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Problem of “otherness” in dissociative disorder
Journal Pre-proof Problem of “otherness” in dissociative disorder Kenichiro Okano MD
PII:
S2468-7499(19)30069-9
DOI:
https://doi.org/doi:10.1016/j.ejtd.2019.100133
Reference:
EJTD 100133
To appear in:
European Journal of Trauma & Dissociation
Received Date:
4 May 2019
Revised Date:
5 August 2019
Accepted Date:
19 September 2019
Please cite this article as: Okano K, Problem of “otherness” in dissociative disorder, European Journal of Trauma and Dissociation (2019), doi: https://doi.org/10.1016/j.ejtd.2019.100133
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Problem of “otherness” in dissociative disorder Author : Kenichiro Okano, MD Department of Education, Kyoto University Address: Kyoto University, Dpt. of Education
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Yoshida-honmachi, Sakyo-ku, Kyoto 606-8501, Japan Email: [email protected]
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Problem of “otherness” in dissociative disorder
The unity of the primary personality remains unchanged; nothing breaks away, nothing is
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split off. Instead, dissociated experiences (…) were always, from the instant of their occurrence, assigned to, and associated with the second system within.
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Pierre Janet (1888, quoted by Dell, 2009. p. 716)
* * * * * * * * * * * * * *
The appearance of a second personality is often presented in the most deceptive manner. Sigmund Freud (Breuer & Freud, 1985, p. 287)
Where does the “problem of otherness” stand? Although our understanding of the dissociative phenomenon and its pathological manifestations have progressed significantly over the past couple of decades, many crucial problems need to be explored and further understood. One of them, which I discuss in this article, is what I would call the “problem of otherness” among the parts of the personality in dissociative identity disorder (DID). In dealing with individuals with DID, the “problem of otherness” addresses the extent to which we validate and recognize the subjective perception of each part of personality (PP) that another PP possesses a different and independent subjectivity. My daily clinical practice makes me believe that majority of PPs tend to believe that they are unique and different
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from other PPs. These PPs want their clinicians to understand that they are much more different and independent from other PPs rather than similar and related. Let us, as clinicians, pause for a while and ask if we grant the status of an independent and distinct personality to each PP of an individual with DID, or regard him/her as a different “part” of a whole personality? Although many of us might feel that there is no definitive answer to this question, I consider that the recent trend is to choose the latter approach more often than the former. We no longer use the term “alter” (which is Latin for other), at least not as often as before, to describe different parts of a personality in DID. We have abandoned the traditional
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term “multiple personality disorder” to avoid an implication that there are different and independent personalities in an individual’s mind (as exemplified by DSM-IV, DSM-5, and ICD-11). It appears that the “problem of otherness” is at least temporarily settled among experts in the direction of not fully validating the PP’s sense of “otherness” with other PPs. However, it
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is unclear as to what extent this trend reflects the clinical reality, including the patient’s subjective experiences.
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A patient of mine, Ms. A, talked about her recent experience as follows:
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“The other day I was driving a car and waiting at a traffic light. When it turned green, a car ahead of me didn’t start for a moment and I heard a voice at the back of my head yelling ‘Gee, weren’t you goofing off? Get started, silly!’ I said to myself ‘My goodness, can’t he be more
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patient?’ Of course, I was driving by myself and it was B, one of my alters, who yelled.” In this example, it seems obvious that Ms. A has a very different perception and emotional reaction compared to that of “B.” From her perspective, B is someone else, another subject, if not another human being. The question is, as clinicians, should we recognize B’s “otherness” from Ms. A such that the latter feels that we understand her subjective experiences. If we are not sure about how we can address this dilemma, think about the following example that emerged from a thought experiment: Ms. C is at a traffic light, in a same way that Ms. A was. When the light turned green and a car ahead of her was inattentive in a similar situation, she heard a voice from her back. “Gee, aren’t you goofing off …” Ms. C said to herself, “Gee, can’t he be more patient??” But in this case, it was her husband in the back seat who yelled. How many of us are sure that we acknowledge Ms. A’s perception of B’s otherness on a comparable level as Ms. C’s perception of her husband, another real person? Perhaps, not many
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of us are. I believe that it is partly because we tend to consider multiple existences of subjects in Ms. A as a sort of fantasy, or something pathological and temporary that needs to be fixed with some kind of therapeutic endeavor. This belief is eloquently expressed in the following description of DID by a reliable diagnostic system: “Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness.” (DSM-5, American Psychiatric Association, 2013). The purpose of this article is to propose that an individual with DID’s perception of his/her
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PPs as “others” is not altogether pathological, but rather a reflection of the healthy aspect of their cognitive function, from psychological as well as neurocognitive viewpoints. When PPs subjectively experience “otherness” among them, they are structurally separated in a biopsychological sense. The degree of that structural separateness corresponds to the strength of
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this sense of “otherness.”
In this article, I use the abbreviation “PP(s)” (parts of personality, van der Hart, et al., 2006)
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to connote what has been referred to as “alters,” “other personalities,” etc., in individuals with DID, partly for the sake of simplicity and to temporarily bypass the issue of what we should call
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Review of Literature
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them, which is actually, the focus of this article.
Although the “problem of otherness” has great clinical significance, related references are rather scarce, due in part to a theoretical ambiguity about how the dissociative process occurs. In this literature review, I start with discussing John O’Neil’s (2009) work, who focused on this very issue from the standpoint of the ambiguity of the term splitting in psychoanalytic literature as well as in that on dissociative disorders. The concept of splitting as a source of confusion in dealing with the problem of “otherness”
According to O’Neil (2009), the notion of splitting, used mainly in psychoanalytic literature to roughly denote dissociation, could be a source of confusion. He argues that, when dissociation is often described as “the splitting of the mind,” two meanings are frequently confused and undifferentiated. He calls them the division and multiplication of the consciousness. The former connotes the dissociation of faculties within one conscious, typically
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represented by the BASK model proposed by Bennet Braun (1988). The latter implies the existence of more than one consciousness. O’Neil points out that this difference has been overlooked due to the fact that “multiplication and division are present in the double meanings of both split and double” (2009, p. 298). He asserts that, while dissociation is often described as the division of the consciousness, he prefers the connotation of “multiplication of the consciousness,” which “better describes dissociative multiplicity” (ibid, p. 298). Hereafter, we refer to this distinction as “splitting as division vs. splitting as multiplication” in the sense that O’Neil explicated. If a mind is divided, we naturally consider that these parts
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are internally and dynamically related. If a mind is multiplied, each mind would be regarded as independent and different from each other. I propose that this confusion between division and multiplication in the dissociative process might be one of the reasons why the “problem of otherness” remains largely unexplored.
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With this distinction in mind, we can take a brief look at the history of the theories of dissociation. By the mid-1800s, clinicians began to observe the splitting of the consciousness in
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hypnosis and clinical phenomena of hysteria (van der Hart and Dorahy, 2009). Sigmund Freud, Joseph Breuer, and Pierre Janet followed suit in adopting the notion of the splitting of the
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consciousness in this sense. In “Studies of Hysteria” (Breuer & Freud, 1895) , Breuer appeared to be content with the notion of dissociation and the theory of splitting of the mind with his idea of the “hypnoid state.” Initially Freud supported this view for only a short period (ibid, Chapter
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1), until he recanted it in the following famous statement in the Chapter 4 of the same book: “Strangely enough, I have never in my own experience met with a genuine hypnoid hysteria” (ibid, p. 286).
Freud was still accepting the notion of the splitting of the mind, but he was thinking about it as division within the same mind, occurring through the mechanism of repression. In a way, Freud did not accept the splitting of the consciousness in its true sense. He never came to believe that a part of the mind is broken away and forms another conscious. Rather, he purported that it still stays somewhere within the individual’s mind, which he named the “unconscious”, and that these parts of the mind are internally and dynamically related. Janet’s view and his “second law of dissociation” Janet first appeared to use dissociation or splitting of the mind in the sense of division, as he thought that splitting of the consciousness occurs, in part, due to the constitutional vulnerability.
