attachment dissociative disorders

1. Attachment & Dissociative Disorders Daniel Brown, Ph.D.

3. Janet�s Dissociation Model Failure to take adaptive action in face of trauma Intensification of affect (�vehement emotions� �Disaggregation� (dissociation) of consciousness with split off �nuclei� of consciousness outside of awareness/control Narrowing of field of consciousness Re-emergence of split off subconscious fixed ideas: Somnambulistic states Hypermnesia & amnesia Conversion symptoms, e.g. paralysis

4. Dis-integrated ExperienceSpiegel & Cardena, 1991 �A structured separation of mental processes � that are ordinarily integrated.� �Involving at least momentarily unbridgeable compartmentalization of experiences�

5. The DSM Model DSM section on dissociation only addresses cognitive forms of dissociation: Memory symptoms (dissociative amnesia) Disruptions in consciousness Depersonalization & derealization Dissociated identity Somatoform (conversion) disorders in a separate section of DSM, as if unrelated to dissociation No place for dissociated behavioral re-enactments

6. Domain of Dissociative Symptoms(Nijenhuis)

7. Structural Theories of Dissociation:Myer�s (1940) Theory Apparently Normal Personality: Apparent normality but: Emotional & bodily anesthesia Amnesia (partial or complete) Trauma left unintegrated

8. Primary Structural Dissociation:

9. Secondary Structural Dissociation

10. Tertiary Structural Dissociation

12. Part 2. Attachment

13. Attachment Security �The state of being secure or untroubled about the availability of the attachment figure� (Ainsworth et al., 1978)

14. Identification of Attachment Behavior:Strange Situation Paradigm Parent-infant dyad introduced to room (1) Parent-infant (3 min.) Parent-infant-stranger (3 min.) Infant-stranger (parent leaves) (3 min.) Parent-infant (3 min.) Infant alone (3 min.) Infant-stranger (stranger enters) (3 min.) Parent-infant (parent returns/stranger leaves) (3 min.) Assessed between 12-18 months

15. Types of Attachment Behavior(Ainsworth et al., 1978) Secure Insecure Avoidant Anxious preoccupied/resistant 15% difficult to classify Disorganized/disoriented (unresolved) (Main & Solomon, 1986)

16. Four Main Attachment Types D

17. SSP: Secure Attachment Mother as secure base for exploration Active exploration with interest Signals or seeks contact when upset Missing & protest when separated Returns to separation once separated Clear preference for care-giver over stranger

18. SSP: Avoidant Attachment Little display of affect or secure-base behavior Little or no proximity seeking behavior Stiffens or moves away from physical contact Explores readily w/o social referencing Interested in toys more than in care-giver Minimal response to separation No distress when left alone Active avoidance upon reunion No differential response to mother vs. stranger

19. SSP: Resistant (Preoccupied) Attachment Distress entering new environment Fearful, passive, or angry Fails to engage in exploration Preoccupation with care-giver & clinging behavior Disorganized by separation Tantrums Difficult to comfort after reunion Failure to return to exploration after reunion

20. SSP: Disorganized Attachment Contradictory sequential or simultaneous attachment behaviors Disorganized behavior with lack of goal-directedness during exploration Incomplete, interrupted, or stereotypical behavioral sequences Disorientation, confusion, & trance behavior Fear or apprehension of care-giver

21. Manifestation of Attachment Behavior Over the Life-Course 1. Secure Attachment Infants Proximity seeking Increased behavioral & mental organization Preschool Social competence Adult Healthy pair-bonding

22. 2. Avoidant Attachment Infants Express little affect Avoids physical contact Avoids mother after separation No preference for mother over stranger Episodes of aggression Preschool Emotional insulation Antisocial or aggressive behavior Attention-seeking Adult Mistrust of relationships Social isolation & estrangement

23. 3. Resistant (Preoccupied) Attachment Infants Clinging and tantrums Difficulty being comforted Preschool Attention-seeking & needy Passive & helpless Impulsive Adult Abandonment fear Dependent, clinging, jealous, Compulsive care-giving

