When we work with alienated children we should know what we are working with in order to avoid treating the wrong thing. In my clinical experience, the problem we are treating, in families where a child is alienated, is not about high conflict and it is not about contact between children and their parents. Neither is it about abuse or about poor parenting by the parent who is being rejected. When working with children who align with a parent and reject the other and particularly when that presentation lasts over long periods and becomes entrenched and highly defensive, including perhaps allegations which escalate, the problem we are treating is alienation in and of children, from their own sense of self. It is the role of the court to determine the cause of the harm and it is the role of psychotherapists who understand the problem and can demonstrate capacity to work within the legal framework to to determine the most effective treatment. Increasingly, it is social workers with statutory power, combined with psychotherapeutic input, that provides the most effective treatment intervention.
Successful resolution for alienated children is the resolution of the splitting defence. Whilst the goals of therapy fall broadly into those set by Johnstone, Walters and Friedlander (2001), the work of the Family Separation Clinic goes one step further than a focus upon child/adult relationships, seeing those as a projection of the internal state of mind of the child. In working with alienated children, FSC seeks to enable the child to recover the whole sense of self which is, in cases of hyper-alignment and rejection, impacted by ego splitting, a primitive defence strategy which is recognised as a response to trauma. (Winnicott, 1965; Van Der Kolk, 1994; Schore, 2010; Fisher, 2017). This trauma, which is the result of the violation of the usual boundaries within a family system, places children in a position within a family which is inappropriate, causing them to be in relationship with adults as if they are equal or in some cases, as if they have executive powers they do not possess. These boundary violations, which were termed parentification and spouseification by Minuchin (1974), are reversals of the normal and healthy parent/child relationship, causing the child to meet the needs of a parent rather than the reverse, as such these violations are recognised as emotional and psychological child abuse.
Working therapeutically with alienated children provides a longitudinal view of the internal experience of the child, both in recovery from alienation and over the developmental phases which follow. This means that the cycle of alienation can be understood from the clinical case material and the longer term harms to the child’s psychological and emotional wellbeing, can be measured and monitored. This is valuable when building treatment routes which can be replicated so that others can understand and treat the right problem. This clinical focus is very different to the academic research because it provides a case study of each unique family being treated, which, over time, provides an evidence base for depth psychotherapeutic work. It is this internal study of the alienated child, which demonstrates that the origin of the drama which unfolds when a child hyper aligns and rejects, is the child who is returned to and stuck in the paranoid/schizoid position of early infancy.
We are British Psychotherapists. At FSC, our work draws upon Object Relations Theory to enable understanding and Structural Therapy which is combined with the contemporary literature on Psychoneurobiological Theory (Schore, 2002) for treatment. In building our understanding of how to treat alienation in a child, we know that, at its core, the problem we are working with arises from ego splitting due to the onset of primitive defences in a child who has been pushed back into the paranoid/schizoid position articulated by Melanie Klein.
The term ‘paranoid-schizoid position’ refers to the anxieties, conflicts and defences and internal and external object relations that Klein considered to be present in the infant’s early months and years and which continue to a to play a role in childhood and adulthood to some extent. Contemporary understanding is that paranoid-schizoid mental states play an important part throughout life. The chief characteristic of the paranoid-schizoid position is the splitting of both self and object into good and bad, with at first little or no integration between them. (Melanie Klein Trust).
What this means for children of divorce and separation, is that their internal world is as impacted as their external world when their parents separate and for those with a parent who is unable to cope with their own internal conflicts and anxieties, there is an additional burden to carry which is that psychological and emotional baggage which belongs to that parent. Some children are compelled to take up this burden by maladapting their attachment relationship to each parent and by carrying the burden of parental internal conflicts via hyper-alignment and rejection. This leaves the child in thrall to the parent who is unable to resolve their own internal conflicts and anxieties and rejecting of the other parent. In order to do this however, the child must go through the process of fragmentation of the ego, in order to protect their sense of self and prevent complete dissociation.
Ego Splitting-APA Definition
In the object relations theory of Melanie Klein and British psychoanalyst W. Ronald D. Fairbairn (1889–1964), fragmentation of the ego in which parts that are perceived as bad are split off from the main ego as a mechanism of protection.
Working with alienated children
Clinical work with alienated children offers a unique insight into the ways that internal attachment maladaptations interact with the external world dynamics. In my experience, the failure to treat the problem fully, often lies in the way that the external world dynamics are impacted by the child’s behaviours. What I mean by this is that the behaviours seen in a child who is alienated, are confusing to those who do not understand what is causing them. For example, alignment between a child and a parent may look like a close loving bond to those who do not recognise the pathological signs of enmeshment or parentification. Understanding what enmeshment presents like as well as recognising the long term harm this emotionally incestuous relationship does to a child, is an essential part of skill development in this area of work.
Emotional incest is a boundary violation. It occurs, for example, when a parent shares information with a child about adult matters with an underlying intent to bind the child to their own world view and in doing so, receive regulation and reassurance from the child that they are aligned with them. This behaviour strips a child of their own independent right to parental care and support which is separate from the adult relationship of their parents. It also requires the child to disavow their own feelings in order to regulate a parent who often feels frighteningly out of control. When children are in this position they can be seen and heard to reflexively repeat, almost mantra like, the narrative of a parent who is violating boundaries, children in these circumstances become over burdened with the inter-psychic conflicts of the parent who is influencing them. Such children are being controlled by a parent who is unable to contain their own intra-psychic conflicts and who is using the child to regulate their anxieties.
Attachment maladaptations in divorce and separation occur in children because they are unable to cope with the demands a parent is making of them. Those attachment maladaptations include rejecting a loved parent in order to regulate the other and/or because a child has re-entered the paranoid/schizoid position in which primitive defences hold sway over their behaviour. Such children behave omnipotently and are often contemptuous of those who try to intervene. Children in such a state of mind are not psychologically or emotionally safe because they are outwith the capacity of either parent to provide good enough care, as such, children in this position are considered to have met the welfare threshold for significant emotional and psychological harm. This is when public law (in the UK) is required to intervene and when social workers are engaged in the work to restore health to the child.
Treatment of the Problem Using a Social Work Pathway
The Social Work Intervention Pathway for Alienated Children, is based upon the principles above which are conversant with child protection in social work. In this pathway, identification and differentiation is undertaken by a Clinical Psychologist or Psychiatrist and the Court provides the overarching framework for management. Using the concept of non accidental injury, the capacity of parents to respond to psychological guidance, behaviour change requirements and psychotherapy, is tested over time and the relationships between the alienated child and both parents are observed. Where a parent shows lack of insight and/or disguised compliance, the child protection route is activated and the parent is constrained from further harming the child. Only when the child is in a safe and protected space, is therapeutic work undertaken.
This pathway to treatment is necessary because the problem we are working with is relational in nature, it arises from the child’s attachment maladaptations and it responds to structural therapeutic intervention which is tailored to the specific dynamics arising in the family. The goals of the clinical trial are to determine whether a parent to whom the child is hyper aligned, has the capacity to show insight and change their behaviours and to determine whether the child can resolve the split state of mind in situ (without structural changes such as a residence transfer – which is either temporary or permanent).
In some situations, direct work with those children is the focus, in other situations, enabling parents to provide healthy care for their children, is the best route to help the child. In every situation, the purpose of our work at FSC is to enable the child to recover what Donald Winnicott called the true self, which is the self which does not suffer from ego splitting. In doing so, our close work with children allows us to understand exactly how these ego splits are caused by divorce and separation and what can be done to assist the child to recover the whole self.
Working Therapeutically With alienated Children
Alienated children suffering ego splits operate internally and externally from different parts of self. The concept of parts of self is one which is well understood in the contemporary literature on trauma, from where interventions can be built which are tailored to the needs of individual children. In my experience, all alienated children respond effectively to the language of parts, in which they are invited to work from the different split off parts of self. For example, all alienated children have an ashamed part of self which is denied and split off from consciousness and the purpose of the angry behaviours seen in children is, in my experience, a drive to keep the ashamed part of self out of consciousness. This is because if the child feels shame for the rejection of a parent, they also feel the love that they have for the parent which is also denied and split off from conscious awareness. One of the goals of therapy therefore, is to enable the child to process the shame they are denying because in doing so they also re-encounter the love that they have for the parent who is rejected. This is about integrating the child’s internal experience of self and in doing so, enabling external integration of their external relationships. What happens to a child who is integrating internally is that they will experience the external relationship as being somehow changed. Many children in recovery from alienation will say that they can now love the rejected parent because that parent has changed. What has really changed, is the intra-psychic world of the child, who no longer has to deny and split off experiences in order to cope. When this happens, children often spontaneously reveal the actions of the influencing parent, this is because when the child is integrated internally, the healthy part of self can fully recognise the harmful behaviours they have been subjected to.
Working with alienated children requires a particular approach, it is not something which can be done in a once-each-week session in therapy but must be done in the moment, often intensively and over significant lengths of time. Therapists doing this work must be able to work symbolically with children (many of the early phases of work are done in silence with children who have no language for what has happened to them). Symbolic working is often done whilst walking or moving together in some way. This is because the traumatic impact upon a child of having to make attachment maladaptations, causes an over reaction in the amygdala, meaning that the child cannot self regulate easily and is often, in the early stages, hyper alert. This hyper alert state of mind, is not caused by the parent the child is rejecting but by the conveyance in the inter-psychic relationship with the aligned parent, that the parent the child is rejecting is somehow dangerous or not to be trusted. Thus, the earliest stages of work with alienated children are focused upon helping them to self soothe and self regulate, ensuring that the internal state of mind is calm before encountering the split off and denied object relationship in the form of the parent in the rejected position. This work is intensive but it is necessary as a foundation stone for what follows which is the encounter with the parent in the rejected position. When that parent has been trained in therapeutic parenting skills, they are alert to all of the ways that a child with attachment maladaptations may react and are thus able to respond from a place of therapeutic care rather than reactive anxiety. In such circumstances, the goal of holding the child in an integrated position internally and externally in the relationship with the parent in the rejected position is achieved more readily.
When the first phase of work with the alienated child is complete and integration of splitting is seen to be sustained, work to test the child’s capacity to encounter the formerly aligned parent is undertaken. This is a more difficult phase of work however, especially if that parent lacks insight and continues to behave as if the child is in a dangerous predicament. In the UK, as elsewhere in the world, where campaign groups are often seen to uphold the distorted beliefs of an influencing parent, therapeutic work is often very difficult with such parents. Where a parent continues to lack insight, the relationship between the child and that parent has to be constrained and supervised over time to prevent the child from being pressured back into the defence of splitting. In all cases, protection of the child must be the first concern because ego splitting is a trauma response and boundary violations will continue to harm the child. In such situations, just as a child is protected from parental boundary violations such as sexual abuse, (which often causes dissociative splitting), a child must be protected in the longer term from boundary violations such as emotional and psychological incestuous abuse, (which causes ego splitting).
Fisher J. (2017). Healing the fragmented selves of trauma survivors : overcoming internal self-alienation. Routledge. https://doi.org/10.4324/9781315886169
Schore, A. N. (2010). Relational trauma and the developing right brain: The neurobiology of broken attachment bonds. In T. Bardon (Ed.), Relational trauma in infancy: Psychoanalytic, attachment and neuropsychological contributions to parent-infant attachment (pp. 19-47). London: Routledge.
Schore, A. N. (2002). Clinical implications of a psychoneurobiological model of projective identification. In S. Alhanati (Ed.), Primitive mental states: Psychobiological and psychoanalytic perspectives on early trauma and personality development, Vol. 2, pp. 1–65). Karnac Books.
Schwartz, R. (2001). Introduction to the internal family systems model. Oak Park, Ill.: TrailheadPublications.
