Dissociation in BPD Impacts Daily Life, Therapy

Intrusive flashbacks of traumatic experiences, losing contact with your body or with reality, a fog descending over your mind, the feeling of watching yourself from a distance or of the world passing you by: dissociation comes in many forms. 'This makes the term difficult to define and measure properly, but also difficult to recognise at an early stage,' says Anne Krause-Utz. 'It is often only recognised by therapists when dissociation becomes acute: the client feels unable to move, falls completely silent, no longer responds to eye contact. But the early warning signs and the more chronic or subtle forms often receive little attention in therapeutic settings and research.'

As a dialectical behaviour therapist, Krause treated people with borderline personality disorder (BPD) in Germany for many years. Since 2017, she has been conducting research in Leiden into dissociation in post-traumatic stress disorder and BPD, among other topics. 'In borderline personality disorder, dissociation is often seen as a side effect of stress and is quickly linked to trauma, but there can be many more causes. A growing body of research shows that if dissociation is not recognised in time and not treated adequately, the severity of borderline symptoms can increase.'

In her recently published book Dissociation in Borderline Personality Disorder: Associations with Trauma and Neurobiology, Krause examines the phenomenon in great detail and describes which treatment techniques can reduce dissociation. These guidelines form part of the current care standard, which she helped to develop.

In your book you write: 'Some researchers place dissociative experiences on a spectrum, while others draw a sharp line between pathological and non-pathological dissociation.' What is your view?

'I see dissociation more as a spectrum. I believe that some forms can be relatively mild, non-disruptive or even useful. Think, for example, of an artist who completely loses themselves in a creative flow; that is a form of dissociative absorption. Daydreaming is also a form of dissociation that we all recognise. The boundary between when dissociation is harmful or enriching is not so clear-cut and largely depends on the context. If you dissociate in many different areas of your life and clearly suffer as a result, then it is not helpful but deeply distressing and can be very damaging. Dissociation can, for instance, interfere with the therapeutic process or disrupt the integration of traumatic experiences. The empirical evidence for this is not entirely clear, but a recent meta-analysis suggests that this is at least the case in BPD.'

You write that we do not dissociate by accident; it often serves a function. Can you explain?

'In extremely stressful, traumatic situations, dissociation can have a useful and protective function; it dampens pain and overwhelming emotions. Think, for example, of people who were abused as children. They often describe an out-of-body experience in which they observe themselves from the outside. In this way, they endure the traumatic experience and keep certain memories at a distance. Dissociation can thus become a learned coping mechanism. In the long term, however, this is counterproductive, because you also lose contact with certain parts of your personality. When it becomes harder to integrate specific memories into a coherent personal narrative, you also fail to experience a stable identity.'

And that interferes with therapy.

'Yes. In the long term, the aim of trauma therapy is that you process the experience and learn that the experience, along with all associated feelings and memories of threat, belongs to the past. Other forms of therapy are also aimed at gaining insight into one's own behavioural patterns. But for that, you need access to your memories, thoughts and emotions. Only then are you able to learn new patterns and, if trauma is involved, to experience that the threat is no longer present in the "here and now". The goal is to learn to integrate these experiences into your sense of self. Studies show that exposure is safe and effective in people who struggle with self-harm and suicidality, and that they should not be "excluded" if they experience dissociation. However, the degree of dissociation does need to be monitored during therapy.'

'To gain insight into your own behavioural patterns, you need access to your memories, thoughts and emotions'

Your book focuses specifically on dissociation in people with borderline personality disorder. You yourself treated people with borderline for many years. What did you learn from that?

'Ending up in that field was more or less a coincidence. I started working as a research assistant in a centre specifically focused on the treatment of borderline personality disorder. At first, I felt intimidated by the complexity; borderline often co-occurs with eating disorders, depression and addiction - a whole package. From the outside, people tend to see the signs of dysregulation: aggression, self-harm. There is an image that people with borderline are intense and dangerous, and that it is difficult to maintain relationships with them. But the more I understood what drives this behaviour, the more I realised that it is not intentional and does not occur in everyone with BPD. It arises from a lack of alternative coping strategies to regulate emotions and deal with loneliness. People with borderline personality disorder are very sensitive, experience intense emotions, and grew up in environments where they did not learn how to cope with those emotions.'

'People with borderline personality disorder experience intense emotions and grew up in environments where they did not learn how to deal with them'

Dissociation in people with borderline personality disorder is linked to a higher risk of self-harm, risky behaviour or suicide. Can you explain that?

'During dissociation, you may feel numb; self-harm can then be a way to reconnect with your body, to feel somethingagain. That numbness can also be a trigger for engaging in risky situations, for example situations in which you might become a victim of abuse. You no longer feel the pain or the fear. Being able to experience emotions is meaningful; they tell us what is and is not good for us. If you no longer have access to those emotions, you cannot properly sense your own needs. Self-harm can also be a way for someone to express emotional pain and a need for support if they have not learned to do so in another way. That, too, is part of therapy: learning to identify needs and communicate them to others.'

'In severe cases, dissociation can contribute to a profound sense of isolation and hopelessness'

What do you hope to achieve with this book?

'I hope the book contributes to a better understanding of dissociation and BPD. That dissociation is highly complex and not necessarily bad or always trauma-related, and that it manifests differently in everyone. And that it is crucial to understand the phenomenon in a biopsychosocial context: how it relates to past experiences, but also to neurobiological vulnerability. Dissociation is not always linked to trauma; people can also develop dissociative tendencies without having experienced traumatic events.

At the same time, it is vital that dissociation is recognised as a relevant treatment target in its own right. In severe cases, it can contribute to a deep sense of isolation and hopelessness. I hope this book contributes to a more diverse and nuanced view of dissociation and BPD. I also hope it helps to reduce the stigma surrounding BPD and to make clear that a great deal of progress has been made in recent years in understanding and treating the disorder.'