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The Developmental Roots of Dissociation: A Multiple Mediation Analysis

Article in Psychoanalytic Psychology · April 2016

DOI: 10.1037/pap0000084

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 DEVELOPMENTAL ROOTS OF DISSOCIATION 1

Note: This is a pre-print version of the article. The final version can be found in the

APA journal Psychoanalytic Psychology, at http://psycnet.apa.org/journals/pap/34/1/96/

The Developmental Roots of Dissociation:

A Multiple Mediation Analysis

Prof. Adriano Schimmenti, PhD

UKE – Kore University of Enna, Italy

Correspondence: Prof. Adriano Schimmenti, PhD, Faculty of Human and Social

Sciences, UKE – Kore University of Enna, Cittadella Universitaria, 94100, Enna, Italy.

E-mail: adriano.schimmenti@unikore.it.
DEVELOPMENTAL ROOTS OF DISSOCIATION 2

The Developmental Roots of Dissociation:

A Multiple Mediation Analysis

 DEVELOPMENTAL ROOTS OF DISSOCIATION 3

ABSTRACT
The current study was aimed to test a developmental model of dissociation.
This model is based on clinical observations and research findings
concerning the role of childhood emotional neglect in the development and
maintenance of dissociative symptoms. Seven hundred ninety-two adult
volunteers completed questionnaires on parental bonding, theory of mind,
alexithymia, and dissociation. Significant associations were found between
the investigated variables, and a multiple mediation analysis showed that the
relationship between childhood emotional neglect and dissociation was
totally mediated by theory of mind and alexithymia. The findings of this
study support the view that childhood experiences of emotional neglect may
foster difficulties mentalizing as well as problems with affect regulation,
with these two factors interacting to generate excessively activated
dissociative processes. This may suggest that individuals who were exposed
to emotional neglect during their childhood and who currently suffer from
dissociative symptoms may greatly benefit from clinical interventions aimed
to foster mentalized affectivity.

Keywords: dissociation, affect dysregulation, mentalization, emotional

neglect, multiple mediation
 DEVELOPMENTAL ROOTS OF DISSOCIATION 4

The Developmental Roots of Dissociation: A Multiple Mediation Analysis

In the psychoanalytic tradition, the term dissociation refers to a defense

mechanism: a process by which behaviors, thoughts, memories, and feelings split from

one another (Kluft, 1990a; O’Neil, 2006; Vaillant, 1994). Dissociation is already

available in the early stages of development (Porges, 2001), and it allows an individual

to avoid emotional distress by screening out excessive or overwhelming stimuli (Schore,

2009). However, it has been postulated that experiences of abuse and neglect in the

context of attachment relationships may force a child to an excessive and pervasive

activation of dissociative defense (Bromberg, 1998; Chefetz, 2015). Abusive and

neglectful parenting styles can indeed lead the child, whose capacities for self-

regulation and cognitive processing of affective states are not fully developed, to

constantly use a dissociative defense as a way to escape from overwhelming feelings

and unbearable mental states arising from such negative interpersonal experiences

(Kluft, 1990b, 2000; van der Kolk, 2014; Putnam, 1997; Schimmenti & Caretti, 2016).

At this point, one’s entire psychic functioning might become organized around

dissociation (Bromberg, 1998; Chefetz, 2015), and symptoms such as depersonalization,

derealization, amnesia, compartmentalization, identity disturbance, and altered

personality (Steinberg, 1993) may emerge as a result.

Decades of clinical and empirical research have shown that child abuse and

neglect are strongly related to dissociative symptoms (Kluft, 1985, 1990a, 2013;

Dalenberg et al., 2012). In fact, an excessive activation of dissociation has been linked

to the dysregulation of affect metabolism derived from child maltreatment (Lanius et al.,

2010), which may indeed generate significant alterations in the network of cortical and
 DEVELOPMENTAL ROOTS OF DISSOCIATION 5

subcortical interactions that foster the development of self-awareness and the ability to

organize mental and affective states (Schimmenti, 2012). These alterations might

involve atypical development of the right brain, the hippocampus, the prefrontal cortex,

the hypothalamic-pituitary axis, the noradrenergic system, and concentrations of

corticotropin-releasing hormone, just to name a few biological dimensions that are

sensitive to parental care. It is rather clear that such alterations may undermine the

development of autobiographical narrative and may damage psychosomatic integration

(Chefetz, 2015). Moreover, all these neurobiological and developmental considerations

might help explain why many psychiatric disorders, and not only dissociative disorders,

have been empirically linked with dissociation. For example, high levels of dissociation

have been found to be related to post-traumatic stress disorder (Carlson, Dalenberg, &

McDade-Montez, 2012), somatic symptom disorders (Sar, Akyüz, Kundakçi, Kiziltan,

& Dogan, 2004), personality disorders (Zanarini, Frankenburg, Jager-Hyman, Reich, &

Fitzmaurice, 2008), substance use disorders (Najavits & Walsh, 2012), and even

psychotic disorders (Braehler et al., 2013).

