About the presenter: Louise Heite is speech pathologist in two middle schools on the Kenai Peninsula of Alaska. She recently completed training at Temple University, where she studied under Woody Starkweather. She has previously been a classroom teacher, an entrepreneur, and an archaeologist. Her interest in stuttering is both professional and personal.

-Discussion-

La Petite Mort: Dissociation and the Subjective Experience of Stuttering

by Louise B Heite
from Alaska, USA

The genesis of this paper lay in a bad scare while driving. I experienced a moment of dissociation simultaneously with a moment of stuttering that almost resulted in a serious accident. After that, I asked every person who stutters whom I encountered if they had ever experienced a disturbance of their senses or of their awareness of their self or surroundings simultaneously with stuttering. A surprising number of them had, some often enough to have developed a personal code to describe the experience. These ranged from the mundane ("lose touch") to the melodramatic ("drowning", "suffocating"). A serious investigation of the phenomenon became the subject of my MA thesis in speech-language pathology, which was presented at Temple University in December, 2000. Below is a very brief condensation of that study. LH, October, 2001

"La Petite Mort"

Many persons who stutter have reported that they experience a disturbance of their sensory perception or of awareness of self or surroundings during the moment of stuttering. In a description of this disruption experienced by a client, Van Riper used the term petite mort ("little death"). The term suggests both the completeness and the intensity of the experience (1982). Because this is a purely subjective experience, inaccessible to the outside observer except through the indirect means of inference from observable behaviors or through client self-report, the phenomenon has received little to no attention from researchers. However, the possibility of dissociation in connection with a stuttering event has implications both for fundamental understanding of stuttering, and for the choice of therapy approaches for particular individuals.

Dissociation

Dissociation is a recognized phenomenon in psychology. It can accompany a wide range of disorders, and can also occur without any accompanying pathological conditions. Diagnostic and Statistical Manual IV, defines dissociation as "a disruption in the usually integrated functions of conscious, memory, identity, or of perception of the environment," which may be "sudden or gradual, transient or chronic." (DSM IV, Mental Disorders, 1994, pp 478- 491).

Fairly common and mild forms of dissociation include, among other symptoms, déjà vu; failure to recognize one's own reflection; or forgetting important details of an event. More serious dissociation can also include sensory disturbance especially of the visual system, a sense of disconnection from one's body; or a feeling of "possession" by a force not under one's own control. More severe dissociation is often regarded as a disorder on its own, and may involve major amnesia for important events; "fugue," or wandering without being aware of where one is; and at its most extreme, multiple personality disorder (DSM IV, 1994, pp 478 – 491).

Other conditions that are associated with dissociation at rates significantly above its occurrence among the general population include neurological conditions (Sierra and Berios, 1998); visual disturbances without pathology of the visual system such as teleopsia, micropsia, and metamorphopsia (Lipsanen et al, 1999); ambidexterity (Hollander, Carasco et al, 1992); personality disorders (Kihlstrom et al, 1994; Tobacyk et al, 1988; Ross et al, 1990); anxiety spectrum disorders (Kenardy et al, 1992); and obsessive-compulsive disorders (Goff et al, 1992).

The Present Study

There is a remarkable similarity among the anecdotal descriptions of the subjective experience of la petite mort .These descriptions resemble the clinical descriptions of several kinds of dissociation. However, as stated above, dissociation is not directly observable. Researchers must depend on inference from overt behaviors, along with subjects' descriptions of their own experiences, to determine whether dissociation is present or not.

Perkins, Kent, and Curlee (1990) have pointed out that the subjective elements of stuttering may have a far more powerful effect on the speaker than the observable behaviors. The neurologist Antonio Damasio (1999, p. 83) stated that studies of most processes of the mind must necessarily rely on the collective narratives of many subjects to arrive at a definition. Thus, the present study has sought to use the collective descriptions of dissociative-like experience of 103 adults who stutter to try to characterize this aspect of the stuttering experience.

