Dissociation can take many forms, including intrusive flashbacks of traumatic experiences, losing touch with your body and reality, feeling foggy in your mind, and feeling like you’re watching yourself from afar or the world is passing you by. “This makes the term not only difficult to properly define and measure, but also difficult to recognize at an early stage,” says Anne-Klaus Utz. “Often, dissociation is only recognized by therapists when it becomes severe; the client feels unable to move, becomes completely silent, and no longer responds to eye contact.” However, early warning signs and more chronic or subtle symptoms often receive little attention in therapeutic settings or research. ”

As a dialectical behavior therapist, Klaus has been treating people with borderline personality disorder (BPD) in Germany for many years. Since 2017, she has been conducting research in Leiden on dissociation, including post-traumatic stress disorder and BPD. “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 other causes.More and more research shows that if dissociation is not recognized in time and appropriate treatment is not given, the severity of borderline symptoms can increase.

In her recently published book Dissociation in borderline personality disorder: links to trauma and neurobiologyKraus examines this phenomenon in detail and explains which therapeutic techniques can alleviate dissociation. These guidelines form part of the current standard of care, and she helped develop them.

In your book, you write, “While some researchers place dissociative experiences on a spectrum, others draw a clear line between pathological and non-pathological dissociation.” what is your view?

“I think of dissociation as a spectrum. I think some forms are relatively benign, non-disruptive, or even useful. For example, think of an artist who is completely immersed in a creative flow. It’s a form of dissociative absorption. Daydreaming is also a form of dissociation, and we all recognize it. The line between dissociation being harmful or enriching is less clear-cut and depends very much on the circumstances. If a person dissociates in a sensitive area and clearly suffers as a result, it is not only unhelpful, but extremely painful, and can be extremely damaging. For example, dissociation can interfere with the therapeutic process and interfere with the integration of traumatic experiences. Although the empirical evidence for this is not entirely clear, recent meta-analyses suggest that this is the case, at least in the case of borderline personality disorder.

You write that we were not separated by chance. In many cases it does the job. Could you please explain?

“In extremely stressful and traumatic situations, dissociation can have a beneficial protective function. It dampens pain and overwhelming emotions. Think, for example, of people who were abused as children. They often describe out-of-body experiences in which they observe themselves from the outside. In this way, they tolerate the traumatic experience. Dissociation can therefore be a learned coping mechanism. But in the long run, this is counterproductive because it also makes it difficult to integrate certain memories into a coherent personal narrative.”

And it interferes with treatment.

‘yes. In the long term, the goal of trauma therapy is to process the experience and learn that it, along with all the emotions and memories of threat associated with it, are in the past. Other forms of therapy also aim to gain insight into one’s own behavioral patterns. But to do that, you need to access your memories, thoughts, and emotions. Only then can new patterns be learned and, if trauma is involved, experienced that the threat is no longer present in the here and now. The goal is to learn how to integrate these experiences into your sense of self. Research shows that exposure is safe and effective for people who struggle with self-harm and suicidal tendencies, and should not be “ruled out” even if they experience dissociation. However, the degree of dissociation must be monitored during treatment. ”

“To gain insight into your own behavioral patterns, you need access to your memories, thoughts, and emotions.”

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

“I ended up in the field more or less by chance. I started working as a research assistant at a center specializing in the treatment of borderline personality disorder, and at first I was intimidated by its complexity. Borderlines often co-occur with eating disorders, depression, and addiction, or a combination of all of them. From the outside, people tend to notice signs of dysregulation, such as aggression and self-harm. People with borderlines tend to be intense, dangerous, and difficult to maintain relationships with. But the more we understand what causes this behavior, we realize that it’s not intentional and doesn’t happen to everyone with borderline personality disorder. It stems from a lack of alternative coping strategies to regulate their emotions and deal with loneliness.

“People with borderline personality disorder grow up in environments where they experience intense emotions and don’t learn how to deal with them.”

Dissociation in people with borderline personality disorder is associated with an increased risk of self-harm, risky behavior, and suicide. Could you please explain that?

“During dissociation, you may become numb. Self-harm can be a way to reconnect with your body and feel something again. That numbness can also be a trigger for you to find yourself in a dangerous situation, for example in a situation where you might be a victim of abuse. You no longer feel pain or fear. Being able to experience emotions has meaning. At best, it tells us what’s not. When we can’t access those feelings, we can’t feel our own needs properly. Self-harm can also be a way for people who haven’t learned how to express it in other ways to express their emotional distress and need for support. That’s part of therapy, too: learning how to identify your needs and communicate them to others.”

“In severe cases, dissociation can cause deep feelings of isolation and hopelessness.”

What do you hope to achieve with this book?

“I hope this book will contribute to a better understanding of dissociation and borderline personality disorder. Dissociation is very complex, it’s not necessarily bad, it’s not necessarily related to trauma, and it manifests differently in different people. And I think it’s important to understand this phenomenon in its biopsychosocial context. This means that it is important to understand how it is related to past experiences and how it is also related to neurobiological vulnerabilities.

At the same time, it is important that dissociation itself is recognized as an appropriate therapeutic goal. In severe cases, it can cause deep feelings of isolation and hopelessness. I hope this book contributes to a more diverse and nuanced view of dissociation and borderline personality disorder. We also hope this article helps reduce the stigma surrounding borderline personality disorder and highlights the great advances that have been made in recent years in understanding and treating this disorder. ”