The developmental origins of dissociation and the role of emotional neglect

During the 1980s, the specific origins of excessively activated dissociative

processes were usually identified with childhood experiences of sexual abuse. This

assumption was likely based on clinical observations wherein the histories of

individuals with multiple personality disorder who had suffered from child sexual abuse

in the context of attachment relationships were described (e.g., Bowman, Blix, & Coons,

1985; Coons, 1986; Kluft, 1987, 1990a; Malenbaum & Russell, 1987; Ross, Norton, &

Wozney, 1989). Multiple personality disorder (now labeled as dissociative identity

disorder in the DSM-5; American Psychiatric Association, 2013) is a clinical condition

 DEVELOPMENTAL ROOTS OF DISSOCIATION 6

characterized by identity fragmentation and extensive memory loss in which two or

more distinct personalities alternately take control of an individual. In this disorder, the

effects of extreme dissociation are clearly represented; a person’s entire identity, not

only its functions, is split and fractionated into separate parts with their own distinct

personality.

On the one hand, a renewed interest in the study of multiple personality disorder

has highly contributed to a better acknowledgement of the detrimental effect of

childhood sexual abuse on an individual’s development (Kluft, 1990a, b); on the other

hand, focusing on the effects of a single and specific form of child maltreatment (sexual

abuse) regarding the development of multiple personality disorder might have

paradoxically slowed down the understanding of the complex relationships between the

entire spectrum of negative attachment experiences in childhood and the presence of

overly activated dissociative processes (Chefetz, 2015; Liotti, 1999). As a matter of fact,

in many cases child sexual abuse co-occurs with other adverse experiences, such as

parental loss, financial hardship, social isolation, violence between parents, rejection,

neglect, parentification, physical abuse, and psychological abuse (Bifulco & Moran,

1998).

It has been postulated that emotional neglect represents a common ground in

which other forms of child maltreatment, including sexual abuse from parents, can

develop and generate psychologically venomous fruits (Schimmenti & Bifulco, 2015).

Emotional neglect occurs when a parent intentionally or unintentionally overlooks signs

that a child needs comfort or attention; it covers a number of parental behaviors that

imply a failure or refusal to provide needed psychological care (e.g., rejection of the

child, failure to express positive feelings to the child, hindering the development of
 DEVELOPMENTAL ROOTS OF DISSOCIATION 7

autonomy, withholding love, and denying the child opportunities for interacting; see

Glaser, 2002; Minty, 2015). In this sense, emotional neglect can be conceptualized as a

specific and potentially traumatogenic configuration of the child–caregiver relational

field in which the child’s affective needs are disowned; as a result, such needs are

subdued to parental demands, desires, conflicts, fears, and projections (Schimmenti &

Caretti, 2010, 2016).

Strikingly, findings from longitudinal studies on dissociation support these

considerations. Indeed, research has shown that increased dissociation scores are more

related to the quality of child–caregiver interactions than to child abuse. For example,

Ogawa, Sroufe, Weinfield, Carlson, & Egeland (1997) found in a sample of 168 late

adolescents aged 18–19 years that the psychological unavailability of the caregiver

during the adolescents’ first two years of life, lack of caregiver attention, and

disorganized attachment at 12–18 months predicted the adolescents’ dissociation scores.

It is noteworthy that the psychological unavailability of the caregiver was the single

strongest predictor of dissociation, while the occurrence of physical or sexual abuse in

childhood, surprisingly, did not add to the prediction in the study by Ogawa and

colleagues. Similarly, Dutra, Bureau, Holmes, Lyubchik, & Lyons-Ruth (2009)

followed a group of 56 late adolescents from infancy to age 19 and found that observed

lack of parental responsiveness and disrupted communication in infancy predicted

participants’ dissociation scores, with self-reported verbal abuse adding to the

prediction. In the study by Dutra and colleagues, the other forms of abuse were not

predictive of dissociation either.

It could be useful here to highlight that such findings do not suggest that

emotional neglect is the only factor leading to high levels of dissociation; they suggest
 DEVELOPMENTAL ROOTS OF DISSOCIATION 8

instead that among the many types of child maltreatment, those related with the

psychological unavailability of the caregivers and their difficulty or unwillingness to

attune with the child’s needs are the most critical variables to take into account for

predicting increased levels of dissociation. Such findings are consistent with the more

general consideration that while physical and sexual abuse in childhood may be

episodic, emotional neglect and lack of parental responsiveness may characterize the

entire developmental environment (Schimmenti & Bifulco, 2015; Infurna et al., 2016).

Children need to perceive positive feelings of being cared for, accepted, and protected

in their family environments in order to grow up secure and healthy (Bowlby, 1988),

and the lack of such positive feelings may constitute a developmental trauma for the

child (Schimmenti & Caretti, 2016), which could undermine his or her developing sense

of self (Bromberg, 2011).

