Literature Review

This literature review will discuss the pathology and etymology of dissociation; the theoretical framework upon which this research is built; and recommended treatment guidelines. Critique of the literature reviewed will be the main focus of this chapter; the gaps in the literature presented here are to support the research’s following objectives: to explore if dissociative episodes or phases are triggered in individuals as a result of loneliness; and, to identify strategies to treat the trigger of loneliness. The gap in the literature presented below has led to the dissertation’s main question: What is the perceived impact of loneliness on the use of dissociation as a coping mechanism?

Pathology and Etymology of Dissociation

Dissociation in the shortest definition possible is the severe, maladaptive form of avoidance a patient develops due to intense fear of or inability to bear psychological pain (Schimmenti & Caretti, 2016). According to research, dissociation stems back to childhood trauma (Ducharme, 2017; Sar et al., 2017; Schimmenti & Caretti, 2016). Even if it occurs for the first time in early adulthood, dissociation’s roots are hypothesized by current research to have been planted since childhood (Schimmenti & Caretti, 2016). This widely accepted theory takes root in Bowlby’s (1973), who investigated how parental attachments in early childhood shape a child’s lifespan resilience to environmental pressures, or adversely, their predisposition to mental illness.
Sar et al. (2017) mention in their study that early direct traumatization in life, such as when the child has to become the parent to their parent(s) or for their own selves, is at times severe enough to cause children to develop a dissociative mechanism to help them cope. To children, lacking the stability and sense of security that comes from having stable parental attachments is akin to feeling without safety at all, at the mercy of their environment and acutely aware of their lack of defenses should this environment attempt to harm them. This anxiety-inducing sensation is capable of rewiring the child’s brain and neurobiological markers to form mechanisms that lead to chronic lifelong anxiety disorder, which underlies dissociative mechanisms (Kalsched, 2017). However, this is not to say that all individuals with abusive childhoods develop a dissociative disorder or mechanism, and a factor to be considered in this is the genetic predisposition to chronic anxiety that plays a pivotal role in developing dissociation (Krause-Utz & Elzinga, 2018). Environmental factors coupled with genetics can sometimes overcome healthy parental attachments and individuals with a genetic predisposition to chronic anxiety may foster dissociation as a coping mechanism (Soffer-Dudek, 2014).

