ミラーニューロンと解離 18

Disturbance of the sense of self in DID reconsidered

Do personalities of DID have any serious disturbance of the sense of self? Let us take a flesh look at this issue from a standpoint of psychiatric symptomatically.

Jaspers, K., Hoenig, J., & Hamilton, M. W. (1997). trans. General psychopathology. London: John Hopkins University Press.

 Karl Jaspers, Hoenig, & Hamilton (1997/1913) delineated the basic sense of self into four domains; living as a self-present, single, temporally persistent, and bodily and demarcated (bounded) subject of experience and action. Jaspers indicated that, in schizophrenia, there are serious disturbances among these domains. In contrast, each PP in individuals with DID would not manifest disturbances among any of them.

Consider the clinical example discussed above. In reference to the sense of self-presence, it is certain that A and B are going through their own experiences without any sense of intrusion. It is because of her intact sense of agency that A feels vexed with complaint of B who resents A’s behavior. Their sense of agency enables A and B to assert herself/himself and attempt to protect her and his own interest around the third party C. As for their sense of singleness, certainly, A and B feel that they are on their own and C feels that she needs to treat A and B separately and independently. As regards to their sense of temporal continuity, A would still claim that, even if she is amnestic about events that occurred while B is out and active, she could provide an ‘‘alibi’’ for herself, such as that she was gone or asleep and therefore she has nothing to do with B’s deeds. B himself would maintain his own temporal continuity, stating that he was “there” watching the interaction between A and C “from inside” at least during the time that he is not “asleep”. The sense of demarcation of A and B certainly exists although B himself has a peculiarly distorted sense of his own body as he is not aware that he is “very big” as a five year old boy and tries to snuggle up to C’s lap, each time literally knocking her away with his adult body size. Although A does not feel that B is inside or out side of her body or anywhere else, B feels that he is outside of A and C interacting each other and observe them with frustration and resentment.

ミラーニューロンと解離 17

Let us consider if A or B suffers any type of disturbed sense of self. Can A or B only be a part of a whole self, as van der Hart etc. indicated? Let us remind ourselves of his statement.

… dissociative parts of the personality together constitute one whole, yet are self-conscious, have at least a rudimentary sense of self. …

Apparently, this condition might apply to A or B. Some might argue that A might be missing a child-like, emotional, and tomboyish part of herself that B might aptly represent, while B might be missing social capacity with stronger mechanism of defense that A might possess. However, it is a very hard question to ask if A, B and possibly other parts would constitute one whole if put together ? The concept of a whole personality itself should be under scrutiny before arguing this issue. How could allegedly 30 year-old female personality and a 6 year-old child personality can be integrated to become a “whole”? How old would they become, then, etc.

If a therapist takes an attitude of regarding each personality as incomplete and not an integrated one, this might quickly alienate at least some of these personalities and impair therapeutic relationship with them. How would some personalities react to the therapist’s statement, such as “you are merely a part of your host personality that you should eventually get integrated into, as you broke off with him (her) sometime in the past.

Isn’t it possible that that therapist is practically denigrating the sense of self of that personality?

 It is very important to treat respectfully the personality whether she is child, adult, male or female, instead of treating them as someone like sub-human and not taking them seriously. It is all the more as many personalities are functioning as an ordinary person in the society. Remember that DID patients are quite often suspected as feigning, pretending to be having that condition, and this speaks to the fact that they quite often appear ordinary and inconspicuous in the society. How can a “partial human” do that? To the point, many personalities of the DID look quite ordinary, each having its own identity.

One condition which might remind of ourselves of that partial or insufficient and rudimentary personality is the condition that we consider as insufficiently crystalized or sublimated personality state. It can often be encountered in a dissociative trans state, characterized as “an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli” (ICD-11 draft).