Childhood trauma and dissociation: searching for the linking mechanisms

The linking mechanisms involved in the relationship between childhood emotional

neglect and dissociation are still under debate. Recent theoretical contributions in the

psychoanalytic field have suggested that lack of mentalization and affect dysregulation

are crucial constructs to take into account in the understanding of this relationship. For

example, Fonagy and colleagues (2002) observed that childhood trauma may inhibit the

natural development of mentalizing abilities and the capacity to think in terms of

internal states, i.e., the capacity to organize the understanding of one’s own and others’

experience in terms of mental state constructs (beliefs, feelings, desires, intentions, and

their expectable transactional relationships in a given situation). Maltreated children

may be constantly forced to dissociate in order to protect themselves from

overwhelming relational experiences that cannot be mentalized (Liotti, 1999). In this

 DEVELOPMENTAL ROOTS OF DISSOCIATION 9

case, dissociation may facilitate the re-establishment of regulation and adaptive

functioning by compartmentalizing trauma-related memories, but at the cost of further

inhibiting mentalization (Ensink, Berthelot, Bernazzani, Normandin, & Fonagy, 2014;

Ensink, Fonagy, Berthelot, Normandin, & Bernazzani, 2015). As a result, the normal

acquisition of an adequate theory of mind (i.e., the ability to attribute and interpret one’s

own and other people’s mental and emotional states, such as beliefs, intents, desires,

perspectives, pretending, knowledge; see Baron-Cohen, Leslie, & Frith, 1985) might be

hindered for these children. Theory of mind is critical for mentalizing processes,

because it constitutes the basic capacity allowing one to interpret reality at both

cognitive and affective levels. Notably, research has shown that the overall accuracy in

identifying complex internal states is reduced in people who have been neglected or

abused in childhood (Nazarov et al., 2014; Pears & Fisher, 2005), even though they

could be even more accurate than other people in the process of identifying negative

feelings (Wagner & Linehann, 1999). This likely happens because their interpersonal

functioning has been sensitized early to threats and dangers, thus their mind has been

forced to operate as a “smoke detector” (van der Kolk, McFarlane & Weisaeth, 1996)

for avoiding further trauma, which is a double-edged sword because while on the one

hand this condition may provide some degree of insulation against overwhelming

stressors (Kluft, 1990b), on the other hand it may also generate many errors in

recognizing and interpreting internal states (Schimmenti, 2015a).

Schimmenti and Caretti (2016) complemented the observations on the role of lack

of mentalization in the excessive activation of the dissociative processes by arguing that

dissociation is directly related to difficulties in emotion modulation and affect tolerance

resulting from child abuse and neglect. Since self-regulation abilities are limited during
 DEVELOPMENTAL ROOTS OF DISSOCIATION 10

infancy and childhood, interpersonal regulation is critical for child development.

Parental unavailability, rejection, and abuse force children to use their underdeveloped

self-regulatory mechanisms to protect themselves from threats and dangers (Schimmenti,

2015b). Thus, children may try to repair the relational failures and to re-establish the

attachment bond through the hyperactivation of the attachment system, which may lead

to the development of state-dependent responses to affective cues, and/or children may

respond instead with extreme disengagement and immobility, a primary regulatory

process involving a metabolic shutdown that serves to conserve energies and to foster

survival (Schimmenti & Caretti, 2016). These two mechanisms likely represent the

emotional precursors of compartmentalization and detachment responses, i.e., the core

domains of dissociative symptoms (Brown, 2006). Again, dissociation may allow

children to survive maltreatment, but at the same time it will also hinder the

development of more mature strategies of affect regulation. In this respect, Schimmenti

and Caretti (2016) suggested a linkage between the affect dysregulation deriving from

parental failures of care and alexithymic conditions. The construct of alexithymia

describes a difficulty identifying and describing feelings, externally oriented thinking,

and a paucity of fantasies and dreams (Nemiah, Freyberger, & Sifneos, 1976; Taylor &

Bagby, 2013; Taylor, Bagby, & Parker, 1997). Although alexithymia is a normally

distributed trait in the community (Parker, Keefer, Taylor, & Bagby, 2008), early

conceptualizations of the construct (Krystal, 1988; Nemiah, Freyberger, & Sifneos,

1976) and many empirical findings (e.g., Bermond, Vorst, & Moorman, 2006; Güleç,

Altintaş, İnanç, Bezgin, Koca, & Güleç, 2014; Schimmenti et al., 2015a) support the

view that the presence of increased levels of alexithymia is related to trauma exposure

in the individual’s life. In particular, Krystal (1988, 1997) argued on the basis of his
 DEVELOPMENTAL ROOTS OF DISSOCIATION 11

clinical observations that alexithymia can result as a consequence of an arrest in affect

development due to psychic trauma in early childhood, and that it can also emerge from

a regression of affect involving dedifferentiation, deverbalization, and resomatization of

affects, which may occur as a response to major trauma in adulthood.

Therefore, it is possible that the likelihood of having low levels of theory of mind

and high levels of alexithymia is increased when parental failures of care have occurred

during one’s childhood, and that theory of mind and alexithymia act as mediators in the

relationship between the quality of care received during childhood and the dissociative

experiences of individuals.