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Additionally, he believed that the purpose of the therapy was personality (re)integration and rehabilitation, which aims to resolve the dissociation of the personality (Janet, 1889, 1909, 1911). However, a close examination of Janet’s theory reveals his belief in dissociation predominantly as multiplication (Janet, 1888). In his thesis in 1888, Janet proposed an idea that he calls the “second law of dissociation.” He asserted that, when dissociation occurs, “The unity of the primary personality remains unchanged; nothing breaks away, nothing is split off. Instead, dissociated experiences (…) were always, from the instant of their occurrence, assigned to, and associated with the second system within” (Janet, 1888 quoted and translated
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by Dell, 2009, p. 716).
This sentence is remarkable as Janet clearly states that the consciousness can exist in different parts. The “second system” (and of course he acknowledges that there can be more than two;
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Janet, 1887), equivalent to what we call PP, is emerged afresh as “nothing breaks away.” Dell (2009) makes a point that, due to this conviction, Janet was totally opposed to Freud’s
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notion of the unconscious, because Janet believes that all psychological acts require consciousness (ibid, p. 716). While acknowledging Dell’s point, I also believe that there could
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have been some similarity of views between Freud and Janet. Paradoxically enough, Freud and Janet might have been agreeing on one point; the mind does not split into parts, like a block of clay tearing off into pieces. Freud’s notion of repression did not imply that the mind is split into
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pieces. Janet also thought that “nothing breaks away” from the original consciousness. Therefore, perhaps, Janet used the term “doubling of the consciousness” (dédoublement de conscience) to describe the existence of a consciousness and “the second system” in the dissociative process. In Janet’s mind, dédoublement was used in the sense of multiplicity instead of division.
Notably, Janet’s view of the “second law of dissociation” became a subject of criticism. Dell (2009) maintains that clinical data occasionally confronts Janet’s view, as in some cases, parts of the personal consciousness are actually split off. He cites an example of a traumatic event in which “some closely related events that had unquestionably been experienced by the person” can be “carried away” into the “second trauma-based consciousness” (p. 733), or another PP. Aftermath of the Freud-Janet controversy What was the impact of the controversy between Freud and Janet, who presented strikingly different and contradicting views? How does it influence our understanding of dissociation? In
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his effort to bridge Freud’s view of repression and Janet’s view of dissociation, and to figure out the impact of their controversy on modern clinicians, Dell acknowledges that their perspectives influenced three meanings of dissociation central to the current clinical discourse; active dissociation, structural dissociation, and automatisms (Dell, 2009, pp. 733–734). Dell indicates that today’s clinicians rightly believe that (1) dissociation is an active and defensive process, as Freud thought, but (2) the resulting cluster of dissociated material and dissociated mental activity is structurally separated from the main consciousness, unlike what Freud thought, and (3) the dissociated material can intrude into one’s main consciousness in a non-dynamic
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fashion, again unlike what Freud believed. Thus, while Freud no longer used the concept of dissociation, as Dell (2009) aptly puts it, “our contemporary understanding of dissociation is deeply ‘infected’ by the concept of repression” (p. 732), especially in its active and defensive meaning. What I would like to add to
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Dell’s view is that the controversy between Freud and Janet, as to what is split off (“repressed” for Freud, “dissociated” for Janet), was not settled. Either it is sexual instinct, as Freud implied,
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or memories of traumatic events, as Janet might have thought. More importantly, in the context of the theme of this article, it remains unsettled whether the splitting of the consciousness
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occurs as duplication (as Freud thought) or multiplication (as Janet thought). However, so long as Point (1) of Dell’s contention indicates that dissociation is commonly believed to be initiated actively and defensively, there remains a nuance of duplication of the consciousness in
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dissociation, and that the resultant PPs would never really be considered as separated and independent from each other. They are regarded as dynamically related, and one PP is causative to, and possibly held responsible for the other PP’s deeds. Thus, the Freud–Janet controversy is considered to have left some influence on the lack of validation of otherness among PPs. .
Dissociation in the psychoanalytic context after Freud Fortunately, some of Freud’s immediate and remote descendants did not go along with his dismissive attitude toward dissociation. Sándor Ferenczi, Ronald Fairbairn, Harry Stuck Sullivan, Phillip Bromberg, and Donnel Stern, among other analysts, integrated the notion of dissociation into their theories, although their ways of using the term differed greatly. However, the above-mentioned influence of the Freud-Janet controversy on the “problem of otherness” remains alive among their theories, except for Ferenczi’s and probably Sullivan’s conceptualizations.
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The first analyst whose stance was clearly different from that of Freud on this topic was Ferenczi, and his writing is worthy of examination. In the 1930s, Ferenczi returned to the place where Freud conceived his trauma theory before he allegedly abandoned it in 1897 (Masson, 1985). In his famous paper of the “confusion of the tongues” (1933), Ferenczi made clear that the splitting of the consciousness in patients occurs due to childhood trauma, basically echoing Breuer’s views. Ferenczi (1933)’s paper dealt with the issue of dissociation in a way that Freud would never approve of. He stressed that clinicians should treat an apparent child personality of
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a dissociative patient separately as a child, instead of intellectually interpreting that it represents a defensive regression in a childish manner. He certainly advocated clinicians to treat the patient’s personality as another person.
“…We talk a lot about the splitting of the personality, but do not seem sufficiently to
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appreciate the depth of these splits. (…) The patient gone off into his trance is a child indeed who no longer reacts to intellectual explanations, only perhaps to maternal friendliness
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… ” (p. 227, emphasis added by this author).
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Ferenczi’s concept of dissociation is well described in the following passage: “If the shocks increase in number during the development of the child, the number and the various kinds of splits in the personality increase too, and soon it becomes extremely difficult to
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maintain contact without confusion with all the fragments each of which behaves as a separate personality yet does not know of even the existence of the others. Eventually it may arrive at a state which—continuing the picture of fragmentation—one would be justified in calling atomization” (p. 229, emphasis added by this author). Ferenczi’s use of terms such as atomization and automaton provides evidence that, in his mind, the dissociated PP forms its own agency and subjectivity. The process of the splitting of the consciousness, according to Ferenczi, appears to be in a transition from division to multiplication, and he was in favor of granting full independence to the child personality. It has not been well recognized that Ronald Fairbairn’s theory of a schizoid mechanism (1952) is closely linked with the concepts of splitting and dissociation discussed by Janet, Morton Prince, and others. Fairbairn did not follow suit in overlooking the notion of dissociation as did many of his contemporary analysts. However, he seems to have observed this schizoid phenomenon in various kinds of psychopathologies, especially against the background of Bleuler (1911)’s proposal of “schizophrenia,” which also appeared to have not only psychotic
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features but also dissociative aspects. Fairbairn’s notion of dissociation was not specific enough, but it was discussed interchangeably with “schizoid” and “splitting” (van der Hart, et al., 2009), lacking a focus on its unique nature of division in the psychic organization. As the schizoid problem became one of the main focuses of the British object relations theory, it drifted away from the concept of dissociation originally described by Breuer in his notion of “hypnoid phenomena.” Sullivan’s discussion of dissociation is also worth examining. For Sullivan, dissociation, not repression, was the primary defensive maneuver, because he understood the primary danger to
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be that of the revival of an intolerable experience of anxiety, not the breakthrough of a primitive endogenous fantasy (Stern, 2009). Sullivan discussed dissociation primarily in the context of the trauma theory. His conceptualization of “good me,” “bad me,” and “not me” is of special interest in order to understand his conceptualization of dissociation. According to Sullivan, “not
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me” is experienced in rather unusual situations in which we try to hide ourselves away or need to numb ourselves because of pain or shame. “Not me” is experienced directly only during a
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severe nightmare or is observed in a dissociative state (Sullivan, 1953). This experience is never learned because of the pain that it involves and is only experienced in primitive states (or what
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he calls the “prototaxic” or “parataxic” level). Sullivan’s description of dissociation allows us to assume that the dissociated “not me” is structurally separated from the main body of consciousness, including “good me” and “bad me,” although its exact nature is not clear.