Van der Kolk, B. A, Hostetler, A, Herron, N, Fisler, E. (1994) Trauma and the Development of Borderline Personality Disorder,
Psychiatric Clinics of North America,Volume 17, Issue 4
Winnicott, D. W. (1965). The Maturational Process and the Facilitating Environment. New York: Int. Univ. Press.
Training for Parents in the Rejected Position
Listening and Learning Circles Summer 2023
The Circles for Summer 2023 are now avaiable for booking here please note that the Circle due to be held on May16th has been cancelled due to my work in the High Court, the next circle is therefore 30th May at 18:00 UK time.
Higher Level Understanding Course
This course is for those who have completed the Holding up a Healthy Mirror Course with me and is a depth experiential course which examines attachment, working with parts, using symbolism for the child without language, communication with alienated children, understanding the recovery route of the alienated child as well as focused mentalisation skills to enable parents to rebuild relationships with children which repair the maladaptations a child has had to make. The course will be useful for those who wish to help themselves and others. There are a few places left and you can book here
Please note that if you are on the list for a concessionary place, you will receive a link to pay by the end of this week.
” … is the child who is returned to and stuck in the paranoid/schizoid position of early infancy.”
I’m curious if there was no indication of a ‘split’ in the children’s infancy, does that mean there was still some sort of ‘damage?’
All of us are split in infancy Caron, we have to be in order to survive the enormity of the world. When a child is pushed back to the paranoid/schizoid position, it means being pushed back to the world of infancy where everything has to be split into manageable pieces of good/bad in order to digest incoming information.
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I find the information you share to be very interesting. I am a masters in Social Work student in the US and am myself a rejected mother. I have 8 children who are all minors and have been affected by varying degrees of alienation. I understand this to be serious and have purchased The Neuobiology of Attachment-Focused Therapy by Baylin and Hughes and Dyadic Developmental Psychotherapy by Becker-Weidman so that I can understand better. I am learning Structural Family Therapy in my Couples and Families class this quarter. I guess my question is how can I learn more about this as a social work student? And as you are in the UK, are there any organizations in the US that have this understanding of parental alienation that I could contact? I desire to be an informed mother so that I can provide the environment my children need for healing but find it difficult to find anyone who could understand the dynamics of the abuse they are enduring and that would be willing to help me. Are there other book resources you could recommend as well?
Hi Celina, we are currently running a social work training pathway in three countries which is being evaluated for us. If you email me at email@example.com I will send you information about our training for parents and some resources for learning as a professional. All of our training will available on demand soon and I will put you on our list for information as it becomes available. Kind Regards Karen
Masochistic and Sadistic Ego States:
Dissociative Solutions to the Dilemma of Attachment to an Abusive Caretaker
Ruth A. Blizard, PhD (2001)
ABSTRACT. A theory describing the development of alternating, dissociated, victim/masochistic and perpetrator/sadistic ego states in persons who grew up with abusive primary caretakers will be proposed and a paradigm for treatment will be derived from the theory. Alternating ego states can be observed throughout the spectrum of dissociative disorders, from Borderline Personality to Dissociative Identity Disorder. Dependence on an abusive caretaker creates a series of relational dilemmas for the child. To maintain attachment, abuse must be dissociated, but to protect the self from abuse, need for attachment must be disavowed. Disorganized attachment may result. Incompatible internal working models, using parallel masochistic and sadistic defensive strategies, may be developed and elaborated into ego states. Masochistic and sadistic defenses are ultimately maladaptive, because they require dissociation of need for either self-protection or attachment. Each defensive attempt at resolving a relational dilemma leads to another impasse, a change in defensive strategy, and perhaps a shift in ego state. When alternating ego states are understood as evolving from defensive schemas developed to negotiate the dilemmas of attachment to an abuser, the following therapeutic techniques can be derived: (1) identifying adaptive needs and maladaptive defenses, (2) interpreting ego state switches as attempts to resolve relational dilemmas, (3) gradually bridging dissociation between states, (4) using transference and countertransference to understand relational patterns, and (5) cultivating more adaptive interpersonal skills within the therapeutic relationship.
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This article will propose a theory of how alternating, dissociated, masochistic and sadistic ego states develop in persons for whom the primary caretaker was an abuser, there were not significant benign relationships, and abuse was severe and chronic. A paradigm for treatment based on that theory will be presented. For these patients, the caretaker may have been alternately nurturing and cruel, or the primary form of contact may have been physical or sexual abuse. The child is caught between the Devil of abuse and the deep blue sea of abandonment, thereby making it impossible for the child to be attached and self-protective at the same time (Blizard, 1997a, b; Blizard & Bluhm, 1994).
The paradoxical demands of survival in an abusive relationship create a series of relational dilemmas (Prior, 1996), leading to development of dissociated ego states with masochistic and sadistic defenses.
Surviving child abuse can result in a number of outcomes in terms of adult psychopathology, depending on a host of variables, including the qualities of significant attachment relationships, and the severity, chronicity and age of onset of trauma (Briere & Conte, 1993; Chu, 1998; Chu & Dill, 1990; Herman & Schatzow, 1987; Kirby, Chu & Dill, 1993; Terr, 1991). Relational dilemmas will be most acute when abuse is inflicted by a primary caretaker. If no significant benign relationship is available to provide an alternate attachment template, then masochistic and sadistic defensive strategies may become the primary modes for interpersonal relating. Howell (1996, 1997b) offers an elegant formulation of how masochistic or sadistic personality organization can develop as a dissociative adaptation to childhood trauma and disrupted attachment, in contrast to earlier psychoanalytic conceptualizations of desire for punishment or pleasure in pain.1
DEVELOPMENT OF DISSOCIATED MASOCHISTIC AND SADISTIC EGO STATES
Alternating Ego States in Dissociative Spectrum Disorders
This paper will describe how alternating, dissociated, masochistic and sadistic ego states may form a common psychodynamic structure throughout the spectrum of dissociative disorders, from Borderline Personality Disorder (BPD) (Kernberg, 1975, 1992; Howell, in press), to Dissociative Identity Disorder (DID) (Putnam, 1989, Ross, 1989), in those persons who were abused by a primary caretaker.
“Dissociation” has been variously defined (Putnam, 1997; Ross, 1989), and appears to be a complex phenomenon to which biological and defensive processes may contribute (Liotti, 1999). There is mounting evidence that peritraumatic dissociation is an automatic response (Coons & Milstein, 1986; Kluft, 1984, 1990; Putnam, 1989; Putnam, Guroff, Silberman, Barban & Post, 1986; Ross, 1989; Ross, Norton, & Wozney, 1989; Spiegel, 1984) resulting from an underlying biological process (Krystal, Bennett, Bremner, Southwick, & Charney, 1996; Nijenhuis, 1999; Nijenhuis, Van der Hart & Steele, in press; Perry, 1999). However, to avoid associations to significant memories, the maintenance of dissociation requires much mental monitoring and maneuvering (Braude, 2000); in other words, psychoanalytic defenses, such as avoidance, repression, denial, projection, compartmentalization, and splitting, ad infinitum. Explanation of the variation in dissociation among abuse survivors will require further study. The thesis to be developed here is centered on the active, organizational process of dissociation of internal working models of attachment (Liotti, 1992, 1999).
To enable discussion from a psychodynamic viewpoint, and include the varying degrees of dissociation seen in BPD and DID, this paper will rely on two compatible definitions of ego state: (1) An organized system of behavior and experience whose elements are bound together by some common principle, and separated from other states by a more or less permeable boundary (Watkins and Watkins, 1997); (2) A specific, consistent mental organization, dominated by a particular affect, linking particular self and object representations (Young, 1988).
BPD may be better understood as a dissociative disorder (Bromberg, 1998; Howell, in press; Ross, 1989). If dissociation is broadly defined as “a disjunction of the association between related mental contents” (Barach, 1991, p. 118), then the splitting between ego states described by Kernberg (1975, 1992), can be viewed as dissociative. Splitting is an ambiguous term (Pruyser, 1975) involving a distinction between the splitting of self- and object-representations and the splitting of the self. The key point is that where representations of self and other normally would be coherent wholes, they are split, and thus dissociated.
Citing the common history of childhood abuse and neglect, several scholars have proposed that BPD and DID be considered chronic forms of posttraumatic stress disorder (PTSD) (Herman, 1992; Herman & van der Kolk, 1987; Ross, 1989; Terr, 1990; Van der Kolk, McFarlane, & Weisaeth, 1996).
Histories of traumatic, childhood abuse were found in 50 to 81% of patients with BPD and 85 to 100% of patients with DID (Putnam, 1997). There is significant diagnostic overlap between BPD and DID (Dell, 1998; Putnam, 1997; Ross, 1997). Historically, the psychoanalytic literature has not formulated BPD as a trauma-based disorder (Howell, in press). More recently, child abuse has been cited as a factor in the development of BPD (Gunderson & Sabo, 1993), and of masochistic and sadistic states (Kernberg, 1992).
In BPD, there is continuity of memory and identity between ego states, but striking discontinuity in mood, perception of the other, and defensive posture, with lack of awareness of the significance of this divergence between states (Howell, in press). In DID, two or more ego states are experienced as distinct identities, and separately assume control, with amnesia between states, (American Psychiatric Association, 1994). Among the hallmarks of BPD, often leading to concurrent diagnosis with DID, are alternation between idealization and devaluation, unstable relationships, and recurrent self-mutilating behavior. If these are viewed as signs of conflict between alternating masochistic and sadistic ego states, then therapy can focus on needs for attachment or self-protection, without labeling bewildering behavior in BPD with a diagnostic term that often induces contemptuous resignation in therapists. Similar therapeutic techniques can be used with trauma-based disorders throughout the dissociative spectrum. Then, it becomes less advantageous to quibble over diagnosis, than to assess the degree of dissociation, so that bridging of ego states can be paced to prevent decompensation.
Dissociation as a Response to Attachment to an Abusing Caretaker
Even when the caretaker is abusive, the child must maintain attachment (Bowlby, 1969/1982) creating an utter dependence for survival on the same person who threatens bodily and/or psychic integrity (Fairbairn, 1952; Main, 1981). This dilemma may cause children to develop a disorganized/disoriented (D) pattern of attachment (Main & Hesse, 1992; Main & Solomon, 1986, 1990), and construct multiple, incompatible, working models of self and the attachment figure (Liotti, 1992, 1999; Main, 1991).
The concept of DID as an attachment disorder (Barach, 1991) was in contrast to previous thinking that dissociation was primarily a result of exposure to trauma (Coons & Milstein, 1984, Kluft, 1984, 1990, Putnam, 1989; Putnam et al., 1986; Ross, 1989; Ross et al., 1989). Bowlby (1980) observed that emotionally neglected children become detached from internal and external signals, ordinarily serving as stimuli for attachment behavior, in order to defend themselves from crying out for help and experiencing abandonment. Barach proposed that children whose primary caretakers were detached or dissociated would develop detachment as a defense. If these children were exposed to “active” abuse, they would be likely to use dissociation to detach from the overwhelming, painful affect of trauma.
Liotti (1992) countered that, when the caretaker is consistently rejecting, the probable outcome would be avoidant attachment, which is a coherent pattern, and, unlike D attachment, would not likely result in dissociation as Barach (1991) inferred.
In contrast to Barach’s thesis, Blizard and Bluhm (1994), and Blizard (1997a, b) proposed, from an object-relations and attachment theory perspective, that dissociation is used as a defense to preserve attachment to an abusing caretaker. Rather than simply becoming detached, the child would dissociate conflicting memories, self-states, and object representations in order to segregate experiences of caretaker nurturance from those of abuse. This would allow the child to preserve a representation of the caretaker as a caring figure to whom attachment could be maintained, while simultaneously sustaining a separate sense of self as powerful, but detached.