Aims of the study

The current study aimed to investigate the relationships between theory of mind,

alexithymia, dissociation, and the quality of the relationship with parents during

childhood in a large adult sample in order to integrate the developmental and clinical

considerations presented in the previous paragraphs into a more comprehensive and

empirical understanding of the developmental origins and actual mechanisms of

dissociation. It was predicted that the scores on dissociation, theory of mind,

alexithymia, and childhood emotional neglect were intercorrelated and that a multiple

mediation model, in which the predictive association between childhoodemotional

neglect and dissociation would be mediated by theory of mind and alexithymia, would

adequately fit the data.

To this purpose, the associations between these variables were examined, and a

multiple mediation model was tested. The model configuring the investigated variables

in a multiple mediated relationship is depicted in Figure 1.

----------
 DEVELOPMENTAL ROOTS OF DISSOCIATION 12

Figure 1 about here

----------

The model in Figure 1 predicts that childhood emotional neglect will be positively

related to dissociation, and that theory of mind and alexithymia will mediate this

predictive association. In detail, the model predicts that the scores on childhood

emotional neglect will be negatively related to theory of mind scores and positively

related to alexithymia scores, that theory of mind scores will decrease dissociation

scores whereas alexithymia scores will increase dissociation scores, and that a

previously significant and positive predictive association between the scores on

childhood emotional neglect and dissociation scores will become not significant after

the inclusion of theory of mind scores and alexithymia scores in the model. Moreover,

the relationship between theory of mind scores and alexithymia scores should further

contribute to the relationship between the scores on childhood emotional neglect and

dissociation scores, such that higher scores on theory of mind should be negatively

related to alexithymia scores and should decrease the impact of alexithymia scores on

dissociation scores.

The multiple mediation model presented in Figure 1 can be conceived as a

specification of the more general trauma model of dissociation, which postulates that

dissociative symptoms and dissociative disorders are directly and indirectly related to

traumatic experiences (Dalenberg et al., 2012, 2014). In fact, it has been theoretically

stressed in the introduction of this article that child abuse and neglect can be extremely

traumatizing because on the psychobiological, affective, and cognitive levels they are

too much for a child to tolerate (Schimmenti & Caretti, 2016). So, in this model the high
 DEVELOPMENTAL ROOTS OF DISSOCIATION 13

scores for dissociation are considered a result of real experiences of parental emotional

neglect.

However, the trauma model of dissociation has a competing theoretical model,

called the fantasy model or sociocognitive model (Spanos, 1996), in which dissociation

is conceived as a personality trait characterized by high levels of suggestibility and a

weak sense of self. Therefore, according to the sociocognitive model of dissociation, a

reverse causation hypothesis for the model depicted in Figure 1 would be true, i.e.,

dissociation, theory of mind, and alexithymia would predict the perception of the

quality of relationships with parents during childhood. Although the sociocognitive

model of dissociation has little empirical support (Dalenberg et al., 2014), it has many

endorsers among clinicians, so the prediction deriving from this competing theoretical

model was checked to partially rule out the possibility of a reverse causation.

Method

Participants

The study sample includes 792 Caucasian adults (358 males, 45.2%; 434 females,

54.8%), recruited in five cities of Sicily, Italy. Participants ranged in age from 18 to 64

years old (M = 35.75, SD = 10.95). The mean number of years of education was 13.09

(SD = 3.40). There were no gender differences in relation to participant age (t(790)=.65, p

= .51) or years of education (t(790)=.60, p =.55).

Procedures

Participants were recruited between April 2013 and June 2014 through public

announcements placed in workplaces and recreational areas of five Italian cities of

different sizes and populations. People who contacted the research office were informed

about the nature of the study, and those who agreed to participate signed an informed
 DEVELOPMENTAL ROOTS OF DISSOCIATION 14

consent and were administered a series of questionnaires. A total of 799 individuals

participated in this study. Seven participants (0.9%) reported the lack of a mother or a

father figure during their childhood, so their responses were excluded from the analysis.

Participants did not receive any compensation for their involvement in the study. At the

end of the study, they were debriefed and thanked. The study was approved by the IRB

for psychological research of the UKE-Kore University of Enna.

Measures

Parental Bonding Instrument (PBI; Parker, Tulping, & Brown, 1979). The PBI is

a self-report measure to assess parenting behaviors. Respondents are asked to recall how

their parents acted toward them during the first 16 years of their life, rating their

mothers’ and fathers’ attitudes separately on 25 questions. Each item is rated on a 4-

point Likert scale (0 to 3). Twelve of the 25 items concern the Care dimension (e.g.,

“Appeared to understand my problems and worries”), which includes items assessing

parental affection, warmth, support, and availability. Care scores range from 0 to 36 for

both mother and father, with higher scores indicating higher care by the parent. The

remaining 13 items concern the Overprotection dimension (e.g., “Tried to make me feel

dependent on him”), which includes items assessing parental intrusiveness, excessive

control, infantilization of the child, and lack of support for the development of

autonomy in the child. Overprotection scores can range from 0 to 39 for both mother

and father, with higher scores indicating more controlling behaviors by the parent.

