Developmental Pathways to Dissociation
Is early trauma the root cause of dissociative disorders?
Most of the literature and research on dissociation focuses on trauma as the root cause of dissociative disorders, and many studies show an association between dissociation and trauma (Putnam, 1997). “The fact that nontraumatized individuals sometimes demonstrate dissociation and that not all trauma survivors dissociate suggests that there may be more to the etiology and development of dissociation than trauma alone.” (Dutra, Bianchi, Siegel and Lyons-Ruth, 2009, p. 84). If early trauma is not the unique cause of dissociation, then what else could cause it?
Are dissociative disorders disorders of attachment?
Peter Barach (1991) was one of the first to emphasize insecure attachment in the etiology of multiple personality disorder (referred to in the DSM-IV as dissociative identity disorder-DID) and suggested it should be viewed as an attachment disorder. Barach emphasized the idea that emotionally neglectful, detached responses from caretakers lead to chronic emotional detachment and dissociation in those who later go on to develop MPD (DID). He also described how such neglectful and detached caretaker responses can lead to failures to detect and protect young children from the impact of later occurring severe trauma. At about the same time, Giovanni Liotti (1992, 2009) emphasized insecure disorganized (type D) attachment and the early formation of multiple internal working models of the self and other as the precursors to the development of severe dissociative disorders later in life. John Bowlby (1973) had previously suggested that infants can internalize unintegrated internal working models of their primary caregivers and themselves.
Can problems with infant attachment be the cause of dissociation? A growing literature on this subject suggests the answer is “Yes,” but many clinicians on first exposure to this literature may assume that the focus has merely shifted to “attachment trauma”. Yet, as we will see, recent prospective longitudinal studies suggest that “attachment trauma” is not the factor most associated with the risk of later developing a dissociative disorder. In fact, it may not be a significant factor at all.
Wait. Isn’t “attachment trauma” the root of vulnerability for adult dissociation?
In adults, “trauma” is generally viewed through the lens of the DSM-IV-TR criteria for the development of posttraumatic stress disorder: “direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person” and “The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior)” (American Psychiatric Association, 2000). Do the infant experiences that lead to a vulnerability to dissociation fit these criteria? Most clinicians have tended to assume so because they view neglectful caretaker behavior as having the potential to induce “abandonment terror.” But what if the research indicated that threat of abandonment is not the central factor in predicting adult dissociation? Could we reorganize our thinking to consider the implications or are we wedded to the concept of trauma as the cause of dissociation?
Prospective Longitudinal Studies of Predictors of Adult Dissociative Disorders
“Ogawa, Sroufe, Weinfield, Carlson, and Egeland (1997) carried out a prospective longitudinal study of 126 high-risk children, following this sample from birth to age 19, in an attempt to test Liotti’s model. According to models of dissociation based in trauma theory, one might expect trauma to be the strongest independent predictor of adult dissociation. Ogawa’s et al. (1997) multiple regression analyses indicated, however, that disorganized attachment and psychological unavailability of the caregiver during infancy were the strongest predictors of clinical levels of dissociation, to the extent that these variables alone accounted for approximately one-quarter of the variance in dissociation at age 19. Surprisingly, trauma history did not significantly add to the predictive value of this equation… …These findings lead to the question of whether disorganized attachment may be as central to the development of dissociation as trauma itself.
These striking findings led Dutra, Bureau, Holmes, Lyubchik and Lyons-Ruth (2009) to further investigate the association between infant attachment and dissociation in another, more recent prospective, longitudinal study of a high risk sample from birth to age 19. Their findings partially confirmed and extended the earlier work by Ogawa et al. (1997). However, Dutra, Bureau, Holmes, Lyubchik and Lyons-Ruth (2009) found early childhood maltreatment did not predict adolescent dissociative symptoms. A range of maternal psychiatric symptoms through child age 9–including anxiety, depressive, dissociative, and posttraumatic stress disorder symptoms–also did not predict adolescent dissociative symptoms. If childhood maltreatment and maternal psychiatric symptoms did not predict adolescent dissociative symptoms, what did? “[Q]uality of maternal communication during infancy” accounted for half of the variance in dissociative symptoms at age 19 (Dutra, Bianchi, Siegel and Lyons-Ruth, 2009, p. 87).
