VIDEO: Dr. Allan Schore on Somatoform Dissociation

Watch an excerpt from PsychAlive’s interview with Dr. Allan Schore.

Dr. Allan Schore talks about the etiology of somatoform dissociation, its role in suicide, and the potential for therapy to alter this trajectory.

Dr. Allan Schore: Well, the classical is the disruption of consciousness and ongoing states of consciousness.  And so therefore, when the infant, let’s say, now is in hyper-arousal and literally is at the limits of where the sympathetic nervous system can drive it – the heart rate is up, etc. – at the limits, what you’ll see is that you’ll see the systems shut down at that point in time.  The infant now stares off into space with a blank look, literally is gone.  Well, there is a discontinuity in that baby’s state of being.  At that point in time, the baby is not processing anything from the outside world, it’s not processing cues coming in from the caregiver, it’s not even processing its own bodily cues coming up.  It’s in this low metabolic state.

So here, the new piece of information that I think also needs to be made here – and it’s interesting, there are pieces that can go from one work in one area of psychopathology, which can be directly applied to another – in the area of dissociation, there is now a move into not only cognitive dissociation, like fugue states, etc., but somatoform dissociation.   Somatoform dissociation is the individual now is cut off from their body.  They cannot read the internal rhythms and flows of their own body, which I would suggest to you that in the severely empty core of the suicidal state, cut off from the body, they can’t even read that.  That becomes extremely dystonic, I mean extremely negative thoughts.

So here’s the matter here of, of being with a patient and talking about these things and all of a sudden, the patient’s gone.  All of a sudden, I mean, being able, therefore, for the therapist to be able to track even low levels of massive disengagement would be critical.  If you don’t track them, essentially, they’ll build in intensity and then you’re dealing with, you know, a massive situation here.  So again, massive.

But, what does it mean again about being able to track your own heart rate when it’s dropping, etc.?  How do we pick up dissociation?  So as we talked about before again, this brings the body into the work and I really have to say that in the case of the field of suicide, there was an understanding now for some time, as you just pointed out that the body is severely dis-regulated, that that is part of this problem here. That the field of suicide never did go too overboard with the cognitive because they knew that the body dis-regulation was a key to that piece there.  And that’s critical and that is therefore reinforced, that is reinforced now by the current neuroscience.

Well, you know, the  hypo-arousal – I mean literally when one is in the hypo-arousal for so long, with borderline personality disorders, in the states of hypo-arousal, not only is there no processing of the body, but the pain sensitivity is severely altered.  So the pain threshold is increased, which is why, in the dissociated state, there no physical pain.  For borderline personality disorders to come out of that state, they’ll cut.  And that’s essentially to literally bring the sympathetic nervous system back on line.

Let me say it again here – in the most severe end of the suicidal crisis, the sympathetic nervous system is hardly operating.  It’s all the dorsal, motor-vagal parasympathetic system, etc.  And so, you’re not even getting that swing and cortisol is low, etc.

So here, yes – and this also gives an understanding of why there are those swings as the person is now attempting to auto-regulate their self out of deep hypo-arousal.  And it may very well be that the “action” – because if the self is in an aggressive state, there still is some semblance of a self.  When the self is in a collapsed, empty state, there is no semblance of that.  So it’s better to generate some form of hyper-arousal, which incidentally could also be done with certain drugs, which we haven’t talked about.  That could also be parts of these kinds of situations.

I had mentioned somatoform dissociations.  In the cases of somatoform dissociation, when the person is cut off from the body, this has been studied by the trauma researchers in Holland and what they’ve found is that in almost all of these cases, there is early relational trauma.  Specifically, there was abuse in which the child was hit.  There was physical pain.  Incidentally, the attachment relationship even sets over the threshold of the pain system also there.  So we’re talking about here, the later consequences of an infant being hit.

Now remember, and I want to point this out, we’re not talking about single incidents trauma, in this whole model we’re talking about chronic ambient trauma, whereby attachment trauma over the first year or two of life, the caregiver and the infant were constantly out of synch with each other.  The baby was in high densities of negative affect.  Perhaps if it was hit, in pain, the time, etc.

So we’re not talking about a specific re-enactment of a specific traumatic situation.  We’re talking about cumulative trauma, chronic trauma.  And that will be repeated again.  That will be repeated again with the expectations of it.  And the expectation would be that times of the most severe distress, if one went to the caregiver, if one opens oneself up and is vulnerable, one will not find safety and comfort, one will (instead) get further dis-regulated.  And that literally is built into their expectations.  And that’s what one is attempting to try to change.

Incidentally, the fact that we’re now looking at earned secure attachments, which means that even with horrific early histories, they can be altered by later life experiences by connecting up with better affect regulators.  Would clearly mean that the attachment can be altered.  And if that is so, that it would also mean that the type D’s, who are suicidal, also could be altered in long term work.

In the case with someone who has never had that, in the case of someone who has never forged a bond of interactive communication attachment to another human being, it would take a while to come to that.  Which is why six sessions is not necessarily going to do this kind of work here.  And it will be a longer term situation.

That said, there are now a number of studies showing borderline personality disorders as severe as this that psychodynamic models that are working for 2 or 3 years definitely are altering the trajectory, therefore you are changing the symptomatology, etc.  So we now have efficacy studies there.  But yes, this is not short term work with these patients.  And therefore, what you find is these patients will move in and out of therapy.  Over and over and over again.

And I want to say again, that, in part, perhaps part of the problem has been that we – because our models have not been as complex as they need to be and they really haven’t outlined the internal psychic structure, the internal world here, in terms of the biology of it, we really haven’t been able to, to form models that are based on it.  But now, as we move forward, I think for the first time, we have kind of psycho biological models which are complex enough now that would lead us to a different approach of the therapy.  A more complex one, a deeper one, but also essentially heightening the affect and the affect regulation of them.  And I think therefore these models will ultimately, you know, lead to more efficacious treatment also.

But remember that essentially attachment is interactive regulation.  So attachment is affect regulation.  I mean, essentially, the internal working models of attachment are encoding strategies of affect regulation.  And, of course, the internal working models, as Bowlby said, are unconscious.

And so essentially that’s what the attempt is to change, not conscious models, which is why therefore too much of counseling, which is just focused on the surface, which could work very well — with more complete personalities, it’s going to be fine — but frequently, let me point out here, because the higher structures of the right hemisphere really never did form in the first place, these patients are not necessarily psychologically minded.  I mean, by definition, they’re not.

And so essentially what we’re looking at is a therapy which can ultimately can allow for the creation of a structure by which the patient can then now for the first time have the reflective capacity to reflect upon the affects within.  So for that reason again because insight never was an effective treatment, we can now understand why insight wasn’t – and I would suggest still – is really not the heart of this.  Really it’s more of an affect regulation model than insight model.

Tags: dissociation, Suicide, therapy, videio