24. 4. Disorganized Attachment Infant Activation of inconsistent & contradictory attachment behaviors No single coherent attachment strategy Trance states Segregated systems Preschool Social inhibition & excessive care-giving Controlling & bossy Adult Clinging and avoidant Disorganized attachment associated with unresolved trauma & loss in care-giver

25. Etiology of Disorganized Attachment Frightening & frightened behavior (Main) Frightening vocalizations & movements Looming & invasions into infant�s space Immobilized, trance-like states, & dissociative lapses Deferential behavior Defers to infant for guidance Disrupted affective communication (Lyons-Ruth) Extreme parental misattunement Competing care-giving strategies Hostile-Helpless states-of-mind (Lyons-Ruth) Prolonged or repeated separation (Bowlby) Seductive or sexualized behavior Unresolved parental states-of-mind with respect to trauma or loss of parent (73%) vs. non-parent (23%) Lapses of monitoring & reasoning �The overall patterning of parental behaviors within the disorganized spectrum may take quite different forms� (Lyons-Ruth & Jacobvitz, 1999)

26. Disrupted Maternal Affective Communication Affective errors Contradictory cues Non-responsive or inappropriately responsive Disorientation Confused Disorganized Intrusive behavior (verbal or physical) Role confusion Role reversal Sexualization Withdrawal (verbal or physical)

27. Maternal Behavior & Infant Attachment Classification

28. Maltreating Parents �A maltreating caregiver is a frightened or frightening caregiver whose current mental state is characterized by a lack of resolution of loss or trauma, resulting in contradictory and unintegrated mental contents.� (Lyons-Ruth & Jacobvitz, 1999, p. 544)

29. Child Maltreatment & Disorganized Attachment Disorganized attachment found in: 82% of maltreated infants (Carlson et al., 1989) 55% of maltreated infants (Lyons-Ruth et al., 1990) �The disorganization of the attachment relationship, rather than simply its insecurity, may be a central mechanism in the emergence of many of the disturbances associated with maltreatment.� (Lyons-Ruth & Jacobvitz, 1999, p. 543)

30. Base Rates of Attachment Pathology

31. The Love Quiz (Hazen & Shaver, 1987) Which best characterizes your romantic relationships: Secure �I find it relatively easy to get close to others and am comfortable depending on them and having them depend on me. I don�t worry about being abandoned or about someone getting too close to me� Avoidant �I am somewhat uncomfortable being close to others; I find it difficult to trust them completely, difficult to allow myself to depend on them. I am nervous when anyone gets too close, and often, others want me to be more intimate than I feel comfortable being.� Ambivalent �I find that others are reluctant to get close as I would like. I often worry that my partner doesn�t really love me or won�t want to stay with me. I want to get very close to my partner, and this sometimes scares people away.�

32. The Relationship Questionnaire(Bartholomew & Horowitz, 1991) Secure: It is easy for me to become emotionally close to others. I am, comfortable depending on others and having others depend on me. I don�t worry about being alone or having others not accept me. Dismissing: I am comfortable without close emotional relationships. It is very important to me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me. Preoccupied: I wan to be completely emotionally intimate with others, but I often find that others are reluctant to get close as I would like. I am uncomfortable being without close relationships, but I sometimes worry that others don�t value me as much as I value them. Fearful: I am uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I worry that I will be hurt if I allow myself to become too close to others. R = 0.78 with AAI

33. The Four-Category Schema of Adult Attachment (Bartholomew, 1990)

34. AAI: General Scoring Principles Coherence Grice�s maxims Quality�believable without contradictions Quantity of information Relevance�answers the questions asked Manner�fresh, clear language Parental behavior scales Loving, rejecting, involving, pressuring State-of-mind scales Derogatory Preoccupied Unresolved