The psychometric properties of the PBI are good, with good internal consistency, high

test-retest reliability, and considerable support for its validity as a measure of actual

parenting in both clinical and non-clinical samples (Parker, 1989). The Italian

translation of the PBI (Scinto, Marinangeli, Kalyvoka, Daneluzzo, & Rossi, 1999) was
 DEVELOPMENTAL ROOTS OF DISSOCIATION 15

used in this study, and consistent with previous research (Schimmenti, Maganuco,

Gelsomino, La Marca, Di Dio, & Gervasi, 2015b) an index on childhood emotional

neglect was calculated by subtracting the sum of PBI maternal and paternal care scores

from the sum of PBI maternal and paternal overprotection scores, that is: [(PBI

mother’s overprotection + PBI father’s overprotection) – (PBI mother’s care + PBI

father’s care)]. Therefore, higher scores on this index indicate higher exposure to

parental emotional neglect during childhood. Cronbach’s alphas of the PBI scales in this

study were .89 for mother’s care, .91 for father’s care, .82 for mother’s control, and .82

for father’s control.

Dissociative Experiences Scale – II (DES-II; Carlson & Putnam, 1993). The

DES-II is a 28-item self-report measure of dissociative experiences (such as experiences

of absorption, emotional detachment, amnesia, depersonalization, derealization, identity

confusion, and compartmentalization). DES-II responses are made by circling a

percentage ranging from 0% to 100% at 10% intervals (corresponding to an 11-point

Likert scale). Items assess the percentage of time individuals experience these

symptoms (e.g., “Some people have the experience of looking in a mirror and not

recognizing themselves. Circle the number to show what percentage of the time this

happens to you.”). The overall score of the DES-II can range from 0% to 100%, and is

the average score obtained by adding up the 28 item scores and dividing by 28. The

psychometric properties of the DES-II are good, with excellent internal consistency,

good test-retest reliability, and good convergent validity (van Ijzendoorn & Schuengel,

1996). The Italian translation of the measure (Schimmenti, 2015a) was used in the

current study to assess dissociation. Cronbach’s alpha of the DES-II in this study

was .94.
 DEVELOPMENTAL ROOTS OF DISSOCIATION 16

Reading the Mind in the Eyes Test – Revised Version (Eyes Test; Baron-Cohen,

Wheelwright, Hill, Raste, & Plumb, 2001). The Eyes Test was used to assess theory of

mind. The Eyes Test is a performance task in which participants are presented with a

series of 36 photographs of the eye region alone, and they are required to select which

of four mental state descriptors (a target word and three foil words) best describe the

thoughts or feelings expressed by the eyes of the individuals in the pictures. A glossary

of the mental state words is provided for participants to consult at any point if required.

One point is assigned for each correct response. Scores on the Eyes Test can range from

0 to 36, with higher scores indicating higher levels of theory of mind. The Eyes Test has

demonstrated sufficient internal consistency, adequate split-half and test-retest

reliability, and good convergent validity (Vellante et al., 2013). The Italian translation

of the measure (Serafin & Surian, 2004) was used in the current study to assess theory

of mind. Cronbach’s alpha of the Eyes Test in this study was .64.

20-item Toronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994;

Bagby, Taylor, & Parker, 1994). The TAS-20 is a 20-item self-report measure for the

assessment of alexithymia. Participants are asked how much they agree (1 = strongly

disagree; 5 = strongly agree) with each statement (e.g., “I have feelings that I can’t quite

identify”). The TAS-20 total score is the sum of responses to all 20 items, so it can

range from 20 to 100. Higher scores indicate higher levels of alexithymia. The TAS-20

has good reliability and validity, and has a 3-factor structure that is consistent across

countries (Taylor & Bagby, 2013). The Italian translation of the measure (Bressi et al.,

1997) was used in the current study to assess alexithymia. Cronbach’s alpha of TAS-20

in this study was .76.

Data analysis
 DEVELOPMENTAL ROOTS OF DISSOCIATION 17

Descriptive statistics were computed for all the variables investigated in the study.

Gender differences were examined through t-test for independent samples. Associations

between the variables were examined though Pearson’s r correlations. The proposed

multiple mediation model was examined using the Process Macro for SPSS (Hayes,

2013), applying Model 6 with 5,000 bias-corrected bootstrap samples and controlling

for sociodemographic variables (i.e., gender, age, and years of education). Given the

cross-sectional nature of the study, Model 6 of the Process Macro was also applied to

test for the reverse causation model, i.e., to partially rule out the possibility that the

participants’ scores on childhood emotional neglect would depend on dissociation,

theory of mind, and alexithymia scores, in accordance with the sociocognitive model of

dissociation. A p value of .05 was set as the critical level for statistical significance (for

bootstrap analyses, if the 95% confidence interval includes 0, then the effect is not

significant, if 0 is not in the interval, then the effect is statistically significant; see Hayes,

2013).

Results

Descriptive statistics are presented in Table 1 for the full sample and

differentiated by gender, along with level of significance for gender differences.

