A NOTION OF "DISSOCIOGENIC STRESS" Ken Okano, M .D. Ken Okano, M .D., is a psychiatrist at the Shawnee Community Mental Health Center in Topeka, Kansas. For reprints, write Ken Okano, M .D., 2401 SW . 6th Ave ., Topeka, Kansas 66606. ABSTRACT Dissociative disorders and the related stress can take different forms in different cultures . In Japanese society, the stress responsible for dissociative disorders appears less visible, embedded in a close rela- tionship with others ( "relational stress " traumatic stress such as childhood sexual and physical abuse . It is more reasonable to include covert and apparently non-traumatic stress as a factor contributing to dissociative disorders, rather than to limit our attention to overt and stereotyped forms of trauma, including childhood sexual and physical abuse . Despite their different mani- festations, covert stress and overt stress can both cause dissociative pathology in certain conditions . I postulate that these conditions involve the suppression of projection and externalization of nega- tive mental contents . The stress in these conditions may be called "dis- sociogenic stress." Whether or not an individual develops a disso- ciative disorder as a result of dissociogenic stress also depends on the individual's constitutionally based dissociative and hypnotic ten- dencies and other exogenous stresses. INTRODUCTION With the deepening of our understanding of trauma and dissociation, we are becoming aware of the diversity of dis- sociative phenomena in different sociocultural contexts . As a clinician in both japan and the United States, I have been interested in a potentially significant difference between these two cultures in the way traumatic disorders manifest themselves . Some clinicians (Watanabe, 1995 ; Oya et al ., 1997) have pointed out that dissociative fugue and disso- ciative amnesia appear to be more prevalent in japan, whereas dissociative identity disorder (DID) is more common in the United States . I will examine this hypothesis and sug- gest a theory to explain the potential similarities and dif- ferences in the way dissociative phenomena manifest them- selves in these two cultures . The Subjective Meaning of Traumatic Stress The more knowledge and data we gain regarding trau- ma and dissociation, the more confused we become about how to define and understand them . There is an enlarge- ment, or even a diffusion, of the notion of trauma, as we real- ize that more and more life events could possibly be includ- ed as forms of traumatic stress . The change in diagnostic criteria in the United States during the past twenty years reflects the vicissitudes in the conceptualization of trauma. In DSM-III (1980), in which post-traumatic stress disorder (PTSD) was first officially acknowledged in American psy- chiatry, trauma causing PTSDwas defined as "a recognizable stressor causing significant distress to almost anyone ." In DSM- III-R (1987), its definition was changed to describe an expe- rience "outside of the range of usual human experience dis- tressing to anyone ." The word "recognizable " in DSM-11Ihad disappeared from DSM-III-R In DSM-N (1994), the stressor was defined as an event in which a person experienced, wit- nessed, or was confronted with events involving actual or threatened death, injury or a threat to one's physical integri- ty, and a new emphasis was put on the individual 's subjec- tive experience of an event as a trauma, including a response of fear, helplessness, and horror. Although this emphasis on the subjective significance of trauma is essential in understanding what traumatic stress means to human beings, it may render the notion of trau- ma ambiguous and diffuse, because in our subjective world anything could potentially become traumatic . This empha- sis on the subjective meaning of trauma could also suggest that trauma may be indistinguishable from ordinary life stres- sors . For example, if an individual can tolerate a seemingly disastrous and catastrophic situation, then the experience is not traumatic . By the same token, another individual might experience trauma as a result of a life event which is trivial and insignificant to most other individuals. If we focus our attention to the traumatic stress respon- sible for dissociative disorders, the same circumstances are observed . A dissociation-generating trauma might not always be identified as such by an outside observer . In fact, clini- cians have asked whether childhood sexual abuse known to be related to dissociative pathology is the same as the trau- ma that causes PTSD . Finkelhor (1988) has contended that infantile sexual abuse should not always be considered as a 130 DISSOCIATION, Vol .2. June 1997 PTSD-related trauma, but rather as a "problem of relation- ship and environment" (p . 