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Notion of dissociation in modern analytic literature The new wave of analytic understanding of dissociation is represented by authors such as Donnel Stern and Phillip Bromberg. Stern’s basic belief is that dissociation is primarily a defensive process. He states:
“… While dissociation is conceived in many ways in the trauma literature, theories of dissociation tend to center around the idea of a self-protective process that takes place when the events of life are beyond tolerance” (Stern, 2009, p. 653). Although there are some variations, the current literature on dissociation proposed by different authors can be described, in general, as the defense model. Their model has a distinct difference as well as a similarity with Freud’s. The difference is clear; Stern proposes that dissociation is one of the main defense mechanisms, whereas Freud thought it was repression, not dissociation. However, there is obviously a similarity between Freud’s idea of repression
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and Stern’s notion of dissociation. Stern, unlike Breuer or Janet, considers dissociation as defensive maneuver, which occurs within a single mind. Therefore, no separated and new mind is needed, and therefore splitting as multiplication is uncalled for. Similar to Stern’s stance, Bromberg asserted that the issue of trauma is crucial in understanding the human mind, and that dissociation plays a significant role in this context. He added that trauma occurs continuously throughout developmental stages. Deeply steeped in the work of Sullivan, he understands dissociation as a mobilized mechanism “where drastically incompatible emotions or perceptions are required to be cognitively processed within the same
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relationship” (Bromberg, 1994, p. 520). Bromberg makes it clear that, although the notion of conflict has played an important role in neurotic people, dissociative patients suffer from an absence of conflict. However, he does not consider that dissociation occurs in isolation from conflict, but states that conflict and dissociation are in a dialectical relationship. According to
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him, due to trauma, a part that Sullivan referred to as “not me” grows, and in a therapeutic environment that is “safe, but not too safe” (Bromberg, 2012, p. 17), that “not me” part gets
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integrated into the system. The implication here is that “not me” would still be somewhere within the original mind and it is destined to be reunited with the whole, indicating that its
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splitting occurs as a division.
To summarize, the new psychoanalytic understandings of dissociation fit within the belief that dissociation is the splitting of the mind in the sense of division. This point is crucial in
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understanding their therapeutic approach, which basically involves not fully validating the “problem of otherness” in PPs, but treating them as representative of the patient’s dissociated parts (PPs) and bringing them back to the dominant mind through interpretative work.
“Multi-track model”: a theoretical basis for the view of splitting as multiplication In this section I discuss a possible neurological basis for the idea of DID representing the splitting of the consciousness as multiplication. In the past, some authors discussed the neurobiological underpinnings of DID. It is well known that Putnam proposed the “discrete behavioral states” model (Putnam, 1997), a groundbreaking work in search for the biological mechanism of DID. According to this model, young children’s sense of self is highly discrete and state-dependent (Wolff, 1966), and their integrative capacity will yield a cohesive sense of self. However, in an abusive environment, their minds remain disintegrated and forms a basis for the pathology of DID.
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Building on Putnam’s model, Kelly Forrest (2001) proposed that the involvement of a specific brain structure, the orbitofrontal cortex (OFC), plays a key role in the development of DID. Based on recent neurodevelopmental research, he underscores the OFC’s protective inhibitory role in the organization of behavior and emotional regulation as well as in the development of the sense of self. In abusive child - caregiver relationship, the OFC attempts to protect the integrity of the organization of behavior within the immediate context by dissociating any conflicting experiences, thus creating the pathology that is represented as DID. In my view, Putnam’s model accurately describes how the mind is structured in DID.
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Specifically, it proposes that the mind comprises separate and “discreet” parts that coexist but are structurally separated. Forrest’s view of the role of the OFC is relevant in explaining how the state of disintegration is perpetuated in its attempt to “sacrifice” complete coherence to survive emotionally. Along with their theories, in the present article, I would like to focus on
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what actually seems to be occurring in the minds of individuals with DID, especially in their OFC-assisted characteristic discrete state of mind.
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It might be plausible to assume that the neural correlates of each PP would exist as a neural network in our central nervous system. When a PP is active, the corresponding network would
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be at work. Thus, the structure of the network would differ significantly if the splitting of the mind in DID occurs as division and if it occurs as multiplication. In this article, I would like to present a model of neural networks that represent the splitting as multiplication. I call this the
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“multi-track model.”
Neural correlates of the consciousness and the Dynamic Core and Global Workspace hypothesis
Several neuroscientists have suggested hypothetical neuronal correlates of consciousness. For instance, Edelman (2005) proposed “a thalamo-cortical system, which is a dense meshwork connectivity between the cortex and thalamus and among different cortical areas” (p. 25), each exhibiting synchrony in gamma frequencies. He called it the “dynamic core.” Edelman et al. (2011) further proposed a hub-like base with synchronizing and re-entrant connections with different contributing cortical areas. They call it the Dynamic Core Model or the Dynamic Core and Global Workspace (DCGW) hypothesis. One of the characteristics of this model is that it considers the consciousness as equivalent to an informational system, comprising complex neural networking between the thalamus and cortical areas that are highly frequent, synchronous, and reciprocal (Figure 1). The re-entrant
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nature of their communication based on Edelman et al.’s observation of neural systems reminds us of the “backpropagation” algorithm (Rumelhart, et al., 1986), which has proved to be crucial in the current advances in deep learning systems. Figure 1.
Another remarkable feature of this model relevant to our discussion, is that it maintains that consciousness is “unitary and integrated,” which typically characterizes its experience of qualia
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(Edelman, 2005). It states that being conscious itself presupposes that it “cannot voluntarily be broken up into separate parts” (ibid, 179), and thus, this model straightforwardly denies the divided nature of subjective experience. I consider that this applies to a PP of an individual with
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DID, which has the neurological correlates of a single dynamic core.
Obviously, Edelman et al.（2011）are talking about our ordinary single mind and they are
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not particularly referring to DID’s multiple consciousnesses. However, their theory of consciousness does not exclude a possibility of the simultaneous existence of multiple
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consciousnesses in an individual (Baars, 2002). We can then hypothesize that there could be multiple conscious systems, where each of them has its own synchronous wave frequency that is slightly different from that of others, but all of them are within the gamma range. They are
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compared to different broadcasting stations using different radio wave frequencies. One circumstantial, but fairly convincing evidence for the possible co-existence of multiple minds in an individual comes from the experiments conducted with individuals with a split brain (Gazzaniga, 1967). In these experiments, when each of the severed hemispheres of a participant was asked to conduct some tasks simultaneously but separately, they could do them well. However, when control participants were assigned two tasks, they understandably got confused and could not perform either of the tasks correctly (Edelman & Tononi, 2000). This practically proves that different personalities/agencies can exist in an ordinary individual’s brain, so long as the structural separation of different “dynamic cores” is secured (in this case, by splitting them surgically). In patients with DID, this functional separation and co-existence of multiple dynamic cores seems to be occurring in a mechanism that is yet to be understood. In this split-brain paradigm, supposedly a single dynamic core is artificially multiplied into two “dynamic cores,” representing consciousnesses that are now different from each other (Figure 2).
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Figure 2. Finally, I present an image of a person with DID possessing multiple dynamic cores, each separated, but potentially overlapping to some extent. Figure 3.