----------

Table 1 about here

----------

The participants’ scores were all in the normal range. There were no gender

differences in relation to participant age or years of education. Male participants showed

significantly lower scores than females on theory of mind. Males were also less
 DEVELOPMENTAL ROOTS OF DISSOCIATION 18

overprotected during their childhood. As a result, their scores on childhood emotional

neglect were significantly lower than female scores.

The intercorrelations between the investigated variables (all df=790) are reported

in Table 2. All of the associations between the variables were in the expected direction.

DES-II scores were negatively correlated with the Eyes Test scores, and positively

correlated with the TAS-20 scores and with the scores on childhood emotional neglect.

Furthermore, DES-II scores were negatively correlated to age and years of education.

The associations between theory of mind, alexithymia, and childhood emotional neglect

were also in the predicted direction. The scores on childhood emotional neglect were

negatively correlated with the Eyes Test scores and positively correlated with the TAS-

20 scores. There was a negative correlation between the Eyes Test scores and TAS-20

scores. .

----------

Table 2 about here

----------

Finally, the multiple mediation model presented in Figure 1 was tested. All

variables were sufficiently normal in their distributions to render the statistics involved

in the mediation analyses valid. However, the predictor and the mediators were mean-

centered to minimize collinearity, heteroskedasticity consistent standard errors were

calculated, and 5,000 bias-corrected bootstrap samples were used in order to minimize

the risk of biased results (Hayes, 2013).

The results of multiple mediation analyses entirely supported the model presented

in Figure 1. After controlling for gender (males coded as 1, female as 2; t=-.96, p=.34,

n.s.), age (t=-8.15, p<.01; B=-.31, SE=.04, CI[-.39, -.24]), and years of education (t=-
 DEVELOPMENTAL ROOTS OF DISSOCIATION 19

2.07, p=.04.; B=-.27, SE=.13, CI[-.52, -.01]), the scores on childhood emotional neglect

were negative predictors of Eyes Test scores (t=-3.81, p<.01; B=-.03, SE =.01, CI[-.04,-

.01]) and positive predictors of TAS-20 scores (t=8.87, p<.01; B=.15, SE=.02,

CI[.11, .18]). Eyes Test scores were negative predictors of TAS-20 scores (t=-7.30,

p<.01; B=-.60, SE =.08, CI[-.77, -.44]). Both Eyes Test scores and TAS-20 scores

predicted DES-II scores in the model, but in opposite directions: Eyes Test scores were

negative predictors of DES-II scores (t=-6.05, p<.01; B=-.70, SE=.12, CI[-.93, -.47]),

whereas TAS-20 scores were positive predictors of DES-II scores (t=7.17, p<.01; B=.30,

SE=.04, CI[.22, .38]). The previously significant and positive association between the

scores on childhood emotional neglect and DES-II scores (t=4.59, p<.01; B=.10, SE=.02,

CI[.07, .14]) became not significant after the inclusion of the Eyes Test scores and TAS-

20 scores in the model (t=1.61, p=.11, n.s.; B=.03, SE=.02, CI[-.01, .07]). This final

model was significant (R2=.24; F(6,785)=38.49, p<.01; t=8.48, p<.01; B=37.52, SE=4.42,

CI[28.84, 46.21]), and bootstrap analysis showed that the scores on childhood emotional

neglect had indirect effects on DES-II scores (B=.07, SE=.01, CI[.05, .09]), through

Eyes Test scores (B=.02, SE=.01, CI[.01, .03]), TAS-20 scores (B=.04, SE=.01,

CI[.03, .06]), and even the relationship between Eyes Test scores and TAS-20 scores

(B= .005, SE=.001, CI[.002, .009]). A summary of the multiple mediation analysis

results is presented in Figure 2.

---

Figure 2 about here

---

In contrast, another multiple mediation analysis did not support the reverse

causation hypothesis based on the sociocognitive model of dissociation: in this analysis,

 DEVELOPMENTAL ROOTS OF DISSOCIATION 20

DES-II was included as a predictor, childhood emotional neglect as the dependent

variable, and the Eyes Test and TAS-20 as the potential mediators. In fact, DES-II

scores did not add to the prediction of childhood emotional neglect in the final model

(t=1.58, p=.11, n.s.; B =.10, SE =.06, CI[-.02, .22]) and had no indirect effects on the

dependent variable through the Eyes Test (B=.02, SE=.02, CI[-.02, .05]), which also

was not significant in the model (B=-.18, SE=.18, CI[-.52, .17]). Therefore, the results

of multiple mediation analyses fully supported the trauma model of dissociation (based

on emotional neglect) presented in Figure 1, whereas the competing sociocognitive

model of dissociation did not find empirical support in the study.

Discussion

This study aimed to empirically test a developmental model of dissociation based

on recent psychoanalytic studies on mentalization and affect regulation (Allen, 2013;

Bromberg, 2011; Chefetz, 2015; Ensink et al., 2014, 2015; Fonagy et al., 2002; Howell,

2005; Jurist, Slade, & Bergner, 2008; Schimmenti & Caretti, 2016; Schore, 2009).