From a cognitive perspective, Freyd (1996) suggested that memory for abuse would be dissociated to enable the child to continue behaving such that the caretaker would maintain attachment to the child. The notion that abuse would be dissociated to preserve attachment was supported by Williams’ (1994) finding that the inability of adult women to recall corroborated childhood abuse was directly related to the closeness of their relationship to the perpetrator.
In support of Barach’s contention, uninvolved caretaking in infancy was the strongest predictor of dissociative symptoms at age 19 (Ogawa, Sroufe, Weinfield, Carlson & Egeland, 1997). However, over 90% of BPD patients reported childhood abuse and neglect (Zanarini, Dubo, Lewis, & Williams, 1997).
Since parental neglect often contributes to occurrence of abuse (Barach, 1991), it would be difficult to conclude that one causes dissociation in the absence of the other without further study.
Development of Dissociated IWM’s: Disorganized Attachment
Liotti (1992, 1999) suggests that, in response to inexplicable, frightening, and dissociated attachment behavior on the part of the caretaker, the child is likely to construct multiple, incoherent, internal working models of the self, corresponding to disorganized/disoriented attachment. If there are other stabilizing relationships, and no abuse, one of the various models of self and other may predominate, with development relatively unimpaired. If exposure to disorganized, dissociative relationships continues, without significant maltreatment, a mild dissociative disorder, with switches among models of the self in reaction to interpersonal stressors, but no amnesic barriers between ego states, may develop.
If there is serious maltreatment, the child cannot integrate irreconcilable experiences of the abusive caretaker into a single, coherent internal working model of attachment. The child develops multiple, incompatible, segregated internal working models of the attachment figure that become the basis for development of dissociated ego states. Congruent memories of experiences are compartmentalized with compatible internal working models and are segregated from incongruent experiences. An amnestic barrier is maintained between incompatible models of attachment, which become increasingly dissociated.
This process is analogous to “dissociative, state-dependent compartmentalization” (Putnam, 1997, p. 71), and “parallel processing” of memories (Freyd, 1996, pp. 89-92).
Liotti (1992, 1999) suggests that disorganized/disoriented attachment may consist of rapid shifts between dissociated, anxious and avoidant attachment patterns. He proposes that these compartmentalized internal working models, with their corresponding memories and modes of behavior, become the distinct ego states observed in dissociative disorders.
Victim and Perpetrator Ego States: Anxious and Avoidant Attachment Patterns
A variety of internal working models of self vis a vis various attachment figures may develop. For the sake of simplicity, this paper will focus on the two self-and-object representations that enable the maintenance of attachment to an abusive, primary caretaker. As these representations of the self, the object, and the pattern of attachment develop from early experiential models, they are elaborated through continuing experiences of care and abuse from the caretaker, and through defensive maneuvers which are necessary for the child to minimize bodily harm, maintain attachment, and preserve psychic integrity.
The early internal working model which operates to maintain attachment to the abusive caretaker does so by incorporating experiences of nurturance and by dissociating awareness of pain, abuse and danger (Young & Gerson, 1991).
Because anger at the caretaker and attempts at self-defense are often met with retribution, this internal working model becomes adaptive by turning anger inward, remaining passive when abused, and placating the caretaker in order to minimize abuse. With time, this model of self and object may develop into a victim/masochistic ego state with an anxious/preoccupied attachment style (Ainsworth, Blehar, Waters & Wall, 1978; Alexander, 1992; Alexander & Anderson, 1994; Dutton, 1998).
In contrast, the internal working model that assimilates experiences of abuse operates in the service of self-protection. An avoidant/dismissive attachment style is developed (Ainsworth, 1978, Alexander, 1992, Alexander & Anderson, 1994, Dutton, 1998), which functions as a dissociative defense against abandonment (Barach, 1991; Bowlby, 1980). Under the current formulation, however, this attachment style would alternate with the preoccupied style, rather than being pervasive, as Barach suggests.
In BPD, when the masochistic ego state is active, the abusive introject functions as a harsh, punitive superego (Howell, 1997a). When the sadistic ego state is activated, the victim role is projected onto the object. Rageful behavior may be experienced as being “overtaken,” and its implications may be disavowed (Howell, in press). In DID, the introjected, abusive object becomes a sadistic, perpetrator, ego state which is experienced as a separate identity from the masochistic ego state (Blizard, 1997a, b).
Boundary Confusion: Internal Dissociation in Response to External Intrusion
Paradoxically, while development of masochistic and sadistic ego states requires the generation of intrapsychic dissociative boundaries, these states may derive from the loss of self-other boundaries. To survive in a relationship with an abusive caretaker, the child must continually focus on the abuser’s facial expressions, body language, and desires, until there is almost no awareness of one’s own thoughts, feelings and bodily cues. This narrowing of focus is comparable to the “freeze” state of an animal threatened by a predator (Nijenhuis, 1999; Nijenhuis et al., in press), and the robotic compliance and hypervigilance observed in abused children (Perry, 1999). The process was aptly described by Ferenczi (1949):
These children feel physically and morally helpless . . . the overpowering . . . authority of the adult . . . compels them to subordinate themselves like automata to the will of the aggressor, to divine . . . his desires and to gratify these; completely oblivious of themselves, they identify themselves with the aggressor. (p. 228)
Internally, the child suppresses or dissociates his own thoughts and emotional states. His total focus on the abuser creates the illusion that he feels the abuser’s feelings. Externally, the abusers in the family do not clearly perceive the child as separate (Bowlby, 1984). They project their own feelings, treating the child as an object or extension of themselves (Adler, 1985; Kohut, 1978), making the child feel he is the source of the abuser’s feelings and actions.
Ferenczi continued, “The most important change, produced in the mind of the child . . . is the introjection of the guilt feelings of the adult” (ibid.).
This boundary confusion sets the stage for the adoption of masochistic defenses. The child’s concentration on the caretaker maximizes her ability to appease the abuser. Introjecting responsibility for the abuse reinforces the illusion she can prevent it. But, inevitably, she is unsuccessful. She may then adopt a sadistic defense by introjecting the aggressor, perceiving herself as in control and exhilarated.
Relational Dilemmas: Preserving Attachment or the Self?
In the long run, neither masochistic nor sadistic defenses fulfill the basic psychic needs for attachment to a consistent object, protection from bodily or emotional injury, and rationality and justice in the world. Because these needs cannot be met simultaneously or reliably, abuse survivors are caught in a series of inherently unresolvable, relational dilemmas (Prior, 1996).
Each attempt to resolve a relational dilemma typically leads to a defensive solution, which in turn contains another dilemma, leading to a vicious cycle of masochistic and sadistic defensive strategies, each presenting another intolerable relational dilemma, as outlined in Figure 1.
Typically, masochistic defenses are used to preserve attachment, for example, rationalization that abuse is justified, introjection of guilt, dissociation of memory of abuse, idealization of the abuser, and turning anger toward the self.
As these repeatedly fail, sadistic defenses may be adopted, with disavowal of need for attachment, introjection of the abuser, and projection of pain and weakness onto a victim. The following case example illustrates the cycle of alternation of masochistic and sadistic ego states, as each dynamic structure is recruited to defend against the next impending threat.
Adaptive Needs, Maladaptive Behaviors, Masochistic and Sadistic Defenses
The attempts to resolve relational dilemmas, described in Figure 1, and illustrated above, are intended to meet adaptive needs for attachment, self-protection, rationality and justice. But the defenses marshaled in their service require dissociation of the alternate needs, resulting in maladaptive behaviors.
These adaptive needs, and the maladaptive behaviors and defenses characteristic of masochistic and sadistic ego states are summarized in Figures 2, 3 and 4.
By comparing masochistic and sadistic defenses, it is apparent that they are almost the converse of one another. Ironically, in both ego states, power to protect the self is sought via maladaptive control of the other, either directly, in the sadistic state, through domination, or vicariously, in the masochistic state, by total preoccupation with the object’s needs. Both ego states rationalize that abuse is deserved. Where the masochistic state tries to balance the scales of justice by devaluing the self and idealizing the abuser, the sadistic state does the reverse.
The structure and organization of the patient’s adaptive needs, the related masochistic and sadistic defenses, and the corresponding maladaptive consequences can serve as a template from which treatment techniques can be derived.
Dissociative Defenses Within and Between Masochistic and Sadistic States Masochistic and sadistic defensive strategies are inherently dissociative.
Because the masochistic defensive structure focuses on maintaining attachment, and dissociates the need for self-protection, it must be kept separate from the sadistic organization, which does the reverse, severing awareness of the two horns of the dilemma. But both these needs are imperative for survival, so, paradoxically, each defensive formation makes a provision for the conflicting need.
In the masochistic defensive structure, the self is protected by absorption in–and appeasement of–the abuser. In order to maintain attachment, the object is idealized. The abusive aspects of the object are dissociated from its internal representation and are introjected as a sadistic ego state, which often serves to protect the self by anticipating abuse and controlling behavior (Blizard, 1997b).
In the hope of protecting the self from abandonment, a controlling object is often sought out.
Treatment of patients with alternating masochistic and sadistic ego states can present quandaries, entanglements and impasses. What began as a dissociative solution for surviving the dilemmas of attachment to an abusive caretaker has developed into a defensive structure that offers illusions of safe attachment or detached self-protection, but in reality perpetuates attachment in abusive relationships. The dissociative nature of these defenses prevents perception of whole objects and acknowledgment of needs for both attachment and self-protection.
Because the traumatic history can evoke fear and distorted perceptions in interpersonal situations, the therapeutic relationship may precipitate volatile transference enactment, possibly potentiating countertransference reactions.
A relational approach to therapy (Davies & Frawley, 1994) offers a safe framework within which to observe the patient’s abuse-based attachment patterns, and explore more adaptive ways of relating. Much of the work of bridging dissociated ego states and comparing transference projections to reality can take place within the real therapeutic relationship.
The therapeutic processes outlined below can help to clarify the underlying defensive structure of alternating ego states, illustrate past and present interpersonal relationship dynamics, and provide a safe framework within which the patient can explore healthier patterns of relating.
A. The dynamics of victim and perpetrator states can be unraveled by observing patients’:
1. adaptive needs for attachment, self protection, and rationality,
2. relational dilemmas, and
3. defenses with their maladaptive consequences.
B. Transference enactment and countertransference responses may reveal:
1. the patient’s roles in past abusive relationships,
2. how perceptions of self and other were shaped,
3. the derivation of defensive strategies,
4. current interpersonal dynamics.
C. Comparison of past and present relationships can help the patient determine whether:
1. current defenses made sense under prior abusive conditions,
2. contemporary relationships present similar no-win situations, and
3. more adaptive behaviors are safe now.
The reader is cautioned that if masochistic states are prevalent, a person continuing to live within an abusive relationship may benefit little from therapy, unless they leave or the partner enters treatment and stops abusing. If sadistic ego states prevail, the patient may be functioning primarily as a sociopath, and would at best be preoccupied with manipulating the therapist.
Identifying Adaptive Needs, Defenses and Maladaptive Consequences
The goals of therapy are integration of dissociated ego states, synthesizing split perceptions of self and other, and development of effective skills for meeting needs for both attachment and self-protection. The therapist can function as“…a relational bridge over which different parts of the self . . . learn of each other’s existence, history, and functions. . . . the therapist attempts to speak empathically to all conflicting developmental and defensive needs” (Schwartz, 1994, p. 200).
The therapist must appraise the patient’s tolerance for awareness of the opposing ego state. Early on, it may be more effective to work within separate ego states. Too much confrontation with ego-dystonic attitudes and behavior may either reinforce dissociative defenses or break them down and lead to decompensation. Establishing rapport can begin during history-taking, by observing the patient’s varying modes of interacting, and making supportive reflections about the adaptive needs and predicaments addressed by the presenting ego state. Later, empathic observations may be made about both sides of the dilemmas. As the patient feels safer in the therapeutic relationship, there will be more appreciation for the purpose of the alternate ego state. Historical interpretations will be useful only after the patient has developed sufficient observing ego to view himself within that context. Figure 5 outlines steps that can be used to interpret defenses, minimize resistance and build adaptive skills.
