UNDERSTANDING THE RELATIONSHIP
BETWEEN TRAUMA AND DISSOCIATION:
The contribution of attachment theory and
research
Giovanni Liotti
APC School of Psychotherapy
Rome
Conference “EMDR and Dissociation”
Metz, November 17, 2015
DISORGANIZED ATTACHMENT (D.A.)
PREDICTS DISSOCIATION
• Two prospective studies support the hypothesis that
infant D.A. predisposes to dissociative mental
processes in later years (Ogawa et al., 1997; Dutra et al.,
2009).
• Infant D.A. is by far the more powerful predictor of
dissociation with respect to reported later trauma
(Dutra et al., 2009).
• Dissociation may be rooted in human relatedness
more than in purely intra-psychic dynamics (LyonsRuth, 2003).
• A proper understanding of D.A. ( slide 3) is
propaedeutic in trying to clarify the elusive concept of
dissociation and its relation to trauma ( slide 4), e.g.
through research on brain connectivity ( slides 5-10)
DISORGANIZED ATTACHMENT
• In the organized patterns of infant attachment (secure,
avoidant and ambivalent) there is no conflict between the
the care-seeking system and the survival defense system
(freezing, fight-flight and feigned death), that are both
activated during the exposure to traumatic events.
• Abnormal tensions between the two psychobiological
systems are caused by parental violently aggressive
behavior that interrupts care-giving or by the helpless
attitude of the caregiver in the face of the infant’s
expression of fear and pain  D.A.
• The attachment system comes to involve expectations of
danger whenever care-seeking needs are felt
DISSOCIATION IS AN ELUSIVE CONCEPT
• “Dissociation is an elusive concept, vague, confusing and
controversial” (Dell, 2009, p. 225, in Dissociation and the
dissociative disorders: DSM V and beyond).
• Part of the difficulty in achieving a less confusing and
controversial definition of dissociation might lie in the
conceptualization of this psychological process as an intrapsychic consequence of psychological trauma.
• A key aspect of the current conceptualizing of dissociation
is that it is an intra-psychic defense against the mental pain
of traumatic memories, disconnecting self-representations
related to trauma from conscious processing and memory.
• Although this assertion may seem surprising or absurd,
there is no convincing statistical evidence that exposure to
traumatic events, per se, adversely affects the memory of
those events  (Kihlstrom, 2005)
THE ROLE OF ATTACHMENT PROCESSES IN
DISSOCIATION
• The finding that dissociation is predicted more by infant
D.A. than by traumatic memories invites to explore the
relational aspects of dissociation besides the intrapsychic ones related to defense against the mental pain
caused by traumatic memories.
• It is possible that dissociative processes take place in
the brain of people with an history of D.A. mainly within
the mental domain of human relatedness, and more
precisely during or immediately after the activation of
their attachment system.
• This hypothesis can be empirically tested by exploring
the mind-brain processes related to D.A.
WHAT KINDS OF MIND-BRAIN
PROCESSES ARE RELATED TO D.A.?
• Dissociation involves deficits in cortical connectivity, that
can be measured by the procedure called EEG
coherence
• If these deficits in cortical connectivity could be assessed
in people with histories of D.A. immediately after the
priming of mental states related to the attachment
system, but not before such priming, we may achieve a
better understanding of the roots of dissociation in human
relatedness (and not only in an individual, intra-psychic,
defense mechanism).
• The administration of the AAI is believed to be an
adequate way of priming the activation of the attachment
system in adults.
EEG COHERENCE: A REMINDER
• EEG Coherence is a computerized measure of the linear
synchronization between two signals recorded at
different locations of the brain. It is a statistical measure
of the average agreement in phase difference (weighted
by amplitude) between two signals measured over time.
It is specific for each EEG frequency band: α (alpha), β
(beta), γ (gamma), δ (delta) and θ (theta).
• It is considered a measure of the functional association
between two brain regions (cortical connectivity).
• Dissociation involves by definition a deficit in the degree
of cortical connectivity.
EXPLORATION OF CORTICAL CONNECTIVITY IN
ATTACHMENT RELATED STATES OF MIND
• A research team headed by Benedetto Farina and Anna
Maria Speranza is studying cortical connectivity 3 minutes
before and after the administration of the AAI in a group of
patients with both cumulative (complex) childhood trauma
and unresolved states of mind (Ulinked to infant D.A.).
This patient group is compared with a control group of adult
subjects whose AAI is coded in the “organized” categories
(F, E, Ds  linked to the organized patterns of infant
attachment).
• Preliminary results: the patient (U) sample shows a specific
type of brain processing of information, suggesting
dissociation, immediately after the administration of the AAI.
Before the administration of the AAI, cortical connectivity
was comparable in the patient and control samples.
An EEG coherence study of complex PTSD
basal EEG
coherence 3
minutes before
administering
the AAI
EEG coherence
measured again 3
minutes after
ending the AAI
3’
before
Base EEG
Relaxed wakefulness, closed
eyes
Skin conductance
3’
after
Base EEG
Relaxed wakefulness, closed
eyes
AAI
Skin conductance
Spectral analysis of EEG
frequency
(range: 1 – 127 Hz)
Spectral analysis of EEG
frequency
(range: 1 – 127 Hz)
EEG coherence
EEG coherence
Adult Attachment Interview - AAI
* Standardized interview for evaluating the
state of mind, the metacognitive monitoring
and the narrative coherence related to
autobiographical memories of past
attachment experiences
* Evokes memories of unresolved attachment
trauma in people with DA
Attachment Disorganization scoring:
(1)
1. incoherence of discourse, memory and
thought concerning attachment
(2)
2. difficulties in emotion regulation
(3)
3. poor metacognitive monitoring
(impairment of the higher-order of integrative
mental functions during the interview)
EEG COHERENCE BEFORE AND AFTER
THE AAI
• There is no significant difference between baseline
measures of EEG coherence before the AAI in the
samples later classified U, F, E, and Ds.