66) . Recently, more attention has been paid to less overt trauma, such as neglect, as an etio- logical factor in dissociative pathology . In his latest work, Ross (1997) argues that in many cases, what may be most signifi- cant in the development of DID is the individual's experi- ence of parental neglect (the "neglect pathway "), rather than overt sexual abuse. Not only does trauma leading to pathological dissocia- tion vary, but its clinical manifestations also take various forms, adding to the complexity of the etiology of dissocia- tive phenomena . This circumstance may indicate that dif- ferent kinds of dissociative disorders are generated by the different kinds of traumatic stress . One way of understand- ing the variety of dissociative manifestations is to consider a spectrum of disorders, in terms of the degree of seriousness of the dissociative experience . Ross (1997) and others rank the dissociative disorders in the following order from least to most serious : dissociative amnesia, dissociative fugue, dis- sociative disorder not otherwise specified (DDNOS) , and DID. According to this notion of a spectrum, relatively minor dis- sociative disorders, such as dissociative amnesia and disso- ciative fugue, emerge temporarily as a result of passing trau- matic stress, whereas DID is caused by a severe and long-lasting childhood trauma (e .g., physical and/or sexual abuse) . This variety of dissociative phenomena in a spectrum indicates that different manifestations of dissociative phenomena may be explained not only by the difference in the nature of the stress, but also by the subjectively experienced intensity of the stress. "RELATIONAL STRESS": TRAUMATIC STRESS IN JAPANESE SOCIETY The previously discussed subjective meaning of trauma is relevant when considering cultural influences on trauma and dissociation . In different cultures, traumatic stress and the resultant dissociative disorders can take quite different forms . Stress that causes dissociative disorders among the Japanese might not appear to the American people as a typ- ical form of trauma . There could also be a significant dif- ference in the way dissociative disorders are manifested in Japan and the United States, although some studies indicate that not much difference in dissociative tendencies is seen in the general population in these two countries (Tanabe et al ., 1992 ; Okano, 1995). What seems to be of significance in Japanese society is the stress that I would call "relational stress ." People expe- rience this kind of stress in their close emotional proximity to others, in which they need to suppress their individual wishes and emotions in order to maintain the relationship with others . In clinical settings, patients are encountered who seem to have developed a serious dissociative pathology due to this type of stress . Two published cases demonstrate how this relational stress may induce dissociative pathology. Watanabe (1995) described in detail two Japanese exam- ples of dissociative disorder . I will summarize these cases . The first case is one of dissociative fugue (my summary) Mr . A, a middle-aged man, worked for a Japanese corporation . He was tired of the huge amount of work assigned by his imme- diate boss, who never tried to listen to his con- cerns . Instead, the boss demanded that Mr. A follow his orders unquestioningly . Ex- hausted and frustrated, and not allowed to express his feelings, Mr . A one day experi- enced a dissociative fugue, lost his identity and abruptly took off from his workplace. Watanabe's second example is a case of dissociative amnesia. Ms . B was a young woman who had experi- enced stress in her marriage for some time, but she could not express her feelings to any- one . She began having amnestic spells when her husband yelled at her during their quar- rels . One day Ms . B harshly punished her five- year-old daughter and then felt bad about it. Out of guilt, Ms . B banged her head against a pillar in the house . As a result, her memo- ry and identity suddenly reverted to when she was 17 years old . While in this state, Ms . B asserted that she had never married and insist- ed that her husband was a total stranger . She reportedly did not recognize her daughter, but took care of her anyway because she "felt sorry for the child ." Ms . B was also found to have a hidden sexual desire toward her own father that she had never been able to ver- balize. In these two cases, no sexual or physical trauma was reported, but rather a type of chronic stress in relationship ("relational stress") with others was considered at least par- tially responsible for the dissociative disorders . We can fur- ther hypothesize that dissociative fugue and dissociative amnesia, which some clinicians postulate as the typical dis- sociative disorders among the Japanese (Watanabe, 1995 ; Oya et al . 1997) , can be caused particularly by this relational stress, as Watanabe's cases well describe . However, there is anoth- er possible explanation of an etiological relationship between dissociative fugue or dissociative amnesia, and relational stress . Compared with repeated sexual and physical trauma, relational stress may be less intense, causing dissociative dis- orders that rank lower in the spectrum of the dissociative disorders described previously . 131 DISSOCIATION, Vol . X, No . 