35. AAI: Secure Attachment Coherent discourse Emotion neither overwhelms nor directs discourse Single discourse strategy Meta-cognitive monitoring Active monitoring of thinking Admission of biases and memory fallibility Appearance-reality distinction Representational diversity Representational change Awareness of unconscious processes Compassion, humor, & forgiveness

36. AAI: Dismissing/Avoidant Attachment Positive, idealized view of attachment figure despite neglect Representations unsupported or contradicted by episodes recounted e.g. �she was a very devoted mom but I couldn�t connect with her� Lack of memory for childhood Active derogation or dismissal of attachment experiences Avoid focus on emotional aspects of attachments Very brief transcripts

37. AAI: Preoccupied Anxious Attachment Preoccupied with past attachment relationships Anger expressed toward primary attachment figure Difficulty finding words or staying focused Described as if reliving childhood experiences Very long discourse Role reversals & contradictions

38. AAI: Unresolved/ disorganized States Lapses in monitoring of reasoning Odd thoughts & thought intrusions Unreality Disconnected ideas Lapses in the monitoring of discourse Prolonged silence Drawn out of context of interview, then returns to normal discourse, e.g. sudden extreme attention to detail Sudden changes in emotional theme Lapses specific to talking about trauma or loss

39. AAI: Cannot Classify (CC) Both dismissing & preoccupied states-of-mind Global switches between both strategies in describing same attachment figure, not just around describing loss or trauma Representative groups: Sexual abuse survivors Multiple, co-morbid psychiatric diagnoses Criminals

40. AAI Classifications Dismissing Ds1 Dismissing of attachment Ds2 Devaluing of attachment Ds3 Restricted Ds4 Fear of loss of child Secure F1 Conscious setting aside of attachment F2 Somewhat dismissing/restricting of attachment but valuing F3 Prototypical secure attachment F4 Strong valuing plus some preoccupation F5 Conflicted, angry preoccupied while accepting attachment Preoccupied E1 Passive E2 Angry/conflicted E3 Fearfully preoccupied by traumatic event Ud Unresolved (disorganized/disoriented) CC Contradictory states of mind [disorganized attachment]

41. Pervasive Developmental Effects �Difficulties in intimate relationships, unintegrated mental representations, negative self-concepts, and problems with affect regulation are expected to be core features of a disorganized attachment relationship.� (Lyons-Ruth & Jacobvitz, 1999, p. 544)

42. AAI Classification & Psychiatric Diagnoses

43. AAI Classification in Borderline and Dysthymic Disorders

44. Attachment & Psycho-pathology Insecure attachment per se does not guarantee psycho-pathology Psychiatric diagnoses nearly always associated with insecure attachment Unresolved/disorganized attachment over-represented among individuals with psychiatric diagnoses (50-78%) 75% & 89% of BPO showed preoccupied, anxious on the AAI (Fonagy et al., 1996; Patrick et al. 1994) Secure attachment under-represented among individuals with psychiatric diagnoses (8%)

45. Minnesota Longitudinal Study of Dissociative Symptoms 1. 168 high-risk infants studied over 19 years from infancy to early adulthood Five developmentally distinct time periods 1. Infancy (0-24 months) 2. Preschool (30-54 months) 3. Elementary school (grades 1-6) 4. Adolescence (16-17 years-old) 5. Early adulthood (19 years-old) Multiple measures at each developmental age

46. Longitudinal Study of Dissociative Symptoms:The Role of Trauma

47. Longitudinal Study of Dissociative Symptoms:The Role Attachment

48. Longitudinal Study of Dissociative Symptoms:Pathological Dissociation

49. Ogawa et al. Longitudinal Study:Conclusions �Age of onset, chronicity, & severity of trauma were highly correlated and predicted level of dissociation� Trauma is a necessary but not sufficient predictor of pathological dissociation in adulthood �Both avoidant & disorganized attachment are strong predictors of dissociation� Dissociation in childhood as normal response to disruption & stress Dissociation in adolescence & adulthood indication of psychopathology Combination of disorganized attachment and later trauma predicts pathological dissociation Dissociative behavior shifts in early adulthood so that trauma is less, and disorganized attachment more, predictive of adult pathological dissociation