Observations about fear of abandonment will be more readily accepted by masochistic states, whereas discussion of need to self-protect may prompt fear of retaliation and defensive idealization of the perpetrator (Howell, 1996, 1997a, b). Sadistic ego states may better receive interpretations about need to protect, as any mention of fear of aloneness will likely heighten the sense of vulnerability and provoke resistance. For a detailed discussion of treatment of malevolent ego states, see Blizard (1997b), Goodman and Peters (1995), and Watkins and Watkins (1989).
Initially, the therapist should take an active role in this process, so that the patient does not end up feeling literally defenseless. Later, the patient can be engaged in discovering her own adaptive needs, the maladaptive consequences of her defenses, and exploring alternatives.
Understanding Ego State Shifts
Addressing the maladaptive aspects of a masochistic defense may trigger a sudden switch to a sadistic ego state, or vice versa, which may unnerve the therapist and leave the patient unable to remember what was being considered a moment ago. When ego state changes are regarded as shifts of defensive tactics to escape relational dilemmas, then apparently unpredictable mood swings and irrational transference reactions can emerge as meaningful defensive maneuvers.
Observing that the preceding defensive tactic may have permitted self-protection but risked abandonment, or vice versa, enables exploration of:
1. The consequences of the defense that led to the shift in ego state,
2. The two sides of the dilemma, and how they’re approached by each of the ego states,
3. Why this shift in defensive strategy was necessary historically,
4. Whether fear of abandonment or abuse is realistic in the present circumstances.
Placing the dilemma within the historical context of powerlessness may help to relieve the patient’s self-condemnation over participating in, experiencing pleasure, or failing to escape abuse. Feeling justified, she can begin to perceive her present situation more realistically, without dissociating major facets of it. Contrasting the lack of viable alternatives in the past with her current life situation permits discovery of more adaptive means for attachment and self-protection, while maintaining awareness of potential threats.
Bridging Dissociated Ego States
Effective interpretation of switches between ego states must take into account whether the dissociation between ego states primarily segregates working models of interpersonal relationships, as in BPD, or creates a separate sense of identity, agency, and history, as in DID. There may be amnesia for traumatic memories in either case. To maintain functioning and avoid flashbacks, decompensation, or suicidal impulses, dissociative barriers must be broached gradually (Fine, 1991). The patient should be taught techniques for containing memories and managing the extent of sharing between ego states (Kluft, 1993, 1996, 1997).
In BPD, the significance of the behavior and uncharacteristic affect of the alternate ego state may be denied. The patient may experience a loss of agency or identity, expressed as “I felt out of control, as if I wasn’t myself.” Confrontation too early with ego-dystonic behavior may break down defenses, leading to depression, suicidal impulses or termination of treatment.
In DID, communication between states may cause intense reactions, because masochistic and sadistic ego states are often entangled in internal dynamics that mirror the relationships of the child with abusive caretakers.
Perpetrator ego states may be perceived of as separate persons, outside the physical body (Blizard, 1997a, b; Young, 1992), increasing the danger that one ego state may try to “kill” the other. A sadistic state may deem a masochistic state too vulnerable, inviting exploitation. She may abuse the victim state to reassert control and disown her own fear. The victim state may collude with the perpetrator state’s abuse to reaffirm the attachment between them. Or in the worst case, if the offending ego state is recognized as a part of the self before there is sufficient ego strength to understand its purpose, death by one’s own hand may be seen as a deserved punishment for abhorrent behavior.
Gradually helping ego states to acknowledge the adaptive roles of other states, within the historical context of their origins, helps the patient accept contradictory aspects of the self. This provides a framework within which masochistic and sadistic ego states can begin to appreciate the contributions of one another to survival, allowing integration of dissociated affects, perceptions, needs and memories into a more adaptive defensive structure.
Transference and Countertransference
In projective identification, perceptions, affects and needs that are not consonant with the prevailing ego state are projected onto the object. The patient behaves as if his disowned characteristics were part of the object, subtly manipulating the therapist to experience the unacceptable feelings and impulses.
“Patient and therapist become the inevitable participants in transference enactment, each unwittingly playing a role written from the patient’s past” (Baker, 1997, p. 214). The patient’s transference enactment may illuminate the dynamics of the active ego state, while the therapist’s countertransference reactions may reveal the disowned ego state.
In a masochistic transference, the patient tends to be dependent and idealizes the therapist, onto whom the abuser role is projected. Anticipating punishment or abandonment, the patient may be overly compliant, denying hurt or anger toward the therapist, unable to self-protect except by withdrawing. By accepting maltreatment as deserved, the patient risks becoming a “sitting duck” for a truly abusive therapist (Kluft, 1990).
Countertransference reactions to a masochistic state make it easy to miss seeing how the patient endangers herself, and be seduced into crossing therapeutic boundaries to rescue her. Conversely, the therapist may be maneuvered into contempt for the patient’s failure to self-protect, and collusion with her belief in martyrdom.
In contrast, in a sadistic transference, the patient appears self-sufficient, dismissing of the therapist, defiant, hypervigilant, and belligerently self-protective. The patient may become an ‘expert,’ projecting vulnerability, and making the therapist feel incompetent. In response to fear of rejection, the patient may intimidate the therapist. As one patient declared, “My fantasy is to kill you and myself so we can spend eternity together.” The risk to the therapist’s safety must continuously be weighed against the patient’s ability to contain acting out (Hall, 1989).
Because the natural response is to focus intently on a sadistic person’s perceptions and expectations, it is easy to be manipulated into a masochistic role, placating the patient, or failing to set therapeutic boundaries. Conversely, when bombarded with sadistic projections, the therapist may feel outrage, lose objectivity, become unable to interpret the vulnerability beneath the defenses, and retaliate sadistically.
For persons who grew up with abusive primary caretakers, caught, as if between the Scylla of abuse and the Charybdis of aloneness, masochistic and sadistic defenses offer only fleeting relief from the swirling vortex of relational dilemmas. Maltreatment must be dissociated to perpetuate attachment, while fear of abandonment must be disavowed to protect the self, an inherently maladaptive defensive strategy. A new therapeutic paradigm, based on understanding adaptive needs, relational dilemmas, and defenses in their historical context, provides a framework for attachment and self-protection to be perceived concurrently and pursued adaptively.
1. While pain or humiliation may be paired with sexual stimulation in the process of sexual abuse and thereby become a conditioned stimulus for sexual arousal, that is beyond the scope of this paper.
THE DEFENSE CASCADE, TRAUMATIC DISSOCIATION AND THE SELF
A Neuroscientific Model
Frank M. Corrigan, Ulrich F. Lanius and Brenna Kaschor
The brain areas critical for the generation of affective and defensive responses are the midbrain periaqueductal gray (PAG) and the hypothalamus (Panksepp, 1998). The brain areas closely interacting with the PAG and hypothalamus for top-down regulation of their functioning are in the prefrontal cortex and anterior cingulate cortex (Price, 2006). Trauma responses involve a rapid interchange between the prefrontal cortex and the midbrain; the cortex exerts a dominant influence when the threat is distant and the midbrain assumes control when the threat is close and immediate (Mobbs et al., 2007). That is, it is much easier to engage in a logical risk/benefit analysis when not already in the clutches of a predator or perpetrator. The learning pertinent to the stimuli or situations relies on the amygdala and the hippocampus so behaviorist paradigms have focused on these structures and their prefrontal controls, ignoring the generation of the affect itself. The areas of medial prefrontal and cingulate cortices that have projections to the PAG and hypothalamus also have projections to these limbic areas to allow a rapid recruitment of learned experience in further responses, creating a network functioning to promote survival and connection.
Individuals with complex posttraumatic stress disorder (PTSD) often have learned that certain defense mechanisms do not work for them, so threat induces a rapid bypassing of active defense mechanisms that have failed them in the past and the associated affects are turned inwards. For example, an assault triggers active defensive responses, with their autonomic components manifest in changes in breathing, blood pressure, and heart rate, through the PAG and hypothalamus. Elements of the situation are learned through limbic system circuitry, especially through basolateral amygdala (McGaugh, 2004) for stimuli, and hippocampus for context. If active defensive responses are overwhelmed by a power imbalance and an inability to escape, passive defensive responses are activated and the prefrontal cortex may go further offline as dissociative neurochemicals intervene. The limbic learning then includes unresolved (i.e., incomplete) defensive responses and unresolved affects, which can be elicited by triggers activating the PAG and hypothalamus even decades after the initial assault.
The PAG has a columnar structure with a rostrocaudal differentiation of inputs that gives it the potential for a range of affective and defensive responses (Bandler & Shipley, 1994). The dorsal PAG involved in active defensive responding engages non-opioid (cannabinoid) analgesia while the ventrolateral PAG has a capacity for opioid-induced analgesia.
Thus, there is an intrinsic neurochemical capacity for both high arousal and low arousal dissociation as part of a peritraumatic response. However, for long-term clinical dissociative responses, especially in relation to structural dissociation, it may be necessary that there is some coactivation of columns, perhaps combined with neurochemical effects at higher levels of the brain. We argue for a critical role of the opioids of the ventrolateral PAG column in the long-term effects of trauma.
The Complexity of Dissociative Experiences
We seek here to offer testable hypotheses for different types of dissociative experience. Neurochemical dissociation is the peritraumatic response to overwhelming affect and is mediated by endogenous cannabinoids and endogenous opioids, amongst other mediators of stress-induced analgesia. Structural dissociation (Van der Hart, Nijenhuis & Steele, 2006) is the long-term consequence of the neurochemical dissociation from extremes of affect and obstructed defensive responding. This is hypothesized to engage “upper level” circuitry (cortex – basal ganglia – thalamus – cortex loop; Alexander, Crutcher, DeLong, 1990), although originally energized by traumatic experience overwhelming “lower level” circuitry (superior colliculi – periaqueductal gray – intralaminar thalamic nuclei – basal ganglia – superior colliculi loop; McHaffie, Stanford, Stein, Coizet, & Redgrave, 2005). Finally, we consider dissociative experiences such as derealization and depersonalization (Simeon & Abugel, 2006) which are harder to study in animal models as they rely on self-report, although some extrapolation from models of state-dependent learning (e.g., Jovasevic et al., 2015) may be justified.
We propose that these dissociative phenomena (i.e., derealization and depersonalization) represent a disturbance of the balance of activations in the cortex such that the integrity of conscious awareness is experienced as, in some way, subjectively abnormal. Derealization can include experiences of feeling alienated from one’s surroundings, from one’s friends and family, and various distortions of perception. Depersonalization can include feelings of not owning one’s body, of not being in charge of certain actions and functions of the body, and perceptual distortions related to the body. As the neuroimaging findings of these phenomena are diverse it is proposed that these groups of dissociative experiences are referred to as intracortical dissociation. It is postulated that these arise from highly charged arousal of systems ascending from the brainstem which disrupt the normally integrated functioning of widespread cortical systems.
Alexithymia may be another manifestation of intracortical dissociation even when it originates in subcortical responses to painful experiences (see below).
Emotions – Basic Affective Circuits
Darwin (1872) emphasized the continuity of emotional phenomena from non-human species to humans. Emotions are essential to survival. They allow successful coping with objects and situations that are potentially dangerous or advantageous. They promote attachment on one hand and defensive responses on the other. They are observable with scientific probes such as psychophysiological and neurophysiological measurements and endocrine assays. In mammals, these emotional responses are dependent on similar areas of the brain across species, leading Panksepp (1998) to study them in laboratory animals and thus define Basic Affective Circuits (Panksepp, 2011).