Theoretical Framework

The sources mentioned here as the theoretical framework amount to seven, but only Dorahy et al. (2015) has looked at the direct link between loneliness and dissociation. The other six sources included make significant contributions in relevant areas that help sustain and elaborate on the workings of such a relationship and how it can indeed exist (Cacioppo, 2016; Kalsched, 2017; Kearney et al., 2016). May (1959) is a part of this literature review despite it being a debatably outdated source, and one with strong ideological underpinnings, because it is the inspiration behind the researcher’s choice to look into this topic, and one that posits an explanation of this perceived link between loneliness and dissociation through an existential psychological perspective; having made a reasonable assumption regarding loneliness, identity, and the social interplay between both.
May (1959) predicted that at their time, the increasing technological advances that were taking place were primary factors of the individual neglecting the individualistic identity and by result, losing touch with an inner part that made it possible for one to be alone but not lonely—in other words, loss of awareness of the self-state. May (1959) claimed that individuals could no longer stand solitude, and once they were rejected from their social circles, were in danger of inner fragmentation severe enough to cause a psychotic episode—depending on how much they depended on social interaction to fill a ‘void’. From afar, such a claim may seem existential at best and lacking sufficient quantitative support. However, dissociation in itself, by testimony of the literature reviewed, is just that—a loss of an ability to connect to the ego, the perpetrator of executive function, the main judge residing in one’s head (Alayarian, 2019; Kalsched, 2017). May (1959) simply noted that this fragmentation became intolerable when vulnerable individuals were left to their own devices, and this inspired the topic of the current dissertation. The ego, when exposed to severe trauma and in preparation of impeding death, is concealed and the individual is left feeling like an empty shell (Cacioppo, 2016). Perhaps May (1959) had built his reasoning on individualistic identity and its neglect in modern society—a different cause to dissociation than the one explored here—but his claim that loss of touch with one’s self is a terrifying experience, at times leading to psychosis, cannot be neglected (Cernis, Freeman, & Ehlers, 2020; Pearce et al., 2017).
Kalsched’s (2017) study makes significant contributions to the study of ego and ego function in dissociation. Coming from a psychoanalytic approach, Kalsched (2017) uses some emotive language and allusions to make sense of trauma, such as his paper’s opening line: “Let your heart break and drop the story” (Chodron, 2013, as cited by Kalsched, 2017, p.475), which is a contradiction of traditional psychoanalytic practice to use such humanistic language. Kalsched (2017), using psychoanalytic theory, equates trauma to the ego hiding the ever-hurting child to protect them from further blows, though this explanation is in general supported by other researchers using other schools and approaches (Alayarian, 2019; van der Hart et al., 2017). In an attempt to demonstrate Kalsched’s (2017) theory visually surrounding the reintegration of the self-state’s fragmented others, the researcher here equates it to a circle; Kalsched (2017) is proposing that in order for reintegration of self to occur, trauma must be faced and reconciled with, which is exactly like a cycle. One must complete the circle, so to speak, in order for one to return completely to one self-state.
The main critique the researcher has on Kalsched’s (2017) paper is that though it is psychoanalytic in nature and terminology, Kalsched (2017) is more or less advocating a cognitive behavioral approach of using exposure to help the patient face the trauma and heal from it, though he fails to specifically note that this is a cognitive behavioral approach. In addition, many trauma clinicians and professionals actually denounce using a cognitive behavioral approach with dissociation patients because they firmly believe that the problem is not solely cognitive in nature, and thus cannot be fixed through a cognitive approach, or at least notsolely , but that rather integrating the body in the process is pivotal for recovery (van der Kolk, 2014).
Other researchers such as van der Hart et al. (2017) and Mosquera and Steele (2017) offer more practical papers on the topic of dissociation, where they attempt to aid clinicians by explaining the cognitive behavioral mechanisms taking place in dissociation and proposing treatment protocols. Though coming from different schools, all three researches support the importance of guiding dissociation patients towards revisiting the trauma and facing it in order to heal (Kalsched, 2017; Mosquera & Steele, 2017; van der Hart et al., 2017). The researcher does wonder whether the three papers being published in the same year is at all relevant to such different schools agreeing on one approach to treating dissociation patients, or whether it is simply to be in accordance with the International Society for the Study of Trauma and Dissociation’s (ISSTD) protocol (2011).
It is worth mentioning here that the protocol published by the ISSTD (2011) is focused on DID patients, and not other DD patients, unlike the researchers discussed above, who are more focused on dissociation ensuing trauma and relevant personality disorders. The main critique here on both sources is that neither seem to be too concerned with what happens if the agreed upon protocol fails; what happens if the patient after considerable time does not show willingness to revisit their trauma? What happens if they do revisit the trauma, become too overwhelmed (even though stabilization has been thoroughly ensured) and their dissociative state worsens? As discussed with participants, it tends to fail and other protocols of treatment are usually adopted instead to help trauma and dissociation patients, like EMDR (van der Berg et al., 2015; see also Results and Discussion sections).
To their merit, Mosquera and Steele (2017) do well in outlining the dissociative spectrum of BPD, which most research fails to focus on as much as they do on DID. Even better, Mosquera and Steele (2017) do well by outlining the different features of BPD, the dissociative versus the non-dissociative symptoms and pathology. To newly-practicing clinicians, this is invaluable and will go a long way in helping them better identify what kind of issues their patients are facing, especially since dissociative symptoms are not easily discernible. Similarly, van der Hart et al. (2017) go to great lengths to explain the underlying mechanisms that causes individuals to resort to dissociation, and the significance of their contribution to the field is undeniable.
Kearney et al. (2016) attempted to identify whether trauma and dissociation could be predictors of loneliness in a sample of college students, and did so through a sampling of psychology major students, surveying them online and running statistical analyses on the data collected. While the source has been a strong part of the theoretical framework, there are several concerns to it; firstly, the sample they ran the assessments on was not necessarily composed of DD patients, even though they screened for clinically significant symptoms of dissociation and the results fell below their cutoff range. While the researchers ran some strong assessments to screen for trauma and dissociative symptoms, conducting a clinical interview to screen for the severity is irreplaceable, especially since trauma does not always result in dissociative symptoms, and having an episode of dissociation is not the same as being a chronic DD patient (Swart, Wildschut, Draijer, Langeland, & Smit, 2020). Thus, in terms of the data being a determinant of anything to do with long-term DDs and the relationship it has with loneliness, it cannot be taken into consideration in complete faith.
However, it is important to note that through their study, trauma patients were more likely to report feeling lonely, and that is not a small finding to report (Kearney et al., 2016). Similarly, Dorahy et al.’s (2015) research was one of the few that looked into a direct relationship between loneliness and dissociation and had a significant impact on the current dissertation. While their results corroborated those of Kearney et al.’s (2016) and the rest of the literature reviewed in that regard, there were some shortcomings to the sample they used as well. First of all, their overall sample consisted of 73 participants altogether; 36 were diagnosed with DID, 13 with chronic PTSD, and 21 with “mixed psychiatric presentations”. Furthermore, their sample consisted of 11 males and 62 females, which furthers the issue of unequal distribution especially since females are more likely to report higher levels of dissociation and loneliness (Kearney et al., 2016; Şar, 2020). The small sample size coupled with unequal distribution between diagnoses and gender causes an issue of reliability and validity of data. Furthermore, effect size for such a sample would not be encouraging and was not reported either.
Finally, Cacioppo (2016) focuses more on the implication of neuroscience into the issue of dissociation and its relationship to loneliness. Cacioppo (2016) argues that the temporo-parietal junction (TPJ) is a pivotal brain region for sense of self, self-agency, and the ability to integrate multisensory information to take place efficiently. Her paper aims to introduce this neurological aspect of the brain into the research on dissociation and loneliness and does a comprehensive job of summarizing and evaluating all the information available on that with neuroimaging, while giving a strong phenomenological explanation on the matter of loneliness and what it is to be a dissociated individual; in fact, Cacioppo’s (2016) take on loneliness for dissociated individuals seems to corroborate May’s (1959), Kearney et al.’s (2016), and Kalsched’s (2017) as well—to feel disconnected from self is to feel disconnected from world because one is no longer certain there is a self left to connect to anyone or anything else. The only shortcoming of Cacioppo’s (2016) claim is that it does not attempt to introduce how neuroimaging can help with the care of dissociative patients. How can it be cost-efficient? How can clinicians rely on it to make better judgements and follow better treatment plans? These are points that would have added more to the practice and research on dissociation.

