The primary aim of this commentary is to describe trauma-related dissociation and altered states of consciousness in the context of a four-dimensional model that has recently been proposed (Frewen & Lanius, 2015). This model categorizes symptoms of trauma-related psychopathology into (1) those that occur within normal waking consciousness and (2) those that are dissociative and are associated with trauma-related altered states of consciousness (TRASC) along four dimensions: (1) time; (2) thought; (3) body; and (4) emotion. Clinical applications and future research directions relevant to each dimension are discussed. Conceptualizing TRASC across the dimensions of time, thought, body, and emotion has transdiagnostic implications for trauma-related disorders described in both the Diagnostic Statistical Manual and the International Classifications of Diseases. The four-dimensional model provides a framework, guided by existing models of dissociation, for future research examining the phenomenological, neurobiological, and physiological underpinnings of trauma-related dissociation.
“Psychological trauma may not only affect the perspective of an individual’s narrative but also the plot and the structure of the narrative. Although often able to maintain first-person perspective, trauma survivors may exhibit distinctly negative self-referential thinking, including “I am a bad person” or “I do not deserve to live”
Traumatized individuals may, however, occasionally exhibit alterations in the perspective of their narrative. These alterations can lead survivors to experience voices in the second-person perspective, for example, telling them, “you are bad” or “you deserve to die,” an experience thought to reflect a dissociative process associated with TRASC. When this occurs, the person is no longer the only storyteller of his/her lived experience but rather another or other narrative voice(s) also speak inside his/her head. These voices may present distinctly different goals, motivations, and affects, in the extreme case creating the experience of possessing multiple selves. Research in the area of voice hearing has suggested that this phenomenon is elevated significantly in individuals suffering from trauma-related disorders, including in individuals diagnosed with PTSD, dissociative disorders, and borderline personality disorders as compared to patients with other psychiatric disorders; voice hearing is also related to the experience of dissociative symptomatology and a history of early life adversity”
“From a clinical perspective on trauma-related voice hearing, it is crucial to create a shared narrative by identifying the strengths of each voice or self state in the present and by encouraging awareness and communication among different voices or self states, thereby facilitating collaboration between or among distinctly compartmentalized and contradictory goals, motivations, and affects associated with each voice or self state. The latter is also critical in fostering of self-compassion, which is sorely lacking in many survivors of chronic trauma due to ongoing conflict among different voices or self states.”
“…while remembering an event, mental time travel is “partial” in that the present self voluntarily directs attention to the past self, thus maintaining awareness of the present self in the present time. In this case, the “I” is proposed to exist in the present self, which outweighs the representation of the past self in past time. In contrast, during a reliving experience, mental time travel occurs “fully,” generally not by choice, and is usually triggered by internal and/or external stimuli that bear some resemblance to a past self-state. In this case, the “I” is thought to inhabit the past self, which is thought to outweigh the presence of the present self, thus lacking a mental time traveler and the ability to voluntarily position oneself in the past or in the future.”
“…it may be critical to strengthen the self among survivors of trauma, in order to facilitate the emergence of a mental time traveler that is able to remember rather than to relive the past. Processes relevant to this development across all four dimensions of consciousness include the encouragement of safe relationships, including the therapeutic relationship, enhancing mindful awareness of the present through mindfulness exercises, emotion regulation, distress tolerance skills, and building capacity for positive affect tolerance. Based on the theoretical assumptions reviewed here, strengthening the sense of self through the use of present-centered therapies in combination with exposure-based treatments may be crucial to successfully overcoming severe dissociative flashbacks.”
“…among individuals who suffer from the aftermath of trauma, the mind/body connection is often severed, leading to the subjective experience of feeling partially or fully detached from one’s body, or alternatively, as if one’s body does not belong to oneself.”
“It is critical for clinicians to understand the subjective experience from which the traumatized individual experiences his/her body and its relation to the surrounding world. Body-scan meditations, intended to facilitate awareness and the monitoring bodily sensations, form a central part of the mindfulness-based stress reduction program developed by Kabat-Zinn (1990) and provide an important means of assessing states of full or partial depersonalization, while at the same time enhancing the capacity for interoceptive awareness and diminishing detachment from bodily states. It is critical to note, however, that body scans must be carried out in a trauma-sensitive way in order to prevent the traumatized individual from becoming overwhelmed during this exercise”
“In the aftermath of trauma, however, it is well documented that emotion dysregulation can range from states of emotional undermodulation during which the individual experiences painful states of fear, anger, guilt, and shame to states of emotional overmodulation, during which the individual experiences emotional detachment such as states of depersonalization, derealization, emotional numbing, and affective shut-down.”
“Clinical efforts to assist individuals in overcoming emotional numbing and affective shutdown may center around assisting the traumatized individual to shift out of his/her shut-down state in order to be able to feel a full range of emotions, particularly pleasure and joy”
Future directions for research are covered:
“Future research is needed to identify more precisely the neurobiology underlying voice hearing and negative self-referential processing in trauma-related disorders as compared to that underlying voice hearing in psychotic-spectrum and other psychiatric disorders. This will be important to facilitate more accurate diagnosis, thereby guiding the most appropriate treatment interventions. Here, it will also be critical to examine how emotional triggers, for example, positive or negative self-related statements, may affect differently the presentation and underlying neurobiology of voice hearing in trauma-related disorders as compared to psychotic and other psychiatric disorders. Moreover, it will be important to examine the integrity of neural networks, such as the default mode network, which has been associated with an integrated sense of self across time , pre- and post-treatment interventions that target specifically the creation of a shared narrative between or among voices that may be associated with different self states.
From a clinical perspective, treatment outcome studies that focus specifically on interventions designed to affect voice hearing in trauma-related disorders should also be urgent foci of investigation”