The sample was drawn from volunteers who responded to an invitation placed on several English-language based stuttering discussion lists on the Internet, as well as volunteers recruited at the National Stuttering Association convention in Tacoma, Washington, in 1999. These persons provided a narrative description of their own experience of stuttering, along with a more standardized description based on a check-box list of symptoms and possible sensations and behaviors. They also provided some basic demographic information. Respondents who did not also experience a dissociative event in connection with their stuttering had an option to provide the narrative and demographic information only.

The questionnaire included eight sections, which can be described as follows:

The study sample is not a normal sample of the population of persons who stutter. Rather, it represents a highly aware subset, who have spent a lot of time thinking about their disorder. Nevertheless, the sample included both men and women from many walks of life, and across the spread of the adult lifespan, with both mean and mode in the middle to late 30's. Except for gender, the demograhics of the sample were not significantly different from other studies involving larger samples of adults who stutter. However, women made up a disproportionately large portion of the sample, representing about 33% rather than the 20% that might be expected based on other studies of the demographics of stuttering. Nevertheless, gender proved not to correlate significantly with other elements that were examined, so the disproportionate number of women probably did not distort the results.

The database assembled from the questionnaires was manipulated in SPSS, using descriptive procedures to define the sample, and the inferential procedures of principal components factor analysis and cluster analysis to draw a picture of petite mort from the information provided by the respondents.

Analysis

Seventy of the 103 respondents reported an experience resembling dissociation during moments of stuttering. The data analysis focused on this subset.

Most people reported their first memory of a petite mort experience at about puberty, though the range of first reported experience stretched from the preschool years through adulthood. Almost half of those who report it say that they always experience it during a moment of stuttering. Most also experience it at a moderate level, and report that it lasts throughout the stuttering episode. The majority also report that that it subsides in synchrony with the subsidence of the stuttering episode and its accopanying secondary behaviors. Almost none of the respondents report it as pleasant.

The eighty-three variables reported on the checkbox forms were grouped as symptoms and descriptors. Descriptors included both demographic information and such information as duration and intensity of the petite mort experience. Principal components factor analysis, a statistical procedure that measures the strength of relationships among a large group of variables, was used to group respondents into four loosely defined groups according to these descriptors. Cluster analysis, a related statistical procedure, was performed on the other symptoms reported in the checkbox survey to delineate clusters of symptoms. These clusters were able to accurately predict membership in the groupings created by the descriptor and demographic variables at a rate of almost 98%.

Respondents whose symptoms placed them in Cluster 1 showed awareness of both their speech behaviors and their secondary stuttering behaviors such as wincing or motions of the hands, feet, and head. Their dissociative characteristics centered on sensory disturbances such as distorted vision or tingling sensations. There was an interaction among the respondents' perceived ability to control the event, the intensity of their petite mort experience, and their awareness of their surroundings.

Members of Cluster II were aware of tension and of irregular breath, but not of primary or secondary stuttering behaviors or even of the petite mortexperience itself. Their dissociative characteristics were strongly depersonalizing, including absence of awareness, loss of touch with or control of their bodies, numbness, and a floating sensation. These people felt that they had no control over the event.

Cluster III was made up exclusively of persons recruited at the NSA convention, although not all respondents recruited at the convention fell into this cluster. Members of Cluster III were distinct from the other two clusters in that their descriptions of their stuttering were dominated by emotional and cognitive elements, rather than specific physical or behavioral events. Their reports of the petite mortexperience were likewise more emotional and cognitive than sensory. There was also a correlation within this group between age of the respondent and the intensity of the petite mortexperience.