Recommended Guidelines for Treatment of Dissociation

The ISSTD published a guiding paper on recommended treatments and procedures to follow with patients diagnosed with trauma and dissociation (ISSTD, 2011). The primary issue with the ISSTD’s (2011) guidelines is that they mainly target DID treatment, and not the rest of the dissociative spectrum. Though comprehensive in approach, the guide aims more for breadth than depth—it introduces and summarizes all practitioners need to know about DID beginning with its history and pathology, to assessment procedures, socioeconomic factors to consider when beginning treatment, and psychotherapeutic modalities that have shown promise (ISSTD, 2011). The guide advocates for a phase-oriented approach to DID, regardless of the psychotherapeutic modality chosen for treatment. It calls on practitioners to focus on stabilization and creating a safe environment for patients in the first phase; confronting and helping patients integrate traumatic memories in the second; and, working on identity reintegration in the last phase. As a guide published by an official body aiming to regulate the study and treatment of dissociation and trauma, this guide has influenced many researchers’ treatment guidelines in their own papers, such as Ducharme’s (2017), and Kalsched’s (2017), who also advocate for the same phase-oriented approach.
Mosquera and Steele (2017) produce solid guidelines on treating BPD patients with comorbid DDs and outline the possible symptoms that could be the underlying cause for dissociation such as triggers, affect dysregulation, childhood traumas, Complex Traumatic Stress Disorder (CTSD), and more. They do not outline a certain psychotherapeutic modality, but they outline certain factors to be wary of, and how best to tackle them with patients, which may be introductory in nature and lacking depth, but is still one of the few sources that looks into BPD-DD treatment plans.
Most of the literature on treating dissociation and/or trauma advocates for CBT, cognitive therapy (CT), prolonged exposure therapy (PE), EMDR, and/or stress inoculation therapy (SIT) (Blankenship, 2017; Cusack et al., 2016). With the limitation outlined above taken into consideration, Blankenship’s (2017) and Cusack et al.’s (2016) papers do make solid contribution in reviewing trials of PTSD patients being treated with one of the modalities outlined above, the limitations of the trial, the effect size, and the strength of evidence in favor of the modality. Cusack et al. (2016) report CT, CBT, and PE as being the modalities with trials reporting the strongest evidence and effect sizes, and EMDR as being of moderate effect size but having lower consistency and certainty.
The primary limitation of the literature in regards to this section of the review is the broad aspects of the dissociative spectrum, its comorbidities, and crossing symptomology. Many researchers try comparing and contrasting between different psychotherapies for treating a dissociative disorder (Cusack et al., 2016; Blankenship, 2017) but the issue here is that they are focusing on one dissociative disorder or symptom. For example, BPD with dissociative symptoms/disorder should follow a different treatment plan than a BPD comorbid depression patient, than a BPD comorbid OCD patient, and so forth. Thus, to advocate for one modality over another is probably an impossible task, because each modality presents limitation for a certain population exhibiting certain symptoms/comorbidities as opposed to another (Blankenship, 2017; Cusack et al., 2016; Mosquera & Steele, 2017).