1 June 1997 A NOTION OF "DISSOCIOGENIC STRESS" In Japanese society, group harmony is highly valued, and the expression of one 's personal feelings or opinions may be suppressed because it could disturb the integrity of the group . People are dependent on each other in a group, in which they silently seek to anticipate others' needs and try to fulfill them, while expecting others to understand and grat- ify their own needs . This relationship is considered to be the basis of the mentality of Amae (Doi, 1971), in which people are trapped in a sort of sadomasochistic relationship (Okano, 1997a) . Although people feel supported and taken care of by others, they experience stress because their individuality and assertiveness are highly suppressed . This relational stress may play an important role in understanding trautnatic stress in Japanese society. This relational stress has a long history in Japan and could have been a cause of dissociative disorders in the past . I con- sider a condition called "Imu" to be a typical example of this type of dissociative disorder . Imu is classed as a culture-bound syndrome similar to "Latah " and "Amok " in Southeast Asia. Imu is a psychopathology seen among the Ainu, an indige- nous ethnic group living on Hokkaido, the northern-most island in the Japanese archipelago . It is also mentioned in DSMNand has been studied in detail by a psychiatrist, Sakaki, and his follower, Uchimura (1947). Patients with Imu demonstrate very curious symptoms. Typically, a decent, intelligent, and talented middle-aged woman suddenly shows totally uncharacteristic behaviors such as picking up whatever is on the ground, and throwing it to whoever is around . These behaviors are triggered when she hears somebody say "tokkoni" or "bicki," meaning "snake" and "frog," respectively . These two animals are con- sidered taboo among the Ainu people . However, this agita- tion is only temporary . Usually within several minutes the person recovers her normal mental state and becomes amnestic about her own behaviors, or feels ashamed of her deed. Uchimura postulated (1947) that the stress that Ainu women experience in interpersonal relationships may be responsible for this condition . He stated: "[Imu may be caused by the] well-known oppressed lifestyle of Ainu women . In a scene that I saw on the street, an old Ainu woman never resisted being kicked into a ditch by one drunk Ainu male . It is to be immediate- ly noticed where the frustration of Ainu women could find its expression . The fit of Imu could be understood as a safety valve for it the true meaning of a hysterical fit as well as an Imu fit is a defense mechanism, a compensatory device that God provided for weak people" (p . 62, Okano translation). This study of Imu more than a half century ago suggests that relational patterns commonly seen in certain cultures and societies could well be a major stress factor leading to dissociative symptoms . However, relational stress in this sense is not limited to Japanese society . It has existed across cul- tures, which explains various forms of hysterical phenome- na as well as culture-bound syndromes in the world. JAPANESE SOCIETY AND CHILDHOOD TRAUMA If Japanese society has a low prevalence of DID, could the high prevalence of relational stress in japan explain it? I suggest that it could . Actually, a society that suffers rela- tional stress could also be one that "inhibits "childhood trau- ma such as sexual abuse and neglect, which appears very prevalent in the United States . In a sense, Japanese society and American society are opposite in terms of interperson- al closeness . Schematically put, relational stress, typically seen among the Japanese, is due to the emotional closeness and lack of psychological distance in relationships with other(s) , whereas trauma in the form of sexual abuse and neglect is due to disruption in, or the absence of, relationships with other(s) . I would like to discuss this issue in more detail. Childhood trauma in Japan, including sexual and phys- ical abuse, is not reported as frequently as in the United States. In my clinical experience in Japan, there were only a few per- sons, among the hundreds of people I interviewed, who spon- taneously reported such an incident . The apparently rare occurrence of sexual and physical trauma in Japan should not always be attributed to underreporting, or to the lack of scrutiny by clinicians . In Japan, the family structure remains more intact because divorce is rather strongly discouraged to preserve the parent-child relationship . This relatively lower divorce rate also helps to prevent parental sexual abuse. Finkelhor (1993) suggests that, in general, children who are living without one or both of their natural parents are at greater risk for abuse . Russell (1986) found that girls grow- ing up in the company of a stepfather were over seven times as likely to be abused as were girls growing up with their nat- ural father . This latter finding may help to explain the lower incidence of sexual abuse in japan, where, because of the lower divorce rate, there is much less chance that daughters will have a stepfather . However, for another perspective, Saito (1994) and others have suggested that there may be many unrecognized or unreported victims of sexual trauma in Japan, if not as many as in the United States. It should be noted that the overly close emotional rela- tionship typically seen between a Japanese caretaker and a child could become a factor promoting relational