Definition and Implications of Petite Mort

The clusterings of symptoms described above resemble the clusterings of dissociative symptoms found in studies of dissociation in the general population (Ross, Joshi, and Curry, 1991; Kihlstrom et al, 1994). The experience of those in Cluster I appear to fall into the category of "fantasy and absorption" as they seem to be absorbed in their stuttering behaviors to the exclusion of other sensations. The experience of those in Cluster II appear to be similar to depersonalization and and derealization, perhaps with a selectively amnestic component. The experinece of those in Cluster III is more general, with components of both absorption and depersonalization, but with the addition of cognitive components.

The narrative descriptions of the petite mortexperience reinforce the description derived from the check-box forms. Those who reported a petite mortexperience described dissociative symptoms and a sense of isolation in their narratives at a rate that was four times higher than those descriptions in the narratives of those who did not report a petite mortexperience. On the other hand, the rate is reversed regarding the physical elements of stuttering.Only those who reported petite mortexperience also reported a disturbance to their sense of time.

The presence of dissociation simultaneously with stuttering may have a serious effect on the course of therapy. A person whose mind has temporarily detached itself from his or her body will have a difficult time maintaining attention on techniques learned in classic stuttering therapy. On the other hand, stress-inoculation, cognitive restructuring, and staged exposure which are used successfully in the treatment of other disorders with a dissociative component, have been shown to be effective for some stutterers also. It is possible that these forms of therapy are therapies of choice for stutterers who experience petite mort, while control-based therapies are more appropriate for those whose stuttering is not accompanied by dissociation. Whether this is so awaits further research.

The following limited bibliography covers only the citations mentioned in this paper. A complete bibliography for the study is available on request.

Damasio, Antonio (1999). The Feeling of What Happens. New York: Harcourt, Brace.

Goff, Donald C, Olin, Jonathan A, Jenike, Michael A, Baer, Lee, and Butolph, M Lynn ( et al 1992). Dissociative symptoms in patients with obsessive-compulsive disorder. The Journal of Nervous and Mental Diseases, 180, pp 332 - 337.

Hollander, Eric, Carrasco, Jose L, Mullen, Linda S, Trungold, Sari, DeCaria, Concetta M, and Towey, James (1992). Left hemisphere activation in depersonalization disorder: a case report. Biological Psychiatry, pp 1157 – 1162.

Kenardy, Justin, Evans, Larry, and Oei, Tian PS (1992). The latent structure of anxiety symptoms in anxiety disorders. American Journal of Psychiatry, 149, pp 1058 – 1061.

Kihlstrom, John F, Glisky, Martha L, and Angiulo, Michael J (1994). Dissociatiotive tendencies and dissociative disorders. Journal of Abnormal Psychology, 103, pp 117 – 124.

Lipsanen, Tapio, Lauerma, Hannu, Pettola, Paivi, and Kallio, Sakari (1999). Visual distortions in dissociation. Journal of Nervous and Mental Disease, 187, pp 109 – 112.

Perkins,W, Kent, R D and Curlee, RF (1990) A theory of neuropsycholinguistic function in stuttering. Journal of Speech and Hearing Research, 34, 734 – 752.

Ross, Colin A, Joshi, Shaun, and Currie, Raymond

1. (1990) Dissociative experiences in the general population. American Journal of Psychiatry, 12 no. 2, pp 1547 – 1552.

2. (1991) Dissociative experiences in the general population: a factor analysis. Hospital and Community, 42, pp 297 – 301.

Sierra, Mauricio and Berios, German E (1998). Depersonalization: neurobiological perspectives, Biological Psychiatry, 44, pp 898 – 908.

Task Force on DSM – IV (1996) Diagnostic and Statistical Manual - IV. Washington DC: American Psychiatric Association pp 477 – 491.

Tobacyk, Jerome J, Wells, Donald H, and Miller, Mark M (1988). Out-of-body experience and personality funtioning. Psychological Reports, 82, pp 481 – 482.

Van Riper, Charles (1982). The Nature of Stuttering (2nd Edition). Englewood Cliffs NJ: Prentice-Hall

-Discussion-

September 5, 2001