Panksepp (2011) suggests that at least seven hardwired basic affective circuits reside in the subcortical (including brainstem) regions of the mammalian brain. These are SEEKING (reflecting a generic drive, motivation and expectancy), FEAR (anxiety, dread, flight), RAGE (anger, attack, fight), LUST (sexual excitement), CARE (nurturance), PANIC/GRIEF (sadness, acute separation distress), as well as PLAY (social joy, opportunity to exercise and experiment with all emotional systems). Here the term “emotion” is used not only for an affective experience which has a clearlydefined subjective component, but also for those basic biological affective responses to environmental events regardless of whether the cortex brings it to full reportable experience or not. In keeping with Lanius, Paulsen, and Corrigan (2014), for clinical purposes we consider shame to be an eighth basic affect in humans as there is visceral pain, a defensive response (to hide), and a sympathetic nervous system activation (Corrigan & Elkin-Cleary, 2018).
Panksepp (2011) emphasizes the role of ancient, in brain evolution terms, subcortical structures like the hypothalamus and midbrain in the expression of emotion. The midbrain, or mesencephalon, is at the topmost part of the brainstem which forms the connection between brain and spinal cord and includes the PAG. That is, while frontal and limbic structures (e.g., the amygdala and the ventromedial prefrontal cortices) may trigger emotions, they are not at the core of emotion generation. Given that emotions can be expressed by decorticate animals, as well as by humans born without a cerebral cortex (Merker, 2007), it appears that the relevant subcortical structures for the expression of emotion (e.g., PAG, hypothalamus) directly signal, chemically and neurally, to other brain regions and to the body.
Thus, the midbrain or mesencephalon can respond to environmental input in a reflexive manner, expressing the entire repertoire of basic emotions. It is instinctual and fast to respond. However, this way of expressing emotion does not necessarily produce complex feelings. The response is largely hardwired – though some basic associative learning is also likely involved –and occurs quickly with sudden state changes, as required by the situation.
In evolutionary terms, the human brain has developed systems for integrating information about “where” one is in relation to “what” is in the environment (Fricchione, 2011), a distinction perhaps most usually seen in relation to the dorsal and ventral visual systems (Goodale & Milner, 2006). Basic affects can be the first response to “what” the organism is oriented towards, an interaction that has its anatomical basis in the midbrain superior colliculi, reticular formation, and PAG, with cortical structures notably absent. When the “what” is so unbelievable, so impossible to countenance, or so incongruent with the expected experience that the capacity of these structures to process the input is overwhelmed, integration with “where” systems cannot readily occur. In this way, memories of unrelated or unexpected “what” stimuli can trigger these untethered basic affects. Grounding in the “where” self, in the body-centered space, becomes more difficult when there are these highly charged intrusions.
The Midbrain Structures
The tegmentum forms the ventral, or lower, part of the midbrain that is involved in many subconscious and reflexive pathways, including the relaying of inhibitory signals to the thalamus for the prevention of unwanted body movement. It includes the rostral part of the reticular formation, several nuclei coordinating eye movements, the red nucleus (involved in motor coordination), substantia nigra (involved in reward and movement), the ventral tegmental area (VTA) (involved in motivational salience, associative learning and positively-valenced emotions, including orgasm; Holstege et al., 2003), as well as the PAG (involved in analgesia, defensive responses, reproductive behavior, maternal behavior, play and joy) (see Figure 37.1).
The colliculi, superior and inferior, two of each, also referred to as the tectum or corpora quadrigemina, form the dorsal or upper part of the midbrain. While the inferior colliculi are active in the processing of auditory input, the superficial layers of the superior colliculi receive projections from the retina and are interconnected with the intermediate and deep layers for integration of visual information with somatosensory, auditory, and even olfactory signals. The general function of the superior colliculi is to coordinate behavioral responses toward specific points in ‘ego-centric’ or body-centered space. The collicular integration of sensory input with other information from the body, in conjunction with basic affective responses mediated by the PAG, immediately ventral to the colliculi, can be the most basic sensorimotor transformation to a stimulus for promotion of the survival of the organism.
The midbrain is in a crucial position for the integration of a single response to widespread activation of the cerebral cortex, what Merker (2013) refers to as the efference cascade. The massive processing power of the cortex cascades from layer five through subcortical centers to an integrative hub in the superior colliculi where a decision can be made about gaze and attention direction. Under normal conditions, there may be more control through pathways from cortex to colliculi but, as with the prefrontal cortex – periaqueductal gray (PFC-PAG) axis, threat conditions will bias the organism towards collicular dominance for rapid and effective responding. The midbrain is also closely connected with the cerebellum and has output tracts to the spinal cord, giving it the circuitry and connectivity for the regulation of the body’s postural orienting to the space around it. Panksepp (2003) suggests that the basis of the self is in the somatic motor map between the superior colliculi and the PAG, an idea explored by Solms (2021), and interestingly the PAG is the last structure to evidence activity in the face of imminent death (Panksepp, personal communication, April 19, 2009).
Integration of Information at the Subcortical (including the Brainstem) Level
Animal defense responses that occur at the level of the PAG (Carrive, 1993) are likely elicited naturally through stimulation of the superior colliculus (e.g., Evans et al., 2018) and the inferior colliculus (e.g., Brandão, Anseloni, Pandóssio, De Araújo, & Castilho, 1999) as electrical and chemical stimulation of the PAG elicits these responses in laboratory animals.
Essentially, the superior and inferior colliculi mediate orienting and goal-directed behavior through the integration of sensory input from the environment and their proximity to the PAG allows generation of affective and defensive responses without the delay of complex cortical processing.
That is, the capacity for integration of information in the lower brain structures depends on the colliculi. It is where sensory integration still occurs under extreme threat. The midbrain is an integrative hub which receives input from the neocortex and limbic system and directs outputs to the basal ganglia, also known as the reptilian brain in the triune brain model (MacLean, 1985), resulting in organized behaviors. Therefore organisms can engage in complex, species-specific, behaviors, and have affective responses in the body, without first thinking them through.
Higher Brain Stem Structures – Alexithymia and Feelings
Alexithymia, the inability to feel, or to experience feelings in a way which can be described in words, may be attributable to a negatively valenced state of the mesolimbic and mesocortical dopamine systems (e.g., Markovic et al., 2021).
However, alexithymia is commonly associated with dissociation (e.g., Reyno, Simmons, & Kinley, 2020) so may also be a manifestation of intracortical disequilibrium. Both states then arise from a disconnection between conscious aspects of experiences and perceptions, and an alteration in the subjective awareness of both the observing self and the body.
Feelings rely on transmission of sensory information to the neocortex, especially the somatosensory cortices, anterior cingulate and insula. It is those cortical structures that mediate body awareness and different patterns of body activation represent neural correlates of feelings, thereby allowing sensory awareness to inform our awareness of feelings.
Under normal circumstances, when an organism is not under threat, sensory information gets relayed by the thalamus to the cerebral cortex, allowing different mnemonic traces to be integrated at the cortical level. Selective thalamic deafferentation of the cortex in dissociative disorders may result in difficulties in integrating thoughts, feelings and experiences into consciousness and memory, negatively impacting emotion awareness/regulation and reflective functioning.
When there is a disruption of body awareness in dissociative disorders there is an alteration of the balance of activation of the medial prefrontal and insular cortices, with altered connectivity of the posterior insula (Harricharan et al., 2019) and altered medial prefrontal inhibition of limbic and brainstem regions (Frewen & Lanius, 2015). As the insular cortex is central to the processing of interoceptive sensations and the subjective awareness of feelings (Craig, 2015), one interpretation of such findings is that in PTSD without dissociation there is increased connectivity between the insula and cortical areas involved in sensorimotor processing and environmental monitoring resulting in a hypersensitivity and hyperarousal state. With dissociative disorders, on the other hand, the insula shows increased connectivity with more posterior cortical areas involved in implicit neural processing, leading to an overdependence on past experiences as compared to conscious awareness of the present when considering responses to the environment.
Under Threat – Decreased Cortical Function
Under threat the brain can shift from dominance of cortical functioning to subcortical functioning with a hierarchical mobilization of defense responses (e.g., Mobbs et al., 2007). Associated brain areas are the extended amygdala, hypothalamus, PAG, the tectum – superior and inferior colliculi, the ventral pontine tegmentum, ventral and dorsal medulla, and spinal cord. Many of these areas are in the brainstem rather than in the limbic system. The brain decreases information processing at the cortical level that is energy-intensive, and relatively slow, in favor of subcortical, mainly brainstem, information processing that is relatively fast and energetically more efficient. It is hypothesized that sensitization to traumatic experience occurs neurochemically in these brainstem and subcortical areas and creates the capacity for triggering by stimuli and contexts. Resilience to adversity may also have its base at this deep level but be dependent on how much of the stress experienced is controllable and escapable versus uncontrollable and inescapable (Horovitz, Richter-Levin, Xu, Jing, & Richter-Levin, 2017).
BASIC Affective Circuits – Defensive Emotions
For this chapter the focus is on those basic affective circuits that are commonly activated under threat. These include SEEKING, FEAR, RAGE, and GRIEF/PANIC. In any perilous situation the dominant defense response evoked will depend on the nature of the threat and the context within which it occurs, the species-specific defense repertoire, as well as on genetic predisposition and individual differences derived from the organism’s attachment and trauma history.
SEEKING safety with a parent or with other conspecifics (animals belonging to the same species) is usually the initial response to a threat. If there is nobody available who provides rescue, perhaps through protection from the threat, FEAR or RAGE are then mobilized. Herd species, as well as anxious individuals, are more likely to initially respond with FEAR and a flight response, whereas predatory species and combative individuals are more likely to engage in RAGE or fight before fleeing. If neither fight nor flight are successful, or are not expected to be successful, the energy expenditure is wasteful, another strategy is required, and ultimately immobility ensues. The more severe and inescapable the threat, the more likely some form of immobilization will occur. This may be initially with rigidity of the body, as in tonic immobility, but as the situation becomes more dire a hypotonic or collapsed immobility will follow. Panksepp and Biven (2012) consider panic attacks to be functions of the activated GRIEF/separation distress, rather than the FEAR, system, and this explains their response to tricyclic antidepressants rather than to benzodiazepines. When the threat to life has been accompanied by an intense feeling of aloneness and abandonment, trauma survivors may have activation of both FEAR and GRIEF systems, a combination of terror and panic which can be utterly confusing.
Defense Responses are Hierarchical
Defense responses occur in a hierarchical manner and the dominance of fight or flight may reflect the position and size of the threat, whether it is physical or social, and whether there is previous sensitization through adverse experiences.
Fight and flight responses are dependent on the dorsal PAG, that is, on the lateral and dorsolateral columns (l/dlPAG).
Initially, active defense responses dominate in the defense cascade. In an infant, the initial defense response to a potential threat is an orienting response, looking away from the threat and towards a place of safety or a person who may provide safety. This may be followed by a more organized SEEKING of a primary attachment figure for protection. If a caregiver – usually a parent – is available and the caregiver’s CARE circuits can be activated, the infant’s sense of safety can be reinstated. In some cases that may involve the caregiver engaging in a fight response or RAGE directed toward the potential threat to protect the infant.
If such support is unavailable in the face of threat, a RAGE and fight response may be mobilized to ward off danger. If the threat is more than the organism may reasonably be able to overcome, or if the fight response has previously proven unsuccessful in similar situations (as in child neglect or abuse), the RAGE response is unlikely to be fully expressed.