Disrupted parent-infant dialogue not maltreatment predicts adult dissociation
Using the Observation of Maternal Interaction Rating Scales (HOMIRS; Lyons-Ruth et al., 1987) to assess mother-infant interactions at home at 12 months and the Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE: Lyons-Ruth et al., 1999) to assess maternal disrupted affective communication at 18 months, Dutra, Bureau, Holmes, Lyubchik and Lyons-Ruth (2009) reported:
“Trauma theory dictates that maternal hostile (negative-intrusive) and/or disoriented behaviors would likely be the strongest predictors of dissociation in young adulthood, but, surprisingly, this is not what was found. Maternal hostile or intrusive behavior was not significantly related to later dissociation. Instead, lack of positive maternal affective involvement, maternal flatness of affect, and overall disrupted maternal communication were the strongest predictors of dissociation in young adulthood. What is notable about these type of maternal interactions is that they all serve to subtly override or ignore the infant’s needs and attachment signals, but without overt hostility.” [Emphasis added.] (Dutra, Bianchi, Siegel and Lyons-Ruth, 2009, p. 87).
In Ogawa et al. (1997) approximately 25% of the variance in DES scores at age 19 was accounted for by the combination of psychological unavailability and infant disorganization. However, 19% of this variance was carried by the psychological unavailability variable alone. In Dutra et al., 2009, p. 88) after controlling for quality of early care, childhood trauma accounted for only 9% of the variance which was not significant. After controlling for gender and demographic risk, 50% of the variance in adult dissociation scores was accounted for by quality of early care (p < .001). Within the quality of early care cluster, level of disrupted communication (assessed in the lab – p < .01), mother’s (lack of) positive affective involvement at home (p < .05), and mother’s flatness of affect at home (p < .05) were all significant predictors of dissociative symptoms.
Early developmental experiences involving parent-infant dialogue and infant disorganization are clearly not the only early vulnerability factors to the later development of adult dissociation. Later occurring traumatic experiences clearly play a role as do undoubtedly genetic, societal and environmental factors. What is so compelling from the latest prospective, longitudinal research from Dutra, Bureau, Holmes, Lyubchik and Lyons-Ruth (2009) is that the portion of the vulnerability for adult dissociation accounted for by disrupted parent-infant dialogue (assessed by AMBIANCE at 12 months), mother’s flatness of affect and lack of mother’s positive affective involvement (assessed by HOMIRS at 18 months) was found to be so much more influential than that of early traumatic experience or mother’s hostile-intrusiveness.
Revisioning our understanding of the foundations of adult dissociative disorders
The findings from Dutra, Bureau, Holmes, Lyubchik and Lyons-Ruth (2009), extending Ogawa’s et al. (1997) earlier work, should serve to shift our attention from early models of vulnerability for adult dissociative disorders as being founded primarily on traumatic experiences, to what Dutra et al. (2009) refer to as disruptions of the parent-infant dialogue. “In contrast to a more discrete traumatic event, the child’s fear of remaining unseen and unheard by his caregiver, resulting in unmet needs, is worked into the fabric of identity from a very early age.” (Dutra, Bianchi, Siegel and Lyons-Ruth, 2009, p. 91).
These findings challenge us to rework our views of what lies at the root of the multiple, complex problems of patients with severe, adult dissociative disorders. Perhaps they will help clinicians broaden a narrow focus of finding out and addressing details about what happened and when, to a consideration of exploring the clinical dialogue itself as the medium for developmental repair. The model of early parent-child dialogue described by Dutra et al. (2009) may help us understand why individuals vary so much in their response to traumatic experiences. Hopefully it will lead to more work to address gaps both in the literature and in the approach that clinicians bring to their work with adults with severe dissociative disorders.
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