Dissociation is generally considered to be a defense mechanism because it distances us from painful or unacceptable realities (e.g., depersonalization, derealization) or it makes a painful reality disappear entirely (i.e., dissociative amnesia). Today’s thought question is: “Are flashbacks dissociative?” Do flashbacks protect us from a painful or unacceptable reality?
Hmmm. This is definitely an interesting question. PTSD patients seldom celebrate the ‘comforting’ or ‘protective’ nature of their flashbacks. 🙂
The Current Draft of DSM5 Insists That Flashbacks Are Dissociative
In contrast to DSM-IV, DSM5 may claim that flashbacks are a dissociative reaction. In the current working draft of DSM5, the list of intrusive symptoms for PTSD includes flashbacks — described as follows:
“Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)…” (www.dsm5.org, emphasis added)
Many dissociation experts have long argued that flashbacks are a dissociative symptom. These experts consider DSM5’s understanding of flashbacks to be a significant advance from DSM-IV. But is it? Is it an advance? Is it even correct?
Four Other Models of Dissociation
If dissociation protects a person from something painful or unacceptable, then flashbacks certainly cannot be an example of dissociation. On the other hand, according to several other descriptions or models of dissociation, flashbacks are definitely dissociative. For example, DSM-IV states that:
“The essential feature of the Dissociative Disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception.” (DSM-IV-TR, p. 519, emphasis added)
Yup, flashbacks are definitely disruptions of the usually integrated functions of consciousness, memory, and perception.
Clinicians in the United States are guided by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Clinicians everywhere else are guided by the World Health Organization’s International Classification of Diseases (ICD-10). According to ICD-10:
“the common theme shared by dissociative (or conversion) disorders is a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.” (World Health Organization, 1992, p. 151, emphasis added)
By this definition, flashbacks are unmistakably dissociative; they are a partial or complete disruption of normal integration.
3. Dell and O’Neil (2009)
OK. That’s what the two ‘Bibles’ say, How do other sources define dissociation? In 2009, John O’Neil and I published a large edited volume whose purpose was to bring clarity to dissociation and the dissociative disorders. In the book’s preface, we offered a three-paragraph definition of dissociation. That definition begins with this sentence:
The essential manifestation of pathological dissociation is a partial or complete disruption of the normal integration of a person’s psychological functioning. (Dell & O’Neil, 2009, p. xxi, emphasis added)
After reading what DSM-IV and ICD-10 had to say on this matter (above), the Dell and O’Neil definition has to feel distinctly familiar. And again, according to this definition, flashbacks must be classified as dissociative.
4. Dell (2006)
Finally, bear with me as I present one final definition of dissociation — my own definition from 2006:
“the phenomena of pathological dissociation are recurrent, jarring intrusions into executive functioning or sense of self by self-states or alter personalities.” (Dell, 2006, p. 8, emphasis added)
Note that this definition of dissociation has two parts. According to the first part, flashbacks are certainly dissociative because they are recurrent jarring intrusions into executive functioning. On the other hand, according to the second part of the definition, flashbacks are dissociative only if they are caused by self-states or alter personalities.
The difference between my 2006 definition of dissociation and the three preceding definitions is that my 2006 definition goes beyond description and phenomenology. Namely, it defines dissociation in terms of a specific mechanism — a self-state or alter personality that intrudes into conscious functioning.
This is where an annoying narrator would say: “The discerning reader will have noticed …” I’ll try to avoid being that annoying, but there is an important point to be made here.
The point is this: In 2006, when I added that mechanism to my definition of dissociation, I added a structural model of dissociation to the DSM-IV and ICD-10 accounts of dissociation.
Translation: Disruptions of normal integrated functioning are dissociative if, and only if, they are caused by a self-state or alter personality (i.e., caused by a dissociative structure of the personality).
Aha! Now the fun really begins. We have a new question: “Are flashbacks caused by dissociated structures?” If they are — and Van der Hart, Nijenhuis, and Steele insist that they are — then:
(1) the flagship symptom of PTSD (i.e., flashbacks) is a dissociative symptom, and
(2) PTSD itself is a dissociative disorder.
The proponents of structural dissociation firmly insist upon both of these points: flashbacks are dissociative and PTSD is a dissociative disorder. But.. The Powers That Be in DSM5-land do not think that PTSD is a dissociative disorder — and I agree with them.
Worse, I think that both the structuralists and the DSM5 Powers That Be are wrong about flashbacks. Although some flashbacks seem to be distinctly dissociative, I think it is a big mistake to classify all flashbacks as dissociative.