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Discussion In this article, I discussed what I call the “problem of otherness” in DID. Specifically, I examined the extent to which we validate each PP’s perception of otherness in other PPs. I suggested that the general trend among clinicians (and perhaps people in general as well) is that
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of not validating it fully, contrary to what many individuals with DID would desire. I considered this trend to stem from the era of the Freud-Janet controversy, partly due to the conceptual ambiguity of the splitting of the mind (in the form of division vs. multiplication), as O’Neil
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argued. In keeping with Freud’s notions, we tend to consider dissociation as a defensive and intentional act, at least when it is initiated, with an assumption that PPs are not really
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structurally separated and that they are rather internally and dynamically connected to each other. This makes us believe that each PP is somewhat causative of and responsible for other
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PPs’ decisions or behaviors. In that case, apparently, many DID patients feel that their subjective experiences are misunderstood and unappreciated by clinicians. I believe that, if we fully validate their experience of otherness among their PPs, it would invite us to treat each PP as a more healthy and wholesome entity, instead of being defective, inefficient, partial, waiting to be integrated with the help of therapeutic interventions or environmental support. However, this view does not deny that each PP can often be grossly skewed and limited in terms of their range of emotional and cognitive tendencies and capacities. The presentation of the neurocognitive hypothetical model was based on Edelman’s “dynamic core” model. As discussed, Edelman pointed out that a healthy mind is invariably unitary; each mind is not a mixture of different subjectivities but is single and unique. This view also leads us to give more serious thought to the “problem of otherness” in DID. The most natural way of hypothesizing the neural correlates of DID is to postulate the co-existence of a “dynamic core,” each corresponding to a PP, which are basically separated and intact multiple
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consciousnesses. This view was, in a sense, predicted by Putnam’s model and was practically demonstrated by the split brain phenomenon. To make this study more coherent, I would like to discuss briefly the pathological manifestations of the division of consciousness, an issue that I have not discussed so far, which is manifested more obviously in the form of psychosis. The paramount disturbance of schizophrenia is considered to be social dysfunction based on the disturbance of the functioning of the self. Karl Jaspers (1997/1913) delineated the basic sense of self into four domains; living as a self-present, single, temporally persistent, and bodily and demarcated (bounded) subject of
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experience and action. He indicated that, in schizophrenia, there are serious disturbances among these domains. In contrast, each PP in individuals with DID would not manifest disturbances among any of them.
Consider Ms. A’s example of experiencing someone yelling from behind during driving (the
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case presented at the beginning of this article). With reference to the sense of self-presence, it is certain that Ms. A knows that she is behind the wheel, attempting to start the car on her own
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motive. It is because of her sense of agency that B’s “remark” came across as abrupt and it made her think of him rather critically, such as “Can’t he be more patient?” As for her sense of
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singleness, certainly, she feels that she is on her own and that she is distinct from B. As for her sense of temporal continuity, Ms. A would still claim that, even if she is amnestic about events that occurred yesterday, when B was mainly out and active, she could provide an “alibi” for
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herself, such as that she was “inside” and “in a deep sleep,” or was vaguely watching what B was doing, as a bystander somewhere inside or through a kind of video screen (as several of my DID patients describe). The sense of demarcation of Ms. A certainly exists although she might sometimes feel in a different location as compared with other non-DID individuals. She might feel that B is very close, even inside her head, such as at the back of her head, which however, is still outside the limit of her control.
Recently, from the neuro-biological standpoint, Ebisch (2016) found that the disturbance of self-function among schizophrenic patients is correlated with that of disintegration in their neural network. Along with our context, this disintegration can be described as some type of fragmentation (apparently more serious than just division) within a single dynamic core that is responsible for the manifestation of schizophrenic symptoms. Before ending this article, I would clarify that my model does not preclude any possible “fusion” of some PPs. In fact, quite often a PP is confused with other PP’s voices or memory
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fragments, or even intentions. In these cases, a PP might be bewildered and disturbed and it may wonder “which are my own thoughts and acts?” This suggests that, quite often, independent dynamic cores can be “cross-wired,” like different broadcasting stations with close radiofrequency. However, this does not necessarily discredit our multi-track model. Rather, this can be one of the reasons why the “problem of others” is not readily validated by some clinicians. We should consider this phenomenon as an unfortunate overlapping rather than a serious internal disturbance that is demonstrated by the schizophrenic condition. I also speculate that, although the general relationship among neural networks corresponding to their PPs is
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through their structural separateness, these networks may not necessarily be neatly separated. Instead, they may be partially “fused.” In these cases, the PPs’ perception of each other might be somewhat less different from each other, compared with those which are fully separated. That is the meaning of my statement in the initial part of this article: “The degree of that
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structural separateness corresponds to the strength of the sense of ‘otherness.’”
Conclusion
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In this article, I discussed the “problem of otherness” in DID, by examining the extent to which we could validate and recognize each PP’s perception of otherness in other PPs. I argued
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that the concept of multiplication of the consciousness better fits the subjective experiences of patients with DID, compared to division of the consciousness, which appear to be is the dominant way of conceptualizing dissociative phenomena even in this modern era. For the
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model that I proposed here, i.e., “multi-track model,” a neural correlate is conceived, by applying Edelman’s concept of Dynamic Core. Limitation of this article involves that hypothesis of the neurological bases of dissociative phenomena presented here can seem too speculative, although it was already hinted in Janet’s audacious notion of the “second law” and Putnam’s discrete behavioral model. This study is an attempt to enrich our clinical experiences and understanding, by informing them with the biological underpinnings of the mechanism of dissociation. Through this article I hope to contribute to a better understanding of the subjective sense of patients with DID, which is often misunderstood as not genuine, but defensive and pathological. There is no conflict of interest in this article. Bibliography
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Baars, B. J. (1988). A Cognitive Theory of Consciousness. Cambridge: Cambridge University Press. Baars, B. J. (2002). The conscious access hypothesis: origins and recent evidence. Trends Cogn. Sci., 6,47-52. Bleuler E. (1911). Dementia praecox oder Gruppe der Schizophrenien. In G. von Aschaffenburg (Ed.), Handbuch der Psychiatrie (pp.1-42 ). Leipzig, Vienna：Deuticke. Braun, B.G. (1988). The BASK model of dissociation. DISSOCIATION 1(1), 4-23.
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Breuer, J., & Freud, S. (1895). Studies on Hysteria. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 1-323). London: Hogarth Press. (Original work published 1895).
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Dell, P. (2009). Understanding Dissociation. In P.F. Dell (Ed.) Dissociation and the Dissociative Disorders - DSM-V and beyond (pp.70-826). London: Routledge (Taylor and
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Ebisch, S. (2016, March). The social self in schizophrenia: A neural network perspective on
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integrative external and internal information processing. Presented at the meeting of the 24th European Congress of Psychiatry, Madrid, Spain.
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Edelman, G., & Tononi, G. (2000). A Universe of Consciousness. New York:Basic Books. Edelman, G. (2005). Wider Than the Sky: The Phenomenal Gift of Consciousness. New Heaven: Yale University Press.
Edelman, G.M., Gally, J.A., & Baars, B.J.（2011）. Biology of Consciousness. Front Psychol. 2:1-7.
Ferenczi , S. (1949). Confusion of the Tongues Between the Adults and the Child—(The Language of Tenderness and of Passion) International Journal of Psycho-Analysis, 30, 225-230. Forrest, K.A. (2001). Toward an etiology of dissociative identity disorder: a neurodevelopmental approach. Conscious Cogn. 10,259-93. Freud, S. (1955). Studies of Hysteria. The standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 1-323). London: Hogarth Press. (Original work published 1895). Gazzaniga, M. (1967). The Split Brain in Man. Scientific American, 217, 24-29.