stress . A close mother-child relationship might stifle the child 's assertiveness and spontaneity . A Japanese mother tends to identify her life with that of her own children . A high preva- lence of parent-child suicide is reported to be one of the marked characteristics ofJapanese society (Harrison, 1997). Besides defining themselves as independent individuals, chil- 132 DISSOCI . X, No, 2, June 1997 dren need to define themselves in relation to their mother. As children grow up, they seek for a mother-surrogate in soci- ety to satisfy their dependency needs . This potentially cre- ates a situation in which one 's identity is trapped within the group to which one belongs, and one thus tends to have dis- sociative pathology in order to survive emotionally. The Notion of "Dissociogenic Stress " The final purpose of my paper is to suggest commonal- ties in the traumatic stresses that cause dissociative disorders in the United States and in japan and then to offer a hypoth- esis about how these stresses create dissociative pathology. The term dissociogenic stress describes a type of traumatic stress that actively causes dissociative pathology . This kind of stress can exist in any culture, and can take various forms, including overt sexual and physical trauma typically seen and reported in the United States . However, in many cases dis- sociogenic stress is a chronic and covert process in which the individual who undergoes this stress might not recognize it as traumatic . The relational stress that I discussed earlier could be a form of dissociogenic stress in certain conditions. I would like to clarify here, however, that dissociogenic stress may not be enough to cause actual dissociative disorders . A dissociative tendency itself is related to an individual's bio- logical as well as constitutional characteristics (Spiegel, 1994) . We could understand that a dissociative disorder is most likely to be induced if an individual with a high disso- ciative tendency and hypnotizability undergoes dissociogenic stress. Thus, dissociogenic stress can take various forms, but for the relational form, it requires a certain condition . This con- dition involves the suppression of projection and the exter- nalization of negative mental contents during the stressful situation . In these negative mental contents I include aggres- sive or sexual wishes and fantasies causing shame or guilt, or bad object images . When we have these negative mental contents, we feel pain and try to expel them via projection and externalization, instead of containing them in our mind . We blame others, express our anger, and regard oth- ers as bad objects, while justifying ourselves and assuming that we are a good object . This process is actively promoted by our interaction with real others, via gaining their sympa- thy and support, or by our using them as an object for blame and aggression . By mobilizing these mechanisms of projec- tion and externalization, we often regain our composure under stressful situations. From a psychodynamic perspective, projection and exter- nalization are regarded as defense mechanisms . In these notions, there is an assumption that negative mental con- tents stem from our own mind and that we unjustly dump them onto others in order to defend ourselves against them. However, the mobilization of these mechanisms in a trau- matic situation may sometimes be totally justified . It is most often the aggressor who originally possesses the negative char- acteristics that are forcefully put into the victim's mind. I will show how the suppression of projection and exter- nalization can lead to dissociation . As Klein (1975) pointed out, we human beings tend to separate negative mental con- tents and positive mental contents ; the latter include plea- surable fantasies and desires as well as benevolent object images . If negative contents cannot be expelled via projec- tion and externalization, they must coexist with positive men- tal contents . However, because of the contradictory nature of negative and positive mental contents, there arises a need to separate them within the internal world, which makes the dissociative process necessary (Okano, 1997b). Projection and externalization may be prohibited in many situations . I would classify these situations into the fol- lowing two categories: 1) external inhibition, when an individual is forced to deny or keep secret certain negative mental contents; 2) internal inhibition, when an individual feels ashamed of, or responsible and guilty for having, negative mental con- tents. Both of these situations are seen in childhood sexual abuse typically reported in the United States, as well as in the relational stress frequently seen among the Japanese . In childhood sexual abuse, the child is often forced to keep the fact of the abuse secret, and is told that she or he is respon- sible for colluding with the abuser . The abused child also finds it extremely shameful to discuss the abuse with others. Finkelhor (1988) hinted that these circumstances form the essential part of trauma (summarized below): Dynamic 1 : Traumatic Sexualization . Quite often victims are rewarded, and learn to use their own sexuality to control