• This means that the presence of traumatic memories per
se does not involve changes in baseline cortical
connectivity.
• However, after the administration of the AAI, there is a
very significant increase of cortical connectivity in the
“organized” sample (without differences among the F, E
and Ds sub-samples) in three frequency bands (α, β, γ)
of the EEG. No such increase is observable in the
“disorganized” (U) sample.
Comparison between cortical connectivity before and
after the AAI
[Farina B., Speranza AM et al (2013). Eur Arch Psychiatry Clin Neurosci]
DISSOCIATION IS A FAILURE IN THE
INTERSUBJECTIVE SHARING OF TRAUMATIC
MEMORIES?
• These preliminary findings suggest that mental states
related to D.A. hinder, at the level of both inner and outer
dialogue, the possibility of sharing with an attachment
figure the experience of fright and pain linked to traumatic
experiences, in the hope of being soothed. This is the
relational base for the lack of the increase in cortical
connectivity that normally follows the retrieval of
personally highly significant early attachment experiences.
• In turn, such a lack of the normally expected increase in
cortical connectivity may be close to the essence of
dissociation. Dissociation may be linked more to particular
representations of self-with- other in attachment
exchanges (forbidding the sharing of traumatic memories
in the hope of being soothed) than to the need of avoiding
mental pain.
No pain is so severe that it cannot be soothed
when it becomes a story to be told to a caring
listener, states the Talmudic tradition. When
one cannot expect to meet a really caring
listener, and expect instead neglect, fear or
aggression, the story cannot be constructed
either in the mind or in the dialogue. This,
rather than an intra-psychic defense against
mental pain, is perhaps the essence of both
post-traumatic dissociation and unresolved
mental states related to attachment
AN IMPLICATION FOR CLINICAL WORK
• Dissociative and borderline patients may manifest
dissociative symptoms and experiences within one or
more psychotherapy session
• The seeming antecedent is the narrative of a traumatic
memory, but sometimes the immediate context is not
related to such a narrative
• It may be hypothesized that in both cases the
manifestation of dissociation is explained by the activation
of the patient’s (disorganized) attachment system during
the interaction with the therapist (i.e., the patient feels the
emotional closeness of the therapist
• In order to avoid the deficit in self-reflection linked to
dissociation, the therapist is advised to monitor signs of
activation of the attachment system in the patient, and
avoid that it becomes prolonged
INDIRECT SUPPORT TO THIS HYPOTHESIS
• … comes from the clinical wisdom on which the guidelines
for the treatment of dissociative patients are based
• Before attempting to work on the traumatic memories,
these guidelines prescribe to construct a solid therapeutic
alliance
• The therapeutic alliance involves the prevailing activation of
a behavioral-motivational system quite different from
attachment, namely the egalitarian cooperative system
(Cortina & Liotti, 2010; Liotti & Gilbert, 2011).
• When the cooperative rather than the attachment system is
active in the clinical exchange, the hindrance to the
narrative of traumatic memories caused by D.A. is
circumvented, so that trauma work and integration of
previously dissociated representation of self-with-other can
proceed.
IMPLICATIONS FOR UNDERSTANDING
THE MECHANISM OF ACTION OF EMDR
• Besides the typical basic technique aimed at increasing
cortical connectivity while priming traumatic memories, the
clinical practice of EMDR seems to possess procedures
that may minimize the likelihood of a protracted activation
of the patient’s attachment system during the trauma work
sessions.
• This intrinsic attitude of looking for the “right emotional
distance” – or the “right degree of emotional closeness” – in
the clinical practice of EMDR is in keeping with what the
research on the role of attachment disorganization in
dissociative trauma-related disorders would suggest as an
important therapeutic tool in the treatment of cPTSD.
REFERENCES
• Cortina, M. & Liotti, G. (2010). Attachment is about safety and protection.
Intersubjectivity is about social understanding and sharing. Psychoanalytic
Psychology, 27, 410-441.
• Dutra, L., Bureau, J., Holmes, B., Lyubchik, A. & Lyons-Ruth, K. (2009).
Quality of early care and childhood trauma: a prospective study of
developmental pathways to dissociation. J. Nerv. & Ment. Dis., 197, 383–
390.
• Kihlstrom, J.F. (2005). Dissociative Disorders. Annual Rev. Clin. Psychol., 1:
227-253.
• Liotti, G. & Gilbert, P. (2011). Mentalizing, motivation and social mentalities:
Theoretical considerations and implications for psychotherapy. Psychology
and Psychotherapy: Theory, Research and Practice, 84: 9-25.
• Lyons-Ruth, K. (2003). Dissociation and the parent-infant dialogue: A
longitudinal perspective from attachment research. Journal of the American
Psychoanalytic Association, 51, 183-213.
• Ogawa, J.R., Sroufe, L.A., Weinfield, N.S., Carlson, E.A. & Egeland, B.
(1997). Development and the fragmented self: Longitudinal study of
dissociative symptomatology in a nonclinical sample. Development and
Psychopathology, 9, 855-879.