50. Longitudinal Study:Contribution of Disorganized Attachment Carlson, 1998 Consequences of disorganized attachment in infancy: Behavioral problems in elementary through high school Dissociative symptoms in elementary through early adulthood Self-harm & accident-proneness Level of psychopathology in early adulthood

51. Longitudinal Study:Carlson�s (1998) conclusions �Attachment disorganization may have particular long-term implications for the development of dissociative symptoms in childhood and adolescence� (p. 1123)

52. Disorganized Attachment:The Contribution of Subsequent Trauma Early attachment disorganization plus Subsequent severe & chronic trauma or abuse crystallizes disorganized/disoriented vulnerability into pathological dissociation Combination of infant attachment disorganization and subsequent severe trauma necessary for development of pathological dissociation Subsequent parental failure to respond to or protect child from the abuse further compounds the use of pathological dissociation (Barach, 1991; Liotti, 1992)

53. Differential Effects of Neglect & Abuse(Alexander, 1993) 112 women with history of sexual abuse Relationship Questionnaire: 14% secure 13% preoccupied 16% dismissing 58% fearful Childhood sexual abuse predicted: Depression PTSD Attachment style predicted: Personality disorder �Basic personality structure�was not associated with abuse characteristics but was instead predicted by adult attachment�

54. Dissociation as Connection or Disconnection? Detachment as final stage in dealing with separation anxiety; detachment as a kind of dissociation from attachment behavior (Barach, 1991) Use of dissociation to preserve attachment to abusing care-giver (Blizard & Bluhm, 1994) Selective dissociation of memories, self-states, object representations to preserve caring representation of care-giver Dissociated amnesia to preserve attachment (Freyd, 1996)

55. Disorganized Attachment & Dissociation �Disorganized behavior of infancy is an early analogue of dissociation and may predispose the child to the use of this defense in subsequent development.� Fonagy, 1998 �Disorganized attachment is an antecedent of the dissociative disorders� Liotti, 1992

56. Liotti�s Model Disorgainzed/disoriented attachment as a more sophisticated construct than detachment to explain dissociative disorders Disorganized attachment as a type of disoriented attachment, not detachment Frightening/frightened parent is both source of comfort and danger to child Results in creation of multiple, conflicting internal working models for attachment

57. Liotti�s Three Pathways Some (not extreme) exposure to frightening/frightened parental behavior, offset by other care-giver(s): High normal dissociative experiences (but not disorder) as adult Extreme frightening/frightened parental behavior but no abuse: Mild DD as adult Extreme frightening/frightened parental behavior plus subsequent serious abuse: Construction of alter behavior & DID

58. Combination of Attachment Pathology& Abuse �One may view MPD as an attachment disorder complicated by the sequelae of active abuse (specific acts which cause physical harm or sexual harm). Barach, 1991, p. 117

59. Perspectives on Dissociation Integration/Continuity Developmental Models (Putnam, Carlson, Harter, Hornstein, Liotti, Main) Dis-integrated experience (Janet, Spiegel & Cardena) Multiplicity/Discontinuity State/trait theories Process/structural theories

60. Normal Self Development �Multiple working models� in normal infants (Liott, 1999; Putnam, 1994) Discrete, discontinuous self-states �smooth out� over course of normal child development (Putnam, 1994) Concrete operational thinking as �major developmental task� for relative unity of self representational system Normal intensification of internal conflict between self-states in mid-adolescence Identity consolidation and reduction of internal conflict in late adolescence & early adulthood

61. Contributions of Disorganized Attachment to Adult Dissociative & Personality Disorders Etiology of disorganized attachment Care-giver problems Unresolved loss & trauma Depression & alcoholism Care-giver behavior Frightening & frightened behavior (M. Main) Dissociative lapses (M. Main) Hositle & helpless behavior (Lyons-Ruth)