ミラーニューロンと解離 1６

Disruption of identity” observed in clinical settings

 The disruption of identity in DID observed in clinical settings is somewhat different from what is alluded to in the criteria found in DSM or ICD that we saw above.  Two or more identities could be aware of each other’s presence or behaviors, and occasionally there might be disruptive interaction of communication. However, they might not be disturbed by each other in any particular ways most of time. Their prominent experience and difficulty is their being amnestic for some periods of time in their daily life. When the switching occurs, a personality loses consciousness and experiences a lapsus of time until he or she “comes to”. Does the experience of A or B indicate that they have serious impairment of their sense of identity? Their experiences are rather like our experience of getting to sleep for several hours and wake up in the morning, something that every one of us experiences. Obviously, there are cases where A, B, and other personalities can be “awake” and active simultaneously. Some of them might experience intrusive experiences from other personalities in a direct way, but some of them do not. It is often observed that two or three personalities are awake independently and converse or interact with each other, like two or three people engaging in conversation. They of course heavily influence each other, but not in a way that their sense of self is threatened by other’s intrusion, like the “made” experience. Their experience is rather assimilated to that of Siamese twins, where two individuals sharing a single body converse and negotiate to achieve their common objectives.  

 Let me show you an example of a situation frequently observed clinically among DID individuals. Suppose that a person has personalities A and B. A interacts with a person C. Then another personality B resents their relationship and feels left out, and asks C for a time for his own with him. C is not altogether agreeable with this request as he does not feel as close to B as to A. B then gets frustrated and tension between A and B mounts.

 This type of conflict happens quite frequently among individuals with DID. Let us consider what kind of disturbance of the sense of self can be found in this relationship.

Let me be more concrete and give my own clinical example. A is a female young adult and B is her boy personality. C is his fiancé, a young male. A is only aware of the existence of C, mainly informed by her fiancé C, except that he has a queasy feeling in her stomach occasionally while interacting with C. B himself reports that he is “asleep” (B’s own expression) most of time, but sometime is awake and observe A’s interaction with C “from inside”. B personally never feels that he is intruded upon by A herself.

ミラーニューロンと解離 15

The essence of this definition of DID involves “marked discontinuities in the sense of self and agency.” However, this statement in ICD-11(draft) does not state clearly how the sense of self is disrupted. DSM-5’s similar definition of DID states more clearly the way this disruption is experienced subjectively by the individual with DID.

Individuals with dissociative identity disorder may report the feeling that they have suddenly become depersonalized observers of their own speech and actions, which they may feel powerless to stop (sense of self). Such individuals may also report perceptions of voices (e.g., a child's voice; crying; the voice of a spiritual being). In some cases, voices are experienced as multiple, perplexing, independent thought streams over which the individual experiences no control. Strong emotions, impulses, and even speech or other actions may suddenly emerge, without a sense of personal ownership or control (sense of agency)(American Psychiatric Association, 2013).

　What this statement in DSM-5 is understood as hallucinatory perceptions and “made” experiences. These are experiences where the personality A is intruded upon by the voices and behaviors of personality B, or vice versa, and thus A or B’s sense of agency is seriously impaired. However, many individuals with DID do not have these experiences in majority of times. Quite often, when A is active, B might be mostly absent (probably in a form of being “asleep” etc.) whereas when B is active, he feels independent and undisturbed by anybody either. In fact, the so-called host personality could be oblivious to the existence of any other personalities for a long time until some circumstantial evidences crop up indicating otherwise. If it is so, the patient with DID might not have these essential experiences of the disruption of the sense of self very often.  The question is whether it is rational to consider these “made” experiences as DID’s essential problem of the disturbance of the sense of self while they are not necessarily present in their experiences.

   One possible speculation is that in the individual with DID, a previously integrated personality ( the one which might have been existed before their identities are split and dissociated) is hypothesized in clinicians’ mind and that virtually integrated self suffers its own integrity by having multiple and interchanging identities. Another possibility is to consider that these identities are only partial and incomplete one and the self disturbance is found in its existence. One of the experts on the theory of Dissociation wrote as follows:

We describe the division of personality in terms of dissociative parts of the personality. This choice of term emphasizes the fact that dissociative parts of the personality together constitute one whole, yet are self-conscious, have at least a rudimentary sense of self …　and are generally more complex than a single psycho-biological state. These dissociative parts are mediated by action systems.