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Janet, P. (1887). L‘Anesthésie systématisée et la dissociation des phénomènes psychologiques.Revue Philosophique, 23, 449-472 . Janet, P. (1888). Les actes inconscients et la mémoire pendant le somnambulisme. Revue Philosophique, 25, 238-279. Janet, P. (1889). L'automatisme psychologique: Essai de psychologie experimentale sur les formes inferieures de l 'activite humaine. Paris: Felix Alcan. Janet, P. (1909). Problèmes psychologiques de I 'emotion. Revue de neurologie, 17, 1551-1687.
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Janet, P. (1911). L 'Etat mental des hysteriques (2nd. Ed.) Paris: F. Alcan. Reprint: Marseille: Lafitte Reprints, 1983.
Jaspers K., Hoenig J., & Hamilton M.W. (1997/1913). trans. General psychopathology. London:
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John Hopkins University Press.
Masson, J.M. (1985). The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887-
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1904. Cambridge, MA, and London, England: The Belknap Press of Harvard University Press. O'Neil, J. A.（2009）. Dissociative Multiplicity and Psychoanalysis. In P.F. Dell (Ed.)
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Dissociation and the Dissociative Disorders - DSM-V and beyond (pp.287-325). London: Routledge (Taylor and Francis).
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Putnam, F. (1997). Dissociation in Children and Adolescents. A Developmental Approach. New York: The Guilford Press.
Rumelhart, D.E., Hinton, G.E., & Williams, R.J. (1986). "Learning representations by backpropagating errors". Nature. 323 (6088), 533–536. Stern, D. (2009) Dissociation and Unformulated Experience: A Psychoanalytic Model of Mind. In P.F. Dell (Ed.) Dissociation and the Dissociative Disorders - DSM-V and beyond (pp.654663). London: W.W.Norton & Co.
van der Hart, O., & Dorahy, M. (2009). History of the Concept of Dissociation. In P.F. Dell (Ed.) Dissociation and the Dissociative Disorders - DSM-V and beyond (pp.3-26). London: Routledge (Taylor and Francis). van der Hart, O., Nijenhuis, E.R.S., & Steele, K. (2006).The Haunted Self. New York, London: W.W.Norton & Co.
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Wolff, P.H. (1966). The causes, controls, and organization of behavior in the neonate. Psychol. Issues, 5, 1-105.
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PII:
S2468-7499(19)30069-9
DOI:
https://doi.org/doi:10.1016/j.ejtd.2019.100133
Reference:
EJTD 100133
To appear in:
European Journal of Trauma & Dissociation
Received Date:
4 May 2019
Revised Date:
5 August 2019
Accepted Date:
19 September 2019
Please cite this article as: Okano K, Problem of “otherness” in dissociative disorder, European Journal of Trauma and Dissociation (2019), doi: https://doi.org/10.1016/j.ejtd.2019.100133
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Problem of “otherness” in dissociative disorder Author : Kenichiro Okano, MD Department of Education, Kyoto University Address: Kyoto University, Dpt. of Education
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Yoshida-honmachi, Sakyo-ku, Kyoto 606-8501, Japan Email: [email protected]
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Problem of “otherness” in dissociative disorder
The unity of the primary personality remains unchanged; nothing breaks away, nothing is
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split off. Instead, dissociated experiences (…) were always, from the instant of their occurrence, assigned to, and associated with the second system within.
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Pierre Janet (1888, quoted by Dell, 2009. p. 716)
* * * * * * * * * * * * * *
The appearance of a second personality is often presented in the most deceptive manner. Sigmund Freud (Breuer & Freud, 1985, p. 287)
Where does the “problem of otherness” stand? Although our understanding of the dissociative phenomenon and its pathological manifestations have progressed significantly over the past couple of decades, many crucial problems need to be explored and further understood. One of them, which I discuss in this article, is what I would call the “problem of otherness” among the parts of the personality in dissociative identity disorder (DID). In dealing with individuals with DID, the “problem of otherness” addresses the extent to which we validate and recognize the subjective perception of each part of personality (PP) that another PP possesses a different and independent subjectivity. My daily clinical practice makes me believe that majority of PPs tend to believe that they are unique and different
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from other PPs. These PPs want their clinicians to understand that they are much more different and independent from other PPs rather than similar and related. Let us, as clinicians, pause for a while and ask if we grant the status of an independent and distinct personality to each PP of an individual with DID, or regard him/her as a different “part” of a whole personality? Although many of us might feel that there is no definitive answer to this question, I consider that the recent trend is to choose the latter approach more often than the former. We no longer use the term “alter” (which is Latin for other), at least not as often as before, to describe different parts of a personality in DID. We have abandoned the traditional
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term “multiple personality disorder” to avoid an implication that there are different and independent personalities in an individual’s mind (as exemplified by DSM-IV, DSM-5, and ICD-11). It appears that the “problem of otherness” is at least temporarily settled among experts in the direction of not fully validating the PP’s sense of “otherness” with other PPs. However, it
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is unclear as to what extent this trend reflects the clinical reality, including the patient’s subjective experiences.
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A patient of mine, Ms. A, talked about her recent experience as follows:
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“The other day I was driving a car and waiting at a traffic light. When it turned green, a car ahead of me didn’t start for a moment and I heard a voice at the back of my head yelling ‘Gee, weren’t you goofing off? Get started, silly!’ I said to myself ‘My goodness, can’t he be more
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patient?’ Of course, I was driving by myself and it was B, one of my alters, who yelled.” In this example, it seems obvious that Ms. A has a very different perception and emotional reaction compared to that of “B.” From her perspective, B is someone else, another subject, if not another human being. The question is, as clinicians, should we recognize B’s “otherness” from Ms. A such that the latter feels that we understand her subjective experiences. If we are not sure about how we can address this dilemma, think about the following example that emerged from a thought experiment: Ms. C is at a traffic light, in a same way that Ms. A was. When the light turned green and a car ahead of her was inattentive in a similar situation, she heard a voice from her back. “Gee, aren’t you goofing off …” Ms. C said to herself, “Gee, can’t he be more patient??” But in this case, it was her husband in the back seat who yelled. How many of us are sure that we acknowledge Ms. A’s perception of B’s otherness on a comparable level as Ms. C’s perception of her husband, another real person? Perhaps, not many
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of us are. I believe that it is partly because we tend to consider multiple existences of subjects in Ms. A as a sort of fantasy, or something pathological and temporary that needs to be fixed with some kind of therapeutic endeavor. This belief is eloquently expressed in the following description of DID by a reliable diagnostic system: “Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness.” (DSM-5, American Psychiatric Association, 2013). The purpose of this article is to propose that an individual with DID’s perception of his/her
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PPs as “others” is not altogether pathological, but rather a reflection of the healthy aspect of their cognitive function, from psychological as well as neurocognitive viewpoints. When PPs subjectively experience “otherness” among them, they are structurally separated in a biopsychological sense. The degree of that structural separateness corresponds to the strength of
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this sense of “otherness.”
In this article, I use the abbreviation “PP(s)” (parts of personality, van der Hart, et al., 2006)
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to connote what has been referred to as “alters,” “other personalities,” etc., in individuals with DID, partly for the sake of simplicity and to temporarily bypass the issue of what we should call
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Review of Literature
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them, which is actually, the focus of this article.