Consistent with research showing that dissociation is linked with parental failures of

care, and not only with child abuse (Draijer & Langeland, 1999; Dutra et al., 2009;

Ogawa et al., 1997), this theoretical model predicted that emotional neglect during

childhood may result in a collapse of mentalizing abilities and in difficulty identifying

feelings, describing feelings, and using them as a guide for one’s own behaviors. This

model also predicted that reduced levels of theory of mind and higher levels of

alexithymia resulting from childhood emotional neglect may foster an over-activation of

the dissociative processes that serve to protect the self from psychically painful

experiences. The rationale of this model is based on the assumption that individuals

who experienced emotional neglect during their childhood are likely to perceive
 DEVELOPMENTAL ROOTS OF DISSOCIATION 21

distressful experiences as disorganizing, exactly because their capacity to reflect on

mental states, which is strictly related to attachment experiences (Fonagy et al., 2002;

Liotti, 1999), might be less developed, and reduced mentalizing might have further

increased their difficulties with psychosomatic integration and affect regulation. As a

result, this condition may have forced them to rely on dissociative processes as a

paradoxically adaptive strategy to cope with overwhelming feelings and unbearable

states of mind (Schimmenti & Caretti, 2016).

The findings of the current study on a relatively large sample of Italian adults

supported this model on the developmental roots of dissociation: dissociation was

positively associated with childhood emotional neglect and alexithymia, while it was

negatively associated to theory of mind; moreover, a multiple mediation analysis

showed that theory of mind scores and alexithymia scores fully mediated the positive

association between the participants’ scores on childhood emotional neglect and their

dissociation scores. These results support the view that adequate parenting fosters the

development of both mentalization (Fonagy et al., 2002) and affect regulation

(Schimmenti & Caretti, 2016), that mentalization further promotes affect regulation

(Ensink et al., 2014a, b), and that mentalization and affect regulation protect from

dissociation (Allen, 2013). In contrast, inadequate parenting may precipitate a

developmental pathway leading to extreme activation of the dissociative processes,

which also involves lack of mentalization and difficulties with emotion regulation. The

controls for sociodemographic variables in the multiple mediation analysis further

suggest that age and education may additionally inform researchers and clinicians on the

relationships between parental care, theory of mind, alexithymia, and dissociation.

Younger and less educated participants were more exposed to the direct and indirect
 DEVELOPMENTAL ROOTS OF DISSOCIATION 22

effects of childhood emotional neglect on dissociation, consistent with empirical

research on dissociation and with the consideration that the capacity for integration and

the sense of self-continuity can improve, even at the neurobiological level, as a result of

age and educational growth (Armstrong, Putnam, Carlson, Libero, & Smith, 1997;

Putnam, 1997; Schimmenti, 2015a, c), among other factors. The sociocultural

environment in which the study was conducted might instead explain the higher scores

on parental overprotection among females. In fact, research has shown that female

children tend to be overprotected in Mediterranean countries (Rosenthal & Roer-Strier,

2001). However, gender did not add to the multiple mediation model. Finally, the

alternative sociocognitive model, which conceives of dissociation as a personality trait

that may exacerbate a negative perception of childhood experiences, did not find

empirical support in the current study.

As with every research, this study comes with a number of limitations. First, the

sample included only adult volunteers from the normal population, so the results of this

study are not immediately generalizable to other people. Future studies should utilize

clinical samples of individuals with current clinical disorders to extend these findings to

other populations. Second, dissociation, alexithymia, and childhood emotional neglect

were assessed by self-reported measures, which may contribute to method variance.

Moreover, the accuracy of individual reports cannot be guaranteed, although the

measures used in the present study are applied worldwide and have demonstrated

adequate psychometric properties. Therefore, future research should prioritize clinician-

administered assessments to increase understanding of the relationship between

childhood emotional neglect and dissociation. Third, a global index on childhood

emotional neglect was developed in this research, which helped for an effective testing
 DEVELOPMENTAL ROOTS OF DISSOCIATION 23

of the theoretical model presented in the article, but prevented further analyses on the

individual effects of maternal and paternal care on dissociation scores. Future research

on the potentially specific effects of maternal and paternal lack of cares on dissociative

symptoms is warranted. Fourth, although an attempt was made to rule out a reverse

causation hypothesis, the cross-sectional nature of this study made it impossible to

definitively establish causal links. Thus, longitudinal studies with clinical and

nonclinical samples are greatly needed to further test the proposed multiple mediation

model on the developmental roots of dissociation. However, this initial study provided

some empirical evidence that reduced mentalizing abilities and increased levels of

alexithymia are implied in the relationship between emotional neglect during childhood

and heightened levels of dissociation. This may have important clinical implications: in

fact, since dissociation has been empirically linked with many psychiatric disorders, it

might be crucial in clinical practice to assess the presence and severity of dissociative

experiences and to explore whether child abuse and neglect, alexithymia, and lack of

mentalization have a critical role in the development of overly activated dissociative

processes and whether these factors continue to exert a strong influence in the

maintenance of a particular disorder.

