On the 12th of June, 1942, my father, a flight sergeant in the RAF, crashed his Hawker Hurricane at 200mph into the side of a hill on Rousay in the Orkney Islands.  He was catapulted of the perspex cockpit into a bed of gorse.  8 days afterwards he regained consciousness, but spoke only French. 

 

So what had happened?  Was the reality of his accident so dreadful that he could not longer exist as the person he was? 

 

Last Wednesday,  at a meeting of the Hallam Institute of Psychotherapy, Stephanie Howlett talked about the psychological state of dissociation.  Stephanie works as a psychoanalytical psychotherapist for the Division of Neurology in Sheffield.  Most of her patients suffer from dissociative or non-epileptic seizures; absences, bizarre movements and  strange behaviour that are not associated with the typical brain waves of epilepsy.    

 

The striking thing about her patients is that they had all experienced severe trauma, not just once but many times.  It was as if the personality was so overwhelmed by the memory of the trauma, that it split into two.  There was one personality, that was apparently normal and kept things in control and an emotional personality that could behave in a strange manner, that often seemed to re-enact the traumatic experience.  The emergence of the emotional personality was triggered by events or objects that reminded the patient of the experience.  Sometimes, the two personalities could occupy different sides of the body – one arm resting still on the lap, the other executing bizarre movements.   

 

These bizarre reactions bore a strong resemblance to the classic descriptions of hysteria, demonstrated by the famous neurologist, Professor Jean-Martin Charcot at L’Hopital, Salpetriere in Paris. 

 

‘Very commonly during fits a woman grasps her throat with her hands as if to tear it open…..she strikes out at things around her and even at the back of the bed, in which she appears to be bouncing up and down.’

 

Unlike the classic epileptiform convulsions, there is something purposeful and meaningful in hysterical fits – an acting out in the theatre of the body. The description above seems to re-enact a traumatic rape.  Childhood sexual abuse is a common theme in dissociative seizures.  Patients often act out the conditions of their abuse; the masturbating hand, or wiping the mouth with the back of the hand. 

 

Seizures are the most bizarre and extreme form of dissociation.  They occur when the memory of what has happened is just too overwhelming.  As such, they may provide an escape from intolerable reality.  But there are other forms of dissociation.  The delusional states of schizophrenia might be regarded as dissociation, enacted in the theatre of the mind.  These also might serve as a refuge from intolerable reality were it not for the fact that psychotic delusions are so often of a paranoid and tormented nature.  

 

Dissociation can also be a useful perspective from which to understand some unexplained medical conditions.  I received a letter the other day from a woman, whom I shall call Linda.  She told me that her husband suffers from Irritable Bowel Syndrome and that for most of the time he is a kind, considerate and loving man, but when he has an attack of abdominal pain, he becomes aggressive and violent.  ‘It is like living with a mad man.  He suddenly changes into a different person.’  So it seems some event triggers off a dissociative state of pain and aggression.  If Linda and her husband could understand what memory these symptoms represented and what triggered them off, they would perhaps find a way to control them. 

 

Patients with Irritable Bowel Syndrome often exhibit an alternating pattern of diarrhoea and constipation. These phases can be associated with changes in personality.  Constipation often occurs with anorexia; a state of control, nothing in, nothing out.  Diarrhoea is a lack of containment; the chaotic emotional personality.  A similar dialectic can occur in bulimia, the control of anorexia oscillating with the chaos of binge eating.  It might also offer a perspective on bipolar disorder, the depression trying to keep the mania in control. 

 

One of my patients explained the struggle between her emotional personality and the personality that is control very clearly. 

 

‘Whenever I feel lonely, I start to panic.  Then I feel like something to eat.  It calms me down but the more I eat, the more I want to eat.  I need to go out.  I go to a bar, pick up a man if I can and take him back to my flat.  Afterwards I feel so disgusted with myself, I am sick.  I have diarrhoea.  The next day, I tidy up, have a shower, put on some clean clothes, exercise in the gym, stop drinking, eat salads and get constipated – but slowly the loneliness starts creeping back again.’   

 

As a re-enactment of the traumatic memory, the emotional personality is shaped by culture.  In a more God-fearing time, dissociation took the form of demonic possession and witchcraft.  People, troubled in spirit for the sins they had committed presented with dramatic behaviours, including  refusal to eat, muteness, crying, shouting, speaking in voices and tongues, disrespectful behaviour and visual hallucinations; also bodily symptoms such as pains, sores, itching, abdominal distension (pseudo-pregnancy) and loss of hearing and sight.  Much later, the dramatic seizures of La grande hysterie were described by Charcot, but quickly disappeared from the wards of ‘Le Salpetriere’ when his successor, Dr Jules-Joseph Dejerine refused to take them seriously.  The culture had changed and the symptoms followed. 

 

It would be a mistake to regard dissociation entirely as a sign of pathology.  Like other psychiatric illness, there is a merging with what may be considered normal.  We can all be sad or anxious; it’s when these states take over our lives, they assume the chronic manifestations of depression or generalised anxiety disorder. Similarly we can all dissociate.  Road rage, panic and paranoia are all common examples of dissociation.  Adulterers, political manipulators may blame their dark (dissociated) side for the shameful acts they commit.  People lose concentration, become tired or develop the giggles when confronted with some difficult situation they can’t deal with.  We are none of us sensible and honourable all of the time.  Sometimes need, desire, fury,  vengeance, guilt and shame just take over and cause us to behave in ways that may shock and upset.  There is a site on the internet called Second Life, where people can have a virtual (dissociated) existence that may service their desire to escape the reality of their lives. 

 

To help people with dissociation reintegrate, you need to understand the three ‘p’s, the predisposing, precipitating and perpetuating factors. Predisposing factors include not only the undisclosed and unresolved trauma, but perhaps also an emotionally deprived childhood that did not provide the capacity or experience to deal with the vicissitudes of life without acting out.  Precipitating factors are the events, objects, people, date, sights, sounds, smells and tastes that remind a person of that trauma. Perpetuating factors are the situations in which those triggers may be activated.  The goal of treatment is to use appropriate grounding and relaxation to calm the fear so that the traumatic memory can be accessed and then to reintegrate this with the apparently normal personality. 

 

My father stopped speaking French and after four years was successfully rehabilitated into his company and family, but for many years after, he could not look out of high buildings without feeling giddy and if he became upset about things, he could readily revert to French.  As a child, I never understood who Sand Fairy Ann (ca ne fait rein) was. 

 

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