Although the “problem of otherness” has great clinical significance, related references are rather scarce, due in part to a theoretical ambiguity about how the dissociative process occurs. In this literature review, I start with discussing John O’Neil’s (2009) work, who focused on this very issue from the standpoint of the ambiguity of the term splitting in psychoanalytic literature as well as in that on dissociative disorders. The concept of splitting as a source of confusion in dealing with the problem of “otherness”
According to O’Neil (2009), the notion of splitting, used mainly in psychoanalytic literature to roughly denote dissociation, could be a source of confusion. He argues that, when dissociation is often described as “the splitting of the mind,” two meanings are frequently confused and undifferentiated. He calls them the division and multiplication of the consciousness. The former connotes the dissociation of faculties within one conscious, typically
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represented by the BASK model proposed by Bennet Braun (1988). The latter implies the existence of more than one consciousness. O’Neil points out that this difference has been overlooked due to the fact that “multiplication and division are present in the double meanings of both split and double” (2009, p. 298). He asserts that, while dissociation is often described as the division of the consciousness, he prefers the connotation of “multiplication of the consciousness,” which “better describes dissociative multiplicity” (ibid, p. 298). Hereafter, we refer to this distinction as “splitting as division vs. splitting as multiplication” in the sense that O’Neil explicated. If a mind is divided, we naturally consider that these parts
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are internally and dynamically related. If a mind is multiplied, each mind would be regarded as independent and different from each other. I propose that this confusion between division and multiplication in the dissociative process might be one of the reasons why the “problem of otherness” remains largely unexplored.
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With this distinction in mind, we can take a brief look at the history of the theories of dissociation. By the mid-1800s, clinicians began to observe the splitting of the consciousness in
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hypnosis and clinical phenomena of hysteria (van der Hart and Dorahy, 2009). Sigmund Freud, Joseph Breuer, and Pierre Janet followed suit in adopting the notion of the splitting of the
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consciousness in this sense. In “Studies of Hysteria” (Breuer & Freud, 1895) , Breuer appeared to be content with the notion of dissociation and the theory of splitting of the mind with his idea of the “hypnoid state.” Initially Freud supported this view for only a short period (ibid, Chapter
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1), until he recanted it in the following famous statement in the Chapter 4 of the same book: “Strangely enough, I have never in my own experience met with a genuine hypnoid hysteria” (ibid, p. 286).
Freud was still accepting the notion of the splitting of the mind, but he was thinking about it as division within the same mind, occurring through the mechanism of repression. In a way, Freud did not accept the splitting of the consciousness in its true sense. He never came to believe that a part of the mind is broken away and forms another conscious. Rather, he purported that it still stays somewhere within the individual’s mind, which he named the “unconscious”, and that these parts of the mind are internally and dynamically related. Janet’s view and his “second law of dissociation” Janet first appeared to use dissociation or splitting of the mind in the sense of division, as he thought that splitting of the consciousness occurs, in part, due to the constitutional vulnerability.
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Additionally, he believed that the purpose of the therapy was personality (re)integration and rehabilitation, which aims to resolve the dissociation of the personality (Janet, 1889, 1909, 1911). However, a close examination of Janet’s theory reveals his belief in dissociation predominantly as multiplication (Janet, 1888). In his thesis in 1888, Janet proposed an idea that he calls the “second law of dissociation.” He asserted that, when dissociation occurs, “The unity of the primary personality remains unchanged; nothing breaks away, nothing is split off. Instead, dissociated experiences (…) were always, from the instant of their occurrence, assigned to, and associated with the second system within” (Janet, 1888 quoted and translated
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by Dell, 2009, p. 716).
This sentence is remarkable as Janet clearly states that the consciousness can exist in different parts. The “second system” (and of course he acknowledges that there can be more than two;
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Janet, 1887), equivalent to what we call PP, is emerged afresh as “nothing breaks away.” Dell (2009) makes a point that, due to this conviction, Janet was totally opposed to Freud’s
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notion of the unconscious, because Janet believes that all psychological acts require consciousness (ibid, p. 716). While acknowledging Dell’s point, I also believe that there could
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have been some similarity of views between Freud and Janet. Paradoxically enough, Freud and Janet might have been agreeing on one point; the mind does not split into parts, like a block of clay tearing off into pieces. Freud’s notion of repression did not imply that the mind is split into
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pieces. Janet also thought that “nothing breaks away” from the original consciousness. Therefore, perhaps, Janet used the term “doubling of the consciousness” (dédoublement de conscience) to describe the existence of a consciousness and “the second system” in the dissociative process. In Janet’s mind, dédoublement was used in the sense of multiplicity instead of division.
Notably, Janet’s view of the “second law of dissociation” became a subject of criticism. Dell (2009) maintains that clinical data occasionally confronts Janet’s view, as in some cases, parts of the personal consciousness are actually split off. He cites an example of a traumatic event in which “some closely related events that had unquestionably been experienced by the person” can be “carried away” into the “second trauma-based consciousness” (p. 733), or another PP. Aftermath of the Freud-Janet controversy What was the impact of the controversy between Freud and Janet, who presented strikingly different and contradicting views? How does it influence our understanding of dissociation? In
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his effort to bridge Freud’s view of repression and Janet’s view of dissociation, and to figure out the impact of their controversy on modern clinicians, Dell acknowledges that their perspectives influenced three meanings of dissociation central to the current clinical discourse; active dissociation, structural dissociation, and automatisms (Dell, 2009, pp. 733–734). Dell indicates that today’s clinicians rightly believe that (1) dissociation is an active and defensive process, as Freud thought, but (2) the resulting cluster of dissociated material and dissociated mental activity is structurally separated from the main consciousness, unlike what Freud thought, and (3) the dissociated material can intrude into one’s main consciousness in a non-dynamic
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fashion, again unlike what Freud believed. Thus, while Freud no longer used the concept of dissociation, as Dell (2009) aptly puts it, “our contemporary understanding of dissociation is deeply ‘infected’ by the concept of repression” (p. 732), especially in its active and defensive meaning. What I would like to add to
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Dell’s view is that the controversy between Freud and Janet, as to what is split off (“repressed” for Freud, “dissociated” for Janet), was not settled. Either it is sexual instinct, as Freud implied,
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or memories of traumatic events, as Janet might have thought. More importantly, in the context of the theme of this article, it remains unsettled whether the splitting of the consciousness
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occurs as duplication (as Freud thought) or multiplication (as Janet thought). However, so long as Point (1) of Dell’s contention indicates that dissociation is commonly believed to be initiated actively and defensively, there remains a nuance of duplication of the consciousness in
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dissociation, and that the resultant PPs would never really be considered as separated and independent from each other. They are regarded as dynamically related, and one PP is causative to, and possibly held responsible for the other PP’s deeds. Thus, the Freud–Janet controversy is considered to have left some influence on the lack of validation of otherness among PPs. .
Dissociation in the psychoanalytic context after Freud Fortunately, some of Freud’s immediate and remote descendants did not go along with his dismissive attitude toward dissociation. Sándor Ferenczi, Ronald Fairbairn, Harry Stuck Sullivan, Phillip Bromberg, and Donnel Stern, among other analysts, integrated the notion of dissociation into their theories, although their ways of using the term differed greatly. However, the above-mentioned influence of the Freud-Janet controversy on the “problem of otherness” remains alive among their theories, except for Ferenczi’s and probably Sullivan’s conceptualizations.
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The first analyst whose stance was clearly different from that of Freud on this topic was Ferenczi, and his writing is worthy of examination. In the 1930s, Ferenczi returned to the place where Freud conceived his trauma theory before he allegedly abandoned it in 1897 (Masson, 1985). In his famous paper of the “confusion of the tongues” (1933), Ferenczi made clear that the splitting of the consciousness in patients occurs due to childhood trauma, basically echoing Breuer’s views. Ferenczi (1933)’s paper dealt with the issue of dissociation in a way that Freud would never approve of. He stressed that clinicians should treat an apparent child personality of
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a dissociative patient separately as a child, instead of intellectually interpreting that it represents a defensive regression in a childish manner. He certainly advocated clinicians to treat the patient’s personality as another person.
“…We talk a lot about the splitting of the personality, but do not seem sufficiently to
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appreciate the depth of these splits. (…) The patient gone off into his trance is a child indeed who no longer reacts to intellectual explanations, only perhaps to maternal friendliness
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… ” (p. 227, emphasis added by this author).
