Cognitive models of dissociation
Richard J. Brown PhD, ClinPsyD
University of Manchester, UK
Manchester Mental Health and Social Care NHS Trust
Identity disturbance
Somatic
symptoms
Depersonalization
Derealization
Amnesia
Reduced
awareness
Defence
mechanism
“DISSOCIATION”
Flashbacks
“Made”
actions
Divided attention
Intrusive
thoughts/feelings
Absorption
Hypnosis
Possession
states
Pseudohallucinations
Modal understanding of dissociation
“… a disruption in the
usually integrated
functions of
consciousness,
memory, identity or
perception of the
environment” (DSMIV-TR; APA, 2000)
 Dissociative amnesia
 Dissociative fugue
 Depersonalization
disorder
 Dissociative identity
disorder (formerly MPD)
 DDNOS
Conversion disorder NOT classified as dissociative in DSM-IV-TR
Modal understanding of dissociation
Core symptoms
 Amnesia
 Depersonalisation
 Identity confusion/alteration
 Derealisation
 Commonly measured using the Dissociative
Experiences Scale (Bernstein & Putnam, 1986)
 Often thought to be precipitated by trauma
 PTSD predicted by “peri-traumatic” dissociation
ICD-10 Dissociative (conversion) disorders
 Dissociative convulsions
 Dissociative motor disorders
 Dissociative anaesthesia
Medically unexplained
neurological symptoms
(somatoform disorders in
DSM-IV)
 Dissociative sensory loss
“Hysteria”
 Dissociative stupor
“Somatoform
dissociation”
 Dissociative amnesia
 Dissociative fugue
Depersonalization disorder
not dissociative in ICD-10
 Dissociative trance/possession
DID coded as dissociative
disorder NOS
 DDNOS
Two distinct types of “dissociation” (Holmes
et al, 2005)
Detachment
Compartmentalization
An altered state of consciousness
characterized by a sense of
separation (or “detachment”) from
aspects of everyday experience
A reversible deficit in the ability to
deliberately control processes or
actions that would normally be
amenable to such control
depersonalization
derealization
emotional numbing
peri-traumatic
dissociation
 amnesia (reversible)
 unexplained neurological
symptoms
 pseudohallucinations
 identity alteration




Detachment and conversion disorder
Detachment
An altered state of consciousness
characterized by a sense of
separation (or “detachment”) from
aspects of everyday experience




depersonalization
derealization
emotional numbing
peri-traumatic
dissociation
• “Panic without panic” in
some patients with PNES
(Goldstein & Mellers, 2006)
 physical not emotional
symptoms of panic attacks
• BUT detachment often
absent in conversion
disorder patients
 conversion symptoms
uncommon in patients with
depersonalization disorder
Compartmentalization
A deficit in the ability to deliberately
control processes or actions that
would normally be amenable to
such control
 reversible
 cannot be overcome by will
 occurs alongside evidence of
intact functioning
 on a continuum from nonpathological to massively
disabling
• Reversibility of
amnesia following
PNES (Kuyk et al, 1999)
• Implicit perception in
conversion sensory
loss (summarised by
Kihlstrom, 1992)
• Intact motor function in
conversion paralysis/
weakness (as in Hoover’s
sign)
Historical model (e.g. Janet, 1907)
• Deficit in attention creates vulnerability to breakdown
of “psychological integration” when exposed to trauma
• Fragmentation leads to traumatic memories becoming
separated (or dissociated) from awareness
• Symptoms generated by activation of traumatic
memories  a kind of somatic flashback or reliving
• Same process for hysterical and hypnotic phenomena
 detachment phenomena not seen as dissociative
 later suggested that memory fragments are kept from
awareness for defensive purposes (Breuer & Freud, 1893-1895)
Neodissociation theories (e.g., Hilgard, 1977;
Woody & Bowers, 1994; Woody & Sadler, 2008)
 Most processing managed
outside of awareness by low
level control systems
EXECUTIVE EGO
(Awareness and volition)
 Awareness/attention/volition
(i.e., “executive ego”) only
needed for initial selection of
lower systems
 most everyday functions are
“dissociated” from consciousness
(consider learning to drive a car)
 symptoms an extension of this
Auditory
processing
INPUT
Visual
processing
INPUT
OUTPUT
OUTPUT
Motor
processing
INPUT
OUTPUT
Pathological dissociation as a monitoring problem
 If behaviour is instigated by the
executive (i.e. “on purpose”)
but is inconsistent with our
goals then we experience it as
having made a mistake
BUT only if we know we did it
on purpose!
 If we don’t realise this (e.g.
because we forget, we weren’t
paying attention, or we don’t
represent it in this way) then
we experience it as happening to us
Executive ego
(Awareness and volition)
Inattention / amnesia
Aware
Output
Unaware
Input
Low level control
structure
Pathological dissociation as a monitoring problem
 If behaviour is instigated by the
executive (i.e. “on purpose”)
but is inconsistent with our
goals then we experience it as
having made a mistake
BUT only if we know we did it
on purpose!