That is, it becomes obstructed and/or internalized. The next defense response, flight, may also be unavailable to a small child if the caregiver is additionally the perpetrator and the source of the threat: there is nowhere to escape to. Again, the defensive response is obstructed while the associated affect, FEAR, is experienced and turned inwards, especially if a display of emotion increases the risk to the child. That is, the terror has no outlet in action, and the situation of threat is experienced as inescapable or uncontrollable. Despair, immobilization, and collapse may ensue. The inhibition of fight-and-flight responses because they will be ineffective, or even make the situation more dangerous, can have long-term consequences. It appears that the internal inhibition is not simply a prefrontal cortex block on defensive action which can easily be thrown off when the event has passed but rather is a deep paralysis of responding, rooted in brainstem systems, that confers increased vulnerability in later years when the required defenses are found, in moments of sudden threat, to be unavailable. This involuntary failure to defend, because of the early learning that obstructs the necessary actions, then adds to the burden of shame and guilt carried by the unfortunate victim who will not be easily convinced that it was early programming rather than a personality characteristic that was contributing to further traumatic experiences.
The enabling of the individual to clear the rapid and involuntary bypass of active defense responses, so that these are again available when required, may reduce the risk of re-traumatization.
Last Resort – Collapse, Despair, Immobilization, Death
The last defensive responses are passive rather than active and are mediated by the ventrolateral column of the PAG. The autonomic components of these responses, which give rise to low blood pressure, bradycardia, and slow breathing, are likely the result of the withdrawal of sympathetic nervous system activation (Keay & Bandler, 2001), and activation of vagal motoneurons by projections from the ventrolateral column of the PAG (vlPAG) (Bandler & Shipley, 1994). Other important changes with this state, such as opioid-induced analgesia and decreased level of arousal, are also mediated by the ventrolateral PAG through opiate receptors. For example, direct injection of ß-endorphin into the PAG produces profound catatonia and immobilization (Sakurada, Sokoloff & Jacquet, 1978), a state antithetical to interpersonal or relational connection. Generally, significant opioid-mediated vlPAG activation under threat is associated with separation, withdrawal, and immobilization, perhaps preparing the organism for impending death. This results in a decrease of cortical functioning, with affective information no longer being relayed to the cerebral cortex, resulting in truncated affective circuits.
These truncated affective circuits can occur with active (fight, flight, hide), as well as with passive (low arousal, collapsed immobility) responses. (Freeze, it was argued in Lanius et al. (2014) could be a high arousal or a low arousal state depending on the activated area of the PAG). The likely reason that affective circuits associated with active defense responses become truncated is the incomplete expression of those l/dlPAG-mediated active defense responses due to immobilization or obstructed expression that results from simultaneous vlPAG-mediated parasympathetic activation or organ-specific sympathetic withdrawal (also see below). That is, while the parasympathetic response predominates, this may be masking concurrent strong sympathetic activation. Thus, active defensive responses will not in themselves necessarily lead to structurally-dissociated states, as these can be fully expressed and recovered from with little emotional impact. Even when they are accompanied by stress-induced analgesia through endogenous cannabinoids (Riebe, Pamplona, Kamprath, & Wotja, 2012), for example, they can clear without long-term impact. People can shrug off even intensely vitriolic exchanges and terrifying flight events and move on in their lives without apparent hurt or continuing fear.
What is different with traumatic experiences, we suggest, is that there is concomitant involvement of passive defense response areas and associated endogenous opioids. Then there may be a subjective experience of being unable to fully express feelings, of numbing out, of not being fully present, of some kind of dysphoric discontinuity with the situation.
The terror, rage, panic or shame, or some combination of the affects associated with the active defense responses, have peaked at a level which necessitates neurochemical capping for physiological safety; then there is not only the high arousal dissociation but the simultaneous emergence of the passive defense responses. To put it another way, when the active defense responses are not expressed freely and effectively, but are instead truncated or obstructed, then the vlPAG with its opioid-mediated potential for dissociation is simultaneously engaged. This, we suggest, forms the basis of structural dissociation and separate ego-states. That is, ego states that hold traumatic material associated with mammalian active defensive responses driven by the l/dlPAG are conditioned to also elicit a vlPAG response, every time they are accessed, thus interfering with therapeutic efforts to integrate them at the cortical level. When the structurally dissociated self-states are sufficiently cortical that they can take executive control it may be that they have then left behind their neurochemical origins in the PAG and are working through relatively independent cortico-striato-thalamo-cortical loops.
Dorsal and Ventral PAG – Active vs Passive Defensive Responses
Lateral/Dorsolateral PAG (l/dlPAG) Activation
The active and passive coping mechanisms mediated by the PAG have characteristic autonomic nervous system (ANS) responses, but they also have skeletomotor and antinociceptive components and it is misleading to see the ANS changes as paramount and somehow independent of the controls in the prefrontal cortex and PAG. For example, l/dlPAG responses include non-opioid (likely cannabinoid) analgesia, increased blood flow to specific muscle groups, depending on whether the preparedness is for fight or flight, as well as hypertension and tachycardia. The vlPAG has projections to the rostroventrolateral medulla (RVLM) for inhibition of sympathoexcitatory neurons, which can block an increase in blood pressure and pulse rate (Longhurst, 2011). Hypothalamic regions, such as the paraventricular nucleus, interact with the prefrontal cortex and the PAG in the control of ANS changes (Dampney, 2011) but the hypothalamus may be functioning independently of the PAG in some pressor responses (catecholamine-induced increases in blood pressure) when the stress is psychological rather than physical (Carrive, 2011). For this chapter we consider the lateral and dorsolateral PAG columns as functionally together although the dorsolateral column receives inputs from highly evolved areas of the medial prefrontal cortex in humans and may have a specific role in emotional responses to cognitive processes (Dampney, 2018).
While common notions of sympathetic nervous system (SNS) and parasympathetic nervous system (PNS) activation suggest that autonomic balance is reciprocal in nature, they ignore the case of psychological stressors that, if sufficiently large, can result in coactivation of the sympathetic and parasympathetic systems (Berntson, Norman, Hawkley, & Cacioppo, 2008). Parasympathetic dominance is generally considered desirable for health outcomes but this may not be the case when high levels of sympathetic coactivation occur. Indeed, massive and simultaneous activation of both sympathetic and parasympathetic activation that can become antagonistic, a so-called “autonomic conflict,” is a potentially lethal phenomenon. Simultaneous signals for tachycardia and bradycardia can result in lethal arrhythmias (e.g., Shattock & Tipton, 2012).
The co-activation of sympathetic and parasympathetic systems may in part reflect the activation and readying of both active defense responses, like fight and flight, and the passive defense response of immobilization, where immobilization interferes with the discharge and completion of the active defense response. Further, it is likely that stress-related opioid release not only truncates the active defensive responses but also triggers high levels of sympathetic and parasympathetic coactivation by simultaneously stimulating both noradrenaline/norepinephrine and acetylcholine (Bouaziz, Tong, Yoon, Hood, & Eisenach, 1996). Tonic immobility is the defensive response state most clearly demonstrated to involve dorsal and ventral PAG coactivation: in this state activation of both SNS and PNS is likely. A combination of entrapment and FEAR sufficient to elicit tonic immobility in animals has been demonstrated to involve the superior colliculus and a coactivation of lateral and ventrolateral PAG columns (Vieira, Menescal-de-Oliveira, & Leite-Panissi, 2011).
Kreibig (2010) emphasized that each organ is innervated by distinct sympathetic and parasympathetic pathways such that individual circuits can be engaged. The direct SNS innervation can activate organs precisely and selectively, separate from the adrenomedullary hormonal system which makes metabolic adjustments, although the two parts may work together when there is an emergency.
As we have seen above, active defensive responses initiated by the l/dlPAG and hypothalamus are generally mobilizing and require energy expenditure mediated by the SNS. The l/dlPAG initiates a RAGE/Fight or FEAR/Flight response that is commonly characterized by a release of adrenaline and noradrenaline associated with increased heart rate, increased blood pressure and cardiac output. Simultaneously, there is skeletal muscle vasodilation with concomitant cutaneous and gastrointestinal vasoconstriction, but this is region-specific depending on the defensive needs of the situation. In addition, pupillary dilation and bronchial dilation may occur, as well as hairs standing on end (piloerection).
The overall effect is to prepare the organism for response to imminent danger. Sympathetic activation essentially has a mobilizing and accelerative function.
Ventrolateral PAG (vlPAG) Activation
In contrast to sympathetic activation, parasympathetic activation has a decelerative or braking impact on the body’s functioning. The parasympathetic response is associated with decreased heart rate and blood pressure, bronchial constriction, and decreased respiration. In addition, constriction of pupils, increased production of saliva and mucus, promotion of digestion, and increased urine secretion may occur. A sense of safety allows the relatively risky – due to heightened immobility and a concomitant inability for the organism to mobilize active defense responses – engagement in excretory functions. During massive stress-related parasympathetic activation, a loss of cortical control over excretory functions can also occur, a phenomenon that may confer a survival advantage in that it may induce disgust in the predator and thus decreased interest in the food value of the victim. The pontine micturition center is largely under the control of the PAG, which mediates the influence of the anterior cingulate and insular cortices (Drake et al., 2010).
Parasympathetic activation is generally considered a positive goal state, being responsible for stimulation of “rest-and-digest” or “feed and breed” responses (e.g., McCorry, 2007). However, parasympathetic activation is likely more complex. In the vlPAG it may depend on whether the hormonal environment is suffused with oxytocin or stress hormones such as corticotropin-releasing factor (CRF). That is, in both instances the organism may exhibit a withdrawal of sympathetic activation. Yet, in one case, the organism may be calm while, in the other, it may have disconnected and be detached from its outer world. The hormonal environment of the vlPAG is likely to be the determining factor, along with the nature of the input from the prefrontal cortex.
Activation of vlPAG in an extreme threat condition acts to decrease metabolic activity and heart rate during hiding and death feigning. When the animal can’t fight or flee, when the terror is intense, and the end of life is imminent, vlPAG activation typically ensues. The sudden withdrawal of SNS activation via the rostroventrolateral medulla is accompanied by activation of dorsal vagal motoneurons via the same pathway. This hard brake ultimately results in immobilization and freezing and a shutdown of the nervous system, in part through an endogenous opioid-mediated dissociative or numbing response, perhaps surrendering and preparing for death. We hypothesize that it is this type of vlPAG activation that accounts for the extensive duration of the “void” states of detachment. The vlPAG has a high density of opioid receptors and its analgesia is opioid-mediated. It is activated by physical restraint, as well as by electric, opioidergic and cholinergic stimulation. It is likely the involvement of the opioid systems of the vlPAG that ensures that obstructed l/dlPAG active defense can be transmuted into differentiated self-states.
The vlPAG-mediated collapsed immobility must be distinguished from the state of tonic immobility commonly encountered in survivors of interpersonal trauma. Tonic immobility is a state of speechless rigidity and terror, which can be seen in animals who are subjected to helpless entrapment. The animal studies show concomitant activation of lPAG and vlPAG (Vieira et al., 2011); that is, concurrent involvement of areas for active and passive defensive responses and their motor and ANS accompaniments. Tonic immobility is sometimes considered to be a passive response, because of the immobility, and sometimes an active response, because of the rigidity of the muscles and the fluctuations in the ANS.
Opioidergic simulation of the vlPAG increases immobilization, an effect that can be reversed with the opioid antagonist naloxone (Monassi, Leite-Panissi, & Menescal-de-Oliveira, 1999). That is, activation of the vlPAG results in immobility, loss of tension of the muscles, bradycardia and reduced respirations. It is no surprise that altered PAG function and connectivity has been reported to be associated with prolonged stress (Della Valle, Mohammadmirzaei, & Knox, 2019), as well as PTSD (Brandão & Lovick, 2019) and its dissociative subtype (Harricharan et al., 2016). Also, immobilization may be at the juncture between traumatic stress and altered immune system functioning as immobilization resulting from acute restraint induces opioid-mediated immune system effects, particularly in the ventromedial hypothalamus and the PAG (Farabollini et al., 1993).