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Ferenczi’s concept of dissociation is well described in the following passage: “If the shocks increase in number during the development of the child, the number and the various kinds of splits in the personality increase too, and soon it becomes extremely difficult to
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maintain contact without confusion with all the fragments each of which behaves as a separate personality yet does not know of even the existence of the others. Eventually it may arrive at a state which—continuing the picture of fragmentation—one would be justified in calling atomization” (p. 229, emphasis added by this author). Ferenczi’s use of terms such as atomization and automaton provides evidence that, in his mind, the dissociated PP forms its own agency and subjectivity. The process of the splitting of the consciousness, according to Ferenczi, appears to be in a transition from division to multiplication, and he was in favor of granting full independence to the child personality. It has not been well recognized that Ronald Fairbairn’s theory of a schizoid mechanism (1952) is closely linked with the concepts of splitting and dissociation discussed by Janet, Morton Prince, and others. Fairbairn did not follow suit in overlooking the notion of dissociation as did many of his contemporary analysts. However, he seems to have observed this schizoid phenomenon in various kinds of psychopathologies, especially against the background of Bleuler (1911)’s proposal of “schizophrenia,” which also appeared to have not only psychotic
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features but also dissociative aspects. Fairbairn’s notion of dissociation was not specific enough, but it was discussed interchangeably with “schizoid” and “splitting” (van der Hart, et al., 2009), lacking a focus on its unique nature of division in the psychic organization. As the schizoid problem became one of the main focuses of the British object relations theory, it drifted away from the concept of dissociation originally described by Breuer in his notion of “hypnoid phenomena.” Sullivan’s discussion of dissociation is also worth examining. For Sullivan, dissociation, not repression, was the primary defensive maneuver, because he understood the primary danger to
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be that of the revival of an intolerable experience of anxiety, not the breakthrough of a primitive endogenous fantasy (Stern, 2009). Sullivan discussed dissociation primarily in the context of the trauma theory. His conceptualization of “good me,” “bad me,” and “not me” is of special interest in order to understand his conceptualization of dissociation. According to Sullivan, “not
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me” is experienced in rather unusual situations in which we try to hide ourselves away or need to numb ourselves because of pain or shame. “Not me” is experienced directly only during a
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severe nightmare or is observed in a dissociative state (Sullivan, 1953). This experience is never learned because of the pain that it involves and is only experienced in primitive states (or what
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he calls the “prototaxic” or “parataxic” level). Sullivan’s description of dissociation allows us to assume that the dissociated “not me” is structurally separated from the main body of consciousness, including “good me” and “bad me,” although its exact nature is not clear.
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Notion of dissociation in modern analytic literature The new wave of analytic understanding of dissociation is represented by authors such as Donnel Stern and Phillip Bromberg. Stern’s basic belief is that dissociation is primarily a defensive process. He states:
“… While dissociation is conceived in many ways in the trauma literature, theories of dissociation tend to center around the idea of a self-protective process that takes place when the events of life are beyond tolerance” (Stern, 2009, p. 653). Although there are some variations, the current literature on dissociation proposed by different authors can be described, in general, as the defense model. Their model has a distinct difference as well as a similarity with Freud’s. The difference is clear; Stern proposes that dissociation is one of the main defense mechanisms, whereas Freud thought it was repression, not dissociation. However, there is obviously a similarity between Freud’s idea of repression
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and Stern’s notion of dissociation. Stern, unlike Breuer or Janet, considers dissociation as defensive maneuver, which occurs within a single mind. Therefore, no separated and new mind is needed, and therefore splitting as multiplication is uncalled for. Similar to Stern’s stance, Bromberg asserted that the issue of trauma is crucial in understanding the human mind, and that dissociation plays a significant role in this context. He added that trauma occurs continuously throughout developmental stages. Deeply steeped in the work of Sullivan, he understands dissociation as a mobilized mechanism “where drastically incompatible emotions or perceptions are required to be cognitively processed within the same
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relationship” (Bromberg, 1994, p. 520). Bromberg makes it clear that, although the notion of conflict has played an important role in neurotic people, dissociative patients suffer from an absence of conflict. However, he does not consider that dissociation occurs in isolation from conflict, but states that conflict and dissociation are in a dialectical relationship. According to
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him, due to trauma, a part that Sullivan referred to as “not me” grows, and in a therapeutic environment that is “safe, but not too safe” (Bromberg, 2012, p. 17), that “not me” part gets
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integrated into the system. The implication here is that “not me” would still be somewhere within the original mind and it is destined to be reunited with the whole, indicating that its
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splitting occurs as a division.
To summarize, the new psychoanalytic understandings of dissociation fit within the belief that dissociation is the splitting of the mind in the sense of division. This point is crucial in
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understanding their therapeutic approach, which basically involves not fully validating the “problem of otherness” in PPs, but treating them as representative of the patient’s dissociated parts (PPs) and bringing them back to the dominant mind through interpretative work.
“Multi-track model”: a theoretical basis for the view of splitting as multiplication In this section I discuss a possible neurological basis for the idea of DID representing the splitting of the consciousness as multiplication. In the past, some authors discussed the neurobiological underpinnings of DID. It is well known that Putnam proposed the “discrete behavioral states” model (Putnam, 1997), a groundbreaking work in search for the biological mechanism of DID. According to this model, young children’s sense of self is highly discrete and state-dependent (Wolff, 1966), and their integrative capacity will yield a cohesive sense of self. However, in an abusive environment, their minds remain disintegrated and forms a basis for the pathology of DID.
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Building on Putnam’s model, Kelly Forrest (2001) proposed that the involvement of a specific brain structure, the orbitofrontal cortex (OFC), plays a key role in the development of DID. Based on recent neurodevelopmental research, he underscores the OFC’s protective inhibitory role in the organization of behavior and emotional regulation as well as in the development of the sense of self. In abusive child - caregiver relationship, the OFC attempts to protect the integrity of the organization of behavior within the immediate context by dissociating any conflicting experiences, thus creating the pathology that is represented as DID. In my view, Putnam’s model accurately describes how the mind is structured in DID.
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Specifically, it proposes that the mind comprises separate and “discreet” parts that coexist but are structurally separated. Forrest’s view of the role of the OFC is relevant in explaining how the state of disintegration is perpetuated in its attempt to “sacrifice” complete coherence to survive emotionally. Along with their theories, in the present article, I would like to focus on
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what actually seems to be occurring in the minds of individuals with DID, especially in their OFC-assisted characteristic discrete state of mind.
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It might be plausible to assume that the neural correlates of each PP would exist as a neural network in our central nervous system. When a PP is active, the corresponding network would
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be at work. Thus, the structure of the network would differ significantly if the splitting of the mind in DID occurs as division and if it occurs as multiplication. In this article, I would like to present a model of neural networks that represent the splitting as multiplication. I call this the
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“multi-track model.”
Neural correlates of the consciousness and the Dynamic Core and Global Workspace hypothesis
Several neuroscientists have suggested hypothetical neuronal correlates of consciousness. For instance, Edelman (2005) proposed “a thalamo-cortical system, which is a dense meshwork connectivity between the cortex and thalamus and among different cortical areas” (p. 25), each exhibiting synchrony in gamma frequencies. He called it the “dynamic core.” Edelman et al. (2011) further proposed a hub-like base with synchronizing and re-entrant connections with different contributing cortical areas. They call it the Dynamic Core Model or the Dynamic Core and Global Workspace (DCGW) hypothesis. One of the characteristics of this model is that it considers the consciousness as equivalent to an informational system, comprising complex neural networking between the thalamus and cortical areas that are highly frequent, synchronous, and reciprocal (Figure 1). The re-entrant
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nature of their communication based on Edelman et al.’s observation of neural systems reminds us of the “backpropagation” algorithm (Rumelhart, et al., 1986), which has proved to be crucial in the current advances in deep learning systems. Figure 1.
