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Perhaps the least appreciated manifestations of dissociation in trauma are in the areas of perceptual alterations and somatic symp-toms. As noted, time perception is often altered, especially with the dissociative response associated with the initial traumatic freeze epi-sode.¹¹The popularly described sensation of “time standing still” is indeed a frequent perception of the MVA victim at the moment of im-pact, as documented in hundreds of my patients. Slowing of time is the most common alteration of time perception. A sense of time alter-ation may persist for some time after the impact, and its duralter-ation of-ten reflects the length of time of the post-MVA freeze episode, or period of dissociation.

Visual perception and acuity are also commonly affected in dis-sociation. Flashback memories are often characterized by marked distortion of shape and color, usually with vivid and bizarre changes that reflect the accompanying state of enhanced arousal, as noted in prior references to MVA experiences. The MVA victim will often re-member the other car in flashbacks and intrusive memories as being enlarged and distorted, and traveling at exaggerated speeds. In earlier chapters, we discussed the frequent association of binocular visual acuity impairment and convergence insufficiency in whiplash pa-tients. These patients often also have less easily explained monocular visual alteration, including monocular diplopia and blurring of vision in one eye.

One such patient was referred to me because of partial vision loss in her right eye following an auto accident two months prior. She had not experienced a blow to her head. The patient had lost control of her car on an icy mountain road, and as the car spun out of control, it slid off of the right side of the road into a shallow ditch. On the other side of the ditch was a cliff. As she watched the edge of the cliff approaching from her right side (perceived in slow motion of course), her car was stopped by impacting a tree, and came to rest. Thereafter, she

devel-oped persistent blurring of vision in her right eye. Ocular refraction showed a consistent refractive error that appeared to be correctable, and she was fitted with a lens that provided clear vision in that eye.

Within minutes after putting on the glasses with the new lens, she de-veloped nausea, palpitations, flashback memories of the accident, and panic. Any further attempts to restore or correct the measurable refractive error in her right eye continued to produce attacks of panic and reexperiencing of the traumatic event through flashbacks. Her vi-sual impairment was diagnosed as being hysterical in nature.

This remarkable patient presents an example of this group of symptoms. The measurable but physically unexplained refractive er-ror in her right eye was clearly a somatic dissociative response driven by the moment of life-threatening danger perceived in that eye at the time of the MVA. Visual images perceived in her right eye activated procedural memory for the terrifying events of the potentially fatal accident and triggered emotionally valenced flashbacks and panic.

Blurring of vision in that eye became a protective dissociative phe-nomenon. The unusual feature of this case, of course, is that the re-fractive error was consistently measurable and reproducible. Dissocia-tion had resulted in a probably temporary but physiologically measur-able alteration in the dissociated end organ. The occurrence of this type of visual distortion in MVAs usually appears related to the asso-ciation of visual cues accompanying the threat at the moment of the accident. In my patient population, it occurs much less often in rear-end accidents in which the victim did not see the car approach-ing, and is especially common when direct visual input of the im-pending threat occurred from one side or the other.

Distortion of proprioceptive awareness of the victim’s body is a common dissociative phenomenon. This is often associated with an in-jured part or region of the body, especially one of the extremities. The patient will note altered sensation, usually a vague sense of numbness, but the exact sensation is usually very difficult to describe. The ex-tremity may be neglected or ignored, and postural abnormalities may result that can be quite remarkable. Examination of the part of the body involved may reveal sensory changes on a variety of tests that will usu-ally be interpreted as “nonphysiological” in nature by the physician.

Stocking or glove patterns of loss of pain, touch, and vibratory sensa-tion are common. Strength testing often shows giveaway weakness.

Somatic Dissociation 105

Patients presenting with these neurological findings will frequently be diagnosed as suffering from conversion hysteria.

A remarkable example of somatic dissociation was seen in an MVA victim treated in my chronic pain program. This young lady had been involved in a rollover accident during which her left arm was crushed by the car as it rolled, tearing off almost the entire skin of her forearm. Amazingly, she suffered minimal nerve damage, but re-quired extensive skin grafting of the forearm. The sensation in the grafted skin was obviously deadened and never returned to normal, but as she recovered she developed increasing vague, hard to de-scribe aching pain that was resistant to all treatment, although it did not fulfill criteria for sympathetically maintained pain. She essen-tially stopped using the arm and hand for any activity. The pain was actually worse in the shoulder than the forearm, and was associated with some evidence of myofascial pain and spasm in the shoulder.

The remarkable feature of her physical examination, however, was her posture. In the standing position, her head was side bent and ro-tated to the right, and her torso was also roro-tated to the right. Her left shoulder blade was rotated backward and the arm almost held behind her, literally out of her view. She was totally unaware of this position of total rejection and dissociation of her entire left arm, even when looking in a mirror. When shown a face-on, full-body photograph of herself, however, she was surprised and shocked at her unusual ap-pearance. With trauma therapy and postural education, the pain largely disappeared in a sequential fashion as her posture approached a more normal status.

In our chronic pain program, we invariably see that the patients’

unconscious posture reflects not only their pain, but also the experi-ence of the traumatic event that produced the pain. The asymmetrical postural patterns, held in procedural memory, almost always reflect the body’s attempt to move away from the injury or threat that caused the injury. Many of these patients manifest the “nonphysiological findings” that have branded them as chronic pain patients by their physicians. With careful exploration of the mechanisms of the source of the pain, however, one will usually find strong evidence for a his-tory of traumatic stress specific to that area of the body. Specific neuromuscular postural patterns that have developed related to their injury are often visible markers for the presence of somatic dissoci-ation, and explain the patterns of “nonphysiological findings.”