However, a question rises, which is whether we can really speculate a "partial" sense of self either theoretically, experiencially or clinically. Can our sense of self be experienced partially?

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ここからは英文に直していく作業である。

This article has a purpose of presenting a hypothesis regarding the way personalities are formed in patients with DID, from a standpoint of mirror neuron. Writing of this paper is motivated by this author’s concern that there is still a big ambiguity about the meaning of PPs in dissociative disorders. The key feature of DID is the existence of multiple personalities (DSM-5). However, it is counter-intuitive for us to believe that one has multiple personalities. As I will state later, our sense of self in each individual is sustained by its being unitary and indivisible. Therefore, there is ample reason that clinicians, let alone general public, have difficulty understanding the meaning of the multiplicity of personalities in the individual. The fact that there is little neurological explanation provided so far might have been worsening this situation.  

Is sense of self disturbed in “distinct personality states”?

 Historically, DID is conceptualized as a state of identity described as follows: Disruption of identity characterized by the presence of two or more distinct personality states (dissociative identities), involving marked discontinuities in the sense of self and agency (ICD-11, draft, as of 2020, World Health Organization.

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ここの部分、書いては消し、書いては消しである。全く収斂していかない。

例えば二つの人格状態

もちろん

ここで臨床的な具体例として、

この

また果たしてA

治療者が個々に出会う交代人格に対して、彼らは全体の部分に過ぎないという見方を取った場合、たちまち治療関係を損ねる可能性があろう。例えばある交代人格がこのように言われたらどうだろうか？　「あなた（

私はこれは

それぞれの交代人格に対して、その人格のもつ自己の感覚をリスペクトすることは、きわめて重要である。ところが交代人格を完全なる他者ととらえる臨床家は少ない。精神分析の伝統では、あくまでも心は一つという方針が変わることはない。しかしそれは解離を扱う臨床家にとってもあまり変わりない。

結局臨床的な観察から言えることは

ただしこの統合されていない交代人格の状態から連想されるのは、いわゆる精緻化されていない人格の存在である。人格の中にはそのプロフィールがあいまいであったり、ぶれたりする状態も少なくない。いわゆる「顔なし」であり、解離性トランス状態において見られる状態 にむしろ一歩近い状態である。

ミラーニューロンと解離 12

DID についてのDSM-5の記載の２）は以下のとおりである。

「解離性同一症をもつ人は，自らが突然自分自身の発語や行為の離人した観察者となり，それを止める力 自己感覚)がないという感覚を報告することがある.そのような人は声の知覚 (例:子どもの声，泣き声，霊的な存在からの声)について報告することもある. 場合によっては，声は，多数の錯綜し互いに独立した思考の流れとして体験され，それに対して本人は制御ができないと感じている.」

これはいわゆる作為体験の例と言える。これはいわばAという人格がBという人格からの侵入を受けている状態であり、そこには自己感の障害が存在しているといえるだろう。しかしではこれが生じない場合、すなわち人格AとBは明確に交代し、その間互いに侵入が体験されない場合もDIDでは頻繁に起き、むしろそのような体験様式の方が、彼らの体験の主たる部分を占めることになる。それらの場合においては自己の障害は見られないということであろうか。
　 百歩譲って、自己感覚および意志作用感の突然の変容または不連続が、このような作為体験以外の形で生じていて、それをDSM-5が記載していないだけであるという場合を考える。その場合は、「複数のパーソナリティ状態によるアイデンティティの破綻」という場合、そこにはある統一した、主となるアイデンティティないしは仮想的に統合されている人格を想定していることになることになりはしないだろうか。そしてその仮想的な統一人格が異なるアイデンティティに分断されていることで、自分が誰かがわからず、混乱している様子をこの定義は描いているように見られる。