Adjacent to the vlPAG in the midbrain is the dorsal raphe nucleus (DRN), which is the source of ascending serotoninergic responses to stressors such as inescapable tail shock in laboratory animals. If the animals are then subjected to another stress, a cold swim stress, cytokine changes indicative of a pro-inflammatory response are seen (Donner et al., 2018). A difference between the relative weighting of ascending projections from the DRN to the cortex and to the amygdala may account for some of the impact of stress and trauma on mood, in addition to inflammatory responses, and it has been proposed that therapeutic interventions in this circuitry may be beneficial for PTSD (Alexander & Vasefi, 2021). In dissociative disorders there are frequently impairments of physical health that appear to be the result of an accumulation of stresses. Given that disorganized attachment predisposes to the development of dissociative disorders (see Schimmenti, Chapter 10, this volume) it is of interest that maternal separation of a rat pup is used in animal models of irritable bowel syndrome (Larauche, Mulak, & Tache, 2012). The critical brain areas for the effects of trauma mediated by CRF and pro-inflammatory cytokines will be in PAG (Borelli et al., 2013) and hypothalamus (Jiang, Rajamanickam & Justice, 2019) in addition to DRN (e.g. Donner et al., 2018) and limbic structures.
The l/dlPAG are involved with positive affect systems such as CARE/Nurturing and it is often unrecognized that positive affects engage the SNS through l/dlPAG. The vlPAG is engaged for states of calmness and connection when its environment is imbued with oxytocin and opioids in a safe and secure, rather than life-threatening, situation. Essentially, the quiescence of the vlPAG activation appears to have been modified in a way that immobilization can occur in the absence of fear to serve the intimate needs of mammals that involve parturition, nursing, and the establishment of social bonds (Carter, 1998; Insel & Young, 2001). The PAG is at the core of the affective connection and attachment that involves the SEEKING and CARE circuits. These require the capacity to switch readily between the SNS activation of dorsal PAG and the soothing and calming emotional regulation of the vlPAG which is, at least in part, oxytocin-mediated.
Peritraumatic Dissociation, Structural Dissociation, Intracortical Dissociation
From the foundations and mechanisms outlined above, which are derived from clinical observation combined with animal and human neuroscience findings, we argue that peritraumatic dissociation reflects an acute neurochemical capping of the physiological components of an affective and defensive response. The neurochemical modulation is acutely necessary not only for analgesia but for the prevention of fatal states of activation. However, that essential regulation can establish circuitry that is a substrate for relatively independent activation of physiological responses to threat stimuli. “Triggers” become detached from the context in which they first occurred and stimulate emotional responses disproportionate to the environmental event. This circuitry is initially at the lower level of midbrain – thalamus –basal ganglia – midbrain looping (as described by McHaffie et al., 2005) but acquires a different form of agency, and autobiographical details, when it additionally engages upper-level circuitry (as described in Alexander et al., 1990). The varieties of presentations of structural dissociation then depend on the relative degree of connection or disconnection between upper and lower levels.
Derealization and depersonalization are hypothesized to be forms of intracortical dissociation in which a disturbance of integrated functioning of the cortex leads to subjective states in which the coherent sense of self in relation to the body and the environment is disrupted. Traumatic activation of ascending noradrenergic systems from the locus coeruleus is hypothesized to be one such mechanism but cholinergic, dopaminergic, and serotoninergic projections may similarly be involved.
We have considered the PAG to be the core structure in affective and defensive responding and therefore key to the development of post-traumatic and dissociative disorders, in their various clinical manifestations. We have highlighted the theory that the long-term effects are not mediated entirely by whether neurochemical dissociation occurs at the time of the traumatic experience but also by whether the combination of active and passive defense responses has specific long-term neurochemical and structural consequences. These consequences include the truncation of resolution of the affective and defensive aspects of traumatic experiences and this leads to the detachment of upper-level circuits through the basal ganglia, thalamus, and cortex for the expression of the different parts of the self. We also offer for testing the hypothesis that intracortical dissociation of the type which presents as the subjective experience of derealization or depersonalization can be the result of overwhelming activation of ascending neurotransmitter systems from the brainstem which initially bypass the affective and defensive aspects of the traumatic experience. The alarm circuitry involving the noradrenergic locus coeruleus, rather than the PAG, is critical in this arousal (Corrigan & Christie-Sands, 2020), but cholinergic, serotoninergic, and dopaminergic systems are also involved in response to adversity (see below).
An animal model of dissociation (Vesuna et al., 2020) which focused on the retrosplenial cortex observed an enhancement of thalamic connectivity with posterior cortical areas and a reduction of connectivity with frontal cortical areas.
It is, we expect, that kind of intracortical disturbance or altered connectivity that would be experienced by the patient as derealization or depersonalization. Shocking disconnection and horrifying misattunements experienced by an infant in a disorganized attachment may activate this pathway momentarily before there is any affective or defensive response (Corrigan & Christie-Sands, 2020).
Attachment – Setting the Stage
Severe dissociative disorders arise from disorganized attachment in infancy (Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006) being followed, or accompanied, by neglect and abuse (Ross, 1997). This means that theories on the neurobiological origins of dissociative disorders require a focus not only on neurochemical responses to threat but also on disorganized attachment. It will be readily seen how erratic responses from the caregiver lead to the activation of basic affects such as fear, rage, grief, and shame – and we have seen how PAG activation can engage neurochemical mediators of dissociation – but what of the urge to attach itself? Are there subcortical systems for connection underlying the advanced attachment capabilities of the prefrontal cortices?
The first point of response to a sensory stimulus is in the superior colliculi. The infant’s midbrain will be activated by mother’s face, voice, and touch. Through the midbrain reticular formation, an area of the tegmentum which contains various nuclei, this connection will have an impact on ascending systems from the brainstem. For example, an unsatisfactory interaction will activate the mesolimbic cholinergic system and manifest as an anxious state with distress vocalizations (Brudzynski, 2021). In contrast, an engaging interaction will result in a motivated movement through dopamine systems ascending from the midbrain. Watt and Panksepp (2009), in a model of depression, have emphasized the importance of oxytocin and opioids in blocking the effects of stress in the context of secure attachments and much of their impact on emotional state may be mediated by the dopamine pathways from the midbrain to the limbic system (mesolimbic) and from the midbrain to the cortex (mesocortical). The basic affective response to a stimulus in the mother-infant interaction comes from an activation of the PAG via the superior colliculi.
Attachment and Endogenous Opiates
Human attachment is at least in part mediated by the endogenous opiate system. Brain circuits involved in the maintenance of affiliative behavior are those most richly endowed with opioid receptors (Kling & Steklis, 1976) and, in general, the endogenous opioid system is activated by positive social interactions. Opioids result in feelings of comfort and alleviate emotional distress arising from loss and social isolation, as well as attenuating the reaction to social separation by powerfully inhibiting separation distress (Panksepp, 1998; Panksepp & Biven, 2012). Bonding to the mother and mother preference particularly appears to be mediated by endogenous opioids (Shayit, Nowak, Keller, & Weller, 2003).
It is important clinically to appreciate that the response to opioids is non-linear: a low basal level of opioids increases, whereas a high level of opioids decreases, motivation to seek out social contact.
Attachment, Stress, and Opioidergic Activation
Stresses like helplessness and terror cause massive opioid activation that coincides with immobilization. Further, the stress associated with immobilization ‘per se’ is a stressor that induces endogenous opioid activation. We have seen that the vlPAG is particularly important in mediating this. Further, such immobilization does not necessarily need to be physical: it can be social. Bandura, Cioffi, Taylor, and Brouillard (1988) gave an unsolvable math task to student probands and found decreased pain perception that could be reversed by an opioid antagonist (naltrexone), consistent with significant opioid activation. In contrast to physical injury, which activates the lateral PAG column, social or psychological stressors tend to activate the dorsolateral column, in addition to the ventrolateral column (Keay & Bandler, 2001).
Oxytocin and opioids combine in the vlPAG to modulate the pain (Yang et al., 2011).
Opioid Effects – Sensory and Affective
Opioids have both sensory and affective effects. Opioids decrease affective aspects of pain not only through release in the PAG but also in the parahippocampal gyrus, amygdala, and anterior insula. Sensory aspects of pain are less affected – with a linear dose relationship evident in primary and secondary somatosensory cortices and the posterior insular cortex (Oertel et al., 2008). Given the regions involved it is likely that opioid activation accounts at least in part for the decreased experience of emotion encountered in alexithymia, as well as having an impact on a person’s sense of self in relation to their body. Disturbances of insular cortex functioning may be involved in some of the dissociation states described collectively as intracortical; altered functional connectivity of the insula has been reported in PTSD (Harricharan et al., 2019).
Interoceptive awareness arising from the anterior insular cortex (Craig, 2015) may be enhanced, at least in certain respects, in some patients with dissociative disorders whereas others have an impairment of this function and have difficulty observing visceral responses. We do not know of any work linking the degree of interoceptive awareness, enhanced, normal or blunted, with behavioral manifestations indicative of emotional dysregulation in dissociative, and other, disorders. For example, there is an association between the withdrawing behavior of mothers towards their infants and self-harm behavior when those infants had grown to be 19 years old (Lyons-Ruth, Bureau, Holmes, Easterbrook, & Brooks, 2013), but correlations with interoceptive awareness and insular connectivity in this group have not been studied. Will there be times in which the emotional pain is so great that some form of self-harm is used as a regulator of it? Will there be other pain conditions manifesting in later life which have their origins in such adversity?
Emotion Dysregulation in PTSD and Dissociative Disorders
The early traumatic experiences encountered in disorganized attachments engender dissociative responses and defenses. The enhanced medial prefrontal cortex activity seen in the dissociative subtype of PTSD, relative to the re-experiencing subtype (Frewen & Lanius, 2015; See Schiavone & R. Lanius, Chapter 39, this volume), may be an adaptive strategy that suppresses the distress in such a way that the child can continue to function apparently normally. That is, the short-term neurochemical defense is replaced by a longer-term functional adaptation with the same goal of reducing the experience of distress. This has the side-effect of a continuing inability to feel and, perhaps, an inability to read emotion, which impairs relationships and inhibits the development of other pathways to emotion regulation. There are then intrusions of affects that are not understood because they are appearing out of context, without clear precipitants, and for which there are no learned methods of coping that are not dissociative. As the person with the dissociative disorder gets older, there is often a breakthrough of memory and associated affect which can be experienced as overwhelming. There is then a rapid switching between the over-control and under-control of the prefrontal cortex with a sense of loss of control of the unpleasant affects. In dissociative PTSD it is found that even at rest there can be intrusions from the PAG (Harricharan et al., 2016), which have an impact on self-agency and self-worth. It is not clear why some patients with complex trauma histories have greater problems with emotional dysregulation while others are more likely to have dissociative disorders. It may be linked to a propensity for hypnotizability (Dell, 2019; See Dell, Chapter 14, this volume), but the biological underpinnings of this are not clear.
Attachment – Seeking for Food
We have seen that the mesolimbic dopamine system is essential for the motivation to attach. Another ascending dopamine system, the nigrostriatal system, is necessary for movement behaviors that work in synchrony with the drive for attachment behaviors (Feldman, 2017) but also for seeking food that is essential for survival. Until this motor system is fully functioning to allow exploratory behavior such as foraging, the nutritional needs of the infant must be met by the parents and primary caregivers. Separation from this primary source of nutrition would be life-threatening so this readily stimulates distress states and the associated vocalizations, for which the mesolimbic cholinergic system is important (Brudzynski, 2021). If the distress vocalizations of this protest state are unmet by a caregiver and an adequate food supply is not forthcoming, despair, in the sense of loss of drive and loss of hope, will develop and the balance of oxytocin and opioids in the vlPAG will shift towards analgesia. With continued absence of adequate caregiving, the vlPAG more fully converts to negative valence – as does the mesolimbic dopamine system (Watt & Panksepp, 2009).