Conclusions

The findings of this study supported the hypothesis that reduced levels of theory

of mind and increased levels of alexithymia may result from parental failures of care

during childhood and may lead to dissociative symptoms. Therefore, it is likely that

people who display excessively activated dissociative processes will greatly benefit

from clinical interventions aimed to enhance mentalization and affect regulation. As

Allen (2013) has recently suggested, when mentalizing is supported in the therapeutic
 DEVELOPMENTAL ROOTS OF DISSOCIATION 24

relationship, patients have more opportunities to recognize and process their

dysregulated feelings and painful mental states on the cognitive and affective levels,

which may lead to clinically significant improvements. For this reason, the

enhancement of mentalized affectivity (Fonagy et al., 2002; Jurist, 2005, 2010) could be

a necessary, albeit difficult, goal to achieve in the treatment of individuals who were

emotionally neglected during their childhood and who show dissociative symptoms.

These patients may need to experientially discover the subjective meaning of their

affective experiences beyond intellectual understanding—in other words, they may need

to discover how to feel and think about their feeling at the same time—before being

ready to process the traumatic memories related to their negative childhood experiences.

This may be a necessary step in clinical work to prevent the overwhelming feelings

related to these memories, previously blocked to some extent by dissociation, from

coming out abruptly with a flood of dysregulation (Bromberg, 1998, 2011; Schimmenti,

2012).

On another level, the findings of this study may be of some relevance in a time in

which psychoanalysis has finally rediscovered the detrimental effects of child sexual

abuse on individuals’ mental and behavioral functioning (Davies & Frawley, 1992;

Shengold, 1989). In fact, these findings may remind us of the need to address in therapy

any childhood experience that threatened and eventually damaged the development of

self and its integration, not just childhood sexual abuse. They may also remind us that

parental neglect, rejection, and lack of responsiveness might have similar negative

effects to other types of maltreatment on child development (Infurna et al., 2016),

because such experiences negatively affect the quality of object relations and the

internal working models of attachment (Draijer & Langeland, 1999; Schimmenti &
 DEVELOPMENTAL ROOTS OF DISSOCIATION 25

Bifulco, 2015). At a more basic level, they can also remind us of Ferenczi’s (1929) old

lesson that emotional neglect—in combination with abuse or not—can deprive children

of the emotional nourishment they need to grow up healthy and in accordance with their

own inherent tendencies and attitudes. The psychoanalytic tradition suggests that

emotional neglect can constitute a trauma for a child (Ferenczi, 1929; Khan, 1963; Kris,

1956), so it might be crucial for clinicians to understand whether this type of trauma

applies to a given patient and to provide treatment accordingly.

 DEVELOPMENTAL ROOTS OF DISSOCIATION 26

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Table 1. Descriptive statistics and gender differences

Full sample (N=792) Males (n=358) Females (n=434)

M (SD) Observed Range M (SD) M (SD) t(790)

DES-II 18.63 (13.86) 0 - 64.29 19.08 (14.04) 18.25 (13.72) .84

Eyes Test 23.10 (4.53) 5 - 33 22.72 (4.76) 23.42 (4.31) 2.20*

TAS-20 47.10 (11.48) 20 - 85 46.76 (11.38) 47.39 (11.57) .76

Mother's Care 26.35 (7.29) 0 - 36 26.68 (7.01) 26.08 (7.51) 1.16

Mother's Overprotection 15.39 (7.37) 0 - 36 14.24 (6.92) 16.35 (7.60) 4.04**

Father's Care 24.10 (8.28) 0 - 36 24.83 (7.46) 23.51 (8.87) 2.24*

Father's Overprotection 14.51 (7.31) 0 - 36 13.14 (6.71) 15.63 (7.59) 4.84**

Childhood Emotional Neglect - 20.56 (22.91) -72 - 54 - 24.13 (21.42) - 17.61 (23.69) 4.02**

Age (years) 35.75 (10.95) 18 - 64 36.03 (10.84) 35.52 (11.05) .51

Years of Education 13.09 (3.40) 5 - 24 13.01 (3.49) 13.15 (3.32) .55

Note: * p <.05; ** p < .01

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Table 2. Pearson’s r correlations between the investigated variables

2 3 4 5 6 7 8 9 10

1. DES-II -.32** .34** .16** -.16** .13** -.11** .10** -.24** -.16**

2. Eyes Test - -.30** -.15** .12** -.12** .04 -.17** -.03 .21**

3. TAS-20 - .35** -.33** .24** .25** -.23** .00 -.19**

4. Childhood Emotional Neglect - -.77** .79** -.72** .76** .06 -.14**

5. Mother's Care - -.45** .54** -.35** -.05 .11**

6. Mother's Overprotection - -.28** .70** .02 -.11**

7. Father's Care - -.29** -.07 .07

8. Father's Overprotection - .03 -.15**

9. Age - -.03

10. Years of Education -

Note: ** p < .01

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Figure 1. Conceptual model of the multiple mediation analysis

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Figure 2. Results of multiple mediation analysis

Note: The values in bracket squares indicate the predictive association between childhood emotional neglect and dissociation without the

inclusion of theory of mind and alexithymia in the model; * p < .01.

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