Dissociative States Under Stress

We have come to the last, and perhaps most difficult to describe and comprehend, symptom on this section of impairments in personal functioning on the DSM 5, namely: “Dissociative states under stress”. When we see this definition, we immediately think of dissociative identity disorder (me Lawrence, and my other me Lawrence); however Borderline Personality Disorder, although having some similarities, is essentially quite different.

Dissociative states refers to a set of neural pathways that are linked together to form a feeling that is almost like an altered state of consciousness. It is almost like the mind has created a mind state that it can hide in whenever the stress becomes too great to handle. Just at the point where our mind heads towards getting an emotional charge from the amygada to handle a conflict, the OFC says “oh no, I can’t deal with this emotion again right now” and reroutes it to this neutral mind state. At this point we may experience a numbing sensation that starts in the brain and then seems to flow throughout the whole nervous system.

It is not continuous, thank the powers that be, but comes and goes depending on the levels of stress and subsequent anxiety. Because of our inability to handle emotional conflicts, there is a sense of paranoia here, but it is much gentler than the kind of paranoia that we see in Paranoid Schizophrenia. By my own experience, I would describe it as a feeling that I do not belong, and the world out there is a dangerous place that requires that I must be always perfect, vigilant, and careful in my interactions with people. I am socially hypersensitive and cautious and I can feel myself shut down whenever the conflict starts to become emotional (and for me that is almost immediately).

One study, although quite different in design, seems to bring what is happening into focus.  Ludascher et al (2007) applied electric stimulation on the right index finger of twelve female patients with BPD and twelve healthy controls. They found significantly elevated pain thresholds in patients with BPD, with a significant positive correlation between pain thresholds and dissociation, as well as between pain thresholds and aversive arousal. In a follow-up study, Ludascher et al (2010) using script-driven imagery, produced dissociative states in participants with BPD. These states on fMRI’s were characterized by decreased pain sensitivity and significantly increased activity in the left inferior frontal gyrus (part of the OFC) which is at least partially responsible for empathy, processing pleasant and unpleasant emotions, self-criticisms, and attention to negative emotions.  From these two studies we see suppression of physical and emotional pain and interference in the functioning of some of the sections of the orbitofrontal cortex (OFC).

Typically when an emotional situation takes place (usually involving intimate relationships or high self-worth activities like work and some sports), the OFC and amygdala are activated, thus empowering us to take action and resolve the situation. Hormones are released and we shift into the sympathetic system. This increases blood pressure and transforms carbs into glucose so that the body is prepared to take action to prevent the expected pain. This works great for escaping sabre tooth tigers. With the increased power, we take flight, and race into our cave that has a small doorway that the tiger cannot fit through, the body relaxes into the parasympathetic stage and we feel a sense of relief as the serotonin pathways are activated. These impulses are then channelled through the pleasure center of the brain producing a sense of joy and accomplishment of having outsmarted that dumb old tiger yet once again. All right and good for escaping sabre tooth tigers, but not so good for resolving emotional issues.

If we have a firm foundation, we go through the process of protecting ourselves emotionally in a slightly difference manner. If the emotional situation is too intense, such as a divorce or break-up, we will not be able to solve the problem through our hormone rush and will eventually wear ourselves out. We need to get out of the sympathetic system. We will eventually but a block in place along those neural circuits connected to the thoughts and feelings associated with the failed relationship.  This is a natural body function that is usually put in place to block the neurotransmitters that are coming from intense pain. The neurons simply withdraw their receptor docks, thereby preventing the messages carried by the neurotransmitters from proceeding from the painful neural pathways to the OFC of the brain. Out of sight, out of mind. Works for most people. Then we congratulate ourselves for escaping the sabre tooth tiger yet once again and we go on with our lives.

But if this process has been corrupted by severe emotional problems during childhood such as emotional neglect, coupled with a super sensitive genetic predisposition, the OFC will not be able to process any additional emotional insult. The whole emotion processing system gets shut down every time there is an event with just a hint of emotional pain.

This theory is supported by Jones et al (1999). They assessed twenty-three patients with BPD, and 23 matched controls, with the Autobiographical Memory Test (AMT) and self-report measures. As expected, participants with BPD scored significantly higher than the control group on measures of depression, anxiety, and trait anger. However, they also scored higher in dissociative experiences that appear to be connected to general memories on the AMT. They concluded that patients with BPD had difficulty in recalling specific autobiographical memories, perhaps related to their tendency to dissociate, which may help them to avoid reliving memories that may have been emotionally painful.

These studies suggests that under stress, we lost souls with BPD tend to shut down emotional pain sensations because of our past painful experiences. Again, in my own case, whenever I was personally or professionally challenged by someone, and I felt my self-worth was at stake, I could actually feel a sense of numbness flowing through my brain and through the rest of my body creating that proverbial lump in the throat. Quite simply, this suggests that some of us with BPD may have developed some kind of defence mechanism to interrupt the flow of pain to and within our brain. In the case of emotional pain, it would appear that we bypass our amygdala thus having an interrupted or numbing response when faced with an emotional situation.

Now this sounds like a perfectly good way to deal with overwhelming emotional situations, but there is a major drawback, which brings me to the last study in this section.  Ebner-Priemer et al (2009) used an aversive differential delay conditioning procedure with 33 unmediated patients with BPD and 35 healthy controls. They discovered BPD patients with high state dissociative experiences showed impairment in responding to emotional learning. They concluded that emotional, amygdala-based learning processes, may be inhibited in acquisition and extinction processes in therapy and should be closely monitored in exposure-based psychotherapy. It would appear that we do not respond well to traditional therapy methods. The amygdala, and parts of the OFC mentioned in these studies, are designed to provide the plan and the power to solve problems especially highly emotional ones. It is part of a circuit that leads to resolutions, a trip through the pleasure center of the brain, and to a nice comforting flow of serotonin. When we shut down these mechanisms, we shut down our ability to solve problems and to feel the joy and contentment of growing through our experiences.  And, unfortunately, we do not respond well to therapy.

So what is the answer? Again, I can only refer to my personal experience. I underwent an extensive therapy including group, cognitive, and an assortment of other strategies, with only limited success. My true healing took place when I begin to see myself as a higher self in conflict with a mind self (aside: talk about dissociative disorder). Only then, with the support of my higher self, was I able to explore my past feelings and emotions, cry with some, yell and scream at others, and feel the hurt and loss with the rest. It allowed me to accept my life-experiences, be thankful for their part in making me strong, and put them behind me. Then when old feeling returned, and I felt the numbing sensation coming on, I would connect to my higher self, and allow it to flood my mind and soul, face my old wounds, cry, and move on.