of subjects with PTSD were retrieved, at least initially, in the form of dissociated mental imprints of sensory and affective elements of the traumatic experience with little or no linguistic component. Sexually abused children also "remembered" their traumas in the form of sensory per- ceptions, and behavioral responses (Burgess, Hartman, & Baker, 1995), as did women reporting childhood sex- ual abuse (Nijenhuis, Van Engen et al., 2001) and trau- ma-reporting EPs of patients with DID (Nijenhuis, Quak et al., 1999). 

The field of consciousness of the EP tends to be highly restricted to the trauma as such and to trauma-related affairs. When EPs have evolved, as happens in DID, they may additionally be focused on matters of the current world that fit their experience and identity. In these cases, their procedural, semantic, and episodic memo- ries have been extended to some degree. However, while the EP has synthesized and personified (aspects of) the trauma into its limited range of memories, thus into the part of the personality it represents, it has failed to integrate current reality to a sufficient extent. This leaves the EP ultimately unable to adapt to present reality. 

Rachel is like a surgeon, she has the keen ability to see exactly what is happenning and exactly what is need. Her precision is like an archer and her knowledge her arrows. I fully reccommend working with her even if you feel like no one knows what to do, Rachel does.

— M.G

Rachel’s approach has changed my life more in the 3 weeks we have worked together than in a lifetime of mental health services and medication. I do not understand why her programmes are not the first port of call for all trauma victims and BPD diagnosis

— Amy R