Dissociation in people who have near-death experiences: out of their bodies or out of their minds?

Summary

Background

Some people who come close to death report having experiences in which they transcend the boundaries of the ego and the confines of time and space. Such neardeath experiences (NDEs) share some features with the phenomenon of dissociation, in which a person's self identity becomes detached from bodily sensation. This study explored the frequency of dissociative symptoms in people who had come close to death.

Methods

96 individuals who had had self-reported NDEs, and 38 individuals who had come close to death but who had not had NDEs completed a mailed questionnaire that included a measure of “depth” of near-death experience (the NDE scale) and a measure of dissociative symptoms (the Dissociative Experiences Scale). Median scores in the two groups were compared with Mann-Whitney U tests. The association between depth of NDE and dissociative symptoms was tested by Spearman's rank-order correlation between scores on the NDE scale and the dissociative experiences scale.

Findings

People who reported NDEs also reported significantly more dissociative symptoms than did the comparison group. Among those who reported NDEs, the depth of the experience was positively correlated with dissociative symptoms, although the level of symptoms was substantially lower than that of patients with pathological dissociative disorders.

Interpretation

The pattern of dissociative symptoms reported by people who have had NDEs is consistent with a non-pathological dissociative response to stress, and not with a psychiatric disorder. A greater understanding of the mechanism of dissociation may shed further light on near-death and other mystical or transcendental experiences.

Introduction

Dissociation is the separation of thoughts, feelings, or experiences from the normal stream of consciousness and memory.¹ Examples range from the common non-pathological experiences of daydreaming, to psychogenic amnesia and the “multiple personalities” seen in dissociative identity disorder.² Although Janet,³ who coined the term dissociation (désagrégations psychologiques), viewed it as a discontinuity in awareness caused by stress but rarely experienced by healthy persons, his contemporaries James⁴ and Prince⁵ argued that dissociation is a continuous variable present to some degree in everyone. Most modern writers regard dissociation as an adaptive response to intolerable physical or emotional trauma common in otherwise normal people and not necessarily causing high levels of distress.⁶ The relation between this common traumatic dissociation and the pathological traits seen in dissociative disorders is controversial.⁷ The 4th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders cautioned that “Dissociation should not be considered inherently pathological and often does not lead to significant distress, impairment, or help-seeking behaviour”.⁸

Dissociative symptoms have been described in disparate groups of trauma victims, including prisoners, hostages, and rape victims.⁹ Spiegel and Cardeña² concluded that 25–50% of trauma survivors experience a sense of detachment. In extreme cases, this dissociated perception may lead to amnesia for the trauma or a distorted memory of it.

The dissociative experiences scale (DES)¹ is the most widely used screening instrument for dissociation. The DES is a 28-item visual analogue scale on which respondents are asked to indicate the percentages of time during which they have different types of dissociative experiences (excluding experiences under the influence of alcohol or drugs). Examples range from the common and non-pathological experience of becoming so absorbed in watching television that the person is unaware of what is happening in the room, to the rare and pathological experiences of having no memory for important past events, or feeling that his or her body belongs to someone else. Individuals with diagnosed dissociative disorders typically have DES scores of 30 or higher; most other groups have scores that are very low, often near zero.⁷

Researchers can calculate the percentage of individuals who score 30 or higher on the DES, using this as a cutoff for dividing a sample into “high dissociators” and “low dissociators”.¹⁰ Although the DES includes items relevant to both normal and pathological dissociation, an eight-item subset of the DES, the DES-T, has been developed as a sensitive measure of purely pathological dissociation. Any score on the DES-T indicates a pathological case of dissociation.

Some people who come close to death report having had a profound experience in which they believed they left their physical bodies and transcended the boundaries of the ego and the ordinary confines of time and space. These experiences, often called near-death experiences (NDE)s, include cognitive elements such as accelerated thought processes and a “life review”, affective elements such as intense feelings of peace and joy, purportedly paranormal elements such as a sensation of being out of the body or visions of future events, and transcendental elements, such as an experienced encounter with deceased relatives or what is interpreted as an unearthly relam.11, 12, 13 Although the term near-death experience was not coined until 1975, transcendental experiences near death were reported in the medical literature of the 19th century,14, 15 and the phenomenon had been described as a discrete syndrome in 1892, when Heim¹⁶ published a collection of such cases. A review of all the published estimates concluded that NDEs probably happen to between 9% and 18% of people who have been demonstrably near death.¹⁷

Several hypotheses have been proposed to explain NDEs; these hypotheses encompass both physiological mechanisms18, 19 and sociopsychological factors,20, 21 but the cause remains unclear. Nevertheless, there is a consistent pattern of change in beliefs, attitudes, and values after these experiences.13, 22, 23 The NDE scale is a 16-item, selfscoring, multiple-choice questionnaire which has documented reliability and validity, and which differentiates NDEs from other responses to a close encounter with death.¹² A score of 7 or higher (of a possible 32) defines an experience as an NDE.

Retrospective studies of people who report NDEs have shown that these individuals are psychologically healthy.24, 25 However, some people who have NDEs report distress or psychosocial impairment that may be related to difficulty in integrating the experience and its sequelae into their lives.²⁶

In the first attempt to understand NDEs psychologically, Pfister²⁷ proposed that people faced with potentially inescapable danger attempt to avoid this unpleasant reality through pleasurable fantasies. This interpretation was elaborated by Noyes and Kletti,¹¹ who viewed the NDE as a type of depersonalisation. However, NDEs differ from depersonalisation on a number of critical points.²⁴ Irwin²⁸ argued that what is altered is not the person's sense of identity, but the association of this identity with bodily sensation. Therefore, he suggested that the NDE is not a type of depersonalisation but one of dissociation of the self identity from bodily sensation and emotions.

Many NDEs include features that are suggestive of dissociation; such features include the partial or total disconnection of the individual's perception experiences, cognitive functioning, emotional state, and sense of identity from the mainstream of the individual's conscious awareness.²⁹ The epitome of disconnection between the self and the body is the sensation of existing outside the physical body and observing it from another spatial location; this so-called “out-of-body experience” is common in NDEs,12, 13 and is also described by trauma victims in whom it is seen as a defence against overwhelming physical threat.⁹

Irwin²⁸ speculated that people who have NDEs may develop a tendency to dissociate in response to very stressful unforeseen events, and Ring²² proposed a developmental theory of sensitivity to extraordinary experiences such as NDEs, in which childhood trauma stimulates the development of a dissociative response as a means of psychological defence. Both authors noted, however, that people who have NDEs do not develop a general dissociative defence which they used to cope with everyday stressors, nor do they have a dissociative disorder. The mental health of most such individuals suggests that NDEs are in fact unrelated to clinical dissociative disorders, which are characterised by persistent, recurrent, or chronic dissociation.⁸ Although individuals who do meet diagnostic criteria for dissociative disorders may benefit from specific treatments for dissociation, the majority do not have dissociative disorders but nevertheless report dissociative symptoms. Do these individuals have sufficient distress or impairment to warrant similar therapeutic interventions? This study examines the frequency and type of dissociation among a sample of people who had NDEs, and among individuals who came close to death but did not have NDEs.