Another remarkable feature of this model relevant to our discussion, is that it maintains that consciousness is “unitary and integrated,” which typically characterizes its experience of qualia
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(Edelman, 2005). It states that being conscious itself presupposes that it “cannot voluntarily be broken up into separate parts” (ibid, 179), and thus, this model straightforwardly denies the divided nature of subjective experience. I consider that this applies to a PP of an individual with
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DID, which has the neurological correlates of a single dynamic core.
Obviously, Edelman et al.（2011）are talking about our ordinary single mind and they are
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not particularly referring to DID’s multiple consciousnesses. However, their theory of consciousness does not exclude a possibility of the simultaneous existence of multiple
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consciousnesses in an individual (Baars, 2002). We can then hypothesize that there could be multiple conscious systems, where each of them has its own synchronous wave frequency that is slightly different from that of others, but all of them are within the gamma range. They are
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compared to different broadcasting stations using different radio wave frequencies. One circumstantial, but fairly convincing evidence for the possible co-existence of multiple minds in an individual comes from the experiments conducted with individuals with a split brain (Gazzaniga, 1967). In these experiments, when each of the severed hemispheres of a participant was asked to conduct some tasks simultaneously but separately, they could do them well. However, when control participants were assigned two tasks, they understandably got confused and could not perform either of the tasks correctly (Edelman & Tononi, 2000). This practically proves that different personalities/agencies can exist in an ordinary individual’s brain, so long as the structural separation of different “dynamic cores” is secured (in this case, by splitting them surgically). In patients with DID, this functional separation and co-existence of multiple dynamic cores seems to be occurring in a mechanism that is yet to be understood. In this split-brain paradigm, supposedly a single dynamic core is artificially multiplied into two “dynamic cores,” representing consciousnesses that are now different from each other (Figure 2).
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Figure 2. Finally, I present an image of a person with DID possessing multiple dynamic cores, each separated, but potentially overlapping to some extent. Figure 3.
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Discussion In this article, I discussed what I call the “problem of otherness” in DID. Specifically, I examined the extent to which we validate each PP’s perception of otherness in other PPs. I suggested that the general trend among clinicians (and perhaps people in general as well) is that
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of not validating it fully, contrary to what many individuals with DID would desire. I considered this trend to stem from the era of the Freud-Janet controversy, partly due to the conceptual ambiguity of the splitting of the mind (in the form of division vs. multiplication), as O’Neil
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argued. In keeping with Freud’s notions, we tend to consider dissociation as a defensive and intentional act, at least when it is initiated, with an assumption that PPs are not really
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structurally separated and that they are rather internally and dynamically connected to each other. This makes us believe that each PP is somewhat causative of and responsible for other
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PPs’ decisions or behaviors. In that case, apparently, many DID patients feel that their subjective experiences are misunderstood and unappreciated by clinicians. I believe that, if we fully validate their experience of otherness among their PPs, it would invite us to treat each PP as a more healthy and wholesome entity, instead of being defective, inefficient, partial, waiting to be integrated with the help of therapeutic interventions or environmental support. However, this view does not deny that each PP can often be grossly skewed and limited in terms of their range of emotional and cognitive tendencies and capacities. The presentation of the neurocognitive hypothetical model was based on Edelman’s “dynamic core” model. As discussed, Edelman pointed out that a healthy mind is invariably unitary; each mind is not a mixture of different subjectivities but is single and unique. This view also leads us to give more serious thought to the “problem of otherness” in DID. The most natural way of hypothesizing the neural correlates of DID is to postulate the co-existence of a “dynamic core,” each corresponding to a PP, which are basically separated and intact multiple
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consciousnesses. This view was, in a sense, predicted by Putnam’s model and was practically demonstrated by the split brain phenomenon. To make this study more coherent, I would like to discuss briefly the pathological manifestations of the division of consciousness, an issue that I have not discussed so far, which is manifested more obviously in the form of psychosis. The paramount disturbance of schizophrenia is considered to be social dysfunction based on the disturbance of the functioning of the self. Karl Jaspers (1997/1913) delineated the basic sense of self into four domains; living as a self-present, single, temporally persistent, and bodily and demarcated (bounded) subject of
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experience and action. He indicated that, in schizophrenia, there are serious disturbances among these domains. In contrast, each PP in individuals with DID would not manifest disturbances among any of them.
Consider Ms. A’s example of experiencing someone yelling from behind during driving (the
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case presented at the beginning of this article). With reference to the sense of self-presence, it is certain that Ms. A knows that she is behind the wheel, attempting to start the car on her own
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motive. It is because of her sense of agency that B’s “remark” came across as abrupt and it made her think of him rather critically, such as “Can’t he be more patient?” As for her sense of
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singleness, certainly, she feels that she is on her own and that she is distinct from B. As for her sense of temporal continuity, Ms. A would still claim that, even if she is amnestic about events that occurred yesterday, when B was mainly out and active, she could provide an “alibi” for
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herself, such as that she was “inside” and “in a deep sleep,” or was vaguely watching what B was doing, as a bystander somewhere inside or through a kind of video screen (as several of my DID patients describe). The sense of demarcation of Ms. A certainly exists although she might sometimes feel in a different location as compared with other non-DID individuals. She might feel that B is very close, even inside her head, such as at the back of her head, which however, is still outside the limit of her control.
Recently, from the neuro-biological standpoint, Ebisch (2016) found that the disturbance of self-function among schizophrenic patients is correlated with that of disintegration in their neural network. Along with our context, this disintegration can be described as some type of fragmentation (apparently more serious than just division) within a single dynamic core that is responsible for the manifestation of schizophrenic symptoms. Before ending this article, I would clarify that my model does not preclude any possible “fusion” of some PPs. In fact, quite often a PP is confused with other PP’s voices or memory
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fragments, or even intentions. In these cases, a PP might be bewildered and disturbed and it may wonder “which are my own thoughts and acts?” This suggests that, quite often, independent dynamic cores can be “cross-wired,” like different broadcasting stations with close radiofrequency. However, this does not necessarily discredit our multi-track model. Rather, this can be one of the reasons why the “problem of others” is not readily validated by some clinicians. We should consider this phenomenon as an unfortunate overlapping rather than a serious internal disturbance that is demonstrated by the schizophrenic condition. I also speculate that, although the general relationship among neural networks corresponding to their PPs is
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through their structural separateness, these networks may not necessarily be neatly separated. Instead, they may be partially “fused.” In these cases, the PPs’ perception of each other might be somewhat less different from each other, compared with those which are fully separated. That is the meaning of my statement in the initial part of this article: “The degree of that
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structural separateness corresponds to the strength of the sense of ‘otherness.’”
Conclusion
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In this article, I discussed the “problem of otherness” in DID, by examining the extent to which we could validate and recognize each PP’s perception of otherness in other PPs. I argued
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that the concept of multiplication of the consciousness better fits the subjective experiences of patients with DID, compared to division of the consciousness, which appear to be is the dominant way of conceptualizing dissociative phenomena even in this modern era. For the
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model that I proposed here, i.e., “multi-track model,” a neural correlate is conceived, by applying Edelman’s concept of Dynamic Core. Limitation of this article involves that hypothesis of the neurological bases of dissociative phenomena presented here can seem too speculative, although it was already hinted in Janet’s audacious notion of the “second law” and Putnam’s discrete behavioral model. This study is an attempt to enrich our clinical experiences and understanding, by informing them with the biological underpinnings of the mechanism of dissociation. Through this article I hope to contribute to a better understanding of the subjective sense of patients with DID, which is often misunderstood as not genuine, but defensive and pathological. There is no conflict of interest in this article. Bibliography
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