62. Effects of Disorganized Attachment Manifestations of disorganized attachment Behavioral Contradictory behavioral strategies Disorganized behavior & mental state Reaction pattern Intense alarm e.g. elevated heart rate Increased dissociative states Affect dysregulation Increase in negative emotional behaviors & defensive aggression

63. Disorganized Attachment:Pathological Development Learned use of dissociation �Segregated systems� (profound integration failure) Increased frequency and duration of �trance states� as a coping strategy Prevents �smoothing out� of self-state shifts over time Failure to consolidate cohesive self Regressive shifts to child-like states Rudimentary alter behavior (Hornstein, 1996) Pathological dissociative states persist in adolescence & early adulthood (Ogawa et al., 1997; Carlson, 1998) Development of factitious behavior through incidental and social learning

64. Dissociation as a Learned Defensive System �If the child is driven to maintain a strong attachment to the primary care-giver, and experiences an intense abandonment depression when the attachment is lost, then the child faces a special set of problems when the primary care-giver is also an abuser�The child may have to go to great lengths to create defenses that will allow the preservation of the attachment to the object.� Blizard & Bluhm, 1994, p.384

65. Disorganized Attachment (4)The Development of DID & DDNOS Reification of �parts� in conflict in mid-adolescence Failure to consolidate identity in late adolescence Emergence of DD, FD, and/or PD in early adulthood (high co-morbidity) Emergence of clinical features of dissociation (e.g. time loss and disremembered experiences), then alter behavior over time Covert alter behavior (�phobia of dissociative identities� van der Hart & Steele) Manifestation of alter behavior & behavioral shaping of alter behavior (Kohlenberg)

66. The Borderline-Dissociative Disorders Continuum (Ross, 1996) �The idea that the dissociative disorders lie on a continuum of increasing complexity, chronicity, and severity related to more extreme trauma was initially proposed by Ross (1985) and Braun (1986)� many individuals with DDNOS have partial, not fully crystallized forms of DID, and require a similar treatment involving memory retrieval and processing, integration of dissociative ego states, and resolution of conflicts between ego states� The relationship between borderline personality disorder and the dissociative disorders has been complicated rather than clarified in DSM-IV, because a ninth criterion for borderline personality disorder has been added: Transient, stress related paranoid ideation or severe dissociative symptoms� To my way of thinking, borderline personality disorder is a simple form of DID in which personality states are less crystalized, less personified, fewer in number, and not separated by the same degree of amnesia. Inversely, DID is a complex variant of borderline personality disorder�.borderline personality disorder exists on a continuum of increasing severity, with DDNOS having a greater degree of complexity than pure borderline personality and DID the greatest degree of elaboration and crystallization. �

67. Mentalization vs. Pathological Internalization (Fonagy, 1998) Secure attachment & mirroring leads to mentalization in the child Dissociation as the converse of mentalization resulting in a disjunction between related mental contents Failed mirroring �The child is likely to internalize the mother�s actual state as part of his or her own self-structure� (p. 157) Deactivation of the reflective function as a defense in face of subsequent trauma

68. Victim & Perpetrator Alters as Metaphors of Insecure Attachment �Typically, masochistic defenses are used to preserve attachment�.As these repeatedly fail, sadistic defenses may be adopted, with disavowal of need for attachment, introjection of the abuser, and projection of pain and weakness onto a victim.� (Blizard, 2001)

69. Part 3: Treatment

70. Psychotherapy for Attachment Pathology: Transference Interpretation Interpretation of insecure attachment style as a defense Holding core affect in the relationship Transformation of core affects

71. The Bowlby Model Activation of attachment behavior Formation of a secure base Proximity-seeking behavior Exploration Activation of the exploratory system New modes of action Autonomy & independence