These changes promote energy conservation to facilitate survival for as long as possible while the young child becomes increasingly helpless and hopeless. The changes in endogenous opioids are now serving to prepare for a painless death. If the caregiver returns and meets the need through feeding with milk, nutrients such as caseomorphine activate opioid receptors and infant calling rates are much reduced. The profoundly relational attention of the caregiver stimulates the release of oxytocin which modulates not only the potentially addictive nature of caseomorphin but also other endogenous opioids.
Neglect in infancy must have many and profound effects on the systems ascending from the brainstem and on their neurochemical environments. Some of these effects are mediated by endogenous opioids. For example, studies with rodents suggest that lack of caregiving during the first few weeks of life decreases the number of opioid receptors in the cingulate gyrus and thalamus (Bonnet, Hiller & Simon, 1976). With fewer receptors to bind available opioids, the capacity of the opioid system to modulate neural functioning likely becomes severely compromised. That is, fewer receptors exist to bind released opioids secondary to stress, and they are likely to become saturated more quickly, thus resulting in more pronounced vlPAG activation, including dissociation, in response to even a relatively minor release of endogenous opioids. The ensuing decreased modulation will increase the likelihood of a sudden or abrupt shutting down of the nervous system. The subgenual anterior cingulate cortex (BA25) is one of the medial prefrontal network areas that has projections to the ventrolateral PAG (Price, 2006) so is likely to be the key prefrontal area for this effect.
In short, with a decreased number of receptors available to bind released opioids, the brain is more sensitive to the release of opioids with the effect of decreased modulation. Not only may the limited number of receptors account for a decreased capacity to experience pleasure, it likely accounts for the increased likelihood of dissociative shutdown in the face of stress in individuals that have adverse attachment histories.
Child Rearing – Pain, Isolation, Social Defeat
We argue that peritraumatic dissociation reflects the consequences of the brain’s inability to integrate information from the outside world, filtered through the colliculi, with the internal concepts of the self and its relationship to the world. The resulting fragmentation requires compartmentalization for continued adaptive functioning in the world.
The caring and reassuring presence of an attuned parent or support figure in the peritraumatic period will help to regulate the distress such that the traumatic event can be processed and integrated into the episodic narrative of the person’s life. The abnormal neurochemical environment that has potentiated the experience of dissociation can be normalized, and the dimensions of time, thought, body and emotion can return to the present (Frewen & Lanius, 2015; See Frewen, Wong & R. Lanius, Chapter 19, this volume).
Child rearing is crucial in determining the likelihood of dissociating under stress as it provides a template for which defense response is dominant in a person’s repertoire. Relational disruption, and the attendant pain, may be followed by fear, rage, grief or shame, all affects dependent on the dorsal PAG. However, stressors such as threat of abandonment, withdrawal of love, lack of connection, and being overpowered physically or emotionally, will also trigger excessive opioid activation in the vlPAG. This in turn makes immobilization more likely, acting as a biological leash that decreases the need for supervision/engagement on the part of a parent and contributes to dissociative responses. Interfering with exploratory behavior – as is frequently the case in overly anxious or excessively disciplinarian parents –has similar effects to neglect, presumably because the impaired opportunities for positive affect are compounded by negative affects in response to feelings of entrapment or threat. Decreased PLAY, CARE, LUST, SEEKING and a lack of exercise of basic affective circuits likely results in a lack of positive emotions and decreased opioid receptors.
Dissociative Disorders – Implications for Therapeutic Interventions
Endogenous opioids are dominant in the passive defense response, whereas endogenous cannabinoids are more involved in the active defense responses. When one starts blocking the opioid system with an opioid antagonist like naltrexone or naloxone, one starts biasing the nervous system away from a passive defense response towards an active defense response.
The attendant opioid withdrawal can have different effects depending on the social context, precipitating either vasopressin release when threat is detected or oxytocin release when there is a sense of safety. Vasopressin is associated with either FEAR, flight, and avoidance or alternatively RAGE, fight and attack. Oxytocin, on the other hand, is associated with an activation of SEEKING and CARE circuitry. Opioid blockade facilitates cognitive processing and cortico-thalamocortical processing of visual stimuli (Lensing et al., 1995) and naltrexone has been found to result in alpha-blocking that is associated with increased exteroceptive awareness (i.e., grounding). We have seen that the administration of opioid antagonists to the vlPAG decreases immobilization and this explains the effects of naltrexone clinically.
For example, beneficial treatment effects have been reported with low-dose naltrexone in patients with dissociative disorders (Pape & Woller, 2015; Pape, 2020) and Complex PTSD (Lanius & Forster, 2020). Among the reported positive effects were a clearer perception of both the environment and the person’s awareness of their inner life; an increased ability to assess and cope with reality; an increased body awareness; better affect tolerance; and improved self-regulation.
While opioid antagonists are potentially problematic, especially when used as a stand-alone treatment for dissociative disorders, their reported benefits have theoretical implications for the pathophysiology of these conditions (Lanius & Corrigan, 2014). Indeed, animal studies suggest that chronic naltrexone administration produces receptor upregulation and increased opioid receptor density (Lesscher, Bailey, Burbach, Van Ree, Kitchen, & Gerrits, 2003), thus potentially reversing some of the neurobiological effects of neglect described by Bonnet et al. (1976). Understanding how the nonlinear effects of opioids interact with an individual’s genetic and epigenetic make-up will be key to unlocking the therapeutic potential of the opioid system in trauma and dissociation. Clinical observations suggest that the administration of opioid antagonists may sensitize the cannabinoid system. That is, cannabis users commonly report requiring lower doses of cannabinoids to achieve the same effect, whether it is therapeutic or recreational, an effect that is, at least in part, mediated by the ventrolateral PAG (Wilson-Poe, Pocius, Herschbach, & Morgan, 2013).
Other implications are that our understanding supports the notion of proceeding in a hierarchical fashion by addressing SEEKING and CARE emotions first. That is, the therapist will focus the initial interventions on relational safety. Then therapy can proceed to the regulation of active defense responses like FEAR and RAGE. Only once the active defense responses are processed with mindfulness does the sympathetic loading disappear, but with this processing then comes a reduction of the sympathetic withdrawal of the shutdown states, at which time lower arousal responses make therapeutic work more successful. Further the role of the lower brain structures in sensory and motor functions supports interventions that focus on basic orienting responses and sensorimotor processing, as well as approaches that are guided by the neuroanatomy of the brainstem such as Deep Brain Reorienting (DBR) (Corrigan & Christie-Sands, 2020).
We argue that the neuroscientific exploration of complex trauma disorders and dissociative disorders will be most effective when based in an understanding of the brain mechanisms for attachment seeking and threat responding. No brain area works in isolation – all are parts of wider systems – but attention to brainstem areas for responding to threat and seeking the connection that precedes attachment offers hypotheses on the origins of disrupted systems. For attachment, we focus on sensorimotor transformation of stimuli related to interpersonal connection in the midbrain superior colliculi and PAG and on the altered drive and motivation to seek attachment that arises in the mesolimbic dopamine system. For threat, we focus on the sensorimotor transformations that occur in the midbrain superior colliculi and PAG and on the resulting affects, positive and negative, and defensive responses. We differentiate active and passive defensive responses according to the activation of the PAG columns and consider the neurochemicals involved in the associated analgesia. Stress-induced analgesia involving endogenous opioids is not just a component of peritraumatic dissociation, but a likely contributor to longer-term structural dissociation. Finally, we propose that trauma-evoked activations of ascending brainstem systems disrupt the continuity of the integrated functions of the neocortex and can lead to the subjective experiences of dereal.
Disorganized Attachment Style And The Moderating Effect of The Inner Loving Parent on Closeness Terror: An Internal Family Systems (IFS) Approach
Dr. Rivka Edery (2023)
Statement of the Problem: Fearful-Avoidant Attachment Style and the Slave-Exile Trap (Terror of Closeness)
Approaching disorganized (fearful-avoidant, unresolved) insecure attachment from the perspective that fear is an emotional trigger introduces the core, original emotional issue with this category of insecure attachment style. The birthplace of this attachment style is a fearful, chaotic, or bizarre caregiver that creates deep terror and confusion in the child. Lack of safety, protection, and a haven from such a hostile, unpredictable early childhood environment, causes parts of the child’s self, not yet developed, to disperse. These parts scatter and form into different, extreme parts that take on intense roles. The persistent deep terror of approaching or being close to the caregiver, unaided, creates an avoidance cycle that can dominate lifelong relationships. In such a living environment, core relational needs are unmet and hijacked (taken over) by parts. Without an early, accurate intervention, these parts hijack the developing child’s system, reinforcing their attachment style over the lifespan. Therefore, the solution begins with learning about attachment theory, personal assessment of one’s attachment style, and the Internal Family Systems (IFS) approach [4-12] to attachment organization. A general overview of IFS is valuable because it explains how “parts” of the person are attached to their caregiver, their roles, symptoms, and extreme measures, and how those same parts similarly connect to others. Healing directly with those parts can create a more centered, balanced, securely attached, non-fragmented inner world for the adult.
Disorganized attachment means “the breakdown of an otherwise consistent and organized emotion regulation strategy” [13,14]. When a small, vulnerable, helpless, defenseless child is utterly dependent on a frightening, cruel, or otherwise dangerous caregiver, the terror of being hurt and abandoned threatens life and limb. This deep, intense fear of a parent, one who is supposed to be a haven but instead a source of profound, prolonged terror, becomes oxygen to the fire of fear to anything that awakens it. It can be a debilitating cycle of approach-avoidance (“slave-exile” trap) in existence orientation and attempts to socialize with others. In a childhood home with chaos, parental maltreatment, or dangerous parents, the child is imprisoned and at the mercy of its primary caregiver. It is an enslaved person trapped in the bizarre world of frightening, hurtful caregivers. The child’s torment is that their primary caregiver, what should be their secure source of love, safety, security, and met needs (trust), causes them to fear. It is primitive, chronic survival terror.
With these conditions, and where the parent is unpredictable, rejecting, and absent (physically, mentally, emotionally), a haven does not exist. What forms is the distrust in human contact, where the dilemma of being a “slave” versus “exile” is born. It is a process of classic conditioning, which is the effect of one’s early childhood treatment. The “slave-exile” dilemma [15-18] is originally a term from psychodynamic therapy and an excellent description of disorganized attachment. The “slave” refers to the high anxiety and desperation of the ambivalent attached. The exile refers to the dismissive, who is highly independent and fearful of being the “slave.”
Fear is a human emotion that various disciplines have extensively studied. Science can confidently point to the brain structures, chemistry, and processes of this powerful, intense, and sometimes mysterious emotion. Included in its many uses, such as keeping humans alive, safe, and alert to dangers, it can also be a very effective inner alarm system. When not overactive or distorted, a mutually trusting relationship develops when a person learns how to tame their fear and build an intimate relationship with it. However, when fear is unexamined, conditioned by severe trauma, and disconnected from oneself, fear can be a powerful emotional trigger that fuels the avoidance cycle in disorganized attachment. Through the attachment lens, the adult with disorganized attachment has a profound fear of getting close to others yet is perhaps equally terrified of being left alone. Disorganized (fearful avoidance) starts with a frightening parent, creating a confused/chaotic child, forming a disorganized-attached adult [14,19-30].
Humans have emotions and need to understand, express, and address them, especially any emotional conflicts. The value of emotional intelligence and resolving internal disputes is knowledge of self, improved relationships, more meaning in life, less risky behaviors , wisdom in engaging in vulnerable situations, and reasonable, stable expectations in relationships. Disorganized attachment creates a challenge for these tasks.