 If we don’t realise this (e.g.
because we forget, we weren’t
paying attention, or we don’t
represent it in this way) then
we experience it as happening to us
Executive ego
(Awareness and volition)
Inattention / amnesia
“A seizure is
happening”
Output
“Have a
seizure”
Input
“Seizure”
control program
Pathological dissociation as a control problem
 Inhibition of the executive (e.g.
by intense emotion) reduces
control over low level systems,
making the system vulnerable to
stimulus-driven activation of
unintended behaviours
 conversion phenomena similar to
everyday action slips
 conversion phenomena similar to
utilisation behaviour in some
patients with frontal lobe damage
Executive ego
(Conscious volition)
Inhibited
Output
Low level control
structure
Input
Internal / external
stimulus
Pathological dissociation as a control problem
 Inhibition of the executive (e.g.
by intense emotion) reduces
control over low level systems,
making the system vulnerable to
stimulus-driven activation of
unintended behaviours
 conversion phenomena similar to
everyday action slips and
utilisation behaviour in some
patients with frontal lobe damage
Executive ego
(Conscious volition)
“I’m having a seizure”
Inhibited
Output
“Seizure”
control program
Input
Seizure “models” in
environment
Integrative cognitive model (Brown, 2002a,b,
2004, 2006; Brown & Oakley, 2004)
 Integrates dissociation concepts within broader
biopsychosocial model of MUS
 assumes that symptoms reflect automatic activation of ideas
about illness in memory (i.e., “rogue representations”)
 process moderated by factors that (a) contribute to the
activation levels of these rogue representations; and/or (b)
compromise the individual’s ability to inhibit them;
 symptoms are involuntary but may involve volitional
processes in a number of ways (e.g., hypervigilance; selffocus; worry/rumination about symptoms; trying to control
normally automatic behaviours; suppression)
Integrative cognitive model (Brown, 2002a,b,
2004, 2006; Brown & Oakley, 2004)
“EXECUTIVE” ATTENTION
(e.g. Worrying about and
looking out for signs of
possible seizures)
INPUT
Epileptic seizures
encountered in
self, others, the
media etc.
CREATION OF
“SEIZURE”
MODEL IN
MEMORY
ACTIVATION
OF “SEIZURE”
MODEL
INTERNAL / EXTERNAL
TRIGGERS (e.g. symptoms
of arousal, stress etc.)
NONEPILEPTIC
ATTACK
Take home messages
1. The term dissociation means different things to
different people; mixed questionnaire findings probably
reflect a tendency to conflate different definitions of
dissociation within the same measure
2. If we define dissociation as the compartmentalization
of information in the cognitive system then conversion
symptoms are dissociative by definition
3. Trauma is not necessary for compartmentalization to
occur but may be relevant in individual cases
4. Detachment is only relevant in a small proportion of
cases of conversion disorder
Take home messages
5. Compartmentalization phenomena reflect the fact that
much of behaviour/mental processing is performed
automatically and outside of awareness
 symptoms can result from psychological processes
without being produced “on purpose” (although voluntary
processes can still be implicated indirectly)
 it is possible to explain conversion disorder without
appealing to emotional conflict or psychological defence
 research / theory implicates attentional processes
6. There is far more theory than evidence!
 much more research is needed
References
Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a
dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735.
Brown, R. J. (2002). The cognitive psychology of dissociative states. Cognitive
Neuropsychiatry, 7, 221-235.
Brown, R. J. (2002). Epilepsy, dissociation and nonepileptic seizures. In M. R. Trimble &
B. Schmitz (Eds.) The Neuropsychiatry of Epilepsy, pp. 189-209. Cambridge, UK:
Cambridge University Press.
Brown, R. J. (2004). Psychological mechanisms of medically unexplained symptoms: An
integrative conceptual model. Psychological Bulletin, 130, 793-812.
Brown, R.J. (2006). Different types of “dissociation” have different psychological
mechanisms. Journal of Trauma and Dissociation, 7, 7-28.
Brown, R. J. & Oakley, D. A. (2004). An integrative cognitive theory of hypnosis and high
hypnotizability. In M. Heap, R. J. Brown & D. A. Oakley, The Highly Hypnotizable
Person: Theoretical, Experimental and Clinical Issues, pp. 152-186. London: BrunnerRoutledge.
Goldstein, L.H. & Mellers, J.D. (2006). Ictal symptoms of anxiety, avoidance behaviour, and
dissociation in patients with dissociative seizures. Journal of Neurology, Neurosurgery
and Psychiatry, 77, 616-21.
Hilgard, E. R. (1977). Divided consciousness: Multiple controls in human thought and
action. New York: Wiley.
References
Holmes, E., Brown, R. J., Mansell, W., Fearon, R. P, Hunter, E., Frasquilho, F. & Oakley,
D. A. (2005). Are there two qualitatively distinct forms of dissociation? A review and
some clinical implications. Clinical Psychology Review, 25, 1-23.
Janet, P. (1907). The Major Symptoms of Hysteria. NY: Macmillan.
Kihlstrom, J. F. (1992). Dissociative and conversion disorders. In D. J. Stein & J. Young
(Eds.), Cognitive science and clinical disorders (pp. 247–270). San Diego, CA:
Academic Press.
Kuyk, J., Spinhoven, P., & van Dyck, R. (1999). Hypnotic recall: A positive criterion in the
differential diagnosis between epileptic and pseudoepileptic seizures. Epilepsia, 40,
485–491.
Woody, E., Bowers, K. (1994). A frontal assault on dissociated control. In: Lynn, S.J.,
Rhue, J.W. (Eds.), Dissociation: Clinical and Theoretical Perspectives. Guilford Press,
NY, USA, pp.52-79.
Woody, E. Z., Sadler, P. (2008). Dissociation theories of hypnosis. In M.R. Nash & A.J.
Barnier (eds). The Oxford Handbook of Hypnosis:Theory, Research and Practice.
Oxford: OUP.