72. Treatment of Attachment Pathology Establishing a secure base Therapist acts as secure base (Holmes, 1996 Sable, 2000) Regaining access to attachment feelings (Sable, 2000) Protocols of �imagined other� Establishing contact with avoidant & encouraging independence in anxious patients Exploration of inner world Disavowed affects & defensive exclusions Self development & affect regulation Therapist as trusted companion during exploration (Sable, 2000) Exploration of new ways to be in the world New social situations, interests, etc. Therapist as �background of safety� (Sandler, 1960)

73. Establishing a New Internal Working Model �The working model of the therapeutic relationship eventually exerts dominance over hurtful experiences and models of the past, countering the patient�s image of himself as unlovable and unworthy of secure affectional ties.� (Sable, 2000, p. 333)

74. Developing Secure Attachment �The aim of therapy is to transform insecure into secure attachment, to move from clinging to intimacy, from avoidance to autonomy�. The therapist tries to behave like a responsive, attuned parent-figure who is neither intrusive nor rejecting, rebuffing nor controlling�overwhelming nor neglectful� (Holmes, 1996, p. 70)

75. Hypnotherapeutic Treatment of Attachment Pathology Object representational development Boundary definition (Baker, 1981) Representing the good internal object Object integration & constancy Security of attachment to ideal parent figures (therapist meditated attachment) (Murray-Jobsis) Establishing the secure base for exploration (Brown, 2002)

76. Attachment in the Treatment of DID �The therapist can note evidence for an attachment disorder in nearly every aspect of the psychotherapy of MPD. From this perspective the resolution of the attachment disorder, rather than the resolution of the effects of sexual and physical trauma, causes the extended and turbulent nature of the psychotherapy of more complex cases of MPD.� (Barach, 1991, p. 117)

77. Multi-Leveled Attachment Protocol View each alter�s communication/behavior as a specific attachment re-enactments Application of specific attachment protocol for each alter personality state to re-activate attachment behavior Use of relationship to active reflective function Establishment of security of attachment & reflective function across alter personality system Move from dismissing, disorganized, or anxious attachment, to secure attachment Use of secure attachment base for affect regulation and self development

78. Stages in Treatment of Attachment Pathology in DID 1. Establishing a secure base With any �part� Using secure base to reduce dissociation & other trauma-related symptoms Secure attachment across the alter system Developing secure attachment with more & more alters Addressing attachment needs of more & more alters across time in the session Addressing attachment needs of a number of alters simultaneously Addressing negative beliefs through attachment Dealing with active resistance & outliers through attachment

79. Stages in Treatment of Attachment Pathology in DID 2. Reaching the goal of inclusion of all alters into the attachment system Dealing with active blocking Insecure vs. healthy attachment Residual dismissing attachment Longing activation Anxious, preoccupied attachment Compassionate attachment & perpetrator acts All alters sharing in the attachment system Generalization beyond the hour

80. Stages in Treatment of Attachment Pathology in DID 3. Affect regulation through attachment Soothing attachment Specific affect states Shame Fear Hopelessness & despair Guilt Rage Conflict resolution through attachment

81. Stages in Treatment of Attachment Pathology in DID 4a. Self Development Secure attachment as the basis for integrated self development Ideal attachment figures to foster self development & enhancement of �real� Self Unburdening habitual reactions that obscure the �Self� Unburdening vs. attachment security

82. Stages in Treatment 4bSigns of Self Development Reduction of internal conflict & system noise Reduced activity of �parts� protective reactions Development of decision-making & choice Sensing the wholeness of self as distinct from �parts�

83. Stages in Treatment of Attachment Pathology in DID 5. The �real� therapeutic relationship Fostering the working alliance across parts Mistrust & other transference issues Therapist as abuser or sadistic abuser Development of anxious attachment to the therapist Manifestations of anxious attachment in treatment Working through anxious attachment Therapist as the �backing� of safety & security for internal & external exploration

84. Stages in Treatment of Attachment Pathology in DID 6. Attachment as the basis of normalization & exploration, & discovery of a healthy life Reducing trauma-related symptoms Relapse prevention Reaching the self�s potential Secure intimacy & healthy peer relationships Resiliency