others. Dynamic 2 : Betrayal By Caretaker . The hitherto trusted care- taker appears unexpectedly, but now as an abuser, and the mother or other caretaker does not understand or does not wish to be involved in the abusive situation. Dynamic 3 : Stigmatization . The victim is given various nega- tive messages, such as that she/he is responsible for the abuse, or is to be ashamed of being abused. Dynamic 4 : Powerlessness. Any sense of autonomy is lost, and one's spontaneity and wishes are stifled. These four dynamics are closely related to both the American and the Japanese situations involving dissociogenic stress . Regarding the situation in the United States, in 133 DISSOCIATION, VolX. 2, June 1997 A NOTION OF "DISSOCIOGENIC STRESS" Dynamic 1, traumatic sexualization, the victim's receiving of a reward from the abuser suppresses the victim's expression of negative affect and promotes self-reproach regarding the traumatic relationship (internal inhibition) . In Dynamic 2, betrayal by the caretaker, the victim's verbal description of trauma to practically anybody is inhibited (external inhibi- tion) . In Dynamic 3, being stigmatized, the victim is forced to have feelings of self-reproach, guilt, or shame (internal inhibition) . The powerlessness in Dynamic 4 involves both internal and external inhibition, which engenders in the vic- tim 's mind a deep sense of helplessness, a feeling that no matter what he or she expresses, no one will ever listen to the negative mental contents. Internal and external inhibition are also seen in the rela- tional stress typically seen in Japanese society . Japanese cul- ture is often characterized as a "shame culture" (Benedict, 1946) , in which the individual is bound by various sociocul- tural beliefs and norms . Spontaneous expression of nega- tive emotions and hidden wishes is discouraged for fear of scrutiny and ostracism by the group and society (external inhibition) . One also tends to feel responsible for stress or inconvenience in interpersonal relationships (internal inhi- bition) . Some cases of dissociative fugue in Japan, such as Watanabe's devoted and self-critical employee who could not express his anger and frustration, can be understood in this context . He could not express his secretive wish to "disap- pear and begin a new life, " except in the form of a dissocia- tive fugue . a73 Acknowledgement: The author thanks Mr . Phillip Beard for his critical comments and editorial help. REFERENCES American Psychiatric Association . (1980) . Diagnostic and Statistical Manual of Mental Disorders,3rd ed . Washington, DC : Author. American Psychiatric Association . (1987) . Diagnostic and Statistical Manual of Mental Disorders,3rd ed ., rev. Washington, DC : Author. American Psychiatric Association . (1994) . Diagnostic and Statistical Manual of Mental Disorders,4th ed . Washington, DC : Author. Benedict, R. (1946) . Chrysanthemum and sword ofJapanese culture . Boston : Houghton Mifflin. Doi, T . (1971) . The anatomy of dependence . Bestor, Trans) . Tokyo and New York : Kodansha International. Finkelhor, D . (1988) . The trauma of child sexual abuse . In G .E. Wyatt & C .J. Powell (Eds .), Lasting effectsof childhood sexual abuse. Newbury Park : Sage Publishing Co. Finkelhor, D . (1993) . Epidemiological factors in the clinical iden- tification of child sexual abuse . Child Abuse & Neglect, 17, 67-70 Harrison, P. (1997) . Suicidal Behavior in Culture and Psychopath- ology . In W.-S. Tseng & J . Streltzer (Eds .), A guide to clinical assess- ment (pp . 157-172) . New York: Brunner/Mazel Publishers. Klein, M. (1975) . Notes on some schizoid mechanisms . In M. Klein, Envy and gratitude and other works, 1946-1963 (pp . 1-24). New York: Free Press . Original work published in 1946. Okano, K. (1997a, May) . Passivity in Amae relationship and the fan- tasy of "genuine love"Paper presented at the 86th annual meeting of the American Psychoanalytic Association, San Diego. Okano, K . (19976) . Splitting and multiple personality disorder. (Japanese) . SeisinkaChiryougaku. 12, 1031-1038. Oya, D., Matsumoto, K, Kudo, K, Irizawa, S ., Oda, Y., & Nokano, K. (1997, March) . Dissociative disorders in japan . Program and Abstracts of the 17th Meeting ofJapanese Social Psychiatry, Tokyo. Ross, C. (1997) .Dissociative identity disorder: Diagnosis, clinical features, and treatment of multiple personalityNew York: Wiley. Saito, S . (1994) . On childhood sexual abuse . (Japanese) . Japanese Journal of Adolescent and Adult Psychiatry, 4,19-38. Spiegel, D., & Vermutten, E. (1994) . Physiological correlates of hyp- nosis and dissociation . In D. Spiegel (Ed.), Dissociation and body(pp . 185-210) .Washington, DC : American Psychiatric Press. Tanabe, H ., & Ogawa, T. (1992) . A measurement of dissociative experiences by questionnaires : Assessment of DES in university stu- dent subjects . (Japanese) . Tsukuba Psychological Research, 14,171- 178. Uchimura, H. (1947) .Essay of a psychiatrist . Tokyo: Domei Shuppansha. Watanabe, N . (1995) . "Expression a la Japanese" Dissociative amnesia and dissociative fugue . (Japanese) . In Multiple personality disorder & personality psychology .38-46) .Tokyo : Asashi Shinbun- sha. 134 DISSOCIAT10N, Col