A person with the dissociative subtype of posttraumatic stress disorder (PTSD) experiences all the symptoms of PTSD as well as depersonalization (detachment from the self) and derealization (detachment from the environment).
Depersonalization and derealization are the two most prominent dissociative symptoms associated with this subtype of PTSD.
Doctors diagnose this disorder in people with PTSD who have persistent or recurrent symptoms of either depersonalization or derealization.
Psychotherapy includes gradual exposure to the stressor or trigger and other strategies.
(See also Overview of Dissociative Disorders and Posttraumatic Stress Disorder [PTSD].)
Dissociation refers to a mental process in which the mind's ability to automatically and fully integrate all aspects of identity, memory, and consciousness fails under the stress of trauma. As a result, a person experiencing dissociation may feel disconnected from the self, and the surrounding environment may seem unreal. Some people with PTSD experience dissociative symptoms (for example, amnesia, flashbacks, numbing, and/or depersonalization/derealization), which commonly occur after exposure to trauma.
Dissociation is linked to a history of experiencing abusive or neglectful parenting, psychologic trauma, and PTSD. Complex trauma, which typically begins early in life and involves a close relationship (for example, one with a caregiver), increases the likelihood that a person will develop dissociative symptoms with PTSD. Other factors associated later in life with dissociative symptoms include physical violence, shame, and guilt.
Did You Know...
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Almost 15% of people with PTSD also experience depersonalization and derealization. As a result, these people
Experience PTSD symptoms more frequently
Have onset of PTSD in childhood
Have high exposure to trauma and more childhood adversities (for example, mental illness in a parent, divorce, and poverty)
Experience severe role impairment (for example, they have difficulties in performing job responsibilities and completing work around the house)
Have more suicidal thoughts and make more suicidal gestures, plans, and attempts
Sudden physical injury (as from a serious illness or accident, physical violence, war, or a natural disaster), or even the threat of such injury, dysregulates emotion and normal development. This, in turn, disrupts the person's experience, alters his or her expectations for the future, and interferes with the ability to cope.
Brain scans of people with PTSD show alterations in the brain structures that help control thinking and regulate emotion. In the dissociative subtype of PTSD, emotions are suppressed to such a degree that depersonalization (a disconnection from the self) and derealization (a disconnection from the surrounding environment) take place.
Symptoms of Dissociative Subtype of PTSD
Symptoms of PTSD include intrusion symptoms (for example, involuntary memories, dreams, or flashbacks). Many people try to avoid remembering the events or physical reminders of those events or experience dissociative amnesia. They may develop negative thought patterns and go on to feel detached or estranged from others, blame themselves for things they did not do, and/or become unable to experience positive emotions. Hypervigilance (the state of constantly assessing threats in the environment), irritability, difficulty concentrating, and sleep disturbance also occur.
The dissociative symptoms for which this subtype of PTSD is named disrupt identity, memory, and consciousness:
Depersonalization: Feeling detached from one's mental processes or body, so that one feels like an outside observer of one's own experience
Derealization: Persistent or recurrent experiences of one's surroundings as being unreal, as though the world were unreal or dreamlike
Diagnosis of Dissociative Subtype of PTSD
A doctor's evaluation, based on specific diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)
To meet the diagnostic criteria for PTSD "with dissociative symptoms," a person with PTSD must also experience persistent or recurrent symptoms of either depersonalization or derealization in response to the stressor.
Treatment of Dissociative Subtype of PTSD
Modified, more gradual approach to psychotherapy used for PTSD
Typically, psychotherapy for PTSD involves prolonged exposure therapy and cognitive therapy to dampen the hyperarousal brought on by PTSD. Because exposure therapy might worsen symptoms of dissociation, psychotherapy for the dissociative subtype of PTSD is modified to include gradual exposure to the stressor (or trigger) as well as
Identifying the dissociative symptoms (specifically, depersonalization and derealization)
Stabilizing, clarifying, and discussing the dissociative symptoms
Exploring stressors that may lead to dissociative episodes
Controlling any risk of revictimization
Hypnosis may also be useful to help people contain and reprocess traumatic memories. This technique may enable them to
Restructure their depersonalization and derealization experiences
Learn to control their need to dissociate
Prognosis for Dissociative Subtype of PTSD
People with this subtype of PTSD distance themselves from confronting the effects of their trauma, particularly if they suffered abuse in childhood and/or have developed dissociative symptoms. These people tend to have difficulty trusting their therapist and have a poorer prognosis.
More Information
The following English-language resources may be useful. Please note that THE MANUALS is not responsible for the content of these resources.
Lanius RA, Brand B, Vermetten E, et al: The dissociative subtype of posttraumatic stress disorder: Rationale, clinical and neurobiological evidence, and implications. Depress Anxiety2(8): 701-708. doi: 10.1002/da.21889
Spiegel D, Lewis-Fernandez R, Lanius R,et al: Dissociative disorders in DSM-5. Ann Rev Clin Psychol 9:299-326, 2013. doi: 10.1146/annurev-clinpsy-050212-185531
